Travel Medicine By Dr. Mona Shawki Moustafa Lecturer of Occupational Health and Industrial Medicine Community Medicine Department Faculty of Medicine-Alexandria University-Egypt
Travel medicine: It is the branch of medicine that deals with the prevention and management of health problems of international travelers.
The number of people traveling internationally is increasing every year. According to statistics of the World Tourism Organization, international tourist arrivals in the year 2006 exceeded 846 million
As more people travel and individuals travel more frequently, the specialty of travel medicine becomes more important. Thus, most clinicians need some basic information to determine the extent of health advice their patients should access prior to their journeys.
International travel can pose various risks to health, depending on the characteristics of both the traveler and the travel.
Morbidity studies suggest that about half of the people from a developed country that stay one month in a developing country will get sick. Treveler’s diarrhea
Mortality studies indicate that: • Cardiovascular disease accounts for most deaths during travel (50-70%). • Injury and accident (25%). • Infectious disease accounts for about 2.8-4% of deaths during and after return from travel.
Key factors in determining the risks to which travelers may be exposed are: • Destination. • Duration and season of travel. • Purpose of travel. • Standards of accommodation and food hygiene. • Behavior of the traveler. • Underlying health of the traveler.
The durationof the visit may determine whether the traveler may be subjected to marked changes in temperature, humidity, or prolonged exposure to atmospheric pollution and likelihood of exposure to infectious agents which will influence decisions on the need for certain vaccinations or anti-malarial medication.
The purpose of the visit is critical in relation to the associated health risks. (conferences versus holidays) • Behavior also plays an important role e.g. going outdoors in the evenings in a malaria-endemic area without taking precautions
Travelers' health is the responsibility of: Clinicians. Travelers. Travel Industry.
Responsibilities of Clinicians A clinician should provide the traveler with: Knowledge that enables them to protect themselves from potential health risks. Emphasize the importance of a pre-travel consultation and educates the patient that international travel can pose special health risks that should be addressed.
Evaluate the traveler including the medical history, the assessment of the epidemiology of endemic diseases or health risks at the destination, and the behavioral risks that may be taken.
Educate the traveler about importance of having a medical kit during his journey and construct him about its contents.
Provide post-travel medical care. The extent of the care given is personally determined according to condition of traveller and travel circumstances. Recognize common disease symptoms and syndromes of international travelers.
Travel health advice should be individually tailored to the person. • For example, the business traveler to Bangkok, Thailand with underlying heart disease staying at a 5-star resort has different risks from those of the healthy refugee camp worker who will travel throughout northern Thailand on the Cambodian border.
Vaccination • Despite their success in preventing disease, vaccines do not fully protect 100% of the recipients. • The vaccinated traveler should not assume that there is no risk of catching the disease against which he has been vaccinated. • All additional precautions against infection should be followed carefully.
The protective effect of vaccines takes a period of time to be fully developed. • The duration varies according to the vaccine, the number of doses required and whether the individual has previously been vaccinated against the same disease. • For this reason, travelers are advised to consult a travel medicine clinic or personal physician 4–6 weeks before departure.
Choice of vaccines for travel Vaccines for travelers include: (1) Vaccines used routinely, particularly for children. (2) Vaccines that may be advised before travel. (3) Vaccines that, in some situations, are mandatory.
Routine vaccination: Diphtheria/pertussis/tetanus (DTP) Hepatitis B (HBV) Haemophilus influenzae type b (Hib) Measles (MMR) Poliomyelitis (OPV or IPV)
Selective use for travelers: Cholera Influenza Hepatitis A (HAV) Japanese encephalitis Lyme disease Pneumococcal disease Rabies Tick-borne encephalitis Tuberculosis (BCG) Typhoid fever
Mandatory vaccination: • Yellow fever (for protection of vulnerable countries) • Meningococcal disease (required by Saudi Arabia for pilgrims visiting Mecca for the Hajj (annual pilgrimage) or for the Umrah.
The International Health Regulations mandates yellow fever vaccination for two different reasons: (1) to protect the individual in areas where there is a risk of yellow fever infection. (2) to protect vulnerable countries from importation of the yellow fever virus.
According to the international measures, The world is divided into three zones: • Infected (endemic) zone. • Infectable (receptive) zone. • Non-infectable zone.
Infected (endemic) zone: In this zone, the three requirements for perpetuation of yellow fever are present; the virus, the vector and suitable environmental conditions. The objective of the control measures is to prevent exportation of the disease and diminish local spread.
Measures applied to infected zone: • Ports and airports: a- should be away from the city. b-Apply insecticides periodically to control mosquito. • The plans: Application of insecticides on planes before leaving. • Individuals: • Those working in the airport and travelers going outside or entering should have valid vaccination certificate . • Cases of yellow fever should not leave the country.
Infectable (receptive) zone: Between endemic zone and latitude 43N and 43S. Only the vector and suitable environmental conditions are present, but there is no virus. • All planes and ships coming from infected areas should be disinfected on arrival. • Only travelers carrying valid vaccination certificates are allowed to enter. Measures applied to infectable zone:
If travelers were not vaccinated or since less than ten days they should be kept in quarantine to complete the six days • Monkeys and apes should be kept in quarantine for seven days.
Non-infectable zone: • The area north and south of the latitude 43. • In this area, there is no virus, no vector and the environmental conditions are not suitable. • Thus, no preventive measures are required.
Yellow fever vaccine • 1 dose • Protection: 10 years • Age range: Minimum age 9 months. Seek medical advice for infants 6-9 months who are travelling to high risk areas
International Certificate of Vaccination or Prophylaxis (ICVP) for Yellow Fever • The International Health Regulations allow countries to require proof of vaccination for entry of travelers arriving from certain countries. • Travelers arriving without a completed ICVP may be quarantined or refused entry unless submitting to onsite vaccination. • Vaccinees should receive a completed ICVP, signed and validated with the center’s stamp where the vaccine was given. • This certificate is valid 10 days after vaccination and for a subsequent period of 10 years.
Malaria chemoprophylaxis • Antimalarial drugs are recommended for prophylaxis of non-immune travelers visiting malaria-endemic areas. • In areas of chloroquine-sensitive malaria, weekly chloroquine is the drug of choice. • In areas where chloroquine-resistant P. falciparum is transmitted, weekly mefloquine or daily doxycycline is recommended. • Chemoprophylaxis should be started 1 week before arriving in a malaria-endemic area and continued during travel and for 4 weeks after leaving the area.
Responsibilities of Travelers • Each traveler needs to realize the value of health and the risks that traveling internationally may pose. • Every traveler’s responsibility is to weigh the personal risk versus benefits of a particular journey.
Recent studies have shown that a small portion of travelers do not even seek general information about their travel destination.
Medical kit and hygiene items • Sufficient medical supplies should be carried to meet all needs for the duration of the trip. • A medical kit should be carried for all destinations where there may be significant health risks, particularly those in developing countries, and/or where the local availability of specific medications is not certain.
Certain categories of medicine should be carried together with a medical prescription, signed by a physician. • Hygiene items should also be carried in sufficient quantity for the entire visit unless their availability at the travel destination is assured. These will include items for dental care, eye care including contact lenses, skin care and personal hygiene.
This kit will include: • Basic medicines to treat common ailments. • First-aid articles. • Special medical items that may be needed by the individual traveler.
Contents of a basic medical kit (First-aid items): • Adhesive tape. • Antiseptic wound cleanser. • Bandages. • Emollient eye drops. • Insect repellent. • Insect bite treatment. • Nasal decongestant. • Oral re-hydration salts. • Scissors and safety pins. • Simple analgesic (e.g. Paracetamol). • Sterile dressing. • Clinical thermometer.
Responsibilities of the Travel Industry • Travel agencies, tour operators, air and cruise lines should learn about the basics of travel medicine as it affects the areas of the world where their customers are traveling. • Their respnsibilities are: • Consult travelers about health risks and preventive actions they should take. (such as the presence of malaria or the fact that vaccinations may be beneficial). • Provide resources in travel medicine.
Mode of travel The mode of travel is an integral part of the travel experience. According to the World Tourism Organization, of the 846 million international tourist arrivals in 2006, air transport represented 45% of arrivals and marine transport accounted for 7%.
Travel by air The volume of air traffic has risen steeply in recent years. Moreover, the number of long-distance flights has increased. According to the International Civil Aviation Organization, the passenger traffic is projected to double between 2006 and 2020.