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Travel Medicine. Practice of “Emporiatrics” Rapid development over the last 25 years Fairfield Hospital in Melbourne started travel clinic in early-mid 80s - one of the world’s first travel clinics Now a recognised clinical entity primarily involved in risk management

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travel medicine
Travel Medicine

Practice of “Emporiatrics”

Rapid development over the last 25 years

Fairfield Hospital in Melbourne started travel clinic in early-mid 80s - one of the world’s first travel clinics

Now a recognised clinical entity primarily involved in risk management

Strong overlap with public health and occupational health and general practice

risk management
Risk Management

Identifying risks for individuals or groups

Advising about risk reduction strategies

Recommending and providing risk reduction interventions

Encouraging behavioural change to change risk level

risk reduction interventions
Risk Reduction Interventions

Information enabling behaviour modification

vaccinations

medications (including antimalarials)

other - travel insurance, pre existing medical problems, nets, syringes, medical kits

knowledge of travel related risks
Knowledge of Travel-related Risks

Knowledge of morbidity and mortality of travellers

Understanding of epidemiology and geography of communicable diseases

Awareness of non-communicable risks

Vaccines, indications, side-effects

Knowledge of post-travel illness presentation and management

Geography , esp of major tourist destinations

Ability to communicate complex issues in simple ways

Understanding of when to refer

provide up to date information
Provide Up-to date Information

Understand basic current epidemiology

Be aware of outbreaks and emergent issues

Provide written material targeting specific risks

Be able to communicate using electronic media

individualise advice
Individualise Advice

Tailored advice to the traveller, itinerary and time

Travellers vary by age, sex, pregnancy, medical history, immune status, current health, medications, vaccination history, allergies and prior travel experience

Itineraries vary by length of stay, activities, environmental exposures, types of accommodation, season and budget

Time variation is obviously important

Advice should be understandable, re-inforced and in various media

Personal advice is more likely to be understood, remembered or facilitate behavioural change.

consider costs
Consider Costs

Advice and recommendations should be within the travellers budget

Costs should be made clear and should presented in some priority order

Alternate strategies may need to be discussed

travel consultation
Travel Consultation

Cornerstone of clinical decision process

Opportunity to define the risk profile

Requires appropriate time, and done in advance of travel.

May need multiple visits, allow a plan

Good documentation essential

Discussion of costs and priorities

Consider family requirements

factors affecting individual risk

TRAVELER

  • Reason for travel
  • Behavior
  • Age and gender
  • Health education
  • Medical history

- Allergies

- Immunosuppressed

- Pre-existing disease

  • Immunization status
  • Special needs

- Pregnant women

- Children

- Elderly

  • TRAVEL
  • Destination
  • Country of origin
  • Duration of stay
  • Itinerary
  • Travel conditions
  • Season
Factors affectingindividual risk

Individual

r

isk

this person this trip this time
“This person, this trip, this time”

Person; medical conditions past and present, allergies, medications, vaccine history, previous travel

Trip: reason, style and comfort level, rural vs urban, accomodation, activities, exposures, budget

Time: duration, season, frequency

special risk groups
Special Risk Groups

Pregnancy

Children

Elderly

Expats and long-term travellers

VFR

Cardiac or Lung disease

Diabetes

HIV infections

Immunocompromised

special itineraries
Special itineraries
  • Cruise ships
  • Diving
  • Extended stay
  • Extreme travel
  • Mass gatherings
  • Wilderness
risk to be considered and discussed
Risk to be considered and discussed

Food and Water

Insects

Animals and Birds

Environmental hazards

Soil

Sun

Heat/humidity

Cold/ dry

Altitude

Marine hazards

Respiratory Hazards

Sex and body-fluid exposure

Vehicular and other Accidents

DVT risk

communicable diseases vaccine preventable
Communicable DiseasesVaccine Preventable

Hep A and B

Typhoid

Yellow fever

Cholera

Diphtheria/tetanus/pertussis

MMR Varicella

Influenza

Japanese Encephalitis

Meningitis ACYW

Plague

Polio

Rabies

Tick-borne encephalitis

Tuberculosis

vaccine classification 3 rs
Vaccine classification-3 Rs
  • Routine ( background) vaccine

Childhood, standard

  • Required ( compulsory) vaccine

Cross borders, entry requirements IHR

  • Recommended ( elective based on risk)

Travel vaccines

Some vaccines can be in more than category. Not all the same or available in all countries

vaccinations 1
Vaccinations 1
  • Category A – considered low risk
    • Western Europe/North America/Japan/UK/NZ/Singapore
  • Should be fully vaccinated & up to date with
    • Diphtheria/tetanus/whooping cough
    • Routine paediatric vaccines
    • MMR
    • Polio
    • Chicken pox
    • Influenza
vaccinations 2
Vaccinations 2
  • Category B Travel – considered to be low to intermediate risk
    • Eastern Europe/Israel/Korea/Malaysia/Pacific Is/South Africa
  • Vaccinations should be as for Category A, plus:
    • Hepatitis A & B
    • Typhoid
    • QFT
vaccinations 3
Vaccinations 3
  • Catergory C Travel – considered to be of higher risk
    • African sub-continent/Central & South America/East Asia/SE Asia/Melanesia
  • Vaccinations should be as for Category B, plus:
    • Polio booster
    • Japanese B Encephalitis
    • Rabies
    • Meningitis
    • Yellow Fever
  • Malaria Prevention
corporate travellers
Corporate Travellers
  • All basics in date: polio, DTPa, MMRV, influenza
  • Travel related basics: hep-A, typhoid, hep-B
  • Other travel specific
  • Ex-pats: rabies, JEV
  • Consider QFT-G baseline
  • Address family needs
personal protection from mosquitoes
Personal Protection from Mosquitoes
  • Avoid outdoor exposure, dawn to dusk
  • Wear long sleeved loose clothing after dusk, light colours
  • Avoid perfumes and colognes
  • Use repellent with 20-40% DEET
  • Use knockdown sprays, coils, vapours, etc indoors
  • Sleep under nets impregnated with permethrin
malarial prophylaxis
Malarial Prophylaxis

3 prong approach

  • behavioral modification
    • awareness of malarial risk
    • minimising exposure to mosquitoes
  • emphasis on extreme significance of early diagnosis & treatment
  • antimalarial chemoprophylaxis
principles of malaria prophylaxis
Principles of malaria prophylaxis
  • No antimalarial gives 100% prevention
  • P vivax and P ovale may be present months after return
  • No global consensus
  • Fever in returned travellers is malaria until proved otherwise
  • Patient compliance and education is essential
medical travel kits
Medical travel kits
  • These are designed to assist travelers in meeting medical needs when their access to quality medical care is compromised.
  • All travel medicine consultants recommend that travelers carry some form of medical first aid kit. A range is available, and often needs to be tailored to meet the specific requirements of the traveler and their proposed itinerary.
  • Many travel clinics sell medical first aid kits; these often contain prescription items.
medical travel kits27
Medical travel kits

Essential items for all travelers

Items to treat cuts, scratches, burns, strains, splinters

Paracetamol

Repellent

Consider condoms

Additional items for Europe, USA, Japan

Antinauseants, eg prochlorperazine

Broad-spectrum antibiotic for respiratory infection

Antacids

Sudafed

Minor sedative

Laxative

medical travel kits28
Medical travel kits

Additional items for less developed countries (gastro kit)

Rehydration solution

Loperamide

Tinidazole

Norfloxacin – or azithromycin for children

Comprehensive medical kit ; Asia, Africa and South America

All of the above

Sterile needles and syringes. Alcohol swabs

Antihistamines

Antifungal and antibiotic cream