1. TRAVEL MEDICINE “When hoof beats might be zebras” Dr. Januchowski

2. OBJECTIVES • Be able to identify the key items to discuss with patients travelling internationally • Be able to discuss with patients the resources available to help them stay healthy while travelling • Know some of the important illness patterns to watch for when patients return from overseas adventures

3. Travel Medicine

4. Travel Medicine

5. Travel Medicine Consultation • Risk Assessment • Risk Communication • Risk Management

6. Risk Assessment • Typically done 1-2 months prior to travel • Itinerary data • Traveler demographics and health/medical history

7. Risk Assessment Itinerary data Traveler demographics Age, sex Vaccination history, including dates, how many doses received in a scheduled series, and prior adverse events Medical and psychiatric history (past and current), including any conditions or medications that suppress the immune system Medications (current or taken in the past 3 months) Allergies (in particular to eggs, latex, yeast, mercury, or thimerosal) Pregnancy and breastfeeding (current status and plans) Any planned surgeries or other medical care during travel (medical tourism) • Countries and regions to be visited, in the order of travel • Visits to urban versus rural areas • Dates and length of travel in each area • Purpose of travel (such as business, vacation, visiting friends and relatives) • Modes of transportation • Planned and possible activities (such as hiking, scuba diving, camping) • Types of accommodations in each area (such as air-conditioned, screened, tents)

8. Risk Communication • Plan based on Risk Assessment • Evidence Based plan of action developed with the traveller

9. Risk Management • Implementation of the plan • Vaccines • Medications • Education • General Guidance

10. Case #1 • 44 y.o. male patient presents 2 months before a planned trip to Suriname for business with his employer, ALCOA

11. Risk Assessment - Itinerary • Countries and regions to be visited, in the order of travel • Visits to urban versus rural areas • Dates and length of travel in each area • Purpose of travel (such as business, vacation, visiting friends and relatives) • Modes of transportation • Planned and possible activities (such as hiking, scuba diving, camping) • Types of accommodations in each area (such as air-conditioned, screened, tents)

12. Risk Assessment – Traveler info • Age, sex • Vaccination history, including dates, how many doses received in a scheduled series, and prior adverse events • Medical and psychiatric history (past and current), including any conditions or medications that suppress the immune system • Medications (current or taken in the past 3 months) • Allergies (in particular to eggs, latex, yeast, mercury, or thimerosal) • Pregnancy and breastfeeding (current status and plans) • Any planned surgeries or other medical care during travel (medical tourism)

15. Let’s talk about vaccines

16. Risk Management – Vaccines • Routine • Required • Recommended

17. Routine Vaccines • Would include childhood immunizations • Boosters (Tdap, MMR)

18. Required Vaccines • Yellow fever vaccine • Sub-Saharan Africa • Tropical South America • Meningococcal vaccine for annual travel to the Hajj in Saudi Arabia

19. Recommended Vaccines • Varies based on • Destination • Itinerary • Traveller demographics • Check website

22. Typhoid • Salmonella enterica • Fecal-oral route of transmission • Fever, headache, malaise • Intestinal perforation and hemorrhage complications • Can be treated with antibiotics

23. Typhoid Vaccine Injectable Oral (Live, attenuated) 4 dose series Good for 5 years Age 6 and older Should complete series one week before travel • One dose series • Good for 2 years • Age 2 and older • Should be given >2 weeks prior to travel Cost for vaccine ~$80-100

24. Yellow Fever • Transmitted by mosquito • Fevers, malaise • Can cause hepatitis, hemorrhagic complications • Supportive treatment

25. Yellow fever vaccine • Must be administered by a certified health center • ~$100-125 • Good for 10 years

26. Yellow fever vaccine • Contraindications • Less than 6 months old • Immunocompromised status • Primary immunodeficiency • HIV with CD4<200 • Malignant neoplasms

27. Risk management • The patient has scheduled times for his vaccinations • What other information can be provided for this traveller?

28. Risk management • Malaria prevention • Treatment of common travel illnesses • General Education • Food and drink safety • Accident avoidance • Safe sexual practices

29. Malaria prevention • Determine risk • Prevent mosquito bites • Medication prophylaxis

31. Malaria Chemoprophylaxis • Atovaquone-proguanil • Chloroquine • Doxycycline • Mefloquine • Primaquine

32. Malaria Chemoprophylaxis

33. What other recommendations?

34. Travel Medicine Kit • Include items for treatment of common illnesses • Watch for flight regulations • International regulations on transport of medications

35. Travel Med Kit • Routine prescribed medicines • Antidiarrheals • Bismuth products (treatment or prophylaxis) • Loperamide (Imodium) • Ciprofloxacin 500 mg BID x 2 • Azithromycin 1 gm x 1 • Rifaximin (non-FDA approved, off label use for prophylaxis) Treatments

36. Travel Med Kit (cont.) • Insect repellents • DEET (30-50%) • Picaridin • Oil of Lemon Eucalyptus or PMD • IR3535 • Permethrin impregnated clothing / bed netting

37. Travel Med Kit (cont.) • Water purification tablets • Pain medicines (OTC) • Sunscreen • Antibacterial skin cleanser / wipes

38. Case (cont.) • The patient travels and returns without any noted incidents. • Proper education allowed the patient to • Know the precautions after return regarding illness reporting • Know the importance of completing malaria prophylaxis medications

39. Post travel visit • Ensure malaria medicines are completed • 4 weeks for doxycycline / mefloquine • 7 days for atovaquone/proguanil • Review travel history

40. Post travel visit - Illnesses • Fever • Persistent GI complaints • Skin lesions or rashes • Respiratory infections

41. Post travel visit - Fever • Malaria (up to one year!) • Dengue • Invasive bacterial diarrhea • Hepatitis A • Typhoid • Rickesial infections • Influenza (remember patterns) • Viral illnesses NOS

42. Post travel visit – GI Concerns • Acute bacterial/parasitic gastroenteritis • Giardia • C. difficile • Unmasking of underlying GI disease • Postinfectious IBS • Lactose intolerance • Celiac disease • Tropical sprue • Brainerd diarrhea

43. Post travel visit – Skin lesions • Non-specific dermatitis • Insect bites • Pyoderma • Scabies • Cutaneous larva migrans

44. Assessing Risk by Incubation Period

45. OBJECTIVES • Be able to identify the key items to discuss with patients travelling internationally • Be able to discuss with patients the resources available to help them stay healthy while travelling • Know some of the important illness patterns to watch for when patients return from overseas adventures

46. Questions? • rjanuchowski@vcom.edu