Introduction to Travel Medicine

Travel and Tourism

Large and growing industry More than 500 millions persons annually cross international borders on commercial airplanes (early 90s) Pleasure, business, study etc Short term travelers, repeated visit, reside or prolonged periods Risk of morbidity and mortality

International Travel
80 70
US Resident travel in millions

900 800
Worldwide arrivals in millions

60 50

700 600 500

US nonresident Inbound (ITA) US Resident Air Outbound (ITA) All US Resident Outbound (ITA) Worldwide arrivals (WTO)

40 400 30 300 20 10 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 200 100 0

Travel and Tourism

Transportations Accommodation Food and beverages Handicrafts, gifts Others related industry

What might happened to travelers

Infections Accidents Disasters

Travelers Health Risks

Of 100,000 travelers to a developing country for 1 month:
50,000 will develop some health problem 8,000 will see a physician 5,000 will be confined to bed 1,100 will be incapacitated in their work 300 will be admitted to hospital 50 will be air evacuated 1 will die
Steffen R et al. J Infect Dis 1987; 156:84-91 6

Infectious Disease Risks to the Traveler

Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV

ETC.

Injury Deaths and International Travel

Motor Vechicle Drowning Air Crash Homicide/Suicide Poisoning Other

N = 601

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

Essential questions to assess predisposing risks and host risk factors

What is your destination(s) state : countries, city/resort/off-the-touristtrail, itinerary What is the purpose of your visit : tourism/business or other professional visit (specify)/visit (to relatives/expatriates), other reasons (military, airline crew, adoption, etc.)

Essential questions to assess predisposing risks and host risk factors

What standard of hygiene do you expect throughout your visit : high (e.g., fivestar hotels)/low (e.g., low budget travel) Are you planning any special activities : e.g. high altitude trekking, diving, hunting, camping, etc. What is your planned date of departure? How long do you intend to stay abroad?

Potential travelers should also answer at least the following set of questions on their health status and medical history :
Do you currently use any medication? If yes, which ones? Are you currently unwell? Do you feel feverish? If yes, do you know what your temperature is? Do you suffer from any chronic illness If yes, which ones? Are you allergic to eggs or medication? If yes, describe.

Travel Notices & Announcements

12

The Patient: Medical Issues

Age-specific issues Underlying illness, immunosuppression Systems review Medical history Medication use Vaccination history Allergies Contraindications to vaccines and medications

13

Potential travelers should also answer at least the following set of questions on their health status and medical history :
Are you pregnant or breast-feeding? Provide details Have you ever had seizures? Provide details Have you ever had psychiatric or psychological problems? Provide details Have you ever had jaundice or hepatitis? Provide details Are you or anybody in your household infected by HIV? Do you have any other immunodeficiency illness? Provide details

The Patient: Other Issues

Reproductive
Pregnant Breastfeeding Preconception

Risk-taking behaviors

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Immunizations to Consider for Adult Travelers

Routine Diphtheria* Tetanus* Pertussis* Measles + Mumps+ Rubella + Varicella Pneumococcus Influenza
* Td or Tdap + MMR

Travel related Hepatitis A Hepatitis B Typhoid Rabies Meningococcal disease Polio Japanese encephalitis Yellow Fever

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Vaccine for Adult Travelers

Routine Updated as needed : diphtheria-tetanus, measles-mumps-rubella Routine for defined groups : influenza, hepatitis B, pneumococcal, varicella Required by some countries Yellow fever Meningococcal

Vaccine for Adult Travelers

Recommended for travelers to developing countries Standard for travelers to developing countries : hepatitis A, typhoid, poliovirus Special for travelers to developing countries : cholera, hepatitis B, meningococcal, Japanese B encephalitis, plague, rabies

Travel Medications: Prophylaxis & Self Treatment

Malaria
chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine

Diarrhea
quinolone

Altitude
acetazolamide

Motion sickness
scopolamine, dimenhydrinate (Dramamine)
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Sources and Acquisition of Infection during Travel

Food and drinks Soil and water Animals and arthropods Other human Air travel Infections acquired en route Infections acquired in temperate and industrialized area

Sources and Acquisition of Infection during Travel

Food and drinks Travelers diarrhea Hepatitis A Typhoid fever Cholera Soil and Water Enteric infections Soil associated fungus (Histoplasma Leptospirosis

capsulatum)

Sources and Acquisition of Infection during Travel

Animals and arthropods Rabies Hantavirus Dengue Malaria Other Human STD Airborne infections

Sources and Acquisition of Infection during Travel

Air Travel Venous thrombosis and pulmonary emboli Influenza, Tuberculosis Infections acquired en route Influenza, rubella Infections acquired in temperate and industrialized area Colorado Tick fever HFRS Murray Valley encephalitis

Environmental Precautions
Air Travel Jet Lag Sun Protection Extreme Heat and Cold
dehydration, heat stroke hypothermia, frostbite

Altitude Water recreation

Drowning, boating & diving accidents Risk of schistosomiasis or leptospirosis Biological and chemical contamination
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Vector Precautions
Covering exposed skin Insect repellent containing DEET 25 50% Treatment of outer clothing with permethrin Use of permethrin-impregnated bed net Use of insect screens over open windows Air conditioned rooms Use of aerosol insecticide indoors Use of pyrethroid coils outdoors 26 Inspection for ticks

Food and Water Precautions

Bottled water Selection of foods
well-cooked and hot

Avoidance of
salads, raw vegetables unpasteurized dairy products street vendors ice
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Bloodborne and STD Precautions

Prevalence of
STDs Hepatitis B Hepatitis C HIV

Unprotected sexual activity Commercial sex workers Tattooing and body piercing Auto accidents Blood products Dental and surgical procedures

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Animal Precautions
Animal avoidance Rabies
Specific animal threats Medical evaluation of bites/scratches Post exposure immunization and immunoglobulin

Envenomations
Snakes, scorpions, spiders Maritime animals

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Deaths Related to International Travel

Cardiovascular Medical Injury Homicide/Suicide Infectious Disease Other

N = 2463

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

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Key concepts: Travel-related illness and Death

Injury are an important cause of travel related death Most infections acquired during travel to tropical and developing countries are cause by pathogens that are widely distributed Risk of infection from exposure to many widely distributed pathogens )e.g. hepatitis A, typhoid fever, salmonellosis) is substantially higher during travel to developing countries than during life at home

Key concepts: Travel-related illness and Death

Unusual infections can be found in temperate and industrialized countries, including United States Recreational activities ( swimming, hiking) facilitate exposure to many pathogens Activities that pose no risk at home may be hazardous in other environment (e.g. eating raw foods, swimming in fresh water, going barefooted, sustaining mosquito bites, petting stray animals)

Key concepts: Travel-related illness and Death

Expensive hotels and posh restaurants are no guarantee of safe food and beverages Disease during and immediately after travel may be unrelated to exposures during travel (acute appendicitis, pyelonephritis) Infections can be acquired en route and on brief layover Travel-associated diseases include non infectious diseases (pulmonary emboli related to prolonged seating, drug reactions0

Have a Nice Vacation