Transcript POST-TRAVEL CONSULTATION

Post-Travel Health
Consultation
Dr Peter A. Leggat
MD, PhD, DrPH, FAFPHM, FACTM, FFTM
Associate Professor
School of Public Health and Tropical Medicine
James Cook University &
Visiting Professor
School of Public Health
University of the Witwatersrand
About the author
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Dr Peter Leggat has co-ordinated the
Australian postgraduate course in
travel medicine since 1993. He has also
been on the faculty of the South African travel
medicine course, conducted since 2000, and
the Worldwise New Zealand Travel Health
update programs since 1998. Dr Leggat has
assisted in the development of travel medicine
programs in several countries and also the
Certificate of Knowledge examination for the
International Society of Travel Medicine.
Objectives of the session
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Review statistics
Briefly review the sorts of problems
travelers have abroad
Examine why it may be important to see
travelers if they are unwell on return and
what policies may be applicable in
practice
Document some important aspects of the
post-travel history and examination
Some References
Steffen et al. Manual of Travel
Medicine and Health. Decker,
2003 Sec 4.
 Leggat et al. Primer of Travel
Medicine. ACTM Publications,
2002 Ch. 19.
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The Continuum of Travel Medicine
Pre-Travel
Preventive Medicine
Visitors
Contingency During Travel Planning
Treatment & Post-Travel
Rehabilitation
The Good News
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Most travelers report no major
problems whilst travelling and
most are asymptomatic on
return
Travelers are exposed to
a variety of hazards
Swiss Travelers
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15-50% of travelers to
developing countries
report some illness or
injury
8% in the study of
10,000 Swiss travelers
consulted a medical
officer
1% required
hospitalization and 3%
had time off work
Insured Australian travelers*
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Approx 20,000 policies issued each year
(incl. Exec. Gold)
About 1600 claims (8%)
400 claims for emergency assistance (2%)
80 ER or clinic referrals (0.4%)
46 Hospital admissions (0.2%)
10 Aeromedical evacuations (0.05%)
*Leggat et al (2005) Emergency assistance provided abroad
to insured travellers from Australia. Travel Med Inf Dis 3: 9-17
Common things occur commonly
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Gastrointestinal-diarrhoeal diseases effecting
20-40% or more of short term travelers
Respiratory tract infection
Cutaneous infections
Trauma and injuries (accidents- commonest
cause of preventable death)
Sexually transmitted infections
Dental problems
Others (remember malaria)
Post-Travel Consultation
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Many travel related problems are
self-limiting
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Why might it be important to see
travelers who have an illness
post-travel?
The traveler may have a life
threatening infections
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Malaria due to P. Falciparum
Viral hepatitis
Typhoid
Amoebiasis/Amoebic liver abscess
Legionnaire’s disease
Melioidosis
Rabies
Others
Travelers may have infections
that pose a risk to public health
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Dengue (2-5 days)
Lassa, Ebola and others (3-21 days)
Japanese Encephalitis (3-7 days)
Yellow fever (3-6 days)
Typhoid (1-2 days)
Malaria (Pv-10 days to year-relapses; Pf
10-28 days)
SARS (2-10 days)
Others
It is important to develop
policies in travel medicine
 Policy
and procedures, including
– Policy of follow-up of travelers
– Policy on notifiable diseases
– Policy on reporting adverse
reactions
– Policy on “eradication” treatment
Policy on follow-up of
travelers
Do you see travellers
 Symptomatic on return?
 Symptomatic whilst aboard?
 Asymptomatic abroad and
asymptomatic now?
 To complete immunization
courses?
It is important that the
clinic have a written policy
It is essential that travellers who
become ill on return seek medical
attention as soon as possible
 The traveller should be advised to
inform the clinic that they have
been or are currently traveling
 It is also important to ask if
patients:
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“Have you been traveling recently?”
Policy on reporting notifiable
diseases and adverse reaction
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Is it a notifiable disease? Early liaison
concerning suspected cases and formal
notification to public health units
Keep a list of notifiable diseases and
reporting forms
Document and report any possible serious
adverse reactions to immunisations and
chemoprophylaxic and other medications
experienced by traveller whilst abroad
Is the traveler part of a clinical trial?
Travel medicine has
assumed a major role in
monitoring global trends
in infectious disease,
especially emerging
infectious diseases
Travel medicine networks
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GeoSentinel (ISTM/CDC)
– May provide early warning of
outbreak amongst travelers
returning to disparate locations
TropNet Europ
 WHO
 Local networks
 Other networks
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Eradication Policy
Do you prescribe empiric
“eradication” treatment?
 If so, what groups of travelers?
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Eradication “Treatment”
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Malaria - primaquine (check G6PD
deficiency), (tafenoquine)
Deworming agent for soil transmitted
“roundworms” (consider strongyloides)
Deworming agent for “flatworms”praziquantel
Deworming agent for filariasis albendazole
Antiprotozoal agent - giardiasis
Others (?)
Groups where eradication
treatment may be considered
Medium to long term travelers or
overseas workers
 Those travellers at high risk of infection
 Those where diagnosis suggestive but
investigations inconclusive
 Where required by authorities-refugees
 Even when on preventive measures!
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Occasionally preventive
measures do fail
Immunizations and
chemoprophylactic agents and
personal protective measures are not
100% protective
 Variable compliance with preventive
advice
 Incorrect/insufficient advice/health
intelligence
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Post-travel Consultation
History
 Examination
 Investigations
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Screening History
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Are they symptomatic now or have been?
Risk assessment - leading to specific history
of possible exposures, e.g. schistosomiasis,
zoonotic disease, sexual history, recently
been diving, have they been bitten?
Is there correspondence in relation to
treatment abroad?
Travel history can be important in terms of
working out possible incubation period and
differential diagnosis
Screening History
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Prophylaxis and compliance - was the
prophylaxis appropriate?
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Could it be a pre-existing condition?
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Could it be related to an
occupational/recreational exposure?
Screening Examination
Post-travel physical examination for
most short term travelers is usually
unremarkable for disease, but may be
useful for assessment of injuries
 Signs of “tropical” disease can be
subtle and can be missed unless
specifically looked for, e.g. rashes,
eschar, jaundice
 Abnormalities unrelated to travel
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Look for the “spot” diagnosis
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Hookworms and
cutaneous larva
migrans: tracking
lesions on the foot (or
other body areas in
contact with sand/soil)
Look for the “spot”diagnosis
Leishmaniasis: non-healing skin
ulcers/lesions, especially on exposed
areas and been to endemic areas
 Eschars-may be associated with
rickettsial infectious such as scrub
typhus
 Skin infection: bacterial and fungal
(ask for occupational and recreational
history)
 Others
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Screening Examination
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When sending specimens to lab, document
current medications, history, what you think
Liaise with lab if unsure what tests available
Stool microscopy M/C/S, O/C/P-most
diarrhoeal disease bacterial>>parasitic>viral
Urine tests-dipstick urinalysis, “terminal”
urine for ova of S. haematobium
Full Blood Count and differentialeosinophilia, anaemia, thrombocytopenia
Screening Examination
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Rapid tests, e.g. Immunochromographic
tests (ICT)-often used for initial screening
for malaria, Bancroftian filariasis, (dengue),
etc
Serological investigations, e.g.
schistosomiasis, filariasis
Blood films for malaria
HIV/STI serology
TB screening-useful if you can compare
with pre-travel
Does the traveler have diarrhea?
Most travelers’ diarrhea is brief,
self-limiting and non-inflammatory
(about 4 days in duration)
 About 20% of travelers have fever
and/or bloody diarrhea
 Enterotoxigenic Escherichia Coli is
probably the most frequent
pathogen in about 40-75 of cases
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Travelers’ diarrhea
Inflammatory diarrhea may be caused
by Campylobacter, Shigella or
Salmonella infection
 Fever, cramping abdominal pain, pus
and/or blood in the stool
 Quinolone antibiotics often employed
(some resistance)
 Remember amoebic dysentery and
giardiasis
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Travelers’ diarrhea
Persistent diarrhea may be giardiasis,
which may need treatment with
tinidazole or metronidazole
 Chronic diarrhea may need further
investigation and referral
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Does the traveler have fever?
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Possible serious infectious
disease causes in travelers
returning from tropical regions:
– Malaria-great mimicker
– Hepatitis A
– Enteric fever (incl typhoid)
– Dengue fever
– Others
Has the traveler been injured
abroad?
Need to document extent of injuries
 Are they covered by any insurance or
superannuation policy?
 Arrange for any further treatment and
follow-up
 Liaise with airlines if further travel
required
 Arrange for assessment for
rehabilitation as necessary
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Post-Travel Consultation
It is important to elicit a history of travel.
 Many short term travelers will present
with illness when they get back,
following the incubation period.
 Investigation and management of some
post-travel illnesses will be urgent
because they are life threatening and/or
a threat to public health.
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