Transcript PM Briefing Enduring Freedom V2.03

TRAVEL MEDICINE
“When hoof beats might be
zebras”
Dr. Januchowski
OBJECTIVES
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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
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Travel Medicine
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Travel Medicine
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Travel Medicine Consultation
• Risk Assessment
• Risk Communication
• Risk Management
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Risk Assessment
• Typically done 1-2 months prior to travel
• Itinerary data
• Traveler demographics and
health/medical history
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Risk Assessment
Itinerary data
Traveler demographics
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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)
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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)
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Risk Communication
• Plan based on Risk
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Assessment
Evidence Based plan
of action developed
with the traveller
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Risk Management
• Implementation of the plan
– Vaccines
– Medications
– Education
– General Guidance
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Case #1
• 44 y.o. male patient presents 2 months
before a planned trip to Suriname for
business with his employer, ALCOA
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Risk Assessment - Itinerary
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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)
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Risk Assessment – Traveler info
• Age, sex
• Vaccination history, including dates, how many doses received in
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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)
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Risk Management – Vaccines
• Routine
• Required
• Recommended
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Routine Vaccines
• Would include childhood immunizations
• Boosters (Tdap, MMR)
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Required Vaccines
• Yellow fever vaccine
– Sub-Saharan Africa
– Tropical South America
• Meningococcal vaccine for annual travel
to the Hajj in Saudi Arabia
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Recommended Vaccines
• Varies based on
– Destination
– Itinerary
– Traveller demographics
• Check website
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Typhoid
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Salmonella enterica
Fecal-oral route of transmission
Fever, headache, malaise
Intestinal perforation and hemorrhage
complications
Can be treated with antibiotics
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Typhoid Vaccine
Injectable
• One dose series
• Good for 2 years
• Age 2 and older
• Should be given >2
weeks prior to travel
Oral (Live, attenuated)
• 4 dose series
• Good for 5 years
• Age 6 and older
• Should complete series
one week before travel
Cost for vaccine ~$80-100
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Yellow Fever
• Transmitted by mosquito
• Fevers, malaise
• Can cause hepatitis, hemorrhagic
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complications
Supportive treatment
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Yellow fever vaccine
• Must be administered by a certified
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health center
~$100-125
Good for 10 years
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Yellow fever vaccine
• Contraindications
– Less than 6 months old
– Immunocompromised status
• Primary immunodeficiency
• HIV with CD4<200
– Malignant neoplasms
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Risk management
• The patient has scheduled times for his
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vaccinations
What other information can be provided
for this traveller?
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Risk management
• Malaria prevention
• Treatment of common travel illnesses
• General Education
– Food and drink safety
– Accident avoidance
– Safe sexual practices
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Malaria prevention
• Determine risk
• Prevent mosquito bites
• Medication prophylaxis
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Malaria Chemoprophylaxis
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Atovaquone-proguanil
Chloroquine
Doxycycline
Mefloquine
Primaquine
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Malaria Chemoprophylaxis
Medicine
Cost
Start prior
Dosing time
Side effects
Misc.
Atovaquoneproguanil
$$$
1-2 days
Daily
Minimal
Chloroquine
$
1-2 weeks
Weekly
Doxycycline
$
1-2 days
Daily
GI / sun
Mefloquine
$$
2 weeks
Weekly
GI / seizure /
psych/cardio
Resistance
Primaquine
$
1-2 days
Daily
G6PD
caution!
Can be used
for vivax term.
prophylaxis
Resistance
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What other recommendations?
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Travel Medicine Kit
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Include items for
treatment of common
illnesses
Watch for flight
regulations
International regulations
on transport of
medications
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Travel Med Kit
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Routine prescribed medicines
Antidiarrheals
– Bismuth products (treatment or prophylaxis)
– Loperamide (Imodium)
– Ciprofloxacin 500 mg BID x 2
Treatments
– Azithromycin 1 gm x 1
– Rifaximin (non-FDA approved, off label use for
prophylaxis)
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Travel Med Kit (cont.)
• Insect repellents
– DEET (30-50%)
– Picaridin
– Oil of Lemon Eucalyptus or PMD
– IR3535
– Permethrin impregnated clothing / bed
netting
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Travel Med Kit (cont.)
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Water purification tablets
Pain medicines (OTC)
Sunscreen
Antibacterial skin cleanser
/ wipes
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Case (cont.)
• The patient travels and returns without
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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
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Post travel visit
• Ensure malaria medicines are
completed
– 4 weeks for doxycycline / mefloquine
– 7 days for atovaquone/proguanil
• Review travel history
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Post travel visit - Illnesses
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Fever
Persistent GI complaints
Skin lesions or rashes
Respiratory infections
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Post travel visit - Fever
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Malaria (up to one year!)
Dengue
Invasive bacterial diarrhea
Hepatitis A
Typhoid
Rickesial infections
Influenza (remember patterns)
Viral illnesses NOS
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Post travel visit – GI Concerns
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Acute bacterial/parasitic gastroenteritis
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Unmasking of underlying GI disease
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Tropical sprue
Brainerd diarrhea
– Giardia
– C. difficile
– Postinfectious IBS
– Lactose intolerance
– Celiac disease
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Post travel visit – Skin lesions
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Non-specific dermatitis
Insect bites
Pyoderma
Scabies
Cutaneous larva migrans
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Assessing Risk by
Incubation Period
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OBJECTIVES
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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
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Questions?
• [email protected]
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