Transcript Part III

Part III
This section will provide an overview of the nonvaccine preventable health and safety issues for
students:
 Insect vectors: focus on malaria and dengue
 Food and water hazards: focus on traveler’s
diarrhea
 Other health and safety risks
Final slides are resources for the full slide set
Insect Vector Diseases
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Malaria
Dengue
Vaccine-preventable: Yellow Fever, Japanese
Encephalitis
Many others: chagas disease, sand flies, bed
bugs, etc
Student accommodations may place them at risk
for insect-borne diseases
Malaria: #1 Infectious Disease
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Serious, potentially fatal parasitic disease
spread by the night-biting anopheles
mosquito
 Present > 100 countries; 300 mil cases yr / 1 mil
die
 1,000 US travelers / yr reported cases
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4 Plasmodium types affect humans
 P. falciparum >95% traveler deaths
 P. vivax, p. ovale p. malariae: delayed onset, late
dx
www.cdc.gov/mmwr/preview/mmwrhtml/ss5402a2.htm#tab6
Traveler’s Malaria Risk
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risk for P. f: Africa (2% travel / 83% cases)
Highest risk for P. vivax: Asia, Latin America
Exposure risk varies: geography, season,
duration, altitude, activities, sleeping
conditions, adherence, VFR
At risk groups: long-stay, adventure travelers
(specific activities), pregnant women, VFR
(BMJ reports 3x-8x higher risk), noncompliant
No vaccine, but considered
preventable & treatable
Malaria Endemic Countries 2003
www.who.int/ith/diseasemaps_index.html
CDC Approach to Malaria Education:
ABCD
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#1: Awareness: of disease & where, when
traveler is @ risk
#2: Bug bite avoidance: prevent bites!
#3: Chemoprophylaxis: take appropriate
Rx medications as prescribed
#4: Diagnose: the early signs &
symptoms: if fever, think malaria & get
prompt care
A Use Maps to Confirm Risk
with Traveler
Teach the Plasmodium Lifecycle
NY Daily News 10/2002
B
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Personal Protective Measures
Use DEET repellants: controlled release, 1935% *
Apply permethrin to clothing, bed nets
Reduce outdoor activity dusk to dawn
Return from rural trips before dark
At night time: use screens or A/C, bed nets,
spray room or tent with flying insect spray
*Information resource:
Fradin,M & Day, J (2003) NEJM, 347: 13-18.
C Malaria Drugs of Choice
Chloroquine
For Resistant Areas: 3 CDC approved
medications Mefloquine
 Doxycycline
 Malarone (Atovaquone/proguanil)
None 100%; need PPM
Screen all students before prescribing!
Adherence issues !
Obtain in U.S.: counterfeit / unavailable abroad
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Chloroquine Resistance
Many Areas Around the World
Source: CDC@ www.cdc.gov/travel
Mefloquine / Lariam
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20+ years of use; very effective most areas
Resistance on Thai borders
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Controversy regarding tolerability / media blitz
“Neuro-psychiatric” side effects reported
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Prescribing guidelines:
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 Screen for contraindications: seizure, psych illness /
psych meds, drug allergy, 1st trimester pregnancy
 Tolerance in past does not insure tolerance next time
 FDA requirement: pharmacists distribute AE handout
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Consider use for: previous use, long-stay traveler,
pregnancy
Doxycycline
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  expensive, readily available
Short half-life; qd x 1 month
after trip
AEs: vaginitis, esophagitis,
photosensitivity, GI upset
Not for pregnancy,
breastfeeding
No known areas of resistance
Consider use for: Thai borders;
no $- backpackers, VFRs,
students
Malarone
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Atovaquone (250mg) + Proguanil (100mg)
Take daily, start 1-2 days before, only 7 days
after trip
 cost
AE’s: GI intolerance- so take with food
Not available everywhere
Consider use for: short-stay traveler, drug
plan, Thai borders, student living in city
without malaria; student unable to take other
choices
Primaquine to Prevent P vivax Relapse
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Additional consideration for students at risk for
infection with P vivax
P vivax relapse infections
Consider adding Primaquine to malaria
regimen to prevent relapse < 3yrs post travel
Potent anti-oxidizing agent: test for G6PD
deficiency to prevent hemolysis
Not used in pregnancy
Consult with malaria expert as needed
Chemoprophylaxis Decision-making
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Is the traveler going to malaria zone?
Will he be exposed? (accommodations, night
exposure, altitude)
Is there drug resistance there?
Are there any drug contraindications: allergies,
meds, pregnancy, psych hx, etc?
What is the traveler’s experience with malaria
meds?
What is the duration of anti-malarial use?
Schwartz E et al. Delayed onset of malaria-implications for
chemoprophylaxis in travelers. NEJM 349;16, 1510-1546;
J Keystone, Wilderness Medical Society presentation, Big Sky 8/05
D Malarial Infection
Majority of U.S. cases present post trip
Fever after trip to malaria zone = malaria
Teach student how to get
immediate, competent
evaluation & care
Patient Teaching Resource
@ www.cdc.gov/malaria/pdf/travelers/pdf
Give to Every Student at Risk
Provider Resource for
Malaria Treatment
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National Center for
Infectious DiseasesDivision of Parasitic
Diseases @ 770-4887788
Internet @
www.cdc.gov/malaria
/diagnosis_treatment/
treatment.htm
Dengue Fever
“Breakbone Fever”
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Age-related flu-like syndrome
Growing problem: now present > 52% of world
Vector: day-time Aedes
Urban & rural risk
DHF variant
Prolonged convalescence possible
Avoidance only: no vaccine, no
chemoprophylaxis at this time
Traveler’s Diarrhea
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#1 most common infection in travelers: 30% /wk
Developed to developing countries (CDC II, III)
Transmission: fecal-oral contamination
60-80% bacterial etiology; viral: 10-20% &
parasites 5-10%
 drug resistant campylobacter jejuni
Syndrome- abrupt, 3+ defecations / d; assoc GI c/o
At risk: level of accommodations, long-stay,
adventurous eaters, VFR, GI or immunity problems
“Boil it, cook it, peel it, or forget it”
Easy to say, hard to do!
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Prevention not always possible
Assess student for risk, self-care skills, resistant
organisms @ destination
Five step approach: Simple & Customized Message
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Educate: food & water consumption “careful vs careless”
Immunizations: Hep A, typhoid
Emphasize handwashing
Counsel self-care: rehydration, use of antimotility agents
and antibiotics to use “on-the-road”
Other
Non-vaccine Preventable
Risks for Student Travelers
 Traffic accidents
 Air travel
 Recreational
hazards
 Climate
 Altitude
 STDs
 Safety & security
 Travel stress
 Medical care abroad
& trip insurance
 Self-care “on the
road”
 Post-trip issues
Traffic Accidents
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#1 cause of morbidity and
mortality in US travelers
abroad
Internationally, more complex
traffic mix as wheeled vehicles,
animals, pedestrians all share
same road
Poor road maintenance &
problematic signage
Lack of roadside care
No motorcycles
No night-time rural travel
Air Travel Hazards
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Barotrauma:
“aerotitis”
Respiratory infection
(Flu, URI, TB
transmission)
Jet lag and sleep
issues
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Dehydration
Contact lens
problems
Allergic reactions to
“disinfection”
“Traveler’s
Thrombosis”
Traveler’s Thrombosis
DVT caused by prolong confinement in cramped position—
can lead to fatal PE
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Overall very low incidence (<1/million travelers)
At risk:
Flights > 5-6 hrs; highest risk flights >10hrs; recent
surgery (< 4wks), pregnancy, cancer, CHF, DVT hx,
obesity, estrogen use
Assess for co-factors, encourage ankle and calf
movement and hydration on flight; refer to expert if 
risk
Teach early s/s- get to proper evaluation & care
Giangrande, P. (2002) Br J Haematol., 117, 509-512.
Geerts et al. (2004) Chest;126, 338S
Sun Hazards
Students often seek out the sun on trips
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Effects of the sun (UV): sunburn & sunstroke,
skin cancer, eye damage
Photo-toxicity with some meds (eg Doxy)
Greater risk @ altitudes, in or near water, snow
Prevention: avoid midday sun, wear clothing
that covers skin, use UVA/UVB sunblock SPF
15+, wear wide-brimmed hat & sunglasses;
checks meds for sun sensitivity
Risky Behaviors: Blood-borne Pathogens
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In many countries, rates of HIV and other
STIs are much higher than in US (50 to 500x)
Travelers need to avoid all behaviors that
expose them to bloodborne pathogens
Studies show 5-67% of travelers have sex with
new partners during travel
Safe sex – counsel travelers to plan ahead &
avoid prostitutes, multiple partners, alcohol
excess
Every Student
Every Trip
Drugs & Alcohol & Sex
Messages
Safety & Security
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Travelers are targets for thieves, others
 Travelers need to adopt “safety-conscious” behaviors
 Bring duplicate documents, leave another set at home
 Seek guidance before walks, jogs, night excursions
 Avoid isolated areas; go in pairs, groups
 Have a plan for the airport
 Bring nothing you can’t avoid to lose
 Know the role & access #’s for embassy
 If travel plans change, keep family & others (school,
Dept of State, etc) informed
Women & Travel
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Cultural issues in many parts of world
Personal safety
Risk for sexual harassment, rape, date
rape
Adjustments to personal care routine
(issues of dress, jewelry, perfume, etc)
Self-care for: contraception, UTI’s, other
Gyn issues
Self-Care During Travel
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At risk groups: adventure travel, trips > 3wks,
persons with medical problems, solo travelers
Know when , where, how to seek help
Purchase travel medical evacuation insurance
and how to access care – important phone #s
Carry ample supply of any Rx drugs
Carry a first aid kit
Travel Kit Basics + Customize
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Usual OTC drugs
Rx drugs- routine and
trip-related
First-aid supplies
Thermometer
Pain / fever meds
Pocket-size dictionary
Instructions for taking
meds (“suitcase
medicine”)
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Stool softener
Anti-motility agent
Decongestant
Insect repellant
Sunscreen
Motion-sickness meds
Foot care
Condoms
Special Groups / Special Supplies
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Benadryl, Epipen, Medic-alert
bracelet (or similar)
Rehydration packets (ORS)
HIV PEP Drug Supply
Emergency contraception “plan B”
Expanded health history / translated in
local / multiple languages
Water Recreation
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Drowning is #2 health risk for US travelers
Swim in salt or well-chlorinated water, not fresh
Adopt safe behavior in recreational waters
Avoid alcohol when pursuing water sports
Engage reliable companies for boating, snorkeling,
scuba, rafting, parasailing, etc
Carefully evaluate outfitters for: compliance with
safety regulations, equipment / guides, life jackets,
emergency services
Caution: think twice about trying new water
activities while traveling internationally
Altitude Illness (AMS)
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 At higher altitude, atmospheric
pressure,  oxygen pressure→ can
lead to hypoxia
 AMS- can occur after 1-6 hrs @
> 2400-3000m
Fatal risk: HACE, HAPE
Risks: rapid ascent for mountain trekking, skiing,
climbing & direct visits to high places: Cuzco,
Kilimanjaro, La Paz, Tibet, etc.
AMS signs / symptoms: headache, fatigue,
insomnia, anorexia/nausea/vomiting
Teach prevention & self-care, use of medications
Improving Teaching
Efficiency& Effectiveness
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Prioritize!
Build on traveler knowledge
Customize & prioritize messages- only 20%
retention rate is usual for most learners
Learning process: hear, see, use
Supplement with checklists, packets of health
ed materials
Group teaching, call-backs for counseling
Web resources
Criteria for Quality TH Care
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Commitment to consistent, individualized care
 Staff selection, training & ongoing education
 Program monitoring and evaluation
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Accurate guidance based on epidemiologic data
 Updated Internet resources for trip research /
recommendations
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“Cold Chain” compliance
 Immunization coordinator & proper equipment
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Compliance with regulations & standards of care
 Written policies and procedures: anaphylaxis, disaster
protocol, needlestick, cold chain, documentation, others
Student Travel Health Challenges
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Short notice!
Not enough money
Flexible trip plans
Confidentiality &
truth-telling
Possibly pregnant
Born outside U.S.
More Challenges
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Pandemic/ Bioterrorism
concerns
Clinic / orphanage work
Very remote travel
Intermittent malaria risk
School sponsored trip
Refuses vaccines
Preparing Students for International Travel
India: 4 months, No Star
China: 4 Day, 5 Star
In Summary- Always a rewarding challenge
Assessment Review Articles
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Spira, A. Preparing the traveller. Lancet, 2003,
361, 1368-1381
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Rosselot, G. Travel health nursing: expanding
horizons for occupational health nurses.
AAOHN J, 2004, 52(1), 28-41.
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Ryan, E & Kain, K. Health advice and
immunizations for travelers. New England J of
Med, 2000, 342(23), 1716-1725.
Additional References
Steffen,R., Rickenbach, M., Wilheim, U., Helminger, A., & Schar,
M.(1987). Health problems after travel to developing countries.
Journal of Infectious Disease, 156(1), 84-91.
 Centers for Disease Control and Prevention. (2001). Health
information for international travel, 2001-2002. Atlanta, GA: U.S.
DHHS, Public Health Service.
 Dupont, H and Steffen, R. eds. (2000)Textbook of travel medicine.
BC Decker, Hamilton, Ontario, Canada.
 Barnett E, Chen R, and Rey M (2004) Vaccines for international
travel. In S Plotkin and W Orenstein (eds, Vaccines, 4th ed.
 Steinberg E et al (2004) Typhoid fever in travelers: Who should be
targeted for prevention? CID, 39, 186-191.
 Thompson R. (2004) Routine and travel immunizations. Shoreland,
Inc., Milwaukee
• Fradin M & Day J (2003) Comparative efficacy of insect repellents
against mosquito bites. NEJM, 347(1): 13-18.
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Additional References
• Schwartz E et al. (2003) Delayed onset of malaria-implications
for chemoprophylaxis in travelers. NEJM, 349(16), 1510-46.
 Thielman N & Guerrant R (2004) Acute infectious diarrhea.
NEJM, 350, 38-47.
 Thompson M & Jong E (2003) Traveler’s diarrhea: prevention
and self-treatment. In E.Jong and R.McMullen (eds), The Travel
and Tropical Medicine Manual, 3rd ed. (pp.75-86)
 Ansdell V & Ericsson C (1999) Prevention and empiric treatment
of traveler’s diarrhea. Med Clin of N Amer, 83, 945-973.
 Ericsson C (1998) Traveler’s diarrhea: epidemiology, prevention,
and self-treatment. Infect D Clin of N Amer, 12, 285-303.
 Giangrande P (2002) Br J Haematol., 117, 509-512.
 Geerts et al. (2004) Chest, 126, 338S
 ISTM Body of Knowledge @www.istm.org
Conflict of Interest Statement
In the past, Gail Rosselot has received speaker
honorariums from Merck, GSK, and Shoreland
and educational grants from Merck, Berna,
Shoreland, and Sanofi-Pasteur.
There was no commercial support for this ACHA
presentation.
Contact information: [email protected]