Transcript Travel Medicine

Travel Medicine
By
Jonathan Phillips D.O.
Internal Medicine Resident Lecture Series
Introduction
Introduction

In 2004, 763 million people crossed international
borders, an increase of 73 percent over that last 15
years. Despite the relative ease of arranging trips
today, travel has associated morbidity and mortality.
These potential consequences arise from:
Exposures to infectious agents indigenous in visited
countries
Modes of transport during travel
Unusual environmental exposures associated with travel to
exotic locales
Pre-Travel Evaluation
Pre-Travel Evaluation
 Medical
consultation should be obtained
at least one month before travel to allow
time for thorough evaluation and for
immunizations. A general medical
history should include:
Pre-Travel Evaluation
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Pertinent underlying medical conditions and current
medications. As an example, splenectomy will
predispose the individual to more severe infections
with malaria, babesiosis, and encapsulated bacteria,
including Neisseria meningiditis.
History of allergies to antimicrobial agents or to
components of vaccines (eggs, gelatin)
Whether the patient is human immunodeficiency
virus- (HIV) infected or pregnant and both of these
conditions raise special issues (see below).
Travel Related Medical Advice
Travel Related Medical Advice

Individuals embarking upon foreign
travel frequently request advice about
food, water, and insect repellents.
Malaria chemoprophylaxis
 Only
about 50 to 60
percent of travelers are
compliant with malaria
chemoprophylaxis;
therefore appropriate
counseling needs to be
stressed.
Food and water
 Infections
that may be acquired from
contaminated food or water include
infectious, or so-called travelers',
diarrhea, hepatitis A and E , and less
commonly others such as trichinellosis.
 In areas where sanitation and personal
hygiene may be poor, it is prudent to be
careful of food and water.
Insect repellents

Advice about insect repellents, bed netting,
and protective clothing should be provided to
prevent mosquito borne infections (eg,
malaria, yellow fever, and dengue fever) and
other insect-borne infections (eg, African
trypanosomiasis), tick-borne infections, and
cutaneous myiasis.
 A study of mosquito repellents found that only
those containing N,N-diethyl-3methylbenzamide (DEET) provided durable
protection.
Tuberculosis
 Travelers
who will be staying for more
than three weeks in countries in which
tuberculosis (TB) is endemic should
also be aware of the risk for acquiring
this disease.
Schistosomiasis

In areas where schistosomiasis is prevalent, swimming in fresh water
should be avoided, although swimming in chlorinated or salt water is
safe. Even short exposures to infested water during rafting or
swimming have caused the onset of acute schistosomiasis.
Travelers also should be cautioned
about the risks of walking barefoot or
in loose fitting footwear on soil and even
beaches that may be contaminated with
human or canine feces which can lead
to avoid exposure to hookworm or
strongyloides larvae. Acquisition of the
larvae can cause cutaneous larva
migrans, hookworm, or strongyloidiasis.

Sexually transmitted diseases

Travelers are also at risk for sexually
acquired diseases during their travels and
seem often not to be fully aware of or
compliant with guidelines for safe sex.
 Specifically, travelers should be cautioned
about sexual contacts, especially in areas
where hepatitis B or HIV is prevalent, and
should be advised to use condoms.
General advice

Patients should take supplies of any
medications they are using since equivalent
drugs may not be available in travel
destinations.
 For medications required for daily use, the
traveler should carry these on board
airplanes, and not leave them in baggage that
might become lost.
 Travelers should also take sunglasses and
sunblocking agents with ultraviolet A and B
protection.
General Advice
General advice

Accidents, especially motor vehicle accidents,
account for about one quarter of deaths
among Americans abroad.
 Travelers should be reminded to diminish
risks by avoiding driving at night, using seat
belts, becoming familiar with local driving
conditions, and avoiding alcohol consumption
while driving.
Preventing Travelers' Diarrhea:
How to Make Drinking Water Safe
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Waterborne disease is common in all parts of the world where
there is poor hygiene and sanitation. Traveler's diarrhea alone,
whose principal causes are contaminated
food and water, is estimated to affect 20-50% of travelers - or
approximately 10 million people per year1.
The most common source of exposure to disease-causing
organisms for travelers is ingestion of contaminated drinking
water and food. An estimated 80% of TD cases
Are caused by bacterial pathogens 2 (e.g., E.coli, Shigella,
Salmonella, Vibrio cholerae). Other pathogens are viruses (e.g.
hepatitis A & E viruses, caliciviruses, rotaviruses) and protozoa
(Giardia lamblia, Cryptosporidium parvum, Entamoeba
What to do before traveling?
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Check with your local disease prevention agency or your
physician for
Recommended vaccines and medications for the countries which
you plan to visit several weeks before you leave.
Your physician could also recommend that you visit a specialized
travel medicine clinic, if one exists nearby.
For more detailed advice, please refer to WHO's International
Travel and Health:
http://www.who.int/ith/en/ -This guide gives helpful tips on the full
range of health risks likely to be encountered at specific
destinations and associated with different types of travel – from
business, humanitarian and leisure travel to backpacking and
adventure tours.
General preventive measures
while traveling
Drink bottled water provided in sealed, tamper-proof
containers and bottled by known brands (which,
preferably, have been certified by responsible
authorities).
 Hotel personnel and/or host families are often good
sources of information about which local brands are
safe.
 Hot beverages such as coffee and tea are often made
with boiled water and are therefore usually safe. Other
beverages should be prepared with safe water (as per
above).
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General preventive measures
while traveling
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Avoid consumption of homemade or non commercial,
unpasteurized juices.
Carbonated bottled beverages (sodas) and pasteurized or
canned juice, sports beverages and pasteurized, boiled or
sterilized milk (without ice) are normally free from
microorganisms which could cause TD.
Bottled beer, wine and other alcoholic beverages are also
normally safe, although drinking alcoholic beverages may in fact,
especially in hot climates, contribute to dehydration unless other
safe liquids are consumed.
Do not eat salads or other uncooked dishes that may have been
washed or prepared with unsafe water.
Symptoms if one does fall ill
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Waterborne disease symptoms vary. Typically, people have one
or more of the following: diarrhea, nausea, vomiting, fever, chills,
and aches.
Besides mild diarrhea, other diseases may include typhoid
(enteric) fever, amoebic and bacillary dysentery, hepatitis A and
E, hemolytic uremic syndrome and others.
Symptoms may last for a few hours to several weeks depending
on the infectious agent and type of medical intervention.
These same signs and symptoms can occur early in the course
of many diseases, some of which can be life threatening. If signs
and symptoms are severe or get progressively worse, medical
attention should be sought.
Treatment
 Most diarrhea episodes are self-limiting and
clear up in a few days. The important thing is to
avoid becoming dehydrated.
 As soon as diarrhea starts, drink more fluids,
such as boiled, bottled or treated water, sports
beverages or any other safe fluids like
carbonated drinks.
 Oral rehydration salts may also be used to help
the body retain fluids.
Treatment
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While it is always risky drinking water of questionable
purity, if a traveler becomes sick with severe diarrhea
and/or vomiting and a safe source of fluids can not be
obtained, it is better to drink the best available fluids,
even if of questionable purity, than to drink nothing at
all.
Anti-diarrheal preparations can provide symptomatic
relief; however, they do not
Treat cholera, bacterial dysentery, protozoal, viral and
other serious diseases that require specific treatment
from a physician.
Special Indications
Special indications for
individuals "at risk"
People with weakened immune systems, pregnant women and
infants are groups especially at-risk from water-borne disease.
Cryptosporidium, for example, is a special danger to people with
weakened immune systems.
 Travelers who fall into this group should make a special effort to
boil water and store it in a clean container. This is the surest way
to avoid waterborne disease and may be the only reliable source
of Cryptosporidium-free water.
 Bottled water certified under national and international water
quality standards are generally considered nearly as safe as
boiled water.
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Special indications for
individuals "at risk"
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Iodine use (to disinfect water) over a long period of time is not
recommended for pregnant women, those with a history of
thyroid disease, and those with known hypersensitivity to iodine.
Excess iodine can interfere with the functioning of the thyroid
gland. Travelers intending to use iodine daily for all water
consumed for
Travelers intending to use iodine daily for all water consumed for
more than 3-4 weeks should consult their physician beforehand,
and not use it in excessive amounts when treating drinking water.
Immunizations
Immunizations
Vaccines
Adult Dose
(Volume)
Pediatric Age
Pediatric Dose
(Volume)
Standard Primary
Schedule
Duration of Protection
Hepatitis A
Havrix (GSK)
1440 EU IM (1
mL)
1-18 yrs
720 EU IM
(0.5 mL)
0 and 6-12 mos
50 U IM (1 mL)
1-18 yrs
25 U IM (0.5
mL)
0 and 6-18 mos
20 mcg IM (1 mL)
Birth-19 yrs
10 mcg IM
(0.5 mL)
0, 1 and 6 mos
10 mcg IM (1 mL)
Birth-19 yrs
5 mcg IM (0.5
mL)
0, 1 and 6 mos
720 EU/20 mcg
IM (1 mL)
Not approved for
<18 yrs
-
0, 1 and 6 mos
Vaqta (Merck)
Probably lifelong after completion of
primary series*
Hepatitis B
Engerix-B (GSK)
Recombivax-HB
(Merck)
Probably lifelong after completion of
primary series
Hepatitis A/B
Twinrix (GSK)
Probably lifelong after completion of
primary series
Immunizations
Japanese encephalitis
1 mL SC
1-3
0.5 mL SC
y
r
s
>3
1 mL SC
y
r
s
50 mcg of each antigen
SC (0.5 mL)
2
4 mcg of each antigen
IM (0.5 mL) (1855 yrs)
Imovax
(Sanof
i
Pasteu
r)
RabAvert
(Chiro
n)
0, 7 and 14 or
(preferably)
30 days
Not established; a single booster is
usually given after 24 months if
ongoing risk
50 mcg of each
y
antigen SC
(0.5 mL)
r
s
Single dose
Repeat every 5 yrs if ongoing risk
11-
4 mcg of each
1
antigen IM
(0.5 mL)
7
y
r
s
Single dose
No data. Likely longer than Menomune
2.5 IU of rabies antigen
IM (1 mL)
Birt
2.5 IU of rabies
h
antigen IM
(1 mL)
0, 7 and 21 or 28 days
Routine boosters not necessary; for those engaging in
requent high-risk activities (cavers, veterinarians,
laboratory workers), serologic testing is recommended
every 2 yrs with booster doses if low levels
2.5 IU of rabies antigen
IM (1 mL)
Birt
2.5 IU of rabies
h
antigen IM
(1 mL)
0, 7 and 21 or 28 days
JE-Vax
(Sanof
i
Pasteur)
Meningococcal
Menomune
(Sanof
i
Pasteu
r)
Menactra
(Sanof
i
Pasteu
r)
Rabies
Immunizations
Typhoid
25 mcg IM (0.5 mL)
2
25 mcg IM (0.5 mL)
y
r
s
Single dose
Repeat every 2 yrs
if ongoing
risk
1 cap PO (contains 2-6x109 viable
CFU of S.typhi Ty21a)
6
1 cap PO (contains 2-6x109 viable
CFU of S.typhi Ty21a)
y
r
s
1 cap every
other
day x 4
doses
Repeat every 5 yrs
if ongoing
risk
4.74 log10 plaque forming units of
17D204 attenuated YF virus
SC (0.5 mL)
9
4.74 log10 plaque forming units of
m 17D204 attenuated YF virus
SC (0.5 mL)
o
s
Single dose
Booster dose every
10 yrs if
ongoing risk
Typhim Vi
(Sanof
i
Pasteu
r)
Vivotif Berna
(Berna
Produc
ts)
Yellow Fever
YF-Vax
(Sanof
i
Pasteu
r)
Competency Exam
Question 1
Medical consult should be obtained how long
before travel?
A. 1 week
B. 2 weeks
C. 4 weeks
D. 6 weeks
Question 1
Medical consult should be obtained how long
before travel?
A. 1 week
B. 2 weeks
C. 4 weeks
D. 6 weeks
Question 2
How many people a year are affected by travelers
diarrhea?
A. 1 million
B. 5 million
C. 10 million
D. 15 million
Question 2
How many people a year are affected by travelers
diarrhea?
A. 1 million
B. 5 million
C. 10 million
D. 15 million
Question 3
An estimated 80% of travelers diarrhea is caused
by?
A. Viruses
B. Protazoa
C. Bacteria
D. Poor hand washing
Question 3
An estimated 80% of travelers diarrhea is caused
by?
A. Viruses
B. Protazoa
C. Bacteria
D. Poor hand washing
End of Lecture
Thank you for your attendance.