Transcript travel
TRAVEL MEDICINE CLINICS Australian Experience DR. TONY GHERARDIN National Medical Adviser Travel Doctor-TMVC Group Australia TRAVEL MEDICINE “that aspect of public health medicine which seeks to prevent illness and injuries occurring to travellers going abroad, and manages problems arising in travellers coming back from abroad.” “protection and promotion of health of tourists.” In any community there will be variable opportunities to be a source and a host for travellers Travel Medicine • Practice of “Emporiatrics” • Rapid development over the last 25 years • Fairfield Hospital in Melbourne started travel clinic in early-mid 80s - one of the world’s first travel clinics • Now a recognised clinical entity primarily involved in risk management • Strong overlap with public health and occupational health and general practice Travel Medicine • Is not “cookbook” stuff • Should not be taken as trivial or just give a couple of jabs • Never should be “ let them see the nurse and I’ll sign off” • If you provide travel medical services, do it properly! Best Practice • Involves trained doctors and nurses who have complimentary roles. • Not “cookbook”, lists alone are weak as provide no context or priority • One stop service is valued by travellers • Links to referral services Risk Management • Identifying risks for individuals or groups • Advising about risk reduction strategies • Recommending and providing risk reduction interventions • Encouraging behavioural change to change risk level Risk Reduction Interventions • Information enabling behaviour modification • vaccinations • medications (including antimalarials) • other - travel insurance, pre existing medical problems, nets, syringes, medical kits Knowledge of Travel-related Risks • Knowledge of morbidity and mortality of travellers • Understanding of epidemiology and geography of communicable diseases • Awareness of non-communicable risks • Vaccines, indications, side-effects • Knowledge of post-travel illness presentation and management • Geography , esp of major tourist destinations • Ability to communicate complex issues in simple ways • Understanding of when to refer Provide Up-to date Information • Understand basic current epidemiology • Be aware of outbreaks and emergent issues • Provide written material targeting specific risks • Be able to communicate using electronic media Vaccine classification-3 Rs • Routine ( background) vaccine Childhood, standard • Required ( compulsory) vaccine Cross borders, entry requirements IHR • Recommended ( elective based on risk) Travel vaccines Some vaccines can be in more than category. Not all the same or available in all countries Key elements of quality service • • • • • • • • Current best practice Organised and professional Up-to-date advice Comprehensive vaccines, medications Range of Kits Appropriate documentation Communication options Value for money Travel Clinic Environment • Established with an understanding of the psychology of a traveller in mind – Appropriate paraphernalia + required tools – IHGs, brochures, kits, travel related products • All contact points in the clinic need to reflect this – All staff need an understanding of travel & travel health requirements Establishing a Travel Medicine Clinic CORE ELEMENTS • • • • • • CREATING THE VISION STAFF PHYSICAL ENVIRONMENT OPERATING PROCEDURES KNOWLEDGE / SKILL BASE COMMITMENT • The demand for Travel Medical services is increased when travellers are going from moredeveloped, healthier environments to less developed, less healthy ones. • The nature and activities of a particular travel clinic will depend on its surrounding socioeconomic environment • The prevailing socio-economic environment in much of the developing world is well suited to an increasing need for Travel Medicine services CORE ELEMENTS CREATING THE VISION DEFINING THE TASK: To provide a comprehensive range of travel medicine services of an international standard to achieve a viable professional practice. QUESTIONS Who are your potential clients? How to identify the target travelers? What charges will apply? – Will it be viable? MARKET RESEARCH MARKET RESEARCH • Demographic Information Population data, Tourism data, Socio-economic markers, Local studies • Acceptance of Preventive Services Perception of Risk • Awareness of Travel medicine services • Opportunities for marketing and promotion CORE ELEMENTS PHYSICAL ENVIRONMENT LOCATION • • • Relevant to target clients Consider International travellers Near other services SPACE • • • • • Adequate waiting, reception area Consulting rooms Nurses Rooms/ Recovery room Storage/Record Keeping Toilets/Sinks/Washbasins The Clinic CORE ELEMENTS PHYSICAL ENVIRONMENT The Clinic ACCESS • Ground Floor preferable, avoid stairs • Broad as possible, maximise appeal LAYOUT • • • • • Waiting / Reception separate Consulting / Nursing rooms separate Recovery room has privacy Access to bathroom / toilets Records / Communications CORE ELEMENTS PHYSICAL ENVIRONMENT The Equipment FURNITURE Reception Chairs / tables Examination couch Lights STORAGE Cupboards - secure / non secure Shelving Refrigerators – main / consulting rooms CORE ELEMENTS PHYISICAL ENVIRONMENT The Equipment STRUCTURAL Toilets / hand basins Sinks INFORMATION TECHNOLOGY / COMMUNICATIONS Computers Phones / Fax / Email MEDICAL EQUIPMENT CORE ELEMENTS STAFF • Professional. Can demonstrate legitimate qualifications • Friendly • Trained • Good Communicators Language Skills Cross Cultural Sensitivity CORE ELEMENTS OPERATING PROCEDURES • Provision of Information and Advice Standardised written information eg. Vaccine side effects All staff deliver a consistent message • Standardised Vaccination Protocols Internationally acceptable Modified for local availability/regulations • Standardised Chemoprophylaxis Protocols Malaria Diarrhoea Jetlag / Motion sickness / Altitude CORE ELEMENTS OPERATING PROCEDURES • Empiric Treatments/ Self Treatments Malaria Diarrhoea • Provision of Medical Kits Different travellers = Different kits • Documentation / Record Keeping Compliance with International Certificates Reporting Adverse events Notifiable Diseases CORE ELEMENTS OPERATING PROCEDURES • Self Diagnostic Kits with Explanations • Compliance with Local Regulations Obtain relevant permits Keep compulsory records • Infection Control Procedures • Emergencies Anaphylaxis / Cardiac Arrest Medical Emergencies MANAGEMENT OF ANAPHYLAXIS • If patient unconscious: Lie on left side, clear airway. • Give adrenaline I.M. Repeat every 5 minutes if required. • Administer oxygen – Use face mask at high rate • Get help • Commence CPR if needed ADRENALINE – 1:1000, 0.01 mg/kg : Adult 0.5 ml Display dosage charts MEDICAL KITS First Aid Components • Adhesive tape • Antiseptic wound cleaner • Bandages • Decongestants • Scissors/safety pins • Sterile dressings • Antidiarrhoeals • Condoms • Water disinfectant • Lubricant eye drops • • • • • • • Insect repellent Insect bite treatment ORS Paracetamol Thermometer Antifungal treatment Sterile needles/syringes • Other Medical travel kits • • • These are designed to assist travelers in meeting medical needs when their access to quality medical care is compromised. All travel medicine consultants recommend that travelers carry some form of medical first aid kit. A range is available, and often needs to be tailored to meet the specific requirements of the traveler and their proposed itinerary. Many travel clinics sell medical first aid kits; these often contain prescription items. Medical travel kits • Essential items for all travelers – Items to treat cuts, scratches, burns, strains, splinters – Paracetamol – Repellent – Consider condoms • Additional items for Europe, USA, Japan – Antinauseants, eg prochlorperazine – Broad-spectrum antibiotic for respiratory infection – Antacids – Sudafed – Minor sedative – Laxative Medical travel kits • Additional items for less developed countries (gastro kit) – – – – • Rehydration solution Loperamide Tinidazole Norfloxacin – or azithromycin for children Comprehensive medical kit ; Asia, Africa and South America – All of the above – Sterile needles and syringes. Alcohol swabs – Antihistamines – Antifungal and antibiotic cream VACCINES SUPPLY • Approved locally • Comprehensive range • Continuous supply DISPOSABLES • Quality assured • reliable HANDLING / STORAGE • Monitored cold chain • Recording batch numbers • Check expiry dates • Proper re-use DISPOSAL ROUTINE • Sharps • Infected materials • Proper disintegration VACCINES ROUTINE: • • • • • • Diphtheria / Tetanus / Pertussis – DTP Hepatitis B Haemophilis influenza type B – HIB Measles / mumps / rubella – MMR Polio – OPV / IVP VZ VACCINES TRAVELLERS • • • • • • • • • • • Hepatitis A Influenza BCG TVO, TVI Cholera Yellow fever, Mn , Pn JEV Rabies, RIG TBE Lyme Other: Q Fever, Plague, Anthrax Cold Chain • Absolutely essential • Vaccines are sensitive, normal range is 20-80C Do not freeze • Must have monitoring • Preferably alarms and backup solutions for problems • Avoid little fridges in every room. PERSONAL PROTECTIVE MEASURES • • • • • • Bed Nets Repellents Clothing Water sterilization / filters Sunblock Others ears eyes compression garments CORE ELEMENTS KNOWLEDGE / SKILL BASE • PROVIDE UP TO DATE KNOWLEDGE Advisories Texts / Official Recommendation Internet • PRE- TRAVEL ADVICE Comprehensive services • POST TRAVEL Assessment and Investigation Medical assessment of returned travellers Basic testing/TST/Urinalysis Recognition of emergencies Referral to specialists ISTM Body of Knowledge • • • • • • • Epidemiology Immunology/Vaccinology Pre-travel Consultation/Management Diseases Contracted During Travel Other Conditions Associated With Travel Post-Travel Management General Travel Medicine Issues Special populations • • • • • • • • • Athletes Corporate Travellers Elderly Infants and children Immigrants Expatriates Pregnant travellers Chronic disease Disabilities Imunocompromised Special itineries • • • • • • Cruise ships Diving Extended stay Extreme travel Mass gatherings Wilderness CORE ELEMENTS KNOWLEDGE / SKILL BASE TREATMENT OF COMMON ILLNESS Fever Diarrhoea Skin Eosinophilia • ACCESS TO EVACUATION Dealing with Insurance Companies. Assessing local medical infrastructure • ADVICE ON INSURANCE CORE ELEMENTS KNOWLEDGE / SKILL BASE • MANAGEMENT OF EMERGENCIES Management of Anaphylaxis Basic Life Support Adrenaline / oxygen Ambulance access / Hospital • RESOURCES FOR LABORATORY TESTING OR REFERRAL Access to Laboratory and Radiology Understanding QA • ABILITY TO PERFORM RESEARCH CORE ELEMENTS COMMITMENT • International links ISTM, Promed, Conferences • Local Promotion / Advertising Signage, Leaflets, Written materials, Talks, Media Consider professional advice • Working with Partners Travellers , Travel Industry , Pharmaceutical industry Medico-legal opinion on Travel Medicine Advice. “ A claim arising from ‘travel’ may be related to either or both from; a/ Inadequate advice before travel. If you choose to advice patients ensure that you provide complete, accurate and up-todate information. b/ delayed or missed diagnosis of an exotic disease in a person recently returned from overseas. Have the ability and the insight to know your limitations. If you choose to provide travel advice, decide which areas you will focus on, commit to remaining up to date in those areas, know where to look up information, and refer the rest to specialist clinics” Dr Paul Nisselle, MDAV