Introduction to travel

medicine
Dr. Peter A Leggat,
a series produced for James Cook University, Australia
 Test Yourself!
1. Which strain of Plasmodium protozoa cause the most serious form of
malaria?
2. Can a patient with psoriasis travelling to the Dominican Republic
take chloroquine? Why?
3. What is the duration of mefloquine prophylaxis required for a two
week holiday to Gambia?
4. Antimalarials are not 100% effective. What other measures can a
traveller take to reduce their risk of contracting malaria?
5. Which antimalarials are thought least likely to cause problems in
pregnancy?
6. Give an example of a live vaccine and an inactivated vaccine.
7. Can hepatitis A vaccine and rabies vaccine be administered on the
same day?
 Objectives
• In this session
– Define travel medicine
– Examine some figures for global and
local migration
– Hopefully gain an appreciation of the
importance of giving travel health advice
– Discuss some of components that are
needed in order to give correct advice to
traveller
What is travel medicine?

It is a science and an art

 What is travel medicine?
• It is that part of health professional
practice that:
– seeks to prevent illnesses and injuries
occurring to travellers going abroad
– manages problems arising in travellers
coming back or coming from abroad
– is concerned about the impact of tourism on
health and also advocates for improved
health and safety services for tourists
– is increasing concerned about refugee and
migrant health
(Primer of Travel Medicine 3rd Ed)
• “the art of travel medicine is
selecting the necessary
prevention strategy without
unnecessary adverse events,
cost or inconvenience”
(Steffen, 1994)
 Challenge of travel medicine
• Sea of global migration of people
– More people travelling
• People travelling further a field
• Rapid movement of travellers
 Travellers from industrialised areas
to developing areas 1999 (WTO)

2.8 2.4
USA / Canada
Europe 6.1
25.0 million 4.6
35.2 million 3.6 Japan
11.4 mio
19 7.8 6.8 1.6
2.3
1.3 4.8
2.5
1.9
1.2 2.6
AUS / NZ
3.3 million

n million travelers
0.2-1 million travelers
Total: ~ 80 million travelers
Globalization of health and safety
• Affects
– Health of local Commerce and Health
populations
– Health determinants
Influenza
– Safety and security SARS

• Results in Terrorism

– Global impacts Tsunami

– Emerging and re-
emerging infectious
disease

Pathogens travel as fast as transportation:

borders are not respected
Travellers are exposed
to a variety of hazards
 The Importance of Travel
Health Measures
• 100,000 travelers to the developing
world for 1 month…..
– 50,000 will become ill
– 8,000 will see a physician
– 5,000 will stay in bed
– 1 will die

Steffen, 1994
The Importance of Travel
Health Measures
• Per 100,000 travellers that have
travel insurance …..
– 8000 will make a claim (8%)
– 2000 will use emergency
assistance (2%)
• 400 ER or clinic referrals (0.4%)
• 200 Hospital admissions (0.2%)
• 50 Aeromedical evacuations (0.05%)
Leggat et al. Travel Med Inf Dis 2005;3:9-17.
 The Importance of Travel
Health Measures
• Mortality
– Cardiovascular Disease (50 to 70%)
– Accidents/Trauma (20-25%), esp. MVAs
– Infectious diseases (2.8-4%)

(Reid and Cossar, BMBull. 1993;257-268; Prociv,

MJA. 1995;163:27-30; Baker et al., PHR
1992;107:155-159; MacPherson et al, JTM. 2000;
2000:227-233; Steffen, Trans RSTM&H 1991;85: 156-
162 )
 Travel medicine is a
continuum

• Travellers do get sick or injured abroad

or when they come back

• The commitment to travel health can

therefore be regarded as a continuum
The Continuum of Travel Medicine

Preventive Medicine
Pre-Travel Visitors

Contingency During Travel Planning

Post-Travel
Treatment &
Rehabilitation
 What do we need to do in
order to be giving the
correct advice to travellers?
Travel Health Advice needs
Information
“Information is power in Travel
Medicine”
Travel Health Advice needs
Training
Training gives you a framework
for using that information
Travel Health Advice needs
Experience
Experience helps put the
information and training in
perspective
Travel Health Advice needs
to be Documented
Documentation is important for
Quality assurance and
reinforcing travel health advice
Travel Health Advice needs
Travellers
Marketing is essential in travel
health, whether in general practice
or in specialist travel clinics
 Giving the correct advice to
travellers
• Giving the correct health advice to
travellers needs:
– Information
– Training
– Experience
– Documentation
– Travellers
 Travel Health Advice needs
Information
• Guidelines
• Policies
• Textbooks, including an World Atlas
• Journals
• Professional organisations
• Staff/colleagues
• Electronic Databases
• WWW
 International Guidelines
• WHO
• International
Health
Regulations
• International
Travel and Health
– www.who.int/ith
– Yellow fever
requirements
 “National Guidelines”

• Travel Health Guidelines

• Malaria Guidelines
• Immunisation Guidelines
• Antibiotic Guidelines
• Journals
• Seminars
You need access to www-sites
• International Society of Travel Medicine
– www.istm.org
• US Centers for Disease Control and
Prevention
– www.cdc.gov/travel
– US Guidelines
– Similar government sites for UK and Canada
• World Health Organization
– http://www.who.int/ith
– The former “yellow book” is now published
as the “blue book” online
It is very useful to have access
to a multicountry travel
medical advisory service
• CDC Travel Health, see
http://www.cdc.gov/travel/index.htm

• MASTA, see http://www.masta.org

• TRAVAX, see http://www.travax.nhs.uk

• Shorelands, see http://www.tripprep.com

Professional Organisations

• Local professional groups

and

•THE ISTM
 ISTM
• International Society of Travel
Medicine
– International Network
• International Clinic Directory
• Useful for marketing/recognition
– www.istm.org
– Listserve
• Outbreak alerts
– Journal
– Geosentinel
– Certificate of Travel Health
– Great Conferences!!
 Journals

Weighing the Evidence

 Weighing the evidence
• “Travel medicine prevention should be
based on epidemiological data.”
Robert Steffen,
1991

• What are the likely risks of a person

travelling to particular destinations?

• What are the likely benefits of

intervention?
 Giving the correct advice to
travellers
• Giving the correct health advice to
travellers needs:
– Information
– Training
– Experience
– Documentation
– Travellers
 Pre-Travel Health Advice needs
Training
• Helps give structure and
consistency
– Provides a framework for practice
– Discusses evidence for practice
• Policy and Procedures Manual
– Consistent approach to travel health
 Part of the commitment is to also
have a consistent and structured
approach to travel health advice
• WHO Checklist
(www.who.int/ith)
– Information on local
conditions
– Prevention
– Accident avoidance
– Medical and dental
check-up
• NZPHR-Prevention
– Vaccinations
Source:
– Health Advice
http://www.who.int/ith
– Prescription
 VACCINATE (IHC)
• Always National schedule
• Often hepatitis A
• Sometimes Japanese encephalitis
meningococcal disease
polio
rabies
yellow fever
Influenza
Pneumococcal disease
Other vaccines
(adapted* from NZPHR; 1996;3(8):57-59)
 ADVISE AND DISCUSS
• Insects repellents, nets, permethrin
• Ingestions care with food and water
diet/teeth (including
airlines/jetlag/DVT)*
• Indiscretions STI’s, HIV
• Injuries accident avoidance, personal
safety
• Immersion schistosomiasis
• Insurance* health and travel insurance*
finding medical assistance o/s*
(adapted* from NZPHR; 1996;3(8):57-59)
 PRESCRIBE
(Script/Dr’s letter/bracelet)

• Always regular medication

medical kit (first aid)*
• Sometimes antimalarial medication
diarrheal self-treatment
condoms
(NZPHR; 1996;3(8):57-59)
 Courses
• Increasing number of travel medicine
academic programs globally
(see educational opportunities at
www.istm.org)
• Get relevant endorsements
– Aviation medical examiner
– Diving medical certification (SPUMS)
– Certificate of Travel Health (ISTM)
– Occupational health training
 Courses
• Weighing the evidence

• Contributing to the discipline through

research (also through GeoSentinel)

• Despite training, still need to keep up to

date and to keep seeing travellers to
help build experience
 Giving the correct advice to
travellers
• Giving the correct health advice to
travellers needs:
– Information
– Training
– Experience
– Documentation
– Travellers
Travel health advice needs experience
• Let’s just do it!
• Affiliation with a group with experience
can be useful
– Travel clinic group
– Travel medical advisory group (eg MASTA,
Worldwise, Travax etc)
– University
• Those NZ GPs that were interested in
travel medicine were significantly more
likely to have had tropical
medicine/developing country experience
(Leggat et al. JTM 1999; 7: 55-58.)
Travel is part of experience
 Travel is part of experience
• Professionals working in travel
medicine need to travel and have that
personal experience to communicate to
travellers
• Helps to put travel health advice in
context and helps to build a positive
travel experience
 Giving the correct advice to
travellers
• Giving the correct health advice to
travellers needs:
– Information
– Training
– Experience
– Documentation
– Travellers
Travel health advice needs to be
documented
• Standardised forms/questionnaires
• Informed consent
• International Health
Certificate/Vaccination record
• Doctor’s letter/copy of
prescription/medialert bracelet
• Written
advice/videos/Books/Health
Correct advice is even better if the
advice is actually followed by the
traveller
• Documentation

• Follow-up

• Use staff resources

• Reinforce health advice

 Giving the correct advice to
travellers
• Giving the correct health advice to
travellers needs:
– Information
– Training
– Experience
– Documentation
– Travellers
 Travel Health Advice needs
Travellers
• Inform own patients concerning the need
for seeking travel health advice, and
seeking this advice early
• Market travel health advice
– Direct, if possible
– Join group/affiliate
– Links/promotion with traveller groups, travel
agents, travel insurance, consulates etc
– Join travellers health networks, such as ISTM,
IAMAT etc
 Take home points
• More people are traveling to more
destinations, becoming exposed to the
health and safety of that destination and also
having the potential to impact on the health
and safety of that destination, especially
through emerging infectious disease
• Travelers’ health is a continuum and includes
the pre-travel health, contingency planning
while abroad and caring the traveler after
travel
• Travel health advice needs information
(including a capacity to undertake a risk
assessment), training, experience,
documentation and travelers