I K Agus Somia

Division of Tropical and Infectious Diseases

Department of Internal Medicine
Faculty of Medicine
Udayana University
Sanglah Hospital Denpasar BALI
• Pemeriksaan masalah kesehatan setelah
berwisata & skrining kesehatan setelah
berwisata
– Pendekatan umum wisatawan pasca wisata
– Demam pada wisatawan pasca wisata
– Skrining pasca wisata
Pre-Travel Preventive Medicine Visitors

Contingency During Travel Planning

Treatment & Post-Travel

Rehabilitation
Post-Travel Consultation
• It is important to elicit a history of travel.
• Many short term travelers will present with
illness when they get back, following the
incubation period.
• Investigation and management of some
post-travel illnesses will be urgent because
they are life threatening and/or a threat
to public health.
Post-travel Consultation
History
Examination
Investigations

Management
Screening
History
• Are they symptomatic now or
have been?
• Prophylaxis and
• Risk assessment - leading to
compliance - was the
specific history of possible prophylaxis appropriate?
exposures, e.g. • Could it be a pre-existing
schistosomiasis, zoonotic condition?
disease, sexual history,
recently been diving, have they • Could it be related to an
been bitten? occupational/recreational
• Is there correspondence in exposure?
relation to treatment abroad?
• Travel history can be important
in terms of working out
possible incubation period and
differential diagnosis
• Risk assessment
preferably starts before
the traveller enters the
consulting room

• Document the risk

assessment
•
Standardised questionnaire

www.who.int/ith
Establish the risks
•Destination
•Mode of travel
•Traveller’s medical history
•Intervention
Risks of the destination
• What countries and what parts of these countries are
they visiting?
• How long are they going to stay?
• What time of the year are they visiting?
• What are the living conditions?
• What are the current security concerns?
• What activities are they undertaking? Do they need a
diving medical?
• What can the traveller tell you?
• Is there anything special about the destination
culturally or legally?
• 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

World Health Organization
www.who.int/ith
Risks of the destination
• Are they travelling alone or as a group?
• What is the traveller’s prior travel
experience?
• What access is there to appropriate
medical care?
• Does the traveller know first aid?
• Does the traveller have travel insurance
with full coverage?
Risks of the destination
• Categorise Living Conditions:
– Rural and remote areas and villages and/or close contact
with local people, e.g. health workers.
– Towns and cities, not rural and remote and/or lower
standard accommodation and/or stay over four
weeks/month.
– Major cities and tourist resorts and/or medium to high
standard accommodation and/or reliable water and food
sources and/or short term stays of less than four
weeks/month.
– In transit and not exposed to local environment, eg
staying in plane or short-term stay in modern airport
terminal.
Risks of the mode of travel

• Modes of travel can present particular medical

problems of varying severity, e.g. motion
sickness, painful ears, phobias, DVT;

• Can they fly?

Risks of the mode of travel
• Some travellers may not meet medical
guidelines to travel or may need special
clearance to fly on commercial aircraft, such
as with
– pre-existing illness,
– pregnancy,
– recent surgery or
– serious physical or mental incapacity
Risks of the mode of travel

• Accidents and injuries

• Travellers may use modes of travel not
normally used, including at destination, e.g.
4WDing, motor bike riding, cycling,
rollerblading, skiing, jet skiing, etc
Risks of medical history
• Past travel history, particularly involving any significant
medical issues,
• Past medical history, eg need for adjusting diabetic
treatment,
• Past surgical history, eg recent surgery,
• Most recent dental examination
• Current medications, including the oral contraceptive pill,
• Last menstrual period for females (are they pregnant?),
• Smoking and alcohol history,
• Allergies, including medications and foods,
• Any current illnesses and regular medication, and
• Are they travelling alone or with children or with older
travellers?
• How fit are they to undertake any proposed exertional
activities?
Obtaining an exposure history in returned travelers
Typical infections/
Exposure history Examples
pathogens to consider
General

Malaria, dengue, chikungunya, Japanese

Rainy season encephalitis, West Nile virus, and other
•When did you mosquito-borne infections
travel?
Meningococcal disease (Neisseria
Dry season
meningitidis)
•How long did you
Long stay Tuberculosis
travel?
•What kind of Local house,
Numerous pathogens, especially vector
places did you stay rudimentary
borne and rodent borne
in? construction
•Where did you Numerous vector-borne diseases and
Rural areas
visit? food- and water-borne pathogens
Obtaining an exposure history in returned travelers
Typical infections/
Exposure history Examples
pathogens to consider
Specific exposures
Pathogens vary depending on activities.
Visit relatives, Travelers active outdoors may have
field research, exposure to ticks, mosquitoes, and other
construction, vectors and associated infections (eg,
•What did you do? safaris, visit slums, help malaria, rickettsiosis, leishmaniasis),
in clinic, sightsee, whereas travelers with close contact with
attend meetings, local people may have exposure via blood,
teach/attend classes secretions, or direct contact (eg, HIV,
hepatitis B, meningococcus, tuberculosis).
Tap water, ice in drinks,
Salmonella spp, Shigella spp,
raw vegetables,
•What did you eat Campylobacter spp, hepatitis A, hepatitis E,
undercooked meats,
or drink? amebic dysentery or liver abscess,
questionable hygiene
eosinophilic meningitis
practices
•Did you have
unpasteurized dairy,
Unpasteurized dairy Brucella, other, Listeria
eq. home-made
cheese?
Obtaining an exposure history in returned travelers
Typical infections/
Exposure history Examples
pathogens to consider
Specific exposures
Campylobacter, Salmonella,
Undercooked meats Escherichia coli O157, Toxoplasma,
Trichinella
•Did you eat raw or
Undercooked Hepatitis A, Vibrios, Clonorchis,
undercooked foods?
shellfish Paragonimus
Raw vegetables,
Fasciola
watercress
•Did you have any Malaria; many arboviruses, including
insect bites such as Mosquitoes dengue, Japanese encephalitis, West
mosquito bites? Nile virus, Rift Valley fever
Rickettsia (in travelers most commonly
•Did you have any
Rickettsia africae), Babesia,
tick bites or go hiking
Ticks Anaplasma, Ehrlichia, Lyme disease,
or walk through tall
Crimean-Congo hemorrhagic fever,
grasses or woods?
tick-borne encephalitis
Obtaining an exposure history in returned travelers
Typical infections/
Exposure history Examples
pathogens to consider
Specific exposures
Rickettsia typhi (endemic typhus), Yersinia
Fleas
pestis
Rickettsia prowazekii (epidemic typhus),
•Did you notice any Lice
Borrelia (relapsing fever)
fleas or other vectors,
or bugs, or were you Mites Orientia tsutsugamushi (scrub typhus)
around animals that Sandflies Leishmania
might have had fleas
or lice? Black flies Onchocerca volvulus
Triatomine bugs American trypanosomiasis
Tsetse flies African trypanosomiasis
Air-borne particles,
•Were you in large Influenza, measles, other respiratory
crowded living
gatherings? infections
conditions
•Did you participate in
Coccidioides imitis (coccidioidomycosis),
digging, excavating, or Soil, excavations
Histoplasma capsulatum (histoplasmosis)
construction?
 Obtaining an exposure history in returned travelers

Typical infections/
Exposure history Examples
pathogens to consider
Specific exposures
•Did you swim, wade, or
Swimming in lakes, ponds,
splash around in fresh Schistosoma, Leptospira
rivers, streams
water?
Bites, spelunking Rabies
Brucella, anthrax, Yersinia pestis, Coxiella
Handling animals
burnetti, Francisella tularensis, Toxoplasma
•Did you have close
contact with any Primates Simian B virus
animals? Any bites,
Yersinia pestis, hantaviruses, Lassa fever
scratches, or licks?
Rodents and other hemorrhagic fevers, rat-bite fever,
Rickettsia typhi
Birds Chlamydophila psittaci, avian influenza
•Did you have sexual
Sexual contact; injections,
contact or contact with
transfusion, medical
blood, body fluids, Acute HIV; hepatitis A, B, C, D; CMV, EBV;
procedure, tattoos, piercings,
secretions, or syphilis; viral hemorrhagic fevers
dental work, shaving by
procedures that may
barber with reused razor
expose you to these?
Obtaining an exposure history in returned travelers
Typical infections/
Exposure history Examples
pathogens to consider
Specific exposures
Verify immunity to MMR, polio, Td/Tdap,
•Have you had these routine hepatitis B, influenza,
routine vaccines chickenpox
immunizations, Age-specific
HPV, shingles, pneumococcal
and were they recommendations
updated before Haemophilus influenzae b,
travel? Asplenic host
meningococcal,
recommendations
pneumococcal
Hepatitis A, Japanese
•Have you had
encephalitis, meningococcal,
travel –
polio, rabies, typhoid, yellow
immunizations?
fever
• Addressing risk in travel medicine is generally
all about trying to modify risks established
from the travel health consultation

• All interventions have potential risks, including

giving the wrong advice
Risks of intervention
• Advice and education
• Vaccination
• Chemoprophylaxis
• Screening and Effective management
Risks of the intervention
• Can the traveller tolerate the intervention?
• Does the risk of the exposure justify the
intervention/cost?
• Can the traveller afford the intervention?
• What do you do if you can’t provide optimal
protection because of risks from the medical
history or other considerations, such as age of
the traveller or cost?
 Screening Examination
• Post-travel physical examination for most short
term travelers is usually unremarkable for
disease, but may be useful for assessment of
injuries
• Signs of “tropical” disease can be subtle and
can be missed unless specifically looked for, e.g.
rashes, eschar, jaundice
• Abnormalities unrelated to travel
Look for the “spot”diagnosis
• Leishmaniasis: non-healing skin ulcers/lesions,
especially on exposed areas and been to
endemic areas
• Eschars-may be associated with rickettsial
infectious such as scrub typhus
• Skin infection: bacterial and fungal
(ask for occupational and recreational history)
• Others
 Screening Examination
• When sending specimens to lab, document current
medications, history, what you think
• Liaise with lab if unsure what tests available
• Stool microscopy M/C/S, O/C/P-most diarrhoeal
disease bacterial>>parasitic>viral
• Urine tests-dipstick urinalysis, “terminal” urine for
ova of S. haematobium
• Full Blood Count and differential- eosinophilia,
anaemia, thrombocytopenia
Screening Examination

• Rapid tests, e.g. Immunochromographic tests (ICT)-

often used for initial screening for malaria,
Bancroftian filariasis, (dengue), etc
• Serological investigations, e.g. schistosomiasis,
filariasis
• Blood films for malaria
• HIV/STI serology
• TB screening-useful if you can compare with pre-
travel
 Initial laboratory evaluation for fever and tropical exposures

Routine laboratory tests

Complete blood count with differential

Liver enzyme and function tests

Blood cultures

Urinalysis (culture if abnormal sediment)

Rapid diagnostic test (if available) and blood smears for malaria

Other tests to consider (depends upon physical examination and exposure history)

Stool culture and/or examination for blood, fecal leukocytes, ova and parasites

Chest radiograph

Serologic tests

Urinary antigens (eg, for Legionella)

Blood smears for Babesia, Borrelia, filaria

Bone marrow aspirate/biopsy

Biopsy of skin lesion, lymph nodes, other masses

Examination of cerebrospinal fluid

Other imaging studies

Post travel
assessment
Travel-associated infections, by incubation period
Disease Usual incubation (range) Distribution
Incubation period <14 days
SARS Cov 2 3 to 5 days (1 to 14 days) Pandemic
Anthrax 1 to 7 days (can be >2 weeks) Endemic in agricultural areas
Bartonellosis (cat-
scratch; trench fever; 1 to 3 weeks Some forms worldwide
Carrion disease)
High risk in parts of
2 to 4 weeks (5 days to 5 Mediterranean, South and
Brucellosis*
months) Central America, Asia, Africa,
Middle East
Chikungunya 2 to 4 days (1 to 14 days) Tropics and subtropics
Southwest US, Mexico, Central
Coccidioidomycosis* 1 to 3 weeks
and South America
Dengue 4 to 8 days (3 to 14 days) Tropics and subtropics
Endemic in many low- and
Diphtheria 2 to 5 days (1 to 10 days)
middle-income countries

Ehrlichiosis (multiple) 7 to 10 days (5 to 14 days) Widespread, including in US

 Travel-associated infections, by incubation period
Disease
Incubation period <14 days
Encephalitis, arboviral
(Japanese encephalitis, West
Nile virus, others)
Enteric fever (typhoid and
paratyphoid fevers)*
Hantavirus infections (eg,
hemorrhagic fever with renal
syndrome; hantavirus
pulmonary syndrome,
others)*
Histoplasmosis (acute)*
HIV (acute)
Influenza
Lassa, Ebola, other viruses
causing hemorrhagic fevers*
Legionellosis
Usual incubation (range)
Japanese encephalitis: 5 to
15 days
West Nile virus: 2 to 14 days
7 to 18 days (6 to 45 days)
HFRS: 2 to 4 weeks (few days
to 2 months)
HPS: 2 weeks (few days to 2
weeks)
10 to 14 days (3 to 25 days)
10 days (1 to 6 weeks)
2 days (1 to 4 days)
7 to 10 days (2 to 21 days)
5 to 6 days (2 to 12 days)
Distribution
Varies with virus
Especially Indian
subcontinent; also Africa
HFRS: especially in parts of
Asia, Europe
HPS: especially in the
Americas
Worldwide (except
Antarctica); especially river
valleys, also caves
Worldwide
Worldwide
Sub-Saharan Africa for Ebola,
Marburg, Lassa viruses
Worldwide
 Travel-associated infections, by incubation period
Disease Usual incubation (range)
Incubation period <14 days
Leptospirosis* 7 to 12 days (2 to 26 days)
7 to 12 days for erythema
Lyme disease* migrans; longer for other
manifestations
Malaria, Plasmodium
10 to 12 days (8 days to months)
falciparum*
Malaria, P. vivax* 14 days (8 days to months)
Measles* 10 to 14 days (8 to 21 days)
2 days to 3 weeks (days to
Melioidosis*
months)
Meningococcal infections 3 to 4 days (2 to 10 days)
2 to 7 days for bubonic (1 to 14
Plague
days)
Distribution
Widespread; more common in
tropical areas
Especially in parts of North America
and Europe
Especially in parts of Africa, Asia,
South America
Especially in parts of Asia, Africa,
South America
Persists in populations with low
vaccine coverage; frequent
importations and outbreaks globally
Widely distributed in tropical areas;
especially common Southeast Asia
Worldwide; epidemiology affected by
vaccine use
Especially common Madagascar;
parts of Africa, Asia, South America;
focus in western United States
 Travel-associated infections, by incubation period
Disease Usual incubation (range) Distribution
Incubation period <14 days
Psittacosis* 7 to 14 days (4 to 28 days) Worldwide
Q fever* 18 to 21 days (4 to 39 days) Worldwide but endemic foci
Widespread; especially parts of Asia,
Rabies* 1 to 2 months (4 days to years)
Africa, Latin America
Focal areas: Africa, South America,
Relapsing fever 7 to 8 days (2 to 18 days)
Asia
Rickettsial infections
High risk in southern Africa but
(spotted fever group and 6 to 7 days (3 to 18 days)
widely distributed in other regions
others)
Scrub typhus (Orientia
8 to 12 days (3 to 21 days) Asia-Pacific region
spp)
Especially eastern Europe and parts
Tickborne encephalitis* 8 days (4 to 28 days)
of Asia
Toxoplasmosis* 1 to 3 weeks (5 to 23 days) Worldwide
10 to 20 days (few days to >2 Widespread; marked variation in
Trichinosis*
months) incidence
Trypanosomiasis,
1 to 3 weeks Sub-Saharan Africa
African*
 Travel-associated infections, by incubation period
Disease Usual incubation (range) Distribution
Incubation period <14 days
Widespread North America, Europe;
Tularemia 3 to 5 days (1 to 14 days)
scattered reports from Asia
Typhoid fever (refer to
enteric fever above)*
Yellow fever 1 to 6 days (3 to 14 days) Africa, Latin America
Zika virus 5 to 6 days (3 to 14 days) Tropics, subtropics
Incubation period 14 days to 6 weeks (refer also to infections above with "*" footnote symbol)
Worldwide; more common in areas
Amebic liver abscess¶ Weeks to months
with poor sanitation
Worldwide; especially in areas with
Hepatitis A 28 days (15 to 50 days)
poor sanitation
6 to 9 weeks (2 weeks to 6 Worldwide; marked variation in
Hepatitis C¶
months) prevalence
Large waterborne outbreaks in Asia,
Hepatitis E¶ 6 weeks (2 to 9 weeks) Africa, Central America; sporadic
elsewhere
Asia, Africa, Middle East, Latin
Leishmaniasis, visceral¶ 2 to 6 months (10 days to >1 year)
America, southern Europe
Travel-associated infections, by incubation period

Disease Usual incubation (range) Distribution

Incubation period 14 days to 6 weeks
Malaria¶ Weeks to months Refer to above
Schistosomiasis
Especially Asia, Africa, Latin
(Katayama 14 to 84 days
America
syndrome)¶
Months to years (4 weeks to Worldwide but marked
Tuberculosis¶
decades) regional variation in incidence
Incubation period >6 weeks
Broad distribution, especially
Fascioliasis 6 to 12 weeks parts of South America, Middle
East, Asia
Hepatitis B 90 days (60 to 150 days) Global
Leishmaniasis,
Refer to above
visceral
Malaria Refer to above
Melioidosis Refer to above
Key elements of the history in returning travelers
Geography
Countries visited or passed through; urban or rural
Dates of travel and duration of stay in each place
Means of transportation
Accommodations (eg, hotel, dormitory, local household, tent)
Activities and exposures during travel
Sex or other intimate contact (eg, type, number of partners, barrier protection)
Animals, including birds (eg, shared living quarters or physical proximity, seeing
rodents, bites, licks) or animal products (eg, hunting, skinning, other)
Arthropod (eg, seeing or receiving bites from mosquitoes, flies, ticks, fleas, other)
Needle and blood exposure (eg, shared needles, injections, acupuncture, tattoos, ear
or other body piercing, dental work, transfusions, surgery)
Food and beverages (eg, raw or undercooked flesh, unpasteurized milk, tap or
surface water, local delicacies)
Soil and water contact (eg, recreational, such as hiking, boating, swimming, hunting,
spelunking or professional activities, such as archeological digs)
Key elements of the history in returning travelers
Host factors

Age and sex

Medical problems and past surgery (eg, splenectomy,
gastrectomy, HIV infection)
Past infections and vaccines
Medications, including immunosuppressive and
immunomodulating agents, over the counter drugs,
antipyretics
Past medical history, including immunosuppression

Preparation for travel (eg, vaccines, chemoprophylaxis)

Pregnancy
Key concepts in the evaluation of illness associated with travel
Diseases unrelated to travel can appear after exotic travel
Infections can be acquired en route or on brief layovers
Fever related to tropical exposures usually begins during travel or shortly after return, but
can rarely be delayed for months or years
Defining the range of relevant incubation periods can help limit the differential diagnosis
Malaria is still possible even if an initial malaria smear is negative
Patients with acute falciparum malaria may have a normal physical examination and no
fever when first seen
Early symptoms of self-limited infections and life-threatening infections may be
indistinguishable
Risks for infectious diseases and manifestations of infections in local residents and in
visitors to a geographic region may differ widely
Risks for infectious diseases vary from one tropical area to another and may vary depending
upon the season and year
Familiar infectious diseases acquired in a tropical, developing area may have an unusual
resistance pattern or may be acquired during an unexpected time of year (eg, influenza in
July)
Terimakasih