TRAVEL HEALTH

Dr Firman Rachman Masjhur SpKP

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 Outline
• Travelers’ Health Epidemiology
• Traveler Assessment
• Itinerary Review
• Sources of Information
• Risks to the Traveler
• Travel Vaccines
• Travel Medications
• Counseling
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 U.S. Residents Traveling Abroad*
Number of Travelers (millions)
65

60

55

50

45

Year
3
*ITA, includes travel to Canada and Mexico
 International Travel
80 900

70 800

700
60 US nonresident
Inbound (ITA)
US Resident travel in millions

Worldwide arrivals in millions

600
50 US Resident Air
Outbound (ITA)
500
40 All US Resident
400 Outbound (ITA)

30 Worldwide arrivals
300 (WTO)

20
200

10 100

0 0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

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 Where Do U.S. Residents Travel?

Of the 17% who traveled outside the U.S. . . .

40

30

20
%

10

0
ada op
e
/ NZ
ico ic a a n / PI s ia
ri ca ean a st
s x r p a
n u r
Au Me
e Ja ni rA Af b E
Ca E Am e a th
e ri b
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l e
r S O c O Ca M i
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5
Source: HealthStyles Survey 2005
VFRs: Visiting Friends and Relatives

• Foreign-born increased 57% since 1990

from 19.8 million to 31.1 million1
• 20% of US population are first- or second-
generation immigrants
• VFRs comprised ~46% of US international
air travelers in 20043

1US Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000, issued
Dec 2003 (Previous: US Census Bureau, Profile of the Born Outside the United States
Population 2000, issues Dec 2003???
2 Angell & Cetron, 2005

32004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported

From: Survey of International Air Travelers, Office of travel and tourism Industries,
USDOC 6
 Travelers’ Health Risks
Of 100,000 travelers to a developing country
for 1 month:
– 50,000 will develop some health problem
– 8,000 will see a physician
– 5,000 will be confined to bed
– 1,100 will be incapacitated in their work
– 300 will be admitted to hospital
– 50 will be air evacuated
– 1 will die
Steffen R et al. J Infect Dis 1987; 156:84-91
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The Patient: Medical Issues
• Age-specific issues
• Underlying illness,
immunosuppression
• Systems review
• Medical history
• Medication use
• Vaccination history
• Allergies
• Contraindications to vaccines and
medications 8
The Patient: Other Issues

• Reproductive
– Pregnant
– Breastfeeding
– Preconception
• Risk-taking behaviors

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 Travel Itinerary
• Full itinerary
– Dates, duration, stopovers
– Seasonal considerations
• Styles of travel
– Rural vs. urban
– Budget vs. luxury
• Accommodation
– Hotel vs. camping
• Activities
– Business vs. tourism
– Adventure, safari
– Missionary/Humanitarian/NGO
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 Travel Health Resources
• CDC Travelers’ Health Website
– www.cdc.gov/travel
• World Health Organization
– www.who.int/int
• State Department
– travel.state.gov
• International Society of Travel Medicine
– www.istm.org
• Health Information for International Travel
– CDC “Yellow Book”
• International Travel and Health
– WHO “Green Book” 11
Travelers’ Health Website
www.cdc.gov/travel

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 Regional Destinations
• Region-specific pages
• Goal to move to country-specific format

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Travel Notices & Announcements

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Deaths Related to International Travel

Cardiovascular
Medical
Injury
Homicide/Suicide
Infectious Disease
Other
N = 2463

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Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
 Infectious Disease Risks to
the Traveler
• Malaria • Schistosomiasis
• Diarrhea • Tuberculosis
• Leishmaniasis • Leptospirosis
• Rabies • Polio
• Dengue • Yellow Fever
• Meningococcal • Measles
Meningitis • JEV

ETC. 16
Injury Deaths and International Travel

Motor Vechicle
Drowning
Air Crash
Homicide/Suicide
Poisoning
Other

N = 601

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Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
 Other Risks to the Traveler
• Accidental injury
• Environmental hazards
• Crime and assault
• Psychiatric problems
• Animal bites, stings and envenomations
• Dermatologic disorders
• Altitude
• …….
ETC. 18
Immunizations to Consider for Adult
Travelers
Routine Travel related
Diphtheria* Hepatitis A
Tetanus* Hepatitis B
Pertussis* Typhoid
Measles + Rabies
Mumps+ Meningococcal disease
Rubella + Polio
Varicella Japanese encephalitis
Pneumococcus Yellow Fever
Influenza

* Td or Tdap 19
+ MMR
 Travel Medications:
Prophylaxis & Self Treatment
• Malaria
– chloroquine, atovaquone/proguanil (Malarone),
doxycycline, mefloquine (Lariam), primaquine
• Diarrhea
– quinolone, azithromycin
• Altitude
– acetazolamide
• Motion sickness
– scopolamine, dimenhydrinate (Dramamine)

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 Patient Counseling

• Sufficient time for patient education

• Tailored to suit traveler
• Fitness for travel
– Understanding impact on existing
conditions
– Advisability of destinations

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 Travel Preparation
• Travel health insurance
– Medical care
– Hospitalization
– Evacuation

• Obtaining medical care abroad

• Awareness of travel notices

• Hand washing and hygiene 22

 Environmental Precautions
• Air Travel
• Jet Lag
• Sun Protection
• Extreme Heat and Cold
– dehydration, heat stroke
– hypothermia, frostbite
• Altitude
• Water recreation
– Drowning, boating & diving accidents
– Risk of schistosomiasis or leptospirosis
– Biological and chemical contamination
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Food and Water Precautions

• Bottled water
• Selection of foods
– well-cooked and hot
• Avoidance of
– salads, raw vegetables
– unpasteurized dairy products
– street vendors
– ice
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 Vector
Precautions
• Covering exposed skin
• Insect repellent containing DEET 25 – 50%
• Treatment of outer clothing with permethrin
• Use of permethrin-impregnated bed net
• Use of insect screens over open windows
• Air conditioned rooms
• Use of aerosol insecticide indoors
• Use of pyrethroid coils outdoors
• Inspection for ticks 25
Bloodborne and STD Precautions
• Prevalence of
– STDs
– Hepatitis B
– Hepatitis C
– HIV
• Unprotected sexual activity
• Commercial sex workers
• Tattooing and body piercing
• Auto accidents
• Blood products
• Dental and surgical procedures 26
 Animal Precautions

• Animal avoidance
• Rabies
– Specific animal threats
– Medical evaluation of bites/scratches
– Post exposure immunization and
immunoglobulin
• Envenomations
– Snakes, scorpions, spiders
– Maritime animals
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 Injury and Crime
• Vehicles
– Risk of road and pedestrian accidents
– Night travel
– Seat belts and car seats

• Use of drugs and alcohol

• Understanding local crime risks

– Scam awareness
– Situational awareness
– Location avoidance 28
 Travel Emergency Kit
• Copy of medical records and extra pair of glasses
• Prescription medications
• Over-the counter medicines and supplies
– Analgesics
– Decongestant, cold medicine, cough suppressant
– Antibiotic/antifungal/hydrocortisone creams
– Pepto-Bismol tablets, antacid
– Band-Aids, gauze bandages, tape, Ace wraps
– Insect repellant, sunscreen, lip balm
– Tweezers, scissors, thermometer
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 Post-Travel Care

• Post-travel checkup
– Long term travelers
– Adventure travelers
– Expatriates in developing world

• Post-travel care
– Fever, chills, sweats
– Persistent diarrhea
– Weight loss
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Questions?

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Other Resources

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 Journals
• American Journal of Tropical Medicine and
Hygiene
• Bulletin of the World Health Organization
• Emerging Infectious Diseases Journal
• Eurosurveillance Weekly
• Journal of Travel Medicine
• Morbidity and Mortality Weekly Report
• Tropical Medicine and International Health
• Vaccine
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 Books
• Textbook of Travel Medicine and Health, 2nd
Ed.
– DuPont, H.L. and Steffen R. (editors)
• The Travel and Tropical Medicine Manual,
3rd Ed.
– Jong, E.C., McMullen, R.
• Travel Medicine
– Keystone, J.S., Kozarsky, P.E., et al

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 Websites
Eurosurveillance
www.eurosurveillance.org
Travax EnCompass
www.travax.com
GIDEON
www.gideononline.com
International SOS
www.internationalsos.com
Medical Advisory Service for Travelers Abroad (MASTA)
http://www.masta.org/
Armed Forces Medical Intelligence Center
www.afmic.detrick.army.mil/
Central Intelligence Agency
www.cia.gov/cia/publications/factbook/ 35