Pre Travel

Consultation
I K Agus Somia

Divisi Penyakt Tropik dan Infeksi

SMF/Bag Ilmu Penyakit Dalam
FK UNUD/RSUP Sanglah Denpasar
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 Outline
• Travelers’ Health Epidemiology
• Traveler Risk Assessment
• Itinerary Review
• Sources of Information
• Risks to the Traveler
• Travel Vaccines
• Travel Medications
• Counseling
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 Travelers’ Health
TOURISM 2020 VISION Epidemiology

International
arrivals are
expected to
reach +1.6
billion:
– 1.2 billion will
be
intraregional
and
– 378 million will
be long-haul
travellers.
 Travelers’ Health Risks
STUDI EPIDEMIOLOGI
----------------------------------------------
- -----------------------------------------
--------------------------------------
-------------------------------------
-------------------------------------
-----------------------------------
Robert Steffen, 2003
Hasil penelitian menunjukkan bahwa dari
antara 100.000 orang yang bepergian ke
negara berkembang selama +1 bulan
100.000 orang yang bepergian
50.000 orang mengalami gangguan
kesehatan
5.000 harus istirahat di tempat tidur
1.100 tidak dapat bekerja
300 orang harus dirawat
50 orang harus dievakuasi melalui udara
1 orang meninggal
 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 6
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
• International Society of Travel Medicine
– www.istm.org
• Health Information for International Travel
– CDC “Yellow Book”
• International Travel and Health
– WHO “Green Book”

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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. 14
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. 16
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 17
+ MMR
Travel Medications:
Prophylaxis & Self Treatment
• Malaria
– atovaquone/proguanil (Malarone)
– Doxycycline
– mefloquine (Lariam)
• Diarrhea
– quinolone, azithromycin
• Altitude
– acetazolamide
• Motion sickness
– scopolamine, dimenhydrinate (Dramamine)
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Patient Counseling
• 6 – 8 weeks before travelling
• 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

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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
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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 24
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 26
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
– antacid
– Band-Aids, gauze bandages, tape, Ace wraps
– Insect repellant, sunscreen, lip balm
– Tweezers, scissors, thermometer
– Anaphylactic kit 27
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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References

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 Journals
• 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/ 33
Terimakasih

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