1 THE PRE-TRAVEL CONSULTATION Gary W. Brunette, MD, MS Travelers’ Health Team Division of Global...

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THE PRE-TRAVEL CONSULTATION

Gary W. Brunette, MD, MSTravelers’ Health Team

Division of Global Migration and QuarantineCenters for Disease Control and Prevention

Outline

• Travelers’ Health Epidemiology

• Traveler Assessment

• Itinerary Review

• Sources of Information

• Risks to the Traveler

• Travel Vaccines

• Travel Medications

• Counseling

U.S. Residents Traveling Abroad*

*ITA, includes travel to Canada and Mexico*ITA, includes travel to Canada and Mexico

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Number of Travelers (millions)

International Travel

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

US Resident travel in millions

Worldwide arrivals in millions

US nonresidentInbound (ITA)

US Resident AirOutbound (ITA)

All US ResidentOutbound (ITA)

Worldwide arrivals(WTO)

Where Do U.S. Residents Travel?

Canada Europe Aus/NZ Mexico

C or S America

Oceania/ PIOther Asia

AfricaCaribbeanMiddle East

Source: HealthStyles Survey 2005

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

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, 200532004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, USDOC

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 dieSteffen R et al. J Infect Dis 1987; 156:84-91

The Patient: Medical Issues

• Age-specific issues• Underlying illness,

immunosuppression• Systems review• Medical history• Medication use• Vaccination history• Allergies • Contraindications to vaccines and

medications

The Patient: Other Issues

• Reproductive– Pregnant– Breastfeeding– Preconception

• Risk-taking behaviors

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

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”

Travelers’ Health Websitewww.cdc.gov/travel

Regional Destinations

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

Travel Notices & Announcements

Cardiovascular

Medical

Injury

Homicide/Suicide

Infectious Disease

Deaths Related to International Travel

N = 2463

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

Infectious Disease Risks to the Traveler

• Malaria• Diarrhea• Leishmaniasis• Rabies• Dengue• Meningococcal

Meningitis

• Schistosomiasis• Tuberculosis• Leptospirosis• Polio• Yellow Fever• Measles• JEV

Motor Vechicle

Drowning

Air Crash

Homicide/Suicide

Poisoning

Injury Deaths and International Travel

N = 601

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.

Immunizations to Consider for Adult Travelers

Routine

Diphtheria*

Tetanus*

Pertussis*

Measles +

Mumps+

Rubella +

Varicella

Pneumococcus

Influenza

Travel related

Hepatitis A

Hepatitis B

Typhoid

Rabies

Meningococcal disease

Japanese encephalitis

Yellow Fever

* Td or Tdap+ 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)

Patient Counseling

• Sufficient time for patient education

• Tailored to suit traveler

• Fitness for travel– Understanding impact on existing

conditions– Advisability of destinations

Travel Preparation

• Travel health insurance– Medical care– Hospitalization– Evacuation

• Obtaining medical care abroad

• Awareness of travel notices

• Hand washing and hygiene

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

Food and Water Precautions

• Bottled water

• Selection of foods– well-cooked and hot

• Avoidance of – salads, raw vegetables– unpasteurized dairy products– street vendors– ice

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

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

Animal Precautions

• Animal avoidance• Rabies

– Specific animal threats– Medical evaluation of bites/scratches– Post exposure immunization and

immunoglobulin

• Envenomations– Snakes, scorpions, spiders– Maritime animals

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

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

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

Questions?

Other Resources

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

• 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

Websites

Eurosurveillancewww.eurosurveillance.org

Travax EnCompasswww.travax.com

GIDEONwww.gideononline.com

International SOSwww.internationalsos.com

Medical Advisory Service for Travelers Abroad (MASTA)http://www.masta.org/

Armed Forces Medical Intelligence Centerwww.afmic.detrick.army.mil/

Central Intelligence Agencywww.cia.gov/cia/publications/factbook/

1 THE PRE-TRAVEL CONSULTATION Gary W. Brunette, MD, MS Travelers’ Health Team Division of Global...

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