Travel medicine for health profession student

Travel medicineTravel medicineAn overviewAn overview

Rachmat Gunadi WachjudiRachmat Gunadi Wachjudi

Department of Internal MedicineDepartment of Internal MedicineFaculty of Medicine Universitas Padjadjaran Faculty of Medicine Universitas Padjadjaran

Travelling Travelling

The path ….The path …. Lahir : Garut 16 Januari 1955Lahir : Garut 16 Januari 1955 Fakultas Kedokteran UNSRI Palembang 72 – 83Fakultas Kedokteran UNSRI Palembang 72 – 83 PUSKESMAS/Dinas Kesehatan Pandeglang 83-89PUSKESMAS/Dinas Kesehatan Pandeglang 83-89 Fakultas Kedokteran UNPAD Bandung 90 – 96Fakultas Kedokteran UNPAD Bandung 90 – 96 RS Al Ikhsan Bandung 96-97RS Al Ikhsan Bandung 96-97 Staf Dep I.P. Dalam 1997-….Staf Dep I.P. Dalam 1997-…. Fakultas Kedokteran UI Jakarta 97Fakultas Kedokteran UI Jakarta 97 Royal Perth/SCG Hospital 98-99Royal Perth/SCG Hospital 98-99 Staf Div Reumatologi 99- ….Staf Div Reumatologi 99- …. Kepala Div Reumatologi 2004 -…Kepala Div Reumatologi 2004 -… Kepala Dep I P Dalam 2014- ….Kepala Dep I P Dalam 2014- …. Hobi : baca, musik, travelling, MCHobi : baca, musik, travelling, MC

What is travel medicine?What is travel medicine?

It is a science and an artIt is a science and an art

What is travel medicine?What is travel medicine? It is that part of health professional It is that part of health professional

practice that:practice that: seeks to seeks to prevent i l lnesses and injuries prevent i l lnesses and injuries

occurring to travellers going abroadoccurring to travellers going abroad manages problems arising in travellers manages problems arising in travellers

coming back or coming from abroadcoming back or coming from abroad is concerned about the impact of tourism on is concerned about the impact of tourism on

health and also advocates for improved health and also advocates for improved health and safety services for touristshealth and safety services for tourists

is increasing concerned about refugee and is increasing concerned about refugee and migrant healthmigrant health

(Primer of Travel Medicine 3(Primer of Travel Medicine 3 r drd Ed) Ed)

““ the art of travel medicine is the art of travel medicine is selecting the necessary selecting the necessary prevention strategy without prevention strategy without unnecessary adverse events, unnecessary adverse events, cost or inconvenience” cost or inconvenience”

(Steffen, 1994)(Steffen, 1994)

Challenge of travel medicineChallenge of travel medicine Sea of global migration of peopleSea of global migration of people

More people travell ingMore people travell ing People travell ing further a fieldPeople travell ing further a field Rapid movement of travellers Rapid movement of travellers

USA / Canada35.2 million

Europe25.0 million Japan

11.4 mio

AUS / NZ3.3 million

Travellers from industrial ised areas Travellers from industrial ised areas to developing areas 1999 (WTO) to developing areas 1999 (WTO)

2.8

2.3 19 7.8

1.9

3.6

6.8

2.51.3

1.6

2.4

4.66.1

4.8

2.6

Total:

n million travelers0.2-1 million travelers~ 80 million travelers

1.2

Travellers are exposed to a variety of hazards

The Importance of Travel The Importance of Travel Health MeasuresHealth Measures

100,000 travelers to the 100,000 travelers to the developing world for 1 month…..developing world for 1 month….. 50,000 wil l become il l50,000 wil l become il l 8,000 wil l see a physician8,000 wil l see a physician 5,000 wil l stay in bed5,000 wil l stay in bed 1 wil l die1 wil l die

Steffen, 1994


Per 100,000 travellers that have Per 100,000 travellers that have travel insurance …..travel insurance ….. 8000 wil l make a claim (8%)8000 wil l make a claim (8%) 2000 wil l use emergency 2000 wil l use emergency

assistance (2%)assistance (2%) 400 ER or clinic referrals (0.4%)400 ER or clinic referrals (0.4%) 200 Hospital admissions (0.2%)200 Hospital admissions (0.2%) 50 Aeromedical evacuations (0.05%)50 Aeromedical evacuations (0.05%)

Leggat et al. Travel Med Inf Dis 2005;3:9-17.


Mortali tyMortali ty Cardiovascular Disease (50 to Cardiovascular Disease (50 to

70%)70%) Accidents/Trauma (20-25%), esp. Accidents/Trauma (20-25%), esp.

MVAsMVAs Infectious diseases (2.8-4%)Infectious diseases (2.8-4%)

(Reid and Cossar, BMBull. 1993;257-268; (Reid and Cossar, BMBull. 1993;257-268; Prociv, MJA. 1995;163:27-30; Prociv, MJA. 1995;163:27-30; Baker et al. , Baker et al. , PHR 1992;107:155-159; MacPherson et al, PHR 1992;107:155-159; MacPherson et al, JTM. 2000; 2000:227-233; Steffen, Trans JTM. 2000; 2000:227-233; Steffen, Trans RSTM&H 1991;85: 156-162RSTM&H 1991;85: 156-162 ) )

Travel medicine is a Travel medicine is a continuumcontinuum

Travellers do get sick or injured Travellers do get sick or injured abroad or when they come backabroad or when they come back

The commitment to travel health can The commitment to travel health can therefore be regarded as a therefore be regarded as a continuumcontinuum

The Continuum of Travel The Continuum of Travel MedicineMedicine

During TravelDuring Travel

Preventive Medicine

Contingency Planning

Treatment & Rehabilitation

VisitorsVisitorsPre-TravelPre-Travel

Post-TravelPost-Travel

What do we need to do in What do we need to do in order to be giving the order to be giving the

correct advice to travellers?correct advice to travellers?

Travel Health Advice Travel Health Advice needs Informationneeds Information

““ Information is power in Information is power in Travel Medicine”Travel Medicine”

Travel Health Advice needsTravel Health Advice needsTrainingTraining

Training gives you a Training gives you a framework for using that framework for using that

informationinformation

Travel Health Advice needsTravel Health Advice needsExperienceExperience

Experience helps put the Experience helps put the information and training in information and training in

perspectiveperspective

Travel Health Advice needsTravel Health Advice needsto be Documentedto be Documented

Documentation is important Documentation is important for Quality assurance and for Quality assurance and reinforcing travel health reinforcing travel health

adviceadvice

Travel Health Advice needsTravel Health Advice needsTravellersTravellers

Marketing is essential in travel Marketing is essential in travel health, whether in general health, whether in general

practice or in specialist travel practice or in specialist travel clinicsclinics

Giving the correct advice to Giving the correct advice to travellerstravellers

Giving the correct health advice Giving the correct health advice to travellers needs:to travellers needs: InformationInformation TrainingTraining ExperienceExperience DocumentationDocumentation TravellersTravellers

Travel Health Advice needs Travel Health Advice needs InformationInformation

GuidelinesGuidelines PoliciesPolicies Textbooks, including an World AtlasTextbooks, including an World Atlas JournalsJournals Professional organisationsProfessional organisations Staff/colleaguesStaff/colleagues Electronic DatabasesElectronic Databases WWWWWW

International GuidelinesInternational Guidelines WHOWHO International International

Health Health RegulationsRegulations

International International Travel and Travel and HealthHealth www.who.int/ ithwww.who.int/ ith Yellow fever Yellow fever

requirements requirements

http://www.who.int/ith

JournalsJournals

Weighing the Evidence

Weighing the evidenceWeighing the evidence

“Travel medicine prevention should be based on epidemiological data.”

Robert Steffen, 1991

What are the l ikely r isks of a person travell ing to particular destinations?

What are the l ikely benefits of intervention?

Risk assessmentRisk assessment Risk assessment Risk assessment

preferably starts preferably starts before the traveller before the traveller enters the consulting enters the consulting roomroom

Document the risk Document the risk assessmentassessment

Establish the risksEstablish the risks DestinationDestination

Mode of travelMode of travel

Traveller’s medical historyTraveller’s medical history

InterventionIntervention

Risks of the destinationRisks of the destination

Outbreak NoticePolio Outbreak in Tajikistan, Cases in Russia, Risk of Spread to other Central Asian Countries Updated: October 22, 2010

CDC Update Oct. 2010

Yellow fever: distribution

“meningitisbelt”—the Sahel

Travelers’ diarrheaTravelers’ diarrhea

Very common. Up to Very common. Up to 50% over 2-4 weeks.50% over 2-4 weeks.

A self-limited illness in A self-limited illness in most international most international travelers.travelers.

Duration can be Duration can be shortened by antibiotics.shortened by antibiotics.

What do U.S. travelers die from in What do U.S. travelers die from in the developing world?the developing world?

About half: heart attacks, strokes (mostly About half: heart attacks, strokes (mostly in the elderly). in the elderly).

About 25%: road traffic accidents.About 25%: road traffic accidents. The rest: drowning, falls from heights, The rest: drowning, falls from heights,

homicide, suicide.homicide, suicide. Infectious disease: only Infectious disease: only

about 1%.about 1%.

Urban medicineUrban medicine Road traffic accidentsRoad traffic accidents Air pollutionAir pollution Heat illnessHeat illness Recreational pharmacologyRecreational pharmacology Psychological Psychological

illnessillness

Air pollutionAir pollution

Mexico City was the Mexico City was the worst city in the world worst city in the world in 1992. Now it’s not in 1992. Now it’s not on the top ten list.on the top ten list.

Nine of worst ten Nine of worst ten cities are in China.cities are in China.

Total suspended Total suspended particulatesparticulates(in mcg/cubic meter)(in mcg/cubic meter)

StockholmStockholm99

Mexico CityMexico City279279

Lanzhou, ChinaLanzhou, China732732

Mexico CityMexico City

Lanzhou, Lanzhou, ChinaChina

photographyphotography If there’s a guy within If there’s a guy within

sight who is carrying sight who is carrying a rifle or machine a rifle or machine gun: ask permission gun: ask permission before you take before you take photographs. photographs.

No glove, no love. No glove, no love.

Risks of the mode of travelRisks of the mode of travel

Modes of travel can present Modes of travel can present particular medical problems of particular medical problems of varying severity, e.g. motion varying severity, e.g. motion sickness, painful ears, phobias, sickness, painful ears, phobias, DVT; DVT;

Can they f ly?Can they f ly?

Road traffic accidentsRoad traffic accidents

The rate of fatalities The rate of fatalities per 100 million miles per 100 million miles driven in the US is driven in the US is 1.1; this is similar to 1.1; this is similar to Western European Western European rates. rates.

The rates in Sri Lanka The rates in Sri Lanka and Turkey are 23 and Turkey are 23 and 44, respectively. and 44, respectively.

Seat belts are good.Seat belts are good.Helmets are good. Better Helmets are good. Better still, stay off anything still, stay off anything two-wheeled and two-wheeled and motorized.motorized.Do not ride on top of a Do not ride on top of a bus or in the back of an bus or in the back of an open truck. open truck. Avoid the roads at night. Avoid the roads at night.

To reduce risk of injury and death from motor vehicle accidents:

Risks of the mode of travelRisks of the mode of travel

Some travellers may not meet Some travellers may not meet medical guidelines to travel or may medical guidelines to travel or may need special clearance to fly on need special clearance to fly on commercial aircraft, such as with commercial aircraft, such as with pre-existing i l lness, pre-existing i l lness, pregnancy, pregnancy, recent surgery or recent surgery or serious physical or mental incapacityserious physical or mental incapacity

Risks of medical historyRisks of medical history Past travel history, particularly involving any significant Past travel history, particularly involving any significant

medical issues,medical issues, Past medical history, eg need for adjusting diabetic Past medical history, eg need for adjusting diabetic

treatment,treatment, Past surgical history, eg recent surgery,Past surgical history, eg recent surgery, Most recent dental examinationMost recent dental examination Current medications, including the oral contraceptive Current medications, including the oral contraceptive

pil l ,pi l l , Last menstrual period for females (are they pregnant?),Last menstrual period for females (are they pregnant?), Smoking and alcohol history, Smoking and alcohol history, Allergies, including medications and foods,Allergies, including medications and foods, Any current i l lnesses and regular medication, andAny current i l lnesses and regular medication, and Are they travell ing alone or with children or with older Are they travell ing alone or with children or with older

travellers?travellers? How fit are they to undertake any proposed exertional How fi t are they to undertake any proposed exertional

activit ies?activit ies?

Risks of medical historyRisks of medical history Asthma - Asthma management plan; Asthma - Asthma management plan;

precipitants; environmental concerns; precipitants; environmental concerns; consider influenza vaccination and consider influenza vaccination and antibiotics for medical kit.antibiotics for medical kit.

Diabetes - Consideration of t ime zone Diabetes - Consideration of t ime zone changes; control changes; control

Ulcer management - Reduced acidity Ulcer management - Reduced acidity may predispose to diarrhoeal diseasemay predispose to diarrhoeal disease

Risks of medical historyRisks of medical history Psoriasis - May get worse with Psoriasis - May get worse with

chloroquinechloroquine

Arthrit is - May have diff icult ies with Arthrit is - May have diff icult ies with treks, climbing (also general f i tness); treks, climbing (also general f i tness); may need standby NSAID treatmentmay need standby NSAID treatment

Hypertension - Caution in prescribing Hypertension - Caution in prescribing mefloquine and Beta blockersmefloquine and Beta blockers

Immunosuppression - Immune response Immunosuppression - Immune response to vaccination may be less; l ive vaccines to vaccination may be less; l ive vaccines may give rise to diseasemay give rise to disease

Risks of medical history-allergiesRisks of medical history-allergies

SulphursSulphurs (Maloprim), Diamox & other (Maloprim), Diamox & other sulphur based medicationssulphur based medications

Egg allergies*Egg allergies* Yellow fever vaccine, Yellow fever vaccine, influenza vaccine, influenza vaccine,

MMRIIMMRII Neomycin, polymixin Measles, Mumps, Neomycin, polymixin Measles, Mumps,

RubellaRubella IodineIodine iodine water purif ication iodine water purif ication

tabstabs QuinineQuinine ChloroquineChloroquine Food allergies Various, including,Food allergies Various, including,

seafood, peanutsseafood, peanuts PetsPets CatsCats

Risks of interventionRisks of intervention Addressing risk in travel medicine Addressing risk in travel medicine

is generally all about trying to is generally all about trying to modify risks established from the modify risks established from the travel health consultationtravel health consultation

All interventions have potential All interventions have potential r isks, including giving the wrong risks, including giving the wrong adviceadvice

Risks of interventionRisks of intervention Advice and educationAdvice and education

VaccinationVaccination

ChemoprophylaxisChemoprophylaxis

Screening and Effective Screening and Effective managementmanagement

Risks of the interventionRisks of the intervention Can the traveller tolerate the Can the traveller tolerate the

intervention?intervention? Does the risk of the exposure justify Does the risk of the exposure justify

the intervention/cost?the intervention/cost? Can the traveller afford the Can the traveller afford the

intervention?intervention? What do you do if you can’t provide What do you do if you can’t provide

optimal protection because of risks optimal protection because of risks from the medical history or other from the medical history or other considerations, such as age of the considerations, such as age of the traveller or cost?traveller or cost?

Risk assessmentRisk assessment PoliciesPolicies

GuidelinesGuidelines

Consensus statementsConsensus statements

Epidemiological evidence Epidemiological evidence (weak to strong) (weak to strong)

Pre-Travel Health Advice Pre-Travel Health Advice needs Trainingneeds Training

Helps give structure and Helps give structure and consistencyconsistency Provides a framework for practiceProvides a framework for practice Discusses evidence for practiceDiscusses evidence for practice

Policy and Procedures ManualPolicy and Procedures Manual Consistent approach to travel Consistent approach to travel

healthhealth

Part of the commitment is to also Part of the commitment is to also have a consistent and structured have a consistent and structured approach to travel health adviceapproach to travel health advice

WHO Checklist WHO Checklist (www.who.int/ ith)(www.who.int/ ith) Information on local Information on local

condit ionscondit ions PreventionPrevention Accident avoidanceAccident avoidance Medical and dental Medical and dental

check-upcheck-up NZPHR-PreventionNZPHR-Prevention

VaccinationsVaccinations Health AdviceHealth Advice PrescriptionPrescription

Source: http://www.who.int/ ith

VACCINATE VACCINATE (IHC)(IHC)

AlwaysAlways National scheduleNational schedule OftenOften hepatit is Ahepatit is A SometimesSometimes Japanese encephalit isJapanese encephalit is

meningococcal disease meningococcal disease polio polio rabies rabies

yellow fever yellow fever Influenza Influenza

Pneumococcal Pneumococcal diseasedisease

Other vaccinesOther vaccines(adapted* from NZPHR; 1996;3(8):57-59)(adapted* from NZPHR; 1996;3(8):57-59)

ADVISE AND DISCUSSADVISE AND DISCUSS InsectsInsects repellents, nets, permethrinrepellents, nets, permethrin IngestionsIngestions care with food and watercare with food and water

diet/teeth (including diet/teeth (including airl ines/jetlag/DVT)*airl ines/jetlag/DVT)*

IndiscretionsIndiscretions STI’s, HIVSTI’s, HIV InjuriesInjuries accident avoidance, personal accident avoidance, personal

safetysafety ImmersionImmersion schistosomiasisschistosomiasis Insurance*Insurance* health and travel insurance*health and travel insurance*

finding medical assistance o/s*finding medical assistance o/s*(adapted* from NZPHR; 1996;3(8):57-59)(adapted* from NZPHR; 1996;3(8):57-59)

PRESCRIBEPRESCRIBE (Script/Dr’s letter/bracelet)(Script/Dr’s letter/bracelet)

AlwaysAlways regular medicationregular medicationmedical kit (f irst medical kit (f irst

aid)*aid)* SometimesSometimes antimalarial medicationantimalarial medication

diarrheal self-diarrheal self-treatmenttreatment condomscondoms

(NZPHR; 1996;3(8):57-59)(NZPHR; 1996;3(8):57-59)

Travel health advice needs experienceTravel 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 Travel is part of experienceexperience

Travel is part of Travel is part of experienceexperience

Professionals working in travel Professionals working in travel medicine need to travel and have medicine need to travel and have that personal experience to that personal experience to communicate to travellerscommunicate to travellers

Helps to put travel health advice in Helps to put travel health advice in context and helps to build a posit ive context and helps to build a posit ive travel experiencetravel experience

Travel health advice needs to Travel health advice needs to be documentedbe documented

Standardised forms/questionnairesStandardised forms/questionnaires Informed consentInformed consent International Health International Health

Certificate/Vaccination recordCertificate/Vaccination record Doctor’s letter/copy of Doctor’s letter/copy of

prescription/medialert braceletprescription/medialert bracelet Written advice/videos/Books/Health Written advice/videos/Books/Health

advisory documentsadvisory documents

Correct advice is even better i f the Correct advice is even better i f the advice is actually fol lowed by the advice is actually fol lowed by the

travellertraveller DocumentationDocumentation

Follow-up Follow-up

Use staff resourcesUse staff resources

Reinforce health adviceReinforce health advice

Travel Health Advice needs Travel Health Advice needs TravellersTravellers

Inform own patients concerning the need for Inform own patients concerning the need for seeking travel health advice, and seeking this seeking travel health advice, and seeking this advice earlyadvice early

Market travel health adviceMarket travel health advice Direct, if possibleDirect, if possible Join group/affiliateJoin group/affiliate Links/promotion with traveller groups, travel agents, Links/promotion with traveller groups, travel agents,

travel insurance, consulates etctravel insurance, consulates etc Join travellers health networks, such as ISTM, IAMAT Join travellers health networks, such as ISTM, IAMAT

etcetc

LBNL Health Services and Travel Medicine•Before you travel overseasoVisit Health Services early for consultationoVaccination series take up to 6 monthsoSome destinations (e.g., CERN) requiremedical clearance from Health ServicesoRegister trip for travel coverage throughUCOP ACE American Insurance Company

•During traveloFollow usual common sense precautionsoRefer to the following website for insurance details:http://www.ucop.edu/risk-services/loss-prevention-control/travel-assistance/index.html

•When you returnoFinish prophylactic medicationsoIf you become ill, advise your doctor about your recent travel

http://www.ucop.edu/risk-services/loss-prevention-control/travel-assistance/index.html

Take home pointsTake home points

More people are traveling to more destinations, More people are traveling to more destinations, becoming exposed to the health and safety of that becoming exposed to the health and safety of that destination and also having the potential to impact on destination and also having the potential to impact on the health and safety of that destination, especially the health and safety of that destination, especially through emerging infectious diseasethrough emerging infectious disease

Travelers’ health is a continuum and includes the pre-Travelers’ health is a continuum and includes the pre-travel health, contingency planning while abroad and travel health, contingency planning while abroad and caring the traveler after travelcaring the traveler after travel

Travel health advice needs information (including a Travel health advice needs information (including a capacity to undertake a risk assessment), training, capacity to undertake a risk assessment), training, experience, documentation and travelersexperience, documentation and travelers

Practical pointsPractical points

Where toWhere to For how longFor how long For what purposeFor what purpose Staying in what kind of placeStaying in what kind of place Guided or notGuided or not Previous developing world travel or notPrevious developing world travel or not

Concerns Concerns

Past medical historyPast medical history AllergiesAllergies

History of antimalarial use if anyHistory of antimalarial use if any MedicationsMedications Medical problemsMedical problems

History of depression, anxietyHistory of depression, anxiety Contraception Contraception

Review of past immunizationsReview of past immunizations

Bibliography Centers for Disease Control and Prevention. CDC Health Information for

International Travel 2010. Atlanta: U.S. Dept. of Health and Human Services, Public Health Service, 2009.

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, McIntyre L, ed. Washington DC: Public Health Foundation, 2009.

Cook, Gordon C, Ed.: Manson’s Tropical Diseases, 20th Ed., W.B. Saunders Co. Ltd, 1996.

DuPont HL, Steffen R (eds.): Textbook of Travel Medicine and Health, 2nd Ed. B.C. Decker, 2001.

Guerrant, Walker, Weller: Tropical Infectious Diseases: Principles, Pathogens, & Practice. Churchill Livingston, 1999.

Jong EC, Sanford C (eds.): The Travel and Tropical Medicine Manual, 4th ed. Saunders/Elsevier, 2008.

Keystone JS, Kozarsky PE, Freedman DO, et al, eds: Travel Medicine. Mosby,

2004.

Bibliography (cont.)

Sanford, C: The Adventurous Traveler’s Guide to Health. University of Washington Press, Seattle, 2008.

Sanford C. (guest editor): Primary Care Clinics: Travel Medicine. Saunders/Elsevier, December 2002.

Strickland. Hunter’s Tropical Medicine and Emerging Tropical Diseases,

8th Ed., W.B. Saunders. 2000.

Thank you

Travel medicine for health profession student

Health & Medicine

Transcript of Travel medicine for health profession student