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
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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*
*ITA, includes travel to Canada and Mexico*ITA, includes travel to Canada and Mexico
45
50
55
60
65
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Number of Travelers (millions)
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International Travel
0
10
20
30
40
50
60
70
80
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
US Resident travel in millions
0
100
200
300
400
500
600
700
800
900
Worldwide arrivals in millions
US nonresidentInbound (ITA)
US Resident AirOutbound (ITA)
All US ResidentOutbound (ITA)
Worldwide arrivals(WTO)
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Where Do U.S. Residents Travel?
0
10
20
30
40
Canada Europe Aus/NZ Mexico
C or S America
Japan
Oceania/ PIOther Asia
AfricaCaribbeanMiddle East
%
Source: HealthStyles Survey 2005
Of the 17% who traveled outside the U.S. . . .
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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
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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
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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
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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”
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Travelers’ Health Websitewww.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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Cardiovascular
Medical
Injury
Homicide/Suicide
Infectious Disease
Other
Deaths Related to International Travel
N = 2463
Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
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Infectious Disease Risks to the Traveler
• Malaria• Diarrhea• Leishmaniasis• Rabies• Dengue• Meningococcal
Meningitis
• Schistosomiasis• Tuberculosis• Leptospirosis• Polio• Yellow Fever• Measles• JEV
ETC.
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Motor Vechicle
Drowning
Air Crash
Homicide/Suicide
Poisoning
Other
Injury Deaths and International Travel
N = 601
Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
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Other Risks to the Traveler
• Accidental injury
• Environmental hazards
• Crime and assault
• Psychiatric problems
• Animal bites, stings and envenomations
• Dermatologic disorders
• Altitude
• …….ETC.
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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
Polio
Japanese encephalitis
Yellow Fever
* Td or Tdap+ MMR
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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
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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
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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
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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
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/