Download - Emporiatrics
Emporiatrics…Dr. Menaal Kaushal
JR II
Department of Community
Medicine
S. N. Medical College
Emporiatrics
Greek origin“emporos”: One who goes on shipboard as a
passenger+
“iatrike”: medicine)
It’s the term coined to: Describe the science
of the health of travellers.
• It is a science which deals with promoting and
protecting the health of international travelers,
providing them the advice related to the travel they
are about to undertake.
• It is a fast developing specialty as the international
travel is fast increasing.
• Every year 660 million people travel internationally.
Definition
•Practice of “Emporiatrics”
•Rapid development over the last 25 years
•Fairfield Hospital in Melbourne started the
first ever travel clinic in early-mid 80’s
•Now a recognized clinical entity primarily
involved in risk management
•Strong overlap with public health and
occupational health and general practice
Travel Medicine
Why a Special Branch for Travelers’ Health?
Travellers face special health risks:
▫ They are subject to disorders induced by Rapid changes
of environment such as upsets in the circadian rhythms,
motion sickness, and diarrhea;
▫ In developing countries they are exposed to Infectious
diseases that do not exist in their home countries such as
malaria, giardiasis, and dengue; and,
▫ They are Separated from familiar and accessible sources
of medical care.
▫ Never before in history have so many people travelled
and have people Travelled so far or so fast.
Types of Travellers:
• Business men and
• Tourists
▫ VFR
▫ Non VFR
They often travel by air or railways (The records of which
are available)
• Immigrants,
• Refugees, and
• Migrant laborers
Who frequently travel by other means
Documented
Undocumented
So Who’s Responsibility is Emporiatrics?
•Meeting the health needs of these travellers
who are moving rapidly between countries
and continents is a responsibility shared by:
▫the medical professionals,
▫by the travellers themselves,
▫by travel organizations,
▫by airline and shipping companies, and
▫by host governments for policy making
• Knowledge of morbidity and mortality of travellers
• Understanding of epidemiology and geography of
communicable diseases
• Awareness of non-communicable risks
• Vaccines, indications, side-effects
• Knowledge of post-travel illness presentation and
management
• Geography , esp of major tourist destinations
• Ability to communicate complex issues in simple ways
• Understanding of when to refer
Knowledge of Travel- Related Risks
• Food and Water
• Insects
• Animals and Birds
• Environmental hazards
▫ Soil
▫ Sun
▫ Heat/humidity
▫ Cold/ dry
• Altitude
• Marine hazards
• Respiratory Hazards
• Sex and body-fluid exposure
• Vehicular and other Accidents
• DVT risk
Risk to be considered and discussed
Factors AffectingIndividual Risk
Individual
r
isk
TRAVEL
Destination
Country of origin
Duration of stay
Itinerary
Travel conditions
Season
TRAVELER
Reason for travel
Behavior
Age and gender
Health education
Medical history
- Allergies
- Immunosuppressed
- Pre-existing disease
Immunization status
Special needs
- Pregnant women
- Children
- Elderly
World
Map
Tropical areas
•Cruise ships
•Diving
•Extended stay
•Extreme travel
•Mass gatherings
•Wilderness
Special itineraries
The Traveller’s Triad
Trip
TravellerTime
•Person: medical conditions past and present,
allergies, medications, vaccine history,
previous travel
•Trip: reason, style and comfort level, rural vs
urban, accommodation, activities, exposures,
budget
•Time: duration, season, frequency
“This Person, This Trip, This Time”
• Identifying risks for individuals or groups
• Advising about risk reduction strategies
• Recommending and providing risk reduction
interventions
• Encouraging behavioral change to change risk
level
Risk Management
•Information enabling behaviour modification
•Vaccinations
•Medications (including antimalarials)
•Other- travel insurance, pre existing medical
problems, nets, syringes, medical kits
Risk Reduction Interventions
•Understand basic current epidemiology
•Be aware of outbreaks and emergent issues
•Provide written material targeting specific
risks
•Be able to communicate using electronic
media
Provide Up-to date Information
•Cornerstone of clinical decision process▫ Opportunity to define the risk profile
▫ Requires appropriate time, and done in advance of
travel.
▫ May need multiple visits, allow a plan
▫ Good documentation essential
▫ Discussion of costs and priorities
▫ Consider family requirements
Travel Consultation
• Tailored advice to the traveller, itinerary and time
• Travellers vary by age, sex, pregnancy, medical history, immune
status, current health, medications, vaccination history,
allergies and prior travel experience
• Itineraries vary by length of stay, activities, environmental
exposures, types of accommodation, season and budget
• Time variation is obviously important
• Advice should be understandable, re-enforced and in various
media
• Personal advice is more likely to be understood,
remembered or facilitate behavioral change.
Individualized Advice
•Advice and recommendations should be
within the travellers budget
•Costs should be made clear and should be
presented in some priority order
•Alternate strategies may need to be
discussed
Consider Costs
• These are designed to assist travelers in meeting
medical needs when their access to quality medical
care is compromised.
• All travel medicine consultants recommend that
travelers carry some form of medical first aid kit. A
range is available, and often needs to be tailored to
meet the specific requirements of the traveler and their
proposed itinerary.
• Many travel clinics sell medical first aid kits; these
often contain prescription items.
Medical travel kits
• Essential items for all travelers
• Items to treat cuts, scratches, burns, strains, splinters
• Paracetamol
• Repellent
• Consider condoms
• Additional items for Europe, USA, Japan
• Antinauseants, eg prochlorperazine
• Broad-spectrum antibiotic for respiratory infection
• Antacids
• Minor sedative
• Laxative
Medical travel kits
Medical travel kits
• Additional items for less developed countries (gastro
kit)
▫ Rehydration solution
▫ Loperamide
▫ Tinidazole
▫ Norfloxacin – or azithromycin for children
• Comprehensive medical kit ; Asia, Africa and South
America
▫ All of the above
▫ Sterile needles and syringes. Alcohol swabs
▫ Antihistamines
▫ Antifungal and antibiotic cream
•No antimalarial gives 100% prevention
•P vivax and P ovale may be present months
after return
•No global consensus
•Fever in returned travellers is malaria until
proved otherwise
Principles of malaria prophylaxis
3 prong approach
•Behavioural modification
▫Awareness of malarial risk
▫Minimising exposure to mosquitoes
•Emphasis on extreme significance of early
diagnosis & treatment
•Antimalarial chemoprophylaxis
Malarial Prophylaxis
• Avoid outdoor exposure, dawn to dusk
• Wear long sleeved loose clothing after dusk,
light colors
• Avoid perfumes and colognes
• Use repellent with 20-40% DEET
• Use knockdown sprays, coils, vapours, etc
indoors
• Sleep under nets impregnated with permethrin
Personal Protection from Mosquitoes
• Category A – considered low risk
▫ Western Europe/North America/Japan/UK/NZ/Singapore
• Should be fully vaccinated & up to date with
▫ Diphtheria/tetanus/whooping cough
▫ Routine paediatric vaccines
▫ MMR
▫ Polio
▫ Chicken pox
▫ Influenza
Vaccinations
•Category B Travel – considered to be low to
intermediate risk
▫Eastern Europe/Israel/Korea/Malaysia/Pacific
Is/South Africa
•Vaccinations should be as for Category A,
plus:
▫Hepatitis A & B
▫Typhoid
▫QFT
Vaccinations
• Category C Travel – considered to be of higher risk
▫ African sub-continent/ Central & South America/ East
Asia/ SE Asia
• Vaccinations should be as for Category B, plus:
▫ Polio booster
▫ Japanese B Encephalitis
▫ Rabies
▫ Meningitis
▫ Yellow Fever
• Malaria Prevention
Vaccinations
•Routine (background) vaccineChildhood, standard
•Required (compulsory) vaccineCross borders, entry requirements IHR
•Recommended (elective based on
risk)Travel vaccines
Some vaccines can be in more than category. Not all the same
or available in all countries
Vaccine Classification- 3Rs
In May 2005, The 58th World Health Assembly adopted the revised International Health
Regulations, “IHR”
•To prevent, protect against, control and
provide a public health response to the
international spread of disease in ways that
are commensurate with and restricted to
public health risks, and which avoid
unnecessary interference with international
traffic.
International Health Regulations IHR (2005)
•The International Health Regulations are a
formal code of conduct for public health
emergencies of international concern.
•They're a matter of responsible citizenship
and collective protection.
•They involve all 193 World Health
Organization member countries.
International Health Regulations IHR (2005)
• They are an international agreement that gives rise to
international obligations. They focus on serious
public health threats with potential to spread beyond
a country's border to other parts of the world.
• Such events are defined as public health emergencies
of international concern, or PHEIC. The revised
International Health Regulations outline the
assessment, the management and the information
sharing for PHEICs.
International Health Regulations IHR (2005)
• IHRs serve a common interest.
• First of all, they address serious and unusual disease
events that are inevitable in our world today.
• They serve a common interest by recognizing that a
health threat in one part of the world can threaten
health anywhere, or everywhere.
• And they are a formal code of conduct that helps
contain or prevent serious risks to public health,
while discouraging unnecessary or excessive traffic
or trade restrictions for, quote, "public health,"
purposes.
IHR focuses to address two main Questions:
1. Is the number of cases and/or number of
deaths for this type of event large for
the given place, time or population?
2. Has the event the potential to have a
high public health impact?
Thank you!!