Faculty of Medicine

Public Health (31505291) الصحة العامة Lecture 25

Migration and Travelers' health

By

Hatim Jaber MD MPH JBCM PhD

13 - 8-2018

1

1. The global health impact of mental health and mental diseases. Drug abuse and Addictive substances

2. Global overview of communicable diseases 3. Global overview Non- Communicable Diseases(NCDs) 4. The global health impact of Hepatitis, Tuberculosis and HIV/AIDS 5. The global health impact of Cardiovascular Diseases , Diabetes and

Obesity 6. Health policy and management, Health priorities 7. Health policies and management within a global health perspective 8. Healthcare service delivery in developed and developing countries 9. Healthcare systems and financing 10. Quality of care and effectiveness in different health services systems 11. Violence and Injuries

12. Migration and Travelers' health 13. Traditional Medicine

Presentation outline

Time

Migration and Health 09:15 to 09:25

Global Compact in Migrants and Refugees 09:25 to 09:35

Travelers Medicine 09: 35 to 09:40

Travelers’ Health Risks 09:40 to 09:50

Infectious Disease Risks to the Traveler 09:50 to 10:15

3

Globalization of health and safety

• Affects – Health of local populations

– Health determinants

– Safety and security

• Results in – Global impacts

– Emerging and re-emerging infectious disease

Commerce and Health

Pathogens travel as fast as transportation: borders are not respected

Tsunami

SARS Influenza

Terrorism

The six “Ds” driving migration:

1. DEMOGRAPHY: pop. replacement rates in industrialized world; & birth rates in

developing countries;

2. DEMAND: labour shortage in industrialized world; labour surplus in developing

countries;

3. DISTANCE shrinking due to technology and travel;

4. DIGITAL REVOLUTION: real-time info on mobility/migrant networks;

5. DISPARITY: Between North–South (economic and social);

6. DISASTERS: Natural, man-made, climate-changes,slow-onset =>

displacement;.6

2014:

S-S 37%:

S-N 35%;

N-N 23%;

N-S 5%

Global Migration Trends 1 billion

Migrants

International Organization for Migration

(IOM) Migration Health Division

H2 Health Promotion & Assistance for

Migrants

H3 Migration Health

Assistance for Crisis Affected Populations

H1

Migration Health

Assessment & Travel

Health Assistance

8

Migration Health

“Addresses the physical, mental and social needs of migrants, and the public health needs of hosting communities, as well as communities of origin, through policies and practices corresponding to the emerging challenges facing mobile populations today”

(IOM, MC/INF/275, 8 Nov. 2004 IOM COUNCIL DOCUMENT – IOM Governing Body www.iom.int)

Operationalizing WHA 61.17 Operational framework to guide Member States and stakeholders in implementing

the strategies of the Resolution WHA 61.17 set at 1st Global Consultation on health of migrants, March 2010

✓ Identify key indicators

✓ Ensure standardization and

comparability of data on migrant

health

✓ Develop and implement policies that

promote equal access to health services

for all migrants

✓ Extend social protection in health and improve social security for all migrants and family members

✓ Ensure health services are culturally,

linguistically and epidemiologically

appropriate

• Address migrant health in global and

regional processes

Monitoring Migrant Health Policy & Legal Frameworks

Migrant sensitive Health Systems

Partnerships, Networks, multi-

country frameworks

Challenges in implementation of

the WHA 61.17

1. Migrants too often remain invisible, marginalized and excluded from HEALTH SYSTEMS/PLANS

2. Migration health absent/poorly described within global health initiatives (eg. UHC,NCD, etc.) and migration & development (GFMD, etc.)

3. migrants still seen as burden on health system and carriers of disease

4. No unit/focal point on migration health at MOH etc

© kwickramage@iom.int

• The impact on the health of low skilled migrant workers and their families have been largely neglected.

• Such research evidence is needed

for policy formulation and developing interventions to ensure a safe, dignified and healthy labour migration experience for millions of migrant workers and their families globally

• Academia have a critical role in

this endevour

• Increasing political and global attention on migrants as a result of the European Migrant crisis and Syrian conflict with its mixed migration flows.

• Some political science commentators said “it took a crisis at the doorstep of Europe for world leaders to galvanize action Global Compact around migrants and refugees”

three-year-old Syrian boy of Kurdish ethnic background

whose image made global headlines after he drowned on 2

September 2015 in the Mediterranean Sea

Global Compact in Migrants and Refugees Member States have committed themselves to

negotiate 2017-2018 “Clearer leadership structures are needed within the UN to forge a system that can;

i) anticipate and react quickly to movements in a crisis;

ii) deliver political messages with a consistent voice;

Iii) assist member states to deliver the migration-related Sustainable Development Goals, and monitor their success in doing so;

iv) formulate common standards for the handling of migration, and develop these into “soft” international law; and

v) where member states are ready, negotiate binding treaties on specific migration issues. It further contends that functioning international cooperation on migration depends on restoring an atmosphere of trust, which at present is alarmingly absent in many aspects of international relations”

Special Representative of the UN Secretary-General for International Migration, Mr. Peter

Sutherland

2016

Timeline of events leading up to 2nd GC: global health diplomacy

1. Adopt a participatory, inter-sectoral and multidisciplinary approach

2. Adopt an inclusive approach covering all migrant flows

3. Adopt an evidence-based approach and develop a national research agenda

4. Adopt a pragmatic and responsive approach

5. Embed a regular reporting and accountability framework

6. Ensure advocacy and engagement at regional and international level

What to do

USA / Canada

35.2 million

Europe

25.0 million Japan

11.4 mio

AUS / NZ

3.3 million

Travellers from industrialised areas to developing areas 1999 (WTO)

2.8

2.3 19 7.8

1.9

3.6

6.8

2.5 1.3

1.6

2.4

4.6 6.1

4.8

2.6

Total:

n million travelers 0.2-1 million travelers

~ 80 million travelers

1.2

What is travel medicine?

• It is that part of health professional practice that: – seeks to prevent illnesses and injuries occurring to travellers

going abroad

– manages problems arising in travellers coming back or coming from abroad

– is concerned about the impact of tourism on health and also advocates for improved health and safety services for tourists

– is increasing concerned about refugee and migrant health (Primer of Travel Medicine 3rd Ed)

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

(Steffen, 1994)

What is travel medicine

Travel medicine is a new multidisciplinary specialty emerging in response to the needs of the travelling population worldwide.

What is travel medicine?

• Travel and aviation medicine have many linkages, especially in terms of fitness to fly and dealing with problems that may arise in travelers due to physiological and psychological stresses of travel.

Increasingly, the discipline of refugee and migrant medicine is also being included in the

specialty area of travel medicine.

Travellers are exposed to a variety of hazards

The Importance of Travel Health Measures

• 100,000 travelers to the developing world for 1 month…..

–50,000 will become ill

–8,000 will see a physician

–5,000 will stay in bed

–1 will die

Steffen, 1994

The Importance of Travel Health Measures…….

• Per 100,000 travellers that have travel insurance …..

–8000 will make a claim (8%)

–2000 will use emergency assistance (2%)

• 400 ER or clinic referrals (0.4%)

• 200 Hospital admissions (0.2%)

• 50 Aeromedical evacuations (0.05%)

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

The Importance of Travel Health Measures........

• Mortality –Cardiovascular Disease (50 to 70%)

–Accidents/Trauma (20-25%),

– Infectious diseases (2.8-4%)

(Reid and Cossar, BMBull. 1993;257-268; Prociv, MJA. 1995;163:27-30; Baker et al., PHR 1992;107:155-

159; MacPherson et al, JTM. 2000; 2000:227-233; Steffen, Trans RSTM&H 1991;85: 156-162 )

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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

Travel medicine is a continuum

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

• The commitment to travel health can therefore be regarded as a continuum

The Continuum of Travel Medicine

During Travel

Preventive Medicine

Contingency Planning

Treatment & Rehabilitation

Visitors Pre-Travel

Post-Travel

Travelers’ Health Risks

• It is conservatively estimated that 30%–50% of travelers become ill or are injured while travelling.

• The main health complaints of returned Australian travelers reported in a recent survey of travel insurance claims were:

- respiratory (20%), - musculoskeletal (17%), - gastrointestinal (14%), - ear, nose and throat (12%), - and dental conditions (7%)

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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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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

Communicable Diseases of Public Health

Significance

Vaccine-Preventable Diseases

• Mumps

• Measles

• Rubella

• Polio

• Tetanus

• Diphtheria

• Pertussis

• Haemophilus influenzae Type B

• Rotavirus

• Hepatitis A

• Hepatitis B

• Meningocococcal disease

• Varicella

• Pneumococcal pneumonia

• Influenza

Source: Centers for Disease Control and Prevention www.cdc.gov/sars/quarantine/exec-2004-04-03.html, (accessed in July 2013)

Quarantinable Diseases Designated

by Presidential Executive Order

Cholera

Diphtheria

Infectious tuberculosis

Plague

Smallpox

Yellow Fever

Viral Hemorrhagic Fevers

Severe Acute Respiratory Syndrome (SARS)

Pandemic Influenza viruses

Source: Centers for Disease Control and Prevention www.cdc.gov/sars/quarantine/exec-2004-04-03.html, (accessed in July 2013)

Events that are reportable as a public health

emergency of international concern (PHEIC) to

WHO

Examples include: Smallpox, Severe Acute Respiratory Syndrome (SARS), Pandemic Influenza and Other public health emergencies of international concern

A PHEIC is defined as an extraordinary event which is determined: (i) to constitute a public health risk to other States

through the international spread of disease and (ii) to potentially require a coordinated international

response.1

1Source: World Health Organization, www.who.int/ihr/procedures/pheic/en/ (accessed July 2014)

Giving the correct advice to travellers

• Giving the correct health advice to travellers needs:

– Information

–Training

– Experience

–Documentation

–Travellers

Giving the correct advice to travellers

• Giving the correct health advice to travellers needs:

– Information

– Training

– Experience

–Documentation

– Travellers

Take home points • More people are traveling to more destinations,

becoming exposed to the health and safety of that destination and also having the potential to impact on the health and safety of that destination, especially through emerging infectious disease

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

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

Challenge of travel medicine

• Sea of global migration of people

– More people travelling

• People travelling further a field

• Rapid movement of travellers