Helping Globetrotting Students Helping Globetrotting Students Travel SafelyTravel Safely

Kelly HoltonKelly HoltonDivision of Global Migration and QuarantineDivision of Global Migration and QuarantineCenters for Disease Control and PreventionCenters for Disease Control and Prevention

Travelers’ Health EpidemiologyTravelers’ Health Epidemiology

Number of US Residents Traveling Number of US Residents Traveling Abroad, 2000-2007Abroad, 2000-2007

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

Study-Abroad StudentsStudy-Abroad StudentsAcademic Year Number of Students1994/95 84,4031995/96 89,2421996/97 99,4481997/98 113,9591998/99 129,7701999/2000 143,5902000/01 154,1682001/02 160,9202002/03 174,6292003/04 191,3212004/05 205,9832005/06 223,5342006/07 241,791

Open Doors (Institute of International Education)Source: Open Doors (Institute of International Education)

Source: Open Doors (Institute of International Education)

Leading Destinations of U.S. Leading Destinations of U.S. Study-Abroad Students, 2006/07Study-Abroad Students, 2006/07

United KingdomUnited Kingdom JapanJapanItalyItaly ArgentinaArgentinaSpainSpain GreeceGreeceFranceFrance South AfricaSouth AfricaChinaChina Czech RepublicCzech RepublicAustraliaAustralia ChileChileMexicoMexico EcuadorEcuadorGermanyGermany AustriaAustriaIrelandIreland New ZealandNew ZealandCosta RicaCosta Rica IndiaIndia

Health Risks to Student TravelersHealth Risks to Student Travelers

Travelers’ Health RisksTravelers’ Health RisksOf 100,000 travelers to a developing country for Of 100,000 travelers to a developing country for

1 month:1 month:– 50,000 will develop some health problem 50,000 will develop some health problem – 8,000 will see a physician8,000 will see a physician– 5,000 will be confined to bed5,000 will be confined to bed– 1,100 will be incapacitated in their work1,100 will be incapacitated in their work– 300 will be admitted to hospital300 will be admitted to hospital– 50 will be air evacuated50 will be air evacuated– 1 will die1 will die

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

Cardiovascular

Medical

Injury

Homicide/Suicide

Infectious Disease

Other

Deaths Related to Deaths Related to International TravelInternational Travel

N = 2463

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

Motor Vechicle

Drowning

Air Crash

Homicide/Suicide

Poisoning

Other

Injury Deaths and Injury Deaths and International TravelInternational Travel

N = 601

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

Infectious Disease Risks to Infectious Disease Risks to the Travelerthe Traveler

MalariaMalariaDiarrheaDiarrheaLeishmaniasisLeishmaniasisRabiesRabiesDengue FeverDengue FeverChikungunya FeverChikungunya FeverMeningococcal Meningococcal MeningitisMeningitisVaricellaVaricellaInfluenzaInfluenzaHepatitis AHepatitis AHepatitis BHepatitis B

SchistosomiasisSchistosomiasisTuberculosisTuberculosisLeptospirosisLeptospirosisPolioPolioYellow FeverYellow FeverMeaslesMeaslesMumpsMumpsRubellaRubellaTetanusTetanusJapanese encephalitisJapanese encephalitis

ETC.

MalariaMalaria

Mosquito-borne disease Mosquito-borne disease Parasite: Parasite: PlasmodiumPlasmodiumMay lead to severe complications or May lead to severe complications or deathdeath~500 million cases/year worldwide~500 million cases/year worldwideRisk in over 100 countriesRisk in over 100 countriesProphylactic medicationProphylactic medication– before, during, and after travelbefore, during, and after travel

Malaria Risk Areas

Yellow FeverYellow Fever

Mosquito-borne viral infectionMosquito-borne viral infection– Aedes aegyptiAedes aegypti

Varying severity:Varying severity:– influenza-like syndrome to influenza-like syndrome to

severe hepatitis and severe hepatitis and hemorrhagic fever hemorrhagic fever

200,000 YF infections cause 200,000 YF infections cause 30,000 deaths per year30,000 deaths per year

Distribution of Yellow Fever

Japanese EncephalitisJapanese EncephalitisFlavivirusFlavivirus transmitted via bite of transmitted via bite of Culex Culex mosquitomosquito50,000 cases and 15,000 deaths yearly 50,000 cases and 15,000 deaths yearly Supportive care onlySupportive care onlyUp to 50% of survivors have significant Up to 50% of survivors have significant neurologic sequelae neurologic sequelae

Distribution of Japanese Distribution of Japanese EncephalitisEncephalitis

Dengue FeverDengue Fever

Mosquito-borne flavivirus endemic in most tropical areas of the worldNo vaccine and no medication for dengueIllness usually mild; it can be severe and cause dengue hemorrhagic (bleeding) fever (DHF)

Distribution of DengueDistribution of Dengue

Chikungunya FeverChikungunya Fever

Mosquito-borne disease - primary vector is Mosquito-borne disease - primary vector is aedes aegyptiaedes aegyptiMainly occurs in areas of Africa and AsiaMainly occurs in areas of Africa and AsiaSymptoms can include sudden fever, Symptoms can include sudden fever, chills, headache, nausea, vomiting, joint chills, headache, nausea, vomiting, joint pain with or without swelling, lower back pain with or without swelling, lower back pain, and a rash. pain, and a rash. No specific drug treatmentNo specific drug treatmentPeople usually recover on their own; People usually recover on their own; fatalities are rarefatalities are rare

Hepatitis AHepatitis A

Viral infection transmitted via fecal-oral Viral infection transmitted via fecal-oral routeroute– Contaminated food and waterContaminated food and water– Person to personPerson to person

Asymptomatic, or ranges in severity Asymptomatic, or ranges in severity from a mild illness to severely disabling from a mild illness to severely disabling disease lasting monthsdisease lasting monthsTreatment is supportiveTreatment is supportive

Distribution of Hepatitis ADistribution of Hepatitis A

Hepatitis BHepatitis B

Viral infection transmitted via bloodborne routeViral infection transmitted via bloodborne route– Sexual contactSexual contact– Transfusions, surgical or dental proceduresTransfusions, surgical or dental procedures– Shared injection needlesShared injection needles

Ranges in severity from no symptoms to fulminant Ranges in severity from no symptoms to fulminant hepatitishepatitisTreatment is supportive Treatment is supportive Risk determined by behavior and prevalence of Risk determined by behavior and prevalence of chronic infections at destinationchronic infections at destination

Distribution of Hepatitis BDistribution of Hepatitis B

TyphoidTyphoid

Acute, life-threatening febrile Acute, life-threatening febrile illness caused by illness caused by Salmonella Salmonella entericaenterica serotype Typhi serotype TyphiTransmission via fecal-oral route, Transmission via fecal-oral route, usually contaminated food or usually contaminated food or waterwaterChronic asymptomatic carrierChronic asymptomatic carrierWorldwide: 22 million cases and Worldwide: 22 million cases and 200,000 related deaths each year 200,000 related deaths each year

Distribution of TyphoidDistribution of Typhoid

Source: sanofi pasteur MSD

Traveler’s DiarrheaTraveler’s Diarrhea

> 50% of travelers away from home > 50% of travelers away from home even for only 2 weeks develop TDeven for only 2 weeks develop TD~ 40% will have to alter itineraries~ 40% will have to alter itineraries~ 20% will be confined to bed~ 20% will be confined to bed

PolioPolio

Viral infection Viral infection Acute onset flaccid paralysisAcute onset flaccid paralysisTransmitted via fecal-oral Transmitted via fecal-oral route or pharyngeal spread route or pharyngeal spread High transmission areas are India, High transmission areas are India, Pakistan, Afghanistan, NigeriaPakistan, Afghanistan, Nigeria

Polio Risk AreasPolio Risk Areas

WHO/POLIO database, as of Sept. 2007

Meningococcal MeningitisMeningococcal MeningitisBacterial infection transmitted via the Bacterial infection transmitted via the respiratory routerespiratory routeOutbreaks in Africa during dry season Outbreaks in Africa during dry season (December to June) (December to June) Associated with crowded conditionsAssociated with crowded conditions

Distribution of Meningococcal Distribution of Meningococcal Disease (“Meningitis Belt”)Disease (“Meningitis Belt”)

RabiesRabies

Acute viral encephalomyelitisAcute viral encephalomyelitisInvariably fatalInvariably fatalHumans contract rabies by being bitten or Humans contract rabies by being bitten or occasionally by being scratched by an occasionally by being scratched by an infected animalinfected animal55,000 deaths per year55,000 deaths per year

Distribution of RabiesDistribution of Rabies

SchistosomiasisSchistosomiasisParasite found in some areas of tropical S. Parasite found in some areas of tropical S. America, Africa, and the Far EastAmerica, Africa, and the Far EastSecond only to malaria in terms of morbidity – Second only to malaria in terms of morbidity – over 200 million infectedover 200 million infectedTransmitted while swimming in fresh water Transmitted while swimming in fresh water lakes, streams, riverslakes, streams, riversMost will have no symptoms; if exposed, Most will have no symptoms; if exposed, requires testing on return, and then treatment requires testing on return, and then treatment if infectedif infectedMissionaries and VFRs more likelyMissionaries and VFRs more likelyto be infected*to be infected*

*Nicolls D & GeoSentinal, ISTM 2005

Geographic Distribution of Geographic Distribution of SchistosomiasisSchistosomiasis

Travel VaccinationsTravel Vaccinations

Immunizations for Adult TravelersImmunizations for Adult Travelers1.1. Routine immunizationsRoutine immunizations

2.2. Required immunizations for Required immunizations for traveltravel

3.3. Recommended Recommended immunizations for travelimmunizations for travel

Routine ImmunizationsRoutine Immunizations

DiphtheriaDiphtheriaTetanusTetanusPertussisPertussisMeaslesMeaslesMumpsMumpsRubellaRubellaVaricellaVaricellaPneumococcusPneumococcusInfluenzaInfluenzaHuman papillomavirus (HPV)Human papillomavirus (HPV)

* Td or Tdap+ MMR

Required Immunizations for TravelRequired Immunizations for Travel

Yellow FeverYellow FeverMeningococcalMeningococcal

Recommended Immunizations Recommended Immunizations for Travelfor Travel

Hepatitis AHepatitis AHepatitis BHepatitis BTyphoid Typhoid Japanese encephalitis Japanese encephalitis PolioPolioRabiesRabies

MedicationsMedications

Travel Medications:Travel Medications:Prophylaxis & Self TreatmentProphylaxis & Self Treatment

MalariaMalaria– chloroquine, atovaquone/proguanil (Malarone), chloroquine, atovaquone/proguanil (Malarone),

doxycycline, mefloquine (Lariam), primaquinedoxycycline, mefloquine (Lariam), primaquine

DiarrheaDiarrhea– quinolone (Cipro), azithromycinquinolone (Cipro), azithromycin

Altitude sicknessAltitude sickness– acetazolamideacetazolamide– dexamethasonedexamethasone

Motion sicknessMotion sickness– scopolamine, dimenhydrinate scopolamine, dimenhydrinate ((Dramamine)Dramamine)

Practice Healthy BehaviorsPractice Healthy Behaviors

Food and Water PrecautionsFood and Water PrecautionsDrinks that are bottled and sealedDrinks that are bottled and sealedSelection of foodsSelection of foods– well-cooked and hotwell-cooked and hot– fruits you can peelfruits you can peelAvoidance of Avoidance of – salads, raw vegetablessalads, raw vegetables– unpasteurized dairy productsunpasteurized dairy products– food from street vendorsfood from street vendors– IceIceHandwashingHandwashing

Insect and Mosquito PrecautionsInsect and Mosquito PrecautionsProtect yourself outsideProtect yourself outside– Cover exposed skinCover exposed skin– Use insect repellentUse insect repellent– Inspect for ticksInspect for ticks– Treat clothing with permethrinTreat clothing with permethrin– Use pyrethroid coils outdoorsUse pyrethroid coils outdoors

Protect yourself insideProtect yourself inside– Stay in air-conditioned rooms Stay in air-conditioned rooms OROR– Use window screens Use window screens – Use permethrin-impregnated bed netsUse permethrin-impregnated bed nets– Use aerosol insecticide indoorsUse aerosol insecticide indoors

Animal PrecautionsAnimal Precautions

Animal bites and scratchesAnimal bites and scratchesEnvenomationsEnvenomations– Snakes, scorpions, spidersSnakes, scorpions, spiders– Marine animalsMarine animals

Avoid all animals, even petsAvoid all animals, even petsIf you are bitten or scratched, seek If you are bitten or scratched, seek medical care right awaymedical care right away

Bloodborne and STD Bloodborne and STD PrecautionsPrecautions

Prevalence ofPrevalence of– STDs STDs – Hepatitis BHepatitis B– Hepatitis CHepatitis C– HIV HIV Unprotected sexual activityUnprotected sexual activityCommercial sex workersCommercial sex workersTattooing and body piercingTattooing and body piercingAuto accidents Auto accidents Blood productsBlood productsDental and surgical proceduresDental and surgical procedures

Environmental PrecautionsEnvironmental PrecautionsSun protectionSun protectionExtreme heat and coldExtreme heat and cold– dehydration, heat strokedehydration, heat stroke– hypothermia, frostbitehypothermia, frostbiteAltitudeAltitudeWater recreationWater recreation– Drowning, boating, & diving accidentsDrowning, boating, & diving accidents– Risk of schistosomiasis or leptospirosisRisk of schistosomiasis or leptospirosis– Biological and chemical contaminationBiological and chemical contamination

Safety PrecautionsSafety Precautions

Wear a helmetWear a helmetWear seatbelts Wear seatbelts Drink responsiblyDrink responsiblyStay alert in crowdsStay alert in crowdsFollow local laws and customsFollow local laws and customsUnderstand local crime risksUnderstand local crime risks

Travel Health KitTravel Health Kit

Copy of medical records and extra pair of glassesCopy of medical records and extra pair of glassesPrescription medicationsPrescription medicationsOver-the counter medicines and suppliesOver-the counter medicines and supplies– AnalgesicsAnalgesics– Decongestant, cold medicine, cough suppressantDecongestant, cold medicine, cough suppressant– Antibiotic/antifungal/hydrocortisone creams Antibiotic/antifungal/hydrocortisone creams – Pepto-Bismol tablets, antacidPepto-Bismol tablets, antacid– Band-Aids, gauze bandages, tape, Ace wrapsBand-Aids, gauze bandages, tape, Ace wraps– Insect repellant, sunscreen, lip balmInsect repellant, sunscreen, lip balm– Tweezers, scissors, thermometerTweezers, scissors, thermometer

Travel Health InsuranceTravel Health Insurance

Health insurance may not cover services Health insurance may not cover services abroadabroadConsider supplemental health insurance Consider supplemental health insurance and evacuation insuranceand evacuation insuranceUS Department of State consular offices US Department of State consular offices can assist in finding medical facilitiescan assist in finding medical facilities

Health MonitoringHealth Monitoring

Post-travel checkup is recommended forPost-travel checkup is recommended for– Long term travelersLong term travelers– Adventure travelersAdventure travelers– Expatriates in developing worldExpatriates in developing world

Post-travel care is recommended forPost-travel care is recommended for– Fever, chills, sweatsFever, chills, sweats– Persistent diarrheaPersistent diarrhea– Weight lossWeight loss

Sources of InformationSources of Information

Travel Health ResourcesTravel Health ResourcesCDC Travelers’ Health WebsiteCDC Travelers’ Health Website– www.cdc.gov/travelHealth Information for International TravelHealth Information for International Travel– CDC “Yellow Book”CDC “Yellow Book”World Health Organization World Health Organization – www.who.int/intInternational Travel and HealthInternational Travel and Health– WHO “Green Book”WHO “Green Book”State Department State Department – travel.state.govInternational Society of Travel MedicineInternational Society of Travel Medicine– www.istm.org

Travelers’ Health WebsiteTravelers’ Health Websitewww.cdc.gov/travelwww.cdc.gov/travel

Travel Notices & AnnouncementsTravel Notices & Announcements

Situation InfoSituation InfoAdvice for Advice for TravelersTravelersDisease InfoDisease InfoProvider InfoProvider InfoResources for Resources for more more information information and Data and Data SourcesSources

Destination PagesDestination Pages

Study Abroad InformationStudy Abroad Information

Your Survival Guide to Safe and Your Survival Guide to Safe and Healthy TravelHealthy Travel

PodcastsPodcasts

Questions?Questions?