What’s new…What’s new… What’s easily forgotten… What’s easily forgotten…

in Travel Medicinein Travel Medicine

Elaine Rosenblatt MSN, FNP-BC, CTHElaine Rosenblatt MSN, FNP-BC, CTHClinical Professor School of NursingClinical Professor School of Nursing

University of Wisconsin, MadisonUniversity of Wisconsin, MadisonApril 23, 2008April 23, 2008

ObjectivesObjectives Understand the importance of Understand the importance of

required, recommended and routine required, recommended and routine immunizationsimmunizations

Discuss recent outbreaks of diseases Discuss recent outbreaks of diseases that affect travelersthat affect travelers

Review ‘often missed’ teaching Review ‘often missed’ teaching opportunitiesopportunities

No financial disclosuresNo financial disclosures

QUIZ QUIZ

What is the most frequent vaccine-What is the most frequent vaccine-preventable disease among preventable disease among travelers going to countries of travelers going to countries of lower hygiene standards?lower hygiene standards?

What is the most common clinical What is the most common clinical illness in travelers to tropical and illness in travelers to tropical and semi-tropical regions?semi-tropical regions?

QUIZQUIZ

What is the most common cause of What is the most common cause of morbidity and mortality in travelers morbidity and mortality in travelers 50 years and older?50 years and older?

What is the most common cause of What is the most common cause of morbidity and mortality in travelers morbidity and mortality in travelers under 50 years of age?under 50 years of age?

Post Exposure Hepatitis APost Exposure Hepatitis A

New guidelines in 2007: if exposed and no New guidelines in 2007: if exposed and no previous vaccination with hepatitis Aprevious vaccination with hepatitis A• For healthy persons aged 12 months to 40 years, For healthy persons aged 12 months to 40 years,

single-antigen hepatitis A vaccine at the age-single-antigen hepatitis A vaccine at the age-appropriate doseappropriate dose

• For persons aged >40 years, IG is preferred; For persons aged >40 years, IG is preferred; vaccine can be used if IG cannot be obtainedvaccine can be used if IG cannot be obtained

• For children aged <12 months, For children aged <12 months, immunocompromised persons, persons who immunocompromised persons, persons who have had chronic liver disease diagnosed, and have had chronic liver disease diagnosed, and persons for whom vaccine is contraindicated, IG persons for whom vaccine is contraindicated, IG should be usedshould be used

Twinrix: Hepatitis A&BTwinrix: Hepatitis A&B

Recommended for at risk who are Recommended for at risk who are age 18 or olderage 18 or older

0, 1, 6 months0, 1, 6 months Accelerated schedule 0, 7, 21 days Accelerated schedule 0, 7, 21 days

with a booster at 1 yearwith a booster at 1 year Became available in 2001Became available in 2001

Twinrix to cover Hepatitis A and BTwinrix to cover Hepatitis A and BIn which case is it appropriate?In which case is it appropriate?

Case A: 40 year old man leaving for Case A: 40 year old man leaving for China and other parts of southeast China and other parts of southeast asia in 2 weeks. Will be gone for 2-3 asia in 2 weeks. Will be gone for 2-3 weeks, but will travel multiple times weeks, but will travel multiple times over the next 1-3 years.over the next 1-3 years.

Case B: 50 year old woman leaving Case B: 50 year old woman leaving for China and other parts of for China and other parts of southeast asia in 6 weeks and will be southeast asia in 6 weeks and will be gone for 3 months.gone for 3 months.

Appropriateness of Twinrix Appropriateness of Twinrix (Hepatitis A and B)(Hepatitis A and B)

Case A: no time for Twinrix before going on trip. Case A: no time for Twinrix before going on trip. But this is okay. He needs hepatitis A before he But this is okay. He needs hepatitis A before he goes, so give hepatitis A vaccine as scheduled. goes, so give hepatitis A vaccine as scheduled.

Can start separate series of hepatitis B at that Can start separate series of hepatitis B at that visit, doing the second dose after he returns and visit, doing the second dose after he returns and the third 5-6 months later (if do at least 6 months the third 5-6 months later (if do at least 6 months later can do at same visit with second hepatitis A.) later can do at same visit with second hepatitis A.)

Hepatitis B is appropriate for this man because of Hepatitis B is appropriate for this man because of multiple trips increasing his risk, not necessarily multiple trips increasing his risk, not necessarily just the first 2-3 week trip. Once he gets the just the first 2-3 week trip. Once he gets the second dose of hepatitis B he will have 80% second dose of hepatitis B he will have 80% protection.protection.

Appropriateness of Twinrix Appropriateness of Twinrix (Hepatitis A and B)(Hepatitis A and B)

Case B: Both vaccines needed for this tripCase B: Both vaccines needed for this trip—long trip to an endemic area. Sufficient —long trip to an endemic area. Sufficient time to do Twinrix in usual schedule. time to do Twinrix in usual schedule.

Once she has second dose, she has over Once she has second dose, she has over 90% protection for hepatitis A and over 90% protection for hepatitis A and over 80% for hepatitis B. She can receive the 80% for hepatitis B. She can receive the third dose in the series when she returns. third dose in the series when she returns.

If she was leaving in 3 weeks could have If she was leaving in 3 weeks could have used the accelerated series.used the accelerated series.

Vaccine ShortagesVaccine Shortages

Yellow FeverYellow Fever: single dose vials; : single dose vials; multiple dose vials available but with multiple dose vials available but with having to use vaccine within 30 having to use vaccine within 30 minutes of reconstitution difficult to minutes of reconstitution difficult to schedule patientsschedule patients

Japanese EncephalitisJapanese Encephalitis: only : only vaccine licensed for use in the US is vaccine licensed for use in the US is no longer being produced; supplies no longer being produced; supplies will be exhausted by mid 2008will be exhausted by mid 2008

Disease Outbreaks that Affect Disease Outbreaks that Affect Travelers 2008Travelers 2008

Yellow Fever: South AmericaYellow Fever: South America Avian FluAvian Flu ChikingunyaChikingunya DengueDengue Mumps: Canada, United States 2 years agoMumps: Canada, United States 2 years ago MeaslesMeasles Hepatitis E Hepatitis E

• Outbreaks on cruise ships Jan-MarOutbreaks on cruise ships Jan-Mar• Hong Kong AprilHong Kong April

Measles Outbreaks 2007-8Measles Outbreaks 2007-8

Israel, Switzerland, Austria, JapanIsrael, Switzerland, Austria, Japan United StatesUnited States

• Wisconsin: as of 4/4/08 3 cases in Milwaukee Wisconsin: as of 4/4/08 3 cases in Milwaukee county and 1 in Waukeshacounty and 1 in Waukesha

• TexasTexas• MichiganMichigan• PennsylvaniaPennsylvania• San DiegoSan Diego• ArizonaArizona• VirginiaVirginia• GeorgiaGeorgia

Travelers’ Diarrhea Self-Travelers’ Diarrhea Self-treatment: Antibioticstreatment: Antibiotics

Antibiotic +/- loperamideAntibiotic +/- loperamide• Quinolones: single dose, max 3 daysQuinolones: single dose, max 3 days• Azithromycin: single dose of 500mg max 3 Azithromycin: single dose of 500mg max 3

daysdays Use in areas of campylobacter resistance, and for Use in areas of campylobacter resistance, and for

children and pregnant womenchildren and pregnant women New data suggesting one time dose of 1000mg is as New data suggesting one time dose of 1000mg is as

effective as the 3 day regimeneffective as the 3 day regimen

• Rifaximin (Xifaxan): new nonabsorbable gi Rifaximin (Xifaxan): new nonabsorbable gi antibiotic, twice daily for 3 daysantibiotic, twice daily for 3 days

See a healthcare provider if symptoms See a healthcare provider if symptoms persist after 3 days of treatmentpersist after 3 days of treatment

Personal Protection MeasuresPersonal Protection Measures

Wear long-sleeved shirts and long Wear long-sleeved shirts and long trouserstrousers

Apply insect repellent containing no Apply insect repellent containing no more than 30% DEET, or use 20% or more than 30% DEET, or use 20% or greater Picaridingreater Picaridin

At dusk, spray aerosolized At dusk, spray aerosolized insecticides (such as those insecticides (such as those containing pyrthrins) in living and containing pyrthrins) in living and sleeping areassleeping areas

Personal Protection MeasuresPersonal Protection Measures

Sleep in a screened or air-Sleep in a screened or air-conditioned roomconditioned room

Use bednetting of good quality with Use bednetting of good quality with small mesh that is not damaged and small mesh that is not damaged and preferably impregnated with preferably impregnated with permethrinpermethrin

Pretreat clothing with permethrinPretreat clothing with permethrin

Advice for AcclimatizationAdvice for Acclimatization

Avoid abrupt ascent to sleeping Avoid abrupt ascent to sleeping altitudes above 9850 ftaltitudes above 9850 ft

Spend 2-3 nights at 8200-9850 ft Spend 2-3 nights at 8200-9850 ft before further ascentbefore further ascent

Add an extra night of acclimatization Add an extra night of acclimatization for every 2000-3000 ft of ascentfor every 2000-3000 ft of ascent

Make day trips to higher elevation Make day trips to higher elevation with return to lower elevation for with return to lower elevation for sleepsleep

Advice for AcclimatizationAdvice for Acclimatization

Avoid alcohol and sedatives for the first 2 Avoid alcohol and sedatives for the first 2 nights at altitude. nights at altitude.

Moderate exercise. Extreme exercise at Moderate exercise. Extreme exercise at altitude may be deleterious.altitude may be deleterious.

Consider acetazolamide 125-250mg bid Consider acetazolamide 125-250mg bid starting 24 hours before ascent and starting 24 hours before ascent and continue for 48 hrs at maximum altitude. continue for 48 hrs at maximum altitude. Caution if sulfa and/or penicillin allergic. Caution if sulfa and/or penicillin allergic. Side effects may include paresthesias, Side effects may include paresthesias, polyuria, nausea, drowsiness, impotence, polyuria, nausea, drowsiness, impotence, myopia, and bitter tastemyopia, and bitter taste

STSTII’s and Travel’s and Travel• Greatest risk age 15-29, Greatest risk age 15-29,

and in SE Asiaand in SE Asia• All travellers do more All travellers do more

risk-taking behaviours risk-taking behaviours while travelling, but while travelling, but highest rates in highest rates in expatriates, backpackers, expatriates, backpackers, business travellers, business travellers, militarymilitary

• Education: safe sex Education: safe sex practices, especially use practices, especially use of condomsof condoms

• Sexual tourism is a big Sexual tourism is a big problemproblem

STSTII’s and Travel: Prevention’s and Travel: Prevention

Abstain from sexual activity, or, if Abstain from sexual activity, or, if you choose to be sexually active, you choose to be sexually active, limit number of partners with high-limit number of partners with high-risk behaviors and limit number of risk behaviors and limit number of new sexual partnersnew sexual partners

Use high quality condomsUse high quality condoms Limit consumption of alcohol, drugsLimit consumption of alcohol, drugs Get Hepatitis B vaccineGet Hepatitis B vaccine Be aware of the possibility of rapeBe aware of the possibility of rape Avoid piercingsAvoid piercings

Safety and Security: Safety and Security: RecommendationsRecommendations

Dress inconspicuouslyDress inconspicuously Leave expensive jewelry at homeLeave expensive jewelry at home Travel in pairs or groups at nightTravel in pairs or groups at night Carry wallet in the front pocket, Carry wallet in the front pocket,

purse straps across the shoulderpurse straps across the shoulder Be cognizant of travel advisoriesBe cognizant of travel advisories Know where to go for medical Know where to go for medical

assistance abroadassistance abroad

Medical TourismMedical Tourism Also called: medical travel or health Also called: medical travel or health

tourism or global healthcare.tourism or global healthcare. Term coined by travel agencies and mass Term coined by travel agencies and mass

media to describe a rapidly-growing media to describe a rapidly-growing practice of traveling abroad for medical practice of traveling abroad for medical treatments and procedurestreatments and procedures

Motivations for patients: saving money Motivations for patients: saving money and access to care in a timely mannerand access to care in a timely manner

Some of the international institutions Some of the international institutions affiliated with top US hospitalsaffiliated with top US hospitals

Medical TourismMedical Tourism Elective and cosmetic procedures as well as Elective and cosmetic procedures as well as

specialized surgeriesspecialized surgeries Businesses have developed to help patients Businesses have developed to help patients

facilitate their treatmentsfacilitate their treatments Sometimes leisure activities included in on Sometimes leisure activities included in on

trip. South Africa for example has medical trip. South Africa for example has medical safarissafaris

Popular destinations include: India, Brunei, Popular destinations include: India, Brunei, Cuba, Colombia, Hong Kong, Hungary, Cuba, Colombia, Hong Kong, Hungary, Jordan, Lithuania, Malaysia, The Philippines, Jordan, Lithuania, Malaysia, The Philippines, Singapore, South Africa, Thailand, and Singapore, South Africa, Thailand, and recently Saudi Arabia, UAE, Tunisia and recently Saudi Arabia, UAE, Tunisia and New ZealandNew Zealand

Medical Tourism: RisksMedical Tourism: Risks Should complications arise, patients might Should complications arise, patients might

not be covered by insurance or able to not be covered by insurance or able to seek compensation via malpractice seek compensation via malpractice lawsuits. But new insurance products are lawsuits. But new insurance products are being promotedbeing promoted

Some countries have different infectious Some countries have different infectious diseases which may result in exposure to diseases which may result in exposure to diseasedisease

Travel soon after surgery can increase the Travel soon after surgery can increase the risk of complications, as can vacation risk of complications, as can vacation activitiesactivities

Unfamiliar legal and ethical issuesUnfamiliar legal and ethical issues

Medical TourismMedical Tourism In US, Joint Commission International (JCI) In US, Joint Commission International (JCI)

fulfills an accreditation rolefulfills an accreditation role In the UK and Hong Kong, the Trent In the UK and Hong Kong, the Trent

International Accreditations Scheme fulfills International Accreditations Scheme fulfills an accreditation rolean accreditation role

Society for International Healthcare Society for International Healthcare Accreditation (SOFIHA) is a group Accreditation (SOFIHA) is a group providing a forum for discussion and providing a forum for discussion and sharing of ideas and practice by providers sharing of ideas and practice by providers of international healthcare accreditation to of international healthcare accreditation to promote safe hospital environment for promote safe hospital environment for patientspatients

Getting Ready for the 29Getting Ready for the 29thth Olympic Olympic Summer GamesSummer Games

Held in Beijing, China and 6 other Held in Beijing, China and 6 other cities from August 8-24, 2008cities from August 8-24, 2008

28 major and 302 minor events in 37 28 major and 302 minor events in 37 venues in Beijing, Hong Kong, venues in Beijing, Hong Kong, Shanghai, Qingdao, Qinhuangdao, Shanghai, Qingdao, Qinhuangdao, Shenyang and TianjinShenyang and Tianjin

Paralympic Games Sept 6-17 in Paralympic Games Sept 6-17 in BeijingBeijing

Getting Ready for the 29Getting Ready for the 29thth Olympic Olympic Summer GamesSummer Games

Travelers Diarrhea—strict food and Travelers Diarrhea—strict food and water hygienewater hygiene

Air Pollution capital in the worldAir Pollution capital in the world None of the game venues in malaria None of the game venues in malaria

areas, but there have been cases of areas, but there have been cases of dengue feverdengue fever

Getting Ready for the 29Getting Ready for the 29thth Olympic Olympic Summer GamesSummer Games

Vaccine preventable diseasesVaccine preventable diseases• Routine vaccines-Td/Tdap, MMRRoutine vaccines-Td/Tdap, MMR• Recommended vaccines—Hepatitis A, Recommended vaccines—Hepatitis A,

Hepatitis B (especially if involved in Hepatitis B (especially if involved in contact sports, plan on sexual actiivity), contact sports, plan on sexual actiivity), influenza, consider meningococcal influenza, consider meningococcal vaccinevaccine

Avian flu—avoid live poultryAvian flu—avoid live poultry

Getting Ready for the 29Getting Ready for the 29thth Olympic Olympic Summer Games: Issues to be aware ofSummer Games: Issues to be aware of

Safety and securitySafety and security Road safety—as a driver and a pedestrianRoad safety—as a driver and a pedestrian There will be a lot of walking between There will be a lot of walking between

venuesvenues Warm—be aware of sunburn, dehydration, Warm—be aware of sunburn, dehydration,

limit exercise to early morning or late limit exercise to early morning or late afternoonafternoon

Assess if there will be any problems with Assess if there will be any problems with customs with the medications you takecustoms with the medications you take

Getting Ready for the 29Getting Ready for the 29thth Olympic Olympic Summer Games: Issues to be aware ofSummer Games: Issues to be aware of

Avoid buying medications there—may be Avoid buying medications there—may be fake or contaminatedfake or contaminated

Avoid tattoos, acupuncture or medical Avoid tattoos, acupuncture or medical treatmentstreatments

STDs—avoid sexual activity that will put STDs—avoid sexual activity that will put you at riskyou at risk

Make sure have travel health insurance Make sure have travel health insurance and consider air evacuation plansand consider air evacuation plans

Getting the Athlete ReadyGetting the Athlete Ready

Personal health issues, including dental Personal health issues, including dental and sexual issuesand sexual issues

How to cope with acclimatization and jetlagHow to cope with acclimatization and jetlag How to cope with culture shock and How to cope with culture shock and

managing personal stresses due to altered managing personal stresses due to altered environmentenvironment

ImmunizationsImmunizations Diet issuesDiet issues Packing a medical kitPacking a medical kit Safety and security issuesSafety and security issues

Questions?Questions?

ChikingunyaChikingunya

Makonde word: “that which bends Makonde word: “that which bends up” referring to the inability of some up” referring to the inability of some patients to walk uprightpatients to walk upright

Originally in Africa and Asia but now Originally in Africa and Asia but now imported to Europe, Australia and imported to Europe, Australia and the USthe US

Transmitted by Aedes aegyptiTransmitted by Aedes aegypti Multiple small joints affectedMultiple small joints affected