Introduction to Travel Med 2012.1.24

Community  Medicine  Beyond  Geography:  Introduc7on  to  Travel  Medicine  

Borwornsom Leerapan, MD PhD SM Department of Community Medicine

January 24, 2013 Pix source: www.neohealth.com.hk/en/vp-travel-medicine.html 

1.  ระบปุจจัยกำหนดสุขภาพซึ่งสงผลตอสุขภาพของนักการเดินทางขามชาติได 2.  ระบกุารปองกันโรคในแตละระดับสำหรับผูที่มีปจจัยเสี่ยงจากการเดินทางได 3.  วิเคราะหคุณลักษณะของระบบบริการสุขภาพสำหรับกลุมนักเดินทางขามชาติได 4.  เขาใจบทบาทหนาที่ของแพทยในการตรวจสุขภาพและการประเมินปจจัยเสี่ยง  5.  ประยุกตใชแหลงขอมูลทางระบาดวิทยา เพื่อใหคำแนะนำดานการสรางเสริม 

สุขภาพและปองกันโรคแกกลุมประชากรที่มีการเดินทางขามชาติได 

Objectives 

Pix source: online.wsj.com 

•  Review the concept of health and health determinants 

•  Review the concept of disease prevention 

•  Introduction to preventive medicine and travel medicine 

•  Practices in travel medicine clinic 

•  Epidemiological data for travelers (e.g. WHO, CDC) 

•  Case studies 

Outline 

Pix source: online.wsj.com 

Health & Health Determinants 

Health  System 

Functions of Health Services Systems 

1.  การสรางเสริมสุขภาพ (Health promotion) 2.  การปองกันโรค (Disease prevention) 3.  การรักษาโรค (Treatment) 4.  การฟนฟูสภาพ (Rehabilitation)  

Levels of Disease Prevention 

1.  Primary prevention 2.  Secondary prevention 3.  Tertiary prevention 4.  Quaternary prevention 

Levels of Disease Prevention 

Pix source: www.ph3c.org 

•  Chronological view 

Without disease But at risk 

Early/ asymptomatic disease 

Established/ full-blown disease 

No disease, but still suffering 

Levels of Disease Prevention 

Pix source: www.ph3c.org 

•  Relational view  Without disease  With disease 

Feeling good 

Feeling bad 

Ø “Up and down the ladder of abstraction” 

Pix source: influxentrepreneur.com/wendyelwell 

Learning Community Medicine 

นามธรรม (the abstract):  •  แนวคิด (concepts) 

•  ทฤษฎี (theories) •  หลักการ (principles) 

•  กลยุทธ (strategies) 

รูปธรรม (the concrete):  •  การเก็บขอมูลและวิเคราะหขอมูล (data) •  กรณีศึกษา (case studies) 

•  การทำงานภาคสนาม (fieldwork) 

•  การนำเสนองาน (presentations) 

Jules Verne (1873) Around the World in Eighty Days 

Pix source: en.wikipedia.org 

Travel Medicine: For Whom? 

Pix source: google.org 

•  The number of travelers crossing international borders has grown from 457 million in 1990 to 763 million in 2004.  

•  More people than ever before are traveling to exotic and

remote destinations. 

•  The time to circumnavigate the earth has decreased over the

last one and a half centuries, from about 1 year to roughly 36h to go from one spot on the globe to any other. 

Travel Medicine: For Whom? 

Source: Keystone et al. (2008) 

Travel Medicine: What? 

Pix source: google.org 

Travel Medicine: What? 

Pix source: google.org 

Travel Medicine: What? 

Travel Medicine: What? 

•  The threat of other health problems, such as injury (e.g. due to motor vehicle accidents) or the exacerbation of underlying illness (e.g. cardiac disease), are far more important than

infectious diseases in terms of traveler mortality. 

•  The practice of travel medicine is closely related to current

global health issues. 

Source: Keystone et al. (2008) 

Travel Medicine: Why Now? 

Pix source: google.org 

Travel Medicine: Why Now?  

•  Diseases such as the plague, yellow fever, smallpox, malaria, cholera, and influenza spread around the world through travel over centuries of exploration and migration. 

•  New, emerging, and re-emerging illnesses such as drug-resistant tuberculosis and malaria, leptospirosis, tick-borne encephalitis 

•  New respiratory illnesses such as Severe Acute Respiratory Syndrome (SARS) or avian influenza (H5N1). 

Source: Keystone et al. (2008) 

Health & Health Determinants 

Health  System 

“Travel Medicine Triad” 

Figure source: Jong EC (2008) 

Practice of Travel Medicine 

•  Pre-travel counseling:  •  Pre-travel visits 

•  Diseases in the travelers:  •  Travelers’ consultations •  Post-travel visits  

Pix source: skypark-glasgow.com 

Practice of Travel Medicine 

•  The maintenance of health of international travelers through health promotion and disease prevention 

–  In pre-travel counseling, providers evaluate infectious disease risks and their magnitude, patterns of drug resistance, current outbreaks of illness, civil and military conflicts, and political barriers to travel at border crossings. 

– Some providers also do the assessment and the management of the ill-returned travelers.  

 Source: Keystone et al. (2008) 

Travel Immunization: 3Rs 

•  Required/Mandatory vaccines:  

– Yellow fever, Meningococcal vaccine (for Hajj pilgrims) 

•  Routine vaccine:  

– EPI vaccines (supported by the government) 

•  Recommended vaccines:  

– Hepatitis A&B, Rabies vaccine, JE vaccine, Typhoid vaccine, Meningococcal vaccine, Cholera vaccine, etc. 

Age  Vaccine 

At Birth  BCG, HBV1 

2 Month  OPV1, DTP-HB1  

4 Month  OPV2, DTP-HB2  

6 Month  OPV3, DTP-HB3  

9 Month  Measles or MMR1* 

18 Month  OPV4, DTP4, JE1, JE2# 

21/2 Year  JE3 

4 Year  OPV5, DTP5 

7 Year (School gr.1)  MMR2 

12 Year (School gr.6)  dT 

Pregnant woman  dT3 (depend on immunization history) 

Expanded Program on Immunization (EPI) in Thailand 

*Started in 2010; # = 1 month apart from JE1 Source: thaigcd.ddc.moph.go.th 

Practice of Travel Medicine 

•  More recently, travel medicine has been broadened to include migration medicine and immigrant health, and has touched on the impact of travel on receiving countries (e.g. communicable

diseases, medical tourism).  

•  Travel medicine is also related to global health issues, such as health care in resource-poor areas, and responding to humanitarian emergencies.  

Source: Keystone et al. (2008) 

Current Global Health Issues 

Ø The practice of travel medicine  is closely related to the priority agenda of the 21st global health

issues:  

Source: Feachem (2010); Pix source: womensrefugeecommission.org 

•  Food, nutrition, and chronic diseases (“eat less and more”) •  Pandemics of infectious diseases, esp. AIDS, TB, Malaria, and

Influenza (“sex and children”) •  Undesirable health systems (“the world’s biggest muddle”) 

•  Inequity in health (“mind the gap”)   

Practice of Travel Medicine 

Pix taken by the speaker, courtesy to Ann M. Settgast, MD 

Practice of Travel Medicine 

Pix taken by the speaker, courtesy to Ann M. Settgast, MD 

Practice of Travel Medicine 

•  Taking patient’s history:  The Two Most Important Questions 1.  “Where were you born?” 2.  “Where have you been?” 

Pix source: skypark-glasgow.com 

Who Is Practicing Travel Medicine? 

•  A multidisciplinary field encompassing a wide variety of specialties and subspecialties, including infectious and tropical diseases, public health

and preventive medicine, primary care, geographic, occupational, military, and wilderness medicine.  

•  In a number of countries, travel medicine is practiced by nurses,

pharmacists, and physicians alike. 

Source: Keystone et al. (2008) 

Resources:  Authoritative Travel Medicine Recommendations 

• US CDC Home Travel Info  

• CDC Yellow Book 

• WHO Green Book 

• Health Canada – Travel Health 

• UK National Travel Health  

Network and Centre 

www.cdc.gov/travel 

www.cdc.gov/travel/contentYellowBook.aspx 

www.who.int/ith 

www.phac-aspc.gc.ca/tmp-pmv/index.html 

www.nathnac.org 

CDC Yellow Book 

Source: CDC (2012) 

CDC Yellow Book 

Source: CDC (2012) 

CDC Yellow Book 

Source: CDC (2012) 

CIA.gov 

ISTM.org 

ISTM.org: Global Travel Clinic Directory 

ThaiTravelMed.org 

Staying Healthy While Traveling 

“Don’t get bit, don’t get hit, don’t get lit,  don’t do it, and don’t eat shit” 

Pix source: neohealth.com.hk/en/vp-travel-medicine.html 

Introduction to Travel Medicine:  Case Studies 

•  A 32-year old, female, American-born Thai, from Los Angeles, California, USA.  

•  She has never travelled outside USA before, and would like to visit friends and relatives in Thailand for about a month. 

•  She also plans to do backpacking in other Southeast Asia countries for about another month. 

•  After having been in Thailand for 5 days, she comes to visit your family medicine clinic, where her relatives are already your patients.  

        Case I 

Pix source: toolkit.smallbiz.nsw.gov.au 

  “Doc, which vaccines do you recommend?” 

Pix  source:  webboard.news.sanook.com  

“Great Indochina Loop” 

Pix source: www.taotaotasi.com 

•  What if she would like to extend her trip to India for another month? 

•  Which vaccine will you recommended for her? –  Rabies vaccine? 

–  Hepatitis A vaccine? 

–  Hepatitis B vaccine? 

–  Typhoid vaccine? 

–  JE vaccine? 

–  Cholera vaccine? 

–  Meningococcal vaccine? 

–  Tetanus, MMR? 

–  BCG? 

Pix source: theglimpseofindia.com 

•  The same patient (a 30-yr old, female, American-born Thai, from California, USA) came back to visit you at your family medicine clinic after her one-month trip in India.  

•  She also brings all nine of her friends who went to the same trip to your family medicine clinic too.  

•  They request a health-screening program for any exotic diseases. 

•  All of them are healthy and have no symptoms. However some of them had diarrhea while traveingl in India, but their symptoms ware already gone. 

 “Doc, which investigations do you recommend?”  

Pix source: webboard.news.sanook.com 

•  Physical examination: 

– all negative 

•  Lab test: 

– CBC: Hct 41% WBC 9000 N 50 L30 Eo15 Platelet 300,000 

•  Stool exam: 

– Parasites not found 

Investigations 

What should you do next? 

Eosinophilia in returned travelers 

•  Physical examination: 

– all negative 

•  Lab test: 

– CBC: Hct 41% WBC 9000 N 50 L30 Eo15 Platelet 300,000 

•  Stool exam: 

– Blastocyst hominis found 

Investigations (Con’t) 

Pix source: dpd.cdc.gov 

What should you do next?   

Blastocystis Hominis  in returned travelers 

•  Antibiotic metronidazole (Flagyl) •  Antiprotozoal medication iodoquinol (Yodoxin, others) •  Combination medication sulfamethoxazole & trimethoprim (Bactrim, Septra, others) 

•  You are a consultant in tropical/travel medicine in your hospital.  

•  One morning, an physician intern makes a phone call to you.  He wants to ask for your opinions about a returned traveler

case that is scheduled to be visiting his family medicine clinic next week. 

             Case II 

Pix source: toolkit.smallbiz.nsw.gov.au 

•  “A 21-year old, male, football player of a Thai professional football club consulted me at the OPD.” 

•  “He and his spouse have just returned from their two-week trip in their home country, Cameroon. This is their 2nd day

after arrival at BKK. They are so worried about Schistosomiasis since they swam in few lakes in Cameroon during their trip.” 

•  “They said don’t recall any rashes or itches after swimming”. 

•  “In fact, in their pre-travel visit, I have already warned them not to swim in fresh water in Africa. Unfortunately they seem to forget my advise.” 

•  “But last night, they saw a news about an outbreak of Schistosomiasis in Africa. They seems to realize my words and getting panic.” 

 “Doc, which investigations do you recommend?” 

Pix source: nongbeempea.blogspot.com/p/blog-page_9600.html 

What history should you take? 

Schistosomiasis in returned travelers 

“Where exactly is Cameroon?”  

Pix source: worldatlas.com 

“Where exactly is Schistosomiasis?” 

Pix source: esciencenews.com: kenyafootball.com; who.int/schistosomiasis/epidemiology; en.wikipedia.org 

•  Schistosoma mansoni •  Schistosoma japonicum 

•  Schistosoma mekongi 

“Where exactly is Schistosomiasis?” 

Pix source: www.taotaotasi.com 

Schistosomiasis Outbreak!! “Construction of dams became popular in Africa for intended economic benefits. By blocking saltwater from flowing into freshwater, governments expected to open thousands of acres of land for development and agricultural prosperity.   In fact, the construction of dams has subsequently been linked to the outbreak of schistosomiasis, damming rivers having changed the habitat favorably for an explosion in the number of schistosome-hosting snails…”         

Source: www.projet-crevette.org/index.php?option=com_content&view=article&id=25&Itemid=149&lang=en 

•  Now, the physician intern says: 

– “Now they have no symptoms except intense worry.” 

– “Their physical exams are completely normal.” 

– “What should I do next?” 

Which investigation will you suggest? (and when?) 

Asymptomatic Schistosomiasis  in returned travelers 

•  It is recommended to wait 2-3 months if there is no symptom then: 

– Request for stool, urine exam for schisto ova. 

– Request for CBC, serology test. 

•  If the test became positive à Treatment should given. 

•  Praziquentel should be given 3 months after exposure in order to get maximum effects. 

Recommendations 

•  In any medical practices, your patients may need: 

– Pre-travel visit (Patients with international traveling) 

– During-the-traveling visit (Foreigner patients) 

– Post-travel visit (Returned travelers) 

•  Prevention, Prevention, Prevention!! 

Lessons Learned 

Pix source: online.wsj.com 

Pix source: : wnww.justfocus.org.nz 

“Think Globally, Act Locally”