Introduction toTravel Medicine

Travel and Tourism

• Large and growing industry• More than 500 millions persons

annually cross international borders on commercial airplanes (early 90s)

• Pleasure, business, study etc• Short term travelers, repeated visit,

reside or prolonged periods• Risk of morbidity and mortality

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International Travel

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1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

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US nonresidentInbound (ITA)

US Resident AirOutbound (ITA)

All US ResidentOutbound (ITA)

Worldwide arrivals(WTO)

Travel and Tourism

• Transportations• Accommodation• Food and beverages• Handicrafts, gifts• Others related industry

What might happened to travelers

InfectionsAccidentsDisasters

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Travelers’ Health Risks

Of 100,000 travelers to a developing country for 1 month:– 50,000 will develop some health problem – 8,000 will see a physician– 5,000 will be confined to bed– 1,100 will be incapacitated in their work– 300 will be admitted to hospital– 50 will be air evacuated– 1 will dieSteffen R et al. J Infect Dis 1987; 156:84-91

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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

Essential questions to assess predisposing risks and host risk

factors

• What is your destination(s) state : countries, city/resort/off-the-tourist-trail, itinerary

• What is the purpose of your visit : tourism/business or other professional visit (specify)/visit (to relatives/expatriates), other reasons (military, airline crew, adoption, etc.)

• What standard of hygiene do you expect throughout your visit : high (e.g., five-star hotels)/low (e.g., low budget travel)

• Are you planning any special activities : e.g. high altitude trekking, diving, hunting, camping, etc.

• What is your planned date of departure?• How long do you intend to stay abroad?

Essential questions to assess predisposing risks and host risk

factors

Potential travelers should also answer at least the following set of questions

on their health status and medical history :

• Do you currently use any medication? If yes, which ones?

• Are you currently unwell?• Do you feel feverish? If yes, do you know

what your temperature is?• Do you suffer from any chronic illness If

yes, which ones?• Are you allergic to eggs or medication? If

yes, describe.

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Travel Notices & Announcements

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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

Potential travelers should also answer at least the following set of questions

on their health status and medical history :

• Are you pregnant or breast-feeding? Provide details

• Have you ever had seizures? Provide details• Have you ever had psychiatric or

psychological problems? Provide details• Have you ever had jaundice or hepatitis?

Provide details• Are you or anybody in your household

infected by HIV? Do you have any other immunodeficiency illness? Provide details

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The Patient: Other Issues

• Reproductive– Pregnant– Breastfeeding– Preconception

• Risk-taking behaviors

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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

Vaccine for Adult Travelers

Routine• Updated as needed : diphtheria-

tetanus, measles-mumps-rubella• Routine for defined groups : influenza,

hepatitis B, pneumococcal, varicellaRequired by some countries• Yellow fever• Meningococcal

Vaccine for Adult Travelers

Recommended for travelers to developing countries

• Standard for travelers to developing countries : hepatitis A, typhoid, poliovirus

• Special for travelers to developing countries : cholera, hepatitis B, meningococcal, Japanese B encephalitis, plague, rabies

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Travel Medications:Prophylaxis & Self Treatment

• Malaria– chloroquine, atovaquone/proguanil (Malarone),

doxycycline, mefloquine (Lariam), primaquine

• Diarrhea– quinolone

• Altitude– acetazolamide

• Motion sickness– scopolamine, dimenhydrinate (Dramamine)

Sources and Acquisition of Infection during Travel

• Food and drinks• Soil and water• Animals and arthropods• Other human• Air travel• Infections acquired en route• Infections acquired in temperate and

industrialized area

Sources and Acquisition of Infection during Travel

Food and drinks• Traveler’s diarrhea• Hepatitis A• Typhoid fever• CholeraSoil and Water• Enteric infections• Soil associated fungus (Histoplasma

capsulatum)• Leptospirosis

Sources and Acquisition of Infection during Travel

Animals and arthropods• Rabies• Hantavirus• Dengue• MalariaOther Human• STD• Airborne infections

Sources and Acquisition of Infection during Travel

Air Travel• Venous thrombosis and pulmonary emboli• Influenza, TuberculosisInfections acquired en route• Influenza, rubellaInfections acquired in temperate and

industrialized area• Colorado Tick fever• HFRS• Murray Valley encephalitis

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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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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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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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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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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

Key concepts: Travel-related illness and Death

• Injury are an important cause of travel related death

• Most infections acquired during travel to tropical and developing countries are cause by pathogens that are widely distributed

• Risk of infection from exposure to many widely distributed pathogens )e.g. hepatitis A, typhoid fever, salmonellosis) is substantially higher during travel to developing countries than during life at home

Key concepts: Travel-related illness and Death

• Unusual infections can be found in temperate and industrialized countries, including United States

• Recreational activities ( swimming, hiking) facilitate exposure to many pathogens

• Activities that pose no risk at home may be hazardous in other environment (e.g. eating raw foods, swimming in fresh water, going barefooted, sustaining mosquito bites, petting stray animals)

Key concepts: Travel-related illness and Death

• Expensive hotels and posh restaurants are no guarantee of safe food and beverages

• Disease during and immediately after travel may be unrelated to exposures during travel (acute appendicitis, pyelonephritis)

• Infections can be acquired en route and on brief layover

• Travel-associated diseases include non infectious diseases (pulmonary emboli related to prolonged seating, drug reactions0

Have a Nice Vacation