Emporiatrics

Emporiatrics…Dr. Menaal Kaushal

JR II

Department of Community

Medicine

S. N. Medical College

Emporiatrics

Greek origin“emporos”: One who goes on shipboard as a

passenger+

“iatrike”: medicine)

It’s the term coined to: Describe the science

of the health of travellers.

• It is a science which deals with promoting and

protecting the health of international travelers,

providing them the advice related to the travel they

are about to undertake.

• It is a fast developing specialty as the international

travel is fast increasing.

• Every year 660 million people travel internationally.

Definition

•Practice of “Emporiatrics”

•Rapid development over the last 25 years

•Fairfield Hospital in Melbourne started the

first ever travel clinic in early-mid 80’s

•Now a recognized clinical entity primarily

involved in risk management

•Strong overlap with public health and

occupational health and general practice

Travel Medicine

Why a Special Branch for Travelers’ Health?

Travellers face special health risks:

▫ They are subject to disorders induced by Rapid changes

of environment such as upsets in the circadian rhythms,

motion sickness, and diarrhea;

▫ In developing countries they are exposed to Infectious

diseases that do not exist in their home countries such as

malaria, giardiasis, and dengue; and,

▫ They are Separated from familiar and accessible sources

of medical care.

▫ Never before in history have so many people travelled

and have people Travelled so far or so fast.

Types of Travellers:

• Business men and

• Tourists

▫ VFR

▫ Non VFR

They often travel by air or railways (The records of which

are available)

• Immigrants,

• Refugees, and

• Migrant laborers

Who frequently travel by other means

Documented

Undocumented

So Who’s Responsibility is Emporiatrics?

•Meeting the health needs of these travellers

who are moving rapidly between countries

and continents is a responsibility shared by:

▫the medical professionals,

▫by the travellers themselves,

▫by travel organizations,

▫by airline and shipping companies, and

▫by host governments for policy making

• Knowledge of morbidity and mortality of travellers

• Understanding of epidemiology and geography of

communicable diseases

• Awareness of non-communicable risks

• Vaccines, indications, side-effects

• Knowledge of post-travel illness presentation and

management

• Geography , esp of major tourist destinations

• Ability to communicate complex issues in simple ways

• Understanding of when to refer

Knowledge of Travel- Related Risks

• Food and Water

• Insects

• Animals and Birds

• Environmental hazards

▫ Soil

▫ Sun

▫ Heat/humidity

▫ Cold/ dry

• Altitude

• Marine hazards

• Respiratory Hazards

• Sex and body-fluid exposure

• Vehicular and other Accidents

• DVT risk

Risk to be considered and discussed

Factors AffectingIndividual Risk

Individual

r

isk

TRAVEL

Destination

Country of origin

Duration of stay

Itinerary

Travel conditions

Season

TRAVELER

Reason for travel

Behavior

Age and gender

Health education

Medical history

- Allergies

- Immunosuppressed

- Pre-existing disease

Immunization status

Special needs

- Pregnant women

- Children

- Elderly

World

Map

Tropical areas

•Cruise ships

•Diving

•Extended stay

•Extreme travel

•Mass gatherings

•Wilderness

Special itineraries

The Traveller’s Triad

Trip

TravellerTime

•Person: medical conditions past and present,

allergies, medications, vaccine history,

previous travel

•Trip: reason, style and comfort level, rural vs

urban, accommodation, activities, exposures,

budget

•Time: duration, season, frequency

“This Person, This Trip, This Time”

• Identifying risks for individuals or groups

• Advising about risk reduction strategies

• Recommending and providing risk reduction

interventions

• Encouraging behavioral change to change risk

level

Risk Management

•Information enabling behaviour modification

•Vaccinations

•Medications (including antimalarials)

•Other- travel insurance, pre existing medical

problems, nets, syringes, medical kits

Risk Reduction Interventions

•Understand basic current epidemiology

•Be aware of outbreaks and emergent issues

•Provide written material targeting specific

risks

•Be able to communicate using electronic

media

Provide Up-to date Information

•Cornerstone of clinical decision process▫ Opportunity to define the risk profile

▫ Requires appropriate time, and done in advance of

travel.

▫ May need multiple visits, allow a plan

▫ Good documentation essential

▫ Discussion of costs and priorities

▫ Consider family requirements

Travel Consultation

• Tailored advice to the traveller, itinerary and time

• Travellers vary by age, sex, pregnancy, medical history, immune

status, current health, medications, vaccination history,

allergies and prior travel experience

• Itineraries vary by length of stay, activities, environmental

exposures, types of accommodation, season and budget

• Time variation is obviously important

• Advice should be understandable, re-enforced and in various

media

• Personal advice is more likely to be understood,

remembered or facilitate behavioral change.

Individualized Advice

•Advice and recommendations should be

within the travellers budget

•Costs should be made clear and should be

presented in some priority order

•Alternate strategies may need to be

discussed

Consider Costs

• These are designed to assist travelers in meeting

medical needs when their access to quality medical

care is compromised.

• All travel medicine consultants recommend that

travelers carry some form of medical first aid kit. A

range is available, and often needs to be tailored to

meet the specific requirements of the traveler and their

proposed itinerary.

• Many travel clinics sell medical first aid kits; these

often contain prescription items.

Medical travel kits

• Essential items for all travelers

• Items to treat cuts, scratches, burns, strains, splinters

• Paracetamol

• Repellent

• Consider condoms

• Additional items for Europe, USA, Japan

• Antinauseants, eg prochlorperazine

• Broad-spectrum antibiotic for respiratory infection

• Antacids

• Minor sedative

• Laxative

Medical travel kits

Medical travel kits

• Additional items for less developed countries (gastro

kit)

▫ Rehydration solution

▫ Loperamide

▫ Tinidazole

▫ Norfloxacin – or azithromycin for children

• Comprehensive medical kit ; Asia, Africa and South

America

▫ All of the above

▫ Sterile needles and syringes. Alcohol swabs

▫ Antihistamines

▫ Antifungal and antibiotic cream

•No antimalarial gives 100% prevention

•P vivax and P ovale may be present months

after return

•No global consensus

•Fever in returned travellers is malaria until

proved otherwise

Principles of malaria prophylaxis

3 prong approach

•Behavioural modification

▫Awareness of malarial risk

▫Minimising exposure to mosquitoes

•Emphasis on extreme significance of early

diagnosis & treatment

•Antimalarial chemoprophylaxis

Malarial Prophylaxis

• Avoid outdoor exposure, dawn to dusk

• Wear long sleeved loose clothing after dusk,

light colors

• Avoid perfumes and colognes

• Use repellent with 20-40% DEET

• Use knockdown sprays, coils, vapours, etc

indoors

• Sleep under nets impregnated with permethrin

Personal Protection from Mosquitoes

• Category A – considered low risk

▫ Western Europe/North America/Japan/UK/NZ/Singapore

• Should be fully vaccinated & up to date with

▫ Diphtheria/tetanus/whooping cough

▫ Routine paediatric vaccines

▫ MMR

▫ Polio

▫ Chicken pox

▫ Influenza

Vaccinations

•Category B Travel – considered to be low to

intermediate risk

▫Eastern Europe/Israel/Korea/Malaysia/Pacific

Is/South Africa

•Vaccinations should be as for Category A,

plus:

▫Hepatitis A & B

▫Typhoid

▫QFT

Vaccinations

• Category C Travel – considered to be of higher risk

▫ African sub-continent/ Central & South America/ East

Asia/ SE Asia

• Vaccinations should be as for Category B, plus:

▫ Polio booster

▫ Japanese B Encephalitis

▫ Rabies

▫ Meningitis

▫ Yellow Fever

• Malaria Prevention

Vaccinations

•Routine (background) vaccineChildhood, standard

•Required (compulsory) vaccineCross borders, entry requirements IHR

•Recommended (elective based on

risk)Travel vaccines

Some vaccines can be in more than category. Not all the same

or available in all countries

Vaccine Classification- 3Rs

In May 2005, The 58th World Health Assembly adopted the revised International Health

Regulations, “IHR”

•To prevent, protect against, control and

provide a public health response to the

international spread of disease in ways that

are commensurate with and restricted to

public health risks, and which avoid

unnecessary interference with international

traffic.

International Health Regulations IHR (2005)

•The International Health Regulations are a

formal code of conduct for public health

emergencies of international concern.

•They're a matter of responsible citizenship

and collective protection.

•They involve all 193 World Health

Organization member countries.

International Health Regulations IHR (2005)

• They are an international agreement that gives rise to

international obligations. They focus on serious

public health threats with potential to spread beyond

a country's border to other parts of the world.

• Such events are defined as public health emergencies

of international concern, or PHEIC. The revised

International Health Regulations outline the

assessment, the management and the information

sharing for PHEICs.

International Health Regulations IHR (2005)

• IHRs serve a common interest.

• First of all, they address serious and unusual disease

events that are inevitable in our world today.

• They serve a common interest by recognizing that a

health threat in one part of the world can threaten

health anywhere, or everywhere.

• And they are a formal code of conduct that helps

contain or prevent serious risks to public health,

while discouraging unnecessary or excessive traffic

or trade restrictions for, quote, "public health,"

purposes.

IHR focuses to address two main Questions:

1. Is the number of cases and/or number of

deaths for this type of event large for

the given place, time or population?

2. Has the event the potential to have a

high public health impact?

Thank you!!