TRAVEL MEDICINE “When hoof beats might be zebras” Dr. Januchowski
Mar 31, 2015
TRAVEL MEDICINE
“When hoof beats might be zebras”
Dr. Januchowski
OBJECTIVES
• Be able to identify the key items to discuss with patients travelling internationally
• Be able to discuss with patients the resources available to help them stay healthy while travelling
• Know some of the important illness patterns to watch for when patients return from overseas adventures
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Travel Medicine
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Travel Medicine
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Travel Medicine Consultation
• Risk Assessment
• Risk Communication
• Risk Management
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Risk Assessment
• Typically done 1-2 months prior to travel
• Itinerary data
• Traveler demographics and health/medical history
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Risk AssessmentItinerary data• Countries and regions to be visited, in
the order of travel
• Visits to urban versus rural areas
• Dates and length of travel in each area
• Purpose of travel (such as business, vacation, visiting friends and relatives)
• Modes of transportation
• Planned and possible activities (such as hiking, scuba diving, camping)
• Types of accommodations in each area (such as air-conditioned, screened, tents)
Traveler demographics• Age, sex
• Vaccination history, including dates, how many doses received in a scheduled series, and prior adverse events
• Medical and psychiatric history (past and current), including any conditions or medications that suppress the immune system
• Medications (current or taken in the past 3 months)
• Allergies (in particular to eggs, latex, yeast, mercury, or thimerosal)
• Pregnancy and breastfeeding (current status and plans)
• Any planned surgeries or other medical care during travel (medical tourism)
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Risk Communication
• Plan based on Risk Assessment
• Evidence Based plan of action developed with the traveller
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Risk Management
• Implementation of the plan–Vaccines
–Medications
–Education
–General Guidance
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Case #1
• 44 y.o. male patient presents 2 months before a planned trip to Suriname for business with his employer, ALCOA
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Risk Assessment - Itinerary• Countries and regions to be visited, in the order of travel
• Visits to urban versus rural areas
• Dates and length of travel in each area
• Purpose of travel (such as business, vacation, visiting friends and relatives)
• Modes of transportation
• Planned and possible activities (such as hiking, scuba diving, camping)
• Types of accommodations in each area (such as air-conditioned, screened, tents)
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Risk Assessment – Traveler info
• Age, sex• Vaccination history, including dates, how many doses received in
a scheduled series, and prior adverse events• Medical and psychiatric history (past and current), including any
conditions or medications that suppress the immune system• Medications (current or taken in the past 3 months)• Allergies (in particular to eggs, latex, yeast, mercury, or
thimerosal)• Pregnancy and breastfeeding (current status and plans)• Any planned surgeries or other medical care during travel
(medical tourism)
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Let’s talk
about
vaccines
Risk Management – Vaccines
• Routine
• Required
• Recommended
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RoutineRoutine Vaccines
• Would include childhood immunizations
• Boosters (Tdap, MMR)
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RequiredRequired Vaccines
• Yellow fever vaccine–Sub-Saharan Africa
–Tropical South America
• Meningococcal vaccine for annual travel to the Hajj in Saudi Arabia
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RecommendedRecommended Vaccines
• Varies based on –Destination
– Itinerary
–Traveller demographics
• Check website
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Typhoid
• Salmonella enterica
• Fecal-oral route of transmission
• Fever, headache, malaise
• Intestinal perforation and hemorrhage complications
• Can be treated with antibiotics22
Typhoid VaccineInjectable
• One dose series
• Good for 2 years
• Age 2 and older
• Should be given >2 weeks prior to travel
Oral (Live, attenuated)
• 4 dose series
• Good for 5 years
• Age 6 and older
• Should complete series one week before travel
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Cost for vaccine ~$80-100
Yellow Fever
• Transmitted by mosquito
• Fevers, malaise
• Can cause hepatitis, hemorrhagic complications
• Supportive treatment
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Yellow fever vaccine
• Must be administered by a certified health center
• ~$100-125
• Good for 10 years
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Yellow fever vaccine
• Contraindications–Less than 6 months old
– Immunocompromised status• Primary immunodeficiency
• HIV with CD4<200
–Malignant neoplasms
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Risk management
• The patient has scheduled times for his vaccinations
• What other information can be provided for this traveller?
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Risk management
• Malaria prevention
• Treatment of common travel illnesses
• General Education –Food and drink safety
–Accident avoidance
–Safe sexual practices28
Malaria prevention
• Determine risk
• Prevent mosquito bites
• Medication prophylaxis
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Malaria Chemoprophylaxis
• Atovaquone-proguanil
• Chloroquine
• Doxycycline
• Mefloquine
• Primaquine
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Malaria ChemoprophylaxisMedicine Cost Start prior Dosing time Side effects Misc.
Atovaquone-proguanil
$$$ 1-2 days Daily Minimal
Chloroquine $ 1-2 weeks Weekly Resistance
Doxycycline $ 1-2 days Daily GI / sun
Mefloquine $$ 2 weeks Weekly GI / seizure / psych/cardio
Resistance
Primaquine $ 1-2 days Daily G6PD caution!
Can be used for vivax term. prophylaxis
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What other recommendations?
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Travel Medicine Kit
• Include items for treatment of common illnesses
• Watch for flight regulations
• International regulations on transport of medications
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Travel Med Kit
• Routine prescribed medicines• Antidiarrheals
– Bismuth products (treatment or prophylaxis)– Loperamide (Imodium)– Ciprofloxacin 500 mg BID x 2– Azithromycin 1 gm x 1– Rifaximin (non-FDA approved, off label use for
prophylaxis)
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Treatments
Travel Med Kit (cont.)
• Insect repellents–DEET (30-50%)–Picaridin–Oil of Lemon Eucalyptus or PMD– IR3535–Permethrin impregnated clothing / bed
netting36
Travel Med Kit (cont.)
• Water purification tablets
• Pain medicines (OTC)
• Sunscreen
• Antibacterial skin cleanser / wipes
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Case (cont.)
• The patient travels and returns without any noted incidents.
• Proper education allowed the patient to–Know the precautions after return regarding
illness reporting–Know the importance of completing malaria
prophylaxis medications
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Post travel visit
• Ensure malaria medicines are completed–4 weeks for doxycycline / mefloquine
–7 days for atovaquone/proguanil
• Review travel history
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Post travel visit - Illnesses
• Fever
• Persistent GI complaints
• Skin lesions or rashes
• Respiratory infections
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Post travel visit - Fever
• Malaria (up to one year!)• Dengue• Invasive bacterial diarrhea• Hepatitis A• Typhoid• Rickesial infections• Influenza (remember patterns)• Viral illnesses NOS 41
Post travel visit – GI Concerns• Acute bacterial/parasitic gastroenteritis
– Giardia– C. difficile
• Unmasking of underlying GI disease – Postinfectious IBS – Lactose intolerance– Celiac disease
• Tropical sprue• Brainerd diarrhea
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Post travel visit – Skin lesions
• Non-specific dermatitis
• Insect bites
• Pyoderma
• Scabies
• Cutaneous larva migrans
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Assessing Risk by Incubation Period
OBJECTIVES
• Be able to identify the key items to discuss with patients travelling internationally
• Be able to discuss with patients the resources available to help them stay healthy while travelling
• Know some of the important illness patterns to watch for when patients return from overseas adventures
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