The document provides an outline for a lecture on travel medicine, covering factors that influence travelers' health, levels of disease prevention, an introduction to travel medicine and preventive care practices, epidemiological data on travelers from sources like WHO and CDC, and case studies on providing recommendations and screening for travelers. The practice of travel medicine involves pre-travel counseling, treating illnesses in travelers, and is related to addressing current global health issues impacted by increased international travel.

1. 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

2. Objectives
1. ระบุปจจัยกำหนดสุขภาพซึ่งสงผลตอสุขภาพของนักการเดินทางขามชาติได
2. ระบุการปองกันโรคในแตละระดับสำหรับผูที่มีปจจัยเสี่ยงจากการเดินทางได

3. วิเคราะหคุณลักษณะของระบบบริการสุขภาพสำหรับกลุมนักเดินทางขามชาติได
4. เขาใจบทบาทหนาที่ของแพทยในการตรวจสุขภาพและการประเมินปจจัยเสี่ยง
5. ประยุกตใชแหลงขอมูลทางระบาดวิทยา เพื่อใหคำแนะนำดานการสรางเสริม
สุขภาพและปองกันโรคแกกลุมประชากรที่มีการเดินทางขามชาติได
Pix source: online.wsj.com

3. Outline
• 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
Pix source: online.wsj.com

4. Health & Health Determinants
Health
System

5. Functions of Health Services Systems
1. การสรางเสริมสุขภาพ (Health promotion)
2. การปองกันโรค (Disease prevention)
3. การรักษาโรค (Treatment)
4. การฟนฟูสภาพ (Rehabilitation)

6. Levels of Disease Prevention
1. Primary prevention
2. Secondary prevention
3. Tertiary prevention
4. Quaternary prevention

7. Levels of Disease Prevention
• Chronological view
Without disease Early/ Established/ No disease,
But at risk asymptomatic full-blown but still
disease disease suffering
Pix source: www.ph3c.org

8. Levels of Disease Prevention
Without disease With disease
• Relational view
Feeling good
Feeling bad
Pix source: www.ph3c.org

9. Learning Community Medicine
Ø “Up and down the ladder of abstraction”
นามธรรม (the abstract):
• แนวคิด (concepts)
• ทฤษฎี (theories)
• หลักการ (principles)
• กลยุทธ (strategies)
รูปธรรม (the concrete):
• การเก็บขอมูลและวิเคราะหขอมูล (data)
• กรณีศึกษา (case studies)
• การทำงานภาคสนาม (fieldwork)
• การนำเสนองาน (presentations)
Pix source: influxentrepreneur.com/wendyelwell

10. Jules Verne (1873)
Around the World in Eighty Days
Pix source: en.wikipedia.org

11. Travel Medicine: For Whom?
Pix source: google.org

12. Travel Medicine: For Whom?
• 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.
Source: Keystone et al. (2008)

13. Travel Medicine: What?
Pix source: google.org

14. Travel Medicine: What?
Pix source: google.org

15. Travel Medicine: What?

16. 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)

17. Travel Medicine: Why Now?
Pix source: google.org

18. 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)

19. Health & Health Determinants
Health
System

20. “Travel Medicine Triad”
Figure source: Jong EC (2008)

21. Practice of Travel Medicine
• Pre-travel counseling:
• Pre-travel visits
• Diseases in the travelers:
• Travelers’ consultations
• Post-travel visits
Pix source: skypark-glasgow.com

22. 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)

23. 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.

24. Expanded Program on Immunization (EPI) in Thailand
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)
*Started in 2010; # = 1 month apart from JE1
Source: thaigcd.ddc.moph.go.th

25. 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)

26. Current Global Health Issues
• 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”)
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

27. Practice of Travel Medicine
Pix taken by the speaker, courtesy to Ann M. Settgast, MD

28. Practice of Travel Medicine
Pix taken by the speaker, courtesy to Ann M. Settgast, MD

29. 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

30. 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)

31. Resources:
Authoritative Travel Medicine Recommendations
• US CDC Home Travel Info www.cdc.gov/travel
• CDC Yellow Book www.cdc.gov/travel/contentYellowBook.aspx
• WHO Green Book www.who.int/ith
• Health Canada – Travel Health www.phac-aspc.gc.ca/tmp-pmv/index.html
• UK National Travel Health www.nathnac.org
Network and Centre

32. CDC Yellow Book
Source: CDC (2012)

33. CDC Yellow Book
Source: CDC (2012)

34. CDC Yellow Book
Source: CDC (2012)

35. CIA.gov

36. ISTM.org

37. ISTM.org: Global Travel Clinic Directory

38. ThaiTravelMed.org

39. 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”

40. Introduction to Travel Medicine:
Case Studies
Pix source: neohealth.com.hk/en/vp-travel-medicine.html

41.
Case I
• 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.
Pix source: toolkit.smallbiz.nsw.gov.au

42.
“Doc, which vaccines do you recommend?”
Pix
source:
webboard.news.sanook.com

43. “Great Indochina Loop”
Pix source: www.taotaotasi.com

44. • 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

45. • 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.

46.
“Doc, which investigations do you recommend?”
Pix source: webboard.news.sanook.com

47. Investigations
• Physical examination:
– all negative
• Lab test:
– CBC: Hct 41% WBC 9000 N 50 L30 Eo15 Platelet 300,000
• Stool exam:
– Parasites not found

48. Eosinophilia in returned travelers
What should you do next?

49. Investigations (Con’t)
• Physical examination:
– all negative
• Lab test:
– CBC: Hct 41% WBC 9000 N 50 L30 Eo15 Platelet 300,000
• Stool exam:
– Blastocyst hominis found
Pix source: dpd.cdc.gov

50. Blastocystis Hominis
in returned travelers
What should you do next?
• Antibiotic metronidazole (Flagyl)
• Antiprotozoal medication iodoquinol (Yodoxin, others)
• Combination medication sulfamethoxazole & trimethoprim (Bactrim, Septra, others)

51.
Case II
• 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.
Pix source: toolkit.smallbiz.nsw.gov.au

52. • “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.”

53. • “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.”

54.
“Doc, which investigations do you recommend?”
Pix source: nongbeempea.blogspot.com/p/blog-page_9600.html

55. Schistosomiasis in returned travelers
What history should you take?

56. “Where exactly
is Cameroon?”
Pix source: worldatlas.com

57. “Where exactly is Schistosomiasis?”
• Schistosoma mansoni
• Schistosoma japonicum
• Schistosoma mekongi
Pix source: esciencenews.com: kenyafootball.com; who.int/schistosomiasis/epidemiology; en.wikipedia.org

58. “Where exactly is Schistosomiasis?”
Pix source: www.taotaotasi.com

59. 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

60. • Now, the physician intern says:
– “Now they have no symptoms except intense worry.”
– “Their physical exams are completely normal.”
– “What should I do next?”

61. Asymptomatic Schistosomiasis
in returned travelers
Which investigation will you suggest?
(and when?)

62. Recommendations
• 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.

63. Lessons Learned
• 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!!
Pix source: online.wsj.com

64. “Think Globally, Act Locally”
Pix source: : wnww.justfocus.org.nz