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Introduction to Travel Med 2012.1.24


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Elaborating the concepts of health determinants and disease prevention to the 3-year medical students by introducing an emerging field of Travel Medicine.

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Introduction to Travel Med 2012.1.24

  1. 1. Community  Medicine  Beyond  Geography:   Introduc7on  to  Travel  Medicine   Borwornsom Leerapan, MD PhD SM Department of Community Medicine January 24, 2013Pix source: 
  2. 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: 
  3. 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: 
  4. 4. Health & Health Determinants  Health   System 
  5. 5. Functions of Health Services Systems 1.  การสรางเสริมสุขภาพ (Health promotion) 2.  การปองกันโรค (Disease prevention) 3.  การรักษาโรค (Treatment) 4.  การฟนฟูสภาพ (Rehabilitation)  
  6. 6. Levels of Disease Prevention 1.  Primary prevention 2.  Secondary prevention 3.  Tertiary prevention 4.  Quaternary prevention 
  7. 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: 
  8. 8. Levels of Disease Prevention  Without disease  With disease  •  Relational view  Feeling good  Feeling bad Pix source: 
  9. 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: 
  10. 10. Jules Verne (1873)  Around the World in Eighty Days Pix source: 
  11. 11. Travel Medicine: For Whom? Pix source: 
  12. 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. 13. Travel Medicine: What? Pix source: 
  14. 14. Travel Medicine: What? Pix source: 
  15. 15. Travel Medicine: What? 
  16. 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. 17. Travel Medicine: Why Now? Pix source: 
  18. 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. 19. Health & Health Determinants  Health   System 
  20. 20. “Travel Medicine Triad” Figure source: Jong EC (2008) 
  21. 21. Practice of Travel Medicine  •  Pre-travel counseling:   •  Pre-travel visits  •  Diseases in the travelers:   •  Travelers’ consultations  •  Post-travel visits   Pix source: 
  22. 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. 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. 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: 
  25. 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. 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: 
  27. 27. Practice of Travel Medicine Pix taken by the speaker, courtesy to Ann M. Settgast, MD 
  28. 28. Practice of Travel Medicine Pix taken by the speaker, courtesy to Ann M. Settgast, MD 
  29. 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: 
  30. 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. 31. 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 
  32. 32. CDC Yellow Book Source: CDC (2012) 
  33. 33. CDC Yellow Book Source: CDC (2012) 
  34. 34. CDC Yellow Book Source: CDC (2012) 
  35. 35. 
  36. 36. 
  37. 37. Global Travel Clinic Directory 
  38. 38. 
  39. 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. 40. Introduction to Travel Medicine:   Case Studies Pix source: 
  41. 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: 
  42. 42.   “Doc, which vaccines do you recommend?” Pix  source:  
  43. 43. “Great Indochina Loop” Pix source: 
  44. 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: 
  45. 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. 46.  “Doc, which investigations do you recommend?”  Pix source: 
  47. 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. 48. Eosinophilia in returned travelers  What should you do next? 
  49. 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: 
  50. 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. 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: 
  52. 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. 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. 54.  “Doc, which investigations do you recommend?” Pix source: 
  55. 55. Schistosomiasis in returned travelers  What history should you take? 
  56. 56. “Where exactly is Cameroon?”  Pix source: 
  57. 57. “Where exactly is Schistosomiasis?”  •  Schistosoma mansoni  •  Schistosoma japonicum  •  Schistosoma mekongi Pix source:;; 
  58. 58. “Where exactly is Schistosomiasis?” Pix source: 
  59. 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:   
  60. 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. 61. Asymptomatic Schistosomiasis   in returned travelers Which investigation will you suggest? (and when?) 
  62. 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. 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: 
  64. 64. “Think Globally, Act Locally” Pix source: :