travel

1. TRAVEL MEDICINE LECTURE
Dr Gordon Amoh
MBChB, MGCP, MWACP, MPH, Cert.(TravMed)
29th September 2022

2. OBJECTIVES
• Introduction to the concept of Travel Medicine
• Conducting Pre-travel consultation and risk assessment for travelers
• Prevention and management of common illnesses or conditions
associated with travel
• Post-travel consultation

3. Outline of Presentation
• Introduction
• Definition and Objectives of Travel medicine
• Importance of Travel Health Measures
• Pre-travel Consultation
• Travelers by Age, with Medical Conditions or Special Needs
• Common Diseases of Importance to Travelers
• Immunizations
• Post-travel Illness and Consultation

4. Introduction
• The number of people traveling internationally continues to grow.
• According to the World Tourism Organization, there were 1.33 billion
worldwide international tourist arrivals in 2017, an increase of 88%
from 2015.
• International arrivals increased 6% in January–April 2018 compared
to the same period in 2017.
• The health problems faced by travelers are considerable and variable
depending on the countries visited and the lifestyle adopted by the
traveler.

5. What is Travel Medicine?
• Travel medicine is an interdisciplinary specialty concerned with the:
- prevention
- management and
- research of health problems associated with travel.
• The science of travel medicine is referred to as Emporiatics.

6. Objectives of Travel Medicine
• It aims to prevent illness & injuries occurring to persons travelling out
of the country and manages health problems arising in travelers
arriving from other countries.
• It also aims to reduce the impact of travel on ecosystems around the
world. This is particularly with respect to the introduction and spread
of disease as well as reduce the emergence and spread of resistant
strains of microorganisms.

7. Why are Travel Health Measures Important? 1
• 100,000 travelers to developing world for 1 month
- 50,000 travelers will develop some sort of health problem during the
course of their trip
- 8,000 travelers will see a physician
- 5,000 travelers will be confined to bed
- 1,100 travelers will be incapacitated in their work either abroad or
upon returning home
- 300 travelers will have to be hospitalized either during their trip or
upon their return

8. Why are Travel Health Measures Important? 2
- 50 travelers will have to be air evacuated out of the country they are
visiting
- 1 traveler will die

9. Estimated Incidence of Illness During Travel in
a Developing Country
• Traveler’s diarrhea 20%-60%
• Acute respiratory infection 5%-20%
• Malaria (No chemoprophylaxis West Africa) 2%
• Dengue fever 0.1%
• Hepatitis A 0.03%-0.3%
• Animal bites with rabies risk 0.3%
Incidence varies based on destination, duration of travel and activities

10. Estimated Incidence of Road Traffic Accidents
When Travelling
• Road traffic collisions are the most frequent cause of death among
travelers.
• The risks associated with road traffic collisions and violence are
greatest in low- and middle-income countries, where trauma care
systems may not be well developed.
• Worldwide, an estimated 1.2 million people are killed each year in
road traffic crashes and as many as 50 million more are injured.

11. Factors that determine the risks in travelers
• The risk of becoming ill or injured during international travel depends
on many factors, such as:
- the mode of transport
-the region of the world visited,
- a traveler’s age and health status,
- the length of the trip and season of travel
- purpose of travel
- standards of accommodation, food hygiene and sanitation and
- behaviour of the traveler

12. The Pre-travel Consultation
• The pre-travel consultation offers a dedicated time to prepare
travelers for the health concerns that might arise during their trips.
• The objectives of the pre-travel consultation are to:
• 1. Perform an individual risk assessment.
• 2. Communicate to the traveler anticipated health risks.
• 3. Provide risk management measures, including immunizations,
malaria prophylaxis, and other medications as indicated.

13. The Pre-travel Consultation 2
• This should be done at least 6 - 8 weeks before traveling.
• The pre-travel consultation is the major opportunity to educate the
traveler about health risks at the destination and how to mitigate
them.
• Involves taking the travelling history, traveler’s personal and medical
history as well as a physical examination.
• Should include a scheduled post-travel medical consultation.

14. The Pre-travel Consultation 3
• Primary care physicians should seek guidance from travel medicine
specialists to address areas of uncertainty.
• Balancing the cautions with an appreciation of the positive aspects of
the journey leads to a more meaningful pre-travel consultation.
• Attention to the cost of recommended interventions may be critical.
Some travelers may not be able to afford all of the recommended
immunizations and medications, a situation that requires prioritizing
interventions.

15. The Pre-travel Consultation 4 - Principles of
Pre-travel health care
• Advise the patient to plan early—at least 8 weeks beforehand.
• Allow adequate time for consultation (e.g. 30–45 minutes).
• Individualize advice.
• Provide current information.
• Provide written as well as verbal advice.
• Provide a letter concerning existing medical illness and treatment.
• Encourage personal responsibility.

16. The Pre-travel Consultation 5 – Risk
Management Topics
• Food and water precautions
• Insect bite prevention
• Immunizations
• Malaria prevention
• STIs
• Travel medical insurance
• Air transportation issues, e.g. DVT
• Environmental risks
• Safety and security
• Travelers with special needs
• Cultural issues

17. The Pre-travel Consultation –
Assessing Individual Risk
• Many elements merit consideration in assessing a traveler’s health risks.
• Certain travelers may confront special risks.
• Recent hospitalization for serious problems may lead the travel health
provider to recommend delaying travel.
• Air travel is contraindicated for certain conditions, such as <3 weeks after
an uncomplicated myocardial infarction and <10 days after thoracic or
abdominal surgery.
• The travel health provider and traveler should consult with the relevant
health care providers most familiar with the underlying illnesses.

18. Information necessary for a risk assessment during
Pre-travel consultations
• Health Background • Past Medical History: Age, Sex,
Underlying conditions, Allergies
(especially any pertaining to
vaccines, eggs, or latex),
Medications
• Special Conditions • Pregnancy
• Breastfeeding
• Disability
• Immunocompromised
• Older age

19. Information necessary for a risk assessment during
Pre-travel consultations
• Special Conditions (cont.) • Psychiatric condition
• Seizure disorder
• Recent surgery
• Recent cardiopulmonary event
• Recent cerebrovascular event
• History of Guillain-Barré
syndrome
• Severe allergies

20. Information necessary for a risk assessment during
Pre-travel consultations
• Immunization history • Routine vaccines
• Travel vaccines
• Prior travel experience • Experience with malaria
chemoprophylaxis
• Experience with altitude
• Illnesses related to prior travel

21. Information necessary for a risk assessment
during Pre-travel consultations
• Trip details - Itinerary
• Countries and specific regions,
including order of countries if >1
country
• Rural or urban
Trip details - Timing • Trip duration
• Season of travel
• Time to departure

22. Information necessary for a risk assessment
during Pre-travel consultations
• Reason for travel • Tourism
• Business
• Visiting friends and relatives
• Volunteer, missionary, or aid work
• Research or education
• Adventure
• Pilgrimage
• Adoption
• Seeking health care (medical
tourism)

23. Information necessary for a risk assessment
during Pre-travel consultations
Travel style
• Independent travel or package
tour
• Traveler risk tolerance
• General hygiene standards at
destination
• Modes of transportation
• Accommodations (such as tourist
or luxury hotel, guest house,
hostel or budget hotel,
dormitory, local home or host
family, or tent)

24. Information necessary for a risk assessment
during Pre-travel consultations
Special activities • Disaster relief
• Medical care (providing or receiving)
• High altitude
• Diving
• Cruise ship
• Rafting or other water exposure
• Cycling
• Extreme sports
• Spelunking
• Anticipated interactions with animals
• Anticipated sexual encounters

25. The Pre-travel Consultation – Communicate Risk
• Once destination-specific risks for a particular itinerary have been
assessed by the provider, they should be clearly communicated to the
traveler.
• The process of risk communication is a 2-way exchange of information
between the clinician and traveler, in which they discuss potential
health hazards at the destination and the effectiveness of preventive
measures, with the goal of improving understanding of risk and
promoting more informed decision making.

26. The Pre-travel Consultation – Manage Risk
• Immunizations are a crucial component of pre-travel consultations,
and the risk assessment forms the basis of recommendations for
travel vaccines.
• The purpose of travel and specific destination within a country will
inform the need for particular vaccinations.
• At the same time, the pre-travel consultation presents an opportunity
to update routine vaccines .
• Another major focus of pre-travel consultations for many destinations
is the prevention of malaria. Pre-travel consultation must carefully
assess travelers’ risk for malaria and recommend preventive
measures.

27. The Pre-travel Consultation – Manage Risk 2
• For travelers going to malaria-endemic countries, it is imperative to discuss
malaria transmission, ways to reduce risk, recommendations for
prophylaxis, and symptoms of malaria.
• Travelers with underlying health conditions require attention to their
health issues as they relate to the destination and activities. They should
be provided medical reports and should carry along their necessary
medications.
• Travelers should be counseled on how to obtain travel medical insurance
and how they can find reputable medical facilities at their destination.

28. The Pre-travel Consultation –Manage Risk 3
• Any allergies or serious medical conditions should be identified on a
bracelet or a card to expedite medical care in emergency situations.
• The pre-travel consultation also provides another setting to remind
travelers of basic health practices during travel, including frequent
handwashing, wearing seatbelts, using car seats for infants and children,
and safe sexual practices.
• General issues such as preventing injury and sunburn also deserve
mention. Written information is essential to supplement oral advice and
enable travelers to review the instructions from their clinic visits.
• Advice on self-treatable conditions may minimize the need for travelers to
seek medical care while abroad and possibly lead to faster return to good
health.

29. Travelers by Age, with Medical
Conditions or Special Needs

30. Age and the risk of traveling
• Newborn: A fit and healthy baby can travel by air 48 h after birth, but
it is preferable to wait until the age of 7 days.
• Adolescents: Risky behavior which can predispose them to injuries
and STIs is the major problem this group.
• Elderly: Advised to ensure comfortable seating, adequate fluids, take
small meals before and during travels, move around and preferably sit
at the aisle.

31. Pregnant women and travel
• It is safest for pregnant women to travel during the second trimester.
• Typical guidelines for a woman with an uncomplicated pregnancy are:
— after the 28th week of pregnancy, a letter from a doctor or midwife
should be carried, confirming the expected date of delivery and that
the pregnancy is normal; — for single pregnancies, flying is permitted
up to the end of the 36th week;
— for multiple pregnancies, flying is permitted up to the end of the
32nd week.

32. Disability and travel
• Physical disability is not usually a contraindication for travel if the
general health status of the traveler is good.
• Airlines have regulations concerning travel for disabled passengers
who need to be accompanied.
• Information should be obtained from the relevant airline well in
advance of the intended travel.

33. Pre-existing illnesses and travel
• People suffering from underlying chronic illnesses should seek
medical advice before planning a journey.
• They should carry all necessary medication and medical items for the
entire duration of the journey.
• All medications, especially prescription medications, should be
packed in carry-on luggage, in their original containers with clear
labels.
• A duplicate supply carried in the checked luggage is a safety
precaution against loss or theft.

34. Diabetes mellitus and travels
• The general rule/ guidance regarding insulin adjustments during air
travel:
• Short acting insulin is better as it is used with each meal and supplemented
by intermediate acting insulin at bedtime on arrival.
• When travelling across several time zones, it is advisable to keep following
the local time of your place of departure until you arrive at your
destination (i.e. don’t change your wristwatch until you reach your
destination) to keep track of your injections and meals.
• When travelling to a time zone ahead of your local time, i.e. travelling east,
your day of travel will be shorter than 24 hours and less insulin is needed.
• When travelling to a time zone behind your local time, i.e. travelling west,
your day of travel will be longer than 24 hours and more insulin is needed.

35. Cardiovascular diseases and travel
• Due to low cabin pressure at high altitude, partial arterial oxygen
pressure drops and blood oxygen saturation also drops to about 90%
results in tachycardia and may result in cardiac decompensation.
• They require some of the following before travels:
-sufficient quantities of cardiac medications for the entire trip,
including sublingual nitroglycerin, and keep in carry-on luggage.
-carry a copy of the most recent ECG.
-carry a pacemaker card, if a pacemaker patient

36. Contraindications to air travel in patients with
cardiac diseases
• Uncomplicated myocardial infarction within 2–3 weeks
• Complicated myocardial infarction within 6 weeks
• Unstable angina
• Congestive heart failure, severe, decompensated
• Uncontrolled hypertension
• Coronary Artery Bypass Grafting within 10–14 days
• CVA within 2 weeks
• Uncontrolled ventricular or supraventricular tachycardia
• Eisenmenger syndrome
• Severe symptomatic valvular heart disease

37. Pulmonary diseases and air travel
• Lung function tests and blood gas determinations need to be assessed
before travels.
• The measurement of arterial blood gas is the single most helpful test
because the PaO2 is considered the best predictor of altitude PaO2 and
tolerance. A stable ground level PaO2 greater than 70 mm Hg is considered
adequate in most cases.
• A simple test to do may also be to see whether the patient can walk 50
yards at a normal pace or climb one flight of stairs without becoming
severely dyspneic.
• Asthmatic patients with labile or severe form are not fit for travels. All
asthmatics should travel with their inhalers.
• Patients with TB can travel after they are no longer infectious.

38. Security issues
• Security checks can cause concerns for travellers who have been
fitted with metal devices such as artificial joints, pacemakers or
internal automatic defibrillators.
• Some pacemakers may be affected by modern security screening
equipment and any traveller with a pacemaker should carry a letter
from their doctor.
• Pacemakers with bipolar configurations are not affected by airline
electronics and airport securities unlike the unipolar devices.

39. Common diseases of importance
to travelers

40. Common diseases of importance to the
international traveler
• The main diseases are traveler's diarrhea and malaria, especially the
potentially lethal Plasmodium falciparum malaria.
• Others including Typhoid, Cholera, STIs, etc
• Some disease are country/ region specific such as;
• Africa: meningitis, typhoid, polio, yellow fever, Ebola virus, etc.
• Asia: above plus Hepatitis A, Japanese encephalitis, etc.
• S. America: yellow fever, etc.

41. Methods of protection against mosquito bites
• Use of protective coverings or clothings
• Insect repellents applied to exposed skin or to clothing repellent
• Mosquito nets (LLINS) while sleeping.
• Aerosol sprays for Indoor sleeping
• Indoor residual spraying (IRS) with insecticides last for 3-6 months
• Screening of windows and doors.
• Avoid contact with high-risk regions such as lakes

42. Chemoprophylaxis against Malaria

43. Traveler’s diarrhea (TD)
• It is the most predictable travel-related illness.
• Attack rates range from 30% to 70% of travelers, depending on the
destination and season of travel.
• Traditionally, it was thought that TD could be prevented by following
simple recommendations such as “boil it, cook it, peel it, or forget
it,” but studies have found that people who follow these rules may
still become ill.
• Poor hygiene practice in local restaurants is likely the largest
contributor to the risk for TD.

44. Traveler’s diarrhea (TD)
• TD is a clinical syndrome that can result from a variety of intestinal
pathogens.
• Bacterial pathogens are the predominant risk, thought to account for
up to 80%–90% of TD.
• Intestinal viruses may account for at least 5%–15% of illnesses.
• Infections with protozoal pathogens are slower to manifest symptoms
and collectively account for approximately 10% of diagnoses.
• In this syndrome, vomiting and diarrhea may both be present, but
symptoms usually resolve spontaneously within 12 hours.

45. Causes of Traveller’s diarrhoea
• Bacteria
• Escherichia coli (toxigenic)
• Shigella
• Campylobacter
• Aeromonas
• Pleasiomanas
• Vibrio (parahemlyticus,
cholera)
•
• Viruses
• Norovirus
• Rotavirus
• Parasites
• Giardia intestinalis
• Entamoeba histolytica
• Isospora belli
• Strongloides stercoralis
• Blastocystis hominis

46. Prophylaxis for traveler’s diarrhea
• Bismuth subsalicylate 2 tablets QID
• Rifaximin (Xifaxan)
• Oral rifamycin antibiotic structurally related to rifampin

47. Traveler’s diarrhea: Presumptive self-
treatment
• Ciprofloxacin 500 PO BID
• Norfloxacin 400 PO BID
• TMP - sulfa DS PO BID
• Azithromycin 500mg daily
• 3 -5 days of therapy +/- antiperistaltic agent

48. Traveler’s diarrhea: when to seek medical
attention
• Fever with chills
• Blood in stool
• Dehydration
• Persistence of symptoms

49. Immunizations: The Three Rs of Travel
Immunization
• Routine
- Childhood or adult immunizations
• Required
- Crossing international borders
• Recommended
- According to the risk of infection
Some immunizations may fall into multiple categories. Not all vaccines
are available in every country

50. Routine Immunizations – Most Countries
• Tetanus
• Diphtheria
• Pertusis
• Hemophilus influenza type b
• Polio
• Measles, Mumps, Rubella
• Hepatitis B
• Influenza
• Pneumococcal

51. Routine Immunizations – Some Countries
• BCG
• Hepatitis A
• Human papillomavirus
• Neisseria meningitides
• Rotavirus
• Tick-borne encephalitis
• Varicella

52. Required Immunizations
• Yellow fever
- Required under International Health regulations (2005)
• Meningococcal meningitis
- Required by Saudi Arabia for religious pilgrims (Hajj)

53. Yellow fever vaccine
• Determine the risk of Yellow fever at destination and if vaccine is
required under International Health Regulations (2005).
• Administer vaccine as a single dose.
• Counsel about avoidance of daytime biting Aedes mosquitoes.
• International certificate of vaccination is valid beginning 10 days after
the vaccine and offers life-long protection.

54. Yellow Fever Maps
Areas of Risk - Africa Areas of Risk – South America

55. Yellow Fever

56. Yellow Fever Vaccine Severe Adverse Events

57. Yellow Fever Vaccine Severe Adverse Events

58. Meningococcal meningitis

59. Meningococcal meningitis
• Neisseria meningitidis: At least 13 antigenically distinct serogroups
• A,B,C,W135 & Y are most common
• Current vaccine for A,C,W135 & Y
• Mandatory: Pilgrims visiting Mecca for the Hajj or for the Umrah
• Recommended: Travelers in areas where there are recurrent
outbreaks of disease

60. Rabies
• Postexposure prophylaxis (PEP) consists of a dose of human rabies immune globulin
(HRIG) and rabies vaccine given on the day of the rabies exposure, and then a dose of
vaccine given again on days 3, 7, and 14.
• For people who have never been vaccinated against rabies previously, postexposure
prophylaxis (PEP) should always include administration of both HRIG and rabies vaccine.
• The combination of HRIG and vaccine is recommended for both bite and non-bite
exposures, regardless of the interval between exposure and initiation of treatment.
• People who have been previously vaccinated or are receiving preexposure vaccination for
rabies should receive only vaccine.

61. Recommended Immunizations
• Hepatitis A
• Hepatitis B
• Typhoid
• Cholera
• Poliomyelitis
• Meningococcal meningtitis
• Japanese encephalitis
• Rabies
• Tick-borne encephalitis

62. Hepatitis A Infection

63. Hepatitis A Vaccines

64. Hepatitis B Infection

65. Hepatitis B Vaccines

66. Combined Hepatitis A and B Vaccine

67. The 6I’s of Travel Medicine
• Insects repellents, nets, permethrin
• Ingestions care with food and water
diet/teeth (including airlines/jetlag/DVT)
• Indiscretions STI’s, HIV, drugs
• Injuries accident avoidance, personal safety
• Immersion schistosomiasis, drowning
• Insurance health and travel insurance

68. Post-travel illness and consultation
• Most post-travel infections become apparent soon after travel, but often present
within the first one month of return, though this may vary based on incubation
period
• Post travel consultation involves taking history on:
• 1.Severity of illness
• 2.Travel itinerary and duration of travel
• 3.Timing of onset of illness in relation to international travel
• 4.Past medical history and medications
• 5.History of a pre-travel consultation
• 6.Travel immunizations
• 7.Adherence to malaria chemoprophylaxis
• 8. Medical care while overseas (such as injections, transfusions)

69. Post-travel illness and consultation 2
• 9. Insect precautions taken (such as repellent, bed nets)
• 10. Individual’s exposures
- Type of accommodations
- Source of drinking water
- Ingestion of raw meat or seafood or unpasteurized dairy products
- Insect or arthropod bites
- Freshwater exposure (such as swimming, rafting)
- Animal bites and scratches
- Body fluid exposure (such as tattoos, sexual activity)

70. Post-travel illness and consultation 3
• Fever after returning from a malaria-endemic area is a medical
emergency.
• Such travelers who develop fever should seek medical attention
immediately.

71. Conclusion
• Travel medicine practitioners are required to have in-depth
knowledge of immunizations, risk associated with specific
destinations, and the implications of traveling with underlying
conditions.
• Travel medicine consultations should be comprehensive and tailored
to the needs of the traveler.
• Family Physicians are well placed to offer travel medicine services due
to the uniqueness of our training and expertise.

72. THANK YOU FOR YOUR
ATTENTION
QUESTIONS?
COMMENTS?

73. REFERENCES
• 1. Centers for Disease Control and Prevention (CDC). Travelers' Health. 2020 [cited 2
August 2020]. Available from:
https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers
• 2. Murtagh J, Rosenblatt J, Coleman J, Murtagh C. John Murtagh's General Practice. 7th
ed. Sydney: McGraw-Hill Education; 2018.
• 3. Introduction to Travel Medicine. International Society of Travel Medicine:
https://www.istm.org/handouts_teachingslides
• 4. WHO. Health risks when travelling [Internet]. Who.int. 2020 [cited 3 August 2020].
Available from: https://www.who.int/news-room/q-a-detail/health-risks-when-traveling
• 5. Medical guidelines for air travels. Aviation, Space, and Environmental Medicine ; 2003
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