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CDC-travel-slides.ppt
1. 1
THE PRE-TRAVEL
CONSULTATION
Gary W. Brunette, MD, MS
Travelers’ Health Team
Division of Global Migration and Quarantine
Centers for Disease Control and Prevention
2. 2
Outline
• Travelers’ Health Epidemiology
• Traveler Assessment
• Itinerary Review
• Sources of Information
• Risks to the Traveler
• Travel Vaccines
• Travel Medications
• Counseling
3. 3
U.S. Residents Traveling Abroad*
*ITA, includes travel to Canada and Mexico
45
50
55
60
65
1
9
9
5
1
9
9
6
1
9
9
7
1
9
9
8
1
9
9
9
2
0
0
0
2
0
0
1
2
0
0
2
2
0
0
3
2
0
0
4
2
0
0
5
Year
Number
of
Travelers
(millions)
4. 4
International Travel
0
10
20
30
40
50
60
70
80
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
US
Resident
travel
in
millions
0
100
200
300
400
500
600
700
800
900
Worldwide
arrivals
in
millions
US nonresident
Inbound (ITA)
US Resident Air
Outbound (ITA)
All US Resident
Outbound (ITA)
Worldwide arrivals
(WTO)
5. 5
Where Do U.S. Residents Travel?
0
10
20
30
40
Canada
Europe
Aus/NZ
Mexico
C
or S
Am
erica
Japan
Oceania/ PI
Other Asia
Africa
Caribbean
Middle East
%
Source: HealthStyles Survey 2005
Of the 17% who traveled outside the U.S. . . .
6. 6
VFRs: Visiting Friends and Relatives
• Foreign-born increased 57% since 1990
from 19.8 million to 31.1 million1
• 20% of US population are first- or
second-generation immigrants
• VFRs comprised ~46% of US
international air travelers in 20043
1US Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000,
issued Dec 2003 (Previous: US Census Bureau, Profile of the Born Outside the
United States Population 2000, issues Dec 2003???
2 Angell & Cetron, 2005
32004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported
From: Survey of International Air Travelers, Office of travel and tourism Industries,
USDOC
7. 7
Travelers’ Health Risks
Of 100,000 travelers to a developing country
for 1 month:
– 50,000 will develop some health problem
– 8,000 will see a physician
– 5,000 will be confined to bed
– 1,100 will be incapacitated in their work
– 300 will be admitted to hospital
– 50 will be air evacuated
– 1 will die
Steffen R et al. J Infect Dis 1987; 156:84-91
8. 8
The Patient: Medical Issues
• Age-specific issues
• Underlying illness,
immunosuppression
• Systems review
• Medical history
• Medication use
• Vaccination history
• Allergies
• Contraindications to vaccines and
medications
9. 9
The Patient: Other Issues
• Reproductive
– Pregnant
– Breastfeeding
– Preconception
• Risk-taking behaviors
10. 10
Travel Itinerary
• Full itinerary
– Dates, duration, stopovers
– Seasonal considerations
• Styles of travel
– Rural vs. urban
– Budget vs. luxury
• Accommodation
– Hotel vs. camping
• Activities
– Business vs. tourism
– Adventure, safari
– Missionary/Humanitarian/NGO
11. 11
Travel Health Resources
• CDC Travelers’ Health Website
– www.cdc.gov/travel
• World Health Organization
– www.who.int/int
• State Department
– travel.state.gov
• International Society of Travel Medicine
– www.istm.org
• Health Information for International Travel
– CDC “Yellow Book”
• International Travel and Health
– WHO “Green Book”
21. 21
Patient Counseling
• Sufficient time for patient education
• Tailored to suit traveler
• Fitness for travel
– Understanding impact on existing
conditions
– Advisability of destinations
22. 22
Travel Preparation
• Travel health insurance
– Medical care
– Hospitalization
– Evacuation
• Obtaining medical care abroad
• Awareness of travel notices
• Hand washing and hygiene
23. 23
Environmental Precautions
• Air Travel
• Jet Lag
• Sun Protection
• Extreme Heat and Cold
– dehydration, heat stroke
– hypothermia, frostbite
• Altitude
• Water recreation
– Drowning, boating & diving accidents
– Risk of schistosomiasis or leptospirosis
– Biological and chemical contamination
24. 24
Food and Water Precautions
• Bottled water
• Selection of foods
– well-cooked and hot
• Avoidance of
– salads, raw vegetables
– unpasteurized dairy products
– street vendors
– ice
25. 25
Vector
Precautions
• Covering exposed skin
• Insect repellent containing DEET 25 – 50%
• Treatment of outer clothing with permethrin
• Use of permethrin-impregnated bed net
• Use of insect screens over open windows
• Air conditioned rooms
• Use of aerosol insecticide indoors
• Use of pyrethroid coils outdoors
• Inspection for ticks
26. 26
Bloodborne and STD Precautions
• Prevalence of
– STDs
– Hepatitis B
– Hepatitis C
– HIV
• Unprotected sexual activity
• Commercial sex workers
• Tattooing and body piercing
• Auto accidents
• Blood products
• Dental and surgical procedures
27. 27
Animal Precautions
• Animal avoidance
• Rabies
– Specific animal threats
– Medical evaluation of bites/scratches
– Post exposure immunization and
immunoglobulin
• Envenomations
– Snakes, scorpions, spiders
– Maritime animals
28. 28
Injury and Crime
• Vehicles
– Risk of road and pedestrian accidents
– Night travel
– Seat belts and car seats
• Use of drugs and alcohol
• Understanding local crime risks
– Scam awareness
– Situational awareness
– Location avoidance
29. 29
Travel Emergency Kit
• Copy of medical records and extra pair of glasses
• Prescription medications
• Over-the counter medicines and supplies
– Analgesics
– Decongestant, cold medicine, cough suppressant
– Antibiotic/antifungal/hydrocortisone creams
– Pepto-Bismol tablets, antacid
– Band-Aids, gauze bandages, tape, Ace wraps
– Insect repellant, sunscreen, lip balm
– Tweezers, scissors, thermometer
30. 30
Post-Travel Care
• Post-travel checkup
– Long term travelers
– Adventure travelers
– Expatriates in developing world
• Post-travel care
– Fever, chills, sweats
– Persistent diarrhea
– Weight loss
33. 33
Journals
• American Journal of Tropical Medicine and
Hygiene
• Bulletin of the World Health Organization
• Emerging Infectious Diseases Journal
• Eurosurveillance Weekly
• Journal of Travel Medicine
• Morbidity and Mortality Weekly Report
• Tropical Medicine and International Health
• Vaccine
34. 34
Books
• Textbook of Travel Medicine and Health, 2nd
Ed.
– DuPont, H.L. and Steffen R. (editors)
• The Travel and Tropical Medicine Manual,
3rd Ed.
– Jong, E.C., McMullen, R.
• Travel Medicine
– Keystone, J.S., Kozarsky, P.E., et al
This is not supposed to include travel without an overnight stay, particularly to Canada and Mexico.
Notice that the specification of the regions was not completely
52% have traveled to developing countries
As expected, the majority of travel is to Canada, western Europe and Mexico.
Christie, the first bullet needs to have the reference I cited. The previous reference is in parentheses, which I think is a typo. I cannot find a source to confirm the second bullet. The paper I have cited there has this information, but I cannot confirm with the US Census reference that is included in the paper (Kip has a copy). The whole reference is Angell SY, Cetron MS. Health Disparities among Travelers Visiting Friends and Relatives Abroad. Annals of Internal Medicine, 2005; 142:1, 67-73.
I have updated the 3rd bullet and reference.
In web use, usually in top 5 CDC sites
Primary Audiences
Traveling public
Health professionals advising travelers
Content Areas
Travel Notices & Announcements
Online Yellow Book
Regional Destination Pages
Resources (Y.Fever Registry, Travel Med Clinics, Contact Us)
Additional Topics & Special Needs Groups
Diseases A-Z
Traveling with Pets, Children, Special Needs Travelers
Travel Industry
VZV (no mention of upper age limit; approved for >=12 months)
>= 13 Years of Age
After the first and second doses, 10.2% and 9.5% of vaccinees, respectively, developed fever (i.e., oral temperature greater than or equal to 100 F {37.7 C}); these febrile episodes occurred throughout the 42-day period and were usually associated with intercurrent illness.
After one and two doses, 24.4% and 32.5% of vaccinees, respectively, had complaints regarding the injection site; rash at the injection site at a peak of 6-20 days and 0-6 days postvaccination, respectively, developed in 3% and 1% of vaccinees, respectively; and a nonlocalized rash consisting of a median number of five lesions developed in 5.5% and 0.9% of vaccinees, respectively, and occurred at a peak of 7-21 days and 0-23 days postvaccination, respectively.
