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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’ HealthEpidemiology • Traveler Assessment • Itinerary Review • Sources of Information • Risks to the Traveler • Travel Vaccines • Travel Medications • Counseling
- 3. 3 U.S. Residents TravelingAbroad* *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 19971998 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 Friendsand 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 Of100,000 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: MedicalIssues • Age-specific issues • Underlying illness, immunosuppression • Systems review • Medical history • Medication use • Vaccination history • Allergies • Contraindications to vaccines and medications
- 9. 9 The Patient: OtherIssues • Reproductive – Pregnant – Breastfeeding – Preconception • Risk-taking behaviors
- 10. 10 Travel Itinerary • Fullitinerary – 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”
- 12.
- 13. 13 Regional Destinations • Region-specificpages • Goal to move to country-specific format
- 14. 14 Travel Notices &Announcements
- 15. 15 Cardiovascular Medical Injury Homicide/Suicide Infectious Disease Other Deaths Relatedto International Travel N = 2463 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
- 16. 16 Infectious Disease Risksto the Traveler • Malaria • Diarrhea • Leishmaniasis • Rabies • Dengue • Meningococcal Meningitis • Schistosomiasis • Tuberculosis • Leptospirosis • Polio • Yellow Fever • Measles • JEV ETC.
- 17. 17 Motor Vechicle Drowning Air Crash Homicide/Suicide Poisoning Other InjuryDeaths and International Travel N = 601 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
- 18. 18 Other Risks tothe Traveler • Accidental injury • Environmental hazards • Crime and assault • Psychiatric problems • Animal bites, stings and envenomations • Dermatologic disorders • Altitude • ……. ETC.
- 19. 19 Immunizations to Considerfor Adult Travelers Routine Diphtheria* Tetanus* Pertussis* Measles + Mumps+ Rubella + Varicella Pneumococcus Influenza Travel related Hepatitis A Hepatitis B Typhoid Rabies Meningococcal disease Polio Japanese encephalitis Yellow Fever * Td or Tdap + MMR
- 20. 20 Travel Medications: Prophylaxis &Self Treatment • Malaria – chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine • Diarrhea – quinolone, azithromycin • Altitude – acetazolamide • Motion sickness – scopolamine, dimenhydrinate (Dramamine)
- 21. 21 Patient Counseling • Sufficienttime for patient education • Tailored to suit traveler • Fitness for travel – Understanding impact on existing conditions – Advisability of destinations
- 22. 22 Travel Preparation • Travelhealth insurance – Medical care – Hospitalization – Evacuation • Obtaining medical care abroad • Awareness of travel notices • Hand washing and hygiene
- 23. 23 Environmental Precautions • AirTravel • 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 WaterPrecautions • 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 exposedskin • 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 STDPrecautions • 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 • Animalavoidance • 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-travelcheckup – Long term travelers – Adventure travelers – Expatriates in developing world • Post-travel care – Fever, chills, sweats – Persistent diarrhea – Weight loss
- 31.
- 32.
- 33. 33 Journals • American Journalof 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 ofTravel 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
- 35. 35 Websites Eurosurveillance www.eurosurveillance.org Travax EnCompass www.travax.com GIDEON www.gideononline.com International SOS www.internationalsos.com MedicalAdvisory Service for Travelers Abroad (MASTA) http://www.masta.org/ Armed Forces Medical Intelligence Center www.afmic.detrick.army.mil/ Central Intelligence Agency www.cia.gov/cia/publications/factbook/
Editor's Notes
- #4 Source http://tinet.ita.doc.gov/view/f-2005-11-001/index.html
- #6 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.
- #7 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.
- #13 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
- #20 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.