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Travel medicine for health profession student

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an overview lecture about travel medicine Challenge and opportunity for medical professionals

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Travel medicine for health profession student

  1. 1. Travel medicineTravel medicine An overviewAn overview Rachmat Gunadi WachjudiRachmat Gunadi Wachjudi Department of Internal MedicineDepartment of Internal Medicine Faculty of Medicine Universitas PadjadjaranFaculty of Medicine Universitas Padjadjaran
  2. 2. TravellingTravelling
  3. 3. The path ….The path ….  Lahir : Garut 16 Januari 1955Lahir : Garut 16 Januari 1955  Fakultas Kedokteran UNSRI Palembang 72 – 83Fakultas Kedokteran UNSRI Palembang 72 – 83  PUSKESMAS/Dinas Kesehatan Pandeglang 83-89PUSKESMAS/Dinas Kesehatan Pandeglang 83-89  Fakultas Kedokteran UNPAD Bandung 90 – 96Fakultas Kedokteran UNPAD Bandung 90 – 96  RS Al Ikhsan Bandung 96-97RS Al Ikhsan Bandung 96-97  Staf Dep I.P. Dalam 1997-….Staf Dep I.P. Dalam 1997-….  Fakultas Kedokteran UI Jakarta 97Fakultas Kedokteran UI Jakarta 97  Royal Perth/SCG Hospital 98-99Royal Perth/SCG Hospital 98-99  Staf Div Reumatologi 99- ….Staf Div Reumatologi 99- ….  Kepala Div Reumatologi 2004 -…Kepala Div Reumatologi 2004 -…  Kepala Dep I P Dalam 2014- ….Kepala Dep I P Dalam 2014- ….  Hobi : baca, musik, travelling, MCHobi : baca, musik, travelling, MC
  4. 4. What is travel medicine?What is travel medicine? It is a science and an artIt is a science and an art
  5. 5. What is travel medicine?What is travel medicine?  It is that part of health professionalIt is that part of health professional practice that:practice that:  seeks toseeks to prevent illnesses and injuriesprevent illnesses and injuries occurring to travellers going abroadoccurring to travellers going abroad  manages problems arising in travellersmanages problems arising in travellers coming back or coming from abroadcoming back or coming from abroad  is concerned about the impact of tourism onis concerned about the impact of tourism on health and also advocates for improvedhealth and also advocates for improved health and safety services for touristshealth and safety services for tourists  is increasing concerned about refugee andis increasing concerned about refugee and migrant healthmigrant health (Primer of Travel Medicine 3(Primer of Travel Medicine 3rdrd Ed)Ed)
  6. 6.  ““the art of travel medicine isthe art of travel medicine is selecting the necessaryselecting the necessary prevention strategy withoutprevention strategy without unnecessary adverse events,unnecessary adverse events, cost or inconvenience”cost or inconvenience” (Steffen, 1994)(Steffen, 1994)
  7. 7. Challenge of travel medicineChallenge of travel medicine  Sea of global migration of peopleSea of global migration of people  More people travellingMore people travelling  People travelling further a fieldPeople travelling further a field  Rapid movement of travellersRapid movement of travellers
  8. 8. USA / Canada 35.2 million Europe 25.0 million Japan 11.4 mio AUS / NZ 3.3 million Travellers from industrialised areasTravellers from industrialised areas to developing areas 1999 (WTO)to developing areas 1999 (WTO) 2.8 2.3 19 7.8 1.9 3.6 6.8 2.5 1.3 1.6 2.4 4.6 6.1 4.8 2.6 Total: n million travelers 0.2-1 million travelers ~ 80 million travelers 1.2
  9. 9. Travellers are exposed to a variety of hazards
  10. 10. The Importance of TravelThe Importance of Travel Health MeasuresHealth Measures  100,000 travelers to the100,000 travelers to the developing world for 1 month…..developing world for 1 month…..  50,000 will become ill50,000 will become ill  8,000 will see a physician8,000 will see a physician  5,000 will stay in bed5,000 will stay in bed  1 will die1 will die Steffen, 1994
  11. 11. The Importance of TravelThe Importance of Travel Health MeasuresHealth Measures  Per 100,000 travellers that havePer 100,000 travellers that have travel insurance …..travel insurance …..  8000 will make a claim (8%)8000 will make a claim (8%)  2000 will use emergency2000 will use emergency assistance (2%)assistance (2%)  400 ER or clinic referrals (0.4%)400 ER or clinic referrals (0.4%)  200 Hospital admissions (0.2%)200 Hospital admissions (0.2%)  50 Aeromedical evacuations (0.05%)50 Aeromedical evacuations (0.05%) Leggat et al. Travel Med Inf Dis 2005;3:9
  12. 12. The Importance of TravelThe Importance of Travel Health MeasuresHealth Measures  MortalityMortality  Cardiovascular Disease (50 toCardiovascular Disease (50 to 70%)70%)  Accidents/Trauma (20-25%), esp.Accidents/Trauma (20-25%), esp. MVAsMVAs  Infectious diseases (2.8-4%)Infectious diseases (2.8-4%) (Reid and Cossar, BMBull. 1993;257-268;(Reid and Cossar, BMBull. 1993;257-268; Prociv, MJA. 1995;163:27-30;Prociv, MJA. 1995;163:27-30; Baker et al.,Baker et al., PHR 1992;107:155-159; MacPherson et al,PHR 1992;107:155-159; MacPherson et al, JTM. 2000; 2000:227-233; Steffen, TransJTM. 2000; 2000:227-233; Steffen, Trans
  13. 13. Travel medicine is aTravel medicine is a continuumcontinuum  Travellers do get sick or injuredTravellers do get sick or injured abroad or when they come backabroad or when they come back  The commitment to travel health canThe commitment to travel health can therefore be regarded as atherefore be regarded as a continuumcontinuum
  14. 14. The Continuum of TravelThe Continuum of Travel MedicineMedicine During TravelDuring Travel Preventive Medicine Contingency Planning Treatment & Rehabilitation VisitorsVisitorsPre-TravelPre-Travel Post-TravelPost-Travel
  15. 15. What do we need to do inWhat do we need to do in order to be giving theorder to be giving the correct advice to travellers?correct advice to travellers?
  16. 16. Travel Health AdviceTravel Health Advice needs Informationneeds Information ““Information is power inInformation is power in Travel Medicine”Travel Medicine”
  17. 17. Travel Health Advice needsTravel Health Advice needs TrainingTraining Training gives you aTraining gives you a framework for using thatframework for using that informationinformation
  18. 18. Travel Health Advice needsTravel Health Advice needs ExperienceExperience Experience helps put theExperience helps put the information and training ininformation and training in perspectiveperspective
  19. 19. Travel Health Advice needsTravel Health Advice needs to be Documentedto be Documented Documentation is importantDocumentation is important for Quality assurance andfor Quality assurance and reinforcing travel healthreinforcing travel health adviceadvice
  20. 20. Travel Health Advice needsTravel Health Advice needs TravellersTravellers Marketing is essential in travelMarketing is essential in travel health, whether in generalhealth, whether in general practice or in specialist travelpractice or in specialist travel clinicsclinics
  21. 21. Giving the correct advice toGiving the correct advice to travellerstravellers  Giving the correct health adviceGiving the correct health advice to travellers needs:to travellers needs:  InformationInformation  TrainingTraining  ExperienceExperience  DocumentationDocumentation  TravellersTravellers
  22. 22. Travel Health Advice needsTravel Health Advice needs InformationInformation  GuidelinesGuidelines  PoliciesPolicies  Textbooks, including an World AtlasTextbooks, including an World Atlas  JournalsJournals  Professional organisationsProfessional organisations  Staff/colleaguesStaff/colleagues  Electronic DatabasesElectronic Databases  WWWWWW
  23. 23. International GuidelinesInternational Guidelines  WHOWHO  InternationalInternational HealthHealth RegulationsRegulations  InternationalInternational Travel andTravel and HealthHealth  www.who.int/ithwww.who.int/ith  Yellow feverYellow fever requirementsrequirements
  24. 24. JournalsJournals Weighing the Evidence
  25. 25. Weighing the evidenceWeighing the evidence  “Travel medicine prevention should be based on epidemiological data.” Robert Steffen, 1991  What are the likely risks of a person travelling to particular destinations?  What are the likely benefits of intervention?
  26. 26. Giving the correct advice toGiving the correct advice to travellerstravellers  Giving the correct health adviceGiving the correct health advice to travellers needs:to travellers needs:  InformationInformation  TrainingTraining  ExperienceExperience  DocumentationDocumentation  TravellersTravellers
  27. 27. Risk assessmentRisk assessment  Risk assessmentRisk assessment preferably startspreferably starts before the travellerbefore the traveller enters the consultingenters the consulting roomroom  Document the riskDocument the risk assessmentassessment
  28. 28. Establish the risksEstablish the risks  DestinationDestination  Mode of travelMode of travel  Traveller’s medical historyTraveller’s medical history  InterventionIntervention
  29. 29.
  30. 30. Risks of the destinationRisks of the destination
  31. 31. Outbreak Notice Polio Outbreak in Tajikistan, Cases in Russia, Risk of Spread to other Central Asian Countries Updated: October 22, 2010 CDC Update Oct. 2010
  32. 32. Yellow fever: distribution
  33. 33. “meningitis belt”—the Sahel
  34. 34. Travelers’ diarrheaTravelers’ diarrhea  Very common. Up toVery common. Up to 50% over 2-4 weeks.50% over 2-4 weeks.  A self-limited illness inA self-limited illness in most internationalmost international travelers.travelers.  Duration can beDuration can be shortened by antibiotics.shortened by antibiotics.
  35. 35. What do U.S. travelers die from inWhat do U.S. travelers die from in the developing world?the developing world?  About half: heart attacks, strokes (mostlyAbout half: heart attacks, strokes (mostly in the elderly).in the elderly).  About 25%: road traffic accidents.About 25%: road traffic accidents.  The rest: drowning, falls from heights,The rest: drowning, falls from heights, homicide, suicide.homicide, suicide.  Infectious disease: onlyInfectious disease: only about 1%.about 1%.
  36. 36. Urban medicineUrban medicine  Road traffic accidentsRoad traffic accidents  Air pollutionAir pollution  Heat illnessHeat illness  Recreational pharmacologyRecreational pharmacology  PsychologicalPsychological illnessillness
  37. 37. Air pollutionAir pollution  Mexico City was theMexico City was the worst city in the worldworst city in the world in 1992. Now it’s notin 1992. Now it’s not on the top ten list.on the top ten list.  Nine of worst tenNine of worst ten cities are in China.cities are in China.
  38. 38. Total suspendedTotal suspended particulatesparticulates (in mcg/cubic meter)(in mcg/cubic meter)  StockholmStockholm 99  Mexico CityMexico City 279279  Lanzhou, ChinaLanzhou, China 732732 Mexico CityMexico City Lanzhou,Lanzhou, ChinaChina
  39. 39. photographyphotography  If there’s a guy withinIf there’s a guy within sight who is carryingsight who is carrying a rifle or machinea rifle or machine gun: ask permissiongun: ask permission before you takebefore you take photographs.photographs.
  40. 40. No glove, no love.No glove, no love.
  41. 41. Risks of the mode of travelRisks of the mode of travel  Modes of travel can presentModes of travel can present particular medical problems ofparticular medical problems of varying severity, e.g. motionvarying severity, e.g. motion sickness, painful ears, phobias,sickness, painful ears, phobias, DVT;DVT;  Can they fly?Can they fly?
  42. 42. Road traffic accidentsRoad traffic accidents  The rate of fatalitiesThe rate of fatalities per 100 million milesper 100 million miles driven in the US isdriven in the US is 1.1; this is similar to1.1; this is similar to Western EuropeanWestern European rates.rates.  The rates in Sri LankaThe rates in Sri Lanka and Turkey are 23and Turkey are 23 and 44, respectively.and 44, respectively.
  43. 43. Seat belts are good.Seat belts are good. Helmets are good. BetterHelmets are good. Better still, stay off anythingstill, stay off anything two-wheeled andtwo-wheeled and motorized.motorized. Do not ride on top of aDo not ride on top of a bus or in the back of anbus or in the back of an open truck.open truck. Avoid the roads at night.Avoid the roads at night. To reduce risk of injury and death from motor vehicle accidents:
  44. 44. Risks of the mode of travelRisks of the mode of travel  Some travellers may not meetSome travellers may not meet medical guidelines to travel or maymedical guidelines to travel or may need special clearance to fly onneed special clearance to fly on commercial aircraft, such as withcommercial aircraft, such as with  pre-existing illness,pre-existing illness,  pregnancy,pregnancy,  recent surgery orrecent surgery or  serious physical or mental incapacityserious physical or mental incapacity
  45. 45. Risks of medical historyRisks of medical history  Past travel history, particularly involving any significantPast travel history, particularly involving any significant medical issues,medical issues,  Past medical history, eg need for adjusting diabeticPast medical history, eg need for adjusting diabetic treatment,treatment,  Past surgical history, eg recent surgery,Past surgical history, eg recent surgery,  Most recent dental examinationMost recent dental examination  Current medications, including the oral contraceptiveCurrent medications, including the oral contraceptive pill,pill,  Last menstrual period for females (are they pregnant?),Last menstrual period for females (are they pregnant?),  Smoking and alcohol history,Smoking and alcohol history,  Allergies, including medications and foods,Allergies, including medications and foods,  Any current illnesses and regular medication, andAny current illnesses and regular medication, and  Are they travelling alone or with children or with olderAre they travelling alone or with children or with older travellers?travellers?  How fit are they to undertake any proposed exertionalHow fit are they to undertake any proposed exertional activities?activities?
  46. 46. Risks of medical historyRisks of medical history  Asthma - Asthma management plan;Asthma - Asthma management plan; precipitants; environmental concerns;precipitants; environmental concerns; consider influenza vaccination andconsider influenza vaccination and antibiotics for medical kit.antibiotics for medical kit.  Diabetes - Consideration of time zoneDiabetes - Consideration of time zone changes; controlchanges; control  Ulcer management - Reduced acidityUlcer management - Reduced acidity may predispose to diarrhoeal diseasemay predispose to diarrhoeal disease
  47. 47. Risks of medical historyRisks of medical history  Psoriasis - May get worse withPsoriasis - May get worse with chloroquinechloroquine  Arthritis - May have difficulties withArthritis - May have difficulties with treks, climbing (also general fitness);treks, climbing (also general fitness); may need standby NSAID treatmentmay need standby NSAID treatment  Hypertension - Caution in prescribingHypertension - Caution in prescribing mefloquine and Beta blockersmefloquine and Beta blockers  Immunosuppression - Immune responseImmunosuppression - Immune response to vaccination may be less; live vaccinesto vaccination may be less; live vaccines may give rise to diseasemay give rise to disease
  48. 48. Risks of medical history-allergiesRisks of medical history-allergies  SulphursSulphurs (Maloprim), Diamox & other(Maloprim), Diamox & other sulphur based medicationssulphur based medications  Egg allergies*Egg allergies* Yellow fever vaccine,Yellow fever vaccine, influenza vaccine,influenza vaccine, MMRIIMMRII  Neomycin, polymixin Measles, Mumps,Neomycin, polymixin Measles, Mumps, RubellaRubella  IodineIodine iodine water purificationiodine water purification tabstabs  QuinineQuinine ChloroquineChloroquine  Food allergies Various, including,Food allergies Various, including, seafood, peanutsseafood, peanuts  PetsPets CatsCats
  49. 49. Risks of interventionRisks of intervention  Addressing risk in travel medicineAddressing risk in travel medicine is generally all about trying tois generally all about trying to modify risks established from themodify risks established from the travel health consultationtravel health consultation  All interventions have potentialAll interventions have potential risks, including giving the wrongrisks, including giving the wrong adviceadvice
  50. 50. Risks of interventionRisks of intervention  Advice and educationAdvice and education  VaccinationVaccination  ChemoprophylaxisChemoprophylaxis  Screening and EffectiveScreening and Effective managementmanagement
  51. 51. Risks of the interventionRisks of the intervention  Can the traveller tolerate theCan the traveller tolerate the intervention?intervention?  Does the risk of the exposure justifyDoes the risk of the exposure justify the intervention/cost?the intervention/cost?  Can the traveller afford theCan the traveller afford the intervention?intervention?  What do you do if you can’t provideWhat do you do if you can’t provide optimal protection because of risksoptimal protection because of risks from the medical history or otherfrom the medical history or other considerations, such as age of theconsiderations, such as age of the
  52. 52. Risk assessmentRisk assessment  PoliciesPolicies  GuidelinesGuidelines  Consensus statementsConsensus statements  Epidemiological evidenceEpidemiological evidence (weak to strong)(weak to strong)
  53. 53. Pre-Travel Health AdvicePre-Travel Health Advice needs Trainingneeds Training  Helps give structure andHelps give structure and consistencyconsistency  Provides a framework for practiceProvides a framework for practice  Discusses evidence for practiceDiscusses evidence for practice  Policy and Procedures ManualPolicy and Procedures Manual  Consistent approach to travelConsistent approach to travel healthhealth
  54. 54. Part of the commitment is to alsoPart of the commitment is to also have a consistent and structuredhave a consistent and structured approach to travel health adviceapproach to travel health advice  WHO ChecklistWHO Checklist (www.who.int/ith)(www.who.int/ith)  Information on localInformation on local conditionsconditions  PreventionPrevention  Accident avoidanceAccident avoidance  Medical and dentalMedical and dental check-upcheck-up  NZPHR-PreventionNZPHR-Prevention  VaccinationsVaccinations  Health AdviceHealth Advice  PrescriptionPrescription Source: http://www.who.int/ith
  55. 55. VACCINATEVACCINATE (IHC)(IHC)  AlwaysAlways National scheduleNational schedule  OftenOften hepatitis Ahepatitis A  SometimesSometimes Japanese encephalitisJapanese encephalitis meningococcal diseasemeningococcal disease poliopolio rabiesrabies yellow feveryellow fever InfluenzaInfluenza PneumococcalPneumococcal diseasedisease Other vaccinesOther vaccines (adapted* from NZPHR; 1996;3(8):57-59)(adapted* from NZPHR; 1996;3(8):57-59)
  56. 56. ADVISE AND DISCUSSADVISE AND DISCUSS  InsectsInsects repellents, nets, permethrinrepellents, nets, permethrin  IngestionsIngestions care with food and watercare with food and water diet/teeth (includingdiet/teeth (including airlines/jetlag/DVT)*airlines/jetlag/DVT)*  IndiscretionsIndiscretions STI’s, HIVSTI’s, HIV  InjuriesInjuries accident avoidance, personalaccident avoidance, personal safetysafety  ImmersionImmersion schistosomiasisschistosomiasis  Insurance*Insurance* health and travel insurance*health and travel insurance* finding medical assistance o/s*finding medical assistance o/s* (adapted* from NZPHR; 1996;3(8):57-59)(adapted* from NZPHR; 1996;3(8):57-59)
  57. 57. PRESCRIBEPRESCRIBE (Script/Dr’s letter/bracelet)(Script/Dr’s letter/bracelet)  AlwaysAlways regular medicationregular medication medical kit (firstmedical kit (first aid)*aid)*  SometimesSometimes antimalarial medicationantimalarial medication diarrheal self-diarrheal self- treatmenttreatment condomscondoms (NZPHR; 1996;3(8):57-59)(NZPHR; 1996;3(8):57-59)
  58. 58. Giving the correct advice toGiving the correct advice to travellerstravellers  Giving the correct health adviceGiving the correct health advice to travellers needs:to travellers needs:  InformationInformation  TrainingTraining  ExperienceExperience  DocumentationDocumentation  TravellersTravellers
  59. 59. Travel health advice needs experienceTravel health advice needs experience  Let’s just do it!  Affiliation with a group with experience can be useful  Travel clinic group  Travel medical advisory group (eg MASTA, Worldwise, Travax etc)  University  Those NZ GPs that were interested in travel medicine were significantly more likely to have had tropical medicine/developing country experience (Leggat et al. JTM 1999; 7: 55-58.)
  60. 60. Travel is part ofTravel is part of experienceexperience
  61. 61. Travel is part ofTravel is part of experienceexperience  Professionals working in travelProfessionals working in travel medicine need to travel and havemedicine need to travel and have that personal experience tothat personal experience to communicate to travellerscommunicate to travellers  Helps to put travel health advice inHelps to put travel health advice in context and helps to build a positivecontext and helps to build a positive travel experiencetravel experience
  62. 62. Giving the correct advice toGiving the correct advice to travellerstravellers  Giving the correct health adviceGiving the correct health advice to travellers needs:to travellers needs:  InformationInformation  TrainingTraining  ExperienceExperience  DocumentationDocumentation  TravellersTravellers
  63. 63. Travel health advice needs toTravel health advice needs to be documentedbe documented  Standardised forms/questionnairesStandardised forms/questionnaires  Informed consentInformed consent  International HealthInternational Health Certificate/Vaccination recordCertificate/Vaccination record  Doctor’s letter/copy ofDoctor’s letter/copy of prescription/medialert braceletprescription/medialert bracelet  Written advice/videos/Books/HealthWritten advice/videos/Books/Health advisory documentsadvisory documents
  64. 64. Correct advice is even better if theCorrect advice is even better if the advice is actually followed by theadvice is actually followed by the travellertraveller  DocumentationDocumentation  Follow-upFollow-up  Use staff resourcesUse staff resources  Reinforce health adviceReinforce health advice
  65. 65. Giving the correct advice toGiving the correct advice to travellerstravellers  Giving the correct health adviceGiving the correct health advice to travellers needs:to travellers needs:  InformationInformation  TrainingTraining  ExperienceExperience  DocumentationDocumentation  TravellersTravellers
  66. 66. Travel Health Advice needsTravel Health Advice needs TravellersTravellers  Inform own patients concerning the need forInform own patients concerning the need for seeking travel health advice, and seeking thisseeking travel health advice, and seeking this advice earlyadvice early  Market travel health adviceMarket travel health advice  Direct, if possibleDirect, if possible  Join group/affiliateJoin group/affiliate  Links/promotion with traveller groups, travel agents,Links/promotion with traveller groups, travel agents, travel insurance, consulates etctravel insurance, consulates etc  Join travellers health networks, such as ISTM, IAMATJoin travellers health networks, such as ISTM, IAMAT etcetc
  67. 67. LBNL Health Services and Travel Medicine •Before you travel overseas oVisit Health Services early for consultation oVaccination series take up to 6 months oSome destinations (e.g., CERN) require medical clearance from Health Services oRegister trip for travel coverage through UCOP ACE American Insurance Company •During travel oFollow usual common sense precautions oRefer to the following website for insurance details: http://www.ucop.edu/risk-services/loss-prevention-control/travel-assistance/index.html •When you return oFinish prophylactic medications oIf you become ill, advise your doctor about your recent travel
  68. 68. Take home pointsTake home points  More people are traveling to more destinations,More people are traveling to more destinations, becoming exposed to the health and safety of thatbecoming exposed to the health and safety of that destination and also having the potential to impact ondestination and also having the potential to impact on the health and safety of that destination, especiallythe health and safety of that destination, especially through emerging infectious diseasethrough emerging infectious disease  Travelers’ health is a continuum and includes the pre-Travelers’ health is a continuum and includes the pre- travel health, contingency planning while abroad andtravel health, contingency planning while abroad and caring the traveler after travelcaring the traveler after travel  Travel health advice needs information (including aTravel health advice needs information (including a capacity to undertake a risk assessment), training,capacity to undertake a risk assessment), training, experience, documentation and travelersexperience, documentation and travelers
  69. 69. Practical pointsPractical points  Where toWhere to  For how longFor how long  For what purposeFor what purpose  Staying in what kind of placeStaying in what kind of place  Guided or notGuided or not  Previous developing world travel or notPrevious developing world travel or not
  70. 70. ConcernsConcerns  Past medical historyPast medical history  AllergiesAllergies  History of antimalarial use if anyHistory of antimalarial use if any  MedicationsMedications  Medical problemsMedical problems  History of depression, anxietyHistory of depression, anxiety  ContraceptionContraception  Review of past immunizationsReview of past immunizations
  71. 71. Bibliography  Centers for Disease Control and Prevention. CDC Health Information for International Travel 2010. Atlanta: U.S. Dept. of Health and Human Services, Public Health Service, 2009.  Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, McIntyre L, ed. Washington DC: Public Health Foundation, 2009.  Cook, Gordon C, Ed.: Manson’s Tropical Diseases, 20th Ed., W.B. Saunders Co. Ltd, 1996.  DuPont HL, Steffen R (eds.): Textbook of Travel Medicine and Health, 2nd Ed. B.C. Decker, 2001.  Guerrant, Walker, Weller: Tropical Infectious Diseases: Principles, Pathogens, & Practice. Churchill Livingston, 1999.  Jong EC, Sanford C (eds.): The Travel and Tropical Medicine Manual, 4th ed. Saunders/Elsevier, 2008.  Keystone JS, Kozarsky PE, Freedman DO, et al, eds: Travel Medicine. Mosby, 2004.
  72. 72. Bibliography (cont.)  Sanford, C: The Adventurous Traveler’s Guide to Health. University of Washington Press, Seattle, 2008.  Sanford C. (guest editor): Primary Care Clinics: Travel Medicine. Saunders/Elsevier, December 2002.  Strickland. Hunter’s Tropical Medicine and Emerging Tropical Diseases, 8th Ed., W.B. Saunders. 2000.
  73. 73. Thank you

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