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Travel medicine for health profession student
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
3. The path âĻ.The path âĻ.
īŽ Lahir : Garut 16 Januari 1955Lahir : Garut 16 Januari 1955
īŽ Fakultas Kedokteran UNSRI Palembang 72 â 83Fakultas Kedokteran UNSRI Palembang 72 â 83
īŽ PUSKESMAS/Dinas Kesehatan Pandeglang 83-89PUSKESMAS/Dinas Kesehatan Pandeglang 83-89
īŽ Fakultas Kedokteran UNPAD Bandung 90 â 96Fakultas Kedokteran UNPAD Bandung 90 â 96
īŽ RS Al Ikhsan Bandung 96-97RS Al Ikhsan Bandung 96-97
īŽ Staf Dep I.P. Dalam 1997-âĻ.Staf Dep I.P. Dalam 1997-âĻ.
īŽ Fakultas Kedokteran UI Jakarta 97Fakultas Kedokteran UI Jakarta 97
īŽ Royal Perth/SCG Hospital 98-99Royal Perth/SCG Hospital 98-99
īŽ Staf Div Reumatologi 99- âĻ.Staf Div Reumatologi 99- âĻ.
īŽ Kepala Div Reumatologi 2004 -âĻKepala Div Reumatologi 2004 -âĻ
īŽ Kepala Dep I P Dalam 2014- âĻ.Kepala Dep I P Dalam 2014- âĻ.
īŽ Hobi : baca, musik, travelling, MCHobi : baca, musik, travelling, MC
4. What is travel medicine?What is travel medicine?
It is a science and an artIt is a science and an art
5. What is travel medicine?What is travel medicine?
īŽ It is that part of health professionalIt is that part of health professional
practice that:practice that:
īŽ seeks toseeks to prevent illnesses and injuriesprevent illnesses and injuries
occurring to travellers going abroadoccurring to travellers going abroad
īŽ manages problems arising in travellersmanages problems arising in travellers
coming back or coming from abroadcoming back or coming from abroad
īŽ 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
īŽ 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. īŽ ââthe 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 inconvenienceâcost or inconvenienceâ
(Steffen, 1994)(Steffen, 1994)
7. Challenge of travel medicineChallenge of travel medicine
īŽ Sea of global migration of peopleSea of global migration of people
īŽ More people travellingMore people travelling
īŽ People travelling further a fieldPeople travelling further a field
īŽ Rapid movement of travellersRapid movement of travellers
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
10. The Importance of TravelThe Importance of Travel
Health MeasuresHealth Measures
īŽ 100,000 travelers to the100,000 travelers to the
developing world for 1 monthâĻ..developing world for 1 monthâĻ..
īŽ 50,000 will become ill50,000 will become ill
īŽ 8,000 will see a physician8,000 will see a physician
īŽ 5,000 will stay in bed5,000 will stay in bed
īŽ 1 will die1 will die
Steffen, 1994
11. The Importance of TravelThe Importance of Travel
Health MeasuresHealth Measures
īŽ Per 100,000 travellers that havePer 100,000 travellers that have
travel insurance âĻ..travel insurance âĻ..
īŽ 8000 will make a claim (8%)8000 will make a claim (8%)
īŽ 2000 will use emergency2000 will use emergency
assistance (2%)assistance (2%)
īŽ 400 ER or clinic referrals (0.4%)400 ER or clinic referrals (0.4%)
īŽ 200 Hospital admissions (0.2%)200 Hospital admissions (0.2%)
īŽ 50 Aeromedical evacuations (0.05%)50 Aeromedical evacuations (0.05%)
Leggat et al. Travel Med Inf Dis 2005;3:9
12. The Importance of TravelThe Importance of Travel
Health MeasuresHealth Measures
īŽ MortalityMortality
īŽ Cardiovascular Disease (50 toCardiovascular Disease (50 to
70%)70%)
īŽ Accidents/Trauma (20-25%), esp.Accidents/Trauma (20-25%), esp.
MVAsMVAs
īŽ 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. Travel medicine is aTravel medicine is a
continuumcontinuum
īŽ Travellers do get sick or injuredTravellers do get sick or injured
abroad or when they come backabroad or when they come back
īŽ The commitment to travel health canThe commitment to travel health can
therefore be regarded as atherefore be regarded as a
continuumcontinuum
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. 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. Travel Health AdviceTravel Health Advice
needs Informationneeds Information
ââInformation is power inInformation is power in
Travel MedicineâTravel Medicineâ
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. Travel Health Advice needsTravel Health Advice needs
ExperienceExperience
Experience helps put theExperience helps put the
information and training ininformation and training in
perspectiveperspective
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. 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. Giving the correct advice toGiving the correct advice to
travellerstravellers
īŽ Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
īŽ InformationInformation
īŽ TrainingTraining
īŽ ExperienceExperience
īŽ DocumentationDocumentation
īŽ TravellersTravellers
22. Travel Health Advice needsTravel Health Advice needs
InformationInformation
īŽ GuidelinesGuidelines
īŽ PoliciesPolicies
īŽ Textbooks, including an World AtlasTextbooks, including an World Atlas
īŽ JournalsJournals
īŽ Professional organisationsProfessional organisations
īŽ Staff/colleaguesStaff/colleagues
īŽ Electronic DatabasesElectronic Databases
īŽ WWWWWW
25. Weighing the evidenceWeighing the evidence
īŽ âTravel medicine prevention should
be based on epidemiological data.â
Robert
Steffen, 1991
īŽ What are the likely risks of a person
travelling to particular destinations?
īŽ What are the likely benefits of
intervention?
26. Giving the correct advice toGiving the correct advice to
travellerstravellers
īŽ Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
īŽ InformationInformation
īŽ TrainingTraining
īŽ ExperienceExperience
īŽ DocumentationDocumentation
īŽ TravellersTravellers
27. Risk assessmentRisk assessment
īŽ Risk assessmentRisk assessment
preferably startspreferably starts
before the travellerbefore the traveller
enters the consultingenters the consulting
roomroom
īŽ Document the riskDocument the risk
assessmentassessment
28. Establish the risksEstablish the risks
īŽ DestinationDestination
īŽ Mode of travelMode of travel
īŽ Travellerâs medical historyTravellerâs medical history
īŽ InterventionIntervention
30. Risks of the destinationRisks of the destination
31.
32. Outbreak Notice
Polio Outbreak in
Tajikistan,
Cases in Russia,
Risk of Spread to
other Central Asian
Countries
Updated:Â October 22,
2010
CDC Update
Oct. 2010
36. Travelersâ diarrheaTravelersâ diarrhea
īŽ Very common. Up toVery common. Up to
50% over 2-4 weeks.50% over 2-4 weeks.
īŽ A self-limited illness inA self-limited illness in
most internationalmost international
travelers.travelers.
īŽ Duration can beDuration can be
shortened by antibiotics.shortened by antibiotics.
37. What do U.S. travelers die from inWhat do U.S. travelers die from in
the developing world?the developing world?
īŽ About half: heart attacks, strokes (mostlyAbout half: heart attacks, strokes (mostly
in the elderly).in the elderly).
īŽ About 25%: road traffic accidents.About 25%: road traffic accidents.
īŽ The rest: drowning, falls from heights,The rest: drowning, falls from heights,
homicide, suicide.homicide, suicide.
īŽ Infectious disease: onlyInfectious disease: only
about 1%.about 1%.
39. Air pollutionAir pollution
īŽ Mexico City was theMexico City was the
worst city in the worldworst city in the world
in 1992. Now itâs notin 1992. Now itâs not
on the top ten list.on the top ten list.
īŽ Nine of worst tenNine of worst ten
cities are in China.cities are in China.
40. Total suspendedTotal suspended
particulatesparticulates
(in mcg/cubic meter)(in mcg/cubic meter)
īŽ StockholmStockholm
99
īŽ Mexico CityMexico City
279279
īŽ Lanzhou, ChinaLanzhou, China
732732
Mexico CityMexico City
Lanzhou,Lanzhou,
ChinaChina
41. photographyphotography
īŽ If thereâs a guy withinIf thereâs 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.
43. Risks of the mode of travelRisks of the mode of travel
īŽ 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;
īŽ Can they fly?Can they fly?
44. Road traffic accidentsRoad traffic accidents
īŽ 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.
īŽ The rates in Sri LankaThe rates in Sri Lanka
and Turkey are 23and Turkey are 23
and 44, respectively.and 44, respectively.
45.
46.
47. 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:
48. Risks of the mode of travelRisks of the mode of travel
īŽ 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
īŽ pre-existing illness,pre-existing illness,
īŽ pregnancy,pregnancy,
īŽ recent surgery orrecent surgery or
īŽ serious physical or mental incapacityserious physical or mental incapacity
49. Risks of medical historyRisks of medical history
īŽ Past travel history, particularly involving any significantPast travel history, particularly involving any significant
medical issues,medical issues,
īŽ Past medical history, eg need for adjusting diabeticPast medical history, eg need for adjusting diabetic
treatment,treatment,
īŽ Past surgical history, eg recent surgery,Past surgical history, eg recent surgery,
īŽ Most recent dental examinationMost recent dental examination
īŽ Current medications, including the oral contraceptiveCurrent medications, including the oral contraceptive
pill,pill,
īŽ Last menstrual period for females (are they pregnant?),Last menstrual period for females (are they pregnant?),
īŽ Smoking and alcohol history,Smoking and alcohol history,
īŽ Allergies, including medications and foods,Allergies, including medications and foods,
īŽ Any current illnesses and regular medication, andAny current illnesses and regular medication, and
īŽ Are they travelling alone or with children or with olderAre they travelling alone or with children or with older
travellers?travellers?
īŽ How fit are they to undertake any proposed exertionalHow fit are they to undertake any proposed exertional
activities?activities?
50. Risks of medical historyRisks of medical history
īŽ 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.
īŽ Diabetes - Consideration of time zoneDiabetes - Consideration of time zone
changes; controlchanges; control
īŽ Ulcer management - Reduced acidityUlcer management - Reduced acidity
may predispose to diarrhoeal diseasemay predispose to diarrhoeal disease
51. Risks of medical historyRisks of medical history
īŽ Psoriasis - May get worse withPsoriasis - May get worse with
chloroquinechloroquine
īŽ 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
īŽ Hypertension - Caution in prescribingHypertension - Caution in prescribing
mefloquine and Beta blockersmefloquine and Beta blockers
īŽ 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
52. Risks of medical history-allergiesRisks of medical history-allergies
īŽ SulphursSulphurs (Maloprim), Diamox & other(Maloprim), Diamox & other
sulphur based medicationssulphur based medications
īŽ Egg allergies*Egg allergies* Yellow fever vaccine,Yellow fever vaccine,
influenza vaccine,influenza vaccine,
MMRIIMMRII
īŽ Neomycin, polymixin Measles, Mumps,Neomycin, polymixin Measles, Mumps,
RubellaRubella
īŽ IodineIodine iodine water purificationiodine water purification
tabstabs
īŽ QuinineQuinine ChloroquineChloroquine
īŽ Food allergies Various, including,Food allergies Various, including,
seafood, peanutsseafood, peanuts
īŽ PetsPets CatsCats
53. Risks of interventionRisks of intervention
īŽ 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
īŽ All interventions have potentialAll interventions have potential
risks, including giving the wrongrisks, including giving the wrong
adviceadvice
54. Risks of interventionRisks of intervention
īŽ Advice and educationAdvice and education
īŽ VaccinationVaccination
īŽ ChemoprophylaxisChemoprophylaxis
īŽ Screening and EffectiveScreening and Effective
managementmanagement
55. Risks of the interventionRisks of the intervention
īŽ Can the traveller tolerate theCan the traveller tolerate the
intervention?intervention?
īŽ Does the risk of the exposure justifyDoes the risk of the exposure justify
the intervention/cost?the intervention/cost?
īŽ Can the traveller afford theCan the traveller afford the
intervention?intervention?
īŽ What do you do if you canât provideWhat do you do if you canât 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
57. Pre-Travel Health AdvicePre-Travel Health Advice
needs Trainingneeds Training
īŽ Helps give structure andHelps give structure and
consistencyconsistency
īŽ Provides a framework for practiceProvides a framework for practice
īŽ Discusses evidence for practiceDiscusses evidence for practice
īŽ Policy and Procedures ManualPolicy and Procedures Manual
īŽ Consistent approach to travelConsistent approach to travel
healthhealth
58. 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
īŽ WHO ChecklistWHO Checklist
(www.who.int/ith)(www.who.int/ith)
īŽ Information on localInformation on local
conditionsconditions
īŽ PreventionPrevention
īŽ Accident avoidanceAccident avoidance
īŽ Medical and dentalMedical and dental
check-upcheck-up
īŽ NZPHR-PreventionNZPHR-Prevention
īŽ VaccinationsVaccinations
īŽ Health AdviceHealth Advice
īŽ PrescriptionPrescription
Source:
http://www.who.int/ith
59. VACCINATEVACCINATE (IHC)(IHC)
īŽ AlwaysAlways National scheduleNational schedule
īŽ OftenOften hepatitis Ahepatitis A
īŽ 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)
60. ADVISE AND DISCUSSADVISE AND DISCUSS
īŽ InsectsInsects repellents, nets, permethrinrepellents, nets, permethrin
īŽ IngestionsIngestions care with food and watercare with food and water
diet/teeth (includingdiet/teeth (including
airlines/jetlag/DVT)*airlines/jetlag/DVT)*
īŽ IndiscretionsIndiscretions STIâs, HIVSTIâs, HIV
īŽ InjuriesInjuries accident avoidance, personalaccident avoidance, personal
safetysafety
īŽ ImmersionImmersion schistosomiasisschistosomiasis
īŽ 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)
62. Giving the correct advice toGiving the correct advice to
travellerstravellers
īŽ Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
īŽ InformationInformation
īŽ TrainingTraining
īŽ ExperienceExperience
īŽ DocumentationDocumentation
īŽ TravellersTravellers
63. Travel health advice needs experienceTravel health advice needs experience
īŽ Letâs just do it!
īŽ Affiliation with a group with experience can be
useful
īŽ Travel clinic group
īŽ Travel medical advisory group (eg MASTA,
Worldwise, Travax etc)
īŽ University
īŽ 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.)
66. Travel is part ofTravel is part of
experienceexperience
īŽ 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
īŽ 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
67. Giving the correct advice toGiving the correct advice to
travellerstravellers
īŽ Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
īŽ InformationInformation
īŽ TrainingTraining
īŽ ExperienceExperience
īŽ DocumentationDocumentation
īŽ TravellersTravellers
68. Travel health advice needs toTravel health advice needs to
be documentedbe documented
īŽ Standardised forms/questionnairesStandardised forms/questionnaires
īŽ Informed consentInformed consent
īŽ International HealthInternational Health
Certificate/Vaccination recordCertificate/Vaccination record
īŽ Doctorâs letter/copy ofDoctorâs letter/copy of
prescription/medialert braceletprescription/medialert bracelet
īŽ Written advice/videos/Books/HealthWritten advice/videos/Books/Health
advisory documentsadvisory documents
69. 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
īŽ DocumentationDocumentation
īŽ Follow-upFollow-up
īŽ Use staff resourcesUse staff resources
īŽ Reinforce health adviceReinforce health advice
70. Giving the correct advice toGiving the correct advice to
travellerstravellers
īŽ Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
īŽ InformationInformation
īŽ TrainingTraining
īŽ ExperienceExperience
īŽ DocumentationDocumentation
īŽ TravellersTravellers
71. Travel Health Advice needsTravel Health Advice needs
TravellersTravellers
īŽ 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
īŽ Market travel health adviceMarket travel health advice
īŽ Direct, if possibleDirect, if possible
īŽ Join group/affiliateJoin group/affiliate
īŽ Links/promotion with traveller groups, travel agents,Links/promotion with traveller groups, travel agents,
travel insurance, consulates etctravel insurance, consulates etc
īŽ Join travellers health networks, such as ISTM, IAMATJoin travellers health networks, such as ISTM, IAMAT
etcetc
72.
73. LBNL Health Services and Travel
Medicine
âĸBefore 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
âĸDuring 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
âĸWhen you return
oFinish prophylactic medications
oIf you become ill, advise your doctor about your recent travel
74. Take home pointsTake home points
īŽ 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
īŽ Travelersâ health is a continuum and includes the pre-Travelersâ 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
īŽ 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
75. Practical pointsPractical points
īŽ Where toWhere to
īŽ For how longFor how long
īŽ For what purposeFor what purpose
īŽ Staying in what kind of placeStaying in what kind of place
īŽ Guided or notGuided or not
īŽ Previous developing world travel or notPrevious developing world travel or not
76. ConcernsConcerns
īŽ Past medical historyPast medical history
īŽ AllergiesAllergies
īŽ History of antimalarial use if anyHistory of antimalarial use if any
īŽ MedicationsMedications
īŽ Medical problemsMedical problems
īŽ History of depression, anxietyHistory of depression, anxiety
īŽ ContraceptionContraception
īŽ Review of past immunizationsReview of past immunizations
77. Bibliography
īŽ 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.
īŽ 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.
īŽ Cook, Gordon C, Ed.: Mansonâs Tropical Diseases, 20th Ed., W.B. Saunders Co.
Ltd, 1996.
īŽ DuPont HL, Steffen R (eds.): Textbook of Travel Medicine and Health, 2nd Ed.
B.C. Decker, 2001.
īŽ Guerrant, Walker, Weller: Tropical Infectious Diseases: Principles, Pathogens, &
Practice. Churchill Livingston, 1999.
īŽ Jong EC, Sanford C (eds.): The Travel and Tropical Medicine Manual, 4th ed.
Saunders/Elsevier, 2008.
īŽ Keystone JS, Kozarsky PE, Freedman DO, et al, eds: Travel Medicine. Mosby,
2004.
78. Bibliography (cont.)
īŽ Sanford, C: The Adventurous Travelerâs Guide to Health. University of
Washington Press, Seattle, 2008.
īŽ Sanford C. (guest editor): Primary Care Clinics: Travel Medicine.
Saunders/Elsevier, December 2002.
īŽ Strickland. Hunterâs Tropical Medicine and Emerging Tropical Diseases,
8th Ed., W.B. Saunders. 2000.
Travel medicine as an area of health science is concerned about health preparation of travelers and management of health problems in travelers. This definition comes from Leggat PA, Goldsmid JM. Primer of Travel Medicine. 3rd Ed. Brisbane: ACTM Publications, 2002.
Steffen states âthe art of travel medicine is selecting the necessary prevention strategy without unnecessary adverse events, cost or inconvenienceâ.
Steffen R, DuPont HL. Travel Medicine: Whatâs that? J Travel Med 1994; 1: 1-3.
There are a lot of people traveling. There are more and more people traveling; they are traveling further a field; and travelers can move rapidly from one part of the world to another.
There are more than 80 million people traveling each year from developed countries to developing countries.
As a consequence of travelers ability to cross borders and traveling to all points of the globe, they are exposed to a variety of hazards.
Steffen reminds us of the importance of taking pre-travel health advice. About half of travelers will experience some travel-related ailment.
Steffen R, DuPont HL. Travel Medicine: Whatâs that? J Travel Med 1994; 1: 1-3.
Some travelers may need to seek medical assistance abroad. The benefits of having travel health insurance are demonstrated here with a small proportion of travelers requiring hospitalization or aeromedical evacuation during travel.
Leggat PA, Griffiths R, Leggat FW. Emergency assistance provided abroad to insured travellers from Australia. Travel Medicine and Infectious Disease. 2005; 3: 9-17.
Despite the emphasis on infectious disease in travel medicine, the single most common preventable cause of death amongst travellers is accidental injury (Prociv, 1995; Steffen, 1991). About 35% of deaths of Australian travellers abroad were the result of ischemic heart disease, with natural causes overall accounting for some 50% of deaths (Prociv, 1995). Trauma accounted for 25% of deaths of Australians abroad (Prociv, 1995). Injuries were the reported cause of 18% of all deaths, with the major group being motor vehicle accidents, accounting for 7% of all deaths, which appeared to be over-represented in developing countries (Prociv, 1995). A similar pattern of mortality was observed in Swiss (Steffen, 1991), American (Baker et al., 1992), and Canadian (MacPherson et al., 2000) travellers abroad. Deaths of Australian tourists overseas have also resulted from air crashes, drowning, boating accidents, skiing accidents, bombs and electrocution (Prociv, 1995). Homicides, suicides and executions combined accounted for about 8% of all deaths (Prociv, 1995). Most fatal accidents in American and Swiss travellers were traffic or swimming accidents (Steffen, 1991; Baker et al., 1992). Deaths of tourists visiting Australia was similarly found to be due mainly to motor vehicle accidents and accidental drowning (Wilks et al., 2003). Infectious disease was reported as the cause of death in only 2.4% of Australians who died while travelling abroad (Prociv, 1995).
Prociv P. Deaths of Australian travellers overseas. Med J Aust 1995; 163: 27-30.
Steffen R. Travel medicine: prevention based on epidemiological data. Trans R Soc Trop Med Hyg 1991;85:156-162.
Baker TD, Hargarten SW, Guptill KS. The uncounted dead - American civilians dying overseas. Public Health Rep 1992; 107: 155-159.
MacPherson DW, Gurillot F, Streiner DL, Ahmed K, Gushulak BD, Pardy G. Death and dying abroad: The Canadian experience. J Travel Med 2000; 7: 227-233.
Wilks J, Pendergast D, Wood N. Accidental deaths of overseas visitors in Australia 1997-2000. J Hospitality Tourism Management 2003; 10: 79-89.
Travelers do get ill or injured abroad or when they return home. The commitment of travel health is a continuum from before the traveler leaves to after the traveler returns home.
Travel medicine is a continuum. We undertake a pre-travel consultation with the traveller, particularly in terms of health education, immunisations and prophylaxis, however we must also undertake contingency planning in case something happens to the traveller while they are abroad. Contingency planning might include advice on travel insurance, finding medical assistance abroad, encouraging first aid training in a family group, provision of a travellersâ first aid medical kit, or simply a doctorâs letter detailing medications to facilitate their replacement should their medications be lost. There is also a need to be concerned about their health post-travel in case the traveller has had an exposure, condition or injury that needs further treatment or rehabilitation.
Superimposed upon this are travellers from other parts of the World who may have had exposure, condition or injury that needs further treatment or rehabilitation during travel and they may also need a further pre-travel health consultation for those who may have changed or modified their itinerary.
With so many travelers traveling to disparate destinations, giving the correct advice becomes a challenge.
In order to provide travel health advice, the travel health adviser needs information. A complete risk assessment needs to be undertaken concerning the individual, the means of travel, the destination, and ultimately of any intervention that will be used. Each of these steps requires information.
Training in travel medicine provides a framework and an approach to using information from the risk assessment.
Information and training then leads to gaining experience. This helps to put the information and training in perspective.
Documentation of each step of the travel health consultation is needed medico-legally, but it is also important for quality assurance and reinforcing travel health advice.
Lastly, travel medicine needs travelers.
Each of these areas will be discussed in turn.
There remain a number of key National Government, World Health Organization (WHO), commercial and related publications, which provide guidelines and advice for travel medicine practice. In addition, there are a number of valuable Internet and related resources, which also provide valuable information on disease distribution and prevention. Access to current policy guidelines and up-to-date health intelligence, usually provided in travel medicine from Internet-based resources, is essential.
The World Health Organization International Travel and Health site is always a useful place to find information on risks of particular destinations (see http://www.who.int/ith). It also discusses mandatory vaccinations required under International Health Regulations.
The two major peer-reviewed journals in the travel medicine area are presently the ISTMâs Journal of Travel Medicine, published by BC Decker, and Travel Medicine and Infectious Diseases, published by Elsevier Science. The Journal of Travel Medicine is the oldest journal in travel medicine and is indexed on PubMed.
Continuing epidemiological research is essential for a better understanding of the epidemiology of travel related diseases and injuries, which in turn leads to the development of improved guidelines in travel medicine and more effective preventive measures to combat infectious diseases and prevent injuries associated with travel.
Travel medicine education is available both nationally and internationally through a range of continuing education programs and academic certificate, diploma, or mastersâ programs.
In the clinic setting, it is preferable that as much information as possible is obtained well before the traveller presents for their first face-to-face consultation.
The process of risk assessment in travel medicine is not unlike risk assessment in other disciplines.
It is important in travel medicine to establish the risks of the destination and the mode of travel in terms of the hazards and the potential exposure to these hazards and to examine the travellerâs medical history to establish host risks, which may impact on selection and use of interventions in the pre-travel health consultation.
These are then weighed up against the risks of the intervention.
These various facets of risk in travel medicine are summarised here.
In establishing the risks of the destination, it can be useful to have an atlas and find the places that travellers are going to.
The risks of the mode of transportation cannot be underestimated.
While considerable attention has been focussed on DVT and VTE, it remains uncertain what the contribution of air travel is to the development of this condition amongst travellers. What seems to be clear is that the development of DVT and VTE is multifactorial.
Some travellers may not meet medical guidelines to travel or may need special clearance to fly on commercial aircraft, such as with pre-existing illness, pregnancy, recent surgery or serious physical or mental incapacity.
Detailed medical information also needs to be obtained from the traveller and their records or referral letter from their usual health provider, which may influence their risks for travel and the advice given to them.
Some examples of risks that can be elicited from the medical history are given here.
These risks may influence the advice or prophylaxis given in the pre-travel health consultation.
Allergies amongst travellers should not be underestimated and some of the common allergies and their potential impact on the travel health consultation.
Addressing risk in travel medicine basically relate to modifying risks established in the pre-travel or post-travel consultation.
The risk of travel may be modified by appropriate preventive measures.
In weighing up the foregoing risk assessment against the decision to use a vaccine or chemoprophylactic agent, it is essential to ask these questions.
There needs to be awareness of current travel health policies, guidelines, consensus statements and other sources of evidence.
Educational programs and training help to provide a framework for travel health practice as well as discussing the evidence for practice. This will in turn lead to the development of a âpolicy and procedures manualâ for practice. This provides a basis for developing a consistent approach to travel health.
Having a checklist or a standardized approach to travel medicine can be useful. The World Health Organization (WHO) provides examples of the types of areas that need to be covered. See http://www.who.int/ith
The areas to be covered in the pre-travel consultation include vaccinations, health and safety advice and medications and prophylaxis (after Ingram et al., 1996).
Ingram RJH, Ellis-Pegler RB. What's new in travel medicine? NZ Public Health Rep 1996; 3(8): 57-59.
The practice or clinic staff can assist by ensuring that this information is obtained before the formal consultation. It is important that the procedure is made time efficient for a practice improve flow and profitability.
The areas to be covered under vaccination, health advice and prescription are overviewed and will be discussed in more detail in the SuperCourse Lecture, Pre-Travel Health Consultation. Vaccinations for travel include mandatory vaccines, a review of routine vaccinations offered under the national schedule, and various travel related vaccines. It is important that those who advise on travel health obtain a copy of their national guidelines for immunization, as well as any other relevant travel health guidelines.
In general, these are the main areas to cover in the pre-travel health consultation, which are covered by a mnemonic â the 6 Iâs, although other mnemonics are used. The World Health Organization checklist mentioned earlier could also be used to help structure travel health advice (See www.who.int/ith).
It is important to plan for a stock of regular medication that is normally taken by the traveler, as well as examining the need for a travelersâ medical kit and prophylaxic drugs, such as for malaria. It is also important that those who advise on travel health obtain a copy of their national guidelines for malaria chemoprophylaxis, as well as any other relevant travel health guidelines.
Experience in travel medicine can be gained in a number of settings.
Making the decision to work in the area of travel medicine is an important first step, which should be followed by training. It may be useful initially for those new to travel medicine to affiliate with a travel clinic group, a medical advisory service or perhaps other institutions, suhc as universities (e.g. university health services). Further, some research in New Zealand found an association between those interested in travel mediicne and having had tropical medicine/developing country experience (Leggat et al., 1999).
Leggat PA, Heydon JL, Menon A. Training, experience and interest of general practitioners in travel medicine in New Zealand. Journal of Travel Medicine. 1999;6: 60-65.
Travel should be considered an important part of experience in travel medicine.
It is useful for travel health advisors to have actually traveled to some of the destinations that their travelers are going to. It aids communication of the risks and the provision of travel health advice, but it also helps build a positive travel experience.
A common theme running through medical and health practice today is documentation.
In travel health practice, documentation of each step of the pre-travel health consultation is essential. Standardized forms could be used for this purpose.
Health and safety advice needs to be reinforced with travelers. Various staff and resources may be employed to follow-up and reinforce travel health advice.
Travel medicine practice cannot exist without travelers.
In the general practice setting, it may be useful to inform potential travelers that the clinic provides this service. For travel clinics, it may be useful to advertise, if possible, and market travel health services to the public, to the industry and to the medical profession. Affiliation with networks can be useful.
Various tools are used to remind travellers of the need to seek travel health advice and seek this advice early. An example of a bookmark provided by travel agents to travellers in Australia is given here. It reinforces the main areas of travel health advice and also the need to seek more comprehensive travel health advice from a qualified source. This bookmark was originally produced by the Australian Travel Health Advisory Group (see http://www.welltogo.com.au)
These points need to be kept in mind while undertaking the Pre-travel health consultation, which is the subject of another SuperCourse Lecture.