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UCSF Travel Clinic Well On Your Way


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UCSF Travel Clinic Well On Your Way

  1. 1. Well On Your Way Travel Advice from the UCSF Student Health Services Travel Clinic Beth Pirkle, RN, CTH May 13, 2009
  2. 2. Objectives <ul><li>Identify elements that should be considered during pre-travel planning and preparation </li></ul><ul><li>Learn strategies for staying well during travel </li></ul><ul><li>Learn what to do if you are sick or injured while abroad </li></ul><ul><li>Identify post-travel healthcare needs </li></ul>
  3. 3. Pre-Travel Self-Education <ul><li>Where Are You Going? </li></ul><ul><li>What Are You Doing? </li></ul><ul><li>With Whom Are You Doing It? </li></ul><ul><li>How Are You Getting There? </li></ul><ul><li>How Long Are You Staying? </li></ul>
  4. 4. Where Are You Going?
  5. 5. Where Are You Going? <ul><li>Developed or Developing Countries? </li></ul><ul><li>Single or Multiple Locales? </li></ul><ul><li>Set or Unfixed Itinerary? </li></ul><ul><li>Urban, Rural, or Both? </li></ul><ul><li>Environment: Beach, Jungle, Mountain? </li></ul><ul><li>Language and Culture Familiarity </li></ul><ul><li>Natural Disasters </li></ul>
  6. 6. What Are You Doing?!?!
  7. 7. What Are You Doing? <ul><li>Clinical Care-giving </li></ul><ul><li>Research </li></ul><ul><li>Physical Activities </li></ul><ul><ul><ul><li>Hiking/Backpacking/Trekking </li></ul></ul></ul><ul><ul><ul><li>Scuba Diving </li></ul></ul></ul><ul><ul><ul><li>Rafting </li></ul></ul></ul><ul><ul><ul><li>Swimming/Snorkeling </li></ul></ul></ul><ul><ul><ul><li>Bicycling </li></ul></ul></ul>
  8. 8. Bolivian “Highway of Death”…
  9. 9. … is now a mountain biking adventure trip…
  10. 10. …with predictable results <ul><li>Friday , April 25, 2008 </li></ul><ul><li>LA PAZ, Bolivia — </li></ul><ul><li>A packed SUV collided with a group of cyclists on Bolivia’s “Highway of Death” on Thursday, killing nine people — including a British man who was the second foreign tourist to die this week along the notorious road. </li></ul><ul><li>The accident took place just minutes after the cyclists began their tour on a paved section </li></ul>
  11. 11. With Whom Are You Doing It? <ul><li>Clinical or Research Group </li></ul><ul><li>NGO </li></ul><ul><li>Organized Tour Group </li></ul><ul><li>Family Member(s) </li></ul><ul><li>Friend(s) </li></ul><ul><li>Solo </li></ul><ul><li>Visiting Friends and Relatives (“VFRs”) </li></ul>
  12. 12. How Are You Getting There? <ul><li>Long-haul plane flights </li></ul><ul><li>Local airlines </li></ul><ul><li>Border crossings </li></ul><ul><li>In-country transportation: </li></ul><ul><li>Buses, ferries, trains, taxis, bicycles </li></ul><ul><li>Most common form of transportation is your own two feet. </li></ul>
  13. 13. How Long Are You Staying? <ul><li>Generally speaking, increased length of stay increases your risk of illness and injury. </li></ul><ul><li>Probably correlates to “getting off the beaten path” where fewer services for tourists exist. </li></ul><ul><li>“ VFRs” are at highest risk. </li></ul>
  14. 14. Pre-Travel Preparation <ul><li>Travel Consult: 4-8 weeks before departure, earlier if you or your trip are complicated. Locate and bring your immunization records to the consult. </li></ul><ul><li>Routine and travel-related vaccinations, prescriptions, and supplies. </li></ul><ul><li>Insurance coverage. </li></ul><ul><li>Special concerns for clinicians, researchers, and volunteers. </li></ul>
  15. 15. Immunizations <ul><li>Routine: MMR, Varicella, Hep B, TdaP </li></ul><ul><li>Travel: Hep A for all travelers </li></ul><ul><li>Polio for parts of India/Nepal and Africa </li></ul><ul><li>Typhoid Fever for S/SE Asia, C/S America, consider for parts of Africa </li></ul><ul><li>Yellow Fever for parts of Africa and C/S America </li></ul><ul><li>Meningococcal Meningitis for parts of Africa and India; consider for all areas if involved in clinical work. </li></ul><ul><li>Rarely: JE, Rabies </li></ul><ul><li>Flu shot if didn’t get during flu event </li></ul>
  16. 16. Medications and Self-Care <ul><li>Bring a well-stocked medical kit. Include OTC meds for URIs, GI upset, pain relief and first aid. Include a thermometer!! </li></ul><ul><li>Rxs for abx, malaria chemoprophylaxis and routine meds; tamiflu if high risk pt. </li></ul><ul><li>Flashlight, duct tape, dental floss </li></ul><ul><li>Consider taking a basic first aid or wilderness med course </li></ul>
  17. 17. Health Science Students Overseas <ul><li>Determine type of health care facility, supervision, type of patients, need for supplies, water purification, and living situation prior to travel. </li></ul><ul><li>HIV PEP referral if indicated. </li></ul><ul><li>Know TB status. PPD prior and 3 months post-travel. </li></ul><ul><li>Consider meningococcal vaccine. </li></ul>
  18. 18. Insurance Coverage <ul><li>Registered students are automatically enrolled in SOS International Traveler’s Insurance. </li></ul><ul><li>Uninsured students are STRONGLY advised to obtain traveler’s insurance. </li></ul><ul><li>Website: </li></ul><ul><li>Member # 11bsgm000060 </li></ul>
  19. 19. University Business and Insurance Coverage <ul><li>Students traveling outside California on “university business” are also covered under the University of California Risk Management program. </li></ul><ul><li>“ University business” : Students, faculty and staff traveling on UC-sponsored business, i.e. a class, conference, rotation or research project funded through the university. </li></ul>
  20. 20. Staying Well While Abroad <ul><li>Prevent traveler’s diarrhea </li></ul><ul><li>Avoid MVAs, including ped and bike vs car </li></ul><ul><li>Minimize street crime temptation </li></ul><ul><li>Prevent injuries </li></ul><ul><li>Prevent altitude sickness </li></ul><ul><li>Diving safety </li></ul><ul><li>Mental health </li></ul><ul><li>Prevent insect bites </li></ul><ul><li>Malaria chemoprophylaxis </li></ul><ul><li>Avoid animal bites </li></ul>
  21. 21. H1N1 Flu <ul><li>5728 cases in 33 countries as of today </li></ul><ul><li>5 deaths outside of Mexico </li></ul><ul><li>Deaths all had underlying chronic conditions </li></ul><ul><li>Illness appears mild </li></ul><ul><li>Higher contagion rate (22-33% vs 5-15% for older flu strains </li></ul><ul><li>Droplet transmission, not oral-fecal: eating pork is fine as long as no one coughs or sneezes on it. </li></ul><ul><li>Younger population d/t less immunity </li></ul><ul><li>Seasonal flu still showing up: Get a flu shot </li></ul>
  22. 22. H1N1 Flu Con’t <ul><li>WHO: No travel restrictions advised </li></ul><ul><li>Individual countries control measures </li></ul><ul><li>Social isolation is primary method of controlling pandemic </li></ul><ul><li>Monitor situation as flu is very mutagenic </li></ul><ul><li>Vaccine is being developed by WHO </li></ul><ul><li>Delay travel if you are ill. Seek appropriate medical care if you fall ill after return. </li></ul><ul><li> </li></ul>
  23. 24. Preventing Traveler’s Diarrhea <ul><li>About 50% of people traveling for 2 weeks or longer experience TD. </li></ul><ul><li>Think common sense and surface area when making food and beverage choices. </li></ul><ul><li>HANDWASHING!!! Carry alcohol gel and use it liberally and often. </li></ul><ul><li>80-85% TD is bacterial: Abx if moderate-severe diarrhea develops </li></ul>
  24. 25. Food Precautions <ul><li>Mango lassi </li></ul><ul><li>“ Barely pink” chicken </li></ul><ul><li>Quiche </li></ul><ul><li>Ice cubes </li></ul><ul><li>Lasagna </li></ul><ul><li>Spinach salad </li></ul><ul><li>Ceviche </li></ul>
  25. 26. Water Precautions <ul><li>Boiling is Best </li></ul><ul><li>Immersion Coil </li></ul><ul><li> </li></ul><ul><li>Purifier </li></ul><ul><li>Halogen </li></ul><ul><li>Bottled Water </li></ul><ul><ul><li>Carbonated </li></ul></ul><ul><ul><li>Know the Source </li></ul></ul><ul><ul><li>Check the Seal </li></ul></ul>
  26. 27. Motor Vehicle Accidents <ul><li>MVAs are the most common cause of death of young travelers. </li></ul><ul><li>Injuries that are survivable in U.S. are often not survivable abroad. </li></ul><ul><li>Motorists in Accra, Ghana: </li></ul><ul><ul><li>722 randomly selected drivers </li></ul></ul><ul><ul><li>21% had blood EtOH >80 mg/dl </li></ul></ul><ul><ul><li>3.7% of bus drivers and 8.0% truck drivers had blood EtOH >80% </li></ul></ul>
  27. 28. Crime and Security <ul><li>Money belt around waist or neck </li></ul><ul><li>Don’t get drunk/high. </li></ul><ul><li>Avoid military-style clothing: No camouflage patterns </li></ul><ul><li>Modest dress: shorts can be problematic for men, too. </li></ul><ul><li>Avoid informal taxis, ask hotel to phone for one </li></ul><ul><li>Leave the laptop at home </li></ul><ul><li>Be prepared for self-reliance in the event of an emergency (fire, flood, earthquake, etc.) </li></ul>
  28. 29. Injury Prevention <ul><li>Drowning #2 after MVAs as cause of death. </li></ul><ul><li>Don’t swim at unmarked beaches/unfamiliar waters </li></ul><ul><li>Do not combine EtOH/drugs with swimming, boating or driving </li></ul><ul><li>Check depth, even in swimming pools with diving boards, before diving </li></ul>
  29. 30. EtOH and Drugs <ul><li>Increased use over baseline = increased risk for accidents and at-risk sexual behaviors. </li></ul><ul><li>Sample of travelers to India, Thailand, Laos, Nepal, Vietnam, 54% used illicit drugs some time on trip </li></ul><ul><li>Most common was cannabis </li></ul><ul><li>Dire legal consequences </li></ul>
  30. 31. Sex <ul><li>>40% of travelers worldwide will have a new sexual partner. </li></ul><ul><li>Most new sexual encounters are unplanned. </li></ul><ul><li>>50% of sexual encounters are with local residents; women are more likely to have sex with fellow travelers. </li></ul><ul><li>Men have more casual sex than women. </li></ul><ul><li>Longer length of travel correlates with increased number of sexual encounters. </li></ul><ul><li>Bring and use condoms every time. </li></ul><ul><li>PEP </li></ul>
  31. 32. High Altitude Illness <ul><li>Learn to recognize signs and symptoms of AMS, HACE, HAPE </li></ul><ul><li>Sxs are rare below 9,000 ft </li></ul><ul><li>Prevention: “Climb high, sleep low” </li></ul><ul><ul><li>Limit rise in sleeping altitude to 300m qd </li></ul></ul><ul><ul><li>Rest 1 day for every 1000m elevation gain (q3-4 days) </li></ul></ul><ul><li>Prevention: Acetazolamide </li></ul>
  32. 33. Diving <ul><li>Licensed Operators, Check References </li></ul><ul><li>Certification Course in U.S. </li></ul><ul><li>Do not fly for at least 24 hours after the last dive. </li></ul><ul><li>Allow more time if multiple dives on the same day or multiple days of diving. </li></ul><ul><li>Malaria chemoprophylaxis other than mefloquine </li></ul>
  33. 34. Mental Health <ul><li>Psychiatric reasons are most common cause for early return from assignment </li></ul><ul><li>Isolation, unfamiliar language/culture, illness are contributing factors </li></ul><ul><li>Under-prepared for clinical demands </li></ul><ul><li>Dangerous conditions and limited supplies </li></ul><ul><li>“Survivor guilt” </li></ul>
  34. 35. Preventing Insect Bites <ul><li>DEET is your friend </li></ul><ul><ul><li>High concentrations last longer </li></ul></ul><ul><ul><li>Extended release </li></ul></ul><ul><li>Picaridin 19% available Europe/Australia, newly available in US. </li></ul><ul><li>Repellants can reduce efficacy of sunscreen: put sunscreen on first. </li></ul><ul><li>Permethrin-treated clothing </li></ul><ul><li>Bed-nets </li></ul><ul><li>Air-conditioning </li></ul>
  35. 36. Malaria Chemoprophylaxis <ul><li>Chloroquine, Mefloquine, Malarone, Doxycycline </li></ul><ul><li>Malarone not easily obtainable in developing world </li></ul><ul><li>All require start before entry in malarial area and for some period of time after leaving </li></ul><ul><li>Do NOT stop taking even if diagnosed with malaria </li></ul>
  36. 37. Avoid Animal Bites
  37. 38. Animal Bites and Rabies <ul><li>More than 55,000 deaths annually from rabies. Rabies is 100% fatal. </li></ul><ul><li>70% from dog bites, 25% from cats, 4% from rats. </li></ul><ul><li>If bitten, WASH BITE for 15 minutes with soap and vigorously running water. </li></ul><ul><li>Seek IMMEDIATE medical care. You will probably need to be evacuated. Need RIG, Vaccine x 5 doses. </li></ul><ul><li>PEP vaccination is available but costly, +/- $600. </li></ul>
  38. 39. What If You Are Sick or Injured? <ul><li>Call SOS </li></ul><ul><li>ABCs and First Aid </li></ul><ul><li>Abx for TD </li></ul><ul><li>Descent for unresolved AMS, HACE or HAPE sxs </li></ul><ul><li>Provider visit if febrile </li></ul><ul><li>Rest and fluids </li></ul><ul><li>Avoid “curbside consults” </li></ul>
  39. 40. Back Home <ul><li>Allow time to adjust for jet lag </li></ul><ul><li>Reverse culture-shock </li></ul><ul><li>Continue your anti-malarials if indicated </li></ul><ul><li>12-week post-travel PPD </li></ul><ul><li>Immediate care for any illness with fever </li></ul><ul><li>Be sure to inform your provider of travel in malarial area up to one year post-travel, especially if you have a fever. </li></ul>