Preparing Students for International Travel

1. Preparing Students for International Travel Gail Rosselot, NP, MS, MPH, COHN-S, CTH Travel Well of Westchester Briarcliff Manor, NY

2. ACHA Presentation FR 180 This presentation was delivered on Friday, June 2, 2006 at the annual meeting of the American College Health Association held at the Marriott Marquis in NYC. It is published on this website as a supplementary resource for those health professionals who attended the program and for other clinicians with an interest in the topic.

3. The Presenter Gail Rosselot is a certified adult nurse practitioner with more than 20 years experience providing travel health care in a variety of clinical settings, including college health, occupational health, ambulatory care and infectious diseases. Ms Rosselot has maintained Travel Well of Westchester, a private practice for consulting, education and patient care, since 1991 in Briarcliff Manor, NY. She writes and lectures frequently on travel health topics at national and international meetings of AAOHN, ACHA, ISTM, and the VNAA. Since 2002 she has taught a short course in pre-travel care, The Westchester Course, as well as on-site clinical practicum.

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5. Overview This 90 minute session will review: • General health risks for international travelers • Pre-travel preparation for the college student • Suggested site requirements to promote quality travel health care in the college setting • Student challenges!

6. Part I • Introduction to travel health and the risks of international travel for students • The pre-travel consultation visit: • assessment of traveler and trip • itinerary search for vaccine & non-vaccine preventable hazards

7. “More and more people are traveling each year to unhealthy places”Jane Howarth, MD, author Bugs, Bites & Bowels • At least 40 million Americans travel internationally each year • 8 million to developing countries • Everyone now travels abroad: young, old, persons with chronic disease, disabilities, and pregnancy • They travel for pleasure, humanitarian work, business, to visit friends and relatives • International student travel for study and all other reasons is increasing at U.S. colleges

8. What is the health experience of travelers? • If 100,000 travelers go to developing countries x 1 month (Steffen et al): • 50,000-75,000 develop some health problem (30% TD) • 8,000 will see a physician about the problem • 5,000 will stay in bed & 300 will be hospitalized • 50 air evacuated & 1 will die • But individual risk will vary depending upon a number of variables Steffen, R et al. (1987) J of Infectious Disease, 156, 84-91

9. CDC, 2001,Health Information for International Travel

10. Important to Remember • Individual health risk is not quantifiable • Travelers at risk for trauma, routine illness & exotic disease • #1 causes of death in travelers: accidents & cardiovascular disease • Risk varies with geographic destination, but also health status of the traveler, trip activity, & duration

11. Travel health care is the prevention & management of injury and illness in travelers

12. Not all travel is alike:risk is individualized, not universal Travel health prevention strategies must be customized, realistic, & attainable

13. The Trip Risk Reduction Process Pre-travel Consultation is cornerstone of care • Risk Assessment • Traveler & Trip • Risk Reduction Efforts • Pharmacological • Immunizations • Medications / Med Kit • Non-Pharmacological • Health counseling • Referrals • Monitoring & Evaluation • Policies & Services

14. Four Step Process • Step 1: • Ask student about his / her health • Step 2: • Ask student about trip plans • Step 3: • Research trip risks & health recommendations • Step 4: • Create and implement plan to reduce travel health risks

15. Risk AssessmentAsk Student About Self: • Age, gender, place of birth • Travel medical evacuation insurance • Who will pay for travel care? • Prior travel experience • Hobbies, recreational interests

16. More Critical Questions for Student • Medical history: chronic, new or unstable problems? other red flags*? • Pregnancy / or risk of pregnancy • Immunity issues? • Meds: all including Rx and OTC • Allergies (vaccines, components, environment, foods, etc) • Immunizations: full history of vaccinations and vaccine preventable diseases, past titers? scheduling problems? documentation issue? * Could be problem during the trip

17. Use Pre-printed Assessment Documentsfor completeness, clarity & continuity For example: Thompson, Routine and Travel Immunizations,2004 Or Rosselot (2004) AAOHN J, 52(1), 28-41

18. Risk AssessmentAsk the Student About Trip • Exact itinerary: all destinations in order of travel- specific regions to be visited; all airport landings; any possible trip extensions? • Departure: how far off? 4 to 6 wks? short-notice? traveler accessible in interim? • Trip duration & season: > 3 wks, long-stay?

19. More Trip Variables • Rural vs urban travel / remote? • Trip purpose & activities: study, leisure, HCW? VFR (visiting friends & relatives)? • Accommodations: 5 – 3 – 0 star, private homes? camping, long-stay apartment? • Modes of transportation: air, car, public buses & trains, biking, hiking, ship • Contact: local people, children, animals?

20. Destination Search • Use a dedicated computer with Internet and printer access • Starts with visit confirmation • Use updated resources only! • Use multiple resources as may be needed for maps, outbreak information, activity risks, and vaccine recommendations • Search all destinations in order of travel, including airport landings

21. Outcome of Itinerary Search • After completing your internet search you will have: a print-out of health and safety risks for trip destinations that includes: • Recommendations for travel vaccinations • Recommendations for travel medications (e.g. anti-malarial agents) • Suggestions for health counseling topics • Area maps and local contact numbers for consulates, others

22. Combining information from your assessment& your itinerary search, you are now creating your risk reduction plan… 1. With the student, identify immunizations needed for this itinerary- then create a schedule for administration 2. Prioritize non-vaccine preventable risks and create a patient education plan 3. Determine if you need to recommend any travel medications or supplies (e.g. repellent). Write or obtain prescriptions for any indicated Rx drugs such as anti-malarials or antibiotics. 4. Determine if you need to make any referrals (e.g. dentist, source for overseas vaccines, etc)

23. U.S. Search Resources • www.cdc.gov/travel: site for patients, good updates on outbreaks, excellent resource for in-depth information on travel health risks • Travax @ www.shoreland.com: subscription software for the provider • International SOS @ www.travelcare.com: subscription software for the provider • U.S. State Department Travel Information @ www.travel.state.gov: information on visas, country alerts, etc • International Society of Travel Medicine @ www.istm.org: members can participate in ListServe to get answers to individual patient issues

24. Accidents Food and water precautions Insect precautions Malaria prevention STI’s Safety & security Environmental: sun, heat, cold, altitude Travel evacuation insurance Special needs Cultural Issues Post-trip / re-entry Risk Reduction Plan- your counseling plan may include any of these topics:

25. End of Part I In the next set of slides, you will review the different travel vaccines available to protect your student