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TRAVEL MEDICINE

TRAVEL MEDICINE. “When hoof beats might be zebras” Dr. Januchowski. OBJECTIVES. Be able to identify the key items to discuss with patients travelling internationally Be able to discuss with patients the resources available to help them stay healthy while travelling

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TRAVEL MEDICINE

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  1. TRAVEL MEDICINE “When hoof beats might be zebras” Dr. Januchowski

  2. OBJECTIVES • Be able to identify the key items to discuss with patients travelling internationally • Be able to discuss with patients the resources available to help them stay healthy while travelling • Know some of the important illness patterns to watch for when patients return from overseas adventures

  3. Travel Medicine

  4. Travel Medicine

  5. Travel Medicine Consultation • Risk Assessment • Risk Communication • Risk Management

  6. Risk Assessment • Typically done 1-2 months prior to travel • Itinerary data • Traveler demographics and health/medical history

  7. Risk Assessment Itinerary data Traveler demographics Age, sex Vaccination history, including dates, how many doses received in a scheduled series, and prior adverse events Medical and psychiatric history (past and current), including any conditions or medications that suppress the immune system Medications (current or taken in the past 3 months) Allergies (in particular to eggs, latex, yeast, mercury, or thimerosal) Pregnancy and breastfeeding (current status and plans) Any planned surgeries or other medical care during travel (medical tourism) • Countries and regions to be visited, in the order of travel • Visits to urban versus rural areas • Dates and length of travel in each area • Purpose of travel (such as business, vacation, visiting friends and relatives) • Modes of transportation • Planned and possible activities (such as hiking, scuba diving, camping) • Types of accommodations in each area (such as air-conditioned, screened, tents)

  8. Risk Communication • Plan based on Risk Assessment • Evidence Based plan of action developed with the traveller

  9. Risk Management • Implementation of the plan • Vaccines • Medications • Education • General Guidance

  10. Case #1 • 44 y.o. male patient presents 2 months before a planned trip to Suriname for business with his employer, ALCOA

  11. Risk Assessment - Itinerary • Countries and regions to be visited, in the order of travel • Visits to urban versus rural areas • Dates and length of travel in each area • Purpose of travel (such as business, vacation, visiting friends and relatives) • Modes of transportation • Planned and possible activities (such as hiking, scuba diving, camping) • Types of accommodations in each area (such as air-conditioned, screened, tents)

  12. Risk Assessment – Traveler info • Age, sex • Vaccination history, including dates, how many doses received in a scheduled series, and prior adverse events • Medical and psychiatric history (past and current), including any conditions or medications that suppress the immune system • Medications (current or taken in the past 3 months) • Allergies (in particular to eggs, latex, yeast, mercury, or thimerosal) • Pregnancy and breastfeeding (current status and plans) • Any planned surgeries or other medical care during travel (medical tourism)

  13. Let’s talk about vaccines

  14. Risk Management – Vaccines • Routine • Required • Recommended

  15. Routine Vaccines • Would include childhood immunizations • Boosters (Tdap, MMR)

  16. Required Vaccines • Yellow fever vaccine • Sub-Saharan Africa • Tropical South America • Meningococcal vaccine for annual travel to the Hajj in Saudi Arabia

  17. Recommended Vaccines • Varies based on • Destination • Itinerary • Traveller demographics • Check website

  18. Typhoid • Salmonella enterica • Fecal-oral route of transmission • Fever, headache, malaise • Intestinal perforation and hemorrhage complications • Can be treated with antibiotics

  19. Typhoid Vaccine Injectable Oral (Live, attenuated) 4 dose series Good for 5 years Age 6 and older Should complete series one week before travel • One dose series • Good for 2 years • Age 2 and older • Should be given >2 weeks prior to travel Cost for vaccine ~$80-100

  20. Yellow Fever • Transmitted by mosquito • Fevers, malaise • Can cause hepatitis, hemorrhagic complications • Supportive treatment

  21. Yellow fever vaccine • Must be administered by a certified health center • ~$100-125 • Good for 10 years

  22. Yellow fever vaccine • Contraindications • Less than 6 months old • Immunocompromised status • Primary immunodeficiency • HIV with CD4<200 • Malignant neoplasms

  23. Risk management • The patient has scheduled times for his vaccinations • What other information can be provided for this traveller?

  24. Risk management • Malaria prevention • Treatment of common travel illnesses • General Education • Food and drink safety • Accident avoidance • Safe sexual practices

  25. Malaria prevention • Determine risk • Prevent mosquito bites • Medication prophylaxis

  26. Malaria Chemoprophylaxis • Atovaquone-proguanil • Chloroquine • Doxycycline • Mefloquine • Primaquine

  27. Malaria Chemoprophylaxis

  28. What other recommendations?

  29. Travel Medicine Kit • Include items for treatment of common illnesses • Watch for flight regulations • International regulations on transport of medications

  30. Travel Med Kit • Routine prescribed medicines • Antidiarrheals • Bismuth products (treatment or prophylaxis) • Loperamide (Imodium) • Ciprofloxacin 500 mg BID x 2 • Azithromycin 1 gm x 1 • Rifaximin (non-FDA approved, off label use for prophylaxis) Treatments

  31. Travel Med Kit (cont.) • Insect repellents • DEET (30-50%) • Picaridin • Oil of Lemon Eucalyptus or PMD • IR3535 • Permethrin impregnated clothing / bed netting

  32. Travel Med Kit (cont.) • Water purification tablets • Pain medicines (OTC) • Sunscreen • Antibacterial skin cleanser / wipes

  33. Case (cont.) • The patient travels and returns without any noted incidents. • Proper education allowed the patient to • Know the precautions after return regarding illness reporting • Know the importance of completing malaria prophylaxis medications

  34. Post travel visit • Ensure malaria medicines are completed • 4 weeks for doxycycline / mefloquine • 7 days for atovaquone/proguanil • Review travel history

  35. Post travel visit - Illnesses • Fever • Persistent GI complaints • Skin lesions or rashes • Respiratory infections

  36. Post travel visit - Fever • Malaria (up to one year!) • Dengue • Invasive bacterial diarrhea • Hepatitis A • Typhoid • Rickesial infections • Influenza (remember patterns) • Viral illnesses NOS

  37. Post travel visit – GI Concerns • Acute bacterial/parasitic gastroenteritis • Giardia • C. difficile • Unmasking of underlying GI disease • Postinfectious IBS • Lactose intolerance • Celiac disease • Tropical sprue • Brainerd diarrhea

  38. Post travel visit – Skin lesions • Non-specific dermatitis • Insect bites • Pyoderma • Scabies • Cutaneous larva migrans

  39. Assessing Risk by Incubation Period

  40. OBJECTIVES • Be able to identify the key items to discuss with patients travelling internationally • Be able to discuss with patients the resources available to help them stay healthy while travelling • Know some of the important illness patterns to watch for when patients return from overseas adventures

  41. Questions? • rjanuchowski@vcom.edu

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