adventure travel areas of increased risk nova scotia safety

11

Adventure Travel Adventure Travel –– Areas of Areas of Increased RiskIncreased Risk

NSSC Conference March 31, 2005NSSC Conference March 31, 2005Jeannette Combes RNJeannette Combes RN

OHNANSOHNANS

22

OBJECTIVESOBJECTIVES•• TRAVEL MEDICINE AS AN INTERNATIONAL / GLOBAL TRAVEL MEDICINE AS AN INTERNATIONAL / GLOBAL

PUBLIC HEALTH ISSUEPUBLIC HEALTH ISSUE

•• CURRENT ISSUES CURRENT ISSUES SAFETY / CARDIOVASCULAR / ADVENTURE TRAVELSAFETY / CARDIOVASCULAR / ADVENTURE TRAVEL

•• PROBLEM AREAS FOR US HEALTH PROVIDERSPROBLEM AREAS FOR US HEALTH PROVIDERSYELLOW FEVER, MALARIA, RABIESYELLOW FEVER, MALARIA, RABIES

•• SPECIAL TRAVELERS SPECIAL TRAVELERS –– ARE YOU A SPECIAL ARE YOU A SPECIAL TRAVELLER?TRAVELLER?

•• OTHER TRAVEL MEDICINE ISSUESOTHER TRAVEL MEDICINE ISSUES

•• SOURCES OF HELP SOURCES OF HELP BOOKS, JOURNALS, LISTSERVS, INTERNETBOOKS, JOURNALS, LISTSERVS, INTERNET

33

TRAVEL MEDICINE IS AN TRAVEL MEDICINE IS AN

INTERNATIONAL / GLOBAL INTERNATIONAL / GLOBAL

PUBLIC HEALTH ISSUEPUBLIC HEALTH ISSUE

44

INTERNATIONAL TOURIST INTERNATIONAL TOURIST ARRIVALSARRIVALS

WORLD TOURISM ORGANIZATION (WTO)WORLD TOURISM ORGANIZATION (WTO)

1998 1998 -- 629 MILLION629 MILLION

1999 1999 -- 652 MILLION 652 MILLION

2000 2000 -- 697 MILLION 697 MILLION

2001 2001 -- 693 MILLION693 MILLION

Keystone JS, et al. Keystone JS, et al. Travel Medicine.Travel Medicine.New York: Mosby; 2004: Chapter 1.New York: Mosby; 2004: Chapter 1.

55

Travel NumbersTravel Numbers

•• Increase in international travelIncrease in international travel•• Increase in Increase in “Adventure Travel”“Adventure Travel”•• (continued growth despite 9/11)(continued growth despite 9/11)•• Increase in elderly travelersIncrease in elderly travelers•• Increase in medicated travelersIncrease in medicated travelers

66

THE BIG PICTURETHE BIG PICTUREGLOBAL HEALTH GLOBAL HEALTH

THE BIG FIVE (6THE BIG FIVE (6thth also) also) -- SMOKING, SMOKING, OBESITY, AIDS/HIV, MALARIA, TB OBESITY, AIDS/HIV, MALARIA, TB -- 66thth is is POLIO POLIO -- work in progresswork in progress

FeachemFeachem RGA. RGA. Tropical Medicine & International HealthTropical Medicine & International Health. 2004. 2004

77

Remember your Risk Assessment Remember your Risk Assessment PrinciplesPrinciples

•• Drive SoberDrive Sober•• Belt up (wear your safety belt)Belt up (wear your safety belt)•• Look where you are goingLook where you are going•• Wear the gearWear the gear•• Get the trainingGet the training•• Health & Safety come hand in handHealth & Safety come hand in hand

99

Why travel ?Why travel ?

•• ““I don’t know whether it’s because I’m I don’t know whether it’s because I’m growing older, and see the sunset from the growing older, and see the sunset from the top of my hill, but I find things more top of my hill, but I find things more fascinating nowadays. Everything opens up fascinating nowadays. Everything opens up avenues of discovery, and with alarm you avenues of discovery, and with alarm you realize you won’t every know a trillionth of realize you won’t every know a trillionth of what there is to know”what there is to know”

1111

She also said ………………She also said ………………

•• Traveling on airplanes was lovely when you were Traveling on airplanes was lovely when you were allowed to smoke. There was a feeling of the allowed to smoke. There was a feeling of the cocktail hour, time for chitcocktail hour, time for chit--chat and courtesies and chat and courtesies and compliments. The aircompliments. The air--conditioning had to work full conditioning had to work full blast to dispel the smoke, and in consequence all blast to dispel the smoke, and in consequence all the cold and flu germs were blown out into the the cold and flu germs were blown out into the ether at the same time. Nowadays they hardly ether at the same time. Nowadays they hardly change the air at all, so almost everyone get some change the air at all, so almost everyone get some sort of cold or bug during the flight, even on short sort of cold or bug during the flight, even on short trips ………………… Joanna Lumley in “No room for trips ………………… Joanna Lumley in “No room for Secrets”Secrets”

1212

PrePre--Planning: BEFORE THE TRIPPlanning: BEFORE THE TRIP•• DURABLE POWER OF ATTORNEY AND ADVANCE DURABLE POWER OF ATTORNEY AND ADVANCE

DIRECTIVESDIRECTIVES•• TRAVEL DOCUMENTS, PASSPORT, VISAS TRAVEL DOCUMENTS, PASSPORT, VISAS •• INTERNATIONAL CERTIF. VACC. (YELLOW BOOKLET)INTERNATIONAL CERTIF. VACC. (YELLOW BOOKLET)•• EMERGENCY CONTACTS AT HOME AND ABROAD EMERGENCY CONTACTS AT HOME AND ABROAD --

GIVE ITINERARY TO HOME PERSON(S)GIVE ITINERARY TO HOME PERSON(S)•• SPECIAL HEALTH NEEDS SPECIAL HEALTH NEEDS –– PREGNANCY / DIABETES / PREGNANCY / DIABETES /

HIV (know your blood type)HIV (know your blood type)•• STATE DEPT ADVISORIES / CDC (Centre for STATE DEPT ADVISORIES / CDC (Centre for

Infectious Diseases) UPDATESInfectious Diseases) UPDATES•• TRAVEL MEDICINE CLINIC FOR MEDS / TRAVEL MEDICINE CLINIC FOR MEDS /

IMMUNIZATIONS IMMUNIZATIONS

1313

BEFORE THE TRIPBEFORE THE TRIP (cont)(cont)•• SENIOR CITIZENS / RETIREESSENIOR CITIZENS / RETIREES•• PREGNANCY, INFANTS, YOUNG CHILDRENPREGNANCY, INFANTS, YOUNG CHILDREN•• VISTING FRIENDS & RELATIVIESVISTING FRIENDS & RELATIVIES•• SAFETY / DRIVING / SAFETY / DRIVING / COMMON SENSECOMMON SENSE•• KEEP LOW PROFILE KEEP LOW PROFILE –– JEWELRY / FURS STAY HOMEJEWELRY / FURS STAY HOME•• LANGUAGE / CULTURELANGUAGE / CULTURE•• TRAVEL INSURANCE TRAVEL INSURANCE –– DOES IT OFFER RETRIVAL?DOES IT OFFER RETRIVAL?

1414

Doctor, is it OK for me to fly?Doctor, is it OK for me to fly?

1515

MEDICAL GUIDELINES FOR MEDICAL GUIDELINES FOR AIRLINE TRAVELAIRLINE TRAVEL

•• www.asma.orgwww.asma.org

•• Aerospace Medical Association. 2003; Aerospace Medical Association. 2003; Medical Medical Guidelines for Airline TravelGuidelines for Airline Travel.. 2nd edition. 2nd edition. (Online in PDF (Online in PDF format)format) oror Aerospace Medical Association Medical Aerospace Medical Association Medical Guidelines Task Force. Guidelines Task Force. Medical Guidelines for Airline Medical Guidelines for Airline Travel, 2nd ed. Travel, 2nd ed. AviatAviat Space Environ MedSpace Environ Med. 2003 . 2003 May;74(5 Suppl):A1May;74(5 Suppl):A1--19. 19.

•• Comprehensive document, includes AED, emergency Comprehensive document, includes AED, emergency medical kits (EMK), medical risks, etc.medical kits (EMK), medical risks, etc.

1616

USEFUL TIPS FOR AIRLINE USEFUL TIPS FOR AIRLINE TRAVELERSTRAVELERS•• www.asma.orgwww.asma.org (click on useful tips)(click on useful tips)

•• PLAN AHEAD PLAN AHEAD Immunizations, donImmunizations, don’’t go if ill, check with yourt go if ill, check with yourdoctor, carry your meds with you, allowdoctor, carry your meds with you, allowample time, loose comfortable clothing,ample time, loose comfortable clothing,sit by wing if prone to air sickness.sit by wing if prone to air sickness.

•• IN FLIGHT IN FLIGHT Eat lightly, drink water/fruit juice, Eat lightly, drink water/fruit juice, little/no alcoholic beverages, walk and/orlittle/no alcoholic beverages, walk and/orexercise in seatexercise in seat

1717

JET LAGJET LAG•• MELATONIN (still controversial)MELATONIN (still controversial)•• PHOTOTHERAPYPHOTOTHERAPY•• SHORTSHORT--ACTING HYPNOTICSACTING HYPNOTICS

MUST AVOID ALCOHOL ( e.g. MUST AVOID ALCOHOL ( e.g. HalcionHalcion))

Excellent discussion of jet lag, pediatric, Excellent discussion of jet lag, pediatric, women women -- pregnancy issues in pregnancy issues in JongJong EC and EC and McMullen R, eds. McMullen R, eds. The Travel and Tropical Medicine The Travel and Tropical Medicine ManualManual. 3rd ed. Philadelphia, Pa: Saunders/Elsevier; . 3rd ed. Philadelphia, Pa: Saunders/Elsevier; 2003.2003.

1818

Jet Lag Jet Lag –– other ways to reduceother ways to reduce

•• When possible, choose daytime flights to minimize loss of When possible, choose daytime flights to minimize loss of sleep and fatiguesleep and fatigue

•• Avoid large fatty meals, caffeine, and alcohol during the Avoid large fatty meals, caffeine, and alcohol during the flightflight

•• Drink lots of waterDrink lots of water•• Regular timed exposure to daytime outdoor light or high Regular timed exposure to daytime outdoor light or high

intensity artificial light can be useful in improving jet lagintensity artificial light can be useful in improving jet lag•• There is no current evidence to the usefulness of There is no current evidence to the usefulness of

homeopathic remedies or diet in the treatment or homeopathic remedies or diet in the treatment or prevention of jet letprevention of jet let

2020

While on the topic of Jet LagWhile on the topic of Jet Lag

•• Prevention of venous stasis (pooling in the legs). Prevention of venous stasis (pooling in the legs). Travelers can help decrease their risk of DVT while Travelers can help decrease their risk of DVT while traveling.traveling.

•• Wear comfortable, looseWear comfortable, loose--fitting clothing when fitting clothing when possible possible –– avoid clothing that binds at the kneeavoid clothing that binds at the knee

•• When practical and safe, walk around in the When practical and safe, walk around in the aircraft cabin at least every hour. This is easiest if aircraft cabin at least every hour. This is easiest if you book an aisle seat.you book an aisle seat.

2121

Preventive Measures DVTPreventive Measures DVT

•• Stand up at your seat and stretch your arms Stand up at your seat and stretch your arms periodically. Many airlines now provide periodically. Many airlines now provide video presentations on stretching exercises.video presentations on stretching exercises.

•• Avoid crossing your legs since this may Avoid crossing your legs since this may decrease blood circulation to your legsdecrease blood circulation to your legs

•• At transit stops, get up and walk aroundAt transit stops, get up and walk around•• Prevent dehydrationPrevent dehydration•• Enjoy yourselfEnjoy yourself

2222

AIRLINE ADVISORIESAIRLINE ADVISORIES•• Check individual airlines Check individual airlines -- 4848--72 hr notice required 72 hr notice required

for oxygen for oxygen -- cannot bring your own on boardcannot bring your own on board•• Example Example -- CathayCathay--Pacific (Hong KongPacific (Hong Kong--based) based)

www.cathaypacific.com/intl/pretrip/smartwww.cathaypacific.com/intl/pretrip/smartwww.cathaypacific.com/intl/pretripwww.cathaypacific.com/intl/pretrip/needs/needs Aviation Aviation Medical Office 011Medical Office 011--852852--27472747--29222922

•• All flights carry All flights carry AEDsAEDs & & EMKsEMKs (drugs, etc) per Dr. (drugs, etc) per Dr. Rose Rose OngOng, Medical Director, Cathay, Medical Director, Cathay--Pacific (email Pacific (email 12/11/04)12/11/04)

2323

AIRPORT CLINICSAIRPORT CLINICS

•• Raffles Medical Group has airport clinics in Raffles Medical Group has airport clinics in Hong Kong & Singapore Hong Kong & Singapore ((www.rafflesmedical.comwww.rafflesmedical.com))

•• WEB GoogleWEB Google®® search ‘airport medical clinics’search ‘airport medical clinics’•• Also:Also:www.usatoday.com/money/2004www.usatoday.com/money/2004--1111--0303--airportairport--clinics.htmclinics.htm for USA airport clinicsfor USA airport clinics

2424

RELATIONS WITH THE RELATIONS WITH THE TRAVEL INDUSTRYTRAVEL INDUSTRY

NEED TO IMPROVE WITH HEALTH NEED TO IMPROVE WITH HEALTH PROVIDERSPROVIDERS

(TRAVEL AGENTS DON(TRAVEL AGENTS DON’’T WANT TO T WANT TO FRIGHTEN CLIENTS)FRIGHTEN CLIENTS)

2525

KEY ISSUES FOR PROVIDER KEY ISSUES FOR PROVIDER AND TRAVELERAND TRAVELER•• WHO single / couple / family / health / WHO single / couple / family / health /

politics politics ---- each member of party each member of party requires evaluationrequires evaluation

•• WHERE countries / time zones / visas / WHERE countries / time zones / visas / warwar

•• WHEN dates / seasonal risks / durationWHEN dates / seasonal risks / duration

•• WHY business / leisure / WHY business / leisure / VFRsVFRs

•• WHAT business / leisure / both / sportsWHAT business / leisure / both / sports

•• HOW livingHOW living

2626

FOR TRAVELERSFOR TRAVELERS•• MALARIA MALARIA -- WHERE? PROPHYLAXIS? Presumptive WHERE? PROPHYLAXIS? Presumptive

rx.? Postrx.? Post--trip compliance? Seek help w. Symptomstrip compliance? Seek help w. Symptoms

•• TB TB

•• AIDS AIDS -- Casual Sex, Sex Tours, Sex Workers (male Casual Sex, Sex Tours, Sex Workers (male and female), local cultures (e.g. Thailand)and female), local cultures (e.g. Thailand)

•• OUTBREAKS OUTBREAKS -- Weather (cholera Weather (cholera -- El Nino, El Nino, TsunamniTsunamni), Smog (Asia), Locusts (Egypt ), Smog (Asia), Locusts (Egypt -- Nov Nov 2004), Meningococcal deaths (Scotland), Tsunami2004), Meningococcal deaths (Scotland), Tsunami

EurosurveillanceEurosurveillance Weekly [electronic resource]Weekly [electronic resource]. . 2004 Nov 18;8(47). (2004 Nov 18;8(47). (www.eurosurveillance.orgwww.eurosurveillance.org) )

2727

CDC PublicationCDC Publication

2828

INTERNATIONALINTERNATIONAL TOURISTSTOURISTS•• CDC WEB SITE 2001 CDC WEB SITE 2001 -- 13.7 MILLION REQUESTS13.7 MILLION REQUESTS

•• CDC CDC -- YF VACCINE YF VACCINE -- <1/3 TRAVELERS TO <1/3 TRAVELERS TO ENDEMIC AREAS GET ITENDEMIC AREAS GET IT

•• MALARIA MALARIA -- >50% SEEK ADVICE, BUT LESS >50% SEEK ADVICE, BUT LESS FOLLOW IT. ALSO MANY GET WRONG ADVICEFOLLOW IT. ALSO MANY GET WRONG ADVICE

•• SARS SARS –– TRAVEL / QUARANTINE (CHINA, TRAVEL / QUARANTINE (CHINA, TORONTO) / BANKRUPT AIRLINESTORONTO) / BANKRUPT AIRLINES

Keystone JS, et al. Keystone JS, et al. Travel Medicine.Travel Medicine.New York: New York: MosbyMosby; 2004: Chapter 1.; 2004: Chapter 1.

2929

WWW.WHO.INT/ITHWWW.WHO.INT/ITH

WHO WHO International Travel and HealthInternational Travel and Health only online in 2004, only online in 2004, updated regularly. Print ed. Again in 2005. (Will appear updated regularly. Print ed. Again in 2005. (Will appear early 2006). early 2006).

‘Click‘Click--on’ map area for advice on’ map area for advice

3030

SWIMMING IN ITALYSWIMMING IN ITALY•• 99--YRYR--OLD BOY, SWIMMING HOLE IN NORTHERN OLD BOY, SWIMMING HOLE IN NORTHERN

ITALY, PO RIVER, HOT SUMMERITALY, PO RIVER, HOT SUMMER

•• 11--DAY FEVER AND SEVERE RIGHTDAY FEVER AND SEVERE RIGHT--SIDED SIDED HEADACHE. FIRST CT SCAN NORMALHEADACHE. FIRST CT SCAN NORMAL

•• SEVERAL FRIENDS AND RELATIVES SWAM IN SAME SEVERAL FRIENDS AND RELATIVES SWAM IN SAME HOLE HOLE –– NO OTHERS ILLNO OTHERS ILL

•• ??? DIAGNOSIS??? DIAGNOSIS

3131

DIAGNOSISDIAGNOSISPRIMARY AMEBIC MENINGOENCEPHALITISPRIMARY AMEBIC MENINGOENCEPHALITIS

–– NaegleriaNaegleria fowlerifowleri –– freefree--living amebaliving ameba–– Human cases rare Human cases rare -- approx 200 cases worldwide approx 200 cases worldwide

>50% in USA>50% in USA–– Frequently fatal, no effective therapyFrequently fatal, no effective therapy–– Increased surface temp / ? Impact global warmingIncreased surface temp / ? Impact global warming–– Key PointKey Point -- environmental conditions during environmental conditions during

leisure travel leisure travel -- new problemsnew problems

CogoCogo PE. PE. Emerging Infectious DiseasesEmerging Infectious Diseases. 2004 Oct.. 2004 Oct.

ElEl Nino Nino Bull. WHOBull. WHO 2000; 78(9):1127. 2000; 78(9):1127.

3232

TRAVEL RISKS TRAVEL RISKS -- URBANURBAN••11-- 4% DEATHS FROM INFECTIOUS 4% DEATHS FROM INFECTIOUS

DISEASESDISEASES

••50% DUE TO Cardio50% DUE TO Cardio--vasularvasular (MI, (MI, STROKE)STROKE)

••REMAINDER REMAINDER ---- MOTOR VEHICLE, MOTOR VEHICLE, DROWNING, FALLS FROM HEIGHTS, DROWNING, FALLS FROM HEIGHTS, HOMICIDEHOMICIDE

Sanford C. Sanford C. J Travel MedJ Travel Med. 2004 Sep. 2004 Sep--Oct. Oct.

3333

AIR POLLUTION AIR POLLUTION –– WORLD WORLD CITIESCITIES

•• PARTICLES PARTICLES London > Birmingham > Cardiff > EdinburghLondon > Birmingham > Cardiff > Edinburgh

Beijing > Mexico City > Bombay > Athens > Moscow Beijing > Mexico City > Bombay > Athens > Moscow ---- all highall high

•• Are you Asthmatic?Are you Asthmatic?

•• USAUSA

Bell, ML, et al. Bell, ML, et al. JAMAJAMA. 2004 Nov 17.. 2004 Nov 17.

3434

ADVENTURE TRAVEL SURVEYADVENTURE TRAVEL SURVEY

•• 142 NZ adventure tourism operators142 NZ adventure tourism operators

•• 1,027 overseas visitor hospitalizations 1,027 overseas visitor hospitalizations (8 / 100,000 visitors) 1982 (8 / 100,000 visitors) 1982 -- 1996 1996

•• Snow sports, bungee jumping, horseback riding, Snow sports, bungee jumping, horseback riding, slips, trips, fallsslips, trips, falls

•• Highest death rate Highest death rate ---- unguided skiing, unguided skiing, mountaineeringmountaineering

•• Poor safety practices and injury reporting Poor safety practices and injury reporting standardsstandards

Bentley, TA, et al. Bentley, TA, et al. J Travel MedJ Travel Med. 2004 Sep. 2004 Sep--Oct. Oct.

3535

Altitude IllnessAltitude Illness

•• Acute Mountain Sickness (AMS) 8,000 ftAcute Mountain Sickness (AMS) 8,000 ft•• High Altitude Pulmonary High Altitude Pulmonary EdemaEdema (HAPE)(HAPE)•• High Altitude Cerebral High Altitude Cerebral EdemaEdema (HACE)(HACE)•• Other altitude related illnesses.Other altitude related illnesses.

3737

Altitude Illness IncidenceAltitude Illness Incidence

Destination AMS HAPE (Ascent Days)Destination AMS HAPE (Ascent Days)

“Western States” 10“Western States” 10--30% 1/10,000 (130% 1/10,000 (1--2 days)2 days)LhasaLhasa 5050--75%75% 11/100 (1/100 (1--2 days)2 days)La Paz 50La Paz 50--75% 175% 1//100 (1100 (1--2 days)2 days)Everest trek 47%Everest trek 47% 1/65 (fly in)1/65 (fly in)(12(12--14,000 ft)14,000 ft)

“Altitude Illness caused by a lower level of oxygen availabl“Altitude Illness caused by a lower level of oxygen available at high e at high elevations”elevations”

3939

Altitude Illness Risk FactorsAltitude Illness Risk Factors

•• Flat Land ResidenceFlat Land Residence•• Rapid AscentRapid Ascent•• Target Altitude too highTarget Altitude too high•• Past History of AMSPast History of AMS•• ExertionExertion•• Children same as adultsChildren same as adults•• Age Age

4040

Risk Factors Risk Factors –– 3 basic rules3 basic rules

•• Each person has their own “acclimatization line” Each person has their own “acclimatization line” Most people it is somewhere 9,000 feet (2,700 Most people it is somewhere 9,000 feet (2,700 meters).meters).

•• Rules Rules –– Learn the early symptoms of altitude Learn the early symptoms of altitude sickness and be willing to recognize when you have sickness and be willing to recognize when you have themthem

•• Never ascend to sleep at a higher altitude with Never ascend to sleep at a higher altitude with symptoms of altitude illnesssymptoms of altitude illness

•• Descent if your symptoms are getting worse while Descent if your symptoms are getting worse while resting at the same altitude.resting at the same altitude.

4141

Acute Mountain SicknessAcute Mountain Sickness

•• Typically 1Typically 1--2 days after “summit”2 days after “summit”•• Rarely “life threatening” but often “trip Rarely “life threatening” but often “trip

threatening”threatening”•• Beginning of a spectrum of altitude illnessBeginning of a spectrum of altitude illness•• Symptoms are classically worse on 2Symptoms are classically worse on 2ndnd nightnightFatigue, headache, nausea, poor sleep Fatigue, headache, nausea, poor sleep –– hangover.hangover.

Treatment: Descent, Diuretics, Oxygen, TylenolTreatment: Descent, Diuretics, Oxygen, Tylenol

4242

High Altitude Pulmonary EdemaHigh Altitude Pulmonary Edema

•• Most common altitude related cause of Most common altitude related cause of deathdeath

•• Historically misdiagnosed as pneumoniaHistorically misdiagnosed as pneumoniaSymptoms (classically worse on the 2Symptoms (classically worse on the 2ndnd

night):fatigue, dyspnea, (short of breathe) night):fatigue, dyspnea, (short of breathe) dry cough dry cough –– can be rapidly fatalcan be rapidly fatal

Treatment: DESCENT, oxygen, Treatment: DESCENT, oxygen, GamowGamow, , NifedpineNifedpine (medications)(medications)

4444

High Altitude Cerebral EdemaHigh Altitude Cerebral Edema

•• ““Clinical progression” AMSClinical progression” AMS•• VasogenicVasogenic edemaedema•• more likely in people with AMS or HAPEmore likely in people with AMS or HAPE•• Typically takes 1Typically takes 1--3 days, but can be rapid3 days, but can be rapid

“life“life--threatening illness!”threatening illness!”ATAXIA (stumbling), altered level of consciousness, ATAXIA (stumbling), altered level of consciousness,

lassitude (extreme fatigue), Shortness of Breath, lassitude (extreme fatigue), Shortness of Breath, TreatmentTreatment: DESCENT, Oxygen, : DESCENT, Oxygen, GamowGamow, ,

DexamethasoneDexamethasone, , MannitolMannitol

4545

PREVENTIONPREVENTION

•• Climb high Climb high –– sleep lowsleep low•• Avoid Alcohol and sedativesAvoid Alcohol and sedatives•• Avoid overexertionAvoid overexertion•• MedicationsMedications•• See your Dr before you goSee your Dr before you go•• Get fitGet fit

4646

Oldest Man to Climb Mount EverestOldest Man to Climb Mount EverestYuichiroYuichiro Miura, 70,Miura, 70,

4747

Heat Illness Risk ObviousHeat Illness Risk Obvious

•• Heat & HumidityHeat & Humidity•• Heavy ClothingHeavy Clothing•• Extremes of ageExtremes of age

4848

Heat Illness Risk Heat Illness Risk –– Not so ObviousNot so Obvious

•• Skin DisordersSkin Disorders•• Beta Blockers, AntiBeta Blockers, Anti--Cholinergic Drugs!Cholinergic Drugs!•• Fast Drugs (cocaine, speed)Fast Drugs (cocaine, speed)•• Dehydration Dehydration –– thirst is a late finding thirst is a late finding –– you you

are already dehydrated!are already dehydrated!

4949

Heat Illness SummaryHeat Illness Summary

•• Be smart Be smart –– not a victimnot a victim•• AcclimatizeAcclimatize•• Stay hydratedStay hydrated•• Watch your medicationsWatch your medications•• Rest, keep coolRest, keep cool•• Take your time Take your time

5050

Sunscreen & PhotosensitivitySunscreen & Photosensitivity

•• LeakLeak--proof containerproof container•• WaterproofWaterproof•• SPF of at least 15SPF of at least 15•• UV “A and B blocker”UV “A and B blocker”

5151

QUESTIONQUESTIONA YOUNG GIRL BACK FROM A A YOUNG GIRL BACK FROM A MEXICAN VACATION 3 DAYS MEXICAN VACATION 3 DAYS EARLIER PRESENTED WITH EARLIER PRESENTED WITH PAINLESS LINEAR AND PAINLESS LINEAR AND SERPIGINOUS LESIONS ON SERPIGINOUS LESIONS ON HER LEGS. SHE HAD NO HER LEGS. SHE HAD NO SYSTEMIC COMPLAINTS. SYSTEMIC COMPLAINTS. SHE HAD BEEN LYING ON SHE HAD BEEN LYING ON THE BEACH. THE BEACH.

THE DIAGNOSIS IS:THE DIAGNOSIS IS:

5252

ANSWERANSWERTHIS IS THIS IS PHYTOPHOTODERMATITISPHYTOPHOTODERMATITIS CAUSED BY THE CAUSED BY THE PHOTOSENSITIZING PSORALENPHOTOSENSITIZING PSORALEN--CONTAINING CONTAINING COMPOUNDS IN THE LIME PEEL. SHE HAD HAD LIME COMPOUNDS IN THE LIME PEEL. SHE HAD HAD LIME WEDGES STUCK ON HER BEER GLASS; THE LIME SKIN WEDGES STUCK ON HER BEER GLASS; THE LIME SKIN PSORALENS DRIPPED DOWN THE SIDE OF THE GLASS PSORALENS DRIPPED DOWN THE SIDE OF THE GLASS WITH WATER CONDENSATION AND DRIPPED ON HER WITH WATER CONDENSATION AND DRIPPED ON HER LEG. VOILA, LOCAL SUNBURN.LEG. VOILA, LOCAL SUNBURN.

www.Medicine.mcgill.ca/TROPMED/cantropmed/www.Medicine.mcgill.ca/TROPMED/cantropmed/image_4.htmimage_4.htm

5353

DrowningDrowning/ Near Drowning/ Near Drowning

•• Immersion HypothermiaImmersion Hypothermia•• DrownDrown

ALWAYS wear life vests (always)ALWAYS wear life vests (always)

5454

Cold water ImmersionCold water Immersion

•• > 50% decrease in breath holding> 50% decrease in breath holding•• Reflex hyperventilation (breath faster)Reflex hyperventilation (breath faster)•• 2% decrease per minute in grip strength2% decrease per minute in grip strength•• Water conducts heat 25 times better than Water conducts heat 25 times better than

air.air.

5555

Cold Illness PreventionCold Illness Prevention

•• You do not adapt!You do not adapt!•• Be smartBe smart•• Avoid dehydrationAvoid dehydration•• Get out of your wet clothesGet out of your wet clothes•• Avoid alcohol & tobaccoAvoid alcohol & tobacco•• Take extra time to warm upTake extra time to warm up•• And always wear a life vest!And always wear a life vest!

5656

Hazardous Marine LifeHazardous Marine Life

•• Coelenterates: JellyfishCoelenterates: Jellyfish•• Rinse with seawater (not freshwater)Rinse with seawater (not freshwater)•• Acetic Acid 5% (Vinegar)Acetic Acid 5% (Vinegar)•• Isopropyl Alcohol 40%Isopropyl Alcohol 40%•• Shave to remove nematocystShave to remove nematocyst

5757

BOX JELLYFISH BOX JELLYFISH -- DEADLYDEADLYBeaches N. AustraliaBeaches N. AustraliaIndoIndo--Pacific Pacific -- Shallow WaterShallow Water

5858

BOX JELLYFISH (SEA WASP)BOX JELLYFISH (SEA WASP)•• MOST VENOMOUS MARINE ANIMAL KNOWNMOST VENOMOUS MARINE ANIMAL KNOWN

•• DEATH CAN OCCUR WITHIN 2DEATH CAN OCCUR WITHIN 2--3 MINUTES3 MINUTES

•• SEASON OCTOBERSEASON OCTOBER--APRIL (WET SEASON)APRIL (WET SEASON)

•• VISITORS TO GREAT BARRIER REEFVISITORS TO GREAT BARRIER REEF

•• CPR / SUPPORT / APPLY VINEGARCPR / SUPPORT / APPLY VINEGAR

•• LOCAL AMBULANCE STAFF CAN GIVE ANTILOCAL AMBULANCE STAFF CAN GIVE ANTI--VENOM FOR VENOM FOR CHIRONEX FLECKERICHIRONEX FLECKERI STINGSSTINGS

•• AUSTRALIAN INSTITUTE OF MARINE SCIENCE AUSTRALIAN INSTITUTE OF MARINE SCIENCE www.aims.gov.au/pages/research/projectwww.aims.gov.au/pages/research/project--net/dma/pages/seawaspnet/dma/pages/seawasp--01.html01.html or or www.aims.gov.auwww.aims.gov.au and and search site for topicssearch site for topics

5959

Hazardous Marine LifeHazardous Marine Life

•• EchinodermataEchinodermata “Sea Urchins”“Sea Urchins”•• Immerse in Hot waterImmerse in Hot water•• Remove embedded spines Remove embedded spines carefullycarefully

6161

Diving Medicine Diving Medicine –– BarotraumaBarotrauma of of DescentDescent

•• Potential problems with airspacesPotential problems with airspacesExternal ear canalExternal ear canalMiddle earMiddle earSinsusesSinsusesTeeth with fillingsTeeth with fillingsGI tractGI tractBoyle’s Law BV = kBoyle’s Law BV = k

6262

BarotraumaBarotrauma of Ascentof Ascent

•• PneumothoraxPneumothorax –– collapsed lungcollapsed lung•• Air EmbolismAir Embolism•• Subcutaneous emphysemaSubcutaneous emphysemaIn other words a lot of lung problemsIn other words a lot of lung problems

6363

Breathing Pressurized GasesBreathing Pressurized Gases

•• Nitrogen NarcosisNitrogen Narcosis –– noticeable at 60noticeable at 60--90 feet, 90 feet, Intoxicating at 200 feetIntoxicating at 200 feet

•• Decompression SicknessDecompression Sickness bubbling out of bubbling out of gas, too rapid gas, too rapid –– a relative term, confusion, a relative term, confusion, decreased level of consciousness.decreased level of consciousness.

6464

Flying After DivingFlying After Diving

•• Recommended Surface Interval for Recommended Surface Interval for Commercial flights:Commercial flights:

•• 12 hours after non12 hours after non--compression divecompression dive•• 24 hours after multiple daily dives24 hours after multiple daily dives•• 24 hours after any dive requiring a 24 hours after any dive requiring a

decompression stopdecompression stopRemember these are best guess guidelines Remember these are best guess guidelines –– suggest suggest

doubling interval for diving at altitude.doubling interval for diving at altitude.

6565

TRAVELERSTRAVELERS’’ DIARRHEADIARRHEA

•• Advice for travelers. Advice for travelers. Treatment Guidelines from Treatment Guidelines from the Medical Letterthe Medical Letter 2004 May;2 (21):332004 May;2 (21):33--40. 40. DDysentery selfysentery self--rx = rx = cipro/levo/norfloxcipro/levo/norfloxfor 3 days for 3 days --> MD help> MD help

•• RifaximinRifaximin ((XifaxanXifaxan) for travelers' diarrhea. ) for travelers' diarrhea. Med Med LettLett Drugs Drugs TherTher. 2004 Sep 13;46(1191):74. 2004 Sep 13;46(1191):74--5. 5. –– New drugNew drug--RifimaximinRifimaximin--nonnon--absorbed, not effective w. absorbed, not effective w.

campylobacter or campylobacter or YersiniaYersinia–– Table of other TD drugs/$ costTable of other TD drugs/$ cost

6666

TRAVELERSTRAVELERS’’ DIARRHEA DIARRHEA (cont)(cont)

•• CDCCDC–– www.cdc.gov/ncidod/dbmd/diseaseinfo/travelersdiarrhea_www.cdc.gov/ncidod/dbmd/diseaseinfo/travelersdiarrhea_

g.htmg.htm–– Bismuth Bismuth subsalicylatesubsalicylate -- avoid w. aspirin allergy, pregnancy, avoid w. aspirin allergy, pregnancy,

meds (meds (antcoagulantsantcoagulants, , probenecidprobenecid, , methotrexatemethotrexate). Also ). Also black tongue/stool and rarely tinnitus black tongue/stool and rarely tinnitus -- dose 2 tabs dose 2 tabs qidqid..

•• ALSO GOOD ARTICLE ON ALSO GOOD ARTICLE ON MDTravelhealth.comMDTravelhealth.com

6767

GIARDIAGIARDIA•• WHITE WATER RAFTING, HIKERS, OTHER WHITE WATER RAFTING, HIKERS, OTHER

ADVENTURE TRAVELADVENTURE TRAVEL•• RX METRONIDAZOLE 500RX METRONIDAZOLE 500--750 MG TID FOR 10 750 MG TID FOR 10

DAYSDAYS•• CAN CAUSE CHRONIC MALABSORPTIONCAN CAUSE CHRONIC MALABSORPTION•• SEE SEE JongJong EC and McMullen R, eds. EC and McMullen R, eds. The Travel and The Travel and

Tropical Medicine ManualTropical Medicine Manual. 3rd ed. Philadelphia, Pa: . 3rd ed. Philadelphia, Pa: Saunders/Elsevier; 2003.Saunders/Elsevier; 2003. Chapter Chapter 2525--26. 26.

•• SUSPECT IN MALABSORPTION OR DIARRHEA SUSPECT IN MALABSORPTION OR DIARRHEA PERSISTING > 1 WEEKPERSISTING > 1 WEEK

•• EXPLOSIVE, FOULEXPLOSIVE, FOUL--SMELLING STOOLS, SMELLING STOOLS, FLATULENCEFLATULENCE

6868

Sea Food Sea Food ToxidromesToxidromes

““Found Found NemoNemo””

6969

Ciguatera Poisoning (Fish Poisoning)Ciguatera Poisoning (Fish Poisoning)

•• SnapperSnapper•• GrouperGrouper•• JackJack•• BarracudaBarracuda•• Coral “reel fish”Coral “reel fish”•• Endemic and it occurs in all topical watersEndemic and it occurs in all topical waters

7070

Ciguatera SymptomsCiguatera Symptoms

•• Onset within 1Onset within 1--3 hours3 hours•• Worsening over 4Worsening over 4--6 hours6 hours•• Nausea vomiting diarrheaNausea vomiting diarrhea•• ParenthesesParenthesesGastroenteritis + neurological symptoms + Gastroenteritis + neurological symptoms + fish ingestionfish ingestion

7171

Problem area for Health Care Problem area for Health Care

providersproviders•• YELLOW FEVERYELLOW FEVER

•• MALARIAMALARIA

•• RABIESRABIES

7272

ISTM SAMPLE QUESTIONISTM SAMPLE QUESTION

WHICH OF THE FOLLOWING DISEASES MUST BE WHICH OF THE FOLLOWING DISEASES MUST BE REPORTED TO WHO UNDER INTERNATIONAL REPORTED TO WHO UNDER INTERNATIONAL HEALTH REGULATIONS? HEALTH REGULATIONS?

a. MENINGOCOCCAL MENINGITISa. MENINGOCOCCAL MENINGITIS

b. EBOLA HEMORRHAGIC FEVERb. EBOLA HEMORRHAGIC FEVER

c. YELLOW FEVERc. YELLOW FEVER

d. HIV/AIDS d. HIV/AIDS

7373

ISTM ANSWERISTM ANSWER

c. YELLOW FEVERc. YELLOW FEVER

7474

ISTM SAMPLE QUESTIONISTM SAMPLE QUESTION

AN UNVACCINATED TRAVELER IS AT RISK OF AN UNVACCINATED TRAVELER IS AT RISK OF CONTACTING YELLOW FEVER IN WHICH ONE OF CONTACTING YELLOW FEVER IN WHICH ONE OF THE FOLLOWING COUNTRIES?THE FOLLOWING COUNTRIES?

a. NICARAGUAa. NICARAGUA

b. SOUTH AFRICAb. SOUTH AFRICA

c. BRAZILc. BRAZIL

d. INDONESIAd. INDONESIA

7575

ISTM ANSWERISTM ANSWER

c. BRAZILc. BRAZIL

7676

YELLOW FEVER VACCINEYELLOW FEVER VACCINE•• 19961996--2002 2002 ---- 4 OF 5 FATAL CASES US / EUROPEAN 4 OF 5 FATAL CASES US / EUROPEAN

TRAVELERS TO SOUTH AMERICA. RISK OF ILLNESS / TRAVELERS TO SOUTH AMERICA. RISK OF ILLNESS / DEATH IN UNVACCINATED TRAVELER 1:1,000 TO DEATH IN UNVACCINATED TRAVELER 1:1,000 TO 1:5,000 PER MONTH IN AREA1:5,000 PER MONTH IN AREA

•• ATTENUATED VIRUS, GOOD >= 10 DAYS AFTER & FOR ATTENUATED VIRUS, GOOD >= 10 DAYS AFTER & FOR 10 YRS. GET STAMPED YELLOW CERTIFICATE10 YRS. GET STAMPED YELLOW CERTIFICATE

•• MUST BE APPROVED BY WHO / GIVEN AT APPROVED MUST BE APPROVED BY WHO / GIVEN AT APPROVED YF VACCINATION CENTERS (STATE HEALTH DEPT YF VACCINATION CENTERS (STATE HEALTH DEPT CERTIFIED KCERTIFIED K--C)C)

•• PREGNANCY PREGNANCY –– ““INDICATED IF EXPOSURE CANNOT BE INDICATED IF EXPOSURE CANNOT BE AVOIDEDAVOIDED”” CDC. CDC. Yellow Book 2003Yellow Book 2003--20042004, p 239., p 239.

•• HIVHIV--AVOID, BUT ? CAN GIVE IF CD4 >200AVOID, BUT ? CAN GIVE IF CD4 >200

•• AVOID MOSQUITOS!!!AVOID MOSQUITOS!!!

7777

FLAVIVIRUSESFLAVIVIRUSESYELLOW FEVER, JE, DENGUE, TBEVYELLOW FEVER, JE, DENGUE, TBEV

•• TBEV (TICKTBEV (TICK--BORNE ENCEPHALITIS VIRUS) BORNE ENCEPHALITIS VIRUS) CENTRAL EUROPE CENTRAL EUROPE -- AUSTRIA / SOUTHERN AUSTRIA / SOUTHERN GERMANYGERMANY

•• HIKERS / CLIMBERS AT RISK HIKERS / CLIMBERS AT RISK -- VACCINE VACCINE AVAILABLE IN EUROPE. NO POSTAVAILABLE IN EUROPE. NO POST--EXPOSURE EXPOSURE VACCINE / DRUGS AVAILABLE.VACCINE / DRUGS AVAILABLE.

•• VACATIONERS VACATIONERS -- AUSTRIA, CZECH REP, GERMANY, AUSTRIA, CZECH REP, GERMANY, SWITZERLAND, HUNGARY, CROATIASWITZERLAND, HUNGARY, CROATIA

•• USE DEET / PERMETHRIN, ETC, PANTS IN SOCKSUSE DEET / PERMETHRIN, ETC, PANTS IN SOCKS

RendiRendi--Wagner P. Wagner P. J Travel Med. J Travel Med. 2004 Sep2004 Sep--Oct.Oct.

7878

YELLOW FEVER YELLOW FEVER -- AMERICASAMERICAS

7979

YELLOW FEVER YELLOW FEVER -- AFRICAAFRICA

8080

MALARIA MALARIA -- AMERICASAMERICAS

8181

MALARIA MALARIA -- ASIAASIA

8282

MALARIA MALARIA -- AFRICAAFRICA

8383

ISTM SAMPLE QUESTIONISTM SAMPLE QUESTIONTHE MOST APPROPRIATE FIRST TEST IN A 25THE MOST APPROPRIATE FIRST TEST IN A 25--YEARYEAR--OLD OLD MALE W. FEVER & DIARRHEA THE PAST WEEK, 4 MALE W. FEVER & DIARRHEA THE PAST WEEK, 4 MONTHS AFTER RETURNING FROM A TRIP TO INDIA IS? MONTHS AFTER RETURNING FROM A TRIP TO INDIA IS? (HE TOOK A FULL COURSE OF MEFLOQUINE AS (HE TOOK A FULL COURSE OF MEFLOQUINE AS RECOMMENDED BEFORE/DURING/AFTER TRIP).RECOMMENDED BEFORE/DURING/AFTER TRIP).

a. STOOL EXAM FOR O & P a. STOOL EXAM FOR O & P b. BLOOD CULTURE (Typhoid) b. BLOOD CULTURE (Typhoid) c. MALARIA SMEARc. MALARIA SMEARd. AMEBIC SEROLOGYd. AMEBIC SEROLOGY

8484

ISTM ANSWERISTM ANSWERc. MALARIA SMEARc. MALARIA SMEAR

–– See also: See also: Steinberg, EB, et al. Typhoid fever in Steinberg, EB, et al. Typhoid fever in travelers: who should be targeted for prevention? travelers: who should be targeted for prevention? Clin Infect Dis.Clin Infect Dis. 2004 Jul 15;39(2):1862004 Jul 15;39(2):186--91. 91.

–– Highest incidence of typhoid (1994 Highest incidence of typhoid (1994 -- 99 reported 99 reported cases travel to Indian subcontinent).cases travel to Indian subcontinent).

(courtesy of Barb Lauderdale)(courtesy of Barb Lauderdale)

8585

MALARIA DEATHS MALARIA DEATHS -- US TRAVELERS US TRAVELERS 1963 1963 -- 2001 (CDC)2001 (CDC)•• 185 FATAL CASES, 66.5% IN US TRAVELERS, 185 FATAL CASES, 66.5% IN US TRAVELERS,

92.7% DUE TO 92.7% DUE TO FALCIPARUM.FALCIPARUM.

•• NO PROPHYLAXIS, POOR COMPLIANCE, SLOW TO NO PROPHYLAXIS, POOR COMPLIANCE, SLOW TO SEEK CARE W. SYMPTOMS, DX DELAYS, RX DELAYS.SEEK CARE W. SYMPTOMS, DX DELAYS, RX DELAYS.

•• NEED TO EDUCATE TRAVELERS AND NEED TO EDUCATE TRAVELERS AND PROVIDERSPROVIDERS!!

•• GREEN BAY, WI GREEN BAY, WI –– PHARMACIST DEATH, NO PHARMACIST DEATH, NO PROPHYLAXISPROPHYLAXIS

Newman, RD, et al. Newman, RD, et al. Ann Intern MedAnn Intern Med. 2004 Oct 5.. 2004 Oct 5.

8686

MALARIA MISDIAGNOSISMALARIA MISDIAGNOSIS•• BIG PROBLEM, ESPECIALLY IN AFRICABIG PROBLEM, ESPECIALLY IN AFRICA•• STUDY OF UNIVERSITY STAFF STUDENTS STUDY OF UNIVERSITY STAFF STUDENTS --

GHANA 2002GHANA 2002•• TENDENCY TO OVERTENDENCY TO OVER--DIAGNOSE W. DIAGNOSE W.

INACCURATE BLOOD SMEARS INACCURATE BLOOD SMEARS •• NEED GOOD LAB & ACCURATE INFORMATIONNEED GOOD LAB & ACCURATE INFORMATION

Causer LM, et al. Causer LM, et al. Clin Infect Dis.Clin Infect Dis. 2004 Dec. 2004 Dec.

Keystone J. Editorial commentary.Keystone J. Editorial commentary. ClinClin Infect Dis.Infect Dis. 2004 Dec. 2004 Dec.

8787

MALARIA PREVENTIONMALARIA PREVENTION•• AVOID MOSQUITO BITES STILL NO. 1AVOID MOSQUITO BITES STILL NO. 1

•• DEET ON SKIN, PERMETHRIN FOR CLOTHES AND BED DEET ON SKIN, PERMETHRIN FOR CLOTHES AND BED NETSNETS

•• TIME OF DAY (anopheles), CITY (TIME OF DAY (anopheles), CITY (aedesaedes))

•• MEDICATIONS FOR CHEMOSUPPRESSIONMEDICATIONS FOR CHEMOSUPPRESSION

•• CHLOROQUINE WHERE SENSITIVECHLOROQUINE WHERE SENSITIVE

•• RESISTANT TO CHLOROQUINERESISTANT TO CHLOROQUINE--MEFLOQUINE, MEFLOQUINE, MALARONE, DOXY.MALARONE, DOXY.

•• PREG / YOUNG CHILDREN NO DOXYPREG / YOUNG CHILDREN NO DOXY

•• STILL RISK FOR MALARIA EVEN WITH PROPHYLAXISSTILL RISK FOR MALARIA EVEN WITH PROPHYLAXIS

8888

MALARIA MISDIAGNOSIS (cont)MALARIA MISDIAGNOSIS (cont)•• TANZANIA TANZANIA -- 10 HOSPITALS, 4474 10 HOSPITALS, 4474

PATIENTS, 1 YEAR. PATIENTS, 1 YEAR.

•• <1/3 HAD MALARIA<1/3 HAD MALARIA

•• MOST CHILDREN FROM LOWMOST CHILDREN FROM LOW--TRANSMISSION AREA WERE PARASITE TRANSMISSION AREA WERE PARASITE FREEFREE

•• MANY FATALITIES (HIGH FEVER) GOT MANY FATALITIES (HIGH FEVER) GOT ANTIMALARIALS BUT ANTIMALARIALS BUT NONO ANTIBIOTICSANTIBIOTICS

ReyburnReyburn H, et al. H, et al. BMJBMJ. 2004 Nov 20. . 2004 Nov 20.

8989

MALARIA MISDIAGNOSIS (cont)MALARIA MISDIAGNOSIS (cont)

EFFECTS ON THE POOR AND VULNERABLEEFFECTS ON THE POOR AND VULNERABLE

•• BETWEEN 32 AND 96 % OVERESTIMATION BY BETWEEN 32 AND 96 % OVERESTIMATION BY CLINICAL DIAGNOSISCLINICAL DIAGNOSIS

•• KEYSTONE KEYSTONE -- FALSE POSITIVE SMEARS UP TO 75%, FALSE POSITIVE SMEARS UP TO 75%, DEPENDING ON THE SETTING. CID, DEC. 2004DEPENDING ON THE SETTING. CID, DEC. 2004

AmexoAmexo M, et al. Malaria misdiagnosis: M, et al. Malaria misdiagnosis: effects on the poor and vulnerable. effects on the poor and vulnerable.

Lancet.Lancet. 2004 Nov 20;364(9448):18962004 Nov 20;364(9448):1896--88..

9090

MALARIA INFO SOURCESMALARIA INFO SOURCES•• CDCCDC

www.cdc.govwww.cdc.gov/malaria/malaria

Hotline 770Hotline 770--488488--77887788

•• IV IV QuinidineQuinidine

Eli Lilly 800Eli Lilly 800--821821--05380538

317317--276276--2000 (after hrs)2000 (after hrs)

9191

Return to Canada from AfricaReturn to Canada from AfricaRETURNED TO MONTREAL AFTER 2 RETURNED TO MONTREAL AFTER 2 WEEKS IN WEST AFRICA WHERE WEEKS IN WEST AFRICA WHERE HE HAD NOTED THE ONSET OF HE HAD NOTED THE ONSET OF MALAISE, LOW GRADE FEVER AND MALAISE, LOW GRADE FEVER AND AN ERYTHEMATOUS NONAN ERYTHEMATOUS NON--INDURATED 6 INCH DIAMETER INDURATED 6 INCH DIAMETER PATCH IN THE RIGHT GROIN. PATCH IN THE RIGHT GROIN. OVER THE SUBSEQUENT WEEK OVER THE SUBSEQUENT WEEK NEW PATCHES APPEARED, WHILE NEW PATCHES APPEARED, WHILE THE ORIGINAL PATCH PERSISTED THE ORIGINAL PATCH PERSISTED BUT SLOWLY FADED. BUT SLOWLY FADED.

THE DIAGNOSIS IS:THE DIAGNOSIS IS:

9292

ANSWER ANSWER -- THE HISTORY!!THE HISTORY!!

LYME DISEASELYME DISEASE (SURPRISE!!)(SURPRISE!!) PRIOR TO AFRICAN PRIOR TO AFRICAN TRIP HAD VISITED SISTER IN PHILADELPHIA, WHO TRIP HAD VISITED SISTER IN PHILADELPHIA, WHO HAD HOME ON FRINGE OF PARK WHERE THERE HAD HOME ON FRINGE OF PARK WHERE THERE WERE DEER. NO TICK BITE. HE RESPONDED TO WERE DEER. NO TICK BITE. HE RESPONDED TO ANTIBIOTICS. ALSO POSITIVE SEROLOGY ANTIBIOTICS. ALSO POSITIVE SEROLOGY CONFIRMED.CONFIRMED.

www.Medicine.mcgill.ca/TROPMED/cantropmed/www.Medicine.mcgill.ca/TROPMED/cantropmed/image5.htmimage5.htm

9393

FEVER IN THE RETURNING FEVER IN THE RETURNING TRAVELERTRAVELER

••WHO, WHEN, WHERE, WHAT, WHO, WHEN, WHERE, WHAT, HOW, ETC.HOW, ETC.

••MALARIA, DENGUE, TYPHOID, MALARIA, DENGUE, TYPHOID, TYPHUSTYPHUS

Blair, JE. Evaluation of fever in the Blair, JE. Evaluation of fever in the international traveler. Unwanted 'souvenir' can international traveler. Unwanted 'souvenir' can have many causes. have many causes. PostgradPostgrad MedMed. 2004 . 2004 Jul;116(1):13Jul;116(1):13--20, 29. 20, 29.

9494

MALARIA MEDSMALARIA MEDS•• START BEFORE TRAVEL START BEFORE TRAVEL --> 4 WKS AFTER > 4 WKS AFTER

((ChloroquineChloroquine, , MefloquineMefloquine, Doxy), Doxy)

•• FOR 7 DAYS AFTER (FOR 7 DAYS AFTER (MalaroneMalarone ((atovoquoneatovoquone / / proguanilproguanil))

•• MALARONE PEDIATRIC TABLETSMALARONE PEDIATRIC TABLETS

•• MALARONE FOR PRESUMPTIVE SELFMALARONE FOR PRESUMPTIVE SELF--TREATMENT (TREATMENT (notnot FansidarFansidar--StevensStevens--Johnson Johnson syndrome)syndrome)

9595

RABIESRABIES•• FOND DU LAC FOND DU LAC -- SUMMER 2004SUMMER 2004

–– TEENAGER & BAT / NO ERTEENAGER & BAT / NO ER–– DEVELOPED RABIESDEVELOPED RABIES–– SO FAR 3SO FAR 3RDRD OR 4OR 4THTH CASE EVER TO SURVIVE CASE EVER TO SURVIVE -- ?? ??

LONG TERM OUTCOMELONG TERM OUTCOME

•• 70,000 DEATHS ANNUALLY, 50% CHILDREN, 70,000 DEATHS ANNUALLY, 50% CHILDREN, Visiting Friends & Relatives Visiting Friends & Relatives -- RISK FOR KIDS RISK FOR KIDS ((BacanerBacaner N, et al. N, et al. JAMA. JAMA. 2004 June 16 .)2004 June 16 .)

9696

RABIES (cont)RABIES (cont)

•• AVOID DOGS (PUPPIES!), CATS, MONKEYS, AVOID DOGS (PUPPIES!), CATS, MONKEYS, BATS, RODENTS, RACCOONS, SKUNKSBATS, RODENTS, RACCOONS, SKUNKS

•• RABIES VIRUS PRESENT ON EVERY RABIES VIRUS PRESENT ON EVERY CONTINENT CONTINENT -- MANY DEATHS / SOME MANY DEATHS / SOME EXCEPTIONSEXCEPTIONS

9898

RABIES VACCINERABIES VACCINE•• SAFE / EFFECTIVE / EXPENSIVESAFE / EFFECTIVE / EXPENSIVE

Different types can be used in same person, Different types can be used in same person, thimerosalthimerosal in RVA and RIG, HDVCin RVA and RIG, HDVC--neomycin, PCEC neomycin, PCEC -- no Hg but antibiotics no Hg but antibiotics -- ?egg allergy)?egg allergy)

•• RIG IN SHORT SUPPLY IN DEVELOPING RIG IN SHORT SUPPLY IN DEVELOPING COUNTRIESCOUNTRIES

•• AWARENESS / SENSE OF URGENCY AWARENESS / SENSE OF URGENCY LACKINGLACKING

9999

RABIESRABIES•• AUSTRALIA (Queensland) AUSTRALIA (Queensland)

–– ABL (bats ABL (bats --flying foxes) flying foxes)

–– LYSSAVIRUS LYSSAVIRUS -- 2 deaths in animal handlers.2 deaths in animal handlers.McCall BJ. McCall BJ. EmergEmerg Infect Dis.Infect Dis. 2000 May2000 May--Jun. Jun.

•• ABL, FLYING FOXABL, FLYING FOX

–– 44--yryr--old boy attacked in Queensland old boy attacked in Queensland -- unprovoked attackunprovoked attack

–– Bat tested pos. for ABLBat tested pos. for ABL

–– Rabies vaccine and RIG givenRabies vaccine and RIG givenPROMEDPROMED--PRO/AH/EDR NOV 11PRO/AH/EDR NOV 11--0404

100100

BATS AND THE EMERGING BATS AND THE EMERGING THREAT OF RABIESTHREAT OF RABIES•• USA MOST HUMAN CASES USA MOST HUMAN CASES -- BAT VIRUS BAT VIRUS

BAT RABIES ONLY 8% OF ANIMAL RABIES (CDC)BAT RABIES ONLY 8% OF ANIMAL RABIES (CDC)

•• AUSTRALIA AUSTRALIA -- BAT LYSSAVIRUS BAT LYSSAVIRUS ONE OF 6ONE OF 6--7 ANTIGENIC TYPES 7 ANTIGENIC TYPES -- SOME SOME PROTECTION FROM CURRENT VACCINE/HRIGPROTECTION FROM CURRENT VACCINE/HRIG

•• PROMISE OF ABS FROM TRANSGENIC PLANTSPROMISE OF ABS FROM TRANSGENIC PLANTS

Bonn D. Bonn D. Lancet Infectious DiseasesLancet Infectious Diseases. 2004 Jan. . 2004 Jan.

101101

102102Source: WHOSource: WHO

103103

RABIES RABIES –– PREEXPOSUREPREEXPOSURE

CDC. CDC. Yellow Book 2003Yellow Book 2003--20042004

104104

RABIES RABIES –– POST EXPOSUREPOST EXPOSURE

CDC. CDC. Yellow Book 2003Yellow Book 2003--20042004

105105

INSECT REPELLANTS ( DEET)INSECT REPELLANTS ( DEET)

•• FradinFradin MS and Day JF. MS and Day JF. NEJMNEJM 2002 Jul 4. 2002 Jul 4. (abstract online at (abstract online at www.nejm.orgwww.nejm.org))

•• FradinFradin MS. MS. Ann. Intern. Med.Ann. Intern. Med. 1998.1998.(online at (online at www.acponline.orgwww.acponline.org))

106106

SOURCES OF HELPSOURCES OF HELP

BOOKSBOOKS

JOURNALSJOURNALS

LISTSERVSLISTSERVS

INTERNET INTERNET

107107

FREE SUBSCRIPTIONSFREE SUBSCRIPTIONS

•• IAC EXPRESSIAC EXPRESS–– Immunization Action Coalition Immunization Action Coalition –– www.immunize.orgwww.immunize.org–– Updates from CDC on Immunization, also VIS (vaccine Updates from CDC on Immunization, also VIS (vaccine

information sheets), other related news.information sheets), other related news.

•• MMWR (online) MMWR (online) www.cdc.gov/mmwr/mmwrsubscribe.htmlwww.cdc.gov/mmwr/mmwrsubscribe.html

•• Emerging Infectious Diseases Emerging Infectious Diseases www.cdc.gov/eidwww.cdc.gov/eid

•• PROMEDPROMED–– www.promedmail.orgwww.promedmail.org--dailydaily–– postings of disease outbreaks worldwidepostings of disease outbreaks worldwide

108108

TROPIMED TROPIMED Geneva, SwitzerlandGeneva, Switzerland

•• SINGLE SUBSCRIPTION US $175/YRSINGLE SUBSCRIPTION US $175/YR•• UPDATED CDUPDATED CD--ROM ISSUED TWICE / YRROM ISSUED TWICE / YR•• MONTHLY EMAIL MONTHLY EMAIL -- EPIDEMIOLOGICAL NEWSEPIDEMIOLOGICAL NEWS•• EXCELLENT HANDOUTS FOR TRAVELEREXCELLENT HANDOUTS FOR TRAVELER--

CLIENTSCLIENTS•• www.tropimed.comwww.tropimed.com

109109

GIDEONGIDEON®®

•• WEB or CD based, AI programWEB or CD based, AI program•• Infectious disease emphasisInfectious disease emphasis•• Good for teaching and busy travel/tropical Good for teaching and busy travel/tropical

medicine/ID practicesmedicine/ID practices•• Four sectionsFour sections--Diagnosis, Diagnosis,

Epidemiology,TherapyEpidemiology,Therapy, Microbiology, Microbiology•• Comprehensive Tropical Medicine Database, Comprehensive Tropical Medicine Database,

continually updated,>300 diseases, >200 continually updated,>300 diseases, >200 countriescountries

110110

ISTM ISTM -- JTMJTM

Official Publication of the International Official Publication of the International Society of Travel Medicine and the Society of Travel Medicine and the Asia Pacific Travel Health SocietyAsia Pacific Travel Health Society

111111

ISTM MEMBERSHIPISTM MEMBERSHIP

•• GO TO GO TO www.istm.orgwww.istm.org•• CLICK ON CLICK ON ‘‘JOIN ISTMJOIN ISTM’’ FROM THE MENU ON LEFT FROM THE MENU ON LEFT

AND FOLLOW INSTRUCTIONSAND FOLLOW INSTRUCTIONS•• MEETINGS Q 2 YRS (Geneva, Innsbruck, New MEETINGS Q 2 YRS (Geneva, Innsbruck, New

York, Lisbon in 2005)York, Lisbon in 2005)•• DUES: $125.00/YR OR $250.00/2 YRSDUES: $125.00/YR OR $250.00/2 YRS

NURSE, PA, STUDENTS: $75.00/$150.00NURSE, PA, STUDENTS: $75.00/$150.00•• BENEFITS BENEFITS

JOURNAL (JOURNAL (JTMJTM) BIMONTHLY) BIMONTHLYACCESS TO LISTSERV ACCESS TO LISTSERV TRAVELMEDTRAVELMEDBIMONTHLY LETTERBIMONTHLY LETTER ““NEWSSHARENEWSSHARE””

112112

IAMATIAMATINTERNATIONAL ASSOCIATION FOR MEDICAL ASSISTANCE TO TRAVELERS INTERNATIONAL ASSOCIATION FOR MEDICAL ASSISTANCE TO TRAVELERS (M. ASSUNTA UFFER(M. ASSUNTA UFFER--MARCOLONGOMARCOLONGO-- CANADA)CANADA)

•• www.iamat.orgwww.iamat.org•• MEMBERSHIP FREE (SMALL DONATION MEMBERSHIP FREE (SMALL DONATION

REQUESTED)REQUESTED)•• PHYSICIAN/CLINIC/ HOSPITAL DIRECTORY FOR PHYSICIAN/CLINIC/ HOSPITAL DIRECTORY FOR

125 COUNTRIES, MEMBERSHIP CARD, ETC.125 COUNTRIES, MEMBERSHIP CARD, ETC.•• CHARTS FOR IMMUNIZATIONS, MALARIA, CHARTS FOR IMMUNIZATIONS, MALARIA,

SCHISTOSOMIASIS, CHAGAS’ DISEASESCHISTOSOMIASIS, CHAGAS’ DISEASE•• INDIVIDUAL TRAVELER CLINIC RECORDINDIVIDUAL TRAVELER CLINIC RECORD•• WORLD CLIMATEWORLD CLIMATE--FOOD SAFETY CHARTSFOOD SAFETY CHARTS•• Guide to Healthy TravelGuide to Healthy Travel (Elaine (Elaine JongJong, MD), MD)

113113

IAMAT (cont)IAMAT (cont)

•• Ms. Ms. MarcolongoMarcolongo, President, is the widow of the , President, is the widow of the founder, who died of founder, who died of HepatocellularHepatocellular Ca following Ca following longlong--term term HepHep--B.B.

•• Elaine Elaine JongJong, MD, is professor of Medicine at the , MD, is professor of Medicine at the University of Washington, Seattle, director of the University of Washington, Seattle, director of the Travel & Tropical Medicine Service, senior author of Travel & Tropical Medicine Service, senior author of 2 texts on Travel Medicine, and chair of the IAMAT 2 texts on Travel Medicine, and chair of the IAMAT advisory board. advisory board.

114114

OTHER ORGANIZATIONSOTHER ORGANIZATIONS

•• AMERICAN SOCIETY OF TROPICAL MEDICINE & AMERICAN SOCIETY OF TROPICAL MEDICINE & HYGIENE HYGIENE www.astmh.orgwww.astmh.org

•• INTERNATIONAL SOCIETY OF INFECTIOUS INTERNATIONAL SOCIETY OF INFECTIOUS DISEASES DISEASES www.promedmail.orgwww.promedmail.org

•• WILDERNESS MEDICAL SOCIETY WILDERNESS MEDICAL SOCIETY www.wms.orgwww.wms.org

•• DIVERS ALERT NETWORK DIVERS ALERT NETWORK www.diversalertnetwork.orgwww.diversalertnetwork.org

115115

TRAVEL CLINIC DIRECTORIESTRAVEL CLINIC DIRECTORIES

•• ASTMH ASTMH www.astmh.orgwww.astmh.org•• ISTM ISTM www.istm.orgwww.istm.org•• MCW MCW HealthLinkHealthLink healthlink.mcw.edu/travelhealthlink.mcw.edu/travel--

links.htmllinks.html))

116116

URGENT MEDICAL CARE ABROADURGENT MEDICAL CARE ABROAD

www.orphandoctor.com/medical/urgentcare.htwww.orphandoctor.com/medical/urgentcare.htmlml

List of clinics by International SOS and List of clinics by International SOS and American Medical Centers (AMC)American Medical Centers (AMC)–– www.internationalsos.comwww.internationalsos.com–– www.amcenters.comwww.amcenters.com

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BOOKSBOOKS•• Keystone JS, et al. Keystone JS, et al. Travel MedicineTravel Medicine. New York: . New York:

MosbyMosby; 2004.; 2004.

•• CDC. CDC. Health Information for International Travel Health Information for International Travel 20032003--0404 (The (The ““Yellow BookYellow Book””). Atlanta, ). Atlanta, GaGa: Centers : Centers for Disease Control and Prevention; 2003. for Disease Control and Prevention; 2003. –– Several new sections Several new sections –– CDCD--ROM from ROM from phf.orgphf.org

http://http://bookstore.phf.orgbookstore.phf.org

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BOOKS (cont)BOOKS (cont)

•• JongJong EC and McMullen R, eds. EC and McMullen R, eds. The Travel The Travel and Tropical Medicine Manualand Tropical Medicine Manual. 3rd ed. . 3rd ed. Philadelphia, Pa: Saunders/Elsevier; 2003.Philadelphia, Pa: Saunders/Elsevier; 2003.

•• Steffen R, et al. Steffen R, et al. Manual of Travel Medicine Manual of Travel Medicine & Health& Health. 2nd ed. Hamilton, . 2nd ed. Hamilton, OntOnt: BC Decker, : BC Decker, 2003. 2003. Includes CDIncludes CD--ROM.ROM.

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BOOKS (cont)BOOKS (cont)•• JongJong, EC. and Zuckerman JN, eds. , EC. and Zuckerman JN, eds.

TravelersTravelers’’ VaccinesVaccines. Hamilton . Hamilton OntOnt: BC : BC Decker; 2004. Includes CDDecker; 2004. Includes CD--ROM.ROM.

•• CDC. CDC. Epidemiology and Prevention of Epidemiology and Prevention of VaccineVaccine--Preventable DiseasesPreventable Diseases (The (The ““Pink Pink BookBook””). 8). 8thth ed. Atlanta, ed. Atlanta, GaGa: Centers for : Centers for Disease Control and Prevention; 2004. Disease Control and Prevention; 2004. appendices, esp. Appendix D appendices, esp. Appendix D ““Translations Translations of Foreign Language Terms.of Foreign Language Terms.””

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BOOKS (cont)BOOKS (cont)

••AuerbachAuerbach PS. PS. Wilderness MedicineWilderness Medicine. 4. 4thth

ed. St Louis: ed. St Louis: MosbyMosby; 2001.; 2001.

••AuerbachAuerbach PS, et al. APS, et al. A Field Guide to Field Guide to Wilderness MedicineWilderness Medicine. 2. 2ndnd ed. St Louis: ed. St Louis: MosbyMosby, 2003 , 2003

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JOURNALS / NEWSLETTERSJOURNALS / NEWSLETTERS•• JTMJTM -- Journal of Travel MedicineJournal of Travel Medicine•• American Journal of Tropical Medicine & HygieneAmerican Journal of Tropical Medicine & Hygiene

(?online)(?online)

•• The LancetThe Lancet•• CIDCID -- Clinical Infectious DiseasesClinical Infectious Diseases

has travel medicine section, Ericsson, editorhas travel medicine section, Ericsson, editor

•• Morbidity and Mortality Weekly ReportMorbidity and Mortality Weekly Report•• Weekly Epidemiological RecordWeekly Epidemiological Record (WHO)(WHO)

•• Emerging Infectious DiseasesEmerging Infectious Diseases (CDC)(CDC)

•• NEWSSHARE NEWSSHARE www.istm.orgwww.istm.org

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INTERNET SOURCESINTERNET SOURCES•• CDC CDC www.cdc.gov/travelwww.cdc.gov/travel

•• WHO WHO www.who.int/ithwww.who.int/ith

•• SHORELAND SHORELAND TRAVAXTRAVAX®® and ENCOMPASS and ENCOMPASS ®® www.shoreland.comwww.shoreland.com•• INTERNATIONAL SOS 215INTERNATIONAL SOS 215--245245--4707 4707 www.internationalsos.comwww.internationalsos.com

Medical Medical evacevac / medical insurance / medical insurance

•• MEDJET ASSIST 800MEDJET ASSIST 800--963963--35383538www.medjetassist.comwww.medjetassist.comAlso serve in USA >150 miles from homeAlso serve in USA >150 miles from home

•• TRAVELMED Listserv (for ISTM members) TRAVELMED Listserv (for ISTM members) www.istm.org/listserv.htmlwww.istm.org/listserv.html

•• US STATE DEPT. US STATE DEPT. www.travel.state.gov/travel/warnings.htmlwww.travel.state.gov/travel/warnings.htmltravel warnings, consular information sheets, public announcementravel warnings, consular information sheets, public announcementsts

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SHORELAND TRAVAXSHORELAND TRAVAX®®

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OTHER INTERNET SOURCESOTHER INTERNET SOURCES•• US STATE DEPT US STATE DEPT

http://http://travel.state.gov/Publications/medical.htmltravel.state.gov/Publications/medical.html–– Air ambulance company listingsAir ambulance company listings–– Medical information for Americans traveling abroadMedical information for Americans traveling abroad

•• www.mdtravelhealth.comwww.mdtravelhealth.comGood list of links to resources, free email alertsGood list of links to resources, free email alerts

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VENDORS OF TRAVEL MED VENDORS OF TRAVEL MED PRODUCTSPRODUCTS•• TRAVEL MEDICINE, INC. TRAVEL MEDICINE, INC.

www.travmed.comwww.travmed.com

•• CHINOOK MEDICAL CHINOOK MEDICAL www.chinookmed.comwww.chinookmed.com

•• MAGELLANMAGELLAN’’S S www.magellans.comwww.magellans.com

•• MASTA UK (MASTA UK (Medical Advisory Services Medical Advisory Services for Travelers Abroad) for Travelers Abroad) www.masta.org/products/index.htmlwww.masta.org/products/index.html

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PHARMACEUTICALPHARMACEUTICAL

VENDORSVENDORS

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AVENTIS PASTEURAVENTIS PASTEUR•• www.us.aventispasteur.comwww.us.aventispasteur.com

•• CUSTOMER SERVICE 800CUSTOMER SERVICE 800--822822--24632463

•• WORLDWIDE WORLDWIDE -- RABIES (IMOVAX & HRIG, RABIES (IMOVAX & HRIG, MENOMUNE, OTHERS)MENOMUNE, OTHERS)

•• GREAT PICTURES IN MEDIA CENTERGREAT PICTURES IN MEDIA CENTER

•• VAX EVAX E--QUIZ QUIZ -- GIVE IT A TRY! GIVE IT A TRY!

•• KID CORNERKID CORNER

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CHIRONCHIRON•• www.chiron.com/biopharmawww.chiron.com/biopharma

•• RABAVERT RABAVERT PCEC rabies vaccinePCEC rabies vaccine

•• FLU VACCINEFLU VACCINEProblems 2004, U.K. plant createdProblems 2004, U.K. plant createdvaccine shortagevaccine shortage

•• OTHER TRAVEL VACCINES OTHER TRAVEL VACCINES YF, oral cholera, TBE YF, oral cholera, TBE -- not available in USAnot available in USA

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GLAXOGLAXO--SMITHKLINESMITHKLINE•• NEW NEW -- PROFESSIONAL EDUCATION SITEPROFESSIONAL EDUCATION SITE

www.travelmedicineweb.orgwww.travelmedicineweb.org--requirerequireregistration and license numberregistration and license number

•• USA APPROVED VACCINES USA APPROVED VACCINES –– EngerixEngerix--B, B, HavrixHavrix, , InfanrixInfanrix ((TdApTdAp), ), PediarixPediarix

((TdAcTdAc--HepBHepB--IPVIPV), ), TwinrixTwinrix ((HepABHepAB))–– www.worldwidevaccines.comwww.worldwidevaccines.com (click on health (click on health

professionals)professionals)–– MalaroneMalarone -- adult / adult / pedspeds

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MERCKMERCK•• MERCK SERVICESMERCK SERVICES

–– www.MerckServices.comwww.MerckServices.com–– Register for online access to health info Register for online access to health info

(requires state license number)(requires state license number)

•• PNEUMOVAX, VAQTA, COMVAX, RECOMBIVAX, PNEUMOVAX, VAQTA, COMVAX, RECOMBIVAX, ETC.ETC.

•• MERCK VACCINESMERCK VACCINES–– www.merckvaccines.comwww.merckvaccines.com–– Patient education resourcePatient education resource–– Requires state license number (MDs, nurses, Requires state license number (MDs, nurses,

pharmacists)pharmacists)

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ROCHEROCHE

•• www.roche.comwww.roche.com

•• LARIAMLARIAM®® (MEFLOQUINE)(MEFLOQUINE)for malaria prevention and treatmentfor malaria prevention and treatment

•• TAMIFLUTAMIFLU®® (OSELTAMIVIR)(OSELTAMIVIR)for prevention and treatment of influenzafor prevention and treatment of influenza

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TRIVIA (?NOT SO TRIVIAL)TRIVIA (?NOT SO TRIVIAL)

1.1. IN 1997, WHAT % OF PREVENTABLE DEATHS IN IN 1997, WHAT % OF PREVENTABLE DEATHS IN US TRAVELERS ABROAD WAS DUE TO INJURY? US TRAVELERS ABROAD WAS DUE TO INJURY? In 1996 500 U.S. Travelers were killed abroad. In 1996 500 U.S. Travelers were killed abroad. (CDC) (CDC)

2.2. ASSUMING ALL ROUTINE IMMUNIZATIONS ARE ASSUMING ALL ROUTINE IMMUNIZATIONS ARE CURRENT, WHAT IS (ARE) THE MOST CURRENT, WHAT IS (ARE) THE MOST IMPORTANT TRAVEL VACCINE(S) FOR A COUPLE IMPORTANT TRAVEL VACCINE(S) FOR A COUPLE IN THEIR 70s GOING TO ASIA IN SEPTEMBER.IN THEIR 70s GOING TO ASIA IN SEPTEMBER.

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ANSWERSANSWERS

1.1. 40 % (CDC)40 % (CDC)

2.2. HEPATITISHEPATITIS--A VACCINE A VACCINE

11--3% MORTALITY IN PEOPLE > 493% MORTALITY IN PEOPLE > 49

YRS OF AGEYRS OF AGE

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CDC CDC -- VIS PAGEVIS PAGE

www.cdc.gov/nip/publications/VIS

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SummarySummary

•• EducateEducate•• ProphylaxisProphylaxis•• AcclimatizeAcclimatize•• Stay coolStay cool•• FloatFloat•• Swim with your bubblesSwim with your bubbles•• And you are what you eat!And you are what you eat!

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Have a Brilliant HolidayHave a Brilliant Holiday

adventure travel areas of increased risk nova scotia safety

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