the pre-travel consultation

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THE PRE-TRAVEL CONSULTATION

Gary W. Brunette, MD, MSTravelers’ Health Team

Division of Global Migration and QuarantineCenters for Disease Control and Prevention

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Outline

• Travelers’ Health Epidemiology• Traveler Assessment• Itinerary Review• Sources of Information• Risks to the Traveler • Travel Vaccines• Travel Medications • Counseling

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U.S. Residents Traveling Abroad*

*ITA, includes travel to Canada and Mexico*ITA, includes travel to Canada and Mexico

45

50

55

60

65

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Number of Travelers (millions)

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International Travel

0

10

20

30

40

50

60

70

80

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

US Resident travel in millions

0

100

200

300

400

500

600

700

800

900

Worldwide arrivals in millions

US nonresidentInbound (ITA)

US Resident AirOutbound (ITA)

All US ResidentOutbound (ITA)

Worldwide arrivals(WTO)

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Where Do U.S. Residents Travel?

0

10

20

30

40

Canada Europe Aus/NZ Mexico

C or S America

JapanOceania/ PIOther Asia

AfricaCaribbeanMiddle East

%

Source: HealthStyles Survey 2005

Of the 17% who traveled outside the U.S. . . .

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VFRs: Visiting Friends and Relatives

• Foreign-born increased 57% since 1990 from 19.8 million to 31.1 million1

• 20% of US population are first- or second-generation immigrants

• VFRs comprised ~46% of US international air travelers in 20043

1US Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000, issued Dec 2003 (Previous: US Census Bureau, Profile of the Born Outside the United States Population 2000, issues Dec 2003??? 2 Angell & Cetron, 200532004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, USDOC

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Travelers’ Health Risks

Of 100,000 travelers to a developing country for 1 month:– 50,000 will develop some health problem – 8,000 will see a physician– 5,000 will be confined to bed– 1,100 will be incapacitated in their work– 300 will be admitted to hospital– 50 will be air evacuated– 1 will dieSteffen R et al. J Infect Dis 1987; 156:84-91

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The Patient: Medical Issues• Age-specific issues• Underlying illness,

immunosuppression• Systems review• Medical history• Medication use• Vaccination history• Allergies • Contraindications to vaccines and

medications

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The Patient: Other Issues

• Reproductive– Pregnant– Breastfeeding– Preconception

• Risk-taking behaviors

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Travel Itinerary• Full itinerary

– Dates, duration, stopovers– Seasonal considerations

• Styles of travel– Rural vs. urban– Budget vs. luxury

• Accommodation– Hotel vs. camping

• Activities– Business vs. tourism– Adventure, safari– Missionary/Humanitarian/NGO

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Travel Health Resources• CDC Travelers’ Health Website

– www.cdc.gov/travel• World Health Organization

– www.who.int/int• State Department

– travel.state.gov• International Society of Travel Medicine

– www.istm.org• Health Information for International Travel

– CDC “Yellow Book”• International Travel and Health

– WHO “Green Book”

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Travelers’ Health Websitewww.cdc.gov/travel

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Regional Destinations• Region-specific pages• Goal to move to country-specific format

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Travel Notices & Announcements

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Cardiovascular

Medical

Injury

Homicide/Suicide

Infectious Disease

Other

Deaths Related to International Travel

N = 2463

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

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Infectious Disease Risks to the Traveler

• Malaria• Diarrhea• Leishmaniasis• Rabies• Dengue• Meningococcal

Meningitis

• Schistosomiasis• Tuberculosis• Leptospirosis• Polio• Yellow Fever• Measles• JEV

ETC.

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Motor Vechicle

Drowning

Air Crash

Homicide/Suicide

Poisoning

Other

Injury Deaths and International Travel

N = 601

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

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Other Risks to the Traveler• Accidental injury• Environmental hazards• Crime and assault• Psychiatric problems• Animal bites, stings and envenomations• Dermatologic disorders• Altitude• …….

ETC.

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Immunizations to Consider for Adult Travelers

RoutineDiphtheria*Tetanus*Pertussis*Measles +Mumps+Rubella +VaricellaPneumococcusInfluenza

Travel relatedHepatitis AHepatitis BTyphoidRabiesMeningococcal diseasePolioJapanese encephalitisYellow Fever

* Td or Tdap+ MMR

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Travel Medications:Prophylaxis & Self Treatment

• Malaria– chloroquine, atovaquone/proguanil (Malarone),

doxycycline, mefloquine (Lariam), primaquine• Diarrhea

– quinolone, azithromycin• Altitude

– acetazolamide• Motion sickness

– scopolamine, dimenhydrinate (Dramamine)

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Patient Counseling

• Sufficient time for patient education• Tailored to suit traveler• Fitness for travel

– Understanding impact on existing conditions

– Advisability of destinations

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Travel Preparation• Travel health insurance

– Medical care– Hospitalization– Evacuation

• Obtaining medical care abroad

• Awareness of travel notices

• Hand washing and hygiene

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Environmental Precautions• Air Travel• Jet Lag• Sun Protection• Extreme Heat and Cold

– dehydration, heat stroke– hypothermia, frostbite

• Altitude• Water recreation

– Drowning, boating & diving accidents– Risk of schistosomiasis or leptospirosis– Biological and chemical contamination

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Food and Water Precautions

• Bottled water• Selection of foods

– well-cooked and hot• Avoidance of

– salads, raw vegetables– unpasteurized dairy products– street vendors– ice

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Vector Precautions

• Covering exposed skin• Insect repellent containing DEET 25 – 50%• Treatment of outer clothing with permethrin• Use of permethrin-impregnated bed net• Use of insect screens over open windows• Air conditioned rooms • Use of aerosol insecticide indoors• Use of pyrethroid coils outdoors• Inspection for ticks

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Bloodborne and STD Precautions• Prevalence of

– STDs – Hepatitis B– Hepatitis C– HIV

• Unprotected sexual activity• Commercial sex workers• Tattooing and body piercing• Auto accidents • Blood products• Dental and surgical procedures

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Animal Precautions

• Animal avoidance• Rabies

– Specific animal threats– Medical evaluation of bites/scratches– Post exposure immunization and

immunoglobulin• Envenomations

– Snakes, scorpions, spiders– Maritime animals

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Injury and Crime• Vehicles

– Risk of road and pedestrian accidents– Night travel– Seat belts and car seats

• Use of drugs and alcohol

• Understanding local crime risks– Scam awareness– Situational awareness– Location avoidance

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Travel Emergency Kit• Copy of medical records and extra pair of glasses• Prescription medications• Over-the counter medicines and supplies

– Analgesics– Decongestant, cold medicine, cough suppressant– Antibiotic/antifungal/hydrocortisone creams – Pepto-Bismol tablets, antacid– Band-Aids, gauze bandages, tape, Ace wraps– Insect repellant, sunscreen, lip balm– Tweezers, scissors, thermometer

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Post-Travel Care

• Post-travel checkup– Long term travelers– Adventure travelers– Expatriates in developing world

• Post-travel care– Fever, chills, sweats– Persistent diarrhea– Weight loss

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Questions?

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Other Resources

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Journals• American Journal of Tropical Medicine and

Hygiene• Bulletin of the World Health Organization• Emerging Infectious Diseases Journal• Eurosurveillance Weekly • Journal of Travel Medicine• Morbidity and Mortality Weekly Report• Tropical Medicine and International Health• Vaccine

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Books• Textbook of Travel Medicine and Health, 2nd

Ed.– DuPont, H.L. and Steffen R. (editors)

• The Travel and Tropical Medicine Manual, 3rd Ed.– Jong, E.C., McMullen, R.

• Travel Medicine– Keystone, J.S., Kozarsky, P.E., et al

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WebsitesEurosurveillance

www.eurosurveillance.orgTravax EnCompass

www.travax.comGIDEON

www.gideononline.comInternational SOS

www.internationalsos.comMedical Advisory Service for Travelers Abroad (MASTA)

http://www.masta.org/Armed Forces Medical Intelligence Center

www.afmic.detrick.army.mil/Central Intelligence Agency

www.cia.gov/cia/publications/factbook/