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Pre-Travel Health Consultation
Dr Peter A. LeggatMD, PhD, DrPH, FAFPHM, FACTM, FFTM
Associate Professor
School of Public Health and Tropical Medicine
James Cook University &
Visiting Professor
School of Public Health
University of the Witwatersrand
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About the author
Dr Peter Leggat has co-ordinated the Australian postgraduate course in travel medicine since 1993. He has also been on the faculty of the South African travel medicine course, conducted since 2000, and the Worldwise New Zealand Travel Health update programs since 1998. Dr Leggat has assisted in the development of travel medicine programs in several countries and also the Certificate of Knowledge examination for the International Society of Travel Medicine.
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By the end of this session
Briefly revisit who provides pre-travel health adviceEmphasize the need for resources in travel medicineOverview the main functions of the pre-travel health consultationIntroduce the concept of documentation in travel medicine
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The Continuum of Travel MedicineThe Continuum of Travel Medicine
During TravelDuring Travel
Preventive Medicine
Contingency Planning
Treatment & Rehabilitation
VisitorsVisitorsPre-TravelPre-Travel
Post-TravelPost-Travel
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Travelers get information from various sources
Travel agent/travel industry
Books, popular press and the Internet
Person “next door”
Pharmacy
General practice / Travel clinics
Government/public health services
Professional and academic bodies
Ref: Leggat PA. Sources of health advice for travelers. J Travel Med 2000;7:85-8
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Giving correct and consistent advice to travelers is important
Giving the correct health advice to travelers needs:InformationTrainingExperienceDocumentationTravellers
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Need to be prepared with adequate resources
Need adequate staff training and continuing educationNeed adequate time and good time managementNeed to have access to national and international guidelines for travel medicineNeed to have health education resourcesNeed to have access to good geographically based epidemiological information regarding risks to health and safety of travelers (internet, computerized databases etc)
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Travel Health Advice Needs Adequate Notice
Travelers need to be informed that they need travel health advice
Travelers need to be informed that they need to seek travel health advice early, about 6-8 weeks prior to travel
A risk assessment must be performed for every traveler
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PRE-TRAVEL HEALTH ADVICE
Immunize travelers Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travelPrescribe appropriate chemoprophylactic and self-treatment medications
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PRE-TRAVEL HEALTH ADVICE
Immunize travelers Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travelPrescribe appropriate chemoprophylactic and self-treatment medications
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VACCINATEAlways National schedule (incl Hep B)Often hepatitis A (non-immune)Sometimes Japanese encephalitismeningococcal disease (Mecca) polio
rabiestyphoid
yellow fever (WHO)Older age gp Influenza(Others) Pneumococcal disease (adapted* from NZPHR; 1996;3(8):57-59)
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IMMUNISE AGAINST
Mandatory vaccinations (WHO)
National schedule vaccinations-update routine immunizations
Vaccinations for most or all travelers
Vaccinations for travelers at special risk+
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“Mandatory” vaccines
Travelers to/from Yellow fever endemic areas
Travelers going to Mecca for the Hajj
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Yellow fever
Source: http://www.cdc.gov/travel/diseases/yellowfever.htm
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Yellow fever
International regulations
WHO International Travel and Health
Specially licensed Yellow Vaccination Centers
Need to document on appropriate certificate of immunization card
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Meningococcal meningitis
Source: http://www.cdc.gov/travel/diseases/menin.htm
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Meningococcal meningitis
Neisseria meningitidis: At least 13 antigenically distinct serogroupsA,B,C,W135 & Y are most commonCurrent vaccine for A,C,W135 & Y NZ is trialing a vaccine against a specific B strainMandatory: Pilgrims visiting Mecca for the Hajj (annual pilgrimage) or for the UmrahRecommended: Travelers “roughing it” in areas where there are recurrent outbreaks of disease
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Routine vaccinations
The travel health consultation is a good opportunity to update national schedule or routine vaccinations
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Vaccinations for most travelers
Diseases associated with poor hygiene & sanitationETEC?Hepatitis ATyphoid
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Cholera
Various new vaccines
Some activity against ETEC in one
Routine use of cholera vaccine is not recommended as risk is low
It is indicated for travelers to cholera endemic areas, who are at high risk for infection (2-3 years protection)
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Travelers at special risk
Geographical risk
Risk because age, pre-existing conditions, or occupation
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Geographical risk
Vector borne diseases Yellow fever Japanese encephalitis Tick borne encephalitis
Wilderness/remote travel Rabies TB
Current epidemics (terrorist threats?) Cholera Plaque
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Japanese encephalitis
Source: http://www.cdc.gov/ncidod/dvbid/jencephalitis/map.htm
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Japanese encephalitis
Travelers spending one month or more in rural areas of Asia, PNG & Torres Strait (Australia), particularly if the travel is during the wet season, and/or there is considerable outdoor activity and/or the standard of accommodation is suboptimal, other travelers spending a year + in Asia (except for Singapore), even if much of the stay is in urban areas
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Dengue
Vaccine in development
Four serotypes (1-4)
Transmitted by certain mosquitoes, including Aedes aegypti
Widespread, especially common in SE Asia
Becoming increasingly recognized in travelers
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Estimated monthly incidence of health problems per 100 000 travellers to developing countries
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Tick borne encephalitis
Seasonal disease in parts of Europe, Scandinavia and RussiaHikers, campers and agricultural workers most at riskSmall mammal ticks found in the undergrowth close to forested areasVaccine available/post-exposure immune globulin
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Tuberculosis-BCG
Travelers over the age of 5 years who will spend prolonged periods in countries of high TB prevalence
Children under 5 years who will be travelling to live in countries of high TB prevalence for > than 3 months
WHO: high risk countries, where annual incidence is in excess of 100 per 100,000 population
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RabiesEndemic in many countries
Is almost a universally fatal disease
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Plague
Yesinia pestis, transmitted via fleas from animal reservoir to humansRare in most parts of the worldVaccination only of those at high risk, usually those engaged in field operations, laboratory workers or others who reside in areas where plague is present
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Risk because age, pre-existing conditions, or
occupationOlder travelers/pre-existing disease InfluenzaPneumococcal infection
Occupational risk (including electives)Hepatitis B (usually part of national
schedule)Q fever
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Influenza
Routinely on annual basis for those 65 years and older
Travelers with chronic disorders of the pulmonary or circulatory systems or other chronic illnesses needing regular follow-up
Those who wish to reduce the risk
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Estimated monthly incidence of health problems per 100 000 travellers to developing countries
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Pneumococcal infection
Routinely on annual basis for those 65 years and older
Travelers with asplenia, immunocompromized travelers
Others
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Q Fever
Bacterium (rickettsia) Coxiella burnetiiRecommendation: those occupationally exposed to cattle, sheep, goats or kangaroos or their productsSerum antibody and skin testing to exclude hypersensitivity reactionContraindications: prior exposure to Q fever or anaphylaxis induced by egg proteins
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It is important to document vaccinations
Vaccination recordVital for those requiring proof of yellow
fever vaccinationEvidence of specific vaccinations and
screening (e.g. HIV, HBV, Syphilis, Tuberculin) needed for entry to various countries, especially longer term travelers, such as scholars and workers
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PRE-TRAVEL HEALTH ADVICE
Immunize travelers Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travelPrescribe appropriate chemoprophylactic and self-treatment medications
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ADVISE AND DISCUSS
Insects
Ingestions
Indiscretions
Injuries
Immersions
Insurance
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ADVISE AND DISCUSS
Insects repellents, nets, permethrinIngestions care with food and water
diet/teeth (including airlines/jetlag/DVT)Indiscretions STI’s, HIV, drugs?Injuries accident avoidance, personal
safetyImmersionschistosomiasis, drowningInsurance*health and travel insurance*
finding medical assistance o/s*(adapted from NZPHR; 1996;3(8):57-59)
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Leitrim County, rural Ireland
Courtesy of Rick Speare
Personal safety is on the radar screen
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Personal safety
There has been heightened concern regarding personal safety and travelers
National foreign affairs sites should be consulted on safety and security at the travelers’ destination(s).
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Personal safety
Source: http://www.cia.gov/cia/publications/factbook/
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SPECIAL RISK GROUPS
Travelers who need special assistance or need assessment as to fitness to flyPregnant travelers/children/HIV travelersAltitude/mountaineering/divingAdventure/outback travelersTravelers to areas of extreme climateSchool/club/other groupsOccupational/students/military/aviationAid/refugee camp workers
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Travel health advice needs documentation
Medialert bracelets-allergies, serious medical conditionsWritten travel health advice (may be part of doctor’s letter)-consider using a proformaTravelers health record ?Other certificates, e.g. diving, airlineIs the traveler being escorted? (aeromedical evacuation)
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Educational Resources
BooksTravel industry guidesPharmaceutical companiesVideos-popular in a number of clinics in the USA
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52 pp, passport sized booklet
152 pp, Small pocket book
192 pp, reader
730 pp, manual
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144 pp, Small pocket book
428 pp, reader
Disease specific
Specific to special groups
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PRE-TRAVEL HEALTH ADVICE
Immunize travelers Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travelPrescribe appropriate chemoprophylactic and self-treatment medications
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PRESCRIBE (Script/Dr’s letter/medialert bracelet)
Always regular medicationmedical kit (first aid)*
Sometimes antimalarial medicationdiarrheal self-treatmentcondoms/PEPOther hygiene pdts
(NZPHR; 1996;3(8):57-59)
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Medication needs documentation
PrescriptionDoctor’s letter-consider using a proformaCustoms/quarantine approvals, if requiredIf part of a clinical trial, contact details/advice regarding adverse reactions (on a laminated card)
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We do not live in an ideal world
Travel health advice will be moderated by
Availability of vaccines
Availability of educational resources
Availability of drugs for chemoprophylaxis and treatment-special authority
Limitations in indications, limitations in available data for use
Risk assessment
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Bottom line of pre-travel health advice
There is probably more to pre-travel health advice than travel immunizations and malaria chemoprophylaxis
Travelers will have different priorities and resources
Need for a risk assessment and access to current epidemiological information available on a geographic basis by country/region