Travel Medicine.pptx

TRAVEL MEDICINE
Dr. Anitha Wilson
26-10-2021 Dr.Anitha Wilson 1

Scheme of Presentation
• Introduction
• Definition
• Why important?
• Travel Epidemiology
• Determinants of health risk during
travelling
• Travel specific health Risk
• Preventive measures & precautions
• Challenges of Travel medicine
• Conclusion
Sources of Information
• Park Textbook of Preventive & Social Medicine-
26th edition
• IAPSM’S text book of community-Kadri
• Maxcy Public Health & Prevention
• WHO: International Travel and Health 2021
• WHO: International Travel and Health chapter
6,7 (2019 updated)
• WHO: Tuberculosis & air travel, Guidelines for
prevention and control (3RD edition)
• Previous Question: Travel Medicine

Introduction
Travel medicine / Emporiatrics
• Medical speciality dealing with Traveller’s health.
• Concerned with prevention & management of International traveller’s health
problems and travel related health matters.
• Deals with
• Epidemiology of health risks to the traveler globally
• Vaccination & prevention of disease
• Pre-travel counseling.

Why important?
• In era of globalization, travelling is inevitable.
• Increase in number & speed of travelling from one geographical part of the world to another.
• UNWTO 2017 international tourist arrivals inflated by 7 %.
Tourism
Medical
tourism
Commerce Trade Academic
Friends &
relatives
(VFR)
Adventure
Religious
&
pilgrimage
51% - Leisure, recreational & holidays.
15% - Business & professional purposes
27% - Specific purposes –VFR, religious & pilgrimages , Health treatment

SDG goals Related with Tourism

Travel Epidemiology
• 35–64% of short-term travellers report some health impairment.
• Infectious diseases major contributors of illness with 1–4% of deaths among travellers.
• CVD’s & injuries - frequent causes of death.
• CVD = 50% & Injury = 22% of deaths.
• Mortality due to CVD in adults is similar to non-travelers.
• Deaths from injury - motor vehicle accidents, drowning & aircraft accidents - several
times higher among travelers.
• Travellers & travel medicine practitioners should be aware of the occurrence of these
diseases in the destination countries.

Determinants of Health risks during travelling
Traveller’s
Health
Pre existing health
issues
Behaviour of
travel
Purpose of travel
Season &
duration of travel
Destination –rural
areas, Stds of
accommodation,
food hygiene,
sanitation
Mode of transport

Travel specific Health Risk
1. Environment Risks  Altitude > 2750m , Heat & humidity, UV radiation
 Recreational waters – Drowning, Immersion hypothermia, Thermal
shock & Cardiac arrest.
 Attacks- animal, snakes, aquatics, insects & Intestinal parasites
2. Infectious disease of Potential Risk  Foodborne & water borne disease – Traveller’s diarrhoea, Hepatitis A , C,
typhoid, cholera.
 Vector borne disease –Malaria, Yellow Fever, Tick borne encephalitis.
 Zoonosis – Rabies, Brucellosis, leptospirosis.
 Airborne d/s –TB, measles, chickenpox, Legionellosis, Influenza.
 Sexually transmitted disease – Hepatitis B, HIV, syphilis.
 Blood borne disease: Hepatitis B / C, HIV, malaria
 Disease (soil) – spores(Anthrax, Tetanus), Parasitic infections.
3. Injuries & Violence  Motor vehicle accidents
 recreational activities-swimming, diving, sailing etc.
 Violence- alcohol, illegal drugs, dacoits.
4. Psychological health Anxiety , mood d/o, suicide attempts.

Psychological health
• Mental health issues leading cause of ill health among travellers.
• International travel is often a stressful experience.
• Separation from family & familiar social support systems in addition to foreign cultures &
languages.
• Under stress of travel - pre-existing mental disorders can be exacerbated.
• People with predisposition towards mental disorder - may emerge for first time during
travel.
• Differences in provision mental health care & in legal systems.
• Clinician decides whether traveler’s care be managed at travel destination or requires
repatriation.
• Psychiatric Emergency m/c medical reason for air evacuation (along with injury &
CVD).
• Criminal offence – psychotropic medication (benzodiazepine) without prescription.

Mode of travel: Health Conditions experienced
Air travel
Cabin Air
pressure low
• Blood O2 less than
sea level
• Medical
conditions
• Gas expansion at
high altitude.
• Pops sound nl
• chewing,
swallowing
• Valsalva
maneuver
• Ear, sinus
infection: pain
Deep Vein
Thrombosis
• Prolonged
immobilisation
• Pulmonary
embolism
• Moving every 2-
3 hr
• Exercise calf
muscle
• Restrict hand
luggage
JET LAG
Symptoms caused
disruption of
internal clock.
• Indigestion &
disturbance of
bowel function
• Difficult to sleep
at night.
• Fatigue &
malaise.
• Rest, light meal,
avoid alcohol &
caffeine.
Motion sickness
Low humidity
inside cabin – skin
dryness, discomfort
Divers avoid air
travel soon after
diving-
decompression
sickness.

Air travel advice with special needs &
medical illness
• Fit & healthy baby > 48hrs after birth.
• Preferable > 7 days.
• Premature babies –medical clearance.
• Cabin air pr. can upset infants –
• Feeding/pacifier - swallowing
• Women with uncomplicated pregnancy
• After 28 weeks – doctor’s letter-
EDD & nl pregnancy.
• Permitted - end of 36 weeks.
• Multiple pregnancies - end of 32
weeks.
Most with medical conditions are safe to travel – appropriate
precautions – oxygen supply.
Pretravel consultation
Frequent travellers – medical card.
Security issues – metal implants, pacemaker – Doctor’s letter.

Aircraft ventillation
Air exchange very 2-3
min.
20-30 air exchange in 1hr.

Transmission of communicable diseases on aircraft
• Transmission of infection occur between passengers - seated in same area of an aircraft.
• i.e same row & in 2 rows front and behind the case.
• As a result of infected individual
• coughing
• sneezing
• touch (direct contact or contact with same parts of aircraft cabin & furnishings).
• Likely to spread to other passengers in situations where aircraft ventilation system is not
operating.
• Auxiliary power unit provide ventilation when aircraft is on the ground.
• Not operated for environmental (noise) or technical reasons.
• Transmission of Tb & influenza

Aircraft disinfection
• To kill insects
• Disinfection –Public Health Measure –mandated by IHR.
• Procedures currently done as specified by WHO includes:
• Treatment of interior using quick acting insecticide spray before take off, with
passengers on board.
• Treatment of interior on ground before passengers board using residual insecticide
aerosol + quick acting spray shortly before landing.
• Regular application of residual spray to all internal surfaces except in food
preparations.

Travel by Sea
• Cruise ship –av.7days
• Approx. 3000 passengers,1000 crew.
• 100 d/s outbreak in last 30 years.
• Closed & crowded environment, unsafe water & food hygiene.
• D/s may spread to other member & crew members---disseminate to home communities.
Precautions:
 Travel health specialist: immunization– Influenza
 Frequent handwashing, Food & water sanitation
 Carry all medicines with prescription in a
container/packet.
Revised IHR :Health Requirements- ship operation
 Guidance on safe water & food (storage).
 Vector & rodent control.
 Waste disposal
 >3days travel - Physician requirement.
Communicable diseases:
 Git illness
 Influenza & resp. illness
 Legionellosis -1994 outbreak
 Varicella & Rubella
NCD :
 CVD events
 Motion sickness
 Injuries & dental emergencies

Preventive Measures & Precautions
Pretravel consultation
Travel medicine specialist / Travel clinic
I. Risk
Assesment
Traveller specific risk Pregnant, Infants, Medical illness,
VFR
Destination specific
Risk
D/s endemicity
Itinerary Specific Risk Mode of transport, urban vs rural
areas, accommodation, purpose of
travel, Recreational activities,
personal behaviours, entering
altitude.

II. Risk management
Strategies for reducing
water & food borne illness
 Avoid consumption of tap water, ice - tap water & raw foods rinsed with tap water
 Avoid unpasteurized dairy products & undercooked meat & fish.
 Consume boiled, treated, or bottled water
 Consume piping hot, thoroughly cooked food
 Seek restaurants / locations of food consumption that have reputations for safety.
Personal protective
Measures
 Avoid outdoor exposure during vector feeding times (eg, for malaria - dusk and dawn) &
avoid areas where vectors known to be active
 Wear full-length, loose-fitting garments to reduce the amount of exposed skin
 Use insecticide-treated bed nets & clothing.
 Use insect repellents that contain DEET or picaridin
 Inspect for ticks during & after high-risk activities, follow appropriate procedures for tick
removal.
1. Preventive counselling / health counselling

Advise on itinery special
risk
Avoid :
• freshwater exposure in areas where schistosomiasis or other parasitic infections
prevalent
• recreational water activities following floods or heavy rainfalls
• approaching animals including domestic animals (rabies prevalent)
• walking barefoot on soil & beaches
Use safer sex practices and avoiding higher-risk partners.
Precautions –motor vehicle accidents/injuries : Rent car, avoid unfamiliar & unlit roads,
seat belts, avoid alcohol.
Avoid one day travel -2750m- break the journey –gradual acclimatization.
Prophylaxis: Acetazolamide 5mg/kg/day – one day b/f travel 7 continued 1-2days of altitude

Risk mx cont..
Pretravel Health counselling –air travel & sea travel.
Chronic illness & frequent travellers:
• Medical Card : Pre existing illness (psychiatry),
Prescriptions, Blood group with doctors letter.
• DM - meal exchange plan, self care.
Travel health Kit
Travel insurance & Assessing medical care abroad
Immunizations – 2 months before travel –Vaccination card
Prophylactic medications – malaria
Treatment advise for Traveller’s diarrhoea
Medical examination after travel.

Travel related
Immunizations
Routine vaccinations
DPT, Hep.b, Hib, RV, Tb,
Polio, MMR,
Pneumococcal, varicella,
HPV, Influenza
(seasonal).
Required vaccinations
Yellow fever vaccine,
Meningococcal vaccine,
polio, influenza vaccine.
Recommended
vaccinations
•Hep. A &/ E, JE,
meningococcal
(A,C,Y,W135), Polio ,
Typhoid, Yellow fever,
Rabies, Tick borne
encephalitis

• Yellow fever vaccination
1. All travelers from endemic risk countries.
2. Certain countries - to prevent importation of virus into countries
- disease may/may not occur, but mosquito vector & non-human
primate hosts are present.
• Vaccination - entry requirement for all travelers arriving (including
airport transit).
• Vaccination against meningococcal disease (tetravalent ACWY
polysaccharide or conjugate vaccine) - Saudi Arabia for pilgrims
visiting Mecca and Medina for the hajj or umrah as well as for guest
workers.
• Selected countries may also recommend vaccination against influenza
for pilgrims to Mecca or Medina.
• Some polio-free countries may also require travelers resident in
countries or areas reported to have wild polioviruses to be vaccinated
against polio in order to obtain an entry visa, as in the case of Brunei
Darussalam, India and Saudi Arabia.

International Certificate Of Vaccination Or Prophylaxis

Medical Heath education & Chemoprophylaxis -Malaria
• Five principles – the ABCDE – of malaria protection
1. Aware of the risk, the incubation period, the possibility of delayed onset, and the main
symptoms.
2. Avoid being Bitten by mosquitoes - dusk and dawn.
3. Chemoprophylaxis)when appropriate, at regular intervals to prevent acute malaria
attacks.
4. Immediately seek Diagnosis and treatment if fever develops 1 week or more after
entering an area where there is malaria risk & up to 3 months after departure from a risk
area.
5. Avoid outdoor activities in Environments that are mosquito breeding places - swamps or
marshy areas, especially in late evenings and at night.

Malaria chemoprophylaxis
• Weekly mefloquine started 2–3 weeks before departure
• Daily prophylaxis with doxycycline or atovaquone–proguanil started 1–2 days before arrival in malaria
risk area
• Weekly chloroquine started 1 week before arrival
• All prophylactic drugs - continued for 4 weeks after last possible exposure to infection since parasites may
still emerge from liver during this period.
• Single exception is atovaquone–proguanil - can be stopped 1 week after return because it is effective against
early liver-stage parasites (liver schizonts).
• If daily doses skipped - atovaquone–proguanil prophylaxis taken for 4 weeks after return.
• Depending on type of malaria at the destination, travellers should be advised about possible late-onset
malaria caused by the persistent hepatic forms of P. vivax and P. ovale.

Malaria chemoprophylaxis during pregnancy
• Areas with exclusively P. vivax transmission - chloroquine prophylaxis used.
• P. falciparum transmission areas -mefloquine prophylaxis given.
• In light of the danger of malaria to mother and fetus, travel to a P. falciparum transmission area during
the first trimester of pregnancy should be avoided or delayed.
• If impossible, good preventive measures should be taken & prophylaxis with mefloquine is indicated.
• Doxycycline is contraindicated during pregnancy.
• Data on safety of exposure to atovaquone–proguanil during pregnancy are limited & therefore not
recommended for use in pregnancy or is recommended only with relevant risk information/warning.

Standby emergency treatment (SBET) - Malaria
Advised to carry antimalarial drugs for self administration.
Indications:
1. For travellers staying in remote locations - access to medical care may be difficult.
2. Travellers in some occupational groups who make frequent short stops in countries or areas with malaria
risk over prolonged period of time. Such travellers choose to reserve chemoprophylaxis for high-risk areas
& seasons only.
3. short-term travellers spending 1 week or more in certain remote rural areas where there is very low risk of
infection.
• Should continue to take measures to protect against mosquito bites, carry a course of antimalarial drugs for
SBET, seek immediate medical care in case of fever, and take SBET if prompt medical help is not available.
• Travellers should realize that self-treatment is a first-aid measure and that they should still seek
medical advice as soon as possible.

Last minute & imminent travel
• Last-minute travel (2 weeks or less until departure) &
imminent travel (48 hours or less until departure).
• General advice given is similar to that provided to other
kinds of travellers.
• Emphasis is laid on;
1. risk management –
a. preventive travel advise, DVT, trauma
b. medical prescriptions - pre-existing conditions,
common ailments during travel (travellers’
diarrhoea or fever)
c. Recommendations for basic first-aid kit .
2. vaccination options
3. administrative requirements (e.g. yellow fever
vaccination).

COVID-19: Travel advice for general public
• COVID-19 prevention measures
• Traveling - closed, confined, or crowded (the three Cs) - higher risk of being exposed to virus that causes
COVID-19.
• Whenever possible, stay in open, well-ventilated settings.
• While travelling, practice prevention measures even if fully vaccinated against COVID-19.
• Some countries exempt travelers who have been fully vaccinated or have proof of recent SARS-CoV-2
infection from certain requirements, such as testing and/or quarantine.
• People with symptoms of COVID-19 – including fever, cough, or shortness of breath – should not travel.
• People in certain groups – over age 60, chronic illnesses & underlying health conditions – face increased risk
of severe illness & death from COVID-19.
• If in these groups - not fully vaccinated and not have immunity from a recent previous COVID-19 infection,
consider postponing travel to areas with widespread COVID-19.

Key consideration COVID 19- aircraft
B/f embarkation
• communication,
coordination &
planning.
• Aircraft –sufficient
medical personal
(PPE).
• Nonmedical staff
trained-detect
symptomatic
passenger.
• EXIT screening –
temperature,
questionnaire.
• Advised to delay
travel - suspected .
On board
• Seating location
mapped –when a
passenger display
symptom.
• Cabin crew - inform
& seek advise
• Dedicated cabin crew
• Use appropriate PPE.
• Mask – tolerable
patients.
• Adjacent seats
• Potential contacts
“Passenger locator
Form”.
• Continous air
recirculation
Upon arrival
Suspected passengers
• Trained personal &
supplies.
• Interview & initial
management.
• Fast track pathway &
transport.
• Contingency plan
• Disinfection of
aircraft
Non suspected
passengers
• Health measure:
Evidence of imminent
public health risk from
arriving passengers
compels the traveller –
additional health
measures-
 Isolation
 Quarantine (Public
health observation)
• Risk communication
(media)

Challenges Of Travel Medicine
1. Lack of travel agents & tour operators –
i. provide information's –Travel insurance.
ii. Responsibility to safeguard the health of travellers
2. Lack of knowledge/awareness by the travellers – health risks.
3. Lack of access- VFR – cost of pre travel consultation not covered by health insurance
programmes especially with large family size.
4. Travel medicine services hampered by cultural & linguistic limitations.

Conclusion
• Most travel-related illnesses are
preventable by
• immunizations
• prophylactic medications
• pretravel health education
• Included in health education should be
mention role of hand hygiene in reducing
the transmission of pathogenic
organisms.
• Health recommendations for international
travel are based primarily on :
• individual risk assessment and any
• traveler plans to visit.
• requirements mandated by public health
authorities of the countries.

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