Describes salient features of travel associated problems

1. MINOR CREDIT SEMINAR
Dr. Adhiraj Mishra, M.V.Sc (1st Year), Div. of Epidemiology
Dr. DK Singh, Principal Scientist, Veterinary Public Health
Dr. Bhoj R Singh, Principal Scientist and Head, Division of Epidemiology

2. MAGNITUDE OF GLOBAL TRAVEL
 International arrivals will
reach 1.6 billion by 2020.
International Tourist (million)
903
940
2007
2010
 Travel to developing
countries increased from
31 % to 47% and to Asia
Pacific and Middle East
have doubled in last
decade.
(UNWTO-2012)
435
1990

3. MODE OF TRAVEL
6%
41%
51%
(UNWTO-2012)

4. REASON OF TRAVEL
International Travel & Health, 2012

5. TRAVEL RELATED RISK factors
 Mode of transport.
 Destination.
 Duration and season of travel.
 Purpose of travel.
 Behaviour of the travellers.
 Underlying health of the travellers.

6. AIR TRAVEL & Associated Risks
 Quality of Aircraft cabin




air & HEPA Filter.
Auxiliary Air Unit.
Aircraft Disinsection.
Disease
transmission:
Coughing, sneezing and
direct or indirect contact.
e.g-TB, Influenza, SARS

7. SEA TRAVEL & Associated Risks
 13 million passengers travel worldwide on cruise ship.
(UNWTO).
 Disease transmission through: Contaminated food &
Water, Whirlpool spa, inhalation. e.g. Gastroenteritis
(2006), Influenza & other RTI, Legionellosis (1994)
(International Travel & Health, 2012)

8. MODES OF DISEASE TRANSMISSION
Routes
Diseases
Food borne &
Waterborne
Traveller’s diarrhoea,
Cholera,
Cryptosporidiosis,
Giardiaisis, Hepatitis A & E, Listeriosis & Typhoid Fever
Air borne
TB, SARS, Mumps, diptheria, measles
Vector Borne
Animal Borne
Malaria, Yellow Fever, Dengue, Japanese Encephalitis,
Chikungunya & Tick borne encephalitis.
Rabies, Brucellosis, Leptospirosis
Blood borne
Hepatitis B & C, HIV/AIDS and Malaria
Sexually Transmitted
Hepatitis, HIV/AIDS & Syphilis
Soil borne
Anthrax, Ascariasis, Trichuris, Fungal infections
Recreational Water
Leptospira, Pseudomanas, Legionellosis, Schistosoma,
CLM, Giardia, Cryptosporidium, Tinea & Cutaneous
papilloma.

9. DISEASE DIAGNOSIS BY GEOSENTINEL SITES
Diagnosis
Cases
Malaria
1,762
Giardiasis
1,296
Dengue Fever
888
Campylobacteriosis
596
Cutaneous Larva migrans
577
Rabies P E Prophylaxis
349
Enteric Fever
262
Spotted Fevers
220
Chikungunya
120
Acute Hepatitis A
94
Confirmed Influenza A/B
84
Leader K, Torresi J et al, 2013

10. SEVERE ACUTE RESPIRATORY SYNDROME (SARS)
 Zoonotic viral disease caused by the SARS-CoV.
 By July 2003, 8,273 cases and 775 deaths reported in
multiple countries (9.6% fatality rate). Within weeks, SARS
spread from Hong Kong to 37 countries in early 2003.
(WHO)
 1st seen- Guangdong Province of China-16th Nov, 2002
 Dr. Liu Jianlun reached Hong Kong-21st Feb, 2003
 Stayed in Metropole Hotel Room No.911 and shifted to
Hospital on 22nd Feb 2003 and died on 4th March

11. Contd.
 American businessman who stayed
in the same hotel, now travelling
from China to Singapore had
emergency landing in Vietnam and
died.
 Disease
spread
to
Canada, Singapore, China, Vietnam
, United States, Mongolia etc.
 WHO issued global alert on 12th
March 2003.
 1st case in India- 32 year man in
Goa, who returned from Hong
Kong and Singapore on 17th April
2003.

12. GLOBAL SPREAD OF SARS
The WHO Report, 2003

13. PANDEMIC INFLUNZA (H1N1)
 “pH1N1", 1st identified in April 2009, and
initially spread in Mexico and then
globally.
 Emerged from pigs in Asia, and was
carried to North America by infected
persons.
 The first case of the Swine flu in India -on
13 May 2009, when a 23 year old man
travelling by Emirates Airline from New
York to Hyderabad via Dubai.

14. AVIAN INFLUNZA (H5N1)
 Avian influenza A (H5N1), first seen in Hong Kong in
1997. Then, it reappeared in Vietnam in 2003 and has
been in continuous circulation ever since.
 H5N1 has primarily affected poultry, from 2003
through 2011, 578 human illnesses in 15 countries were
reported, with an alarming case-fatality ratio of 59%.
 The countries with the most cases of human disease
(Indonesia, Vietnam, and Egypt) account for 80% of
all cases and 78% of all deaths.
(Ostroff SM, 2012)

15. AVIAN INFLUENZA IN CHINA
 Avian influenza A (H7N9) virus was first reported in
China among human beings and poultry.
 Till 6th Nov, 2o13, 139 H7N9 human infections were
reported & 45 people died. (ProMED-Mail).
 Person-to-person spread of H7N9 is rare.

16. PREVENTION OF RESPIRATORY
INFECTIONS






Frequent washing of hands with
soap & water.
Disinfection
of
household
surfaces.
Wear disposable gloves and
apron and N-95 mask.
Eye protection (e.g. face shield or
goggles) if splash or spray of
body fluids is likely.
Thermal Screening at airport &
Quarantine.
Social distancing.

17. HIV/AIDS and Travel
 HIV-I pandemic started by
mid 70s and 80s spread to
five continents through air
travel, sea travel and human
migration.
 Case of ‘Patient Zero’, a
Canadian flight attendant
who travelled extensively
worldwide.
 In the United States, the
rapid spread of AIDS
between 1984 and 1990 can
be modelled accurately
using air traffic flows
between cities.
(CDC, Yellow Book 2012)

18. DRUG RESISTANCE
 MRSA, Strains of N. gonorrhoeae & multidrug resistant
Acinetobacter
travellers.
baumannii
have been
spread
(Ostroff SM, 2012)
by

19. Travel of NDM-1
 First detected in patient’s stool
who returned to Sweeden after
hospitalisation in India in Jan
2008.
 A total of 37 isolates with
NDM-1 were recovered from
50 UK patients and 143 from
patients
at
Indian
subcontinent
 Since Aug 2010, it has
worldwide distribution except
in Central and South America.

20. GLOBAL SPREAD OF NDM (June2012)
Ostroff SM, 2012

21. DENGUE VOYAGE
 In 2000, Dengue spread to the US
via infected travellers.
60
50
40
30
20
10
0
South East
South
Asia
Central Asia
Central
America
South
America
Caribbean Sub Saharan
Africa
Cases of Dengue among travellers (Leader K, Torresi J et al 2013)

22. CHIKUNGUNYA FLIGHTS
 Restricted to Africa & Asia
and after the Kenya
outbreak in 2004 it
appeared in islands of
Indian Ocean in 2005 and
then
reached
Indian
Subcontinent in 2006.
 Travellers to India and
Indian visitors then spread
it to Europe, North
America and Australia
having viable vectors.

23. WEST NILE VIRUS
The West Nile Virus is
believed to reach United
States in 1999 via mosquitoes
that crossed oceans by aircraft
wheel wells.
(CDC Yellow Book 2012)

24. MASS GATHERINGS (MG)

25. HAJJ PILIGRIMAGE & DISEASES
Health Requirements
Entry Visa:
for
Yellow Fever-Risk area
Meningococcal Meningitis.
(A,C,Y,W135)
Poliomyelitis-Oral Vaccine.
Seasonal Influenza.
(Weekly Epid. Report, 2013)

26. Spread of Emerging Diseases
 MERS-CoV-EMC/2012
a novel
Corona virus first reported on
24th Sept, 2012 in Saudi Arabia.
 As on 19th Nov, 2013 157 people
affected
with
66
deaths.
(ProMED Mail)
 ‘Sacrifice Voucher’ can spread
Meat borne Zoonoses.
 Blood Borne Pathogen like
Heaptitis B, C and HIV.
(Balaban V, Ahmed, Q, 2011)

27. KUMBH MELA
100 million people, 600 km pipes, 92 million litres clean
water/day, 35,000 temporary toilets and 10,000 night soil
sweepers.
( Balsari S, 2013)

28. SPORTS EVENTS
London Olympic 2012:
 15,000 athletes, 70,000
volunteers,
20,000
journalists
and
10
million spectators.
FIFA World Cup 2010:
South Africa
 32 national teams & 3.2
million spectators
World Cup Cricket, 2007
Caribbean islands:
 16 participating nations
and 1 million spectators.

29. INTERNATIONAL ORGANISATIONS

30. FOOD AND WATER PRECAUTIONS
 Bottled water.
 Selection of foods
 well-cooked and hot.
 Avoidance of
 salads, raw vegetables, raw or
undercooked eggs and meat.
 unpasteurized dairy products
 street vendors
 Ice.
30

31. VECTOR PRECAUTIONS
 Protective Clothing.
 Insect repellent containing DEET 25 – 50%
 Treatment of outer clothing with
permethrin or etofenprox.
 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
31

32. BLOODBORNE DISEASES & STD PRECAUTIONS
Avoid
 Unprotected sexual activity
 Commercial sex workers
 Tattooing and body piercing
 Blood products
 Dental and surgical procedures
32

33. INTERNATIONAL HEALTH REGULATIONS, 2005
 Came into force on 15th June 2007.
Their main objectives are to ensure:
(1) Routine, preventive measures (e.g. at ports and airports)
and the use by all countries of internationally approved
documents (e.g. vaccination certificates);
(2)The notification to WHO of all events that may constitute
a public health emergency of international concern; and
(3) The implementation of any temporary recommendations
should the WHO Director-General have determined that
such an emergency is occurring.
(International travel & health, 2012)

34. ANIMAL TRAVEL & DISEASES
Species
Diseases
Bovine
Bovine Spongiform Encephalopathy, CBPP, FMD, BVD.
Equine
Equine Infectious Anaemia, Glanders, Dourine, Equine
Infectious Metritis,
Infectious Equine Abortion,
Piroplasmosis, Equine Influenza, VEE.
(AQ&CS, Govt. Of India)
Caprine & Ovine
Borders Disease, PPR.
Swine
Nipah Viral Encephalitis,
Respiratory Syndrome.
Porcine
Avain
Reproductive
&
HPAI, LPAI, IBD, New Castle Diseases.
•The Livestock Importation Act, 1898.
•The Prevention & Control of Infectious and Contagious
Diseases in Animal Act , 2009

35. WHAT TO DO?
 Pre-travel Medical Consultation.
 Strengthening of travel industry.
 Redefine responsibility of the travellers.
 Introduction of Travel Health & Mass Gathering Health in
Public Health Curriculum.
 Medical Insurance of travellers.