Keeping our Traveling Keeping our Traveling Students Safe and Students Safe and

HealthyHealthy

Jean Haulman MDJean Haulman MDMarch 6, 2009March 6, 2009

www.kidsforsavingearth.org

RisksRisks

Loss of Loss of inhibitionsinhibitions

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1850 1900 1950 2000

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days to circlethe globe

internationalarrivals

Your favorite Your favorite “exotic” disease“exotic” disease

is only anis only an airplane ride airplane ride

awayaway

Transportation hazardsTransportation hazards

http://www.blueskyaviation.mn/medevac.html

Injury: Land & WaterInjury: Land & Water

Leading cause of death in Leading cause of death in travelers is Motor Vehicle travelers is Motor Vehicle

Accidents (<55 y/o)Accidents (<55 y/o)

Auto accidentsAuto accidents According to the Association for Safe According to the Association for Safe

International Road Travel, the risk is International Road Travel, the risk is 20-80 times higher in developing 20-80 times higher in developing countries than in the U.S. countries than in the U.S.

Approximately 750 Americans die Approximately 750 Americans die annually in auto accidents abroad, and annually in auto accidents abroad, and approximately 25,000 are injured. approximately 25,000 are injured.

Why does this occur?Why does this occur?

Modes of Transportation are Modes of Transportation are UniqueUnique

Conditions leading to MVAsConditions leading to MVAsPoor road conditions Poor road conditions Poor vehicle Poor vehicle

maintenancemaintenanceLack of seatbeltsLack of seatbelts33rdrd world countries do world countries do

not always have the not always have the same rules of the roadsame rules of the road

http://www.explorenorth.com/blog/deathroad.jpg

http://www.autocult.com.au/img/gallery/full/nickop196.jpg

Road signsRoad signs

Road signs may be Road signs may be confusingconfusing

Advice for drivers in Advice for drivers in IndiaIndia

http://2.bp.blogspot.com/...qHw5g5ewdM/s400/2Indianroadsignsmall.jpg

http://www.infoforhealth.org/pr/m15/p6a.jpg

Traffic in CairoTraffic in Cairo

Donor-mobileDonor-mobile

AAA Abroad:AAA Abroad:Roadside service variesRoadside service varies

Rule: Pedestrians do not always Rule: Pedestrians do not always have the right of wayhave the right of way

http://www.cartoonstock.com/newscartoons/cartoonists/aia/lowres/aian23l.jpg

RisksRisksDrowning is second leading Drowning is second leading

cause of mortality for cause of mortality for travelerstravelers

What is the common What is the common denominator for MVA and denominator for MVA and

drowning?drowning?

RisksRisks

Illness – Destination SpecificIllness – Destination Specific

What are the options for What are the options for prevention and prevention and

treatment?treatment?First step: Pack your common First step: Pack your common

sensesenseSecond Step: Schedule a pre Second Step: Schedule a pre travel consultation. Novice travel consultation. Novice

students need in person students need in person consultation.consultation.

Pre-Travel Counseling Pre-Travel Counseling VisitVisit

Focus is preventionFocus is prevention Advice given regarding ways to Advice given regarding ways to

minimize destination specific risks minimize destination specific risks • Disease and environment educationDisease and environment education

Traffic risks, drowning risksTraffic risks, drowning risks Insect precautionsInsect precautions Food and water Food and water

• VaccinesVaccines• Medications for travelers’ diarrhea (TD), Medications for travelers’ diarrhea (TD),

malaria prophylaxis, altitude sickness, HIV malaria prophylaxis, altitude sickness, HIV PEP for traveling health care studentsPEP for traveling health care students

Travel Clinic ConsultationTravel Clinic Consultation ItineraryItinerary Reason for travelReason for travel AccommodationsAccommodations Duration of travelDuration of travel Modified byModified by

• Medical and immunization historyMedical and immunization history• AllergiesAllergies• Special needsSpecial needs

Itinerary and Reasons for Itinerary and Reasons for TravelTravel ItineraryItinerary

• Country and regionCountry and region• City vs. ruralCity vs. rural

Reason for travel: Reason for travel: backpacking, trekking, backpacking, trekking, spelunking, business, study spelunking, business, study abroadabroad

Accommodations: Hotel, Accommodations: Hotel, tent, hostel, cave, host tent, hostel, cave, host familyfamily

http://www.arr-the-kraken.com/images/oz_02.jpg

http://ritz-carlton-boston-commons.visit-boston-massachusetts.com/boston-ritz-carlton-suite.jpg

AccommodationsAccommodations Host familiesHost families

• Hepatitis A, TyphoidHepatitis A, Typhoid• Local waterLocal water• Well waterWell water

Crowded living conditions, group Crowded living conditions, group travel, exposure to ill persons:travel, exposure to ill persons:• Meningococcal diseaseMeningococcal disease• InfluenzaInfluenza• TuberculosisTuberculosis

Rule: There is so such thing as safe drinking water in a 3rd world country unless it comes from a sealed bottle.

Travel location(s) and Travel location(s) and duration of stayduration of stay

Diseases follow geographic patterns Diseases follow geographic patterns and seasonal variationsand seasonal variations

The longer the stay the greater the risk The longer the stay the greater the risk of travel related illnessof travel related illness

Short stays are considered <2-3 weeksShort stays are considered <2-3 weeks Long stays are > 1 monthLong stays are > 1 month

Pre-travel Pre-travel Consultation Consultation VACCINES: Routine, VACCINES: Routine,

Recommended and RequiredRecommended and Required

Why insure completion and Why insure completion and update of routine vaccines? update of routine vaccines?

WorldWorld vs vs USUS Diphtheria: 9,235Diphtheria: 9,235 Measles: 30-40 mMeasles: 30-40 m Pertussis 20-40 mPertussis 20-40 m Polio: >35,000Polio: >35,000 Mumps: UnknownMumps: Unknown TetanusTetanus

>300,000>300,000(most neonatal)(most neonatal)

0 cases in 20050 cases in 2005 64 cases: 2008 *64 cases: 2008 * 25,827 in 200425,827 in 2004 Last wild case 1979Last wild case 1979 5,783 cases in 20065,783 cases in 2006 @ 40 cases in 2006@ 40 cases in 2006

86% imported

RecommendedRecommended Hepatitis AHepatitis A TyphoidTyphoid Hepatitis BHepatitis B RabiesRabies PolioPolio MeningococcalMeningococcal JEVJEV (HPV)(HPV)

Recommended VaccinesRecommended Vaccines Hepatitis A vaccine: Hepatitis A vaccine:

• 11stst dose can be given on the way to the airport dose can be given on the way to the airport• Most common vaccine-preventable illness in Most common vaccine-preventable illness in

returned travelers, next to influenzareturned travelers, next to influenza Typhoid vaccine: recommended for all 3Typhoid vaccine: recommended for all 3rdrd

world travel unless staying in 4-5 star world travel unless staying in 4-5 star accommodations and never eating from accommodations and never eating from the streetthe street• 1140 US cases reported 1999-2003, 74% 1140 US cases reported 1999-2003, 74%

importedimported

VaccinesVaccines Hepatitis AHepatitis A

• 2 brand of vaccines 2 brand of vaccines available, equally effectiveavailable, equally effective

• Given 6 months apartGiven 6 months apart• Expected lifetime Expected lifetime

immunityimmunity

TyphoidTyphoid• 2 types of vaccines available2 types of vaccines available• Injectable: good for 2 yearsInjectable: good for 2 years

Can cause sore armCan cause sore arm May feel run down for 1 dayMay feel run down for 1 day Students and insurances Students and insurances

preferprefer• Oral: good for 5 yearsOral: good for 5 years

Live attenuatedLive attenuated Can cause nauseaCan cause nausea Cannot take concurrent Cannot take concurrent

antibioticsantibiotics 1 pill qod x 4 doses1 pill qod x 4 doses Should complete 4 dose Should complete 4 dose

schedule at least 10 days schedule at least 10 days prior to departureprior to departure

Hepatitis B vaccineHepatitis B vaccine Encouraged for all Encouraged for all

travelers at risk for travelers at risk for MVA while travelingMVA while traveling

Recommended for Recommended for sexual partner seeking sexual partner seeking travelerstravelers

Recommended for Recommended for travelers seeking travelers seeking medical procedures, medical procedures, tattoos, and/or tattoos, and/or piercingspiercings

3 dose vaccine given 3 dose vaccine given at 0, 1, and 6 monthsat 0, 1, and 6 months

First cancer First cancer preventing vaccinepreventing vaccine Courtesy of Patricia Walker MD

Ramsey Clinical Assts St. Paul, MN

Hepatitis A/B VaccineHepatitis A/B Vaccine Given as series of 3Given as series of 3 Standard schedule 0, 1, 6 monthsStandard schedule 0, 1, 6 months

• 3 doses of standard hepatitis B3 doses of standard hepatitis B• 3 doses of ½ standard dose for hepatitis A3 doses of ½ standard dose for hepatitis A

New FDA approved accelerated dosingNew FDA approved accelerated dosing• Advantage for travelersAdvantage for travelers• Given at day 0, 7, 21-28 days, booster at 1 Given at day 0, 7, 21-28 days, booster at 1

yearyear• Can fit in complete series prior to travelCan fit in complete series prior to travel

Polio 2003:

Polio Travel as a risk factor: 2003 and 2005, 25

previously polio-free countries were re-infected due to imports of the virus

As of March 2008, only four countries in the world (Afghanistan, India, Nigeria, Pakistan,) are still considered to be endemic for Polio

However new case reports appear monthly in most sub Saharan countries

Recent imported case from Indonesia to Australia

Rule: If it has fur and teeth do not touch it.

Vaccines in short supply Rabies vaccine: current shortage, not

available for pre travel use Disease is 100% fatal Only post exposure vaccination is available HRIG (expensive) + 5 doses of vaccine on

days 0,3,7,14,28

Vaccines for specific destinationsVaccines for specific destinations

JEV: SE AsiaJEV: SE Asia Short supplyShort supply MosquitoMosquito Dusk to dawnDusk to dawn Rainy seasonRainy season 30% mortality30% mortality Given as a 3 dose Given as a 3 dose

series 0,7,21 daysseries 0,7,21 days Can cause allergic Can cause allergic

reactionreaction New 2 dose vaccine New 2 dose vaccine

close to FDA approvalclose to FDA approval

Yellow Fever: Required Required vaccine Can be obtained only

at a yellow fever certified center

Must be documented on the official CDC or WHO yellow card

50% mortality from disease

Vaccine has rare serious side effects

1 vaccine q 10 years

Meningococcal InfectionsMeningococcal Infections For travelers going to For travelers going to

Africa during the dry Africa during the dry seasonseason

Required for travelers Required for travelers going to the Hajj in going to the Hajj in Saudi ArabiaSaudi Arabia

Sporadic outbreaks in Sporadic outbreaks in other African countriesother African countries

2 vaccines2 vaccines• Meningococcal Meningococcal

Conjugate vaccine: age Conjugate vaccine: age 2-55 yrs2-55 yrs

• Meningococcal Meningococcal Polysaccharide: Polysaccharide: Approved for age 3 Approved for age 3 months and oldermonths and older

MedicationsMedications

DIARRHEA PreventionDIARRHEA PreventionA.K.A.A.K.A.

Montezuma’s revengeMontezuma’s revengeAztec two-stepAztec two-step

The trotsThe trotsTurkey TrotsTurkey Trots

TuristaTurista

Distribution of TDDistribution of TD

Why is diarrhea more Why is diarrhea more common in the developing common in the developing

world?world?

Travelers’ diarrheaTravelers’ diarrhea Incidence highest for Incidence highest for

travelers going to a travelers going to a 33rdrd world country world country

Food is the vector for Food is the vector for travelers’ diarrhea travelers’ diarrhea more often than more often than waterwater

Travelers’ diarrheaTravelers’ diarrhea

Acute, self-limiting illness; resolves Acute, self-limiting illness; resolves within about 5 days. within about 5 days.

3-10% of pts with TD will have 3-10% of pts with TD will have symptoms lasting longer than 2 weeks.symptoms lasting longer than 2 weeks.

Up to 3% of travelers have TD lasting Up to 3% of travelers have TD lasting over 30 days. over 30 days.

Most symptoms occur while abroad and Most symptoms occur while abroad and are never reportedare never reported

Treatment for Travelers’ Treatment for Travelers’ Diarrhea (short term travelers)Diarrhea (short term travelers)

Ciprofloxacin 500mg up to q 12 hours for Ciprofloxacin 500mg up to q 12 hours for 3 days (adults)3 days (adults) OROR

Azithromycin 10mg/kg up to 500mg q 24 Azithromycin 10mg/kg up to 500mg q 24 hrs for up to 3 days (peds and adults) ORhrs for up to 3 days (peds and adults) OR

Azithromycin 1000mg all at once (adults)Azithromycin 1000mg all at once (adults)

Newer option: Rifaximin 200mg tid for 3 Newer option: Rifaximin 200mg tid for 3 days days

Travelers prefer to sit hereTravelers prefer to sit here

http://www.advillas.com/images/newImages/AdvillasBeachSunset.jpg

--not here----not here--

Malaria preventionMalaria preventionFever is malaria until proven otherwiseFever is malaria until proven otherwise

ANDANDMany developing countries treat every Many developing countries treat every

fever with malaria medicationfever with malaria medication

Malaria ChemoprophylaxisMalaria Chemoprophylaxis Chloroquine: weekly medicine, most of the Chloroquine: weekly medicine, most of the

world has resistant parasites – world has resistant parasites – @$0.61-3.94/pill/week@$0.61-3.94/pill/week

Mefloquine (Larium): weekly medicine - Mefloquine (Larium): weekly medicine - @$11.33/pill/week, spotty resistance, can @$11.33/pill/week, spotty resistance, can cause psychosiscause psychosis

Doxycycline: daily, cheap - @ $0.26/pill, no Doxycycline: daily, cheap - @ $0.26/pill, no world resistance known, can cause stomach world resistance known, can cause stomach upset and vaginal yeast infection.upset and vaginal yeast infection.

Atovaquone-Proguanil (Malarone): daily - @ Atovaquone-Proguanil (Malarone): daily - @ $7.33/pill$7.33/pill

Altitude: Acute Mountain Altitude: Acute Mountain SicknessSickness

May lead to headache, May lead to headache, insomnia, fatigue, insomnia, fatigue, nauseanausea

Occurs in @ 40-50% of Occurs in @ 40-50% of lowland persons lowland persons moving quickly to moving quickly to 14,000 ft (4250m) 14,000 ft (4250m)

PreventionPrevention• Ascend slowlyAscend slowly• AcetazolamideAcetazolamide

125 mg bid125 mg bid 250 mg qhs250 mg qhs

http://terrigick.typepad.com/.a/6a00e551f461c38833010536b4bd95970b-500wi

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What to expect when What to expect when illness happens during illness happens during

traveltravel

Medical Care may be DifferentMedical Care may be Different

Medical careMedical care The standards of health care delivery The standards of health care delivery

differ in poorer countriesdiffer in poorer countries

The modernization of buildings and The modernization of buildings and number of sky scrapers doesn’t number of sky scrapers doesn’t always correlate with modern health always correlate with modern health care deliverycare delivery

Modern & Shanty are often Modern & Shanty are often neighborsneighbors

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http://images.google.com/imgres?imgurl=http://www.tr-ac-net.org/DBimages/

http://3.bp.blogspot.com/

Clean and modern on the outsideClean and modern on the outside

doesn’t necessarily mean clean doesn’t necessarily mean clean and modern on the insideand modern on the inside

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Standards of Medical CareStandards of Medical Care May reuse syringes, needlesMay reuse syringes, needles May have primitive sterilization May have primitive sterilization

techniques (alcohol and a match)techniques (alcohol and a match) Medications and vaccines may be Medications and vaccines may be

counterfeitcounterfeit Overnight stay usually requires Overnight stay usually requires

assistance (bedding, food, etc)assistance (bedding, food, etc) May be dirty, may see rodents, flies May be dirty, may see rodents, flies

and mosquitoesand mosquitoes

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Conditions may be crowdedConditions may be crowded

Hospital wards varyHospital wards vary

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Tanzania: Surgical gown Tanzania: Surgical gown sterilizationsterilization

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Medical care while travelingMedical care while traveling Advise small medical kitAdvise small medical kit Syringe kits for high risk destinationsSyringe kits for high risk destinations Have medical/evacuation insurance:Have medical/evacuation insurance:

• Access America (Word Access): 1-800-284-Access America (Word Access): 1-800-284-83008300

• International SOS: 1-800-468-5232International SOS: 1-800-468-5232• ASA, Inc.: 1-888-ASA-8288ASA, Inc.: 1-888-ASA-8288• Gateway:1-800-282-4495Gateway:1-800-282-4495• Travel Assistance: 1-800-821-2828Travel Assistance: 1-800-821-2828• Medjet assistance: 1-800-9MEDJETMedjet assistance: 1-800-9MEDJET• Divers Alert Network Divers Alert Network

Have health insurance on returnHave health insurance on return

Medicine KitMedicine Kit Sunscreen Sunscreen NSAIDsNSAIDs MoleskinMoleskin Non Neomycin-containing antibiotic, band-Non Neomycin-containing antibiotic, band-

aidsaids Antifungal cream (wear white cotton socks)Antifungal cream (wear white cotton socks) Hydrocortisone creamHydrocortisone cream Stool softeners, loperamideStool softeners, loperamide AntihistaminesAntihistamines Flashlight, copy of passportFlashlight, copy of passport

What happens when travelers What happens when travelers return home illreturn home ill

Unexplained fever is an emergency Unexplained fever is an emergency and is malaria until proven otherwiseand is malaria until proven otherwise

Also seek consultation forAlso seek consultation for• Unusual rashesUnusual rashes• Persistent diarrheaPersistent diarrhea• Persistent coughPersistent cough• Unusual weight loss or fatigueUnusual weight loss or fatigue

CreditsCredits http://www.istm.org/ International Society of Travel International Society of Travel

Medicine (ISTM) teaching slide setMedicine (ISTM) teaching slide set www.cdc/gov www.immunize.org http://www.who.int/en/ http://www.shoreland.com/http://www.shoreland.com/ http://www.promedmail.org/

Many ThanksMany ThanksJean Haulman MDJean Haulman MD