POLICY FOR TRAVELLER

http://wwwnc.cdc.gov/travel http://www.who.int/ith/en/

World Flight Tracking (08/06/2015)

Indonesia Flight Tracking (08/06/2015)

2014 Ebola Outbreak Reported Cases (Suspected, Probable, and Confirmed) in Guinea, Liberia, and Sierra Leone This graph shows the total reported cases (suspected, probable, and confirmed) in Guinea, Liberia, and Sierra Leone provided in WHO situation reports beginning on March 25, 2014, through the most recent situation report on June 3, 2015. 5

Total Cases (Suspected, Probable, and Confirmed) EVD Cases and Deaths* Reporting Date Total Cases (Suspected, Probable, and Confirmed) Confirmed Cases Total Deaths Guinea 4 June 15 3,657 3,227 2,431 Liberia** 9 May 15 10,666 3,151 4,806 Sierra Leone 12,850 8,623 3,912 Italy 20 May 15 1 United Kingdom*** 29 Dec 14 Nigeria*** 15 Oct 14 20 19 8 Spain*** 27 Oct 14 Senegal*** United States*** 24 Oct 14 4 Mali*** 23 Nov 14 7 6 TOTAL 27,076 15,010 11,155 Updated case counts available at http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html. * Total cases include probable, suspected, and confirmed cases. Reported by WHO using data from ministries of health **One case of Ebola was confirmed on March 20, 2015. No cases of Ebola were identified during 21 days of monitoring of contacts of this case. WHO declared the end of the Ebola outbreak in Liberia on May 9, 2015, after 42 days (two incubation periods) had passed since the last Ebola patient was buried. Public health authorities are maintaining active surveillance so that any new cases of Ebola are rapidly identified. ***There are currently no Ebola cases in Senegal, Nigeria, Spain, the United States, the United Kingdom, and Mali. 6

What Is Middle East Respiratory Syndrome (MERS)? Middle East Respiratory Syndrome (MERS) is a viral respiratory illness. MERS is caused by a coronavirus called Middle East Respiratory Syndrome Coronavirus. MERS-CoV was first reported in 2012 in Saudi Arabia. Source: NBC News

Where Did MERS - CoV Come From… At this time, it is unclear where the virus developed. MERS-CoV most likely came from an animal source. In addition to humans, it has been found in camels in Qatar, Egypt and Saudi Arabia, and in a bat in Saudi Arabia. (CDC) Camels in a few other countries have also tested positive for antibodies to MERS-CoV which means they were previously infected with MERS-CoV or a closely related virus.

How Is MERS-CoV Transmitted… MERS-CoV is transmitted by water droplets that are expelled from the lungs when a person breathes, coughs or sneezes. MERS-CoV has been shown to be transmitted by close contact with a person who is infected with the virus. A close contact to the ill person includes: Health care provider providing care to an ill patient. Family member who is taking care of the ill person at home. Anyone who visited the person when the person was ill. A person who has traveled with the ill person within the past 14 days.

Am I At Risk For Developing MERS-CoV... The groups at highest risk for developing MERS-CoV are: Infants/Children Elderly People with immune system problems Chronic Heart, Lung and Kidney problems Pregnant women People with Diabetes A person who has traveled to one of the locations that has had confirmed lab tests that are positive for MERS-CoV.

What Are The Symptoms… Most people with MERS-CoV develop respiratory illness with these symptoms: Fever above 100.4ºF Cough/ Runny nose Shortness of breath Pneumonia Chills/ Body Aches Sore Throat Headache Nausea/Vomiting Diarrhea Symptoms usually develop 2-14 days after exposure to a person infected with MERS-CoV Or following travel from countries in or near the Arabian Peninsula within 14 days before onset of symptoms.

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 die Steffen R et al. J Infect Dis 1987; 156:84-91

The Patient: Medical Issues Age-specific issues Underlying illness, immunosuppression Systems review Medical history Medication use Vaccination history Allergies Contraindications to vaccines and medications

The Patient: Other Issues Reproductive Pregnant Breastfeeding Preconception Risk-taking behaviors

Travel Itinerary Full itinerary Styles of travel Accommodation 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

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”

Deaths Related to International Travel Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

Infectious Disease Risks to the Traveler Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis ETC.

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

Immunizations to Consider for Adult Travelers Routine Diphtheria* Tetanus* Pertussis* Measles + Mumps+ Rubella + Varicella Pneumococcus Influenza Travel related Hepatitis A Hepatitis B Typhoid Rabies Meningococcal disease Polio Japanese encephalitis Yellow Fever VZV (no mention of upper age limit; approved for >=12 months) >= 13 Years of Age After the first and second doses, 10.2% and 9.5% of vaccinees, respectively, developed fever (i.e., oral temperature greater than or equal to 100 F {37.7 C}); these febrile episodes occurred throughout the 42-day period and were usually associated with intercurrent illness. After one and two doses, 24.4% and 32.5% of vaccinees, respectively, had complaints regarding the injection site; rash at the injection site at a peak of 6-20 days and 0-6 days postvaccination, respectively, developed in 3% and 1% of vaccinees, respectively; and a nonlocalized rash consisting of a median number of five lesions developed in 5.5% and 0.9% of vaccinees, respectively, and occurred at a peak of 7-21 days and 0-23 days postvaccination, respectively.

Travel Medications: Prophylaxis & Self Treatment Malaria chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine Diarrhea quinolone, azithromycin Altitude acetazolamide Motion sickness scopolamine, dimenhydrinate (Dramamine)

Patient Counseling Sufficient time for patient education Tailored to suit traveler Fitness for travel Understanding impact on existing conditions Advisability of destinations

Travel Preparation Travel health insurance Medical care Hospitalization Evacuation Obtaining medical care abroad Awareness of travel notices Hand washing and hygiene

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

Food and Water Precautions Bottled water Selection of foods well-cooked and hot Avoidance of salads, raw vegetables unpasteurized dairy products street vendors ice

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

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

Animal Precautions Animal avoidance Rabies Envenomations Specific animal threats Medical evaluation of bites/scratches Post exposure immunization and immunoglobulin Envenomations Snakes, scorpions, spiders Maritime animals

Injury and Crime Vehicles Use of drugs and alcohol 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

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

Post-Travel Care Post-travel checkup Post-travel care Long term travelers Adventure travelers Expatriates in developing world Post-travel care Fever, chills, sweats Persistent diarrhea Weight loss

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