1. By Hatim Jaber MD MPH JBCM PhD 23-24 - 7-2017
Faculty of Medicine Public Health ( ) الصحة العامة Lecture Migration and Travelers' health By
Hatim Jaber
MD MPH JBCM PhD

2. Migration and Travelers' health
The global health impact of mental health and mental diseases. Drug abuse and Addictive substances
Global overview of communicable diseases
Global overview Non- Communicable Diseases(NCDs)
The global health impact of Hepatitis, Tuberculosis and HIV/AIDS
The global health impact of Cardiovascular Diseases , Diabetes and Obesity
Health policy and management, Health priorities
Health policies and management within a global health perspective
Healthcare service delivery in developed and developing countries
Healthcare systems and financing
Quality of care and effectiveness in different health services systems
Violence and Injuries
Migration and Travelers' health

3. Presentation outline Migration and Health 08:00 to 08:10
Time
Migration and Health
08:00 to 08:10
Global Compact in Migrants and Refugees
08:10 to 08:20
Travelers Medicine
08: 20 to 08:30
Travelers’ Health Risks
08:30 to 08:40
Infectious Disease Risks to the Traveler
08:40 to 09:00
09:00 to 09:15

4. Globalization of health and safety
Affects
Health of local populations
Health determinants
Safety and security
Results in
Global impacts
Emerging and re-emerging infectious disease
Commerce and Health
Influenza
SARS
Terrorism
Tsunami
Pathogens travel as fast as transportation: borders are not respected

5. Global Migration Trends
1 billion Migrants
2014:
S-S 37%:
S-N 35%;
N-N 23%;
N-S 5%
The six “Ds” driving migration:
DEMOGRAPHY: pop. replacement rates in industrialized world; & birth rates in developing countries;
DEMAND: labour shortage in industrialized world; labour surplus in developing countries;
DISTANCE shrinking due to technology and travel;
DIGITAL REVOLUTION: real-time info on mobility/migrant networks;
DISPARITY: Between North–South (economic and social);
DISASTERS: Natural, man-made, climate-changes,slow-onset => displacement;.6

6. International Organization for Migration (IOM) Migration Health Division
Health Promotion & Assistance for Migrants H3
Migration Health Assistance for Crisis Affected Populations H1
Migration Health Assessment & Travel Health Assistance

7. Migration Health
“Addresses the physical, mental and social needs of migrants, and the public health needs of hosting communities, as well as communities of origin, through policies and practices corresponding to the emerging challenges facing mobile populations today”
(IOM, MC/INF/275, 8 Nov. 2004
IOM COUNCIL DOCUMENT – IOM Governing Body 8

8. Operationalizing WHA 61.17 Monitoring Migrant Health
Operational framework to guide Member States and stakeholders in implementing the strategies of the Resolution WHA set at 1st Global Consultation on health of migrants, March 2010
Operationalizing WHA 61.17
Monitoring Migrant Health
Policy & Legal Frameworks
Identify key indicators
Ensure standardization and comparability of data on migrant health
Develop and implement policies that promote equal access to health services for all migrants
Extend social protection in health and improve social security for all migrants and family members
Migrant sensitive Health Systems
Partnerships, Networks, multi- country frameworks
Ensure health services are culturally, linguistically and epidemiologically appropriate
Address migrant health in global and regional processes

9. Challenges in implementation of the WHA 61.17
Migrants too often remain invisible, marginalized and excluded from HEALTH SYSTEMS/PLANS
Migration health absent/poorly described within global health initiatives (eg. UHC,NCD, etc.) and migration & development (GFMD, etc.)
migrants still seen as burden on health system and carriers of disease
No unit/focal point on migration health at MOH etc ©

10. The impact on the health of low skilled migrant workers and their families have been largely neglected.
Such research evidence is needed for policy formulation and developing interventions to ensure a safe, dignified and healthy labour migration experience for millions of migrant workers and their families globally
Academia have a critical role in this endevour

11. Increasing political and global attention on migrants as a result of the European Migrant crisis and Syrian conflict with its mixed migration flows.
Some political science commentators said “it took a crisis at the doorstep of Europe for world leaders to galvanize action Global Compact around migrants and refugees”
three-year-old Syrian boy of Kurdish ethnic background whose image made global headlines after he drowned on 2 September in the Mediterranean Sea

12. Global Compact in Migrants and Refugees Member States have committed themselves to negotiate
“Clearer leadership structures are needed within the UN to forge a system that can;
i) anticipate and react quickly to movements in a crisis;
ii) deliver political messages with a consistent voice;
Iii) assist member states to deliver the migration-related Sustainable Development Goals, and monitor their success in doing so;
iv) formulate common standards for the handling of migration, and develop these into “soft” international law; and
v) where member states are ready, negotiate binding treaties on specific migration issues. It further contends that functioning international cooperation on migration depends on restoring an atmosphere of trust, which at present is alarmingly absent in many aspects of international relations”
Special Representative of the UN Secretary-General for International Migration, Mr. Peter Sutherland

13. Timeline of events leading up to 2nd GC: global health diplomacy
2016
Timeline of events leading up to 2nd GC: global health diplomacy

14. What to do
Adopt a participatory, inter-sectoral and multidisciplinary approach
Adopt an inclusive approach covering all migrant flows
Adopt an evidence-based approach and develop a national research agenda
Adopt a pragmatic and responsive approach
Embed a regular reporting and accountability framework
Ensure advocacy and engagement at regional and international level

16. Travellers from industrialised areas to developing areas 1999 (WTO)
2.8
2.4
Europe
25.0 million
6.1
USA / Canada
35.2 million
4.6
3.6
Japan
11.4 mio
7.8
1.6 19
6.8
2.3
1.3
4.8
2.5
1.9
1.2
2.6
AUS / NZ
3.3 million
n million travelers
0.2-1 million travelers
Total:
~ 80 million travelers

17. What is travel medicine?
It is that part of health professional practice that:
seeks to prevent illnesses and injuries occurring to travellers going abroad
manages problems arising in travellers coming back or coming from abroad
is concerned about the impact of tourism on health and also advocates for improved health and safety services for tourists
is increasing concerned about refugee and migrant health (Primer of Travel Medicine 3rd Ed)

18. What is travel medicine
“the art of travel medicine is selecting the necessary prevention strategy without unnecessary adverse events, cost or inconvenience”
(Steffen, 1994)
Travel medicine is a new multidisciplinary specialty emerging in response to the needs of the travelling population worldwide.

19. What is travel medicine?
Travel and aviation medicine have many linkages, especially in terms of fitness to fly and dealing with problems that may arise in travelers due to physiological and psychological stresses of travel.
Increasingly, the discipline of refugee and migrant medicine is also being included in the specialty area of travel medicine.

20. Travellers are exposed to a variety of hazards

21. The Importance of Travel Health Measures
100,000 travelers to the developing world for 1 month…..
50,000 will become ill
8,000 will see a physician
5,000 will stay in bed
1 will die
Steffen, 1994

22. The Importance of Travel Health Measures…….
Per 100,000 travellers that have travel insurance …..
8000 will make a claim (8%)
2000 will use emergency assistance (2%)
400 ER or clinic referrals (0.4%)
200 Hospital admissions (0.2%)
50 Aeromedical evacuations (0.05%)
Leggat et al. Travel Med Inf Dis 2005;3:9-17.

23. The Importance of Travel Health Measures........
Mortality
Cardiovascular Disease (50 to 70%)
Accidents/Trauma (20-25%),
Infectious diseases (2.8-4%)
(Reid and Cossar, BMBull. 1993; ; Prociv, MJA. 1995;163:27-30; Baker et al., PHR 1992;107: ; MacPherson et al, JTM. 2000; 2000: ; Steffen, Trans RSTM&H 1991;85: )

24. Deaths Related to International Travel
Hargarten S et al, Ann Emerg Med, :

25. Travel medicine is a continuum
Travellers do get sick or injured abroad or when they come back
The commitment to travel health can therefore be regarded as a continuum

26. The Continuum of Travel Medicine
Preventive Medicine
Pre-Travel
Visitors
During Travel
Contingency Planning
Post-Travel
Treatment & Rehabilitation

27. Travelers’ Health Risks
It is conservatively estimated that 30%–50% of travelers become ill or are injured while travelling.
The main health complaints of returned Australian travelers reported in a recent survey of travel insurance claims were:
respiratory (20%),
musculoskeletal (17%),
gastrointestinal (14%),
ear, nose and throat (12%),
and dental conditions (7%)

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

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

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

31. Injury Deaths and International Travel
Hargarten S et al, Ann Emerg Med, :

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

33. 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
* Td or Tdap
+ MMR

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

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

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

37. 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

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

39. 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

40. 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

41. 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

42. 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

43. 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

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

45. Communicable Diseases of Public Health Significance Vaccine-Preventable Diseases
Mumps
Measles
Rubella
Polio
Tetanus
Diphtheria
Pertussis
Haemophilus influenzae Type B
Rotavirus
Hepatitis A
Hepatitis B
Meningocococcal disease
Varicella
Pneumococcal pneumonia
Influenza
Source: Centers for Disease Control and Prevention (accessed in July 2013)

46. Quarantinable Diseases Designated by Presidential Executive Order
Cholera
Diphtheria
Infectious tuberculosis
Plague
Smallpox
Yellow Fever
Viral Hemorrhagic Fevers
Severe Acute Respiratory Syndrome (SARS)
Pandemic Influenza viruses
Source: Centers for Disease Control and Prevention (accessed in July 2013)

47. A PHEIC is defined as an extraordinary event which is determined:
Events that are reportable as a public health emergency of international concern (PHEIC) to WHO
A PHEIC is defined as an extraordinary event which is determined:
to constitute a public health risk to other States through the international spread of disease and
to potentially require a coordinated international response.1
Examples include: Smallpox, Severe Acute Respiratory Syndrome (SARS), Pandemic Influenza and Other public health emergencies of international concern
1Source: World Health Organization,
(accessed July 2014)

48. Giving the correct advice to travellers
Giving the correct health advice to travellers needs:
Information
Training
Experience
Documentation
Travellers

49. Giving the correct advice to travellers
Giving the correct health advice to travellers needs:
Information
Training
Experience
Documentation
Travellers

50. Take home points
More people are traveling to more destinations, becoming exposed to the health and safety of that destination and also having the potential to impact on the health and safety of that destination, especially through emerging infectious disease
Travelers’ health is a continuum and includes the pre-travel health, contingency planning while abroad and caring the traveler after travel
Travel health advice needs information (including a capacity to undertake a risk assessment), training, experience, documentation and travelers

51. Challenge of travel medicine
Sea of global migration of people
More people travelling
People travelling further a field
Rapid movement of travellers