1. TRAVEL MEDICINE When hoof beats might be zebras Dr. Januchowski

2. OBJECTIVES Be able to identify the key items to discuss with patients travelling internationally Be able to discuss with patients the resources available to help them stay healthy while travelling Know some of the important illness patterns to watch for when patients return from overseas adventures 2

3. Travel Medicine 3

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5. Travel Medicine Consultation Risk Assessment Risk Communication Risk Management 5

6. Risk Assessment Typically done 1-2 months prior to travel Itinerary data Traveler demographics and health/medical history 6

7. Risk Assessment Itinerary data Countries and regions to be visited, in the order of travel Visits to urban versus rural areas Dates and length of travel in each area Purpose of travel (such as business, vacation, visiting friends and relatives) Modes of transportation Planned and possible activities (such as hiking, scuba diving, camping) Types of accommodations in each area (such as air-conditioned, screened, tents) Traveler demographics Age, sex Vaccination history, including dates, how many doses received in a scheduled series, and prior adverse events Medical and psychiatric history (past and current), including any conditions or medications that suppress the immune system Medications (current or taken in the past 3 months) Allergies (in particular to eggs, latex, yeast, mercury, or thimerosal) Pregnancy and breastfeeding (current status and plans) Any planned surgeries or other medical care during travel (medical tourism) 7

8. Risk Communication Plan based on Risk Assessment Evidence Based plan of action developed with the traveller 8

9. Risk Management Implementation of the plan – Vaccines – Medications – Education – General Guidance 9

10. Case #1 44 y.o. male patient presents 2 months before a planned trip to Suriname for business with his employer, ALCOA 10

11. Risk Assessment - Itinerary Countries and regions to be visited, in the order of travel Visits to urban versus rural areas Dates and length of travel in each area Purpose of travel (such as business, vacation, visiting friends and relatives) Modes of transportation Planned and possible activities (such as hiking, scuba diving, camping) Types of accommodations in each area (such as air-conditioned, screened, tents) 11

12. Risk Assessment – Traveler info Age, sex Vaccination history, including dates, how many doses received in a scheduled series, and prior adverse events Medical and psychiatric history (past and current), including any conditions or medications that suppress the immune system Medications (current or taken in the past 3 months) Allergies (in particular to eggs, latex, yeast, mercury, or thimerosal) Pregnancy and breastfeeding (current status and plans) Any planned surgeries or other medical care during travel (medical tourism) 12

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15. 15 Lets talk about vaccines

16. Risk Management – Vaccines Routine Required Recommended 16

17. Routine Routine Vaccines Would include childhood immunizations Boosters (Tdap, MMR) 17

18. Required Required Vaccines Yellow fever vaccine – Sub-Saharan Africa – Tropical South America Meningococcal vaccine for annual travel to the Hajj in Saudi Arabia 18

19. Recommended Recommended Vaccines Varies based on – Destination – Itinerary – Traveller demographics Check website 19

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22. Typhoid Salmonella enterica Fecal-oral route of transmission Fever, headache, malaise Intestinal perforation and hemorrhage complications Can be treated with antibiotics 22

23. Typhoid Vaccine Injectable One dose series Good for 2 years Age 2 and older Should be given >2 weeks prior to travel Oral (Live, attenuated) 4 dose series Good for 5 years Age 6 and older Should complete series one week before travel 23 Cost for vaccine ~$80-100

24. Yellow Fever Transmitted by mosquito Fevers, malaise Can cause hepatitis, hemorrhagic complications Supportive treatment 24

25. Yellow fever vaccine Must be administered by a certified health center ~$100-125 Good for 10 years 25

26. Yellow fever vaccine Contraindications – Less than 6 months old – Immunocompromised status Primary immunodeficiency HIV with CD4<200 – Malignant neoplasms 26

27. Risk management The patient has scheduled times for his vaccinations What other information can be provided for this traveller? 27

28. Risk management Malaria prevention Treatment of common travel illnesses General Education – Food and drink safety – Accident avoidance – Safe sexual practices 28

29. Malaria prevention Determine risk Prevent mosquito bites Medication prophylaxis 29

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31. Malaria Chemoprophylaxis Atovaquone-proguanil Chloroquine Doxycycline Mefloquine Primaquine 31

32. Malaria Chemoprophylaxis MedicineCostStart priorDosing timeSide effectsMisc. Atovaquone- proguanil $$$1-2 daysDailyMinimal Chloroquine$1-2 weeksWeeklyResistance Doxycycline$1-2 daysDailyGI / sun Mefloquine$$2 weeksWeeklyGI / seizure / psych/cardio Resistance Primaquine$1-2 daysDailyG6PD caution! Can be used for vivax term. prophylaxis 32

33. What other recommendations? 33

34. Travel Medicine Kit Include items for treatment of common illnesses Watch for flight regulations International regulations on transport of medications 34

35. Travel Med Kit Routine prescribed medicines Antidiarrheals – Bismuth products (treatment or prophylaxis) – Loperamide (Imodium) – Ciprofloxacin 500 mg BID x 2 – Azithromycin 1 gm x 1 – Rifaximin (non-FDA approved, off label use for prophylaxis) 35 Treatments

36. Travel Med Kit (cont.) Insect repellents – DEET (30-50%) – Picaridin – Oil of Lemon Eucalyptus or PMD – IR3535 – Permethrin impregnated clothing / bed netting 36

37. Travel Med Kit (cont.) Water purification tablets Pain medicines (OTC) Sunscreen Antibacterial skin cleanser / wipes 37

38. Case (cont.) The patient travels and returns without any noted incidents. Proper education allowed the patient to – Know the precautions after return regarding illness reporting – Know the importance of completing malaria prophylaxis medications 38

39. Post travel visit Ensure malaria medicines are completed – 4 weeks for doxycycline / mefloquine – 7 days for atovaquone/proguanil Review travel history 39

40. Post travel visit - Illnesses Fever Persistent GI complaints Skin lesions or rashes Respiratory infections 40

41. Post travel visit - Fever Malaria (up to one year!) Dengue Invasive bacterial diarrhea Hepatitis A Typhoid Rickesial infections Influenza (remember patterns) Viral illnesses NOS 41

42. Post travel visit – GI Concerns Acute bacterial/parasitic gastroenteritis – Giardia – C. difficile Unmasking of underlying GI disease – Postinfectious IBS – Lactose intolerance – Celiac disease Tropical sprue Brainerd diarrhea 42

43. Post travel visit – Skin lesions Non-specific dermatitis Insect bites Pyoderma Scabies Cutaneous larva migrans 43

44. 44 Assessing Risk by Incubation Period

45. OBJECTIVES Be able to identify the key items to discuss with patients travelling internationally Be able to discuss with patients the resources available to help them stay healthy while travelling Know some of the important illness patterns to watch for when patients return from overseas adventures 45

46. Questions? rjanuchowski@vcom.edu 46