1. 1 THE PRE-TRAVEL CONSULTATION Gary W. Brunette, MD, MS Travelers’ Health Team Division of Global Migration and Quarantine Centers for Disease Control and Prevention

2. 2 Outline Travelers’ Health Epidemiology Traveler Assessment Itinerary Review Sources of Information Risks to the Traveler Travel Vaccines Travel Medications Counseling

3. 3 U.S. Residents Traveling Abroad* *ITA, includes travel to Canada and Mexico

4. 4 International Travel

5. 5 Where Do U.S. Residents Travel? Source: HealthStyles Survey 2005 Of the 17% who traveled outside the U.S....

6. 6 VFRs: Visiting Friends and Relatives Foreign-born increased 57% since 1990 from 19.8 million to 31.1 million 1 20% of US population are first- or second-generation immigrants VFRs comprised ~46% of US international air travelers in 2004 3 1 US Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000, issued Dec 2003 (Previous: US Census Bureau, Profile of the Born Outside the United States Population 2000, issues Dec 2003??? 2 Angell & Cetron, 2005 3 2004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, USDOC

7. 7 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

8. 8 The Patient: Medical Issues Age-specific issues Underlying illness, immunosuppression Systems review Medical history Medication use Vaccination history Allergies Contraindications to vaccines and medications

9. 9 The Patient: Other Issues Reproductive –Pregnant –Breastfeeding –Preconception Risk-taking behaviors

10. 10 Travel Itinerary Full itinerary –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

11. 11 Travel Health Resources CDC Travelers’ Health Website –www.cdc.gov/travelwww.cdc.gov/travel World Health Organization –www.who.int/intwww.who.int/int State Department –travel.state.govtravel.state.gov International Society of Travel Medicine –www.istm.orgwww.istm.org Health Information for International Travel –CDC “Yellow Book” International Travel and Health –WHO “Green Book”

12. 12 Travelers’ Health Website www.cdc.gov/travel

13. 13 Regional Destinations Region-specific pages Goal to move to country-specific format

14. 14 Travel Notices & Announcements

15. 15 Deaths Related to International Travel N = 2463 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

16. 16 Infectious Disease Risks to the Traveler Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV ETC.

17. 17 Injury Deaths and International Travel N = 601 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

18. 18 Other Risks to the Traveler Accidental injury Environmental hazards Crime and assault Psychiatric problems Animal bites, stings and envenomations Dermatologic disorders Altitude ……. ETC.

19. 19 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

20. 20 Travel Medications: Prophylaxis & Self Treatment Malaria –chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine Diarrhea –quinolone, azithromycin Altitude –acetazolamide Motion sickness –scopolamine, dimenhydrinate ( Dramamine)

21. 21 Patient Counseling Sufficient time for patient education Tailored to suit traveler Fitness for travel –Understanding impact on existing conditions –Advisability of destinations

22. 22 Travel Preparation Travel health insurance –Medical care –Hospitalization –Evacuation Obtaining medical care abroad Awareness of travel notices Hand washing and hygiene

23. 23 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

24. 24 Food and Water Precautions Bottled water Selection of foods –well-cooked and hot Avoidance of –salads, raw vegetables –unpasteurized dairy products –street vendors –ice

25. 25 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

26. 26 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

27. 27 Animal Precautions Animal avoidance Rabies –Specific animal threats –Medical evaluation of bites/scratches –Post exposure immunization and immunoglobulin Envenomations –Snakes, scorpions, spiders –Maritime animals

28. 28 Injury and Crime Vehicles –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

29. 29 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

30. 30 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

31. 31 Questions?

32. 32 Other Resources

33. 33 Journals American Journal of Tropical Medicine and Hygiene Bulletin of the World Health Organization Emerging Infectious Diseases Journal Eurosurveillance Weekly Journal of Travel Medicine Morbidity and Mortality Weekly Report Tropical Medicine and International Health Vaccine

34. 34 Books Textbook of Travel Medicine and Health, 2 nd Ed. –DuPont, H.L. and Steffen R. (editors) The Travel and Tropical Medicine Manual, 3 rd Ed. –Jong, E.C., McMullen, R. Travel Medicine –Keystone, J.S., Kozarsky, P.E., et al

35. 35 Websites Eurosurveillance www.eurosurveillance.org Travax EnCompass www.travax.com GIDEON www.gideononline.com International SOS www.internationalsos.com Medical Advisory Service for Travelers Abroad (MASTA) http://www.masta.org/ Armed Forces Medical Intelligence Center www.afmic.detrick.army.mil/ Central Intelligence Agency www.cia.gov/cia/publications/factbook/