1. Introduction to travel medicine Dr Peter A Leggat MD, PhD, DrPH, FAFPHM, FACTM, FFTM Associate Professor, School of Public Health and Tropical Medicine, James Cook University, Australia, & Visiting Professor, School of Public Health, University of the Witwatersrand

2. About the author  Dr Peter Leggat has co-ordinated the Australian postgraduate course in travel medicine since 1993. He has also been on the faculty of the South African travel medicine course, conducted since 2000, and the Worldwise New Zealand Travel Health update programs since 1998. Dr Leggat has assisted in the development of travel medicine programs in several countries and also the Certificate of Knowledge examination for the International Society of Travel Medicine.

3. Objectives  In this session –Define travel medicine –Examine some figures for global and local migration –Hopefully gain an appreciation of the importance of giving travel health advice –Discuss some of components that are needed in order to give correct advice to traveller

4. What is travel medicine? It is a science and an art

5. 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 3 rd Ed)

6.  “the art of travel medicine is selecting the necessary prevention strategy without unnecessary adverse events, cost or inconvenience” (Steffen, 1994) (Steffen, 1994)

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

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

9. 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 Pathogens travel as fast as transportation: borders are not respected Tsunami SARS Influenza Terrorism

10. Travellers are exposed to a variety of hazards

11. 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

12. 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.

13. The Importance of Travel Health Measures  Mortality –Cardiovascular Disease (50 to 70%) –Accidents/Trauma (20-25%), esp. MVAs –Infectious diseases (2.8-4%) (Reid and Cossar, BMBull. 1993;257-268; Prociv, MJA. 1995;163:27-30; Baker et al., PHR 1992;107:155-159; MacPherson et al, JTM. 2000; 2000:227-233; Steffen, Trans RSTM&H 1991;85: 156- 162 )

14. 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

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

16. What do we need to do in order to be giving the correct advice to travellers?

17. Travel Health Advice needs Information “Information is power in Travel Medicine”

18. Travel Health Advice needs Training Training gives you a framework for using that information

19. Travel Health Advice needs Experience Experience helps put the information and training in perspective

20. Travel Health Advice needs to be Documented Documentation is important for Quality assurance and reinforcing travel health advice

21. Travel Health Advice needs Travellers Marketing is essential in travel health, whether in general practice or in specialist travel clinics

22. Giving the correct advice to travellers  Giving the correct health advice to travellers needs: –Information –Training –Experience –Documentation –Travellers

23. Travel Health Advice needs Information  Guidelines  Policies  Textbooks, including an World Atlas  Journals  Professional organisations  Staff/colleagues  Electronic Databases  WWW

24. International Guidelines  WHO  International Health Regulations  International Travel and Health –www.who.int/ith www.who.int/ith –Yellow fever requirements

25. “National Guidelines”  Travel Health Guidelines  Malaria Guidelines  Immunisation Guidelines  Antibiotic Guidelines  Journals  Seminars

26. You need access to www-sites  International Society of Travel Medicine –www.istm.org www.istm.org  US Centers for Disease Control and Prevention –www.cdc.gov/travel www.cdc.gov/travel –US Guidelines –Similar government sites for UK and Canada  World Health Organization –http://www.who.int/ith http://www.who.int/ith –The former “yellow book” is now published as the “blue book” online

27. It is very useful to have access to a multicountry travel medical advisory service  CDC Travel Health, see http://www.cdc.gov/travel/index.htm http://www.cdc.gov/travel/index.htm  MASTA, see http://www.masta.org http://www.masta.org  TRAVAX, see http://www.travax.nhs.uk http://www.travax.nhs.uk  Shorelands, see http://www.tripprep.com http://www.tripprep.com

28. Professional Organisations  Local professional groups and and  THE ISTM

29. ISTM  International Society of Travel Medicine –International Network  International Clinic Directory  Useful for marketing/recognition –www.istm.org www.istm.org –Listserve  Outbreak alerts –Journal –Geosentinel –Certificate of Travel Health –Great Conferences!!

30. Journals Weighing the Evidence

31. Weighing the evidence   “Travel medicine prevention should be based on epidemiological data.” Robert Steffen, 1991   What are the likely risks of a person travelling to particular destinations?   What are the likely benefits of intervention?

32. Giving the correct advice to travellers  Giving the correct health advice to travellers needs: –Information –Training –Experience –Documentation –Travellers

33. Pre-Travel Health Advice needs Training  Helps give structure and consistency –Provides a framework for practice –Discusses evidence for practice  Policy and Procedures Manual –Consistent approach to travel health

34. Part of the commitment is to also have a consistent and structured approach to travel health advice  WHO Checklist (www.who.int/ith) –Information on local conditions –Prevention –Accident avoidance –Medical and dental check-up  NZPHR-Prevention –Vaccinations –Health Advice –Prescription Source: http://www.who.int/ith

35. VACCINATE (IHC)  AlwaysNational schedule  Oftenhepatitis A  SometimesJapanese encephalitis meningococcal disease polio rabies yellow fever Influenza Pneumococcal disease Other vaccines (adapted* from NZPHR; 1996;3(8):57-59) Other vaccines (adapted* from NZPHR; 1996;3(8):57-59)

36. ADVISE AND DISCUSS  Insectsrepellents, nets, permethrin  Ingestionscare with food and water diet/teeth (including airlines/jetlag/DVT)*  IndiscretionsSTI’s, HIV  Injuriesaccident avoidance, personal safety  Immersionschistosomiasis  Insurance*health and travel insurance* finding medical assistance o/s* (adapted* from NZPHR; 1996;3(8):57-59)

37. PRESCRIBE (Script/Dr’s letter/bracelet)  Alwaysregular medication medical kit (first aid)*  Sometimesantimalarial medication diarrheal self-treatment condoms (NZPHR; 1996;3(8):57-59)

38. Courses  Increasing number of travel medicine academic programs globally (see educational opportunities at www.istm.org) www.istm.org  Get relevant endorsements –Aviation medical examiner –Diving medical certification (SPUMS) –Certificate of Travel Health (ISTM) –Occupational health training

39. Courses  Weighing the evidence  Contributing to the discipline through research (also through GeoSentinel)  Despite training, still need to keep up to date and to keep seeing travellers to help build experience

40. Giving the correct advice to travellers  Giving the correct health advice to travellers needs: –Information –Training –Experience –Documentation –Travellers

41. Travel health advice needs experience  Let’s just do it!  Affiliation with a group with experience can be useful –Travel clinic group –Travel medical advisory group (eg MASTA, Worldwise, Travax etc) –University  Those NZ GPs that were interested in travel medicine were significantly more likely to have had tropical medicine/developing country experience (Leggat et al. JTM 1999; 7: 55-58.)

42. Travel is part of experience

43.  Professionals working in travel medicine need to travel and have that personal experience to communicate to travellers  Helps to put travel health advice in context and helps to build a positive travel experience

44. Giving the correct advice to travellers  Giving the correct health advice to travellers needs: –Information –Training –Experience –Documentation –Travellers

45. Travel health advice needs to be documented  Standardised forms/questionnaires  Informed consent  International Health Certificate/Vaccination record  Doctor’s letter/copy of prescription/medialert bracelet  Written advice/videos/Books/Health advisory documents

46. Correct advice is even better if the advice is actually followed by the traveller  Documentation  Follow-up  Use staff resources  Reinforce health advice

47. Giving the correct advice to travellers  Giving the correct health advice to travellers needs: –Information –Training –Experience –Documentation –Travellers

48. Travel Health Advice needs Travellers  Inform own patients concerning the need for seeking travel health advice, and seeking this advice early  Market travel health advice –Direct, if possible –Join group/affiliate –Links/promotion with traveller groups, travel agents, travel insurance, consulates etc –Join travellers health networks, such as ISTM, IAMAT etc

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