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TRAVEL MEDICINE BEFORE, DURING, and AFTER the TRIP

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TRAVEL MEDICINE BEFORE, DURING, and AFTER the TRIP TRAVEL MEDICINE BEFORE, DURING, and AFTER THE TRIP LARRY M. BUSH, MD, FACP Affiliate Professor of Clinical Medicine Charles E. Schmidt College of Medicine Florida Atlantic University Affiliate Associate Professor of Medicine University of Miami‐Miller School of Medicine Palm Beach County, Florida U.S. Residents Traveling Abroad 65 60 55 50 Number45 of Travelers (millions) 1995 *ITA, includes travel199 6to Canada and Mexico 1997 1998 * 1999 2000 Year 2001 2002 2003 2004 2005 3 TRAVEL EPIDEMIOLOGY TRAVEL EPIDEMIOLOGY 2015 – 1.2 BILLION INTERNATIONAL TOURIST ARRIVALS 2018 – ESTIMATED TO BE 2 BILLION ASIA, MIDDLE EAST, ANDAFRICA TRAVEL INCREASING 14 DAYS – MEDIAN DURATION OF TRIP 22% WERE > 28 DAYS; 3% > 6 MONTHS 75% TO MALARIA AND 38% TO YELLOW FEVER ENDEMIC COUNTRIES 3% HAVE IMMUNE COMPROMISED CONDITIONS OR MEDICATIONS ONLY 40 % SOUGHT OUT PRE-TRAVEL CLINIC CONSULTATION Average annual number of global airline passengers by decade, 1950-2010 Million of Passenger (Mil) IATA 2010 Decade Commercial Air Traffic Over a 24 Hour Period The global air network Where Do U.S. Residents Travel? 40 Of the 17% who traveled outside the U.S. 30 % 20 10 0 Canada Europe Aus/NZ Mexico Source: HealthStyles Survey 2005 C or S America Japan Oceania/ PI Other Asia Africa Caribbean Middle East 8 VFRs: Visiting Friends and Relatives • Foreign-born increased 57% since 1990 from 19.8 million to 31.1 million1 • 20% of US population are first- or second-generation immigrants • VFRs comprised ~46% of US international air travelers in 20043 1US 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 32004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, USDOC 13 Structured Approach to Medical Consultation before International Travel. Freedman DO et al. N Engl J Med 2016;375:247-260. 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 16 TRAVEL FACTS K” ”….NO MATTER HOW FAST I RUN I CAN’T SEEM TO GET AWAY FROM ME. ….NO MATTERmm WHERE I AM I’M ALWAYS ONE DAY AWAY FROM WHERE I WANT TO BE.” Jackson Browne (‘The Pretender’)..’ The Patient: Medical Issues • Age-specific issues • Underlying illness, immunosuppression • Systems review • Medical history • Medication use • Vaccination history • Allergies • Contraindications to vaccines and medications 18 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 19 Other Risks to the Traveler • Accidental injury • Environmental hazards • Crime and assault • Psychiatric problems • Animal bites, stings and envenomations • Dermatologic disorders • Altitude • ……. ETC. 20 The Patient: Other Issues • Reproductive – Pregnant – Breastfeeding – Preconception • Risk-taking behaviors 21 Travel Preparation • Travel health insurance – Medical care – Hospitalization – Evacuation • Obtaining medical care abroad • Awareness of travel notices • Hand washing and hygiene 22 Immunizations to Consider for Adult Travelers Routine Travel related Diphtheria* Hepatitis A Tetanus* Hepatitis B Pertussis* Typhoid Measles + Rabies Mumps+ Meningococcal disease Rubella + Polio Varicella Japanese encephalitis Pneumococcus Yellow Fever Influenza * Td or Tdap 24 + MMR THE PREGNANT TRAVELER What do we advise pregnant travelers? Travel medicine and Pregnancy Mezger N et al. Travelling when pregnant. Rev Med Suisse. 2005; 11: 1263-1266. (in French) Travel during the 2nd trimester Favor comfortable type of travel, without long air or road transportation Avoid traveling if at risk pregnancy Check for adequate insurance coverage Choose destination where good health services exist Avoid region of high malaria endemicity For any vaccination or medication risks and benefits should be carefully weighed, pregnant women are more vulnerable and at higher risk of complications “Pregnancy should not deter a women from receiving vaccines that are safe and will protect her health and that of her child.” SAFTEY HAS NOT BEEN DETERMINED FOR MANY, OTHERS CONTRAINDICATED WHO, 2005 op cit 32 Bring a color copy of your passport. Label the outside of your passport with your passport number The Risk Landscape The World We Live In... Coups Natural Disasters Insurgency Opportunistic Crime Piracy Terrorism Kidnapping Lawlessness War Civil Unrest Medical Illness Hijacking Threats Extreme Weather Typhoid Fever Imprisonment Dengue Travel-related infections Air Quality Hepatitis Language and cultural barriers Airline Catastrophes Vehicle Accidents Immigration & Visas Rural Isolation Deaths Related to International Travel Cardiovascular Medical Injury Homicide/Suicide Infectious Disease Other N = 2463 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626 35 Injury Deaths and International Travel Motor Vechicle Drowning Air Crash Homicide/Suicide Poisoning Other N = 601 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626 36 What health risks are associated with air travel? Epidemiology of DVT from Air Travel Risk Factors for DVT • Increasing Age (above 40 years) • Pregnancy • Previous or Family history of DVT • Clotting disorders • Recent major surgery • Estrogen hormone therapy & OCs • Immobility •Gender Economy Class Syndrome?? DVT and Long Haul Travel • Increasing Age • Increasing Duration of Travel • Immobility • Seating Constraints and Posture • Cabin Environment (low humidity) • Excessive alcohol and/or caffeine • Obesity? •Height? Changing Demographics of Air Travel • Aircraft seats designed for persons who average 5’7’’ and 170 lbs. • More vulnerable passengers are now able to fly from an economic perspective • Projected increase in air travel Airline Seat Pitch 80 70 60 50 40 inches 30 20 10 0 First Business Economy Skytrax Airline Seat pitch Air France 31 British Airways 31 American Airlines 33 Lufthansa 31 Northwest/KLM 31 Swissair 32 United 31 Travel as a risk factor for venous thromboembolic disease VTED Control p-value Age (years) 65.3 66.0 n.s. Hypertension (%) 11.8 18.1 n.s Sex (% male) 51.8 66.2 0.04 VTED history (%) 11.8 4.4 0.02 Obesity (%) 33.7 20.0 0.01 Recent travel (%) 24.4 7.5 <0.001 Ferrari 1999 Travel and risk of venous thrombosis Odds Cases Controls Ratio Plane Travel 4% 13% 1.0 (0.3 - 1.4) Kraaijenhagen 2000 The information reviewed suggests that .. • The short-term and long-term health hazards of air travel are of interest • There is little scientific evidence to quantify the association between air travel and DVT • There is inconsistent evidence of a link between cancer and cosmic radiation …AND TRAVEL 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 58 VECTOR Vector Precautions • Covering exposed skin • Insect repellent containing DEET 30 – 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 MOSQUITO RELATED INFECTIONS MALARIA‐ENDEMIC ‐‐‐ WESTERN HEMISPHERE MALARIA‐ENDEMIC ‐‐‐EASTERN HEMISPHERE Pregnancy and malaria WHO. International Travel and Health. Geneva: WHO, 2005. “Travel to malaria- endemic areas should be avoided during pregnancy, if at all possible” “…or intend to get pregnant” (McGready et al, 2004) Why? Pregnancy and malaria Chemoprophylaxis Recommended options for chloroquine resistant areas Mefloquine Doxycycline Malarone 250mg weekly 100mg daily 250mg/100mg daily 2nd/3rd trimester (from 2000) Alternatives include: − chloroquine 300mg weekly + proguanil 200mg daily − Sulfadoxine-Pyrimethamine DENGUE FEVER • Over 40% of the world's population at risk from dengue. • WHO currently estimates may be 50–100 million dengue infections worldwide every year. • Before 1970, only nine countries had experienced severe dengue epidemics. • The disease is now endemic in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, South-east Asia and the Western Pacific. The American, South-east Asia and the Western Pacific regions are the most seriously affected. • Cases across the Americas, South-east Asia and Western Pacific have exceeded 1.2 million cases in 2008 and over 2.3 million in 2010. • In 2010, 1.6 million cases of dengue were reported in the Americas alone, of which 49,000 cases were severe dengue. http://www.who.int/mediacentre/factsheets/fs117/en/index.html Chikungunya fever “Chikungunya”: derived from local language in Tanzania – “that which bends up” or “stooped walk” YELLOW FEVER VACCINE RECOMMENDED - AMERICAS YELLOW FEVER VACCINE RECOMMENDED - AFRICA JAPANESE ENCEPHALITIS ‐‐‐‐ RISK Japanese Encephalitis Vaccine • Inactivated vaccine • Efficacy = 91% • Booster every 3 years • Not approved for children under 3 years • Side effects – Local reaction (10-25%) – Fever
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