·:{iC0Fp'16 ACOFP 53rd Annual & Scientific Seminars

Travel : A Dose of Prevention

Kelli Glaser, DO, FACOFP

3/17/2016

Travel Medicine: A Dose of Prevention ACOFP Convention 2016 in San Juan, Puerto Rico

Kelli Glaser, DO, FACOFP President, DOCARE International Chair, Department of Family and Community Medicine A.T. Still University- School of osteopathic Medicine in Arizona

Learning Objectives

• Discuss the frequency of travel related illness.

• Develop a methodical process for evaluation of patients potential travel health risks.

• Describe components of preventive education and other services typically provided to travelers.

• Identify and utilize resources for specific travel health information.

Overview

• Definitions • of Travel Illness • Pre Travel Evaluation • Risk Assessment • Risk Mitigation • Post Travel Evaluation • Resources

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Definitions

• Travel Medicine- The field of medicine concerned with the prevention of for the peoples in the regions being visited and the prevention of disease and adverse health events in the international traveler.

• Pre-travel consultation- To reduce the traveler's risk of illness and during travel through preventive counseling, medication, and immunization.

Epidemiology of Travel Illnesses

• 1 Billion Travelers crossed international boundaries in 2012 • Travel-related health problems have been reported in 22%–64% of travelers to developing countries. • Only 40.5% of all ill travelers had pre-travel medical visits • The most common illness categories: • Gastrointestinal (34 %) • Dermatologic (19.5%) • Febrile (23%)- , dengue, enteric, spotted-fever rickettsioses, chikungunya, and nonspecific viral syndromes were the most frequent contributors to acute fever.

Presentations to GeoSentinel by diagnostic category and region (2007–2011)1

1Data from Leder K, Torresi J, Libman MD, Cramer JP, Castelli F, Schlagenhauf P, et al. GeoSentinel surveillance of illness in returned travelers, 2007–2011. Ann Intern Med. 2013 Mar 19;158(6):456–68.

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Risk Determination

• Patient Specific Risks

• Destination Risks

• Itinerary Specific Risks

High Risk Travelers

Pre-existing medical conditions • Pregnancy • Disability • Immunocompromised • Recent illness or • Chronic (Diabetes, cardiac or pulmonary or renal conditions, blood disorders, mental illness, and seizures)

High Risk Travelers

VFR- Visiting Friends & Relatives • Travelers that migrated from a developing country to an industrialized region, and are visiting their country of birth. High risk destinations • Long duration of travel • Misconceptions of disease risk and immunity • Less access to culturally competent pre-travel (18% had pre-travel visit) • May have language or financial barriers.

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Destination Risks

Countries and regions visited • Developed vs. developing • Urban vs. rural • Ecology • Season of travel

Itinerary specific risks

• Travel style • Reason for travel: • Types of accommodations • • Modes of transportation • Business • Visiting friends and relatives • Weather- Heat stroke/hypothermia • Volunteer, missionary, or aid work • High-risk activities during travel • Seeking health care () • Extreme sports- potential for injury • Altitude sickness above 2500 to 3500 m • Research or education • Scuba diving- Barotrauma, Decompression illness • Adventure • Water activities- leptospirosis, … • Pilgrimage • Caving- rabies and histoplasmosis • Adoption • CDC Disease directory and Resource pages • information about variety of other diseases and travel considerations that impact health

Risk Mitigation

• Prevention with immunization and chemoprophylaxis • Emergency Preparedness • Education on basic safety precautions while traveling • Travel health kit • Empower the traveler to self-diagnose and treat common health problems, particularly if in remote settings.

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Immunizations

• ACP Immunization Advisor- Mobile Application • General travel recommendations

• http://wwwnc.cdc.gov/travel/destinations/list • Destination specific vaccine recommendations

Common

Travel Routine • Hepatitis A • Hepatitis B • Japanese Encephalitis • HPV • Rabies • Influenza • Typhoid • Measles, Mumps, Rubella • • Meningococcal • Cholera (not available in US) • Pneumococcal • Tickborne encephalitis (not available in US) • Polio • Rotavirus • Tetanus, diphtheria, pertussis • Varicella • Zoster

Preparing for Travel Emergencies

 Register with Smart Traveler Enrollment Program (STEP)  Keep contact information for the nearest US Embassy or Consulate for where you are traveling.  Make copies of your travel documents and itinerary incase of loss and store in a separate place.  Leave contact information and copies of travel documents with loved ones, school, employers.  Purchase Emergency Medical and Evacuation Insurance $50,000+ coverage limit on medical and $500,ooo+ coverage limit on evacuation  Research reputable medical facilities at destination prior to departure  Carry recent medical reports/test results.  or serious medical conditions should be identified on a bracelet or card  Money-carry emergency cash

If you are a victim of a crime • Contact the Office of Overseas Citizens Services 1-888-407-4747 (from overseas: 202-501-4444) or the U.S. Embassy or Consulate nearest you

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Personal Safety • Prior to travel check for alerts and warnings with the US Dept. of State • Awareness of surroundings • Don’t attract attention • Dress within cultural norms • Don’t bring unnecessary valuables • Secure money and • Avoid intoxication • Abide by local laws • Protective clothing • • Secure and safe transportation

Other Environmental Hazards

• Drinking water • Sealed or purification with Iodine or chlorine tablets, UV light, or filtration. • Food • Packaged, pealed or cooked • Vector born diseases • Clothing choice, bug nets, repellant • Malaria chemoprophylaxis • Animal bites • Walking barefoot • Swimming in freshwater • Sun exposure and sunburn

Common Supplies in a Travel Health Kit First aid supplies Medications  Disposable vinyl gloves  Pain- acetaminophen or ibuprofen  Antibacterial gel  - light or sleep medications  Alcohol wipes  Motion sickness- meclizine, scopolamine  Bandages  Malaria- chemoprophylaxis dependent upon travel region  Gauze  Travelers’ diarrhea- ciprofloxacin, pepto-bismol, loperamide  Elastic compression wrap  Allergic reactions- diphenhydramine, albuterol, epinephrine  Tape  Respiratory - saline spray, cold medications, antibiotic  Moleskin  Urinary tract infections- antibiotic of choice  Safety pins  Skin conditions-topical antibiotic, antihistamine, steroid,  Condoms anti-fungals  Water purification  Vaginal yeast infections- fluconazole  Sunscreen  Altitude illness- chemoprophylaxis (acetazolamide) and  Insect repellant with >20% DEET treatment (dexamethasone, promethazine)  Bednet  Occupational exposure to HIV (health care workers)  Safety Equipment (helmets, eyeware)

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Post-Travel Evaluation

• Considerations in diagnosis • Travel Itinerary • Timing of illness in relation to travel • Known travel exposures • Preventive measures received • Past medical history • Severity of illness • Consultation with travel medicine or infectious disease specialist

Summary

• Illness during or after traveling is common, however accurate epidemiological statistics for travel illness are difficult to obtain. • Pre-travel evaluation can help prevent travel related illness and injury through risk assessment and risk mitigation. • To address the needs of VFR travelers, pre-travel services should be convenient, affordable, and culturally sensitive. • Empower travelers with knowledge and supplies needed to prevent, treat and seek assistance travel related illness. • When prevention fails, timely evaluation is essential to diagnosis of travel related illness.

References and Resources

• Risk Assessment in Travel Medicine: How to Obtain, Interpret, and use risk data for informing pre-travel advice. Karin Leder, MD, Et Al. Journal of Travel Medicine, 2015, Volume 22(1):13-20. • Travel Medicine, What’s involved? When to refer? Brian Aw, MD, et al. Canadian Family , December 2014, Volume 60:1091-1103. • http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/the-pre-travel-consultation • http://wwwnc.cdc.gov/travel/yellowbook/2016/table-of-contents • http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travel-health-kits • http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/water-disinfection-for-travelers • http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/protection-against-mosquitoes-ticks- other-arthropods • http://travel.state.gov/content/passports/en/alertswarnings.html • http://wwwnc.cdc.gov/travel/page/travel-information-centers • http://wwwnc.cdc.gov/travel/diseases

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