Pre-Travel Health Consultation : Pre-Travel Health Consultation Dr Peter A. Leggat
MD, PhD, DrPH, FAFPHM, FACTM, FFTM
Associate Professor
School of Public Health and Tropical Medicine
James Cook University &
Visiting Professor
School of Public Health
University of the Witwatersrand
About the author : 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.
By the end of this session : By the end of this session Briefly revisit who provides pre-travel health advice
Emphasize the need for resources in travel medicine
Overview the main functions of the pre-travel health consultation
Introduce the concept of documentation in travel medicine
Slide4 : The Continuum of Travel Medicine Preventive Medicine Contingency Planning Treatment & Rehabilitation
Travelers get information from various sources : Travelers get information from various sources Travel agent/travel industry
Books, popular press and the Internet
Person “next door”
Pharmacy
General practice / Travel clinics
Government/public health services
Professional and academic bodies Ref: Leggat PA. Sources of health advice for travelers. J Travel Med 2000;7:85-8
Giving correct and consistent advice to travelers is important : Giving correct and consistent advice to travelers is important Giving the correct health advice to travelers needs:
Information
Training
Experience
Documentation
Travellers
Need to be prepared with adequate resources : Need to be prepared with adequate resources Need adequate staff training and continuing education
Need adequate time and good time management
Need to have access to national and international guidelines for travel medicine
Need to have health education resources
Need to have access to good geographically based epidemiological information regarding risks to health and safety of travelers (internet, computerized databases etc)
Travel Health Advice Needs Adequate Notice : Travel Health Advice Needs Adequate Notice Travelers need to be informed that they need travel health advice
Travelers need to be informed that they need to seek travel health advice early, about 6-8 weeks prior to travel
A risk assessment must be performed for every traveler
PRE-TRAVEL HEALTH ADVICE : PRE-TRAVEL HEALTH ADVICE Immunize travelers
Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel
Prescribe appropriate chemoprophylactic and self-treatment medications
PRE-TRAVEL HEALTH ADVICE : PRE-TRAVEL HEALTH ADVICE Immunize travelers
Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel
Prescribe appropriate chemoprophylactic and self-treatment medications
VACCINATE : VACCINATE Always National schedule (incl Hep B)
Often hepatitis A (non-immune)
Sometimes Japanese encephalitis meningococcal disease (Mecca) polio rabies typhoid
yellow fever (WHO)
Older age gp Influenza (Others) Pneumococcal disease (adapted* from NZPHR; 1996;3(8):57-59)
IMMUNISE AGAINST : IMMUNISE AGAINST Mandatory vaccinations (WHO)
National schedule vaccinations-update routine immunizations
Vaccinations for most or all travelers
Vaccinations for travelers at special risk+
“Mandatory” vaccines : “Mandatory” vaccines Travelers to/from Yellow fever endemic areas
Travelers going to Mecca for the Hajj
Yellow fever : Yellow fever Source: http://www.cdc.gov/travel/diseases/yellowfever.htm
Yellow fever : Yellow fever International regulations
WHO International Travel and Health
Specially licensed Yellow Vaccination Centers
Need to document on appropriate certificate of immunization card
Meningococcal meningitis : Meningococcal meningitis Source: http://www.cdc.gov/travel/diseases/menin.htm
Meningococcal meningitis : Meningococcal meningitis Neisseria meningitidis: At least 13 antigenically distinct serogroups
A,B,C,W135 & Y are most common
Current vaccine for A,C,W135 & Y
NZ is trialing a vaccine against a specific B strain
Mandatory: Pilgrims visiting Mecca for the Hajj (annual pilgrimage) or for the Umrah
Recommended: Travelers “roughing it” in areas where there are recurrent outbreaks of disease
Routine vaccinations : Routine vaccinations The travel health consultation is a good opportunity to update national schedule or routine vaccinations
Vaccinations for most travelers : Vaccinations for most travelers Diseases associated with poor hygiene & sanitation
ETEC?
Hepatitis A
Typhoid
Cholera : Cholera Various new vaccines
Some activity against ETEC in one
Routine use of cholera vaccine is not recommended as risk is low
It is indicated for travelers to cholera endemic areas, who are at high risk for infection (2-3 years protection)
Travelers at special risk : Travelers at special risk Geographical risk
Risk because age, pre-existing conditions, or occupation
Geographical risk : Geographical risk Vector borne diseases
Yellow fever
Japanese encephalitis
Tick borne encephalitis
Wilderness/remote travel
Rabies
TB
Current epidemics (terrorist threats?)
Cholera
Plaque
Japanese encephalitis : Japanese encephalitis Source: http://www.cdc.gov/ncidod/dvbid/jencephalitis/map.htm
Japanese encephalitis : Japanese encephalitis Travelers spending one month or more in rural areas of Asia, PNG & Torres Strait (Australia), particularly if the travel is during the wet season, and/or there is considerable outdoor activity and/or the standard of accommodation is suboptimal,
other travelers spending a year + in Asia (except for Singapore), even if much of the stay is in urban areas
Dengue : Dengue Vaccine in development
Four serotypes (1-4)
Transmitted by certain mosquitoes, including Aedes aegypti
Widespread, especially common in SE Asia
Becoming increasingly recognized in travelers
Estimated monthly incidence of health problems per 100 000 travellers to developing countries : Estimated monthly incidence of health problems per 100 000 travellers to developing countries
Tick borne encephalitis : Tick borne encephalitis Seasonal disease in parts of Europe, Scandinavia and Russia
Hikers, campers and agricultural workers most at risk
Small mammal ticks found in the undergrowth close to forested areas
Vaccine available/post-exposure immune globulin
Tuberculosis-BCG : Tuberculosis-BCG Travelers over the age of 5 years who will spend prolonged periods in countries of high TB prevalence
Children under 5 years who will be travelling to live in countries of high TB prevalence for > than 3 months
WHO: high risk countries, where annual incidence is in excess of 100 per 100,000 population
Rabies : Rabies Endemic in many countries
Is almost a universally fatal disease
Plague : Plague Yesinia pestis, transmitted via fleas from animal reservoir to humans
Rare in most parts of the world
Vaccination only of those at high risk, usually those engaged in field operations, laboratory workers or others who reside in areas where plague is present
Risk because age, pre-existing conditions, or occupation : Risk because age, pre-existing conditions, or occupation Older travelers/pre-existing disease
Influenza
Pneumococcal infection
Occupational risk (including electives)
Hepatitis B (usually part of national schedule)
Q fever
Influenza : Influenza Routinely on annual basis for those 65 years and older
Travelers with chronic disorders of the pulmonary or circulatory systems or other chronic illnesses needing regular follow-up
Those who wish to reduce the risk
Estimated monthly incidence of health problems per 100 000 travellers to developing countries : Estimated monthly incidence of health problems per 100 000 travellers to developing countries
Pneumococcal infection : Pneumococcal infection Routinely on annual basis for those 65 years and older
Travelers with asplenia, immunocompromized travelers
Others
Q Fever : Q Fever Bacterium (rickettsia) Coxiella burnetii
Recommendation: those occupationally exposed to cattle, sheep, goats or kangaroos or their products
Serum antibody and skin testing to exclude hypersensitivity reaction
Contraindications: prior exposure to Q fever or anaphylaxis induced by egg proteins
It is important to document vaccinations : It is important to document vaccinations Vaccination record
Vital for those requiring proof of yellow fever vaccination
Evidence of specific vaccinations and screening (e.g. HIV, HBV, Syphilis, Tuberculin) needed for entry to various countries, especially longer term travelers, such as scholars and workers
PRE-TRAVEL HEALTH ADVICE : PRE-TRAVEL HEALTH ADVICE Immunize travelers
Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel
Prescribe appropriate chemoprophylactic and self-treatment medications
ADVISE AND DISCUSS : ADVISE AND DISCUSS Insects
Ingestions
Indiscretions
Injuries
Immersions
Insurance
ADVISE AND DISCUSS : ADVISE AND DISCUSS Insects repellents, nets, permethrin
Ingestions care with food and water diet/teeth (including airlines/jetlag/DVT)
Indiscretions STI’s, HIV, drugs?
Injuries accident avoidance, personal
safety
Immersion schistosomiasis, drowning
Insurance* health and travel insurance* finding medical assistance o/s* (adapted from NZPHR; 1996;3(8):57-59)
Personal safety is on the radar screen : Leitrim County, rural Ireland
Courtesy of Rick Speare Personal safety is on the radar screen
Personal safety : Personal safety There has been heightened concern regarding personal safety and travelers
National foreign affairs sites should be consulted on safety and security at the travelers’ destination(s).
Personal safety : Personal safety Source: http://www.cia.gov/cia/publications/factbook/
SPECIAL RISK GROUPS : SPECIAL RISK GROUPS Travelers who need special assistance or need assessment as to fitness to fly
Pregnant travelers/children/HIV travelers
Altitude/mountaineering/diving
Adventure/outback travelers
Travelers to areas of extreme climate
School/club/other groups
Occupational/students/military/aviation
Aid/refugee camp workers
Travel health advice needs documentation : Travel health advice needs documentation Medialert bracelets-allergies, serious medical conditions
Written travel health advice (may be part of doctor’s letter)-consider using a proforma
Travelers health record ?
Other certificates, e.g. diving, airline
Is the traveler being escorted? (aeromedical evacuation)
Educational Resources : Educational Resources Books
Travel industry guides
Pharmaceutical companies
Videos-popular in a number of clinics in the USA
Slide47 : 52 pp, passport sized booklet 152 pp, Small pocket book 192 pp, reader 730 pp, manual
Slide48 : 144 pp, Small pocket book 428 pp, reader Disease specific Specific to special groups
PRE-TRAVEL HEALTH ADVICE : PRE-TRAVEL HEALTH ADVICE Immunize travelers
Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel
Prescribe appropriate chemoprophylactic and self-treatment medications
PRESCRIBE (Script/Dr’s letter/medialert bracelet) : PRESCRIBE (Script/Dr’s letter/medialert bracelet) Always regular medication medical kit (first aid)*
Sometimes antimalarial medication diarrheal self-treatment condoms/PEP Other hygiene pdts (NZPHR; 1996;3(8):57-59)
Medication needs documentation : Medication needs documentation Prescription
Doctor’s letter-consider using a proforma
Customs/quarantine approvals, if required
If part of a clinical trial, contact details/advice regarding adverse reactions (on a laminated card)
We do not live in an ideal world : We do not live in an ideal world Travel health advice will be moderated by
Availability of vaccines
Availability of educational resources
Availability of drugs for chemoprophylaxis and treatment-special authority
Limitations in indications, limitations in available data for use
Risk assessment
Bottom line of pre-travel health advice : Bottom line of pre-travel health advice There is probably more to pre-travel health advice than travel immunizations and malaria chemoprophylaxis
Travelers will have different priorities and resources
Need for a risk assessment and access to current epidemiological information available on a geographic basis by country/region