Introduction to travel medicine : 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
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.
Objectives : 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
What is travel medicine? : What is travel medicine? It is a science and an art
What is travel medicine? : 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 3rd Ed)
Slide6 : “the art of travel medicine is selecting the necessary prevention strategy without unnecessary adverse events, cost or inconvenience”
(Steffen, 1994)
Challenge of travel medicine : Challenge of travel medicine Sea of global migration of people
More people travelling
People travelling further a field
Rapid movement of travellers
Slide8 : 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
Globalization of health and safety : 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
Slide10 : Travellers are exposed to a variety of hazards
The Importance of Travel Health Measures : 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
The Importance of Travel Health Measures : 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.
The Importance of Travel Health Measures : 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 )
Travel medicine is a continuum : 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
Slide15 : The Continuum of Travel Medicine Preventive Medicine Contingency Planning Treatment & Rehabilitation
What do we need to do in order to be giving the correct advice to travellers? : What do we need to do in order to be giving the correct advice to travellers?
Travel Health Advice needs Information : Travel Health Advice needs Information “Information is power in Travel Medicine”
Travel Health Advice needs Training : Travel Health Advice needs Training Training gives you a framework for using that information
Travel Health Advice needs Experience : Travel Health Advice needs Experience Experience helps put the information and training in perspective
Travel Health Advice needs to be Documented : Travel Health Advice needs to be Documented Documentation is important for Quality assurance and reinforcing travel health advice
Travel Health Advice needs Travellers : Travel Health Advice needs Travellers Marketing is essential in travel health, whether in general practice or in specialist travel clinics
Giving the correct advice to travellers : Giving the correct advice to travellers Giving the correct health advice to travellers needs:
Information
Training
Experience
Documentation
Travellers
Travel Health Advice needs Information : Travel Health Advice needs Information Guidelines
Policies
Textbooks, including an World Atlas
Journals
Professional organisations
Staff/colleagues
Electronic Databases
WWW
International Guidelines : International Guidelines WHO
International Health Regulations
International Travel and Health
www.who.int/ith
Yellow fever requirements
“National Guidelines” : “National Guidelines” Travel Health Guidelines
Malaria Guidelines
Immunisation Guidelines
Antibiotic Guidelines
Journals
Seminars
You need access to www-sites : You need access to www-sites International Society of Travel Medicine
www.istm.org
US Centers for Disease Control and Prevention
www.cdc.gov/travel
US Guidelines
Similar government sites for UK and Canada
World Health Organization
http://www.who.int/ith
The former “yellow book” is now published as the “blue book” online
It is very useful to have access to a multicountry travel medical advisory service : 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
MASTA, see http://www.masta.org
TRAVAX, see http://www.travax.nhs.uk
Shorelands, see http://www.tripprep.com
Professional Organisations : Professional Organisations Local professional groups
and
THE ISTM
ISTM : ISTM International Society of Travel Medicine
International Network
International Clinic Directory
Useful for marketing/recognition
www.istm.org
Listserve
Outbreak alerts
Journal
Geosentinel
Certificate of Travel Health
Great Conferences!!
Journals : Journals Weighing the Evidence
Weighing the evidence : 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?
Giving the correct advice to travellers : Giving the correct advice to travellers Giving the correct health advice to travellers needs:
Information
Training
Experience
Documentation
Travellers
Pre-Travel Health Advice needs Training : 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
Part of the commitment is to also have a consistent and structured approach to travel health advice : 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
VACCINATE (IHC) : VACCINATE (IHC) Always National schedule
Often hepatitis A
Sometimes Japanese encephalitis meningococcal disease polio rabies yellow fever Influenza Pneumococcal disease
Other vaccines (adapted* from NZPHR; 1996;3(8):57-59)
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
Injuries accident avoidance, personal safety
Immersion schistosomiasis
Insurance* health and travel insurance* finding medical assistance o/s* (adapted* from NZPHR; 1996;3(8):57-59)
PRESCRIBE (Script/Dr’s letter/bracelet) : PRESCRIBE (Script/Dr’s letter/bracelet) Always regular medication medical kit (first aid)*
Sometimes antimalarial medication diarrheal self-treatment condoms (NZPHR; 1996;3(8):57-59)
Courses : Courses Increasing number of travel medicine academic programs globally (see educational opportunities at www.istm.org)
Get relevant endorsements
Aviation medical examiner
Diving medical certification (SPUMS)
Certificate of Travel Health (ISTM)
Occupational health training
Courses : 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
Giving the correct advice to travellers : Giving the correct advice to travellers Giving the correct health advice to travellers needs:
Information
Training
Experience
Documentation
Travellers
Travel health advice needs experience : 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.)
Slide42 : Travel is part of experience
Travel is part of experience : Travel is part of experience 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
Giving the correct advice to travellers : Giving the correct advice to travellers Giving the correct health advice to travellers needs:
Information
Training
Experience
Documentation
Travellers
Travel health advice needs to be documented : 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
Correct advice is even better if the advice is actually followed by the traveller : Correct advice is even better if the advice is actually followed by the traveller Documentation
Follow-up
Use staff resources
Reinforce health advice
Giving the correct advice to travellers : Giving the correct advice to travellers Giving the correct health advice to travellers needs:
Information
Training
Experience
Documentation
Travellers
Travel Health Advice needs Travellers : 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
Take home points : 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