travel medicine when hoof beats might be zebras dr. januchowski

TRAVEL MEDICINE

“When hoof beats might be zebras”

Dr. Januchowski

OBJECTIVES

• Be able to identify the key items to discuss with patients travelling internationally

• Be able to discuss with patients the resources available to help them stay healthy while travelling

• Know some of the important illness patterns to watch for when patients return from overseas adventures

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Travel Medicine

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Travel Medicine

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Travel Medicine Consultation

• Risk Assessment

• Risk Communication

• Risk Management

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Risk Assessment

• Typically done 1-2 months prior to travel

• Itinerary data

• Traveler demographics and health/medical history

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Risk AssessmentItinerary data• Countries and regions to be visited, in

the order of travel

• Visits to urban versus rural areas

• Dates and length of travel in each area

• Purpose of travel (such as business, vacation, visiting friends and relatives)

• Modes of transportation

• Planned and possible activities (such as hiking, scuba diving, camping)

• Types of accommodations in each area (such as air-conditioned, screened, tents)

Traveler demographics• Age, sex

• Vaccination history, including dates, how many doses received in a scheduled series, and prior adverse events

• Medical and psychiatric history (past and current), including any conditions or medications that suppress the immune system

• Medications (current or taken in the past 3 months)

• Allergies (in particular to eggs, latex, yeast, mercury, or thimerosal)

• Pregnancy and breastfeeding (current status and plans)

• Any planned surgeries or other medical care during travel (medical tourism)

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Risk Communication

• Plan based on Risk Assessment

• Evidence Based plan of action developed with the traveller

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Risk Management

• Implementation of the plan–Vaccines

–Medications

–Education

–General Guidance

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Case #1

• 44 y.o. male patient presents 2 months before a planned trip to Suriname for business with his employer, ALCOA

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Risk Assessment - Itinerary• Countries and regions to be visited, in the order of travel

• Visits to urban versus rural areas

• Dates and length of travel in each area

• Purpose of travel (such as business, vacation, visiting friends and relatives)

• Modes of transportation

• Planned and possible activities (such as hiking, scuba diving, camping)

• Types of accommodations in each area (such as air-conditioned, screened, tents)

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Risk Assessment – Traveler info

• Age, sex• Vaccination history, including dates, how many doses received in

a scheduled series, and prior adverse events• Medical and psychiatric history (past and current), including any

conditions or medications that suppress the immune system• Medications (current or taken in the past 3 months)• Allergies (in particular to eggs, latex, yeast, mercury, or

thimerosal)• Pregnancy and breastfeeding (current status and plans)• Any planned surgeries or other medical care during travel

(medical tourism)

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Let’s talk

about

vaccines

Risk Management – Vaccines

• Routine

• Required

• Recommended

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RoutineRoutine Vaccines

• Would include childhood immunizations

• Boosters (Tdap, MMR)

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RequiredRequired Vaccines

• Yellow fever vaccine–Sub-Saharan Africa

–Tropical South America

• Meningococcal vaccine for annual travel to the Hajj in Saudi Arabia

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RecommendedRecommended Vaccines

• Varies based on –Destination

– Itinerary

–Traveller demographics

• Check website

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Typhoid

• Salmonella enterica

• Fecal-oral route of transmission

• Fever, headache, malaise

• Intestinal perforation and hemorrhage complications

• Can be treated with antibiotics22

Typhoid VaccineInjectable

• One dose series

• Good for 2 years

• Age 2 and older

• Should be given >2 weeks prior to travel

Oral (Live, attenuated)

• 4 dose series

• Good for 5 years

• Age 6 and older

• Should complete series one week before travel

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Cost for vaccine ~$80-100

Yellow Fever

• Transmitted by mosquito

• Fevers, malaise

• Can cause hepatitis, hemorrhagic complications

• Supportive treatment

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Yellow fever vaccine

• Must be administered by a certified health center

• ~$100-125

• Good for 10 years

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Yellow fever vaccine

• Contraindications–Less than 6 months old

– Immunocompromised status• Primary immunodeficiency

• HIV with CD4<200

–Malignant neoplasms

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Risk management

• The patient has scheduled times for his vaccinations

• What other information can be provided for this traveller?

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Risk management

• Malaria prevention

• Treatment of common travel illnesses

• General Education –Food and drink safety

–Accident avoidance

–Safe sexual practices28

Malaria prevention

• Determine risk

• Prevent mosquito bites

• Medication prophylaxis

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Malaria Chemoprophylaxis

• Atovaquone-proguanil

• Chloroquine

• Doxycycline

• Mefloquine

• Primaquine

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Malaria ChemoprophylaxisMedicine Cost Start prior Dosing time Side effects Misc.

Atovaquone-proguanil

$$$ 1-2 days Daily Minimal

Chloroquine $ 1-2 weeks Weekly Resistance

Doxycycline $ 1-2 days Daily GI / sun

Mefloquine $$ 2 weeks Weekly GI / seizure / psych/cardio

Resistance

Primaquine $ 1-2 days Daily G6PD caution!

Can be used for vivax term. prophylaxis

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What other recommendations?

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Travel Medicine Kit

• Include items for treatment of common illnesses

• Watch for flight regulations

• International regulations on transport of medications

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Travel Med Kit

• Routine prescribed medicines• Antidiarrheals

– Bismuth products (treatment or prophylaxis)– Loperamide (Imodium)– Ciprofloxacin 500 mg BID x 2– Azithromycin 1 gm x 1– Rifaximin (non-FDA approved, off label use for

prophylaxis)

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Treatments

Travel Med Kit (cont.)

• Insect repellents–DEET (30-50%)–Picaridin–Oil of Lemon Eucalyptus or PMD– IR3535–Permethrin impregnated clothing / bed

netting36

Travel Med Kit (cont.)

• Water purification tablets

• Pain medicines (OTC)

• Sunscreen

• Antibacterial skin cleanser / wipes

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Case (cont.)

• The patient travels and returns without any noted incidents.

• Proper education allowed the patient to–Know the precautions after return regarding

illness reporting–Know the importance of completing malaria

prophylaxis medications

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Post travel visit

• Ensure malaria medicines are completed–4 weeks for doxycycline / mefloquine

–7 days for atovaquone/proguanil

• Review travel history

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Post travel visit - Illnesses

• Fever

• Persistent GI complaints

• Skin lesions or rashes

• Respiratory infections

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Post travel visit - Fever

• Malaria (up to one year!)• Dengue• Invasive bacterial diarrhea• Hepatitis A• Typhoid• Rickesial infections• Influenza (remember patterns)• Viral illnesses NOS 41

Post travel visit – GI Concerns• Acute bacterial/parasitic gastroenteritis

– Giardia– C. difficile

• Unmasking of underlying GI disease – Postinfectious IBS – Lactose intolerance– Celiac disease

• Tropical sprue• Brainerd diarrhea

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Post travel visit – Skin lesions

• Non-specific dermatitis

• Insect bites

• Pyoderma

• Scabies

• Cutaneous larva migrans

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Assessing Risk by Incubation Period

OBJECTIVES

• Be able to identify the key items to discuss with patients travelling internationally

• Be able to discuss with patients the resources available to help them stay healthy while travelling

• Know some of the important illness patterns to watch for when patients return from overseas adventures

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Questions?

• rjanuchowski@vcom.edu

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