THE PRETRAVEL CONSULTATION

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THE PRE-TRAVEL CONSULTATION

• Gary W. Brunette, MD, MS
• Travelers Health Team
• Division of Global Migration and Quarantine
• Centers for Disease Control and Prevention

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Outline

• Travelers Health Epidemiology
• Traveler Assessment
• Itinerary Review
• Sources of Information
• Risks to the Traveler
• Travel Vaccines
• Travel Medications
• Counseling

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U.S. Residents Traveling Abroad
ITA, includes travel to Canada and Mexico
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International Travel
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Where Do U.S. Residents Travel?
Of the 17 who traveled outside the U.S. . . .
Source HealthStyles Survey 2005
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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

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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 15684-91

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The Patient Medical Issues

• Age-specific issues
• Underlying illness, immunosuppression
• Systems review
• Medical history
• Medication use
• Vaccination history
• Allergies
• Contraindications to vaccines and medications

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The Patient Other Issues

• Reproductive
• Pregnant
• Breastfeeding
• Preconception
• Risk-taking behaviors

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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

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Travel Health Resources

• CDC Travelers Health Website
• www.cdc.gov/travel
• World Health Organization
• www.who.int/int
• State Department
• travel.state.gov
• International Society of Travel Medicine
• www.istm.org
• Health Information for International Travel
• CDC Yellow Book
• International Travel and Health
• WHO Green Book

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Travelers Health Websitewww.cdc.gov/travel
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Regional Destinations

• Region-specific pages
• Goal to move to country-specific format

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Travel Notices Announcements
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Deaths Related to International Travel
N 2463
Hargarten S et al, Ann Emerg Med, 1991. 20622-626
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Infectious Disease Risks to the Traveler

• Schistosomiasis
• Tuberculosis
• Leptospirosis
• Polio
• Yellow Fever
• Measles
• JEV

• Malaria
• Diarrhea
• Leishmaniasis
• Rabies
• Dengue
• Meningococcal Meningitis

ETC.
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Injury Deaths and International Travel
N 601
Hargarten S et al, Ann Emerg Med, 1991. 20622-626
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Other Risks to the Traveler

• Accidental injury
• Environmental hazards
• Crime and assault
• Psychiatric problems
• Animal bites, stings and envenomations
• Dermatologic disorders
• Altitude
• .

ETC.
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Immunizations to Consider for Adult Travelers

• Routine
• Diphtheria
• Tetanus
• Pertussis
• Measles
• Mumps
• Rubella
• Varicella
• Pneumococcus
• Influenza

• Travel related
• Hepatitis A
• Hepatitis B
• Typhoid
• Rabies
• Meningococcal disease
• Polio
• Japanese encephalitis
• Yellow Fever

Td or Tdap MMR
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Travel MedicationsProphylaxis Self Treatment

• Malaria
• chloroquine, atovaquone/proguanil (Malarone),
  doxycycline, mefloquine (Lariam), primaquine
• Diarrhea
• quinolone, azithromycin
• Altitude
• acetazolamide
• Motion sickness
• scopolamine, dimenhydrinate (Dramamine)

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Patient Counseling

• Sufficient time for patient education
• Tailored to suit traveler
• Fitness for travel
• Understanding impact on existing conditions
• Advisability of destinations

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Travel Preparation

• Travel health insurance
• Medical care
• Hospitalization
• Evacuation
• Obtaining medical care abroad
• Awareness of travel notices
• Hand washing and hygiene

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Environmental Precautions

• Air Travel
• Jet Lag
• Sun Protection
• Extreme Heat and Cold
• dehydration, heat stroke
• hypothermia, frostbite
• Altitude
• Water recreation
• Drowning, boating diving accidents
• Risk of schistosomiasis or leptospirosis
• Biological and chemical contamination

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Food and Water Precautions

• Bottled water
• Selection of foods
• well-cooked and hot
• Avoidance of
• salads, raw vegetables
• unpasteurized dairy products
• street vendors
• ice

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Vector Precautions

• Covering exposed skin
• Insect repellent containing DEET 25 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

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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

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Animal Precautions

• Animal avoidance
• Rabies
• Specific animal threats
• Medical evaluation of bites/scratches
• Post exposure immunization and immunoglobulin
• Envenomations
• Snakes, scorpions, spiders
• Maritime animals

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Injury and Crime

• Vehicles
• Risk of road and pedestrian accidents
• Night travel
• Seat belts and car seats
• Use of drugs and alcohol
• Understanding local crime risks
• Scam awareness
• Situational awareness
• Location avoidance

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Travel Emergency Kit

• Copy of medical records and extra pair of glasses
• Prescription medications
• Over-the counter medicines and supplies
• Analgesics
• Decongestant, cold medicine, cough suppressant
• Antibiotic/antifungal/hydrocortisone creams
• Pepto-Bismol tablets, antacid
• Band-Aids, gauze bandages, tape, Ace wraps
• Insect repellant, sunscreen, lip balm
• Tweezers, scissors, thermometer

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Post-Travel Care

• Post-travel checkup
• Long term travelers
• Adventure travelers
• Expatriates in developing world
• Post-travel care
• Fever, chills, sweats
• Persistent diarrhea
• Weight loss

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Questions?
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Other Resources
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Journals

• American Journal of Tropical Medicine and Hygiene
• Bulletin of the World Health Organization
• Emerging Infectious Diseases Journal
• Eurosurveillance Weekly
• Journal of Travel Medicine
• Morbidity and Mortality Weekly Report
• Tropical Medicine and International Health
• Vaccine

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Books

• Textbook of Travel Medicine and Health, 2nd Ed.
• DuPont, H.L. and Steffen R. (editors)
• The Travel and Tropical Medicine Manual, 3rd Ed.
• Jong, E.C., McMullen, R.
• Travel Medicine
• Keystone, J.S., Kozarsky, P.E., et al

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Websites

• Eurosurveillance
• www.eurosurveillance.org
• Travax EnCompass
• www.travax.com
• GIDEON
• www.gideononline.com
• International SOS
• www.internationalsos.com
• Medical Advisory Service for Travelers Abroad
  (MASTA)
• http//www.masta.org/
• Armed Forces Medical Intelligence Center
• www.afmic.detrick.army.mil/
• Central Intelligence Agency
• www.cia.gov/cia/publications/factbook/