Emporiatrics

Emporiatrics- Travel medicine, vaccination for travellers, IHR

1. Emporiatrics… Dr. Menaal Kaushal JR II Department of Community Medicine S. N. Medical College

2. Emporiatrics Greek origin “ emporos ”: O ne who goes on shipboard as a passenger + “ iatrike ”: medicine ) It’s the term coined to: D escribe the science of the health of travellers .

3. It is a science which deals with promoting and protecting the health of international travelers , providing them the advice related to the travel they are about to undertake . It is a fast developing specialty as the international travel is fast increasing. Every year 660 million people travel internationally . Definition

4. Practice of “Emporiatrics” Rapid development over the last 25 years Fairfield Hospital in Melbourne started the first ever travel clinic in early-mid 80’s Now a recognized clinical entity primarily involved in risk management Strong overlap with public health and occupational health and general practice Travel Medicine

5. Why a Special Branch for Travelers’ Health? Travellers face special health risks : They are subject to disorders induced by R apid changes of environment such as upsets in the circadian rhythms, motion sickness, and diarrhea; I n developing countries they are exposed to I nfectious diseases that do not exist in their home countries such as malaria, giardiasis, and dengue; and, They are S eparated from familiar and accessible sources of medical care. N ever before in history have so many people travelled and have people T ravelled so far or so fast.

6. Types of Travellers: B usiness men and Tourists VFR Non VFR They often travel by air or railways (The records of which are available) Immigrants, R efugees , and Migrant laborers W ho frequently travel by other means Documented Undocumented

7. So Who’s Responsibility is Emporiatrics? Meeting the health needs of these travellers who are moving rapidly between countries and continents is a responsibility shared by: the medical professionals, by the travellers themselves, by travel organizations , by airline and shipping companies, and by host governments for policy making

8. Knowledge of morbidity and mortality of travellers Understanding of epidemiology and geography of communicable diseases Awareness of non-communicable risks Vaccines, indications, side-effects Knowledge of post-travel illness presentation and management Geography , esp of major tourist destinations Ability to communicate complex issues in simple ways Understanding of when to refer Knowledge of Travel - Related Risks

9. Food and Water Insects Animals and Birds Environmental hazards Soil Sun Heat/humidity Cold/ dry Altitude Marine hazards Respiratory Hazards Sex and body-fluid exposure Vehicular and other Accidents DVT risk Risk to be considered and discussed

10. Factors Affecting Individual Risk Indi v idua l r i sk TRAVEL Destination Country of origin Duration of stay Itinerary Travel conditions Season TRAVELER Reason for travel Behavior Age and gender Health education Medical history - Allergies - Immunosuppressed - Pre-existing disease Immunization status Special needs - Pregnant women - Children - Elderly

11. World Map Tropical areas

12. Pregnancy Children Elderly Expatriates and long-term travellers VFR (visiting friends and relatives) Cardiac or Lung disease Diabetes HIV infections Immunocompromised Special Risk Groups

13. Cruise ships Diving Extended stay Extreme travel Mass gatherings Wilderness Special itineraries

14. The Traveller’s Triad

15. Person: medical conditions past and present, allergies, medications, vaccine history, previous travel Trip: reason, style and comfort level, rural vs urban, accommodation, activities, exposures, budget Time: duration, season, frequency “This Person, This Trip, This Time”

16. Identifying risks for individuals or groups Advising about risk reduction strategies Recommending and providing risk reduction interventions Encouraging behavioral change to change risk level Risk Management

17. Information enabling behaviour modification Vaccinations Medications (including antimalarials ) O ther- travel insurance, pre existing medical problems, nets, syringes, medical kits Risk Reduction Interventions

18. Understand basic current epidemiology Be aware of outbreaks and emergent issues Provide written material targeting specific risks Be able to communicate using electronic media Provide Up-to date Information

19. Cornerstone of clinical decision process Opportunity to define the risk profile Requires appropriate time, and done in advance of travel. May need multiple visits, allow a plan Good documentation essential Discussion of costs and priorities Consider family requirements Travel Consultation

20. Tailored advice to the traveller, itinerary and time Travellers vary by age, sex, pregnancy, medical history, immune status, current health, medications, vaccination history, allergies and prior travel experience Itineraries vary by length of stay, activities, environmental exposures, types of accommodation, season and budget Time variation is obviously important Advice should be understandable, re -enforced and in various media Personal advice is more likely to be understood, remembered or facilitate behavioral change. Individualized Advice

21. Advice and recommendations should be within the travellers budget Costs should be made clear and should be presented in some priority order Alternate strategies may need to be discussed Consider Costs

22. These are designed to assist travelers in meeting medical needs when their access to quality medical care is compromised. All travel medicine consultants recommend that travelers carry some form of medical first aid kit. A range is available, and often needs to be tailored to meet the specific requirements of the traveler and their proposed itinerary. Many travel clinics sell medical first aid kits; these often contain prescription items. Medical travel kits

23. Essential items for all travelers Items to treat cuts, scratches, burns, strains, splinters Paracetamol Repellent Consider condoms Additional items for Europe, USA, Japan Antinauseants , eg prochlorperazine Broad-spectrum antibiotic for respiratory infection Antacids Minor sedative Laxative Medical travel kits

24. Medical travel kits Additional items for less developed countries (gastro kit ) Rehydration solution Loperamide Tinidazole Norfloxacin – or azithromycin for children Comprehensive medical kit ; Asia, Africa and South America All of the above Sterile needles and syringes. Alcohol swabs Antihistamines Antifungal and antibiotic cream

25. No antimalarial gives 100% prevention P vivax and P ovale may be present months after return No global consensus Fever in returned travellers is malaria until proved otherwise Principles of malaria prophylaxis

26. 3 prong approach Behavioural modification Awareness of malarial risk Minimising exposure to mosquitoes Emphasis on extreme significance of early diagnosis & treatment Antimalarial chemoprophylaxis Malarial Prophylaxis

27. Avoid outdoor exposure, dawn to dusk Wear long sleeved loose clothing after dusk, light colors Avoid perfumes and colognes Use repellent with 20-40% DEET Use knockdown sprays, coils, vapours , etc indoors Sleep under nets impregnated with permethrin Personal Protection from Mosquitoes

28. Category A – considered low risk Western Europe/North America/Japan/UK/NZ/Singapore Should be fully vaccinated & up to date with Diphtheria/tetanus/whooping cough Routine paediatric vaccines MMR Polio Chicken pox Influenza Vaccinations

29. Category B Travel – considered to be low to intermediate risk Eastern Europe/Israel/Korea/Malaysia/Pacific Is/South Africa Vaccinations should be as for Category A, plus: Hepatitis A & B Typhoid QFT Vaccinations

30. Category C Travel – considered to be of higher risk African sub-continent / Central & South America / East Asia / SE Asia Vaccinations should be as for Category B, plus: Polio booster Japanese B Encephalitis Rabies Meningitis Yellow Fever Malaria Prevention Vaccinations

31. Routine (background ) vaccine Childhood , standard Required (compulsory ) vaccine Cross borders, entry requirements IHR Recommended (elective based on risk) Travel vaccines Some vaccines can be in more than category. Not all the same or available in all countries Vaccine Classification - 3Rs

32. In May 2005, The 58th World Health Assembly adopted the revised International Health Regulations , “IHR” To prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks , and which avoid unnecessary interference with international traffic .

33. International Health Regulations IHR (2005) The International Health Regulations are a formal code of conduct for public health emergencies of international concern. They're a matter of responsible citizenship and collective protection. They involve all 193 World Health Organization member countries.

34. International Health Regulations IHR (2005) They are an international agreement that gives rise to international obligations. They focus on serious public health threats with potential to spread beyond a country's border to other parts of the world. Such events are defined as public health emergencies of international concern, or PHEIC. The revised International Health Regulations outline the assessment, the management and the information sharing for PHEICs.

35. International Health Regulations IHR (2005) IHRs serve a common interest. First of all, they address serious and unusual disease events that are inevitable in our world today. They serve a common interest by recognizing that a health threat in one part of the world can threaten health anywhere, or everywhere. And they are a formal code of conduct that helps contain or prevent serious risks to public health, while discouraging unnecessary or excessive traffic or trade restrictions for, quote, "public health," purposes.

36. IHR focuses to address two main Questions: Is the number of cases and/or number of deaths for this type of event large for the given place, time or population? Has the event the potential to have a high public health impact?

37. Yellow fever Plague Cholera Typhoid Meningococcal meningitis SARS Influenza Internationally Quarantinable diseases

38. For visiting some countries or on incoming travel the traveler must have a valid vaccination certificate attached to the passport. At the entry point or exit ie . airports, ports, land entry points, the authorities will check the certificates. No valid certification traveler may face quarantine or deportation. Continued….

39. Thank you!!