Emporiatrics

1. Emporiatrics Dr. Gopalrao M.D. Ph.D. Professor & Head, Community Medicine Department

2. 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

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

4. Knowledge of Travel-related Risks 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

5. 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

6. 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

7. Special Risk Groups Pregnancy Children Elderly Expats and long-term travellers VFR Cardiac or Lung disease Diabetes HIV infections Immunocompromised

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

9. “This person, this trip, this time” Person; medical conditions past and present, allergies, medications, vaccine history, previous travel Trip: reason, style and comfort level, rural vs urban, accomodation, activities, exposures, budget Time: duration, season, frequency

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

11. Risk Reduction Interventions Information enabling behaviour modification vaccinations medications (including antimalarials) other - travel insurance, pre existing medical problems, nets, syringes, medical kits

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

13. Travel Consultation 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

14. Individualise Advice 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-inforced and in various media Personal advice is more likely to be understood, remembered or facilitate behavioural change.

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

16. 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

17. Medical travel kits 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 Sudafed Minor sedative Laxative

18. 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

19. 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 Patient compliance and education is essential Principles of malaria prophylaxis

20. 3 prong approach behavioral modification awareness of malarial risk minimising exposure to mosquitoes emphasis on extreme significance of early diagnosis & treatment antimalarial chemoprophylaxis Malarial Prophylaxis

21. Avoid outdoor exposure, dawn to dusk Wear long sleeved loose clothing after dusk, light colours 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

22. 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 1

23. 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 2

24. Catergory C Travel – considered to be of higher risk African sub-continent/Central & South America/East Asia/SE Asia/Melanesia Vaccinations should be as for Category B, plus: Polio booster Japanese B Encephalitis Rabies Meningitis Yellow Fever Malaria Prevention Vaccinations 3

25. 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-3 Rs

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

27. 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….

28. Thank You