Emporiatrics.pptx

Study of travellers

1. Emporiatrics we cannot make travelers bullet-proof but it is possible to make them bullet-resistant Dr. Amit Kumar Thakur Dept. of Public Health Dentistry Government Dental College & Research Institute, Bengaluru

2. Contents Introduction Types of travels Air travel Sea travel Travel related risk Environmental related risk Other related risks Pre travel advice

3. Contents Post travel evaluation Public health concern Destination India Travel insurance Role of travel industry professionals Responsibility of the traveler Conclusion References

4. INTRODUCTION “ Travel broadens the mind” and people have been extolling the merits of travel for a very long time. The general belief is that travel is good for travellers , mentally and physically. But while travel can indeed be interesting and exciting and good for the mental and physical wellbeing, all too often, it can be harmful to a traveller’s health . The increase in the numbers of travellers and the speed at which they travel, has not only had economic, cultural, and social repercussions, but medical, epidemiological, and medico-legal consequences as well.

5. INTRODUCTION Travellers face special health risks. Firstly , they are subject to disorders induced by rapid changes of environment such as upsets in the circadian rhythms, motion sickness, and diarrhoea ; Secondly , in developing countries they are exposed to infectious diseases that do not exist in their home countries such as malaria, giardiasis, and dengue; and, Thirdly , they are separated from familiar and accessible sources of medical care. Nevertheless, the lure of travel seems undiminished.

6. INTRODUCTION Travel medicine is an emerging subspeciality that aims to keep disease and injury at bay by arming travellers with education, vaccinations, medical supplies, and resources to cope with problems on the way . Travel medicine or emporiatrics is the branch of medicine that deals with the prevention and the management of the health problems of international travelers. Emporiatrics (Greek emporos one who goes on shipboard as a passenger+iatrike medicine) is the term coined to describe the science of the health of travellers . Emporiatrics is the term coined to describe the science of the health of traveler.

7. Types of travel Basically there are three types of travel Air Water Land

8. According to CDC (The Centers for Disease Control and Prevention ) Adopting a child from another Country Adventure Travel Business Travel Cruise Ship Travel Medical Tourism Studying Abroad Travel to Cold Climates Travel to High Altitudes Travel to Hot Climates Travel to Mass Gatherings

9. TRAVEL BY AIR Airlines have the right to refuse to carry passengers with conditions that may worsen, or have serious consequences, during the flight. They may require medical clearance from their medical department/adviser if there is an indication that a passenger could be suffering from any disease or physical or mental condition that: may be considered a potential hazard to the safety of the aircraft; adversely affects the welfare and comfort of the other passengers and/or crew members; requires medical attention and/or special equipment during the flight; may be aggravated by the flight.

10. Transmission of communicable diseases on aircraft Research has shown that there is very little risk of any communicable disease being transmitted on board an aircraft . Transmission of infection may occur between passengers who are seated in the same area of an aircraft, usually as a result of the infected individual coughing or sneezing or by touch (direct contact or contact with the same parts of the aircraft cabin and furnishings that other passengers touch). Highly contagious conditions, such as influenza, are more likely to be spread to other passengers in situations where the aircraft ventilation system is not operating.

11. To minimize the risk of passing on infections, travellers who are unwell, particularly if they have a fever, should delay their journey until they have recovered . Individuals with a known active communicable disease should not travel by air. Airlines may deny boarding to passengers who appear to be infected with a communicable disease.

12. Problems encountered during air travel Motion sickness Ozone Cabin humidity and dehydration Cabin air pressure Jet lag Immobility, circulatory problems and deep vein thrombosis (DVT)

13. Contraindications to air travel Travel by air is normally contraindicated in the following cases: Infants less than 48 hours old. Women after the 36th week of pregnancy (32nd week for multiple pregnancies). Those suffering from: angina pectoris or chest pain at rest; any active communicable disease; decompression sickness after diving;

14. increased intracranial pressure due to haemorrhage , trauma or infection; infections of the sinuses or of the ear and nose, particularly if the eustachian tube is blocked ; recent myocardial infarction and stroke (elapsed time since the event depending on severity of illness and duration of travel); recent surgery or injury where trapped air or gas may be present, especially abdominal trauma and gastrointestinal surgery, craniofacial and ocular injuries, brain operations, and eye operations involving penetration of the eyeball;

15. severe chronic respiratory disease, breathlessness at rest, or unresolved pneumothorax; sickle-cell anaemia ; psychotic illness, except when fully controlled. The above list is not comprehensive, and fitness for travel should be decided on a case-by-case basis . Recent dental procedures such as fillings are not usually a contraindication to flying. However, unfinished root canal treatment and dental abscesses are reasons for caution, and it is recommended that individuals seek advice with regard to travel plans from the surgeon or dental practitioner most familiar with their case.

16. TRAVEL BY SEA The passenger shipping industry (cruise ships and ferries) has expanded considerably in recent decades. In 2008, 13 million passengers worldwide travelled on cruise ships. Cruise itineraries cover all continents, including areas that are not easily accessible by other means of travel. The average duration of a cruise is about 7 days, but cruise voyages can last from several hours to several months. A typical cruise ship now carries up to 3000 passengers and 1000 crew The revised International Health Regulations (2005) address health requirements for ship operations.

17. According to Article 8 of the International Labour Organization Convention (No. 164) “Concerning Health Protection and Medical Care for Seafarers” (1987), vessels carrying more than 100 crew members on an international voyage of 3 days or longer must provide a physician for care of the crew. These regulations do not apply to passenger vessels and ferries sailing for less than 3 days, even though the number of crew and passengers may exceed 1000.

18. Ferries often do not have an emergency room but a ship’s officer or a nurse is designated to provide medical help. The contents of the ship’s medical chest must be in accordance with the international recommendations and national laws for ocean-going trade vessels, but there are no special requirements for additional drugs for passenger ships.

19. Senior citizens represent about one-third of passengers. Cruises of longer duration often attract older travellers , a group likely to have more chronic medical problems, such as heart and lung disease. More than half of all emergency visits to health clinics on board are made by passengers who are over 65 years of age; the most common health problems are respiratory tract infection, injuries, motion sickness and gastrointestinal illness.

20. Prescription medicines should be carried in the original packages or containers, together with a letter from a medical practitioner attesting to the traveller’s need for those medicines. Cruise ship travellers who may require particular medical treatment should consult their health-care providers before booking . It is important to view a ship’s medical facility as an infirmary and not as a hospital.

21. Although most of the medical conditions that arise aboard ship can be treated as they would be at an ambulatory care centre at home, more severe problems may require the patient to be treated in a fully staffed and equipped land-based hospital after stabilization on the ship . Knowledge of the type and quality of medical facilities along the itinerary is important to determine whether passengers or crew members can be sent ashore for additional care or need to be evacuated by air back to the home port. Most cruise vessels do not have assigned space for a dental office, and very few have a resident dentist.

22. The rapid movement of cruise ships from one port to another, with the likelihood of wide variations in sanitation standards and infectious disease exposure risks, often results in the introduction of communicable diseases by embarking passengers and crew members. More than 100 disease outbreaks associated with ships have been identified in the past 30 years. This is probably an underestimate because many outbreaks are not reported and some may go undetected.

23. Outbreaks of measles, rubella, varicella, meningococcal meningitis, hepatitis A, legionellosis , and respiratory and gastrointestinal illnesses among ship passengers have been reported. Such outbreaks are of concern because of their potentially serious health consequences and high costs to the industry. In recent years, influenza and norovirus outbreaks have been public health challenges for the cruise industry.

24. Noncommunicable diseases Because of temperature and weather variations, changes in diet and physical activities, cruise ship passengers – particularly the elderly – may experience worsening of existing chronic health conditions . Cardiovascular events are the most common cause of mortality on cruise ships . Motion sickness can occur, especially on smaller vessels. Injuries and dental emergencies are also frequently reported

25. Precautions The risk of communicable and non-communicable diseases among cruise ship passengers and crew members is difficult to quantify because of the broad spectrum of cruise ship experiences, the variety of destinations and the limited available data . In general, cruise ship travellers should: Before embarking, consult their health-care provider, a physician or travel health specialist on prevention guidelines and immunizations, specifically taking into account:

26. the health status of the individual, the duration of travel, the countries to be visited and likely activities ashore ; all routinely recommended medical condition age-specific immunizations ; influenza vaccination as available regardless of season, particularly if the traveller belongs to one of the groups for whom annual vaccination against influenza is routinely recommended the need to provide a prescription for anti-influenza medication, for treatment or prophylaxis, can then be discussed; immunization and other (e.g. malaria) recommendations that apply to each country on the itinerary;

27. M edication against motion sickness, particularly if the individual is prone to motion sickness. See a dentist to make sure they have good oral health and no active problems. Consider purchasing a special health insurance policy for trip cancellation, additional medical coverage and/or medical evacuation if necessary. Abstain from embarking on a cruise if symptomatic with acute illness.

28. Carry all prescription medicines in the original packet or container, together with a doctor’s letter. Carry out frequent hand-washing, either with soap and water or using an alcohol-based hand sanitizer. Avoid self-medication in the case of diarrhoea or high fever while on board, but report immediately to the ship’s medical service.

29. TRAVEL RELATED RISK Key factors in determining the risks to which a traveler may be exposed are Mode of transport Destination(s) Duration and season of travel Purpose of travel Standards of accommodation, food hygiene and sanitation Behaviour of the traveller Underlying health of the traveller .

30. Destinations where accommodation, hygiene and sanitation, medical care and water quality are of a high standard pose relatively few serious risks to the health of travellers , except those with pre-existing illness. The same is true of business travellers and tourists visiting most major cities and tourist centres and staying in good-quality accommodation .

31. In contrast, destinations where accommodation is of poor quality, hygiene and sanitation are inadequate, medical services do not exist and clean water is unavailable may pose serious risks for the health of travellers . This applies, for example, to personnel from emergency relief and development agencies and to tourists who venture into remote areas .

32. In these settings, stringent precautions must be taken to avoid illness. Travel warnings from governmental sources should be taken seriously; they are likely to have implications for travel and for travel insurance. The epidemiology of infectious diseases in the destination country is of importance to travellers .

33. Travellers and travel medicine practitioners should be aware of the occurrence of these diseases in the destination countries. Unforeseen natural or man-made disasters may occur; outbreaks of known or newly emerging infectious diseases are often unpredictable . New risks to international travellers should be updated from WHO web site (http://www.who.int ) . Similarly, up-to-date information on safety and security risks should be acquired from authoritative web sites (http://www.who.int/ith/links/national_links/en/index.html).

34. The mode of transport, duration of visit and the behaviour and lifestyle of the traveller are important in determining the likelihood of exposure to infectious diseases and will influence decisions on the need for certain vaccinations or antimalarial medication. The duration of visit may also determine whether the traveller is subjected to marked changes in altitude, temperature and humidity or to prolonged exposure to atmospheric pollution.

35. Understanding the purpose of the visit and the type of travel planned is critical in relation to the associated travel health risks. However , behaviour also plays an important role; for example, going outdoors in the evenings in a malaria-endemic area without taking precautions to avoid mosquito bites may result in the traveller becoming infected with malaria .

36. Exposure to insects, rodents or other animals, infectious agents and contaminated food and water, combined with the absence of appropriate medical facilities, makes travel in many remote regions particularly hazardous. Whatever their destination or mode of travel, it is important that travellers should be aware of the risk of accidents under the influence of alcohol or drugs and, mainly, in relation to road transport or the practice of sports.

37. ENVIRONMENTAL HEALTH RISKS Travellers often experience abrupt and dramatic changes in environmental conditions, which may have detrimental effects on health and well-being. The negative impact of sudden changes in the environment can be minimized by taking simple precautions. Altitude Heat and humidity

38. Ultraviolet radiation from the sun Foodborne and waterborne health risks Travellers ’ diarrhoea Recreational waters Animals and insects

39. OTHER TRAVEL RELATED RISKS Exposure to blood and other body fluids Blood transfusion Accidental exposure to blood or other body fluids

40. Infectious disease and potential risks Amoebiasis Anthrax Brucellosis Chikungunya Coccidioidomycosis Dengue Giardiasis Haemorrhagic fevers

41. Hepatitis C Hepatitis HIV/AIDS and other sexually transmitted infections Legionellosis Leishmaniasis (cutaneous, mucosal and visceral forms) Leptospirosis (including Weil disease) Listeriosis Lyme Borreliosis (Lyme disease) Lymphatic filariasis

42. Malaria Plague SARS (Severe Acute Respiratory Syndrome) Schistosomiasis ( Bilharziasis ) Trypanosomiasis Typhus fever (Epidemic louse-borne typhus) Zoonotic influenza

43. Injuries and violence Road traffic injuries Injuries in recreational waters Interpersonal violence

44. THE SPECTR U M O F TRAVEL HEALTH PROBLEMS It is worth looking at some figures to see how commonly health problems occurred among travellers , to look for the patterns in the sorts of problems they had, and to learn whether they sought any advice before their departure.

45. MORTALITY AND MORBIDITY Mortality studies have indicated that cardiovascular diseases account for most of the deaths during travel (50%-70%), while injuries and accidents follow (~25%).Infectious diseases account for about 2.8%-4% of the deaths during/from travel. Morbidity studies have suggested that about half of the people from a developed country who stay for one month in a developing country will get sick. Traveller’s diarrhoea is the most common problem which is being encountered.

46. Common Travel D iseases 1. Traveler’s diarrhoea 2. Dengue fever 3. Malaria 4. Lyme disease 5. Hepatitis 6. Parasital infection 7. Typhoid 8. Yellow fever 9. Sexually transmitted diseases

47. PRE-DEPARTURE ADVICE Protecting the traveller’s health and safety while they are overseas includes the following measures 1. Medical examinations and screening – To ensure that the travellers will be fit if they are intending to live and work overseas, or to ensure that those travellers with current health issues are fit to travel.

48. The Patient: 1. Medical Issues •Age-specific issues • Underlying illnesses, immunosuppression • Medical history • Medication use • Vaccination history • Allergies • Contraindications to vaccines and medications

49. Pregnant • Risk-taking behaviours Advice should be given about: • The general health measures while travelling, • Protective measures to avoid infection, immunization requirements, and health and accident insurance. • The patient and the doctor should also discuss about the certification for, and the use of medication while travelling.

50. Pregnancy Since during the first trimester there is a risk of miscarriage and in the third trimester of premature labour , abruption, and other serious complications, the second trimester is the safest period to travel. Pregnant travellers should stay well hydrated. Pregnant travellers ought not to receive live vaccines, but if the risk is high enough then even yellow fever can be given.

51. If travelling through a malarious area , fastidious personal protective measures against mosquito bites are essential. Pregnant travelers must be careful to avoid traveller’s diarrhoea . Antibiotics such as fluoroquinolones , doxycycline/tetracycline, and trimethoprim- sulfamethoxazole are contraindicated during pregnancy ; if antibiotic treatment is needed for traveller’s diarrhoea a third-generation cephalosporin is the best choice. Contracting hepatitis E during pregnancy has a maternal mortality rate of up to 40%.

52. Thromboembolic complications are more frequent during pregnancy . Medication of any type during pregnancy should be taken only in accordance with medical advice. Travel to sleeping altitudes over 3000 m or to remote areas is not advisable during pregnancy.

53. Age Air travel may cause discomfort to infants as a result of changes in cabin air pressure and is contraindicated for infants less than 48 h old. Infants and young children are particularly sensitive to sudden changes in altitude and to ultraviolet radiation. They have special needs with regard to vaccinations and antimalarial precaution. They become dehydrated more easily than adults in the event of inadequate fluid intake or loss of fluid as a result of diarrhoea or vomiting.

54. Children may have greater problems with hygiene and with their natural curiosity can expose themselves to infection and injury, especially from animals. Medications, such as malarial chemoprophylaxis and antibiotics for presumptive treatment, that are dosed by weight require special attention. Advanced age is not necessarily a contraindication for travel if the general health status is good. Elderly people should seek medical advice before planning long-distance travel.

55. Immunocompromised travellers Travellers with weakened immune systems, such as those with HIV infection, malignancy, transplantation, severe diabetes, end-stage renal disease, or on high-dose corticosteroids (>2 mg per kg daily or >20 mg prednisone) are at greater risk than others for illness during their trips, and for adverse events from vaccinations, especially with live-virus vaccines. HIV-infected individuals who have CD4 percentages greater than 25% (no evidence of suppression ) can take live vaccines including measles and yellow fever; inactivated vaccines are generally safe irrespective of CD4 status, although the immune response to vaccines may be reduced. Such patients need to be more aggressive about self-treatment and seeking prompt medical care at the first signs of illness.

56. Pre-existing illness People suffering from underlying chronic illnesses should seek medical advice before planning a journey. Conditions that increase health risks during travel include: cardiovascular disorders chronic hepatitis chronic inflammatory bowel disease chronic renal disease requiring dialysis chronic respiratory diseases diabetes mellitus epilepsy

57. immunosuppression due to medication or to HIV infection previous thromboembolic disease severe anaemia severe mental disorders any chronic condition requiring frequent medical intervention transplantation oncological conditions chronic haematological conditions

58. Travellers with a chronic illness should carry all necessary medication and medical items for the entire duration of the journey. All medications, especially prescription medications, should be packed in carry-on luggage, in their original containers with clear labels. A duplicate supply carried in the checked luggage is a safety precaution against loss or theft. With heightened airline security, sharp objects and liquids in quantities of more than 100 ml will have to remain in checked luggage .

59. Travellers should carry the name and contact details of their physician on their person with other travel documents, together with information about the medical condition and treatment, and details of medication (generic drug names included) and prescribed doses. This information should also be stored electronically for remote retrieval, e.g. on a secure database. A physician’s attestation should also be carried, certifying the necessity for any drugs or other medical items (e.g. syringes) carried by the traveller that may be questioned by customs officials and/ or security personnel.

60. Vaccination Before departure, travellers should be advised about the risk of disease in the country or countries they plan to visit and the steps to be taken to prevent illness. There is no single vaccination schedule that fits all travellers . Each schedule must be individualized according to the traveller’s previous immunizations, countries to be visited, type and duration of travel, and the amount of time available before departure.

61. Chikungunya

62. Dengue

63. Hepatitis A

64. Hepatitis B

65. Japanese encephalitis

66. Meningitis belt

67. Polio

68. Rabies

69. Yellow fever

70. 2. Psychological preparation – To identify the potential sources of stress and personal difficulty while overseas, and to provide personal protection strategies against consequent problems . 3. Provision of a medical kit – To ensure that the travellers have first aid supplies and medications for personal use when adequate medical advice is not available.

71. Contents of a basic medical kit First-aid items: adhesive tape antiseptic wound cleanser or alkaline soap bandages scissors safety pins emollient (lubricant) eye drops insect repellent insect bite treatment

72. antihistamine tablets nasal decongestant oral rehydration salts simple analgesic (e.g. paracetamol ) sterile dressing

73. clinical thermometer sunscreen earplugs tweezers adhesive strips to close small wounds. Additional items according to destination and individual needs:

74. medication for pre-existing medical conditions antidiarrhoeal medication (to include an antisecretory agent, an antimotility drug, oral rehydration salts, with appropriate written instructions regarding their use) antibiotics targeting the most frequent infections in travellers (e.g. travellers’ diarrhoea , and infections of skin and soft-tissue, respiratory tract and urinary tract) antibacterial ointment

75. antifungal powder antimalarial medication mosquito net and insecticide to treat fabrics (clothes, nets, curtains) adequate supplies of condoms and oral contraceptives medication for pre-existing medical conditions sterile syringes and needles water disinfectant spare eyeglasses and/or spare contact lenses (and solution) other items to meet foreseeable needs, according to the destination and duration of the visit.

76. 4. First aid training Encouraging travellers to remote locations to to equip themselves with the knowledge of basic first aid is useful, but in reality, most of the travellers do not bother to do this . First aid should also be promoted in relation to the use of traveller’s first aid kits.

77. 5. Preventive measures for the prevention of thermal injuries – This includes the pre-travel acclimatization to heat, education, and dealing with travellers who are at a high risk of thermal stress . 6 . Advice regarding accidents and related hazards – ensuring that the travellers are minimally disrupted by travel to/from their destination, and are advised regarding the avoidance of accidents and other health or safety hazards, for example, animal bites, while they are overseas.

78. 7 . Special provisions for specific travel hazards – this may include protection against altitude sickness for mountaineers and occupational health advice for people who are working overseas, for diving medicine, medical student electives, etc . 8 . Protection against tropical diseases – to ensure that the travellers are advised, and where appropriate, vaccinated, against the many tropical diseases which may be a risk at their destination.

79. Checklist

80. THE POST-TRAVEL EVALUATION Travel-related health problems have been reported in as many as 22%–64% of travelers to developing countries . Although most of these illnesses are mild, up to 8% of travelers are ill enough to seek care from a medical provider. Most post-travel infections become apparent soon after travel, but incubation periods vary, and some diseases can present months to years after initial infection.

81. Travellers who are well on their return rarely need assessment . However , when a traveller returns ill from a journey abroad it can be difficult to decipher whether the condition is the result of a disease directly related to travel , especially in the case of tropical disease, or whether a routine cosmopolitan disease was acquired while travelling; statistically, routine illness is more likely than exotic disease.

82. Important elements of a medical history in an ill returned traveler Severity of illness Travel itinerary and duration of travel Timing of onset of illness in relation to international travel Past medical history and medications History of a pre-travel consultation Travel immunizations Adherence to malaria chemoprophylaxis

83. Individual exposures Type of accommodations Insect precautions taken (such as repellent, bed nets) Source of drinking water Ingestion of raw meat or seafood or unpasteurized dairy products Insect or arthropod bites Freshwater exposure (such as swimming, rafting) Animal bites and scratches Body fluid exposure (such as tattoos, sexual activity) Medical care while overseas (such as injections, transfusions)

84. DESTINATION INDIA Rich in history, vibrant culture, and diversity, India is the birthplace of 4 world religions: Hinduism , Buddhism, Jainism, and Sikhism. India is becoming more popular for US travelers, and rates of travel from the United States are increasing. International businesses are flourishing in India; tourists are flocking to the temples, beaches, and the Taj Mahal . For some new US residents, India remains their homeland, and they make frequent visits to family and friends.

85. Because tourists could not possibly visit all the tourist sites in India during a 2-week holiday, they usually select a part of India for any given trip. HEALTH ISSUES Immunizations All travelers to India should be up-to-date with their routine immunizations and are advised to consider hepatitis B vaccine

86. . Particularly important is making sure that the traveler is immune to measles. India has not had a case of wild poliovirus since early 2011 and is therefore considered to have interrupted transmission. Hepatitis A Vaccine Typhoid Vaccine Japanese Encephalitis Vaccine Rabies Vaccine Malaria

87. Other Infections Dengue Chikungunya Hepatitis E Animal bites and wounds Travellers diarrhea Tuberclosis

88. INSURANCE FOR TRAVELLERS Travellers are strongly advised to travel with comprehensive travel insurance as a matter of routine and to declare any underlying health conditions to their travel insurer. Travellers should be aware that medical care abroad is often available only at private medical facilities and may be costly. In places where good-quality medical care is not readily available, travellers may need to be evacuated in case of accident or illness.

89. If death occurs abroad, repatriation of the body can be extremely expensive and may be difficult to arrange. Travellers are advised ( i ) to seek information about possible reciprocal health-care agreements between the country of residence and the destination country (see http://www.who.int/ith/links/national_links/en/index.html), and ( ii) to obtain comprehensive travellers’ health insurance for destinations where health risks are significant and medical care is expensive or not readily available.

90. This health insurance should include coverage for changes to the itinerary, emergency evacuation for health reasons, hospitalization, medical care in case of illness or accident and repatriation of the body in case of death. Travellers should discuss with the parties concerned any issues or claims as they happen and not upon return from the trip.

91. Travel agents and tour operators usually provide information about travellers’ health insurance and should advise travellers about the importance and benefits of travel insurance. It should be noted that some countries now require proof of adequate health insurance as a condition for entry. Moreover, some travel insurers require proof of immunizations and/or malaria prophylaxis as a condition of their approval for treatment or repatriation. Travellers should know the procedures to follow to obtain assistance and reimbursement. A copy of the insurance certificate and contact details should be carried with other travel documents in the hand luggage

92. PUBLIC HEALTH CONCERN The control or containment of known existing risks to public health is one of the most powerful ways to improve international health security since these risks constitute the vast majority of day-to-day events with the potential for a public health emergency. Preparedness and readiness for these threats are dependent on strong generic preparedness measures at national and international levels but also requires specific preparedness measures relating to surveillance, risk reduction, and response and containment.

93. The development of specific risk reduction and containment processes is dependent on understanding the nature of the threat and implementing specific measures to reduce risk, which often requires cross sectoral communication and collaboration . Equally the development of interventions and the appropriate stockpiling of critical supplies require specific disease knowledge and a variety of partnerships within the public and private sector.

94. The existing international disease control programmes , addressing infectious diseases as well as food-safety and environmental safety, are essential contributors to WHO global alert and response systems. At national level, threat specific initiatives and programmes can often be a driving force in meeting core capacities requirements (e.g. poliomyelitis). It is however crucial that integrated approaches be taken as much as possible and that all threat specific preparedness and readiness be seen in the context of the overall planning and management of public health emergencies

95. ROLE OF TRAVEL INDUSTRY PROFESSIONALS Tour operators, travel agents, airline and shipping companies each have an important responsibility to safeguard the health of travellers . It is in the interests of the travel industry that travellers have the fewest possible problems when travelling to, and visiting, foreign countries. Contact with travellers before the journey provides a unique opportunity to inform them of the situation in each of the countries they are visiting.

96. The travel agent or tour operator should provide travellers with the following health-related guidance (or the tools to access this information ): Advise travellers to consult a travel medicine clinic or medical practitioner as soon as possible after planning a trip to any destination where significant health risks may be foreseen, particularly those in developing countries, preferably 4–8 weeks before departure.

97. Advise last-minute travellers to visit to a travel medicine clinic or medical practitioner, which can be done as late as the day before or day of departure. Inform travellers of any particular hazards to personal safety and security presented by the destination and suggest appropriate precautions including checking authoritative web sites (http://www.who.int/ith/links/national_links/ en/index.html) on a regular basis.

98. Encourage travellers to take out comprehensive travellers’ health insurance and provide information on available policies. Inform travellers of the procedures for obtaining assistance and reimbursement, particularly if the insurance policy is arranged by the travel agent or company.

99. RESPONSIBILITY OF THE TRAVELLER Travellers can obtain a great deal of information and advice from medical and travel industry professionals to help prevent health problems while abroad. However , travellers are responsible for their health and well-being while travelling and on their return, as well as for preventing the transmission of communicable diseases to others. The following are the main responsibilities of the traveller :

100. the decision to travel; recognizing and accepting any risks involved; seeking health advice in good time, preferably 4–8 weeks before travel; complying with recommended vaccinations and other prescribed medication and health measures; careful planning before departure; carrying a medical kit and understanding its use; obtaining adequate insurance cover;

101. taking health precautions before, during and after the journey; obtaining a physician’s attestation pertaining to any prescription medicines, syringes, etc. being carried; the health and well-being of accompanying children; taking precautions to avoid transmitting any infectious disease to others during and after travel;

102. full reporting to a medical professional of any illness on return, including information about all recent travel; being respectful of the host country and its population; practising responsible sexual behaviour and avoiding unprotected sexual contact.

103. CONCLUSION & SUMMARY Giving adequate advice on travel health requires a good knowledge about the local health hazards overseas, the public health measures, and the effectiveness of immunization and prophylaxis. The traveller’s general practitioners are the most likely persons whom they approach for travel health advice, yet, the general practitioners receive very little, if any training in travel health, tropical health, or aviation medicine. In summary, travel medicine will be established as an interdisciplinary special discipline in the coming years and it will be characterized by new risks and on the other hand, by newer methods of therapy and prophylaxis.

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