Travel Medicine.pptx

Travel medicine

1. TRAVEL MEDICINE Dr. Anitha Wilson 26-10-2021 Dr.Anitha Wilson 1

2. Scheme of Presentation Introduction Definition Why important? Travel Epidemiology Determinants of health risk during travelling Travel specific health Risk Preventive measures & precautions Challenges of Travel medicine Conclusion Sources of Information Park Textbook of Preventive & Social Medicine-26 th edition IAPSM’S text book of community-Kadri Maxcy Public Health & Prevention WHO: International Travel and Health 2021 WHO: International Travel and Health chapter 6,7 (2019 updated) WHO: Tuberculosis & air travel, Guidelines for prevention and control (3 RD edition) Previous Question: Travel Medicine 26-10-2021 Dr.Anitha Wilson 2

3. Introduction Travel medicine / Emporiatrics Medical speciality dealing with Traveller’s health. Concerned with prevention & management of International traveller’s health problems and travel related health matters. Deals with Epidemiology of health risks to the traveler globally Vaccination & prevention of disease Pre-travel counseling. 26-10-2021 Dr.Anitha Wilson 3

4. Why important? In era of globalization, travelling is inevitable. Increase in number & speed of travelling from one geographical part of the world to another. UNWTO 2017 international tourist arrivals inflated by 7 %. 26-10-2021 Dr.Anitha Wilson 4 51% - Leisure, recreational & holidays. 15% - Business & professional purposes 27% - Specific purposes –VFR, religious & pilgrimages , Health treatment

5. SDG goals Related with Tourism 26-10-2021 Dr.Anitha Wilson 5

6. Travel Epidemiology 35–64% of short-term travellers report some health impairment . I nfectious diseases major contributors of illness with 1–4% of deaths among travellers . CVD’ s & injuries - frequent causes of death. CVD = 50% & Injury = 22% of deaths. M ortality due to CVD in adults is similar to non-travelers. D eaths from injury - motor vehicle accidents, drowning & aircraft accidents - several times higher among travelers. Travellers & travel medicine practitioners should be aware of the occurrence of these diseases in the destination countries. 26-10-2021 Dr.Anitha Wilson 6

7. Determinants of Health risks during travelling 26-10-2021 Dr.Anitha Wilson 7

8. Travel specific Health Risk Environment Risks Altitude > 2750m , Heat & humidity, UV radiation Recreational waters – Drowning, Immersion hypothermia, Thermal shock & Cardiac arrest. Attacks- animal, snakes, aquatics, insects & Intestinal parasites Infectious disease of Potential Risk Foodborne & water borne disease – Traveller’s diarrhoea , Hepatitis A , C, typhoid, cholera. Vector borne disease –Malaria, Yellow Fever, Tick borne encephalitis. Zoonosis – Rabies, Brucellosis, leptospirosis. Airborne d/s –TB, measles, chickenpox, Legionellosis, Influenza. Sexually transmitted disease – Hepatitis B, HIV, syphilis. Blood borne disease: Hepatitis B / C, HIV, malaria Disease (soil) – spores(Anthrax, Tetanus), Parasitic infections. Injuries & Violence Motor vehicle accidents recreational activities-swimming, diving, sailing etc. Violence- alcohol, illegal drugs, dacoits. Psychological health Anxiety , mood d/o, suicide attempts. 26-10-2021 Dr.Anitha Wilson 8

9. Psychological health Mental health issues leading cause of ill health among travellers . International travel is often a stressful experience. S eparation from family & familiar social support systems in addition to foreign cultures & languages. Under stress of travel - pre-existing mental disorders can be exacerbated. P eople with predisposition towards mental disorder - may emerge for first time during travel. D ifferences in provision mental health care & in legal systems. C linician decides whether traveler’s care be managed at travel destination or requires repatriation. Psychiatric Emergency m/c medical reason for air evacuation (along with injury & CVD). Criminal offence – psychotropic medication (benzodiazepine) without prescription. 26-10-2021 Dr.Anitha Wilson 9

10. Mode of travel: Health Conditions experienced Air travel 26-10-2021 Dr.Anitha Wilson 10 Cabin Air pressure low Blood O2 less than sea level Medical conditions Gas expansion at high altitude. Pops sound nl chewing, swallowing Valsalva maneuver Ear, sinus infection: pain Deep Vein Thrombosis Prolonged immobilisation Pulmonary embolism Moving every 2-3 hr Exercise calf muscle Restrict hand luggage JET LAG Symptoms caused disruption of internal clock. Indigestion & disturbance of bowel function Difficult to sleep at night. Fatigue & malaise. Rest, light meal, avoid alcohol & caffeine. Motion sickness Low humidity inside cabin – skin dryness, discomfort Divers avoid air travel soon after diving-decompression sickness.

11. Air travel advice with special needs & medical illness 26-10-2021 Dr.Anitha Wilson 11 Fit & healthy baby > 48hrs after birth. Preferable > 7 days. Premature babies –medical clearance. Cabin air pr. can upset infants – Feeding/pacifier - swallowing Women with uncomplicated pregnancy After 28 weeks – doctor’s letter- EDD & nl pregnancy. Permitted - end of 36 weeks. Multiple pregnancies - end of 32 weeks . Most with medical conditions are safe to travel – appropriate precautions – oxygen supply. Pretravel consultation Frequent travellers – medical card. Security issues – metal implants, pacemaker – Doctor’s letter.

12. Aircraft ventillation 26-10-2021 Dr.Anitha Wilson 12 Air exchange very 2-3 min. 20-30 air exchange in 1hr.

13. Transmission of communicable diseases on aircraft Transmission of infection occur between passengers - seated in same area of an aircraft. i.e same row & in 2 rows front and behind the case. As a result of infected individual coughing sneezing touch (direct contact or contact with same parts of aircraft cabin & furnishings). Likely to spread to other passengers in situations where aircraft ventilation system is not operating. Auxiliary power unit provide ventilation when aircraft is on the ground. Not operated for environmental (noise) or technical reasons. Transmission of Tb & influenza 26-10-2021 Dr.Anitha Wilson 13

14. Aircraft disinfection To kill insects Disinfection –Public Health Measure –mandated by IHR. Procedures currently done as specified by WHO includes: Treatment of interior using quick acting insecticide spray before take off, with passengers on board. Treatment of interior on ground before passengers board using residual insecticide aerosol + quick acting spray shortly before landing. Regular application of residual spray to all internal surfaces except in food preparations. 26-10-2021 Dr.Anitha Wilson 14

15. Travel by Sea Cruise ship –av.7days Approx. 3000 passengers,1000 crew. 100 d/s outbreak in last 30 years. Closed & crowded environment, unsafe water & food hygiene. D/s may spread to other member & crew members---disseminate to home communities. 26-10-2021 Dr.Anitha Wilson 15 Precautions: Travel health specialist: immunization– Influenza Frequent handwashing, Food & water sanitation Carry all medicines with prescription in a container/packet. Revised IHR :Health Requirements- ship operation Guidance on safe water & food (storage). Vector & rodent control. Waste disposal >3days travel - Physician requirement. Communicable diseases : Git illness Influenza & resp. illness Legionellosis -1994 outbreak Varicella & Rubella NCD : CVD events Motion sickness Injuries & dental emergencies

16. Preventive Measures & Precautions 26-10-2021 Dr.Anitha Wilson 16 Pretravel consultation Travel medicine specialist / Travel clinic Risk Assesment Traveller specific risk Pregnant, Infants, Medical illness, VFR Destination specific Risk D/s endemicity Itinerary Specific Risk Mode of transport, urban vs rural areas, accommodation, purpose of travel, Recreational activities, personal behaviours, entering altitude.

17. Risk management Strategies for reducing water & food borne illness Avoid consumption of tap water, ice - tap water & raw foods rinsed with tap water Avoid unpasteurized dairy products & undercooked meat & fish. Consume boiled, treated, or bottled water Consume piping hot, thoroughly cooked food Seek restaurants / locations of food consumption that have reputations for safety. Personal protective Measures Avoid outdoor exposure during vector feeding times ( eg , for malaria - dusk and dawn) & avoid areas where vectors known to be active Wear full-length, loose-fitting garments to reduce the amount of exposed skin Use insecticide-treated bed nets & clothing. Use insect repellents that contain DEET or picaridin Inspect for ticks during & after high-risk activities, follow appropriate procedures for tick removal. 26-10-2021 Dr.Anitha Wilson 17 1. Preventive counselling / health counselling

18. Advise on itinery special risk Avoid : freshwater exposure in areas where schistosomiasis or other parasitic infections prevalent recreational water activities following floods or heavy rainfalls approaching animals including domestic animals (rabies prevalent) walking barefoot on soil & beaches Use safer sex practices and avoiding higher-risk partners. Precautions –motor vehicle accidents/injuries : Rent car, avoid unfamiliar & unlit roads, seat belts, avoid alcohol. Avoid one day travel -2750m- break the journey –gradual acclimatization. Prophylaxis: Acetazolamide 5mg/kg/day – one day b/f travel 7 continued 1-2days of altitude 26-10-2021 Dr.Anitha Wilson 18

19. Risk mx cont.. 26-10-2021 Dr.Anitha Wilson 19 Pretravel Health counselling –air travel & sea travel. Chronic illness & frequent travellers: Medical Card : Pre existing illness (psychiatry), Prescriptions, Blood group with doctors letter. DM - meal exchange plan, self care. Travel health Kit Travel insurance & Assessing medical care abroad Immunizations – 2 months before travel –Vaccination card Prophylactic medications – malaria Treatment advise for Traveller’s diarrhoea Medical examination after travel.

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21. Yellow fever vaccination All travelers from endemic risk countries. Certain countries - to prevent importation of virus into countries - disease may/may not occur, but mosquito vector & non-human primate hosts are present. Va ccination - entry requirement for all travelers arriving (including airport transit). Vaccination against meningococcal disease (tetravalent ACWY polysaccharide or conjugate vaccine) - Saudi Arabia for pilgrims visiting Mecca and Medina for the hajj or umrah as well as for guest workers. Selected countries may also recommend vaccination against influenza for pilgrims to Mecca or Medina. Some polio-free countries may also require travelers resident in countries or areas reported to have wild polioviruses to be vaccinated against polio in order to obtain an entry visa, as in the case of Brunei Darussalam, India and Saudi Arabia. 26-10-2021 Dr.Anitha Wilson 21

22. International Certificate Of Vaccination Or Prophylaxis 26-10-2021 Dr.Anitha Wilson 22

23. Medical Heath education & Chemoprophylaxis -Malaria F ive principles – the ABCDE – of malaria protection A ware of the risk, the incubation period, the possibility of delayed onset, and the main symptoms. Avoid being B itten by mosquitoes - dusk and dawn. C hemoprophylaxis )when appropriate, at regular intervals to prevent acute malaria attacks. Immediately seek D iagnosis and treatment if fever develops 1 week or more after entering an area where there is malaria risk & up to 3 months after departure from a risk area. Avoid outdoor activities in E nvironments that are mosquito breeding places - swamps or marshy areas, especially in late evenings and at night. 26-10-2021 Dr.Anitha Wilson 23

24. Malaria chemoprophylaxis Weekly mefloquine started 2–3 weeks before departure Daily prophylaxis with doxycycline or atovaquone–proguanil started 1–2 days before arrival in malaria risk area Weekly chloroquine started 1 week before arrival All prophylactic drugs - continued for 4 weeks after last possible exposure to infection since parasites may still emerge from liver during this period. S ingle exception is atovaquone–proguanil - can be stopped 1 week after return because it is effective against early liver-stage parasites (liver schizonts). I f daily doses skipped - atovaquone–proguanil prophylaxis taken for 4 weeks after return. Depending on type of malaria at the destination, travellers should be advised about possible late-onset malaria caused by the persistent hepatic forms of P. vivax and P. ovale . 26-10-2021 Dr.Anitha Wilson 24

25. Malaria chemoprophylaxis during pregnancy Areas with exclusively P. vivax transmission - chloroquine prophylaxis used. P. falciparum transmission areas - mefloquine prophylaxis given. In light of the danger of malaria to mother and fetus, travel to a P. falciparum transmission area during the first trimester of pregnancy should be avoided or delayed. If impossible, good preventive measures should be taken & prophylaxis with mefloquine is indicated . Doxycycline is contraindicated during pregnancy. Data on safety of exposure to atovaquone–proguanil during pregnancy are limited & therefore not recommended for use in pregnancy or is recommended only with relevant risk information/warning. 26-10-2021 Dr.Anitha Wilson 25

26. Standby emergency treatment (SBET) - Malaria A dvised to carry antimalarial drugs for self administration. Indications: For travellers staying in remote locations - access to medical care may be difficult. Travellers in some occupational groups who make frequent short stops in countries or areas with malaria risk over prolonged period of time. Such travellers choose to reserve chemoprophylaxis for high-risk areas & seasons only. short-term travellers spending 1 week or more in certain remote rural areas where there is very low risk of infection. S hould continue to take measures to protect against mosquito bites, carry a course of antimalarial drugs for SBET, seek immediate medical care in case of fever, and take SBET if prompt medical help is not available. Travellers should realize that self-treatment is a first-aid measure and that they should still seek medical advice as soon as possible. 26-10-2021 Dr.Anitha Wilson 26

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28. Last minute & imminent travel Last-minute travel (2 weeks or less until departure) & imminent travel (48 hours or less until departure). General advice given is similar to that provided to other kinds of travellers . Emphasis is laid on; risk management – preventive travel advise, DVT, trauma medical prescriptions - pre-existing conditions, common ailments during travel ( travellers’ diarrhoea or fever) Recommendations for basic first-aid kit . vaccination options administrative requirements (e.g. yellow fever vaccination). 26-10-2021 Dr.Anitha Wilson 28

29.   COVID-19: Travel advice for general public COVID-19 prevention measures Traveling - closed, confined, or crowded (the three Cs) - higher risk of being exposed to virus that causes COVID-19. Whenever possible, stay in open, well-ventilated settings.  While travelling, practice prevention measures even if fully vaccinated against COVID-19. Some countries exempt travelers who have been fully vaccinated or have proof of recent SARS-CoV-2 infection from certain requirements, such as testing and/or quarantine. People with symptoms of COVID-19 – including fever, cough, or shortness of breath – should not travel.   People in certain groups – over age 60, chronic illnesses & underlying health conditions – face increased risk of severe illness & death from COVID-19. If in these groups - not fully vaccinated and not have immunity from a recent previous COVID-19 infection, consider postponing travel to areas with widespread COVID-19 . 26-10-2021 Dr.Anitha Wilson 29

30. Key consideration COVID 19- aircraft 26-10-2021 Dr.Anitha Wilson 30 B/f embarkation communication, coordination & planning. Aircraft –sufficient medical personal (PPE). Nonmedical staff trained-detect symptomatic passenger. EXIT screening –temperature, questionnaire. Advised to delay travel - suspected . On board Seating location mapped –when a passenger display symptom. Cabin crew - inform & seek advise Dedicated cabin crew Use appropriate PPE. Mask – tolerable patients. Adjacent seats Potential contacts “ Passenger locator Form ”. Continous air recirculation Upon arrival Suspected passengers Trained personal & supplies. Interview & initial management. Fast track pathway & transport. Contingency plan Disinfection of aircraft Non suspected passengers Health measure: Evidence of imminent public health risk from arriving passengers compels the traveller –additional health measures- Isolation Quarantine (Public health observation) Risk communication (media)

31. Challenges Of Travel Medicine Lack of travel agents & tour operators – provide information's –Travel insurance. Responsibility to safeguard the health of travellers Lack of knowledge/awareness by the travellers – health risks. Lack of access- VFR – cost of pre travel consultation not covered by health insurance programmes especially with large family size. Travel medicine services hampered by cultural & linguistic limitations. 26-10-2021 Dr.Anitha Wilson 31

32. Conclusion Most travel-related illnesses are preventable by immunizations prophylactic medications pretravel health education Included in health education should be mention role of hand hygiene in reducing the transmission of pathogenic organisms. Health recommendations for international travel are based primarily on : individual risk assessment and any traveler plans to visit. requirements mandated by public health authorities of the countries. 26-10-2021 Dr.Anitha Wilson 32

33. 26-10-2021 Dr.Anitha Wilson 33 THANKYOU