THE PRE-TRAVEL CONSULTATION Gary W. Brunette, MD, MS Travelers Health Team Division of Global Migration and Quarantine Centers for Disease Control and Prevention 1 Outline

Travelers Health Epidemiology Traveler Assessment Itinerary Review Sources of Information Risks to the Traveler Travel Vaccines Travel Medications Counseling 2 U.S. Residents Traveling Abroad* 65 60

55 50 45 Number of Travelers (millions) 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year *ITA, includes travel to Canada and Mexico 3 International Travel 80

900 70 800 700 60 600 50 500 400 300 Worldwide arrivals

(WTO) 30 200 10 US Resident Air Outbound (ITA) All US Resident Outbound (ITA) 40 US20Resident travel in millions

US nonresident Inbound (ITA) Worldwide arrivals in millions 100 0 0 1996 1997 1998 1999

2000 2001 2002 2003 2004 2005 4 Where Do U.S. Residents Travel? 40

Of the 17% who traveled outside the U.S. . . . 30 %20 10 0 Canada Europe Aus/NZ Mexico C or S America Africa Japan Caribbean Oceania/Other PI Asia Middle East

Source: HealthStyles Survey 2005 5 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 secondgeneration immigrants VFRs comprised ~46% of US international air travelers in 20043 US 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,

6 USDOC 1 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; 156:84-91 7

The Patient: Medical Issues Age-specific issues Underlying illness, immunosuppression Systems review Medical history Medication use Vaccination history Allergies Contraindications to vaccines and medications 8 The Patient: Other Issues Reproductive

Pregnant Breastfeeding Preconception Risk-taking behaviors 9 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 10 Travel Health Resources CDC Travelers Health Website World Health Organization

State Department International Society of Travel Medicine Health Information for International Travel CDC Yellow Book International Travel and Health WHO Green Book 11 Travelers Health Website

12 Regional Destinations Region-specific pages Goal to move to country-specific format 13 Travel Notices & Announcements 14 Deaths Related to International Travel Cardiovascular Medical Injury

Homicide/Suicide Infectious Disease Other N = 2463 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626 15 Infectious Disease Risks to the Traveler

Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis

ETC. Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV 16 Injury Deaths and International Travel Motor Vechicle Drowning Air Crash

Homicide/Suicide Poisoning Other N = 601 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626 17 Other Risks to the Traveler

Accidental injury Environmental hazards Crime and assault Psychiatric problems Animal bites, stings and envenomations Dermatologic disorders Altitude . ETC. 18 Immunizations to Consider for Adult Travelers

Routine Diphtheria* Tetanus* Pertussis* Measles + Mumps+ Rubella + Varicella Pneumococcus Influenza * Td or Tdap + MMR Travel related Hepatitis A Hepatitis B Typhoid

Rabies Meningococcal disease Polio Japanese encephalitis Yellow Fever 19 Travel Medications: Prophylaxis & Self Treatment Malaria chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine Diarrhea quinolone, azithromycin

Altitude acetazolamide Motion sickness scopolamine, dimenhydrinate (Dramamine) 20 Patient Counseling Sufficient time for patient education Tailored to suit traveler Fitness for travel Understanding impact on existing conditions Advisability of destinations 21

Travel Preparation Travel health insurance Medical care Hospitalization Evacuation Obtaining medical care abroad Awareness of travel notices Hand washing and hygiene 22 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 23 Food and Water Precautions Bottled water

Selection of foods well-cooked and hot Avoidance of salads, raw vegetables unpasteurized dairy products street vendors ice 24 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 25 Inspection for ticks

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 26 Animal Precautions Animal avoidance Rabies Specific animal threats Medical evaluation of bites/scratches Post exposure immunization and

immunoglobulin Envenomations Snakes, scorpions, spiders Maritime animals 27 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 28 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 29

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 30 Questions? 31 Other Resources

32 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 33 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 34 Websites Eurosurveillance Travax EnCompass GIDEON International SOS Medical Advisory Service for Travelers Abroad (MASTA) Armed Forces Medical Intelligence Center Central Intelligence Agency 35

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