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Jontari Field Epidemiology Training Program (FETP)

Objectives This Session


1. 2. 3. 4. 5. 6. General preview Define travel medicine Component of travel medicine Other risk of travel medicine Travel medicine information Travel prevention

International, Institutional Prevention:

International Health Regulations, the most recent: 2005, Enacted July 2007

General Preview

Travellers from Industrialised Areas to Developing areas 2010 (WTO)

2.8
USA / Canada 35.2 million

2.4

3.6

Europe 25.0 million

4.6 1.6

6.1
Japan 11.4 million

2.3

19

7.8

6.8
2.5 1.9

1.3

4.8 2.6
INA <1 million AUS / NZ 3.3 million

1.2

n= million travelers 0.2-1 million travelers


Total:
~ 999 million travelers

Travel Distination World wide (N:999 million)

Type of Travelled world wide

General preview
1. Number of people traveling internationally increasing every year. 2. WTO; 2010 reached 999 million.

3. Expected 1 billion 2011/2012


4. Approximately 642 billion Euros (2008)

Challenge of travel medicine


1) Global migration of people (More people travelling). 2) More people sick travelling. 3) Rapid movement of travellers same with pathogens.

List of travel-related diseases (Indonesia)


Travelers diarrhea Cholera Malaria Escherichia coli diarrhea Hepatitis A Schistosomiasis - found in fresh Water Typhoid fever Insect born diseases Parasitic diseases Dengue fever Filariasis Japanese encephalitis HIV -AIDS Hepatitis B Amebiasis Diptheria - endemic to the region Tuberculosis Chickungunya

Epidemics in Indonesia: Dengue, hepatitis A, leptospirosis, etc

Hepatitis A - or immune globulin (IG) hepatitis B if you might be exposed to blood (for example, health-care workers), have sexual contact with the local population, stay longer than 6 months, or be exposed through medical treatment Japanese encephalitis only if you plan to visit rural areas for 4 weeks or more, except under special circumstances, such as a known outbreak of Japanese encephalitis Rabies - if you might be exposed to wild or domestic animals through your work or recreation

Typhoid Tetanus - booster dose as needed, diphtheria - booster dose as needed, measles - booster dose as needed

Globalization of health and safety


Affects: 1) Health of local populations. 2) Health determinants. 3) Safety and security
Results in 1) Global impacts. 2) Emerging and reemerging infectious disease.

Commerce and Health


Influenza SARS Terrorism Tsunami

Pathogens travel as fast as transportation: borders are not respected

The Continuum of Travel Medicine


Preventive Medicine

Pre-Travel

Visitors

Contingency During Travel Planning

Treatment & Rehabilitation

Post-Travel

1. Pre-travel a) Consultation (age, pregnancy & disability). b) Health education c) Immunization d) Prophylaxis 2. During travel a) First aid medical kit b) Doctors letter 3. After travel (if) a) Had exposure b) Injury c) Further consultation after travel

Travel Medicine Must Intake questions


Where to For how long For what purpose Staying in what kind of place Guided or not Past medical history (allergies, medication, medical problems, pregnancy) Past Immunization

What is travel medicine?

What is travel medicine?


It is that part of health professional practice that:
1) Prevent illnesses and injuries occurring to travellers going abroad. 2) Manages problems arising in travellers coming back or coming from abroad. 3) Concerned about the impact of tourism on health and also advocates for improved health and safety services for tourists. 4) Increasing concerned about refugee and migrant health
(Primer of Travel Medicine 3rd Ed)

Travellers are exposed to a variety of hazards

The Importance of Travel Health Measures

Mortality:
1) Cardiovascular Disease (50 to 70%). 2) Accidents/Trauma (20-25%). 3) Infectious diseases (2.8-4%).

(Mac.Pherson et al, JTM. 2000:227-233)

Deaths Related to International Travel

Cardiovascular Medical Injury Homicide/Suicide Infectious Disease Other


N = 2.463

19

Injury Deaths and International Travel

Motor Vechicle Drowning Air Crash Homicide/Suicide Poisoning Other


N = 601

20

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, 2004 21

The Importance of Travel Health Measures


Per 100,000 travellers that have travel insurance ..
a) 8000 will make a claim (8%). b) 2000 will use emergency assistance (2%) 400 ER or clinic referrals/Dirujuk (0.4%) 200 Hospital admissions (0.2%) 50 Aeromedical evacuations/Airport (0.05%)

Leggat et al. Travel Med Inf Dis 2005;3:9-17.

COMPONENTS OF TRAVEL MEDICINE

COMPONENTS OF TRAVEL MEDICINE


Immunizations Infectious diseases, STDs Food & water precautions Travellers diarrhea Malaria & other insect-borne diseases Jet lag Environmental risks

Immunizations
Advised recommendations:
Routine (wajib) Required (tambahan) Recommended (anjuran)

Immunizations (cont.)
1. Routine (7 immunizations):
T-dap/DPT (Tetanus + Diphtheria +Pertusis); Africa, Asia, America, Middle East, Europe. (3x/>2 bln) MMR/Campak (2x/9 bln); Africa & Asia. Influenza (seasonal) Australia, China Hepatitis A & Hepatitis B: all destinations (3x/<1bln) Polio (4x/<1bln) Varicella (1x/9 bln) Tuberculosis (BCG/1x/<2 bln)

Immunizations (cont)
2. Required (Tambahan) Yellow fever (virus/manusia/A.aegypty), Influenza (virus/manusia/unggas/babi) Meningococcal (virus/bakteri/manusia) (for Hajj):
tropical Africa tropical South America [none in Asia]

Yellow fever: Distribution

Immunizations (cont)
3. Recommended (anjuran)
Typhoid fever (1x/>2thn) Consider: rabies (3x/all age) Consider: Japanese encephalitis (3x/adult) Cholera: No.

Rabies avoidance: never hold hands with a gorilla.

COMPONENTS OF TRAVEL MEDICINE


Immunizations Infectious diseases, STDs Food & water precautions Travellers diarrhea Malaria & other insect-borne diseases Jet lag Environmental risks

Infectious Disease Risks to the Traveler


Malaria Diarrhea Leishmaniasis (Protozoa/Peny. Kulit/lendir) Rabies Dengue Meningococcal Meningitis (Bakteri/virus/unknown/ droplet) Schistosomiasis (demam keong/cacing) Tuberculosis Leptospirosis (Bakteri/kutup (-) Polio (Virus polio) Yellow Fever (inveksi virus/vektor nyamuk) Measles (virus campak/droplet) 31

Insects and other vectors of disease


Vector Aquatic snails (keong) Main diseases transmitted Schistosomiasis (bilharziasis) Parasite Type

Mosquitoes: 1.Aedes

a.Dengue fever b.Rift Valley fever c.Yellow fever d. Chikungunya a. Lymphatic filariasis b. Malaria a. Japanese encephalitis b. Lymphatic filariasis c. West Nile fever

a.Virus b.Virus (africa) c.Viral hemorrhagic

2. Anopheles 3. Culex

a. Worm b. Plasmodium a. viral disease b. parasitic (nematoda) c. Virus

Malaria
1) Protozoan organism, vector is Anopheles mosquito. 2) Illness characterized by high fevers, sweats, chills. 3) P. falciparum is the most prevalent species worldwide; associated with significant mortality. 4) There are approx. 100 countries in which malaria is endemic.

COMPONENTS OF TRAVEL MEDICINE


Immunizations Infectious diseases, STDs, Malaria & other insect-borne diseases Food & water precautions Travellers diarrhea Jet lag Environmental risks

3. Foodborne and waterborne health risks

1. 2. 3. 4. 5.

Cholera. Cryptosporidiosis Hepatitis A and E Salmonella. Shigella

4. Travellers diarrhoea source (80%)

Treatment of diarrhoea

1. Most diarrhoeal episodes are self-limiting, with recovery in a few days. 2. avoid becoming dehydrated. 3. fluid intake should be maintained with safe liquids (boil, bottled) 4. < 2 thn (50-100 ml)/0.5 L 5. 2-9 thn (100-200 ml)/1 L 6. > 10 thn (as much as wanted)/2 L /a day.

Dietary strategy to reduce risk of travelers diarrhea


The (relatively) safe list:
1) 2) 3) 4) 5) 6) 7) Boiled anything. Bottled anything;water, beer, pop (if sealed). Dry foods, e.g. bread. Packaged foods. Well-cooked food. Fruits (oranges, bananas) Wash hand

COMPONENTS OF TRAVEL MEDICINE


Immunizations Infectious diseases, STDs, Malaria & other insect-borne diseases Food & water precautions Travellers diarrhea Jet lag Environmental risks

Jet Lag

Tips to reduce Jet Lag


Adequate rest before flight Avoid alcohol and caffeine before and during flight Drink plenty of fluids Wear comfortable clothing and shoes For morning arrivals plan to stay awake

Other Risks to the Traveler

Other Risks to the Traveler


Accidental injury Environmental hazards Crime and assault (teroris) Psychiatric problems Animal bites Dermatologic disorders Altitude (heat stroke) .etc
44

Travelers die from in the developing world?


About half: heart attacks, strokes (mostly in the elderly). About 25%: road traffic accidents. The rest: drowning, falls from heights, homicide, suicide.

Infectious disease: only about 1%.

Road traffic accidents

To reduce risk of injury and death from motor vehicle accidents:


1) Seat belts are good 2) Helmets are good. 3) Do not ride on top of a bus or in the back of an open truck. 4) Avoid the roads at night.

Eq. Hubungan Temporal


Penggunaan sabuk pengaman
Penggunaan Sabuk Pengaman (%)

6.000 5.000 4.000 3.000 2.000 1.000

Cedera fatal & Serius

1982

1983

Jml Kasus

Travel Medicine Information


Information is power in Travel Medicine

Giving the correct health advice to travellers needs


Information (destination) Training (frame work) Experience Documentation Marketing (specialist travel clinics)

Travel Health Advice needs Information (yang dibutuhkan seorang dokter)


Guidelines Policies Textbooks, including an World Atlas Journals Professional organisations Staff/colleagues Electronic Databases WWW

National Guidelines
Travel Health Guidelines Malaria Guidelines Immunisation Guidelines Antibiotic Guidelines Journals Seminars

Giving the correct health advice to travellers needs


Information (destination) Training (frame work) Experience Documentation Marketing (specialist travel clinics)

Pre-Travel Health Advice needs Training


Helps give structure and consistency
Provides a framework for practice Discusses evidence for practice

Policy and Procedures Manual


Consistent approach to travel health

PRESCRIBE
(Script/Drs letter/bracelet)

Always Regular medication medical kit (first aid) Sometimes Anti malarial medication Diarrheal self-treatment. Condoms.

Giving the correct health advice to travellers needs


Information (destination) Training (frame work) Experience (paling sulit) Documentation Marketing (specialist travel clinics)

Travel is part of experience


Professionals working in travel medicine need to travel and have that personal experience to communicate to travellers Helps to put travel health advice in context and helps to build a positive travel experience

Travel is part of experience

Giving the correct health advice to travellers needs


Information (destination) Training (frame work) Experience Documentation Marketing (specialist travel clinics)

Correct advice is even better if the advice is actually followed by the traveller

Documentation Follow-up

Use staff resources Reinforce health advice

Traveled Prevention

Traveled Prevention
1. Check-list for the traveller a) Risk related to the area (urban or rural) b) Type of accommodation (hotel, camping) c) Length of stay d) Altitude (alcohol) e) Security of problem (e.g: conflict) f) Availability of medical facility 2. Vaccination (4-8 weeks before departure) 3. Malaria 4. Specific local disease who travel med.PDF - Ixxxviii 5. Meningococcal disease is required by Saudi Arabia for pilgrims visiting Mecca for the Hajj.

Travellers with pre-existing medical conditions and special needs


1. Age (48 hours); change altitude & ultraviolet radiation (infant/7 days, elderly: seek advice medical). 2. Pregnancy; (not generally contradictive) second trimester, malaria & Hepatitis E (28th weeks) letter from doctor/midwife. (primi 36th weeks/Multiple 32th). 3. Disability; General status is good. 4. Pre-existing illness (chronic illness); cardiovascular, dialysis, DM, epilepsy, HIV & mental disorders

Contraindications to air travel


1. 2. 3. 4. 5. Infants (less than 48 h old) Women after the 36th week of pregnancy (32nd week for multiple pregnancies). Angina pectoris or chest pain at rest. Active communicable disease Recent surgery or injury (especially abdominal trauma and gastrointestinal surgery, craniofacial and ocular injuries, brain operations, and eye operations) Increased intracranial pressure due to haemorrhage, trauma or infection. Recent myocardial infarction and stroke (elapsed time since the event de-pending on severity of illness and duration of travel). Severe chronic respiratory disease (Pneumothorax) Psychotic illness, except when fully controlled.

6. 7.

8. 9.

SEKIAN DAN TERIMAKASIH

Non Communicable diseases cruise ship


1. 2. 3. 4. Because of temperature Weather variations Changes in diet Physical activities

1. Cardiovascular events 2. Motion sickness (kapal kecil) 3. Injury 4. Dental emergency

Prevention and control


1. 2. 3. 4. 5. 6. 7. 8. Consult their health-care provider before embarking health status of the cruise ship traveller Specific immunizations depend on proper disinfection filtration and storage of source water designing piping systems without dead ends Regular cleaning and disinfection. AVOID SELF-medication in the case of diarrhoea or high fever while on board.

REPORT IMMEDIATELY TO THE SHIPS MEDICAL SERVICE.

Animals and insects


Undomesticated animals tend to avoid contact with humans and most do not attack unless provoked: 1. Rabies (most important infectious health hazard from animal bites) 2. After any animal bite (wound should be cleansed with disinfectant or with soap or detergent and water). 3. treated with post-exposure rabies vaccination and immunoglobulin (VAR) 4. Snakes, scorpions and spiders

Precaution
1. Avoid direct contact with domestic animals in areas where RABIES OCCURS, and with all wild and captive animals. 2. Avoid behaviour that may STARTLE (mengejutkan), frighten or THREATEN (menakut-nakuti) an animal.

3. Ensure that children do not APPROACH (mdekati), TOUCH (myentuh) or otherwise provoke any animal.
4. Treat any animal bite immediately by WASHING with disinfectant or soap and seek medical advice 5. If a significant risk of exposure to rabies is foreseen (dipastikan), seek medical advice before travelling.

Insects and other vectors of disease


1. Vectors play an essential role in the transmission of many infectious diseases. 2. Many vectors are bloodsucking insects. 3. producing microorganism during a blood meal from an infected host (human or animal) 4. later inject it into a new host. 5. Water plays a key role in the life-cycle of most vectors. 6. There is a relationship between rainfall (breeding sites). 7. Temperature is also a critical factor (Dengue, Malaria, Filariasis)

Life circle Schistosomiasis

Epidemiology Schistosomiasis

Japanese encephalitis (viral disease)

Japanese encephalitis (viral disease)

PICTURE SPECIES WORM CAUSE LYMPHATIC FILARIASIS IN INDONESIA (POSITIVE MICROFILARIASIS) (Source: Health Department Agam District)

POSITIF MICROFILARIASIS If the speciment blood we find species worm causes lymphatic filariasis by the laboratory test (microscopically)

DISTRIBUTION OF CASES IN AGAM DISTRICT 2005-2008 BEFORE STUDY SPATIAL


(Source: Health Department Agam District)

Sub-District

2005

2006

2007

2008

Tanjung Mutiara

30

34

34

49

Lubuk Basung

35

IV. Nagari

Palembayan

Tanjung Raya

TOTAL

37

44

48

91

PHOTO OF PEOPLE WITH ELEPHANTIASIS

Distribution Of Lymphatic Filariasis In Agam District 2005-2008 After Study Spatial


Sub-District 2005 2006 2007 2008
BEFORE ANALYSIS AFTER ANALYSIS

Tanjung Mutiara Lubuk Basung IV. Nagari Palembayan Tanjung Raya TOTAL

30 7 37

34 9 1 44

34 9 3 1 1 48

49 35 5 1 1 91

34 50 5 1 1 91

Case-clustering (Satscan)

SATSCAN is a method to measure or find clustering between all cases based on geoanalyses distance all filariasis cases.
1.Coordinates : 00,185790 S/-99.775720 E 2.Radius : 840 m (high risk)

3.Population :15 cases 4.Odds ratios : 2,3 5.p-Value : 0,006 (<0,05)

Study Objective
1. To confirm spatial distribution of Lymphatic Filariasis in Agam District to ensure interventions target appropriate populations at-risk.
To assist risk factor for Lymphatic Filariasis in Agam District.

2.

Epidemiology Schistosomiasis

Epidemiology Schistosomiasis, Indonesia

Dengue Virus
1. Causes dengue fever and dengue hemorrhagic fever 2. (20 million) cases of dengue infection result in an estimated 24.000 deaths annually 3. Flavivirus group. 4. Transmitted by mosquitoes (female). 5. (4 serotypes/DEN-1, 2, 3, 4)

Epidemiology Dengue

Epidemiology Dengue

Number of cases dengue

Dengue Viruses
Each serotype provides specific lifetime immunity, and short-term cross-immunity All serotypes can cause severe and fatal disease Genetic variation within serotypes Some genetic variants within each serotype appear to be more virulent or have greater epidemic potential

Aedes aegypti
Dengue transmitted by infected female mosquito Primarily a daytime feeder Lives around human habitation Lays eggs and produces larvae preferentially in artificial containers

Dengue fever

Key Point Dengue 1. Beda DHF dengan DF bukan perdarahan 2. Hemokonsentrasi bukan PCV > 3 X Hb 3. Kurang tepat bila pemeriksaan Dengue blot dilakukan pada awal penyakit 4. Deteksi keadaan syok jangan terfokus pada tekanan darah saja. 5. Jangan lupa memantau diuresis 6. DSS bukan hanya DBD grade IV saja

PENATALAKSANAAN 1. Terlalu dini/agresif memberi IVFD 2. Terlambat menghentikan/ memperlambat tetesan IVFD. 3. Terlambat memberikan cairan koloid pada kebocoran plasma yang hebat. 4. Terlambat memberi transfusi darah pada perdarahan tersembunyi. 5. Terlalu agresif memberi suspensi trombosit. 6. Jangan lupa memberi Oksigen pada kasus DSS

Protection against vectors


1. 2. 3. 4. 5. Insect repellents Mosquito nets Aerosol sprays Protective clothing Screening of windows

HIV/AIDS

AIDS : Kasus Baru dan Kumulatif 1987 s/d 30 Juni 2006

10 Provinces in Indonesia with the highest reported AIDS cases up to June 30, 2005
1800 1611 1600 1400 1200 1000 800 600 435 400 255 185 156 200 0 DKI Papua Jatim Jabar Bali Jakarta

111

107

72

61

52 Riau

Sumut Kalbar Sulut Kep. Riau AIDS

Cumulative percentage on reported AIDS cases in Indonesia by age group up to June 30, 2005
60 50 40 53.87

Percent

30 20 10

25.58

8.46

0.83
0
< 1 yr

0.57
1-4 yrs

0.18

3.90

1.94

0.74

3.93

5-14 yrs 15-19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60 yrs

Unkown

Age groups

Cumulative Percentage on AIDS Cases in Indonesia by Mode of Transmission up to June 30, 2005
50 45 47.2

40 35

36.4

Percent

30 25 20 15 10 5 0
Homosexual Heterosexual

5.8 0.1 IDU


Blood Transfusion

8.8 1.6 Perinatal Unknown

Risk factors

KASUS HIV/AIDS BERDASARKAN KELOMPOK UMUR DI PROPINSI NUSA TENGGARA BARAT

20 18 16 14
(KASUS)

12 10 8 6 4 2 0

1,8-9 1 0

10-14 0 0

15-19 3 0

20-24 15 8

25-29 19 11

30-34 13 11

35-39 8 1

40-44 3 3

45-49 1 0

Unknown 0 2

HIV AIDS

KASUS HIV/AIDS MENURUT PROFESI DI PROPINSI NTB TAHUN 1992 - 2006 (30 DESEMBER)

25

20

(KASUS)

15

10

0 GUIDE 2 1 NAPI 5 1 SWAST CLN TKI A 3 0 21 15 M TN TKW 2 0 PNS/HO IBU RT SOPIR NOR 6 2 3 1 0 1 PKJ WST 0 1 PLJ/M H S 3 2 BRH KSR 0 2 WPS 7 0

TDK PROFES BEKERJ IONAL A 1 0 11 9

HIV AIDS

PERSENTASE KUMULATIF KASUS HIV/AIDS BERDASARKAN FAKTOR RISIKO TAHUN 1992 - 2006 (30 DESEMBER)
45.00

42.42

40.00

35.00

31.31
30.00

(PERSENTASE)

25.00

22.22

20.00

15.00

10.00

5.00

3.03 1.01 0.00


Darah donor Tidak tahu

0.00 Heteroseksual Homoseksual IDUs Ferinatal

(FAKTOR RISIKO)

Risk Behaviours among High School Students in Jakarta


Sex with more than 0.8 0.2 one partner

Have Sex within last Year

3.5 5.5 5.3 8.9

Female Male

Ever had Sex

Ever Inject drugs

0.5 2.5 6.3 34.2 4.3

Ever try drugs

Ever drink till drunk

29.8
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0

Persentase pelajar SMA di Jakarta dan Surabaya yang melaporkan pernah berhubungan seks
(Sumber : Utomo dan Dharmaputa, 2000)

25
22

20

15
11.4

10
8.8 8

5
2 0.5 1997
Remaja pria di Jakarta Remaja pria di Surabaya

4.3

1998
Remaja perempuan di Jakarta Remaja perempuan di Surabaya

HIV Prevalence among Sex Workers in Riau and Papua

Papua

Riau

Source: Indonesian Ministry of Health, BSS

HIV Prevalence among Waria (Transvestites), Male Sex Workers, and Gay Men

21.7 Waria

3.8 Male Sex Workers HIV rates for Gay Men and Male Sex Workers in 2002 similar to rates for Waria in 1996 2.5 Gay

Source: Indonesian Ministry of Health, BSS

60

HIV Prevalence trend among IDUs In Jakarta and Bogor, Year 1996 - 2002
48
RSKO, Jakarta

50

Percent HIV positive

45 41

40

Yayasan Kita, Bogor

30

30

20 16 10

14

16

0
1996

0
1997 1998 1999 2000 2001 2002

(Source: P2M & PL)

HIV Prevalence among Blood Donors


2003 Data incomplete: through November 2003 Number of tests: 112,000

Number of tests: 618,000

Source: PMI

ODHA

ODHA (22 thn) hamil 7 Bulan Gambar diambil 22 Juli 2004 Meninggal 27 Juli 2004

KEY POINT BEFORE THE TRIP


Pre-travel consultation
1.If you have any medical problems (discuss with doctor before travel). 2.Medications that need (hand baggage). 3.Check with your travel agent, doctor or the Port Health Office for the types of vaccines required. 4.If you need vaccination, tell the doctor about any allergies you may have before receiving the vaccine.

DURING THE TRIP Avoiding mosquito-borne diseases 1.Mosquito can transmit several lethal diseases such as yellow fever, dengue fever and malaria. 2.Avoid being outdoors during mosquito feeding times (between dusk and dawn for Malaria; daytime for Dengue Fever). 3.While outdoors, wear long-sleeved clothing to cover the arms , legs, and particularly the ankles.

4.Apply insect repellent to exposed skin.


5.Choose one containing DEET ( N , N-Diethyl -3-toluamide). Repeated application may be required. Concentration of 'DEET' should not exceed 35% for adult and 20% for children. 6.If accommodations allow entry of mosquitoes, use a mosquito net over the bed.

KEY POINT DURING THE TRIP

Sexually transmitted diseases:


1.Beware of the dangers of casual sex while you are abroad. 2. A single exposure is sufficient to transmit the HIV virus (which causes AIDS) 3.Using condoms correctly provides some protection from getting those sexually transmitted diseases. 4.The golden rule is to refrain from promiscuity and never have sex with strangers.

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