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Pre-Travel

Health
Consultation
Dr Peter A. Leggat
MD, PhD, DrPH, FAFPHM, FACTM, FFTM
Associate Professor
School of Public Health and Tropical Medicine
James Cook University &
Visiting Professor
School of Public Health
University of the Witwatersrand
About the author

Dr Peter Leggat has co-ordinated the Australian


postgraduate course in travel medicine since
1993. He has also been on the faculty of the
South African travel medicine course,
conducted since 2000, and the Worldwise New
Zealand Travel Health update programs since
1998. Dr Leggat has assisted in the
development of travel medicine programs in
several countries and also the Certificate of
Knowledge examination for the International
Society of Travel Medicine.
By the end of this session
Briefly revisit who provides pre-travel
health advice
Emphasize the need for resources in
travel medicine
Overview the main functions of the pre-
travel health consultation
Introduce the concept of documentation in
travel medicine
The Continuum of Travel Medicine

Pre-Travel
Pre-Travel Preventive Medicine
Visitors
Visitors

Contingency During
During Travel
Travel Planning

Treatment & Rehabilitation Post-Travel


Post-Travel
Travelers get information
from various sources
Travel agent/travel industry
Books, popular press and the Internet
Person next door
Pharmacy
General practice / Travel clinics
Government/public health services
Professional and academic bodies
Ref: Leggat PA. Sources of health advice for travelers. J Travel Med 2000;7:85-8
Giving correct and consistent
advice to travelers is
important
Giving the correct health advice to
travelers needs:
Information

Training

Experience

Documentation

Travellers
Need to be prepared with
adequate resources
Need adequate staff training and continuing
education
Need adequate time and good time management
Need to have access to national and international
guidelines for travel medicine
Need to have health education resources
Need to have access to good geographically
based epidemiological information regarding
risks to health and safety of travelers (internet,
computerized databases etc)
Travel Health Advice
Needs Adequate Notice
Travelers need to be informed that they
need travel health advice

Travelers need to be informed that they


need to seek travel health advice early,
about 6-8 weeks prior to travel

A risk assessment must be performed


for every traveler
PRE-TRAVEL HEALTH
ADVICE
Immunize travelers
Advise/educate travelers on other
precautions that should be taken
against conditions to which they are
likely to be exposed during travel
Prescribe appropriate
chemoprophylactic and self-treatment
medications
PRE-TRAVEL HEALTH
ADVICE
Immunize travelers
Advise/educate travelers on other
precautions that should be taken
against conditions to which they are
likely to be exposed during travel
Prescribe appropriate
chemoprophylactic and self-treatment
medications
VACCINATE
Always National schedule (incl Hep B)
Often hepatitis A (non-immune)
Sometimes Japanese encephalitis
meningococcal disease (Mecca) polio rabies
typhoid
yellow fever (WHO)
Older age gp Influenza (Others)
Pneumococcal disease (adapted* from NZPHR; 1996;3(8):57-
59)
IMMUNISE AGAINST
Mandatory vaccinations (WHO)
National schedule vaccinations-
update routine immunizations
Vaccinations for most or all travelers
Vaccinations for travelers at special
risk+
Mandatory vaccines
Travelers to/from Yellow fever endemic
areas

Travelers going to Mecca for the Hajj


Yellow fever

Source: http://www.cdc.gov/travel/diseases/yellowfever.htm
Yellow fever
International regulations
WHO International Travel
and Health
Specially licensed Yellow
Vaccination Centers
Need to document on
appropriate certificate of
immunization card
Meningococcal
meningitis

Source: http://www.cdc.gov/travel/diseases/menin.htm
Meningococcal
meningitis
Neisseria meningitidis: At least 13 antigenically
distinct serogroups
A,B,C,W135 & Y are most common
Current vaccine for A,C,W135 & Y
NZ is trialing a vaccine against a specific B
strain
Mandatory: Pilgrims visiting Mecca for the Hajj
(annual pilgrimage) or for the Umrah
Recommended: Travelers roughing it in
areas where there are recurrent outbreaks of
disease
Routine vaccinations
The travel health consultation is a good
opportunity to update national schedule
or routine vaccinations
Vaccinations for most
travelers

Diseases
associated with
poor hygiene &
sanitation
ETEC?

Hepatitis A
Typhoid
Cholera
Various new vaccines
Some activity against ETEC in one
Routine use of cholera vaccine is not
recommended as risk is low
It is indicated for travelers to cholera
endemic areas, who are at high risk for
infection (2-3 years protection)
Travelers at special risk
Geographical risk

Risk because age, pre-existing


conditions, or occupation
Geographical risk
Vector borne diseases
Yellow fever
Japanese encephalitis
Tick borne encephalitis

Wilderness/remote travel
Rabies
TB

Current epidemics (terrorist threats?)


Cholera
Plaque
Japanese encephalitis

Source: http://www.cdc.gov/ncidod/dvbid/jencephalitis/map.htm
Japanese encephalitis
Travelers spending one month or more in rural
areas of Asia, PNG & Torres Strait (Australia),
particularly if the travel is during the wet
season, and/or there is considerable outdoor
activity and/or the standard of accommodation
is suboptimal,
other travelers spending a year + in Asia
(except for Singapore), even if much of the
stay is in urban areas
Dengue
Vaccine in development

Four serotypes (1-4)

Transmitted by certain mosquitoes, including


Aedes aegypti

Widespread, especially common in SE Asia

Becoming increasingly recognized in travelers


Estimated monthly incidence of health problems
per 100 000 travellers to developing countries
Tick borne encephalitis

Seasonal disease in parts of Europe,


Scandinavia and Russia
Hikers, campers and agricultural workers most
at risk
Small mammal ticks found in the undergrowth
close to forested areas
Vaccine available/post-exposure immune
globulin
Tuberculosis-BCG
Travelers over the age of 5 years who will
spend prolonged periods in countries of high
TB prevalence
Children under 5 years who will be travelling
to live in countries of high TB prevalence for >
than 3 months
WHO: high risk countries, where annual
incidence is in excess of 100 per 100,000
population
Rabies
Endemic in many
countries

Is almost a
universally fatal
disease
Plague
Yesinia pestis, transmitted via fleas
from animal reservoir to humans
Rare in most parts of the world
Vaccination only of those at high risk,
usually those engaged in field
operations, laboratory workers or others
who reside in areas where plague is
present
Risk because age, pre-
existing conditions, or
occupation
Older travelers/pre-existing disease
Influenza

Pneumococcal infection
Occupational risk (including electives)
Hepatitis
B (usually part of national
schedule)
Q fever
Influenza
Routinely on annual basis for those 65
years and older
Travelers with chronic disorders of the
pulmonary or circulatory systems or
other chronic illnesses needing regular
follow-up
Those who wish to reduce the risk
Estimated monthly incidence of health problems
per 100 000 travellers to developing countries
Pneumococcal infection
Routinely on annual basis for those 65
years and older
Travelers with asplenia,
immunocompromized travelers
Others
Q Fever

Bacterium (rickettsia) Coxiella burnetii


Recommendation: those occupationally
exposed to cattle, sheep, goats or
kangaroos or their products
Serum antibody and skin testing to exclude
hypersensitivity reaction
Contraindications: prior exposure to Q fever
or anaphylaxis induced by egg proteins
It is important to
document vaccinations
Vaccination record
Vitalfor those requiring proof of yellow
fever vaccination
Evidence of specific vaccinations and
screening (e.g. HIV, HBV, Syphilis,
Tuberculin) needed for entry to various
countries, especially longer term travelers,
such as scholars and workers
PRE-TRAVEL HEALTH
ADVICE
Immunize travelers
Advise/educate travelers on other
precautions that should be taken
against conditions to which they are
likely to be exposed during travel
Prescribe appropriate
chemoprophylactic and self-treatment
medications
ADVISE AND DISCUSS
Insects
Ingestions
Indiscretions
Injuries
Immersions
Insurance
ADVISE AND DISCUSS
Insects repellents, nets, permethrin
Ingestions care with food and water diet/teeth
(including airlines/jetlag/DVT)
Indiscretions STIs, HIV, drugs?
Injuries accident avoidance, personal
safety
Immersion schistosomiasis, drowning
Insurance* health and travel insurance*
finding medical assistance o/s* (adapted from NZPHR;
1996;3(8):57-59)
Personal safety is on
the radar screen

Leitrim County, rural Ireland


Courtesy of Rick Speare
Personal safety
There has been heightened concern
regarding personal safety and travelers

National foreign affairs sites should be


consulted on safety and security at the
travelers destination(s).
Personal safety

Source: http://www.cia.gov/cia/publications/factbook/
SPECIAL RISK GROUPS
Travelers who need special assistance or
need assessment as to fitness to fly
Pregnant travelers/children/HIV travelers
Altitude/mountaineering/diving
Adventure/outback travelers
Travelers to areas of extreme climate
School/club/other groups
Occupational/students/military/aviation
Aid/refugee camp workers
Travel health advice
needs documentation
Medialert bracelets-allergies, serious
medical conditions
Written travel health advice (may be part
of doctors letter)-consider using a
proforma
Travelers health record ?
Other certificates, e.g. diving, airline
Is the traveler being escorted?
(aeromedical evacuation)
Educational Resources
Books
Travel industry guides
Pharmaceutical companies
Videos-popular in a number of
clinics in the USA
152 pp, Small
pocket book
52 pp,
passport sized
booklet

192 pp, reader

730 pp,
manual
144 pp, Small
pocket book

Disease specific

Specific to special
groups 428 pp, reader
PRE-TRAVEL HEALTH
ADVICE
Immunize travelers
Advise/educate travelers on other
precautions that should be taken
against conditions to which they are
likely to be exposed during travel
Prescribe appropriate
chemoprophylactic and self-treatment
medications
PRESCRIBE
(Script/Drs letter/medialert bracelet)

Always regular medication


medical kit (first aid)*
Sometimes antimalarial medication
diarrheal self-treatment
condoms/PEP
Other hygiene pdts
(NZPHR; 1996;3(8):57-59)
Medication needs
documentation
Prescription
Doctors letter-consider using a
proforma
Customs/quarantine approvals, if
required
If part of a clinical trial, contact
details/advice regarding adverse
reactions (on a laminated card)
We do not live in an
ideal world
Travel health advice will be moderated by
Availability of vaccines
Availability of educational resources
Availability of drugs for chemoprophylaxis
and treatment-special authority
Limitations in indications, limitations in
available data for use
Risk assessment
Bottom line of pre-
travel health advice
There is probably more to pre-travel
health advice than travel immunizations
and malaria chemoprophylaxis
Travelers will have different priorities and
resources
Need for a risk assessment and access
to current epidemiological information
available on a geographic basis by
country/region