Pre-Travel Health Consultation

Dr Peter A. LeggatMD, 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 adviceEmphasize the need for resources in travel medicineOverview the main functions of the pre-travel health consultationIntroduce the concept of documentation in travel medicine

The Continuum of Travel MedicineThe Continuum of Travel Medicine

During TravelDuring Travel

Preventive Medicine

Contingency Planning

Treatment & Rehabilitation

VisitorsVisitorsPre-TravelPre-Travel

Post-TravelPost-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:InformationTrainingExperienceDocumentationTravellers

Need to be prepared with adequate resources

Need adequate staff training and continuing educationNeed adequate time and good time managementNeed to have access to national and international guidelines for travel medicineNeed to have health education resourcesNeed 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 travelPrescribe 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 travelPrescribe appropriate chemoprophylactic and self-treatment medications

VACCINATEAlways National schedule (incl Hep B)Often hepatitis A (non-immune)Sometimes Japanese encephalitismeningococcal disease (Mecca) polio

rabiestyphoid

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 serogroupsA,B,C,W135 & Y are most commonCurrent vaccine for A,C,W135 & Y NZ is trialing a vaccine against a specific B strainMandatory: Pilgrims visiting Mecca for the Hajj (annual pilgrimage) or for the UmrahRecommended: 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 & sanitationETEC?Hepatitis ATyphoid

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 RussiaHikers, campers and agricultural workers most at riskSmall mammal ticks found in the undergrowth close to forested areasVaccine 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

RabiesEndemic in many countries

Is almost a universally fatal disease

Plague

Yesinia pestis, transmitted via fleas from animal reservoir to humansRare in most parts of the worldVaccination 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

occupationOlder travelers/pre-existing disease InfluenzaPneumococcal 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 burnetiiRecommendation: those occupationally exposed to cattle, sheep, goats or kangaroos or their productsSerum antibody and skin testing to exclude hypersensitivity reactionContraindications: prior exposure to Q fever or anaphylaxis induced by egg proteins

It is important to document vaccinations

Vaccination recordVital for those requiring proof of yellow

fever vaccinationEvidence 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 travelPrescribe appropriate chemoprophylactic and self-treatment medications

ADVISE AND DISCUSS

Insects

Ingestions

Indiscretions

Injuries

Immersions

Insurance

ADVISE AND DISCUSS

Insects repellents, nets, permethrinIngestions care with food and water

diet/teeth (including airlines/jetlag/DVT)Indiscretions STI’s, HIV, drugs?Injuries accident avoidance, personal

safetyImmersionschistosomiasis, drowningInsurance*health and travel insurance*

finding medical assistance o/s*(adapted from NZPHR; 1996;3(8):57-59)

Leitrim County, rural Ireland

Courtesy of Rick Speare

Personal safety is on the radar screen

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 flyPregnant travelers/children/HIV travelersAltitude/mountaineering/divingAdventure/outback travelersTravelers to areas of extreme climateSchool/club/other groupsOccupational/students/military/aviationAid/refugee camp workers

Travel health advice needs documentation

Medialert bracelets-allergies, serious medical conditionsWritten travel health advice (may be part of doctor’s letter)-consider using a proformaTravelers health record ?Other certificates, e.g. diving, airlineIs the traveler being escorted? (aeromedical evacuation)

Educational Resources

BooksTravel industry guidesPharmaceutical companiesVideos-popular in a number of clinics in the USA

52 pp, passport sized booklet

152 pp, Small pocket book

192 pp, reader

730 pp, manual

144 pp, Small pocket book

428 pp, reader

Disease specific

Specific to special groups

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 travelPrescribe appropriate chemoprophylactic and self-treatment medications

PRESCRIBE (Script/Dr’s letter/medialert bracelet)

Always regular medicationmedical kit (first aid)*

Sometimes antimalarial medicationdiarrheal self-treatmentcondoms/PEPOther hygiene pdts

(NZPHR; 1996;3(8):57-59)

Medication needs documentation

PrescriptionDoctor’s letter-consider using a proformaCustoms/quarantine approvals, if requiredIf 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