Travel AdvisoriesTravel Advisories

Know before you go!Know before you go!

•http://travel.gc.ca/travelling/advisories

Travel Medicine 101Travel Medicine 101

CASECASE

• A 25 year old female medical student is A 25 year old female medical student is going on a 3 week medical trip to Ghana in going on a 3 week medical trip to Ghana in December. She is going to work in a rural December. She is going to work in a rural hospital and then travel to the coast for hospital and then travel to the coast for sightseeing.sightseeing.

– What vaccines does she need?What vaccines does she need?– What about malaria prophylaxis?What about malaria prophylaxis?– What advice will you give her?What advice will you give her?

Travel MedicineTravel Medicine

• In the past, we were In the past, we were dependent on the dependent on the Yellow Yellow BookBook by the CDC by the CDC– Now OnlineNow Online

– http://wwwnc.cdc.gov/wwwnc.cdc.gov/travel/destinations/listtravel/destinations/list

– Look up a destination and Look up a destination and it will tell you what you it will tell you what you needneed

Hepatitis A PrevalenceHepatitis A Prevalence

Common Vaccines for Common Vaccines for TravelTravel• Hepatitis AHepatitis A

– Endemic in most developing countriesEndemic in most developing countries– Fecal-Oral TransmissionFecal-Oral Transmission– Incubation period 15-50 daysIncubation period 15-50 days– Most adults have not been vaccinated against Most adults have not been vaccinated against

it it – 2 dose series; 0 & 6 months2 dose series; 0 & 6 months– Effective in as little as 2 weeks prior to travel, Effective in as little as 2 weeks prior to travel,

give even if leaving in less than 2 weeksgive even if leaving in less than 2 weeks– 1 dose gives 95% protection, 2 doses= 99%1 dose gives 95% protection, 2 doses= 99%

Hepatitis A IncidenceHepatitis A Incidence

-18% of cases in the US are related to travel

-Most are in travelers to Mexico, Central and South America

Hepatitis B PrevalenceHepatitis B Prevalence

Common Vaccines for Common Vaccines for TravelTravel• Hepatitis BHepatitis B

– Blood & body fluid transmission, Shared Blood & body fluid transmission, Shared Needles, Mother to child during birthNeedles, Mother to child during birth

– Incubation Period 60-150 daysIncubation Period 60-150 days– Not recommended for routine travelNot recommended for routine travel– Important for those in health care field Important for those in health care field

or those staying prolonged periods of or those staying prolonged periods of time or those with high risk sexual time or those with high risk sexual behaviorsbehaviors

Common Vaccines for Travel:Common Vaccines for Travel:MeningococcusMeningococcus• Passed by airborne particles, intimate contact, or Passed by airborne particles, intimate contact, or

contact with nasal secretionscontact with nasal secretions• Meningitis Belt in Africa (dry season highest risk Meningitis Belt in Africa (dry season highest risk

Dec-Jun)Dec-Jun)• Required for Hajj and Umrah pilgrims in Saudi Required for Hajj and Umrah pilgrims in Saudi

ArabiaArabia

Common Vaccines for Common Vaccines for TravelTravel• Typhoid (Salmonella Typhi)Typhoid (Salmonella Typhi)

Typhoid FeverTyphoid Fever

• Fecal-Oral transmissionFecal-Oral transmission• 400 Cases in US travelers yearly400 Cases in US travelers yearly

– Risk Highest in Southern AsiaRisk Highest in Southern Asia

• 22 million cases & 200k deaths worldwide22 million cases & 200k deaths worldwide• Incubation period of 1-3 weeksIncubation period of 1-3 weeks• Good hand washing and food precautions Good hand washing and food precautions

are helpful in preventionare helpful in prevention• Shed in feces for 6 weeks to 3 months Shed in feces for 6 weeks to 3 months

after infectionafter infection

Typhoid Fever Vaccine Typhoid Fever Vaccine IndicationsIndications

You should get it if:You should get it if:

•You are travelling to infected areaYou are travelling to infected area

•Adventurous travelersAdventurous travelers

•Traveling for more than 3 weeksTraveling for more than 3 weeks

•Rural travelRural travel

Yellow Fever Endemic ZonesYellow Fever Endemic Zones

Common Vaccines for Travel:Common Vaccines for Travel:Yellow FeverYellow Fever• Transmitted by daytime biting mosquitoTransmitted by daytime biting mosquito

– Vaccine required for entry into countries where Vaccine required for entry into countries where Yellow Fever is present, or if traveling through a Yellow Fever is present, or if traveling through a country where transmission may be possible. 10 days country where transmission may be possible. 10 days prior to travel.prior to travel.

– Increased risk in W Africa at end of rainy season Increased risk in W Africa at end of rainy season (July-October)(July-October)

– Increased risk in S America in rainy season (Jan-May)Increased risk in S America in rainy season (Jan-May)– Protection is for 10 yearsProtection is for 10 years

Need to be sure that the traveler really needs it. Need to be sure that the traveler really needs it. Since 1996, 12-36 US travelers have gotten YFV-AVD Since 1996, 12-36 US travelers have gotten YFV-AVD

and 58% have died from it. and 58% have died from it. Some of these patients weren’t even traveling to a Some of these patients weren’t even traveling to a

country where the vaccine was indicated.country where the vaccine was indicated.

Common Vaccines for Common Vaccines for TravelTravel• RabiesRabies

• Bites by dogs, bats, raccoons, foxes, Bites by dogs, bats, raccoons, foxes, jackals, cats, mongooses, skunks, and jackals, cats, mongooses, skunks, and wolves wolves

•Hikers/BackpackersHikers/Backpackers

•Cavers/Adventure TravelersCavers/Adventure Travelers

•Non-travelers: Veterinarians, Animal control Non-travelers: Veterinarians, Animal control workers and rabies researchersworkers and rabies researchers

Access to appropriate treatment/vaccines is a Access to appropriate treatment/vaccines is a factor as wellfactor as well

Less commonly used vaccinesLess commonly used vaccines

• CholeraCholera– ““Virtually no risk” for Virtually no risk” for

travelers who maintain travelers who maintain proper food safety proper food safety precautions and usual precautions and usual tourist itineraries tourist itineraries according to the CDCaccording to the CDC

– Vaccine not available in Vaccine not available in the USthe US

– Haiti Epidemic 2011Haiti Epidemic 2011• Pack antibiotics, ORS, Pack antibiotics, ORS,

Water purification tabsWater purification tabs

• Japanese Japanese EncephalitisEncephalitis– Short term travelers Short term travelers

to urban areas have to urban areas have very low risk (1 per very low risk (1 per million)million)

– Those staying in Those staying in high risk areas for high risk areas for long periods of time long periods of time should consider itshould consider it

Japanese Encephalitis AreasJapanese Encephalitis Areas

MalariaMalaria

• Transmitted by the mosquito that bites from Transmitted by the mosquito that bites from dusk to dawndusk to dawn

• Transmission will usually not occur:Transmission will usually not occur:– In urban areas, except in Africa and IndiaIn urban areas, except in Africa and India– At high altitudes (parasite is sensitive to cold) > 1500mAt high altitudes (parasite is sensitive to cold) > 1500m– During cooler seasons in some areas During cooler seasons in some areas – In deserts (excluding the oases) In deserts (excluding the oases) – In some islands in the Pacific Ocean, which have no local In some islands in the Pacific Ocean, which have no local AnophelesAnopheles

species capable of transmitting malaria species capable of transmitting malaria – In some countries, where transmission has been interrupted through In some countries, where transmission has been interrupted through

successful eradication. successful eradication. • Generally, in warmer regions closer to the equator:Generally, in warmer regions closer to the equator:

– Transmission will be more intense Transmission will be more intense – Malaria is transmitted year-round Malaria is transmitted year-round

The highest transmission is found in Africa, south of the Sahara.The highest transmission is found in Africa, south of the Sahara.

Malaria Distribution Malaria Distribution & Chloroquine & Chloroquine ResistanceResistance

http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria.aspx

Accessed June 21, 2010

Insect PrecautionsInsect Precautions

• restriction of outdoor activities between restriction of outdoor activities between dusk and dawn dusk and dawn

• screened-in accommodations screened-in accommodations • light-coloredlight-colored, long-sleeved shirts and pants , long-sleeved shirts and pants • topical application of effective insect topical application of effective insect

repellants to skin and clothingrepellants to skin and clothing• use of bed nets, tents, clothing, sleeping use of bed nets, tents, clothing, sleeping

bags, etc. bags, etc. • mosquito-proofing of living quarters by mosquito-proofing of living quarters by

spraying insecticide and eliminating spraying insecticide and eliminating standing water standing water

• avoid perfumesavoid perfumes

Traveler’s DiarrheaTraveler’s Diarrhea

• Definition: 3 or more unformed stools Definition: 3 or more unformed stools in a 24-hour periodin a 24-hour period

• Occurs in up to 60% of travelers Occurs in up to 60% of travelers • PathogensPathogens

– Bacterial: Enterotoxigenic E. Coli, Bacterial: Enterotoxigenic E. Coli, Shigella, Campylobacter, SalmonellaShigella, Campylobacter, Salmonella

– Protozoa: Giardia, CyclopsoraProtozoa: Giardia, Cyclopsora– Viral: Norwalk and RotavirusViral: Norwalk and Rotavirus

Food Precautions- Do ThisFood Precautions- Do This

• ““Cook it, boil it, peel it or forget it.”Cook it, boil it, peel it or forget it.”• Eat at establishments that are known to cater to Eat at establishments that are known to cater to

foreigners or that are specifically known by other foreigners or that are specifically known by other foreigners to be safe. foreigners to be safe.

• Eat foods that are well-cooked and served Eat foods that are well-cooked and served steaming hot. steaming hot.

• Eat breads, tortillas, crackers, biscuits, and other Eat breads, tortillas, crackers, biscuits, and other baked goods. baked goods.

• Eat fruits, nuts, and vegetables with thick skins, Eat fruits, nuts, and vegetables with thick skins, peels, or shells that you remove yourself. peels, or shells that you remove yourself.

• Eat canned foods. Eat canned foods. • Always wash your hands with soap before eating Always wash your hands with soap before eating

and after using the toilet. and after using the toilet.

Food Precautions- Not thisFood Precautions- Not this

• Eat any food from street vendors or market stalls. Eat any food from street vendors or market stalls. • Eat leafy or uncooked vegetables and salads. Some Eat leafy or uncooked vegetables and salads. Some

organisms in soil and water are not destroyed by normal organisms in soil and water are not destroyed by normal cleaning methods. cleaning methods.

• Eat undercooked, raw, or cold meat, seafood, and fish. Eat undercooked, raw, or cold meat, seafood, and fish. • Eat or drink unpasteurized dairy products such as cheese, Eat or drink unpasteurized dairy products such as cheese,

yogurt, and milk. Be particularly wary of ice cream and yogurt, and milk. Be particularly wary of ice cream and other frozen confections that may have been made or other frozen confections that may have been made or stored in contaminated containers. stored in contaminated containers.

• Eat cold sauces such as mayonnaise, salad dressing, Eat cold sauces such as mayonnaise, salad dressing, chutneys, or salsas, which are usually raw and made by chutneys, or salsas, which are usually raw and made by hand. hand.

• Eat buffet foods such as lasagna, casseroles, and quiches—Eat buffet foods such as lasagna, casseroles, and quiches—unless you know they are fresh (not reheated) and have unless you know they are fresh (not reheated) and have been kept steaming hot. Avoid buffets where there are no been kept steaming hot. Avoid buffets where there are no food covers or fly controls. food covers or fly controls.

• Eat creamy desserts, custards, or sauces that may not have Eat creamy desserts, custards, or sauces that may not have been adequately refrigerated. been adequately refrigerated.

Beverage Precautions- Do Beverage Precautions- Do ThisThis• Use sealed bottled water or chemically treated, filtered, or Use sealed bottled water or chemically treated, filtered, or

boiled water for drinking and for brushing teeth. boiled water for drinking and for brushing teeth. • Drink beverages made only with boiled water whenever Drink beverages made only with boiled water whenever

possible (such as hot tea and coffee). Water boiled for any possible (such as hot tea and coffee). Water boiled for any length of time (even 1 minute) is safe to drink. length of time (even 1 minute) is safe to drink.

• Drink canned, boxed, or commercially bottled carbonated Drink canned, boxed, or commercially bottled carbonated water and drinks. International brands are safest. Beware of water and drinks. International brands are safest. Beware of unsealed containers that may have been re-filled. unsealed containers that may have been re-filled.

• Safely drink beer and wine. Safely drink beer and wine. • Purify your own water if one of these options is not Purify your own water if one of these options is not

available. Decide which method to use for water purification available. Decide which method to use for water purification and bring along the appropriate equipment. and bring along the appropriate equipment.

• Carry safe water with you if you are going out for the day Carry safe water with you if you are going out for the day and where availability of safe water is not assured. and where availability of safe water is not assured.

• Breast-feeding is the safest food source for infants who are Breast-feeding is the safest food source for infants who are still nursing. If formula is used, it must be prepared with still nursing. If formula is used, it must be prepared with boiled water and sterilized containers. boiled water and sterilized containers.

Beverage Precautions- Not Beverage Precautions- Not thisthis• Drink tap water. Drink tap water. • Rinse toothbrush in tap water. Rinse toothbrush in tap water. • Use ice unless it is made from boiled, bottled, or purified Use ice unless it is made from boiled, bottled, or purified

water. Freezing does not kill the organisms that cause water. Freezing does not kill the organisms that cause diarrhea. diarrhea.

• Assume that water is safe because it is chlorinated. Assume that water is safe because it is chlorinated. Chlorination does not destroy all the organisms that can Chlorination does not destroy all the organisms that can make you ill. make you ill.

• Drink from wet cans or bottles-the water on them may be Drink from wet cans or bottles-the water on them may be contaminated. Dry wet cans/bottles before opening and contaminated. Dry wet cans/bottles before opening and clean all surfaces that will have contact with the mouth. clean all surfaces that will have contact with the mouth. (use a straw instead)(use a straw instead)

• Drink fruit juice unless it comes directly from a sealed Drink fruit juice unless it comes directly from a sealed container; otherwise it may have been diluted with tap container; otherwise it may have been diluted with tap water. water.

Road safety/ViolenceRoad safety/Violence

• Infectious diseases account for only Infectious diseases account for only 2%2% of deaths abroad by US travelers of deaths abroad by US travelers

• 881 US traveler deaths abroad in 2009881 US traveler deaths abroad in 2009– 26% were in Mexico, next highest Costa 26% were in Mexico, next highest Costa

Rica at 3.7% Rica at 3.7%

State Department Data. http://travel.state.gov/law/family_issues/death/death_600.html

Accessed June 23, 2010

Deaths of Americans Abroad 2003-Deaths of Americans Abroad 2003-

0505

CDC Yellow Book 2010. Accessed June 16, 2010. http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/injuries-

safety.aspx