Travel Medicine

P R E S E N T E D B Y:

D R . S U LTA N A L N H AY E R

ABFM,SBFM,

HCM (USA)

A S S O C I AT E P R O F E S S O R FA M I LY M E D I C I N E ,

QASSIM UNIVERSITY

New notes by: Fahad alharbi , Nasser aljazwa

Outline

’ Travelers’ Health Epidemiology

’ Traveler Assessment

’ Sources of Information

’ Most Common problems of Travel

’ Risks to the Traveler

’ Travel Vaccines

’ Travel Medications

’ Counseling

he read it

all

Deaths Related to International Travel

The

The
most common cause of death among elderly is CVS
most common cause of death among elderly women is CVS
Mf

The most common cause of death among international travelers is CVS

Cardiovascular

Medical

Injury

Homicide/Suicide

Infectious Disease

Other

N = 2463

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626



The Patient: Medical Issues

’ Age-specific issues

’ Underlying illness, immunosuppression

’ Systems review

’ Medical history

’ Medication use

’ Vaccination history

’ Allergies

most imp

Travel Health Resources

Miffed

’ CDC Travelers’ Health Website

www.cdc.gov/travel

’ World Health Organization

www.who.int/int

’ State Department

travel.state.gov

’ International Society of Travel Medicine

www.istm.org

’ Health Information for International

Travel

CDC “Yellow Book”

’ International Travel and Health

WHO “Green Book”

Motion Sickness

10

’ normal physiologic response to a stimulus.

’ more frequently in women and in children

’ Excessive stimulation of the vestibular apparatus by

motion is the primary cause

’ The incidence ranges from < 1% on airplanes to

nearly 100% on ships in rough seas.

Risk Factors

11

’ Poor ventilation (eg, with exposure to fumes, smoke,

or carbon monoxide)

’ Emotional factors (eg, fear, anxiety)

’ Migraine headaches

’ Labyrinthitis

’ Hormonal factors (eg, pregnancy, use of hormonal

contraceptives)

Symptoms and Signs

12

’ nausea, vomiting, pallor, sweating, and vague

abdominal discomfort.

’ Pain, shortness of breath, focal weakness or

neurologic deficits, and visual and speech

disturbances are absent.

The difference b/w motion sickness and panic attack?

1- symptoms: vertigo or dizziness more with motion sickness whereas palpitations, SOB and dry mouth with panic

attack

2- panic attack without trigger

Treatment

13

’ Prophylactic drugs (eg, scopolamine, antihistamines,

antidopaminergic drugs)

’ Antiemetic drugs (eg, serotonin antagonists)

as ondansetron

’ Sometimes IV fluid and electrolyte replacement

’ To minimize, recommended (position in the vehicle

least subject to motion, sleep when possible, obtain

sit away from the window

adequate ventilation

Scopolamine

us oral

14 Patch

’ anticholinergic, is effective for prevention.

’ The patch is a good choice for longer trips because it

is effective for up to 72 h.

’ It is applied behind the ear 4 h before its effect is

required.

’ The oral form is effective within 30 min and is given

as 0.4 mg to 0.8 mg 1 h before travel and then every

8 h as needed.

Scopolamine is the drug for prevention and treatment for motion sickness

If someone came to you and said my flight after 1 hour and I have motion sickness

Give him oral form because it is faster than patch

but if someone asks you for long trip, skin patch is the choice

15

Scopolamine

16

’ contraindicated in people who are at risk of angle-

closure glaucoma.

’ If an elderly person becomes confused and develops

a fixed, dilated pupil while traveling,

consider scopolaminetoxicity (as well as intracranial

hematoma with brain herniation).

Working in shift
Jet lag
Biological clock

the circadian rhythm the body adapted to

17

’ known as time zone change syndrome or

desynchronosis

’ occurs when people travel rapidly across time zones

or when their sleep is disrupted, for example,

because of shift work.

’ It is a physiological condition that results from a

disruption in the body's circadian rhythms

Jet lag

18

’ affect mood, ability to concentrate, and physical and

mental performance.

’ Disturbed sleep — such as insomnia, early waking

or excessive sleepiness.

’ Daytime fatigue.

’ Difficulty concentrating.

’ Stomach problems, constipation or diarrhea.

’ A general feeling of not being well.

’ Mood changes.

Before Travel

19

’ steps to minimize the effects of jet lag.

’ Exercise, eat a healthful diet, and get plenty of rest.

’ A few days before you leave, start going to bed an hour or

two later than usual (before traveling west) or earlier than

usual (before traveling east) to shift your body’s clock.

’ Break up a long trip with a short stop in the middle, if

possible.

If someone will travel to china what advise you will give ?

2 days before the flight try to sleep 2 hours earlier than the usual sleeping time

If someone will travel to USA what advise you will give ?

2 days before the flight try to sleep 2 hours later than the usual sleeping time

During Travel

20

-Avoid large meals, alcohol, and caffeine.

Drink plenty of water.

y PUT

On long flights, get up and walk around periodically.

Sleep on the plane, if you can.

After You Arrive

21

’ Don’t make any important decisions the first day.

’ Eat meals at the appropriate local time.

’ Spend time in the sun.

’ Drink plenty of water, and avoid excess alcohol or caffeine.

’ If you are sleepy during the day, take short naps (20–30

minutes) so you can still sleep at night.

Infectious Disease Risks

to the Traveler22

Traveller

’ Diarrhea

Most common ’ Schistosomiasis

’ Malaria

’ Tuberculosis

’ Leishmaniasis

’ Leptospirosis

’ Rabies

’ Polio

’ Dengue

’ Yellow Fever

’ Meningococcal

’ Measles

Meningitis ’ JEV

ETC.

Other Risks to the Traveler

23

’ Accidental injury

’ Environmental hazards

’ Crime and assault

’ Psychiatric problems

’ Animal bites, stings and envenomations

’ Dermatologic disorders

’ Altitude

Immunizations to Consider for Adult

Travelers

24

Travel related

Hepatitis A before travel, check if if someone is going to a certain country, you

he is hepatitis should look for the common disease in this

Hepatitis B immune or not country in the CDC and educate him about these
diseases

Typhoid examples he mentioned:

Rabies Brazil> zika virus

Jamaica> malaria

Meningococcal disease Niger epola virus

Polio

Japanese encephalitis

Yellow Fever

Patient Counseling
25
K

’ Sufficient time for patient education

’ Travel Preparation

’ Environmental Precautions

’ Food and Water Precautions

’ Vector Precautions

’ Bloodborne and STD Precautions

’ Animal Precautions

’ Injury and Crime

Travel Preparation

26

’ Travel health insurance

Medical care

Hospitalization

’ Obtaining medical care abroad

’ Awareness of travel notices

’ Hand washing and hygiene

‫ﺟﺎب ﺳﯿﻨﺎرﯾﻮ واﺣﺪ ﻋﻨﺪه ﺿﻐﻂ وﺳﻜﺮي ورﺑﻮ اﻟﺦ وﯾﺎﺧﺬ أدوﯾﺔ ﻟﮭﻦ وﯾﺒﻲ ﯾﺮوح ﻟﻠﺤﺞ وش‬

‫ﺗﻨﺼﺤﮫ؟‬

‫ اﻟﻨﻈﺎﻓﺔ وﻧﻈﺎﻓﺔ اﻷﻛﻞ اﻟﺦ‬،‫ ﻣﻮﺿﻮع اﻟﺸﻤﺲ‬،‫ ﯾﻠﺒﺲ ﺳﻮارة ﻓﯿﮭﺎ ﻣﻌﻠﻮﻣﺎﺗﮫ‬،‫ﯾﺤﻔﻆ اﻷدوﯾﺔ زﯾﻦ‬

Environmental Precautions

27

’ Motion sickness

’ Jet Lag

’ Sun Protection
’ Extreme Heat and Cold

dehydration, heat stroke

hypothermia

Food and Water

28 Precautions

’ Bottled water

’ Selection of foods

well-cooked and hot

’ Avoidance of

salads, raw vegetables

For

unpasteurized dairy products brucellosis

street vendors ‫رﻛﺰ ﻋﻠﯿﮫ ﺷﻮي‬

ice

29

Vector Precautions

‫ﺟﺎب ﺳﯿﻨﺎرﯾﻮ واﺣﺪ ﯾﺒﻲ ﯾﺮوح ﻟﻠﺴﻮدان‬

‫وش ﺗﻨﺼﺤﮫ؟‬

indonesialmdas
’ Covering exposed skin

malaria

’ 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

’ Inspection for ticks

‫أﯾﻀﺎ ً ﻟﻮ ﻻﺣﻈﺖ أﻋﺮاض رح ﻷﻗﺮب‬

‫ﻣﺮﻛﺰ ﺻﺤﻲ‬

Bloodborne and STD Precautions

‫ﺟﺎب ﺳﯿﻨﺎرﯾﻮ واﺣﺪ ﯾﺒﻲ ﯾﺮوح ﻟﺘﺎﯾﻠﻨﺪا وش‬

’ Prevalence of 30 ‫ﺗﻨﺼﺤﮫ؟‬
‫ ﻓﯿﻌﺘﺒﺮ ﺟﻮاﺑﻚ‬STDs ‫اذا ﻣﺎﺟﺒﺖ ﻣﻮﺿﻮع‬

STDs ‫ﻧﺎﻗﺺ‬

Hepatitis B

Hepatitis C

HIV

’ Unprotected sexual activity

’ Tattooing and body piercing

’ Auto accidents

’ Blood products

’ Dental and surgical procedures

Animal Precautions

31

’ Animal avoidance

’ Rabies

Specific animal threats

Medical evaluation of bites/scratches

Post exposure immunization and

immunoglobulin ‫ﺟﺎب ﺳﯿﻨﺎرﯾﻮ واﺣﺪ ﯾﺒﻲ ﯾﺮوح ﻟﻠﺒﺮازﯾﻞ أو اﻟﺸﺎطﺊ‬

‫اﻟﻜﺎرﯾﺒﻲ وش ﺗﻨﺼﺤﮫ؟‬

‫ﻻ ﺗﺮﺗﺒﻚ وﺗﻔﻜﺮ وش اﻟﺸﻲ اﻟﺨﺎص ﺑﻜﻞ دوﻟﺔ‬

pre travel- during travel- post ‫اﺑﺪأ ﺑﺎﻟﺒﯿﺴﻚ‬

travel

‫ﻣﺜﻼً اﻟﺒﺮازﯾﻞ ﯾﻌﻨﻲ راح ﯾﻄﻮل ﺑﺎﻟﻄﯿﺎرة‬

DVT ‫ﻓﻼزم ﯾﺮاﻋﻲ ﻣﻮﺿﻮع‬

‫ وﻣﺎﯾﺠﻠﺲ وﻗﺖ طﻮﯾﻞ‬prophylaxis

‫ﺑﺪون ﺣﺮﻛﺔ‬

Injury and Crime

32

’ Vehicles

Risk of road accidents

Night travel

Seat belts and car seats

’ Use of drugs and alcohol

’ Understanding local crime risks

Situational awareness

Location avoidance

Travel Emergency Kit

33

’ 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

antacid

Band-Aids, gauze bandages, tape, Ace wraps

Insect repellant, sunscreen, lip balm

scissors, thermometer

Post-Travel Care

During first 2 weeks

34

’ Post-travel checkup

Long term travelers

Adventure travelers

’ Post-travel care

Fever, chills, sweats

Persistent diarrhea

Weight loss

Travelers Diarrhea

’ Between 20%-50% international travelers

Onset: usually first week of travel but may occur later

’ Most common agent: enterotoxigenic Escherichia

coli (ETEC)
’ Primary source of infection: ingestion of fecally

contaminated food or water. Or ice

’ Most important risk determinant: traveler's

destination

High-risk: young adults, immunocompromised, pts with

inflammatory-bowel disease , diabetes.

Travelers Diarrhea

’ Prevention: food and liquid hygiene and provision

for prompt self-treatment in the event of illness

Hydration,

’ Usually resolves in 3-5 days

’ Antibiotic prophylaxis is not recommended for

most travelers

‫ﻣﻦ ھﻨﺎ اﻟﻰ اﻟﻨﮭﺎﯾﺔ اﻟﻠﻲ ﻗﺮاه ﺑﺤﺪده ﺑﺎﻟﻠﻮن اﻻﺣﻤﺮ اﻟﻐﺎﻣﻖ‬

Management

37

’ For most travelers, we suggest a fluoroquinolone for

empiric therapy of travelers' diarrhea when

indicated. Exceptions include children, pregnant

women, and travelers to Asia, for

whom azithromycin is preferable.

38

’ Azithromycin administered as a single 1 g dose had a

higher cure rate than a three day regimen of either

azithromycin (500 mg daily) or levofloxacin (500 mg

daily); cure rates were 96, 85, and 71 percent,

respectively.

’ Antimotility agents (Motilium)are usually not

necessary for mild diarrhea. In more severe cases, we

generally advise that antimotility agents only be

taken in conjunction with antibiotics. These agents

should be discontinued promptly if abdominal pain

develops, other symptoms worsen, or diarrhea

persists.

Prolonged Diarrhea

’ Greater than 2 weeks

’ Less likely to isolate specific organism

’ More likely to be parasitic

Giardia lamblia, Cryptosporidium parvum, Entamoeba

histolytica, and Cyclospora cayetanensis most frequently

identified

detected in fewer than 1/3 travelers with chronic diarrhea

and in only 1-5% travelers with acute diarrhea

Malaria

‫ ووش افضل‬resistant ‫ماكن اللي فيها‬0‫مهم تعرف ا‬

‫ لكل حالة‬drug

Malaria

’ Largely preventable

’ Incubation period: 10

days to 1 year

’ Signs and symptoms: GI

symptoms, cyclical fevers,

anemia, splenomegaly

’ Diagnosis: thick and thin

peripheral blood smear

Thrombocytopenia without

leukocytosis

CDC Public Health Image Libra

Infecting Organisms

’ Plasmodium falciparum: potentially fatal and

considered an emergency

Acquired in Africa = 3:1 likelihood

95% have clinical onset within 2 months exposure

’ Other species: P. vivax, P. ovale, P. malariae,

fevers occurring at regular intervals of 48 to 72 hours

Malaria

Chemoprophylaxis

Largely based on

resistance patterns to

chloroquine phosphate

or hydroxychloroquine

sulfate.

(IDSA Travel Medicine Guidelines)

(IDSA Travel Medicine Guidelines)

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‫ﯾﺎﺧﺪه ﻛﻞ اﺳﺒﻮع ﻣﺮه وﯾﻨﺼﺢ ان‬
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‫اﻟﻤﺮﯾﺾ ﯾﺠﻲ ﻗﺒﻞ ﯾﺴﺎﻓﺮ ب‬
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‫اﺳﺎﺑﯿﻊ اﻟﻰ ﺷﮭﺮ‬
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It is daily medication and

He said read about it

Given once per week

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Mr. M, a 45-year-old Muslim man, visits your office in

September. He was born in Dearborn, Michigan and

attended public school there. He is going on

pilgrimage to Mecca with his father in November. He

thinks he needs some vaccines before he goes.

What vaccines does he need?

Meningeococcal vaccine

51


Meningococcal Disease

’ Vaccine required

to attend the Hajj

(annual pilgrimage

to Mecca)

If under age 15,

polio vaccination

needed also

http://news.bbc.co.uk/cbbcnews/hi/pictures/galleries/newsid_1832000/1832100.stmproof

Quadrivalent meningococcal vaccine is required by Saudi

Arabia for religious pilgrims to Mecca for the Hajj or Umrah.

All adults and children >2 years of age must have received

a single dose of quadrivalent A/C/Y/W-135.

Children between 3 months and 2 years of age must show

proof of vaccination with 2 doses of meningococcal

A monovalent vaccine with a 3-month interval between the

doses. Hajj pilgrims must have had the meningococcal

vaccine ≤3 years and ≥10 days before arriving in Saudi

Arabia.

53


Meningococcal Disease

‫ﻗﺮاه‬

’ Revaccination

If high-risk (epidemic area or travel)

÷If vaccine given at 2-6 years old

Repeat after 3 years, then every 5 years

÷If vaccine given >6 years old

Repeat every 5 years

DVT ‫مريكا )رحلة طويلة( تنصحه يتحرك عشان يتجنب ال‬0 ‫ واحد جاك يبي يروح‬M‫ مث‬:‫حظة قالها‬M‫م‬

assessment ‫وتسوي له‬

Hepatitis A Virus

‫ﻗﺮاه‬

’ Transmitted through fecal contimination of food

and drink

’ Treatment: supportive (no antivirals)

’ Vaccination

Should be immunized at least 2-4 weeks prior to traveling

Single dose: 100% protection by 4 wks

2nd dose administered 6 months later results in antibody

titers likely to last many decades

For hepatitis B there is 3 How can we know if the

doses :the first then after 1 vaccine still effective or
month then at 6 month no? via antibodies
 57

Questions?
 58

Other Resources
 Journals
59

’ 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
 Books
60

’ 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
 Websites
61
Eurosurveillance
www.eurosurveillance.org
Travax EnCompass
www.travax.com
GIDEON
www.gideononline.com
International SOS
www.internationalsos.com
Medical Advisory Service for Travelers Abroad (MASTA)
http://www.masta.org/
Armed Forces Medical Intelligence Center
www.afmic.detrick.army.mil/
Central Intelligence Agency
www.cia.gov/cia/publications/factbook/
 62

THANK YOU