Dr. Shelub discusses the benefits of a pre-travel consultation.

1. Travel Medicine and the Pre-
Travel Consultation
Aaron Shelub
AaronShelub @aaronshelubmd
Board Certified Internal Medicine
Board Certified Infectious Disease
Certified Yellow Fever Vaccine
Provider
May 21st 2012
1
CDC presentation for healthcare professionals

2. 2

3. Outline
• Travelers’ Health Epidemiology
• Traveler Assessment
• Itinerary Review
• Sources of Information
• Risks to the Traveler
• Common diseases of concern
• Travel Vaccines
• Travel Medications
• Counseling
3

4. U.S. Residents Traveling Abroad*
Number of Travelers (millions)
65
60
55
50
45
95
96
97
98
99
00
01
02
03
04
05
19
19
19
19
19
20
20
20
20
20
20
*ITA, includes travel to Canada Year
4
and Mexico

5. International Travel
80 900
70 800
700
US Resident travel in millions
Worldwide arrivals in millions
60 US nonresident
Inbound (ITA)
600
50 US Resident Air
Outbound (ITA)
500
40 All US Resident
400 Outbound (ITA)
30 Worldwide arrivals
300 (WTO)
20
200
10 100
0 0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
5

6. Where Do U.S. Residents Travel?
Of the 17% who traveled outside the U.S. . . .
40
30
%
20
10
0
Z I a t
ad
a
ro
p e
/N ico ric
a a n
a/
P s ia ric ea
n as
n s x e ap i rA Af b E
Ca E u Au Me Am
J
ea
n e rib le
S Oc Ot
h
Ca M idd
or
C
6
Source: HealthStyles Survey 2005

7. VFRs: Visiting Friends and Relatives
• 12% of US population are first- or second-generation
immigrants in 2008 2
• VFRs comprised ~34% of US international air travelers
in 20083
• 68% of imported malaria cases in US civilians occurred
among VFRs 4
• 66% of typhoid cases (South Asia and Latin america) 5
1US Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000, issued Dec 2003 (Previous: US Census Bureau, Profile of the
Born Outside the United States Population 2000, issues Dec 2003
2 Yellow Book page 547, 2012 edition
3 Yellow Book page 547, 2012 edition
4 yellow book pg 548, 2012 edition 7
5 yellow book pg 548, 2012 edition

8. 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 R et al. J Infect Dis 1987; 156:84-91
8

9. Estimated Incidence rate per month of infections and
fatal accidents among travelers to developing countries
9
Yellow book page 12 2012 version

10. Yellow book figure 1-2 Proportionate morbidity among ill travelers returning from the developing world according to region of travel.
10

11. 11

12. The Patient: Medical Issues
• Age-specific issues
• Underlying illness,
immunosuppression
• Systems review
• Medical history
• Medication use
• Vaccination history
• Allergies
• Contraindications to vaccines and
medications 12

13. The Patient: Other Issues
• Reproductive
– Pregnant
– Breastfeeding
– Preconception
• Risk-taking behaviors
13

14. Travel Itinerary
• Full itinerary
– Dates, duration, stopovers
– Seasonal considerations
• Styles of travel
– Rural vs. urban
– Budget vs. luxury
• Accommodation
– Hotel vs. camping
• Activities
– Business vs. tourism
– Adventure, safari
– Missionary/Humanitarian/NGO
– -Sexual or Medical tourism
14

15. 15

16. Travel Health Resources
• 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”
– www. Healthmap.org
16

17. Travelers’ Health Website
www.cdc.gov/travel
17

18. Regional Destinations
• Region-specific pages
• Goal to move to country-specific format
18

19. Travel Notices & Announcements
19

20. Figure 2-01. Leading causes of injury death for US citizens
in foreign countries, 2007–2009
Data from US Department of State. Death of US citizens abroad by non-natural causes. Washington, DC: US Department of State; 20
2010.
Available from: http://travel.state.gov/law/family_issues/death/death_600.html .
2Excludes deaths of US citizens fighting wars in Afghanistan or Iraq.

21. Table 2-12. Estimated traffic death rates in the 20
countries most frequently traveled by US residents
• Country reported # rate/100,000
• Mexico 22,103 20.7
• Thailand 12,492 19.6
• India 105,725 16.8
• China 96,611 16.5
• Greece 1,657 14.9
1Data from the US Department of Commerce. 2008 United States resident travel abroad. Washington, DC: US Department of Commerce; 2010. Available
from: http://tinet.ita.doc.gov/outreachpages/download_data_table/2008_US_Travel_Abroad.pdf (PDF) and World Health Organization. Global Status
Report on Road Safety: Time for Action. Geneva: WHO; 2009. Available from: http://whqlibdoc.who.int/publications/2009/9789241563840_eng.pdf .
(PDF)
2Deaths reported in the local population in 2007. For comparison, the number of reported traffic deaths in the United States was 42,642, with an estimated
traffic death rate of 13.9 per 100,000

22. Infectious Disease Risks to
the Traveler
• Malaria • Schistosomiasis
• Diarrhea • Tuberculosis
• Leishmaniasis • Leptospirosis
• Rabies • Polio
• Dengue • Yellow Fever
• Meningococcal • Measles
Meningitis • JEV
ETC. 22

23. Other Risks to the Traveler
• Accidental injury
• Environmental hazards
• Crime and assault
• Psychiatric problems
• Animal bites, stings and envenomations
• Dermatologic disorders
• Altitude
• …….
ETC. 23

24. Case presentation
• 38 yo male with no significant pmh
returns from Mexico with fever 101.3,
fatigue and muscle aches.
• He was camping outside and on a
“vision quest”
• Labs reveal wbc 2.4 and mild anemia
• Feels better with IVF
24

25. Dx?
25

26. Probable Dengue Fever
26

27. Dengue Fever Risk Areas
27

28. Dengue Fever
• positive-strand RNA viruses of the genus
Flavivirus, family Flaviviridae
• bite of an infected Aedes aegypti mosquito
• World Health Organization (WHO) estimates
that 50 million cases of dengue occur every
year,
• Infection rates (based on serology) among
febrile travelers returning from dengue-
endemic areas in the tropics are 3%–8% 28

29. Dengue Fever Clinical
Presentation
• travel  tropics and subtropics before symptom
onset (incubation usual 4-7d)
• acute febrile illness with 2 or more of the following:
headache, retroorbital pain, muscle aches, joint pain,
rash, hemorrhagic manifestation, or leukopenia.
• Dengue shock syndrome (DSS) is defined as a
syndrome in a patient who meets the criteria for DHF
and has hypotension, narrow pulse pressure (≤20
mm Hg), or frank shock.
29

30. Dengue Fever dx and Rx
• Dx: serologic testing for IgM anti-DENV.
• Rx: Supportive care
• DHF/DSS: abrupt change from fever to
hypothermia, severe abdominal pain,
persistent vomiting, bleeding, difficulties
breathing, or altered mental status (such as
irritability, confusion, lethargy)- IVF
30

31. Dengue Fever Prevention
• being bitten highest during the early
morning,
• several hours after daybreak,
• late afternoon before sunset.
• insecticides to get rid of mosquitoes
31

32. Immunizations to Consider for Adult
Travelers
Routine Travel related
Diphtheria* Hepatitis A
Tetanus* Hepatitis B
Pertussis* Typhoid
Measles + Rabies
Mumps+ Meningococcal disease
Rubella + Polio
Varicella Japanese encephalitis
Pneumococcus Yellow Fever
Influenza
* Td or Tdap 32
+ MMR

33. Hepatitis A
• Person to person contact, contaminated water, shellfish and
other foods
• Shed in feces
• Very common vaccine-preventable infection
• Rural areas, trekking, poor sanitation = highest risk
• Abrupt onset of fever, malaise, anorexia, nausea and abdominal
discomfort then jaundice
• No treatment
33

34. 34

35. Hepatitis A cont.
• Prevention with vaccination
• Havrix 0,6-12 months
• Vaqta 0,6-18 months
• Twinrix 0,1,6 months
• Immune globulin 0.02 ml/kg 1-2 months
35

36. Hepatitis B
• Contact with blood, body fluids
• Risk by prevalence
• 90 days incubation,
• Jaundice, nausea,vomiting,abdominal
pain
• Progression to chronic Hep B 30-90%
• No treatment
• Vaccine preventative, 0,1,6 months
• All unvaccinated people traveling to
areas int to high prevalence
36

37. 37

38. Typhoid fever
• Acute life threatening
febrile illness
• Bacterium Salmonella
enterica serotype Typhi
• Consumption of water
or food contaminated
by feces
• 22 million cases
typhoid fever, 200,000
related deaths/ year 38
• Southern Asia travelers

39. Typhoid Fever Cont.
• Insidious fatigue,
• fever low high,
• HA, malaise,
• anorexia,
• hepatosplenomegaly,
• rose colored rash
39

40. Typhoid Fever cont.
• Complications: intestinal hemorrhage or
perforation
• Clinical dx
• Rx: Empiric floroquinolone
• Vaccines:
Oral live attenuated, Vi capsular polysacchride
vacc
40

41. 41

42. Yellow Fever
• Flavirus
• Vectorborne transmission
• Aedes or Haemagogus spp. Mosquito
• “Epidemiological silence” ≠ no risk
• Non-specific flu like illness, fever,chills,
HA,myalgias,n/v
• 15%jaundice,hemorrhagic sx,shock
multisystem failure, (case fatality
hepatorenal 20-50%)
42

43. 43

44. 44

45. Yellow Fever cont.
• Rx= supportive only
• Prevention: avoid mosquito bites,
vaccinate (YF-Vax)
• Several countries require proof of
vaccination from all arriving travelers or
• Travelers going through endemic
countries.
45

46. Malaria
• 1 0f 4 protozoan species genus
Plasmodium
• Transmitted by Anopheles mosquito
• Major international public health
problem
• 350 – 500 million infections worldwide,
1 million deaths annually.
46

47. 47
http://science.nationalgeographic.com/science/photos/malaria/#/malaria-parasites_1059_600x450.jpg

48. Malaria Cont.
• fever and influenzalike
symptoms,
• chills, headache, myalgias,
and malaise;
• symptoms at intervals
• severe disease, seizures,
mental confusion, kidney
failure, acute respiratory
disease syndrome (ARDS),
coma, and death may occur.
48

49. Malaria cont.
• P. falciparum = medical
emergency,
• clinical deterioration can
occur rapidly and
unpredictably.
• consider malaria: patient
with a febrile illness who has
recently returned from a
malaria-endemic country.
• Smear microscopy = gold
standard for malaria
diagnosis.
49

50. 50

51. 51

52. 52

53. Malaria Cont.
• seek medical evaluation as soon as
possible
• CDC Malaria Hotline (770-488-7788 or toll-
free at 1-855-856-4713) from 9:00 am to 5:00
pm Eastern Time
• Atovaquone-proguanil
• .Artemether-lumefantrine
53

54. Malaria cont.
Prophylaxis:
Mosquito avoidance
Chemoprophylaxis:
Atovaquone-
proguanil
Doxycycline
Others- side effect
issues
54
http://science.nationalgeographic.com/science/photos/malaria/#/mosquito-nets_1104_600x450.jpg

57. Travelers’ Diarrhea
• 30% to 70% of travelers
• “boil it, peel, it, or forget it,”
traditional
• Bacterial pathogens
predominant risk
• most common pathogen is
enterotoxigenic Escherichia
coli
• High-risk areas include most
of Asia, the Middle East,
Africa, Mexico, and Central
and South America.
57

58. 58

59. Travelers Diarrhea risk factors
• bouts of TD ≠ protect
against future attacks
• stool contamination in the
environment will be higher
and more accessible to flies
• poorly functioning
refrigeration,
59

60. Travelers diarrhea Sx’s and
prevention
• sudden onset mild cramps and urgent loose stools 
severe abdominal pain, fever, vomiting, and bloody
diarrhea.
Prevention:
• freshly cooked and served piping hot.
• avoid beverages diluted with nonpotable water
(reconstituted fruit juices, ice, and milk)
• bismuth subsalicylate (BSS), Pepto-Bismol
60
• alcohol-based hand cleaners

61. Travelers Diarrhea prevention
and Rx
• Lactobacillus GG and Saccharomyces
boulardii, = Results are inconclusive,
• Prophylactic abx = discouraged
• Rx:
ciprofloxacin or levofloxacin, azitrhomycin
Antimotility agents
Oral Rehydration Therapy
61

62. Travel Medications:
Prophylaxis & Self Treatment
• Malaria
– chloroquine, atovaquone/proguanil (Malarone),
doxycycline, mefloquine (Lariam), primaquine
• Diarrhea
– quinolone, azithromycin
• Altitude
– acetazolamide
• Motion sickness
– scopolamine, dimenhydrinate (Dramamine)
62

63. Patient Counseling
• Sufficient time for patient education
• Tailored to suit traveler
• Fitness for travel
– Understanding impact on existing
conditions
– Advisability of destinations
63

64. Travel Preparation
• Travel health insurance
– Medical care
– Hospitalization
– Evacuation
• Obtaining medical care abroad
• Awareness of travel notices
• Hand washing and hygiene 64

65. Environmental Precautions
• Air Travel
• Jet Lag
• Sun Protection
• Extreme Heat and Cold
– dehydration, heat stroke
– hypothermia, frostbite
• Altitude
• Water recreation
– Drowning, boating & diving accidents
– Risk of schistosomiasis or leptospirosis
– Biological and chemical contamination
65

66. Food and Water Precautions
• Bottled water
• Selection of foods
– well-cooked and hot
• Avoidance of
– salads, raw vegetables
– unpasteurized dairy products
– street vendors
– ice
66

67. Vector
Precautions
• Covering exposed skin
• Insect repellent containing DEET 25 – 50%
• 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
• Use of pyrethroid coils outdoors
• Inspection for ticks 67

68. Bloodborne and STD Precautions
• Prevalence of
– STDs
– Hepatitis B
– Hepatitis C
– HIV
• Unprotected sexual activity
• Commercial sex workers
• Tattooing and body piercing
• Auto accidents
• Blood products
• Dental and surgical procedures
68

69. Animal Precautions
• Animal avoidance
• Rabies
– Specific animal threats
– Medical evaluation of bites/scratches
– Post exposure immunization and
immunoglobulin
• Envenomations
– Snakes, scorpions, spiders
– Maritime animals
69

70. Injury and Crime
• Vehicles
– Risk of road and pedestrian accidents
– Night travel
– Seat belts and car seats
• Use of drugs and alcohol
• Understanding local crime risks
– Scam awareness
– Situational awareness
– Location avoidance 70

71. Travel Emergency Kit
• 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
– Pepto-Bismol tablets, antacid
– Band-Aids, gauze bandages, tape, Ace wraps
– Insect repellant, sunscreen, lip balm
– Tweezers, scissors, thermometer
71

72. Post-Travel Care
• Post-travel checkup
– Long term travelers
– Adventure travelers
– Expatriates in developing world
• Post-travel care
– Fever, chills, sweats
– Persistent diarrhea
– Weight loss
72

73. Questions?
73

74. Other Resources
74

75. Journals
• 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
75

76. Books
• 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
76

77. Websites
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/ 77

78. Travel Insurance sites
• Department of State (www.travel.state.gov )
• International SOS(www.internationalsos.com)
• MEDEX (www.medexassist.com )
• International Association for Medical
Assistance to Travelers (www.iamat.org )
• American Association of Retired Persons
78
(www.aarp.org )

79. Aaron Shelub MD
• Aaron Shelub @aaronshelubmd
• https://twitter.com/#!/aaronshelubmd
• http://www.zocdoc.com/doctor/aaron-
shelub-md-30618
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80. End
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81. Picture of diseases from vacc
shop
81