Travel health pre travel evaluation

1. TRAVEL HEALTH
PRE – TRAVEL EVALUATION
DR OGECHUKWU MBANU
FAMILY MEDICINE
DEPARTMENT AKTH

2. PRETEST
• 1…. A family of four is leaving in January for a 2-
year stay in Chad. The family consists of a 46-
year-old father, a 34-year-old mother who is 5
months pregnant, a 4-year-old boy, and a 2-
year-old girl. A meningitis epidemic has just
begun in Chad. Assuming that the epidemic
strain is covered by an available vaccine, which
members of the family should be vaccinated?
A. Father and mother only
B. Father, mother, and 4-year-old boy
C. Father and the two children
D. The entire family

3. 2…Regarding Key elements of pre-
travel risk assessment which is
false
A.Pre-travel health status of the
traveler is important
B.Mode of transport is important
C.Destination(s) is important
D.Duration and season of travel is
of no consequence

4. 3….A traveller to Mexico develops
sudden onset of severe, watery
diarrhea, with four bowel
movements in the first hour and a
fever of 38.5 Cï‚° (101.3ï‚° F). The
best treatment at this time is
• A. metronidazole
• B. ciprofloxacin
• C. oral rehydration solution
• D. bismuth subsalicylate tablets

5. • 4... Which of the following vaccinations is
contraindicated for a traveller who has the
Acquired Immunodeficiency Syndrome (AIDS)
and a CD4 count of 200/mm (normal range
400/mm - 1500/mm )?
A. Japanese B encephalitis
B. Hepatitis A
C. Pneumococcal
D. Varicella

6. 5…Which of the following is the most
appropriate advice for preventing acute
mountain sickness?
(A) Take acetazolamide beginning with onset of
symptoms.
(B) Keep fluid intake low enough to prevent
pulmonary and cerebral edema.
(C) Spend two to three nights at 1500 to 2500
meters before going higher.
(D) Rest in place at onset of symptoms and
breathe emergency oxygen, if available

7. OUTLINE
1. Introduction
2. Epidemiology
3. Risks/health risk assessment
4. Medical consultation before travel
5. Special situations
6. Travel related problems
7. Immunization
8. Globally targeted travelers diseases
9. Travel health kit
10.Conclusion
11.Refrences

8. INTRODUCTION
• Also called Emporiatic Medicine is the science of the
health of travelers.
• safety of travellers ,prevention and management of
health problems before, during and after the travel.
• It includes the specialties such as:-
1 .Tropical medicine
2.Aviation medicine
3.Immunization medicine
4.Accident medicine
5.Behavioral medicine
6.Infectious diseases
• Categories travellers include Businessmen ,Tourists,
Immigrants going home (VFR’s),Students ,Missionaries
Military ,pilots,etc
• MEANS OF TRANSPORT : by air, sea, train or land

9. The Continuum of Travel health
During Travel
Preventive health
Contingency Planning
Treatment & Rehabilitation
VisitorsPre-Travel
Post-Travel

10. AIMS OF TRAVEL HEALTH
• Prevention of illnesses and injuries amongst
travelers
• Management of health related problems
• Advocates for improved health and safety
services
• Refugee and migrant health
• Health Risk Assessment for travelers
• Impact of travel on ecosystem e.g. the
introduction and spread of disease and
disease resistance e.g. spread of the Ebola
virus.

11. EPIDEMIOLOGY
• international tourist arrivals worldwide in 2010 940
million(world tourism organization)
• Leisure , recreation and holidays accounted for 51% or
446 million
• 15% for business and professional purposes
• 27% for other purposes, sush as visiting friends and
relatives (VFR), religion, health treatment, etc.
• 51% travelled by air
• 49% travelled by surface eg road (41%), rail (2%) or sea
(6%)
• Increase in air transport arrivals
• International arrivals expected to reach 1.6 billion by
2020.

12. Epidemiology in travel health cont’d
• Per 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

13. Epidemiology cont’d
• Per 100,000 travellers that have travel insurance …..
• 8000 will make a claim (8%)
• 2000 will use emergency assistance (2%)
• 400 emergency or clinic referrals (0.4%)
• 200 Hospital admissions (0.2%)
• Note that :
• Cardiovascular Disease -50 to 70%
• Accidents/Trauma -20-25%
• Infectious diseases -2.8-4%
• Traveler’s diarrhea -20-60%
• Respiratory infection- 5-20%
• Malaria (without prophylaxis)- 2%
• Hepatitis A- 0.03-0.3%
• Animal bites with rabies risk 0.3%

14. RISKS TO TRAVELERS
• Changes in altitude, humidity, temperature
• exposure to infectious diseases
• Poor quality accomodation,hygiene and
sanitation
• Inadequate medical services
• Lack of availability of clean drinking water
• Road traffic Accidents
• Unforeseen natural or man-made disasters
• exposure to atmospheric pollution
• outbreaks of known/ newly emerging infectious

15. Fog caused by air pollution in one of the urban citties

16. Air polution at mexico and lanzhou ,
china respectively
•Total suspended
particulates
(in mcg/cubic meter)
•Stockholm(sweden)
is 9
•Mexico City is 279
•Lanzhou,China 732

18. HEALTH RISKS ASSESSMENT
• Key elements of risk assessment are
1. Pre-travel health status of the traveler
2. Mode of transport
3. Destination(s)
4. Duration and season of travel
5. Purpose of travel
6. Standards of accommodation, food hygiene
and sanitation
7. Behavior and lifestyle of the traveler
8. Epidemiology of infectious diseases, road
traffic accidents (RTA)etc in the region

19. HEALTH RISKS ASSESSMENT CONT’D
• For those with underlying health problems, an
assessment is also made of:
1. Availability of appropriate medical services
in the destination,
2. Emergency treatment packs,
3. Self-treatment kits (e.g. a travellers’
diarrhoea kit);
4. Any associated public health risks (e.g. the
risk of infecting others)

20. MEDICAL CONSULTATION BEFORE TRAVEL
• 4–8 weeks before the journey
• preferably earlier if long-term travel or
overseas work
• For last-minute travelers as late as the day of
travel can be beneficial
• information about health risks (including traffic
accidents)
• Evaluation of need for any vaccinations
• Evaluation /advice on existing medical
problems
• malaria prophylaxis if needed

21. consultation before travel cont’d
• The travelers budget
• Comprehensive travel insurance.
• Medical items , the traveler may require
• A model checklist , protocol or Pre -
departure questionnaire
• All relevant information is obtained and
recorded
• provision of a basic medical kit
• Post travel consultation appointment

22. consultation before travel cont’d
Evaluation of patient ;
• Bio-data
• Any presenting complaints
• Past medical and surgical history
• Existing medical issues: Pregnancy ,disability
Breastfeeding ,Immunocompromise ,
Psychiatric condition , Seizure disorder
,cardiopulmonary events
• Drug history

23. Evaluation of patient cont’d
• Immunization history : Routine/travel vaccines
• Previous travel experience
• Trip Details
• Itinerary: : Countries and specific regions, order
of countries if >1 country ,Rural or urban
• Timing: Trip duration ,Season of travel, Time to
departure
• Reason for travel : Tourism ,Bussiness, VFR etc
• Travel style: Independent or package tour,
Modes of transportation and accommodations

24. Evaluation of patient cont’d
• Comprehensive physical examination
• Investigations: determined by
patients specific need and the
country of destination
• May include ;chest x- ray, mantoux
test , serology for hepatitis B,C, RVS,
VDRL , ECG, EEG etc

25. SPECIAL SITUATIONS; AGE
• New born: No limitations’ except babies less
than 7 days old.
• Elderly: no contraindication, should be advised
to ensure:
 comfortable seating,
 Adequate fluids,
 small meals
 move around and preferable to sit at the aisle.
• Adolescents: Risky behaviour – eg engaging
prostitutes, drug related issues

26. UNUSUALLY HIGH ALTITUDES
• Altitudes greater than 8000ft(2450m) can lead to
HIGH ALTITUDE ILLNESS.
• These includes;
Acute mountain sickness(AMS);- starts from 14000ft
• Non specific, Headache, nausea, vomiting, insomnia,
fatigue ,malaise ,like alcohol intoxication
High altitude cerebral oedema(HACE);-AMS with
AMS ,AMS +obvious weakness, ataxic gait, mental
function, level of consciousness , coma
High altitude pulmonary oedema(HAPE);- cough –
initially non productive ,then frothy sputum, SOB
,tachycardia , haemoptysis , loss of consciousness
26

27. PRECAUTIONS
• Gradual acclimatization over 2- 4 days
• Begin exertion at <8000ft , 2 to3 nights between
8000-10,000ft before ascending >10,000
• Sleep no more than 1500ft higher each day
• Avoid alcohol or sedatives
• Avoid dehydration or hypothermia
• Consider acetazolamide 250mg bid – start the day
before ascent ,1) when climbing >11,400ft , 2)if hx of
altitude sickness, or3) when acclimatization is not
possible
• Don't go higher if altitude sickness is present;
descend, if symptoms don’t improve in 12hours, get
supplemental oxygen & dexamethasone
27

28. Travellers with chronic problems
• chronic illnesses : diagnosis ,drug doses on their
persons e.g a hand band
• A medical report
• Medicines in hand luggage with prescriptions
• For the disabled-
Inform airline ahead
Specify required assistance
Arrange for companion
Request seat near toilet
• For HIV patients - avoid live vaccine if
CD4<200iu/L patients with CD4>500iu/L fare
better

29. DIBETES MELLITUS
• Have some snacks, crackers, nuts or sugar
cubes.
• Early signs of hypoglycemia
• Well equipped with supplies eg insulin
• Diabetic I.D tags or bracelets is worn
• A card with the insulin dose should be
carried.
• Maintain the departure timing throughout
the journey, for meals and medication
• Adjust to arrival/local time after arrival at
the final destination

30. HEART DISEASES
• Persons with stable heart disease can
travel
• Not recommended if recent heart attack
, unstable angina or uncontrolled CCF.
• Recent ECG and a medical report
• Pacemakers may activate metal detectors
• Mefloquine not to be given concurrently
with antiarrhythmics or B-blockers.
• Tailor activities to their physical
capabilities.

31. PREGNANT TRAVELLERS
• Second trimester preferable
• Most airlines will not carry passengers after
35weeks of pregnancy on international flights or
36weeks on domestic flights. For twin pregnancies ,
32 weeks is the limit.
• If unstable e.g PIH postpone travel
• Avoid Long hours of immobilization
• Use seatbelts continuously, belted low
• Avoid gaseous meal : causes expansion in the
bowel during travel with resultant pain
• Avoid live vaccine except polio vaccine when
indicated

32. POST OPERATIVE FLIGHT PERMIT
• 24 hours after keyhole surgery
• 10 days after simple abdominal surgery
• 10 to 14 days after chest surgery or a coronary
artery bypass graft
• One day after simple cataract or corneal laser
surgery
• Seven days after more complicated eye
surgery
• two to six weeks after surgery for retinal
detachment
32

33. POST OPERATIVE FLIGHT PERMIT
• Seven days after brain surgery
• One day after a colonoscopy
• One day after surgery where a plaster cast
is applied, for flights that are less than two
hours long, or two days for longer flights
Three months if:
• Lung resection
• Joint replacement, such as a hip or knee
replacement
33

34. TRAVEL RELATED PROBLEMS
• Motion sickness; occurs in all means of travel,
chemoprophylaxis can be helful
• Jet Lag
• Altitude Illness
• Barometric changes
• Claustrophobia
• Stress & anxiety
• Motion sickness

35. Travel related problems cont’d
Barometric changes ;
• cabin air pressure gases to expand as the
air craft ascends .
• On descent,there is  in air pressure gases
contract.
• Air escapes the middle ear and sinuses on
accent and flows back on descent.
• altitude of about 2,100 m (7,000 feet)
above sea level , causes in oxygen
saturation of Hb.

36. travel related problems cont’d
Barotraumas (decompression sickness)
• Physical damage to body tissue due to
difference in pressure between a gas space
inside or in contact with the body and the
surrounding gas or fluids
• Causes Tissue rupture
• Introduction of gas circulationair embolism
Damage to :-
Middle ear – barotitis / aerotitis/ aero plane ear
paranasal sinuses – aero sinusitis
 teeth – barodontalgia,

37. Travel related problems cont’d
Effect of barotrauma
• symptoms includes clogging of the ear ,
ear pain, hearing loss ,dizziness , tinnitus
,bleeding from the ear etc
• If ear ,nose,or sinus infections are
present flying should be postponed.
• decongestant nasal drops shortly before
flight and before descent may be helpful
if flight cannot be postponed

38. Travel related problems cont’d
Control of the effect of
barotrauma
• Chewing of gums
• Frequent swallowing
• Use of pacifiers in babies
• Valsalva manoeuvre

39. Travel related problems cont’ d
JET LAG : Desynchronosis or circadian dysrhythmia,
• Caused by alterations to the body's circadian
rhythms (CR)due to rapid long-distance trans-
meridian (east–west or west–east) travel.
• North–south flights that do not cross time zones do
not cause jet lag
• CR goes out of synchronisation with the destination
time, as it experiences daylight and darkness contrary
to the rhythms to which it has grown accustomed
• It may last several days
• Recovery period of one day per time zone crossed is
a suggested

40. JET LAG CONT’D
• Adjustment to the new time zone is faster for
east–west travel than for west–east.
• Westward adjustment = in days , about half the
number of time zones crossed;
• Eastward adjustment= takes about two-thirds the
number of time zones crossed
• Affects the physical /mental performance e.g
athletes
• Ship or train is slower thus not much jet lag
• Different from travel fatigue which does not
involve a shift in CR

41. JET LAG CONT’D
common symptoms of jet lag:-
• Anxiety
• Dehydration
• Disorientation
• Exhaustion
• Headache
• Indigestion, and
• Impaired Coordination

42. JET LAG CONT’D -- PREVENTION
 BEFORE FLIGHT
• Reduce stress , Eat light healthy meals
• Maintain exercise routine
• Go to bed earlier for a couple of nights before leaving if
you are traveling east
• Go to bed later for a couple of nights if you are traveling
west
DURING FLIGHT
• Arrive at the airport early and wear comfortable clothes
• Use flight time as time zone transition time
• Sleep as much as you can on the plane
• Get up and stretch or walk the aisle , drink plenty of water
42

43. JET LAG CONT’D -- PREVENTION
DURING FLIGHT
• Avoid alcohol before and during the flight
Slows down your circadian rhythm
Increases dehydration
• Avoid Beverages with caffeine
• Avoid Sleeping pills
AFTER FLIGHT
• Carefully control exposure to light or avoid bright lights
• Try to sleep and eat on new time zone schedule
• Stick to established daily routines
• Expose yourself to sunlight
• Keep naps to less than 45 min. or to more than 2 hours

44. JET LAG CONT’D
After flight :-
Other measures include:
• Timed light exposure
• Light therapy , used by professional athleths
• Special glasses, usually battery-driven, provide
light to the eyes, inhibiting the production of
melatonin
• Timed melatonin administration
• Timing of exercise and food consumption
• Short-acting sleep medications

45. travel related problems cont’d
MOTION SICKNESS :
• Disturbance in the inner ear due to repeated
motion e.g. swell of the sea, plane in turbulent air
• Affects the organs of balance and equilibrium in
the inner ear.
• Motion is sensed by the brain through :
 the inner ear (sensing motion, acceleration, and
gravity),
 the eyes (vision), and the deeper tissues of the
body
 surface (proprioceptors)

46. Motion sickness cont’d
• For Intentional movement eg. when we walk,
the input from all three pathways is
coordinated by our brain.
• During unintentional movement eg.when
driving in a car, there may be dis-coordination
among the inputs from the three pathways
• Symptoms includes – nausea, vomiting ,
dizzyness, sweating, malaise,
• Drugs used for management includes –
meclizine ,diphenhydramine .prometazine
,dimenhydrinate

47. Motion sickness cont’d – prevention :-
• Ride where eyes will see the same motion that body
and inner ears feel.
• In a car, sit in front seat , look at the distant scenery.
• On a boat, go up on the deck and watch the motion of
the horizon.
• In an airplane, sit by the window and look outside,
choose a seat over the wings
• Do not read while traveling and do not sit in a seat
facing backward.
• Do not watch or talk to another traveler who is having
motion sickness.
• Avoid strong odors and spicy food

48. IMMUNIZATION
• Immunization is the administration of a vaccine to
stimulate a protective immune response if there is
subsequent contact with the infectious agent.
• Vaccines rarely protect 100% of the recipients
• So precautions against infection should still be
followed
• Schedule for vaccination must be personalized and
tailored to the individual traveller’s
1. Immunization history
2. The countries to be visited
3. The type and duration of travel
4. And the amount of time available before departure

49. IMMUNIZATION cont’d
• Routine ,Required ,Recommended
• Non-immunized or incompletely immunized
should :-
1. Get routine vaccinations recommended in
national immunization schedules, and
2. Those needed for travel
• Inactivated vaccines can be given at any time or
with any live vaccine with no interference of
immunity
• Most live vaccines can be given simultaneously
with each other
49

50. IMMUNIZATION cont’d
• If two live-virus vaccines are not administered
on the same day, then allow a 4 weeks
interval between administration
• Time intervals for vaccines requiring more
than one dose should be followed
• Slight variation can be made to accommodate
the needs of travellers who may not be able
to complete the schedule
• Significant shortening of the intervals
however is not recommended

51. IMMUNIZATION cont’d -- Routine immunization :
• Routine vaccinations can be boosters to standard
immunizations of childhood especially tetanus and
diphtheria
1. Diphtheria, tetanus, and pertussis
2. Hepatitis B
3. Haemophilus influenzae type b
4. Human papillomavirus
5. Measles, mumps and rubella
6. Poliomyelitis
7. Rotavirus
8. Tuberculosis (BCG) ,Pneumococcal vaccine
9. Yellow fever etc
51

52. Immunization cont’d -- Required vaccination :-
• Those required by WHO or some ministries of health
of some countries
• Yellow fever is required by WHO for all travelers
• Meningitis vaccine mandatory for all pilgrim to Saudi
Arabia
• Administered by authorized center & the
international immunization certificate (Yellow card)
issued ,they include;
• Hepatitis A
• Japanese encephalitis
• Meningococcal infection
• Tick-borne encephalitis ,others are typhoid fever
,rabies ,yellow fever, cholera etc
52

53. Immunization cont ’d -- Recommended vaccine
• Given on the basis of risk of exposure as assessed
from the traveller's
1. itinerary and
2. immune status
They include:
• Hepatitis A, hepatitis B, or Twinrix
• Rabies, Typhoid, cholera
• Chicken pox, Influenza,
• Japanese encephalitis, meningococcal,
• Pneumococcal and tick-borne encephalitis
53

54. Table 1: Travelers' Common Immunisation Schedule, Side Effects and
Precautions
Vaccine
Nigeria
n
Childho
od
Schedul
e
Standa
rd
Regim
en
Booster
s
Age
Minimu
m
interval
before
travel
Adverse
Effects
Remarks
Yellow
Fever
(YF-Vax)
0.5 mls
SC at 9
months
0.5 mls
SC
0.5 mls
every 10
years
>9
months
> 10
days
Headache,
myalgia,
fever,
encephalitis
especially in
the elderly
Contraindicated in pregnancy,
patients with egg allergy and
immunocompromised
patients. Avoid concurrent
administration with other live
virus vaccines (MMR, Oral
Polio, varicella, Oral ty21a)
Meningoc
occal
(Menomu
ne)
0.5 mls
SC at 2
years
0.5 mls
SC
0.5 mls
every 3
to 5
years
>2 years > 10
days
injection site
soreness
Safe in pregnancy
Hepatitis
B
(Recombi
vax;
Engerix
B)
0.5 mls
at birth,
6 weeks
and 14
weeks
1 ml im
at 0, 1,
and 6
months
1 ml
every 10
years
>20
years
> 10
days
injection site
soreness,
headache
Safety in pregnancy not
determined. Contraindicated
in yeast hypersensitivity. Age
20 yrs is used here only if
childhood doses have been
administered 54

55. Typhoid
(Vivotif
Berna
Oral
Ty21a)
Not
applicab
le
4
capsul
es-one
given
alternat
e days.
4
capsule
regimen
every 5
years
>6 years immedia
tely
Nausea,
vomiting,
cramping
pain.
The capsule most be
refrigerated; each capsule
should be taken whole (do not
chew) with cool liguid 1 hour
before a meal. It is
contraindicated in pregnancy
and immunocompromised
patients. Start mefloquine or
chloroquine at least 3 days
after completion of the
vaccine.
Typhoid
(Typhim
VI)
Not
applicab
le
0.5 mls
im
0.5 mls
im every
2 years
2 years immedia
tely
Nausea,
vomiting,
cramping
pain.
Safety in pregnancy not
determined.
Rabies
(HDCV)
Not
applicab
le
1 ml im
at the
deltoid
area
0, 7,
21or
28
days.
(three
doses)
same
dosage
every 2-
5 years
all ages immedia
tely
Myalgia,
lymphadeno
pathy
Pregnancy not a
contraindication to pre-
exposure therapy. After
animal bite rabies vaccine is
needed on day 0 and 3 if pre-
exposure vaccination has
been given. Mefloquine and
chloroquine may interfere with
intradermal Imovax if
administered concurrently.
55

56. Rabies
(Imovax,
Rabivax)
Not
applicabl
e
1 ml im
at 0, 7,
21, 28
days.
same
dosage
every 2-5
years
all ages immediat
ely
Myalgia,
lymphadeno
pathy
Pregnancy not a contraindication
to pre-exposure therapy. After
animal bite rabies vaccine is
needed on day 0 and 3 if pre-
exposure vaccination has been
given. Mefloquine and
chloroquine may interfere with
intradermal Imovax if
administered concurrently.
Hepatitis A
(Havrix;
Vaqta)
Not
applicabl
e
1 ml im 1 ml im
6-12
months
after first
dose
>19 years immediat
ely
injection site
soreness,
headaches
Safety in pregnancy not
determined
Polio Oral
(live
vaccine)
2 drops
by mouth
at birth,
6wks,
10wks
and 14
wks
three
doses
of 2
drops at
weekly
interval
s
one dose
of 2
drops by
mouth
all ages immediat
ely
Nil Can be administered in
Pregnancy if the traveler is going
to a highly endemic area.
Cholera
(parenteral
)
Not
applicabl
e
0.5 mls
SC at 0
and 7
days
0.5 mls
after 6
months
>6
months
immediat
ely
Injection site
soreness
Safety in pregnancy not
determined
56

57. Cholera
(Live
Oral
CVD
103-Hgr)
Not
applica
ble
A dose
by
mouth
in an
empty
stoma
ch
A dose
by
mouth
after 6
months
> 2
years
immedi
ately
Nil Safety in pregnancy not
determined
Tetanus
toxoid
0.5 mls
im at 6,
10, 14
weeks
in the
combin
ation as
DPT
two
doses
of 0.5
mls im
at 0
and 4
weeks
single
dose of
0.5 mls
im at
least 6
months
from
2nd
dose
>6
weeks
immedi
ately
Fever,
injection
site
soreness
Very safe in pregnancy
Measles,
Mumps,
Rubella
(MMR)
Not
applica
ble
0.5
mls
SC
A dose
sc at 4-
6 years
old and
once in
adult life
.
>15
months
immedi
ately
Fever Not safe in pregnancy
57

58. Varicella
(Varivax)
Not
applica
ble
0.5
mls im
None
recom
mende
d now
>12
months
immedi
ately
vaccine
associated
rash may
develop in
5% of
vaccinees
Not safe in pregnancy
Japanes
e
encepha
litis (Je-
Vax)
Not
applica
ble
1 ml
SC on
days
0,7,
30
1 ml
SC
every
2-3
years
>3
years
at least
10
days
before
departu
re
Fever,
headache,
nausea,
vomiting
Safety in pregnancy not
determined
58

59. GLOBALLY TARGETED TRAVELERS DISEASES
• Main diseases of global burden to travelers;
1)Malaria
2)Cholera
3)Travelers diarrhoea
• Advise on risk of HIV & other STDs, benefits
of safe sex, or preferably abstinence
• Some other diseases are country specific &
vaccinations are recommended eg ;
Africa - meningitis, typhoid, poliomyelitis,
yellow fever, etc
Asia - above plus Hepatitis A ,Japanese E
South America - as above +/- yellow fever
59

60. Globally targeted travelers diseases cont’d -- Malaria
• Big killer especially for travelers from non-endemic area
• Risk assessment based on(1) itinerary(2), species of
malaria at the destination(3) season(4) duration of travel
and (5)access to medical care should be made
• Travellers should be encouraged on
1. risk awareness,
2. avoidance of bites(nets, repellants—
DEET,permetrine) ,Wear clothing that reduces
exposure
3. Stay in screened or air conditioned rooms
4. Chemoprophylaxis
5. prompt diagnosis and treatment
60

62. RISK ASSESSMENT AND PREVENTIONMalaria risk Type of prevention
Type I Very limited risk of malaria
transmission
Mosquito bite prevention
only
Type II Risk of P. vivax malaria only or
fully chloroquine-sensitive P.
falciparum
Mosquito bite prevention
plus chloroquine
chemoprophylaxis
Type III Risk of P. vivax and P. falciparum
malaria transmission, combined
with emerging chloroquine
resistance
Mosquito bite prevention
plus chloroquine +
proguanil
chemoprophylaxis
Type IV (1) High risk of P. falciparum
malaria, in combination with
reported antimalarial drug
resistance; or
(2) Moderate/low risk of P.
falciparum malaria, in
Mosquito bite prevention
plus atovaquone–
proguanil (malarone),
doxycycline or
mefloquine
chemoprophylaxis (select

63. Malaria prophylaxis
Mefloquine 250 mg (base) once wkly. Start 1-2 wks before entering malarious area and
continuing until 4 wks after leaving.
Sulfadoxine-pyrimethamine 500/25 mg wkly Start 1-2 wks before entering malarious area and
continuing until 4 wks after leaving.
Doxycycline 100 mg daily Start 1-2 day before entering malarious areas and
continues until 4 wks after leaving. Not suitable
for pregnant women and children below 8
years. The drug should be taken with food and
not used simultaneously with antacid or
bismuth-containing product.
Atovaquone/proguanil 250/100 mg tab, one tab
daily
Start 1-2 day before entering malarious area and
continuing until 7 days after leaving.
Proguanil 200 mg daily Start 1-2 day before entering malarious area and
continuing until 4 wks after leaving.
Chloroquine 300 mg (base) once wkly Start 1-2 wks before entering malarious area and
continuing until 4 wks after leaving.
Chloroquine/Proguanil As for Chloroquine and
Proguanil above
This combination has been safely used in pregnant
women.
Primaquine 30 mg base once daily Start 1-2 day before entering malarious areas and
continues until 4 wks after leaving. It very good
for areas with P-vivax and P-ovale infection.
Take drug with food. Contraindicated in
pregnancy and persons with G6PD deficiency
63

64. Globally targeted travelers diseases cont’d -- Cholera :-
 Two types of oral cholera vaccines are available:
1. Dukoral
2. Shanchol and mORCVAX
• Efficacy is 52% in the 1st year after being given and 62% in
the 2nd year, with minimal side effects.
• Available in > 60 countries
• Complete protection within 8 days
 Parenteral (subcutaneos) cholera vaccine provides limited
brief protection against 01, may not provide any protection
against 0139,
• It has a high cost-benefit ratio; therefore, the vaccine is not
recommended for travellers
• Given on days 0 & 7, and booster at 6 months
64

66. Cholera cont’d
• Preventive measures : drink clean water , cook
foods well & eat hot , avoid shell fish , peel instead
of wash fruits
• Antibiotic treatments for 1 to 3 days shortens the
course of the disease and reduces severity
• Doxycycline is firstline,Other antibiotics include
cotrimoxazole, erythromycin, tetracycline,
chloramphenicol, and furazolidone.
• NOTE
CDC – On Vaccination for Cholerae
• Cholera vaccine is no longer required, nor
recommended for the vast majority of travellers by
the Centres for Disease Control and Prevention
(CDC).

67. TRAVELLERS DIARRHOEA (TD)
• Most common illness affecting travelers
• Occurs within the 1st 14 days of travel, if caused by
enterotoxic E. coli
• Typically, self-limiting lasts 3-5 days
• Each year affects 20%–50% of international
travelers ( >10 million people)
• In 10% persistent diarrhoea,
• 30% are confined to bed
• 40%change itinery,
• 10%post infection IBS
• Commoner in the developing world ,rates > 60%

68. ETIOLOGY OF TRVELLERS DIARRHOEA
Bacteria (60%)
 E.coli(ETEC ,EAEC)
 Shigella
 Salmonella
 Campylobacter
 Aeromonas
 Plasiomonas
Unknown (20% - 30%)
Others – lactose intolorance ,
irritable bowel
Rifaximin is effective for E coli
Parasitic (3%)
 Giadia
 Cryptosporidium
 Entamoeba histolytica
 Cyclospora
 Isospora
 Dientamoeba
Viral (10%)
 Norovirus
 Rotavirus
Travellers diarrhoea affects
more of young adults

70. TD – Treatment
• Usually no dehydration in adults, but should
fluid
• Self management is recommended
• Seek medical attention if it persists after 48 hours
Steps to take includes:
Rehydration(ORS - especially for young children)
symptom management
Fluoroquinolones are 1st line agent ,Azithromycin
in cases of resistance
• Loperamide is not recommended if gross blood in
the stool or a temperature > 38.50C, or in children
70

71. TD -- Prevention
• Eat at restaurants with a good reputation
for food safety
• Peel fruits and vegetables
• Eat steaming hot, thoroughly cooked
food
• Avoid tap water, ice cubes, fresh salads,
unpasteurized dairy products, cold sauces
and toppings, undercooked or reheated
food
71

72. YELLOW FEVER

73. YELLOW FEVER(YF) cont’d
• YF Vaccination certificate is the only compulsory
health certificate needed for international travel
• valid for 10 yrs
• WHO (2013) says it is valid for life
• Attenuated live vaccine
• Effective 10days after vaccination
• Vaccination may not be required if travelling to a
low risk or No risk region
• Those with waivers may still be denied entry
,quarantined or vaccinated at the point of entry
• There is an outbreak currently in brazil

74. TRAVEL HEALTH KIT
• Personal Prescriptions
• Condoms
• Antimalarial medications
• OTC antidiarrheals and antibiotic for diarrhea
• allergy meds
• laxative
• antacid
• Epi-Pen (with hx allergy)
• insect repellant (DEET)
• sunscreen
• oral re-hydration salts
• first aid items
• migraine regimen
• Any other standing instructions
• Travellers should carry a medical card or other document
showing their blood group

75. CONCLUSION
• There are common illnesses associated
with travelers and endemic areas
associated with some of the diseases
• Pre-travel evaluation ensures safety of
travelers, prevention and management of
health problems before and during travel

77. REFERENCE
• Steffen R et al. J infect dis 1987; 156:84-916
• Leggat et al. Travel med inf dis 2005;3:9-17.
• Primer of travel medicine 3rdd ed
• Lecture on emporiatrics by dr Maqsood Hayat
• Emporiatrics by Dhanush Anand
• International travel and health– WHO 2012
• Travel health: immunization and chemoprophylaxis by Aboi J.K . Madaki
• The pre-travel consultation Gary W. Brunette, MD, MS
• Travelers’ health team division of global migration and quarantine
centercholera, malaria, tuberculosis
• (TB) and aidss for disease control and prevention
• INFECTIOUS DISEASE CHOLERA by: kamal Bahadur Budha
• Vibrio cholerae update dr.T.V.Rao
• MDMOTION SICKNESS dr Jignesh Vora
• Wikipedia