Travel Medicine – what is it? Ancaster Travel Medicine Clinic Why Travel at all? Travel expands the mind BUT Loosens the bowels Source: Lost in the myths of Travel medicine Canadian Travel Statistics     In 2005, Canadians took a record high of >6.2 million trips to countries other than the US1 1  Spent a record $9.4 billion Travel to Asia has surged 60.1% from 20001 Preference for overseas travel (vs. USA) has increased over the past decade2:  1993: 15.9% of trips abroad to overseas countries  2004: 29.3% of trips abroad to overseas countries In 2004, overnight visits to the Caribbean were up 16.7% from 20032 1. Statistics Canada. The Daily, May 29, 2006. http://www.statcan.ca/Daily/English/060529/d060529b.htm 2. Statistics Canada. The Daily, May 27, 2005. www.statcan.ca/Daily/ Tourism 2020 World Tourism Organisation www.unwto.org/facts/menu.html 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 Traveler’s Illness       Traveler’s Diarrhea ARI Malaria W. Africa Dengue Fever Hepatitis A Rabies 20-60% 5-10% 2% 0.1% 0.03-0.5% 0.3% Respiratory Tract Infections in Travelers: Geosentinel Surveillance Network 1997-2001 N=1100/21,000 CID 2003;36:399-406 Vaccine-preventable illness per No.. 100,000 Travellers 100,000 100 HAV FLU 1,000 ETEC 10,000 Steffen, J.Wilderness Med: 1994;5;56 TYPH HBV 10 CH 1 0 ETEC Influenza HAV HBV Typhoid Cholera Old Diseases    Change in Range of Diseases Japanese encephalitis Chikungunga Fever Re-emergence of Diseases Dengue Fever Change in Epidemiology of Diseases Malaria, Influenza Emerging Diseases 1981 HIV/AIDS 1986 Ehrlichosis Cyclosporiasis 1989 Hepatitis C 1993 Hanta virus Pulmonary Syndrome 1994 Hendra virus 1996 Australian Lyssavirus 1997 Avian Influenza 1999 Nipah Virus 2001 West Nile virus 2003 SARS 2004 Avian Influenza 2009 H1N1 Influenza New Diseases  36 Hours by Plane!  Air borne - e.g. Plague  Vector borne – e.g. VHF  Water borne – e.g. cyclospora Travel Medicine   Risk Assessment  Risks of traveler  Risks of destination Risk Management  Disease management  Vaccination Risk Assessment  The 5W+ questionnaire:       Who: healthy, chronically/acutely compromised? Where: area of low, moderate, high risk; urban vs. rural? What: activities planned? When: time of year, duration of trip? Why: business, pleasure, pilgrimage, visiting friends/relatives? + How: method of travel, accommodation, solo vs. group? Adapted from: Canada Communicable Disease Report. Vol. 25 (ACS-6.7), 1 Dec. 1999. Travel Itinerary  Full itinerary    Styles of travel    Rural vs. urban Budget vs. luxury Accommodation   Dates, duration, stopovers Seasonal considerations Hotel vs. camping Activities    Business vs. tourism Adventure, safari Missionary/Humanitarian/NGO Risks of Destination Infectious diseases Non Infectious Traffic Accidents Personal Safety Injury Risk DVT Animal Bites etc….. Deaths Related to International Travel Cardiovascular Medical Injury Homicide/Suicide Infectious Disease Other N = 2463 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626 The Patient: Other Issues   Reproductive - Pregnant - Breastfeeding - Preconception Risk-taking behaviors - Physical activities - Drug Use - Sexual activity Infectious Disease Risks to the Traveler       Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis        ETC. Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV Immunizations for Adult Travelers 1. 2. 3. Routine immunizations Required immunizations for travel Recommended immunizations for travel Routine Immunizations Diphtheria* Tetanus* Pertussis* Measles + Mumps+ Rubella + Varicella Pneumococcus Influenza * Td or Tdap + MMR Required Immunizations for Travel   Yellow Fever Meningococcal Recommended Immunizations for Travel Hepatitis A Hepatitis B Typhoid Japanese encephalitis Polio Rabies Travel Medicine Basics for all Travelers    Diarrhea Hepatitis A and B +/- Typhoid fever Traveler’s Diarrhea Traveler’s Diarrhea     10-60% traveler’s get diarrhea 40% change itinerary 20% confined to bed 1% hospitalized CDC, 2005 Factors associated with Diarrhea Consumption of: Cold milk Ice cubes Steak tatar Oysters ( raw ) Salads Incidence of diarrhea 26.2% 22.4% 50% 66.7% 34.6% Bismuth in Prevention of Traveler’s Diarrhoea Risk Reduction  High dose 64%  Low dose 54%  Dose 2 tabs qid max 3 weeks J Trav med 11:239 2004 Antibiotics for self-treatment of TD Drug Single dose 3 Days  Cipro 1000mg 500mg bid  Noroxin 800mg 400mg bid  Zithro 1000mg 500mg od Diarrhoea Management Oral Rehydration Mild Immodium WHO Solution Resolution • Gastrolyte • Pedialyte (loose BMs) No Response in 24 hr. No Response in 24hr. Severe Antibiotics (fever and systemic symptoms) • Quinolone • Zythromycin ORS + Zythromicin Children Adults Boil it, cook it, peel it, or FORGET IT! Easy to remember… ...Impossible to do Lawrence Green,1995 ! Hepatitis A & B Hepatitis A in Non-immune Children linked to Overseas Travel Childcare Centres Middlesex London ON 2004 15 lab confirmed cases Christchurch New Zealand 2005 21 lab confirmed cases Hepatitis Risk in Canadian Travelers      Travel time 36.5 million days/year Incidence in Canada 6.15/10000 Hep A acquired abroad 16% (4-28%) % immunised prior 19% (14-24%) Risk of Hep A in non immune traveler = approx 1:3000/month J Trav Med 11:92 2004 Trends in Hepatitis A Age Group 1992 1998 < 1 year 1-10 years 11-19 years 20-49 years > 50 years 64.6% 3.1% 20.7% 61.01% 100% 20.7% 0.66% 1.8% 64.4% 94.1% J Med Virol 2001 64:104-8 1/27/2004 16 Hepatitis A Vaccine Inactivated virus Protection rate 90% 1 dose 95-100% 2 doses Duration of Protection Lifetime Amnaestic memory Hepatitis B Epidemiology of Hep B in Canada   Acute HBV infection: 2.3 / 100 000 HBV carriers: 0.5-1.0% High risk of HBV transmission       Adventure traveling Inexperienced travelers Young travelers (20 to 29 years old) Alcohol, illicit drug use Motorcycle and/or off-road vehicle use Men Hepatitis B Risk Behaviours         Sporting activities 51.0% (of total Cosmetic procedures Holiday romance Sharing grooming items Assisting person bleeding Dental treatments Tattoos, acupuncture etc Medical Attention 28.8% 8.6% 6.3% 4.7% 3.1% 2.6% 1.3% sample) J Trav Med 2000 7: 170 % Blood/Body Fluid Exposure  Medical Acupuncture Tattoos/Piercing Shared Razors etc Injury Sexual 4.0% 1.2% 0.5% 5.5% 0.8% 9.0%  Total 15%  J.Trav Med 8:263 2001      HAV & HBV vaccines in Canada   Monovalent: ® ® ®  HAV: Havrix , Avaxim , Epaxal Berna , Vaqta® ® ®  HBV: Engerix-B , Recombivax HB Bivalent: ®  Twinrix HAV & HBV vaccines in Canada   Monovalent: ® ® ®  HAV: Havrix , Avaxim , Epaxal Berna , Vaqta® ® ®  HBV: Engerix-B , Recombivax HB Bivalent: ®  Twinrix Twinrix Accelerated Schedule (day 0,7,21 days + HBV 1yr.) (n = 100/grp) Mo. 1 2 3 Anti-HAV Sc (% ) GMT 100 832 100 956 100 662 Anti-HBV Sp (%) GMT 82 123 86 83 97 247 Nothdurft, Vaccine. 2002;20:1157-62. Typhoid Fever  Who should be vaccinated? Specific Destinations? Off the beaten track? Adventurous Eater? Typhoid     Transmission via fecaloral route, usually contaminated food or water Acute, life-threatening febrile illness 22 million cases and 200,000 related deaths occur worldwide each year Risk for Travelers 1:5000 Typhoid: the vaccines    Moderately effective approx 85% V1 polysaccharide IM boost q3 years Ty21a Oral 4 doses boost q7 years Hepatitis A / Typhoid Vaccine Vivaxim™ (Sanofi Pasteur) Clin. Ther. 2004;26:1048 • Avaxim + Typhim vi; dual chamber; IM • Seroconversion: @ 1 mo.: HAV 100%, Typhoid anti-Vi a/b 92% • Age: >16 yrs. • Booster :HAV in 6-12 mo. and typhoid 3yr • Indication : HBV immune, VFR’s The Patient: Medical Issues         Age-specific issues Underlying illness, immuno-suppression Systems review Medical history Medication use Vaccination history Allergies Contraindications to vaccines and medications Outline         Travelers’ Health Epidemiology Traveler Assessment Itinerary Review Sources of Information Risks to the Traveler Travel Vaccines Travel Medications Counseling 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 Food and Water Precautions   Bottled water Selection of foods   well-cooked and hot Avoidance of     salads, raw vegetables unpasteurized dairy products street vendors ice 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 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 Animal Precautions  Animal avoidance  Rabies     Specific animal threats Medical evaluation of bites/scratches Post exposure immunization and immunoglobulin Envenomations   Snakes, scorpions, spiders Maritime animals 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 Academic Summary Travel History Assessment of Risk Management of Risk INFORMATION IMMUNIZATION MEDICATIONS Sun Screens Altitude Sickness Jet Lag Insect Protection Food/Water Protection TD Prevention Safe Sex Safe Travel Personal Security Swimming/Walking Barefoot Travel Insurance Documentation Travel Kits Routine Required Recommended Self Rx for TD Malaria Rx Travel Health Resources Health Canada -www.hc-sc.gc.ca/hl-vs/travel-voyage/indexeng.php Public HealthAgency of Canada -www.phac-aspc.gc.ca/tmp-pmv/index-eng.php CDC Travelers’ Health Website  www.cdc.gov/travel  www.who.int/int  www.istm.org  CDC “Yellow Book”  WHO “Green Book” World Health Organization International Society of Travel Medicine   Health Information for International Travel International Travel and Health