Keeping our Traveling Students Safe and Healthy Jean

Keeping our Traveling Students Safe and Healthy Jean Haulman MD March 6, 2009

www. kidsforsavingearth. org Risks Loss of inhibitions

Your favorite “exotic” disease is only an airplane ride away

Transportation hazards http: //www. blueskyaviation. mn/medevac. html

Injury: Land & Water Leading cause of death in travelers is Motor Vehicle Accidents (<55 y/o)

Auto accidents n n n According to the Association for Safe International Road Travel, the risk is 20 -80 times higher in developing countries than in the U. S. Approximately 750 Americans die annually in auto accidents abroad, and approximately 25, 000 are injured. Why does this occur?

Modes of Transportation are Unique

Conditions leading to MVAs Poor road conditions Poor vehicle maintenance Lack of seatbelts 3 rd world countries do not always have the same rules of the road http: //www. explorenorth. com/blog/deathroad. jpg http: //www. autocult. com. au/img/gallery/full/nickop 196. jpg

Road signs may be confusing Advice for drivers in India http: //2. bp. blogspot. com/. . . q. Hw 5 g 5 ewd. M/s 400/2 Indianroadsignsmall. j pg

Traffic in Cairo http: //www. infoforhealth. org/pr/m 15/p 6 a. jpg

Donor-mobile

AAA Abroad: Roadside service varies

Rule: Pedestrians do not always have the right of way http: //www. cartoonstock. com/newscartoons/cartoonists/aia/lowres/aian 23 l. jpg

Risks Drowning is second leading cause of mortality for travelers

What is the common denominator for MVA and drowning?

Risks Illness – Destination Specific

What are the options for prevention and treatment? First step: Pack your common sense Second Step: Schedule a pre travel consultation. Novice students need in person consultation.

Pre-Travel Counseling Visit n n Focus is prevention Advice given regarding ways to minimize destination specific risks • Disease and environment education Traffic risks, drowning risks n Insect precautions n Food and water n • Vaccines • Medications for travelers’ diarrhea (TD), malaria prophylaxis, altitude sickness, HIV PEP for traveling health care students

Travel Clinic Consultation n n Itinerary Reason for travel Accommodations Duration of travel Modified by • Medical and immunization history • Allergies • Special needs

Itinerary and Reasons for Travel n Itinerary http: //www. arr-the-kraken. com/images/oz_02. jpg • Country and region • City vs. rural n n Reason for travel: backpacking, trekking, spelunking, business, study abroad Accommodations: Hotel, tent, hostel, cave, host family http: //ritz-carlton-boston-commons. visit-boston-massachusetts. com/boston-ritz-carlton-suite. jpg

Accommodations n Host families Rule: There is so such Typhoidthing as safe drinking water in a 3 rd world country unless it comes from a sealed bottle. • • • n Hepatitis A, Local water Well water • • • Meningococcal disease Influenza Tuberculosis Crowded living conditions, group travel, exposure to ill persons:

Travel location(s) and duration of stay n n Diseases follow geographic patterns and seasonal variations The longer the stay the greater the risk of travel related illness Short stays are considered <2 -3 weeks Long stays are > 1 month

Pre-travel Consultation VACCINES: Routine, Recommended and Required

Why insure completion and update of routine vaccines? World vs US n n n Diphtheria: 9, 235 Measles: 30 -40 m Pertussis 20 -40 m Polio: >35, 000 Mumps: Unknown Tetanus >300, 000 (most neonatal) 86% imported n n n 0 cases in 2005 64 cases: 2008 * 25, 827 in 2004 Last wild case 1979 5, 783 cases in 2006 @ 40 cases in 2006

Recommended n n n n Hepatitis A Typhoid Hepatitis B Rabies Polio Meningococcal JEV (HPV)

Recommended Vaccines n Hepatitis A vaccine: • 1 st dose can be given on the way to the airport • Most common vaccine-preventable illness in returned travelers, next to influenza n Typhoid vaccine: recommended for all 3 rd world travel unless staying in 4 -5 star accommodations and never eating from the street • 1140 US cases reported 1999 -2003, 74% imported

Vaccines n Hepatitis A • 2 brand of vaccines available, equally effective • Given 6 months apart • Expected lifetime immunity n Typhoid • 2 types of vaccines available • Injectable: good for 2 years n n n Can cause sore arm May feel run down for 1 day Students and insurances prefer • Oral: good for 5 years n n n Live attenuated Can cause nausea Cannot take concurrent antibiotics 1 pill qod x 4 doses Should complete 4 dose schedule at least 10 days prior to departure

Hepatitis B vaccine n n n Encouraged for all travelers at risk for MVA while traveling Recommended for sexual partner seeking travelers Recommended for travelers seeking medical procedures, tattoos, and/or piercings 3 dose vaccine given at 0, 1, and 6 months First cancer preventing vaccine Courtesy of Patricia Walker MD Ramsey Clinical Assts St. Paul, MN

Hepatitis A/B Vaccine n n Given as series of 3 Standard schedule 0, 1, 6 months • 3 doses of standard hepatitis B • 3 doses of ½ standard dose for hepatitis A n New FDA approved accelerated dosing • Advantage for travelers • Given at day 0, 7, 21 -28 days, booster at 1 year • Can fit in complete series prior to travel

Polio n 2003:

Polio n n Travel as a risk factor: 2003 and 2005, 25 previously polio-free countries were reinfected due to imports of the virus As of March 2008, only four countries in the world (Afghanistan, India, Nigeria, Pakistan, ) are still considered to be endemic for Polio However new case reports appear monthly in most sub Saharan countries Recent imported case from Indonesia to Australia

Rule: If it has fur and teeth do not touch it.

Vaccines in short supply n n Rabies vaccine: current shortage, not available for pre travel use Disease is 100% fatal Only post exposure vaccination is available HRIG (expensive) + 5 doses of vaccine on days 0, 3, 7, 14, 28

Vaccines for specific destinations JEV: SE Asia § § § § Short supply Mosquito Dusk to dawn Rainy season 30% mortality Given as a 3 dose series 0, 7, 21 days Can cause allergic reaction New 2 dose vaccine close to FDA approval

Yellow Fever: Required n n n Required vaccine Can be obtained only at a yellow fever certified center Must be documented on the official CDC or WHO yellow card 50% mortality from disease Vaccine has rare serious side effects 1 vaccine q 10 years

Meningococcal Infections n n For travelers going to Africa during the dry season Required for travelers going to the Hajj in Saudi Arabia Sporadic outbreaks in other African countries 2 vaccines • Meningococcal Conjugate vaccine: age 2 -55 yrs • Meningococcal Polysaccharide: Approved for age 3 months and older

Medications DIARRHEA Prevention A. K. A. Montezuma’s revenge Aztec two-step The trots Turkey Trots Turista

Distribution of TD

Why is diarrhea more common in the developing world?

Travelers’ diarrhea n n Incidence highest for travelers going to a 3 rd world country Food is the vector for travelers’ diarrhea more often than water

Travelers’ diarrhea n n Acute, self-limiting illness; resolves within about 5 days. 3 -10% of pts with TD will have symptoms lasting longer than 2 weeks. Up to 3% of travelers have TD lasting over 30 days. Most symptoms occur while abroad and are never reported

Treatment for Travelers’ Diarrhea (short term travelers) n n Ciprofloxacin 500 mg up to q 12 hours for 3 days (adults) OR Azithromycin 10 mg/kg up to 500 mg q 24 hrs for up to 3 days (peds and adults) OR Azithromycin 1000 mg all at once (adults) Newer option: Rifaximin 200 mg tid for 3 days

Travelers prefer to sit here http: //www. advillas. com/images/new. Images/Advillas. Bea ch. Sunset. jpg

--not here--

Malaria prevention Fever is malaria until proven otherwise AND Many developing countries treat every fever with malaria medication

Malaria Chemoprophylaxis n n Chloroquine: weekly medicine, most of the world has resistant parasites – @$0. 61 -3. 94/pill/week Mefloquine (Larium): weekly medicine @$11. 33/pill/week, spotty resistance, can cause psychosis Doxycycline: daily, cheap - @ $0. 26/pill, no world resistance known, can cause stomach upset and vaginal yeast infection. Atovaquone-Proguanil (Malarone): daily - @ $7. 33/pill

Altitude: Acute Mountain Sickness http: //terrigick. typepad. com/. a/6 a 00 e 551 f 461 c 38833010536 b 4 bd 95970 b-500 wi n n n May lead to headache, insomnia, fatigue, nausea Occurs in @ 40 -50% of lowland persons moving quickly to 14, 000 ft (4250 m) Prevention • Ascend slowly • Acetazolamide n n 125 mg bid 250 mg qhs http: //farm 1. static. flickr. com/8/7741477_a 1 c 3 f 15619_b. jpg

What to expect when illness happens during travel Medical Care may be Different

Medical care n n The standards of health care delivery differ in poorer countries The modernization of buildings and number of sky scrapers doesn’t always correlate with modern health care delivery

Modern & Shanty are often neighbors http: //images. google. com/imgres? imgurl=http: //www. tr-acnet. org/DBimages/ http: //lifegoesonintehran. com/images/03_2008/9 b-building. jpg

http: //3. bp. blogspot. com/

Clean and modern on the outside

doesn’t necessarily mean clean and modern on the inside http: //www. secretchina. com/news/up 2007/allimg/0706/9_21174418. jpg

Standards of Medical Care n n n May reuse syringes, needles May have primitive sterilization techniques (alcohol and a match) Medications and vaccines may be counterfeit Overnight stay usually requires assistance (bedding, food, etc) May be dirty, may see rodents, flies and mosquitoes

Conditions may be crowded http: //www. bnp. org. uk/wpcontent/uploads/ghanahospital. jpg http: //www. sos-

Hospital wards vary http: //www. medisend. org/images/pr 86 -1 -lg. jpg

http: //www. globalpas. org/gpasblog/uploaded_images/ward-761111. jpg

Tanzania: Surgical gown sterilization http: //images. google. com/imgres? imgurl=http: //movetcd. com/images/DSCF 3188. JPG&imgrefurl=http: //movetcd. com/MOVE 2. html

Medical care while traveling n n n Advise small medical kit Syringe kits for high risk destinations Have medical/evacuation insurance: • Access America (Word Access): 1 -800 -2848300 • International SOS: 1 -800 -468 -5232 • ASA, Inc. : 1 -888 -ASA-8288 • Gateway: 1 -800 -282 -4495 • Travel Assistance: 1 -800 -821 -2828 • Medjet assistance: 1 -800 -9 MEDJET • Divers Alert Network n Have health insurance on return

Medicine Kit n n n n n Sunscreen NSAIDs Moleskin Non Neomycin-containing antibiotic, band-aids Antifungal cream (wear white cotton socks) Hydrocortisone cream Stool softeners, loperamide Antihistamines Flashlight, copy of passport

What happens when travelers return home ill n n Unexplained fever is an emergency and is malaria until proven otherwise Also seek consultation for • • Unusual rashes Persistent diarrhea Persistent cough Unusual weight loss or fatigue

Credits n n n n http: //www. istm. org/ International Society of Travel Medicine (ISTM) teaching slide set www. cdc/gov www. immunize. org http: //www. who. int/en/ http: //www. shoreland. com/ http: //www. promedmail. org/

Many Thanks Jean Haulman MD