10/18/2011. The Older Adult Traveler. Each Year, over 3 million Americans >65 years travel internationally. It s a jungle out there!

Transcription

1 The Older Adult Traveler It s a Jungle Out There Jeffrey D. Schlaudecker, MD University of Cincinnati College of Medicine Department of Family and Community Medicine Division of Geriatric Medicine Associate Program Director, The Christ Hospital/UC FMR It s a jungle out there! Each Year, over 3 million Americans >65 years travel internationally At a pre travel clinic: 33% older than 60 years 1.5% older than 80 years 1

2 Lecture Objectives At the end of this lecture, the learner will be able to: Review the basic elements of a pre travel visit Identify major causes of morbidity and mortality in older adult travelers List resources available to patients and providers for travel health information Describe specific situations where additional vaccinations are required for travel Pre travel Risk Assessment Compared to staying home, M & M increased in travelers 1 5% of travelers to developing countries ti consult medical help while abroad % evacuated emergently 1/100,000 die abroad (15x higher in Nepal) Pre Travel Consultation Review of Current Health Status Get in shape! Review of Travel related morbidity/mortality Travel stress: flying, walking, eating, drinking Infectious Risk Vaccine review 2

3 Elements of Travel Preparation General advice Medical problem review for stability Food/water safety animal hazards general safety jet lag medical supplies Travelers diarrhea Malaria and other vector borne diseases Routine immunizations Travel specific immunizations Mortality in Travel Cause of death/injury for those less than 50 years old? HINT: Mortality in Travel Cause of death/injury for those older than 50 years old? HINT: 3

4 Mortality in Travel 50% Trauma 50% Disease related (CV #1) Fatal VTE in traveler: 5/1,000,000 Mortality in Travel (con t) MVC Death rate 2 3x age matched nontraveling peers Highest risk in traffic deaths in Bermuda in age (RR of 17 compared to native population) Mortality in Travel (con t) Drowning 16% of all deaths (due to injuries) among US travelers 4

5 Mortality in Travel (con t) Infectious Disease: 25 US deaths Almost exclusively P. falciparum HIV: Swiss study: 10% HIV acquired abroad Travel Risk Assessment 4 6 weeks prior to travel WHO will be traveling? (PMHx, age, gender) WHERE (coutries: urban, rural) WHEN (how soon, duration, season) WHY are they going? WHAT will they be doing? HOW will they be living? WHO will be traveling? (PMHx, age, gender) 5

6 WHO will be traveling: Traveling with Medical Conditions The fit traveler Respiratory conditions Travel with all rescue medications onplane Cardiac conditions CABG not a risk factor for in flight emergencies Travel INR monitoring available from some cardiolog Diabetes No risk to insulin even on hour flights WHERE (coutries: urban, rural) We re going to see the country WHEN (how soon, duration, season, political climate) 6

7 WHY are they going? To sit around the pool with my friends Prevalence of casual sex among international travelers: 20.2% (50% unprotected) WHAT will they be doing? I m spending time with locals HOW will they be living? I m going to Bali for business 7

8 Morbidity in Travelers Morbidity in Travelers Travelers Diarrhea >3 unformed stools in 24 hours WITH: fecal urgency, cramps, n/v, fever, etc. TD in developing world: 20 66% in first 2 week 50 80% bacterial etiology Contaminated food and water Salads, unpeeled fruits, poorly cooked meats, unpasteurized dairy, tap water Food from street vendors especially risky Freezing does not kill, thus ice can be contaminated even liquor with a high alcohol content does not sterilize contaminated ice TD Treatment» Cipro 500mg po bid for 3 days at first onset of symptoms» Alternatives: levofloxacin 500mg po once zithromax ih (recommended ddin places with ih high rates of quinolone resistant Campylobacter ie Thailand) Antidiarrheals Loperamide Rehydration is the most important treatment Homemade ORS: one liter of clean water, one teaspoon of table salt (NaCl), 8 teaspoons of sugar 8

9 Travel Related Illness Jet Lag: Hydrate Avoid alcohol Melatonin (0.5 to 5mg) may promote sleep and decrease jet lag in travelers crossing >5 time zones Air Terminal Stress: The physical and mental stress of the airport Light carry on bags, alow plenty of time, etc. Traveling with O2 Cabin pressurized to ft. If able to walk one city block or climb one flight of stairs generally ok for flight Low humidity: 25% Trapped air expansion Sinus, tooth fillings, middle ear (bullous lung dz?) O2 should be arranged h prior to departure Contact airlines for information Inside the Cabin 9

10 Medical Help Abroad Medical Evacuation Medical Air Evacuation $50, ,000 Consider details of policy Closest vs preference VTE and Travel Risk increases in flights over 6 hours Some current flights >20h ASA doesn t prevent Below knee graduated compression stockings Reduce leg edema and VTE risk Personal Health records EKG Ample supple of chronic medications Common OTC medications Itinerary, Passport copies to family Travel Health Kit 10

11 High Risk Activities Consider Pre Travel Consultation at specialized center Diving High Altitude La Paz, Bolivia 13,500 ft Wilderness Travel Extreme Physical Stress (heat, cold, exercise) Vaccinations Routine Influenza Tdap MMR Polio Varicella Location Specific Hep A Hep B Typhoid Yellow Fever JEE Rabies Hepatitis A Transmitted contaminated food and water Risk of disease ranges from 1 5/1000 per week of stay in a tourist area Brown = high risk 11

12 Typhoid Vaccine Recommended where exposure to contaminated food and water possible longer stays adventuresome eating Vaccines have limited efficacy 60 73% in published trials Adverse events to parenteral vaccine local reactions (7%) headache (1.5 3%) Dark: high risk Light: mod risk Typhoid Vaccines Vaccine Route Minimum Age (Yr) Vi capsular polysaccharide # of Doses Booster frequency (Yr) IM 2 years 1 2 Ty21a Oral 6 years 4 5 IM = Intramuscular Yellow Fever Endemic Zone in South America & Africa (2009) Vaccine required q 10 y 12

13 Yellow Fever Vaccine Associated Neurotropic & Viscerotropic Disease Occurs exclusively in first time vaccinees Onset 4 to 28 days post immunization Risk may be increased in those > 60 years Significant mortality (50%) Risk ~ 4 6 cases/million doses distributed Prevention of Japanese Encephalitis Effective vaccines are available Greatest risk: rural farming areas during transmission season during outbreaks Prevention of Rabies Pre exposure prophylaxis with vaccine may be indicated Additional doses of vaccine still needed if exposure to infectedanimal occurs Use if evacuation difficult 13

14 Influenza in the Americas Viboud et al., 2006 Malaria Prevention Malaria is transmitted by mosquitoes Prevented by combined approach using chemoprophylaxis and personal protective measures against mosquito bites, including: Impregnated bed nets Protective clothing Insect repellents Chemoprophylaxis: chloroquine, mefloquine, Malarone, doxycycline Protection Times of Insect Repellents Product Active Ingredient Protection Time (minutes) OFF! Deep Woods DEET, 23.8% / OFF! Skintastic DEET, 6.65% 65% / OFF! Skintastic for Kids DEET, 4.75% / Natrapel Citronella, 10% / Skin-So-Soft Bug Guard Citronella, 0.1% /- 7.9 Repella Wrist Band DEET, 9.5% 0.3 +/- 0.2 Modified from: Fradin and Day, NEJM 2002;347:

15 Resources Traveler s Health by region Traveling with Children, Safe Water, Vaccine info, etc U.S. State Dept. Resources Country descriptions i Travel warnings Emergency services for Americans living abroad WHO urges travellers to Nigeria to be up todate with vaccination against polio 30 June 2004 WHO has been informed of the intention to resume polio immunization campaigns in early July in the state of Kano, Nigeria. However given the current high risk of polio infection in northern Nigeria, WHO is urging travellers to the country to adhere to immunization recommendations and be up to date with vaccination against poliomyelitis. Disease Tracking by country Traveler Health Humanitarian Crisis 15

16 AFGHANISTAN Afghanistan is a developing nation in the lowest 25% of the world's economies. It is a landlocked country located in south central Asia. The climate is characterized by dry summers with temperatures ranging from F (18 29 C) and cold winters (especially in the north) with average temperatures of 32 F (0 C). Weather is milder during spring and fall. IMMUNIZATION RECOMMENDATIONS Hepatitis A Recommended for: all travelers. Typhoid Recommended for: all travelers. Hepatitis B Recommended for: all travelers. Yellow fever Required for travelers coming from infected countries. Recommended for: no traveler when not required. Rabies Recommended for: all travelers. Cholera Recommended for: aid and refugee workers only. Vaccine is available in most countries, but not in the U.S. Influenza Flu is transmitted November to April and all travelers are at increased risk. Recommended for: all travelers over age 50; all travelers of any age with any chronic or immunocompromising conditions. Consider for any traveler wishing to decrease risk of influenza or non specific respiratory illness. Consider anti virals as standby therapy for those inadequately immunized. MORE!!! STFM presents: Shots FREE!! For Palm and Pocket PC 16