Health and Safe Travel - Coping with Travel Medicine First Annual Summer School Mount Juliet, June 2007 Dom Colbert MD FRCSI BSc CTH MFTM Irish Society of Travel Medicine 1
Four recent mistakes A doctor gives yellow fever to one of a couple going to India. The other half comes to me because he has seen on the internet that there is no need for this He is right. There is no yellow fever in India. It is still confined to Sub Saharan Africa and some parts of Central and South America.
WHB give C and P to a group of school girls going to Kolkata in April. Their leader comes to me and asks the pertinent question She is right. Malaria risk in India follows this pattern: Kolkata May to November Delhi July to September Chennai July to December Mumbai July to October Goa..7 cases p falciparum Dec 2006 -Jan 2007! QuickTime and a TIFF (Uncompressed) decomp are needed to see this pictur
A doctor gives C and P to someone backpacking in East Africa. She gets malaria. Was flown to S Africa very sick and has confirmed falciparum malaria. This is a serious mistake and the girl could have died. She was a student in Trinity at the time. The doctor thought he read that C and P was ok for Africa. QuickTime and a TIFF (Uncompressed) decompre are needed to see this picture
Should I give typhoid to a an 18 month old toddler going to visit family in India?> No it is not used under 2 years of age. Please note the difference between a booster e.g. for hep A and starting from scratch as in typhoid vaccine!
HOW RISKY IS FOREIGN TRAVEL? Rose examined records of 7 million US tourists who went to less developed countries(<90 days, median 19 days) 60-70% chance of getting an illness 8% sought medical care < 1.0% hospitalized On return 26% had a bout of diarrhea, a respiratory illness, a skin problem or a fever!
INDIVIDUAL RISK VARIES WHERE you go WHEN you go WHAT you did DURATION of trip OWN HEALTH STATUS PRECAUTIONS taken UNEXPECTED.
OVERALL RISKS % DIARRHEA 34 RESPIRATORY INFECTION 26 SKIN DISORDER 8 FEVER 7 MOUNTAIN SICKNESS 6 MOTION SICKNESS 5 ACCIDENT INJURY 5 NON SPECIFIC FEVER 3 OTHER 13 (e.g. unmasks disease, AIDS HIV Hepatitis, snake bites etc )
The Big Four DIARRHEA RESPIRATORY ILLNESS SKIN PROBLEM FEVER
Although infections account for only 1% this is still a large number Republic 43 cases reported of malaria in 2005 ( 2 died). 100+ reported 2006 2000 reported in the UK in 2005 (9 died) In UK 75% have not taken antimalarial prophylactics In 20% the wrong antimalarial or failure to comply In 5% of cases other types of malaria
Two-thirds of cases occur in people of African or South Asia ethnic origin and over half of the cases occur in those who had been visiting friends and relatives (VFRs) in endemic areas. Most patients with falciparum malaria acquire infection in Africa: West Africa is the commonest geographical source. Most Plasmodium vivax infections are acquired in South Asia.
Malaria The minimum incubation period for falciparum is 6 days. Most present in the first month, almost all present within 6 months Approximately three-quarters in the UK & ROI are caused by Plasmodium falciparum, which is capable of invading a high proportion of red blood cells and rapidly leading to severe or life-threatening multiorgan disease. Vivax or ovale infections commonly present after 6 months and may be delayed for years.
Diagnosis of Malaria Three thick and thin blood slides is still the gold standard in diagnosis but P. falciparum can be diagnosed almost as accurately using rapid diagnostic tests (RDTs) which detect plasmodial antigens or enzymes RDTs are not as reliable for other Plasmodium species.
Symptoms of malaria No specific symptoms Most patients complain of fever, headache and general malaise. Gastrointestinal disturbances, jaundice or respiratory symptoms occasionally occur and are often responsible for misdiagnosis. Thrombocytopenia is highly suggestive of malaria in all kinds of malaria
Who gets malaria. Two-thirds of cases occur in people of African or South Asia ethnic origin and over half of the cases occur in those who had been visiting friends and relations (VFRs) in endemic areas. Immunity lost rapidly Most patients with falciparum malaria acquire infection in Africa especially West Africa. Most Plasmodium vivax infections are acquired in South Asia. Backpackers, younger tourists, adventure trailers at risk
FATALITIES THE BIG THREE HEART ATTACK INJURY - ACCIDENTS INFECTIONS ( only 1%)
CVS Accident
Vehicle accidents per 100 million kilometers Take accident rate in Finland as 1.0 Rate in UK is 0.9 ROI is 1.7 Europe: north 3.0 east 5.0 Spain 5.3 South Africa >10.0 Turkey 20.0 Kenya 41.0 Egypt 44.0.No figures for India
Travel Medicine includes Preventive and curative medicine in all areas related to the travelling public before and after travel Screening, diagnosis and treatment of immigrants from countries of different ethnic origin and where diseases not associated with Ireland are endemic. Some working knowledge of travellers rights and responsibilities and of our rights and responsibilities in relation to them 2
Recognizing Travel Medicine as a special entity Australia, N Zealand, South Africa now Hungary(2006) demand training in Travel medicine before granting y fever license This can be possession of a Certificate in Travel Medicine, proof of attendance at a Course or other
Europe Each country has started some sort of Travel Health Society usually based on existing organizations that were once totally devoted to Tropical Medicine For example Irish Soc Travel Med, The College of Nursing Travel Health Forum,(UK) National Travel Health Network (UK),Health Protection Scotland,British Travel Health Associatioin, The Swedish Soc for Tropical Medicine, the Norwegian Forum for Travel Medicine, The Danish Soc Travel Medicine etc.. 6 Helsinki NECTM 2008 May 21-24
North America The International Society of Travel medicine based in Stone Mountain Georgia Brings all groups together, produces a regular Journal of Travel Medicine and runs a biannual international scientific conference. Also operates Geosentinal an e- mail service based on information from participating members world wide. ( Note that the French send Lettre d informations santevoyages 7 )
Certificate in Travel medicine Becoming a requirement in some countries e.g. Australia, South Africa CERTIFICATE EXAM IN TRAVEL HEALTH (IRELAND) held in RCSI and run in conjunction with the Irish Soc Tr Medicine Next date Oct 2006. Fee 250. Open to all health care professionals Travel Health Course RCSI/ISTM 500 ( 400 for ISTN members) March 2008
International transport carries diseases of all kinds Infectious agents, vectors, rodents all come along especially by ship Aedes Aegypti has appeared in countries where it was previously eliminated. Asian A albopictus recently arrived in the USA Dengue has spread to all warmer climates. Mosquitoes, flies, cockroaches -20% 15% and 50% respectively carried to China by air, land and sea in 2003! Four aircraft carrying rodents originated in Saudia,Japan, Russia and Hong Kong Don t forget runway and airport malaria..even suitcase malaria!. 8
The Irish Experience Central Statistics Office Dublin 2006
These statistics tell us that 4.8 million people took trips abroad from Ireland in 9 months Jan-Sept 2005 of these 226,000 went to developing countries British stats tell us that up to 40% of these were VFRs ( visiting friends and relatives)
IRISH Surveys 1999 and 2005 400 000 Irish adults visited a designated at risk country between 1996-1999 Numbers have significantly increased since 2000 as you can see from CSO figures (Aer Rianta) 10
IRISH SURVEY 1999 Of those surveyed Africa was nominated as a risk area (66%), India was first for 27% and malaria and snakes as a risk for most even when not a real risk Virtually no one talked about Turkey (cluster of cholers Sept 2005 8 Belgian tourists), Morocco, Tunisia, Egypt or Mexico Only one in ten knew that hepatitis A could be contacted by contaminated water Six in ten associated malaria and mosquitoes and typhoid and water 11
IRISH SURVEY 1999/ 2005 Non Vaccinated - REASONS as per cent Is not important 28 No time 8 Brief visit 8 Travel Agent 4 Complacency 4 No real reason 44 13
Numbers of Irish vaccinated very low Only 7% of those visiting North Africa Only 25% ( one in 4.0) visiting sub-saharan Africa Only 20%( one in 3.5) visiting Thailand, India, Malaysia, Only 6% of those visiting Turkey Only 4% of those visiting Tunisia 14
2005 Feb Dublin Airport..have you any malaria tablets with you going to a malaria country? NO 75% 25% YES
Why not? Don t take tablets when nothing wrong with me 22 Mosquitos don t bite 10me The disease is not dangerous 6 Cost 1 Allegeric 1 Malaria prevention does not work 1 75% 25% Side effects 1 Other Don t know 24 23 No Yes Not stated 17
Have You Malaria Tablets? (Base: Malaria Sample= 199) Of those who said YES What are they for? Prevention 78 Stand by emergency treatment 6 Both 12 No Reply 4 75% 25% No Yes 3.
Is giving vaccines a piece of cake? Phone Calls Shopping around Come back sick Time consuming Outlay Knowledge base - up to date Reactions real imagined Register with HSE
Typical reaction to tetanus - the more often it is given the worse the reaction
Patients Information and Misinformation Lonely Planet Travel Agent Family doctor Rough Guide Internet Travel clinic Newspapers Hearsay TV programs 17
Information. ISTM.IE Irish Soc Travel medicine on the web with 4 different linked sites. To join contact anneh.redmond@eircom.net Newsletter gives Courses / Seminars/ Exams Travax (normally 250/year. Members of ISTM ge for 30!!) WHO, CDC, MD Travel Health, CSO and Dept of Health and Children International Society, Books: WHO blue book A Primer of Travel Medicine Colbert 2005 Travel Chart updates 3 times a year
a few simple questions Do I give polio all the time to every traveller? Is it OPV or IPV. What are the real differences? Is polio likely to be contracted by the traveller?
Global campaign started in 1988 By 2003 no of Countries endemic reduced from 125 to 6. BY mid 2004 polio Had returned to 22 countries of which 10 had been free the previous Year!
Is one mosquito repellent better than another? Does lariam really cause hallucinations? What abut garlic, vitamin B and homeopathic medicine? Can I take an OCP and doxycycline? Should I give hep A vaccine to children? Is diamox any good? What should I charge?
What about ID versus IM rabies? Is Japanese encephalitis a real risk? if so where? What about Hep B?
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