Introduction to Travel Medicine Josiah Akinde BPharm. MBA MHS DTM Member Travel Medicine Faculty Royal College of Physicians & Surgeon, Glasgow Member, Pharmacy Working Group, ISTM
Disclosures I was a member of the Professional Development Committee of the CPhM until August 2014 I am the Pharmacy Operations Manager for the Loder Group in Alberta and I also practice Pharmacy in the Community at Pharmasave 337 in Sundre, Alberta. Most of the slides in this presentation are part of the training slides on Introduction to Travel Medicine put together by ISTM.
Learning Objectives To give Pharmacists a broad understanding of travel medicine To get an appreciation of the importance of giving travel health advice Discuss some of the components needed in order to give correct advice to travellers To have an overview of major travel-related diseases and distribution of same Discuss the common vaccine-preventable travel diseases and their vaccines. To get information about available resources that aid in travel risk assessment and follow-up
What does travel medicine do? It is that part of health professional practice that: seeks to prevent illnesses and injuries occurring to travellers going abroad manages problems arising in travellers coming back or coming from abroad is concerned about the impact of tourism on health and also advocates for improved health and safety services for tourists is increasingly concerned about refugee and migrant health Leggat PA, Goldsmid JM. Primer of Travel Medicine. 3 rd Ed. Brisbane: ACTM Publications, 2002.
Travel Medicine - A Science or an Art? It is both Science that you can learn and an art that you develop through regular practice
Why Travel Medicine International Tourist Arrivals by Region 2000 2001 % Change 2000/01 2010 % Change 2000/10 2020 Projection % Change 2010/20 World 696.8 692.6-0.6% 940.2 +34.9% 1360 +44.7% Africa 27.2 28.4 +4.3% 50.3 +84.9% 85 +69% Americas 128.5 120.8-6.0% 149.7 +16.5% 199 +32.9% Asia & Pacific 115.3 121 +5.2% 204 +76.9% 355 +74% Europe 402.5 399.7-0.7% 475.3 +18.1% 620 +30.4% Middle East 23.2 22.7-2.5% 60.9 +262.5% 101 +65.8% Sources: 1. World Tourism Organization @ www.world-tourism.org 2. Canadian Tourism Industry A Special Report. 2012 HLT Advisory, Tourism Industry Association of Canada and Visa Canada
Why do People Travel Tourism Business Study Abroad Research Visiting Friends and Families Missionary Work Responding to International Disasters Socio-economic Migrants Political Migrants & Asylum Seekers
Who are the Travellers They are as unique as their Itineraries Reasons for their trips Cover all age ranges Very young to very old Have variety of health concerns and conditions Could be very healthy or extremely fragile Varying medical conditions e.g pregnant or nursing, multiple health issues like the elderly etc. And as a Result...
Travellers are faced with various Infectious diseases... While some destinations have become safer; New diseases have emerged in other areas (SARS, H5N1 & H1N1) Other diseases have re-emerged largely due to low immunization rates In developing countries and, people refusing immunization for various reasons, and transmission by migration.
Travellers are exposed to a variety of hazards
The Continuum of Travel Medicine Pre-Travel Preventive Medicine Visitors Contingency During Travel Planning Treatment & Rehabilitation Post-Travel Leggat, P; Introduction to Travel Medicine Presentation
The Pre-travel Consultation Objectives 1. To assess the traveller s trip plans and determine potential health hazards 2. To educate the travellers regarding the anticipated risks and methods for prevention 3. To provide: A. immunization for vaccine-preventable disease B. Medications for prophylaxis, self-treatment or both. 4. To empower the traveller to manage his or her health throughout the troip
Major Topics for Pre-travel Consult Discussion Immunizations Review routine immunizations and those indicated for the specific itinerary. Malaria chemoprophylaxis Travelers diarrhea Other vectorborne diseases Altitude illness Other environmental hazards Determine if there is a risk of malaria. Discuss personal protective measures. Discuss risks and benefits of chemoprophylaxis, and recommended choices of chemoprophylaxis for the itinerary. Recommend strategies to minimize diarrhea. Discuss antibiotics for self-treatment and adjunct medications such as loperamide. Define risk of disease in specific itinerary and insect precautions needed. Determine if the itinerary puts the traveler at risk of altitude illness. Discuss preventive measures such as gradual ascent, adequate hydration, and medications to prevent and treat. Caution the traveler to avoid contact with animals to reduce the potential for bites and scratches that can transmit rabies. Advise to avoid walking barefoot as parasites can enter intact or damaged skin. Advise to avoid wading or swimming in freshwater where there is risk for schistosomiasis or leptospirosis. Remind travelers to apply sunscreen to skin exposed to the sun. Personal safety Sexual health and bloodborne pathogens Discuss precautions the traveler can take to minimize risks specific to the trip, such as traffic accidents, alcohol excess, personal assault, robbery, or drowning. Provide information on travel health and medical evacuation insurance. Caution the traveler to avoid activities that can lead to sexually transmitted infections, unwanted pregnancy, or bloodborne infections. Remind travelers to use condoms if they do have sex. Adapted from CDC Health Information for International Travel 2014
Vaccine to Prevent Yellow Fever VACCINE TRADE NAME (MANUFAC TURER) AGE DOSE ROUTE SCHEDULE BOOSTER 17D yellow fever vaccine YF-Vax (Sanofi Pasteur) 9 months 1 0.5 ml 2 SC 1 dose 10 years 3 Abbreviation: SC, subcutaneous. 1 Ages 6 8 months and 60 years are precautions for use of yellow fever vaccine. 2 YF-Vax is available in single-dose and multiple-dose (5-dose) vials. 3 Revaccination every 10 years is recommended for people at continued risk of exposure to yellow fever virus and is required for entry by certain countries under the International Health Regulations of the World Health Organization. Adapted from CDC Health Information for International Travel 2014
Contraindications and precautions to yellow fever vaccine administration CONTRAINDICATIONS Allergy to vaccine component Age <6 months Symptomatic HIV infection or CD4 T- lymphocytes <200/mm 3 (or <15% of total in children aged <6 years) 1 Thymus disorder associated with abnormal immune-cell function Primary immunodeficiencies Malignant neoplasms Transplantation Immunosuppressive and immunomodulatory therapies PRECAUTIONS Age 6 8 months Age 60 years Asymptomatic HIV infection and CD4 T- lymphocytes 200 499/mm 3 (or 15% 24% of total in children aged <6 years) 1 Pregnancy Breastfeeding Adapted from CDC Health Information for International Travel 2014
Vaccine to Prevent Meningococcal Disease VACCINE TRADE NAME (MANUFACTUR ER) AGE DOSE ROUTE SCHEDULE BOOSTER Meningococcal polysaccharide diphtheria toxoid conjugate vaccine Menactra (Sanofi Pasteur) 9 23 mo 2 55 y 0.5 ml 0.5 ml IM IM 0, 3 mo 1 dose If at continued risk 1 Meningococcal oligosaccharide diphtheria CRM 197 conjugate vaccine Menveo (Novartis) 2 55 y 0.5 ml IM 1 dose If at continued risk 1 Meningococcal polysaccharide vaccine Menomune (Sanofi Pasteur) 2 y 0.5 ml SC 1 dose If at continued risk 2 Abbreviations: IM, intramuscular; SC, subcutaneous. 1 Revaccination with meningococcal conjugate vaccine is recommended after 3 years for children who were previously vaccinated at ages 9 months to 6 years. Revaccination with meningococcal conjugate vaccine is recommended after 5 years for people who were previously vaccinated at ages 7 55 years, and every 5 years thereafter for people who are at continued risk. 2 Revaccination with meningococcal polysaccharide vaccine is recommended for adults >55 years who remain at increased risk 3 5 years after the last dose. Adapted from CDC Health Information for International Travel 2014
Avoiding Tick-Borne Encephalitis DEET/ Permethrin Wear trousers tucked into socks Stay on the path in natural areas Check self for ticks and remove ASAP Use tweezers Don t use oils/ heat/ nail varnish Avoid unpasteurised dairy products Vaccine is available Expensive and difficult to obtain in NZ
Adult -4 tablets qd *3/7 & Children by weight Dosed over 3/7 by patient`s weight
Key take-home points as we round up...
ADVISE AND DISCUSS Insects - repellents, nets, permethrin, appropriate clothing Ingestions - care with food and water, diet/teeth (including airlines/jetlag/dvt)* Indiscretions - STI s, HIV Injuries - accident avoidance, personal safety Immersion fresh water avoidance (schistosomiasis) Insurance* - health and travel insurance* finding medical assistance o/s* (adapted* from NZPHR; 1996;3(8):57-59) Leggat, P; Introduction to Travel Medicine Presentation
VACCINATE Always - National schedule Often - Hepatitis A Sometimes - Japanese encephalitis meningococcal disease polio rabies yellow fever Influenza Pneumococcal disease Other vaccines (adapted* from NZPHR; 1996;3(8):57-59) Leggat, P; Introduction to Travel Medicine Presentation
PRESCRIBE/RECOMMEND Always Sometimes regular medication medical kit (first aid)* antimalarial medication diarrheal self-treatment condoms (NZPHR; 1996;3(8):57-59) Leggat, P; Introduction to Travel Medicine Presentation
PHAC Travel Health http://www.phac-aspc.gc.ca/tmp-pmv/ NACI Canada http://www.phac-aspc.gc.ca/naci-ccni/ International Society of Travel Medicine www.istm.org US Centers for Disease Control and Prevention www.cdc.gov/travel US Guidelines Similar government sites for UK and Canada World Health Organization Resources http://www.who.int/ith The former yellow book is now published as the blue book online CDC Travel Health http://www.cdc.gov/travel/index.htm MASTA http://www.masta.org TRAVAX http://www.travax.nhs.uk
Thank you