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

3. www.kidsforsavingearth.org Risks Loss of inhibitions

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

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

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

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

9. Modes of Transportation are Unique

10. 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/nickop196.jpg

11. Road signs Road signs may be confusing Advice for drivers in India http://2.bp.blogspot.com/...qHw5g5ewdM/s400/2Indianroadsignsmall.j pg

12. http://www.infoforhealth.org/pr/m15/p6a.jpg Traffic in Cairo

13. Donor-mobile

14. AAA Abroad: Roadside service varies

15. Rule: Pedestrians do not always have the right of way http://www.cartoonstock.com/newscartoons/cartoonists/aia/lowres/aian23l.jpg

16. Risks Drowning is second leading cause of mortality for travelers

17. What is the common denominator for MVA and drowning?

18. Risks Illness – Destination Specific

21. 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.

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

23. Travel Clinic Consultation Itinerary Itinerary Reason for travel Reason for travel Accommodations Accommodations Duration of travel Duration of travel Modified by Modified by Medical and immunization historyMedical and immunization history AllergiesAllergies Special needsSpecial needs

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

25. Accommodations Host families Host families Hepatitis A, TyphoidHepatitis A, Typhoid Local waterLocal water Well waterWell water Crowded living conditions, group travel, exposure to ill persons: Crowded living conditions, group travel, exposure to ill persons: Meningococcal diseaseMeningococcal disease InfluenzaInfluenza TuberculosisTuberculosis Rule: There is so such thing as safe drinking water in a 3 rd world country unless it comes from a sealed bottle.

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

27. Pre-travel Consultation VACCINES: Routine, Recommended and Required

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

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

30. Recommended Vaccines Hepatitis A vaccine: Hepatitis A vaccine: 1 st dose can be given on the way to the airport1 st dose can be given on the way to the airport Most common vaccine-preventable illness in returned travelers, next to influenzaMost common vaccine-preventable illness in returned travelers, next to influenza Typhoid vaccine: recommended for all 3 rd world travel unless staying in 4-5 star accommodations and never eating from the street 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% imported1140 US cases reported 1999-2003, 74% imported

31. Vaccines Hepatitis A Hepatitis A 2 brand of vaccines available, equally effective2 brand of vaccines available, equally effective Given 6 months apartGiven 6 months apart Expected lifetime immunityExpected lifetime immunity Typhoid Typhoid 2 types of vaccines available Injectable: good for 2 years Can cause sore arm May feel run down for 1 day Students and insurances prefer Oral: good for 5 years 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

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

33. Hepatitis A/B Vaccine Given as series of 3 Given as series of 3 Standard schedule 0, 1, 6 months Standard schedule 0, 1, 6 months 3 doses of standard hepatitis B3 doses of standard hepatitis B 3 doses of ½ standard dose for hepatitis A3 doses of ½ standard dose for hepatitis A New FDA approved accelerated dosing New FDA approved accelerated dosing Advantage for travelersAdvantage for travelers Given at day 0, 7, 21-28 days, booster at 1 yearGiven at day 0, 7, 21-28 days, booster at 1 year Can fit in complete series prior to travelCan fit in complete series prior to travel

34. Polio 2003:

35. Polio Travel as a risk factor: 2003 and 2005, 25 previously polio-free countries were re- infected 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

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

37. Vaccines in short supply 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

38. 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

39. Yellow Fever: Required 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

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

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

42. Distribution of TD

43. Why is diarrhea more common in the developing world?

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

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

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

48. Travelers prefer to sit here http://www.advillas.com/images/newImages/AdvillasBea chSunset.jpg

49. --not here--

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

53. Malaria Chemoprophylaxis Chloroquine: weekly medicine, most of the world has resistant parasites – @$0.61-3.94/pill/week 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 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. 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 Atovaquone-Proguanil (Malarone): daily - @ $7.33/pill

54. Altitude: Acute Mountain Sickness May lead to headache, insomnia, fatigue, nausea May lead to headache, insomnia, fatigue, nausea Occurs in @ 40-50% of lowland persons moving quickly to 14,000 ft (4250m) Occurs in @ 40-50% of lowland persons moving quickly to 14,000 ft (4250m) Prevention Prevention Ascend slowlyAscend slowly AcetazolamideAcetazolamide 125 mg bid 125 mg bid 250 mg qhs 250 mg qhs http://terrigick.typepad.com/.a/6a00e551f461c38833010536b4bd95970b-500wi http://farm1.static.flickr.com/8/7741477_a1c3f15619_b.jpg

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

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

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

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

59. Clean and modern on the outside

60. doesn’t necessarily mean clean and modern on the inside http://www.secretchina.com/news/up2007/allimg/0706/9_21174418.jpg

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

62. http://www.sos- arsenic.net/images/hospital2.jpg http://www.bnp.org.uk/wp- content/uploads/ghana- hospital.jpg Conditions may be crowded

63. Hospital wards vary http://www.medisend.org/images/pr86-1-lg.jpg

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

65. Tanzania: Surgical gown sterilization http://images.google.com/imgres?imgurl=http://movetcd.com/images/DSCF3188.JPG&imgrefurl=http://movetcd.com/MOVE2.html

66. Medical care while traveling Advise small medical kit Advise small medical kit Syringe kits for high risk destinations Syringe kits for high risk destinations Have medical/evacuation insurance: Have medical/evacuation insurance: Access America (Word Access): 1-800-284- 8300Access America (Word Access): 1-800-284- 8300 International SOS: 1-800-468-5232International SOS: 1-800-468-5232International SOSInternational SOS ASA, Inc.: 1-888-ASA-8288ASA, Inc.: 1-888-ASA-8288 Gateway:1-800-282-4495Gateway:1-800-282-4495 Travel Assistance: 1-800-821-2828Travel Assistance: 1-800-821-2828Travel AssistanceTravel Assistance Medjet assistance: 1-800-9MEDJETMedjet assistance: 1-800-9MEDJET Divers Alert NetworkDivers Alert NetworkDivers Alert NetworkDivers Alert Network Have health insurance on return Have health insurance on return

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

68. What happens when travelers return home ill Unexplained fever is an emergency and is malaria until proven otherwise Unexplained fever is an emergency and is malaria until proven otherwise Also seek consultation for Also seek consultation for Unusual rashesUnusual rashes Persistent diarrheaPersistent diarrhea Persistent coughPersistent cough Unusual weight loss or fatigueUnusual weight loss or fatigue

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

70. Many Thanks Jean Haulman MD