Pre and post travel health visits Your health record Immunizations Essential health items to pack Health services while abroad Your health behavior while abroad Diarrheal Diseases Vector-borne diseases Other health hazards Shared experiences and tips Discussion Topics
Pre-travel Health Care Establish a relationship with a travel health practitioner. –“At least 6-8 weeks prior to departure.” –Immunizations for “globally availability.” –Anti-malarials & other prescription items. –Advice on other aspects of travel health. International health clinics & resources Maintenance checks before “hitting the road” (e.g., general health, dental, eyes).
International Travel Insurance Emergency Evacuation In-country Medical Expenses –Outpatient –Ambulance –Inpatient –Intensive Care –Dental Other Coverages
Post-Travel Health Care Continue anti-malarial medication as prescribed (usually for 4 weeks after return). See your physician if you develop the following within 1 year: fever, chills, headache, nausea, abdominal pain, diarrhea. Seek medical care for any other acute and/or chronic symptoms (i.e., skin conditions, neuro- psychiatric, urinary, etc.) that occur after return.
Your Health Record “Yellow Card” –Vaccination record –Available @ health clinics that provide international travel health care services. Leave a photocopy with Health Team Keep on hand when traveling.
Health History Essential information to record in your “Yellow Card” or passport: –Eyeglass prescription –Emergency Contact –Blood type –Chronic medications –Allergies Food Insect Drug Seasonal
Which Vaccines Are Needed? Some vaccines are recommended in any setting. Others may vary from place to place. Consult : –your travel health practitioner –OFDA health team –WWW.CDC.GOV Traveler’s Health
International Health Regulations A certificate of cholera immunization is no longer required by any country. –1973 amendment by World Health Assembly A certificate of yellow fever immunization is required by many countries for travelers arriving from infected areas (e.g. Africa, South America). –Vaccine is highly efficacious. –Vaccine must be WHO-approved & administered at an approved center. –Certificate is valid for 10 years starting 10 days after vaccination.
Up-to-Date Routine Vaccines Tetanus/Diphtheria –Booster every 10 years after primary series Polio –1 dose in adult life after primary series depending on area of travel Measles –Based on previous vaccination history or titer.
Up-to-Date Routine Vaccines Influenza –One dose each year before flu season. –Flu season varies: USA: Nov. - March Southern Hemisphere: April - Sept. Tropics: Throughout the year
For Travel to Areas Where Sanitary Conditions are Poor Hepatitis A –2 doses (@ 0, 6-18 months) –Consider for any travel to a developing country
For Travel to Areas Where Sanitary Conditions are Poor Typhoid –1 dose every 2 years (injection), or 1 capsule every other day X4 doses every 5 years [Note: the oral capsule is less convenient and its effectiveness may be decreased by simultaneous administration of antibiotics and antimalarials]. For travelers staying in areas of questionable sanitation.
For Travel to Remote Areas or Areas w/ Special Risks Hepatitis B –3 doses (@ 0, 1 & 6 months) –Long-term travelers (>6mo) or ANY traveler who may have contact with blood or body fluids Yellow Fever –1 dose every 10 years –May be required by country of destination. Endemic in Latin America & Central Africa
For Travel to Remote Areas or Areas w/ Special Risks Japanese Encephalitis –3 doses @ 0, 7 & 30 days, booster every 2-3 years –Risk areas include all of India, the Indian Subcontinent and Western Pacific. –Risk varies by season and geographic location.
For Travel to Remote Areas or Areas w/ Special Risks Meningococcal (serotypes A, C, Y, W-135) –1 dose, booster every 3-5 years Countries in and around the “meningitis belt” in Sub-Saharan Africa. –mostly serotypes A & C –Epidemics common during dry season (Dec - June) Increased risk among mass gatherings/displaced populations.
For Travel to Remote Areas or Areas w/ Special Risks Rabies –Prophylaxis: pre-exposure: 4 doses @ 0, 7, 21 & 28 days booster every 2-5 years based on titers –If bitten by an animal with known or suspected rabies: if prior vaccination, 2 doses on days 0 & 3 if no prior vaccination, Rabies Immune globulin followed by 5 doses (@ days 0, 3, 7, 14, 21)
Immunization Tips Many vaccines require multiple doses and time to take effect -- PLAN AHEAD!! Aim to be “globally available” Who Pays? - Depends on hiring scheme. i.e. PSC, Direct Hire, Military Where to get? - State Department Clinic, Travel Clinics, Private Plans. Other types of prevention should always be practiced to prevent transmission of infectious diseases.
Don’t Forget Prescription Medications –Adequate supply Divided supply among two pieces of luggage. **Keep in original, labeled prescription bottles** Carry a copy of practitioner’s medical prescription. Spare Eyeglasses/Contact lenses Copies of important documents (e.g., Passport, Health Insurance Papers, Yellow Card) MedEvac insurance
Items to Discuss with Your Travel Health Practitioner “Allergy Kit” (i.e. Ana-Kit, Epi-Pen) Prescription antihistamines –May not cause drowsiness. Antibiotics for moderate and severe diarrhea. Sterile Syringes and needles –Carry a medical certificate of explanation.
“Know Yourself” Malaria Prophylaxis Condoms Feminine Hygiene/Vaginal Antifungal Sunscreen (also a hat, sunglasses, etc.) Soap Shampoo Other…
Use Common Sense This is not “home” Laws and Customs/Culture are different Medical Services available are different Many items may not be available or the quality may be questionable. That dog or cat is probably not someone’s pet or vaccinated Take Nothing For Granted!
Health Services While Abroad Different standards may exist. –Blood supply, sterility of instruments Payment is often required up front. Consult the embassy for recommended facilities if needed. Unreliable availability and quality of pharmaceuticals. Medevac insurance is wise.
Taking Care of Yourself: “ Accidents & injuries kill more travelers than exotic infectious diseases.” Wear a seatbelt Drink in moderation Jog/walk in safe places Be aware of your surroundings and those around you Know your quarters - door locks, smoke detectors, balconies, emergency exits
STRESS Take time to unwind –Run –Walk –Read –Radio –Play
Coping With Stress Listen to your body –How do you exhibit being stressed? –How do you cope with stress? Minimize Jet Lag Talk with colleagues Do you need someone else to talk to Critical Incidence Stress Debriefing (CISD) Stress will have an effect at both the individual and team level
Food Choose fruits & vegetables that can be peeled. Avoid unpasteurized dairy products Avoid raw or uncooked foods except for fruits & vegetables
Food Avoid food from street vendors Piping hot food is safer Baked goods are safer Avoid using ice Avoid using table condiments Ask for restaurant recommendations
Fluid Intake Avoid tap water if possible –Contaminants could include bacteria, viruses, organic chemicals, heavy metals. Use bottled water - ensure it is sealed If unsure of water source use bottled water for toothbrushing and washing. Treat any drinking water that is not bottled. Coffee, tea, beer, wine and soda are suitable choices - best to drink from original container
Water Treatment Boiling - most reliable, not always convenient. –Vigorous, rolling boil for 1 minute - let cool to room temperature –If at altitude (>6,562 ft [2km]) boil for 3 minutes or use chemical disinfection Portable Filter or Purification Unit –May not filter out viruses. Chemical Disinfection with iodine tablets –Follow manufacturer’s instructions carefully
Diarrheal Diseases Most common health problem among travelers to developing countries. Different causes: –Viral (rotavirus) –Bacterial (cholera, shigellosis, E. coli) –Protozoal (giardiasis) –Stress –Other Treat according to type.
Categorizing Diarrhea Mild: up to 3 loose stools per day; no fever or blood in stools. Treat w/ loperamide & diet. Moderate: >3 loose stools per day; no fever or blood in stools. Treat w/ loperamide, antibiotics & diet. Severe:loose, bloody stools with fever or copious, rice water stools. Avoid antidiarrheals. Treat w/antibiotics. Seek medical care. ALL FORMS SHOULD BE TREATED WITH REHYDRATION!
Vectors of Disease Mosquitoes Ticks Flies Snails Fleas, lice and mites
Mosquitoes Different species transmit different diseases malaria yellow fever dengue filariasis Japanese encephalitis Night biters vs. day biters Breeding areas vary by species. Urban vs. rural
Malaria 4 protozoan species: –P. falciparum –P. vivax –P. ovale –P. malariae Transmitted by Anopheles mosquitoes. –Bite between sunset and sunrise. –Breed in sunlit streams, shaded lagoons, rice fields & marshes. Disease is characterized by: –Fever, chills, sweats –Flu-like symptoms –P. falciparum may progress to disorientation, delirium, coma, etc.
Malaria Priority: Prevention Is malaria present? See www.cdc.gov site.www.cdc.gov Are drug-resistant strains present? Prophylaxis - both personal & environmental –Prescription medication –Long pants/Long-sleeved shirts –Insect Repellant –Netting treated with insecticide (i.e. Permethrin) –Awareness of possible breeding grounds –Limit night-time outdoor activity
Anti-malarial Prophylaxis Chloroquine –300 mg base/week starting 2 weeks before, for duration of stay & for 4 weeks after. –For non-chloroquine resistant areas. Mefloquine –250 mg/week starting 2 weeks before, for duration of stay & for 4 weeks after. –Avoid if history of seizures, psychiatric disorders or cardiac condition. Doxycycline –100 mg/day starting 1-2 days before, daily while there & daily for 4 weeks after.
Vector Protection Long pants/Long-sleeved shirts DEET (30% - 40%) or other insect repellant Permethrin treated bed netting Permethrin treated outer clothing, especially pants legs & waist, shirt sleeves & collars Hard-soled, closed-toe shoes Avoid areas of long grass, heavy brush Avoid wading in rivers, lakes, or streams –if unavoidable, immediate and vigorous towel drying may help
Environment Sun Exposure –Sunburn –Heat Exhaustion –Heat Stroke –Winter
Sunburn Avoid sun exposure during the height of the day Wear protective, loose-fitting clothing –long pants/skirt and long-sleeved shirt –hat –sunglasses Apply sunscreen –Minimum SPF 15 (30 or higher recommended) –Apply 30 minutes before exposure & reapply liberally –UVA & UVB protection
Heat Exhaustion and Stroke Exhaustion –dizzy, fatigue –headache –pale & clammy –fast, shallow breathing –muscle cramps –intense thirst –Rehydrate Stroke –Medical Emergency –hot, dry, flushed skin –no sweating –high body temperature –rapid heartbeat –confusion –loss of consciousness –Cool
Exposure to Cold Wear Multiple Layers - loose fitting Proper fitting footwear Hat and mittens - 40% of heat lost through head Hydrate
Frostbite Treatment: –Warm environment ASAP –Unless necessary, do not walk on frostbitten feet –Immerse in warm (not hot) water –Warm using body heat –Do not rub frostbitten area –Do not use heating pad, heat lamp or stove to warm –Medical attention
Hypothermia Symptoms: –Shivering/exhaustion –Confusion/fumbling hands –Memory loss/slurred speech –drowsiness Treatment: –Warm environment and remove any wet clothing –Warm center of body first –Warm beverages - NO caffeine or alcohol –Medical attention
Landmines and Ordnance Estimated 110 million mines currently in 64 countries –Heavily Mined: Cambodia Egypt Angola Bosnia-Herzegovina Many areas with unexploded ordnance Be aware of where you are walking or driving
Importance of Maintaining Health Of little use to DART, and its mission, if unable to fulfill role Decreased stress on family and others Easier, and cheaper to prevent than treat