1. Pre-Travel Health Consultation Dr Peter A. Leggat MD, PhD, DrPH, FAFPHM, FACTM, FFTM Associate Professor School of Public Health and Tropical Medicine James Cook University & Visiting Professor School of Public Health University of the Witwatersrand

2. About the author Dr Peter Leggat has co-ordinated the Australian postgraduate course in travel medicine since 1993. He has also been on the faculty of the South African travel medicine course, conducted since 2000, and the Worldwise New Zealand Travel Health update programs since 1998. Dr Leggat has assisted in the development of travel medicine programs in several countries and also the Certificate of Knowledge examination for the International Society of Travel Medicine.

3. By the end of this session Briefly revisit who provides pre-travel health advice Emphasize the need for resources in travel medicine Overview the main functions of the pre- travel health consultation Introduce the concept of documentation in travel medicine

4. The Continuum of Travel Medicine During Travel Preventive Medicine Contingency Planning Treatment & Rehabilitation Visitors Pre-Travel Post-Travel

5. Travelers get information from various sources Travel agent/travel industry Books, popular press and the Internet Person “next door” Pharmacy General practice / Travel clinics Government/public health services Professional and academic bodies Ref: Leggat PA. Sources of health advice for travelers. J Travel Med 2000;7:85-8

6. Giving correct and consistent advice to travelers is important Giving the correct health advice to travelers needs: Information Training Experience Documentation Travellers

7. Need to be prepared with adequate resources Need adequate staff training and continuing education Need adequate time and good time management Need to have access to national and international guidelines for travel medicine Need to have health education resources Need to have access to good geographically based epidemiological information regarding risks to health and safety of travelers (internet, computerized databases etc)

8. Travel Health Advice Needs Adequate Notice Travelers need to be informed that they need travel health advice Travelers need to be informed that they need to seek travel health advice early, about 6-8 weeks prior to travel A risk assessment must be performed for every traveler

10. PRE-TRAVEL HEALTH ADVICE Immunize travelers Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel Prescribe appropriate chemoprophylactic and self-treatment medications

11. PRE-TRAVEL HEALTH ADVICE Immunize travelers Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel Prescribe appropriate chemoprophylactic and self-treatment medications

12. VACCINATE AlwaysNational schedule (incl Hep B) Oftenhepatitis A (non-immune) SometimesJapanese encephalitis meningococcal disease (Mecca) polio rabies typhoid yellow fever (WHO) Older age gpInfluenza (Others)Pneumococcal disease (adapted* from NZPHR; 1996;3(8):57-59)

13. IMMUNISE AGAINST Mandatory vaccinations (WHO) National schedule vaccinations- update routine immunizations Vaccinations for most or all travelers Vaccinations for travelers at special risk+

14. “Mandatory” vaccines Travelers to/from Yellow fever endemic areas Travelers going to Mecca for the Hajj

15. Yellow fever Source: http://www.cdc.gov/travel/diseases/yellowfever.htm

16. Yellow fever International regulations WHO International Travel and Health Specially licensed Yellow Vaccination Centers Need to document on appropriate certificate of immunization card

17. Meningococcal meningitis Source: http://www.cdc.gov/travel/diseases/menin.htm

18. Meningococcal meningitis Neisseria meningitidis: At least 13 antigenically distinct serogroups A,B,C,W135 & Y are most common Current vaccine for A,C,W135 & Y NZ is trialing a vaccine against a specific B strain Mandatory: Pilgrims visiting Mecca for the Hajj (annual pilgrimage) or for the Umrah Recommended: Travelers “roughing it” in areas where there are recurrent outbreaks of disease

19. Routine vaccinations The travel health consultation is a good opportunity to update national schedule or routine vaccinations

20. Vaccinations for most travelers Diseases associated with poor hygiene & sanitation ETEC? Hepatitis A Typhoid

21. Cholera Various new vaccines Some activity against ETEC in one Routine use of cholera vaccine is not recommended as risk is low It is indicated for travelers to cholera endemic areas, who are at high risk for infection (2-3 years protection)

22. Travelers at special risk Geographical risk Risk because age, pre-existing conditions, or occupation

23. Geographical risk Vector borne diseases Yellow fever Japanese encephalitis Tick borne encephalitis Wilderness/remote travel Rabies TB Current epidemics (terrorist threats?) Cholera Plaque

24. Japanese encephalitis Source: http://www.cdc.gov/ncidod/dvbid/jencephalitis/map.htm

25. Japanese encephalitis Travelers spending one month or more in rural areas of Asia, PNG & Torres Strait (Australia), particularly if the travel is during the wet season, and/or there is considerable outdoor activity and/or the standard of accommodation is suboptimal, other travelers spending a year + in Asia (except for Singapore), even if much of the stay is in urban areas

26. Dengue Vaccine in development Four serotypes (1-4) Transmitted by certain mosquitoes, including Aedes aegypti Widespread, especially common in SE Asia Becoming increasingly recognized in travelers

27. Estimated monthly incidence of health problems per 100 000 travellers to developing countries

28. Tick borne encephalitis Seasonal disease in parts of Europe, Scandinavia and Russia Hikers, campers and agricultural workers most at risk Small mammal ticks found in the undergrowth close to forested areas Vaccine available/post-exposure immune globulin

29. Tuberculosis-BCG Travelers over the age of 5 years who will spend prolonged periods in countries of high TB prevalence Children under 5 years who will be travelling to live in countries of high TB prevalence for > than 3 months WHO: high risk countries, where annual incidence is in excess of 100 per 100,000 population

30. Rabies Endemic in many countries Is almost a universally fatal disease

31. Plague Yesinia pestis, transmitted via fleas from animal reservoir to humans Rare in most parts of the world Vaccination only of those at high risk, usually those engaged in field operations, laboratory workers or others who reside in areas where plague is present

32. Risk because age, pre- existing conditions, or occupation Older travelers/pre-existing disease Influenza Pneumococcal infection Occupational risk (including electives) Hepatitis B (usually part of national schedule) Q fever

33. Influenza Routinely on annual basis for those 65 years and older Travelers with chronic disorders of the pulmonary or circulatory systems or other chronic illnesses needing regular follow-up Those who wish to reduce the risk

34. Estimated monthly incidence of health problems per 100 000 travellers to developing countries

35. Pneumococcal infection Routinely on annual basis for those 65 years and older Travelers with asplenia, immunocompromized travelers Others

36. Q Fever Bacterium (rickettsia) Coxiella burnetii Recommendation: those occupationally exposed to cattle, sheep, goats or kangaroos or their products Serum antibody and skin testing to exclude hypersensitivity reaction Contraindications: prior exposure to Q fever or anaphylaxis induced by egg proteins

37. It is important to document vaccinations Vaccination record Vital for those requiring proof of yellow fever vaccination Evidence of specific vaccinations and screening (e.g. HIV, HBV, Syphilis, Tuberculin) needed for entry to various countries, especially longer term travelers, such as scholars and workers

38. PRE-TRAVEL HEALTH ADVICE Immunize travelers Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel Prescribe appropriate chemoprophylactic and self-treatment medications

39. ADVISE AND DISCUSS Insects Ingestions Indiscretions Injuries Immersions Insurance

40. ADVISE AND DISCUSS Insectsrepellents, nets, permethrin Ingestionscare with food and water diet/teeth (including airlines/jetlag/DVT) IndiscretionsSTI’s, HIV, drugs? Injuriesaccident avoidance, personal safety Immersionschistosomiasis, drowning Insurance*health and travel insurance* finding medical assistance o/s* (adapted from NZPHR; 1996;3(8):57-59)

41. Leitrim County, rural Ireland Courtesy of Rick Speare Personal safety is on the radar screen

42. Personal safety There has been heightened concern regarding personal safety and travelers National foreign affairs sites should be consulted on safety and security at the travelers’ destination(s).

43. Personal safety Source: http://www.cia.gov/cia/publications/factbook/

44. SPECIAL RISK GROUPS Travelers who need special assistance or need assessment as to fitness to fly Pregnant travelers/children/HIV travelers Altitude/mountaineering/diving Adventure/outback travelers Travelers to areas of extreme climate School/club/other groups Occupational/students/military/aviation Aid/refugee camp workers

45. Travel health advice needs documentation Medialert bracelets-allergies, serious medical conditions Written travel health advice (may be part of doctor’s letter)-consider using a proforma Travelers health record ? Other certificates, e.g. diving, airline Is the traveler being escorted? (aeromedical evacuation)

46. Educational Resources Books Travel industry guides Pharmaceutical companies Videos-popular in a number of clinics in the USA

47. 52 pp, passport sized booklet 152 pp, Small pocket book 192 pp, reader 730 pp, manual

48. 144 pp, Small pocket book 428 pp, reader Disease specific Specific to special groups

49. PRE-TRAVEL HEALTH ADVICE Immunize travelers Advise/educate travelers on other precautions that should be taken against conditions to which they are likely to be exposed during travel Prescribe appropriate chemoprophylactic and self-treatment medications

50. PRESCRIBE (Script/Dr’s letter/medialert bracelet) Alwaysregular medication medical kit (first aid)* Sometimesantimalarial medication diarrheal self-treatment condoms/PEP Other hygiene pdts (NZPHR; 1996;3(8):57-59)

51. Medication needs documentation Prescription Doctor’s letter-consider using a proforma Customs/quarantine approvals, if required If part of a clinical trial, contact details/advice regarding adverse reactions (on a laminated card)

52. We do not live in an ideal world Travel health advice will be moderated by Availability of vaccines Availability of educational resources Availability of drugs for chemoprophylaxis and treatment-special authority Limitations in indications, limitations in available data for use Risk assessment

53. Bottom line of pre-travel health advice There is probably more to pre-travel health advice than travel immunizations and malaria chemoprophylaxis Travelers will have different priorities and resources Need for a risk assessment and access to current epidemiological information available on a geographic basis by country/region