Keeping our Traveling
Students Safe and
Healthy
Jean Haulman MD
March 6, 2009
www.kidsforsavingearth.org
Risks
Loss of
inhibitions
400
500
350
450
400
350
250
300
200
250
150
200
150
100
100
50
50
0
0
1850
1900
1950
2000
millions
days
300
days to circle
the globe
international
arrivals
Your favorite
“exotic” disease
is only an
airplane ride
away
Transportation hazards
http://www.blueskyaviation.mn/medevac.html
Injury: Land & Water
Leading cause of death in
travelers is Motor Vehicle
Accidents (<55 y/o)
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.
Approximately 750 Americans die
annually in auto accidents abroad, and
approximately 25,000 are injured.
Why does this occur?
Modes of Transportation are
Unique
Conditions leading to MVAs
Poor road conditions
Poor vehicle maintenance
Lack of seatbelts
3rd 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
Road signs
Road signs may be
confusing
Advice for drivers in
India
http://2.bp.blogspot.com/...qHw5g5ewdM/s400/2Indianroadsignsmall.j
pg
Traffic in Cairo
http://www.infoforhealth.org/pr/m15/p6a.jpg
Donor-mobile
AAA Abroad:
Roadside service varies
Rule: Pedestrians do not always
have the right of way
http://www.cartoonstock.com/newscartoons/cartoonists/aia/lowres/aian23l.jpg
Risks
Drowning is second leading cause
of mortality for travelers
What is the common denominator
for MVA and drowning?
Risks
Illness – Destination Specific
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.
Pre-Travel Counseling Visit


Focus is prevention
Advice given regarding ways to minimize
destination specific risks
• Disease and environment education



Traffic risks, drowning risks
Insect precautions
Food and water
• Vaccines
• Medications for travelers’ diarrhea (TD),
malaria prophylaxis, altitude sickness, HIV
PEP for traveling health care students
Travel Clinic Consultation





Itinerary
Reason for travel
Accommodations
Duration of travel
Modified by
• Medical and immunization history
• Allergies
• Special needs
Itinerary and Reasons for Travel

Itinerary
http://www.arr-the-kraken.com/images/oz_02.jpg
• Country and region
• City vs. rural


Reason for travel: backpacking,
trekking, spelunking, business,
study abroad
Accommodations: Hotel, tent,
hostel, cave, host family
http://ritz-carlton-boston-commons.visit-boston-massachusetts.com/boston-ritz-carlton-suite.jpg
Accommodations

Host families
• Hepatitis A,
• Local water
• Well water

Rule: There is so such
Typhoidthing as safe drinking
water in a 3rd world
country unless it comes
from a sealed bottle.
Crowded living conditions, group travel,
exposure to ill persons:
• Meningococcal disease
• Influenza
• Tuberculosis
Travel location(s) and duration
of stay




Diseases follow geographic patterns and
seasonal variations
The longer the stay the greater the risk
of travel related illness
Short stays are considered <2-3 weeks
Long stays are > 1 month
Pre-travel Consultation
VACCINES: Routine,
Recommended and Required
Why insure completion and
update of routine vaccines?
World
vs
US






Diphtheria: 9,235
Measles: 30-40 m
Pertussis 20-40 m
Polio: >35,000
Mumps: Unknown
Tetanus >300,000
(most neonatal)
86% imported






0 cases in 2005
64 cases: 2008 *
25,827 in 2004
Last wild case 1979
5,783 cases in 2006
@ 40 cases in 2006
Recommended








Hepatitis A
Typhoid
Hepatitis B
Rabies
Polio
Meningococcal
JEV
(HPV)
Recommended Vaccines

Hepatitis A vaccine:
• 1st dose can be given on the way to the airport
• Most common vaccine-preventable illness in
returned travelers, next to influenza

Typhoid vaccine: recommended for all 3rd
world travel unless staying in 4-5 star
accommodations and never eating from the
street
• 1140 US cases reported 1999-2003, 74% imported
Vaccines

Hepatitis A
• 2 brand of vaccines
available, equally effective
• Given 6 months apart
• Expected lifetime immunity

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
Hepatitis B vaccine





Encouraged for all
travelers at risk for
MVA while traveling
Recommended for
sexual partner seeking
travelers
Recommended for
travelers seeking
medical procedures,
tattoos, and/or
piercings
3 dose vaccine given at
0, 1, and 6 months
First cancer preventing
vaccine
Courtesy of Patricia Walker MD
Ramsey Clinical Assts St. Paul, MN
Hepatitis A/B Vaccine


Given as series of 3
Standard schedule 0, 1, 6 months
• 3 doses of standard hepatitis B
• 3 doses of ½ standard dose for hepatitis A

New FDA approved accelerated dosing
• Advantage for travelers
• Given at day 0, 7, 21-28 days, booster at 1
year
• Can fit in complete series prior to travel
Polio

2003:
Polio




Travel as a risk factor: 2003 and 2005, 25
previously polio-free countries were reinfected 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
Rule: If it has fur and teeth do not touch it.
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
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
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
Meningococcal Infections




For travelers going to
Africa during the dry
season
Required for travelers
going to the Hajj in Saudi
Arabia
Sporadic outbreaks in
other African countries
2 vaccines
• Meningococcal Conjugate
vaccine: age 2-55 yrs
• Meningococcal
Polysaccharide: Approved
for age 3 months and
older
Medications
DIARRHEA Prevention
A.K.A.
Montezuma’s revenge
Aztec two-step
The trots
Turkey Trots
Turista
Distribution of TD
Why is diarrhea more common
in the developing world?
Travelers’ diarrhea


Incidence highest for
travelers going to a 3rd
world country
Food is the vector for
travelers’ diarrhea
more often than water
Travelers’ diarrhea




Acute, self-limiting illness; resolves
within about 5 days.
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.
Most symptoms occur while abroad and
are never reported
Treatment for Travelers’
Diarrhea (short term travelers)




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 1000mg all at once (adults)
Newer option: Rifaximin 200mg tid for 3
days
Travelers prefer to sit here
http://www.advillas.com/images/newImages/AdvillasBea
chSunset.jpg
--not here--
Malaria prevention
Fever is malaria until proven otherwise
AND
Many developing countries treat every
fever with malaria medication
Malaria Chemoprophylaxis




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
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
Altitude: Acute Mountain
Sickness
http://terrigick.typepad.com/.a/6a00e551f461c38833010536b4bd95970b-500wi



May lead to headache,
insomnia, fatigue,
nausea
Occurs in @ 40-50%
of lowland persons
moving quickly to
14,000 ft (4250m)
Prevention
• Ascend slowly
• Acetazolamide


125 mg bid
250 mg qhs
http://farm1.static.flickr.com/8/7741477_a1c3f15619_b.jpg
What to expect when
illness happens during
travel
Medical Care may be Different
Medical care


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
Modern & Shanty are often
neighbors
http://images.google.com/imgres?imgurl=http://www.tr-acnet.org/DBimages/
http://lifegoesonintehran.com/images/03_2008/9b-building.jpg
http://3.bp.blogspot.com/
Clean and modern on the outside
doesn’t necessarily mean clean
and modern on the inside
http://www.secretchina.com/news/up2007/allimg/0706/9_21174418.jpg
Standards of Medical Care





May reuse syringes, needles
May have primitive sterilization
techniques (alcohol and a match)
Medications and vaccines may be
counterfeit
Overnight stay usually requires
assistance (bedding, food, etc)
May be dirty, may see rodents, flies
and mosquitoes
Conditions may be crowded
http://www.bnp.org.uk/wpcontent/uploads/ghanahospital.jpg
http://www.sos-
Hospital wards vary
http://www.medisend.org/images/pr86-1-lg.jpg
http://www.globalpas.org/gpasblog/uploaded_images/ward-761111.jpg
Tanzania: Surgical gown
sterilization
http://images.google.com/imgres?imgurl=http://movetcd.com/images/DSCF3188.JPG&imgrefurl=http://movetcd.com/MOVE2.html
Medical care while traveling



Advise small medical kit
Syringe kits for high risk destinations
Have medical/evacuation insurance:
• Access America (Word Access): 1-800-2848300
• International SOS: 1-800-468-5232
• ASA, Inc.: 1-888-ASA-8288
• Gateway:1-800-282-4495
• Travel Assistance: 1-800-821-2828
• Medjet assistance: 1-800-9MEDJET
• Divers Alert Network

Have health insurance on return
Medicine Kit









Sunscreen
NSAIDs
Moleskin
Non Neomycin-containing antibiotic, band-aids
Antifungal cream (wear white cotton socks)
Hydrocortisone cream
Stool softeners, loperamide
Antihistamines
Flashlight, copy of passport
What happens when travelers
return home ill


Unexplained fever is an emergency and
is malaria until proven otherwise
Also seek consultation for
•
•
•
•
Unusual rashes
Persistent diarrhea
Persistent cough
Unusual weight loss or fatigue
Credits







http://www.istm.org/
International Society of Travel
Medicine (ISTM) teaching slide set
www.cdc/gov
www.immunize.org
http://www.who.int/en/
http://www.shoreland.com/
http://www.promedmail.org/
Many Thanks
Jean Haulman MD