THE PRE-TRAVEL
CONSULTATION
Gary W. Brunette, MD, MS
Travelers’ Health Team
Division of Global Migration and Quarantine
Centers for Disease Control and Prevention
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Outline
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Travelers’ Health Epidemiology
Traveler Assessment
Itinerary Review
Sources of Information
Risks to the Traveler
Travel Vaccines
Travel Medications
Counseling
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65
60
55
50
20
05
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04
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03
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01
20
00
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99
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98
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97
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96
45
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Number of Travelers (millions)
U.S. Residents Traveling Abroad*
Year
*ITA, includes travel to Canada and Mexico
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80
900
70
800
700
60
600
50
500
40
400
30
300
20
200
10
Worldwide arrivals in millions
US Resident travel in millions
International Travel
US nonresident
Inbound (ITA)
US Resident Air
Outbound (ITA)
All US Resident
Outbound (ITA)
Worldwide arrivals
(WTO)
100
0
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
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Where Do U.S. Residents Travel?
Of the 17% who traveled outside the U.S. . . .
40
%
30
20
10
0
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Source: HealthStyles Survey 2005
VFRs: Visiting Friends and Relatives
• Foreign-born increased 57% since 1990
from 19.8 million to 31.1 million1
• 20% of US population are first- or
second-generation immigrants
• VFRs comprised ~46% of US
international air travelers in 20043
1US
Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000,
issued Dec 2003 (Previous: US Census Bureau, Profile of the Born Outside the
United States Population 2000, issues Dec 2003???
2 Angell & Cetron, 2005
32004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported
From: Survey of International Air Travelers, Office of travel and tourism Industries,
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USDOC
Travelers’ Health Risks
Of 100,000 travelers to a developing country
for 1 month:
– 50,000 will develop some health problem
– 8,000 will see a physician
– 5,000 will be confined to bed
– 1,100 will be incapacitated in their work
– 300 will be admitted to hospital
– 50 will be air evacuated
– 1 will die
Steffen R et al. J Infect Dis 1987; 156:84-91
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The Patient: Medical Issues
• Age-specific issues
• Underlying illness,
immunosuppression
• Systems review
• Medical history
• Medication use
• Vaccination history
• Allergies
• Contraindications to vaccines and
medications
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The Patient: Other Issues
• Reproductive
– Pregnant
– Breastfeeding
– Preconception
• Risk-taking behaviors
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Travel Itinerary
• Full itinerary
– Dates, duration, stopovers
– Seasonal considerations
• Styles of travel
– Rural vs. urban
– Budget vs. luxury
• Accommodation
– Hotel vs. camping
• Activities
– Business vs. tourism
– Adventure, safari
– Missionary/Humanitarian/NGO
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Travel Health Resources
• CDC Travelers’ Health Website
– www.cdc.gov/travel
• World Health Organization
– www.who.int/int
• State Department
– travel.state.gov
• International Society of Travel Medicine
– www.istm.org
• Health Information for International Travel
– CDC “Yellow Book”
• International Travel and Health
– WHO “Green Book”
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Travelers’ Health Website
www.cdc.gov/travel
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Regional Destinations
• Region-specific pages
• Goal to move to country-specific format
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Travel Notices & Announcements
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Deaths Related to International Travel
Cardiovascular
Medical
Injury
Homicide/Suicide
Infectious Disease
Other
N = 2463
Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
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Infectious Disease Risks to
the Traveler
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Malaria
Diarrhea
Leishmaniasis
Rabies
Dengue
Meningococcal
Meningitis
ETC.
Schistosomiasis
Tuberculosis
Leptospirosis
Polio
Yellow Fever
Measles
JEV
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Injury Deaths and International Travel
Motor Vechicle
Drowning
Air Crash
Homicide/Suicide
Poisoning
Other
N = 601
Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
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Other Risks to the Traveler
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Accidental injury
Environmental hazards
Crime and assault
Psychiatric problems
Animal bites, stings and envenomations
Dermatologic disorders
Altitude
…….
ETC.
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Immunizations to Consider for Adult
Travelers
Routine
Diphtheria*
Tetanus*
Pertussis*
Measles +
Mumps+
Rubella +
Varicella
Pneumococcus
Influenza
* Td or Tdap
+ MMR
Travel related
Hepatitis A
Hepatitis B
Typhoid
Rabies
Meningococcal disease
Polio
Japanese encephalitis
Yellow Fever
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Travel Medications:
Prophylaxis & Self Treatment
• Malaria
– chloroquine, atovaquone/proguanil (Malarone),
doxycycline, mefloquine (Lariam), primaquine
• Diarrhea
– quinolone, azithromycin
• Altitude
– acetazolamide
• Motion sickness
– scopolamine, dimenhydrinate (Dramamine)
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Patient Counseling
• Sufficient time for patient education
• Tailored to suit traveler
• Fitness for travel
– Understanding impact on existing
conditions
– Advisability of destinations
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Travel Preparation
• Travel health insurance
– Medical care
– Hospitalization
– Evacuation
• Obtaining medical care abroad
• Awareness of travel notices
• Hand washing and hygiene
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Environmental Precautions
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Air Travel
Jet Lag
Sun Protection
Extreme Heat and Cold
– dehydration, heat stroke
– hypothermia, frostbite
• Altitude
• Water recreation
– Drowning, boating & diving accidents
– Risk of schistosomiasis or leptospirosis
– Biological and chemical contamination
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Food and Water Precautions
• Bottled water
• Selection of foods
– well-cooked and hot
• Avoidance of
– salads, raw vegetables
– unpasteurized dairy products
– street vendors
– ice
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Vector
Precautions
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Covering exposed skin
Insect repellent containing DEET 25 – 50%
Treatment of outer clothing with permethrin
Use of permethrin-impregnated bed net
Use of insect screens over open windows
Air conditioned rooms
Use of aerosol insecticide indoors
Use of pyrethroid coils outdoors
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Inspection for ticks
Bloodborne and STD Precautions
• Prevalence of
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STDs
Hepatitis B
Hepatitis C
HIV
Unprotected sexual activity
Commercial sex workers
Tattooing and body piercing
Auto accidents
Blood products
Dental and surgical procedures
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Animal Precautions
• Animal avoidance
• Rabies
– Specific animal threats
– Medical evaluation of bites/scratches
– Post exposure immunization and
immunoglobulin
• Envenomations
– Snakes, scorpions, spiders
– Maritime animals
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Injury and Crime
• Vehicles
– Risk of road and pedestrian accidents
– Night travel
– Seat belts and car seats
• Use of drugs and alcohol
• Understanding local crime risks
– Scam awareness
– Situational awareness
– Location avoidance
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Travel Emergency Kit
• Copy of medical records and extra pair of glasses
• Prescription medications
• Over-the counter medicines and supplies
– Analgesics
– Decongestant, cold medicine, cough suppressant
– Antibiotic/antifungal/hydrocortisone creams
– Pepto-Bismol tablets, antacid
– Band-Aids, gauze bandages, tape, Ace wraps
– Insect repellant, sunscreen, lip balm
– Tweezers, scissors, thermometer
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Post-Travel Care
• Post-travel checkup
– Long term travelers
– Adventure travelers
– Expatriates in developing world
• Post-travel care
– Fever, chills, sweats
– Persistent diarrhea
– Weight loss
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Questions?
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Other Resources
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Journals
• American Journal of Tropical Medicine and
Hygiene
• Bulletin of the World Health Organization
• Emerging Infectious Diseases Journal
• Eurosurveillance Weekly
• Journal of Travel Medicine
• Morbidity and Mortality Weekly Report
• Tropical Medicine and International Health
• Vaccine
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Books
• Textbook of Travel Medicine and Health, 2nd
Ed.
– DuPont, H.L. and Steffen R. (editors)
• The Travel and Tropical Medicine Manual,
3rd Ed.
– Jong, E.C., McMullen, R.
• Travel Medicine
– Keystone, J.S., Kozarsky, P.E., et al
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Websites
Eurosurveillance
www.eurosurveillance.org
Travax EnCompass
www.travax.com
GIDEON
www.gideononline.com
International SOS
www.internationalsos.com
Medical Advisory Service for Travelers Abroad (MASTA)
http://www.masta.org/
Armed Forces Medical Intelligence Center
www.afmic.detrick.army.mil/
Central Intelligence Agency
www.cia.gov/cia/publications/factbook/
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