DEVELOPMENT IN TRAVEL MEDICENE

1. DEVELOPMENT IN TRAVEL MEDICENE Dr GOTRA SAPUTRA M.Kes

2. What is travel medicine? • bagian dari praktek profesional kesehatan yang: • berusaha untuk mencegah penyakit dan cedera terjadi untuk wisatawan pergi ke luar negeri • mengelola masalah yang timbul dalam perjalanan kembali atau datang dari luar negeri • memperhatikan tentang dampak pariwisata terhadap kesehatan dan juga melakukan advokasi untuk peningkatan pelayanan kesehatan dan keselamatan bagi wisatawan • meningkatkan perhatian tentang pengungsi dan migran • (Primer of Travel Medicine 3rd Ed)

3. “the art of travel medicine is selecting the necessary prevention strategy without unnecessary adverse events, cost or inconvenience” (Steffen, 1994)

4. Challenge of travel medicine • Sea of global migration of people • More people travelling • People travelling further a field • Rapid movement of travellers

5. Travel statistics (WORLD TOURIST ORGANISATION) • wisatawan mancanegara pada tahun 2008 mencapai 922 juta. • Wisata mancanegara diperkirakan mencapai 1 miliar pada tahun 2010 • Wisata mancanegara diperkirakan mencapai 1,6 miliar pada tahun 2020. • Lebih dari setengah (52%) wisatawan berpergian menggunakan pesawat udara • sisanya menggunakan jalan (39%), kereta api (3%) dan jalur air (6%).

6. Travellers are exposed to a variety of hazards

7. PERTANYAAN • Travellers from industrialised areas to developing areas • Bagaimana masyarakat dari developing areas yang akan pergi keluar negeri ( negara berkembang lainya atau negara maju) • Apakah tidak ada resiko kesehatan yang mengancam?

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

9. Travel Doctor Group • Started in 1987 • Network of clinics, largest travel med practices in Australia • Network in NZ, South Africa, Singapore • 100,000 travellers each year, • 40% corporate work, Govt and Private Co.

10. Recommendation skill • Keahlian dokter • Pengkajian kesehatan dasar • Manajemen Risk • Strategi penetalaksanaan penyakit • (meningitis), Ixiaro (Japanese encephalitis), H1N1 (“Swine” flu) • Konsultasi pasca perjalanan • Ketrampilan komunikasi

11. KLINIK KEDOKTERAN WISATA • KHUSUS TERINTEGRASI • Klinik dokter umum • Klinik di rumah sakit • Travel klinik swasta • Klinik pelabuhan/maskapai penerbangan • Klinik hotel atau tujuan wisata

12. Objectives • Pre-travel konsultasi/preparation • Vaccinations • Bekal profilaksis • Health check • Medical kit • Konsultasi/Medical support while away

13. General preparation • Appropriate clothing, luggage • Care with travel documents • Seek travel medical advice early • Document medications • Have travel insurance

14. Health Preparation • Try to be fit • Stabilise any chronic medical conditions • Have a medical checkup if health has been poor or symptoms present • Consider vaccines • Take required medicines and useful personal supplies • Be aware of health risks

15. Travel Preparation • Travel health insurance • Medical care • Hospitalization • Evacuation • Obtaining medical care abroad • Awareness of travel notices • Hand washing and hygiene

16. TRAVEL VACCINATION • Safe, effective way to reduce morbidity from travel diseases • Three vaccine categories: recommended, required and routine • Contact with unvaccinated population = loss of “herd” immunity and increased disease risk • Procrastination a major problem: ideally see patients >1 month before travel • Often not covered by insurance

21. Travel Medications:Prophylaxis & Self Treatment • Malaria • chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine • Diarrhea • quinolone, azithromycin • Altitude • acetazolamide • Motion sickness • scopolamine, dimenhydrinate (Dramamine)

22. STI’s and Travel • Greatest risk age 15-29, and in SE Asia • All travellers do more risk-taking behaviours while travelling, but highest rates in expatriates, backpackers, business travellers, military • Education: safe sex practices, especially use of condoms • Sexual tourism is a big problem

23. Patpong District, Bangkok

24. Medical Tourism: Risks • Should complications arise, patients might not be covered by insurance or able to seek compensation via malpractice lawsuits. But new insurance products are being promoted • Some countries have different infectious diseases which may result in exposure to disease • Travel soon after surgery can increase the risk of complications, as can vacation activities • In US, Joint Commission International (JCI) fulfills an accreditation role • In the UK and Hong Kong, the Trent International Accreditations Scheme fulfills an accreditation role

25. Environmental Precautions • 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

26. Vector Precautions • 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 • Inspection for ticks

27. Insect Avoidance • Dengue Fever- bite of the Aedes mosquito • rise in urban populations and poor sanitation • poor water storage and waste disposal • increase in urban mosquito breeding • no current vaccine Japanese Encephalitis- bite of the Culex mosquito • prevalent in rural areas of Asia and Indonesia • summer seasonal risk in temperate areas • rural agricultural areas such as flooded terraces • swine and wild birds amplify risk • vaccine available!

28. Skin Lesions in Travelers • Arthopod Bites- Myiasis -botfly larvae will penetrate skin and mature leading to a nodule. Tungiasis (sand flea larvae are expelled under skin after a blood meal). Rickestiae will see a necrotic ulcer

29. Animal Precautions • Animal avoidance • Rabies • Specific animal threats • Medical evaluation of bites/scratches • Post exposure immunization and immunoglobulin • Envenomations • Snakes, scorpions, spiders • Maritime animals

30. Giving the correct advice to travellers • Giving the correct health advice to travellers needs: • Information • Training • Experience • Documentation • Travellers

31. Professional Organisations • Local professional groups and • THE ISTM

32. ISTM • International Society of Travel Medicine • International Network • International Clinic Directory • Useful for marketing/recognition • www.istm.org • Listserve • Outbreak alerts • Journal • Geosentinel • Certificate of Travel Health • Great Conferences!!

33. Resources/Recommendations • New Travel Programs and Web Support • New CDC Yellow Book • Special Case Travelers • New Approaches to Traveler’s Diarrhea • New Recommendations for Malaria Prevention • New Travel Vaccines: Tdap, Menactra (meningitis), Ixiaro (Japanese encephalitis), H1N1 (“Swine” flu)

34. Free Web Travel Information Sources Full Listing CDC Yellow Book Appendix B • www.cdc.gov/travel CDC Travel Info (best) • www.tripprep.comShoreland’s Travel Health Online • www.mdtravelhealth.com/ MD Travel Health • www.who.int/ith/en World Health Organization Int’l Travel • www.astmh.org American Society of Trop. Medicine • www.travel.state.gov U.S. State Dept. (202-647-5222) • www.iamat.org Int. Assoc. Med. Assist. To Travelers • www.promedmail.org Pro-MED program for monitoring emerging disease • www.healthmap.org/en Health Map --Global Disease Alert • www.medletter.com Medical Letter (Travel Health Summary) • www.fallingrain.com Altitude Finder • www.odci.gov/cia/publications/pubs.html CIA (select World Fact Book) Travel Subscription Services e.g.Shoreland TRAVAX Encompass, CultureGrams, SOS Travel Care, and Gideon are even more useful but entail an annual fee

35. New CDC Yellow Book Features • Pre-Travel Consultation: risk assessment, risk communication, risk management • Post-Travel Consultation • Select Destinations /Travel Itineraries • Infectious Diseases Related to Travel • Yellow Fever /Malaria Tables • Special Traveler Populations: Children, Special Needs, Immigrants/Refugees • Appendices: • A. Practice of Travel medicine • B. Electronic Resources • C. Travel Vaccine Summary Table

36. CDC Malaria Interactive Mapwww.cdc.gov/malaria/features/risk_map.htm Search Feature: Country and City

37. Computer Travel Information Services(all entail an annual fee) • SOS Travel Carewww.internationalsos.com • Shoreland TRAVAXwww.shoreland.com and Shoreland TRAVAX Encompass (online) www.travax.com • Exodus Software www.exodus.ie • Tropimed www.tropimed.com • Travel Medicine Advisor (online) www.ahcmedia.com or orders@ahcmedia.com

38. Other Subscription Sites ( fee) • Gideon (for diagnosing the ill returning traveler) www.gideononline.com • CultureGrams (concise 4 page cultural summary by country) www.culturegrams.com • VaxisEHR from Travis Medical(electronic health record)www.vaxisehr.com/travel

39. Journals Weighing the Evidence

41. Travelers’ Health Websitewww.cdc.gov/travel

42. Regional Destinations • Region-specific pages • Goal to move to country-specific format

43. Travel Notices & Announcements

44. World Malaria Risk

45. Common cause of febrile illness in returning travelers: Prevention is only available strategy Global Dengue Risk

47. Thank-you and Bon Voyage