TRAVEL MEDICINE CLINICS Australian Experience

1. TRAVEL MEDICINE CLINICSAustralian Experience DR. TONY GHERARDIN National Medical Adviser Travel Doctor-TMVC Group Australia

2. TRAVEL MEDICINE “that aspect of public health medicine which seeks to prevent illness and injuries occurring to travellers going abroad, and manages problems arising in travellers coming back from abroad.” “protection and promotion of health of tourists.” In any community there will be variableopportunities to be a source and a host for travellers

3. Travel Medicine Practice of “Emporiatrics” Rapid development over the last 25 years Fairfield Hospital in Melbourne started travel clinic in early-mid 80s - one of the world’s first travel clinics Now a recognised clinical entity primarily involved in risk management Strong overlap with public health and occupational health and general practice

4. Travel Medicine Is not “cookbook” stuff Should not be taken as trivial or just give a couple of jabs Never should be “ let them see the nurse and I’ll sign off” If you provide travel medical services, do it properly!

5. Best Practice • Involves trained doctors and nurses who have complimentary roles. • Not “cookbook”, lists alone are weak as provide no context or priority • One stop service is valued by travellers • Links to referral services

6. Risk Management Identifying risks for individuals or groups Advising about risk reduction strategies Recommending and providing risk reduction interventions Encouraging behavioural change to change risk level

7. Risk Reduction Interventions Information enabling behaviour modification vaccinations medications (including antimalarials) other - travel insurance, pre existing medical problems, nets, syringes, medical kits

8. Knowledge of Travel-related Risks Knowledge of morbidity and mortality of travellers Understanding of epidemiology and geography of communicable diseases Awareness of non-communicable risks Vaccines, indications, side-effects Knowledge of post-travel illness presentation and management Geography , esp of major tourist destinations Ability to communicate complex issues in simple ways Understanding of when to refer

9. Provide Up-to date Information Understand basic current epidemiology Be aware of outbreaks and emergent issues Provide written material targeting specific risks Be able to communicate using electronic media

10. Vaccine classification-3 Rs • Routine ( background) vaccine Childhood, standard • Required ( compulsory) vaccine Cross borders, entry requirements IHR • Recommended ( elective based on risk) Travel vaccines Some vaccines can be in more than category. Not all the same or available in all countries

11. Key elements of quality service • Current best practice • Organised and professional • Up-to-date advice • Comprehensive vaccines, medications • Range of Kits • Appropriate documentation • Communication options • Value for money

12. Travel Clinic Environment • Established with an understanding of the psychology of a traveller in mind • Appropriate paraphernalia + required tools • IHGs, brochures, kits, travel related products • All contact points in the clinic need to reflect this • All staff need an understanding of travel & travel health requirements

13. Establishing a Travel Medicine Clinic CORE ELEMENTS • CREATING THE VISION • STAFF • PHYSICAL ENVIRONMENT • OPERATING PROCEDURES • KNOWLEDGE / SKILL BASE • COMMITMENT

14. The demand for Travel Medical services is increased when travellers are going from more-developed, healthier environments to less developed, less healthy ones. • The nature and activities of a particular travel clinic will depend on its surrounding socio-economic environment • The prevailing socio-economic environment in much of the developing world is well suited to an increasing need for Travel Medicine services

15. CORE ELEMENTSCREATING THE VISION DEFINING THE TASK: To provide a comprehensive range of travel medicine services of an international standard to achieve a viable professional practice. QUESTIONS Who are your potential clients? How to identify the target travelers? What charges will apply? – Will it be viable? MARKET RESEARCH

16. MARKET RESEARCH • Demographic Information Population data, Tourism data, Socio-economic markers, Local studies • Acceptance of Preventive Services Perception of Risk • Awareness of Travel medicine services • Opportunities for marketing and promotion

17. CORE ELEMENTSPHYSICAL ENVIRONMENTThe Clinic LOCATION • Relevant to target clients • Consider International travellers • Near other services SPACE • Adequate waiting, reception area • Consulting rooms • Nurses Rooms/ Recovery room • Storage/Record Keeping • Toilets/Sinks/Washbasins

18. CORE ELEMENTSPHYSICAL ENVIRONMENTThe Clinic ACCESS • Ground Floor preferable, avoid stairs • Broad as possible, maximise appeal LAYOUT • Waiting / Reception separate • Consulting / Nursing rooms separate • Recovery room has privacy • Access to bathroom / toilets • Records / Communications

19. CORE ELEMENTSPHYSICAL ENVIRONMENTThe Equipment FURNITURE Reception Chairs / tables Examination couch Lights STORAGE Cupboards - secure / non secure Shelving Refrigerators – main / consulting rooms

20. CORE ELEMENTS PHYISICAL ENVIRONMENTThe Equipment STRUCTURAL Toilets / hand basins Sinks INFORMATION TECHNOLOGY / COMMUNICATIONS Computers Phones / Fax / Email MEDICAL EQUIPMENT

21. CORE ELEMENTSSTAFF • Professional. Can demonstrate legitimate qualifications • Friendly • Trained • Good Communicators Language Skills Cross Cultural Sensitivity

22. CORE ELEMENTS OPERATING PROCEDURES • Provision of Information and Advice Standardised written information eg. Vaccine side effects All staff deliver a consistent message • Standardised Vaccination Protocols Internationally acceptable Modified for local availability/regulations • Standardised Chemoprophylaxis Protocols Malaria Diarrhoea Jetlag / Motion sickness / Altitude

23. CORE ELEMENTS OPERATING PROCEDURES • Empiric Treatments/ Self Treatments Malaria Diarrhoea • Provision of Medical Kits Different travellers = Different kits • Documentation / Record Keeping Compliance with International Certificates Reporting Adverse events Notifiable Diseases

24. CORE ELEMENTS OPERATING PROCEDURES • Self Diagnostic Kits with Explanations • Compliance with Local Regulations Obtain relevant permits Keep compulsory records • Infection Control Procedures • Emergencies Anaphylaxis / Cardiac Arrest Medical Emergencies

25. MANAGEMENT OF ANAPHYLAXIS • If patient unconscious: Lie on left side, clear airway. • Give adrenaline I.M. Repeat every 5 minutes if required. • Administer oxygen – Use face mask at high rate • Get help • Commence CPR if needed ADRENALINE– 1:1000, 0.01 mg/kg : Adult 0.5 ml Display dosage charts

26. First Aid Components Adhesive tape Antiseptic wound cleaner Bandages Decongestants Scissors/safety pins Sterile dressings Antidiarrhoeals Condoms Water disinfectant Lubricant eye drops Insect repellent Insect bite treatment ORS Paracetamol Thermometer Antifungal treatment Sterile needles/syringes Other MEDICAL KITS

27. Medical travel kits • These are designed to assist travelers in meeting medical needs when their access to quality medical care is compromised. • All travel medicine consultants recommend that travelers carry some form of medical first aid kit. A range is available, and often needs to be tailored to meet the specific requirements of the traveler and their proposed itinerary. • Many travel clinics sell medical first aid kits; these often contain prescription items.

28. Medical travel kits Essential items for all travelers Items to treat cuts, scratches, burns, strains, splinters Paracetamol Repellent Consider condoms Additional items for Europe, USA, Japan Antinauseants, eg prochlorperazine Broad-spectrum antibiotic for respiratory infection Antacids Sudafed Minor sedative Laxative

29. Medical travel kits Additional items for less developed countries (gastro kit) Rehydration solution Loperamide Tinidazole Norfloxacin – or azithromycin for children Comprehensive medical kit ; Asia, Africa and South America All of the above Sterile needles and syringes. Alcohol swabs Antihistamines Antifungal and antibiotic cream

30. SUPPLY Approved locally Comprehensive range Continuous supply HANDLING / STORAGE Monitored cold chain Recording batch numbers Check expiry dates Proper re-use DISPOSABLES Quality assured reliable DISPOSAL ROUTINE Sharps Infected materials Proper disintegration VACCINES

31. VACCINES ROUTINE: • Diphtheria / Tetanus / Pertussis – DTP • Hepatitis B • Haemophilis influenza type B – HIB • Measles / mumps / rubella – MMR • Polio – OPV / IVP • VZ

32. TRAVELLERS Hepatitis A Influenza BCG TVO, TVI Cholera Yellow fever, Mn , Pn JEV Rabies, RIG TBE Lyme Other: Q Fever, Plague, Anthrax VACCINES

33. Cold Chain • Absolutely essential • Vaccines are sensitive, normal range is 20-80C Do not freeze • Must have monitoring • Preferably alarms and backup solutions for problems • Avoid little fridges in every room.

34. PERSONAL PROTECTIVE MEASURES • Bed Nets • Repellents • Clothing • Water sterilization / filters • Sunblock • Others ears eyes compression garments

35. CORE ELEMENTSKNOWLEDGE / SKILL BASE • PROVIDE UP TO DATE KNOWLEDGE Advisories Texts / Official Recommendation Internet • PRE- TRAVEL ADVICE Comprehensive services • POST TRAVEL Assessment and Investigation Medical assessment of returned travellers Basic testing/TST/Urinalysis Recognition of emergencies Referral to specialists

36. ISTM Body of Knowledge • Epidemiology • Immunology/Vaccinology • Pre-travel Consultation/Management • Diseases Contracted During Travel • Other Conditions Associated With Travel • Post-Travel Management • General Travel Medicine Issues

37. Special populations • Athletes • Corporate Travellers • Elderly Infants and children • Immigrants • Expatriates • Pregnant travellers • Chronic disease • Disabilities • Imunocompromised

38. Special itineries • Cruise ships • Diving • Extended stay • Extreme travel • Mass gatherings • Wilderness

39. CORE ELEMENTSKNOWLEDGE / SKILL BASE TREATMENT OF COMMON ILLNESS Fever Diarrhoea Skin Eosinophilia • ACCESS TO EVACUATION Dealing with Insurance Companies. Assessing local medical infrastructure • ADVICE ON INSURANCE

40. CORE ELEMENTSKNOWLEDGE / SKILL BASE • MANAGEMENT OF EMERGENCIES Management of Anaphylaxis Basic Life Support Adrenaline / oxygen Ambulance access / Hospital • RESOURCES FOR LABORATORY TESTING OR REFERRAL Access to Laboratory and Radiology Understanding QA • ABILITY TO PERFORM RESEARCH

41. CORE ELEMENTSCOMMITMENT • International links ISTM, Promed, Conferences • Local Promotion / Advertising Signage, Leaflets, Written materials, Talks, Media Consider professional advice • Working with Partners Travellers , Travel Industry , Pharmaceutical industry

42. Medico-legal opinion on Travel Medicine Advice. “ A claim arising from ‘travel’ may be related to either or both from; a/ Inadequate advice before travel. If you choose to advice patients ensure that you provide complete, accurate and up-to-date information. b/ delayed or missed diagnosis of an exotic disease in a person recently returned from overseas. Have the ability and the insight to know your limitations. If you choose to provide travel advice, decide which areas you will focus on, commit to remaining up to date in those areas, know where to look up information, and refer the rest to specialist clinics” Dr Paul Nisselle, MDAV