PROBLEMS & PREVENTION IN TRAVEL RELATED HEALTH PROBLEMS

1. PROBLEMS & PREVENTION IN TRAVEL RELATED HEALTH PROBLEMS Dr GOTRA SAPUTRA M.KES

2. Travel risks • Travel statistics • Increasing people travel each year • Destinations becoming more exotic • Most illness during travel is diarrheal • Diarrheal (30%) • Respiratory (2%) • Malaria (2%) • Hep A (0.5%) • Gonorrhea (0.5%) • 2nd most common illness is non-tropical, e.g. DVT, MI, etc • Travel-related deaths only 1-4% • >50% deaths during travel are from chronic disease issues (CVD– MI, CVA etc.) • Remainder: MVA, drowning, falls, accidents

3. 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%).

4. Travel risks For every 100,000 travelers to developing countries: • 50,000 will have a health problem. • 8,000 will have to visit a physician. • 5,000 will have to stay in bed. • 1,100 will be completely incapacitated. • 300 will be hospitalized. • 50 will be air evacuated. • 1 will die.

6. Injury Deaths in International Travel N = 601 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

7. Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV Infectious Disease Risks to the Traveler ETC.

8. PENYAKIT INFEKSI EMERGING DI DUNIA

9. Other Risks to the Traveler • Accidental injury • Environmental hazards • Crime and assault • Psychiatric problems • Animal bites, stings and envenomations • Dermatologic disorders • Altitude • ……. ETC.

12. Establish the risks • Destination • Mode of travel • Traveller’s medical history • Intervention

13. Risks of the destination • What countries and what parts of these countries are they visiting? • How long are they going to stay? • What time of the year are they visiting? • What are the living conditions? • What are the current security concerns? • What activities are they undertaking? Do they need a diving medical? • What can the traveller tell you? • Is there anything special about the destination culturally or legally?

14. Risks of the destination • Are they travelling alone or as a group? • What is the traveller’s prior travel experience? • What access is there to appropriate medical care? • Does the traveller know first aid? • Does the traveller have travel insurance with full coverage?

15. Risks of the destination • Categorise Living Conditions: • Rural and remote areas and villages and/or close contact with local people, e.g. health workers. • Towns and cities, not rural and remote and/or lower standard accommodation and/or stay over four weeks/month. • Major cities and tourist resorts and/or medium to high standard accommodation and/or reliable water and food sources and/or short term stays of less than four weeks/month. • In transit and not exposed to local environment, eg staying in plane or short-term stay in modern airport terminal.

16. Disease or safety risks may be associated only with particular parts or areas of a country and not be a uniform risk throughout a country.

17. Risks of the mode of travel • Modes of travel can present particular medical problems of varying severity, e.g. motion sickness, painful ears, phobias, DVT; • Can they fly?

18. Risks of the mode of travel • Some travellers may not meet medical guidelines to travel or may need special clearance to fly on commercial aircraft, such as with • pre-existing illness, • pregnancy, • recent surgery or • serious physical or mental incapacity

19. Risks of the mode of travel • Accidents and injuries • Travellers may use modes of travel not normally used, including at destination, e.g. 4WDing, motor bike riding, cycling, rollerblading, skiing, jet skiing, etc

20. Risks of medical history • Past travel history, particularly involving any significant medical issues, • Past medical history, eg need for adjusting diabetic treatment, • Past surgical history, eg recent surgery, • Most recent dental examination • Current medications, including the oral contraceptive pill, • Last menstrual period for females (are they pregnant?), • Smoking and alcohol history, • Allergies, including medications and foods, • Any current illnesses and regular medication, and • Are they travelling alone or with children or with older travellers? • How fit are they to undertake any proposed exertional activities?

21. Risks of medical history • Asthma - Asthma management plan; precipitants; environmental concerns; consider influenza vaccination and antibiotics for medical kit. • Diabetes - Consideration of time zone changes; control • Ulcer management - Reduced acidity may predispose to diarrhoeal disease

22. Risks of medical history • Psoriasis - May get worse with chloroquine • Arthritis - May have difficulties with treks, climbing (also general fitness); may need standby NSAID treatment • Hypertension - Caution in prescribing mefloquine and Beta blockers • Immunosuppression - Immune response to vaccination may be less; live vaccines may give rise to disease

23. Risks of medical history-allergies • Sulphurs (Maloprim), Diamox & other sulphur based medications • Egg allergies* Yellow fever vaccine, influenza vaccine, MMRII • Neomycin, polymixin Measles, Mumps, Rubella • Iodine iodine water purification tabs • Quinine Chloroquine • Food allergies Various, including, seafood, peanuts • Pets Cats

24. Risks of intervention • Addressing risk in travel medicine is generally all about trying to modify risks established from the travel health consultation • All interventions have potential risks, including giving the wrong advice

25. Risks of intervention • Advice and education • Vaccination • Chemoprophylaxis • Screening and Effective management

26. Risks of the intervention • Can the traveller tolerate the intervention? • Does the risk of the exposure justify the intervention/cost? • Can the traveller afford the intervention? • What do you do if you can’t provide optimal protection because of risks from the medical history or other considerations, such as age of the traveller or cost?

27. 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

28. 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

29. Medical Tourism • Also called: medical travel or health tourism or global healthcare. • Elective and cosmetic procedures as well as specialized surgeries • Sometimes leisure activities included in on trip. South Africa for example has medical safaris • Popular destinations include: India, Brunei, Cuba, Colombia, Hong Kong, Hungary, Jordan, Lithuania, Malaysia, The Philippines, Singapore, South Africa, Thailand, and recently Saudi Arabia, UAE, Tunisia and New Zealand

30. 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

31. 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

32. Food and Water Precautions • Bottled water • Selection of foods • well-cooked and hot • Avoidance of • salads, raw vegetables • unpasteurized dairy products • street vendors • ice

33. Eating overseas may pose a challenge

35. 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

36. 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!

37. 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

38. Skin Ulcers Tularemia Atypical Mycobacterial Endemic fungal STD’s –genital ulcers- Syphilis, LGV,Chanchroid Creeping Eruptions Cutaneous larva migrans (hookworm larva) Loiasis Strongyloidiasis. Skin Lesions in Travelers

40. Cutaneous Leishmaniasis

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

42. Rabies

43. At the Shore…….

46. Motion sickness • Cephalic and gastric phase • 85% gastric • Anticipatory motion sickness • General concept is to learn to like motion • Isoptohyoscine qtts • Ephedrine or CNS stimulant • Corticosteroids

47. SALTWATER: Sea Lice • Path: Lanuche trapped under suit ⇨ severe itching • DX: Papules/pustules under suit • Rx: Vinegar/Urine stat Steroids later Wash clothes(Sinnott J, S Med J 14,44,1996)

49. SALTWATER: Jellyfish • Path: Nematocyst allergy • DX: See jellyfish or feel sting • 6 Hr: Vinegar (?Urine, NH3, Baking Soda) Not ETOH • Late: Topical steroid Oral steroids