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Part III

Part III. This section will provide an overview of the non-vaccine preventable health and safety issues for students: Insect vectors: focus on malaria and dengue Food and water hazards: focus on traveler’s diarrhea Other health and safety risks

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Part III

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  1. Part III This section will provide an overview of the non-vaccine preventable health and safety issues for students: • Insect vectors: focus on malaria and dengue • Food and water hazards: focus on traveler’s diarrhea • Other health and safety risks Final slides are resources for the full slide set

  2. Insect Vector Diseases • Malaria • Dengue • Vaccine-preventable: Yellow Fever, Japanese Encephalitis • Many others: chagas disease, sand flies, bed bugs, etc Student accommodations may place them at risk for insect-borne diseases

  3. Malaria: #1 Infectious Disease • Serious, potentially fatal parasitic disease spread by the night-biting anopheles mosquito • Present > 100 countries; 300 mil cases yr / 1 mil die • 1,000 US travelers / yr reported cases • 4 Plasmodium types affect humans • P. falciparum >95% traveler deaths • P. vivax, p. ovale p. malariae: delayed onset, late dx www.cdc.gov/mmwr/preview/mmwrhtml/ss5402a2.htm#tab6

  4. Traveler’s Malaria Risk • risk for P. f: Africa (2% travel / 83% cases) • Highest risk for P. vivax: Asia, Latin America • Exposure risk varies: geography, season, duration, altitude, activities, sleeping conditions, adherence, VFR • At risk groups: long-stay, adventure travelers (specific activities), pregnant women, VFR (BMJ reports 3x-8x higher risk), noncompliant No vaccine, but considered preventable & treatable

  5. Malaria Endemic Countries 2003 www.who.int/ith/diseasemaps_index.html

  6. CDC Approach to Malaria Education: ABCD • #1: Awareness: of disease & where, when traveler is @ risk • #2: Bug bite avoidance: prevent bites! • #3: Chemoprophylaxis: take appropriate Rx medications as prescribed • #4: Diagnose: the early signs & symptoms: if fever, think malaria & get prompt care

  7. A Use Maps to Confirm Risk with Traveler

  8. Teach the Plasmodium LifecycleNY Daily News 10/2002

  9. B Personal Protective Measures • Use DEET repellants: controlled release, 19-35% * • Apply permethrin to clothing, bed nets • Reduce outdoor activity dusk to dawn • Return from rural trips before dark • At night time: use screens or A/C, bed nets, spray room or tent with flying insect spray *Information resource: Fradin,M & Day, J (2003) NEJM, 347: 13-18.

  10. C Malaria Drugs of Choice • Chloroquine For Resistant Areas: 3 CDC approved medications- • Mefloquine • Doxycycline • Malarone (Atovaquone/proguanil) None 100%; need PPM Screen all students before prescribing! Adherence issues ! Obtain in U.S.: counterfeit / unavailable abroad

  11. Chloroquine Resistance Many Areas Around the World Source: CDC@ www.cdc.gov/travel

  12. Mefloquine / Lariam • 20+ years of use; very effective most areas • Resistance on Thai borders • Controversy regarding tolerability / media blitz • “Neuro-psychiatric” side effects reported • Prescribing guidelines: • Screen for contraindications: seizure, psych illness / psych meds, drug allergy, 1st trimester pregnancy • Tolerance in past does not insure tolerance next time • FDA requirement: pharmacists distribute AE handout • Consider use for: previous use, long-stay traveler, pregnancy

  13. Doxycycline •   expensive, readily available • Short half-life; qd x 1 month after trip • AEs: vaginitis, esophagitis, photosensitivity, GI upset • Not for pregnancy, breastfeeding • No known areas of resistance • Consider use for: Thai borders; no $- backpackers, VFRs, students

  14. Malarone • Atovaquone (250mg) + Proguanil (100mg) • Take daily, start 1-2 days before, only 7 days after trip •  cost • AE’s: GI intolerance- so take with food • Not available everywhere • Consider use for: short-stay traveler, drug plan, Thai borders, student living in city without malaria; student unable to take other choices

  15. Primaquine to Prevent P vivax Relapse • Additional consideration for students at risk for infection with P vivax • P vivax relapse infections • Consider adding Primaquine to malaria regimen to prevent relapse < 3yrs post travel • Potent anti-oxidizing agent: test for G6PD deficiency to prevent hemolysis • Not used in pregnancy • Consult with malaria expert as needed

  16. Chemoprophylaxis Decision-making • Is the traveler going to malaria zone? • Will he be exposed? (accommodations, night exposure, altitude) • Is there drug resistance there? • Are there any drug contraindications: allergies, meds, pregnancy, psych hx, etc? • What is the traveler’s experience with malaria meds? • What is the duration of anti-malarial use? Schwartz E et al. Delayed onset of malaria-implications for chemoprophylaxis in travelers. NEJM 349;16, 1510-1546; J Keystone, Wilderness Medical Society presentation, Big Sky 8/05

  17. D Malarial InfectionMajority of U.S. cases present post trip Fever after trip to malaria zone = malaria Teach student how to get immediate, competent evaluation & care

  18. Patient Teaching Resource@ www.cdc.gov/malaria/pdf/travelers/pdfGive to Every Student at Risk

  19. Provider Resource for Malaria Treatment • National Center for Infectious Diseases-Division of Parasitic Diseases @ 770-488-7788 • Internet @ www.cdc.gov/malaria/diagnosis_treatment/treatment.htm

  20. Dengue Fever“Breakbone Fever” • Age-related flu-like syndrome • Growing problem: now present > 52% of world • Vector: day-time Aedes • Urban & rural risk • DHF variant • Prolonged convalescence possible • Avoidance only: no vaccine, no chemoprophylaxis at this time

  21. Traveler’s Diarrhea • #1 most common infection in travelers: 30% /wk • Developed to developing countries (CDC II, III) • Transmission: fecal-oral contamination • 60-80% bacterial etiology; viral: 10-20% & parasites 5-10% •  drug resistant campylobacter jejuni • Syndrome- abrupt, 3+ defecations / d; assoc GI c/o • At risk: level of accommodations, long-stay, adventurous eaters, VFR, GI or immunity problems

  22. “Boil it, cook it, peel it, or forget it”Easy to say, hard to do! • Prevention not always possible • Assess student for risk, self-care skills, resistant organisms @ destination • Five step approach: Simple & Customized Message • Educate: food & water consumption “careful vs careless” • Immunizations: Hep A, typhoid • Emphasize handwashing • Counsel self-care: rehydration, use of antimotility agents and antibiotics to use “on-the-road”

  23. Traffic accidents Air travel Recreational hazards Climate Altitude STDs Safety & security Travel stress Medical care abroad & trip insurance Self-care “on the road” Post-trip issues Other Non-vaccine Preventable Risks for Student Travelers

  24. Traffic Accidents • #1 cause of morbidity and mortality in US travelers abroad • Internationally, more complex traffic mix as wheeled vehicles, animals, pedestrians all share same road • Poor road maintenance & problematic signage • Lack of roadside care • No motorcycles • No night-time rural travel

  25. Barotrauma: “aerotitis” Respiratory infection (Flu, URI, TB transmission) Jet lag and sleep issues Dehydration Contact lens problems Allergic reactions to “disinfection” “Traveler’s Thrombosis” Air Travel Hazards

  26. Traveler’s Thrombosis DVT caused by prolong confinement in cramped position—can lead to fatal PE • Overall very low incidence (<1/million travelers) • At risk: Flights > 5-6 hrs; highest risk flights >10hrs; recent surgery (< 4wks), pregnancy, cancer, CHF, DVT hx, obesity, estrogen use • Assess for co-factors, encourage ankle and calf movement and hydration on flight; refer to expert if  risk • Teach early s/s- get to proper evaluation & care Giangrande, P. (2002) Br J Haematol., 117, 509-512. Geerts et al. (2004) Chest;126, 338S

  27. Effects of the sun (UV): sunburn & sunstroke, skin cancer, eye damage Photo-toxicity with some meds (eg Doxy) Greater risk @ altitudes, in or near water, snow Prevention: avoid midday sun, wear clothing that covers skin, use UVA/UVB sunblock SPF 15+, wear wide-brimmed hat & sunglasses; checks meds for sun sensitivity Sun HazardsStudents often seek out the sun on trips

  28. Risky Behaviors: Blood-borne Pathogens • In many countries, rates of HIV and other STIs are much higher than in US (50 to 500x) • Travelers need to avoid all behaviors that expose them to bloodborne pathogens • Studies show 5-67% of travelers have sex with new partners during travel • Safe sex – counsel travelers to plan ahead & avoid prostitutes, multiple partners, alcohol excess

  29. Every StudentEvery Trip Drugs & Alcohol & Sex Messages

  30. Safety & Security • Travelers are targets for thieves, others • Travelers need to adopt “safety-conscious” behaviors • Bring duplicate documents, leave another set at home • Seek guidance before walks, jogs, night excursions • Avoid isolated areas; go in pairs, groups • Have a plan for the airport • Bring nothing you can’t avoid to lose • Know the role & access #’s for embassy • If travel plans change, keep family & others (school, Dept of State, etc) informed

  31. Women & Travel • Cultural issues in many parts of world • Personal safety • Risk for sexual harassment, rape, date rape • Adjustments to personal care routine (issues of dress, jewelry, perfume, etc) • Self-care for: contraception, UTI’s, other Gyn issues

  32. Self-Care During Travel • At risk groups: adventure travel, trips > 3wks, persons with medical problems, solo travelers • Know when , where, how to seek help • Purchase travel medical evacuation insurance and how to access care – important phone #s • Carry ample supply of any Rx drugs • Carry a first aid kit

  33. Usual OTC drugs Rx drugs- routine and trip-related First-aid supplies Thermometer Pain / fever meds Pocket-size dictionary Instructions for taking meds (“suitcase medicine”) Stool softener Anti-motility agent Decongestant Insect repellant Sunscreen Motion-sickness meds Foot care Condoms Travel Kit Basics + Customize

  34. Special Groups / Special Supplies • Benadryl, Epipen, Medic-alert bracelet (or similar) • Rehydration packets (ORS) • HIV PEP Drug Supply • Emergency contraception “plan B” • Expanded health history / translated in local / multiple languages

  35. Water Recreation • Drowning is #2 health risk for US travelers • Swim in salt or well-chlorinated water, not fresh • Adopt safe behavior in recreational waters • Avoid alcohol when pursuing water sports • Engage reliable companies for boating, snorkeling, scuba, rafting, parasailing, etc • Carefully evaluate outfitters for: compliance with safety regulations, equipment / guides, life jackets, emergency services • Caution: think twice about trying new water activities while traveling internationally

  36. Altitude Illness (AMS) • At higher altitude, atmospheric pressure,  oxygen pressure→ can lead to hypoxia • AMS- can occur after 1-6 hrs @ > 2400-3000m • Fatal risk: HACE, HAPE • Risks: rapid ascent for mountain trekking, skiing, climbing & direct visits to high places: Cuzco, Kilimanjaro, La Paz, Tibet, etc. • AMS signs / symptoms: headache, fatigue, insomnia, anorexia/nausea/vomiting • Teach prevention & self-care, use of medications

  37. Improving Teaching Efficiency& Effectiveness • Prioritize! • Build on traveler knowledge • Customize & prioritize messages- only 20% retention rate is usual for most learners • Learning process: hear, see, use • Supplement with checklists, packets of health ed materials • Group teaching, call-backs for counseling • Web resources

  38. Criteria for Quality TH Care • Commitment to consistent, individualized care • Staff selection, training & ongoing education • Program monitoring and evaluation • Accurate guidance based on epidemiologic data • Updated Internet resources for trip research / recommendations • “Cold Chain” compliance • Immunization coordinator & proper equipment • Compliance with regulations & standards of care • Written policies and procedures: anaphylaxis, disaster protocol, needlestick, cold chain, documentation, others

  39. Student Travel Health Challenges • Short notice! • Not enough money • Flexible trip plans • Confidentiality & truth-telling • Possibly pregnant • Born outside U.S.

  40. More Challenges • Pandemic/ Bioterrorism concerns • Clinic / orphanage work • Very remote travel • Intermittent malaria risk • School sponsored trip • Refuses vaccines

  41. Preparing Students for International Travel China: 4 Day, 5 Star India: 4 months, No Star In Summary- Always a rewarding challenge

  42. Assessment Review Articles • Spira, A. Preparing the traveller. Lancet, 2003, 361, 1368-1381 • Rosselot, G. Travel health nursing: expanding horizons for occupational health nurses. AAOHN J, 2004, 52(1), 28-41. • Ryan, E & Kain, K. Health advice and immunizations for travelers. New England J of Med, 2000, 342(23), 1716-1725.

  43. Additional References • Steffen,R., Rickenbach, M., Wilheim, U., Helminger, A., & Schar, M.(1987). Health problems after travel to developing countries. Journal of Infectious Disease,156(1), 84-91. • Centers for Disease Control and Prevention. (2001). Health information for international travel, 2001-2002. Atlanta, GA: U.S. DHHS, Public Health Service. • Dupont, H and Steffen, R. eds. (2000)Textbook of travel medicine. BC Decker, Hamilton, Ontario, Canada. • Barnett E, Chen R, and Rey M (2004) Vaccines for international travel. In S Plotkin and W Orenstein (eds, Vaccines, 4th ed. • Steinberg E et al (2004) Typhoid fever in travelers: Who should be targeted for prevention? CID, 39, 186-191. • Thompson R. (2004) Routine and travel immunizations. Shoreland, Inc., Milwaukee • Fradin M & Day J (2003) Comparative efficacy of insect repellents against mosquito bites. NEJM, 347(1): 13-18.

  44. Additional References • Schwartz E et al. (2003) Delayed onset of malaria-implications for chemoprophylaxis in travelers. NEJM, 349(16), 1510-46. • Thielman N & Guerrant R (2004) Acute infectious diarrhea. NEJM, 350, 38-47. • Thompson M & Jong E (2003) Traveler’s diarrhea: prevention and self-treatment. In E.Jong and R.McMullen (eds), The Travel and Tropical Medicine Manual, 3rd ed. (pp.75-86) • Ansdell V & Ericsson C (1999) Prevention and empiric treatment of traveler’s diarrhea. Med Clin of N Amer, 83, 945-973. • Ericsson C (1998) Traveler’s diarrhea: epidemiology, prevention, and self-treatment. Infect D Clin of N Amer, 12, 285-303. • Giangrande P (2002) Br J Haematol., 117, 509-512. • Geerts et al. (2004) Chest, 126, 338S • ISTM Body of Knowledge @www.istm.org

  45. Conflict of Interest Statement In the past, Gail Rosselot has received speaker honorariums from Merck, GSK, and Shoreland and educational grants from Merck, Berna, Shoreland, and Sanofi-Pasteur. There was no commercial support for this ACHA presentation. Contact information: garosselot@aol.com

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