# Presentation: 541450

## THE PRE-TRAVEL CONSULTATION

- Gary W. Brunette, MD, MS
- Travelers’ Health Team
- Division of Global Migration and Quarantine
- Centers for Disease Control and Prevention

## Outline

**Travelers’ Health Epidemiology**
**Traveler Assessment**
**Itinerary Review**
**Sources of Information**
**Risks to the Traveler **
**Travel Vaccines**
**Travel Medications **
**Counseling**

## U.S. Residents Traveling Abroad*

***ITA, includes travel to Canada and Mexico**

## International Travel

## Where Do U.S. Residents Travel?

- Source: HealthStyles Survey 2005

**Of the 17% who traveled outside the U.S. . . . **

**Notes:**

This is not supposed to include travel without an overnight stay, particularly to Canada and Mexico.
Notice that the specification of the regions was not completely 

52% have traveled to developing countries 
As expected, the majority of travel is to Canada, western Europe and Mexico.  

## VFRs: Visiting Friends and Relatives

**Foreign-born increased 57% since 1990 from 19.8 million to 31.1 million****1**
**20% of US population are first- or second-generation immigrants**
**VFRs comprised ~46% of US international air travelers in 2004****3**
**	****1****US 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**
**	****3****2004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, USDOC**

**Notes:**
Christie, the first bullet needs to have the reference I cited. The previous reference is in parentheses, which I think is a typo. I cannot find a source to confirm the second bullet. The paper I have cited there has this information, but I cannot confirm with the US Census reference that is included in the paper (Kip has a copy). The whole reference is Angell SY, Cetron MS. Health Disparities among Travelers Visiting Friends and Relatives Abroad. Annals of Internal Medicine, 2005; 142:1, 67-73.
I have updated the 3rd bullet and reference.

## 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

## The Patient: Medical Issues

**Age-specific issues**
**Underlying illness, immunosuppression**
**Systems review**
**Medical history**
**Medication use**
**Vaccination history**
**Allergies **
**Contraindications to vaccines and medications**

## The Patient: Other Issues

**Reproductive**
**Pregnant**
**Breastfeeding**
**Preconception**
**Risk-taking behaviors**

## 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

## Travel Health Resources

**CDC Travelers’ Health Website**
- _[www.cdc.gov](http://www.cdc.gov/travel)__[/travel](http://www.cdc.gov/travel)_
**World Health Organization **
- _[www.who.int/int](http://www.who.int/int)_
**State Department **
- _[travel.state.gov](http://www.travel.state.gov/)_
**International Society of Travel Medicine**
- _[www.istm.org](http://www.istm.org/)_
**Health Information for International Travel**
**CDC “Yellow Book”**
**International Travel and Health**
**WHO “Green Book”**

## Travelers’ Health Websitewww.cdc.gov/travel

**Notes:**
In web use, usually in top 5 CDC sites
Primary Audiences
Traveling public
Health professionals advising travelers
Content Areas
Travel Notices & Announcements
Online Yellow Book
Regional Destination Pages
Resources (Y.Fever Registry, Travel Med Clinics, Contact Us)
Additional Topics & Special Needs Groups
Diseases A-Z
Traveling with Pets, Children, Special Needs Travelers
Travel Industry

## Regional Destinations

**Region-specific pages**
**Goal to move to country-specific format**

## Travel Notices & Announcements

## Deaths Related to International Travel

**Deaths Related to International Travel**

- N = 2463

- Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

## Infectious Disease Risks to the Traveler

**Malaria**
**Diarrhea**
**Leishmaniasis**
**Rabies**
**Dengue**
**Meningococcal Meningitis**

**Schistosomiasis**
**Tuberculosis**
**Leptospirosis**
**Polio**
**Yellow Fever**
**Measles**
**JEV**

- ETC.

## Injury Deaths and International Travel

**Injury Deaths and International Travel**

- N = 601

- Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

## Other Risks to the Traveler

**Accidental injury**
**Environmental hazards**
**Crime and assault**
**Psychiatric problems**
**Animal bites, stings and envenomations**
**Dermatologic disorders**
**Altitude**
**......****.**

- ETC.

## Immunizations to Consider for Adult Travelers

_**Routine**_
**Diphtheria***
**Tetanus***
**Pertussis***
**Measles +**
**Mumps+**
**Rubella +**
**Varicella**
**Pneumococcus**
**Influenza**

_**Travel related**_
**Hepatitis A**
**Hepatitis B**
**Typhoid**
**Rabies**
**Meningococcal disease**
**Polio**
**Japanese encephalitis**
**Yellow Fever**

- * Td or Tdap
- + MMR

**Notes:**
VZV (no mention of upper age limit; approved for >=12 months)
>= 13 Years of Age 
After the first and second doses, 10.2% and 9.5% of vaccinees, respectively, developed fever (i.e., oral temperature greater than or equal to 100 F {37.7 C}); these febrile episodes occurred throughout the 42-day period and were usually associated with intercurrent illness.
After one and two doses, 24.4% and 32.5% of vaccinees, respectively, had complaints regarding the injection site; rash at the injection site at a peak of 6-20 days and 0-6 days postvaccination, respectively, developed in 3% and 1% of vaccinees, respectively; and a nonlocalized rash consisting of a median number of five lesions developed in 5.5% and 0.9% of vaccinees, respectively, and occurred at a peak of 7-21 days and 0-23 days postvaccination, respectively. 

## Travel Medications:Prophylaxis & Self Treatment

- Malaria
- chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine
- Diarrhea
- quinolone, azithromycin
- Altitude
- acetazolamide
- Motion sickness
- scopolamine, dimenhydrinate (Dramamine)

## Patient Counseling

**Sufficient time for patient education**
**Tailored to suit traveler**
**Fitness for travel**
**Understanding impact on existing conditions**
**Advisability of destinations**

## Travel Preparation

**Travel health insurance**
**Medical care**
**Hospitalization**
**Evacuation**
**Obtaining medical care abroad**
**Awareness of travel notices**
**Hand washing and hygiene**

## 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**

## Food and Water Precautions

**Bottled water**
**Selection of foods**
**well-cooked and hot**
**Avoidance of **
**salads, raw vegetables**
**unpasteurized dairy products**
**street vendors**
**ice**

## 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**

## Bloodborne and STD Precautions

**Prevalence of**
**STDs **
**Hepatitis B**
**Hepatitis C**
**HIV **
**Unprotected sexual activity**
**Commercial sex workers**
**Tattooing and body piercing**
**Auto accidents **
**Blood products**
**Dental and surgical procedures**

## Animal Precautions

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

## 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**

## 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**

## 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**

## Questions?

## Other Resources

## 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

## 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

## Websites

- Eurosurveillance
- 	_[www.eurosurveillance.org](http://www.eurosurveillance.org/)_
- Travax EnCompass
- 	_[www.travax.com](http://www.travax.com/)_
- GIDEON
- 	_[www.gideononline.com](http://www.gideononline.com/)_
- International SOS
- 	_[www.internationalsos.com](http://www.internationalsos.com/)_
- Medical Advisory Service for Travelers Abroad (MASTA)
- 	_[http://](http://www.masta.org/)__[www.masta.org](http://www.masta.org/)__[/](http://www.masta.org/)_
- Armed Forces Medical Intelligence Center
- 	_[www.afmic.detrick.army.mil](http://www.afmic.detrick.army.mil/)__[/](http://www.afmic.detrick.army.mil/)_
- Central Intelligence Agency
- 	_[www.cia.gov/cia/publications/factbook/](http://www.cia.gov/cia/publications/factbook/)_