Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Travel Med
Travel Medicine - Key Features
1. Make sure travelers get up to date, timely, itinerary-specific advice from a reliable source (e.g., travel clinic, travel website).
-seek medical advice at least 4-6weeks before departure to leave time for immunizations
-local travel clinic
-websites: Health Canada, Centre for Disease Control, World Health Organization, Committee to Advise on Tropical Medicine and Travel (CATMAT) by the Public Health Agency of Canada
-recommendation to register with the Gov't of Canada prior to travelling at www.travel.gc.ca
- • in Japan, after the earthquake, people who were registered were evacuated first
2. When seeing patients planning travel, discuss the common, non-infectious perils of travel (e.g., accidents, safer sex, alcohol, safe travel for women).
- motor vehicle accidents (higher rate of tourist death than all infectious disease combined), safe sex (countries with higher rates of HIV, Hep B and C, pcn resistant gonorrhoea), alcohol, safe travel for women, sun exposure, dehydration, travel induced conditions (barotrauma, jet lag, motion sickness, DVT)
-risk assessment: who (pt), where (destinations), when (departure date and trip duration), why (purpose), what (activities), how (nature and style of travel)
3. In patients presenting with symptoms of infection without an obvious cause, especially those with a fever, enquire about recent travel history to identify potential sources (especially, but not exclusively, malaria).
-malaria: blood films
-dengue: IgG testing
-consider stool testing for parasites
-HIV seroconversion
4. Provide prevention and treatment advice and prescribe medications for common conditions associated with travel (e.g., traveler’s diarrhea, altitude sickness).
-contaminated food and water
- • e coli, Hep A (3-5 cases/1000 travellers/month), salmonella, parasites(ex giardi), typhoid fever, campylobacter
- • "boil it, cook it, peel it, or forget it", drink bottled water
- • traveller's diarrhea:
- ◦ Pep to-Bismol 2 tabs qid for prophylaxis (unless ASA allergy)
- ◦ ciprofloxacin 500 mg po bid M:5days for treatment in adults, azythromycin in children
- ◦ azithromycin is also recommended (currently) for Thailand, Vietnam, India,Mexico in the summer, and Nepal (due to Cipro resistance)
- ◦ loperamide if no fever or bloody stools
- ◦ electrolyte replacement
- altitude sickness
- • acetazolamide 250mg po bid
- • allow 2-3 days to acclimatize before strenuous activity
-insect bites
- • depends on season, altitude, location
- • dusk to dawn biting mosquito risk of malaria
- • day biting mosquito risk of dengue
- • DEET (no DEET if children <6 mos, 10% DEET if 6mos-2 years), protective clothing, stay indoors, mosquito nets
-malaria prophylaxis
- • chloroquine if chloroquine sens area: start 1 week before, take weekly, take 4 weeks after
- • mefloquine if chl-resistant: start 1 week before, take weekly, 4 weeks after, can cause nausea, dizziness, difficulty sleeping, moodiness, vivid dreams, do not give if psych or sz hx
- • doxycycline if chl-resistant and can't tolerate mefloquine: start 2 days before, take daily, 4 weeks after, causes photo sens
- • malarone if chl-resistant: start 2 days before, take daily, 7 days after, less reactions but expensive
-rabies
- • dogs, bats, cats, monkeys, racoons, foxes, skunks are carriers, transmitted by licking, scratching, biting
- • vaccine expensive (600$), post exposure prophylaxis (Ig serum) availability dependent on country
5. Ensure patients understand how to manage their chronic disease while traveling (e.g., diabetes, asthma, international normalized ratios [INRs]).
- diabetes, asthma, pregnancy, cardiovascular and pulmonary disease, INRs
-medical alert bracelets, appropriate medications, travel insurance, rescue meds (ie puffers)
6. Use patient visits for travel advice as an opportunity to update routine vaccinations.
- Td q 10yrs, MMR booster if only received once dose in childhood, Hep B if not received, Pertussis booster, polio if not received
-single Hep A vaccine gives roughly 95% immunity in 4 weeks, booster given in 6-12 mos confers immunity for at least 20 yrs
-single Hep B vaccine gives 60% immunity, usual dosage regime is 0, 1, 6 mos but can be given 0, 7, and 21 days
-depending on travel, pts may require yellow fever and meningococcus vaccinations for border crossings
-food and water risks: typhoid, Hep A
-destination specific: Japanese encephalitis, yellow fever, malaria, meningitis
-long term stay: rabies, Mantoux, Hep B
-high risk travellers: diabetes, pregnancy, immunosuppressed (beware of live attenuated vaccines)
7. Advise patients to check insurance coverage issues especially in regard to recent changes in chronic disease and any recent treatment changes.
-detailed signed contract with emergency repatriation
8. Advise patients traveling with medications to have an adequate supply, documentation of need for use, and to transport them securely (e.g., carry-on bag).
-pharmacy labelled, carry-on bag, personal identification (medical alert bracelet)