EmporiatricsDr. Gopalrao M.D. Ph.D.

Professor & Head,Community Medicine Department

It is a science which deals with promoting and protecting the health of international travelers, providing them the advice related to the travel they are about to undertake.

It is a fast developing specialty as the international travel is fast increasing.

Every year 660 million people travel internationally.

Definition

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

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

Food and Water InsectsAnimals and BirdsEnvironmental hazards Soil Sun Heat/humidity Cold/ dryAltitude Marine hazards Respiratory HazardsSex and body-fluid exposure Vehicular and other Accidents DVT risk

Risk to be considered and discussed

Factors affectingindividual risk

Individual

r

isk

TRAVEL

Destination

Country of origin

Duration of stay

Itinerary

Travel conditions

Season

TRAVELER

Reason for travel

Behavior

Age and gender

Health education

Medical history

- Allergies

- Immunosuppressed

- Pre-existing disease

Immunization status

Special needs

- Pregnant women

- Children

- Elderly

Special Risk Groups Pregnancy Children Elderly Expats and long-term travellers VFR Cardiac or Lung disease Diabetes HIV infections Immunocompromised

Cruise ships Diving Extended stay Extreme travel Mass gatherings Wilderness

Special itineraries

“This person, this trip, this time” Person; medical conditions past and

present, allergies, medications, vaccine history, previous travel

Trip: reason, style and comfort level, rural vs urban, accomodation, activities, exposures, budget

Time: duration, season, frequency

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

Risk Reduction Interventions

Information enabling behaviour modification

vaccinations medications (including

antimalarials) other - travel insurance, pre

existing medical problems, nets, syringes, medical kits

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

Travel Consultation

Cornerstone of clinical decision process Opportunity to define the risk profile Requires appropriate time, and done in advance

of travel. May need multiple visits, allow a plan Good documentation essential Discussion of costs and priorities Consider family requirements

Individualise Advice Tailored advice to the traveller, itinerary and time Travellers vary by age, sex, pregnancy, medical

history, immune status, current health, medications, vaccination history, allergies and prior travel experience

Itineraries vary by length of stay, activities, environmental exposures, types of accommodation, season and budget

Time variation is obviously important Advice should be understandable, re-inforced and in

various media

Personal advice is more likely to be understood, remembered or facilitate behavioural change.

Consider Costs

Advice and recommendations should be within the travellers budget

Costs should be made clear and should presented in some priority order

Alternate strategies may need to be discussed

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

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

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.

Medical travel kits

No antimalarial gives 100% prevention P vivax and P ovale may be present months

after return No global consensus Fever in returned travellers is malaria until

proved otherwise Patient compliance and education is

essential

Principles of malaria prophylaxis

3 prong approach behavioral modification

◦ awareness of malarial risk◦ minimising exposure to mosquitoes

emphasis on extreme significance of early diagnosis & treatment

antimalarial chemoprophylaxis

Malarial Prophylaxis

Avoid outdoor exposure, dawn to dusk Wear long sleeved loose clothing after dusk,

light colours Avoid perfumes and colognes Use repellent with 20-40% DEET Use knockdown sprays, coils, vapours, etc

indoors Sleep under nets impregnated with

permethrin

Personal Protection from Mosquitoes

Category A – considered low risk◦ Western Europe/North America/Japan/UK/NZ/Singapore

Should be fully vaccinated & up to date with◦ Diphtheria/tetanus/whooping cough◦ Routine paediatric vaccines◦ MMR◦ Polio◦ Chicken pox◦ Influenza

Vaccinations 1

Category B Travel – considered to be low to intermediate risk◦ Eastern Europe/Israel/Korea/Malaysia/Pacific Is/South

Africa Vaccinations should be as for Category A, plus:

◦ Hepatitis A & B◦ Typhoid◦ QFT

Vaccinations 2

Catergory C Travel – considered to be of higher risk◦ African sub-continent/Central & South America/East

Asia/SE Asia/Melanesia Vaccinations should be as for Category B, plus:

◦ Polio booster◦ Japanese B Encephalitis◦ Rabies◦ Meningitis◦ Yellow Fever

Malaria Prevention

Vaccinations 3

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

Vaccine classification-3 Rs

Yellow fever Plague Cholera Typhoid Meningococcal meningitis SARS Influenza

Internationally Quarantinable diseases

For visiting some countries or on incoming travel the traveler must have a valid vaccination certificate attached to the passport.

At the entry point or exit ie. airports, ports, land entry points, the authorities will check the certificates.

No valid certification traveler may face quarantine or deportation.

Continued….

Thank You