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Travel Medicine

Community Medicine Department 2015

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Objectives

 Definition of travel medicine and its concepts.

 Validity of travel medicine.

 Magnitude of the problem and the importance of travel

medicine.

 Characteristics that makes travelers more susceptible to

diseases.

 Epidemiology of common travel related diseases.

 Prevention and control.

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Definition (PHAC)

 Travel medicine is the field of medicine concerned with the

promotion of health and respect for the peoples, cultures and
environment of regions being visited in addition to the
prevention of disease or other adverse health outcomes in
the international traveller as well as any impact on the health
of the local population.
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 The practice of travel medicine is distinct from the practice of

tropical medicine as it focuses on health promotion as a
means to maintain the health and well-being of travellers, as
well as the health of the indigenous populace being visited;
tropical medicine focuses on the diagnosis and treatment of
illness associated with travel.
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Concepts of Travel Medicine
Disease Pretravel risk Disease managment Screening
preventions and
precautions assessment

1-immunization/ This balances the The proper -Early screening of

vaccination health of the treatment of the the symptoms after
2-chemoproplaxis traveler (the infectious and non travelers departed
3-advise for self traveler’s age, infectious diseases back to their
treatment underlying health to the travelers in countries Limiting
4- travelers conditions, epidemiological or the progression of
instructions medications, and non the diseases
5-medication immunization epidemiological especially the
package . history)with the regions. contiguous disease
details of the .
planned trip (the
season of travel,
itinerary, duration,
and planned
activities) .
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Validity of Travel Medicine

 Clinical trials based: Travel medicine standards are

increasingly based on evidence and are moving away from
reliance on the opinion of experts .

 Knowledge based: The knowledge base for the travel

medicine provider includes: epidemiology, transmission, and
prevention of travel-associated infectious diseases; a
complete understanding of vaccine indications and
procedures; prevention and management of noninfectious
travel-associated health risks; and recognition of major
syndromes in returned travelers (e.g., fever, diarrhea, and
rash)
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The magnitude and the importance of
travel medicine
 Over a billion people cross international borders yearly

 Precautions differ as time changes because there are many

changes in global infectious diseases epidemiology .

 Changing patterns of drug resistance

 More travelers= more travelers with chronic disease

 Providing prophylaxis and treatments to protect travelers and

prevent the transmission of infectious disease to minimize the
number of cases.
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High Risk Groups

 Pregnant Travelers

 Children

 Travelers with Weakened Immune Systems Elderly and

travelers with Chronic Illnesses.

 Long-Term Travelers

 Adventurous travelers
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International Health Regulation (IHR):

 Since 15 June 2007 the world has been implementing the IHR. This
legally-binding agreement significantly contributes to global
public health security by providing a new framework for the
coordination of the management of events that may constitute a
public health emergency of international concern, and will
improve the capacity of all countries to detect, assess, notify and
respond to public health threats. (WHO)
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Purpose of IHR

 to prevent, protect against, control and provide a public

health response to the international spread of disease in
ways that are commensurate with and restricted to public
health risks, and which avoid unnecessary interference with
international traffic and trade. (WHO)
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Key factors in traveler exposure risks

 Mode of transport

 Destination(s)

 Duration and season of travel

 Purpose of travel

 Standards of accommodation, food hygiene and sanitation

 Behavior of the traveler

 Underlying health of the traveler

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 http://wwwnc.cdc.gov/travel/

 http://wwwnc.cdc.gov/travel/notices

 http://www.who.int/ith/precautions/en/
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General Precautions

 Travellers can experience:

 changes in altitude, humidity, temperature and exposure to
a variety of infectious diseases.
 Areas of overcrowding and poor hygiene.
 Accidents.
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Traveler’s responsibilities

 Travel related risks

 Medical consultation before and after travel

 Assessment of health risks associated with travel

 Medical kit and toilet items

 Insurance
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Proactive, Prepared, Protected

BE PROACTIVE

- Learn about your destination.

- See a doctor before you travel.

- Think about your health status

BE PREPARED
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Pack smart:
 What to Pack in Your Travel Health Kit?
 Medicines:
 Prescription medicines you usually take
 Special prescriptions for the trip:
 Medicines to prevent malaria, if needed
 Over the counter medicines:
 Anti-diarrheal medication
 Antihistamine
 Other important items:
 First-aid supplies. E.g. Digital thermometer and Oral
rehydration solution packets
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What diseases do you think of when

you think of travel?
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+ STIs
What are they?  Sexual transmitted infections depend on the behavior rather than
the country you visit.
 Some examples of these infections are HIV, herpes simplex virus
and hepatitis C and B.
Route of These are some routs of transmission: blood as hepatitis C, vaginal
transmission fluids and semen as HIV, also, from the mother to her child during
pregnancy and childbirth as herpes simplex virus.

Epidemiology Worldwide infections, about 1 million people acquire a sexually

transmitted infection every day.
Prevention 1. Avoid sexual activity with strangers .
2. Use condom in every sexual contacts.
3. Order sterilized needle in tattooing and avoid sharing razor,
needles and shavers.
4. There is vaccination for some of the infections :
- Hepatitis B : it should begin 6 months before travelling, IM, 3-dose
vaccine series (Day 0 – 30 – 6months), e.g: Engerix-B
- There are no vaccines to prevent HIV or Hepatitis C
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Water-Borne Diseases
Schistosomiasis
What is it?  It is parasite infection by the genus schistosoma.
 There are four types: Schistosoma mansoni, S.
haematobium,
S. japonicum, and s.haematobium
Route of Is a water-borne infection, this parasite can affect the body
transmission by penetrating the skin, and larval cercariae can be found in
contaminated bodies of freshwater.
Epidemiology There is a high prevalence of schistosomiasis in Africa, also,
there are types of it Schistosoma mansoni and S.
haematobium which more common in Africa,
s.haematobium can be found in the Middle East and S.
japonicum more in Indonesia and parts of China.
Prevention There is no vaccine or drugs that prevent the infection, but
avoiding swimming, drinking or washing the clothes in lakes
and fresh water in disease-endemic countries can help in
prevention.
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Food/Drink Related Diseases
Cholera
What is it? It is bacterial infection and the cause of this infection is bacterium vibrio
cholera. It’s affects an estimated 3–5 million people worldwide, and causes
58,000–130,000 deaths a year as of 2010.

Route of It is fecal oral rout, mostly transmitted by drinking water contaminated

transmission with bacteria.
Epidemiology WHO reported that the most recent epidemics was in Africa, about 48% of
cases were reprted from Africa in 2012
Prevention 1. Drink bottled water.
2. Wash your hand before eating and after using the bathroom or use
hand sanitizer if water and soup not available.
3. There is a vaccine for cholera:
- Dukoral, dissolving the buffer granules in 150 mL of water, Two doses
are required, given a minimum of 1 week and up to 6 weeks apart,
single booster dose up to 2 years after completion of the primary
course.
- The booster dose for who are at risk of exposure to cholera.
+ Typhoid
What is it? Typhoid fever is a serious disease caused by the bacterium
called Salmonella enteric serotype Typhi (S. Typhi)

Route of Transmitted through the ingestion of food or drink

transmission contaminated by the feces or urine of infected people.
Epidemiology It's a worldwide disease, however countries at high risk are
regions like South Asia, developing countries in Asia, Africa,
the Middle East, the Caribbean, Central and South America.

Prevention 1. Wash your hands carefully.

2. Avoid drinking untreated water.
3. Avoid raw fruits and vegetables.
4. Get vaccinated : Two vaccines are available:
- One is injected in a single dose about two weeks before
exposure 0.5 mL IM once in the deltoid
- The other is given orally in four capsules, with one
capsule to be taken every other day 3- 0.5 mL IM every 2
years if there is continued exposure to Salmonella typhi.
Hepatitis A
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What is it? An acute infectious disease of the liver caused by the hepatitis A
virus (HAV)
Route of 1-Fecal-oral route: Contaminated food or drinks
transmission 2-person-to-person when poor fecal hygiene is practiced (e.g.
between children or during certain sexual practices).
Epidemiology Worldwide but most common in regions with poor food and
water hygiene, including: Indian sub-continent (especially India,
Pakistan, Bangladesh and Nepal), Africa, The Middle East, parts
of the Far East (excluding Japan), Central and South America and
Mexico
Prevention 1. keep good personal hygiene.
2. Wash your hands frequently
3. Get vaccinated :the vaccine should be given two weeks before
you leave, although it can be given up to the day of your
departure if necessary.
- Havrix(R): 1 mL IM followed by a 1 mL booster dose 6 to 12
months following primary immunization.
- VAQTA(R): 1 mL IM followed by a 1 mL booster dose 6 to 18
months after primary immunization.
Primary immunization is recommended at least 2 weeks
before expected exposure to hepatitis A virus.
Traveler’s Diarrhea
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What is it? It happens commonly with most of the travelers. caused
by many organism such as salmonella, E-coli , Rotavirus
and Norvavirus
Route of transmission Fecal-oral route: by eating or drinking contaminated food
or water.
Epidemiology Worldwide however travelers who visit areas with poor
standards of hygiene and sanitation are at greater risk .

Prevention 1. Avoid eating raw, undercooked or uncovered food.

2. Avoid food from street vendors.
3. Drink only bottled drinks and try not to drink anything
with ice as it might be made with contaminated water.
4. Wash and peel fruits and vegetables.
5. Make sure dairy products are properly pasteurized
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Living Vector Diseases
Japanese encephalitis
What is it? Caused by Flavivirus, causes brain swelling, & may
cause long term nerve damage.
Route of Mosquito bite.
transmission
Epidemiology Occurs in almost all Asian countries and parts of the
western Pacific Mainly in rural agricultural areas.
Prevention 1. Protection from mosquito bites
2. JE vaccine ( Ixiaro ) "inactivated":
- Considered if travelers are spending one month or
more in an endemic area, or less than a month but
spending large time outdoors.
- Adults: 2 doses (0.5 mL) IM, on day 0 & 28, must be
completed ≥1 week before travel.
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Malaria

What it it? Serious fatal disease, caused by Plasmodium parasite.

Route of Mosquito bite.

transmission
Epidemiology Most malaria cases and deaths occur in sub-Saharan Africa.
However, Asia, Latin America, and to a lesser extent the Middle
East and parts of Europe are also affected.
Prevention 1- Protection from mosquito bites.
2- Chemoprophylaxis (Atovaquone-proguanil, Chloroquine
phosphate, doxycyclin, Hydroxychloro-quine sulfate,
Mefloquine&Primaquine), taken before, during & after return
from travel. The Duration depends on the drug type.
- E.g.: Chloroquine phosphate (only for Chloroquine sensitive
areas): 300 mg base (500 mg salt) orally, once/week. Taken 1
to 2 weeks before travel, during travel & 4 weeks after coming
back.
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Yellow Fever
What is it? Caused by Flavivirus

Route of Mosquito bite.

transmission
Epidemiology Presented endemically in tropical areas of South
America and Africa.
Prevention 1- Protection from mosquito bites.
2- vaccine: YF-vax" live-virus"
- people age >9 months dose is 0.5 mL SC.
- at least 10 days before travel. This is a legal
requirement for those countries requiring a yellow
fever certificate (International Certificate of
Vaccination).
- single dose protects for 10 years, booster every 10
years.
+ Leishmaniasis
What is it? its caused by Leishmaniaparasitesand its have 3 main
types :
-Cutaneous (most common)
Mucocutaneous-
-Viscera

Route of female phlebotomine sand flies. The

transmission Leishmaniaparasites are spread to a human when he or
she is bitten by the infected sand fly

Epidemiology Common in Afghanistan

Bolivia, Brazil and Peru
Bangladesh, Brazil, Ethiopia, India and Sudan.

Prevention No vaccine available

Avoid outdoor activities
using nets treated with insecticide while sleeping
+ Rabies
What is it? Rabies is a zoonotic disease that caused by Lyssavirus
,and usually transmitted by dogs

Route of contact with the saliva of an infected animal, most

transmission often from licks, bites or scratches
Epidemiology Rabies mostly in asia and Africa
Prevention 1-Vaccinating dogs, cats, rabbits, and ferrets against
rabies
2-Keeping pets under supervision
3-Not handling wild animals or strays
Contacting an animal control officer upon observing a
wild animal or a stray, especially if the animal is acting
strangely
If bitten by an animal, washing the wound with soap
and water for 10 to 15 minutes and contacting a
healthcare provider to determine if post-exposure
prophylaxis is required
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Air Borne Diseases
Corona

What is it? Corona is caused byMiddle East Respiratory Syndrome

Coronavirus (MERS- CoV)

Route of It spreads via air by coughing and sneezing, and close

transmission personal contact (i.e. shaking hands).

Epidemiology Middle East specifically Arabian Peninsula

Prevention there is no vaccine for MERS-CoV, but there is still more to

learn about this new strain of coronaviru
Tuberculosis
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What is it? Tuberculosis is a disease caused by a bacterium called Mycobacterium Tuberculosis

Route of Active TB is preceded by latent TB and is air-borne.

transmission Latent TB is not contagious and can stay inactive for years. In fact, it gets activated
when you have a weak immune system.

Epidemiology Tuberculosis occurs globally, and it is estimated that about one-third of the world’s
population has latent TB infection (LTBI). In addition, about 10% of individuals with
LTBI will develop active TB.

Prevention 1-Travelers have to avoid close contact with people who are having active TB in
crowded areas.
2-Vaccination:
Travelers do not need the bacillus Calmette–Guérin vaccine but the vaccine may be
considered for long term travelers to countries with a high risk of TB
For example, young children (< 5 years of age) who may not have access to regular
tuberculin skin test. In addition, travellers who may not be able to follow the
recommended preventative measures against TB medical or personal reasons.
-Doses:
Adult and children aged 12 months and above:
A dose of 0.1 ml of the vaccine is injected strictly by the intradermal route.
Infants under 12 months of age:
A dose of 0.05 ml of the vaccine is injected strictly by the intradermal route.
 Meningococcal Disease
+What is it? Meningococcal Disease is caused byNeisseria Meningitidis
Route of Mingococal disease is spread from close and prolonged contact with an
transmission infected person through saliva or secretions (fluids) from the nose and
throat. E.g. sneezing, coughing, and sharing eating or drinking utensils.
Epidemiology In sub-Saharan Africa (the meningitis belt extends from Senegal to Ethiopia).
Also, in Saudi Arabia due to Hajj.
Prevention 1-Travelers have to wash their hands frequently
2-they should practice proper cough and sneeze etiquette
3-they have to avoid close contact with people who are having the disease
4-vaccination:
there are two meningococcal vaccines available
- Meningococcal conjugate vaccine (MCV4) whichis for people 55 years of
age and younger.
-Meningococcal polysaccharide vaccine (MPSV4) which is for people older
than 55.
travelers do not need the meningococcal vaccines, but either meningococcal
polysaccharide vaccine or meningococcal conjugate vaccine is recommended
for travelers if they travel to any country in which the disease is common
such as certain parts of Africa and Saudi Arabia because of annual Hajj and
Umrah.
For children and adults 2-55 years of age, MCV4 is administered as a single
0.5 ml dose intramuscularly. On the other hand, MPSV4 is administered 0.5
ml subcutaneously
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References
1. Hill R, Ericsson C, Pearson R et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of
America. Clin Infect Dis 2006;43:1499-539.

2. http://www.cdc.gov/TB/TOPIC/vaccines/default.htm

3. http://travel.gc.ca/travelling/health-safety/diseases/tuberculosis

4. http://www.cdc.gov/vaccines/vpd-vac/mening/who-vaccinate.htm

5. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a607020.html#skip

6. http://www.vaccines.gov/diseases/meningitis/index.html

7. http://www.immunizationinfo.org/vaccines/typhoid-

8. http://www.mayoclinic.org/diseases-conditions/typhoid-fever/basics/prevention/con-20028553

9. http://www.drugs.com/dosage/typhoid-vaccine-inactivated.html

10. http://www.who.int/gho/epidemic_diseases/cholera/en/

11. http://wwwnc.cdc.gov/travel/

12. http://travel.gc.ca
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13. http://en.wikipedia.org/wiki/Hepatitis_A

14. http://www.nhs.uk/Conditions/Hepatitis-A/Pages/Vaccination.aspx

15. http://www.drugs.com/dosage/hepatitis-a-adult-
vaccine.html#Usual_Adult_Dose_for_Hepatitis_A_Prophylaxis

16. http://wonder.cdc.gov/wonder/prevguid/p0000433/p0000433.asp

17. http://www.cdc.gov/ncidod/dbmd/diseaseinfo/travelersdiarrhea_g.htm

18. http://www.doctortravel.ca/index.php?page=hepatitis-b

19. http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/hand
book10-4-1

20. http://www.who.int/mediacentre/factsheets/fs107/en/

21. http://www.who.int/mediacentre/factsheets/fs110/en/