Heather Tonga, PA-C, MS, MHA

Transcription

1 Heather Tonga, PA-C, MS, MHA

2 Identify recommended immunizations, prophylactic medications and health-related requirements for travel world-wide, and advise patients where to get immunizations. Be prepared to counsel patients traveling to lessdeveloped countries on food and water safety and treatment of travelers diarrhea; counsel on other safety issues such as carrying medicines, 1st aide kits, insects and weather protection Give advice to travelers on how to negotiate a foreign healthcare system, and where to seek help in emergencies

3 Travel Health Assessment General Travel Advice Individualizing Travel Advice Pregnant woman visiting family in Mexico City PA volunteering for a medical mission in Indonesia Young adult traveling the world Travel Medicine Resources

4 WHERE? Where exactly is patient expecting to travel? WHEN? What time of year? How soon? For how long? HOW? Modes of travel? Types of accommodation? Funds? WHAT? Rural or urban? Business, pleasure or volunteer? WHO? Alone, group, partner? Staying with who?

5 Chronic health problems Unresolved acute health problems Medications and Allergies Immunization history Pregnancy, breastfeeding Immune suppression Special dietary concerns Risk taking behaviors and perception of risk

6 Non-CV Medical Problems? Infectious Disease? Airplane crash? What do you think they are? Car crash? Injuries? CV Medical Problem?

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8 Travel consult Address health problems Prescriptions Routine Adult Immunizations and by Location Tdap, MMR, Varicella, Pneumococcus, Influenza Travel health insurance Medical care abroad Injury and Accident prevention STDs and Blood borne pathogens

9 Sanitation and Hygiene Food and Water safety and differences Animal bites and stings Weather Oceans and Mountains Skin, feet and hands

10 Travel problems Crime, war, disasters, violence, assault and corruption Drugs and Alcohol Economic differences Cultural differences

11 Health insurance documents Proof of yellow fever vaccination Copies of all prescriptions Contact card : Carry a contact card containing the street addresses, phone numbers, and addresses of the following: Family member or close contact remaining in the United States Health care provider(s) at home Lodging at your destination Area hospitals or clinics, including emergency services U.S. embassy or consulate in the destination country or countries

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13 26 y.o. woman who is 22 weeks pregnant plans an airplane flight from Portland to visit her family home for a month in Mexico City. Planning trip to Lake Guerroro to go fishing. She plans to leave in 2 weeks and will be there for the month of February. Her family is considered middle class and has a car. No alcohol, drugs or tobacco.

14 Problem List: 20 week pregnancy. Gravida 3, Para 2 Obese with a BMI of lb weight gain so far. Gestational diabetes controlled with diet. Last HgbA1C 6.9 Medicines: Prenatal vitamins, Vitamin D No allergies Immunizations: Childhood vaccines in Mexico. Moved to U.S. at 22 y.o. Tested non-immune to Hepatitis B, Immune to Varicella and Rubella in this pregnancy. Hepatitis A unknown. Risk: Having grown up in Mexico, she does not think she has any risks or healthcare needs except her diabetic diet

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16 Address Medical Issues Prenatal check up and education Vitamins Diabetes education and plan Preterm labor Immunizations Tdap, Influenza, Hepatitis A and B Medical care abroad Family s medical provider Travelers diarrhea Injury and Accident prevention Vehicles

17 30-70% of travelers despite precautions Fecal-oral transmission Most common bacterial pathogens (in order of frequency): enterotoxigenic Escherichia coli, Campylobacter jejuni, Shigella spp., and Salmonella spp Giardia is the most common protozoal pathogen Relative risk: High: Asia, Middle East, Africa, Mexico, Central and S. America Moderate: Eastern Europe, S. Africa, Caribbean Low: U.S., Canada, Australia, New Zealand, Japan, N. and W. Europe

18 Symptoms Bacterial, Viral, Protozoal Prevention Food and water safety Prophylaxis with bismuth salicylate (Pepto Bismol) (precaution with gout) not in pregnancy Treatment Bacterial Cipro Azythromycin Loperamide (Imodium) Oral rehydration

19 Sanitation and Hygiene Family s knowledge Weather and Water Heat and sun Leptospirosis Insect bites and stings Travel problems Deep Vein Thrombosis Documents

20 Caused by spirochetes of the genus Leptospira Prevalent in fresh water lakes in Mexico Symptoms: Conjunctivitis, myalgias, fever, jaundice Risk Weil syndrome: 10% vasculitis, renal failure, hemorrhagic pneumonia 40% fatal Treatment Amoxicillin or Doxycycline mild Penicillin IV if severe

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22 55 y.o. male PA will go for the 1 st time out of North America. He plans to leave in 3 months to spend 4 weeks in rural Kalimantan (Borneo). He will travel with his wife and a group and stay in the Christian mission s facilities near their clinic. Funds are not a problem, and he plans to vacation in Bali for 2 weeks of February after his mission.

23 Problem list: Well-controlled hypertension Hypothyroid History of recurrent gout History of Depression Medications: Lisinopril, Levoxyl, Indocin prn Allergies: None Immunizations: Tdap, Influenza, Hepatitis B, MMR up to date Diet: DASH diet, low purines except alcohol Risk: Drinks 3-4 beers/day. Worried about culture shock and how he will cope with unknown living situation, poor sanitation, and inadequate medical supplies.

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25 Medical Problems Chronic medical problems Prescriptions Psychological stress Immunizations Hepatitis A, Typhoid, Malaria prophylaxis, Japanese encephalitis? TB tests Travel health insurance Medical care abroad Injury and Accident prevention Vehicles Blood borne pathogens

26 Caused by protozoan species of the genus Plasmodium Transmitted by infective female Anopheles mosquito or occasionally blood exposure Causes an estimated 215 million infections worldwide and 655,000 deaths annually Relative risk High West Africa & Oceania Moderate other Africa, S. America and S. Asia Low Central America & other Asia

27 Symptoms mild (flu-like) and severe (seizures, confusion, renal failure, ARDS, coma, death) Onset < 14 days, occasionally months Smear microscopy gold standard for Diagnosis Treat as an emergency Prophylaxis: Atovaquone-Proguanil (Malarone) 250/100mg sig: 1 qd, 1-2 d prior, 7 d after. Not pregnancy, kids. Well tolerated. Doxycycline 100 mg sig: 1 qd, 1-2 d prior, 4 wks after. Not pregnant or kids under 8 y.o. Sunburn risk, GI side effects Chloroquine 300 mg sig: 1 qweek, 1-2 wks prior, 4 wks after. OK in pregnancy and kids. Much resistance Mefloquine (Lariam) 228 mg sig: 1 qweek, >2 wks prior, 4 wks after, OK in pregnancy and kids, Psych side effects risk

28 Typhoid caused by Salmonella enterica serotype Typhi Paratyphoid caused by S. enterica serotype Paratyphi A, B, or C Transmission fecal-oral route, food and water Worldwide: Typhoid: 22 mil cases, 200,000 deaths, 6 mil cases paratyphoid U.S. 400 cases typhoid, 100 cases paratyphoid South Asia 6-30 x higher risk, also in E and SE Asia, Africa, Caribbean, Central and S America Multi-drug resistant strains Onset 6-30 d, Symptoms (increasing temp over 3-4d) and Diagnosis clinical Prevention Live virus oral vaccine 50-80% effective typhoid Ingest safe food and water

29 Cause: Japanese encephalitis (JE) virus is a single-stranded RNA virus that belongs to the genus Flavivirus and is closely related to West Nile and Saint Louis encephalitis viruses Transmission: Culex mosquito Enzootic cycle between mosquitoes, pigs and wading birds Prolonged rural travel: incidence 5 50 cases per 100,000

30 <1% of people infected with JE virus develop clinical disease incubation 5 15 days Symptoms: sudden onset fever, HA, vomiting, change in mental status, neuro deficits, weakness and movement disorders, seizures 20-30% fatal, 30-50% serious sequelae Prevention: Ixiaro vaccine 2 doses Day 0 and Day 28 and booster 1 year later

31 Sanitation and Hygiene Expectations and preparation, pollution, trash Food and Water safety and differences Biological and chemical contamination, Tolerance, bottled water, cooked hot foods Indonesian diet Animal bites and stings Weather Heat and sun

32 Travel problems Motion sickness, aerophobia, jet lag, sleep problems, DVT prevention Alcohol Current habits and relation to Muslim culture Economic differences Begging and street marketing, Lifestyles, Income, Theft Cultural differences Primarily Muslim, animalism

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34 23 y.o. healthy female who has lived all her life in northern climates plans to spend 6-8 months traveling. She will start from Alaska in January, and plans to end up in Argentina. She is not sure about her route, exactly how she will travel, or where she will stay. She plans to start travel with a male friend. She does have enough funds to travel inexpensively and has emergency funds to get home if necessary. She plans to leave in 2 weeks. She is fluent in Spanish, and has travelled internationally in the past.

35 Problem List: No chronic or acute health problems Medicines and Allergies: None Immunizations: Routine childhood vaccines up to date including Hepatitis A and B, Meningitis, HPV, Tdap booster Risk: High risk taker, but does have knowledge about keeping valuables safe when traveling. Uncertain travel route, living situation, and companions. Female who may be traveling alone. Expects to stay in low cost accommodations.

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37 What is essential 2 weeks prior to travel? Complete history and physical Immunizations and Medicines Influenza, Typhoid, Yellow fever, Malaria prophylaxis, Travelers diarrhea medicines and 1 st aid kit, TB test Travel health insurance? Medical care abroad Injury and Accident prevention Prevention and Caution Vehicles Sex, Blood and Risk taking

38 Cause is a single-stranded RNA virus that belongs to the genus Flavivirus Transmitted by mosquito 3-6 d incubation Symptoms: HA, myalgias, N/V, dizziness, bleeding, fever + slow pulse, jaundice, low BP, Low WBC, plts, High Creat, LFTs, bili 20-50% die severe dz in 7-10 d Yellow fever occurs in sub-saharan Africa and tropical South America Risk for illness and death in a 2 week stay West Africa are 50 per 100,000 and 10 per 100,000, respectively South America are 5 per 100,000 and 1 per 100,000, respectively

39 Immunization in authorized clinic Live virus vaccine 10 days after 90% immunity 30 days 99% immunity 10 year re-vaccinate

40 Sanitation and Hygiene Food and Water safety and differences Animal bites and stings Weather How to pack for variation Oceans and Mountains Skin, feet and hands Shoes, scabies, lice and bedbugs, sleeping sheets

41 Travel problems Sleep, travel stressors, psychological support Crime, war, disasters, violence, assault and corruption Scams, situational awareness, location avoidance, exit strategy Drugs and Alcohol Assess current habits, risk taking, exposure Economic differences Begging and street marketing, Lifestyles, Income, Theft, assess preparedness Cultural differences Tolerance, familiarity, respect, safety

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43 Travelers Health. Centers for Disease Control and Prevention. Website. Brunette MD MPH, Gary W., CDC. CDC Health Information for International Travel 2014: The Yellow Book. Centers for Disease Control and Prevention. wwwnc.cdc.gov/travel/yellowbook/ Web. Pickering MD FAAP, Larry K. et.al. Red Book: 2012 Report of the Committee on Infectious Diseases: Red Book Print. PA s for Global Health Website