Medical Tourism - Health Risks and Precautions in Travel Medicine

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1 Travel Medicine: Rural GP Conference 2014 Dr Jenny Visser Dept Primary Healthcare and General Practice University of Otago, Wellington Briar Campbell

2 Workshop Overview Any specific questions/topics? Brief overview of Travel Medicine Key resources Update Travel Vaccines

3 Any specific QUESTIONS/TOPICS?

4 Why Travel Medicine?: People Travel. International Tourist Arrivals 2012: >1 billion for the first time

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6 PURPOSE OF TRAVEL Worldwide

7 How many NZers travel/year? Total NZ Residents short-term departures 2012: 2.17 million 2011: 2.09 million 2010: 2.03 million 2009: 1.98 million 2008: 1.97 Million

8 NZ Resident short-term departures: Top 10 main destination 2011 & approx % #1 Australia (46%) #2 USA (5%) #3 Fiji (5%) #4 China (3%) #5 Cook Islands (3%) #6 England (2%) #7 Samoa (2%) #8 UK (2%) #9 India (2%) #10 Thailand (2%)

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10 Travellers get sick Between 20-70% of international travellers suffer some illness About 5% need to seek medical care About 1% hospitalised Steffen R, Amitirigala I, Mutsch M. Health Risks Among Travelers Need for Regular Updates. Journal of Travel Medicine. 2008;15(3):145-6.

11 Risk assessment: Is an integral part of the pre and post travel consultation It determines what health and safety advice interventions are given Needs up to date information Takes time Must be documented Leggat, P. Risk assessment in travel medicine. Trave Med Inf Dis 2006;4:

12 Assessing Risk Hazard+Exposure+Susceptibility Individualised Risk Assessment Risk Management/Health Promotion

13 Scenario..Friday afternoon Patient about to leave By the way Doc, booked a holiday to Bali for a week. What jabs do I need? Your response?

14 Travel Medicine resources Travel Medicine practitioners Electronic: World Health Organisation Centre for Disease Control and Prevention (USA) Fit for Travel BPAC NZ Ministry Foreign Affairs Travel Medicine Research Reviews

15 World Health Organisation Travel Health Homepage International Travel & Health Disease Topics

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17 Centre for Disease Control and Prevention Travel Health Homepage Health Information for International Travel owbook-2012-home.htm

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19 UK Resources Fit for Travel The National Travel Health and Network Centre

20 UpToDate UpToDate general information and patient education eladvice?source=search_result&search=trav el&selectedtitle=1~150

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22 NZ Travel Advisories NZ MFAT Safe Travel

23 Scenario 24 year old about to embark on a 12 month backpacking trip through Asia, Europe and Africa. What more do you need to know? What topics do you need to cover in the pre-travel consultation?

24 Pre-Travel Consultation: What information do you need? About them Demographics Travel experience Health Recent illnesses/operations/ hospitalisations Ongoing & specific medical conditions Regular & intermittent medications Allergies (general and specific) Past DVT/VTE Pregnancy/Contraception Previous vaccinations About the trip When do they leave Destinations (macro & micro) How long Mode of transport Planned accommodation Planned activities

25 Pre-Travel Consultation:Range of topics to covered Fitness to Fly Issues Vaccinations Preventing travellers diarrhoea and food and water-borne illnesses. Prevention of Vector-borne Diseases Malaria Dengue Chikungunya Sexual & Reproductive Health (including STIs) Other Infectious Diseases Schistosomiasis Activity specific advice Altitude Trekking Scuba diving Management of ongoing medical conditions Psychological preparedness Safety & Security Issues Medical Kit Post Travel visit

26 How are you going to fit this into your busy practice? Refer some/all Yellow Fever Nearest approved vaccinator Rabies/JE Identify pre-travel consultations Book dedicated consultation 30 minutes Submit itinerary before Multiple visits Team approach Interproffesional Written material/online traveller resources

27 Vaccinations for Travel: The Three Rs Routine National vaccination schedule Childhood Adult boosters Influenza Required Yellow Fever Meningococcal Recommended for travel

28 WHO Routine Diphtheria Tetanus Pertussis Poliomyelitis Measles Mumps Rubella Varicella Haemophilus influenza type b Pneumococcal disease Hepatitis B Human papillomavirus* Rotavirus* Influenza* Tuberculosis (BCG)*

29 Travel Vaccines-Recommended Hepatitis A Typhoid fever Cholera Japanese encephalitis Meningococcal disease Rabies Tick-borne encephalitis Yellow fever (personal protection)

30 Travel Vaccines- Required Yellow fever (public health) Meningcoccal disease International Health Regulations 2005

31 Rationalising Travel Vaccines STEP 1: What vaccine preventable diseases are a hazard, what is exposure & susceptibility? STEP 2: Risk Assessment: Which ones are a high enough risk to justify vaccination? STEP 3: Negotiate with the traveller STEP 4: Which vaccines and when? Split into those Highly recommended/ must haves Recommended/ less important

32 The Pre-Travel Consultation and Vaccines Always Routine Required Nearly always* Tetanus, Diphtheria & Pertussis Hepatitis A Often* Typhoid Influenza Hepatitis B Sometimes* Yellow fever Meningitis Rabies Cholera Japanese encephalitis Pneumococcal (* Assuming travel to developing country)

33 Common errors Revaccinating for hepatitis B Ordering serology Giving a single Twinrix pre-travel Over-prescribing malaria chemoprophylaxis (especially SE Asia) Poor advice regarding rabies

34 Prescribe, Schedule & Administer

35 Administration of Vaccines The maximum number of vaccines that can be given at one visit is: One Two Four Six No limit

36 Administration of Vaccines The maximum number of injections that can be given into one muscle is: One Two Four No limit

37 Live vaccines General administration principles?

38 MMR & Hepatitis B in 2014 Hepatitis B Age up to 27yr 3 x Hep B vaccinations, so immune Age prob (pre-school catch-up programme) Age poss (catch up programme extended in 1990) Age 40+ likely non immune MMR Age up to 25yr 2 x MMR, so immune Age prob 1 x MMR only so vaccinate Age prob 1 x measles only so vaccinate Age 45+ prob childhood disease so immune

39 Vaccination Scenario 50-year old Dan going on a high end 3-week African adventure. Starting with 2 days in Stellenbosch, Capetown, before flying to Skeleton Coast & visiting Etosha in Namibia, Chobe & the Delta in Botswana, staying in Livingstone and seeing Vic Falls in Zambia before flying to Zanzibar via Dar Es Salaam for a spice island wind down with 4 days on the beach. Dan will transit in Jo-Burg on way back to NZ. He leaves in I month

40 Vaccine Consult Vaccination/Disease Hx MMR Varicella Recommend ADT or AdTap (if > 10years) Influenza Hepatitis A Rabies Discuss Typhoid Hepatitis B Dukoral Yellow Fever Risk of exposure very low May require proof of vaccination (South Africa) Zambia Tanzania

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42 Vaccine Schedule Vaccine Visit one - Day 0 Visit two Day 7 Visit three Day ADT or Boostrix 0.5ml/IM Vivaxim* 1.0ml/IM Stamaril 0.5ml/SC Fluvax 0.5ml/IM Verorab 0.5ml/IM Engerix 1.0ml/IM * 2 nd Hepatitis A vaccine due 6 18months

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44 Vaccination. There is no magic list Many vaccine preventable diseases and few absolute guidelines Need to make a careful risk assessment and advise which vaccinations would be beneficial for each specific traveller Need to strike the right balance. Just because there is a vaccine does not mean every traveller should get it Travel vaccines are NOT cheap, the cost to the traveller (or employer/aid agency) rapidly adds up

45 Want to learn more? Postgraduate qualifications in Travel Medicine University of Otago, Wellington. See lington ac.nz Join NZ Society of Travel Medicine Conference August 30 th /31 st Rotorua