THE PRE-TRAVEL

CONSULTATION

Gary W. Brunette, MD, MS

Travelers Health Team
Division of Global Migration and Quarantine
Centers for Disease Control and Prevention 1
 Outline
Travelers Health Epidemiology
Traveler Assessment
Itinerary Review
Sources of Information
Risks to the Traveler
Travel Vaccines
Travel Medications
Counseling
2
U.S. Residents Traveling Abroad*
65

60

55

50

45
Number of Travelers (millions)

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

3
*ITA, includes travel to Canada and Mexico
 International Travel
80 900

70 800

700
60 US nonresident
Inbound (ITA)
600
50 US Resident Air
Outbound (ITA)
500
40 All US Resident
400 Outbound (ITA)

30 Worldwide arrivals
300 (WTO)

US20Resident travel in millions 200 Worldwide arrivals in millions

10 100

0 0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

4
 Where Do U.S. Residents Travel?

Of the 17% who traveled outside the

40 U.S. . . .
30

%20

10

Japan Africa
Canada Europe Aus/NZ Mexico
Oceania/Other
PI Asia Caribbean
Middle East
C or S America

5
Source: HealthStyles Survey 2005
VFRs: Visiting Friends and Relatives

Foreign-born increased 57% since 1990

from 19.8 million to 31.1 million 1
20% of US population are first- or second-
generation immigrants
VFRs comprised ~46% of US international
air travelers in 20043

1US Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000, issued
Dec 2003 (Previous: US Census Bureau, Profile of the Born Outside the United States
Population 2000, issues Dec 2003???
2 Angell & Cetron, 2005

32004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported

From: Survey of International Air Travelers, Office of travel and tourism Industries,
USDOC 6
 Travelers Health Risks
Of 100,000 travelers to a developing country
for 1 month:
50,000 will develop some health problem
8,000 will see a physician
5,000 will be confined to bed
1,100 will be incapacitated in their work
300 will be admitted to hospital
50 will be air evacuated
1 will die
Steffen R et al. J Infect Dis 1987; 156:84-91
7
The Patient: Medical Issues
Age-specific issues
Underlying illness,
immunosuppression
Systems review
Medical history
Medication use
Vaccination history
Allergies
Contraindications to vaccines and
medications 8
The Patient: Other Issues

Reproductive
Pregnant
Breastfeeding
Preconception
Risk-taking behaviors

9
 Travel Itinerary
Full itinerary
Dates, duration, stopovers
Seasonal considerations
Styles of travel
Rural vs. urban
Budget vs. luxury
Accommodation
Hotel vs. camping
Activities
Business vs. tourism
Adventure, safari
Missionary/Humanitarian/NGO 10
 Travel Health Resources
CDC Travelers Health Website
www.cdc.gov/travel
World Health Organization
www.who.int/int
State Department
travel.state.gov
International Society of Travel Medicine
www.istm.org
Health Information for International Travel
CDC Yellow Book
International Travel and Health
WHO Green Book 11
Travelers Health Website
www.cdc.gov/travel

12
 Regional Destinations
Region-specific pages
Goal to move to country-specific format

13
Travel Notices & Announcements

14
Deaths Related to International Travel

Cardiovascular
Medical
Injury
Homicide/Suicide
Infectious Disease
Other

N = 2463

15
Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
 Infectious Disease Risks to
the Traveler
Malaria Schistosomiasis
Diarrhea Tuberculosis
Leishmaniasis Leptospirosis
Rabies Polio
Dengue Yellow Fever
Meningococcal Measles
Meningitis JEV

ETC. 16
Injury Deaths and International Travel

Motor Vechicle
Drowning
Air Crash
Homicide/Suicide

Poisoning
Other

N = 601

17
Hargarten S et al, Ann Emerg Med, 1991. 20:622-626
 Other Risks to the Traveler
Accidental injury
Environmental hazards
Crime and assault
Psychiatric problems
Animal bites, stings and envenomations
Dermatologic disorders
Altitude
.
ETC. 18
Immunizations to Consider for Adult
Travelers
Routine Travel related
Diphtheria* Hepatitis A
Tetanus* Hepatitis B
Pertussis* Typhoid
Measles + Rabies
Mumps+ Meningococcal disease
Rubella + Polio
Varicella Japanese encephalitis
Pneumococcus Yellow Fever
Influenza

* Td or Tdap 19
+ MMR
 Travel Medications:
Prophylaxis & Self Treatment
Malaria
chloroquine, atovaquone/proguanil (Malarone),
doxycycline, mefloquine (Lariam), primaquine
Diarrhea
quinolone, azithromycin
Altitude
acetazolamide
Motion sickness
scopolamine, dimenhydrinate (Dramamine)

20
 Patient Counseling

Sufficient time for patient education

Tailored to suit traveler
Fitness for travel
Understanding impact on existing
conditions
Advisability of destinations

21
 Travel Preparation
Travel health insurance
Medical care
Hospitalization
Evacuation

Obtaining medical care abroad

Awareness of travel notices

Hand washing and hygiene 22

 Environmental Precautions
Air Travel
Jet Lag
Sun Protection
Extreme Heat and Cold
dehydration, heat stroke
hypothermia, frostbite
Altitude
Water recreation
Drowning, boating & diving accidents
Risk of schistosomiasis or leptospirosis
Biological and chemical contamination
23
Food and Water Precautions

Bottled water
Selection of foods
well-cooked and hot
Avoidance of
salads, raw vegetables
unpasteurized dairy products
street vendors
ice
24
 Vector
Precautions
Covering exposed skin
Insect repellent containing DEET 25 50%
Treatment of outer clothing with permethrin
Use of permethrin-impregnated bed net
Use of insect screens over open windows
Air conditioned rooms
Use of aerosol insecticide indoors
Use of pyrethroid coils outdoors
Inspection for ticks 25
Bloodborne and STD Precautions
Prevalence of
STDs
Hepatitis B
Hepatitis C
HIV
Unprotected sexual activity
Commercial sex workers
Tattooing and body piercing
Auto accidents
Blood products
Dental and surgical procedures 26
 Animal Precautions

Animal avoidance
Rabies
Specific animal threats
Medical evaluation of bites/scratches
Post exposure immunization and
immunoglobulin
Envenomations
Snakes, scorpions, spiders
Maritime animals
27
 Injury and Crime
Vehicles
Risk of road and pedestrian accidents
Night travel
Seat belts and car seats

Use of drugs and alcohol

Understanding local crime risks

Scam awareness
Situational awareness
Location avoidance 28
 Travel Emergency Kit
Copy of medical records and extra pair of glasses
Prescription medications
Over-the counter medicines and supplies
Analgesics
Decongestant, cold medicine, cough suppressant
Antibiotic/antifungal/hydrocortisone creams
Pepto-Bismol tablets, antacid
Band-Aids, gauze bandages, tape, Ace wraps
Insect repellant, sunscreen, lip balm
Tweezers, scissors, thermometer
29
 Post-Travel Care

Post-travel checkup
Long term travelers
Adventure travelers
Expatriates in developing world

Post-travel care
Fever, chills, sweats
Persistent diarrhea
Weight loss
30
Questions?

31
Other Resources

32
 Journals
American Journal of Tropical Medicine and
Hygiene
Bulletin of the World Health Organization
Emerging Infectious Diseases Journal
Eurosurveillance Weekly
Journal of Travel Medicine
Morbidity and Mortality Weekly Report
Tropical Medicine and International Health
Vaccine 33
 Books
Textbook of Travel Medicine and Health, 2 nd
Ed.
DuPont, H.L. and Steffen R. (editors)
The Travel and Tropical Medicine Manual,
3rd Ed.
Jong, E.C., McMullen, R.
Travel Medicine
Keystone, J.S., Kozarsky, P.E., et al

34
 Websites
Eurosurveillance
www.eurosurveillance.org
Travax EnCompass
www.travax.com
GIDEON
www.gideononline.com
International SOS
www.internationalsos.com
Medical Advisory Service for Travelers Abroad (MASTA)
http://www.masta.org/
Armed Forces Medical Intelligence Center
www.afmic.detrick.army.mil/
Central Intelligence Agency
www.cia.gov/cia/publications/factbook/ 35