Creating a Travel Medicine Clinic

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Creating a Travel Medicine Clinic

• By
• Kathlene S. Waller, MD, MPH
• Lisa A. Duggan RN, BSN

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Travel Quiz!!

• What percent of travelers report an illness or
  impairment during their trip (up to 90 days)?
• What percent of travelers require hospital
  admission abroad?
• What are the chances a traveler will seek
  medical care while traveling in a developing
  country?
• What is the most common malady affecting
  travelers and what are the chances you will have
  it during a month-long trip to a developing
  country?
• What is the most common zoonosis in the world?

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Travel Quiz!!

• What is the risk of Tuberculosis in travelers?
• How many people die worldwide from rabies each
  year?
• What is the most common bacterial etiology of
  travelers diarrhea worldwide?
• Travelers acquire Japanese Encephalitis at what
  rate?
• What is the outcome of those symptomatic with
  Japanese Encephalitis?

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I. Set up of the Clinic

• A. History
• B. Staffing
• C. Education
• D. Protocols
• E. Handouts and Brochures
• F. Costs

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I. Set up of the Clinic

• Advertising
• Student travel agency, student newspaper,
  website
• Study abroad and health fairs
• Coordination with the International Office
• Group presentations

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II. Resources for Information

• Web-based sources
• Public Access
• -Centers for Disease Control and Prevention
• Travel Information wwwn.cdc.gov/travel
• -U.S. Department of State www.travel.state.gov
• -World Health Organization (WHO) www.who.int
• -Central Intelligence Agency www.cia.gov
• World Factbook-maps

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II. Resources for Information

• Web-based Sources
• Public Access
• -Travel Medicine, Inc. www.travmed.com
• Travel Health Guide
• -International Association for Medical Assistance
  to Travelers www.iamat.org
• -Lonely Planet online www.lonelyplanet.com
• -Study Abroad Student Handbook www.studentsabroad.
  com
• -International Society for Infectious Diseases
  (Promed) www.promedmail.org

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III. Resources for Information

• Web -based Sources
• Private/Member Services
• -International SOS www.Travelcare.com
• -Astral www.Tropimed.com
• -Shoreland www.Travax.com
• By Application
• -Argus Global Watchboard
• www.argusglobal.georgetown.edu

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II. Resources for Information

• Books
• 1. CDC Health Information for International
  Travel 2008 Department of Health and Human
  Services
• 2. International Travel Health Guide 2006-2007
  Rose and Keystone 13th Edition
• 3. The Travel and Tropical Medicine Manual
• Jong and McMullen 2003, 3rd Edition

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II. Resources for Information

• B. Books
• 4. Epidemiology and Prevention of
  Vaccine-Preventable Diseases January 2007
• 10th Edition Department of Health and Human
  Services
• 5. Travel and Routine Immunizations A
  Practical Guide for the Medical Office July
  2007-June 2008 16th Edition Shoreland

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II. Resources for Information

• C. Phone
• -CDC Malaria Hotline [phone]
• [phone] after
  hours
• D. Organizations
• -International Society of Travel Medicine
• (ISTM) www.istm.org
• -American Society of Tropical Medicine and
  Hygiene (ASTMH) www.astmh.org

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III. The Travel Appointment
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III. The Travel Appointment

• A. Risk Assessment
• 1. Destination
• -Location (remote?), accommodation (VFR?),
  length of travel, activities, purpose of travel
• -Climate/environment
• -Availability of potable water
• -Availability of quality health care
• a. Resources
• b. Insurance
• c. IAMAT

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III. The Travel Appointment

• Risk Assessment
• 2. Past Medical History
• -Medical and Psychiatric conditions
• stable?
• prescriptions
• -Allergies/Asthma
• as needed medications
• 3. Previous vaccinations and diseases
• -Childhood
• -Previous Travel

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III. The Travel Appointment

• A. Risk Assessment
• 4. Travel Notices in Effect
• -Current issues in a region such as
• Highly Pathogenic Avian Influenza
• Dengue Fever
• Measles/Mumps Outbreaks
• Chikungunya fever

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III. The Travel Appointment

• Risk Assessment
• 5. Safety and Security
• U.S. Department of State
• Travel Warnings
• Public Announcements
• Worldwide Caution
• Crime

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III. The Travel Appointment

• Risk Management
• 1. Immunizations
• a. Routine/Childhood-Hepatitis B, Influenza,
  MMR, Td (Tdap), Varicella, Polio
• b. Travel-Hepatitis A, Typhoid, Polio

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III. The Travel Appointment

• 1. Immunizations
• c. Special Circumstances-Cholera, Japanese
  Encephalitis, Meningococcal, Yellow Fever,
  Tickborne Encephalitis, Rabies

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Japanese Encephalitis
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Meningococcal Disease
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Yellow Fever
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Tickborne Encephalitis
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Rabies
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III. The Travel Appointment

• Risk Management
• 2. Travelers Diarrhea
• a. Identifying high risk factors-H2 blocker use
• b. Handouts on avoiding contaminated food
• c. Use of OTC medications such as bismuth
  subsalicylate and loperamide
• d. Probiotics
• e. Rehydration solutions
• f. Bloody stools and/or high fever

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III. The Travel Appointment

• Risk Management
• 2. Travelers Diarrhea
• Antibiotics
• Ciprofloxacin 500mg.
• -Take one pill twice daily for 3-5 days.
• -Ages 18 and older
• -Can also be used for respiratory symptoms,
  urinary tract infections or skin/wound infections

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III. The Travel Appointment

• B. Risk Management
• 2. Travelers Diarrhea
• Antibiotics
• Azithromycin
• -Take one gram daily until symptoms
  resolved (1-3 days)
• -Available for children gt6 months
• (dose by weight)
• -Can also be used for respiratory symptoms
  or skin/wound infections
• -Effective against Quinolone resistant
  pathogens

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III. The Travel Appointment

• Risk Management
• 2. Travelers Diarrhea
• Antibiotics
• Rifaximin 200mg.
• -Take one pill three times daily for three
  days.
• -Non-invasive
• -Effective against E. coli only
• -Use for prevention?

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III. The Travel Appointment

• Risk Management
• 3. Malaria
• a. Risk level of destination
• b. Handouts/discussion on insect avoidance
• c. Medications
• Chloroquine
• Mefloquine
• Atovaquine/Proquanil
• Doxycycline
• Primaquine

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Malaria
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Arthropod Borne Infectious Diseases
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III. The Travel Appointment

• Risk Management
• 4. Other Arthropod Borne Infectious Diseases
• a. Dengue
• b. Japanese Encephalitis
• c. Leishmaniasis
• d. Chikungunya Fever
• e. Trypanosomiasis
• f. Myiasis

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Dengue Fever
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III. The Travel Appointment

• Risk Management
• 5. Other Issues
• a. Water borne diseases
• -Schistosomiasis
• -Leptospirosis
• b. Tuberculosis
• c. Sexual Health Issues
• d. Altitude Sickness
• e. Motion Sickness/Flight Issues

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IV. Followup after Travel

• Fever
• Always ask about travel.
• Think Malaria!!
• B. Travelers diarrhea

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Travel Quiz!!

• What percent of travelers report an illness or
  impairment during their trip (up to 90 days)?
  70
• What percent of travelers require hospital
  admission abroad? lt1
• What are the chances a traveler will seek
  medical care while traveling in a developing
  country? 5-8
• What is the most common malady affecting
  travelers and what are the chances you will have
  it during a month-long trip to a developing
  country? diarrhea/35-60
• What is the most common zoonosis in the world?
  Leptospirosis

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Travel Quiz!!

• What is the risk of Tuberculosis in travelers?
  3 per year in a high risk area
• How many people die worldwide from rabies each
  year? 55,000
• What is the most common bacterial etiology of
  travelers diarrhea worldwide?
  Enterotoxigenic E. coli (ETEC)
• Travelers acquire Japanese Encephalitis at what
  rate? 1 per 1,000,000
• What is the outcome of those symptomatic with
  Japanese Encephalitis? 1/3 die, 1/3 permanent
  neurologic impairment, 1/3 recover

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Questions or Comments?