travel medicine for physicians

John Sinnott, MD, FACPJohn Sinnott, MD, FACPAssociate Dean, International AffairsAssociate Dean, International Affairs

Director, Division of Infectious DiseaseDirector, Division of Infectious DiseaseUniversity of South Florida University of South Florida

College of MedicineCollege of Medicine

Travel Medicine for PhysiciansTravel Medicine for Physicians

Let’s Look at Travel

Research Before Traveling:•Europe: www.ricksteves.com •Elsewhere: Lonely Planet Guide•CIA World Fact Book

– www.cia.gov/cia/publications/factbook •US Department of State

– http://travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html •Tourism information

– www.towd.com •Medical kits and other travel products

– http://www.adventuremedicalkits.com/ – http://www.travmed.com/

Do not leave the US without reading about your destination!

Online Resources for the Traveler• Travel Gear: www.magellans.com

• Passports: http://travel.state.gov/passport/passport_1738.html

• Visas: http://travel.state.gov/visa/visa_1750.html

• Tourism info: www.towd.com

• Airports/flights:– http://www.flytecomm.com/cgi-bin/trackflight – www.quickaid.com – general airport info

• Weather: www.worldclimate.com – www.weather.com – www.accuweather.com

Online Resources for the Traveler• Money: www.x-rates.com • Communications: http://www.countrycallingcodes.com/ -

International calling code directory– North America: www.allareacodes.com – www.frequentflyer.oag.com – toll-free number site with

hotels, car-rentals, airlines, etc.– Phone cards: www.nobel.com

• Electrical systems: www.kropia.com/electric.htm • Foreign languages: www.babelfish.altavista.com • Metric conversions: www.sciencemadesimple.com • On the Ground: www.amtrak.com

– www.aaa.com – http://subway.umka.org/

IN GENERAL:

• Trauma - Cars, falls, swimming

• Social - Sex, drugs = hazards

• General - Label meds, travel light

• ID - Malaria, zoonoses

• Eating - Hot food served hot, CO H2O

• Wildlife - Avoid animals, insects

SCOPE OF PROBLEM - Yearly• 24M travel to developed areas

– 6M ill (25%)• 6M travel to developing countries

– 3M ill (50%)– 2M exposed to malaria

• Mortality: 3000 (.0015%) – 2000 MVA– 600 Falls– 200 ID– 100 Misc (CDC, 2008)

BEFORE TRAVELING:“Think the trip through”

• Place– Developing vs. industrialized

– Hotels vs. “roughing it”

– Season: weather, vectors

– Air: jet lag, URI

– Ship: LRI, diarrhea

– Altitude: HAPE, HACE

“Bucket Shops”• Global Touch - http://www.globaltouch.net/ - Offers consolidator tickets

to travel agents and the public.

• Justfares.com - http://www.justfares.com - Offers flights online or via live agents.

• OZ Flights - http://www.ozflights.co.uk/ - Offers flights from UK to Australia and New Zealand.

• Corporate Flyer - http://www.flyfirstclass.com/ - Discounted business and first class international airline tickets.

• Flight Coordinators - http://www.flightcoordinators.com/ - Offers international flights from the US.

• Executive Class Travel - http://www.executivetravelservice.com - Offers discounts on first class and business class tickets.

• Travel Club International - http://www.unpublishedairfare.com Specializing in unpublished airfare to Europe, South America & Asia.

• IBN United - http://www.ibnunited.com/ Air consolidator to selected European and Middle East destinations.

• Holiday Deal Finder - http://www.holidaydealfinder.co.uk Offers both scheduled air and charter flights from UK airports.

• AirFareOutlet.ca - http://www.AirfareOutlet.ca Offers Air from major Canadian gateways, to destinations around the world. Compares consolidator fares against published fares.

• BizTravelDeals.com - http://www.biztraveldeals.com Offers First class, and Business class, consolidator airfares to all global destinations.

“Bucket Shops”

• Sky Bird Travel and Tours - http://www.skybirdtravel.com/ Consolidators that supplies international airfares to travel agents.

• Airline Tickets Direct - http://www.airlineticketsdirect.com Books flights to or from Canada with major Canadian airlines.

• DiscoveryWorld.com - http://www.discoveryworld.com/ Offering airfares to Europe, Asia, Australia, Africa, South and Central America leaving from all major US gateways.

• Airtravel Network - http://www.airtravel.net Provides airfare to several international destinations

“Bucket Shops”

flyfirstclass.com

• How to get a good seat!! Double secret information• Sign up for airline FF program• Go to seatguru.com• Pick three choices then call airline and negotiate

Seatguru.com

Books for the Traveler

• 300 Incredible Things for Travelers on the Internet, Ken Leebow $8.95

• The Rough Guide to Travel Online (Rough Guides $11.99)

Trauma

Medical student, Dominican Republic

SOS Card

CHECKLIST:• Labeled meds _______• Liquid meds and pastes in baggie _______• Xerox passport ( 6 mos) _______• Get Visa _______• RX eyeglasses _______• MD, phone # _______• MED evac insurance _______• Trip Insurance _______• Vaccine Card _______• Int’l Drivers License _______• Eyeshades ______________

CHECKLIST:• Neck cushion _______

• Ear plugs _______

• Carry-on with UW and coat _______

• Hat _______

• Sunglasses _______

• Label outside of passport withpassport # _______

• Magnifying glass and sterile needle _______

• Leave irreplaceable valuables at home _______

• VISA Photos _______

• Snacks _______

• Travel adapters __________________

Put all liquids and pastes in a clear bag for Transportation Security

Administration. Label all medicines.

Consider a travel vest

Don’t bring medications without a label!

Bring a color copy of your passport. Label the outside of your passport

with your passport number

Invest in a passport holder

Traveling essentials

Splinter removal and foot protection

Sexually Transmitted Diseases

• Sense of anonymity

• Less inhibited

• Condoms often unused

• “Hooking up”

Take enough medicine not just to treat yourself, but to treat fellow travelers

Doctor’s Meds: I• A-B

– Ampicillin-sulbactam– Quinolone: Lo + Hi dose, Xifaxan– Neosporin/cortisone otic qtts– Quinolone eye qtts– Z-Pak – 2– Tamiflu – course for each traveler

• Supplies– Suture – 4-0/nylon– Paper tape, 4x4’s– Ace wrap

Doctor’s Meds: II• Analgesia

– Oxycontin or Hydrocodone– Compazine Spansules– Cox-2 [NSAID]

• G-I:– Metoclopramide– Anti-motility

• Skin:– Steroids: topical and oral– Misc: Long acting injectable steroid

• Meds for Jet Lag: – armodefinil / zolpidem / melatonin debate

Doctor’s Meds: III

• Motion: Isoptohyascine .025% qtts SL or scop patches, ? methylphenidate

• Chronic meds: Put in 2 places for complete trip

• Sleep meds: zolpidem

Neck cushion, eye mask, headset, ipod, earplugs

General Security& Safety Concerns

U.S. Department of State

http://travel.state.gov/

VACCINES: HD• YF

• Cholera

• Typhoid

• MMR

• Polio

• Rabies

• Hep B, A

• Plague• Meningococcus• HIB• Influenza• Pneumococcal• Japanese B

encephalitis• Gamma globulin

http://wwwnc.cdc.gov/travel/content/vaccinations.aspx

CDC Vaccination Recommendations

http://wwwnc.cdc.gov/travel/content/vaccinations.aspx

MEDS: MEDICAL PROPHYLAXIS

• Location?• Malaria – Malarone

[atovaquone + proguanil], Mefloquine, Doxy

• GI – Quinolone vs. Xifaxan• Misc - Doxy

MALARIA PROPHYLAXIS: 1o

• Bed nets

• Repellents

• Clothing

• Meds

Chemoprophylaxis

• www.who.int/ith/

• www.CDC.gov

• CDC: 877-394-8747

• Acute Dx/TX: 770-488-7100

Traveler’s Diarrhea

• 50% of travelers affected in some areas

Travelers Diarrhea• 80% bacterial, 15% viral, 5% other• Bacterial

– Enterotoxogenic E. coli – gastro enteritis– Salmonella – gastro enteritis– Shigella – dysentery, small volume muco

purulent– Camplyobacter – dysentery– S. aureus – acute vomiting

• Viruses– Norovirus

• Parasitic ?

Current Medical Diagnosis and Treatment, 2007.

General Features

• Benign, self-limited disease• One week into travel• Prophylaxis recommended

– For inflammatory bowel Dz, HIV, IBS, immunosuppression: give prophylaxis

• In others: treat symptomatically

Current Medical Diagnosis and Treatment, 2007.

Gastroenteritis [NVD] for Dummies

• Cause: E. coli, salmonella, shigella, campylobacter, norovirus

• Transmission: fecal oral• Incubation: 1 hr or 3 d• SSx: NVD• Dx: clinical• TX: metaclopramide, quinolone ;;;zithro in

Asia

Dysentery

• Small volume muco-purulent stoolsShigella, Campylobacter

Acute vomiting

• S. aureus

Acute Diarrhea w/ no lab

T > 101, abdominal pain, Bloody diarrhea

HIV, IC >65

Rehydration +

Rifaxin 3D orQuinolone 5D

Zithromax X 3D

Rehydration

Adapted from: Figure 14-1 and 14-6, 559. Current Medical Diagnosis and Treatment, 2008

NO YES

CDC Health Information for International Travel 2008. Found at http://wwwn.cdc.gov/travel/YellowBookListofMaps.aspx.

Self-Rehydration Therapy for Diarrhea

• With sugar and salt (raw sugar or molasses can be used instead of sugar)– 1 liter (.3 gallon) of clean water

– 1/2 tsp SALT

– 8 level tsps sugar or substituteNeed 3 L/ D, drink q5 min

Werner D. Where There is No Doctor: A Village Healthcare Handbook for

Africa, p161.

Safe Eating:• Clean rims

• Bottled water

• Carbonated drinks

• Black coffee

• Hot foods served hot

• Look at the kitchen

• Go local

UNSAFE:“We speak English! Credit Cards Accepted!”

• Ice

• Vendors

• Raw food

• Pastries

• Unpeeled fruit

• Dairy- Milk, Ice cream

Exotic and Trendy Cuisine• Raw fish, seafood and worms in the time of cholera…..

– Anisakiasis:* caused by larval stages of marine nematodes, or “herring worms”• Hallmark: sudden abdominal pain, 1 to 24 hr after consumption of raw fish

• Nausea, vomiting, fever, often with worm regurgitated

– Pseudoterranova decipiens: pathogen of seals, sea lions, walruses

– Anisakis simplex: pathogen of porpoises, whales• 1- to 4-cm-long larval worm in 50% of cases

– Pacific > Atlantic

• Raw Beef, Raw Pork, and Dysentery • Steak Tartare and Toxoplasmosis and salmonella

*Hawkes S, Hart GJ, et al. 1995. Risk behavior and STD acquisition in geniourinary clinic attenders who have travelled. Genitourin. Med. 71:351-354.

Disinfecting H2O

• Boil – five minutes

• Bleach – 1 drop/1 glass

• CL tablets

Environment

• Air travel ⇨ walk vs rest

• Jacket

• Medical alert bracelet

• Heat exhaustion, stroke

• Hat

• Sunglasses

• Hydration

On the Plane: Level 2 Anesthesia

• No caffeine• Window/Bulkhead/Emergency exit• Eat at once or before travel• Sleep med (?) – short acting/long acting• Neck pillow• Sleep mask• Ear plugs• Pillows, blankets• Tell flight attendant• Stay hydrated, if awake, walk

On Arrival:

• Set watch to local time on landing

• DO NOT SLEEP! DO NOT SLEEP!

• Go to sleep at your normal time in new place!

• Use a sleeping aid and? Provigil• ?? melatonin

At the Shore…

Motion Sickness

• Cephalic and gastric phase

• 85% gastric

• Anticipatory motion sickness

• General concept is to learn to like motion1] Isopto- hyascine qtts

2] ephedrine or CNS stimulant

3] corticosteroids

SALTWATER: Sea Lice

• Path: Lanuche trapped under suit ⇨ severe itching

• DX: Papules/pustules under suit

• Rx: Vinegar/Urine stat

Steroids laterWash clothes

(Sinnott J, S Med J 14,44,1996)

SALTWATER: Jellyfish

• Path: Nematocyst allergy• DX: See jellyfish or feel

sting• 6 Hr: Vinegar (?Urine, NH3,

Baking Soda) Not ETOH• Late: Topical steroid

Oral steroids

SALTWATER: Sea Urchin Puncture

• Path: Venomous spines ⇨ FB

inflammation

• Rx: Hot H20 110-113o

Pain meds

Remove spines

• Caveat: Near joint/tendon

Infection

SALTWATER: Sting Ray

• Path: Venomous Puncture

• Rx: Hot water

Scrub

Antibiotics

Pain meds

• Prevent: Shuffle feet

SUNBURN: SEVERE

• Cool shower

• NSAID and steroid topical

• Steroid oral, hydration

Freshwater: Swimmer’s Ear

•ENDThank you very much.

Doctor’s Meds: IV

• HIV Test Kit

• Ace Bandage

• Band Aids

• Paper Tape

Colloquialisms for Travelers Diarrhea

• Cypress Rush• Egypt Tummy• Casablanca Crud• Basra Belly• Karachi Crouch• Delhi Belly • Montezuma’s Revenge • Thai-dal Wave • Turista• Backdoor Sprint• Aztec Two-step

• Greek Gallop• Hong Kong Dog• Aden Gut• Malta Dog• Rangoon Runs• Tokyo Trots• Tourist Trot• Trotsky’s Revenge • Turkey Trots• Maladie de la Mer Rouge