Part IIIThis section will provide an overview of the non-

vaccine preventable health and safety issues for students:

Insect vectors: focus on malaria and dengue Food and water hazards: focus on traveler’s

diarrhea Other health and safety risks

Final slides are resources for the full slide set

Insect Vector Diseases

Malaria Dengue Vaccine-preventable: Yellow Fever, Japanese

Encephalitis Many others: chagas disease, sand flies, bed

bugs, etc

Student accommodations may place them at risk for insect-borne diseases

Malaria: #1 Infectious Disease

Serious, potentially fatal parasitic disease spread by the night-biting anopheles mosquito Present > 100 countries; 300 mil cases yr / 1 mil

die 1,000 US travelers / yr reported cases

4 Plasmodium types affect humans P. falciparum >95% traveler deaths P. vivax, p. ovale p. malariae: delayed onset, late

dx

www.cdc.gov/mmwr/preview/mmwrhtml/ss5402a2.htm#tab6

Traveler’s Malaria Risk

risk for P. f: Africa (2% travel / 83% cases) Highest risk for P. vivax: Asia, Latin America Exposure risk varies: geography, season,

duration, altitude, activities, sleeping conditions, adherence, VFR

At risk groups: long-stay, adventure travelers (specific activities), pregnant women, VFR (BMJ reports 3x-8x higher risk), noncompliant

No vaccine, but considered preventable & treatable

Malaria Endemic Countries 2003

www.who.int/ith/diseasemaps_index.html

CDC Approach to Malaria Education:

ABCD #1: Awareness: of disease & where, when

traveler is @ risk #2: Bug bite avoidance: prevent bites! #3: Chemoprophylaxis: take appropriate

Rx medications as prescribed #4: Diagnose: the early signs &

symptoms: if fever, think malaria & get prompt care

A Use Maps to Confirm Risk with Traveler

Teach the Plasmodium LifecycleNY Daily News 10/2002

B Personal Protective Measures

Use DEET repellants: controlled release, 19-35% *

Apply permethrin to clothing, bed nets Reduce outdoor activity dusk to dawn Return from rural trips before dark At night time: use screens or A/C, bed nets,

spray room or tent with flying insect spray

*Information resource:Fradin,M & Day, J (2003) NEJM, 347: 13-18.

C Malaria Drugs of Choice ChloroquineFor Resistant Areas: 3 CDC approved

medications- Mefloquine Doxycycline Malarone (Atovaquone/proguanil)None 100%; need PPMScreen all students before prescribing!Adherence issues ! Obtain in U.S.: counterfeit / unavailable abroad

Chloroquine Resistance Many Areas Around the World

Source: CDC@ www.cdc.gov/travel

Mefloquine / Lariam 20+ years of use; very effective most areas Resistance on Thai borders

Controversy regarding tolerability / media blitz “Neuro-psychiatric” side effects reported

Prescribing guidelines: Screen for contraindications: seizure, psych illness / psych meds,

drug allergy, 1st trimester pregnancy Tolerance in past does not insure tolerance next time FDA requirement: pharmacists distribute AE handout

Consider use for: previous use, long-stay traveler, pregnancy

Doxycycline

expensive, readily available Short half-life; qd x 1 month

after trip AEs: vaginitis, esophagitis,

photosensitivity, GI upset Not for pregnancy,

breastfeeding No known areas of resistance Consider use for: Thai borders;

no $- backpackers, VFRs, students

Malarone Atovaquone (250mg) + Proguanil (100mg) Take daily, start 1-2 days before, only 7 days

after trip cost AE’s: GI intolerance- so take with food Not available everywhere Consider use for: short-stay traveler, drug

plan, Thai borders, student living in city without malaria; student unable to take other choices

Primaquine to Prevent P vivax Relapse

Additional consideration for students at risk for infection with P vivax

P vivax relapse infections Consider adding Primaquine to malaria

regimen to prevent relapse < 3yrs post travel Potent anti-oxidizing agent: test for G6PD

deficiency to prevent hemolysis Not used in pregnancy Consult with malaria expert as needed

Chemoprophylaxis Decision-making

Is the traveler going to malaria zone? Will he be exposed? (accommodations, night

exposure, altitude) Is there drug resistance there? Are there any drug contraindications: allergies,

meds, pregnancy, psych hx, etc? What is the traveler’s experience with malaria

meds? What is the duration of anti-malarial use?

Schwartz E et al. Delayed onset of malaria-implications for chemoprophylaxis in travelers. NEJM 349;16, 1510-1546; J Keystone, Wilderness Medical Society presentation, Big Sky 8/05

D Malarial InfectionMajority of U.S. cases present post trip

Fever after trip to malaria zone = malariaTeach student how to get

immediate, competent

evaluation & care

Patient Teaching Resource@ www.cdc.gov/malaria/pdf/travelers/pdf

Give to Every Student at Risk

Provider Resource for Malaria Treatment

National Center for Infectious Diseases-Division of Parasitic Diseases @ 770-488-7788

Internet @ www.cdc.gov/malaria/diagnosis_treatment/treatment.htm

Dengue Fever“Breakbone Fever”

Age-related flu-like syndrome Growing problem: now present > 52% of world Vector: day-time Aedes Urban & rural risk DHF variant Prolonged convalescence possible Avoidance only: no vaccine, no

chemoprophylaxis at this time

Traveler’s Diarrhea

#1 most common infection in travelers: 30% /wk Developed to developing countries (CDC II, III) Transmission: fecal-oral contamination 60-80% bacterial etiology; viral: 10-20% &

parasites 5-10% drug resistant campylobacter jejuni Syndrome- abrupt, 3+ defecations / d; assoc GI c/o At risk: level of accommodations, long-stay,

adventurous eaters, VFR, GI or immunity problems

“Boil it, cook it, peel it, or forget it” Easy to say, hard to do!

Prevention not always possible Assess student for risk, self-care skills, resistant

organisms @ destination Five step approach: Simple & Customized Message

Educate: food & water consumption “careful vs careless” Immunizations: Hep A, typhoid Emphasize handwashing Counsel self-care: rehydration, use of antimotility agents

and antibiotics to use “on-the-road”

Other Non-vaccine Preventable

Risks for Student Travelers

Traffic accidents Air travel Recreational

hazards Climate Altitude

STDs Safety & security Travel stress Medical care abroad

& trip insurance Self-care “on the

road” Post-trip issues

Traffic Accidents #1 cause of morbidity and

mortality in US travelers abroad

Internationally, more complex traffic mix as wheeled vehicles, animals, pedestrians all share same road

Poor road maintenance & problematic signage

Lack of roadside care No motorcycles No night-time rural travel

Air Travel Hazards

Barotrauma: “aerotitis”

Respiratory infection (Flu, URI, TB transmission)

Jet lag and sleep issues

Dehydration Contact lens

problems Allergic reactions to

“disinfection” “Traveler’s

Thrombosis”

Traveler’s ThrombosisDVT caused by prolong confinement in cramped position—

can lead to fatal PE

Overall very low incidence (<1/million travelers) At risk:

Flights > 5-6 hrs; highest risk flights >10hrs; recent surgery (< 4wks), pregnancy, cancer, CHF, DVT hx, obesity, estrogen use

Assess for co-factors, encourage ankle and calf movement and hydration on flight; refer to expert if risk

Teach early s/s- get to proper evaluation & care

Giangrande, P. (2002) Br J Haematol., 117, 509-512.Geerts et al. (2004) Chest;126, 338S

Sun HazardsStudents often seek out the sun on trips

Effects of the sun (UV): sunburn & sunstroke, skin cancer, eye damage

Photo-toxicity with some meds (eg Doxy) Greater risk @ altitudes, in or near water, snow Prevention: avoid midday sun, wear clothing

that covers skin, use UVA/UVB sunblock SPF 15+, wear wide-brimmed hat & sunglasses; checks meds for sun sensitivity

Risky Behaviors: Blood-borne Pathogens

In many countries, rates of HIV and other STIs are much higher than in US (50 to 500x)

Travelers need to avoid all behaviors that expose them to bloodborne pathogens

Studies show 5-67% of travelers have sex with new partners during travel

Safe sex – counsel travelers to plan ahead & avoid prostitutes, multiple partners, alcohol excess

Every StudentEvery Trip

Drugs & Alcohol & Sex Messages

Safety & Security Travelers are targets for thieves, others Travelers need to adopt “safety-conscious” behaviors Bring duplicate documents, leave another set at home Seek guidance before walks, jogs, night excursions Avoid isolated areas; go in pairs, groups Have a plan for the airport Bring nothing you can’t avoid to lose Know the role & access #’s for embassy If travel plans change, keep family & others (school,

Dept of State, etc) informed

Women & Travel

Cultural issues in many parts of world Personal safety Risk for sexual harassment, rape, date

rape Adjustments to personal care routine

(issues of dress, jewelry, perfume, etc) Self-care for: contraception, UTI’s, other

Gyn issues

Self-Care During Travel

At risk groups: adventure travel, trips > 3wks, persons with medical problems, solo travelers

Know when , where, how to seek help Purchase travel medical evacuation insurance

and how to access care – important phone #s Carry ample supply of any Rx drugs Carry a first aid kit

Travel Kit Basics + Customize

Usual OTC drugs Rx drugs- routine and

trip-related First-aid supplies Thermometer Pain / fever meds Pocket-size dictionary Instructions for taking

meds (“suitcase medicine”)

Stool softener Anti-motility agent Decongestant Insect repellant Sunscreen Motion-sickness meds Foot care Condoms

Special Groups / Special Supplies

Benadryl, Epipen, Medic-alert bracelet (or similar)

Rehydration packets (ORS) HIV PEP Drug Supply Emergency contraception “plan B” Expanded health history / translated in

local / multiple languages

Water Recreation Drowning is #2 health risk for US travelers Swim in salt or well-chlorinated water, not fresh Adopt safe behavior in recreational waters Avoid alcohol when pursuing water sports Engage reliable companies for boating, snorkeling,

scuba, rafting, parasailing, etc Carefully evaluate outfitters for: compliance with

safety regulations, equipment / guides, life jackets, emergency services

Caution: think twice about trying new water activities while traveling internationally

Altitude Illness (AMS)

At higher altitude, atmospheric pressure, oxygen pressure→ can lead to hypoxia

AMS- can occur after 1-6 hrs @ > 2400-3000m

Fatal risk: HACE, HAPE Risks: rapid ascent for mountain trekking, skiing,

climbing & direct visits to high places: Cuzco, Kilimanjaro, La Paz, Tibet, etc.

AMS signs / symptoms: headache, fatigue, insomnia, anorexia/nausea/vomiting

Teach prevention & self-care, use of medications

Improving Teaching Efficiency& Effectiveness

Prioritize! Build on traveler knowledge Customize & prioritize messages- only 20%

retention rate is usual for most learners Learning process: hear, see, use Supplement with checklists, packets of health

ed materials Group teaching, call-backs for counseling Web resources

Criteria for Quality TH Care Commitment to consistent, individualized care

Staff selection, training & ongoing education Program monitoring and evaluation

Accurate guidance based on epidemiologic data Updated Internet resources for trip research /

recommendations “Cold Chain” compliance

Immunization coordinator & proper equipment Compliance with regulations & standards of care

Written policies and procedures: anaphylaxis, disaster protocol, needlestick, cold chain, documentation, others

Student Travel Health Challenges

Short notice! Not enough money Flexible trip plans Confidentiality &

truth-telling Possibly pregnant Born outside U.S.

More Challenges

Pandemic/ Bioterrorism concerns

Clinic / orphanage work Very remote travel Intermittent malaria risk School sponsored trip Refuses vaccines

Preparing Students for International Travel

India: 4 months, No Star China: 4 Day, 5 Star

In Summary- Always a rewarding challenge

Assessment Review Articles

Spira, A. Preparing the traveller. Lancet, 2003, 361, 1368-1381

Rosselot, G. Travel health nursing: expanding horizons for occupational health nurses. AAOHN J, 2004, 52(1), 28-41.

Ryan, E & Kain, K. Health advice and immunizations for travelers. New England J of Med, 2000, 342(23), 1716-1725.

Additional References Steffen,R., Rickenbach, M., Wilheim, U., Helminger, A., & Schar,

M.(1987). Health problems after travel to developing countries. Journal of Infectious Disease, 156(1), 84-91.

Centers for Disease Control and Prevention. (2001). Health information for international travel, 2001-2002. Atlanta, GA: U.S. DHHS, Public Health Service.

Dupont, H and Steffen, R. eds. (2000)Textbook of travel medicine. BC Decker, Hamilton, Ontario, Canada.

Barnett E, Chen R, and Rey M (2004) Vaccines for international travel. In S Plotkin and W Orenstein (eds, Vaccines, 4th ed.

Steinberg E et al (2004) Typhoid fever in travelers: Who should be targeted for prevention? CID, 39, 186-191.

Thompson R. (2004) Routine and travel immunizations. Shoreland, Inc., Milwaukee

• Fradin M & Day J (2003) Comparative efficacy of insect repellents against mosquito bites. NEJM, 347(1): 13-18.

Additional References• Schwartz E et al. (2003) Delayed onset of malaria-implications

for chemoprophylaxis in travelers. NEJM, 349(16), 1510-46. Thielman N & Guerrant R (2004) Acute infectious diarrhea.

NEJM, 350, 38-47. Thompson M & Jong E (2003) Traveler’s diarrhea: prevention

and self-treatment. In E.Jong and R.McMullen (eds), The Travel and Tropical Medicine Manual, 3rd ed. (pp.75-86)

Ansdell V & Ericsson C (1999) Prevention and empiric treatment of traveler’s diarrhea. Med Clin of N Amer, 83, 945-973.

Ericsson C (1998) Traveler’s diarrhea: epidemiology, prevention, and self-treatment. Infect D Clin of N Amer, 12, 285-303.

Giangrande P (2002) Br J Haematol., 117, 509-512. Geerts et al. (2004) Chest, 126, 338S ISTM Body of Knowledge @www.istm.org

Conflict of Interest Statement

In the past, Gail Rosselot has received speaker honorariums from Merck, GSK, and Shoreland and educational grants from Merck, Berna, Shoreland, and Sanofi-Pasteur.

There was no commercial support for this ACHA presentation.

Contact information: garosselot@aol.com