Travel Health Travel Health – – Risk assessment and Risk assessment and

preventionprevention

Dr Peter TayMBBS; DTM RCPS(Glasg);

MMed (OM); AFTM (Glasg); FAMS

Summary International Travel Travel health Accidents & Injuries Health hazards associated with flying Travel related illness Fitness to travel Preventing ill health during travel

International Travel The WTO (World Tourism Organization)

reports that international tourist arrivals in the year 2006 exceeded 840 million1

The majority of international travel was for : – Leisure, recreation and holiday (51%)– Business travel (16%)– 27% (225 million) represented travel for other

reasons such as visiting friends and relatives (VFR), religious purposes/pilgrimages and health treatment

– For the remaining 8% of arrivals, the purpose of visit was not specified

What is Travel Health ?

Travel Health

“ People in their home environment live in a state of equilibrium with the physical environment and with the local strains of micro-organisms. Exposure of the traveller to the different health risks of the visited area is determined by destination, duration of visit, purpose of visit, behaviour of the traveller and physical and biological status of the traveller”.

Dr Hussein A Gezairy, Regional Director, WHO Eastern Mediterranean Region

Accidents and Injuries

Accidents and Injuries A Scottish study2 of 952 travellers who died abroad

found that cardio-vascular disease was the major cause of death in the older age group whereas in the younger group, traumatic deaths were commonest.

Among business travellers and expatriates, studies3,4 have reported a higher incidence of injuries, especially back injuries compared to non-travelling employees and up to 20% of reported health events were found to be due to accidents with sprains, strains and fractures accounting for 74% of those cases. Sports activity accounted for 51% of accidents and 12% were due to road traffic accidents (MVC’s).

Health Hazards associated with Flying

Humidity, Radiation & Motion sickness

Humidity of cabin air is usually low (< 20%) due to frequent air exchanges. Giving rise to skin dryness and discomfort to the eye and upper respiratory tract

Cosmic radiation comes from the sun and outer space. It is more intense over the polar regions. However, health risks to the occasional traveller is extremely small.

Air travellers seldom develop motion sickness except in the case of severe turbulence. Susceptible individuals are advised to sit in the middle sections of the plane, avoid spicy, fatty, gas-forming foods.

Chemical Exposures On the ground, pollutants associated with most airports

are volatile organic compounds, carbon monoxide, oxides of nitrogen, particulates and ozone.

During flight, at higher altitudes, Ozone is the main pollutant and can lead to airway irritation and reduced lung function. Most modern aircraft are fitted with catalytic converters to remove ozone from cabin air6.

Disinsection is a requirement in a number of countries. The pesticide group in most common use are pyrethroids and the WHO found no evidence of harmful effects if the insecticides were used as prescribed.

Deep Vein Thrombosis (DVT) Misnomer : “economy class syndrome”

Due to relative immobility therefore associated with travelling in general.

WHO : risk of thromboembolism approx. 2X after travel lasting 4 hours. Passengers taking multiple flights over a short period are also at risk7.

Risk of developing DVT associated with8 : Travelling in general, with the risk associated with flying similar to that

of travelling by car, bus or train A Body Mass Index (BMI) of more than 30 kg/m2

Very tall individuals (above 1.90 m in height) Those who use Oral Contraceptives, and Those who are below 1.60 m in height (for air travel specifically)

Prevention : moving around the cabin to reduce immobility; calf exercises to stimulate circulation; avoidance of alcohol (dehydration & promotes immobility) and keeping well hydrated during the flight.

Jet Lag

May lead to – Indigestion & bowel disturbance, – general malaise, – daytime sleepiness, – reduced physical and mental performance9. – chronic exposure may lead to cognitive deficits 10

Prevention :– getting adequate sleep in the destination country – use of short acting sedatives– use of melatonin : recommendation that it be taken by

adult travellers flying across five or more time zones, particularly in the easterly direction11

Disruption of the body’s “internal clock” and its circadian rhythms

Occurs especially when crossing multiple time zones

Psychological Aspects

For biz travel, a World Bank study13 found that almost 75% of employees and 50% of spouses reported high or very high stress levels associated with business travel. Concerns were with :– negative impact on their family– inability to refuse travel– personal health concerns– lack of control over travel– interference from last minute changes in itinerary

Main problems encountered are stress and fear of flying. One study of 238 travellers12 found that flight delays were perceived as a source of anxiety for 50% of respondents, take-off and landing by 40% and customs and baggage reclaim for 1/3.

Communicable Diseases Commercial aircraft designed after 1980 recycle up to 50% of cabin

air through HEPA filters

Risk of ID transmission passenger is confined in close quarters for a prolonged period of time

The CDC14 found that 4 passengers were infected with TB during a 9-hour flight and the WHO15 concluded that TB transmission was possible especially during long flights (e.g. 8 hr duration). Most important factors in disease spread were infectiousness of the patient, proximity to the source, ventilation and degree of crowding.        

Indeed, any disease that is spread via droplets (e.g. influenza, meningococcal disease & measles) may be spread in this way. In 2003, SARS16 very quickly spread from Hong Kong to Viet Nam, Singapore, Canada and Germany.

Travel Related Illness

Review of literature shows that the overall incidence of TRI ranges from 37.0% to a high of 65.5% 17-21

Prevalence of specific diseases :– Traveller’s diarrhoea (TD) was the commonest reported

illness, ranging from 26.3% to 59.0%

Prevalence of TRI

– The second most commonly reported illness was respiratory tract infection which ranged from 12% to 29%

– Skin problems (sun burn, dermatophytosis, allergic rash) made up the third most common illness reported

– other illnesses reported were jet lag, insomnia, constipation, acute mountain sickness, headache and myalgia

Tropical Diseases Malaria Schistosomiasis

(Bilharzia) Filariasis Leishmaniasis Rabies Dysentery Cholera Typhoid Myiasis Nematode, cestode

infestation Chingukunya

Fitness to Travel

Fitness to Fly22

At this altitude, there is 25% less oxygen (SaO2 90 - 93%) - caution in coronary, cerebrovascular, pulmonary & anaemic patients

Gases in cavities expand (Boyle’s law : v 1/p) Cabin Humidity 10 – 20 %

Medical Clearance may be needed :– After recent illness, injury, surgery or hospitalization– With existing unstable medical conditions– If oxygen or other medical equipment on board is required– If travelling for medical reasons

Cruising altitude 30,000 – 40,000 ft but cabin pressurized to 5000 - 8000 ft (1524 - 2438m)

Medical Guidelines for Flying23

Condition Travel after

SurgeryMajor procedure 10 daysCranial surgery 7 daysCataract 1 dayRetinal surgery 2 weeks (intraocular gas)Tonsillec/adenoidec-tomy 2 weeks (bleeding)Abdominal surgery 1 - 2 weeks (less if lumen unopened)Laparascopic Surgery 24 hours if no bloatednessAngioplasty 3 - 5 days if uncomplicatedCABG 10 - 14 days, 4 weeks preferredColonoscopy 1 day (gas)

CardiacUncomplicated MI min 7 days, 2 - 3 weeks preferredStable angina No restrictionsStable CHF No restrictions

PulmonaryStable asthma No restrictionsCOPD PaO2 > 70 mm Hg; "50m test"Pneumothorax 2 - 3 weeks after drainage

OthersNormal pregnancy up to 36 weeksCVA 2 weeksEar/Sinus infection Until betterAnaemia HB < 8.5g/dLInfections non-infectious (certification)Post-SCUBA 12 - 24 hours

Aerospace Medical Association Medical Guidelines Task Force : Medical Guidelines for Airline Travel 2nd Ed. Aviation, Space and Environmental Medicine 2003; 74 (5)

Preventing Ill HealthDuring Travel

Prevention (1)

– Destination– Duration and season– Purpose and activity– Mode of travel– Accommodation– Food & water hygiene– Behaviour of traveller– Underlying health of traveller

Pre-travel risk assessment

Internet Trvl Agent

Booking

Travel

• Risk Assmt ?

• See doctor ?

NATAS

Immunizations

Is malaria prophylaxis required ?

Travel Health Advice– Sources of information

Travel Health kit

Travel Insurance

Prevention (2)

ImmunizationsVaccine Viral Bacterial

MeaslesMumpsRubellaVaricellaYellow FeverRotavirus

BCGHepatitis AJapanese encephalitisPoliomyelitisRabiesTick-Borne EncephalitisH. Papilloma Virus

CholeraPertussis

Diphtheria

TetanusHepatitis BInfluenza

Meningoc. ACYW135PneumococcalTyphoid

Conjugate H. Influenzae Type B

Subunit

Capsular polysaccharide

Live attenuated

Inactivated / killed

Inactivated Toxoid

What is recommended ?

Give 4 – 6 weeks

Anti-malarials To take or not to take ?

– Do a risk assessment• Is there chloroquine-resistance ?• Season of travel• Availability of medical facilities• Age, sex, pregnancy, personal medical history

Bite prevention– Long-sleeved shirts, long pants, socks– Avoid being outdoors during dusk & dawn– Use of insect repellent (DEET; Neem tree; Citronella)– Air-conditioned rooms– Screened windows & doors– Mosquito nets (pyrethroid-impregnated)– Use of pyrethroid coils/electrical burners

Emergency stand-by medication

Caution : Anti-malarialsName Mefloquine Doxycycline Atovaquone/ProguanilTrade name Lariam® (Roche) Vibramycin® (Pfizer) Malorone™ (GSK)Side effects GI disturbances

· Headache· Loss of balance· Sleep disturbances· Panic attacks, hallucinations

GI disturbances· Vaginal candidiasis· Oesophagitis (technique)· Erythema

Headache· Abdominal pain· Diarrhoea

Contraindications Avoid preg 3/12 after completing course· During 1st trimester· Children < 5 kg· Cardiac Conduction disorders· H/o neuropsy dis, incl depression & convulsions· Epilepsy in Pt or 1st deg relative· Hypersensitivity to quinine or mefloquine

 Preg incl 1/52 after completing course· Breast feeding mothers· Children < 12 years old· SLE· H/o tetracycline allergy

Pregnancy and lactation· Known hypersensitivity· Severe renal impairment

Traveller’s Health Kit

Suggested Contents of Traveller's Health Kit (24, 25)Over-the-counter medications :- Analgesics (ibuprofen, acetaminophen, aspirin)- Antiemetics (dimenhydrinate)- Electrolytes for oral rehydration (ORS)- Nasal decongestant- Topical hydrocortisonePrescription medications : - Traveller's usual medications- Standby antibiotic for traveller’s diarrhoea (e.g. Ciprobay)Malaria chemoprophylaxisJet lag medication (e.g. zopiclone, melatonin)Influenza prevention/treatment (e.g. oseltamivir)First aid :- Bandages- Plasters- Sterile dressing- Adhesive tape- Needles and syringes- Antiseptic/Antibiotic ointment- Thermometer- Scissors & safety pinsOthers :- N, N-diethyl-m-toluamide insect repellent (DEET)- Emollient eye drops- Hand cleansing gel- Non-latex gloves - Masks- Condoms

Most Commonly used items in Coca-Cola© travel kit26

Item % usageAnalgesic medication (acetaminophen, ibuprofen, aspirin) 33.0

Diarrhoea medication (loperamide, bismuth subsalicylate) 28.0Sinus medication (psudoephedrine) 27.0Insect spray 24.0Sunscreen 21.0Thermometer 12.0Bandages 11.0Antibiotic ointment (Neosporin/hydrocortisone) 7.1Motion sickness (Dramamine) 4.0Water purification tablets 0.9Electrolyte drink 0.9Needles 0.9IV supply 0.4

Sutures, non-sterile gloves, chlorpheniramine, diphenhydramine Unused

Travel Health Advice

Travel Health AdviceAdvice regarding potential risks and risk-taking behaviour is essential. These cover :

– Personal hygiene– Food & water hygiene (e.g. filtration, boiling)– Sunburn avoidance (e.g. sunglasses, sunscreen, hat)– Motion sickness – Altitude sickness – Heat disorders – Insect/Animal avoidance – “Safe” sex – Accident & crime avoidance

• Driving, motorcycles, scooters etc.• Hazardous pursuits e.g. bungee jumping, scuba diving,

caving, skiing

– Alcohol usage – Substance use/abuse– When to self-treat (e.g. diarrhoea, skin infections, malaria) – When and where to seek acute medical care while overseas

Travel Insurance

Cost of medical care overseas can be prohibitive

Huge costs associated with medical evacuation, ranging from commercial flights to chartered aircraft

Conclusion International travel volume is on the increase with travel

for leisure/pleasure, business and VFR being the top 3 reasons

Travel related health risks have to do with factors such as destination, duration, purpose of travel, activity, standards of accommodation, behaviour of the traveller and the underlying health condition of the traveller

On-line databases are excellent sources of travel health information

A pre-travel risk assessment is essential in reducing the risks associated with travel

A health consultation is recommended 4 – 6 weeks prior to travel

Do not forget travel insurance

Thank you