Travel Medicine for Physicians
John Sinnott, MD, FACP
Associate Dean, International Affairs
Director, Division of Infectious Disease
University of South Florida
College of Medicine
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
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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:
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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”
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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.
“Bucket Shops”
• 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
flyfirstclass.com
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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:
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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
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CHECKLIST:
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Neck cushion
Ear plugs
Carry-on with UW and coat
Hat
Sunglasses
Label outside of passport with
passport #
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Magnifying glass and sterile needle
Leave irreplaceable valuables at home
VISA Photos
Snacks
Travel adapters
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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
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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
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YF
Cholera
Typhoid
MMR
Polio
Rabies
Hep B, A
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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
o
MALARIA PROPHYLAXIS: 1
• Bed nets
• Repellents
• Clothing
• Meds
Chemoprophylaxis
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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 stools
Shigella, Campylobacter
Acute vomiting
• S. aureus
Acute Diarrhea w/ no lab
T > 101, abdominal pain,
Bloody diarrhea
HIV, IC >65
NO
Rehydration
YES
Rehydration
+
Rifaxin 3D or
Quinolone 5D
Zithromax X 3D
Adapted from: Figure 14-1 and 14-6, 559. Current
Medical Diagnosis and Treatment, 2008
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 substitute
Need 3 L/ D, drink q5 min
Werner D. Where There is No Doctor: A Village Healthcare Handbook for
Africa, p161.
Safe Eating:
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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!”
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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
• Hat
• Sunglasses
• Hydration
• Air travel ⇨
walk vs rest
• Jacket
• Medical alert
bracelet
• Heat exhaustion,
stroke
On the Plane: Level 2 Anesthesia
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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
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Cephalic and gastric phase
85% gastric
Anticipatory motion sickness
General concept is to learn to like motion
1] 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 later
Wash 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:
• Rx:
• Caveat:
Venomous spines ⇨ FB
inflammation
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Hot H20 110-113
Pain meds
Remove spines
Near joint/tendon
Infection
SALTWATER: Sting Ray
• Path:
• Rx:
Venomous Puncture
Hot water
Scrub
Antibiotics
Pain meds
• Prevent: Shuffle feet
SUNBURN: SEVERE
• Cool shower
• NSAID and steroid topical
• Steroid oral, hydration
Freshwater: Swimmer’s
Ear
• END
Thank you very much.
Doctor’s Meds: IV
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HIV Test Kit
Ace Bandage
Band Aids
Paper Tape
Colloquialisms for Travelers
Diarrhea
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Cypress Rush
Egypt Tummy
Casablanca Crud
Basra Belly
Karachi Crouch
Delhi Belly
Montezuma’s Revenge
Thai-dal Wave
Turista
Backdoor Sprint
Aztec Two-step
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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
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