Patient Evaluation in Travel Medicine

Backbone of the travel medicine consultation .

• Food/water precautions
• Malaria Advice
• Immunisation Recommendations
• Individualized risk-based counseling

Essential Information for Assessment

• Specific Itinerary--- places and time spent there

• Purpose of trip---pleasure –business—returning expatriate

• Mode of travel---5-star—backpacking—budget

• Urban vs. Rural

• Type of travel within Destination

• Activities while abroad

• Date of departure

• Length of trip

• Medications list

• Chronic illnesses

• Allergies

• Client’s country of origin

• Previous vaccinations

• Pregnancy

• Ages of clients

Itinerary –specifics

• Incidence/prevalence infectious/vector-transmitted disease

• Need for water and food precautions

• Mandatory and recommended immunizations

• Malaria chemoprophylaxis issues

• Personal security risks from crime, MVA’s

Hi-risk areas for above include tropical and subtropical Africa---Indian subcontinent—tropical South America—Southeast Asia

Purpose of trip

• Pleasure---specific details to follow

• Business

Length of time important—if short and protected—i.e. in meetings and then A/C hotels--- lower risk travelers diarrhea­----malaria prophylaxis may be riskier than chances of acquisition of disease.

BUT such clients may need to consider T.D. prophylaxis if etiquette makes it impossible to refuse any food.

Returning Expatriates

• ↑ susceptibility to disease due to ↓ perception of risk
• ↓ precautions and resumption of old habits

Mode of travel

• 5 Star –usually less risk for T.D./Malaria –( but not always)
• Backpacking/camping -- ↑ risk of T.D./Malaria due to:

            ↑ water risks due to poor sewage and lower personal hygiene i.e. Hep A/Typhoid

            ↑  risk of diseases\injuries from local animals

            ↑  risk vector transmitted diseases

Type of travel within country

·        Local buses, trains, scooters, car hire, planes

 ↑ danger in India, Africa, China

  Highest morbidity\mortality in travel is M.V.A.’s—not disease

Urban vs Rural

·        Urban

            ↑ crime ↓ personal security

            ↑ dengue if relevant

·        Rural

↑ T.D. due to ↓ sewage and services

↑ malaria

↑ morbidity – difficulty accessing appropriately equipped medical facilities

? self treatment  kits

↑ risk rabies

Risky activities

·        Adventure Tourism

Climbing

Diving

Hiking at altitude

Water sports

Bungee jumping

Caving\Spelunking

Skiing

(may be associated with little or no experience)

·        Sex

Sex tourists—typical destinations

Young people

Males traveling alone or in groups (often middle aged)

Long term travelers

People on long term contracts in developing countries

Date of Departure

·        ? Necessity for immunization if imminent departure and short trip

·        Time needed for immunizations to be effective

Length of Trip

·        Amount of malarial prophylaxis

·        ? Necessity for self treatment packs i.e. Steri-Aide

·        Amount of antibiotics for T.D.

List of Medications

·        ? Electrolyte imbalances due to combination of meds and adverse environmental or diseased states

Chronic Illnesses

·        Cardiovascular disease – must be stable – special considerations must include any activities at altitude taking into account effects of medication

·        Pulmonary diseases

Altitude factors

Flu prophylaxis

Acquisition of pathogens due to recirculated air on long flights

• Diabetes

Insulin readjustments on flights crossing 3 time zones

Adequate meds\test strips\Insulin

Documentation re need for injection equipment

Foot precautions

• G.I. disease

I.B.D. ↑ susceptibility T.D. and ↑ morbidity

Chronic hepatitis--↑ deterioration if acquisition of other types of hepatitis in hyperendemic areas

• Skin diseases
• HIV\immunocompromised states

Danger of live vaccines

Poor immune response to inactivated vaccines

(need to know CD 4 count)

• Psychiatric disorders

Unsuitability for Lariam

General unsuitability for long term travel or employment

• Epilepsy

Unsuitability for Lariam

All travelers need suitable supplies of medications and preferably knowledge of  specialized medical facilities at destination.

Allergies

• Eggs—special precautions with MMR, Yellow fever or flu shots
• Foods in general-- difficult to avoid allergens if food preparation or contents alien
• Vaccines or chemoprophylaxis

Country of Origin of Client

      If birth place and upbringing in developing country usually no necessity for Hep A vaccine.

Pregnancy

·        Malaria very dangerous to foetus

·        ↑ Susceptibility DVT’s on long haul flights

·        Rarely affects immunization decisions

Previous Vaccinations

• Determines level of immunity and immunization needs

Ages of Clients

• Children

Age appropriate medication dosage

Age appropriate immunization

Age appropriate use of insect repellent

↑ Morbidity T.D.

↑ Morbidity\Mortality malaria

↑ Risk of injury—minor\major trauma\accidents

                             Animal encounters

                             Foot damage           

           ↑ Sun damage—use sunblock

           Ear pain during flight

           Travel sickness

Parent supervision\education paramount

Infant travel C/I’d to tropical and subtropical areas

• Elderly travelers

↑ Serious comorbid diseases and meds

↑ Susceptibility environmental stress i.e. cold\heat\wind\altitude

↑ Susceptibility\morbidity to infections\vector borne diseases\dehydration

↓ Special senses—vision\hearing

↓ Muscle tone—reaction time

Inadvisable to be subjected to excess stress  

For all travelers

Advise against crowded itineraries producing unnecessary stress, worsening jet lag. Also always  mention bednets, sunscreen and insect repellent as necessary.

Fitness to Fly

Absolute Contradictions

·        Unstable Angina

• Severe CHF
• Recent MI
• Acute Psychosis
• Acute Infectious Disease
• Unhealed Surgical wounds and Abdominal surgery within 10 days
• Diseases states involving gas trapping in abdominal cavities

Middle ear infections and Eustachian tube dysfunction

Recent middle/inner ear surgery

Recent Pneumothorax

Recent chest surgery

Recent laporoscopy

• Decompression sickness due to diving

Relative Contraindications

• Antenatal complications or history thereof
• Previous venous thromboembolic disease
• COPD—needs oxygen supplement at ground level  or po2’s less 70%
• CV\pulmonary disease – inability to walk 100 m on flat without dyspnea
• Flying phobia – needs psychological treatment 

Ref:  Manual of Travel and Health         Du Pont and Steffen

Prepared by David Lewis