Download Travel Medicine - University of Washington

Travel Medicine
Speakers: Dr. Matt Thompson, Dr. Rachel Bishop, Dr. Chris Sanford
First Speaker: Dr. Thompson
Please refer to Dr. Thompson’s power point slides
The most common illness affecting those traveling abroad is traveler’s diarrhea. The most
worrisome health issues include sexually transmitted diseases, trauma, myocardial infarction, injury.
Infectious disease related illnesses, including HIV and cholera, are less common.
Pre-travel risk assessment
1.
Food and water borne disease: Generally spread by fecal-oral route
Consider boiling water or using bottled water
Traveler’s diarrhea: responds to antibiotic treatment
Hepatitis A virus: most preventable disease for which vaccine is
available
Typhoid: oral vaccine available, 500 cases/year in the US
Cholera: incidence of 1 in 500,000 travelers/month
2. Yellow Fever:
Huge problem overseas
Associated with 25-50% fatality
Vaccine available that is required to enter many countries
3. Malaria:
Not common among US travelers
More common in immigrant populations who later go to home country
for a visit and can’t afford to go to travel clinic
Prevention: bed nets, chemoprophylaxis (growing resistance to
chloroquine, mefloquine and doxycycline)
4. Rabies:
Quite uncommon
Expensive vaccine
Vaccine recommended for long trips, zoological work
5. Trauma:
Avoid driving while intoxicated
6. Contact with humans:
Some health concerns include measles, parasites
7. Health care workers:
Hepatitis A and B vaccine recommended
No good vaccine available against tuberculosis
Other health concerns: needle sticks, meningitis
8. Sexually transmitted diseases:
There is a low rate of safe sex practices among travelers
9. Physical hazards:
Heat, sunlight, high altitude
Second Speaker: Dr. Bishop
Dr. Bishop has worked in Nepal, Chile and Dharamsala, India. While in Nepal, she ran a district
clinic serving mostly sherpas. Two percent of the clinic population were travelers. Four healthcare
workers worked in the hospital, 15 health care workers were distributed within the community. While in
India, she worked at a tuberculosis clinic. In Chile, she served as the chief medic during the outbreak of the
Hanta virus.
Dr. Bishop took a three month tropical medicine course in London which she found useful for
going overseas.
Some medical cases affecting tourists that she was involved with include high altitude pulmonary
edema, trauma (ankle fracture, frostbite from inappropriate footwear), and transport of trekkers.
In treating locals, she was involved with the care of a child who incurred a suprachondylar
fracture. Treatment involved utilizing ketamine anesthetic while reducing the fracture. Local health
officials were trained in this procedure.
While working in expedition medicine, Dr. Bishop was involved with putting the first Nepali
woman on the summit. She also worked as a base camp doctor and mountain guide.
While working abroad, Dr. Bishop encountered many situations in which non-area physicians and
medical students would set up makeshift clinics along trails. She believes this type of healthcare
undermines the local healthcare system and creates an environment of mistrust for local healthcare workers.
If working abroad, Dr. Bishop recommends teaching local health care workers, learning local customs, and
working with existing establishments. AVOID MEDICAL TOURISM.
Third Speaker: Dr. Sanford
Dr. Sanford finished his residency in 1988. He worked in urgent care clinics for a couple of years.
In 1990, he moved to Arlington, Washington and found that working as a small town physician wasn’t for
him. He then began work as a travel medicine physician at a clinic in Everett, Washington. A couple of
years later, he attended a travel medicine course in Peru. While there, he saw diseases that he had never
encountered before. Upon returning, he started working at Hall Health at the University of Washington.
His work now consists of providing primary care, occupational therapy, writing manuals for health
care providers of pre-traveling patients, and providing care to ill travelers who have returned from their
trips. He is also involved with research studying big city hazards to tourists including motor vehicle
accidents and encounters with sex workers. He trains Chinese physicians and exchanges information with
them about healthcare. He is also involved in volunteer work in the Amazon jungle region.
Different ways to be Involved with Travel Medicine:
1. Private Family Practitioner or Internist: Only a minority of patients who are seen will be travelers,
however, no certification is required.
2. Work in county tuberculosis clinic
3. Multispecialty clinic
4. Academia
5. Research
Shotgun charity work is a problem. If providing healthcare in a place for a week or less, the odds are
50-50 of doing harm.
Questions
1.
What are the disconnections between the perceptions and realities of the risks to travelers?
People come in wanting to talk about esoteric diseases, not STDS, motor vehicle accidents, seat belts,
helmets, or standard vaccines.
Dr. Sanford: It is important to address all of the aforementioned issues.
Dr. Thompson: Patients have different risks they are willing to put up with. Get a sense of that.
Dr. Bishop: Get evacuation insurance.
2.
What is the role of the psychiatrist in travel medicine, international health?
Dr. Bishop: Psychiatric stories are the worst that I have to tell. Lots of young people with drugs, religious
conversion, traveling without psychiatric medications. Patients with schizophrenia have a difficult time
with change (e.g., driving on the other side of the road). Patients lose insight, don’t want care. There are
important legal and moral issues to consider as a health care provider. Often embassies are not interested in
helping with these situations. It is useful to know how to manage psychiatric medications. Offering antidepressants often helps.
Dr. Thompson: For returning travelers, depression is a common long term consequence.
Dr. Sanford: I discourage patients from going abroad at a time of crisis. There are increased stressors
while living abroad. I counsel such patients to stay home. In the case of delusional parasitosis, patients do
get better with anti-psychotic medications but are resistant to taking them.
3.
Do local religious beliefs conflict with your help?
Dr. Bishop: Sick and dying patients would invite the local lama to say prayers, light candles. In the
Buddhist environment there is no blame, no suing. Physicians are thanked for providing care and helping
the patient to the next life.
Dr. Thompson: Religious leaders provide care and education and have incredible dedication to the people.
They do an amazing job. Some missionaries who push a certain philosophy are in the minority. Almost all
patients went to a spiritual healer before coming to western medicine. Only a few had bad outcomes.
4.
Which local careers enable part time involvement with travel medicine?
Dr. Sanford: Urgent care, family practice. The best time to ask for time off is at the beginning of a new
job during the “honeymoon period”. Any specialty can work.
Dr. Thompson: It is difficult to balance a clinic in the US with work abroad. Options include a rotating
sabbatical: work five years, take six months off (this approach works at Group Health), locums: work three
to six months then go abroad, travel between appointments (eg, between residency and work, between
moves). This can be difficult with a cost-conscious healthcare environment. Be creative.
Dr. Bishop: It is possible to work in a travel medicine clinic full time. I did this in Katmandu. There are
“SOS clinics” internationally. In this type of clinic the chief physician is from the US or UK, other
physicians are local. It is also possible to work as a travel medicine physician and evacuate expatriates
through air missions.
5.
How do you make travel medicine your sole medical practice? How do you do it part time?
Dr. Thompson: I see travel patients as part of my Belltown clinic practice. There can be an issue of billing
patients enough for your time.
Dr. Sanford: A minority of providers can do travel medicine while practicing in the US.
clinic time in family medicine. It can be repetitive doing only travel medicine.
I spend 50% of
Dr. Bishop: There is a website that lists all travel medicine physicians.
6.
What sources of information are available on the internet?
Dr. Thompson: The CDC website has a huge amount of detail. The WHO has a great website. Those are
the two I use in clinic.
Dr. Sanford: Our clinic subscribes to “Shoreland”. The site has maps showing outbreaks in various
regions. ASTMH.org is good for vaccination research and lists travel medicine courses. ISTM.org is more
clinically oriented.
7.
Dr. Bishop, what is the name of the organization you worked with in Nepal?
Dr. Bishop: It was linked with my residency program. I also worked for Himalayan Trust. Opportunities
for working in Nepal as a medical student include United Mission to Nepal. Also, teaching hospitals will
take medical students doing an elective. I established lots of connections through the Liverpool Tropical
Medicine course.
8.
How do you integrate travel medicine with a family?
Dr. Bishop: I met my spouse while working in India. Childcare is inexpensive and wonderful. The risks
include civil war, bullets in the garden, dogs, pervasive diarrhea. I have lived in supportive expatriate
communities. Physician-teacher couples do it well.
Dr. Thompson: My spouse is not in medicine, she has a PhD in English literature. Her career may have
suffered a bit moving every three years. We work as a team.
Dr. Sanford: Realize that your spouse may not want to save the world. It does need to be a team effort. It
is hard to be a single parent while the other parent is abroad.
9.
What insurance do you recommend for travelers?
Dr. Bishop: Evacuation insurance. You need bonafide travel insurance. Carry a credit card to be able to
pay up front.
Dr. Sanford: Evacuation insurance is $125 for 2-3 week trips.
10. What are the specific precautions for those traveling to do healthcare?
Dr. Thompson: Get vaccinated against MMR, Diphtheria, Hepatitis B virus. Medical students are often
given anti-retrovirals. BCG can protect against pulmonary tuberculosis. Bring gloves.
Dr. Bishop: Don’t get the BCG. If given to patients greater than 12 years old, there is no evidence it does
any good. Get a PPD before and after you go.
Dr. Sanford: Take something that provides solace and comfort (e.g. journal, walkman). In HIV endemic
areas take 3-5 days of post-exposure prophylaxis. Fly back if the exposure was significant.