HEALTH EDUCATION PROGRAM

   St Mary of Zion Ethiopian Orthodox Tewahdo Church

   Travelers Health
   by Dr Getachew Feleke
   July 2019

---

 Introduction
​
Millions of people travel globally every day. Travel from resource rich to resource limited countries can be associated with travel related illnesses. Most at risk are those who travel to their country of birth as they are more likely to socialize, stay with family and share food and drinks. These diaspora don’t necessarily feel they are at risk and are less likely to take precautions.
Risk of travel associated illnesses is related to where one is going, the length of stay, the time (month) of travel, activities during travel and the underlying health status of the traveler.
Travel associated illnesses can be prevented or reduced if appropriate precautions are taken. The goal of this presentation is to increase awareness of common travel related illnesses. Travel to Ethiopia is the focus of the presentation, but the information may be relevant to other destinations too.
Tips to all travelers
In long distance flights, getting up, walking or stretching every couple of hours to avoid blood clots is advised. Prolonged sitting may result in blood clot (deep venous thrombosis: DVT) which is a serious health hazard.
Travelers taking medication must carry enough supply of the medicines for the duration of the trip.
Mapping out available health service at the destination is advised. .Travelers may also consider buying travel insurance. 
Getting pre-travel advice and immunization from an experienced clinician is advisable
Common travel associated illnesses
-Diarrhea
-Fever/chills: many infectious causes 
-Respiratory infections
​-Other (bites, traffic accident, sexually transmitted infections, skin rash)
Causes of travel associated illnesses
-Contaminated Food and water: Poor sanitary conditions lead to contamination of the food and water with human excreta (feces). Human excreta contain germs .Eating and drinking germ contaminated food and drinks cause illnesses such as traveler's diarrhea, hepatitis, typhoid, amoeba and cholera
-  Ingesting raw foods such as eggs, milk and salad may lead to traveler’s diarrhea.
-Not washing hands and using contaminated utensils are risk factors for upset stomach/diarrhea
Poor sanitary conditions and poor hygiene can result from lack of knowledge, lack of clean water, crowding, lack of bathrooms/latrines (open defecation), or other environmental and cultural factors
         Vector (Mosquito) bites: Infectious diseases such as malaria, yellow fever and dengue fever are transmitted by mosquitoes. 
Malaria, a most serious infection that affects millions of people is transmitted by the bite of an infected female anopheles mosquito. Yellow fever and Dengue is transmitted by a different mosquito. 
          Contact with contaminated hands, utensils, environment: Infectious diseases can be transmitted from person to person through contact. Unclean hands, utensils, environment, etc play an important role in this regard. Diarrhea, vomiting, influenza are examples.
          Airborne (Breathing contaminated air): Infectious agents(germs) maybe floating in the air we breathe. For the most part, these bugs come from infected persons nearby who cough and sneeze without covering mouth and nose; Measles and tuberculosis are spread this way.

The germ causing meningitis is spread similarly but requires close person to person contact
            Blood/body fluids exposure: Serious infections such as HIV, Hepatitis B. and hepatitis C are acquired from blood or body fluids of an infected person. This occurs via contaminated needles, sharps (blades, surgical instrument), unprotected sexual contact and rarely transfusion. It is important to note that these infections are not transmitted through hugs, handshakes, eating together, etc.
             Bites; scratches; cuts, puncture wounds Rabies is a deadly disease that results from the bite or scratch of a rabid animal, mainly dogs. Bats and raccoons are important carriers in the US
 Accidents that result in open wound can predispose to tetanus, a serious preventable infection 
Traffic accidents can present serious health risks to travelers 
Prevention of travel associated illnesses. 
Many travel associated diseases are preventable! Preventive measures include:
1) Vaccination: vaccines are available against: Hepatitis A. Hepatitis B, Yellow fever, Influenza,
Rabies, Typhoid fever, meningococcal meningitis and cholera. Pre-travel consultation regarding vaccination is advised. It is important to be up to date with routine childhood and adult vaccines.  (Measles, mumps, rubella, polio, tetanus, diphtheria, pertussis, hepatitis B, influenza.)
2) Mosquito avoidance: These important measures include
-Staying indoors at dusk and dawn. Malaria transmitting Mosquitoes bite early evening (dusk) and early morning (dawn).
-Cover as much of the exposed skin as possible, 
-apply insect repellents to exposed skin
-use bed nets preferably impregnated with insecticide
3) Chemoprophylaxis (Using drugs to prevent infections) .
-This mostly applies to malaria. There are effective drugs that can protect from malaria.
-Taking the pills start before the travel date and continued during and for few days after travel.
 General behavioral precautions
-Wash hands after using the toilet and before eating or use hand sanitizer.
-Eat well cooked food while hot. Avoid cold foods. Food can be contaminated after it is cooked.  
-Drink boiled water, bottled water or chemically treated water 
-Fruits that you can peel are safe. Rinsing/ washing fruits, salads with water may not be safe as the water may be contaminated
-Avoid ice from tap water
-Avoid crowded places
-Avoid contact with animals
-Avoid unprotected sexual contact, unsafe body piercing, tattoos 
-If dog bite occurs, wash wound with clean water immediately
What can be done if one gets sick while travelling?
         Travelers’ diarrhea.  This is the most common condition a traveler encounters. Travelers’ diarrhea may be mild, moderate or severe. Fluid replacement is important.
Mild diarrhea: Usually self-limited. It can be self-managed with fluids and anti-diarrheal drugs such as Bismuth sub salicylate or loperamide (lomotil). 
Moderate to severe diarrhea is best managed by health care provider. Self-treatment with antidiarrheal drugs is acceptable. If there is no improvement in 2 to 3 days, a clinic visit is warranted,
Some travelers carry antibiotics ( ciprofloxacin ; azithromycin). In situations where no medical care is available, taking antibiotics as a temporary measure may be acceptable.
            Fever:   this may be caused by infectious diseases, that Include malaria typhoid and meningitis. Fever lasting over 24-48 hours must be taken seriously, and must be evaluated by a healthcare provider.   
Being vaccinated or being on preventive drugs may not be fully protective. Serious infection such as malaria, typhoid, and meningitis can be deadly unless treatment is started early.
Fever in the returning traveler:
Fever may be caused by many infectious diseases, Including malaria typhoid and meningitis. Fever lasting over 24-48 hours must be taken seriously, and must be evaluated by a healthcare provider.   
It is important to remember that being vaccinated or being on preventive drugs may not be fully protective. 
Fever in the returning traveler could be a sign of a serious infection. Malaria and typhoid are two infections that can present in a returning traveler. If these infections are not treated early they can be deadly. The returning traveler who has fever must seek medical treatment immediately. 
It is important to inform the doctor all the travel details (itinerary) including vaccinations and medications taken. It is preferable to consult with a doctor experienced in travel medicine. 

​Summary
Travel associated illnesses are common. Diaspora visiting friends and relatives are most affected. Traveler's diarrhea, hepatitis, typhoid and malaria make up the majority of travel related illnesses.
These infections can be prevented with pre-travel immunization (hepatitis A; hepatitis B; Typhoid) or taking preventive drugs (malaria).
Behavioral precautions are important in avoiding travel associated illnesses. 
       -Eating well cooked food while hot, avoiding raw foods and drinking boiled or bottled water.
        -avoiding mosquito bites (staying indoors, covering skin, using insect repellent and bed nets.
Mild to moderate traveler's diarrhea can be self-managed by taking fluids and anti-diarrhea drugs
Fever can be a sign of serious infection .Consulting a health care provider is advisable.
Fever in the returning traveler must be taken seriously and warrants seeking medical help.

 Selected vaccines for travelers

Hepatitis A –Transmission is via the fecal-oral route (by contaminated food or water)
                     --The vaccine is protective; two doses are required given 6 month apart
                     -- Vaccination is recommended for individuals who are not already immune 
                      -- The vaccine may be taken any time before travel.   
Hepatitis B: Transmission is via blood and body fluid exposure.
                     -The vaccine is protective; three doses are required at 0, 1 and 6 months
                     -Vaccination is recommended for individuals who are not immune
                    -Hepatitis B vaccine is currently included in as one of the routinely given childhood vaccines
Meningitis:  -Transmission is from person to person (close contact)
                      -The vaccine is single dose.  
                      -Vaccination is recommended for travel during the dry season (December to June)
                     -The vaccine is best given 10 days or earlier before travel. 
                     -Booster doses are required in 3-5 years.
Typhoid Fever: Transmission is via contaminated food and or water
                           -The vaccine is moderately protective
                          -Vaccination recommended especially for those travelling rural areas,
                         -These vaccine comes in an oral and injection form. The oral vaccine comes in 4 doses 
                          The injection form is a single dose. Protection may last for 3 to 5 years.
Rabies:          -Transmission is by bite or scratch of a rabid animal primarily dogs 
                     -The vaccine is protective.it is not routinely available.
                     - The vaccine is recommended for travelers at risk of coming in contact with animals              
                    -If a bite/scratch occurs immediate medical attention is warranted

    Yellow fever:-Transmission is via a mosquito bite 
                            -The vaccine is protective. It is a one-time injection with lifelong protection.
                             -Vaccination is recommended if travelling to endemic countries.
                             -Yellow fever vaccination is a requirement to enter some countries
  Tetanus: The tetanus causing spore (germ) is commonly found in the soil.
      -wound (cut, lacerations) contaminated with soil may cause tetanus.
     -The vaccine is protective .It comes as a combined vaccine against tetanus, diphtheria,  pertussis (Whooping cough); it is one of the routinely given childhood vaccines
     -Repeat vaccination (booster) every 10 years is recommended.