Emporiatrics or Travel Medicine
Author: Dr. Anju Shah, MD
Emporiatrics or Travel Medicine, deals with the prevention and management of health problems of international travelers. Globalization has lead to exposure of travelers to diseases endemic to certain regions and has also led to spread of many diseases. The most recent being the spread of SARS-CoV-2 (Coronavirus) pandemic. The knowledge of global epidemiology of health risks to travelers, vaccinology, malaria prevention and pre travel counseling are all part of Emporiatrics.
A pre travel consultation should be set up four to six weeks before departure. This should involve contingency planning during travel and post travel follow up and care. A medical tourism platform with online consultation like https://portal.credencemedicure.com/, can be a great help towards this end.
The following prophylactic measures are recommended before commencing international travel:
This is one of the most common vaccine preventable disease. It is transmitted by fecal-oral route. If the patient is leaving within two weeks, then both the vaccine and immune serum globulin are recommended. A booster dose given six months after the initial vaccination confers immunity for approximately ten years. All travelers going to less developed countries should get Hepatitis A vaccine.
Vaccination for Hepatitis B is suggested for people who work closely with indigenous population, for those who may be involved in sexual intercourse or plan to receive medical or dental care. It is also recommended for people who plan to stay abroad for more than six months. The WHO recommends 0, 1 and 6 month vaccine schedule, though schedules may vary based on a countries national immunization program
When traveling to developing countries, typhoid vaccination is recommended especially when prolonged exposure to contaminated food and water is expected. The vaccine is of two types- an oral live attenuated form and a capsular polysaccharide vaccine given parenterally. The live attenuated vaccine needs to be refrigerated and is contraindicated in immunocompromised individuals. Fever and headache are rare side effects of the vaccine. The polysaccharide form is the preferred vaccine since it doesn’t need to be refrigerated and is safe for immunocompromised patients.
Adults traveling to developing countries, who have never received a polio vaccine should receive three doses of the inactivated polio vaccine. Those who have been previously immunized, only need a onetime booster dose. The live attenuated polio vaccine has fallen into disfavor because of the risk of vaccine associated disease.
Travelers traveling to areas where meningococcal meningitis is endemic or epidemic, such as the sub Saharan Africa, should be immunized with the polysaccharide vaccine. Hikers and other tourists traveling to Nepal and Northern India also need to be immunized. Saudi Arabia requires immunization for pilgrims to Mecca. Travelers who have functional or actual asplenia and those who have terminal Complement deficiencies should also be vaccinated. In USA, CDC recommends routine vaccination for adolescents aged 11-12 years with a booster at the age of sixteen.
Vaccination against Rabies is recommended for people traveling to areas where rabies is common among domesticated animals, example, most of Africa, Central and South America and Asia. Since Chloroquine can blunt the response to the intradermal form of rabies vaccine, the intramuscular form of the vaccine should be administered. But rabies vaccine is not routinely advised for most travelers.
Even if pre exposure vaccination is given, immediate medical treatment is required if there is a bite or scratch by an animal suspected to have rabies (cats, dogs, bats or other carnivores). Cleaning of the wound and post exposure prophylaxis is required. This is given as two doses of rabies vaccine if previously vaccinated (without rabies immune globulin) and as four doses of rabies vaccine along with rabies immune globulin if not previously vaccinated.
Malaria prophylaxis is required for travelers traveling to malaria endemic areas. These are Central and South America, most of Africa and Asia. The highest transmission rates are found in sub Saharan Africa and parts of Oceana such as Papua New Guinea.
Malaria prevention includes avoiding mosquito bites, through the use of repellents or insecticide treated bed nets and specific medicines to prevent malaria. Mefloquine is the agent of choice for malaria prophylaxis. It can have neuropsychiatric side effects like hallucinations, depression, suicidal ideations, and unusual behavior. It is given once a week. Doxycycline is an acceptable alternative to Mefloquine. For pregnant patients, Chloroquine is the preferred drug for chemoprophylaxis.
Patients should avoid eating raw fruits and vegetables, street vendor salads, tap/ iced water. Those who develop mild loose stools without fever or blood can safely take loperamide and drink plenty of fluids. Antibiotics like fluoroquinolone or azithromycin are reserved for patients with moderate to severe symptoms.
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