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TRAVEL MEDECINE or prevention and vaccination for travellers - September 2007
Interview with Professor Robert Steffen, Director of the Infectious Diseases Division of the Institut de Médecine Sociale et Préventive of the University of Zurich, Collaborating Centre of the World Health Organization and author of Tropimed®, the database for travel medicine professionals.
Tourism and business travel are continuously expanding. Prevention and treatment of diseases that may be contracted during travel are more and more important today. Each year, many thousands of Swiss seeking sunshine return from their travels with beautiful photos but also certain health issues seem to arise at this time. Proper preparation for travel thus means not overlooking possible sanitary risks. Vaccinations naturally should be considered by the consulting physician.
In fact, travellers planning to visit developing countries should plan to be vaccinated relatively early. For people travelling outside of usual tourist itineraries or staying in developing countries, we often recommend vaccination against hepatitis B or rabies. Rabies vaccination requires two injections and hepatitis B vaccination requires three injections, and both of these vaccinations must be obtained over a minimum of 21 days. Oral vaccination against typhoid fever also requires time, each of three capsules must be taken in an interval of two days (i.e. days 1, 3, and 5). This becomes fully effective only ten days after the last capsule. It should also be noted that vaccines may cause side-effects. There may be some pain, and perhaps even a slight fever of short duration. It is best to be vaccinated four to six weeks before departure.
First, the old colonial adage about food that one should "peel it, cut it, cook it or forget it" still applies. This clearly reduces the risk of diarrhea. Studies show, however, that 98% of Swiss travellers succumb to delicious salad buffets or accept ice cubes in their drinks, some even eat raw oysters or tartar steaks in the tropics. As a matter of fact, it's often difficult for travellers to resist these temptations and eat only meals served at 60° centigrade minimum and eat only fruit that can be
peeled. On the other hand, with the high frequency of diarrhea, it is certainly recommended to travel with necessary medications. We'll return to this in a moment.
When travelling in developing countries, diarrhea is clearly the most frequently occurring illness. On the other hand, when travelling in North America and Western Europe, it is clearly constipation. Chills, for example with the flu, are also frequent. In tropical Africa, there is often malaria transmission, and in 90% of cases, this is Malaria tropica, which can be fatal. Among the infectious diseases that may be avoided by vaccination, influenza, hepatitis A and hepatitis B are indisputably the top three.
I would like to emphasize once more that the primary causes of Swiss deaths in the third world are not infectious diseases, but traffic and bathing accidents. The infectious diseases may be prevented by vaccinations or preventive medicines. Among those that threaten travellers in developing countries, rabies is clearly the most dangerous. Once the symptoms appear, the chance of survival is zero. It may be prevented by three doses of vaccine before travelling or by an immediate treatment administered in a large medical centre as soon as possible after being bitten by a dog or having contact with a suspected animal.
Every traveller with a fever who has just returned from a malaria-infested region is imperatively recommended to see a physician within 24 hours. The physician will perform a blood test to confirm or reject the diagnosis of malaria. One must also see a physician for persistent diarrhea and other health problems. On the other hand, it's not necessary to have a medical examination after each visit to the tropics, even for long stays.
In fact, travel medicine is interdisciplinary and is not limited to tropical medicine or infectious diseases. Many travellers go trekking to high peaks or go scuba diving, for example. Naturally, the body is subjected to special stresses. For people who are more risk prone than others, for example, pregnant women, malaria can be particularly dangerous and young children with diarrhea can dehydrate in just a few hours and the condition can become very serious. There are also people who have pre-existing diseases, for among senior citizens or people with congenital blood coagulation and for whom long distance flights may trigger thrombosis.
The objective of international sanitary regulations is to prevent the spread of diseases to countries in which they are not prevalent or at least to limit the risk of spreading the diseases. The individual traveller's health is of little interest to the authorities in the countries that are visited, even if this formula seems convincing. The recommendations provided by the Recommandations du Comité d'experts en médecine des voyages (Expert committe for travel medicine) in collaboration with the federal public health office focus on the goal of providing all travellers with all recommendations for protection of health during travel in regions with special risks. The differences between the various national recommendations result from the fact that the same medications, for example anti-malaria medications, are not available in all countries.
In travel medicine, individual advice is required because travellers have different objectives and different medical problems may arise during a trip. Moreover, each traveller is different, a family with young children or a diabetic patient needs different recommendations compared to a business man planning to spend 48 hours at meetings in a luxury hotel in the capital city.
9. Vaccination against measles is now recommended for all travellers. Is this connected with the WHO goal of eradicating the disease?
During the last two years, small outbreaks of measles have appeared in Switzerland and numerous children and adults have been hospitalized. For some people, this disease even led to encephalitis which is an inflammation of the brain and this unfortunately left some of these patients with permanent consequences. It has been shown that the measles viruses specifically analyzed in Switzerland primarily match foreign sub-types, which means that they were imported from Asia and respectively Africa. This is why there is now increased vigilance to make sure that people under 40 years of age, at one time or another in their lives, are vaccinated two times with the MMR vaccine (measles, mumps, rubella). Protection of the Swiss population is a priority, but the WHO goal to eradicate measles is secondary since measles now appears most often among adults and much more often leads to complications in this age group.
10. Can you give some advice to physicians who do not specialise in travel medicine but who wish to acquire more extensive knowledge in this subject?
Swiss physicians have very diverse interests and not all are interested in travel medicine. In consultations in which issues related to travel medicine arise, less-informed physicians can refer their clients to a travel medicine centre or to a physician specializing in tropical medicine.