an overview lecture about travel medicine Challenge and opportunity for medical professionals

1. Travel medicineTravel medicine
An overviewAn overview
Rachmat Gunadi WachjudiRachmat Gunadi Wachjudi
Department of Internal MedicineDepartment of Internal Medicine
Faculty of Medicine Universitas PadjadjaranFaculty of Medicine Universitas Padjadjaran

2. TravellingTravelling

3. The path ….The path ….
 Lahir : Garut 16 Januari 1955Lahir : Garut 16 Januari 1955
 Fakultas Kedokteran UNSRI Palembang 72 – 83Fakultas Kedokteran UNSRI Palembang 72 – 83
 PUSKESMAS/Dinas Kesehatan Pandeglang 83-89PUSKESMAS/Dinas Kesehatan Pandeglang 83-89
 Fakultas Kedokteran UNPAD Bandung 90 – 96Fakultas Kedokteran UNPAD Bandung 90 – 96
 RS Al Ikhsan Bandung 96-97RS Al Ikhsan Bandung 96-97
 Staf Dep I.P. Dalam 1997-….Staf Dep I.P. Dalam 1997-….
 Fakultas Kedokteran UI Jakarta 97Fakultas Kedokteran UI Jakarta 97
 Royal Perth/SCG Hospital 98-99Royal Perth/SCG Hospital 98-99
 Staf Div Reumatologi 99- ….Staf Div Reumatologi 99- ….
 Kepala Div Reumatologi 2004 -…Kepala Div Reumatologi 2004 -…
 Kepala Dep I P Dalam 2014- ….Kepala Dep I P Dalam 2014- ….
 Hobi : baca, musik, travelling, MCHobi : baca, musik, travelling, MC

4. What is travel medicine?What is travel medicine?
It is a science and an artIt is a science and an art

5. What is travel medicine?What is travel medicine?
 It is that part of health professionalIt is that part of health professional
practice that:practice that:
 seeks toseeks to prevent illnesses and injuriesprevent illnesses and injuries
occurring to travellers going abroadoccurring to travellers going abroad
 manages problems arising in travellersmanages problems arising in travellers
coming back or coming from abroadcoming back or coming from abroad
 is concerned about the impact of tourism onis concerned about the impact of tourism on
health and also advocates for improvedhealth and also advocates for improved
health and safety services for touristshealth and safety services for tourists
 is increasing concerned about refugee andis increasing concerned about refugee and
migrant healthmigrant health
(Primer of Travel Medicine 3(Primer of Travel Medicine 3rdrd
Ed)Ed)

6.  ““the art of travel medicine isthe art of travel medicine is
selecting the necessaryselecting the necessary
prevention strategy withoutprevention strategy without
unnecessary adverse events,unnecessary adverse events,
cost or inconvenience”cost or inconvenience”
(Steffen, 1994)(Steffen, 1994)

7. Challenge of travel medicineChallenge of travel medicine
 Sea of global migration of peopleSea of global migration of people
 More people travellingMore people travelling
 People travelling further a fieldPeople travelling further a field
 Rapid movement of travellersRapid movement of travellers

8. USA / Canada
35.2 million
Europe
25.0 million
Japan
11.4 mio
AUS / NZ
3.3 million
Travellers from industrialised areasTravellers from industrialised areas
to developing areas 1999 (WTO)to developing areas 1999 (WTO)
2.8
2.3 19 7.8
1.9
3.6
6.8
2.5
1.3
1.6
2.4
4.6
6.1
4.8
2.6
Total:
n million travelers
0.2-1 million travelers
~ 80 million travelers
1.2

9. Travellers are
exposed to a variety
of hazards

10. The Importance of TravelThe Importance of Travel
Health MeasuresHealth Measures
 100,000 travelers to the100,000 travelers to the
developing world for 1 month…..developing world for 1 month…..
 50,000 will become ill50,000 will become ill
 8,000 will see a physician8,000 will see a physician
 5,000 will stay in bed5,000 will stay in bed
 1 will die1 will die
Steffen, 1994

11. The Importance of TravelThe Importance of Travel
Health MeasuresHealth Measures
 Per 100,000 travellers that havePer 100,000 travellers that have
travel insurance …..travel insurance …..
 8000 will make a claim (8%)8000 will make a claim (8%)
 2000 will use emergency2000 will use emergency
assistance (2%)assistance (2%)
 400 ER or clinic referrals (0.4%)400 ER or clinic referrals (0.4%)
 200 Hospital admissions (0.2%)200 Hospital admissions (0.2%)
 50 Aeromedical evacuations (0.05%)50 Aeromedical evacuations (0.05%)
Leggat et al. Travel Med Inf Dis 2005;3:9

12. The Importance of TravelThe Importance of Travel
Health MeasuresHealth Measures
 MortalityMortality
 Cardiovascular Disease (50 toCardiovascular Disease (50 to
70%)70%)
 Accidents/Trauma (20-25%), esp.Accidents/Trauma (20-25%), esp.
MVAsMVAs
 Infectious diseases (2.8-4%)Infectious diseases (2.8-4%)
(Reid and Cossar, BMBull. 1993;257-268;(Reid and Cossar, BMBull. 1993;257-268;
Prociv, MJA. 1995;163:27-30;Prociv, MJA. 1995;163:27-30; Baker et al.,Baker et al.,
PHR 1992;107:155-159; MacPherson et al,PHR 1992;107:155-159; MacPherson et al,
JTM. 2000; 2000:227-233; Steffen, TransJTM. 2000; 2000:227-233; Steffen, Trans

13. Travel medicine is aTravel medicine is a
continuumcontinuum
 Travellers do get sick or injuredTravellers do get sick or injured
abroad or when they come backabroad or when they come back
 The commitment to travel health canThe commitment to travel health can
therefore be regarded as atherefore be regarded as a
continuumcontinuum

14. The Continuum of TravelThe Continuum of Travel
MedicineMedicine
During TravelDuring Travel
Preventive Medicine
Contingency Planning
Treatment &
Rehabilitation
VisitorsVisitorsPre-TravelPre-Travel
Post-TravelPost-Travel

15. What do we need to do inWhat do we need to do in
order to be giving theorder to be giving the
correct advice to travellers?correct advice to travellers?

16. Travel Health AdviceTravel Health Advice
needs Informationneeds Information
““Information is power inInformation is power in
Travel Medicine”Travel Medicine”

17. Travel Health Advice needsTravel Health Advice needs
TrainingTraining
Training gives you aTraining gives you a
framework for using thatframework for using that
informationinformation

18. Travel Health Advice needsTravel Health Advice needs
ExperienceExperience
Experience helps put theExperience helps put the
information and training ininformation and training in
perspectiveperspective

19. Travel Health Advice needsTravel Health Advice needs
to be Documentedto be Documented
Documentation is importantDocumentation is important
for Quality assurance andfor Quality assurance and
reinforcing travel healthreinforcing travel health
adviceadvice

20. Travel Health Advice needsTravel Health Advice needs
TravellersTravellers
Marketing is essential in travelMarketing is essential in travel
health, whether in generalhealth, whether in general
practice or in specialist travelpractice or in specialist travel
clinicsclinics

21. Giving the correct advice toGiving the correct advice to
travellerstravellers
 Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
 InformationInformation
 TrainingTraining
 ExperienceExperience
 DocumentationDocumentation
 TravellersTravellers

22. Travel Health Advice needsTravel Health Advice needs
InformationInformation
 GuidelinesGuidelines
 PoliciesPolicies
 Textbooks, including an World AtlasTextbooks, including an World Atlas
 JournalsJournals
 Professional organisationsProfessional organisations
 Staff/colleaguesStaff/colleagues
 Electronic DatabasesElectronic Databases
 WWWWWW

23. International GuidelinesInternational Guidelines
 WHOWHO
 InternationalInternational
HealthHealth
RegulationsRegulations
 InternationalInternational
Travel andTravel and
HealthHealth
 www.who.int/ithwww.who.int/ith
 Yellow feverYellow fever
requirementsrequirements

24. JournalsJournals
Weighing the
Evidence

25. Weighing the evidenceWeighing the evidence
 “Travel medicine prevention should
be based on epidemiological data.”
Robert
Steffen, 1991
 What are the likely risks of a person
travelling to particular destinations?
 What are the likely benefits of
intervention?

26. Giving the correct advice toGiving the correct advice to
travellerstravellers
 Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
 InformationInformation
 TrainingTraining
 ExperienceExperience
 DocumentationDocumentation
 TravellersTravellers

27. Risk assessmentRisk assessment
 Risk assessmentRisk assessment
preferably startspreferably starts
before the travellerbefore the traveller
enters the consultingenters the consulting
roomroom
 Document the riskDocument the risk
assessmentassessment

28. Establish the risksEstablish the risks
 DestinationDestination
 Mode of travelMode of travel
 Traveller’s medical historyTraveller’s medical history
 InterventionIntervention

29. 

30. Risks of the destinationRisks of the destination

32. Outbreak Notice
Polio Outbreak in
Tajikistan,
Cases in Russia,
Risk of Spread to
other Central Asian
Countries
Updated: October 22,
2010
CDC Update
Oct. 2010

33. Yellow fever: distribution

34. “meningitis
belt”—the Sahel

36. Travelers’ diarrheaTravelers’ diarrhea
 Very common. Up toVery common. Up to
50% over 2-4 weeks.50% over 2-4 weeks.
 A self-limited illness inA self-limited illness in
most internationalmost international
travelers.travelers.
 Duration can beDuration can be
shortened by antibiotics.shortened by antibiotics.

37. What do U.S. travelers die from inWhat do U.S. travelers die from in
the developing world?the developing world?
 About half: heart attacks, strokes (mostlyAbout half: heart attacks, strokes (mostly
in the elderly).in the elderly).
 About 25%: road traffic accidents.About 25%: road traffic accidents.
 The rest: drowning, falls from heights,The rest: drowning, falls from heights,
homicide, suicide.homicide, suicide.
 Infectious disease: onlyInfectious disease: only
about 1%.about 1%.

38. Urban medicineUrban medicine
 Road traffic accidentsRoad traffic accidents
 Air pollutionAir pollution
 Heat illnessHeat illness
 Recreational pharmacologyRecreational pharmacology
 PsychologicalPsychological
illnessillness

39. Air pollutionAir pollution
 Mexico City was theMexico City was the
worst city in the worldworst city in the world
in 1992. Now it’s notin 1992. Now it’s not
on the top ten list.on the top ten list.
 Nine of worst tenNine of worst ten
cities are in China.cities are in China.

40. Total suspendedTotal suspended
particulatesparticulates
(in mcg/cubic meter)(in mcg/cubic meter)
 StockholmStockholm
99
 Mexico CityMexico City
279279
 Lanzhou, ChinaLanzhou, China
732732
Mexico CityMexico City
Lanzhou,Lanzhou,
ChinaChina

41. photographyphotography
 If there’s a guy withinIf there’s a guy within
sight who is carryingsight who is carrying
a rifle or machinea rifle or machine
gun: ask permissiongun: ask permission
before you takebefore you take
photographs.photographs.

42. No glove, no love.No glove, no love.

43. Risks of the mode of travelRisks of the mode of travel
 Modes of travel can presentModes of travel can present
particular medical problems ofparticular medical problems of
varying severity, e.g. motionvarying severity, e.g. motion
sickness, painful ears, phobias,sickness, painful ears, phobias,
DVT;DVT;
 Can they fly?Can they fly?

44. Road traffic accidentsRoad traffic accidents
 The rate of fatalitiesThe rate of fatalities
per 100 million milesper 100 million miles
driven in the US isdriven in the US is
1.1; this is similar to1.1; this is similar to
Western EuropeanWestern European
rates.rates.
 The rates in Sri LankaThe rates in Sri Lanka
and Turkey are 23and Turkey are 23
and 44, respectively.and 44, respectively.

47. Seat belts are good.Seat belts are good.
Helmets are good. BetterHelmets are good. Better
still, stay off anythingstill, stay off anything
two-wheeled andtwo-wheeled and
motorized.motorized.
Do not ride on top of aDo not ride on top of a
bus or in the back of anbus or in the back of an
open truck.open truck.
Avoid the roads at night.Avoid the roads at night.
To reduce risk of injury and death from
motor vehicle accidents:

48. Risks of the mode of travelRisks of the mode of travel
 Some travellers may not meetSome travellers may not meet
medical guidelines to travel or maymedical guidelines to travel or may
need special clearance to fly onneed special clearance to fly on
commercial aircraft, such as withcommercial aircraft, such as with
 pre-existing illness,pre-existing illness,
 pregnancy,pregnancy,
 recent surgery orrecent surgery or
 serious physical or mental incapacityserious physical or mental incapacity

49. Risks of medical historyRisks of medical history
 Past travel history, particularly involving any significantPast travel history, particularly involving any significant
medical issues,medical issues,
 Past medical history, eg need for adjusting diabeticPast medical history, eg need for adjusting diabetic
treatment,treatment,
 Past surgical history, eg recent surgery,Past surgical history, eg recent surgery,
 Most recent dental examinationMost recent dental examination
 Current medications, including the oral contraceptiveCurrent medications, including the oral contraceptive
pill,pill,
 Last menstrual period for females (are they pregnant?),Last menstrual period for females (are they pregnant?),
 Smoking and alcohol history,Smoking and alcohol history,
 Allergies, including medications and foods,Allergies, including medications and foods,
 Any current illnesses and regular medication, andAny current illnesses and regular medication, and
 Are they travelling alone or with children or with olderAre they travelling alone or with children or with older
travellers?travellers?
 How fit are they to undertake any proposed exertionalHow fit are they to undertake any proposed exertional
activities?activities?

50. Risks of medical historyRisks of medical history
 Asthma - Asthma management plan;Asthma - Asthma management plan;
precipitants; environmental concerns;precipitants; environmental concerns;
consider influenza vaccination andconsider influenza vaccination and
antibiotics for medical kit.antibiotics for medical kit.
 Diabetes - Consideration of time zoneDiabetes - Consideration of time zone
changes; controlchanges; control
 Ulcer management - Reduced acidityUlcer management - Reduced acidity
may predispose to diarrhoeal diseasemay predispose to diarrhoeal disease

51. Risks of medical historyRisks of medical history
 Psoriasis - May get worse withPsoriasis - May get worse with
chloroquinechloroquine
 Arthritis - May have difficulties withArthritis - May have difficulties with
treks, climbing (also general fitness);treks, climbing (also general fitness);
may need standby NSAID treatmentmay need standby NSAID treatment
 Hypertension - Caution in prescribingHypertension - Caution in prescribing
mefloquine and Beta blockersmefloquine and Beta blockers
 Immunosuppression - Immune responseImmunosuppression - Immune response
to vaccination may be less; live vaccinesto vaccination may be less; live vaccines
may give rise to diseasemay give rise to disease

52. Risks of medical history-allergiesRisks of medical history-allergies
 SulphursSulphurs (Maloprim), Diamox & other(Maloprim), Diamox & other
sulphur based medicationssulphur based medications
 Egg allergies*Egg allergies* Yellow fever vaccine,Yellow fever vaccine,
influenza vaccine,influenza vaccine,
MMRIIMMRII
 Neomycin, polymixin Measles, Mumps,Neomycin, polymixin Measles, Mumps,
RubellaRubella
 IodineIodine iodine water purificationiodine water purification
tabstabs
 QuinineQuinine ChloroquineChloroquine
 Food allergies Various, including,Food allergies Various, including,
seafood, peanutsseafood, peanuts
 PetsPets CatsCats

53. Risks of interventionRisks of intervention
 Addressing risk in travel medicineAddressing risk in travel medicine
is generally all about trying tois generally all about trying to
modify risks established from themodify risks established from the
travel health consultationtravel health consultation
 All interventions have potentialAll interventions have potential
risks, including giving the wrongrisks, including giving the wrong
adviceadvice

54. Risks of interventionRisks of intervention
 Advice and educationAdvice and education
 VaccinationVaccination
 ChemoprophylaxisChemoprophylaxis
 Screening and EffectiveScreening and Effective
managementmanagement

55. Risks of the interventionRisks of the intervention
 Can the traveller tolerate theCan the traveller tolerate the
intervention?intervention?
 Does the risk of the exposure justifyDoes the risk of the exposure justify
the intervention/cost?the intervention/cost?
 Can the traveller afford theCan the traveller afford the
intervention?intervention?
 What do you do if you can’t provideWhat do you do if you can’t provide
optimal protection because of risksoptimal protection because of risks
from the medical history or otherfrom the medical history or other
considerations, such as age of theconsiderations, such as age of the

56. Risk assessmentRisk assessment
 PoliciesPolicies
 GuidelinesGuidelines
 Consensus statementsConsensus statements
 Epidemiological evidenceEpidemiological evidence
(weak to strong)(weak to strong)

57. Pre-Travel Health AdvicePre-Travel Health Advice
needs Trainingneeds Training
 Helps give structure andHelps give structure and
consistencyconsistency
 Provides a framework for practiceProvides a framework for practice
 Discusses evidence for practiceDiscusses evidence for practice
 Policy and Procedures ManualPolicy and Procedures Manual
 Consistent approach to travelConsistent approach to travel
healthhealth

58. Part of the commitment is to alsoPart of the commitment is to also
have a consistent and structuredhave a consistent and structured
approach to travel health adviceapproach to travel health advice
 WHO ChecklistWHO Checklist
(www.who.int/ith)(www.who.int/ith)
 Information on localInformation on local
conditionsconditions
 PreventionPrevention
 Accident avoidanceAccident avoidance
 Medical and dentalMedical and dental
check-upcheck-up
 NZPHR-PreventionNZPHR-Prevention
 VaccinationsVaccinations
 Health AdviceHealth Advice
 PrescriptionPrescription
Source:
http://www.who.int/ith

59. VACCINATEVACCINATE (IHC)(IHC)
 AlwaysAlways National scheduleNational schedule
 OftenOften hepatitis Ahepatitis A
 SometimesSometimes Japanese encephalitisJapanese encephalitis
meningococcal diseasemeningococcal disease
poliopolio
rabiesrabies
yellow feveryellow fever
InfluenzaInfluenza
PneumococcalPneumococcal
diseasedisease
Other vaccinesOther vaccines
(adapted* from NZPHR; 1996;3(8):57-59)(adapted* from NZPHR; 1996;3(8):57-59)

60. ADVISE AND DISCUSSADVISE AND DISCUSS
 InsectsInsects repellents, nets, permethrinrepellents, nets, permethrin
 IngestionsIngestions care with food and watercare with food and water
diet/teeth (includingdiet/teeth (including
airlines/jetlag/DVT)*airlines/jetlag/DVT)*
 IndiscretionsIndiscretions STI’s, HIVSTI’s, HIV
 InjuriesInjuries accident avoidance, personalaccident avoidance, personal
safetysafety
 ImmersionImmersion schistosomiasisschistosomiasis
 Insurance*Insurance* health and travel insurance*health and travel insurance*
finding medical assistance o/s*finding medical assistance o/s*
(adapted* from NZPHR; 1996;3(8):57-59)(adapted* from NZPHR; 1996;3(8):57-59)

61. PRESCRIBEPRESCRIBE
(Script/Dr’s letter/bracelet)(Script/Dr’s letter/bracelet)
 AlwaysAlways regular medicationregular medication
medical kit (firstmedical kit (first
aid)*aid)*
 SometimesSometimes antimalarial medicationantimalarial medication
diarrheal self-diarrheal self-
treatmenttreatment condomscondoms
(NZPHR; 1996;3(8):57-59)(NZPHR; 1996;3(8):57-59)

62. Giving the correct advice toGiving the correct advice to
travellerstravellers
 Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
 InformationInformation
 TrainingTraining
 ExperienceExperience
 DocumentationDocumentation
 TravellersTravellers

63. Travel health advice needs experienceTravel health advice needs experience
 Let’s just do it!
 Affiliation with a group with experience can be
useful
 Travel clinic group
 Travel medical advisory group (eg MASTA,
Worldwise, Travax etc)
 University
 Those NZ GPs that were interested in travel
medicine were significantly more likely to have
had tropical medicine/developing country
experience (Leggat et al. JTM 1999; 7:
55-58.)

64. Travel is part ofTravel is part of
experienceexperience

66. Travel is part ofTravel is part of
experienceexperience
 Professionals working in travelProfessionals working in travel
medicine need to travel and havemedicine need to travel and have
that personal experience tothat personal experience to
communicate to travellerscommunicate to travellers
 Helps to put travel health advice inHelps to put travel health advice in
context and helps to build a positivecontext and helps to build a positive
travel experiencetravel experience

67. Giving the correct advice toGiving the correct advice to
travellerstravellers
 Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
 InformationInformation
 TrainingTraining
 ExperienceExperience
 DocumentationDocumentation
 TravellersTravellers

68. Travel health advice needs toTravel health advice needs to
be documentedbe documented
 Standardised forms/questionnairesStandardised forms/questionnaires
 Informed consentInformed consent
 International HealthInternational Health
Certificate/Vaccination recordCertificate/Vaccination record
 Doctor’s letter/copy ofDoctor’s letter/copy of
prescription/medialert braceletprescription/medialert bracelet
 Written advice/videos/Books/HealthWritten advice/videos/Books/Health
advisory documentsadvisory documents

69. Correct advice is even better if theCorrect advice is even better if the
advice is actually followed by theadvice is actually followed by the
travellertraveller
 DocumentationDocumentation
 Follow-upFollow-up
 Use staff resourcesUse staff resources
 Reinforce health adviceReinforce health advice

70. Giving the correct advice toGiving the correct advice to
travellerstravellers
 Giving the correct health adviceGiving the correct health advice
to travellers needs:to travellers needs:
 InformationInformation
 TrainingTraining
 ExperienceExperience
 DocumentationDocumentation
 TravellersTravellers

71. Travel Health Advice needsTravel Health Advice needs
TravellersTravellers
 Inform own patients concerning the need forInform own patients concerning the need for
seeking travel health advice, and seeking thisseeking travel health advice, and seeking this
advice earlyadvice early
 Market travel health adviceMarket travel health advice
 Direct, if possibleDirect, if possible
 Join group/affiliateJoin group/affiliate
 Links/promotion with traveller groups, travel agents,Links/promotion with traveller groups, travel agents,
travel insurance, consulates etctravel insurance, consulates etc
 Join travellers health networks, such as ISTM, IAMATJoin travellers health networks, such as ISTM, IAMAT
etcetc

73. LBNL Health Services and Travel
Medicine
•Before you travel overseas
oVisit Health Services early for consultation
oVaccination series take up to 6 months
oSome destinations (e.g., CERN) require
medical clearance from Health Services
oRegister trip for travel coverage through
UCOP ACE American Insurance Company
•During travel
oFollow usual common sense precautions
oRefer to the following website for insurance details:
http://www.ucop.edu/risk-services/loss-prevention-control/travel-assistance/index.html
•When you return
oFinish prophylactic medications
oIf you become ill, advise your doctor about your recent travel

74. Take home pointsTake home points
 More people are traveling to more destinations,More people are traveling to more destinations,
becoming exposed to the health and safety of thatbecoming exposed to the health and safety of that
destination and also having the potential to impact ondestination and also having the potential to impact on
the health and safety of that destination, especiallythe health and safety of that destination, especially
through emerging infectious diseasethrough emerging infectious disease
 Travelers’ health is a continuum and includes the pre-Travelers’ health is a continuum and includes the pre-
travel health, contingency planning while abroad andtravel health, contingency planning while abroad and
caring the traveler after travelcaring the traveler after travel
 Travel health advice needs information (including aTravel health advice needs information (including a
capacity to undertake a risk assessment), training,capacity to undertake a risk assessment), training,
experience, documentation and travelersexperience, documentation and travelers

75. Practical pointsPractical points
 Where toWhere to
 For how longFor how long
 For what purposeFor what purpose
 Staying in what kind of placeStaying in what kind of place
 Guided or notGuided or not
 Previous developing world travel or notPrevious developing world travel or not

76. ConcernsConcerns
 Past medical historyPast medical history
 AllergiesAllergies
 History of antimalarial use if anyHistory of antimalarial use if any
 MedicationsMedications
 Medical problemsMedical problems
 History of depression, anxietyHistory of depression, anxiety
 ContraceptionContraception
 Review of past immunizationsReview of past immunizations

77. Bibliography
 Centers for Disease Control and Prevention. CDC Health Information for
International Travel 2010. Atlanta: U.S. Dept. of Health and Human Services,
Public Health Service, 2009.
 Centers for Disease Control and Prevention. Epidemiology and Prevention of
Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, McIntyre L,
ed. Washington DC: Public Health Foundation, 2009.
 Cook, Gordon C, Ed.: Manson’s Tropical Diseases, 20th Ed., W.B. Saunders Co.
Ltd, 1996.
 DuPont HL, Steffen R (eds.): Textbook of Travel Medicine and Health, 2nd Ed.
B.C. Decker, 2001.
 Guerrant, Walker, Weller: Tropical Infectious Diseases: Principles, Pathogens, &
Practice. Churchill Livingston, 1999.
 Jong EC, Sanford C (eds.): The Travel and Tropical Medicine Manual, 4th ed.
Saunders/Elsevier, 2008.
 Keystone JS, Kozarsky PE, Freedman DO, et al, eds: Travel Medicine. Mosby,
2004.

78. Bibliography (cont.)
 Sanford, C: The Adventurous Traveler’s Guide to Health. University of
Washington Press, Seattle, 2008.
 Sanford C. (guest editor): Primary Care Clinics: Travel Medicine.
Saunders/Elsevier, December 2002.
 Strickland. Hunter’s Tropical Medicine and Emerging Tropical Diseases,
8th Ed., W.B. Saunders. 2000.

79. Thank you