1.MINOR CREDIT SEMINARDr. Adhiraj Mishra, M.V.Sc (1st Year), Div. of Epidemiology Dr. DK Singh, Principal Scientist, Veterinary Public Health Dr. Bhoj R Singh, Principal Scientist and Head, Division of Epidemiology

2. MAGNITUDE OF GLOBAL TRAVEL International arrivals will reach 1.6 billion by 2020.International Tourist (million)90394020072010 Travel to developing countries increased from31 % to 47% and to Asia Pacific and Middle East have doubled in last decade. (UNWTO-2012)4351990 3. MODE OF TRAVEL6%41%51% (UNWTO-2012) 4. REASON OF TRAVELInternational Travel & Health, 2012 5. TRAVEL RELATED RISK factors Mode of transport. Destination. Duration and season of travel. Purpose of travel. Behaviour of the travellers. Underlying health of the travellers. 6. AIR TRAVEL & Associated Risks Quality of Aircraft cabin air & HEPA Filter. Auxiliary Air Unit. Aircraft Disinsection. Disease transmission: Coughing, sneezing and direct or indirect contact. e.g-TB, Influenza, SARS 7. SEA TRAVEL & Associated Risks 13 million passengers travel worldwide on cruise ship.(UNWTO). Disease transmission through: Contaminated food & Water, Whirlpool spa, inhalation. e.g. Gastroenteritis (2006), Influenza & other RTI, Legionellosis (1994) (International Travel & Health, 2012) 8. MODES OF DISEASE TRANSMISSION RoutesDiseasesFood borne & WaterborneTravellers diarrhoea, Cholera, Cryptosporidiosis, Giardiaisis, Hepatitis A & E, Listeriosis & Typhoid FeverAir borneTB, SARS, Mumps, diptheria, measlesVector Borne Animal BorneMalaria, Yellow Fever, Dengue, Japanese Encephalitis, Chikungunya & Tick borne encephalitis. Rabies, Brucellosis, LeptospirosisBlood borneHepatitis B & C, HIV/AIDS and MalariaSexually TransmittedHepatitis, HIV/AIDS & SyphilisSoil borneAnthrax, Ascariasis, Trichuris, Fungal infectionsRecreational WaterLeptospira, Pseudomanas, Legionellosis, Schistosoma, CLM, Giardia, Cryptosporidium, Tinea & Cutaneous papilloma. 9. DISEASE DIAGNOSIS BY GEOSENTINEL SITES DiagnosisCasesMalaria1,762Giardiasis1,296Dengue Fever888Campylobacteriosis596Cutaneous Larva migrans577Rabies P E Prophylaxis349Enteric Fever262Spotted Fevers220Chikungunya120Acute Hepatitis A94Confirmed Influenza A/B84 Leader K, Torresi J et al, 2013 10. SEVERE ACUTE RESPIRATORY SYNDROME (SARS) Zoonotic viral disease caused by the SARS-CoV. By July 2003, 8,273 cases and 775 deaths reported inmultiple countries (9.6% fatality rate). Within weeks, SARS spread from Hong Kong to 37 countries in early 2003. (WHO) 1st seen- Guangdong Province of China-16th Nov, 2002 Dr. Liu Jianlun reached Hong Kong-21st Feb, 2003 Stayed in Metropole Hotel Room No.911 and shifted to Hospital on 22nd Feb 2003 and died on 4th March 11. Contd. American businessman who stayedin the same hotel, now travelling from China to Singapore had emergency landing in Vietnam and died. Disease spread to Canada, Singapore, China, Vietnam , United States, Mongolia etc. WHO issued global alert on 12th March 2003. 1st case in India- 32 year man in Goa, who returned from Hong Kong and Singapore on 17th April 2003. 12. GLOBAL SPREAD OF SARSThe WHO Report, 2003 13. PANDEMIC INFLUNZA (H1N1) pH1N1", 1st identified in April 2009, andinitially spread in Mexico and then globally. Emerged from pigs in Asia, and was carried to North America by infected persons. The first case of the Swine flu in India -on 13 May 2009, when a 23 year old man travelling by Emirates Airline from New York to Hyderabad via Dubai. 14. AVIAN INFLUNZA (H5N1) Avian influenza A (H5N1), first seen in Hong Kong in1997. Then, it reappeared in Vietnam in 2003 and has been in continuous circulation ever since. H5N1 has primarily affected poultry, from 2003 through 2011, 578 human illnesses in 15 countries were reported, with an alarming case-fatality ratio of 59%. The countries with the most cases of human disease (Indonesia, Vietnam, and Egypt) account for 80% of all cases and 78% of all deaths. (Ostroff SM, 2012) 15. AVIAN INFLUENZA IN CHINA Avian influenza A (H7N9) virus was first reported inChina among human beings and poultry. Till 6th Nov, 2o13, 139 H7N9 human infections were reported & 45 people died. (ProMED-Mail). Person-to-person spread of H7N9 is rare. 16. PREVENTION OF RESPIRATORY INFECTIONS Frequent washing of hands with soap & water. Disinfection of household surfaces. Wear disposable gloves and apron and N-95 mask. Eye protection (e.g. face shield or goggles) if splash or spray of body fluids is likely. Thermal Screening at airport & Quarantine. Social distancing. 17. HIV/AIDS and Travel HIV-I pandemic started bymid 70s and 80s spread to five continents through air travel, sea travel and human migration. Case of Patient Zero, a Canadian flight attendant who travelled extensively worldwide. In the United States, the rapid spread of AIDS between 1984 and 1990 can be modelled accurately using air traffic flows between cities. (CDC, Yellow Book 2012) 18. DRUG RESISTANCE MRSA, Strains of N. gonorrhoeae & multidrug resistantAcinetobacter travellers.baumanniihave beenspread(Ostroff SM, 2012)by 19. Travel of NDM-1 First detected in patients stoolwho returned to Sweeden after hospitalisation in India in Jan 2008. A total of 37 isolates with NDM-1 were recovered from 50 UK patients and 143 from patients at Indian subcontinent Since Aug 2010, it has worldwide distribution except in Central and South America. 20. GLOBAL SPREAD OF NDM (June2012)Ostroff SM, 2012 21. DENGUE VOYAGE In 2000, Dengue spread to the USvia infected travellers. 6050 40 30 20 100 South East South Asia Central AsiaCentral AmericaSouth AmericaCaribbean Sub Saharan AfricaCases of Dengue among travellers (Leader K, Torresi J et al 2013) 22. CHIKUNGUNYA FLIGHTS Restricted to Africa & Asiaand after the Kenya outbreak in 2004 it appeared in islands of Indian Ocean in 2005 and then reached Indian Subcontinent in 2006. Travellers to India and Indian visitors then spread it to Europe, North America and Australia having viable vectors. 23. WEST NILE VIRUS The West Nile Virus is believed to reach United States in 1999 via mosquitoes that crossed oceans by aircraft wheel wells. (CDC Yellow Book 2012) 24. MASS GATHERINGS (MG) 25. HAJJ PILIGRIMAGE & DISEASES Health Requirements Entry Visa:forYellow Fever-Risk area Meningococcal Meningitis.(A,C,Y,W135) Poliomyelitis-Oral Vaccine. Seasonal Influenza. (Weekly Epid. Report, 2013) 26. Spread of Emerging Diseases MERS-CoV-EMC/2012a novel Corona virus first reported on 24th Sept, 2012 in Saudi Arabia. As on 19th Nov, 2013 157 people affected with 66 deaths. (ProMED Mail) Sacrifice Voucher can spread Meat borne Zoonoses. Blood Borne Pathogen like Heaptitis B, C and HIV. (Balaban V, Ahmed, Q, 2011) 27. KUMBH MELA 100 million people, 600 km pipes, 92 million litres clean water/day, 35,000 temporary toilets and 10,000 night soil sweepers. ( Balsari S, 2013) 28. SPORTS EVENTS London Olympic 2012: 15,000 athletes, 70,000 volunteers, 20,000 journalists and 10 million spectators. FIFA World Cup 2010: South Africa 32 national teams & 3.2 million spectators World Cup Cricket, 2007 Caribbean islands: 16 participating nations and 1 million spectators. 29. INTERNATIONAL ORGANISATIONS 30. FOOD AND WATER PRECAUTIONS Bottled water. Selection of foods well-cooked and hot. Avoidance of salads, raw vegetables, raw orundercooked eggs and meat. unpasteurized dairy products street vendors Ice. 30 31. VECTOR PRECAUTIONS Protective Clothing. Insect repellent containing DEET 25 50% Treatment of outer clothing with permethrin or etofenprox. Use of permethrin-impregnated bed net Use of insect screens over open windows Air conditioned rooms Use of aerosol insecticide indoors Use of pyrethroid coils outdoors 31 32. BLOODBORNE DISEASES & STD PRECAUTIONS Avoid Unprotected sexual activity Commercial sex workers Tattooing and body piercing Blood products Dental and surgical procedures32 33. INTERNATIONAL HEALTH REGULATIONS, 2005 Came into force on 15th June 2007.Their main objectives are to ensure: (1) Routine, preventive measures (e.g. at ports and airports) and the use by all countries of internationally approved documents (e.g. vaccination certificates); (2)The notification to WHO of all events that may constitute a public health emergency of international concern; and (3) The implementation of any temporary recommendations should the WHO Director-General have determined that such an emergency is occurring. (International travel & health, 2012) 34. ANIMAL TRAVEL & DISEASES SpeciesDiseasesBovineBovine Spongiform Encephalopathy, CBPP, FMD, BVD.EquineEquine Infectious Anaemia, Glanders, Dourine, Equine Infectious Metritis, Infectious Equine Abortion, Piroplasmosis, Equine Influenza, VEE. (AQ&CS, Govt. Of India)Caprine & OvineBorders Disease, PPR.SwineNipah Viral Encephalitis, Respiratory Syndrome.PorcineAvainReproductive&HPAI, LPAI, IBD, New Castle Diseases.The Livestock Importation Act, 1898. The Prevention & Control of Infectious and Contagious Diseases in Animal Act , 2009 35. WHAT TO DO? Pre-travel Medical Consultation. Strengthening of travel industry. Redefine responsibility of the travellers. Introduction of Travel Health & Mass Gathering Health inPublic Health Curriculum. Medical Insurance of travellers.