Sertifikat Tamasia 2020

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The 4^th International Forum on Travel and Adventure Medicine of Asia (TAMASIA) 24-25 January 2020, Jakarta – Indonesia

Symposium session: Corporate Travelers

Prevention of Jet Lag and Venous Thromboembolism during a Long-Haul Flight

I Made Ady Wirawan

Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University Jl. PB Sudirman Denpasar, Bali, Indonesia. Email: ady.wirawan@unud.ac.id

Abstract

A long haul flight is generally defined as a flight that lasts for 6 hours or longer. However, the more important thing is the number of time zone shifts instead of the length of travel.

Traveling across 3 or more time zones westward or eastward put some negative health consequences. This presentation covers two important effects of a long-haul flight i.e. jet lag and venous thromboembolism. Jet leg occurs due to desynchrony of internal body clock or circadian rhythm. The three mechanisms that are proven to be effective in preventing jet lag are light exposure/avoidance, melatonin intake, and exercise. Venous thromboembolism occurs due to partial or total blockage of the deep veins due to blood clots, usually in legs (known as deep vein thrombosis), or if left untreated the clots can break and result in pulmonary embolism. The three key measures include general prevention such as calf exercises, sitting in aisle, and prevent dehydration during flight, and other preventive

measures are the use of graduated elastic compression stockings (GECS), and pharmacologic prevention. Both conditions, jet lag and venous thromboembolism, are preventable and the risks in each traveler should be assessed to provide a more adequate preventive measures.

Keywords: jet lag, DVT, air travel, circadian system

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The 4

^th

International Forum on

Travel and Adventure Medicine of Asia (TAMASIA)

Jakarta | 24-25 January 2020

Asia-Pacific Travel Health Society (APTHS) - Indonesia Chapter

Secretariat: Jl. Jalak No. 11, Bogor 16161 | E-mail: info.tamasia@gmail.com | Website: www.tamasia.net

Jakarta, September 13, 2019 No: 05/e/TAM/ix/2019

To: Dr. Ady Wirawan, MD, MPH, PhD Re: Invitation as Speaker

Encl.: program and acceptance letter

Dear Dr. Ady Wirawan, MD, MPH, PhD

On behalf of the Organizing Committee of “The 4

^th

International Forum on Travel and Adventure Medicine of Asia (TAMASIA)”, to be held in Jakarta, Indonesia on January 24-25, 2020, it is our great pleasure to invite you to share your expertise.

You talk has been arranged as follows:

Day : Saturday, January 25, 2020

Time : 13.45 - 14.30 (including 15 minutes discussion)

Topic : “Prevention of Jet Lag and Venous Thromboembolism during Long-Haul Flight“

Please confirm your acceptance of the invitation by signing the letter of acceptance enclosed. We also need your recent curriculum vitae (CV). Please send the letter of acceptance and CV to the Organizing Committee at: info.tamasia@gmail.com. These documents will be submitted to the Indonesian Medical Association for applying CME credit.

Thank you in advanced for your kind attention and participation.

Sincerely yours,

Dr. Edi Alpino R. Siregar, MKK Dr. Levina S. Pakasi

Chair of the Organizing Committee APTHS Counselor Member

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The 4

^th

International Forum on

Travel and Adventure Medicine of Asia (TAMASIA)

Asia-Pacific Travel Health Society (APTHS) - Indonesia Chapter Secretariat: Jl. Jalak No. 11, Bogor 16161. Tel: 0812-8837 0355.

E-mail: info.tamasia@gmail.com | Website: www.tamasia.net

Friday, 24 January 2020

Basic Course in Travel Medicine

Exam and Certificate

Course Instructors:

1. Dr. Levina S. Pakasi (Asia-Pacific Executive Board Couselor Member) 2. Dr. M. D. Daniel Hadinoto, M.Kes, DTM, Sp.KP

07.30 – 08.00 : Re-registration 08.00 – 08.30 : Morning coffee 08.30 – 09.00 : Pre-test

09.00 – 09.30 : Module 1: Introduction to Travel Medicine

09.30 – 10.30 : Module 2: Risk Assessment and Risk Management 10.30 – 11.00 : Clinical scenario

11.00 – 11.30 : Module 3: Informational Resources in Travel Medicine 11.30 – 13.00 : Friday prayer and lunch break

13.00 – 14.00 : Module 4: Fitness to Travel 14.00 – 15.00 : Module 5: Vaccination Practice 15.00 – 15.30 : Clinical scenario

15.30 – 16.00 : Afternoon coffee

16.00 – 18.00 : Written examination

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The 4

^th

International Forum on

Travel and Adventure Medicine of Asia (TAMASIA)

Travel Medicine Workshops

Saturday, 25 January 2020

Time Program

07.30 – 08.30 Re-registration 08.30 – 09.00 Pre-test

09.00 – 09.30 Opening

Speech by the Chair of the Organizing Committee (Edi A.R. Siregar) Speech by the CEO of YARSI Hospital (Mulyadi Muchtiyar)

Speech by the Chairman of YARSI Foundation 09.30 – 10.00 Key-note speech

Update on Internartional Health Regulation and Vaccine Policy Benget Saragih – Ministry of Health, Republic of Indonesia 10.00 – 10.30 Coffee break

10.30 – 11.15 Plenary Lecture-1

Mass Gathering Medicine: Lessons from the Hajj Ziad Memish, Saudi Arabia

11.15– 12.00 Plenary Lecture-2

Occupational Health for Long-Term Travelers and Expatriates Edi A.R. Siregar, Indonesia

12.00 – 13.00 Lunch break and prayer

13.00 – 15.00 Venue 1 Venue 2

Hajj and Umrah Pilgrimage Corporate Travelers

Session 1: Infectious Disease Risks Session 1: Non-Infectious Disease Risks 13.00 – 13.30 Update on emerging infections in the

Middle East

Ziad Memish, Saudi Arabia

Travel-associated illness among corporate travelers

Daniel Hadinoto, Indonesia 13.30 – 13.45 Discussion

13.45 – 14.15 Vaccine recommendation for hajj and umrah

Edi Alpino R. Siregar, Indonesia

Prevention of jet lag and venous thromboembolism during long-haul flight

Ady Wirawan, Indonesia

14.15 – 14.30 Discussion Discussion

14.30 – 15.00 Coffee break Coffee break

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The 4

^th

International Forum on

Travel and Adventure Medicine of Asia (TAMASIA)

Scientific program - continue

15.00 – 17.30 Session 2: Non-Infectious Disease Risks

Session 2: Infectious Disease Risks 15.00 – 15.30 Assessment of pilgrims with

cardiovascular risks Cardiologist - tba

Malaria prevention and rabies pre- exposure prophylaxis for corporate travelers

Wasin Matsee, Thailand 15.30 – 15.45 Discussion

15.45 – 16.15 Assessment of pilgrims with renal impairment

Faisal Hasibuan, Indonesia

Yellow fever and JE vaccinations for corporate travelers

Wasin Matsee, Thailand

16.30 – 17.00 Assessing fitness to fly for elderly pilgrims

Trevino A. Pakasi, Indonesia

Quadrivalent influenza vaccination for corporate travelers

Dhani Arifandi, Indonesia

17.15 – 17.30 Post-test and closing Post-test and closing

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1/25/20

1

Prevention of jet lag and venous thromboembolism during

a long-haul flight

I Made Ady Wirawan

Department of Public Health and Preventive Medicine Faculty of Medicine, Udayana University

Presented at The 4th International Forum on Travel and Adventure Medicine of Asia (TAMASIA), Jakarta |24-25 January 2020

Three key measures!

• Light exposure/

avoidance

• Exogenous melatonin

• Exercise

Prevention of jet lag

• General measures

• Compression stockings

• Pharmacological prophylaxis

Prevention of VTE

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2 Long-haul flight

• Short-haul is a flight lasting anywhere from 30 minutes to 3 hours

• Medium-haul is defined by flights lasting between 3-6 hours

• Long-haul flights are those that extend beyond 6 hours

• No international standard definition and many airlines use air time or geographic boundaries instead

Long-haul flight

• Air travel across several time zones, causes negative effects—some of which occur during flight and some of which occur in the days after flight

• Anecdotally, these effects are often referred to collectively as jet lag

• This is actually two separate phenomena—travel fatigue and jet lag—

each with their own causes and consequences

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Travel fatigue refers to a

collection of symptoms that occur duringor immediately afterlong flights

These symptoms include

• fatigue

• disorientation

• headache

Primarily caused by

• sleep loss

• dehydration

• hypoxia

Travel fatigue

• discomfort associated with being in an aircraft with confined space

• recline-restricted seats

• low air pressure

• low humidity

Jet lag

Collection of symptoms that occur in the days after flight across threeor more time zones

These symptoms include

• headache, irritability, daytime sleepiness, difficulty sleeping at night, poor mental and physical performance, and poor gastrointestinal function

Primarily caused by the mismatch between the circadian system, or internal body clock

• which is synchronized to time cues in the departure time zone,

• and the desired timing of sleep and wake, which are typically synchronized to time cues in the destination time zone

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4 Westward flight

• Immediately after westward flight, the circadian system will be running ahead of the local time zone

• For example, after a flight from Denpasar to London (8 h west)

• When the body clock is ready for bed at 23:00 Denpasar time, it will only be 15:00 in London.

• To adjust to the new time zone, the circadian system has to delay, or shift backward, or move later

Eastward flight

• Immediately after eastward flight, the circadian system will be running behind the local time zone

• For example, after a flight from London to Denpasar (8 h east)

• When it is time to get up at 07:00 in Denpasar, it is only 23:00 in London, so the body clock will be ready for bed

• To adjust to the new time zone, the circadian system has to advance,

or shift forward, or move earlier

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5

Delays and advances in the timing of the circadian system can be facilitated by

appropriately timed lightexposure, melatoniningestion, and/or exercise

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6 Case study

• A businessman will fly to Auckland from Jakarta (shift of 6 hours). The flight will arrive at 13.00 local time. He usually sleep at 23.00 and wake up at 07.00.

• How can we use light exposure/avoidance and ingestion of exogenous melatonin to facilitate adaptation to the time zone shift, please

describe in a chart!

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8 Could adaptation begin before long-haul travel?

To delay the circadian system in the 3–4 days prior to westward travel

• gradually move bedtime and get-up time later (i.e., 30–60min per day)

• maximize evening light exposure

• minimize morning light exposure

• take 3.0mg of melatonin 1 h after rising from bed

To advance the circadian system in the 3–4 days prior to eastward travel

• gradually move bedtime and get- up time earlier (i.e., 30–60min per day)

• minimize evening light exposure

• maximize morning light exposure

• take 3.0mg of melatonin 6.5 h

before bed

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9 Venous Thromboembolism (VTE)

Deep vein thrombosis (DVT) occurs where there is a partial or total blockage of the deep venous system of the body by blood clot, usually in the legs Pulmonary embolism (PE) --- when part of the clot/thrombus breaks away and lodges in the lungs, which can be fatal

The symptoms of VTE do not usually develop immediately and diagnosis can be problematic

The majority of VTE cases, occur within the first 2 weeks after landing, with a mean interval of 4 days, while the risk is present for 4 weeks

VTE symptoms and signs

DVT

• inflamed veins

• redness of the lower legs

• a swollen or painful calf or thigh

• fever and discolouration of the skin over the affected area

PE

• short of breath

• pleuritic chest pain

• hemoptysis

• syncope

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10 VTE epidemiology

Venous thrombosis related to air travel was first reported in 1954 in a 54- year old doctor, who developed DVT following a 14-hour flight

The risk of venous thromboembolism (VTE) is increased 1.5 to 4 fold following long-haul travel

The absolute risk of a symptomatic DVT within 4 weeks of flights >4 h is 1/4600 flights

The risk of severe PE occurring immediately after air travel increases with duration of travel, up to 4.8 per million in flights >12 h

Risk factors related to planes and flights

• Hypoxia

• Position during the flight

• Dehydration

• Flight duration

• Class and location of seat

‘Economy class syndrome’ --- prolonged sitting in confined

conditions is a major factor in developing venous thrombosis

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11 Passenger-related risk factors

• Oral contraceptives, Hormone Replacement Therapy (HRT), and pregnant women

• Obesity

• Recent surgery

• Cancer

• Thrombophilia

• Others

• risk of VTE 20 times greater in passengers who have recently undergone surgery, and

• up to 18 times greater in passengers with a diagnosis of active cancer

VTE prophylaxis

General measures

Graduated Elastic Compression Stockings (GECS) Pharmacological prophylaxis

Platelet antiaggregant Low Molecular Weight

Heparin (LMWH) Direct Oral Anticoagulants (DOACSs)

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12 General prevention for VTE

• Calf muscle exercises – move feet and legs, with plantar dorsiflexion

• Aisle seat – walking

• Regular intake of water or juice

• Reduce alcoholic beverages, coffee, or tea

Graduated Elastic Compression Stockings (GECS)

• Increases venous return from the lower limbs -- reduces venous stasis

• High-risk travellers -- wear below- the-knee GECS providing 15 to 30 mmHg pressure at the ankle during the flight

• For all other long-haul passengers,

the recommendation is not to wear

GECS

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13 Pharmacological prophylaxis

• Platelet antiaggregant (aspirin)

•

not recommended

•

risk of bleeding

• Low Molecular Weight Heparin (LMWH)

•

for passengers considered at high risk of development of VTE

•