1. 1 UNITED STATES TRAVELERS 1) 25 Million each year 2) 5 Million to developing nations a) ¼ - ½ get some illness (2.5 million) b) 1/100 – 1/1000 get serious illness (25,000 – 250,000) – malaria and filariasis

2. 2 SCOPE OF THE TRAVEL INDUSTRY 1. A trillion dollar industry 2. Over 7 million jobs 3. In developing nations, often the major source of foreign currency

3. 3 DEFINITION OF A TRAVELER Someone who goes from an area of the world slightly fecally contaminated to an area where contamination is moderate to severe.

4. 4 THE FECAL VENEER

5. 5 International Travel May be Required: Yellow Fever Cholera May be Recommended: Typhoid Plague Measles Polio Rabies Hepatitis A Hepatitis B

6. 6 Required Immunizations for Travel A.Yellow Fever -Every 10 years for travel to areas infected with yellow fever and to rural areas endemic for yellow fever – equatorial SouthAmerica and Africa. B.Cholera -New serotype Vibrio cholera 0139 now affecting Indian subcontinent and Asia. For most travelers, risk remains low. -no country now requires vaccination for direct travel from the United States. -no vaccine will protect against V. cholerae 0139.

7. 7 Yellow Fever Attenuated live virus vaccine Administered at designated centers Only one injection required Protection afforded for 10 years Areas of risk: Equatorial Africa, Central and South America

8. 8 Cholera Vaccines Inactivated, parenteral - poorly protective (50%) for only a few months -uncomfortable side effects -rarely recommended Experimental A.Inactivated oral vaccine-Whole cell (WC) and B subunit/whole cell (BS/WC) B.Attenuated, live oral vaccine-CVD 103-HgR

9. 9 CHOLERA Vaccine of limited usefulness Risk to U.S. travelers is low (10 cases since 1961, 7 had been vaccinated) Indicated if passing through endemic regions One injection meets international requirements Full series of 3 shots for select patients Boosters may be required every 6 months

10. 10 Polio The Americas have now (9/29/94) been declared polio- free! A.Inactivated, parenteral – enhanced (elPV) - should be used in adults ( 18 yrs) never previously immunized B.Attenuated, live oral – OPV - can be used to boost previously immunized adults - risk of paralysis 1/1.4 million with first dose; 1/41,500,000 in previously immunized

11. 11 The Global Effort to Eradicate Polio by 2000 Before vaccines, 500,000 people a year were paralyzed or died from contracting polio. In 1996, 400 million children were vaccinated against polio. Since 1988, cases of polio have dropped 90 percent.

12. 12 TYPHOID Attenuated, live oral-Ty 21a mutant of S. Typhi (Vivotif Berna) - well tolerated, 60-70% effective Inactivated, parenteral-Vi polysaccharide of S. Typhi (Typhim Vi) - well tolerated, 64-72% effective, single dose

13. 13 Japanese B Encephalitis Consider travel for > 1 month in rural areas (particularly with rice and pig farming) in Far East Adverse reactions include local in20% and systemic in 10% Hypersensitivity reactions in 0.01% to 1% which may occur after any dose and be delayed up to 10 days In passive surveillance by Connaught, none of these reactions have been reported in 200,000 doses distributed

14. 14 TETANUS & DIPHTHERIA EVERYONE SHOULD RECEIVE A PRIMARY SERIES TETANUS-DIPHTHERIA TOXOID BOOSTER IS INDICATED EVERY 10 YEARS TdAP

15. 15 MMR 1)Live attenuated measles, mumps, rubella 2)Two dose regimen 3)Avoid Gamma Globulin

16. 16 OTHER VACCINES Hepatitis A – most common in developing world Hepatitis B Meningococcal Rabies

17. 17 Uncommon or Unavailable Vaccines 1)Smallpox 2)Typhus 3)Anthrax 4)BCG

18. 18 Resurgence of Malaria Risk in over 100 countries 300 million cases with 3 million deaths annually Major problem in Africa and Oceania Marked increase in drug resistance Deaths from malaria each year = those from AIDS in the past decade

19. 19 MALARIA 1. Prevention-mosquito control 2. Prophylaxis-depends on geography 3. Therapy-two principles A.Decrease parasite load B.Then eradicate parasite

20. 20 PLASMODIA 1)Falciparum-malignant 2)Vivax-has liver phase 3)Ovale-has liver phase 4)Malariae-chronic

21. 21 MALARIA-CLINICAL 1)Fever, chills, ha, myalgias, nausea 2)Diarrhea, abdominal pain, fatigue, confusion 3)Fevers become cyclic 4)Complications-DIC, splenic rupture, anemia

22. 22 MOSQUITO PROTECTION 1.DEET 2.Appropriate Clothing 3.Permethrin 4.Screens

23. 23 ANOPHELES MOSQUITO 1)Silent 2)Night Biting 3)Female

24. 24 Table 1. Drugs used in the prophylaxis of malaria DrugAdult Dose Chloroquine300 mg base (500 mg salt) phosphateorally, once/week (Aralen*) Hydroxychloroquine310 mg base (400 mg salt) sulfate orally, once/week (Plaquenil*) Malarone250 mg Atovoquone/ 100 mg Proguanil, daily Mefloquine228 mg base (250 mg salt) (Lariam*)orally, once/week Doxycycline100 mg orally, once/day Primaquine15 mg base (26.3 mg salt) orally, _______________________________________________________________________________ The dose (250 mg for an adult) should be taken once each week for 4 weeks, followed by one dose every other week

25. 25 HYGIENE ABROAD a)Water Acquisition b)Other Beverages c)Food Precautions d)Restaurant Evaluation

26. 26 Travelers Diarrhea – The Litany Aztec Two Step-Delhi Belly-Rome Runs La Turista-Greek Gallop-Sumatra Spurts Hong Kong Dog-Turkey Trots Cairo Crud-Montezumas Revenge

27. 27 Etiology of Travelers Diarrhea 1.E. Coli50% 2.Shigella/Salmonella10% 3.Campylobacter 8% 4.Viral10% 5.Parasites 2% 6.Unknown20%

28. 28 Infectious Doses of Enteric Pathogens Shigella10-100 Campylobacter1000-100,000 Salmonella100,000 E. Coli100 million Cholera100 million Giardia10-100 Amoebas10-1000

29. 29 Travelers Diarrhea Precautions 1.Water Precautions 2.Food Precautions 3.Common Sense

30. 30 Water Precautions: Avoid 1.Tap water if not treated 2.Ice cubes 3.Fresh milk 4.Bottled water with broken seal Safe 1.Bottled H²O, seal intact 2.Water at facility w/purifier 3.Soft drinks 4.Beer & wine 5.Coffee & tea if H²O boiled

31. 31 Water Precautions (2) - Alcohol will not disinfect water - Be leery of how glassware, dishes & utensils have been handled and washed - Dont gargle or brush your teeth with water you wouldnt drink - If in doubt, draw a glass of HOT water and let it cool, having passed through a hot water heater, it will be pasteurized

32. 32 FOOD PRECAUTIONS Safe: Meat and fish dishes well done & eaten hot. Vegetables that are thoroughly cooked. Nuts, fruits & vegetables to be peeled, shelled or skinned if purchased intact with no breaks in shell or skin. Chinese restaurants enjoy a reputation of serving safe tasty food worldwide.

33. 33 FOOD PRECAUTIONS Avoid: Raw eggsSteak tartare Raw meatsUndercooked meats Cold PlattersCustards PastriesRaw vegetables SaladsDairy products Raw shellfishCertain seafood

34. 34 RESTAURANT GUIDE Presence of window and door screens State of trash containment Status of the Restrooms Presence of roaches & flies Chinese restaurants

35. 35 TRAVELERS DIARRHEA SYMPTOMATIC TREATMENT 1)Dietary restrictions 2)Pepto Bismol 3)Immodium 4) Lomotil 5)Lactobacillus

36. 36 Oral Therapy for Acute Diarrhea Developed in 1950s-Glucose and electrolytes Misconception about hypernatremia 1960s-Coupled transport of sodium and glucose Clinical studies with cholera showed efficacy Subsequent studies worldwide

37. 37 TRAVELERS DIARRHEA PROPHYLAXIS 1)Generally not advised 2)Short trips only 3)Complications 4)Resistant organisms

38. 38 TRAVELERS DIARRHEA PROPHYLAXIS 1) Pepto Bismol 2) Antibiotics a)Quinolones b) Rifaximin

39. 39 EARLY TREATMENT OF TRAVELERS DIARRHEA 1) Effective and proven 2) Short course – 3 Days 3) Pepto Bismol – Less effective 4) Antibiotics a) Quinolones b) Rifaximin c) Azithromicin

40. 40 Special Risks of Travel 1)Motor vehicle accidents 2)Motion sickness 3)High altitude 4)Bites/stings/sun 5)Jet lag

41. 41 ACUTE MOUNTAIN SICKNESS HEADACHE WEAKNESS & LASSITUDE GI DISTRESS DIZZINESS SHORTNESS OF BREATH ANOREXIA DISTURBED SLEEP

42. 42 OTHER INFECTIOUS DISEASE RISKS a) STDs b) HIV c) Schistosomiasis d) Lepto-spirosis e) Dengue f) Plague g) Sleeping sickness h) Parasites