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Travel Associated Infections Sunanda Gaur, MD. Travelers’ Health Risks Of 100,000 travelers to a developing country for 1 month: –50,000 will develop.

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Presentation on theme: "Travel Associated Infections Sunanda Gaur, MD. Travelers’ Health Risks Of 100,000 travelers to a developing country for 1 month: –50,000 will develop."— Presentation transcript:

1 Travel Associated Infections Sunanda Gaur, MD

2 Travelers’ Health Risks Of 100,000 travelers to a developing country for 1 month: –50,000 will develop some health problem –8,000 will see a physician –5,000 will be confined to bed –1,100 will be incapacitated in their work –300 will be admitted to hospital –50 will be air evacuated –1 will die Steffen R et al. J Infect Dis 1987; 156:84-91 (ISTM)

3 Infectious Disease Risks to the Traveler Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis Hepatitis A Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV ETC.

4 Diseases in Returning Travelers Fever : Malaria, Dengue,Typhoid, nonspecific Diarrhea : Giardiasis, Amebiasis, bacterial, non specific Dermatologic : Insect bites, CLM, allergic rashes Non diarrheal Intestinal disorders : Hepatitis, Strongyloidosis N Engl J Med 2006; 354:119-130

5 Fever in the Returned Traveler Geosentinal sites study CID 2007 44: 1560-8 ( n=6957) Malaria 21% Acute Diarrheal Disease 15% Respiratory Illness 14% Dengue 6% Salmonella Infections 2% Tick borne Illness 2% 3% had vaccine preventable illness ( Hep A, Typhoid Fever, Influenza )

6 Causes of imported fever by region Africa Asia Americas Malaria 35% Unknown etiology 19%Unknown etiology 33% Unknown etiology 25%Respiratory 13%Respiratory 16% Respiratory 10%Dengue 12%Dengue 9% Bacterial enteritis 5%Malaria 11%Bacterial enteritis 9% Rickettsial 4%Bacterial Enteritis 9%, Typhoid 3% Malaria 4 % Bottieau et al Arch Int Med 166: 1642, 2005

7 Travel Health Resources CDC Travelers’ Health Website – World Health Organization – State Department – International Society of Travel Medicine – Health Information for International Travel –CDC “Yellow Book” International Travel and Health –WHO “Green Book”

8 Travelers’ Health Website

9 Traveler's Diarrhea In general, up to 50% of travelers develop at least one episode of diarrhea during a two week stay Onset usually within 2-3 days of arrival, > 90% occur within the first two weeks A self limiting illness with significant morbidity

10 Causes of Traveler’s Diarrhea CausePercent Isolation Bacteria50-75 Escherichia coli Enterotoxigenic Enteroadhesive Enteroinvasive 5-70 ? Campylobacter spp.0-30 Salmonella spp.0-15 Shigella0-15 Aeromonas0-10 Plesiomonas0-5 Other0-5

11 Causes of Traveler’s Diarrhea CausePercent Isolation Protozao Giardia lamblia Entamoeba histolytica Cryptosporidium ssp. Cyclospora cayetanensis 0-5 ? Viruses Rotavirus Enterovirus 0-20 ? No pathogen isolated10-40

12 Food and Beverage Precautions Boil it, peel it, cook it or FORGET IT !!

13 Food and Water Precautions Bottled water Selection of foods –well-cooked and hot Avoidance of –salads, raw vegetables –unpasteurized dairy products –street vendors –ice

14 Traveler’s Diarrhea Prevention : Antimicrobial prophylaxis is not recommended. Early self therapy is recommended Oral rehydration Fluoroquinolones remain drug of choice Resistance is developing in some regions Azithromycin ( Mexico, Thailand, Morocco ), ? preferable Rifaximin ( non bloody stools, no fever) Non specific agents ( Bismuth subsalycilate, loperomide)

15 Destination Specific Vaccines VaccineRisk Region Yellow feverParts of Africa and South America. ( Hepatitis BSE Asia, parts of Africa, Middle East, Pacific Islands, parts of South America Hepatitis AAll except Japan, Australia, New Zealand, north and west Europe, North America (except Mexico) TyphoidDeveloping countries MeningococcalSub Saharan Africa Japanese EncephalitisIndian Subcontinent, SE Asia CholeraOutbreak setting RabiesSouth and SE Asia, Mexico, parts of South and Central America and Africa PlagueOutbreak Setting

16 The Meningococcal Meningitis Belt

17 Don’t Forget the “Routine Vaccines” MMR dT ( New dTaP ) Varicella IPV Hepatitis B

18 Malaria


20 MALARIA Plasmodium vivax* Plasmodium falciparum* Plasmodium ovale Plasmodium malariae * most common

21 Malaria Risk Oceania1: 5 ( chloroquin res Vivax) Sub-Saharan Africa1:50 ( falciparum) South Asia1:250 ( mainly vivax) SE Asia1:2500 ( multi res falciparum) Mexico/Central Am1:10,000 ( Chloroquin sens)

22 Malaria life cycle

23 Malaria All febrile returning travelers should be considered to have malaria until proven otherwise Serial blood smears (thick and thin) every 8-12 hours in the first 24 – 48 hours Thick smears are 10 – 40 times more sensitive than thin smears. Thin smears important for quantitation of parastemia Important to identify the species

24 Fatal Malaria 45 fatal cases between 1980 – 1992 98% caused by P. falciparum 82% acquired in Sub-Saharan Africa Most cases were associated with lack of chemoprophylaxis, suboptimal chemoprophylaxis, delay in seeking medical attention, and delay in diagnosis

25 “ABCD” of malaria reduction –A Awareness of risk –B Bite prevention –C Chemoprophylaxis –D Diagnosis

26 Mosquito Bite Prevention

27 Vector Precautions Covering exposed skin Insect repellent containing DEET 30 – 50% Treatment of outer clothing with permethrin 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 Inspection for ticks

28 Malaria Prophylaxis DrugMefloquine UsageIn areas with chloroquine resistant Plasmodium falciparum and vivax. Highly effective Adult Dose22mg base (250 mg salt) orally, once/week, continue for 1 week after return Side effects25% mild headache, GI upset, malaise, anxiety 1/250-1/500 nightmares, irritability, depression CommentsContraindicated in persons allergic to mefloquine. Not recommended for persons with epilepsy and other seizure disorders; with severe psychiatric disorders; or with cardiac conduction abnormalities.

29 Malaria Prophylaxis DrugDoxycycline UsageAn alternative to mefloquine Adult Dose100 mg orally, once/day Pediatric Dose >8 years of age: 2mg/kg of body weight orally/day up to adult dose of 100 mg/day CommentsContraindicated in children < 8 years of age, pregnant women, and lactating women.

30 Malaria Prophylaxis DrugChloroquine phosphate UsageIn areas with chloroquine sensitive Plasmodium flaciparum Adult Dose300 mg base (500 mg salt) orally, once/week Pediatric Dose 5 mg/kg base (8.3 mg/kg (salt)) orally once/week up to maximum adult dose of 300 mg base Comments

31 Malarone (Atovaquone and Proguanil Hydrochloride) Atovaquone - a broad spectrum antiprotozoal inhibits the parasites mitochondrial electron transport. Treatment with Atovaquone alone results in rapid development of resistance. Atovoquone and Proguanil are synergistic against multi drug resistant P. falciparum Several studies have demonstrated the efficacy of this combination in treatment and prophylaxis of multidrug resistant P. falciparum Daily dosing ( 2-3 days prior, 7 days after), high cost Occasional headache, GI upset

32 Typhoid Fever Caused by S.typhi or S. paratyphi In US 445 cases/year between 1967 – 1994 72% of cases in the recent years (1985-1994) occurred in returning travelers Travel to Mexico and India account for >50% of cases Fever, chills, headache, malaise, abdominal pain, and constipation are common symptoms. Blood cultures positive in 40-66%, bone marrow culture positive in 90% Increasing antibiotic resistance – particularly in India – consider Ceftriaxone or Ciprofloxacin as first line therapy

33 Commercially Available Typhoid Vaccines Available in the United States DrugTy21aViCPS TypeLive AttenuatedPolysaccharide RouteOral IM Min Age of Receipt 62 No. Doses 41 Booster frequency,y 52 Side Effects(incidence) <5%<7%

34 Oral Ty21a Vaccine Live attenuated vaccine Enteri coated capsule – 1 cap every other day x 4 doses Efficacy – 65% Minimal to no side effects Contraindicated in immune compromised individuals Mefloquine can inhibit growth of Ty21a in vitro; delay vaccine at least 24 hours before or after Mefloquine Concommitant or antimicrobials may effect vaccine efficacy


36 Hepatitis A Vaccine Inactivated Vaccine Approved for children 2-18 years old and adults Highly Immunogenic –88 – 90% seroconversion in 2 weeks –99% seroconversion after 2 nd dose Duration of protection – under evaluation Indicated for: –Foreign travel –Residence in communities with high endemicity –Patients with chronic liver disease –Homosexual/bisexual men –IVDU –Occupational risk

37 Yellow fever Endemic Zones

38 Yellow Fever Vaccine Live vaccine Required if entering endemic area or going from an endemic region to non-endemic region Approved for children > 9 months old Do not administer simultaneously with cholera vaccine Under 4 months – unsafe (high incidence of post vaccination encephalitis) Adverse effect ( viscerotropic disease) : 1 in 2-3 million

39 World Distribution of Dengue 1999 Areas infested with Aedes aegypti Areas with Aedes aegypti and recent epidemic dengue

40 Travel related Tick-Borne Diseases Tick Borne Relapsing Fever Israel, Africa, South Asia Every 3-5 days fever episodes African TBFSouthern AfricaFever, h/a,eschars Mediterranean Spotted fever Mediterranean, South Asia, E&S Africa Similar to African TBF, more severe TBECentral and E EuropeFever, Meningo- encephalitis Lyme BorreliosisEuropeRash, 7 th nerve palsy, aseptic meningitis

41 Bloodborne and STD Precautions Prevalence of –STDs –Hepatitis B –Hepatitis C –HIV Unprotected sexual activity Commercial sex workers Tattooing and body piercing Auto accidents Blood products Dental and surgical procedures

42 Post Exposure HIV prophylaxis Assess likelihood of exposure Assess degree of exposure Begin ARV prophylaxis within 12-24 hrs. 2-3 drug combinations recommended depending on exposure risk. To be continued for 4 weeks. or

43 Pre Travel Check List Routine immunization Hepatitis AImmune Dose 1 Dose 2 PolioImmune One dose IPV MeningococcalOne dose Booster TyphoidOral 4 doses One dose IM Booster MalariaChloroquin Mefloquin Malarone Doxy DiarrheaLoperamide Ciprofloxacin Azithromycin Oral rehydration AllergyAntihistamine Epi Pen Soft tissue infectionCefalexin bacitracin Motion sickness/GERDDramamine/H2 blocker Food and water precautionsInstruction Adventure/long stayRabies Yellow fever JE Special problemsAsthma Diabetes Mantoux status

44 Travel Emergency Kit Copy of medical records and extra pair of glasses Prescription medications Over-the counter medicines and supplies –Analgesics –Decongestant, cold medicine, cough suppressant –Antibiotic/antifungal/hydrocortisone creams –Pepto-Bismol tablets, antacid –Band-Aids, gauze bandages, tape, Ace wraps –Insect repellant, sunscreen, lip balm –Tweezers, scissors, thermometer

45 Kibera, Nairobi


47 Post-Travel Care Post-travel checkup –Long term travelers –Adventure travelers –Expatriates in developing world Post-travel care –Fever, chills, sweats –Persistent diarrhea –Weight loss

48 Rabies Rabies in travelers – an underestimated risk 1980 – 1997 12/36 (33%) of human rabies deaths in US have been related to rabid animals outside the US Canine rabies in endemic in the Indian Subcontinent, China, SE Asia, Philippines, Latin America, Africa and the former Soviet Union In many rabies endemic countries, only Equine RIG and older Semple rabies vaccines are available Equine RIG – significant risk of serum sickness Semple type rabies vaccine is not as effective, and theoretical danger of allergic myeloencephalitis exists Pre-exposure prophylaxis should be considered in selected cases

49 Japanese Encephalitis Vaccine Inactivated vaccine Efficacy = 91% Booster every 3 years Not approved for children under 3 years Side effects –Local reaction (10-25%) –Fever (10-25%) –Hypersensitivity reaction (0.6%) Indications –Expatriates living in Asia –Travel to endemic regions for >30 days during transmission season, especially travel to rural areas

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