1. Preparing the Traveler UNCLASSIFIED Stephen J. Thomas, MD Director, Viral Diseases Branch Walter Reed Army Institute of Research AUG 2013

2. UNCLASSIFIED Slide 2 Disclaimer The views expressed in this presentation are those of the speaker and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government

3. UNCLASSIFIED Slide 3 Outline Introduction –Dynamics of tropical disease –Example - Nipah Preparing the Traveler –Asking the right questions –Routine vaccinations –Travel medicine literature –Geographic distribution of threats –Vaccination –Diarrhea

4. UNCLASSIFIED Slide 4 Introduction

5. UNCLASSIFIED Slide 5 Understand the Dynamics of Tropical Diseases HOST VECTORSTHREATS Ecology / Environment Demographics, special populations Circulating animal and human pathogens Mosquitoes, ticks, bats, birds, dogs, cats, etc. Temperature, rainfall, cultural & agricultural practices, etc.

6. UNCLASSIFIED Slide 6 Example - Nipah Virus Highly pathogenic paramyxovirus –Isolated from CSF –Sungai Nipah village Natural host are fruit bats Causes severe febrile encephalitis Outbreaks –Peninsular Malaysia and Singapore (1998 – 1999) –Bangladesh: 2001, 2003, 2004, 2005, 2007 and 2008 –India: 2001 and 2007

7. UNCLASSIFIED Slide 7 Nipah Transmission Dynamics Pigs crowded in pens Pens near fruit trees Fruit bat home destroyed Fruit bats relocate to fruit trees Bat fluids contain Nipah Aerosolized virus infects pigs Pigs infect handlers

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11. UNCLASSIFIED Slide 11 Preparing the Traveler Asking the Right Questions

12. UNCLASSIFIED Slide 12 Asking the Right Questions Who, Where, When, Why and What? Who is the host / traveler? –Immunologic background, medical problems, etc. Where are they going? –Geographic region, known threats. When are they going? –Seasonal variations in disease threat epidemiology Why are they going there and what will they do? –Defines likely exposure risks –Defines required prophylaxis / PPMs Know what you do not know. Look it up. Seek consultation.

13. UNCLASSIFIED Slide 13 Practice Evidenced Based Medicine http://www.idsociety.org/uploadedFiles/IDSA/Guidelines- Patient_Care/PDF_Library/Travel%20Medicine.pdf

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15. UNCLASSIFIED Slide 15 Travel Medicine Resources U.S. Department of State –www.travel.state.govwww.travel.state.gov MILVAX –www.vaccines.mil/QuickReferencewww.vaccines.mil/QuickReference CIA Factbook –www.cia.gov/cia/publications/factbookwww.cia.gov/cia/publications/factbook National Center for Medical Intelligence –www.intelink.gov/my.policywww.intelink.gov/my.policy AMEDD Virtual Library –Travax International Society of Travel Medicine website) –http://www.istm.org/http://www.istm.org/

16. UNCLASSIFIED Slide 16 US CDC http://wwwnc.cdc.gov/travel/ http://wwwnc.cdc.gov/travel/yellowbook/2014/table-of-contents

17. UNCLASSIFIED Slide 17 DoD On-Line Infectious Diseases Consults id.consult@us.army.mil Infect.cntrl.consult@us.army.mil pmom.consult@us.army.mil Began in January 2005 839 teleconsultations thru July 2013 35 teleconsultations received January – July 2013 6 teleconsultations received in July 2013 First teleconsultation received from Niger 7.4% of all teleconsultations received in the AKO Program

18. UNCLASSIFIED Slide 18 Locations Submitting Teleconsultations Supported Facility US, Canadian & Australian Navy afloat Afghanistan Bosnia Chad Continental US Egypt – MFO Sinai Haiti Relief Germany Hurricane Katrina Iraq Italy - Sicily Kuwait Kyrgyzstan Okinawa Pakistan Qatar Niger United Arab Emirates Turkey Djibouti Ecuador Morocco BelizePhilippines Japan Congo Mauritania Senegal Papua New Guinea Albania Ghana Guatemala Botswana Turkmenistan Bahrain Thailand Guinea Mali Guam Spain Honduras Yemen Laos Belgium UkraineEl Salvador Kenya Bangladesh Jordan Saudi Arabia Sudan Solomon Islands Ethiopia Chili http://www.cia.gov/cia/publications/factbook/reference_maps/pdf/time_zones.pdf Peru Nepal

19. UNCLASSIFIED Slide 19 Percentage of Consultations 99.52% of all teleconsultations are answered in less than 24 hours Reply Time by Percentage of Consultations

20. UNCLASSIFIED Slide 20 Key Elements of the Consult Patient History –When did it start –Patient symptoms now? –Getting better? Worse? Staying the same? Spreading? –Previous treatments and outcomes? –Laboratory tests results (if any)? –Your Dx / DDx –Your question Limitations you have in managing the patient 20

21. UNCLASSIFIED Slide 21 Key Elements of the Consult Patient Demographics –Age –Gender –Branch of service (if not MIL, state their nationality) –Identify if contractor, detainee, foreign military, etc. Include digital images if appropriate PDFs of EKGs JPEGs of radiographs Copies of laboratory and pathology reports Do not send any patient identifying info(HIPAA applies)

22. UNCLASSIFIED Slide 22 Preparing the Traveler Refer to the Traveler Literature

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27. UNCLASSIFIED Slide 27 Preparing the Traveler Geographic Distribution of Disease

28. UNCLASSIFIED Slide 28 Yellow Fever

29. UNCLASSIFIED Slide 29 Chikungunya

30. UNCLASSIFIED Slide 30 Dengue

31. UNCLASSIFIED Slide 31 Dengue

32. UNCLASSIFIED Slide 32 Hepatitis A

33. UNCLASSIFIED Slide 33 Hepatitis E

34. UNCLASSIFIED Slide 34 HIV

35. UNCLASSIFIED Slide 35 Japanese Encephalitis

36. UNCLASSIFIED Slide 36 Malaria

37. UNCLASSIFIED Slide 37 Malaria / Mefloquine Resistant

38. UNCLASSIFIED Slide 38 Melioidosis

39. UNCLASSIFIED Slide 39 Meningitis

40. UNCLASSIFIED Slide 40 Middle East Respiratory Syndrome-Coronavirus CountriesCases (Deaths) France2 (1) Italy3 (0) Jordan2 (2) Qatar2 (1) Saudi Arabia74 (39) Tunisia2 (0) United Kingdom (UK)3 (2) United Arab Emirates (UAE)6 (2) Total94 (47) APRIL 2012 - Present

41. UNCLASSIFIED Slide 41 Rabies

42. UNCLASSIFIED Slide 42 Schistosomiasis

43. UNCLASSIFIED Slide 43 Tuberculosis

44. UNCLASSIFIED Slide 44 Preparing the Traveler Vaccination

45. UNCLASSIFIED Slide 45 Vaccination Confirm up to date routine vaccinations for adults –Documentation or considered susceptible Confirm past travel related vaccination history Calculate risk: benefit ratio –Disease threat versus vaccine adverse event Consider special populations –Pregnant, immunosuppressed, known allergic past rxns Remember – Diseases extinct in the US, alive and well in other locations (examples: polio, measles, etc.)

46. UNCLASSIFIED Slide 46 Vaccine Preventable Diseases (Routine) http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.pdf

47. UNCLASSIFIED Slide 47 Vaccine Preventable Diseases (Traveler)

48. UNCLASSIFIED Slide 48 Preparing the Traveler Diarrhea

49. UNCLASSIFIED Slide 49 Risk of Traveler’s Diarrhea

50. UNCLASSIFIED Slide 50 Traveler’s Diarrhea (TD) Attack rates range from 30% to 70% of travelers Clinical syndrome from a variety of intestinal pathogens –Bacterial pathogens are the predominant risk (80%–90%) –Viruses have been isolated (5%–8%), Norovirus may > % –Protozoal pathogens (10%), longer-term travelers Bacteria –Enterotoxigenic Escherichia coli (#1), Campylobacter jejuni, Shigella spp., and Salmonella spp. Enteroadherent and other E. coli species are also common. Aeromonas spp. and Plesiomonas spp. as well. Viral –Norovirus, rotavirus, and astrovirus. Protozoal –Giardia, Entamoeba histolytica and Cryptosporidium uncommon –Cyclospora (Nepal, Peru, Haiti, and Guatemala) –Dientamoeba fragilis is a low-grade but persistent pathogen

51. UNCLASSIFIED Slide 51 Traveler’s Diarrhea (TD) Prevention –Food and beverage selection Wash it, boil it,cook it, peel it: reduces, does not eliminate risk –Non-antimicrobial drugs for prophylaxis Bismuth subsalicylate (Pepto-Bismol) –Not in travelers w/ aspirin allergy, renal insufficiency, or gout. –Not for use with anticoagulants, probenecid, or methotrexate. –Not generally recommended for children aged <12. –Studies have not established safety for periods >3 weeks. –Probiotics (Lactobacillus GG and Saccharomyces boulardii) Study results are inconclusive Insufficient information to recommend the use of bovine colostrum –Prophylactic Antibiotics Diarrhea attack rates are reduced by 90% or more At this time, prophylactic antibiotics not be recommended for most Ease of treating diarrhea versus side effects of antibiotics

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53. UNCLASSIFIED Slide 53 Preparing the Traveler Malaria

54. UNCLASSIFIED Slide 54 Malaria MALARIA KILLS SERVICE MEMBERS! #1 threat if you are traveling to a malarious region Any fever in any traveler who is in or who has been to a malarious region has malaria until proven otherwise

55. UNCLASSIFIED Slide 55 Marines deploy to Liberia, 44 contract malaria despite prophylaxis and PPMs

56. UNCLASSIFIED Slide 56 Differences Between CIV and MIL Populations

57. UNCLASSIFIED Slide 57 Differences Between CIV and MIL Populations

58. UNCLASSIFIED Slide 58 Differences Between CDC and US military’s use of malaria chemoprophylaxis

59. UNCLASSIFIED Slide 59 Differences Between CDC and US military’s use of malaria chemoprophylaxis

60. UNCLASSIFIED Slide 60 Differences Between CDC and US military’s use of malaria chemoprophylaxis

61. UNCLASSIFIED Slide 61 Preparing the Traveler Vector Avoidance

62. UNCLASSIFIED Slide 62 Vector Avoidance Mosquitoes, sand flies, chiggers, ticks Malaria, dengue, CCHF, scrub typhus, leishmaniasis Be smart, be knowledgeable, be safe –Geographic areas with known risk –Avoid man-made creation of local breeding areas –Understand feeding habits Protect yourself

63. UNCLASSIFIED Slide 63 DoD Repellent System

64. UNCLASSIFIED Slide 64 (Woodland) NSN 3740-01-516-4415 (Desert) NSN 3740-01-518-7310 Fits on standard cot Set-up: throw it Self-supporting No cot or pole set needed Zips open and closed on both sides Factory-treated with permethrin – 25 washings or one year Has attached floor for use on ground Water resistant Flame retardant 2 pounds Pop-Up Bednet

65. UNCLASSIFIED Slide 65 Preparing the Traveler Animal Contact

66. UNCLASSIFIED Slide 66 Dogs: Rabies, skin and soft tissue, crush Unpredictable Not man’s best friend on deployment 1 sec.

67. UNCLASSIFIED Slide 67 Defining Event

68. UNCLASSIFIED Slide 68 Cats: Needle-like teeth, inoculate bacteria, deep tissue space/planes, joints Necrotizing fasciitis is a medical and surgical emergency!

69. UNCLASSIFIED Slide 69 Monkeys: Rabies, Herpes B virus There is no cure for stupid! Stay away!

70. UNCLASSIFIED Slide 70 Preparing the Traveler Additional Risks

71. UNCLASSIFIED Slide 71 Additional Concerns Trauma –Motor vehicle accidents –Wear a belt, helmet, 4 wheels when possible Water exposure –Rip tide and undertow –Infectious diseases (leptospirosis, shistosomiasis) Sexually transmitted infections –HIV, resistant organisms –Human trafficking Environment –Heat, cold, altitude Alcohol and drugs –Bad decisions, dangerous decisions

72. UNCLASSIFIED Slide 72 Preparing the Traveler Conclusion

73. UNCLASSIFIED Slide 73 The Ten Commandments of Travel Medicine Acquire a pre-travel consultation from your provider Wash your hands and avoid eating poop Vaccinate Invest in DEET, PPMs Respect traffic, local rules Don’t drink and do anything Respect and believe fever Stay away from the animals Avoid STIs Take your prophylaxis KNOW WHAT YOU DON’T KNOW!

74. UNCLASSIFIED Slide 74 Preparing the Traveler Back Up Slides

75. UNCLASSIFIED Slide 75 Soliciting a Detailed Medical History

76. UNCLASSIFIED Slide 76 Chief Complaint Localizing –Focal lesion (cellulitis) –Bite (arthropod, animal, human) –Post-traumatic (altercation, vegetation) –Anatomical (CNS, GU, GI, etc.) Generalized and systemic –Fever, chills, rigors –Muscle and / or joint pain –Fatigue

77. UNCLASSIFIED Slide 77 History of Present Illness Key information –Detailed chronology of illness Patient was well until…DATE…when…X…happened Appearance / disappearance of signs / symptoms –Non-specific illnesses may declare themselves Identify patterns if they exist –Example: patterns of fever (every 3 days) –Incorporate important medical background of patient Age (impacts presentation, fever curves, etc.) Immunodeficient (HIV, medications, malignancy)

78. UNCLASSIFIED Slide 78 History of Present Illness Key information –Incorporate activities / exposures Animals, arthropods, people, vegetation Urban, rural environment exposure Indoor or outdoor activities –Incorporate relevant active (recent) medications Prophylaxis, immunomodulators, OTC medications –Incorporate relevant associated travel history

79. UNCLASSIFIED Slide 79 Review of Systems Pertinent positives and negatives –Specifically mention if no fever –CNS: evidence of meningitis, encephalitis, any neuro –Respiratory: tracheobronchitis, pneumonia –Oropharynx: pharyngitis, bleeding gums, dentition –GI: diarrhea with blood, mucus, rice water appearance –GU: discharge, dysuria, abnormal menses –Skin: rash, location, itching, character –Extremities: localized pain, joint versus bone pain

80. UNCLASSIFIED Slide 80 Past Medical/Surgical History Drill down on relevant pre-existing medical conditions –Immunosuppressive conditions Drill down on chronic or re-occurring conditions –Examples: frequent respiratory infections, meningitis Presence or absence of organs –Appendix, gallbladder, spleen, thymus Previous surgical interventions –Heart surgery (valve) –Implant of any hardware or foreign material Known lab / radiologic abnormalities –Examples: lung nodule/Ca++, heart block, etc.

81. UNCLASSIFIED Slide 81 Medications / Immunizations Rx and OTC (previous antibiotics) Immunosuppressives –Examples – prednisone, DMARDS Anti-pyretics (ASA, NSAIDS, acetaminophen) –Manipulate fever curve Prophylaxis (detailed account) –Test understanding (especially malaria prophylaxis) Anything which could impact absorption or metabolism of chronic or prophylactic medications impacting their performance. All routine and travel specific vaccinations!

82. UNCLASSIFIED Slide 82 Social History Activities, hobbies, occupation (defines potential exposures) –Examples: hunter, gardener, fishing Sexual practices –Examples: monogamous, MSM, high risk behaviors Drugs and alcohol –Needle based drugs, potential for cirrhosis, etc. Tobacco –American or foreign Food –OCONUS (“on economy”), imported Pets –Type, acquisition history, level of interface

83. UNCLASSIFIED Slide 83 Family History First degree relatives –Immunosuppressive conditions –Recurrent infections Individuals sharing household –Recent medical events (including vaccinations) “Sick contacts” –Immunosuppressive conditions –Recent or current illness If yes, explore diagnosis if known Hospitalized?

84. UNCLASSIFIED Slide 84 Travel Where (geographic specific infections) When (rainy season = vectors) Activities during travel (urban, rural) Accommodations (hotel with A/C, outdoors) Food (hot, cold, water, hotel, street, etc.) Precautions (any PPM?)

85. UNCLASSIFIED Slide 85 Medical History Informing Diagnosis

86. UNCLASSIFIED Slide 86 Mandell et al. PPID 7 th ed.

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