Major regional Disease Risks of International Travel Ronald D. Warner, DVM, MPVM, PhD Professor Director, TravelMed Clinic TTUHSC School of Medicine - Lubbock ~ 2 billion people travel by air each year; 2009, The Lancet. Americans took 64 million trips outside the U.S. in Many “exotic” diseases are only a plane flight away... … in either direction !!

TTUHSC Dept Family and Community Medicine’s TravelMed Clinic “activity” zCY 2009: 198 clients; traveling to 79 countries z , over 1800 travelers to ~ 137 countries --- the “Top 20“destinations have been: Brazil, Kenya, China, India, Peru, South Africa, Uganda, Costa Rica, Viet Nam, Thailand, Mexico, Tanzania, Panama, Ecuador, Guatemala, Russia, Egypt, Nigeria, Honduras, and Belize ( the rest: Algeria to Zimbabwe )

the more-common Infect. disease risks … estimated disease burdens, world-wide zMalaria: ~1-3M human deaths/year; tropical Latin America, India, SE Asia, and Africa; 1 in 5 deaths of African children zTyphoid fever: ~16 to 33 million cases/year, with 216,000 deaths zDengue fever: estimated 50 million cases/year; 125,000 are fatal zRabies: ~60K human deaths/yr.; India, China, Pakistan, Bangladesh, and the Philippine Islands account for the majority zYellow Fever: ~ 30,000 human deaths/year; most in S. America z hepatitis A: estimated 26,975 cases/year, with 4,000 deaths z… a/o 10 Feb 2010: 478 human cases of avian H5N1 influenza (bird flu); 282 fatalities [Indonesia, Viet Nam, China, Thailand, Egypt]

primary: Risk Assessment  Past and current health status reminder : carry all required meds in original containers  travel plans; itinerary * destination(s)... any required vaccinations ? ** length of stay *** activities while there  current vaccinations  endemic & epidemic diseases at destination(s) - primary prevention - list of recommended vaccinations - “scripts” for recommended prophylactic meds

Routine “adult” vaccines are important  Tetanus-diphtheria (Td) * - recently Tdap for those y/o * booster every 10 years  Measles-mumps-rubella (MMR), if not “current” esp. for those born after 1956  current Influenza vacc, esp. if traveling Oct – Feb, and/or > 65 y/o. Remember: “opposite” flu season in the S. Hemisphere  Pneumococcal vacc, if > 65 y/o and esp. if serious underlying cardio-pulmonary disease(s) zpossibly, an adult Polio booster ** ; esp. for some countries in Africa, mid-East, India or SE Asia ** only i.m. IPV (original Salk); oral polio vaccine no longer available

Arthropod- or insect-borne diseases of most concern for international travel  malaria : anti-malaria pills before, during, & after your trip, as directed  yellow fever : modified-live virus vaccine; good for 10 years  dengue fever : no vaccine or pill available  Japanese encephalitis : 2 - vaccine series; one month apart  African or American trypanosomiasis : no vaccines or pills available  Tick-borne encephalitis; no vaccine in U.S.

Malaria – endemic in W. Hemisphere map from CDC web site.

Malaria – endemic in E. Hemisphere map from CDC web site

Mefloquine–resistant Malaria ; E. Hemisphere map from CDC web site.

Yellow Fever - endemic in the Americas map from CDC web site.

Yellow Fever - endemic in Africa map from CDC web site.

Dengue – endemic in the W. Hemisphere map from CDC web site.

Dengue – endemic in the E. Hemisphere map from CDC web site.

Japanese Encephalitis virus – endemic risk areas E. Hemisphere map from CDC web site.

Counseling (primary prevention) Re: insect/arthropod avoidance & animal bites zProtect yourself from insects: well-screened residence; and dusk & dawn: wear long sleeves & long pants; & use 25-50% DEET repellent; do not use scented toiletries … may need permethrin-impregnated bed nets * dengue (usually day-time biters); ** malaria (often night-time biters) zTake anti-malarial preventive Rx before, during, & after the trip, as directed. zWhen in E. African “savanna”, wear long sleeves & trousers; both of tan / khaki or other neutral colors zdon’t handle monkeys, dogs, cats, bats; avoid animal bites zavoid poisonous / venomous species (snakes, jellyfish, etc)

Water- / Food-borne ( hand-to-mouth ) diseases of most concern for international travel  hepatitis A: good vaccines available; booster 6-12 months  typhoid: good Vi capsular polysaccharide vaccine available (inject) [oral vaccine available once again; however, matter of compliance]  many others ; viruses, bacteria, and parasites: * adequate food & water hygiene  polio: possible IPV booster, if none since 18 y/o  cholera: poor vaccine efficacy; vaccine now unavailable in US * adequate food & water hygiene

Counseling (primary prevention) Re: food & water ‘hygiene’  Drink only bottled water, boiled water, and/or factory-sealed carbonated beverages … if water is “suspect”, ice is also suspect zMay want to take iodine tablets --- to “treat” boiled water  Foods: “wash it, peel it, boil or cook it … or forget it !!” * don’t eat food purchased from street vendors * generally, avoid dairy products in developing nations (pasteurization often suspect) * cold vegetable & fruit salads, and puddings are especially risky  take over-the-counter anti-diarrheal medications that you use at home; unwise to routinely take a broad-spectrum antibiotic

Person-to-person transmitted diseases of most concern for international travel  Influenza: esp those > 65 y/o, or w/cardio-respiratory co-morbidities.  hepatitis B: esp for those who do medical mission work, or who plan to have sexual contact w/“natives” while traveling.  meningococcal disease: esp in sub-Saharan Africa; also Saudi Arabia during the annual hajj.  measles & rubella: esp young children traveling internationally.  pneumococcal disease: esp for those > 65 y/o, and w/cardio- respiratory co-morbidities.  diphtheria & pertussis: esp those traveling to E. Europe.  all STDs ( including HIV ): esp in young, single, and/or sexually-active.

countries with recent Epidemics of Meningococcal Meningitis map from CDC web site.

Counseling (primary prevention) Re: personal hygiene zWash hands often w/soap & water. zprevent fungal & parasitic infections: keep feet clean/dry, and do not go barefoot, esp. on “unclean” beaches. - Freshwater swimming: only in adequately chlorinated pools. zDon’t share needles w/anyone; & if sex, then safest sex !! ztake: sun-block, sun glasses, broad-brimmed hat, as needed zIf going to High altitude, > 7000 ft, altitude illness; Rx: acetazolamide [ Diamox ® ] at 125mg QID mg, BID zall medications: Keep them in original containers !! … take enough for time + few days; take copy of ‘scripts’

Sources of information : Disease risks in countries outside the USA  US Centers for Disease Control & Prevention (CDC): “ Travelers’ Health Topics ” * [on-line] * a very “rich” source  Pro-MED Digest; moderated listserve (several times/week)  Various other on-line sites: i.e., World Health Organization (WHO); vaccine manufacturers; Eurosurveillance weekly; & many others  an atlas; US State Dept. web site; your state Health Dept; and/or you may wish to consult an infectious disease physician

Questions ?? zI’m enjoying a great trip through life, and many of you have been a part of it; thanks …