1. Travel Health, Summer 2008 Adapted from: Martha C. Carlough, MD, MPH

2. Objectives: Review general immunization tips Reminder: go to Student Health for immunizations Mosquito borne diseases: general information, prevention strategies Traveler's diarrhea: general information, prevention strategies, treatment

3. Travel health supplies: Sun screen Sun glasses Spare glasses Prescription meds Band-aids Thermometer Analgesics Antiseptics Disposable syringes Mosquito Repellant Malaria Prophylaxis Diarrhea Rx Antiseptic Hand Gel Passport and Copy Immunization card Info about US Embassy and English speaking clinics Traveler’s Insurance

4. 10 Commandments of Travel Medicine Consult thy health care provider long before leaving Thou shalt wear seat belts and helmets Thou shalt take thy malaria pills as directed Thou shalt prevent insect bites Thou shalt eat and drink wisely Thou shalt not go swimming in unchlorinated fresh water Thou shalt wear thy shoes Thou shalt make new friends but be careful Thou shalt be prepared for emergencies Thou shalt finish thy malaria medicine when returning Dr. Elaine Jong

5. Travel vaccinations: Costly, painful, but potentially life-saving….. Contact with unvaccinated population = loss of herd immunity and increased disease risk Procrastination a major problem: ideally see patients AT LEAST one month before travel Often travel vaccines are not covered by health insurance Three categories: recommended, required and routine

6. General rules for immunizations: Immunocompromised or pregnant patients should not receive live vaccines All traveling pts, but especially those going to a yellow fever risk country, should carry an yellow immunization card with their passport If children are traveling, their routine childhood vaccines should also be up to date Immunization availability, recommendations and geographic specificity are constantly changing….don’t count on memory for recommendations

7. Mosquito borne infections:  Dengue  Malaria  Yellow fever  Japanese B encephalitis

9. Prevent mosquito exposure: Avoid bites – long sleeved, light clothing, avoid being out at dawn/dusk, don’t walk barefoot, don’t dry clothes on the ground, use insecticide (Permethrin) treated bednets (ITNs) Long termers should choose housing carefully to avoid fecund water; window screens DEET containing insect repellant (17-35%) N,N diethyl-m-toluamide apply to skin at dusk—not on clothes/gear Toxicity risk in children on high concentrations (10-12% is safe) “Avon skin-so-soft” – it’s worthless No uniform approach to malaria prophylaxis exists —many “go bare”, have inadequate coverage or inappropriate coverage – counsel appropriately Alternative med coverage – papaya, Thiamine, U/S

10. Dengue “Breakbone” Fever Flaviviruses (RNA), 4 types, transmitted by Aedes aegypti mosquito Bite during the DAY Typically breed in water containers More common in the fall 100 million infections each year and rising - ?due to global warming In Honduras (2002) there were 32,000 cases of dengue and 863 cases of hemorrhagic dengue

11. Classic Dengue: 2-7d incubation w/ sudden onset of HA, fever, arthralgias, conjunctivitis, eyelid puffiness, facial flushing, palmar erythema, nausea/vomiting, lymphadenopathy and rash lasting 1-5d after fever (supportive treatment only), about half of cases have thrombocytopenia, usually less severe in younger pts

12. Dengue Hemorrhagic Fever <10% of cases Shock syndrome Initial course followed 3-7 days later by hypotension, tachycardia, petechiae, GI hemorrhage and renal failure

13. WHO diagnostic criteria for DHF Fever for 2-7 days Thrombocytopenia (<100,000/mm 3 ) Increased vascular permeability (ex: hemoconcentration with 20% increase in HCT, pleural effusion, ascites) Bloody gums, hematuria, menorrhagia + tourniquet test or other hemorrhagic sign (Other lab findings: leukopenia,  AST)

15. Inflate BP cuff to a level between the SBP and DBP for 5 minutes. A positive test is if there are 20 or more petechiae per square inch

16. Treatment of Dengue Supportive- oral fluids, IVF (D 5 NS), transfusions x 48 hours Colloidal solutions for severe shock Tylenol better than ibuprofen Cover patient with bednet to prevent spread

17. Prevention Community-based approaches cover or get rid of open water containers where larvae breed use copepods or fish that eat larvae, larvicides Wear long sleeves/ long pants Use DEET and ITNs Don’t leave the US

18. Malaria Types Definition: potentially fatal blood borne parasitic disease spread from person to person through bites of infected female Anopheles mosquitoes Plasmodium vivax – 50% world malaria, temperate (liver phase adaptation) and tropical, some chloroquine resistance in PNG and Indonesia and spreading; recurrent attacks Plasmodium falciparum—40% (most dangerous), tropical, chloroquine resistance wide spread P. ovale – W. Africa and spotty elsewhere (liver phase) P. malaria– spotty, mildest (infects other primates and humans), persists in blood (not liver) x years

20. What’s Wrong With This Picture?

21. Malaria - Basic facts 300-500 million infections each year 5 species of parasite: Plasmodium falciparum, P.vivax, P.ovale, P. malariae, P. knowlesi Incubation period in P. falciparum is 12-14 days Transmitted by the Anopheles mosquito which bites most commonly between dusk and dawn 3000 children die daily from malaria in SSA; 10,000 pregnant women die per year

22. Malaria in Travelers Malaria risk greater than ever: 30,000 world travelers infected/year—over 1000 in U.S. #1 life-threatening infectious disease for travelers: 4% -20% mortality P. falciparum Risk greatest in Africa and SE Asia Resurgence due to chloroquine-resistant P. falciparum (CRPF) and mosquito resistance to insecticides

23. Malaria Risk One month travel without prophylaxis Oceania1:5 Africa1:50 S.Asia1:250 S.E.Asia1:2,500 C. America 1:10,000

24. Map of drug resistance

25. Uncomplicated malaria Fever/chills Headache Myalgias N/V, diarrhea Dry cough

26. Complications of malaria Anemia Hypoglycemia P. falciparum only: cerebral malaria (coma, seizures) renal failure ( “ black water fever ” – hematuria) pulmonary edema

27. Treatment in Honduras Uncomplicated Chloroquine Adults: Oral: 1 g on day 1, followed by 500 mg 6 hours later, followed by 500 mg on days 2 and 3. Children: Oral: 10 mg/kg (base) on day 1, followed by 5 mg/kg 6 hours later and 5 mg/kg on days 2 and 3

28. Treatment in Honduras Complicated malaria Supportive care: Hydration, replace electrolytes and glucose, watch for renal failure and pulmonary edema, use benzodiazepines for seizures, Tylenol IV quinine for a 7 day course When able, add additional oral med (Fansidar or Doxycyclcine)

29. MY VACATION

30. Traveler’s diarrhea: to pre-treat or not to pre-treat??? Usually caused by enterotoxigenic e. coli and is a self limiting disease lasting only a few days. Less common causes: Campylobacter, Shigella, Salmonella, Yersinia, Amoebiasis, Giardiasis, other parasites (Giardia, Entameba, Cryptosporidium), viral (Rotavirus, Norwalk-like virus). BAD SIGNS: FEVER, BLOOD, COLIC

31. Traveler’s Diarrhea - Options: CDC does NOT recommend pre-treatment unless special circumstances Consider for high risk patients e.g. immune compromise, leukemia, chronically ill, reduced gastric acid (those taking PPI, H2 blockers) Contraindication: stay > 3 weeks Options: Bismuth subsalicylate two 262 mg tab QID Ciprofloxacin 500 mg daily Trimethoprim-Sulfamethoxazole DS one q day Doxycycline 100 mg daily

32. Best recommendation is prevention: The world is covered with a thin layer of feces Avoid cooled or reheated foods Peel/iodinate all fruits and vegetables Be certain utensils (and cook’s hands!) are clean and dry. No ice! Boil It, Cook It, Peel It or Forget It

33. The choice…boil, filter, treat: Disinfect water by boiling 3-5 minutes Chemical disinfection of water chlorine bleach 5% tincture of iodine 2% tetraglycine hydroperiodide tablets (Potable Aqua) Filter Pumps – with micropore or ceramic core – have to be less than 0.2 microns to filter bacteria/giardia Pregnant women should drink BOILED water because of the Hepatitis E risk

34. Treatment for traveler’s diarrhea: Tincture of time, and lots of fluids (ORS) Avoid lactose products Consider Immodium for NON-BLOODY diarrhea…. 4mg x 1, then 2mg after each stool If associated with fever or bloody stools or not resolving: Cipro or Norflox TMP-SMZ for children

35. Wash Your Hands Before Eating!!!

36. Traveling during pregnancy: It is difficult to get insurance, particularly for evacuation, that covers pregnancy – check in advance Hand carry records; have appropriate expectations for care Pregnancy and airplanes – 32 weeks international, 36 weeks domestic limits (need letter from MD), walk/support stockings, seat belt below belly….. Avoid insect bites (malaria is more severe in pregnancy) – up to 20% DEET has been demonstrated to be safe Adventure sports – avoid water skiing, scuba diving, or travel over 12,000 ft. Remember, center of gravity changes during pregnancy – increased risk of falls.

37. General travel health recommendations: Decrease risk of DVT’s – one ASA per day of travel on airplanes Jet lag - In general, it takes one day per time zone to recover Avoid caffeine and alcohol and drink plenty of water Get out in the sunlight when you arrive for a few hours and DON’T nap Shower/bathe after arrival to rehydrate Melatonin – limited evidence, but many find useful (3-6mg)

38. Travel Health Information – Governmental and Non-Profit www.cdc.gov/travel/www.cdc.gov/travel/ CDC Travel Info www.who.int/ith/www.who.int/ith/ World Health Organization www.paho.orgwww.paho.org – Pan American Health Organization www.cyinfo.comwww.cyinfo.com – GIDEON – international surveillance of disease www.hc-sc.gc.cawww.hc-sc.gc.ca – Health Canada www.travel.state/govwww.travel.state/gov - State Department

39. Travel Health Information - Malaria www.malaria.org/www.malaria.org/ - Malaria Foundation Inter’l www.rbm.who.intwww.rbm.who.int – WHO Roll Back Malaria

40. Travel Health Information - Commercial www.tripprep.comwww.tripprep.com - Travel Health On Line www.travmed.comwww.travmed.com – Travel Medicine www.travdoc.comwww.travdoc.com – TravDoc www.mdtravelhealth.comwww.mdtravelhealth.com – MD Travel Health www.travelhealth.co.ukwww.travelhealth.co.uk – Travel Health UK www.masta.orgwww.masta.org – Minding Your Health Abroad

41. Travel Health Information – Specialty areas Mountain medicine – www.thebmc.co.ukwww.thebmc.co.uk Pregnant Traveler – www.pregnanttraveler.com www.pregnanttraveler.com Airplane travel health - http://www.flighthealth.org http://www.flighthealth.org Patient education materials – www.cdc.gov www.familydoctor.orgwww.familydoctor.org (healthy living)

42. Travel Health – Societies/Agencies www.istm.org/www.istm.org/ International Society of Travel Medicine www.astmh.orgwww.astmh.org American Society of Tropical Medicine and Hygiene www.iamat.orgwww.iamat.org – International Association for Medical Assistance to Travelers

43. THE END