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John Leander Po, MSc, MD, PhD President, Arizona Infectious Diseases Society (ARIDS) Chair, Infectious Diseases Section, Banner Estrella Medical Center Clinical Assistant Professor, University of Arizona College of Medicine- Phoenix Arizona Infectious Disease Training and Exercise Arizona State University Memorial Union July 27,2011 EMERGING INFECTIOUS DISEASES (EID): The Returning Traveler

EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

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Page 1: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

John Leander Po, MSc, MD, PhDPresident, Arizona Infectious Diseases Society (ARIDS)

Chair, Infectious Diseases Section, Banner Estrella Medical Center

Clinical Assistant Professor, University of Arizona College of Medicine- Phoenix

Arizona Infectious Disease Training and ExerciseArizona State University Memorial Union

July 27,2011

EMERGING INFECTIOUS DISEASES (EID):The Returning Traveler

Page 2: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Objectives• Acknowledge how global travel has affected the

spread of EIDs

• Understand the factors that contribute to the emergence of EIDs

• List the groups of EIDs seen in returning travelers

• Know the trends of diagnoses of EIDs in returning travelers

• Be aware of Internet resources available to the healthcare provider of a retiring traveler.

Page 3: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Longer Distance, Shorter travel timeAll within the past century!

Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719.

2wks

1 wk 1 day

Average travel time ,England to Australia 1925–2000

Page 4: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Global Shipping (2008) and Airline Routes (2010)

Halpern et al. (2008) Global Map of Human Impacts to Marine Ecosystems. Santa Barbara, National Center for Ecological Analysis and Synthesis. http://spatial-analyst.net/wiki/index.php?title=Image:Shipping_routes.png Accessed: 17July2011

Distribution of global airports and flight routes accessed from the openflights.org Accessed: 17July2011http://spatial-analyst.net/wiki/index.php?title=Image:Airroute.png

Diversity of Travel Types

Page 5: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Increased Number of TravelersReturning to the US Since 1950

IOM (Institute of Medicine). 2010. Infectious disease movement in aborderless world. Washington, DC: The National Academies Press.

International tourist arrivals by region (in millions) 1950-2020.

Page 6: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Global Differences in Health Care Capabilities

IOM (Institute of Medicine). 2010. Infectious disease movement in aborderless world. Washington, DC: The National Academies Press.

Page 7: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719
Page 8: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Why does it matter?

Page 9: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Economic Impact Measured in Billions

Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html

Page 10: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Scenario

• 28 year old businessman presents to the ED with 4 days of fever, loose stool, dysuria and an erythematous rash…– 1 week after returning from India – New Delhi Sheraton, 2 weeks (seminar)– Immigrated to the US as a teenager – Saw parent in a large New Delhi medical center– Visited family in a village in rural province

– No PPX for malaria

Page 11: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Where does one start?What does this case highlight?

Factors in the emergence of EIDs

Page 12: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

IOM (Institute of Medicine). 2010. Infectious disease movement in aborderless world. Washington, DC: The National Academies Press.

BLAH-BLAH-BLAH….

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TRAVELERSOCIO-

ECONOMICSENVIRONMENT

CLIMATE

ANIMALSECOLOGY

EIDs from the returning traveler:

Convergence of Systems

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“The Returning Traveler”…from where?

– Maricopa County?– Arizona?– Southwestern US?– US?– North America?– Sub-Saharan Africa?– United Kingdom?

TRAVELERSOCIO-

ECONOMICSENVIRONMENT

CLIMATE

ANIMALSECOLOGY

Page 15: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Eisenberg JNS, et al. Environmental Health Perspectives • VOLUME 115 | NUMBER 8 | August 2007

Page 16: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

“The Returning Traveler”…from what?

– Business trip?– Safari?– Ecotour?– Missionary work?– Family reunion?– Sex tour?

TRAVELERSOCIO-

ECONOMICSENVIRONMENT

CLIMATE

ANIMALSECOLOGY

Page 17: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Factors to Consider: Risk in Returning Travelers

• Consumption– Potable water safety– Food types (raw, cooked)

• Activities– Activities in fresh water– Adventure travel, including spelunking– Sexual contacts, tattoos, body piercing

• Exposures: – Insect and arthropod bites (mosquito, tick, other)– Animal bites and scratches– Hospitalizations and other medical care

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-5-post-travel-evaluation/general-approach-to-the-returned-traveler.htm#2926Centers for Disease Control and Prevention. CDC Health Information for International Travel 2012. New York: Oxford University Press; 2012. Accessed July 25, 2011

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“The Returning Traveler”…“in what state?”

– Immunocompromised?– Vaccinated?– Aware of risks?– Medications?

TRAVELERSOCIO-

ECONOMICSENVIRONMENT

CLIMATE

ANIMALSECOLOGY

Page 19: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Factors to Consider: Preparation

• Past medical history and medications• Travel purpose, itinerary (duration)

• Association with mass gathering (Hajj, for example)

• Type of accommodation• Use of bed nets and insect repellents

• Pre-travel prophylaxis• immunization history• Adherence to malaria chemoprophylaxis (before,

during, and after travel)

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-5-post-travel-evaluation/general-approach-to-the-returned-traveler.htm#2926Centers for Disease Control and Prevention. CDC Health Information for International Travel 2012. New York: Oxford University Press; 2012.

Page 20: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

EID

SanitationFarming

Deforestation

ReproductivityDisplacement

Biodiversity changes

EncroachmentFood source

Domestication

TRAVELERSOCIO-

ECONOMICS

ANIMALSECOLOGY

ENVIRONMENTCLIMATE

P. Daszak et al, 2011. Wildlife & Emerging Diseases: drivers, maps and the road ahead.

Page 21: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

P. Daszak et al, 2011. Wildlife & Emerging Diseases: drivers, maps and the road ahead.

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Imported measles cases in U.S. residents

January 2001-February 2011(N = 172) by age group

Spectrum of DiseaseThe Returning Traveler

DISEASEEMERGENCE

PERSISTENCERE-EMERGENCE

Dengue

Chikungunya

Duvenhage virus XDR M.

tuberculosis

NDM-1 E. coli

MDR Gonorrhea

Influenza

Measles

Anthrax

Page 23: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

EID HOTSPOTS

• Jones et al (2008) 335 EID events from 1940-2004– Non-random pattern– Reporting bias: trend continues to hold despite factoring into

data

• Distribution of EIDs– 60.3% Zoonoses (72% wildlife)– 54.3% Bacterial or Rickettsial

• World “hotspots”– Socio-economics– Environment– Ecology

Jones et al, Nature 451, 990-993 (21 February 2008)

DISEASEEMERGENCE

Page 24: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html

ZOONOTIC, WILDLIFE ZOONOTIC, NON-WILDLIFE

DRUG RESISTANT PATHOGENS

VECTOR-BORNE

Page 25: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

EID events from 1940 2004

Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html

Page 26: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

DISEASEEMERGENCE

PERSISTENCERE-EMERGENCE

SanitationFarming

Deforestation

ReproductivityDisplacement

Biodiversity changes

EncroachmentFood source

Domestication

TRAVELERSOCIO-

ECONOMICS

ANIMALSECOLOGY

ENVIRONMENTCLIMATE

P. Daszak et al, 2011. Wildlife & Emerging Diseases: drivers, maps and the road ahead.

Page 27: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Trends in Diagnoses of EIDs:The Returning Traveler

Page 28: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

GeoSentinel network

Joseph Torresi & Karin Leder, Nature Reviews Microbiology 7, 895–901

Page 29: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

GeoSentinel network and reporting structure.

Joseph Torresi & Karin Leder, Nature Reviews Microbiology 7, 895–901. 2008

Page 30: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Number of EID events per decade.

Nature 451, 990-993(21 February 2008)

Mainly BacterialIncreased viruses & prions

IncreasedZoonotic Transmission

Page 31: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Nature 451, 990-993(21 February 2008)

Number of EID events per decade.Increased drug

resistanceIncreased

Non-vector-borne transmission

Page 32: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Common Diseases in Travelers Reporting to the GeoSentinelNetwork.

Joseph Torresi & Karin Leder, Nature Reviews Microbiology 7, 895–901

Page 33: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

% Febrile Travelers Dx with More Common Infectious Diseases, (Region of Travel)

Sub-saharan Africa: Malaria, Respiratory, Diarrhea

Northern Africa:Diarrhea, Respiratory, Malaria

Joseph Torresi & Karin Leder, Nature Reviews Microbiology 7, 895–901, 2008

Page 34: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Returning Traveler: General trends• Malaria within the top 3 dx from every region

• Febrile illness: likely from Africa & Southeast Asia– Sub-Saharan Africa: 1) Malaria 2) Rickettsial disease

• Most common febrile illness from every region outside sub-Saharan Africa: Dengue (past 10 yrs)

• Southeast Asia: Respiratory disease most likely

• Southcentral Asia: Acute diarrhea disproportionately in travelers

Page 35: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

Selected emerging diseases 430 B.C. to 1981 A.D.MDR = multidrug-resistant; SARS = severe acute respiratory syndrome;

vCJD = variant Creutzfeldt-Jakob disease; XDR = extensively drug-resistant.

Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html accessed 19Jul2011

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Selected emerging diseases 1977-2007(representative examples of where epidemics occurred)

Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html

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New and ongoing outbreaks since June 16, 2011

http://www.healthmap.org/predict/

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Scenario

• 28 year old businessman presents to the ED with 4 days of fever, loose stool, dysuria and an erythematous rash…– 1 week after returning from India – New Delhi Sheraton, 2 weeks (seminar)– Immigrated to the US as a teenager – Saw parent in a large New Delhi medical center– Visited family in a village in rural province

– No PPX for malaria

Page 39: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

DISPROPORTIONATE INFECTIOUS DISEASE RISKS IN VFRS*

• Lack of awareness of risk (over-confidence)– Lower rates of vaccination (HAV, Typhoid)– Infrequent use of malaria chemoprophylaxis– Less mosquito netting use; food/water use

• Pre-travel health care barriers– ≤30% have a clinic visit– Financial barrier– Clinics are not geographically convenient

• Cultural and language barriers – Lack of trust in the medical system

• Higher-risk destinations– Longer stays– Last minute planning

http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-8-advising-travelers-with-specific-needs/immigrants-returning-home-to-visit-friends-and-relatives-vfrs.htmCenters for Disease Control and Prevention. CDC Health Information for International Travel 2012. New York: Oxford University Press; 2012.

*Immigrants Returning Home to Visit Friends & Relatives

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CDC Travelers’ Healthhttp://wwwnc.cdc.gov/travel/

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Promedmail.orghttp://www.promedmail.org

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Geosentinelhttp://www.istm.org/geosentinel/

main.html

Page 43: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719

MD Travel Healthhttp://mdtravelhealth.com/

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JULY 18, 2011

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http://www.polioeradication.org/Aboutus/Progress/Progresstowardspolioeradication.aspx

Polio Outbreak in Tajikistan, Cases in Russia, Ri Central Asian Countries

July 18, 2011 at 18:05 EDT

Page 46: EMERGING INFECTIOUS DISEASES: The Returning …...Longer Distance, Shorter travel time All within the past century! Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719