Travel Health, Summer 2008Adapted from:

Martha C. Carlough, MD, MPH

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

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

10 Commandments of Travel Medicine

Consult thy health care provider long before leavingThou shalt wear seat belts and helmetsThou shalt take thy malaria pills as directedThou shalt prevent insect bitesThou shalt eat and drink wiselyThou shalt not go swimming in unchlorinated fresh waterThou shalt wear thy shoesThou shalt make new friends but be carefulThou shalt be prepared for emergenciesThou shalt finish thy malaria medicine when returning

Dr. Elaine Jong

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

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

Mosquito borne infections:

Dengue Malaria Yellow fever Japanese B encephalitis

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 screensDEET 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 appropriatelyAlternative med coverage – papaya, Thiamine, U/S

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

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

Dengue Hemorrhagic Fever

<10% of cases

Shock syndrome

Initial course followed 3-7 days later by hypotension, tachycardia, petechiae, GI hemorrhage and renal failure

WHO diagnostic criteria for DHF

Fever for 2-7 daysThrombocytopenia (<100,000/mm3)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)

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

Treatment of Dengue

Supportive- oral fluids, IVF (D5NS), transfusions x 48 hours

Colloidal solutions for severe shock

Tylenol better than ibuprofen

Cover patient with bednet to prevent spread

Prevention

Community-based approachescover 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

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

What’s Wrong With This Picture?

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

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. falciparumRisk greatest in Africa and SE AsiaResurgence due to chloroquine-resistant P. falciparum (CRPF) and mosquito resistance to insecticides

Malaria Risk

One month travel without prophylaxis

Oceania 1:5Africa 1:50S.Asia 1:250S.E.Asia 1:2,500C. America 1:10,000

Map of drug resistance

Uncomplicated malaria

Fever/chills

Headache

Myalgias

N/V, diarrhea

Dry cough

Complications of malaria

Anemia

Hypoglycemia

P. falciparum only:

cerebral malaria (coma, seizures)

renal failure (“black water fever” – hematuria)

pulmonary edema

Treatment in Honduras

Uncomplicated

ChloroquineAdults: 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

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)

MY VACATION

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

Traveler’s Diarrhea - Options:CDC does NOT recommend pre-treatment unless special circumstancesConsider for high risk patients e.g. immune compromise, leukemia, chronically ill, reduced gastric acid (those taking PPI, H2 blockers)Contraindication: stay > 3 weeksOptions:

Bismuth subsalicylate two 262 mg tab QIDCiprofloxacin 500 mg dailyTrimethoprim-Sulfamethoxazole DS one q dayDoxycycline 100 mg daily

Best recommendation is prevention:

The world is covered with a thin layer of fecesAvoid cooled or reheated foodsPeel/iodinate all fruits and vegetablesBe certain utensils (and cook’s hands!) are clean and dry.No ice!

Boil It, Cook It, Peel It or Forget It

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

Treatment for traveler’s diarrhea:

Tincture of time, and lots of fluids (ORS)Avoid lactose productsConsider 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 NorfloxTMP-SMZ for children

Wash Your Hands Before Eating!!!

Traveling during pregnancy:It is difficult to get insurance, particularly for evacuation, that covers pregnancy – check in advanceHand carry records; have appropriate expectations for carePregnancy 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 safeAdventure sports – avoid water skiing, scuba diving, or travel over 12,000 ft. Remember, center of gravity changes during pregnancy – increased risk of falls.

General travel health recommendations:

Decrease risk of DVT’s – one ASA per day of travel on airplanesJet lag - In general, it takes one day per time zone to recoverAvoid caffeine and alcohol and drink plenty of waterGet out in the sunlight when you arrive for a few hours and DON’T napShower/bathe after arrival to rehydrateMelatonin – limited evidence, but many find useful (3-6mg)

Travel Health Information – Governmental and Non-Profit

www.cdc.gov/travel/ CDC Travel Infowww.who.int/ith/ World Health Organizationwww.paho.org – Pan American Health Organizationwww.cyinfo.com – GIDEON – international surveillance of diseasewww.hc-sc.gc.ca – Health Canadawww.travel.state/gov - State Department

Travel Health Information - Malaria

www.malaria.org/ - Malaria Foundation Inter’l

www.rbm.who.int – WHO Roll Back Malaria

Travel Health Information - Commercial

www.tripprep.com - Travel Health On Line

www.travmed.com – Travel Medicine

www.travdoc.com – TravDoc

www.mdtravelhealth.com – MD Travel Health

www.travelhealth.co.uk – Travel Health UK

www.masta.org – Minding Your Health Abroad

Travel Health Information – Specialty areas

Mountain medicine – www.thebmc.co.uk Pregnant Traveler – www.pregnanttraveler.com Airplane travel health - http://www.flighthealth.orgPatient education materials –

www.cdc.govwww.familydoctor.org (healthy living)

Travel Health – Societies/Agencies

www.istm.org/ International Society of Travel Medicine

www.astmh.org American Society of Tropical Medicine and Hygiene

www.iamat.org – International Association for Medical Assistance to Travelers

THE END