Disclosures. Travel Medicine. Lecture Outline 1. Why should you know about travel medicine? 2. The pre-travel visit 3. Post-travel evaluation

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1 Travel Medicine Disclosures David Sears, MD Assistant Professor UCSF, Division of Infectious Diseases None Lecture Outline 1. Why should you know about travel medicine? 2. The pre-travel visit 3. Post-travel evaluation Lecture Outline 1. Why should you know about travel medicine? 2. The pre-travel visit 3. Post-travel evaluation 1

2 International Travelers Travelers Crossing International Borders ~1 billion travelers cross international borders each year 74 million United States residents traveled internationally in 2015 Almost half traveled to a developing country UNWTO World Tourism Barometer. World Tourism Organization; 2011.Office of Travel and Tourism Industries 2010 Outbound Analysis, US Dept of Commerce Outbound Analysis: 2015 U.S. Travel and Tourism Statistics Keystone. Travel Medicine 3 rd Ed What is the magnitude of travel related morbidity/mortality? 20-70% had some health impairment while abroad ~8% will seek medical care while abroad Infectious diseases are common Keystone. Travel Medicine 3 rd Ed Hill. CID 2006; 43; Keystone. Travel Medicine 3 rd Ed

3 What is the magnitude of travel related morbidity/mortality? Who should seek pre-travel care? Fatalities in French Travelers Travelers to resource poor settings Travelers with significant medical issues Keystone. Travel Medicine 3 rd Ed Lecture outline 1. Why should you know about travel medicine? 2. The pre-travel visit 3. Post-travel evaluation Pre-Travel Consultation 1. Assess the health of the traveler 2. Assess the risk of travel 3. Educate 4. Vaccinate 5. Prescribe 3

4 Pre-Travel Consultation 1. Assess the health of the traveler 2. Assess the risk of travel 3. Educate 4. Vaccinate 5. Prescribe Assess the Health of the Traveler Exacerbation of underlying illnesses is the most common cause of fatality in US travelers Disease Chronic pulmonary disease CAD Thrombophilic state IDDM Neurovascular disease Immunosuppression Consideration 1) If not on O2 but PaO2 <70 give 2L for flight 2) If on O2 then increase by 1-3L/min for flight Delay if recent MI DVT prevention Letter for needles/syringes Delay if recent CVA May affect vaccination and prophylactic decisions Pre-Travel Consultation 1. Assess the health of the traveler 2. Assess the risk of travel 3. Educate 4. Vaccinate 5. Prescribe Main Purpose of Travel 2015 U.S. Travelers Vacation (53%) Visiting Friends or Family (27%) Business (10%) Miscellaneous (7%) Conventions (3%) 2015 Outbound Analysis: 2015 U.S. Travel and Tourism Statistics 4

5 Assess the Risk of Travel CDC Yellow Book Your resource for assessing geographic and seasonal risk Destination(s) Season Duration of stay Planned activities Accommodations Purpose of travel Pre-Travel PREP Searchable resource linked to CDC Yellow Book data Pre-Travel Consultation 1. Assess the health of the traveler 2. Assess the risk of travel 3. Educate 4. Vaccinate 5. Prescribe 5

6 Educational Topics Accident prevention Insect avoidance Safe food and water Altitude Safe sex Animal avoidance Scuba Travel insurance Educational Topics Accident prevention Insect avoidance Safe food and water Altitude Safe sex Animal avoidance Scuba Travel insurance Non-Natural Causes of Death Among US Travelers WEAR A HELMET!!! (or, better yet, don t ever get on a motorbike) Natural Disaster Maritime Accident Air Accident Drug-Related Terrorism Car Accident (Ped) Other Accident Drowning Homicide Suicide Car Accident July 2015 June

7 Educational Topics Accident prevention Insect avoidance Safe food and water Altitude Safe sex Animal avoidance Scuba Travel insurance Mosquitoes Viruses Dengue fever Chikungunya fever Zika virus Jap. encephalitis Yellow fever WNV Protozoa Malaria Helminths Filariasis Insects Botfly Which Insect Repellant to Use? Product Active Ingredient Complete Protection Time OFF Deep Woods DEET (24%) 302 minutes Picardin 20% (Sawyer) Picardin (20%) >300 minutes Sawyer Controlled Release DEET (20%) 234 minutes OFF Skintastic DEET (8%) 112 minutes OFF Skintastic for kids DEET (4.75%) 88 minutes Avon Skin So Soft + IR3535 IR3535 (7.5%) 23 minutes Herbal Armor Citronella (12%) 14 minutes Apply sunscreen before repellant Where pants and long sleeves Use permethrintreated clothing Mosquito nets at night Other Strategies Fradin MS, Day JF. NEJM 2002; 347; Roey. PLoS Negl Trop Dis 2014 Dec; 8(12): e

8 Dengue Fever Mosquito vector: Aedes species (primarily daytime feeder) Between million infections yearly Also cases in Africa (likely more in coastal countries of sub-saharan Africa) US dengue: endemic in Puerto Rico, prior outbreaks in FL, HI, TX Dengue Fever: Clinical Disease Incubation: Short (4-7 days); if symptoms start >14d after exposure unlikely to be dengue Clinical Manifestations: Fever, headache, joint and muscle aches Nausea and vomiting Rash Lab abnormalities: leukopenia, thrombocytopenia, transaminitis Dengue Hemorrhagic Fever/Shock Occurs 3-7 days into illness, often w/ end of fever Flushing erythema 1-2 days post onset of symptoms 3-5 days Dengue rash Morbilliform eruption w/ petechiae and islands of sparing Viral load detected by RT-PCR Dengue Diagnostics Viraemia NS1 IgG IgM Acute illness Days Antibodies quantified by ELISA 1-7 days since symptom onset: test serum for dengue RT-PCR and IgM by ELISA (if either is + this is confirmatory in right clinical context) >7 days since symptom onset: test serum for IgM by ELISA (if + this is confirmatory in right clinical context) **IgM can cross-react with other flaviviruses (WNV, Zika) Pincus. J Am Acad Dermatol 2008; 58; Guzman. Nature Reviews Micro 2010; 8; S7-S16 8

9 Chikungunya Fever Mosquito vector: Aedes species (primarily daytime feeder) No local transmission in the Americas until late 2013; now endemic US chikungunya: some local transmission in Puerto Rico, FL, and US Virgin Islands Chikungunya Fever: Clinical Disease Incubation period 2-4 days (1-14); if symptoms start >14d after exposure unlikely to be chikungunya Clinical manifestations (resolve within 7d) Fever + Polyarthralgias 2-4 days later Rash: ~ 50%, maculopapular Labs: Lymphopenia, thrombocytopenia, transaminitis Severe complications/deaths in elderly Chikungunya Diagnostics 1-7 days since symptom onset: test serum for chikungunya RT-PCR and IgM by PCR or IFA (if either + this is confirmatory in right clinical context) >7 days since symptom onset: test serum for IgM by ELISA or IFA (if + this is confirmatory in right clinical context) 9

10 Lab and Clinical Features: Chikungunya vs. Dengue Antiviral Treatment Options Chikungunya Dengue Lymphopenia Neutropenia Thrombocytopenia Hemoconcentration - ++ Arthralgia Myalgia + ++ Hemorrhage - + Shock - + Note: little difference in rates of fever, HA, rash Educational Topics Accident prevention Insect avoidance Safe food and water Altitude Safe sex Animal avoidance Scuba Travel insurance Food and Water Safety Many common travel-related infections are transmitted by contaminated food/water Diarrhea Hepatitis A Hepatitis E Typhoid fever Parasites 10

11 Prevention of Food-Borne Disease Most studies failed to correlate guideline adherence to risk of travelers diarrhea Where you eat is way more important than what you eat! Safe options? Drinks: Bottled H20, soft-drinks Foods: Hot, processed, packaged, peeled Educational Topics Accident prevention Insect avoidance Safe food and water Altitude Safe sex Animal avoidance Scuba Travel insurance Altitude Acclimatize! Climb high, sleep low Descent (or O2) is the most reliable tx Acetazolamide for prevention (and tx) Educational Topics Accident prevention Insect avoidance Safe food and water Altitude Safe sex Animal avoidance Scuba Travel insurance 11

12 Educational Topics Accident prevention Insect avoidance Safe food and water Altitude Safe sex Animal avoidance Scuba Travel insurance Rabies in the US vs. the Developing World United States Exceedingly rare >90% of cases in bats, foxes, raccoons, and skunks Developing World No good surveillance data >90% of exposures and 99% of deaths are from dogs Educational Topics Accident prevention Insect avoidance Safe food and water Altitude Safe sex Animal avoidance Scuba Travel insurance Scuba and Travel Scuba and Planes If doing one dive a day: wait 12hrs before flight If doing multiple dives a day: wait 24-48hrs before flight Also, this is pretty easy for anyone to draw, so make sure your outfitter (and you) are certified Schwartz; Annals 2012; 156; ITC

13 Educational Topics Accident prevention Insect avoidance Safe food and water Altitude Safe sex Animal avoidance Scuba Travel insurance Pre-Travel Consultation 1. Assess the health of the traveler 2. Assess the risk of travel 3. Educate 4. Vaccinate 5. Prescribe Vaccine Preventable Diseases Travel-Related Vaccines Routine vaccines should be up to date Required vaccines Other travel-related vaccines May Be Required Yellow fever Meningococcus* Polio* *By Saudi Arabia for pilgrims during the Hajj Others to Consider Hepatitis A Hepatitis B Typhoid fever Japanese encephalitis Rabies vaccine 13

14 Yellow Fever Clinical Transmission : mosquitoes Risk 50/100,000 in W. Africa and 5/100,000 in S. America Sx: ranges from mild fever/ha to biphasic illness w/ multi-organ failure Vaccine: live-attenuated, single dose for most patients Typhoid Fever Clinical Transmission: food/water Risk: 400 cases annually US Travel #1 risk factor Sx: fever +/- diarrhea (~2/3) +/- sepsis Vaccines (50-80% protective): two options Intramuscular (inactivated) booster Q2 years Oral (live attenuated) booster Q5 years Check WHO Country List of Requirements CDC Yellow Book 2016 Other Travel-Related Vaccines Disease Notes Meningococcus Travel to the meningitis belt (below) or the Hajj Polio Oral and injectable options; travel to countries w/ active/recent transmission (or the Hajj) Japanese encephalitis Rabies Recommended if staying in rural areas during transmission season in east and SE Asia Risk of animal contact +/- no access to rabies immunoglobulin Pre-Travel Consultation 1. Assess the health of the traveler 2. Assess the risk of travel 3. Educate 4. Vaccinate 5. Prescribe 14

15 Prophylaxis and Self-Treatment: Medications for Travelers Malaria Traveler s diarrhea Altitude illness Motion sickness Treatment for common acute conditions Malaria: U.S. Epidemiology About 1500 cases/yr The majority of travelers returning to the United States with malaria were -Foreign-born -Returning to their country of birth to visit family -Not prescribed malaria chemoprophylaxis 70% from Africa 70% P. falciparum Wilson. CID 2007; 44; Global Epidemiology Malaria Chemoprophylaxis Drug Areas of use Directions Pros/Cons Atovaquone/ proguanil All Daily; 1 wk post Pro: minimal SEs Con: costly Chloroquine Chloroquinesusceptible Weekly; 4 wks post Pro: weekly Con: GI upset Doxycycline Mefloquine All Mefloquinesusceptible Daily; 4 wks post Weekly; 4 wks post Pro: cheap Con: photosensitivity Pro: cheap, ok in pregnancy Con: neuropsych SEs WHO: World Malaria Report. Geneva, Switzerland: World Health Organization;

16 Returning Travelers: Treatment Travelers Diarrhea (TD) To select treatment answer the following: Severe or uncomplicated? Where was the traveler? What is the distribution of Plasmodium species and what are the rates of chloroquine resistance? Was chemoprophylaxis taken? Pregnancy test? How much do you trust your microscopist? If any doubt about the species or resistance assume the worst: P. falciparum w/ chloroquine resistance! #1 travel-related illness: 30-70% of travelers Pathogens: Bacteria 80-90%: ETEC, campy, shigella, salmonella Viruses 10%: Norovirus, rotavirus Course: Bacterial and viral diarrhea lasts 3-5 days Longer durations suggests other diseases Prevention of TD Prevention Avoidance of contaminated food/water Prophylaxis Bismuth subsalicylate 2 tabs QID Rifaximin 200 mg PO QD-BID (vs. placebo) TD: 15% vs. 54% in Mexican travelers Self-Treatment of TD Ciprofloxacin: 500 mg PO BID for 1-3 days Azithromycin: SE Asia, children, pregnancy 500 mg PO QD x 3 days or 1000 mg PO x 1 Rifaximin: not for invasive infections 200 mg PO TID x 3 days Loperamide: not for invasive infections Added benefit, use in emergency DuPont HL. Annals of Internal Medicine 2005; 142;

17 Lecture Outline 1. Why should you know about travel medicine? 2. The pre-travel visit 3. Post-travel evaluation Top 5 Complaints of Returning Travelers Leading to MD Visit Fever without localizing findings Acute diarrhea Dermatological disorders Chronic diarrhea Nondiarrheal gastrointestinal disorders Freedman. NEJM 2006; 354; Top 5 Complaints of Returning Travelers Leading to MD Visit Fever without localizing findings Acute diarrhea Dermatological disorders Chronic diarrhea Nondiarrheal gastrointestinal disorders How to Determine Etiology of Fever in Returned Traveler Patients need immediate evaluation Destination(s) Incubation period Exposures Exam findings/labs Prophylaxis/immunizations Freedman. NEJM 2006; 354;

18 Destination: Etiology of Fever by Region Visited Incubation Period Etiology of fever according to interval after travel 800 Cases Unknown Dengue EBV/CMV Rickettsia Malaria Typhoid Dengue Freedman DO. NEJM Other Considerations Zika Chikungunya Typhoid Yellow fever Carribean C. America S. America Sub Saharan Africa South Central Asia SE Asia Wilson. CID 2007; 44; Exposures? Insect? Animals? Fresh water? What did they consume and where? Sick contacts? Sexual activity? Drug use? Caves? Wounds? Bites? Initial Testing CBC w/ differential LFTs Blood cultures x 2 Thick and thin blood smear (x2-3 at 12-24hr intervals if suspicion remains) CXR Additional testing based on history, exam, and initial blood work 18

19 Top 5 Complaints of Returning Travelers Leading to MD Visit Fever without localizing findings Acute diarrhea Dermatological disorders Chronic diarrhea Nondiarrheal gastrointestinal disorders Acute Diarrhea Most likely travelers diarrhea Consider empiric treatment Ciprofloxacin, azithromycin (use in SE Asia due to FQ resistance), rifaximin (not good for invasive disease) Beware post-infectious IBS (3-10%); can persist for many months Freedman. NEJM 2006; 354; Top 5 Complaints of Returning Travelers Leading to MD Visit Fever without localizing findings Acute diarrhea Dermatological disorders Chronic diarrhea Nondiarrheal gastrointestinal disorders Freedman. NEJM 2006; 354; Most Common Dermatological Diagnoses in Returning Travelers Cutaneous larva migrans Insect bite Skin abscess Superinfected insect bite Allergic rash Ledermen ER. Int J Infect Dis 2008; 12;

20 Botfly Dermatobia hominis Leishmaniasis McGraw TA. J Am Acad Dermatol 2008; 58; Returning from Panama Returning from Portugal Returning from Israel 20

21 Top 5 Complaints of Returning Travelers Leading to MD Visit Fever without localizing findings Acute diarrhea Dermatological disorders Chronic diarrhea Nondiarrheal gastrointestinal disorders Chronic Diarrhea Protozoal infections Giardia Cryptosporidium Entamoeba histolytica Other: Cyclospora, isospora, etc Other infections C. difficile colitis Non-infectious etiologies Freedman. NEJM 2006; 354; Evaluation of Chronic Diarrhea Bacterial culture Stool O&P x 3 Other tests Giardia antigen Stool AFB stain (cryptosporidium, isospora, etc.) Stool Cryptosporidium antigen Stool Entamoeba histolytica antigen Top 5 Complaints of Returning Travelers Leading to MD Visit Fever without localizing findings Acute diarrhea Dermatological disorders Chronic diarrhea Nondiarrheal gastrointestinal disorders Freedman. NEJM 2006; 354;

22 Nondiarrheal Gastrointestinal Disorders Intestinal nematode infection Strongyloides, schistosomiasis, ascaris Gastritis/PUD Acute hepatitis Hepatitis A, E, B Constipation Evaluation of Nondiarrheal Gastrointestinal Disorders Check LFTs CBC w/ differential (eos?) Stool O&P x 3 Serology: Strongyloides and schistosoma IgG GI referral for other diagnoses Summary Travel health risks are dependent on underlying medical conditions as well as itinerary, duration of travel, purpose of travel, and activities Travelers should be up to date on routine and travel-specific vaccinations Travelers should be given prophylactic and self-treatment medications as appropriate Recommend evacuation insurance to travelers, particularly those at high-risk A febrile returning traveler is a medical emergency When in doubt, ask the CDC THANK YOU!!! 22