Travel Medicine: Vaccination, Prophylaxis, and Imported Diseases

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1 Travel Medicine: Vaccination, Prophylaxis, and Imported Diseases Saahir Khan, MD, PhD Infectious Diseases Fellow University of California Irvine September 6, 2017

2 Sources Freedman, D. O., Chen, L. H. & Kozarsky, P. E. Medical Considerations before International Travel, NEJM, 375, (2016). UpToDate MKSAP Infectious Diseases

3 Approach to Pre-Travel Consultation Freedman, D. O., Chen, L. H. & Kozarsky, P. E. Medical Considerations before International Travel, 375, (2016).

4 Case Study: Risk Assessment 28yo healthy male up to date on routine vaccinations plans travel to Uganda for 1 month global health medical school rotation Lodging is urban in capital city of Kampala, activities include working in urban infectious diseases hospital, with rafting in Nile, and safari in national park

5 Update Routine Vaccinations MMR Tdap Influenza Pneumococcus (for elderly or high risk) HPV (for young) Zoster (for elderly) Freedman, D. O., Chen, L. H. & Kozarsky, P. E. Medical Considerations before International Travel, 375, (2016).

6 Travel-Related Vaccination Hepatitis A (blue) + B Typhoid (orange) Rabies (red) Freedman, D. O., Chen, L. H. & Kozarsky, P. E. Medical Considerations before International Travel, 375, (2016).

7 Destination-Specific Vaccination Yellow Fever (yellow) Meningococcus (red) Japanese Encephalitis (purple) Cholera (blue) Polio Tick-Borne Encephalitis (orange) Freedman, D. O., Chen, L. H. & Kozarsky, P. E. Medical Considerations before International Travel, 375, (2016).

8 Specific Vaccine Recommendations Rabies for planned outdoor activities Japanese encephalitis for rural itinerary Meningococcus ACYW-135 for Hajj pilgrimage Polio booster for Pakistan/Afghanistan Cholera for aid workers to outbreak regions Tick-borne encephalitis at destination for planned outdoor activities Freedman, D. O., Chen, L. H. & Kozarsky, P. E. Medical Considerations before International Travel, 375, (2016).

11 Case Study: Vaccinations Update routine vaccinations Tdap, influenza given MMR immunity demonstrated Vaccinate against travel-related illness Typhoid, hepatitis A given Rabies not given based on itinerary Vaccinate against regional illnesses Yellow fever, meningococcus ACYW-135 given

12 Malaria Species Distribution Plasmodium falciparum (orange) Plasmodium vivax (purple) Both (red)

13 Malaria Resistance Distribution Chloroquine-sensitive (blue) Chloroquine-resistant (gray)

14 Specific Malaria Recommendations Atovaquone-Progaunil preferred for shortterm travel (least side-effects, highest cost) Mefloquine preferred for long-term travel (weekly dosing) or chloroquine if sensitive Doxycycline is lowest cost Primaquine only if exclusively vivax Primaquine added if suspected vivax exposure

16 Case Study: Malaria Prophylaxis Atovaquone-proguanil from 1 day before departure until 7 days after return Primaquine not added on return as no suspected exposures

17 Traveler s Diarrhea Steffen, R., Hill, D. R. & DuPont, H. L. Traveler's diarrhea: a clinical review. JAMA 313, (2015).

18 Traveler s Diarrhea Treatment Primary treatment is hydration Antimotility (loperamide) and antisecretory (Bi) medications if no fever or bloody stools Ciprofloxacin is primary antibiotic therapy Azithromycin for South/Southeast Asia where fluoroquinolone-resistant E. coli are prevalent Duration is single dose or 3 days Steffen, R., Hill, D. R. & DuPont, H. L. Traveler's diarrhea: a clinical review. JAMA 313, (2015).

20 Case Study: Other Considerations Working in infectious diseases hospital Risk of TB inhalation: N95 masks, PPD on return Risk of HIV needle-stick: have PEP available on site Swimming in Nile Risk of Schistosomiasis: empiric praziquantel at 6 wks Safari in national park Risk of African sleeping sickness: Protective clothing and DEET to prevent tsetse fly bites Endemic malaria: sleep with mosquito net

21 Fever in Returned Traveler

calf and lumbar paraspinal tenderness, aseptic meningitis, jaundice, kidney failure Peripheral smear, antigen immunoassay

22 Travel-Related Non-Localized Fever Disease Features Diagnosis Treatment Malaria Typhoid fever Leptospirosis Paroxysmal fever, intraerythrocytic parasites, thrombocytopenia Prolonged fever, diarrhea or constipation, rose spot rash Conjunctival suffusion, calf and lumbar paraspinal tenderness, aseptic meningitis, jaundice, kidney failure Peripheral smear, antigen immunoassay Stool/blood culture, antibody Serological assays Artemesinin combination therapy or chloroquine Ceftriaxone, ciprofloxacin, or azithromycin Doxycycline

23 Travel-Related Fever + Arthralgia Diagnosis: PCR (< 7 days), IgM (> 7 days) Treatment: Supportive (NSAIDs for CHIKV)

24 Travel-Related Fever + Jaundice Disease Features Diagnosis Treatment Yellow fever Abrupt fever and headache, relative bradycardia, jaundice PCR (< 7 days), IgM (> 7 days) Supportive Viral hepatitis Fatigue and anorexia, low-grade fever, hepatomegaly, dark urine, clay-colored stools, transaminitis Serology, PCR Supportive, tenofovir (HBV), NS5a inhibitors (HCV) Mononucleosis syndrome (CMV, EBV) Sore throat, fever, posterior cervical LAD, splenomegaly, atypical lymphocytes Serology Supportive

25 Travel-Related Fever + Cough Disease Features Diagnosis Treatment Histoplasmosis Novel coronaviruses (SARS, MERS) Nonproductive cough, chest pain (fibrosing mediastinitis), fever Flu-like syndrome prodrome, diarrhea, dry cough with progressive dyspnea, lymphopenia, thrombocytopenia, elevated lactate dehydrogenase Respiratory culture, urine antigen Respiratory PCR Itraconazole, Ambisome Supportive Legionellosis Pneumonia, diarrhea, fever, elevated aminotransferases, hyponatremia Serology Azithromycin, levaquin, doxy

26 Travel-Related Fungal Diseases

27 Travel-Related Animal and Tick Exposures Disease Features Diagnosis Treatment Rickettsial infection Tick or flea exposure, maculopapular or petechial rash, eschar, lymphadenopathy Serology, tissue PCR Doxycycline Coxiella (Q fever) Farm animal exposure, atypical pneumonia, elevated aminotransferases Serology, tissue PCR Doxycycline Brucellosis Farm animal exposure, undulant fever, arthralgia, hepatosplenomegaly Serology, tissue culture Doxycycline and rifampin Japanese encephalitis High fever, altered consciousness, cranial nerve palsies PCR, Serology Supportive Rabies Paresthesias or pain at wound site, fever, nausea and vomiting, hydrophobia, delirium, agitation IFA of secretions, Autopsy Supportive

28 Fever in Returning Traveler: Recent

29 Fever in Returning Traveler: Late

30 Threats to Public Health: Zika Virus CDC recommends Zika virus testing for: Anyone with possible Zika virus exposure* who has or recently experienced symptoms of Zika Symptomatic pregnant women with possible Zika virus exposure Asymptomatic pregnant women with ongoing possible Zika virus exposure Pregnant women with possible Zika virus exposure who have a fetus with prenatal ultrasound findings consistent with congenital Zika virus infection Zika testing may be considered for: Asymptomatic pregnant women with recent possible but no ongoing exposure to Zika virus (i.e., travelers) Zika virus testing is not recommended for: Non-pregnant asymptomatic individuals Preconception screening *Possible exposure includes living in, traveling to, or having unprotected sex with someone who lives in or traveled to an area with risk of Zika

31 Threats to Public Health: MERS-CoV Schneider, E. et al. Patients under Investigation for MERS-CoV. Em Infect. Dis. 21, (2015). Clinical Features Epidemiologic Risk Severe illness Fever 1 and pneumonia or acute respiratory distress syndrome (based on clinical or radiological evidence) Milder illness Fever 1 and symptoms of respiratory illness (not necessarily pneumonia; e.g., cough, shortness of breath) Fever 1 or symptoms of respiratory illness (not necessarily pneumonia; e.g., cough, shortness of breath) and and and A history of travel from countries in or near the Arabian Peninsula 2 within 14 days before symptom onset, or close contact 3 with a symptomatic traveler who developed fever 1 and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula 2. or A member of a cluster of patients with severe acute respiratory illness (e.g., fever 1 and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments in the US. A history of being in a healthcare facility (as a patient, worker, or visitor) within 14 days before symptom onset in a country or territory in or near the Arabian Peninsula 2 in which recent healthcare-associated cases of MERS have been identified. Close contact 3 with a confirmed MERS case while the case was ill.

32 Centers for Disease Control and Prevention, United States Threats to Public Health: Ebola 1. Elevated body temperature or subjective fever or symptoms, including severe headache, fatigue, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND 2. An epidemiologic risk factor within the 21 days before the onset of symptoms - Travel to Guinea, Sierra Leone, or Liberia - Contact with contagious patient or clinical specimens with Ebola

33 Summary Pre-travel consultation begins with risk assessment Vaccinations are given as routine updates, for common travel-related diseases, and for destination-specific and activity-specific risks Malaria prophylaxis is given based on expected species and resistance, usually Malarone Traveler s diarrhea treatment primarily symptomatic, antibiotic usually Cipro x 3 days Counsel traveler on strategies to mitigate risks Assess illness in returning traveler for common imported etiologies and public health risks based on symptoms, incubation, and epidemiology

34 Backup Slides

35 Why Do Pre-Travel Medical Consultation? Over 1 billion international visits worldwide each year About half of all travelers seek travel medicine consultation Pre-travel consultation can reduce morbidity of travelrelated illness Schlagenhauf, P. et al. Travel-associated infection presenting in Europe ( ). Lancet Infect Dis 15, (2015).

36 Vaccinations in Travelers LaRocque, R. C. et al. Global TravEpiNet: analysis of high-risk US international travelers, Clin Infect Dis. 54, (2012).

39 Imported Diseases: Common Etiologies GeoSentinel surveillance of illness in returned travelers, , (2013).

40 Imported Diseases: Common Etiologies GeoSentinel surveillance of illness in returned travelers, , (2013).

41 Imported Diseases: Common Etiologies GeoSentinel surveillance of illness in returned travelers, , (2013).

Post Travel Fever. Dr. Eyal Leshem. Center for Geographic Medicine Sheba Medical Center Tel Hashomer, Israel

Post Travel Fever. Dr. Eyal Leshem. Center for Geographic Medicine Sheba Medical Center Tel Hashomer, Israel Post Travel Fever Dr. Eyal Leshem Center for Geographic Medicine Sheba Medical Center Tel Hashomer, Israel Introduction Fever in returned traveler: Trivial vs. life threatening infections Tropical and