TRAVEL MEDICINE BEFORE, DURING, AND AFTER THE TRIP LARRY M. BUSH, MD, FACP

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1 TRAVEL MEDICINE BEFORE, DURING, AND AFTER THE TRIP LARRY M. BUSH, MD, FACP Affiliated Professor of Clinical Medicine Charles E. Schmidt College of Medicine Florida Atlantic University

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3 The global air network

4 Commercial Air Traffic Over a 24 Hour Period

5 TRAVEL EPIDEMIOLOGY TRAVEL EPIDEMIOLOGY BILLION INTERNATIONAL TOURIST ARRIVALS 2013 ESTIMATED TO BE 2 BILLION ASIA, MIDDLE EAST, ANDAFRICA TRAVEL INCREASING 14 DAYS MEDIAN DURATION OF TRIP 22% WERE > 28 DAYS; 3% > 6 MONTHS 75% TO MALARIA AND 38% TO YELLOW FEVER ENDEMIC COUNTRIES 3% HAVE IMMUNE COMPROMISED CONDITIONS OR MEDICATIONS ONLY 40 % SOUGHT OUT PRE-TRAVEL CLINIC CONSULTATION

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9 TRAVEL FACTS K.NO MATTER HOW FAST I RUN I CAN T SEEM TO GET AWAY FROM ME..NO MATTER mm WHERE I AM I M ALWAYS ONE DAY AWAY FROM WHERE I WANT TO BE. Jackson Browne ( The Pretender )..

10 The Risk Landscape The World We Live In... Coups Natural Disasters Insurgency Piracy Hijacking Terrorism Lawlessness Opportunistic Crime Kidnapping War Civil Unrest Medical Illness Threats Extreme Weather Typhoid Fever Dengue Imprisonment Travel-related infections Hepatitis Air Quality Language and cultural barriers Airline Catastrophes Vehicle Accidents Rural Isolation Immigration & Visas

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12 Travel Clinic Should be carried out by persons who have training in the field, particularly for travelers who have complex itineraries or special health needs Primary care physicians and nonspecialists should be able to advise travelers who are in good health and visiting low-risk destinations with standard planned activities.

13 Travel Clinic Epidemiology, transmission and prevention of travel-associated infectious diseases A complete understanding of vaccine indications and procedures Prevention and management of noninfectious travel health risks Recognition of major syndromes in returned travelers (e.g., fever, diarrhea, and rash)

14 Structured Approach to Medical Consultation before International Travel. Freedman DO et al. N Engl J Med 2016;375:

15 Bring a color copy of your passport. Label the outside of your passport with your passport number

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21 What health risks are associated with air travel?

22 Risk Factors for DVT Increasing Age (above 40 years) Pregnancy Previous or Family history of DVT Clotting disorders Recent major surgery Estrogen hormone therapy & OCs Immobility Gender

23 Economy Class Syndrome??

24 DVT and Long Haul Travel Increasing Age Increasing Duration of Travel Immobility Seating Constraints and Posture Cabin Environment (low humidity) Excessive alcohol and/or caffeine Obesity? Height?

25 Changing Demographics of Air Travel Aircraft seats designed for persons who average 5 7 and 170 lbs. More vulnerable passengers are now able to fly from an economic perspective Projected increase in air travel

26 inches Airline Seat Pitch First Business Economy Skytrax

27 Airline Seat pitch Air France 31 British Airways 31 American Airlines 33 Lufthansa 31 Northwest/KLM 31 Swissair 32 United 31

28 Epidemiology of DVT from Air Travel

29 Travel as a risk factor for venous thromboembolic disease VTED Control p-value Age (years) n.s. Hypertension (%) n.s Sex (% male) VTED history (%) Obesity (%) Recent travel (%) <0.001 Ferrari 1999

30 Travel and risk of venous thrombosis Cases Controls Odds Ratio Plane Travel 4% 13% 1.0 ( ) Kraaijenhagen 2000

31 The information reviewed suggests that.. The short-term and long-term health hazards of air travel are of interest There is little scientific evidence to quantify the association between air travel and DVT There is inconsistent evidence of a link between cancer and cosmic radiation

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33 Deaths Related to International Travel Cardiovascular Medical Injury Homicide/Suicide Infectious Disease Other N = 2463 Hargarten S et al, Ann Emerg Med, :

34 Injury Deaths and International Travel N = 601 Motor Vechicle Drowning Air Crash Homicide/Suicide Poisoning Other Hargarten S et al, Ann Emerg Med, :

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36 AND TRAVEL

37 Bloodborne and STD Precautions Prevalence of STDs Hepatitis B Hepatitis C HIV Unprotected sexual activity Commercial sex workers Tattooing and body piercing Auto accidents Blood products Dental and surgical procedures 37

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40 MOSQUITO RELATED INFECTIONS

41 Vector Precautions Covering exposed skin Insect repellent containing DEET 30 50% Treatment of outer clothing with permethrin Use of permethrin-impregnated bed net Use of insect screens over open windows Air conditioned rooms Use of aerosol insecticide indoors Use of pyrethroid coils outdoors Inspection for ticks

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47 MALARIA-ENDEMIC --- WESTERN HEMISPHERE

48 MALARIA-ENDEMIC ---EASTERN HEMISPHERE

49 M000MMM0000,,,,,,M

50 Severe malaria Clinical Features Impaired consciousness/coma Prostration or sit up with assistance Convulsions Deep breathing, respiratory distress (acidotic breathing) Circulatory collapse/shock, systolic blood pressure <70 mm Hg Jaundice Hemoglobinuria Abnormal spontaneous bleeding Acute renal failure Pulmonary edema (radiologic) Pathophysiology Parasitemia > 5% Sequestration of erythrocytes with mature forms of the parasite in deep vascular beds of vital organs small infarcts, capillary leakage, and organ dysfunction Anemia, thrombocytopenia 10-20% fatality with treatment

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58 YELLOW FEVER VACCINE RECOMMENDED - AMERICAS

59 YELLOW FEVER VACCINE RECOMMENDED - AFRICA

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68 JAPANESE ENCEPHALITIS ---- RISK

69 Japanese Encephalitis Vaccine Inactivated vaccine Efficacy = 91% Booster every 3 years Not approved for children under 3 years Side effects Local reaction (10-25%) Fever (10-25%) Hypersensitivity reaction (0.6%) Indications Expatriates living in Asia Travel to endemic regions for >30 days during transmission season, especially travel to rural areas

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72 DENGUE FEVER Over 40% of the world's population at risk from dengue. WHO currently estimates may be million dengue infections worldwide every year. Before 1970, only nine countries had experienced severe dengue epidemics. The disease is now endemic in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, South-east Asia and the Western Pacific. The American, South-east Asia and the Western Pacific regions are the most seriously affected. Cases across the Americas, South-east Asia and Western Pacific have exceeded 1.2 million cases in 2008 and over 2.3 million in In 2010, 1.6 million cases of dengue were reported in the Americas alone, of which 49,000 cases were severe dengue.

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75 Chikungunya fever Chikungunya : derived from local language in Tanzania that which bends up or stooped walk

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79 Meningococcal meningitis Neisseria meningitidis: At least 13 antigenically distinct serogroups A,B,C,W135 & Y are most common Current vaccine for A,C,W135 & Y NZ is trialing a vaccine against a specific B strain Mandatory: Pilgrims visiting Mecca for the Hajj (annual pilgrimage) or for the Umrah Recommended: Travelers roughing it in areas where there are recurrent outbreaks of disease

80 The Meningococcal Meningitis Belt

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84 RABIES

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90 Travelers Diarrhea

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94 Travelers Diarrhea Between 20%-50% international travelers Onset: usually first week of travel but may occur later Most common agent: enterotoxigenic Escherichia coli (ETEC) Primary source of infection: ingestion of fecally contaminated food or water. Most important risk determinant: traveler's destination Latin America, Africa, the Middle East, and Asia High-risk: young adults, immunocompromised, pts with inflammatory-bowel disease, diabetes, and persons taking H-2 blockers or antacids.

95 Causes of Traveler s Diarrhea Cause Percent Isolation Bacteria Escherichia coli Enterotoxigenic Enteroadhesive Enteroinvasive ?? Campylobacter spp Salmonella spp Shigella 0-15 Aeromonas 0-10 Plesiomonas 0-5 Other 0-5

96 Causes of Traveler s Diarrhea Cause Protozao Giardia lamblia Entamoeba histolytica Cryptosporidium ssp. Cyclospora cayetanensis Percent Isolation ?? Viruses Rotavirus Enterovirus ? No pathogen isolated 10-40

97 Food and Water Precautions Bottled water Selection of foods well-cooked and hot Avoidance of salads, raw vegetables unpasteurized dairy products street vendors ice

98 Food and Beverage Precautions Boil it, peel it, cook it or FORGET IT!!

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103 ANTIBIOTIC PROPHYLAXIS IS GENERALLY NOT RECOMMENDED

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105 Prolonged Diarrhea Greater than 2 weeks Less likely to isolate specific organism More likely to be parasitic Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica, and Cyclospora cayetanensis most frequently identified detected in fewer than 1/3 travelers with chronic diarrhea and in only 1-5% travelers with acute diarrhea

106 Relative Risk of Chronic Enteropathogenic Infections Acquired during Travel Abroad. Ross AG et al. N Engl J Med 2013;368:

107 Enteropathogens Causing Chronic Illness in the Returning Traveler. Ross AG et al. N Engl J Med 2013;368:

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110 Typhoid Fever Typically present 1-3 weeks after ingestion of food or water contaminated with Samonella enterica serotype typhi Have visited Indian subcontinent, in the Philippines, or in Latin America Fever and constitutional symptoms May have insidious onset Abdominal pain, cough, chills Diarrhea may eventually develop

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112 GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION

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114 HEPATITS E ---- ENDEMIC COUNTRIES

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116 CHOLERA. Cholera, is a Greek word, which means the gutter of the roof. It is caused by bacteria: Vibrio cholerae, which was discovered in 1883 by Robert Koch during a diarrheal outbreak in Egypt : 91 CASES IN US TRAVELERS 75% FROM CARIBBEAN 2016: ORAL VACCINE (CVD 103-HgR) VAXCHORA ENDEMIC IN 50 COUNTIRES SINGLE DOSE > 18 YRS OLD

117 Diseases in Returning Travelers Fever : Malaria, Dengue,Typhoid, nonspecific Diarrhea : Giardiasis, Amebiasis, bacterial, non specific Dermatologic : Insect bites, CLM, allergic rashes Non diarrheal Intestinal disorders : Hepatitis, Strongyloidosis N Engl J Med 2006; 354:

118 Fever in the Returned Traveler Geosentinal sites study CID : ( n=6957) Malaria 21% Acute Diarrheal Disease 15% Respiratory Illness 14% Dengue 6% Salmonella Infections 2% Tick borne Illness 2% 3% had vaccine preventable illness ( Hep A, Typhoid Fever, Influenza )

119 Causes of imported fever by region Africa Asia Americas Malaria 35% Unknown etiology 19% Unknown etiology 33% Unknown etiology 25% Respiratory 13% Respiratory 16% Respiratory 10% Dengue 12% Dengue 9% Bacterial enteritis 5% Malaria 11% Bacterial enteritis 9% Rickettsial 4% Bacterial Enteritis 9%, Typhoid 3% Malaria 4 % Bottieau et al Arch Int Med 166: 1642, 2005

120 Travel related Tick-Borne Diseases Tick Borne Relapsing Fever Israel, Africa, South Asia Every 3-5 days fever episodes African TBF Southern Africa Fever, h/a,eschars Mediterranean Spotted fever Mediterranean, South Asia, E&S Africa Similar to African TBF, more severe TBE Central and E Europe Fever, Meningoencephalitis Lyme Borreliosis Europe Rash, 7 th nerve palsy, aseptic meningitis

121 Skin lesions in the returning traveler

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123 Am. J. Trop. Med. Hyg., 76(1), 2007, pp Surveillance

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125 Swimmer s itch Cercarial dermatitis Non-human schistosomes Distribution of rash is limited to areas of the body immersed in water. Itchy red papules, may become vesicular, develop hours to a day after exposure Human schistosomes can also cause a rash

126 Seabathers itch Salt water exposure Jellyfish larvae release nematocysts, inject toxin Distribution matches areas covered by bathing suit, etc. Inflammatory papules, can become vesicular or pustular

127 Dirofilariasis Mediterranean, but many parts of the world (US) Dog heartworm Can be transmitted to humans by mosquitoes Cutaneous or pulmonary syndrome

128 CUTANEOUS LEISMANIASIS

129 Cutaneous Larva Migrans Most frequently on lower extremities buttocks and anogenital region, trunk, and upper extremities less often Starts as pruritic papule and develops into elevated, serpiginous, reddish-brown lesions in 2-3 days 10% of cases vesiculobullous

130 Loaisis (Loa Loa) L

131 MYIASIS (Maggots of Tumbu Fly)

132 HERPES B VIRUS ---- Not so Cute

133 THE PREGNANT TRAVELER

134 What do we advise pregnant travelers?

135 Travel medicine and Pregnancy Mezger N et al. Travelling when pregnant. Rev Med Suisse. 2005; 11: (in French) Travel during the 2nd trimester Favor comfortable type of travel, without long air or road transportation Avoid traveling if at risk pregnancy Check for adequate insurance coverage Choose destination where good health services exist Avoid region of high malaria endemicity For any vaccination or medication risks and benefits should be carefully weighed, pregnant women are more vulnerable and at higher risk of complications

136 Pregnancy and malaria WHO. International Travel and Health. Geneva: WHO, Travel to malariaendemic areas should be avoided during pregnancy, if at all possible or intend to get pregnant (McGready et al, 2004) Why?

137 Pregnancy and malaria Chemoprophylaxis Recommended options for chloroquine resistant areas Mefloquine 250mg weekly 2nd/3rd trimester Doxycycline 100mg daily Malarone 250mg/100mg daily (from 2000) Alternatives include: chloroquine 300mg weekly + proguanil 200mg daily Sulfadoxine-Pyrimethamine

138 Pregnancy should not deter a women from receiving vaccines that are safe and will protect her health and that of her child. WHO, 2005 op cit SAFTEY HAS NOT BEEN DETERMINED FOR MANY, OTHERS CONTRAINDICATED

139 Death during travel CONTACT THE US EMBASSY OR CONSULATE DEATH CERTIFICATE ( IN ENGLISH) NEEDED UNLESS CREMATED SPECIAL RULES IF DEATH FROM QUARANTINABLE COMMUNICABLE DISEASE INSURANCE SOLD FOR PURPOSES OF TRANSPORTING BODY BACK TO USA

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142 WHERE I LIVE WHAT COULD BE NICER?