Travel Medicine. An emerging specialty Dr Dom Colbert. MD BSc FRCSI CTH FFTM (Glasg)

Transcription

1 Travel Medicine An emerging specialty Dr Dom Colbert MD BSc FRCSI CTH FFTM (Glasg)

2 So whats new in 2011? Legionella lake Garda Tularimia Germany via Turkey Polio Madagascar Visceral Leishmaniasis S. Soudan Unexplained Deaths Chang Mai Chikungunya in India 54 cases so far 2

3 Pakistan now accounts for almost one third of all cases worldwide in 2011, Typhoid in Zimbabwe Malaria in Greece 66 cases so far

4 Usual immunizations in Travel Clinic Yellow Fever Hepatitis A Hepatitis B Typhoid Diphtheria/Tetanus/Polio Meningitis Rabies Cholera Tick Borne Encephalitis Varicella - Flu -pertussis ( acellular) 3 5

5 Of these the less common ones Japanese encephalitis Tick Borne Encephalitis Varicella Flu Pertussis 6

6 A word ontetanus/diphth/pertussis 1/4 of prolonged cough illnesses in adults are due to pertussis Adults are often the source of infection for kids. Childhood protection only lasts 10 years and wanes after that Travel for the adults is a chance to give a booster. Tdap (=adult/adolescent booster with the three aforementioned) All pertussis vaccines in Ireland are acellular 7

7 This slides does not show the incidence of painlful arms after each vaccine 8

8 Sexual activity In 2007 J Tr Med a survey of guides on the Inca Trail revealed that 30% approx had symptoms of STI 15% used sex workers Only 40% of all used condoms All tour guides lived in Cuzco 25% expats sexually active Ghana

9 Returned traveler (RT)versus Immigrant / Refugee (IR) RT presents early, with URTI, Fever,TD, Skin Lesion and Unknown ( Fever malaria-dengue...leptospirosis, infect mononucleosis like syndromes) IR presents later with TB, Schistosomiasis, helminths, Hepatitis B other 10 10

10 Strange things do happen to tourists S mekongi presented in a 21 year old in Beaumont ( IMJ vol 101 no10 Dec 2008) She swam in Laos, Cambodia and Vietnam. Several cases of neuroschistosomiasis being reported in travellers..treat with steroids not praziquantel if any way acute ( Eric Caumes and Marie Vidailhet, Paris, 2010) 11

11 Travellers Diarrhea Bacterial,Helminthic, Viral Commonest is bacterial when travelling eg E Coli, Campylobacter, Shigella Commonest is helminthic once they get home: giardia, d fragilis amoebiasis, cyclospora cayetanensis Viral and unknown common enough. Norovirus esp on cruise ships 12

12 This is only a very general rule Commonest TD is Bacterial SE Asia Parasitic elsewhere 13

13 Probiotics for and against Do not dismiss out of hand!

14

15 Incidence of yellow fever in travellers /100,000 (Wilder Smith 2010) But clearly whether you get it or not depends on risks taken, where you are, exposure, immune status etc. 17

16 What do you know about yellow fever vaccine? Is it a live vaccine? Do you need a special license to give it? Can a nurse give it legally? Name three contraindications to giving it What serious complications may it have assuming given correctly and to suitable person? 18

17 Text

18 Only four countries remain endemic; Afghanistan, India, Pakistan and Nigeria. 20

19 Koplik spots Bull Neck vaccination is especially advised for visits to endemic areas mixing with local population (e.g. health workers or teachers) and these groups should also receive ten yearly boosters of the 21 low dose vaccine. The World Health Organisation

20

21 2010 map puts all Russia as high risk Map shows prevalence not incidence do you know the difference? 23

22 The Joint Committee on Vaccination and Immunisation (JCVI) has agreed that a 20 year interval for a booster dose of vaccine for those at ongoing risk. Specific advice should be sought for those with impaired immune responses. 24

23

24 QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture. 3% of febrile Returned travelers

25 bat_rabies.jpg 16 27

26 PREVALENCE OF CHOLERA Map of cholera outbreaks in 2004 Haiti 2010 Source: SBL Vaccines. Imported cholera 1993 Ğ

27 PREVALENCE OF CHOLERA Cholera is on the rise worldwide Adapted from: WHO report on global surveilance of epidemic-prone infectious diseases 20 29

28 Dukoral.. 2 oral doses Each dose contains 25 x 109 V cholerae 01 strains etc. plus..recombinant cholera toxin B subunit 1 mg Chiron vaccines 30

29 N meningitidis ( meningococcus) A,B,C, W-135, X, Y viz 6 of the 13 recognized serogroups cause disease GR negative aerobic diplococcus Humans are the sole reservoir Niche is the upr resp tract Carriage up to 15% in adolescents. It is an immunizing event for carrier. Can carry for several months in some people 31

30 CRF = case fatality rate. After Steffen et al

31 33

32

33 Flavivirus principal vector C tritaeniorhynchus esp twilight

34 25 36

35

36

37 Legionella. Legionnaires disease described in 1976 Acquired by inhalation or aspiration and has mortality rate of 10% - 30% Colonisation of water systems depends on temp, sediment accumulation and commensal microflora Turkey: Alayna hotels evaluated in 2007 colonisation varied between 61-92% Exceeds 100 CFUin >2/3 samples 39

38 Trypanosomiasis - African Afrian trypanosomiasis carried by tsetse fly common in parts of Africa (Uganda, Kenya and Malawi). 2 Australian travellers contracted it visiting game parks in Malawi. Short term! Fever, nausea, vomiting, diarrhea like malaria! Chancre at bite site East africa incubation period 1-4 weeks West Africa incubation period is months to years 40

39 Tsetse flies can bite through your clothes..wear thick ones! DEET unproven against them Avoid bushes during the heat of the day where the flies rest 41

40 Leishmania 20 cases of imported to Australia (J Tr Med 2008,Stark et al) S America, Afghanistan, Pakistan About half in immigrants Most were CL 2 VL 1 post kala azar dermal leishmniasis L brazieliensis is resistant to miltefosine ( only oral agent available) 42

41 Leishmaniasis Case numbers have doubled in the Netherlands and tripled in the UK in the past decade 43

42 Infectious mononucleosislike syndromes Fever Pharyngitis Lymphadenop;athy Mononucleosis >50% of WBC sometimes you also get splenomegaly and exanthema 44 44

43 Many sites with malaria interactive maps Are very very slow to come up however and that is a pain

44 About 14 types of mosquito carry malaria to man. % types of disease causing plasmodia What is wrong with this picture? P falciparum P vivax P ovale P malariae P knowelesi

45

46

47 Malarone 96 % effective against p. falciparum 84% effective against p. vivax 49

48 Resistance to artimisinin Artemisinin combination therapy (ACT), is the recommended strategy for clinical care and avoidance of drug resistance. Clinically relevant artemisinin resistance has not yet been reported but is likely to occur Evidence of Artemisinin-Resistant Malaria in Western Cambodia (Dec 2008) NEJM Malarone reisistance already (2009) 50

49 Doctors in Sweden have reported resistance to Malarone, (BMJ 2003). A study indicated that P falciparum, was resistant to Malarone in vitro. Two patients treated at a Gothenburg hospital with adequate blood levels failed to respond French report one case from Comoras Cases (2) reported form Lagos, Nigeria 51

50

51 Information Sources Travel Chart - defunct now Books..especially Colberts MCQ (2009)!!! Recommended Text officially for the Travel Course in Glasgow Irish Society of Travel medicine (ISTM) TRAVAX CDC, WHO, Fit For Travel, TravelClinic.com 53

52 Thank you for being such a great group ( flattery of course ) 54

53 55

54 Do not do forget Northern European Conference on Travel Medicine Burlington Hotel Dublin June Tuesday 6 -Friday 8 June Loads of CME /CPD ponts Tax Relief 100 euro off if a member of Travel Med Soc Ireland 56