Travel Medicine for the Community Provider Advances in ID 2016

Transcription

1 Travel Medicine for the Community Provider Advances in ID 2016 Disclosures and Disclaimers No Financial Disclosures Not meant to be an exhaustive reference Prasanna Jagannathan, MD Assistant Professor Division of HIV, Infectious Diseases, and Global Medicine San Francisco General Hospital, UCSF $49.95 (Oxford Press) $9.99 (Google Play or App store) (Free) Goals 1. Preparing for travel Assessing/Managing Risk Current guidance on Zika and other arboviral infections Immunizations Meds (prophylactic, self treatment) 2. Returning travelers Epidemiology of infections in a returning travelers Approach to diagnosis Case 1: Getting ready to travel 29 yo female comes to primary care clinic planning to go to El Salvador to visit family Last visited El Salvador 3 years previously G2P2, youngest child is 2 years of age Sexually active with husband No other medical problems 1

2 What travel risk are you most worried about in this patient? 1) Zika virus infection 2) Dengue virus infection 3) Malaria 4) Diarrheal illness 5) Injury 6) Something else? Goals 1. Preparing for travel Assessing/Managing Risk Current guidance on Zika and other arboviral infections Immunizations Meds (prophylactic, self treatment) 2. Returning travelers Epidemiology of infections in returning travelers Approach to diagnosis PMH Assessing Individual Risk Age Gender Underlying Conditions Pregnancy Breastfeeding Immunocompromised Seizure Disorder Psychiatric Recent surgery Recent cardiopulmonary or cerebrovascular event Vaccination history Meds Drug interactions All Vaccines, Eggs, Latex Prior travel hx Experience with malaria prophylaxis Illnesses related to prior travel Assessing Risk of Travel Itinerary Travel style Countries and specific Package tour or regions independent Rural or urban Special activities Timing High altitude/climbing Duration, season Diving Time to departure Cruise ship Reason for Travel Rafting Tourism Extreme sports Business Animal contact Visiting friends and relatives Sex Volunteer, missionary, aid work, education Adventure 2

3 PMH 29 yo female, otherwise healthy G2P2, not breastfeeding Sexually active with husband Healthy, no medical conditions Childhood vaccinations up to date No medications Mild shellfish allergy Case 1 Travel plans Would like to leave in one month Visiting family in San Salvador (the capital) for one month, no plans on travelling to rural area, contact with animals Managing risk: Educational topics Insect avoidance Safe sex and pregnancy Injury prevention Safe food and water Altitude Animal avoidance Evacuation insurance/access to medical care overseas Managing risk: Educational topics Insect avoidance Safe sex and pregnancy Injury prevention Safe food and water Altitude Animal avoidance Evacuation insurance/access to medical care overseas Which insect repellant would you not advise your patient to use? 1) DEET containing repellant 2) Picardin containing repellant 3) Lemon eucalyptus containing repellant 4) Citronella containing repellant 5) IR 3535 containing repellant 6) I have no idea! 3

4 Insect avoidance Vector borne diseases are some of the most common travel associated infection Mosquitos Flies Ticks Mosquitos Aedes, culex, anopheles Transmit several vectors Flaviviruses: Zika virus, Dengue fever Jap. encephalitis, Yellow fever, WNV Alphaviruses Chikungunya fever Protozoa and helminths Malaria Lymphatic filariasis Aedes aegypti Anopheles Zika Virus: Updated Epi Dengue fever 4

5 Chikungunya cases as of Oct 30, 2015 Flies Protozoa Leishmaniasis Helminths Loa lao Phlebotomus sp L. panamensis via Costa Rica, courtesy of Brian Schwartz Ticks African tick bite fever (Rickettsia africae) Lyme disease (Borrelia afzelii and garinii) Tick borne encephalitis (TBEV) Tache noire How to prevent insect exposure? Avoid outbreaks Avoid high risk periods Keep indoor from dusk to dawn (anopheles) Aedes most commonly feed at dusk and dawn, indoors, and shady areas, but they can bite and and spread infection all year long and at ay time of day Physical barriers Proper clothing (long sleeved clothing, skirts) Permethrin treated insecticide bed nets Insect Repellants: which ones? 5

6 Which insect repellant to use? What about Lemon Eucalyptus? Product Active Ingredient Complete Protection Time OFF Deep Woods DEET (24%) 302 minutes Sawyer Controlled Release DEET (20%) 234 minutes OFF Skintastic DEET (8%) 112 minutes OFF Skintastic for kids DEET (4.75%) 88 minutes Picardin 20% (Sawyer) Picardin (20%) >300 minutes Avon Skin So Soft Bug Guard Plus IR3535 IR3535 (7.5%) 22.9 minutes Herbal Armor Citronella (12%) 14 minutes Fradin MS, Day JF. N Engl J Med 2002;347: Roey et al PLoS Negl Trop Dis Dec; 8(12): e3326. Rodriguez et al Journal of Insect Science Oct 2015 Image from Katie Park/NPR (Jan 2016) Managing risk: Educational topics Insect avoidance Safe sex and pregnancy Injury prevention Safe food and water Altitude Animal avoidance Evacuation insurance/access to medical care overseas What travel advice would you not give this patient? 1) If pregnant, postpone your trip 2) If you are going to El Salvador, don t get pregnant until ) After you return from El Salvador, you should avoid getting pregnant for at least 8 weeks 4) If your husband develops symptoms consistent with Zika on your trip: don t try to get pregnant for at least 6 months 6

7 CDC guidance re: ZIKA, travel, pregnancy and sexual transmission CDC guidance re: ZIKA, travel, pregnancy and sexual transmission Pregnant women should not travel to areas of ongoing Zika virus transmission Non pregnant women traveling to Zika infected areas: There is no evidence that Zika virus will cause congenital infection in pregnancies conceived after the resolution of maternal viremia. After sx onset, Zika viremia may range from a few days to 1 week Longest duration of viremia in the published literature was 11 days Women with symptomatic Zika should wait at least 8 weeks before attempting conception Women with asymptomatic Zika should also wait at least 8 weeks from last exposure before attempting conception CDC guidance re: ZIKA, travel, pregnancy and sexual transmission CDC has reported 6 cases of sexual transmission from male > female All from men with symptoms, and occurred within 3 weeks of symptom onset. Virus isolated from semen possibly up to 10 weeks after symptom onset. Based on these data, previously infected men and their female partners should wait >6 months after sx onset before attempting conception Although no reported cases of sexual transmission from asymptomatic men, men with possible Zika virus exposure without sx should wait at least 8 weeks after possible exposure before attempting conception. Managing risk: Educational topics Insect avoidance Safe sex and pregnancy Injury prevention Safe food and water Altitude Animal avoidance Evacuation insurance/access to medical care overseas 7

8 Leading causes of injury death for US citizens in foreign countries, US citizens 10 times more likely to die as the result of an injury than from an infectious disease Managing risk: Educational topics Insect avoidance Safe sex and pregnancy Injury prevention Safe food and water Altitude Animal avoidance Evacuation insurance/access to medical care overseas Data from travel.state.gov Prevention of food borne disease Many common travel related infections are transmitted by contaminated food/water Traveler s diarrhea, typhoid, Hep A, Hep E, parasitic infections Safe options? Bottled water, even for brushing teeth! Carbonated soft drinks Hot foods, packaged, peeled, dry goods Watch out for buffets, foods left out for long periods Antibiotic prophylaxis: not routinely recommended, could consider in high risk hosts Managing risk: Educational topics Insect avoidance Safe sex and pregnancy Injury prevention Safe food and water Altitude (see extra slides) Animal avoidance Evacuation insurance/access to medical care overseas 8

9 Goals 1. Preparing for travel Assessing/Managing Risk Current guidance on Zika and other arboviral infections Immunizations Meds (prophylactic, self treatment) 2. Returning travelers Epidemiology of infections in returning travelers A couple of cases Case 2 23 yo female research assistant needs travel advice prior to going to Uganda for work Leaving in 6 weeks PMH 23 yo female Healthy, no medical conditions Childhood vaccinations up to date Hep A, B Meningococcus at age 15 No medications No allergies Case 2 Travel plans Going to Uganda for 4 weeks for research study Rural area with ongoing malaria transmission Planned weekend trips: Safari Gorilla trek in the bush White water rafting in the Nile River After educating her about insect avoidance, injury prevention, and safe water practices, what vaccine would you not consider for this patient? 1) Typhoid 2) Rabies 3) Polio 4) Yellow Fever 5) Meningococcus 9

10 Vaccine preventable diseases Routine vaccination should be up to date Travel related vaccines Includes vaccines required by some countries All commonly used vaccines can safely and effectively be given simultaneously Travel related vaccines Typhoid fever Yellow fever Rabies vaccine Meningococcus Hepatitis A and B* Japanese encephalitis** Polio vaccine** *If not yet vaccinated as a child or adolescent ** If traveling to endemic area with ongoing transmission Typhoid Fever Transmission: food/water > 400 cases annually US Travel #1 risk factor 2 vaccines (50 80% protective) Intramuscular (inactivated) booster Q2 years Give >2 wks prior to exposure Not for infants <2 yrs Oral (live attenuated) booster Q5 years Every other day for 4 doses Must be refrigerated Complete 1 week before exposure; not for children <6 yrs Yellow Fever Transmission: mosquito : 10 travelers 5 West Africa, 5 South America 8/10 died YF Risk: illness (death) W. Africa: 50(10)/100,000 S. America: 5(1)/100,000 Vaccine required and regulated Live vaccine Side effects rare but significant CDC Yellow Book

11 Rabies Pre exposure vaccination Consider primary course (3 shots at $250/shot) if travelling to areas were rabies is enzootic and immediate access to appropriate medical care, including PEP, is limited Postexposure prophylaxis Previously vaccinated: 2 doses of cell culture vaccine Unvaccinated: 1 dose rabies immunoglobulin + 4 doses rabies vaccine Meningoccal Vaccine In US: 3 conjugate, 1 polysaccharaide vaccine For travelers to meningitis belt: No prior vaccination: Age 2 55 MenACWY, Age >55: MPSV4 Previously vaccinated age 9 months to 6 years Additional dose of MenACWY 3 years after last Previously vaccinated age 7 years to 55 yo MenACWY 5 years after last dose Age >55: MPSV4 5 years after last dose After vaccinating her for typhoid, mening, and yellow fever (refused rabies due to cost), what medication would you not prescribe this patient? Praziquantel? 1) Ciprofloxacin 2) Atovaquone proguanil 3) Chloroquine 4) Praziquantel 5) Azithromycin 6) Lactobacillus sp probiotic N Engl J Med 2016; 374:469 February 4,

12 Prophylactic/self treatment medications for travelers Travelers diarrhea* Malaria* Altitude illness (Acetazolamide) Jet lag (i.e. zolpidem at destination) Motion sickness (scopalamine patches) Common infections (UTI, SSTI, yeast infection) Travelers diarrhea (TD) #1 travel related illness: 30 70% of travelers Pathogens: Bacteria 80 90%: ETEC, campy, shigella, salmonella Viruses 5 8%: Norovirus, rotavirus Parasites: ~10%: giardia >> E. histolytica, cryptosporidium, cyclospora Course: Bacterial and viral diarrhea lasts 3 5 days Longer durations suggests other diseases Best approach: self treatment Fluoroquinolones: best studied Ciprofloxacin 500 mg PO BID for 1 3 days Improvement within 6 12 hrs, shortens illness by 1.5 days Azithromycin: increasing resistance of campylobacter, shigella to fluroquinolones especially in SE Asia 500 mg PO QD x 3 days or 1000 mg PO x 1 Also preferred for children, pregnancy Rifaximin: not for invasive infections 200 mg PO TID x 3 days Oral rehydration (sodas, broth, ORT) Bismuth salicylate (Pepto Bismol, Kayopectate) Loperamide: not for invasive infections Areas where malaria is endemic: 2015 cdc-malaria.ncsa.uiuc.edu 12

13 Malaria in U.S. travelers: cases (1,925 cases reported in 2011) 79% acquired in sub Saharan Africa Only 34% had taken prophylaxis Of these, 11% took a medicine not CDC recommended Of those with adherence data (n=182), 65% reported nonadherence 14% cases were severe; 6 deaths 4/6 individuals who died did not take prophylaxis (no data on other 2 individuals) MMWR Surveill Summ. 2014;63(12):1 Malaria chemoprophylaxis Drug Areas of use Directions Pro/cons Atovaquone/ proguanil Doxycycline Mefloquine Chloroquine All All Mefloquinesusceptible (not SE Asia) Carribean, Central America, QD Daily; 1 2 days pre > 1 wk post BID Daily; 1 2 days pre > 4 wks post Weekly; 2 wks pre > 4 wks post Weekly; 1 2 wks pre > 4 wks post Pro: Minimal SEs Con: $ Pro: $ Con: Photos; GI Pro: $, ok in preg, kids Con: Dreams, avoid psych/seizure meds Pro: Weekly Con: GI upset Atovaquone-progunail only needs to be given 7 days after exposure due to activity in liver stage of infection Anti-relapse therapy: P. Vivax and P. Ovale associated with dormant hypnozoite stage If at risk for these infections (i.e. places with >90% P vivax) -- Give primaquine for last 14 days of therapy Goals 1. Preparing for travel Assessing/Managing Risk Current guidance on Zika and other arboviral infections Immunizations Meds (prophylactic, self treatment) 2. Returning travelers Epidemiology of infections in a returning travelers Approach to diagnosis Freedman DO. NEJM

14 Case 3 60 yo male returned from trip to India visiting relatives presenting with 2 days of fever, chills, muscle aches Traveled to India for 2 weeks Previously well, no other illnesses Did not take malaria prophylaxis HPI ROS: +HA, chills, myalgia No diarrhea, abdominal pain, cough, shortness of breath Extracurriculars: Visiting friends and family Stayed predominantly in cities of Bangalore and Chennai and did not travel to rural areas Not sexually active Reports lots of mosquito bites during stay Case 3 PE Temp 103, HR 105, BP 120/75 Clear lungs, soft abdomen, heart tachy without murmurs, faint rash on chest, lower extremities Labs CBC: 8.8 < 13.5 > 85 Renal Panel: Na 138, Cr 0.9 LFTs: AST 75, ALT 76 What s the diagnosis (best guess?) 1) Malaria 2) Dengue 3) Chikungunya 4) Zika 5) Ricketsial infection 6) Something else Diagnoses in ill returned travelers Resp/pharyngeal, 10.90% Dermatologic, 19.50% Neuro, 1.70% Febrile Illness, 23.30% GU/STI/Gyn, 2.90% Gastrointestinal Diagnosis, 34% N=42173 Travelers Leder K. Ann Intern Med

15 How to determine etiology of febrile illness in returned traveler Etiology of illness according to region Patients need immediate evaluation Destination(s) Incubation period Exposures Exam findings/labs Prophylaxis/immunizations Leder K. Ann Intern Med Etiology of febrile illness according to interval after travel Wilson ME. CID Exposures/Pr ophylactics Insect or animal exposures? Fresh water exposure? What did they consume? Other ill travelers? Sexual activity? Vaccination history? Malaria prophylaxis? Symptoms or exam findings? Symptoms Abdominal pain? Headache? Exam findings Rash? Lymphadenopathy? Arthritis? 15

16 Initial lab testing CBC w/ differential LFTs Blood cultures x 2 Thick and thin blood smear x 2 Urinalysis CXR Additional testing based on history/exam Patient course Febrile for 3 days Platelets continued to decline to 10, admitted, requiring daily platelet infusions LFTs rose up to max AST 320, ALT 315 Blood cultures x 2 neg Thick and thin blood smear x 2 neg Urinalysis neg CXR: neg Additional testing returned: Arboviral Serologies sent: Chikungunya: negative IgM, negative IgG Dengue: IgM (nl <0.9); IgG 0.28 (normal <0.9) Were these the correct tests to order? Does he have dengue? Differentiating dengue, chik, and zika Infection Dengue Chikungunya Zika Clinical Presentation Febrile illness, rash, myalgia, arthralgia Febrile illness, rash, myalgia, arthralgia Febrile illness, rash, myalgia, arthralgia Severity of illness 75% asymptomatic Of symptomatic: most commonly mild; 5% can be severe hemorrhagic sx ~25% asymptomatic Of symptomatic: high fever and joint pains (b/l, symmetric; hands/feet) Severe disease rare Dengue light Severe disease uncommon Lab abnormalities Leukopenia, thrombocytopeniua, hyponatremia, elevated AST/ALT Lyphopenia, thrombocytopenia, elevated Cr, AST/ALT Leukopenia, thrombocytopeniua, hyponatremia, elevated AST/ALT Significant cross-reactivity between ELISAs for different flaviviruses CDC Revised testing algorithm 2/16 for Zika, dengue: RT-PCR now preferred diagnostic for patients with acute febrile illness 16

17 How would you counsel this patient re: his future risk for dengue? 1) Don t go back to India or other countries where dengue is endemic 2) Be careful if you go back: you might get really sick if you get Dengue again 3) It s ok to travel to dengue endemic areas: Your risk of severe dengue is the same whether it is your first or second infection Summary Travel health risks are dependent on underlying medical conditions as well as itinerary, duration of travel, purpose of travel, and planned activities Appropriate pre travel visit should assess these risks and provide appropriate guidance Education re: risks For insect avoidance, remember that DEET and picardin are best, ok to use lemon eucalyptus Assessment and provision of travel specific vaccinations Prescription of prophylactic and self treatment medications as appropriate A febrile returning traveler is a medical emergency Thanks! Extra Slides 17

18 International travel continues to rise Reason for travel and 2 most frequent destinations 1.2 billion travelers crossed international boarders in 2015 Up from 763 million in million traveled from the US internationally in million in Jan 2016 alone! UNWTO World Tourism Barometer. World Tourism Organization; 2016.Office of Travel and Tourism Industries 2014 Outbound Analysis, US Dept of Commerce 2015 China India India Ghana Haiti Kenya India China Service Work 15% Research/Education 9% VFR 11% Business 15% Leisure 50% N=13,235 India S. Africa/Thailand Larocque R. Clin Infect Dis What is the magnitude of travel related morbidity/mortality Zika Virus: Updated Epi 22 64% report some illness 34% report GI illnesses 23 28% report fevers 8% require medical care 1/100,000 death Steffen R Int J Antimicrob Agents Freedman NEJM 2006 Hill DR. CID

19 Algorithm for pregnant women with potential Zikaexposure Altitude illness Many popular destination are at high altitude Kiliminjaro: 19,341 Feet! Biggest risk: Hypoxia at 10,000 ft, PaO2 is 69% of sea-level Depends on rate of ascent, duration of exposure Acute mountain sickness (HA, nausea) High-altitude cerebral /pulmonary edema (lifethreatening) Prevention of altitude illness Behavioral Gradual ascent (allow > 1 day to get to 9K feet) Sleep at lower altitudes Minimize ETOH and exercise in first hours If symptoms develop do not ascend further! If sx get worse while resting: DESCEND Pharmacological Acetazolamide 125 mg PO BID, start 2 days before ascent, during ascent, and 2 days after reaching apex Chronic diarrhea Protozoal infections Giardia Cryptosporidium Entamoeba histolytica Other: Cyclospora, isospora, etc Other infections C. difficile colitis Non infectious etiologies 19

20 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 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 Post infectious irritable bowel syndrome 3 10% of travelers after episode of TD Diagnosis of exclusion Last months years Connor BA. Clin Inf Dis

21 5 most common dermatological diagnoses in returning travelers Cutaneous larva migrans Insect bite Skin abscess Superinfected insect bite Allergic rash Ledermen ER. J Infect Dis Leptospirosis Spirochete bacteria Infection through skin (cuts/abrasions) or mucous membranes Humans infected by direct contact with water/soil contaminated by urine from infected animals Prior outbreaks in river rafters, Borneo EcoChallenge Incubation period 2 days 3 weeks Acute phase (~ 7days) presents as febrile illness 2 nd phase (Weil Disease) = severe, occurs in 5 10% of patients > renal failure, pulmonary hemorrhage MMWR Apr New Guidance? Greater proportion of imported shigella infections resistant to ciprofloxacin Travelers should be encouraged to - Use bismuth subsalicylate or loperamide for treatment of mild to moderate TD - Reserve antibiotics for severe cases of TD - Consider Azithromycin for empiric treatment 21