Health Problems During Travel

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Audra Elliott
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Health Problems During Travel Health problems during travel: 64% Diarrhea: 46% Respiratory infections: 26% Skin problems: 8% Injuries: 5% Highest risk travel: Indian subcontinent Hill, DR: J Travel

1 Health Problems During Travel Health problems during travel: 64% Diarrhea: 46% Respiratory infections: 26% Skin problems: 8% Injuries: 5% Highest risk travel: Indian subcontinent Hill, DR: J Travel Med. 7:259, 2000 Health Problems After Travel Illnesses after travel: 26% Illness began after return home: 70% Falciparum malaria: 3 patients (0.4% patients; 1.5% illnesses after travel) Hill, DR: J Travel Med. 7:259,

General travel advice Don t drink the water Avoid unpeeled, uncooked fruits and vegetables Food should be well-cooked Avoid insect bites Don t swim in fresh water in the tropics Be careful about STDs

2 General travel advice Don t drink the water Avoid unpeeled, uncooked fruits and vegetables Food should be well-cooked Avoid insect bites Don t swim in fresh water in the tropics Be careful about STDs Vectors and their diseases Mosquitoes: Malaria, Dengue, Yellow fever, Viral encephalitis, Lymphatic filariasis Blackflies: Onchocerciasis Sand flies: Leishmaniasis, Bartonellosis Tsetse flies: African trypanosomiasis Kissing bugs: Chagas disease Fleas: Plague, Typhus Lice: Typhus, Bartonellosis Midges: Visceral filariasis Mites: Rickettsialpox, Tsutsugamushi fever Ticks: Lyme disease, RMSF, Other rickettsiae, Babesiosis, Ehrlichiosis, Relapsing fever 2

3 Immunizations Advised for some or all adults regardless of travel Required in some countries Advised in certain travel circumstances Immunizations Advised for some or all adults regardless of travel Tetanus Mumps Influenza Diphtheria Rubella Pneumococcus Measles Polio Hepatitis B Immunizations Required in some countries (need certificate of vaccination) Yellow fever Not: Cholera Not: Small pox 3

4 Immunizations Advised in certain travel circumstances Hepatitis A Typhoid Meningococcal Rabies Japanese encephalitis Plague Hepatitis A Developing world: nearly all adults have been infected U.S. Seroprevalence in adults much lower ~100,000 cases / year ~70 deaths / year from fulminant hepatitis Travelers to high-risk areas Risk of infection high (3.6% / year) 4

5 Hepatitis A Vaccine Two formalin-inactivated killed virus vaccines available in U.S. Seroconversion >95% after 2 doses Protection high What about immune globulin? Passive vaccination against hepatitis A No longer needed in anyone receiving the newer hepatitis A vaccines Consider use only for those in need of immediate protection the newer vaccines should offer adequate protection after ~ 2 weeks It is OK to give the two vaccines simultaneously Typhoid Systemic febrile illness due to infection with Salmonella typhi Initially relatively mild illness Can progress to serious complications (intestinal perforation, death) Endemic in developing countries U.S.: ~400 reported cases / year; most acquired during foreign travel 5

Typhoid vaccines Two vaccines released in 1990 s Efficacy of each good (~50-80%) Both well tolerated Ty21a: Live, attenuated, oral vaccine Typhim Vi: Injectable polysaccharide vaccine Who should get

6 Typhoid vaccines Two vaccines released in 1990 s Efficacy of each good (~50-80%) Both well tolerated Ty21a: Live, attenuated, oral vaccine Typhim Vi: Injectable polysaccharide vaccine Who should get which vaccine? Tetanus booster (q 10 yrs), Hepatitis A: Just about everyone traveling anywhere Polio: Once as an adult; risk is remote Yellow fever: When required; Travel to rural areas S. America and Africa Typhoid: Long-term travel; Those not following food and drink precautions Meningococcal: Travelers to Mecca on Haj; Longterm travelers 6

7 Traveler s Diarrhea Delhi belly La turista Rome runs Casablanca crud Greek gallop Malta dog Turkey trots Montezuma s revenge Aztec two-step Poona poohs Basra belly Aden gut Traveler s Diarrhea Causes Enterotoxigenic E. coli Shigella Salmonella Other bacteria: Campylobacter, Vibrio, etc. Viruses: Rotavirus, Norwalk, Enteroviruses, etc. Parasites: Giardia, Amoeba, Cryptosporidium Traveler s Diarrhea Clinical Presentation Onset usually during first week of travel Secretory, watery diarrhea Fever in only 10-20% Bloody stools in < 10% Duration usually 2-4 days 7

8 Traveler s Diarrhea Treatment Fluid replacement Antimotility agents: Imodium, Lomotil Pepto Bismol Antibiotics: Usually quinolones Traveler s Diarrhea Prevention Food and drink precautions Pepto Bismol Antibiotics (usually quinolones) Traveler s Diarrhea New Drug: Rifaximin (Xifaxan) Non-absorbed antibiotic Related to Rifampin As effective as Cipro against mild traveler s diarrhea Do not use for complicated disease 8

Drugs for treatment of traveler s diarrhea Drug Dosing Cost 1 Ciprofloxacin 500 mg BID x 3d $30 Azithromycin 1000 mg x 1 or $31 or $47 500 mg qd x 3d Rifaximin 200 mg TID x 3d $33 Doxycycline 100 mg

9 Drugs for treatment of traveler s diarrhea Drug Dosing Cost 1 Ciprofloxacin 500 mg BID x 3d $30 Azithromycin 1000 mg x 1 or $31 or $ mg qd x 3d Rifaximin 200 mg TID x 3d $33 Doxycycline 100 mg BID x 3d <$5 1 Med. Lett. 46:74, 2004 Traveler s Diarrhea Consensus Treatment: An antibiotic plus an antimotility agent, beginning soon after symptoms start. Chemoprophylaxis: Not recommended routinely, but daily antibiotic therapy is effective. 9

10 Malaria Hundreds of millions of cases per year Over one million deaths per year U.S.: About 1500 cases per year 5-10 deaths per year Human malaria parasites Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium malariae Plasmodium knowlesi 10

11 Incidence of malaria in the USA CDC, Malaria surveillance, 2005 Region of acquisition of malaria for episodes diagnosed in the USA CDC, Malaria surveillance, 2005 Purpose of travel in those diagnosed with malaria in the USA CDC, Malaria surveillance,

12 Under-appreciated malaria risk: those returning to their country of origin Species in malaria infections diagnosed in the USA CDC, Malaria surveillance,

Malaria Clinical presentation Febrile paroxysm Respiratory and GI symptoms are common Uncommon findings: rash, lymphadenopathy Fever pattern usually not

13 Malaria Clinical presentation Febrile paroxysm Respiratory and GI symptoms are common Uncommon findings: rash, lymphadenopathy Fever pattern usually not regular Severe disease: falciparum malaria Falciparum malaria Cerebral malaria Renal failure Noncardiogenic pulmonary edema Anemia Hypoglycemia Shock Death 13

Malaria diagnosis Interval between return from travel and onset of malarial illness P.

diagnosis- RDTs BinaxNOW malaria test FDA approved 2007 Detects: P.

hospital and commercial labs; under consideration as point-of-care test How good is the

14 Malaria diagnosis Interval between return from travel and onset of malarial illness P. falciparum occurs early CDC, Malaria surveillance, 2005 New method for malaria diagnosis- RDTs BinaxNOW malaria test FDA approved 2007 Detects: P. falciparum-specific antigen (HRP2) Antigen all human plasmodia (aldolase) Approved for hospital and commercial labs; under consideration as point-of-care test How good is the test? P. falciparum P. vivax Sensitivity 99.7% 93.5% Specificity 94.2% 99.8% (tested at parasite density > 5,000/µl) 14

15 Antimalarial drugs 4-aminoquinolines: Chloroquine, Amodiaquine Quinine, Mefloquine, Halofantrine Antifolates: Sulfadoxine/Pyrimethamine, LapDap Artemisinins: Artesunate, Artemether, etc. Antibiotics: Doxycycline, Clindamycin Malarone Primaquine Artemisinin-based combination therapy Artemisinins very potent Short half-life of artemisinins helps to prevent selection resistant parasites Partner drugs have longer half-lives, and eliminate small numbers of remaining parasites Artemisinin Parasite Density Partner Drug New Infections Artemether/lumefantrine Artesunate/amodiaquine Artesunate/mefloquine DHA/piperaquine Treatment of malaria in the U.S. (2008) Nonfalciparum malaria Chloroquine Also Primaquine for vivax and ovale (after G6PD shown to be normal) Falciparum malaria Quinine plus Doxycycline (adults) Quinine plus Clindamycin (children) Malarone (atovaquone/proguanil) Mefloquine Severe disease: IV Quinidine 15

16 Treatment of malaria in the U.S. Nonfalciparum malaria Chloroquine Also Primaquine for vivax and ovale (after G6PD shown to be normal) Falciparum malaria Coartem Quinine plus Doxycycline (adults) Quinine plus Clindamycin (children) Malarone (atovaquone/proguanil) Mefloquine Severe disease IV Quinidine IV Artesunate Artemisinins for the treatment of severe malaria IM artemether equivalent to IM quinine IV artesunate superior to IV quinine 1461 patients in Asia: mortality 15% vs. 11% (34.7% risk reduction) Systematic review similar risk reduction Drugs may also be administered rectally Not yet widely used for severe malaria in most developing countries Dondorp, et al, Lancet 2005, 366, Rosenthal, NEJM 2008, 358: IV Artesunate for the treatment of severe malaria in the USA Available only through CDC Requires dx malaria and either severe disease or inability to take oral medications Must call CDC ( or ) Drug released from CDC quarantine stations 16

20 countries Rapidly clears parasitemia and symptoms Well-tolerated Efficacy in

17 Coartem (Riamet) for uncomplicated falciparum malaria Artemether (20 mg) + Lumefantrine (120 mg) Standard therapy for uncomplicated falciparum malaria in > 20 countries Rapidly clears parasitemia and symptoms Well-tolerated Efficacy in non-immune population littlestudied 4 tablets BID x 3 days Approved by FDA April,

18 Chemoprophylaxis of malaria Chloroquine Mefloquine Doxycycline Malarone Chemoprophylaxis of malaria Drug Dosing Toxicity Cost 1 Chloroquine Weekly Very safe Cheap Mefloquine Weekly CNS $63 Doxycycline Daily GI & Skin $4 Malarone Daily GI $103 1 Wholesale cost for a 2-week trip Antimalarial chemoprophylaxis Summary Is prophylaxis really needed? Many cities in endemic countries are not a risk Cities in Africa and Indian subcontinent are high risk Detailed information available from CDC ( Areas without chloroquine resistance: Chloroquine Areas with chloroquine resistant falciparum malaria Mefloquine usually first choice, but contraindicated with psych disease or seizure disorder Malarone adequate replacement for mefloquine, but expensive, especially for a long trip Doxycycline particularly for areas with multidrug resistance (esp. rural SE Asia) 18

19 Health Problems After International Travel Diarrhea Prolonged traveler s diarrhea Protozoan parasites Tropical sprue Noninfectious 19

20 Diarrhea After Return From Travel Reasonable to manage as traveler s diarrhea For simple diarrhea, presumptive therapy with a quinolone and antimotility agent is OK Inflammatory diarrhea Stool culture and O&P Presumptive therapy with a quinolone Persistent diarrhea Repeat O&P to rule out giardiasis, other parasites Consider presumptive therapy with Flagyl Consider GI consultation for endoscopy Health Problems After International Travel Febrile Illness Malaria Acute schistosomiasis Typhoid Amebiasis Hepatitis prodrome Rickettsial illnesses Dengue Leptosporosis Other viral illnesses Brucellosis Acute HIV Other protozoa TB Chikungunya virus Fever in returned travelers 195 patients admitted to a London hospital Most common diagnoses Malaria: 82 (42%) No dx: 49 (25%) Gastroenteritis: 14 (7%) Dengue fever: 12 (6%) Bacterial pneumonia: 8 (4%) Upper respiratory tract infection: 6 (3%) Hepatitis A: 6 (3%) Typhoid: 6 (3%) Doherty, et al.: QJM 88:271,

21 Fever in returned travelers 232 patients admitted to an Australian referral hospital over a 3 year period Most common diagnoses Malaria: 62 (27%) Gastroenteritis: 33 (14%) Upper respiratory tract infection: 28 (12%) No dx: 22 (9%) Dengue fever: 18 (8%) Bacterial pneumonia: 14 (6%) Typhoid: 8 (3%) Hepatitis A: 6 (3%) O Brien, et al., CID 33:603, 2001 Dengue fever Endemic in many areas and spreading Transmitted by Aedes mosquitoes Incubation period: 4-7 days Major clinical features: fever, headache, musculoskeletal pain, diffuse rash, minor bleeding problems Dengue hemmorhagic fever 21

22 Fever after return from travel Workup Physical exam Blood smears Blood cultures Consider serologies Other tests based on presentation Health Problems After International Travel Eosinophilia Acute schistosomiasis Strongyloidiasis Filariasis Ascariasis Hookworms Other helminths Travel Advice Summary General Food and drink precautions Avoid insect bites Immunizations Tetanus Yellow fever Hepatitis A, Typhoid, Meningococcus Diarrhea Food and drink precautions Antibiotics and antimotility agents Malaria Avoid mosquito bites Prophylaxis: Usually Mefloquine or Malarone Prompt evaluation of febrile returned travelers 22

Infections in Travelers

Infections in Travelers Lisa Winston, MD University of California, San Francisco San Francisco General Hospital Outline Part 1 Outline Part 2 Before getting sick Risk assessment Personal precautions Immunizations