WOEMA Travel Medicine 2012 The World is our workplace Steven S Krotzer MD, DTMH, MPH

Transcription

1 WOEMA Travel Medicine 2012 The World is our workplace Steven S Krotzer MD, DTMH, MPH Krotzer.steven@mayo.edu Disclosure Information: Western Occupational Health Conference 2012 Steven S.Krotzer MD,DTMH,MPH Mayo Clinic, Scottsdale I have nothing to disclose. I will not discuss off label use and/or investigational use in my presentation million million million million million million World Tourism Organization

2 World Travel million tourist arrivals worldwide 98 million visits to exotic destinations 8 % Americans Half have no protection 30-70% ill 8% physician/hospital encounters 1/1000 ( 98,000) medical evacuations 1/100,000 dead Objective: Safe Travel Review the morbidity and mortality associated with travel Prioritize the most effective strategies for protecting the traveler Prevention Strategies Fitness for travel Food and water hygiene Self treatment traveler s diarrhea Vector precautions Immunizations Malaria prevention

3 Swine flu March 24-april 29, 2009: 2155 cases Mexico city with 100 deaths Within 8 weeks: every country on Earth capable of confirmatory testing verified disease activity. 134,000 laboratory confirmed cases, 816 deaths (Travax news alert July 20, 2009)

4 YELLOW FEVER

5 Businessman 2 weeks New Delhi, Mumbai, Bangalore, Hyderabad Most common cause of death? 1) dysentery 2) typhoid 3) mv accident 4) malaria 5) heart attack % Mortality in American Travelers 2463 deaths Cardiac (49%) Trauma (23%) Infectious Disease (1%) Unknown (25%) Hartgarten SW, Baker TD, Ogtil k, Overseas fatalities of US Citizens: an Anaalysis of Deaths Related to International Travel. Ann Emerg Med 1991:20;

6 Cardio-pulmonary Fitness for Travel TRAUMA

7 Worldwide : Trauma is #1 MVA / Pedestrian Trauma Deaths / 10,000 motor vehicles UK 1.4 / yr Asia 9-67 / yr Africa / yr Drowning Homicide suicide Kopcits E, Croper M. Traffic Fatalities and Economic Growth Accid Anal Prev 2005;37:

8 2 weeks in India. Most common infectious disease? 1) hepatitis A 2) typhoid 3) ET E Coli 3) Dengue 4) influenza Month of Travel Steffan et al. J Travel Med. Vol 15:3; Japanese encephalitis

9 Self treatment of traveler s diarrhea Most traveler s diarrhea hydration, Imodium, AND ciprofloxacin 500 B.I.D X 3 or Azithromycin 500 mg daily X 3 (Or rifaxamin) stools with blood, fever hydration, seek medical care PRIMARY PREVENTION Traveler's diarrhea HAND WASHING Water Fraud Avoid the uncooked? Efficacy

10 2 weeks in India during Monsoons. Serious Preventable vector borne disease? 1) Japanese Encephalitis 2) Chickungunya 3) Dengue 4) malaria 5) lieshmaniasis Aedes egypti

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12 Prospective study Myanmar. Thein et al Am J Trop Med Hyg: 1997;176:313 Protection against Vectors DEET 30-50% Covering up Permethrin impregnated nets. clothing, Window screens Duct tape Air conditioning Efficacy Vector Precautions 1188 bites / hr reduced to 1 bite / hr or less for 8 hours with ultr-thon or 50% DEET on exposed skin + Permethrin impregnated clothing Lille TH, Schreck CE, Rahe AJ. Effectiveness of Personal Proection against Mosquitos in Alaska. J Entomology 1988; 25 (6)

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15 2 weeks in India during the Monsoons Most common vaccine preventable disease? 1) hepatitis A 2) typhoid 3) tetanus 4) influenza Steffan et al Month of Travel Japanese encephalitis

16 Swiss study influenza in Travelers 1-3 % travelers all ages, all times of year, tropics and subtropics, serologically proven to have influenza during short term travel. Highest incidence India. Mutsch M, Tavernini, Marx A. Influenza Virus Infection in Travelers to Tropical and Subtropical Countries. Clin Inf Dis 2005; 40 (9): 1282

17 Month of Travel Japanese encephalitis MMWR 2011;60:1169

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19 Tourist to Bali, Indonesia 24 yo healthy male 5 days at 3 star resort on the beach May No travel inland. No preparation. Rash, fever June 3. Hospitalized June 7-9. Presumed Dengue. Subsequent outbreak in Indiana June 20 five family members all presented with fever and rash. Nasophyangeal swabs positive for measles genotype G9 As of August 2011, 198 cases and 15 outbreaks confirmed in USA, highest since 1996, all related to travel

20 MEASLES ROUTINE IMMUNIZATIONS Polio Influenza Routine immunizations Pneumoccocus dtap MMR polio

21 Hepatitis A Case fatality rate > 2 % over age % protection 2 weeks, 100% 4 weeks Havrix for imminent departures (evidence that post exposure Havrix is effective in preventing hepatitis in contacts NEJM 2007) Booster 6-18 months. Late booster effective even at 5 to 8 years Typhoid Vaccines Oral Typhoid TY21A ($54) age > 6 years 3-4 capsules Q.O.D booster 3-7 years npo, no hot liquids or antibiotics; cold chain field efficacy unknown Typhim Vi ($73) age > 2 years 0.5 ml IM deltoid booster in 2 3 years

22 Hepatitis B High Risk Behavior Cultural Freefall % American travelers have sex With a stranger. Half had no prior intention (therefore Unprotected!) ¾ of those were women. Other nationalities 6-56 % Croughs et al. J Trav Med 2008;15: 6-12

23 Meningitis Belt Menactra quadrivalent conjugate vaccine ages 2-55 booster 5 years Japanese Encephalitis Japanese Encephalitis % mortality

24 Rabies High Risk Rabies Incidence animal bites 2-4% per year Prevalence rabies feral dogs Bangkok 5% Human rabies essentially universally fatal 70% dog bites provoked by Human (CDC) Pre-exposure series alone: cases but no deaths Pre-exposure series + 2 injections post exposure: 100% effective in preventing cases and deaths. NO need for RIG! YELLOW FEVER % Mortality

25 Yellow Fever 200,000 cases/yr 30-50%mortality Jan cases 5 star resort Columbia Potential for urban epidemics Live attenuated Yellow Fever Vaccine 0.5 ml SQ NEVER < 9 months, pregnant, egg sensitivity, immunocmpromised 32 deaths / 57 severe reactions Neurological disease 1/8,000,000 hypersensitivity rxn 1/1,000,000 viscerotropic disease 1 in 400,000 s/p thymectomy, increasing age (1 in 40,000 age 60)

26 Jungle Yellow Fever ( Iguassu Falls ) Howler monkeys Living in high canopy Haemogogus and Sabethes mosquitoes

27 Travel vaccinations Hepatitis A Typhoid Hepatitis B Meningitis Japanese encepahalitis Rabies Yellow fever Malaria Prevention

28 MALARIA in Travelers ASIA 2.5 / 10,000 traveler-weeks Central and South America 2.5 / 100,000 traveler-weeks New Guinea, Vanuatu SOLOMON ISLANDS 5/100 traveler-weeks Sub- Saharan Africa 1/100 traveler-weeks Malaria

29 Prevalence of parasitemia In children decreased 5% For every 100 meters Increase in elevation. 82% at 300 M 12% at 1,700 M Bodker et al Am J Trop Med 74( 5 ), 2006 Pp

30 Seasonal Risk Malaria Incidence malaria per month

31 Behavior of Malaria Vectors A. gambiae ss West Africa Peri-domestic, urban endophyllic > exophyllic 2 AM - 4 AM A. albimanus Central America / Haiti Coastal, rural, exophyllic Dusk to midnight

32 Behavior of Malaria Vectors A. balabacensis Hill forest outdoors Bites late at night A. minimus Mountains, hills, rice fields Indoors 10 PM-2 AM Drugs for Malaria Prophylaxis Chloroquine 500 mg mefloquine 250 mg doxycycline 100 mg malarone 250 atovaquone/100 progaunil Primaquine radical cure Primary prophylaxis Emergency Standby Treatment Malarone or artemether/lumafantrine

33 Iron Man Triathlon In Malaysia 60 % participants Developed Leptospirosis Prevented by Weekly doxycycline 200 mg

34 Cardiopulmonary events and trauma: Most common cause of death in travelers Enterotoxigenic e. coli: single most common Infectious disease in travelers Dengue: most common vector borne disease In travlers Influenza: most common vaccine preventable Disease in travelers BEWARE OF DOG