Case. Objectives. Case. Case. Case. Case

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2 Objectives 1. Implement travel history inquiry in all appropriate clinical settings 2. Evaluate systematically the causes of fever in travelers 3. Counsel prospective travelers on ways to prevent common travel-related infectious diseases 4. Identify resources available to the clinician for the counseling, evaluation, and management of travelrelated infectious diseases A 32 year-old otherwise healthy nurse presents to the Emergency Department with 2 days of fever, chills, and vomiting A 32 year-old otherwise healthy nurse presents to the Emergency Department with 2 days of fever, chills, and vomiting 2 weeks prior she had returned from West Africa where she was in a medical mission. A 32 year-old otherwise healthy nurse presents to the Emergency Department with 2 days of fever, chills, and vomiting 2 weeks prior she had returned from Brazil where she was in a medical mission. A 63 y/o business man with COPD presents to your office with 3 days of cough, shortness of breath, and fever A 63 y/o business man with COPD presents to your office with 3 days of cough, shortness of breath, and fever He returned 5 days prior from a trip to the Middle East, where he visited a friend at a local hospital.

3 Always Obtain a Travel History Helps with differential diagnosis Helps implement appropriate infection control interventions A 47 y/o physician presents to your office with fever. He had returned from vacation a few days before. He had a great trip to the Dominican Republic: went hiking in the forest, spent time in a semi-deserted beach, tasted local food and drink, and engaged in sexual activity with a couple of locals. He had not taken any vaccines or prophylactic medication Infectious Risks of Travelers Arthropod-related infections Arthropod-related Food-related Sex-related Related to specific activities or locations Medical tourism -related Antimicrobial resistance Mosquito Malaria Dengue Chikungunya Zika Yellow fever Japanese encephalitis Sandfly Leishmaniasis Tick Lyme disease Anaplasmosis Rocky Mountain Spotted Fever Flea Murine typhus Plague Tularemia Malaria million infections, 1 million deaths annually Between , ~8K cases reported to CDC 62% from sub-saharan Africa 19% Asia 16% Caribbean, Central and South America 3% Other Risk varies by Intensity of transmission Time and type of travel Aedes spp. transmitted diseases Dengue Chikungunya Zika virus West Nile virus Aggressive daytime biter Urban

4 Dengue Most common arthropod-borne viral disease of humans Risk to travelers ~1/1000 travelers to endemic areas Zika virus infection Two reasons for concern Ability to spread broadly and rapidly Potential to cause serious health complications Clinical Manifestations Incubation period 2-7 days 80% asymptomatic Mild dengue-like illness 2-5 days Fever, body aches, rash, conjunctivitis Complications Neurologic and teratogenic Spatial and temporal association Cause and effect has not been firmly established yet, but is likely Complications of Zika Congenital infection Microcephaly, brain calcification, ocular disease Miscarriage? Guillain-Barre syndrome Best described in French Polynesia outbreak in ~32,000 Zika cases (8750 registered) 74 patients with neurological/autoimmune conditions after Zika 42 with GBS Observed in Brazil, Colombia, El Salvador, others. Pan American Health Organization / World Health Organization. Epidemiological Update: Neurological syndrome, congenital anomalies and Zika virus infection. 17 January, Washington, D.C.: PAHO/WHO; 2016 Zika in pregnancy As of Feb 17, 2016, 9 pregnant travelers with lab-confirmed Zika 2 miscarriage (2 in 1 st trimester) 2 abortions (both with malformations, 1 st trimester) 3 live births 1 severe microcephaly (1 st trimester) 2 apparently healthy (2 nd and 3 rd trimester) 2 are still pregnant (1 st and 2 nd trimester) Food-related illness Traveler s diarrhea Hepatitis A Typhoid fever Giardiasis MMWR March 4, 2016 / 65(08);

5 Traveler s Diarrhea Most common travel-related infection 30%-50% of travelers to high-risk areas during a 1-2 week stay 50,000 cases each day Etiology Bacteria (80%-85%) Parasitic (10%) Viruses (5%-10%) Treatment of Traveler s Diarrhea Oral rehydration therapy Antibiotics (single dose to 3 days) Fluoroquinolones Azithromycin Antidiarrheals Bismuth 1 oz or 2 tabs q30 min x8 doses Careful with drug interactions Antimotility agents (loperamide and diphenoxylate) Hepatitis A Caused by hepatitis A virus Most common vaccine-preventable travelrelated infection Acquired person-to-person or through contaminated food or water Risk is highest for those who: Live in or visit rural areas Trek in back-country areas Frequently eat or drink in settings of poor sanitation Typhoid fever Acute, life-threatening febrile illness caused by Salmonella enterica serotype Typhi 22 million cases, 200,000 deaths worldwide each year 400 cases per year in US, mostly travelers Risk is greatest in South Asia, and developing countries in Asia, Africa, the Caribbean, and Central and South America Highest risk in travelers visiting relatives or friends Sexually Transmitted Infections 340M infections annually worldwide 18.9M in the US Travelers are at increased risk: Commercial sex Increased sexual promiscuity Casual sex relationships Sex destinations : SE Asia Sexually Transmitted Infections Common: Gonorrhea (incl. FQ-resistant) Syphilis HIV Less common Chancroid Lymphogranuloma venereum (LGV) Granuloma inguinale

6 Other travel-related infections Coccidioidomycosis (Valley fever) Histoplasmosis Filariasis Schistosomiasis Leptospirosis Japanese encephalitis Yellow fever Meningococcal disease Rabies Tetanus Trypanosomiasis Tuberculosis Fever in the returning traveler The differential diagnosis of fever in the returning traveler is vast. Symptoms are usually non-specific Epidemiology (location, activities, risk factors) is very important Laboratory tests and management should be guided by clinical and travel history A family comes to the office for evaluation. They are excited about a once-in-a-lifetime trip they are planning to SE Asia. They are planning activities for all: see modern and traditional China, hike in the rainforest, sample traditional food, enjoy the nightlife. They are asking for pre-travel counseling and any necessary shots. Risk assessment Know itinerary (not just the country, but specific areas/cities/elevation) Trip duration Know expected activities Food sources Know what is going around that part of the world Infectious Risks of Travelers Arthropod-related Food-related Sex-related Related to specific activities or locations Types of pre-travel recommendations Counseling and advice Vaccines Self-treatable conditions: traveler s diarrhea, URI, altitude illness, motion sickness Prophylactic medication First aid and medical care abroad

7 Protection against mosquitoes, ticks, and other arthropods Avoid outdoor activity at dawn and dusk or after dark Wear long-sleeved shirts (tucked-in), long pants (tucked into socks and boots), and hats Inspect for ticks regularly Use bed nets (treated with permethrin) Repellents DEET or picaridin for skin Permethrin for clothing, shoes, tents, mosquito nets Malaria: Prevention If chloroquine resistance is NOT present Chloroquine (weekly) 1-2 wks before to 4 wks after trip If chloroquine resistance present Atovaquone/proguanil (Malarone )(daily) 1-2 d before to 7 d after trip Doxycycline (daily) 1-2 d before to 4 wks after trip Mefloquine (Lariam ) (weekly) 1-2 wks before to 4 wks after trip Prevention of food-borne illness Wash hands or use alcohol-based hand gel prior to eating, after using bathroom or changing diapers, and after direct contact with preschool children or animals Only eat: Food that has been cooked and is still hot Fruit that has been washed with clean water and has been peeled by the traveler Food that has been commercially wrapped Remember water and ice! Boiled and hot Chlorine, iodine Filters Prevention/Management of Traveler s Diarrhea Instruction re: food and beverage selection Bismuth subsalicylate (from 40% to 14%) 2 oz or 2 tabs 4 times daily Blackening of tongue and stool, constipation Probiotics (inconclusive data) Rifaximin (40% to 4%) Non-absorbable Careful with complacency Mostly for short-term travelers who are high-risk hosts and/or critical trips STI: prevention No travel-specific vaccines available Education and counseling Abstinence or mutual monogamy Correct and consistent use of male latex condoms Travel-related vaccines (as indicated, besides routine, age-specific vaccines) Hepatitis A Typhoid Meningococcal vaccine Td/Tdap Yellow fever Japanese encephalitis Rabies

8 Hepatitis A: Prevention Hepatitis A vaccine Should be given routinely to travelers to areas with high or intermediate endemicity At least 1 dose before departure Ideally, 2 doses (0, 6 months) Hepatitis A immune globulin Should be given when travel will begin within 2 weeks after vaccination or when vaccine cannot be given (selected patients) Typhoid fever: Prevention Typhoid vaccine Recommended for travelers to areas with risk of exposure to S. typhi. Not 100% effective (50%-80%) One dose IM given 2 weeks before exposure Booster every 2 years Traveler s Health Kit: Medications (when applicable) Personal prescription medications Acetaminophen, aspirin, ibuprofen for pain or fever Antihistamine +/- decongestant Over the counter antidiarrheals Antibiotic for self-treatment of mod-sev diarrhea Mild laxative Antacid Antifungal/antibacterial ointment or cream 1% hydrocortisone cream Antimalarial medications Anti-motion sickness medication High-altitude prevention medication Epinephrine auto-injector for people with severe allergic reaction Traveler s Health Kit: Other items Antibacterial hand wipes or alcohol-based hand gel Insect repellent Sunscreen Aloe gel for sunburns Water purification tablets Oral rehydration solution packets Basic first-aid items Digital thermometer Moleskin for blisters Latex condoms Resources for travel counseling CDC website The Yellow Book World Health Organization