Emporiatrics: The Art and Science of Travel Medicine

Transcription

1 Emporiatrics: The Art and Science of Travel Medicine Archana Chatterjee, M.D., Ph.D. Professor and Chair, Dept. of Pediatrics, Univ. of South Dakota Sanford School of Medicine/ Sanford Children s Specialty Clinic

2 Disclosures Grant/Research Funding GSK, Merck, Astra Zeneca Speakers Bureau Merck, Pfizer, Sanofi Advisory Board Pfizer

3 Learning Objectives Discuss the prevention and treatment of common medical conditions in travelers. Explain travel-related immunizations. Describe the screening and evaluation of returning travelers.

4 Travel Medicine Aimed at prevention & treatment of medical complications in travelers Embraces tropical medicine, pharmacology, epidemiology, public health, preventive medicine, occupational medicine and infectious diseases

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6 Travel Medicine About 1 billion people travel each year Doubling of passengers on US airlines next two decades by air alone within 22%-64% of travelers report some illness; most are mild and self-limited, such as diarrhea, respiratory infections, and skin disorders Up to 60% of children will become ill during international travel, and up to 19% will require medical care Travelers visiting friends and relatives in their country of origin constitute the group with the highest morbidity, especially from malaria and typhoid Over the past 40 years, average of 21 in-flight deaths per year Incidence of emergencies 1 per 35,000 passengers

7 Who Needs to see a Travel Medicine Expert? High-risk or adventure traveler Immunocompromised traveler Traveler with underlying chronic disease Traveler planning to live abroad for a long time Women who are pregnant or plan to become pregnant soon Young children Travelers with complicated itineraries

8 Financial challenges Individualized Risk Assessment Medical planning for travel requires 6 to 8 weeks at minimum Medical history, including medications, disabilities, immune status, immunizations, surgeries, allergies, and pregnancy or breast-feeding Prior travel experience Specific itinerary, including regions, season, and dates Activities (e.g., adventure travel and events involving mass gatherings) Type of accommodations Travelers risk tolerance

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10 Pre-Travel Preparations 20 to 80% of travelers do not seek pre-travel health consultation! Start with clean bill of health at least 6 weeks before travel Visit physician, dentist Carry printed instructions (in lay language) Update routine immunizations Obtain travel-related vaccines Carry a medical kit Keep to schedule as much as possible Confirm air travel arrangements

11 Question 1 1 What is the most common vaccine-preventable disease among travelers? A. Rotavirus B. Measles C. Influenza D. Malaria

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13 Immunizations for International Travel Risk assessment Time before departure Budget/insurance coverage Allergies Pregnancy, immunocomp. state Legal requirements

14 TdaP MMR Polio Varicella HBV Routine Immunizations Meningococcal Pneumococcal Influenza Some routinely recommended immunizations should be given early/on an accelerated schedule.

15 Question 2 1 Which of the following vaccines may be required for travel to certain countries? A. Cholera B. Typhoid C. Japanese encephalitis D. Yellow Fever

16 Travel Immunizations Required (for some countries) yellow fever Recommended Hepatitis A vaccine vs. Ig Typhoid oral vs. injectable Rabies pre- vs. post-exposure Japanese encephalitis Tickborne encephalitis Possibly required BCG available from Organon USA Inc, 56 Livingston Ave, Roseland, NJ

17 Travel Immunizations (cont.) YF vaccine recommended for > 9 mo traveling to areas of South America and Africa in which risk exists for YF transmission; only available at certified centers in the US. Risk of severe AE 1:250,000 with 1 st dose. Hepatitis A For <1 yo, Immune Globulin Intramuscular may be indicated (HepA not licensed in US < 1 year). May interfere with varicella and MMR vaccines for up to 3 months.

18 Travel Immunizations (cont.) Typhoid - Efficacy 60-80%; adherence to PO vaccine 70%; PO vaccine for 6 yo, parenteral vaccine 2 yo. Revaccination required after 5 years for oral and 2 years for inactivated vaccine. Rabies Pre-exposure prophylaxis with 3 doses for high-risk travelers. JE - requires 28 days to complete. Licensed for people >2 months of age; 2-dose primary series. <1 case/ million travelers. Short-term travelers (<1 mo visit) restricted to urban areas at minimal risk, but risk varies (season, destination, duration, and activities). Give vaccine if ongoing JE outbreak.

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20 Basic Travel Health Kit Sufficient prescription meds in labeled bottles List of medical conditions, allergies, meds with doses Analgesic (Aspirin, Tylenol, NSAID) Antibiotic for self-treatment of diarrhea Antidiarrheal (Pepto-Bismol, Imodium) Antihistamine Antimalarial Antinausea/motion sickness medication Antibiotic, antifungal, hydrocortisone creams

21 Basic Travel Health Kit Antiseptic Cold/cough/sinus remedies Thermometer Insect repellant Lancets/syringes/needles Sleeping medication (melatonin) Sunscreen Water purifier or tablets Wound dressings

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23 Question 3 1 Is the following statement true or false? Travelers with bloody diarrhea should be given antibiotics and antimotility agents.

24 Travelers Diarrhea (Delhi Belly) Most common health problem affecting travelers (10-60%) Defined as passage of >3 unformed stools in a 24 hour period plus at least one symptom of enteric disease, during or up to 7 days after travel, not lasting longer than 2 weeks (usually 4-5 days) Mortality rare, morbidity substantial - 1% hospitalized, 20% confined to bed at least for a day, 40% have to change itinerary

25 Travelers Diarrhea Epidemiology Risk - ~7% in developed countries - ~20% in southern Europe, Japan, Israel, South Africa, the Caribbean - 20%-60% in Africa, Middle East, Latin America and Asia Prior experience not protective 90% of cases occur in first two weeks Infants, young adults at highest risk

26 Host Risk Factors in Travelers Diarrhea (Montezuma s Revenge) Blood group O Achlorhydria Antacids H2 inhibitors Immunodeficiency HIV, IgA, etc. IBD Extremes of age

27 Causes of Travelers Diarrhea (Tut s Tummy) Bacterial ETEC, other E. coli, C. jejuni, Salmonella, Shigella, Aeromonas, P. shigelloides, B. fragilis Viral rotavirus, norovirus Parasitic E. histolytica, G. intestinalis, Cryptosporidium, Cyclospora No pathogen identified

28 Treatment of Travelers Diarrhea Oral rehydration Dietary adjustment Symptomatic treatment bismuth subsalicylate, loperamide (avoid if bloody diarrhea), kaopectate diphenoxylate Antibiotics single dose-3 days FQ, azithromycin, non-absorbed abx rifaximin, TMP/SMZ (Abx resistance may occur) Combination therapy

29 Dietary Advice for Avoiding Travelers Diarrhea Food piping hot, peeled fruit, cooked vegetables, processed/packaged Beverages boiled/bottled water, carbonated, iodized water, irradiated/ pasteurized milk, NO ice, alcohol Dietary practices recommended restaurants, avoid street vendors, temperature of food

30 Prevention of Travelers Diarrhea Hand hygiene Education Boil it, peel it, cook it or forget it Chemoprophylaxis Bismuth subsalicylate 65% protective (4 doses/day) Abx TMP/SMZ (70-80%), FQ (90% - q d dosing)?vaccine

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32 Question 1 Which of the following is the most common cause of fever in a returning traveler? A. Dengue B. Malaria C. TB D. Influenza

33 Malaria Epidemiology World s most important parasitic disease - In 2015 an estimated 212 million cases occurred worldwide; 429,000 people died, mostly children in the African Region. 90% of malaria incidence and majority of deaths occur in tropical Africa Risk of malaria per month of travel among travelers not receiving chemoprophylaxis range from 3.4% in West Africa to 0.34% on the Indian subcontinent and 0.034% in South America. Nighttime exposure to mosquitoes confers highest risk

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35 Malaria in the U.S. Approximately 1500 cases reported to CDC annually 40%-70% cases not reported 90% of travelers do not become ill until returning home Potential medical emergency and should be treated accordingly Engage CDC resources!

36 Malaria : The Disease Clinical features depend on hostresistance, infecting species, degree of parasitemia, use of chemoprophylaxis Incubation period variable - average days, may be up to 12 months Fever, malaise, HA, chills, sweats in 80% of cases GI s/s, hypotension less frequent

37 Malaria : The Disease Hemolysis of RBCs, cytokine release, adherence of parasitized RBCs to vascular endothelium, disruption of microcirculation, organ failure (brain, lung, kidney) Diagnosis by thick blood film, PCR Antigen detection by Mab and acridine stained buffy coat for P. falciparum

38 Malaria Risk in Travelers Risks factors: -Rural travel -Nighttime exposure -Unscreened accomodation -Travel to areas with drug-resistance -Failure to use personal protective measures and prophylaxis

39 Malaria Prevention in Travelers Assess individual risk - geographic area, type of accomodation, duration of stay, season, preventive measures Prevent mosquito bites - screening, insecticide-impregnated bed nets, repellants Chemoprophylaxis Early diagnosis and treatment

40 Insect Precautions Suitable clothing Bed nets Repellants -DEET -Permethrin -Oil of citronella -New agents picaridin, lemon eucalyptus oil Will also prevent other infections: dengue, chikungunya, zika, JE, leishmaniasis, rickettsial diseases

41 Malaria Chemoprophylaxis Zone No resistance Chloroquine Resistant Chloroquine and Mefloquine Resistant Drug of Choice Chloroquine Mefloquine Doxycycline Alternate Drug Doxycycline Doxycycline Chloroquine + Proguanil

42 Malaria Chemoprophylaxis Regimens Start antimalarial at least one week before travel, take daily/weekly during travel, continue up to 4 weeks after travel (except for Malarone) May need to assess tolerance 2-3 weeks before travel

43 New Drugs for Malaria Prevention Primaquine - gametocidal, activity against blood and tissue stages, daily dosing, hemolytic anemia in G6PD def. Etaquine - longer half-life - weekly dose Malarone (Atovaquone/Proguanil) - daily dose, GI side effects (start one day before travel until 7 days after return) Azithromycin - daily dose, useful in pregnancy, children

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45 Special Travel-Related Anthrax Tuberculosis Dengue Chikungunya Zika Leptospirosis Plague Infections Tick-borne encephalitis Typhus STDs

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47 Accident/Injury Prevention Wear sensible shoes Observe water safety rules Avoid strange/wild animals Wear seatbelts Avoid local medications Wear sunglasses and sunblock

48 Medical Facilities Abroad International Association for Medical Assistance to Travelers American Citizens Services Shoreland Medical Marketing, Inc. Friends, family, embassies University, private or mission hospitals preferred over government institutions Local Lions/Rotary Club members Check health insurance

49 STDs Screening Tests for Returning Travelers Parasitic dz stool, serology Tuberculosis TST/IGRA 8-10 weeks after return if >1 month in country with high prevalence/known TB exposure. Fever malaria vs. other tropical illness blood smears, PCR, cultures Chronic diarrhea protozoa/helminths Eosinophilia blood, stool exam Skin lesions exposures, appearance, associated findings, biopsy

50 Summary Travel-related illnesses are common Appropriate pre-travel preparation is necessary for individualized risk assessment and counseling Expert advice should be sought in special circumstances Routine and travel-related immunizations should be reviewed Traveler s diarrhea should be discussed Malaria prophylaxis may be needed Accident/Injury prevention and insect precautions should be addressed All travelers should carry a basic travel health kit Returning travelers may need screening and evaluation Travel medicine resources should be accessed as needed

51 Travel Medicine Resources CDC Health Information for International Travel AAP Red Book 800-CDC-INFO Internet Listservs, State/Local Health Depts. Freedman et. al., Medical Considerations before International Travel. N Engl J Med 2016

52 Bon Voyage!...There s no place like home!

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