Travel Medicine. Simin Torabzadeh MD, FACP University of California, Irvine

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1 Simin Torabzadeh MD, FACP University of California, Irvine

2 500 Million People Travel Annually 63 Million Americans Pre-Travel Counseling Common Preventable Problems

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5 Risk Factors for Disease Age under 25 Prolonged stay Prolonged contact with native people Trips to rural areas Significant Pre-existing co morbidity High risk sexual behavior

6 Immunization Review Behavioral Counseling Prevention of Malaria/Insect Born Diseases Management of Traveler s Diarrhea Prevention of Sexually Transmitted Diseases

7 Immunizations: Routine Conditional Routine Travel Specific

8 Routine Immunizations: DPT Hib Td MMR (Before 1957) Polio (Now endemic in Nigeria/India and Pakistan/Afghanistan) Varicella Hep B

9 Conditional Routine Immunizations: Influenza Pneumococcal

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11 Travel Specific Immunizations: Hep A - Areas outside Canada, Japan, Australia Scandinavia, or Western Europe - 2 injections 6-18 months apart Immune Globulin ml/kg< 3 months stay ml/kg> 3 months stay

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13 Yellow Fever Equatorial Africa, South America 10days before travel 10years immunity Official Seal 3 weeks interval between cholera

14 Cholera - Incomplete immunity Typhoid - Tropical area, developing countries - Oral: 4-5 years immunity: not< 6 years - inject able: 2 years immunity: older > 2 years Plague - Not routine - Anthropologists or Archaeologists - Warning in Republic of Congo

15 Meningococcal Meningitis - During Pilgrimage to Saudi Arabia - Sub-Saharan Africa (Dec-June) - India, Nepal - 2 years immunity - Not for < 2 years old - Menactra shortage

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17 Rabies Only to high risk travelers Series of injections days 0,7,21,30 3 weeks before chloroquine intake Japanese Encephalitis Prolonged visit Rural Asia 3 Doses Sub Q days 0,7,30 Anaphylaxis

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19 Food & Beverage Hygiene If you can t boil it, cook it or peel it, forget it Avoid raw vegetables Consume cooked foods Use bottled water No ice Tincture of iodine Portable water filters

20 Measures Against Insect Bites: Limit dawn and dusk activities Wear long sleeves, long pants Use insect repellents containing DEET Sleep under the screen

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22 Environmental Protection Sun Protection Hats Protective Clothing Sunscreen (SPF> 15) Sun avoidance while taking Doxycycline,TCN, Retin-A or Griseofulvin

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24 Altitude Sickness Acute mountain sickness> 10,000 ft : Headache, Dizziness, SOB, Nausea, Difficulty sleeping hours Takes 2-3 days Use Diamox mg bid 24hours before travel & 5 days after

25 Pulm Edema Life threatening Immediate descent Nifedipine 30mg bid Cerebral Edema Headache, Ataxia, Altered Mentation, Psychosis Immediate descent

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27 Air Travel Not until 6 weeks after MI Pregnant women > 36 weeks Prevent venous stasis Thromboembolism - Hx of DVT - HRT - Recent surgery - ETOH during flight - Immobility

28 (Travel Medicine Travel Contraindications: Recent MI Uncontrolled HTN Unstable Angina Pneumothorax Recent Cardiothoracic or abdominal surgery Active TB or Varicella Sever immunosuppresion Recent stroke

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30 Motion Sickness Dramamine 50mg 4-6 hrs, 2hrs onset, 8hrs duration Transderm-scopolamine patch q 3 days, 6-8hrs, 72hrs Phenergan 25mg bid, 2hrs, 12-18hrs Antivert 25-50mg, 2hrs, 12-18hrs

31 Food & Waterborne Illness Traveler s Diarrhea Million cases/year - increased risk at central & south America, Africa & Middle east - intermediate risk at Mediterranean, Caribbean and China - improper cooking, peeled fruits, contaminated water, food from street vendors

32 Pepto-Bismol 2-4 times/day (prophylaxis) Imodium or Lomotil Cipro 500mg bid for 3-7 days Bactrim DS(No longer recommended) Rifaximin and Azithromycin Oral rehydration with Na/K/NaHco3/Glucose in water Fluid replacement/tcn 500mg qid for cholera or Emycin or Bactrim DS for children Cipro or Bactrim for Typhoid fever

33 Malaria 300 Million affected/year 1.5 Million death/year Low risk above 1500 meters Blood borne parasite through mosquito Plasmodium Falciparum> 95% of deaths in Southeast Asia & Africa Plasmodium Vivax in Central & South America

34 Clinical Presentation: Fever, Myalgia, HA, N/V, Arthralgia, Diarrhea, Anemia, Jaundice, HSM, Elevated LFT s Chemoprophylaxis one week before, during and four weeks after travel 1. Chloroquin 500mg/week Central America/Mexico/Tropical south America/Iraq/Turkey/East Europe - Pediatric: 9.3mg/kg

35 - Side effects: N/V, HA, Bitter taste, Macular degeneration, aggravates psoriasis 2. Mefloquin 250mg/week Central, South and East Africa/China/Mideast - Relative contraindication: Ca blockers & Digoxin - Contraindication: Seizure disorder, Psychiatric Hx & Cardiac conduction abnormalities

36 3. Doxycycline: 100mg/d 2 days before, during and 4weeks after travel - Side effect: Photosensitivity, GI upset - Contraindication: Pregnancy, Child<8

37 Dengue Fever - Southeast Asia, South America, Caribbean - Saddle back fever curve - No effective vaccination Yellow Fever - Tropical Africa, South America, West Africa

38 - Mild flu like to hemorrhagic disease - Faget s sign - Single subq inj (official)

39 Leishmaniasis Bite of sand flies Visceral, cutaneous & mucocutaneous Papular lesion Splenomegaly Pentamidine & Amphotericin B (treatment) No vaccine

40 Japanese Encephalitis Korea, Japan & China Cephalgia, Meningeal signs, Choreathetosis, seizure and coma Extremely low risk

41 SARS Viral respiratory illness 1 st in Feb 2003 in Asia Total of 8098 worldwide affected 774 death No reported cases since May 2005

42 Avian Influenza H5N1 virus affects birds First cases since 2003 Direct contact with infected poultry No human to human transmission reported Countries: Indonesia/Thailand/Vietnam/China Cambodia/Egypt/Turkey/Iraq _ Total 138 deaths _ Treat with Oseltamivir or Zanamivir

43 Sexual Safety Abstain Use latex condoms Avoid sex workers Use ETOH responsibly Obtain Hep B vaccine

44 Drug Interactions B-blockers, Quinidine with Mefloquin Antacids with Doxycyclin and Tetracyclin Aspirin with varicella vaccine

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