emerging infectious diseases: the returning …...longer distance, shorter travel time all within...
TRANSCRIPT
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John Leander Po, MSc, MD, PhDPresident, Arizona Infectious Diseases Society (ARIDS)
Chair, Infectious Diseases Section, Banner Estrella Medical Center
Clinical Assistant Professor, University of Arizona College of Medicine- Phoenix
Arizona Infectious Disease Training and ExerciseArizona State University Memorial Union
July 27,2011
EMERGING INFECTIOUS DISEASES (EID):The Returning Traveler
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Objectives• Acknowledge how global travel has affected the
spread of EIDs
• Understand the factors that contribute to the emergence of EIDs
• List the groups of EIDs seen in returning travelers
• Know the trends of diagnoses of EIDs in returning travelers
• Be aware of Internet resources available to the healthcare provider of a retiring traveler.
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Longer Distance, Shorter travel timeAll within the past century!
Morens DM, et al. Lancet Infect Dis. 2008 November ; 8(11): 710–719.
2wks
1 wk 1 day
Average travel time ,England to Australia 1925–2000
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Global Shipping (2008) and Airline Routes (2010)
Halpern et al. (2008) Global Map of Human Impacts to Marine Ecosystems. Santa Barbara, National Center for Ecological Analysis and Synthesis. http://spatial-analyst.net/wiki/index.php?title=Image:Shipping_routes.png Accessed: 17July2011
Distribution of global airports and flight routes accessed from the openflights.org Accessed: 17July2011http://spatial-analyst.net/wiki/index.php?title=Image:Airroute.png
Diversity of Travel Types
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Increased Number of TravelersReturning to the US Since 1950
IOM (Institute of Medicine). 2010. Infectious disease movement in aborderless world. Washington, DC: The National Academies Press.
International tourist arrivals by region (in millions) 1950-2020.
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Global Differences in Health Care Capabilities
IOM (Institute of Medicine). 2010. Infectious disease movement in aborderless world. Washington, DC: The National Academies Press.
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Why does it matter?
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Economic Impact Measured in Billions
Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html
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Scenario
• 28 year old businessman presents to the ED with 4 days of fever, loose stool, dysuria and an erythematous rash…– 1 week after returning from India – New Delhi Sheraton, 2 weeks (seminar)– Immigrated to the US as a teenager – Saw parent in a large New Delhi medical center– Visited family in a village in rural province
– No PPX for malaria
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Where does one start?What does this case highlight?
Factors in the emergence of EIDs
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IOM (Institute of Medicine). 2010. Infectious disease movement in aborderless world. Washington, DC: The National Academies Press.
BLAH-BLAH-BLAH….
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TRAVELERSOCIO-
ECONOMICSENVIRONMENT
CLIMATE
ANIMALSECOLOGY
EIDs from the returning traveler:
Convergence of Systems
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“The Returning Traveler”…from where?
– Maricopa County?– Arizona?– Southwestern US?– US?– North America?– Sub-Saharan Africa?– United Kingdom?
TRAVELERSOCIO-
ECONOMICSENVIRONMENT
CLIMATE
ANIMALSECOLOGY
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Eisenberg JNS, et al. Environmental Health Perspectives • VOLUME 115 | NUMBER 8 | August 2007
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“The Returning Traveler”…from what?
– Business trip?– Safari?– Ecotour?– Missionary work?– Family reunion?– Sex tour?
TRAVELERSOCIO-
ECONOMICSENVIRONMENT
CLIMATE
ANIMALSECOLOGY
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Factors to Consider: Risk in Returning Travelers
• Consumption– Potable water safety– Food types (raw, cooked)
• Activities– Activities in fresh water– Adventure travel, including spelunking– Sexual contacts, tattoos, body piercing
• Exposures: – Insect and arthropod bites (mosquito, tick, other)– Animal bites and scratches– Hospitalizations and other medical care
http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-5-post-travel-evaluation/general-approach-to-the-returned-traveler.htm#2926Centers for Disease Control and Prevention. CDC Health Information for International Travel 2012. New York: Oxford University Press; 2012. Accessed July 25, 2011
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“The Returning Traveler”…“in what state?”
– Immunocompromised?– Vaccinated?– Aware of risks?– Medications?
TRAVELERSOCIO-
ECONOMICSENVIRONMENT
CLIMATE
ANIMALSECOLOGY
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Factors to Consider: Preparation
• Past medical history and medications• Travel purpose, itinerary (duration)
• Association with mass gathering (Hajj, for example)
• Type of accommodation• Use of bed nets and insect repellents
• Pre-travel prophylaxis• immunization history• Adherence to malaria chemoprophylaxis (before,
during, and after travel)
http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-5-post-travel-evaluation/general-approach-to-the-returned-traveler.htm#2926Centers for Disease Control and Prevention. CDC Health Information for International Travel 2012. New York: Oxford University Press; 2012.
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EID
SanitationFarming
Deforestation
ReproductivityDisplacement
Biodiversity changes
EncroachmentFood source
Domestication
TRAVELERSOCIO-
ECONOMICS
ANIMALSECOLOGY
ENVIRONMENTCLIMATE
P. Daszak et al, 2011. Wildlife & Emerging Diseases: drivers, maps and the road ahead.
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P. Daszak et al, 2011. Wildlife & Emerging Diseases: drivers, maps and the road ahead.
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Imported measles cases in U.S. residents
January 2001-February 2011(N = 172) by age group
Spectrum of DiseaseThe Returning Traveler
DISEASEEMERGENCE
PERSISTENCERE-EMERGENCE
Dengue
Chikungunya
Duvenhage virus XDR M.
tuberculosis
NDM-1 E. coli
MDR Gonorrhea
Influenza
Measles
Anthrax
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EID HOTSPOTS
• Jones et al (2008) 335 EID events from 1940-2004– Non-random pattern– Reporting bias: trend continues to hold despite factoring into
data
• Distribution of EIDs– 60.3% Zoonoses (72% wildlife)– 54.3% Bacterial or Rickettsial
• World “hotspots”– Socio-economics– Environment– Ecology
Jones et al, Nature 451, 990-993 (21 February 2008)
DISEASEEMERGENCE
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Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html
ZOONOTIC, WILDLIFE ZOONOTIC, NON-WILDLIFE
DRUG RESISTANT PATHOGENS
VECTOR-BORNE
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EID events from 1940 2004
Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html
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DISEASEEMERGENCE
PERSISTENCERE-EMERGENCE
SanitationFarming
Deforestation
ReproductivityDisplacement
Biodiversity changes
EncroachmentFood source
Domestication
TRAVELERSOCIO-
ECONOMICS
ANIMALSECOLOGY
ENVIRONMENTCLIMATE
P. Daszak et al, 2011. Wildlife & Emerging Diseases: drivers, maps and the road ahead.
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Trends in Diagnoses of EIDs:The Returning Traveler
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GeoSentinel network
Joseph Torresi & Karin Leder, Nature Reviews Microbiology 7, 895–901
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GeoSentinel network and reporting structure.
Joseph Torresi & Karin Leder, Nature Reviews Microbiology 7, 895–901. 2008
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Number of EID events per decade.
Nature 451, 990-993(21 February 2008)
Mainly BacterialIncreased viruses & prions
IncreasedZoonotic Transmission
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Nature 451, 990-993(21 February 2008)
Number of EID events per decade.Increased drug
resistanceIncreased
Non-vector-borne transmission
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Common Diseases in Travelers Reporting to the GeoSentinelNetwork.
Joseph Torresi & Karin Leder, Nature Reviews Microbiology 7, 895–901
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% Febrile Travelers Dx with More Common Infectious Diseases, (Region of Travel)
Sub-saharan Africa: Malaria, Respiratory, Diarrhea
Northern Africa:Diarrhea, Respiratory, Malaria
Joseph Torresi & Karin Leder, Nature Reviews Microbiology 7, 895–901, 2008
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Returning Traveler: General trends• Malaria within the top 3 dx from every region
• Febrile illness: likely from Africa & Southeast Asia– Sub-Saharan Africa: 1) Malaria 2) Rickettsial disease
• Most common febrile illness from every region outside sub-Saharan Africa: Dengue (past 10 yrs)
• Southeast Asia: Respiratory disease most likely
• Southcentral Asia: Acute diarrhea disproportionately in travelers
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Selected emerging diseases 430 B.C. to 1981 A.D.MDR = multidrug-resistant; SARS = severe acute respiratory syndrome;
vCJD = variant Creutzfeldt-Jakob disease; XDR = extensively drug-resistant.
Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html accessed 19Jul2011
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Selected emerging diseases 1977-2007(representative examples of where epidemics occurred)
Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberghttp://www.nap.edu/catalog/12586.html
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New and ongoing outbreaks since June 16, 2011
http://www.healthmap.org/predict/
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Scenario
• 28 year old businessman presents to the ED with 4 days of fever, loose stool, dysuria and an erythematous rash…– 1 week after returning from India – New Delhi Sheraton, 2 weeks (seminar)– Immigrated to the US as a teenager – Saw parent in a large New Delhi medical center– Visited family in a village in rural province
– No PPX for malaria
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DISPROPORTIONATE INFECTIOUS DISEASE RISKS IN VFRS*
• Lack of awareness of risk (over-confidence)– Lower rates of vaccination (HAV, Typhoid)– Infrequent use of malaria chemoprophylaxis– Less mosquito netting use; food/water use
• Pre-travel health care barriers– ≤30% have a clinic visit– Financial barrier– Clinics are not geographically convenient
• Cultural and language barriers – Lack of trust in the medical system
• Higher-risk destinations– Longer stays– Last minute planning
http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-8-advising-travelers-with-specific-needs/immigrants-returning-home-to-visit-friends-and-relatives-vfrs.htmCenters for Disease Control and Prevention. CDC Health Information for International Travel 2012. New York: Oxford University Press; 2012.
*Immigrants Returning Home to Visit Friends & Relatives
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CDC Travelers’ Healthhttp://wwwnc.cdc.gov/travel/
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Promedmail.orghttp://www.promedmail.org
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Geosentinelhttp://www.istm.org/geosentinel/
main.html
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MD Travel Healthhttp://mdtravelhealth.com/
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JULY 18, 2011
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http://www.polioeradication.org/Aboutus/Progress/Progresstowardspolioeradication.aspx
Polio Outbreak in Tajikistan, Cases in Russia, Ri Central Asian Countries
July 18, 2011 at 18:05 EDT
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