Travel Medicine Dr Edie Baxter

Dr Paul Bonnar

Dr Edie Baxter has no conflicts of interest regarding this topic

Dr. Paul Bonnar currently participating in a clinical trial with Finch Therapeutics

Summer 2019

Lisa

• 56 year old female health care worker

• PMH: IBS, recurrent UTIs, previous GI bleed

• Medications: amitriptyline 20 mg, vaginal estrogen,

rabeprazole 20 mg

• Travel to Dominican Republic for winter vacation,

wants something “to prevent stomach upset”

Karen

• 29 year old female, otherwise healthy

• Trip booked to South East Asia

• General preconception counselling, also

asks your advice regarding zika virus

Themba

• 35 year old man, immigrated from South Africa 10 years ago

• Current visit is regarding HTN

• In arranging for follow up he mentions to you he will not be able to return for 2-3 months as he will be visiting relatives in rural South Africa

Resources

• CATMAT: https://www.canada.ca/en/public-health/services/catmat.html

Resources

• https://wwwnc.cdc.gov/travel

Malaria

Malaria

• Protozoan parasite• P. falciparum

• P. vivax

• P. ovale

• P. malariae

Clinical presentation:• fever, influenza-like symptoms, headache,

N/V, general malaise

Consider malaria:• any patient with febrile illness, recently

returned from malaria endemic country7 days 1 year

Malaria

• Assess level of risk:• Aware of risk

• Know how to prevent Bites

• Chemoprophylaxis as appropriate

• Understand need for urgent Diagnosis and treatment if develop a fever

• Highest risk = visiting friends and relatives

Prevention Measures

• Physical barriers

• INSECT REPELLANTS

• DEET

• Icaridin

• Oil of lemon eucalyptus (p-menthane-3,8-diol) products, that are registered in Canada

• NOT recommended: citronella and soybean oil, wristbands, neckbands, and ankle bands impregnated with repellents

• NOT for children < 2 months

• DEET concentration not >30% for children

• Apply Sunscreen FIRST then insect repellant

Malaria- Dominican Republic

https://www.cdc.gov/malaria/travelers/country_table/d.html

Malaria- Dominican Republic

https://www.canada.ca/en/public-health/services/catmat/appendix-1-malaria-risk-recommended-chemoprophylaxis-geographic-area.html#d

Malaria Prophylaxis

Atovaquone 250 mg/Proguanil 100 mg

• Prophylaxis in all areas

• Pediatric dosing in children >5kg

• Start 1-2 days prior to travel

• Continue for 7 days after return

• Generally well tolerated

• Not for pregnancy/breastfeeding

• Not in severe renal impairment

Doxycycline

• Prophylaxis for all areas

• 100 mg orally, start 1-2 daysprior (peds >8y, 2.2 mg/kg)

• Continue for 4 weeks after return

• Not for pregnancy and children<8

• Vaginal candidiasis, sun sensitivity, GI upset

Malaria Prophylaxis

Chloroquine• Adult dose 300 mg/week• OK for pregnant patients and

pediatrics (5 mg/kg)• Start 1-2 weeks prior• Continue for 4 weeks on return• High degree of resistance: best

used in Caribbean and Central America WEST of Panama Canal

Mefloquine• Adult dose 228 mg base (250 mg

salt) once weekly• Can be used in pregnancy and

pediatrics• Good for people who had tolerated

it previously• Contraindicated with active or

recent depression, anxiety, psychosis, schizophrenia, seizure disorder, cardiac conduction abnormalities

Malaria Prophylaxis

Primaquine

• One of most effective agents for P vivax

• Reasonable choice for travel to places with >90% P vivax

• 1-2 days prior to travel, daily

• 7 days upon return

• NOT in pregnancy or pediatrics

• Can cause fatal hemolysis in patients with G6PD deficiency

Tafenoquine

• One of most effective agents for P vivax, also prevents P. falciparum

• 3 days prior to travel, once per week and continue 1 week after return

• NOT in pregnancy or pediatrics

• Not in patients with G6PD deficiency

Zika Virus

• ssRNA virus, Flavivirus

• Transmission bite of infected Aedes mosquito

• First identified in Western Hemisphere 2015

• Most infections are asymptomatic• Fever, maculopapular rash, arthralgias, non-purulent conjunctivitis, myalgias,

headache, edema, lymphadenopathy

• Vertical transmission leads to congenital zika microcephaly, other neurologic consequences

• Full range of disabilities caused by congenital zika- not yet known

Pregnancy and preconception counselling

• Pregnant women should avoid travel to area with risk of Zika

• Pregnant women may use insect repellants as indicated on product label

• Male partners of pregnant women who travel to areas with risk of zika– abstain or use condoms for duration of pregnancy

• If contemplating pregnancy:• Men 3 months after return from area with risk of zika transmission

• Women 2 months after return from area with risk of zika transmission

• **zika can stay in semen longer than in other body fluids**

http://rcp.nshealth.ca/clinical-practice-guidelines/zika-virus-pregnancy

Travelers’ Diarrhea

• “boil it, peel it, cook it, or forget it”

• Most common travel related illness

• Clinical syndrome bacteria most common• E. coli (enterotoxigenic & enteroaggregative Escherichia coli)

• Campylobacter jejuni• Shigella spp• Salmonella spp (non-typhoid)

• Virus• Norovirus, rotavirus, astrovirus

• Protozoal pathogens• Giardia, Entamoeba histolytica, Cryptosporidium, Cyclospora

• Long term health consequences:

• IBS• Reactive Arthritis• Guillain Barre

J Travel Med. 2017 Apr 1;24(suppl_1):S57-S74. doi:

10.1093/jtm/tax026.

“DUKORAL has never been properly shown to reduce the incidence of TD using randomized controlled trials, especially in Canadians.”

CATMAT:

• not be routinely

administered to Canadian travellers as a means of preventing travellers' diarrhea (TD); Conditional recommendation, moderate confidence in estimate of effect versus placebo.

Prevention:

• Bismuth subsalicylate: • 2 tabs (or 2 oz) QID in tablet or liquid form

• Lower doses may also be effective

• Caution re: contraindications and side effects

Canadian Family Physician July 2019, 65 (7) 483-486

Travelers’ Diarrhea- treatmentSelf limiting: most should NOT receive abx

https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea#table211

CATMAT suggests that loperamide be considered as an option in the treatment of TD; Conditional recommendation, low to moderate confidence in estimate of effect compared to placebo.

Longer term consequences

• More severe and longer illness durations associated with increased risk of post-infectious IBS

• No published evidence that antimicrobials for travelers’ diarrhea prevent secondary consequences: IBS, reactive arthritis, Guillain-Barre

J Travel Med. 2017 Apr 1;24(suppl_1):S57-S74. doi:

10.1093/jtm/tax026.

ESBL-PE• Median duration of colonization was

30 days• 11.3 % remained colonized at 12

months

Impact of colonization with travel-acquired ESBL-PE?

78 year old female

returned from India

11 months prior

Pneumonia

unresponsive to

doxycycline &

Piptazo

Typhoid

• Salmonella enterica: Typhi, Paratyphi A,B,C

• Consumption of contaminated food and water (human feces)

• Most North American acquisition is from (highest risk):• Southern Asia (India, Pakistan, Bangladesh)

• Other high risk regions:• Africa, Southeast Asia

• Lower risk:• East Asia, South America, Caribbean

Typhoid Vaccines Available in Canada

https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-23-typhoid-vaccine.html#a3

Yellow Fever

• Live attenuated vaccine, available since 1930s

• No efficacy studies have ever been done

• Current shortage of vaccine

• Many countries require proof of vaccination for entry

• Recommended for individuals > 9 months to age 60, travelling or living in areas with risk

• International Certificate of Vaccination or Prophylaxis against yellow fever now extended from 10 years to lifetime

CDC Yellow Book 2020, Health Information for International Travelers

Hep A/B

• Viral hepatitis is most common travel-related, vaccine preventable disease

• CATMAT: all non-immune travelers to developing countries should consider vaccination with inactivated hep A and recombinant hep B vaccine

Hep B schedule

https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-7-hepatitis-b-vaccine.html#a52

Incomplete or unknown history?

https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-6-hepatitis-a-vaccine.html#p4c5a6

Meningitis

• High risk areas• sub-Saharan Africa

• during Hajj or Umrah pilgrimages

https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2015-41/ccdr-volume-41-05-may-7-2015/ccdr-volume-41-05-may-

Journal of Infection (2009) 59, 1-18

Illness in returned traveler

Where?

When?

Why?

What?

~ 5-20% travelers to the developing world will have a fever on their return

Illness in returned traveler

Where?

When?

Why?

What?

Where?

• Details of travel: countries, duration, • Malaria endemic country?• Yellow fever• Dengue and Chikungunya

• Urban or rural?

• Accomodations

• Forested, high altitude? • Transmission of malaria is less likely at altitudes over 2000m

Illness in returned traveler

Where?

When?

Why?

What?

When?

• When did they go?

• When did they return?

• When did the symptoms start?

• Was it the rainy season?Increased risk of vector borne diseases

INCUBATION PERIOD

Incubation period of common infections

Incubation period of common infections

MEDIUM 10-21d- Malaria- Typhoid fever

• SHORT (<10 days)• Dengue• Chikungunya

LONG (>21 days)- Hep A- Malaria- TB- HIV

Illness in returned traveler

Where?

When?

Why?

What?

Why?

• Activities• VFR

• Caves, animals, freshwater…

• Healthcare exposure, refugee camp, humanitarian aid worker

• Sexual history

• Package holiday?• Low risk

Illness in returned traveler

Where?

When?

Why?

What?

What?

• Symptoms?

• What food and water exposure?

• Illness during travel, use of antibiotics?

• What vaccinations and prophylaxis?

Case

• 60 yo male from Halifax

• Lives in Haiti for 3 years with World Food Program, returns home every 3 months

• Mostly office work, many mosquitoes

• Episodes of diarrhea

Case

• Drove to airport: delay for 24 hours

• Started feeling unwell• Entire body aching• Headache• Anorexia

• On plane• Fever, nausea, vomiting• Myalgias slowly better

• At home• confusion

“It’s not dengue doc”

• Presented to HI• T = 39.0• BP: 86/52 mmHg• HR 110 bpm• No ecchymoses or bruising or pururpa (wet or dry)• Maculopapular rash arms, trunk

• Labs• PLT = 82• Hgb = 102• WBC=2.2• ALT = 80

Dengue

• symptoms within 14 days

• day-biting Aedes mosquito

• >100 million dengue infections worldwide / year

Symptoms

• Most subclinical (adults more likely to have symptoms), varies with age and virus type

• Bite > replicates in local lymph node > 4-6 days disseminates > cleared ~ 7 days later (at time of defervescence)

• Incubation 4-7 days

• Headache/retroorbital pain

• Myalgia/arthralgia (in particular back pain)

• Rash (macular, sparing the palms and soles, clusters of petechiae on extensor surfaces, often itchy)

• Second episode of fever and symptoms can occur after initial recovery

• Minor bleeding form mucosal surfaces (severe if predispositions)

Physical and Labs

• Conjunctival injection, pharyngeal erythema, lymphadenopathy, and hepatomegaly

• Facial puffiness, petechiae (on the skin and/or palate), and bruising (particularly at venipuncture sites)

• Hepatitis:• Increased L. enzymes (AST > ALT)

• Levels higher in DHF

• Leukopenia, neutropenia, thrombocytopenia

tourniquet test

• inflating a blood pressure cuff on the arm to midway between systolic and diastolic blood pressures for 5 minutes

• The skin below the cuff is examined for petechiae one to two minutes after deflating the cuff;

• presence of 10 or more new petechiae in one square inch area is considered a positive test

Classification

• Dengue hemorrhagic fever: all of the following• Fever or history of acute fever lasting 2 to 7 days, occasionally biphasic

• Hemorrhagic tendencies

• Thrombocytopenia < 100

• Evidence of plasma leakage due to increased vascular permeability• HCT ≥ 20 increased

• drop in HCT following volume-replacement treatment ≥ 20

• Signs of plasma leakage such as pleural effusion, ascites, and hypoproteinemia

Treatment

• Supportive

• Acetaminophen

• Acetylsalicylic acid (aspirin), ibuprofen, or other nonsteroidal anti-inflammatory agents (NSAIDs) may aggravate hemorrhagic complications or induce Reye’s syndrome and should be avoided

Chikungunya

Symptoms

• Incubation period of 3 to 7 days (range 1 to 14 days)

• Fever may be high grade (>39ºC); the usual duration of fever is 3 to 5 days (range 1 to 10 days).

• Skin manifestations have been reported in 40 to 75% of patients

• maculopapular rash: starts on the limbs and trunk, can involve the face, and may be patchy or diffuse.

• Pruritus 25-50%

Chikungunya

• Polyarthralgia begins two to five days after onset of fever • multiple joints (often 10 or more joints)

• Bilateral, symmetric and involves distal joints more than proximal joints.

• hands (50 to76%), wrists (29 to 81%), and ankles (41 to 68%).

• axial skeleton 34 to 52%

• Pain may be intense and disabling, leading to immobilization.

• Joint swelling is highly specific for chikungunya;• Dengue:

• abdominal pain and leukopenia• Bleeding manifestations and thrombocytopenia are relatively specific for dengue.

• After 1 year: at least 20% of patients still have severe recurrent joint pain (uncommon in dengue)

Physical & labs

• Periarticular edema or swelling • large joint effusions were noted in 15% of cases

• Peripheral lymphadenopathy, most often cervical (9 to 41%)

• Conjunctivitis

• Common laboratory abnormalities are lymphopenia and thrombocytopenia. Hepatic transaminases and creatinine may be elevated

Treatment

• Supportive

• Acetaminophen, NSAIDs

• Persistent or relapsed disease —• longstanding disease, beyond three months after the onset of infection, may

require DMARDS such as methotrexate

Top 3 tropical infections?

Top 3 tropical infections causing fever?

• Malaria

• Dengue fever

• Typhoid fever

Top 3 tropical infections causing fever?

• Malaria

• Dengue fever

• Typhoid fever

Non-tropical infections should always be considered, ex:

• Influenza• EBV• Skin and soft tissue infections• HIV• Meningitis

Non-infectious causes• DVT/PE!• Drugs• Malignancy