travel related infectious disease - webbertraining.com · tropical and infectious disease dangerous...

Travel Related Infectious DiseaseDr. Robert Wheeler

A Webber Training Teleclass

Hosted by Paul Webber [email protected] page 1www.webbertraining.com

Travel RelatedInfectious Disease

Robert E. Wheeler, MD, FACEP

Hosted by Paul [email protected]

www.webbertraining.com 2

Risks of Foreign Travel

More than 60 million people from the United States and 17 million from Canada travel internationally each year

25% of these travelers go to developing countries

Tropical and infectious diseaseDangerous transportationHazardous activitiesLimited health care resources

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Foreign Travel Risk Factors

Destination(s)Duration of tripActivitiesHealth statusVaccinations Protection against insect bitesMalaria prophylaxis

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Traveler’s Diarrhea

Most common travel related illnessLoose/watery stools, abdominal cramps, bloating, nausea, urgency, feverSudden onsetDuration usually less than 1 weekMay become chronic

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Traveler’s Diarrhea - Causes

Typically acquired via ingestion of fecally contaminated food and/or waterUndercooked meat & seafoodRaw fruits & vegetablesWater, ice, dairy productsInadequate personal hygiene practices

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Traveler’s Diarrhea - Risk Factors

DestinationDuration of visitComplacency with prevention measuresStreet vendors > restaurants >home cooked mealsYoung travelers > old




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TD Biological Agents

Enterotoxigenic Escherichia coli (ETEC)Most common cause of TD worldwide

SalmonellaShigellaCampylobactorVibrioListeria E. coli

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TD Biological Agents

NorovirusRotavirusGiardia lambliaEntamoeba histolyticaCryptosporidiumCyclospora

Giardia

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Travelers’ Diarrhea - Prevention

“Boil it, cook it, peel it or forget it!”Proper hand hygieneSafe fluids

Bottled water, juice, beer, sodaHot coffee and tea

Bismuth subsalicylate (Pepto-Bismol)60 cc or 2 tablets qid

Prophylactic antibiotics not recommended10

Travelers’ Diarrhea - Treatment

Clear (safe) PO fluidsBismuth subsalicylate (Pepto-Bismol)

30 cc or 1 tablet PO q 1 hour PRNMaximum of 8 doses in 24 hours

Loperamide (Immodium)4 mg PO, then 2 mg after each watery stoolMaximum of 8 tablets a day

Atropine/diphenoxylate (Lomotil)Two 0.025/2.5 mg tablets or 10 cc liquid PO qid

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Travelers’ Diarrhea - Empiric RX

Azithromycin 1 gm PO x 1 doseLevofloxacin 500 mg PO x 1 doseCefixime 400 mg PO qd for 1-3 daysCiprofloxacin 500 mg PO bid for 1-3 daysOfloxacin 400 mg PO bid for 1-3 days

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Malaria

300-500 million cases each year worldwide2-3 million deaths annuallyCaused by the Plasmodium protozoan parasiteTransmitted by female Anopheles mosquito




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Malaria Parasite

Plasmodium falciparum40-60% of malaria95% of deathsChloroquine resistance

Plasmodium vivax30-40% of cases

Plasmodium ovaleWest Africa

Plasmodium malariaeP. falciparum

Central America

South America

Sub-Saharan Africa

India Far East

Oceania

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Malaria

FeverChillsSweatsHeadacheMyalgiaMalaise

AnemiaHepatomegalySplenomegalyJaundiceRenal failureComaDeath

Symptoms Complications

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Malaria Diagnosis

Clinical signs & symptomsThick & thin blood smearsAntigen test kits

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Malaria Prevention

Risk awarenessProtective clothingMosquito nettingN,N-diethylmetatoluamide (DEET)PermethrinDrug prophylaxis




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Malaria Drug Prophylaxis

Start 1-2 weeks prior to travelContinue for 4 weeks post travelChloroquine (Aralen) 500 mg q weekHydroxy-chloroquine (Plaquenil) 400 mg q weekMefloquine (Lariam) 250 mg q weekDoxycycline 100 mg qd

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Malaria Drug Prophylaxis

Atovaquone/proquanil (Malarone) 250/100 mg qdStart I week pre-travel / continue for 1 week post travel

Proquanil (Paludrine) 200 mg qdTaken with weekly chloroquineAn alternative to mefloquine or doxycycline

Primaquine 30 mg qdTo prevent relapse from P.vivax and P.ovaleContinue for 14 days post travel

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Malaria Treatment

Chloroquine 1 gm PO, 0.5 gm in 6 hours then 0.5 gm qd x 2 days plusprimaquine 30 mg PO qd x 14 days for P. vivax or P. ovale.Quinine sulfate 650 mg PO tid plusdoxycycline 100 mg PO bid x 7 daysPyrimethamine-sulfadoxine (Fansidar)3 tablets, 75/1500 mg total single dose

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SARSSevere Acute Respiratory SyndromeThe Emerging Disease of 2003Origins in Guangdong Province, China

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SARS-CoVCausative agent for SARSCoronavirusInter-species transmission from civets

CivetSARS-CoV24

SARS Transmission

Close person to person contactRespiratory dropletsContaminated environmental surfacesAerosolInhalation & mucous membrane contact




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SARS Infection

Incubation period of 2-10 daysFever > 380C (100.40F)Dry coughDyspneaChills, rigors, headache, myalgia, sore throat, rhinorrhea, diarrhea PneumoniaAcute Respiratory Distress Syndrome

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SARS Surveillance

Clinical signs & symptomsTravel to a suspect or confirmed SARS area within the previous 10 daysClose contact with a suspect or confirmed SARS case within 10 days

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SARS Diagnosis

Positive surveillance criteriaDiagnostic lab tests

RT-PCREnzyme immunoassaySARS-CoV culture

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SARS Treatment

Supportive careSteroids (?)Ribavirin (?)Interferon (?)Isolation

RespiratoryDropletContact

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Lyme BorreliosisLyme DiseaseCaused by Borrelia burgdorferiTransmitted via Ixodes species ticksReservoir hosts

White-footed mouseWhite-tailed deerDusky-footed wood ratDogs, cats, birds,sheep, cattle, horses Ixodes scapularis

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World-wide Distribution of Lyme Disease




Lyme Disease in the United States

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Lyme Borreliosis - Prevention

Risk awarenessAvoidance of tick-prone environmentsLight colored protective clothingDaily body surface examination for ticks N,N-diethylmetatoluamide (DEET)Permethrin

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Lyme Borreliosis – Stage 1Ixodes bite/feeding

Inoculation requires 1-2 days of attachment7-14 days incubation periodErythema Migrans (Bull’s-Eye Rash)Fever, headache,myalgia, arthralgia,fatigue

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Lyme Borreliosis – Stage 2Early disseminated phaseWeeks to months after inoculationNeurologic manifestations

Facial palsyAseptic meningitisEncephalitisRadiculoneuritisNeuropsychiatricdisturbances

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Lyme Borreliosis – Stage 2

Cardiac manifestationsAtrioventricular heart blockPericarditisMyocarditisCardiomyopathy

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Lyme Borreliosis – Stage 3Late disseminated phaseMonths to years after inoculationProgressive arthralgiaArthritis




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Lyme Borreliosis - Diagnosis

Clinical signs & symptomsEnzyme immunoassayIndirect fluorescent antibodyWestern immunoblot

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Lyme Borreliosis - Treatment

ProphylaxisDoxycycline 200 mg PO

Early RX- Erythema MigransDoxycycline 100 mg PO bid x 14-21 daysAmoxicillin 500 mg PO tid x 14-21 daysCefuroxime 500 mg PO bid x 14-21 daysErythromycin 250 mg PO qid x 14-21 days

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Lyme Borreliosis - Treatment

Later RX - ArthritisDoxycycline 100 mg PO bid x 30-60 daysAmoxicillin 500 mg PO qid x 30-60 daysCeftriaxone 2 gm IV qd x 14-28 daysPenicillin 20-24 mU IV qd x 14-28 days

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Lyme Borreliosis - TreatmentLater RX - CNS

Ceftriaxone 2 gm IV qd x 14-28 daysPenicillin 20-24 mU IV qd x 14-28 days

Later RX - CarditisCeftriaxone 2 gm IV qd x 14-28 daysPenicillin 20-24 mU IV qd x 14-28 daysIf only first degree AV block, may consider:Doxycycline 100 mg PO bid x 14-21 daysAmoxicillin 500 mg PO tid x 14-21 days

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Vaccine Preventable Disease

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Hepatitis C

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Vaccine Preventable Disease (?)




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VaccinesRoutine Immunizations

DTPMMRPolio InfluenzaPneumococcusH. influenza bVaricella

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VaccinesRecommended per destination(s)

Hepatitis A, BImmune globulinMeningococcusJapanese encephalitisPlague

RabiesTick-borne encephalitisTuberculosis (?)Typhoid fever

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VaccinesRequired per destination(s)

Yellow fever Cholera

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Travel Preparation &Disease Prevention

Destination researchDisease awarenessHealth statusDisease prophylaxisMedical & travel insuranceTravel medical kit

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Post-travel Illness

FeverCoughChillsDiarrheaNausea/vomiting

Abdominal painWeight lossFatigueRashMyalgia/arthralgia




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Travel Medicine ResourcesHealth Information for International Travel 2003-2004 (The Yellow Book); CDCInternational Travel and Health 2004WHOTextbook of Travel Medicine and HealthHerbert L. Dupont, MD and Robert Steffen, MDThe Travel and Tropical Medicine ManualElaine Jong, MD and Russell McMullen, MDWilderness MedicinePaul S. Auerbach, MD

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Travel Medicine Resources

Centers for Disease Controlwww.cdc.govHealth Canadawww.hc-sc.gc.caInternational Society of Travel Medicinewww.istm.orgWorld Health Organizationwww.who.int

Travel widely…but travel wisely.ISTM

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Robert E. Wheeler, MD, FACEPVoyager Medical Seminars9 Corduroy RoadAmherst, NH 03031-2724603.672.5775 Voice/[email protected]

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