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Preparing the Traveler

Preparing the Traveler. Stephen J. Thomas, MD Director, Viral Diseases Branch Walter Reed Army Institute of Research AUG 2013. UNCLASSIFIED. Disclaimer.

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Preparing the Traveler

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  1. Preparing the Traveler Stephen J. Thomas, MD Director, Viral Diseases Branch Walter Reed Army Institute of Research AUG 2013 UNCLASSIFIED

  2. Disclaimer The views expressed in this presentation are those of the speaker and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government

  3. Outline • Introduction • Dynamics of tropical disease • Example - Nipah • Preparing the Traveler • Asking the right questions • Routine vaccinations • Travel medicine literature • Geographic distribution of threats • Vaccination • Diarrhea

  4. Introduction

  5. Understand the Dynamics of Tropical Diseases Demographics, special populations Temperature, rainfall, cultural & agricultural practices, etc. HOST Circulating animal and human pathogens Mosquitoes, ticks, bats, birds, dogs, cats, etc. VECTORS THREATS Ecology / Environment

  6. Example - Nipah Virus • Highly pathogenic paramyxovirus • Isolated from CSF • Sungai Nipah village • Natural host are fruit bats • Causes severe febrile encephalitis • Outbreaks • Peninsular Malaysia and Singapore (1998 – 1999) • Bangladesh: 2001, 2003, 2004, 2005, 2007 and 2008 • India: 2001 and 2007

  7. Nipah Transmission Dynamics • Pigs crowded in pens • Pens near fruit trees • Fruit bat home destroyed • Fruit bats relocate to fruit trees • Bat fluids contain Nipah • Aerosolized virus infects pigs • Pigs infect handlers

  8. Preparing the TravelerAsking the Right Questions

  9. Asking the Right QuestionsWho, Where, When, Why and What? • Who is the host / traveler? • Immunologic background, medical problems, etc. • Where are they going? • Geographic region, known threats. • When are they going? • Seasonal variations in disease threat epidemiology • Why are they going there and what will they do? • Defines likely exposure risks • Defines required prophylaxis / PPMs • Know what you do not know. Look it up. Seek consultation.

  10. Practice Evidenced Based Medicine http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Travel%20Medicine.pdf

  11. Travel Medicine Resources • U.S. Department of State • www.travel.state.gov • MILVAX • www.vaccines.mil/QuickReference • CIA Factbook • www.cia.gov/cia/publications/factbook • National Center for Medical Intelligence • www.intelink.gov/my.policy • AMEDD Virtual Library • Travax • International Society of Travel Medicine website) • http://www.istm.org/

  12. US CDC • http://wwwnc.cdc.gov/travel/ • http://wwwnc.cdc.gov/travel/yellowbook/2014/table-of-contents

  13. DoD On-Line Infectious Diseases Consults • id.consult@us.army.mil • Infect.cntrl.consult@us.army.mil • pmom.consult@us.army.mil • Began in January 2005 • 839 teleconsultations thru July 2013 • 35 teleconsultations received January – July 2013 • 6 teleconsultations received in July 2013 • First teleconsultation received from Niger • 7.4% of all teleconsultations received in the AKO Program

  14. Locations Submitting Teleconsultations http://www.cia.gov/cia/publications/factbook/reference_maps/pdf/time_zones.pdf Afghanistan Chili Honduras Japan Niger Solomon Islands US, Canadian & Australian Navy afloat Albania Congo Germany Jordan Okinawa Spain Supported Facility Bahrain Continental US Ghana Kenya Pakistan Sudan Nepal Bangladesh Djibouti Guam Kuwait Papua New Guinea Thailand Belgium Ecuador Guatemala Kyrgyzstan Peru Turkey Belize Egypt – MFO Sinai Guinea Laos Philippines Turkmenistan Bosnia El Salvador Hurricane Katrina Mali Qatar Ukraine Botswana Ethiopia Iraq Mauritania Saudi Arabia United Arab Emirates Chad Haiti Relief Italy - Sicily Morocco Senegal Yemen

  15. Reply Time by Percentage of Consultations 99.52% of all teleconsultations are answered in less than 24 hours Percentage of Consultations

  16. Key Elements of the Consult • Patient History • When did it start • Patient symptoms now? • Getting better? Worse? Staying the same? Spreading? • Previous treatments and outcomes? • Laboratory tests results (if any)? • Your Dx / DDx • Your question • Limitations you have in managing the patient

  17. Key Elements of the Consult • Patient Demographics • Age • Gender • Branch of service (if not MIL, state their nationality) • Identify if contractor, detainee, foreign military, etc. • Include digital images if appropriate • PDFs of EKGs • JPEGs of radiographs • Copies of laboratory and pathology reports • Do not send any patient identifying info(HIPAA applies)

  18. Preparing the TravelerRefer to the Traveler Literature

  19. Preparing the TravelerGeographic Distribution of Disease

  20. Yellow Fever

  21. Chikungunya

  22. Dengue

  23. Dengue

  24. Hepatitis A

  25. Hepatitis E

  26. HIV

  27. Japanese Encephalitis

  28. Malaria

  29. Malaria / Mefloquine Resistant

  30. Melioidosis

  31. Meningitis

  32. Middle East Respiratory Syndrome-Coronavirus APRIL 2012 - Present

  33. Rabies

  34. Schistosomiasis

  35. Tuberculosis

  36. Preparing the TravelerVaccination

  37. Vaccination • Confirm up to date routine vaccinations for adults • Documentation or considered susceptible • Confirm past travel related vaccination history • Calculate risk: benefit ratio • Disease threat versus vaccine adverse event • Consider special populations • Pregnant, immunosuppressed, known allergic past rxns • Remember – Diseases extinct in the US, alive and well in other locations (examples: polio, measles, etc.)

  38. Vaccine Preventable Diseases (Routine) http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.pdf

  39. Vaccine Preventable Diseases (Traveler)

  40. Preparing the TravelerDiarrhea

  41. Risk of Traveler’s Diarrhea

  42. Traveler’s Diarrhea (TD) • Attack rates range from 30% to 70% of travelers • Clinical syndrome from a variety of intestinal pathogens • Bacterial pathogens are the predominant risk (80%–90%) • Viruses have been isolated (5%–8%), Norovirus may > % • Protozoal pathogens (10%), longer-term travelers • Bacteria • Enterotoxigenic Escherichia coli (#1), Campylobacter jejuni, Shigella spp., and Salmonella spp. Enteroadherent and other E. coli species are also common. Aeromonas spp. and Plesiomonas spp. as well. • Viral • Norovirus, rotavirus, and astrovirus. • Protozoal • Giardia, Entamoeba histolytica and Cryptosporidium uncommon • Cyclospora (Nepal, Peru, Haiti, and Guatemala) • Dientamoeba fragilis is a low-grade but persistent pathogen

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