Travel Associated Infections

1. Travel Associated Infections Sunanda Gaur, MD

2. Travelers’ Health Risks Of 100,000 travelers to a developing country for 1 month: • 50,000 will develop some health problem • 8,000 will see a physician • 5,000 will be confined to bed • 1,100 will be incapacitated in their work • 300 will be admitted to hospital • 50 will be air evacuated • 1 will die Steffen R et al. J Infect Dis 1987; 156:84-91 (ISTM)

3. Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis Hepatitis A Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV Infectious Disease Risks to the Traveler ETC.

4. Diseases in Returning Travelers • Fever : Malaria, Dengue ,Typhoid, nonspecific • Diarrhea : Giardiasis, Amebiasis, bacterial, non specific • Dermatologic : Insect bites, CLM, allergic rashes • Non diarrheal Intestinal disorders : Hepatitis, Strongyloidosis N Engl J Med 2006; 354:119-130

5. Fever in the Returned TravelerGeosentinal sites studyCID 2007 44: 1560-8 ( n=6957) • Malaria 21% • Acute Diarrheal Disease 15% • Respiratory Illness 14% • Dengue 6% • Salmonella Infections 2% • Tick borne Illness 2% • 3% had vaccine preventable illness ( Hep A, Typhoid Fever, Influenza )

6. Causes of imported fever by region Bottieau et al Arch Int Med 166: 1642, 2005

7. Travel Health Resources • CDC Travelers’ Health Website • www.cdc.gov/travel • World Health Organization • www.who.int/int • State Department • travel.state.gov • International Society of Travel Medicine • www.istm.org • Health Information for International Travel • CDC “Yellow Book” • International Travel and Health • WHO “Green Book”

8. Travelers’ Health Websitewww.cdc.gov/travel

9. Traveler's Diarrhea • In general, up to 50% of travelers develop at least one episode of diarrhea during a two week stay • Onset usually within 2-3 days of arrival, > 90% occur within the first two weeks • A self limiting illness with significant morbidity

10. Causes of Traveler’s Diarrhea

11. Causes of Traveler’s Diarrhea

12. Food and Beverage Precautions Boil it , peel it, cook it or FORGET IT !!

13. Food and Water Precautions • Bottled water • Selection of foods • well-cooked and hot • Avoidance of • salads, raw vegetables • unpasteurized dairy products • street vendors • ice

14. Traveler’s Diarrhea • Prevention : Antimicrobial prophylaxis is not recommended. • Early self therapy is recommended • Oral rehydration • Fluoroquinolones remain drug of choice • Resistance is developing in some regions • Azithromycin ( Mexico , Thailand, Morocco ), ? preferable • Rifaximin ( non bloody stools, no fever) • Non specific agents ( Bismuth subsalycilate, loperomide)

15. Destination Specific Vaccines

16. The Meningococcal Meningitis Belt

17. Don’t Forget the “Routine Vaccines” • MMR • dT ( New dTaP ) • Varicella • IPV • Hepatitis B

18. Malaria

19. Malaria

20. MALARIA • Plasmodium vivax* • Plasmodium falciparum* • Plasmodium ovale • Plasmodium malariae * most common

21. Malaria Risk • Oceania 1: 5 ( chloroquin res Vivax) • Sub-Saharan Africa 1:50 ( falciparum) • South Asia 1:250 ( mainly vivax) • SE Asia 1:2500 ( multi res falciparum) • Mexico/Central Am 1:10,000 ( Chloroquinsens)

22. Malaria life cycle

23. Malaria • All febrile returning travelers should be considered to have malaria until proven otherwise • Serial blood smears (thick and thin) every 8-12 hours in the first 24 – 48 hours • Thick smears are 10 – 40 times more sensitive than thin smears. Thin smears important for quantitation of parastemia • Important to identify the species

24. Fatal Malaria • 45 fatal cases between 1980 – 1992 • 98% caused by P. falciparum • 82% acquired in Sub-Saharan Africa • Most cases were associated with lack of chemoprophylaxis, suboptimal chemoprophylaxis, delay in seeking medical attention, and delay in diagnosis

25. “ABCD” of malaria reduction • A Awareness of risk • B Bite prevention • C Chemoprophylaxis • D Diagnosis

26. Mosquito Bite Prevention

27. Vector Precautions • Covering exposed skin • Insect repellent containing DEET 30 – 50% • Treatment of outer clothing with permethrin • Use of permethrin-impregnated bed net • Use of insect screens over open windows • Air conditioned rooms • Use of aerosol insecticide indoors • Use of pyrethroid coils outdoors • Inspection for ticks

28. Malaria Prophylaxis

29. Malaria Prophylaxis

30. MalariaProphylaxis

31. Malarone (Atovaquone and Proguanil Hydrochloride) • Atovaquone - a broad spectrum antiprotozoal inhibits the parasites mitochondrial electron transport. • Treatment with Atovaquone alone results in rapid development of resistance. • Atovoquone and Proguanil are synergistic against multi drug resistant P. falciparum • Several studies have demonstrated the efficacy of this combination in treatment and prophylaxis of multidrug resistant P. falciparum • Daily dosing ( 2-3 days prior, 7 days after), high cost • Occasional headache, GI upset

32. Typhoid Fever • Caused by S.typhi or S. paratyphi • In US 445 cases/year between 1967 – 1994 • 72% of cases in the recent years (1985-1994) occurred in returning travelers • Travel to Mexico and India account for >50% of cases • Fever, chills, headache, malaise, abdominal pain, and constipation are common symptoms. • Blood cultures positive in 40-66%, bone marrow culture positive in 90% • Increasing antibiotic resistance – particularly in India – consider Ceftriaxone or Ciprofloxacin as first line therapy

33. Commercially Available Typhoid Vaccines Available in the United States

34. Oral Ty21a Vaccine • Live attenuated vaccine • Enteri coated capsule – 1 cap every other day x 4 doses • Efficacy – 65% • Minimal to no side effects • Contraindicated in immune compromised individuals • Mefloquine can inhibit growth of Ty21a in vitro; delay vaccine at least 24 hours before or after Mefloquine • Concommitant or antimicrobials may effect vaccine efficacy

35. GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION

36. Hepatitis A Vaccine • Inactivated Vaccine • Approved for children 2-18 years old and adults • Highly Immunogenic • 88 – 90% seroconversion in 2 weeks • 99% seroconversion after 2nd dose • Duration of protection – under evaluation • Indicated for: • Foreign travel • Residence in communities with high endemicity • Patients with chronic liver disease • Homosexual/bisexual men • IVDU • Occupational risk

37. Yellow fever Endemic Zones

38. Yellow Fever Vaccine • Live vaccine • Required if entering endemic area or going from an endemic region to non-endemic region • Approved for children > 9 months old • Do not administer simultaneously with cholera vaccine • Under 4 months – unsafe (high incidence of post vaccination encephalitis) • Adverse effect ( viscerotropic disease) : 1 in 2-3 million

39. World Distribution of Dengue 1999 Areas infested with Aedes aegypti Areas with Aedes aegypti and recent epidemic dengue

40. Travel related Tick-Borne Diseases

41. Bloodborne and STD Precautions • Prevalence of • STDs • Hepatitis B • Hepatitis C • HIV • Unprotected sexual activity • Commercial sex workers • Tattooing and body piercing • Auto accidents • Blood products • Dental and surgical procedures

42. Post Exposure HIV prophylaxis • Assess likelihood of exposure • Assess degree of exposure • Begin ARV prophylaxis within 12-24 hrs. • 2-3 drug combinations recommended depending on exposure risk . To be continued for 4 weeks. • http://www.cdc.gov/mmwr/PDF/rr/rr5409.pdf or http://www.ucsf.edu/hivcntr/hotlines/PEPline

43. Pre Travel Check List

44. Travel Emergency Kit • Copy of medical records and extra pair of glasses • Prescription medications • Over-the counter medicines and supplies • Analgesics • Decongestant, cold medicine, cough suppressant • Antibiotic/antifungal/hydrocortisone creams • Pepto-Bismol tablets, antacid • Band-Aids, gauze bandages, tape, Ace wraps • Insect repellant, sunscreen, lip balm • Tweezers, scissors, thermometer

45. Kibera, Nairobi

47. Post-Travel Care • Post-travel checkup • Long term travelers • Adventure travelers • Expatriates in developing world • Post-travel care • Fever, chills, sweats • Persistent diarrhea • Weight loss

48. Rabies • Rabies in travelers – an underestimated risk • 1980 – 1997 12/36 (33%) of human rabies deaths in US have been related to rabid animals outside the US • Canine rabies in endemic in the Indian Subcontinent, China, SE Asia, Philippines, Latin America, Africa and the former Soviet Union • In many rabies endemic countries, only Equine RIG and older Semple rabies vaccines are available • Equine RIG – significant risk of serum sickness • Semple type rabies vaccine is not as effective, and theoretical danger of allergic myeloencephalitis exists • Pre-exposure prophylaxis should be considered in selected cases

49. Japanese Encephalitis Vaccine • Inactivated vaccine • Efficacy = 91% • Booster every 3 years • Not approved for children under 3 years • Side effects • Local reaction (10-25%) • Fever (10-25%) • Hypersensitivity reaction (0.6%) • Indications • Expatriates living in Asia • Travel to endemic regions for >30 days during transmission season, especially travel to rural areas