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A Travel Medicine Case

A Travel Medicine Case. Thomas Miller MD. Case #1. Jack called from San Francisco at 7:30 pm. “Dad I am leaving for Indonesia in 2 days. Do I need any shots before I go. What about Malaria prevention?”. Topics of Discussion. The travel consultation Travelers’ diarrhea Immunizations

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A Travel Medicine Case

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  1. A Travel Medicine Case Thomas Miller MD

  2. Case #1 Jack called from San Francisco at 7:30 pm. “Dad I am leaving for Indonesia in 2 days. Do I need any shots before I go. What about Malaria prevention?”

  3. Topics of Discussion • The travel consultation • Travelers’ diarrhea • Immunizations • Malaria prophylaxis • Complications

  4. The Travel Consultation • Risk assessment • Risk reduction • Shared decisions • Resources • www.cdc.gov/travel • Travax • Yellow book Ideally conducted 4 weeks prior to departure, but 2 weeks will do

  5. Medical history Chronic illnesses Immune status Vaccination history Travel itinerary Destination Style of travel Duration Planned activities Risk assessment

  6. Medical history • Healthy 24 year old • Complete childhood immunizations • Hepatitis A and B vaccines given in school • Before college • Meningococcus • Updated MMR

  7. Mentawai Islands, Sumatra Indonesia

  8. Destination: IndonesiaBali and Mentawai Islands • CDC Traveler’s Health • Immunizations • Routine • Hepatitis A • Hepatitis B • Typhoid • Rabies • Japanese encephalitis • Malaria prevention • Other than chloroquine • Medicine for diarrhea

  9. Other considerations • Style of travel • Hostel style • Not airconditioned • Not usual tourist destination • Duration – 1 month • Planned activities

  10. Travelers’ Diarrhea • Epidemiology • Most common illness in travelers to resource poor areas • 90% of travelers will make an error in what they eat or drink within several days • 50% of travelers will experience illness over the course of a 2-3 week vacation • The illness • >2 loose stools over 24 hrs • Fever, nausea, vomiting, cramping • Duration 3-5 days

  11. Cause • Bacteriologic enteropathogens – 90% • Enterotoxigenic E. Coli • Others: Camphylobacter, Salmonella, Shigella • Viruses: rotavirus and noravirus • Parasites: giardia, crytosporidium, cyclospora Food contamination more common that water

  12. Prevention • Standard food safety measures • “Boil it; cook it; peel it or forget it.” • Bottled beverages • Restaurant hygiene a bigger factor • Chemoprophylaxis • Peptobismol: 2 tabs qid • Fluoroquinolones – Ciprofloxacin 500mg qd • Infection rates reduced from 50% to 5%

  13. Not routinely recommended • Mild disease that responds to treatment • Last for 24-36 hours with improvement within 6-12hr • Usual side effects • C dif • Promotion of resistant bacteria

  14. Special Populations • VIP’s • Vulnerable hosts • Immune incompetent • HIV, transplant, chemotherapy • Inflammatory bowel disease • Renal insufficiency • Diabetes

  15. Treatment • Loperamide (imodium): antisecretory • Fluoroquinolones • Ciprofloxacin 500bid x 1 day • Can be extended for 3 days if needed • Shortens the course of illness by 1.5 days • Improvement noted with 6-12hr • Oral rehydration • Sodas and broth • Oral rehydration therapy

  16. Rifaximin • New nonabsorbable antibiotic • A rifamycin • Broad spectrum of activity against gram pos. and neg. organisms • Approved for the treatment of uncomplicated travelers’ diarrhea • Little effect on gut flora

  17. Tested in Central America, Caribbean, Kenya • Dose: 200mg tid • Comparable to fluoroquinolones in effect • TLUS cut from 60hr to 30hr • Side effects similar to placebo • Prophylactic use • Dose: 200mg qd • 75% effective

  18. Disadvantages • Not effective for invasive disease - dysentery • Fever • Systemic toxicity • Bloody diarrhea • Cost – $3.80/pill

  19. A Vaccine for TD? • Background • Enterotoxigenic E coli causes most TD • Heat-labile enterotoxin (LT) is found in 2/3 of ETEC • Natural immunity to LT occurs and provides protection • Oral cholera vaccine cross reacts with LT and protects against TD • LT is strongly antigenic • Too toxic for oral, nasal and parenteral routes

  20. Transdermal immunization (Patch) • Tested in a small feasibility study • No difference in occurrence of TD • Reduced the incidence of severe diarrhea • Vaccine recipients experienced a milder illness • Skin reactions occurred at the site of application

  21. My patient • Standard precautions • Not a VIP • No chronic diseases • Loperamide • Ciprofloxacin 500 bid x 3 days max

  22. Immunizations • Routine • Hepatitis A • Hepatitis B • Typhoid • Rabies • Japanese encephalitis

  23. Typhoid Vaccine • Typhoid fever • Caused by Salmonella enterica • Source: contaminated food or water • Risk in South Asia highest • Fever, headache, malaise, not diarrhea • 400 cases per year in US travelers • Second most common cause of fever in return travelers

  24. Typhoid vaccine – 50-80% effective • Oral live attenuated virus • Every other day for 4 doses • Must be refrigerated • Completed one week before exposure • Headache and fever occur rarely • Boost after 5 years • $30-40 • IM: capsular polysaccharide • Single dose • Complete 2 weeks prior to exposure • Local erythema and indration rarely • Boost at 2 years • $30-40

  25. My patient • Leaves in 2 days, but stays for a month • Refrigeration • $$$ and convenience

  26. The shared decision • Oral Typhoid vaccine called to a San Francisco pharmacy • A nice stewardess • Cold pack

  27. Rabies • Don’t pet the dogs • Time is on our side • Japanese Encephalitis

  28. Malaria Prevention • Malaria • Fever, headache, back pain, myalgias • 1500 cases per year reported to CDC • Can be fatal • Accounts for 21% of fever in returned travelers • Conveyed by Anopheles mosquito • Feeds from dusk until dawn • No risk in urban areas outside of sub-Saharan Africa and India – business travel • Risk varies significantly from locale to locale

  29. Relative Risk of Malaria among Travelers, 2000 through 2002 Freedman D. N Engl J Med 2008;359:603-612

  30. Source of Cases over 10 Years Sub-Saharan Africa 60% Asia 14% Caribbean, Central and South America 13% Oceana .03%

  31. Visiting Friends and Relatives (VFR Travelers) • Born in endemic regions and moved away and subsequent generations • At greatest risk for Malaria • More than 50% of cases • Explanation for risk • High risk conditions living with family • Don’t use chemoprophylaxis • Misperceptions about immunity • Peer pressure • Cost

  32. Prevention • Avoidance • Chemoprophylaxis

  33. Avoidance • Limit night time outings • Clothing: long sleeves and pants • Screened or air conditioned rooms • Mosquito netting • Permethrin coated clothes • 30% DEET – effective for 4-8 hours

  34. NEJM-2002 Comparative Study of Insect Repellents • 15 Volunteers inserted their arms into a cage with 10 hungry mosquitoes • Pretested with untreated arm • Tested 16 different products • Time to first bite recorded

  35. Results • DEET superior to all other products • Higher concentrations provided longer protection • 24% solution protected for 300 min • Controlled release formulation was no better • Skin-So-Soft worked for 23 min • Citronella worked for 20 min

  36. Medical Letter - 2005

  37. CONCLUSION — The 7% picaridin formulation currently sold in the US might be as effective in repelling mosquitoes as low concentrations of DEET, but no data are available. Higher strength products sold in Europe (with 20% picaridin) protect against mosquitoes for up to 8 hours and against ticks for a shorter period of time. If higher concentrations become available in the US, picaridin could replace DEET due to its superior tolerability, but its long-term safety is less well established

  38. 20% Picaridin • Now available in US • As effective as Deet • No odor • Not a solvent

  39. Chemoprophylaxis • Chloroquine: first choice for Mexico, much of Central America and Caribbean • Malarone (atovaquone-proguanil) • Best tolerated • Daily dosing and continued for 1 week after return • Expensive - $300 for 30 day trip • Doxycycline 100mg qd • Cheap and effective • Solar sensitizer and gastrointestinal side effects • Must be continued for 1 month after return • Mefloquine • Associated with psychiatric side effects • Primaquine • G6PD testing required

  40. Our patient • Considers cost and risk of solar sensitization • Doxycycline and sunscreen

  41. How did we do?

  42. Jack’s Second Call Dad, Robby has had diarrhea for a week, going over 10 times per day and getting up at night. The cipro has not helped at all. He also has fevers and chills. He wonders whether he needs to come home and see a doctor. He is not having blood in his stool and he is not vomiting. He is still surfing, but it has been hard.

  43. Resistant TD • Reported first in Thailand, but now spreading throughout SE Asia • Among military personnel in Thailand Camphylobacter causes 20-60% of TD • 85% are resistant to fluoroquinolone

  44. RCT: Azithromycin vs Levofloxacin • 156 military personnel with TD enrolled and randomized (85% using doxycycline for malaria prophylaxis) • Azithromicin 1gm once • Azithromicin 500mg bid x 3 days • Levofoxacin 500mg qd x 3 days • Pathogens • Bacterial pathogens identified in 81% • Camphylobacter – 64% • 50% levoquin resistant • 93% ciprofloxacin resistant • Salmonella – 17% • E coli – 10%

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