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Emergency Department Evaluation of Fever in the Returning Traveler. Dr. Aric Storck October 31, 2002. Objectives. Approach to the febrile traveler History Travel history Vaccinations Chemoprophylaxis Laboratory studies Treatment overview of common imported diseases. Background.

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Emergency department evaluation of fever in the returning traveler

Emergency Department Evaluation of Fever in the Returning Traveler

Dr. Aric Storck

October 31, 2002


Objectives
Objectives Traveler

  • Approach to the febrile traveler

    • History

      • Travel history

      • Vaccinations

      • Chemoprophylaxis

    • Laboratory studies

    • Treatment

  • overview of common imported diseases


Background
Background Traveler

  • >500,000,000 people cross international boundaries each year

  • >12,000,000 North Americans travel to developing countries each year

  •  international travel =  importation of exotic infectious diseases

Suh, K, et al. Evaluation of Fever in the Returned Traveler. Medical Clinics of North America 1999:83(4)997-1018.


Travelers get sick …. Traveler

  • 20-70% of travelers report health problems while traveling

  • 1-5% seek medical attention abroad

  • 0.01-0.1% require emergency medical evacuation

  • 1 in 100,000 dies

Kain K, Ryan E. Health Advice and Immunization for Travelers. NEJM 2000;342(23)1716-1725.


Low awareness of traveler s health issues
Low awareness of traveler’s health issues Traveler

  • Many travelers do not seek predeparture medical consultation

    • Poor understanding of risks

    • Not covered by health insurance

    • Shortage of physicians with travel medicine expertise


For example
For example … Traveler

  • Study of 353 North American passengers boarding international flights to regions where Hepatitis A is endemic

    • 72% did not obtain immunizations

    • 78% did not know the route of transmission of hepatitis A

    • 95% unable to identify fever, abdominal pain, jaundice as symptoms

    • 88% of flight crew were not immunized

  • Quoted in: Thanassi M, Thanassi W. EMR 1998;9(22)239-246


The result
The result …. Traveler

  • 1-2% of unimmunized travelers visiting a developing country for >1 month will develop hepatitis A

    • Steffen R. Risk of hepatitis A in travelers: the European experience. Journal of Infectious Disease 1995;171:S24-28.

  • 300 / 100,000 travelers / month in tourist areas of developing countries

  • 5-7 x increased risk for “backpackers”

    • Quoted in:Kain K, Ryan E. Health Advice and Immunization for Travelers. NEJM 2000;342(23)1716-1725.


After the holiday
After the holiday … Traveler

  • Swiss study

    • 4% of travelers to developing countries for >3 weeks develop fever

    • 61-71% remained febrile upon return

      Steffen R, et al. Health problems after travel to developing countries. J Infect Dis 1987;156:84-91.

  • 5% of travelers consult MD upon return

    Thanassi M, Thanassi W. EMR 1998;9(22)239-246



Ed evaluation of the febrile traveler
ED evaluation of the febrile traveler Department!

  • What infections are possible given the patient’s travel history

  • What infections are probable given the patient’s medical history and presentation

  • What infections are life-threatening or contagious or both


General Medical History Department!

  • Immunocompromise

    • Increased risk of all infectious diseases

  • Decreased gastric acidity (achlorhydria, H2 blockers, PPI)

    • Increased risk of enteric illness (eg: cholera, typhoid)

  • Chronic respiratory disease

    • Increased risk of respiratory infections


  • Asplenia Department!

    • Encapsulated organisms

  • Sickle Cell Trait / G6PD deficiency

    • Confer protection against malaria


Pre travel history
Pre-travel History Department!

  • ? pre-departure medical consultation

  • Vaccination status

    • Which vaccines

    • When

  • Chemoprophylaxis

    • Which specific medication

    • Dosing schedule

    • Patient compliance




Travel history
Travel History Department!

  • Precise dates of travel

    • Arrival & departure from endemic regions

  • Countries and regions visited

    • Urban

    • Rural

  • Type of accommodation

    •  hotel

    • Bamboo hut


  • Infection prophylaxis Department!

    • Insect repellants

    • Mosquito nets

    • Bottled water

  • Activities

    • Freshwater exposure (rafting, swimming...)

    • Trekking

    • Contact with animals

    • Drug use


Sexual contacts
Sexual contacts Department!

  • 66% of 213 Australians going to Thailand reported plans to have sex

  • 25% of Swedish women on charter holidays reported a sexual encounter with an unknown partner

  • 18.6% of 757 patients at Hospital for Tropical Diseases in London reported new sexual partner during last trip

    • Only 36% regularly used condoms

Quoted in: Matteelli A, Carosi G. Sexually Transmitted Diseases in Travelers. Clinical Infectious Diseases 2001;32:1063-1067.


Sex and the long term traveler
Sex and the long-term traveler Department!

  • 60% of 1080 Peace Corps had sexual encounter with new partner

    • 40% with local partner

    • 1/3 used condoms

  • 50% of Belgian expatriates in Central Africa reported extramarital sex

    • 1/3 with commercial sex workers

Quoted in: Matteelli A, Carosi G. Sexually Transmitted Diseases in Travelers. Clinical Infectious Diseases 2001;32:1063-1067.


Commonest causes of fever
Commonest causes of fever (%) Department!

sources: O’Brien D, et al.Clinical Infectious Diseases 2001;33:603-9. Suh, K, et al. Medical Clinics of North America 1999:83(4)997-1018.


Incubation periods
Incubation Periods Department!

  • Short (<1 week)

    • GI bacterial pathogens

    • Dengue Fever

    • Yellow Fever

  • Medium (1-2 weeks)

    • Malaria

    • Typhoid

    • Trypanosomiasis


Incubation periods1
Incubation Periods Department!

  • Long (>3 weeks)

    • Viral hepatitis

    • Malaria

    • Schistosomiasis

    • Tuberculosis

    • Amoebic liver abscess

    • Rabies


Fever associated signs and symptoms
Fever Department!Associated Signs and Symptoms


Frequency of presenting symptoms in febrile returned travelers
Frequency of presenting symptoms in febrile returned travelers

O’Brien D, et al. Fever in Returned Travelers. Clinical Infectious Diseases 2001;33:603-9


Diarrhea
Diarrhea travelers

  • Traveler’s Diarrhea (e. coli)

    • Most common travel related illness

    • Only 15% febrile

  • Dysentery (bloody diarrhea)

    • Campylobacter, Salmonella, Shigella

  • Typhoid

    • 30-50% c/o diarrhea

  • Viral, protozoal, helminth

  • Malaria


Jaundice
Jaundice travelers

  • Hepatitis A

    • Most common cause

  • Yellow fever

  • Hemorrhagic fevers

  • Leptosporosis

  • Malaria

    • 20% jaundiced secondary to hemolysis


Respiratory complaints
Respiratory complaints travelers

  • The usual suspects

    • CAP, influenza

  • Tuberculosis

    • Usually due to reactivation

    • Suspect in immigrants, not in travelers

  • P.falciparum

    • ARDS (often fatal)

  • Helminths

    • Strongyloides, schistosoma, ascaris

  • Protozoa

    • Entamoeba histolytica, trypanosoma


Dermatologic complaints
Dermatologic complaints travelers

  • Rose spots - Typhoid

    • faint pink macules/papules on trunk

  • Maculopapular exanthem

    • Dengue fever

    • Viral hemorrhagic fevers

  • Petechiae / ecchymotic lesions

    • Meningococcemia

    • Dengue

    • Viral hemorrhagic fevers


Neurologic complaints
Neurologic complaints travelers

  • Meningitis

    • Meningococcal

    • Aseptic (enterovirus, rickettsiae, typhoid...)

  • Encephalitis

    • Arbovirus (eg: Japanese encephalitis)

  • Cerebral malaria (P.falciparum)

    • Looks like toxic coma

    • Consider empiric antimalarial therapy if neurologic SSx and diagnosis uncertain


Splenomegaly
Splenomegaly travelers

  • Common and non-specific

  • Malaria

    • OR 7.9; 95% CI 2.4-27.3; P<0.001

      O’Brien D, et al. Fever in Returned Travelers. Clinical Infectious Diseases 2001;33:603-9

  • Trypanosomiasis

  • Dengue


Hepatomegaly
Hepatomegaly travelers

  • Malaria

    • OR 4.0; 95%CI 1.3-12.5; P=0.006

      O’Brien D, et al. Fever in Returned Travelers. Clinical Infectious Diseases 2001;33:603-9


Lymphadenopathy
Lymphadenopathy travelers

  • EBV

  • HIV

  • Dengue

  • NOT in malaria


Typhoid fever
Typhoid Fever travelers

Salmonella typhi


Typhoid fever1
Typhoid Fever travelers

  • Gram negative bacilli

    • Salmonella typhi

    • Salmonella paratyphi

  • Fecal-oral route

    • Contaminated food or water

  • Incubation period 5-21 days


Typhoid fever2
Typhoid Fever travelers

  • Endemic in almost all developing countries

  • 16,000,000 clinically significant cases annually (WHO)

  • Many more subclinical cases

  • 600,000 deaths annually


Typhoid fever3
Typhoid Fever travelers


Typhoid fever4
Typhoid Fever travelers


Classical presentation
Classical Presentation travelers

  • Week 1

    • Fever

    • Bacteremia

  • Week 2

    • Abdominal pain

    • Rash (Rose spots)

  • Week 3

    • Hepatosplenomegaly

    • Intestinal perforation / hemorrhage


Diagnosis
diagnosis travelers

  • Laboratory

    • Anemia

    • Leukocytosis / leukopenia

    • Abnormal LFTs

  • Isolation of bacteria

    • Blood culture – positive in 40-80%

    • Stool culture – positive in 30-40%

    • Bone marrow – positive in 98%


Treatment
Treatment travelers

  • Fluoroquinolone

    • Ciprofloxacin 500 mg bid

    • Ofloxacin 400 mg bid

  • Plus 3rd generation cephalosporin

    • High levels of resistance in some strains

    • Continue while sensitivities pending

    • Ceftriaxone 2-3 g od


Typhoid mary
Typhoid Mary … travelers

  • 2-5% of hosts become asymptomatic carriers

    • Very high risk of transmitting disease to others if involved in food preparation

    • Mary Mallon – responsible for 54 cases of typhoid and 3 deaths in New York


Hepatitis a
Hepatitis A travelers

  • Most common vaccine-preventable illness in travelers

  • Fecal-oral transmission via food and water

  • Risk as high as 2 cases / 100 travellers / 4 week stay

    • 10-100x more common than typhoid

    • 1000x more common than cholera

  • Thanassi M, Thanassi W. EMR 1998;9(22)239-246


Hepatitis a1
Hepatitis A travelers

  • Incubation period 15 – 30 days

  • Fever in pre-icteric phase

  • Often asymptomatic in children

  • Jaundice by age group

    • <6 = <10%

    • 6-14 = 40-50%

    • >14 = 70-80%


Hepatitis a complications
Hepatitis A travelersComplications

  • Fulminant hepatitis

  • Cholestatic hepatitis

  • Relapsing hepatitis

  • No chronic sequelae

  • Overall mortality 1:1000 cases (varies widely according to age)


Hepatitis a2
Hepatitis A travelers


Hepatitis a3
Hepatitis A travelers

From:http://www.worldwidevaccines.com/public/diseas/hepa23.asp


Age specific mortality
Age Specific Mortality travelers

Source: CDC


Diagnosis treatment
Diagnosis & Treatment travelers

  • Clinical

    • Fever

    • Jaundice

    • RUQ pain

  • Laboratory

    • Transaminitis

    • Cholestatis

    • Hepatitis serology

  • Treatment

    • Supportive


Dengue fever
Dengue Fever travelers


Dengue virus
Dengue virus travelers

  • Causes both

    • Dengue Fever – benign self limited illness

    • Dengue Hemorrhagic Fever (DHF) – life threatening

  • Flavivirus composed of single-stranded RNA

  • Arbovirus transmitted by the Aedes aegypti mosquito

  • No vaccination, no chemoprophylaxis, no specific treatment


  • Four serotypes (DEN 1,2,3,4) travelers

    • No cross immunity

  • Prior infection with different serotype, co-infection with >1 serotype increases risk of DHF

  • Incubation period 4-7 days

    • Do not include in DDx if >14 days from exposure

  • Symptoms persist 3-10 days (avg =5)


Aedes aegypti
Aedes aegypti travelers

  • Bite during day

  • Urban dwellers


Distribution of travelersAedes aegypti in 1970 (end of mosquito eradication program), and in 1997

Source: CDC


American countries with laboratory-confirmed hemorrhagic fever (red shaded areas), prior to 1981 and from 1981 to 1997

Source: CDC


The epidemic
The epidemic… fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • Declining vector control

  • Poor water supply systems

  • Increasing use of non-biodegradable containers

  • Increased air travel

  • Increased urban population density


Dengue fever clinical features
Dengue Fever fever (red shaded areas), prior to 1981 and from 1981 to 1997Clinical Features

  • High Fever

  • Severe headache – retro-ocular

  • Bony pains (aka. break-bone fever)

  • Nausea and vomiting

  • Blanching macular rash

  • Hemorrhagic manifestations

  • Altered LOC


Hemorrhagic manifestations
Hemorrhagic Manifestations fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • Mild

    • Petechiae, ecchymosis

    • Gingival bleeding

    • Epistaxis

    • GI bleed

  • Severe

    • Hemorrhagic shock


Diagnosis1
Diagnosis fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • History

    • Travel to endemic area within past 2 weeks

  • Clinical

    • Evidence of increased vascular permeability (pleural effusions, ascites)

    • Hemorrhage

    • Tourniquet test


Tourniquet test
Tourniquet Test fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • Inflate BP cuff to MAP x 5 minutes.

  • >20 petechiae / square inch suggests dengue


Diagnosis2
Diagnosis fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • Laboratory Diagnosis

    • Routine Blood Work

      • Generally neutropenic and thrombocytopenic

    • Dengue serology (definitive)

      • Viral culture – only within 5 days of onset of symptoms

      • IgM ELISA – after 5 days of symptoms


Treatment1
Treatment fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • Outpatient

    • Well hydrated

    • No hemorrhagic manifestations

  • Outpatient observation

    • Mild hemorrhagic manifestations

    • Dehydration

  • Hospitalization

    • Severe hemorrhage

    • Shock


Treatment2
Treatment fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • Supportive

  • Educate outpatients about danger signs

  • Close follow-up needed

    • HPTP

    • Odyssey Travel Clinic


Malaria
Malaria fever (red shaded areas), prior to 1981 and from 1981 to 1997

Merozoite of p. falciparum


Malaria what is it
Malaria, what is it? fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • Protozoal infection caused by

    • Plasmodium falciparum

      • Africa, East Asia, Oceania, Haiti

      • 50% of all cases

      • 95% of all deaths

    • Plasmodium vivax

      • Central America, Middle East, India, SE Asia

    • Plasmodium ovale

    • Plasmodium malariae

  • NB: Mixed infections common


Malaria the vector
Malaria fever (red shaded areas), prior to 1981 and from 1981 to 1997the vector

Anopheles mosquito

  • Also maternal-fetal, blood transfusions, dirty needles, etc.


Malaria life cycle
Malaria life-cycle fever (red shaded areas), prior to 1981 and from 1981 to 1997


Malaria epidemiology
Malaria fever (red shaded areas), prior to 1981 and from 1981 to 1997Epidemiology

  • >2 billion people (41% of the world population) live in malaria-risk areas

  • Endemic to >100 countries

  • Every year

    • 300-500 million people get malaria

    • 1.5-2.7 million people die from malaria

      • 90% in rural, sub-Saharan Africa

      • Disproportionately in children <5


Malaria, not hard to get ….. fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • Studies of European / North American travelers to Kenya and Peace Corps volunteers in Africa

    • Malarial attack rate of 15/1000 per month

    • 2-4% mortality in those infected

      Quoted in: Stanley J. Malaria. Emergency Medicine Clinics of North America 1997;15(1)113-155.


Malaria in canada
Malaria in Canada fever (red shaded areas), prior to 1981 and from 1981 to 1997

  • 1994 – 430 cases reported

  • 1995 – 621 cases reported

  • 1997 – 1036 cases reported

  • Per capita rate 10x as high as USA

  • 1994-1997 – tenfold increase in severe malaria requiring admission to ICU

Kain K, et al. Malaria deaths in visitors to Canada and in Canadian travellers; a case series. CMAJ 2001;164(5)656-659


Malaria1
Malaria fever (red shaded areas), prior to 1981 and from 1981 to 1997


Malaria symptoms
Malaria Symptoms fever (red shaded areas), prior to 1981 and from 1981 to 1997

Headache

Muscle aches

Diarrhea

Fever

Chills

Vomiting

Coughing

Abdominal pain

Malaria symptoms usually appear within 7 to 21 days of the mosquito bite, but may not appear until later


Interval between date of entry and onset of illness by plasmodium species for imported malaria cases in the United States (1992)

Adapted from MMWR 44:1-14, 1995


Malaria is
Malaria is …. plasmodium species for imported malaria cases in the United States (1992)

  • Usually preventable

  • Almost always curable

Nobody should die of malaria!


Early diagnosis and treatment of malaria is crucial to preventing morbidity and mortality
Early diagnosis and treatment of malaria is crucial to preventing morbidity and mortality


Case in point
Case in point … preventing morbidity and mortality

  • Vietnam War

    • Mortality of US soldiers from malaria 40 times greater when treated by civilian MD vs. military MD

      Stanley J. Malaria. Emergency Medicine Clinics of North America 1997;15(1)113-155.

  • 40% of malaria mortality in US is due to missed diagnosis

    Stanley J. Malaria. Emergency Medicine Clinics of North America 1997;15(1)113-155.


Plasmodium falciparum
Plasmodium Falciparum preventing morbidity and mortality

Two merozoites of Plasmodium falciparum (blue and pink) in red blood cell


Plasmodium falciparum1
Plasmodium Falciparum preventing morbidity and mortality

  • Potentially fatal due to:

    • Expression of membrane proteins causing adherence of red cells to endothelial walls

      • End organ microcirculatory occlusion and tissue ischemia

      • Death usually due to brain or lung injury

  • Other species rarely fatal as they do not induce cytoadherence


Plasmodium falciparum malaria
Plasmodium Falciparum Malaria preventing morbidity and mortality

  • Renal failure

  • Hepatic failure

  • Pulmonary Edema

  • Seizures

  • Coma

  • Death (up to 7% of North American and European travelers)

    • Lobel HO, Kozansky PE. Update on prevention of malaria for travelers. JAMA. 1997; 278(21): 1767-1771.


preventing morbidity and mortalityFEVER OCCURRING IN A TRAVELLER WITHIN 3 MONTHS OF DEPARTURE FROM A MALARIA-ENDEMIC AREA IS A MEDICAL EMERGENCY …”

Canadian recommendations for the prevention and treatment of malaria among international travellers. CATMAT, Laboratory for Disease Control. Canadian Communicable Disease Report 2000;26(Supp 2):I-vi, 1-42


Malaria diagnosis
Malaria preventing morbidity and mortalityDiagnosis

  • Current Standard of Care

    • Thick film – screen for malaria

    • Thin film – species identification

  • Gold Standard

    • PCR

      • detect low levels of parasitemia and mixed infections

  • The Future

    • Dipsticks – presently being investigated


Malaria diagnosis1
Malaria preventing morbidity and mortalityDiagnosis

  • Thick/Thin films often negative with low levels of parasitemia

  • A high index of suspicion requires repeat films q12h x 3 to rule out malaria

  • NB: malaria is a reportable disease in every province


Malaria laboratory investigations
Malaria preventing morbidity and mortalitylaboratory investigations

  • All of the following are necessary to determine severity of disease

    • CBC

    • LFTs, bilirubin

    • INR, aPTT

    • BUN, Creatinine

    • Glucose

    • Urinalysis

    • G6PD

      • prior to initiating treatment with primaquine for non-falciparum malaria


The three essential questions
The three essential questions … preventing morbidity and mortality

  • Is this infection caused by P. falciparum?

  • Is this a severe or complicated infection?

  • Was this infection acquired in an area of known drug resistance?


Malaria treatment
Malaria preventing morbidity and mortalityTreatment

  • Choice of treatment based on

    • Species of malaria

    • Level of parasitemia

    • Likelihood of drug resistance

    • Severity of infection

    • Patient specific factors (age, immunocompromise, etc.)


Malaria drug resistance
Malaria preventing morbidity and mortalitydrug resistance

Kain, K et al. Malaria deaths in visitors to Canada and in Canadian travellers.

CMAJ (2001);164(5)654-9


Criteria for severe p falciparum
Criteria for severe preventing morbidity and mortalityP.falciparum

Either

  • History of recent possible exposure and no other recognized pathology

    Or

  • Asexual forms of Plasmodium falciparum on blood smear


And 1 or more of
And 1 or more of: preventing morbidity and mortality

  • Decreased LOC

  • Severe normocytic anemia

  • Renal failure

  • Pulmonary edema

  • Hypoglycemia

  • Shock

  • Spontaneous bleeding / DIC

  • Seizures

  • Acidosis

  • Hemaglobinuria

  • >5% parasitemia in non-immune individuals


When in doubt
When in doubt …. preventing morbidity and mortality


Treat all infections as severe drug resistant plasmodium falciparum
Treat all infections as severe, drug-resistant, preventing morbidity and mortalityPlasmodium Falciparum


Treatment of uncomplicated falciparum malaria
Treatment of uncomplicated preventing morbidity and mortalityfalciparum malaria

  • Malarone 4 tabs po od x 3 days

    OR

  • Quinine sulfate 350mg po tid x 7 days

    AND

  • Doxycycline 100mg po bid x 7 days


Uncomplicated p falciparum
Uncomplicated preventing morbidity and mortalityP. falciparum

  • Can treat as outpatient if:

    • First dose of medication given in ER and tolerated

    • Patient has reliable supply of medication

    • Patient has reliable supervision

    • Patient has close follow-up

      • Malaria smears od/bid until negative

      • Odyssey clinic


Treatment of severe falciparum malaria
Treatment of severe preventing morbidity and mortalityFalciparum Malaria

  • Immediate hospitalization

    • Mortality rate >20%

  • IV quinine

    • Available 24 hours a day through pharmacy at Alberta Children’s Hospital

    • Comes with detailed instructions

  • IV quinidine

    • equally effications but more cardiotoxic

    • Requires cardiac monitoring


Treatment non falciparum malaria
Treatment preventing morbidity and mortalityNon-Falciparum Malaria

  • Chloroquine 1.5g po over 3 days

    • 300 mg po bid on days 1-2

    • 300 mg po od on day 3

  • 80% chloroquine resistance of P.vivax in Papua New Guinea and Irian Jaya

  • Reports of resistance in Indonesia, Myanmar, Guyana, Solomon Islands


Prevention of relapse in non falciparum malaria
Prevention of Relapse in preventing morbidity and mortalityNon-Falciparum Malaria

  • Primaquine 15mg po od x 14 days

    • Absolute contraindication: G6PD deficiency

    • MUST CHECK G6PD LEVEL FIRST!

  • Plus one of

    • Doxycycline 100mg po bid x 7 days

    • Fansidar – single dose of 3 tabs

    • Clindamycin 10mg/kg iv loading dose followed by 5mg/kg iv q8h until blood is clear of parasites (only if unable to tolerate 1 or 2)

  • Canadian recommendations for the prevention and treatment of malaria among international travellers. CATMAT, Laboratory for Disease Control. Canadian Communicable Disease Report 2000;26(Supp 2):I-vi, 1-42


    Non falciparum malaria
    Non-falciparum Malaria preventing morbidity and mortality

    • Can treat as outpatient if:

      • First dose of medication given in ER and tolerated

      • Patient has reliable supply of medication

      • Patient has reliable supervision

      • Patient has close follow-up

        • Malaria smears od/bid until negative

        • Odyssey Clinic


    The most important factors that determine the preventing morbidity and mortality survival of patients with falciparum malaria are early diagnosis and prompt initiation of appropriate treatment.

    Canadian recommendations for the prevention and treatment of malaria among international travellers. CATMAT, Laboratory for Disease Control. Canadian Communicable Disease Report 2000;26(Supp 2):I-vi, 1-42


    Where do i send my patients for follow up
    Where do I send my patients for follow-up? preventing morbidity and mortality

    Dr. Susan Kuhn

    Odyssey Travel & Tropical Medicine Clinic

    208 2004 14th Street NW

    Calgary, AB

    T2M 3N3

    Tel: (403) 210-4770


    Summary
    Summary preventing morbidity and mortality

    • Tropical infectious diseases are coming to an Emergency Department near you

    • Many potentially lethal diseases are easily diagnosed and treated

    • The first step to making a diagnosis is to think about it


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