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Travel Medicine. Christopher Sanford, MD, MPH, DTM&H Acting Asst. Professor, Dept. of Family Med. Clinical Asst. Professor, Dept. of Global Health University of Washington Seattle, Washington, USA November 2010. Overview of pre-travel encounter:.

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slide1

Travel

Medicine

Christopher Sanford, MD, MPH, DTM&H

Acting Asst. Professor, Dept. of Family Med.

Clinical Asst. Professor, Dept. of Global Health

University of Washington Seattle, Washington, USA

November 2010

overview of pre travel encounter
Overview of pre-travel encounter:
  • 1) Intake questions: itinerary, medical history incl. immunizations, etc.
  • 2) Advised immunizations
  • 3) Malaria: PPMs, medication.
  • 4) Travelers’ diarrhea: diet, self-tx med
  • 5) Everything else: urban medicine: cars, smog, etc.; resources.
intake questions
Intake questions
  • Where to
  • For how long
  • For what purpose
  • Staying in what kind of place
  • Guided or not
  • Previous developing world travel or not
intake questions4
Intake questions
  • Past medical history
    • Allergies
      • History of antimalarial use if any
    • Medications
    • Medical problems
      • History of depression, anxiety
    • LMP, birth control
      • None of antimalarials proven safe in pregnancy
  • Review of past immunizations
immunizations
Immunizations
  • Advised recommendations:
    • Routine
    • Required
    • Recommended
immunizations cont
Immunizations (cont.)
  • 1. Routine:
    • Tdap (tetanus + diphtheria +pertussis)
    • MMR
    • Influenza—seasonal
    • Hepatitis A
    • Hepatitis B
    • Polio
    • Varicella
slide7
Tdap
  • Give Tdap –start at age 11.
  • Then in 10 years pt gets usual Td.
  • Tdap is a once/life vaccine.
table 2 20 countries with endemic diphtheria 2010 cdc yellow book
Table 2-20. Countries with endemic diphtheria [2010 CDC Yellow Book]
  • Africa: Algeria, Angola, Egypt, Niger, Nigeria, Sudan, and sub-Saharan countries
  • Americas: Bolivia, Brazil, Colombia, Dominican Republic, Ecuador,Haiti, and Paraguay
  • Asia/South Pacific: Afghanistan, Bangladesh, Bhutan, Burma (Myanmar), Cambodia,China, India, Indonesia, Laos, Malaysia, Mongolia, Nepal, Pakistan, Papua New Guinea,
  • Philippines, Thailand, and Vietnam
  • Middle East: Iran, Iraq, Saudi Arabia, Syria, Turkey, and Yemen
  • Europe: Albania, Russia, and countries of the former Soviet Union

Pertussis: Risk for Travelers

Pertussis remains endemic worldwide, even in areas with high vaccination rates.

slide9
MMR
  • 2 doses, at least 4 weeks apart
  • Those born prior to 1957 assumed to be immune.
  • Of the 127 U.S. residents with measles in 2008, 7 were vaccinated, 21 had unknown vaccination histories, and 99 were not vaccinated. Of the 99 cases in unvaccinated U.S. residents: 67% were among persons unvaccinated because of their personal or religious beliefs.
  • The majority were import-associated.

http://www.cdc.gov/mmwr/PDF/wk/mm5754.pdf

measles deaths in africa
Measles deaths in Africa
  • Measles deaths among children under five years old in Africa:
  • 2000: 733,000
  • 2008: 118,000 (United Nations data)
influenza
Influenza
  • Important: international travelers develop influenza more often than do folks who stay at home.
  • In temperate regions in Southern Hemisphere (e.g., Australia) flu season is April-November
  • Near equator, influenza is year-round.
hepatitis a
Hepatitis A
  • Appropriate for every nation in the developing world.
  • “The most frequent vaccine-preventable disease in international travelers.”
  • 2 doses, at least 6 months apart.
  • Minimum age: 12 months.
  • Don’t give Ig to immunocompetent travelers over the age of one year.
  • Lifetime protection.
hepatitis b
Hepatitis B
  • 3 doses: at time 0, 1, and 6 months.
  • A large proportion of travelers have risks.
  • Twinrix: hepatitis A + hepatitis B
  • Schedule: 0, 1, 6 months
polio
Polio
  • One dose as an adult on top of the usual pediatric series.
  • If going to area with polio:
    • Now in about 25 countries in Africa
    • And the Indian subcontinent: India, Pakistan, Bangladesh
    • None in the Americas
pakistan
Pakistan
  • [2] PakistanDate: Tue 13 Oct 2009Source: IRIN [edited]<http://www.irinnews.org/Report.aspx?ReportId=86560>Polio outbreak in Swat----------------------Health officials say 13 cases of polio have been confirmed in  Pakistan's volatile Swat District over the past 4 months, mainly  because vaccinators have been unable to access children there for more  than a year. Fierce fighting between government troops and Taliban  militants, which began in May [2009], has displaced hundreds of  thousands of people from Swat. Before the army campaign in the area  which ended in July [2009], militants had prevented access for  anti-polio teams.
slide16

CDC Update

Oct. 2010

Outbreak NoticePolio Outbreak in

Tajikistan,

Cases in Russia,

Risk of Spread to

other Central Asian

Countries

Updated: October 22,

2010

varicella
Varicella
  • Two doses of varicella-containing vaccine are now recommended for all susceptible persons older than one year without contraindications. The first dose should be administered at 12–15 months of age and the second dose at 4–6 years of age.
  • The minimum interval for children younger than 13 years is 3 months. The ACIP now recommends that all others at least 13 years of age without evidence of immunity be vaccinated with two doses of varicella vaccine at an interval of 4–8 weeks
  • In temperate climates, varicella tends to be a childhood disease, with peak incidence during late winter and early spring. In tropical climates, infection tends to occur at older ages, resulting in higher susceptibility among adults than in temperate climates.

http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/varicella.aspx

immunizations cont18
Immunizations (cont.)
  • 2. Required: a short list.
  • Yellow fever:
    • tropical Africa
    • tropical South America
    • [none in Asia]
yellow fever
Yellow fever
  • Required for entry into:
  • In South America:
    • Bolivia, and French Guiana
yellow fever21
Yellow fever
  • Required for entry into:
  • Africa:
    • Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Cote de I’voire, Democratic Republic of Congo, Gabon, Ghana, Liberia, Mali, Mauritania (for stay over 2 weeks), Niger, Rwanda, Sao Tome and Principe, Sierra Leone, and Togo.
  • Not required for return to U.S. regardless of previous destination.
  • Booster doses required at ten year intervals.
meningococcal
Meningococcal:
  • Required for Hajj (Muslim pilgrimage to Mecca)
    • Must be tetravalent
    • All meningococcal meningitis vaccine given in the US is tetravalent
  • Recommended for high risk travelers
    • Meningitis belt of sub-Saharan Africa
    • Crowded living conditions, e.g. dorm
2009 2010 2 nd and 3 rd required hajj vaccines seasonal and pandemic influenza
2009-2010: 2nd and 3rd required Hajj vaccines: seasonal and pandemic influenza
  • Ministry of Health of Saudi Arabia states:
  • Seasonal influenza vaccine required
  • Pandemic (H1N1) flu required “if such vaccination is universally available”
    • http://wwwnc.cdc.gov/travel/content/in-the-news/saudi-arabia-hajj-2009.aspx
slide24

“meningitis

belt”—the Sahel

immunizations cont25
Immunizations (cont.)
  • 3. Recommended
    • Typhoid fever
    • Consider: rabies
    • Consider: Japanese encephalitis
    • Cholera: No.

Rabies avoidance: never hold hands with a gorilla.

typhoid fever
Typhoid fever
  • Present throughout developing world.
  • Risk in increased in long-stay travelers, and those off the beaten path.
  • Either oral (good for 5 years).
    • Minimum age 6 years. 4 pills. One pill every other day.
  • Or via injection (good for 2 years).
    • Minimum age 2 years. One dose.
rabies
Rabies
  • Three doses, over 28 days.
  • Expensive.
  • Rabies rare in travelers.
  • Consider for prolonged stay, backpackers, spelunkers, others with significant risk.
  • Pre-exposure series does not remove need for immediate post-exposure treatment.
japanese encephalitis
Japanese encephalitis
  • Spread by mosquitoes, present throughout South and Southeast Asia.
  • Expensive
  • Rare--rural only. Associated with rice and pig farming.
  • Vaccine
    • Older: JE-VAX. Three doses: d. 0, 7, 30.
    • New: Ixiaro. Two doses, d. 0 & 28. For 17 y.o. and older. FDA approved March 2009.
live vaccines
Live vaccines
  • TOY MMR BSVI
  • (oral typhoid, OPV, yellow fever, measles, mumps, rubella, BCG, smallpox, varicella, influenza [intranasal])
  • Avoid in travelers with immunocompromise, pregnancy.
  • Safe to give in HIV-pos. travelers with CD4 counts over 400
    • (or over 200, or over 500—authorities differ)
    • (except BCG—never give BCG to an HIV-positive person regardless of CD4 count)
malaria
Malaria
  • Protozoan organism, vector is Anopheles mosquito.
  • Illness characterized by high fevers, sweats, chills.
  • P. falciparum is the most prevalent species worldwide; associated with significant mortality.
  • There are approx. 100 countries in which malaria is endemic.
ppms personal protection measures bam bug avoidance measures
PPMs (personal protection measures) = BAM (bug avoidance measures)
  • Personal protection measures are at least as important as medications.

Also benefit for diseases other than malaria, e.g. dengue fever.)

    • DEET (20-35% not 100%) or picaridin (20%, not 6-9%) to exposed skin.
    • Permethrin to clothes, once every two weeks.
    • Bed net, preferably impregnated with permethrin
    • Long sleeves/pants
malaria medications
Malaria: medications
  • Chloroquine still effective in only a handful of countries.
    • Mexico, and Central America to west of Panama Canal
    • Island of Hispaniola (Dominican Republic and Haiti)
    • North Africa (prophylaxis not recommended)
chloroquine sensitive areas
chloroquine-sensitive areas
  • chloroquine or Plaquenil once/week
    • Schedule: start one week before entry, take once/week while in malaria country, take for four weeks after exit.
    • In US, Plaquenil is one-fifth cost of chloroquine
    • Dose
      • chloroquine: 300 mg base = 500 mg salt once/week
      • Plaquenil: 310 mg base = 400 mg salt once/week
chloroquine resistant countries
Chloroquine-resistant countries
  • 3 options:
  • doxycycline
  • mefloquine (Larium)
  • atovaquone/proguanil (Malarone)
doxycycline
doxycycline

Dose: 100 mg once/day.

Start one day prior to entry to malaria area, take once/day while, continue for 28 days after leaving malaria area.

Cheap. Approx. 16-20 cents/pill.

Side effects:

photosensitivity. Less than one percent.

esophageal erosion. Don’t swallow tablet “dry”

mefloquine larium
mefloquine (Larium)
  • 250 mg (salt) once/week. Start one week prior to entry into malaria area, continue once/week while there, continue once/week for four weeks after leaving malaria area.
  • Price: intermediate.
  • Contraindications: people with any type of psychiatric history ever (e.g., depression, anxiety) should not take this.
mefloquine larium cont
mefloquine (Larium) (cont.)
  • Contraindications (cont.)
    • No one should take this who:
      • Has had cardiac conduction defects
      • Seizures (aside from uncomplicated febrile seizures in childhood)
      • Doesn’t want to take it.
malarone atovaquone and proguanil
Malarone (atovaquone and proguanil)
  • Expensive. ~US $8.00/tablet
  • Once/day: begin one day prior to entry into malaria area; take one/day while there, continue once/day for 7 days after exiting malaria area.
  • Only one adult strength: Each tablet: 250 mg atovaquone + 100 mg proguanil
  • Side effects: lowest rate of the 3 drugs for chloroquine-resistant malaria.
  • Rash, GI upset, mood changes.
travelers diarrhea
Travelers’ diarrhea
  • Very common. Up to 50% over 2-4 weeks.
  • A self-limited illness in most international travelers.
  • Duration can be shortened by antibiotics.
synonyms
Synonyms
  • Aztec two-step
  • Delhi belly
  • Hong Kong dog
  • Montezuma’s revenge
  • Rangoon runs
  • Turista
  • etc., etc., etc. (DuPont & Steffen [see bibliography] lists 32 synonyms)
cause of travelers diarrhea
Cause of travelers’ diarrhea
  • Usually bacterial, usually ETEC (enterotoxigenic E. coli). Relatively recently described EAEC (entero-adherent E. coli) also common
  • More rare causes:
    • Other bacteria: Shigella, Salmonella, Campylobacter
    • Protozoan: Giardia
    • viral
study on 74k international travelers
Study on 74K international travelers
  • Survey on TD [travelers’ diarrhea] among tourists to Goa (India), Mombasa (Kenya), Montego Bay (Jamaica), and Fortaleza (Brazil).
  • Rate of diarrhea in cautious, and adventurous eaters.
  • Steffen R, Tornieporth N, Costa Clemens SA, et al. Epidemiology of travelers' diarrhea: details of a global survey. J Travel Med 2004;11(4):231-238.
slide46
“There were no differences in [prohibited] food scores between those who did and did not have TD [travelers’ diarrhea]”
  • “Cumulatively, a number of other studies over the past 20 years… have shown similar results.”
  • Steffen R, Tornieporth N, Costa Clemens SA, et al. Epidemiology of travelers' diarrhoea: details of a global survey. J Travel Med 2004;11(4):231-238.
no evidence of benefit
No evidence of benefit
  • More expensive hotel or restaurant
  • Garlic
  • Lemon juice
traditional wisdom the bad list
Traditional wisdom: The bad list:

→ Food from street stands (street vendors)

→ Salads → Raw food, such as sushi→ Buffets, even at nice hotels or restaurants, in which food sits out for several hours

→ Tap water

→ Ice. Freezing doesn’t kill most of the microorganisms that can cause diarrhea.

traditional wisdom dietary strategy to reduce risk of travelers diarrhea
Traditional wisdom: Dietary strategy to reduce risk of travelers’ diarrhea
  • The (relatively) safe list:→ Boiled anything.

→ Bottled anything—water, beer, pop (if sealed).

→ Dry foods, e.g. bread.

→ Packaged foods.

→ Well-cooked food.

→ Fruits which require peeling (oranges, bananas)

two strategies i don t recommend
Two strategies I don’t recommend:
  • Prophylactic antibiotics
    • Cipro 500 mg qd, not to exceed 3 weeks, reduces risk of TD
    • These can have side effects in

and of themselves

  • Pepto-Bismol
    • It works: you chew 2 tablets,

four times/day, for the whole trip.

    • Benefit: 50-65% reduction in travelers’ diarrhea
    • Drawbacks: black tongue, weird black poop
one option continuous prophylaxis
One option: continuous prophylaxis
  • Xifaxan (rifaximin), a non-absorbed antibiotic.
  • Not inexpensive. US $5-6/tablet
  • Effective in Africa and Latin America, less so in SE Asia.
  • Prophylaxis dose: 200 mg q.d. or b.i.d.
  • Treatment dose: 200 mg t.i.d. x 3 days
standard of care stand by medication
Standard of care: Stand-by medication
  • Taken only if symptoms develop
  • For most of the world: a fluoroquinolone (e.g., ciprofloxacin, levofloxacin). Cipro dose: 500 mg b.i.d., stop when better (for up to 48 hours).
  • For Southeast Asia*, and Indian subcontinent: azithromycin, one dose only (for adults, one gram once).
  • Duration without treatment: 3-5 days.
  • Duration with treatment: 12-24 hours.
    • *Brunei, Burma (Myanmar), Cambodia, East Timor, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand, Vietnam
travelers diarrhea caveats
Travelers’ diarrhea caveats:
  • Take self-treatment medication only for “normal” diarrhea
    • If blood in stool,
    • Or fever,
    • Or significant abdominal pain,
    • Or if not better 2 days after starting antibiotics—

 See a doc!

2 nd self treatment drug
2nd self-treatment drug
  • An antimotility drug: e.g. loperamide (Imodium A-D)
  • 2 at onset of symptoms, then 1 after each loose BM, not to exceed six/day.
  • Contraindicated in presence of symptoms consistent with “invasive organism” (blood in stool, fever, significant abd. pain).
td carry along med algorithm
TD carry-along med algorithm:
  • Pt feels good Takes nothing
  • Mild diarrhea Imodium A-D only
  • Watery diarrhea Imodium A-D + antibiotic
  • Sick See doc
    • Blood in stool
    • Fever
    • Significant abd. pain
special oral rehydration solution
Special oral rehydration solution

-Only needed at extremes of age.

-No need to “rest”

the gut during

recovery.

should you carry more than one medication for travelers diarrhea
Should you carry more than one medication for travelers’ diarrhea?
  • Cipro for ETEC
  • azithromycin for Campylobacter
  • metronidazole (Flagyl) for Giardia
  • ??
  • No. These can’t be distinguished without laboratory exam.
slide58
For those with a fascination with poop and its aberrations, I refer you to Ericsson, DuPont, and Steffen’s 315-page Travelers’ Diarrhea (BC Decker, Hamilton, 2003).
urban medicine
Urban medicine
  • Road traffic accidents
  • Air pollution
  • Heat illness
  • Recreational pharmacology
  • Psychological

illness

what do u s travelers die from in the developing world
What do U.S. travelers die from in the developing world?
  • About half: heart attacks, strokes (mostly in the elderly).
  • About 25%: road traffic accidents.
  • The rest: drowning, falls from heights, homicide, suicide.
  • Infectious disease: only about 1%.
road traffic accidents
Road traffic accidents
  • The rate of fatalities per 100 million miles driven in the US is 1.1; this is similar to Western European rates.
  • The rates in Sri Lanka and Turkey are 23 and 44, respectively.
slide64

To reduce risk of injury and death from

motor vehicle accidents:

Seat belts are good.

Helmets are good. Better

still, stay off anything

two-wheeled and

motorized.

Do not ride on top of a

bus or in the back of an

open truck.

Avoid the roads at night.

air pollution
Air pollution
  • Mexico City was the worst city in the world in 1992. Now it’s not on the top ten list.
  • Nine of worst ten cities are in China.
slide66

Mexico City

Total suspended particulates

(in mcg/cubic meter)

  • Stockholm 9
  • Mexico City 279
  • Lanzhou, China 732

Lanzhou,

China

slide67
Sulfur dioxide is formed by the burning of fossil fuels, such as oil and gas.

Sulfur dioxide

(in mcg/cubic meter)

  • Los Angeles, California: 9
  • Guiyang, China: 424

Guiyang, China

what does this bad air mean to the young fit short term traveler
What does this bad air mean to the young, fit, short-term traveler?
  • Usually not much other than irritated eyes and a sore chest.

Hangzhou, China

(daytime)

who can get into trouble with heavily polluted air
Who can get into trouble with heavily polluted air?
  • Those with pre-existing conditions:
    • Asthma
    • Chronic bronchitis, emphysema
    • Coronary artery disease
slide70
Those with asthma: carry an oral steroid
  • Those with chronic bronchitis or emphysema: carry “rescue cocktail:”
    • Additional inhaler
    • Appropriate antibiotic
    • Oral steroid.
slide71
Sex
  • Sex with a new partner while traveling is common.
  • Many studies show that one-quarter to one-third of travelers have sex with a new partner while abroad.
    • Associated with inc. likelihood of having new partner while abroad: male, young, traveling alone, long duration of travel.
  • A significant number of travelers do not use condoms.
security
Security
  • Pickpocketing is not uncommon in the developing world.
  • Wallet not in pants pocket, but around neck or waist in a money belt.
  • Have hotel call for taxi.
  • Hotel safety boxes are usually safe.
  • Don’t take anything (camera, jewelry) that you would be significantly bummed if you lost
security leave the laptop at home
Security: leave the laptop at home.
  • Laptop
  • Expensive
  • Needs electricity
  • Needs adaptor plug for most of developing world
  • Can be damaged by humidity or rough handling
  • Useless in bright sunlight
  • High potential for rip-off
  • Clipboard or spiral-bound notebook
  • Cheap
  • No need for electricity
  • No adaptor plug required
  • Relatively indestructible
  • Not hampered by bright sunlight
  • Near-zero potential for rip-off
photography
photography
  • If there’s a guy within sight who is carrying a rifle or machine gun: ask permission before you take photographs.
everything else
Everything else
  • Paranoia regarding needles in the developing world is prudent.
    • Tattoos and perforations: developed world better.
  • The equatorial sun--burns skin quickly. Sunblock, hat with brim.
  • Mental health: take something that will take you to your happy place (music player, novel…)
  • Evacuation insurance: it costs $50-75K to hire a medical jet to evac someone to developed world. Consider buying evac insurance
    • Medex, International SOS, DAN (Divers’ Alert Network)
websites to give to travelers
Websites to give to travelers:
  • cdc.gov -- the entire “Yellow Book” (Health Information for International Travelers) is

searchable by illness or

geographic area

  • state.gov -- crime,

security, terrorism

the message you give is necessarily paradoxical
The message you give is necessarily paradoxical:
  • First you list thirty causes of premature demise…
  • Then you say, “But it sounds like a great trip and I think you’ll have fun!”
slide79
Don’t look glum.
  • Recall that a majority of travelers look back on their international travel as a highpoint of their lives.
  • Most travelers return with fond memories and a desire for more developing world travel.
bibliography
Bibliography

Centers for Disease Control and Prevention. CDC Health Information for International Travel 2010. Atlanta: U.S. Dept. of Health and Human Services, Public Health Service, 2009.

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, McIntyre L, ed. Washington DC: Public Health Foundation, 2009.

Cook, Gordon C, Ed.: Manson’s Tropical Diseases, 20th Ed., W.B. Saunders Co. Ltd, 1996.

DuPont HL, Steffen R (eds.): Textbook of Travel Medicine and Health, 2nd Ed. B.C. Decker, 2001.

Guerrant, Walker, Weller: Tropical Infectious Diseases: Principles, Pathogens, & Practice. Churchill Livingston, 1999.

Jong EC, Sanford C (eds.): The Travel and Tropical Medicine Manual, 4th ed. Saunders/Elsevier, 2008.

Keystone JS, Kozarsky PE, Freedman DO, et al, eds: Travel Medicine. Mosby, 2004.

bibliography cont
Bibliography (cont.)

Sanford, C: The Adventurous Traveler’s Guide to Health. University of Washington Press, Seattle, 2008.

Sanford C. (guest editor): Primary Care Clinics: Travel Medicine. Saunders/Elsevier, December 2002.

Strickland. Hunter’s Tropical Medicine and Emerging Tropical Diseases, 8th Ed., W.B. Saunders. 2000.