Travel Health in the Developing World Chris Sanford, MD, MPH, DTM&H Medical Officer, IMSURT-West Clinical Asst. Professor, Dept. of Family Med. Co-Director, Travel Clinic, Hall Care Center University of Washington Seattle, Washington, USA
How to be a doctor • 1) If someone makes a statement—say “Hmmm.”
How to be a doctor (cont.) • 2) If someone asks a question, say, “It depends.”
How to be a doctor (cont.) • 3) If someone expresses concern, say, “We see this.”
Overview of pre-travel encounter • The trip: itinerary, etc. • Past medical history incl. immunizations. • Advised immunizations • Malaria: PPMs, medication. • Travelers’ diarrhea: diet, carry-along med • Urban medicine: cars, smog, etc. • Resources
Overview • 2) Past 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
Immunizations • Review of past immunizations • Advised recommendations: • Routine • Required • Recommended
Immunizations (cont.) • 1. Routine: • Td (tetanus + diphtheria)—within 10 years • MMR • Influenza • Hepatitis B • polio
Immunizations (cont.) • 2. Required: a short list. • Yellow fever: • tropical Africa • tropical South America • [none in Asia]
Meningococcal: • Required for Hajj (Muslim pilgrimage to Mecca) • Recommended for high risk travelers • Meningitis belt of sub-Saharan Africa • Crowded living conditions, eg dorm
Immunizations (cont.) • 3. Recommended • Everyone: Hepatitis A & Influenza • Consider: rabies • Consider: Japanese encephalitis • Cholera: No. Rabies avoidance: never hold hands with a gorilla.
Malaria • Personal protection measures are more important than medications. • DEET to skin (20-30% not 100%) • Permethrin to clothes • Bednet, preferably impregnated with permethrin • Long sleeves/pants • Also benefit for diseases other than malaria, e.g. dengue.
Malaria: medications • There are approx. 100 countries with malaria. Chloroquine still effective in only a handful. • 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 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 • 3 options: • doxycycline • mefloquine (Larium) • atovaquone/proguanil (Malarone)
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 cents/pill. Side effects: photosensitivity. Less than one percent. esophogeal erosion. Don’t swallow tablet “dry”
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.) • Side effects (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 + proguanil) • Expensive. • 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.
What about carry-along standby self-treatment, instead of prophylaxis? My vote: no. You can’t diagnosis malaria clinically. Diagnosis is only possible via laboratory exam (thick and thin smears of blood). Card diagnostic test is not yet ready for prime time. May be an option in the future.
Travelers’ diarrhea • A self-limited illness in most international travelers. • Duration can be shortened by antibiotics. • Very common. Up to 50% over 2-4 weeks.
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
Dietary strategy to reduce risk of travelers’ diarrhea • Not much evidence that eating practices reduce risk. • The (relatively) safe list:→Dry foods, such as bread. • →Packaged foods. • →Well-cooked food. • →Bottled anything—water, beer, pop. • → Boiled anything.
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. • “This study adds to a growing literature that conventional advice on avoidance of specific food and drink items seems to be ineffective in reducing risk.” • “Where one eats may be more important than what one eats.” • survey on TD [travelers’ diarrhea] among tourists to Goa (India), Mombasa (Kenya), Montego Bay (Jamaica), and Fortaleza (Brazil). • 73,630 travelers (15,631 from Goa, 15,180 from Mombasa, 30,369 from Montego Bay, and 12,449 from Fortaleza)
Total ("any") TD attack rates in each of the 4 resorts, respectively, were 54%, 55%, 24%, and 14%. Total (any) TD incidence rates per 2 weeks were 52%, 63%, 37%, and 20%; incidence rates for classical TD per 2 weeks were 36%, 36%, 19%, and 9%. • The median time of onset of TD was 3 to 4 days after arrival. The risk increased over 12 to 14 days and then declined • food score scale was developed to quantitate consumption of 12 usually forbidden food and beverage items (e.g., tap water, ice cubes, raw shellfish, salad, creamy dressings, etc.).
“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 that were reviewed in a plenary lecture at the ISTM Conference in New York in 2003 have shown similar results.”
The bad list: things to avoid: • →Food from street stands (street vendors). An exception would be something that’s piping hot. For example, an ear of corn just off a fire should be okay. • →Salads. It’s near-impossible to sterilize lettuce. Often, in the developing world,“wastewater”— raw sewage— is used as fertilizer. Vegetables thrive on it, but often carry Salmonella, Shigella, and a host of other infections. I advise limiting your salad eating to the developed world. If your trip is prolonged, you might consider taking a once-a-day multivitamin.→Raw food, such as sushi.→Buffets, even at nice hotels or restaurants, in which food sits out for several hours. • →Tap water, even to brush your teeth. (Despite the fact that most cases of travelers’ diarrhea are transmitted by food, not water,) • →Ice. Freezing doesn’t kill most of the germs that can give you the trots.
Two strategies I don’t recommend: • Prophylactic antibiotics • 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
Stand-by medication • Taken only if symptoms develop • For most of the world: a fluoroquinolone (eg, ciprofloxacin, levofloxacin) • For Southeast Asia*: azithromycin, one dose only. • 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: • 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!
2nd self-treatment drug • An antimobility drug: e.g. loperamide (Imodium AC) • 2 at onset of symptoms, then 1 after each loose BM not to exceed six/day.
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? • Cipro for ETEC • azithromycin for Campylobacter • metronidazole (Flagyl) for Giardia • ?? • No. These can’t be distinguished without laboratory exam.
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 • Road traffic accidents • Air pollution • Heat illness • Recreational pharmacology • Psychological illness
What do US 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 • 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.
So does Turkey have the worst roads in the world? • No! Turkey collects good statistics. • In Ghana, only 10% of traffic fatalities are collected and tallied.
So does Ghana have the worst roads in the world? • No! Ghana has a stable government. In states failed or otherwise harboring complex humanitarian emergencies, deaths/mile traveled are probably much higher.
Tippling and driving • The percentage of drivers with blood alcohol levels higher than 80 mg/dl, indicating impairment, has been found to be 0.4% in Denmark, 3.4% in France—and 21% in Accra, the capital of Ghana. And alarmingly, 4% of bus drivers and 8% of truck drivers in Ghana were found to have blood alcohol levels above this level. • Mock CM et al: J Crash Prevent Injury Control 2001; 2(3)pp. 193-202.
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, even if you’re told the view is wonderful. • Do you not want to become • A) a missile, then • B) a stiff