Healthy Travel for Business or Pleasure

1. Healthy Travel for Business or Pleasure The OMC Clinical Staff Joe Falco, M.D., M.P.H., Jai Subramani, M.D., M.P.H. & Pat Edwards, ANP., COHN-S/CM With thanks to Carol Davis, D.O., M.P.H. May 7, 2008

3. Talk objectives To advise you of: • General precautions to take before and during travel to prevent illness and injury (Falco) • Specific infectious diseases and other health threats (Subramani) • For Travelers on official BNL business– procedures services and obligations (Edwards)

4. The Key to Safe Travel Prevention • Addressing health issue and taking preventive actions before travel • Playing it safe when traveling • Preventing injuries • Preventing diseases

5. For all individuals going on a long trip– domestic or international Make sure you’re healthy enough to travel • Any health conditions addressed and stable– heart disease, diabetes, high blood pressure, arthritis--see your doctor/practitioner and dentist if haven’t recently, and do so several weeks before travel. • Don’t be shy about speaking with physician about travel-associated stress/anxiety/phobias • See your dentist if due or symptoms • Have enough regular medications for trip • Up-to-date on routine vaccinations • dT (tetanus/diptheria) every 10 years (and one-time TdaP as adulty for pertussis protection) • Make sure immune to measles/mumps/rubella (history/titers) or adequately vaccinated (at least 2 MMR vaccinations over lifetime) • Flu vaccine if flu season (Nov.-April; year-round in tropics) • Pneumococcal vaccine if over 65 or chronic illnesses/no spleen) • One Inactivated Polio Vaccination (IPV) some time during adulthood, especially if traveling to the Indian sub-continent, or Africa.

6. If traveling outside the U.S. • Check health or business insurance policy for overseas coverage • When in doubt, get traveler’s health insurance (and consider trip cancellation insurance)– check with travel agent or web resources (Edwards). • Check with travel agent or web resources for medical care clinics where you’ll be going. (http://www.iamat.org; Edwards). • Check State Department web site for information about crime and civil unrest where you’ll be going http://www.travel.state.gov/travel/warnings.html. • Consider putting together a travel kit with medications and medical supplies you might need on trip (Edwards will discuss OMC’s travel kit)

8. Special preventive measures—Travel to developing world Consult CDC travel web site: www.cdc.gov/travel-- general recommendations and travel alerts Visit a travel medicine clinic at least 6 – 8 weeks before travel (OMC for official business travelers; see list for others) Be prepared to provide Travel Medicine specialist with relevant info Who is traveling? Provide the age, sex, health, and vaccination history of everyone going on the trip. Patients should bring (and always travel with) a copy of their own vaccination records. All routine vaccinations should be reviewed and updated. Where are you traveling? Provide itineraries, names and orders of countries you plan to visit. Necessary vaccinations and medications are determined based on CDC guidelines for a particular area. When are you traveling? The season may affect likelihood of contracting certain diseases (e.g.; monsoon season, flu season). Why are you traveling? (Business vs. personal or adventure travel) What will you be doing during travel? How will you be traveling and living while abroad? How long will you be staying or living abroad?

9. Location-specific vaccine recommendations Typhoid: • Entire developing world, especially Asia, Africa, and Latin America • Oral or injected—both are effective and low frequency of serious side effects • Oral– live vaccine: 4 capsules over one week. Good for 5 years. • Single shot—cell surface component of typhoid (not-live): good for 2 years

11. Hepatitis B: contaminated injection and other equipment used for health care-related procedures and blood transfusions from unscreened donors. Unprotected sex and sharing illegal drug injection

12. While you’re traveling Measures you should take To prevent deep vein thrombosis To prevent injury To prevent illness—Dr. Subramani

13. Deep Vein Thrombosis DVT: Blood clot that can form in the veins of the legs, potentially traveling to the lungs. Triggered by immobility during airplane, train, vehicular travel lasting more than 4 hours. Risk factors: Older than age 40 Pregnancy Chronic diseases: cardiovascular, cancer, kidney disease--nephrotic syndrome Smokers Varicose veins Contraceptive use Estrogen replacement therapy Obesity Family history and Personal History

14. Deep Vein Thrombosis (cont’d) Prevention Frequent stretching, walking around (every 2 hours) Increase water intake: avoid dehydration Limit alcohol and caffeine consumption Avoid sleeping pills because sleep minimizes mobility

15. Deep Vein Thrombosis (cont’d) Use foot rests as much as possible to keep one’s thighs clear of the seat. Wear elastic compression stockings that are designed to reduce the risks of DVT. CDC recommends those at higher risk for clots take anticoagulant medication.

16. Injury prevention Quiz: What are the 2 most common causes of traveler deaths abroad? • Motor vehicle accidents • ….

18. Preventing Injury from Motor Vehicles and other Travel Adventures Observe local ordinances and regulations. Use public transportation whenever possible. Consult with travel agent or guide books re: reputable taxi & limo services and other means of transportation Avoid high crime areas and be aware of political situation and civil unrest: http://www.travel.state.gov/travel/warnings.html Use seat belts (and helmets—bikes, motorbikes/cycles). Participate only in activities/sports/swimming/driving compatible with personal skill level.

20. Specific Infectious Diseases JaishreeSubramani, M.D., M.P.H.

21. DISEASES SPREAD BY MOSQUITOS • MALARIA • DENGUE FEVER • YELLOW FEVER • VIRAL ENCEPHALITIS • VIRAL HEMORRHAGIC FEVERS

22. Malaria

23. Malaria Rural travel risk>> Urban Transmitted by Anopheles mosquito Caused by four species of protozoa Symptoms: fever, chills, headaches, nausea, vomiting, body aches, general malaise. Also possible: jaundice, liver enlargement, increased breathing rate, anemia, seizures, coma, blood coagulopathy, cardiovascular shock and collapse, acute kidney failure, death.

24. Malaria (cont’d) Avoid mosquitoes by taking protective measures. Use protective clothing: long sleeved shirts/pants. Use DEET repellant. Use bed netting if rural or if locked windows not available. Prophylactic medications when indicated are widely used based on CDC recommendations for intended destinations.

25. MALARIA -WESTERN HEMISPHERE

26. MALARIA -EASTERN HEMISPHERE

27. MEFLOQUINE RESISTANT MALARIA

28. Travel in Chloroquine Resistant areas

29. Travel in Chloroquine Resistant areas Atovaquone/proguanil (Malarone) • 250 mg atovaquone and 100 mg proguanil hydrochloride. • Begin 1-2 days before travel and continue daily for 7 days after leaving the area.. • Daily, at the same time each day . • Contraindicated in persons with severe renal impairment • Contraindicated in children <5 kg, pregnant women, and women breastfeeding. • Side effects- abdominal pain, nausea, vomiting, and headache

30. Dengue fever , Western Hemisphere.

31. Dengue Fever, Eastern Hemisphere.

32. Dengue and Dengue Hemorrhagic Fever • Dengue viruses are transmitted from person to person by Aedes mosquitoes . • Dengue fever "break bone fever“- acute onset of high fever, 3-14 days after the bite. • Frontal headache, retro-orbital pain ,muscle/joint pain, nausea, vomiting, and often a maculopapular rash.(1 wk) • weakness, malaise (several weeks). • Bleeding into the skin ,gums, intestines seen in DHF • DHF if not treated can be fatal

33. Treatment of Dengue fever • Fluids • Rest • Antipyretics (avoid aspirin) • Monitor blood pressure, hematocrit, platelet count, level of consciousness • Continue monitoring after fever subsides. • No vaccines are currently available

34. YELLOW FEVER

35. Yellow fever- the Americas

36. Yellow fever • Transmitted to humans through the bite of infected mosquitoes. (Yellow fever virus, a flavivirus) • Ranges in severity from a self-limited febrile illness to severe hepatitis and hemorrhagic fever. • Acute stage-fever and chills, severe headache, back pain, general muscle aches, nausea, fatigue, and weakness . • Intermediate stage-hemorrhagic symptoms . • Late stages- patients can develop hypotension, shock. • Vaccine available, Treatment –supportive.

37. Viruses transmitted by mosquitoes • Chikungunya fever • Japanese Encephalitis (flavivirus) • St. Louis encephalitis • West Nile encephalitis . • Western equine encephalitis .

38. FOOD /WATER BORNE DISEASES • Escherichia coli infections • Shigellosis or bacillary dysentery • Giardiasis (microscopic parasite,Tx -tinidazole, metronidazole ) • Cryptosporidiosis(50% associated with swimming pools) Nitazoxanide- Adult dosage 500 mg BID x 3 days. • Noroviruses (Raw shellfish ,oysters) • Hepatitis A. (vaccine available) • Less common salmonella, cholera, rotavirus infections, and a variety of protozoan and helminthic parasites.

39. Travelers’ Diarrhea

40. Travelers’ Diarrhea • Clinical syndrome resulting from microbial contamination of ingested food and water. • Most of these are bacterial in origin. 80%-85% • Parasites about 10% & viruses 5% .

41. BACTERIAL ENTERIC PATHOGENS • Enterotoxigenic Escherichia coli (ETEC) • Enteroaggregative E. coli (EAEC) • Campylobacter jejuni • Salmonella • Shigella. • Vibrio

42. Travelers’ Diarrhea • Abrupt onset of loose, watery or semi-formed stools with abdominal cramps and rectal urgency. • Nausea, bloating, and fever, may be present. • Generally self-limited and lasts 3-4 days even without treatment. • Medical attention to be sought for diarrhea with high fever or blood.

43. Prevention of TD • Wash hands thoroughly with soap and water. • Eat foods that are freshly cooked and served piping hot . • Avoid water and beverages diluted with non-potable water (reconstituted fruit juices, ice, and milk). • Avoid raw or undercooked meat and seafood and raw fruits and vegetables. • Bismuth subsalicylate (BSS), which is the active ingredient in Pepto-Bismol reduces the incidence of TD from 40% to 14%.

44. Bismuth subsalicylate • Two chewable tablets four times per day . • Blackening of the tongue and stool and may cause nausea, constipation, and rarely tinnitus. • To be avoided by travelers with aspirin allergy, renal insufficiency, gout and by those taking anticoagulants, probenecid, or methotrexate. • Caution in administering BSS to children with viral infections, such as varicella or influenza, because of risk of Reye syndrome.

45. Treatment • ANTIBIOTICS (ciprofloxacin or levofloxacin-3 days of antibiotic) • ANTIMOTILITY AGENTS (loperamide (lomotil) and diphenoxylate) • ORAL REHYDRATION (only beverages that are sealed or carbonated) . • TREATMENT OF TD CAUSED BY PARASITES (e.g.; Giardiasis- Flagyl)

46. Typhoid Fever • acute, life-threatening febrile illness . • caused by the bacterium Salmonella typhi . • persistent, high fever as high as 103° to 104 • headache, malaise, anorexia, splenomegaly, a rash of flat, rose-colored spots, and relative bradycardia. • Antibiotics should be guided by antimicrobial sensitivity, particularly for travelers to South Asia.

47. Typhoid Fever-Treatment • Ciprofloxacin still remains the drug of choice. • In cases of treatment failure, third-generation cephalosporins such as ceftriaxone can be used. • Azithromycin in some cases. • Oral hydration. • IV hydration.

48. Schistosomiasis

49. Schistosomiasis Transmitted by freshwater snails. (Sub-Saharan areas) Caused by schistosoma flukes . Infected freshwater snails release larvae that are capable of penetrating the unbroken skin of the human host. (wading, swimming) Schistosomiasis is most prevalent in sub-Saharan Africa.

50. Schistosomiasis • Symptoms- fever, loss of appetite, weight loss muscle pain, diarrhea, nausea, and cough. • Can lead to disease of the kidneys, GI tracts, bladder, and lungs. • hepatic or intestinal and urinary schistosomiasis • Diagnosis of infection is usually confirmed by serologic studies. • No vaccine is available • Praziquantel is the drug of choice.