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TRAVEL MEDICINE. EVALUATION OF FEVER AND MEDICAL EMERGENCIES IN THE RETURNING TRAVELER. Outline of Travel Medicine Issues. Evaluation of Fever in the Returning Traveler Medical Emergencies in Travelers Traveler’s Diarrhea Prevention of Infection: Vaccines and Antibiotic Prophylaxis

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  2. Outline of Travel Medicine Issues • Evaluation of Fever in the Returning Traveler • Medical Emergencies in Travelers • Traveler’s Diarrhea • Prevention of Infection: Vaccines and Antibiotic Prophylaxis • Geographic Infections : Abroad and at Home

  3. Overview of Travel Related Illness • 20 to 70 % of 50 million travelers to the developing world report illness associated with travel. • 1 to 5 % end up seeking medical care • 1 in 100,000 dies of a travel related illness

  4. Evaluation of Fever in the Returning Traveler • Careful documentation regarding • Time of onset of symptoms • Travel locales and accommodations • Activities and exposures • Host factors – medical /immune status

  5. Evaluation of Fever – Time Factor • Timing of exposures –a powerful tool • Calculation of incubation periods • Duration of total travel- probability of an infection increases with stay( ie. relative risk of malaria is 80 fold for stays of >6 mos compared to a week) • Short-term travel rarely leads to helminthic infections; seen more commonly in immigrants • Fevers due to infection occurring more than one year after travel is distinctly uncommon.

  6. Less than 2 weeks Malaria Ricketsiae Dengue Typhoid Diarrheal illnesses. 6 weeks or moreMalaria TB Hepatitis B Leishmaniasis Rabies Two – Six weeks Malaria Hepatitis A, E Leptospirosis Amebic abscess Schistosomiasis Incubation Periods

  7. Evaluation of Fever:Prophylaxis History • Detailed vaccine/prophylaxis history- This does not exclude certain illnesses (ie: efficacy of yellow fever vaccine is greater than typhoid vaccine) • Malarial prophylaxis regimen may fail based on resistance patterns and patient compliance

  8. Evaluation of Fever:Exposures • Food and Beverage Intake • Arthropod and Animal contacts • Recreational Activities- Hiking, Water exposures –fresh and salt water • Sexual contacts

  9. Evaluation of Fever - Workup • Physical exam should carefully focus on: Skin for lesions, rash, genital lesions Lymph node, spleen and liver enlargement • Laboratory Tests: CBC with diff., LFT’s, Blood cultures, CXR and malarial smears x 3 Stool studies if symptomatic- O&P, cultures for enteric pathogens (SSCY) Serology if indicated by LFT’s (Hepatitis A,B,E, or E.Histolytica).

  10. Fever and Eosinophilia • Peripheral eosinophilia is associated with helminthic infections that migrate through tissues - rarely with luminal infections • Acute Schistosomiasis • Acute Trichinosis • Acute Strongyloides • Lymphatic Filariasis

  11. Evaluation of FeverEmergencies • Hemorrhagic Fevers Meningococcus Rickettsiae Leptospirosis Plague- Yersinia *Dengue Other viral hemorrhagic fevers (Lassa, Rift Valley, Congo-Crimean)

  12. Hemorrhagic Fevers:Dengue Fever • Endemic in Caribbean, Central and South America and South Asia • Estimated 100 million cases/yr, with symptoms ranging from mild fever to shock and death. • Four distinct serotype (1-4) of this flavivirus, transmitted by mosquito • Prior exposure increases risk of DHF-shock

  13. Dengue:Clinical Picture • Incubation period of 3-10 days • Fever, retro-orbital headache, myalgias-arthralgias –”break-bone fever” • Rash occurs 2- 5 days post fever onset,seen in 50% • GI symptoms in about 50% • Thrombocytopenia, leukopenia - 16-55% • Hemorrhagic Fever- seen with vascular leak and shock state • Serologic studies • Treatment is supportive only

  14. Evaluation of Fever Emergencies Fever and Confusion and lethargy P.falciparum malaria (cerebral form) N.meningococcus Rickettsiae – R. conori, proweseki

  15. Malaria • Fever in traveler from malarial region • Highest after rainy season; uncommon at altitude >2000 ft • Over 1,500 cases in US /yr • Appropriate prophylaxis is about 80% effective. • Incubation period varies by species- P.falciparum- 12-14 d P. vivax/ovale -up to 2 mos, can be years P.malariae- 35 days *P. knowlesi- transmitted in SE Asia; endemic in monkeys

  16. Malaria:Evaluation and Rx • Fever associated with sweats, headache, myalgias. • Anemia, thrombocytopenia • Thick smears q 6-12 hours for 48 hrs. First smear + in 95%. • Parasitemia of greater than 3% should be hospitalized; greater than 5% have significant mortality when treated.

  17. Malaria:Treatment For Chloroquine-sensitive species (P.vivax/ovale/malariae): • Chloroquine 600mg, followed by 300mg at 6, 24 , 48 hrs. For Chloroquine-Resistant P.falciparum Quinine+Doxycycline -7 days Malarone – 3 days (if no malarone prophylaxis) Mefloquine – 1250 mg in divided doses

  18. Evaluation of Fever Emergencies • Respiratory Distress Malaria Hanta virus Influenza SARS Avian Influenza.

  19. Travelers’ Diarrhea • Travel to the developing world carries a 40-60% risk of diarrhea- usually benign and self-limited. • More than 90% is bacterial, and food/water borne. • Most common pathogen – Enterotoxin E.coli (ETEC). • Parasitic enteritis requires a more contaminated environment than usually encountered by tourists. • Note: Airline food is prepared in departure city.

  20. Travelers’ Diarrhea- Risk Factors • Low Risk (<10%) – N.Europe,Australia, US, Canada-but note high Giardia risk in US West/NE mountains • Moderate Risk (up to 20%) – Caribbean, Mediterranean, and Israel • High Risk (>30%) – Asia, Africa, Mexico, Central and South America • Gastric bypass and resection, histamine blockers will allow bacteria to survive to small bowel.

  21. Travelers’ Diarrhea: Clues to Pathogens • Watery and Afebrile Most common pathogen is ETEC- the prototype travelers’ diarrhea is self limited • Bloody Diarrhea with Fever Salmonella, Shigella, Campylobacter and Yersina are invasive; E.histolytica. • Vibrio cholerae will cause a profound secretory diarrhea (“rice water”), with highest risk of dehydration/death.

  22. Travelers’ Diarrhea: Therapy • Prevention: prophylactic antibiotics are not recommended unless a person’s medical condition or dehydration risk is severe- IBD Renal Immunosuppresion AIDS • Empiric Abx- quinolones; for convenience, consider qd dosing with levofloxacin indicated in cases of fever, blood or pus, and > 4 daily stools.

  23. Skin Lesions in Travelers • Arthopod Bites- Myiasis -botfly larvae will penetrate skin and mature leading to a nodule. Tungiasis (sand flea larvae are expelled under skin after a blood meal). Rickestiae will see a necrotic ulcer

  24. Skin Ulcers Tularemia Atypical Mycobacterial Endemic fungal STD’s –genital ulcers- Syphilis, LGV,Chanchroid Creeping Eruptions Cutaneous larva migrans (hookworm larva) Loiasis Strongyloidiasis. Skin Lesions in Travelers

  25. Cutaneous Leishmaniasis

  26. Preventable Traveler’s Infections • Yellow Fever – viral, mosquito-borne,lethal • Malaria – parasitic, mosquito-borne, lethal • Typhoid Fever –bacterial, food-borne,contagious • Hepatitis A – viral, food-borne, contagious • Meningococcus – bacterial, contagious, lethal, seasonal and epidemic. • Japanese Encephalitis- viral, mosquito-borne, seasonal, lethal, low-risk for short-term travelers

  27. Yellow Fever Prevention • An Equatorial infection in both East/West • A live-virus vaccine • Only vaccination legally required by certain countries for entry. • Four reported cases of vaccine-related multi-organ failure, with three deaths in 1996-98 in USA. • Contraindicated for pregnant and immunodeficient persons (live-virus). • Single IM dose; booster every ten years

  28. Malaria Prevention • Nearly 300 million cases worldwide each year, with more than one million deaths. • Four species: Plasmodium falciparum, vivax, ovale and malariae. Fatalities with falciparum. • Several hundred cases/year in US travelers. During 1980-93, 3005 US cases with 51 deaths (1.7%). • Highest risk occurs in Sub-Saharan Africa. • Need to consider up-to-date resistance patterns.

  29. Malarial Prevention • Prophylactic antibiotics are 90-95% effective. • Regimens routinely require starting pills 1-2 weeks prior to, and for 4 weeks following exposure. • Chloroquine is the first-line agent for travel to areas that still have chloroquine-sensitive P.falciparum, restricted to Central America, Middle East. • Chloroquine resistant strains of P.vivax have now appeared in Africa and Asia

  30. Malaria Prevention • Topical insect repellants which include (DEET). Can see dermatitis, and neurotoxicity from absorption (caution with children-use lower %) • Mosquito netting sprayed with permethrin. • Note: Yellow Fever is transmitted by mosquitos that bite during daytime, malaria transmitted at night. • PREGNANCY- Chloroquine is safe, Mefloquine appears safe, Malarone data is still insufficient.

  31. Malaria Prevention for Travel to Chloroquine Resistant (CR)Regions • Mefloquine- 250 mg q week (-1 to 4+ travel) active against all species, yet resistant strains of P.falciparum now exist in Africa and in Thai-Cambodian-Myanmar regions. Side effects include neuropsychiatric and GI. • Malarone– combination of atovaquone/proguanil. Taken qd 1-2 days prior to,during, and one week post. Equivalent to mefloquine vs. CR P.falciparum. • Doxycycline- 100 mg qd 1-2 days prior, 4 wks. post travel. Issue of photosensitivity.

  32. Typhoid Fever and Prevention • Salmonella typhi is still prevalent in Asia, Africa and Latin America. • Risk appears greatest in Indian subcontinent. • Vaccination is best advised for those going to more remote regions, or during reported outbreaks • Oral vaccine(Vivotif)- taken prior to travel qod x 4, and can be boosted every 5 years. • Injectable(Typhim)- provides protection for 1-2 yrs • Both vaccinations provide about 50-80% protection

  33. Homeland Security - Travel Medicine in the USA • Endemic infections must be considered in evaluation of fever after US travel. • Recreational activities increase the chance of exposure to arthropods and the endemic fungi • Ticks – Babesios (New England coast/islands) Lyme (Northeast coast, WI,CA) RMSF (Appalachia, Northeast) Erhlichiosis (Northeast, MO, AR) Tick Paralysis ( Rocky Mts.)

  34. US Travel Medicine • Endemic Mycoses – Pulmonary/Systemic Blastomycosis – LA, WI, Miss. River valley Histoplasmosis – Ohio, St.Lawrence and Mississippi river valleys Coccidiomycosis - desert SW, San Joaquin • Hanta Virus Pulmonary Syndrome- NM,CO,AZ • Plague- flea bite, AZ bubonic not pneumonic

  35. Prevention of Infections Related to Travel – Abroad and At Home • Potential exposures should signal a series of immunizations and prophylaxis. • Resources: • WWW. ISTM.org. • WWW. Cdc.gov • WWW. Tropnet.net • Travel Medicine Clinics

  36. Be Careful Out There BON VOYAGE

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