Ambulatory Conference: Travel Medicine Hollis Ray, MD June 6, 2011.
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Transcript of Ambulatory Conference: Travel Medicine Hollis Ray, MD June 6, 2011.
Ambulatory Ambulatory Conference: Conference:
Travel Travel MedicineMedicine
Hollis Ray, MDHollis Ray, MD
June 6, 2011June 6, 2011
Travel Clinic
Should be carried out by persons who have training in the field, particularly for travelers who have complex itineraries or special health needs
Primary care physicians and non-specialists should be able to advise travelers who are in good health and visiting low-risk destinations with standard planned activities.
Travel Clinic
Epidemiology, transmission and Epidemiology, transmission and prevention of travel-associated infectious prevention of travel-associated infectious diseasesdiseases
A complete understanding of vaccine A complete understanding of vaccine indications and proceduresindications and procedures
Prevention and management of non-Prevention and management of non-infectious travel health risksinfectious travel health risks
Recognition of major syndromes in Recognition of major syndromes in returned travelers (e.g., fever, diarrhea, returned travelers (e.g., fever, diarrhea, and rash)and rash)
Immunization Update vaccines/boosters: tetanus, pertussis,
diphtheria, Haemophilus influenzae type b, measles, mumps, rubella, varicella, Streptococcus pneumoniae, and influenza
Hepatitis A and B, poliomyelitis, and Neisseria meningitidis– for travel as well as for routine health care.
Yellow fever vaccine: endemic zones (Africa and S. America)– some countries may require as a condition for entry
Vaccines against Japanese encephalitis, rabies, tick-borne encephalitis and typhoid fever– Administered based on a risk assessment– Quadrivalent meningococcal vaccine is required by Saudi
Arabia for religious pilgrims to Mecca for the Hajj or Umrah.
Most Common Diagnoses
Short Incubation Period (<2 weeks)– Malaria– Typhoid fever– Dengue– Rickettsial disease– Hepatitis A
Long Incubation Period (>4 weeks)– Malaria– Tuberculosis
MalariaMalaria
Malaria Largely preventable Incubation period: 10
days to 1 year Signs and symptoms:
GI symptoms, cyclical fevers, anemia, splenomegaly
Diagnosis: thick and thin peripheral blood smear– Thrombocytopenia
without leukocytosisCDC Public Health Image Library
Infecting Organisms
Plasmodium falciparum: potentially fatal and considered an emergency– Acquired in Africa = 3:1 likelihood– 95% have clinical onset within 2 months
exposure– Peripheral blood smear: parasitemia > 2%,
only ring forms, banana-shaped gametocyte, erythrocytes of all sizes infected, erythrocytes contain no Schuffner granules
Other species: P. vivax, P. ovale, P. malariae, P. knowlesi– fevers occurring at regular intervals of 48 to 72
hours
Severe MalariaSevere Malaria Cerebral malaria, with abnormal behavior, Cerebral malaria, with abnormal behavior,
impairment of consciousness, seizures, impairment of consciousness, seizures, coma, or other.coma, or other.
Severe anemia due to hemolysisSevere anemia due to hemolysis Hemoglobinuria Hemoglobinuria Pulmonary edema or ARDS, which may Pulmonary edema or ARDS, which may
occur even after the parasite counts have occur even after the parasite counts have decreased in response to treatment decreased in response to treatment
Abnormalities in blood coagulation and Abnormalities in blood coagulation and thrombocytopeniathrombocytopenia
Shock Shock
Treatment of Severe Malaria Treatment of Severe Malaria in the United States in the United States
ArtesunateArtesunate for hospitalized patients with for hospitalized patients with Severe malaria disease Severe malaria disease High levels of malaria parasites in the High levels of malaria parasites in the
blood blood Inability to take oral medications Inability to take oral medications Lack of timely access to intravenous Lack of timely access to intravenous
quinidine quinidine Quinidine intolerance or contraindications Quinidine intolerance or contraindications Quinidine failureQuinidine failure
Malaria Chemoprophylaxis
Largely based on resistance patterns to chloroquine phosphate or hydroxychloroquinesulfate.
(IDSA Travel Medicine Guidelines)
(IDSA Travel Medicine Guidelines)
(IDSA Travel Medicine Guidelines)
Typhoid Fever
Typically present 1-3 weeks after ingestion of food or water contaminated with Samonella enterica serotype typhi
Have visited Indian subcontinent, in the Philippines, or in Latin America
Fever and constitutional symptoms– May have insidious onset– Abdominal pain, cough, chills– Diarrhea may eventually develop
Typhoid Fever
Diagnosis: identify organism in urine, blood, stool, or bone marrow
Vaccines partially effective
Treatment: 3rd gen. cephalosporin, floroquinolone, or azithromycin– Relapse: 2-3 weeks
after treatment
Typhoid Rash
Dengue Fever
Primary vector: Aedes mosquito Caused by one of four different
serotypes of Flavivirus Incubation period: 4-7 days Fever, severe myalgias, retro-orbital
pain Leukopenia and thrombocytopenia Dengue shock syndrome and dengue
hemorrhagic fever: second infection with a different serotype
Dengue Fever
Diffuse erythema or nonspecific maculopapular or petechial rash
No specific treatment – IV fluids
Primary preventive approach: mosquito repellent and screens
(NEJM 2002)
TravelersDiarrhea
Travelers DiarrheaTravelers Diarrhea Between 20%-50% international travelers
– Onset: usually first week of travel but may occur later
Most common agent: enterotoxigenic Escherichia coli (ETEC)
Primary source of infection: ingestion of fecally contaminated food or water.
Most important risk determinant: traveler's destination– Latin America, Africa, the Middle East, and Asia– High-risk: young adults, immunocompromised,
pts with inflammatory-bowel disease , diabetes, and persons taking H-2 blockers or antacids.
Travelers Diarrhea Prevention: food and liquid hygiene and
provision for prompt self-treatment in the event of illness – Hydration, loperamide (if no fever >38.5
degrees C & no gross blood or mucus in stool)– Short course (1 dose to 3 days) of a
fluoroquinolone, azithromycin or rifaximin Usually resolves in 3-5 days Antibiotic prophylaxis is not recommended
for most travelers
Prolonged Diarrhea
Greater than 2 weeks Less likely to isolate specific
organism More likely to be parasitic
– Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica, and Cyclospora cayetanensis most frequently identified
– detected in fewer than 1/3 travelers with chronic diarrhea and in only 1-5% travelers with acute diarrhea
Hepatitis A Virus
Transmitted through fecal contimination of food and drink
Treatment: supportive (no antivirals) Vaccination
– Should be immunized at least 2-4 weeks prior to traveling
– Single dose: 100% protection by 4 wks– 2nd dose administered 6 months later
results in antibody titers likely to last many decades
Rickettsial Diseases Tick transmitted,
occur throughout the world, typically named for geographic region– African tick bite
fever (sub-Saharan)– Meditterranean tick
bite fever (N. Africa and Middle East)
– Exception: RMSF
African tick typhus
(NEJM 2002)
Rickettsial Diseases
Headache, fever, myalgias and often a truncal maculopapular or vesicular rash
Clinical clue: eschar at site of bite Treatment: doxycycline, self-limited
Fungal Infections
Coccidioidomycosis: Southwest US, Mexico, and parts of South America
Histoplasmosis: Ohio River valley, Mexico, Central America
Penicillium marneffei: Southeast Asia, parts of China, Hong Kong, and Taiwan– Disseminated infection increasing in
immunocompromised patients (AIDS)
Scabies
Due to Sarcoptes scabiei infection Common in
– Developing world– Adventurous backpackers
Sexually active travelers are those most commonly infected
(Foot of a person who had recently visited the Caribbean)
(NEJM 2002)
Cutaneous Larva Migrans Most frequent serpiginous lesion among
travelers Results from migration of animal
hookworms (e.g., Ancylostoma braziliense and A. caninum) in superficial tissues
Usually acquired after direct skin contact with soil or sand contaminated with dog or cat feces
Lesions– may initially be papular or vesicular– Pruritic– commonly found on the foot or buttock
QUESTIONS
The End