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Travel Medicine and the Pre-Travel Consultation

Aaron ShelubAaronShelub @aaronshelubmd

Board Certified Internal MedicineBoard Certified Infectious Disease

Certified Yellow Fever Vaccine Provider

May 8th 2012CDC presentation for healthcare professionals

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Outline

• Travelers’ Health Epidemiology• Traveler Assessment• Itinerary Review• Sources of Information• Risks to the Traveler • Common diseases of concern• Travel Vaccines• Travel Medications • Counseling

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U.S. Residents Traveling Abroad*

*ITA, includes travel to Canada and Mexico*ITA, includes travel to Canada and Mexico

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Year

Nu

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International Travel

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1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

US

Res

iden

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n m

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Wor

ldw

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US nonresidentInbound (ITA)

US Resident AirOutbound (ITA)

All US ResidentOutbound (ITA)

Worldwide arrivals(WTO)

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Where Do U.S. Residents Travel?

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20

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Canada

Europe

Aus/NZ

Mexico

C or S A

merica

Japan

Oceania/ PI

Other Asia

Africa

Caribbean

Middle East

%

Source: HealthStyles Survey 2005

Of the 17% who traveled outside the U.S. . . .

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VFRs: Visiting Friends and Relatives

• Foreign-born increased 57% since 1990 from 19.8 million to 31.1 million1

• 20% of US population are first- or second-generation immigrants

• VFRs comprised ~46% of US international air travelers in 20043

1US Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000, issued Dec 2003 (Previous: US Census Bureau, Profile of the Born Outside the United States Population 2000, issues Dec 2003??? 2 Angell & Cetron, 200532004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, USDOC

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Travelers’ Health Risks

Of 100,000 travelers to a developing country for 1 month:– 50,000 will develop some health problem – 8,000 will see a physician– 5,000 will be confined to bed– 1,100 will be incapacitated in their work– 300 will be admitted to hospital– 50 will be air evacuated– 1 will dieSteffen R et al. J Infect Dis 1987; 156:84-91

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Estimated Incidence rate per month of infections and fatal accidents among travelers to developing countries

Yellow book page 12 2012 version

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Yellow book figure 1-2 Proportionate morbidity among ill travelers returning from the developing world according to region of travel.

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The Patient: Medical Issues

• Age-specific issues• Underlying illness,

immunosuppression• Systems review• Medical history• Medication use• Vaccination history• Allergies • Contraindications to vaccines and

medications

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The Patient: Other Issues

• Reproductive– Pregnant– Breastfeeding– Preconception

• Risk-taking behaviors

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Travel Itinerary• Full itinerary

– Dates, duration, stopovers– Seasonal considerations

• Styles of travel– Rural vs. urban– Budget vs. luxury

• Accommodation– Hotel vs. camping

• Activities– Business vs. tourism– Adventure, safari– Missionary/Humanitarian/NGO– -Sexual or Medical tourism

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Travel Health Resources

• CDC Travelers’ Health Website– www.cdc.gov/travel

• World Health Organization – www.who.int/int

• State Department – travel.state.gov

• International Society of Travel Medicine– www.istm.org

• Health Information for International Travel– CDC “Yellow Book”

• International Travel and Health– WHO “Green Book”

Travelers’ Health Websitewww.cdc.gov/travel

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Regional Destinations

• Region-specific pages• Goal to move to country-specific format

Travel Notices & Announcements

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Figure 2-01. Leading causes of injury death for US citizens in foreign countries, 2007–2009

Data from US Department of State. Death of US citizens abroad by non-natural causes. Washington, DC: US Department of State; 2010. Available from: http://travel.state.gov/law/family_issues/death/death_600.html .2Excludes deaths of US citizens fighting wars in Afghanistan or Iraq.

Table 2-12. Estimated traffic death rates in the 20 countries most frequently traveled by US residents

• Country reported # rate/100,000

• Mexico 22,103 20.7

• Thailand 12,492 19.6

• India 105,725 16.8

• China 96,611 16.5

• Greece 1,657 14.9

1Data from the US Department of Commerce. 2008 United States resident travel abroad. Washington, DC: US Department of Commerce; 2010. Available from: http://tinet.ita.doc.gov/outreachpages/download_data_table/2008_US_Travel_Abroad.pdf (PDF) and World Health Organization. Global Status Report on Road Safety: Time for Action. Geneva: WHO; 2009. Available from: http://whqlibdoc.who.int/publications/2009/9789241563840_eng.pdf . (PDF)2Deaths reported in the local population in 2007. For comparison, the number of reported traffic deaths in the United States was 42,642, with an estimated traffic death rate of 13.9 per 100,000

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Infectious Disease Risks to the Traveler

• Malaria• Diarrhea• Leishmaniasis• Rabies• Dengue• Meningococcal

Meningitis

• Schistosomiasis• Tuberculosis• Leptospirosis• Polio• Yellow Fever• Measles• JEV

ETC.

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Other Risks to the Traveler

• Accidental injury

• Environmental hazards

• Crime and assault

• Psychiatric problems

• Animal bites, stings and envenomations

• Dermatologic disorders

• Altitude

• …….ETC.

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Case presentation

• 38 yo male with no significant pmh returns from Mexico with fever 101.3, fatigue and muscle aches.

• He was camping outside and on a “vision quest”

• Labs reveal wbc 2.4 and mild anemia

• Feels better with IVF

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Dx?

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Probable Dengue Fever

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Dengue Fever Risk Areas

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Dengue Fever• positive-strand RNA viruses of the genus

Flavivirus, family Flaviviridae

• bite of an infected Aedes aegypti mosquito

• World Health Organization (WHO) estimates that 50 million cases of dengue occur every year,

• Infection rates (based on serology) among febrile travelers returning from dengue-endemic areas in the tropics are 3%–8%

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Dengue Fever Clinical Presentation

• travel tropics and subtropics 2 weeks before symptom onset

• acute febrile illness with 2 or more of the following: headache, retroorbital pain, muscle aches, joint pain, rash, hemorrhagic manifestation, or leukopenia.

• Dengue shock syndrome (DSS) is defined as a syndrome in a patient who meets the criteria for DHF and has hypotension, narrow pulse pressure (≤20 mm Hg), or frank shock.

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Dengue Fever dx and Rx

• Dx: serologic testing for IgM anti-DENV.

• Rx: Supportive care

• DHF/DSS: abrupt change from fever to hypothermia, severe abdominal pain, persistent vomiting, bleeding, difficulties breathing, or altered mental status (such as irritability, confusion, lethargy)- IVF

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Dengue Fever Prevention

• being bitten highest during the early morning,

• several hours after daybreak,

• late afternoon before sunset.

• insecticides to get rid of mosquitoes

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Immunizations to Consider for Adult Travelers

Routine

Diphtheria*

Tetanus*

Pertussis*

Measles +

Mumps+

Rubella +

Varicella

Pneumococcus

Influenza

Travel related

Hepatitis A

Hepatitis B

Typhoid

Rabies

Meningococcal disease

Polio

Japanese encephalitis

Yellow Fever

* Td or Tdap+ MMR

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Hepatitis A• Person to person contact, contaminated water, shellfish and

other foods

• Shed in feces

• Very common vaccine-preventable infection

• Rural areas, trekking, poor sanitation = highest risk

• Abrupt onset of fever, malaise, anorexia, nausea and abdominal discomfort then jaundice

• No treatment

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Hepatitis A cont.

• Prevention with vaccination

• Havrix 0,6,12 months

• Vaqta 0,6-18 months

• Twinrix 0,1,6 months

• Immune globulin 0.02 ml/kg 1-2 months

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Hepatitis B• Contact with blood, body fluids• Risk by prevalence • 90 days incubation, • Jaundice, nausea,vomiting,abdominal

pain• Progression to chronic Hep B 30-90%• No treatment• Vaccine preventative, 0,1,6 months• All unvaccinated people traveling to

areas int to high prevalence

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Typhoid fever• Acute life threatening

febrile illness

• Bacterium Salmonella enterica serotype Typhi

• Consumption of water or food contaminated by feces

• 22 million cases typhoid fever, 200,000 related deaths/ year

• Southern Asia travelers

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• Insidious fatigue,

• fever low high,

• HA, malaise,

• anorexia,

• hepatosplenomegaly,

• rose colored rash

Typhoid Fever Cont.

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Typhoid Fever cont.• Complications: intestinal hemorrhage or

perforation

• Clinical dx

• Rx: Empiric floroquinolone

• Vaccines:Oral live attenuated, Vi capsular polysacchride

vacc

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Yellow Fever

• Flavirus

• Vectorborne transmission

• Aedes or Haemagogus spp. Mosquito

• “Epidemiological silence” ≠ no risk

• Non-specific flu like illness, fever,chills, HA,myalgias,n/v

• 15%jaundice,hemorrhagic sx,shock multisystem failure, (case fatality hepatorenal 20-50%)

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Yellow Fever cont.

• Rx= supportive only

• Prevention: avoid mosquito bites, vaccinate (YF-Vax)

• Several countries require proof of vaccination from all arriving travelers or

• Travelers going through endemic countries.

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Malaria

• 1 0f 4 protozoan species genus Plasmodium

• Transmitted by Anopheles mosquito

• Major international public health problem

• 350 – 500 million infections worldwide, 1 million deaths annually.

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http://science.nationalgeographic.com/science/photos/malaria/#/malaria-parasites_1059_600x450.jpg

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Malaria Cont.

• fever and influenzalike symptoms,

• chills, headache, myalgias, and malaise;

• symptoms at intervals

• severe disease, seizures, mental confusion, kidney failure, acute respiratory disease syndrome (ARDS), coma, and death may occur.

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Malaria cont.

• P. falciparum = medical emergency,

• clinical deterioration can occur rapidly and unpredictably.

• consider malaria: patient with a febrile illness who has recently returned from a malaria-endemic country.

• Smear microscopy = gold standard for malaria diagnosis.

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Malaria Cont.

• seek medical evaluation as soon as possible

• CDC Malaria Hotline (770-488-7788 or toll-free at 1-855-856-4713) from 9:00 am to 5:00 pm Eastern Time

• Atovaquone-proguanil

• .Artemether-lumefantrine

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Malaria cont. Prophylaxis:Mosquito avoidance

Chemoprophylaxis:Atovaquone-

proguanil

Doxycycline

Others- side effect issues

http://science.nationalgeographic.com/science/photos/malaria/#/mosquito-nets_1104_600x450.jpg

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Travelers’ Diarrhea

• 30% to 70% of travelers• “boil it, peel, it, or forget it,”

traditional• Bacterial pathogens

predominant risk • most common pathogen is

enterotoxigenic Escherichia coli

• High-risk areas include most of Asia, the Middle East, Africa, Mexico, and Central and South America.

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Travelers Diarrhea risk factors

• bouts of TD do not appear to protect against future attacks

• environments where large numbers of people do not have access to plumbing or outhouses, the amount of stool contamination in the environment will be higher and more accessible to flies

• poorly functioning refrigeration, which can result in unsafe food storage and

an increased risk for disease.

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Travelers diarrhea Sx’s and prevention• sudden onset mild cramps and urgent loose stools severe

abdominal pain, fever, vomiting, and bloody diarrhea.

• alcohol-based hand cleaners (containing at least 60% alcohol) may make it easier for travelers to clean their hands before eating.

• freshly cooked and served piping hot are safer than foods that may have been sitting for some time in the kitchen or in a buffet.

• avoid beverages diluted with nonpotable water (reconstituted fruit juices, ice, and milk)

• prevention = bismuth subsalicylate (BSS), Pepto-Bismol •

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Travelers Diarrhea prevention and Rx

• Lactobacillus GG and Saccharomyces boulardii, = Results are inconclusive,

• Prophylactic abx = discouraged

• Rx:

ciprofloxacin or levofloxacin, azitrhomycin

Antimotility agents

Oral Rehydration Therapy

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Travel Medications:Prophylaxis & Self Treatment

• Malaria– chloroquine, atovaquone/proguanil (Malarone),

doxycycline, mefloquine (Lariam), primaquine

• Diarrhea– quinolone, azithromycin

• Altitude– acetazolamide

• Motion sickness– scopolamine, dimenhydrinate (Dramamine)

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Patient Counseling

• Sufficient time for patient education

• Tailored to suit traveler

• Fitness for travel– Understanding impact on existing

conditions– Advisability of destinations

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Travel Preparation

• Travel health insurance– Medical care– Hospitalization– Evacuation

• Obtaining medical care abroad

• Awareness of travel notices

• Hand washing and hygiene

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Environmental Precautions• Air Travel• Jet Lag• Sun Protection• Extreme Heat and Cold

– dehydration, heat stroke– hypothermia, frostbite

• Altitude• Water recreation

– Drowning, boating & diving accidents– Risk of schistosomiasis or leptospirosis– Biological and chemical contamination

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Food and Water Precautions

• Bottled water

• Selection of foods– well-cooked and hot

• Avoidance of – salads, raw vegetables– unpasteurized dairy products– street vendors– ice

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Vector Precautions

• Covering exposed skin• Insect repellent containing DEET 25 – 50%• Treatment of outer clothing with permethrin• Use of permethrin-impregnated bed net• Use of insect screens over open windows• Air conditioned rooms • Use of aerosol insecticide indoors• Use of pyrethroid coils outdoors• Inspection for ticks

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Bloodborne and STD Precautions

• Prevalence of– STDs – Hepatitis B– Hepatitis C– HIV

• Unprotected sexual activity• Commercial sex workers• Tattooing and body piercing• Auto accidents • Blood products• Dental and surgical procedures

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Animal Precautions

• Animal avoidance• Rabies

– Specific animal threats– Medical evaluation of bites/scratches– Post exposure immunization and

immunoglobulin

• Envenomations– Snakes, scorpions, spiders– Maritime animals

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Injury and Crime• Vehicles

– Risk of road and pedestrian accidents– Night travel– Seat belts and car seats

• Use of drugs and alcohol

• Understanding local crime risks– Scam awareness– Situational awareness– Location avoidance

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Travel Emergency Kit

• Copy of medical records and extra pair of glasses• Prescription medications• Over-the counter medicines and supplies

– Analgesics– Decongestant, cold medicine, cough suppressant– Antibiotic/antifungal/hydrocortisone creams – Pepto-Bismol tablets, antacid– Band-Aids, gauze bandages, tape, Ace wraps– Insect repellant, sunscreen, lip balm– Tweezers, scissors, thermometer

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Post-Travel Care

• Post-travel checkup– Long term travelers– Adventure travelers– Expatriates in developing world

• Post-travel care– Fever, chills, sweats– Persistent diarrhea– Weight loss

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Questions?

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Other Resources

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Journals

• American Journal of Tropical Medicine and Hygiene

• Bulletin of the World Health Organization• Emerging Infectious Diseases Journal• Eurosurveillance Weekly • Journal of Travel Medicine• Morbidity and Mortality Weekly Report• Tropical Medicine and International Health• Vaccine

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Books

• Textbook of Travel Medicine and Health, 2nd Ed.– DuPont, H.L. and Steffen R. (editors)

• The Travel and Tropical Medicine Manual, 3rd Ed.– Jong, E.C., McMullen, R.

• Travel Medicine– Keystone, J.S., Kozarsky, P.E., et al

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Websites

Eurosurveillancewww.eurosurveillance.org

Travax EnCompasswww.travax.com

GIDEONwww.gideononline.com

International SOSwww.internationalsos.com

Medical Advisory Service for Travelers Abroad (MASTA)http://www.masta.org/

Armed Forces Medical Intelligence Centerwww.afmic.detrick.army.mil/

Central Intelligence Agencywww.cia.gov/cia/publications/factbook/

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Travel Insurance sites• Department of State (www.travel.state.gov )

• International SOS(www.internationalsos.com)

• MEDEX (www.medexassist.com )

• International Association for Medical Assistance to Travelers (www.iamat.org )

• American Association of Retired Persons (www.aarp.org )

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Aaron Shelub MD

• Aaron Shelub @aaronshelubmd

• https://twitter.com/#!/aaronshelubmd

• http://www.zocdoc.com/doctor/aaron-shelub-md-30618

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End

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Picture of diseases from vacc shop