Travel Medicine It’S More Than Just " I'm Taking a Trip What Shots Do I Need?" Issues and Information Sources CT Academy of Family Physicians October 2015

General Principles of Travel Medicine It’s more than just " I'm taking a trip what shots do I need?" Issues and Information Sources CT Academy of Family Physicians October 2015

Kenneth R. Dardick, MD DTM&H Connecticut Travel Medicine Storrs, CT 1

Minority shareholder in Shoreland (Travax)® Chair, Examination Committee, ISTM

•Learn about the epidemiology and basic science of Travel Medicine •Learn how to identify destination-specific risks to the traveler •Learn how to find reliable travel health information on the internet

ISTM

The International Society of Travel Medicine Certificate of Knowledge (CTH®) is a symbol of achievement in the field of travel medicine. As the first international certificate devoted solely to travel health, it recognizes professionals who have demonstrated expertise in the unique body of knowledge associated with the practice of travel medicine

11th APTHC Asia Pacific Travel Health Conference Kathmandu, Nepal 2-5 March 2016

6th Northern European Conference on Travel Medicine London 1-4 June 2016 10

• 1 billion+ international travel 2012 (WTO 2013) • 60 million Americans 2012 (ITA 2013) • 8-10 million Americans to underdeveloped areas • 22 million Americans visit malarious areas (200,000 to areas of high risk)

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Health issues for travelers are common • Overall 20% develop illness while abroad • 50% of travelers to tropics become ill • only 0.2-0.5% require hospitalization

Reid and Cossar, Brit Med Bull 1993

Here I’ll discuss a few recent cases to illustrate that all of us in Primary Care deal with travel health issues whether we realize it or not.

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Vignettes -1 • 60 yo priest from New London on a mission to Haiti fell walking on a rocky path - tri-malleolar fracture; carried down the hillside on a door to the clinic. • 55 yo Biologist studying moths in deepest Amazon developed Bell’s palsy (hint: he carried it in with him) • 20 yo student from Mansfield attending college in Scotland will spend her junior year “traveling all over” • 59 yo woman seen with “fever, body aches, stomach pain” just returned from 10 days in Peru. (see next slide for the answer which showed up 2 days later!)

14 15 Vignettes - 2 • 15 yo boy, fever 102, myalgias, pleuritic pain, just returned from Tanzania, Zanzibar; game parks. Was in the office 2 days earlier for his HPV vaccine, never mentioned the illness (STAT malaria smears neg, probably viral; cleared with no active treatment) • 15 yo boy, brought by his mother to “check his chest congestion” and “by the way he’s leaving at 6am tomorrow for London, England” (reviewed management of asthma – maint. and rescue inhaler use)

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Vignettes – 3 ● 61 yo male, h/o melanoma, prostate cancer, hypertension; presents with sudden onset leg and posterior calf pain, leaving in 4 days for a trip to Thailand (venous doppler neg) ● 66 yo male, Wellness Visit – at the end of the visit, “oh, by the way I’m leaving for Costa Rica in two weeks, may have malaria exposure” (was given Hep A, typhoid vaccine, returned for malaria and general travel counseling)

•Many travelers leave on short notice – 25% leave < 2 wks after decision to travel •25% do not know the language at their destination •33% have no knowledge of local customs

From a survey of travelers by Norwich Union 2004

Region General Information Travel Health Information Europe (5500) 73% 52%

Africa -Johannesburg (219) 79% 86%

US – JFK (404) 62% 36%

Australasia (2100) 60% 32%

Journal of Travel Medicine, Jan-Feb 2004 19

Region GP Travel Med. Travel Agent Specialist Europe (5500) 57% 35% 30%

Africa -Johannesburg (219) 23% 25% 11%

US – JFK (404) 60% 10%

Australasia (2100) 73% 12% 25%

Journal of Travel Medicine, Jan-Feb 2004 20

Region Malaria Prophylaxis Europe (5500) 47%

Africa -Johannesburg (219) 74%

US – JFK (404) 41%

Australasia (2100) 40%

Journal of Travel Medicine, Jan-Feb 2004 21

©2015 Kenneth Dardick MD/Connecticut Travel Medicine 1978 “…many travel personnel lax about warning against risk of malaria…” Rolfe E CMAJ 1978 1990 “…the travel agent was most frequently consulted for advice and these 133 travellers (22%) reported the least illness.” Cossar JH,Reid D,Fallon RJ et al: Journal of Infection 1990

©2015 Kenneth Dardick MD/Connecticut Travel Medicine But times change… 2012 “…the personal computer/Internet continued to be the primary means of booking the trip (40 percent) vs. 29 percent for travel agents”

US Dept of Commerce ITA 2012

“Malaria prevention information on online travel operator websites is most often absent or inadequate. Even on websites where such information is of good quality, it can be difficult to access”

Bazaz, Green and Green 2010

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Are we giving accurate advice: PCP’s do a poor job US primary care physicians: <20% accurate malaria advice < 4% accurate immunization advice common errors: • advising unneeded malaria prevention • unnecessary shots • ignoring special health risks J Travel Medicine, June 1994, Keystone et al 28

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Are we giving accurate advice: Travel Clinics a bit better US Travel Clinics • 62-84% gave accurate malaria advice • 25-46% gave accurate immunization advice common errors: • advising unneeded malaria prevention • unnecessary shots • ignoring special health risks

J Travel Medicine, June 1994, Keystone et al

Pharmacists in a university travel clinic provided better advice than non- specialty trained PCPs in a student health clinic

Pharmacists PCP • Antibiotics ordered consistent with guidelines: 96% 50% • Antibiotics not ordered when not recommended: 3% 21% • Antimalarials not ordered when indicated: 1%

15% Durham, Goad, Neinstein and Lou; Journal of Travel Medicine 2010 30

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Trained Nurses Provide Quality Pre-travel Advice Travel clinics affilliated with the University of Utah Staffed by RN or LPN 64% see > 10 travel patients per week Rigorous curriculum and CME Chart review – 0.5% errors required contacting the traveler for correction

Sofarelli, Ricks, Anand, Hale; Journal of Travel Medicine, 2011

Hill, Ericsson, Pearson et al; Clinical Infectious Diseases, 2006; The Practice of Travel Medicine: Guidelines by the Infectious Diseases Society of America

• Pre-travel • During travel • Post-travel

1. General issues for any travel 2. Discussion of hygiene and sanitation issues 3. Specific advice for each country 4. Personal issues for individual health problems

• Increased rate for travelers • Increased morbidity/mortality compared to accdents at home

• Check for coverage outside the U.S. (e.g. Medicare is not valid) • Medical Assistance/Evacuation coverage is about $1-$2 per person per day

• Carry by hand, do not check with luggage • Prepare a list of generic/trade names • Carry in original pharmacy bottles • Prepare a letter for those with needles/syringes • Extra glasses, lenses, copy of EKG

• Sea, air, land • Avoid neck/head motion • Avoid closed spaces, perfumes • Eat lightly

• Transderm-Scop (scopolamine) is best preventive – dry mouth is common, some drowsiness – not with BPH, glaucoma, <12 y.o. – wash hands after application • Antihistamines are effective – Diphenhydramine, dimenhydrinate, promethazine, meclizine

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Pre-Travel General Issues “Economy Class Syndrome” • Applies to ALL travelers – not just Economy Class • Most significant for flights 10-12 hours in the air • Wear 20-30mm compression stockings • Drink plenty of fluids • Walk around, stretch • Avoid alcohol, caffeine

• Elevation > 2500m to 3500m presents risk • Andes, Alps, Himalayas, Rockies • Factors: rate of ascent, sleeping altitude, predisposition • avoid dehydration • consider pre-medication • learn about AMS, HAPE, HACE syndromes 42

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Pre-Travel General Issues Extremes of Sun/Heat/Cold • Unconditioned, out-of-season traveler • SPF 15, re-apply after sweating, swimming • Oxybenzone to block UVA • Acclimatize, acclimatize, acclimatize

•Principle: Untreated sewage and animal waste may contaminate food and drink •Simple rule: “Cook it, Peel it, Boil it ...or forget it!”

Salsa in Guadalajara restaurants – what % is contaminated with E. coli?

Salsa in Guadalajara restaurants – what % is contaminated with E. coli? Answer: 66%

Adachi et al, Annals Int Med, 136:884-887

Now, the control group was restaurants in Houston. So, for $Big Buck$ and a trip to Guadalajara – what is the % of salsa in Houston restaurants which are contaminated with E. coli?

Now, the control group was restaurants in Houston. So, for $Big Buck$ and a trip to Guadalajara – what is the % of salsa in Houston restaurants which are contaminated with E. coli? And the answer is…..40%

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Hygiene / Sanitation - 6 Now, the control group was restaurants in Houston. So, for $Big Buck$ and a trip to Guadalajara – what is the % of salsa in Houston restaurants which are contaminated with E. coli? And the answer is…..40% - but at least in Houston the mean level of contamination was much lower: Guad: 3600-11,000 CFU/gm Hous: 2.5-7.5 CFU/gm Adachi et al, Annals Int Med, 136:884-887

• Business/Professional/Meetings • Visiting Friends and Relatives (VFR) • Trekker/Backpacker/Overland • Recreation

• Leave on short notice • Self-described “experts” • Only 60-80% as likely to use preventive measures against malaria (compared to tourists) • File more claims for infectious disease and psychiatric illness

• 10 million trips abroad 44% of total (not Canada or Mexico) • 45% of imported malaria is VFR • 40% of typhoid (vs 4% in tourists) • Hep A 8x tourists (UK)

Angell and Cetron, Annals Int Med 2005

Angell and Cetron, Annals Int Med 2005 56

• Immunizations • Insect-borne diseases • Water-borne diseases

Individualized based on: • Destination (business center vs 3rd world; ? Tropics) • Itinerary (4-star vs trekker) • Personal health history (illness, meds, allergies, age)

• Hepatitis A 3000/million travelers • Hepatitis B 800/million travelers • Typhoid 30/million travelers • Polio – asymptomatic20/million travelers – symptomatic 1/million travelers

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Country-specific Advice Immunizations • Few countries have “required”shots (usually only Yellow Fever) • Changes in requirements/recommendations are common • Up-to-date information can best be obtained electronically by subscription or on the Internet

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Country-specific Advice Immunizations • Primary sources – CDC: www.cdc.gov/travel – WHO: www.who.int/ith/en/ • Other secondary sources – ProMed-Mail: www.promedmail.org – GIDEON: www.gideononline.com – Travel Medicine, 3rd edition; Keystone et al

• Computer databases – Shoreland – Travel Care

• 300 million cases per year • 2 million deaths per year • Greatest risk is VFR (“visiting friends and relatives)

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Country-specific Advice Insect-borne Diseases Malaria • Preventive medications (1): – Doxycycline 100mg daily – start 1-2 days before, continue for 4 wks after leaving – Atovaquone/proguanil – daily – start 1-2 days before, continue for 1 wk after leaving – Mefloquine 250 mg weekly – start 1-2 wks before (or 3 day loading dose), continue for 4 weeks after leaving

• Preventive medications (2): • Chloroquine 500 mg weekly – start 1-2 wks before, continue for 4 wks after leaving (Mexico, Haiti, Central America, Middle East) • Primaquine (8 aminoquinoline - G6PD issue) – 15-30 mg daily, continue for 1 wk after leaving

• Long-sleeve shirts, long pants • Repellent with polymer-DEET or picaridin on the skin • 0.5% Permethrin on clothing, netting, tents – Combination DEET/permethrin reduces bites by 99.9% • Pyrethrin “knock-down” spray • …but nothing works all the time, so be familiar with symptoms of various syndromes (malaria, leishmaniasis, Lyme disease) 66

2013 – US Federal Court jury awards $41.7 million to a 15 year-old girl who contracted tickborne encephalitis in 2007 on a trip to China (Hotchkiss School). It was claimed that she was not warned about this disease and there was no provision to make sure she used repellent.

BUT - she was the very first case of TBE ever known in that area!

Since 1957 – 10 Billion uses 1961-2000 - 42 published cases •Cutaneous 12 (irritant bullous) •Allergic 5 (urticaria) •Ingestion 7 (3 deaths) •Encephalopathy 18 < 8yrs, 14 cases, 3 deaths, 11 resolved 27-41 yrs, 4 cases, all resolved EPA re-registered DEET in 1980 – estimate risk of 1/100 million (max), not oncogenic or teratogenic, not uniquely toxic to children 68

Interaction between DEET and sunscreen Alcohol in DEET interferes with sunscreen effectiveness – apply the DEET first, let the alcohol evaporate, then OK to apply the sunscreen

Comparison in the field (Black saltmarsh mosquitos in the Everglades) Mean complete protection times: DEET (5.6) Picaridin, KBR3023-Bayrepel (5.4) PMD – eucalyptus (3.8) IR3535-Skin-so-Soft BugGuard Plus (3.0)

Ethanol controls provided 0 percent repellency.

“Wait a minute! McCallister, you fool! This isn’t what I said to bring!” 70

Will the real Family(ies) please stand up? All contain DEET – Off Family which is best? Repel Sawyer Repel Cutter Families Family Family Family 71 ©2015 Kenneth Dardick MD/Connecticut Travel Medicine Country-specific Advice Insect-borne Diseases Avoiding bites….

My vote is Sawyer Family – sustained release, lasts the longest, lowest absorption

Sawyer Family 72 ©2015 Kenneth Dardick MD/Connecticut Travel Medicine Country-specific Advice Water-borne Disease • Traveler’s Diarrhea is most common • Parasitic diseases (rare in short-term travelers) – Giardia – Cyclospora – Cryptosporidia – Amoebiasis • Schistosomiasis (wading, swimming, watersports)

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Special considerations for certain travelers • Diabetes – Adjust insulin or oral agents on E/W, not N/S travel – Provide letter for those traveling with needles – Proper care of insulin (?refrigeration) – Power requirements and replacement supplies for blood glucose meters

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Special considerations for certain travelers • Ulcer/gastritis – H2 blockers and proton pump inhibitors reduce acidity and increase risk of enteric infections • Pregnancy – No sulfa, quinolones or tetracyclines – Problems with some anti-malarials • Children – Problems with palatability of anti-malarials – No quinolones or tetracyclines

• Completed chemotherapy 3 months ago • Low-dose or alternate day corticosteroid therapy • Topical steroids (unless prolonged/extensive use) • Intra-articular steroids • Antibiotic therapy • Low-grade febrile illness or mild URI 76

• Travel in this group is very common •36% travelled outside Canada or US •48% of trips were to the tropics •44% were visiting friends or relatives (VFR) • A large number (86%) were taking 2 or more immunosuppressive drugs J Travel Med (2004 Jan-Feb) 11(1):37-43 , Boggild et al

Many received pre-travel advice (66%), but it was usually from transplant specialists (78%) and the advice was of very poor quality

J Travel Med (2004 Jan-Feb) 11(1):37-43 , Boggild et al

• 63% traveled to areas endemic for Hepatitis A, but only 5% received Hepatitis A immunization • 50% traveled to areas endemic for malaria and dengue but <25% used Personal Protective Measures (repellents, nets) • <20% carried medication for treatment of travelers’ diarrhea 79

• Many became ill – 17% • 10% engaged in risky behaviors – injections for medical treatment, body piercing, casual sex – 50% without using condoms

•Review health information •Give traveler printed information •Focus on behavioral issues •Review guidelines for signs and symptoms that should prompt medical attention while traveling and on return, especially for those visiting malarious areas.

•Information •Immunizations •Immediate availability

• Location of the Office • Appointments • Use of Space • Finances • Billing • Practice Identity • Health Information for • Staff Travelers • Advertising • Professional Societies – Direct • Certification – Soft • Supplies/Equipment • Hours Open • Resources

Certification ● ISTM (CTH, CPD) ○ Upcoming CTH® Examinations ■ 2 March 2016 in Kathmandu, Nepal ■ 1 June 2016 in London, England, UK ● ASTMH

©2015 Kenneth Dardick MD/Connecticut Travel Medicine Important Internet Resources for Travel Health Information www.asma.org (Aerospace Medical Association) www.astmh.org (American Society of Tropical Medicine and Hygiene) www.cdc.gov/travel (CDC) www.gideononline.com (Global Infectious Disease and Epidemiology Online Network) www.istm.org (International Society of Travel Medicine) www.travax.com (Shoreland – paid subscription) www.who.int/ith (WHO)