TRAVEL MEDICINE BEFORE, DURING, and AFTER THE TRIP
LARRY M. BUSH, MD, FACP Affiliate Professor of Clinical Medicine Charles E. Schmidt College of Medicine Florida Atlantic University
Affiliate Associate Professor of Medicine University of Miami‐Miller School of Medicine Palm Beach County, Florida
U.S. Residents Traveling Abroad*
65
60
55
50
45 Number of TravelersNumber of (millions) 5 6 7 8 9 0 1 2 3 4 9 9 9 0 0 0 9 9 9 0 0 0 00 005 1 1 199 199 1 2 2 2 200 2 2 Year 3 *ITA, includes travel to Canada and Mexico TRAVEL EPIDEMIOLOGY TRAVEL EPIDEMIOLOGY
2015 – 1.2 BILLION INTERNATIONAL TOURIST ARRIVALS
2018 – ESTIMATED TO BE 2 BILLION
ASIA, MIDDLE EAST, ANDAFRICA TRAVEL INCREASING
14 DAYS – MEDIAN DURATION OF TRIP
22% WERE > 28 DAYS; 3% > 6 MONTHS
75% TO MALARIA AND 38% TO YELLOW FEVER ENDEMIC COUNTRIES
3% HAVE IMMUNE COMPROMISED CONDITIONS OR MEDICATIONS
ONLY 40 % SOUGHT OUT PRE-TRAVEL CLINIC CONSULTATION Average annual number of global airline passengers by decade, 1950-2010 Million of Passenger (Mil)
IATA 2010 Decade Commercial Air Traffic Over a 24 Hour Period The global air network Where Do U.S. Residents Travel?
Of the 17% who traveled outside the U.S. . . . 40
30
% 20
10
0 I da pe Z o an P ia ca n st a o /N ic rica p / s ri ea a n r us ex e a ia A f b E a Eu A M m J n er A ib le C A ea h ar d S c t C id r O O M o C
8 Source: HealthStyles Survey 2005
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, 2005 32004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, USDOC 13
Structured Approach to Medical Consultation before International Travel.
Freedman DO et al. N Engl J Med 2016;375:247-260. 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 16 TRAVEL FACTS
K” ”….NO MATTER HOW FAST I RUN I CAN’T SEEM TO GET AWAY FROM ME.
….NO MATTERmm WHERE I AM I’M ALWAYS ONE DAY AWAY FROM WHERE I WANT TO BE.”
Jackson Browne (‘The Pretender’)..’ The Patient: Medical Issues
• Age-specific issues • Underlying illness, immunosuppression • Systems review • Medical history • Medication use • Vaccination history • Allergies • Contraindications to vaccines and
medications 18 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 die Steffen R et al. J Infect Dis 1987; 156:84-91 19 Other Risks to the Traveler
• Accidental injury • Environmental hazards • Crime and assault • Psychiatric problems • Animal bites, stings and envenomations • Dermatologic disorders • Altitude • …….
ETC. 20 The Patient: Other Issues
• Reproductive – Pregnant – Breastfeeding – Preconception • Risk-taking behaviors
21 Travel Preparation • Travel health insurance – Medical care – Hospitalization – Evacuation
• Obtaining medical care abroad
• Awareness of travel notices
• Hand washing and hygiene 22
Immunizations to Consider for Adult Travelers
Routine Travel related Diphtheria* Hepatitis A Tetanus* Hepatitis B Pertussis* Typhoid Measles + Rabies Mumps+ Meningococcal disease Rubella + Polio Varicella Japanese encephalitis Pneumococcus Yellow Fever Influenza * Td or Tdap 24 + MMR
THE PREGNANT TRAVELER What do we advise pregnant travelers? Travel medicine and Pregnancy Mezger N et al. Travelling when pregnant. Rev Med Suisse. 2005; 11: 1263-1266. (in French)
Travel during the 2nd trimester
Favor comfortable type of travel, without long air or road transportation
Avoid traveling if at risk pregnancy
Check for adequate insurance coverage
Choose destination where good health services exist
Avoid region of high malaria endemicity
For any vaccination or medication risks and benefits should be carefully weighed, pregnant women are more vulnerable and at higher risk of complications “Pregnancy should not deter a women from receiving vaccines that are safe and will protect her health and that of her child.”
SAFTEY HAS NOT BEEN DETERMINED FOR MANY, OTHERS CONTRAINDICATED WHO, 2005 op cit 32 Bring a color copy of your passport. Label the outside of your passport with your passport number The Risk Landscape
The World We Live In... Coups Natural Disasters Insurgency Opportunistic Crime Piracy Terrorism Kidnapping Lawlessness War Civil Unrest Medical Illness Hijacking Threats Extreme Weather Typhoid Fever Imprisonment Dengue Travel-related infections Air Quality Hepatitis Language and cultural barriers Airline Catastrophes Vehicle Accidents Immigration & Visas Rural Isolation Deaths Related to International Travel
Cardiovascular Medical Injury Homicide/Suicide Infectious Disease Other N = 2463
Hargarten S et al, Ann Emerg Med, 1991. 20:622-626 35 Injury Deaths and International Travel
Motor Vechicle Drowning Air Crash Homicide/Suicide
Poisoning Other N = 601
Hargarten S et al, Ann Emerg Med, 1991. 20:622-626 36
What health risks are associated with air travel?
Epidemiology of DVT from Air Travel Risk Factors for DVT • Increasing Age (above 40 years) • Pregnancy • Previous or Family history of DVT • Clotting disorders • Recent major surgery • Estrogen hormone therapy & OCs • Immobility •Gender
Economy Class Syndrome?? DVT and Long Haul Travel • Increasing Age • Increasing Duration of Travel • Immobility • Seating Constraints and Posture • Cabin Environment (low humidity) • Excessive alcohol and/or caffeine • Obesity? •Height? Changing Demographics of Air Travel
• Aircraft seats designed for persons who average 5’7’’ and 170 lbs. • More vulnerable passengers are now able to fly from an economic perspective • Projected increase in air travel Airline Seat Pitch
80 70 60 50 40 inches 30 20 10 0 First Business Economy Skytrax Airline Seat pitch Air France 31 British Airways 31 American Airlines 33 Lufthansa 31 Northwest/KLM 31 Swissair 32 United 31 Travel as a risk factor for venous thromboembolic disease VTED Control p-value
Age (years) 65.3 66.0 n.s. Hypertension (%) 11.8 18.1 n.s Sex (% male) 51.8 66.2 0.04 VTED history (%) 11.8 4.4 0.02 Obesity (%) 33.7 20.0 0.01 Recent travel (%) 24.4 7.5 <0.001
Ferrari 1999 Travel and risk of venous thrombosis
Odds Cases Controls Ratio
Plane Travel 4% 13% 1.0 (0.3 - 1.4)
Kraaijenhagen 2000 The information reviewed suggests that .. • The short-term and long-term health hazards of air travel are of interest • There is little scientific evidence to quantify the association between air travel and DVT • There is inconsistent evidence of a link between cancer and cosmic radiation …AND TRAVEL 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 58 VECTOR Vector Precautions
• Covering exposed skin • Insect repellent containing DEET 30 – 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
MOSQUITO RELATED INFECTIONS
MALARIA‐ENDEMIC ‐‐‐ WESTERN HEMISPHERE MALARIA‐ENDEMIC ‐‐‐EASTERN HEMISPHERE
Pregnancy and malaria
WHO. International Travel and Health. Geneva: WHO, 2005.
“Travel to malaria- endemic areas should be avoided during pregnancy, if at all possible”
“…or intend to get pregnant” (McGready et al, 2004)
Why? Pregnancy and malaria
Chemoprophylaxis Recommended options for chloroquine resistant areas
Mefloquine Doxycycline Malarone 250mg weekly 100mg daily 250mg/100mg daily 2nd/3rd trimester (from 2000)
Alternatives include: − chloroquine 300mg weekly + proguanil 200mg daily
− Sulfadoxine-Pyrimethamine
DENGUE FEVER
• Over 40% of the world's population at risk from dengue. • WHO currently estimates may be 50–100 million dengue infections worldwide every year. • Before 1970, only nine countries had experienced severe dengue epidemics. • The disease is now endemic in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, South-east Asia and the Western Pacific. The American, South-east Asia and the Western Pacific regions are the most seriously affected. • Cases across the Americas, South-east Asia and Western Pacific have exceeded 1.2 million cases in 2008 and over 2.3 million in 2010. • In 2010, 1.6 million cases of dengue were reported in the Americas alone, of which 49,000 cases were severe dengue.
http://www.who.int/mediacentre/factsheets/fs117/en/index.html
Chikungunya fever
“Chikungunya”: derived from local language in Tanzania – “that which bends up” or “stooped walk”
YELLOW FEVER VACCINE RECOMMENDED - AMERICAS YELLOW FEVER VACCINE RECOMMENDED - AFRICA
JAPANESE ENCEPHALITIS ‐‐‐‐ RISK Japanese Encephalitis Vaccine
• Inactivated vaccine • Efficacy = 91% • Booster every 3 years • Not approved for children under 3 years • Side effects – Local reaction (10-25%) – Fever (10-25%) – Hypersensitivity reaction (0.6%) • Indications – Expatriates living in Asia – Travel to endemic regions for >30 days during transmission season, especially travel to rural areas
Travel related Tick-Borne Diseases
Tick Borne Relapsing Israel, Africa, South Every 3-5 days fever Fever Asia episodes
African TBF Southern Africa Fever, h/a ,eschars
Mediterranean Spotted Mediterranean , South Similar to African TBF, fever Asia, E&S Africa more severe
TBE Central and E Europe Fever, Meningo- encephalitis
Lyme Borreliosis Europe Rash, 7th nerve palsy, aseptic meningitis
RABIES
ANTHRAX 9NOT JUST RELATED TO BIOTERRORISM
CCUTANEOUS HUMA H HUMAN – TO – HUMAN SPREAD DISEASES
RESPIRATORY
DIRECT CONTACT
BLOOD BORNE
SEXUALLY
VERTICALLY (MOTHER - TO - FETUS)
FLU: Everyone 6 months & older needs flu vaccine every year NEISSERIA MENINGITIDIS Gangrene Caused by N meningitidis Infection
Courtesy of R Rudoy, MD, Honolulu, Hawaii, USA Ecchymoses
Courtesy of R Rudoy, MD, Honolulu, Hawaii, USA
MENINGOCOCCAL VACCINATION – ADULTS 2019
MenACWY – MENACTRA® or MENVEO® (Conjugated Vaccine)
2-Dose Series, >8-weeks apart, REVACCINATE q-5 years
Special Situations – Anatomic or Functional Asplenia HIV, Complement Deficiency, Eculizumab use
------1-Dose, (revaccinate if q-5 years if risk remains)
TRAVEL to Countries with HYPERENDEMIC or EPIDEMIC disease
FIRST year COLLEGE STUDENTS living in RESIDENTIAL HOUSING (NOT previously vaccinated)
MILITARY RECRUITS
The Meningococcal Meningitis Belt
GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION
HEPATITS ‘A’ and PRE-TRAVEL IMMUNE GLOBULIN
NEW RECOMMENDATION:
ONLY CONSIDERED IN ADDITION TO VACCINATION IF:
• TRAVEL IN <2-WEEKS TIME:
• ADULTS >40-YEARS • IMMUNOCOMPROMISED PERSONS • INDIVIDUALS WITH CHRONIC LIVER DISEASE • OTHER CHRONIC MEDICAL CONDITIONS
• AND …RISK OF EXPOSURE AND HAV-ASSOCIATED COMPLICATIONS ;
Hepatitis B In the World
• 2 billion people have been infected (1 out of 3 people). • 400 million people are chronically infected. • 10-30 million will become infected each year. • An estimated 1 million people die each year from hepatitis B and its complications. • Approximately 2 people die each minute from hepatitis B.
MEASLES : RUBEOLA : SARAMPION : MORBILLI : “FIRST DISEASE”
Classic Macular-Papular Rash – Face and Trunk C
Coryza, Conjunctivitis and Cough Koplick Spots
Travelers Diarrhea
Travelers 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.
Causes of Traveler’s Diarrhea
Cause Percent Isolation
Bacteria 50-75
Escherichia coli 5-70 Enterotoxigenic 5-70 Enteroadhesive ? Enteroinvasive ? Campylobacter spp. 0-30
Salmonella spp. 0-15
Shigella 0-15
Aeromonas 0-10
Plesiomonas 0-5
Other 0-5 Causes of Traveler’s Diarrhea
Cause Percent Isolation Protozao 0-5 Giardia lamblia 0-5 Entamoeba histolytica 0-5 Cryptosporidium ssp. ? Cyclospora cayetanensis ?
Viruses 0-20 Rotavirus 0-20 Enterovirus ?
No pathogen isolated 10-40 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 Relative Risk of Chronic Enteropathogenic Infections Acquired during Travel Abroad.
Ross AG et al. N Engl J Med 2013;368:1817-1825. Food and Water Precautions
• Bottled water • Selection of foods – well-cooked and hot • Avoidance of – salads, raw vegetables – unpasteurized dairy products – street vendors – ice
Food and Beverage Precautions
Boil it , peel it, cook it or FORGET IT !! FOOD POSIONING from MARINE TOXINS
Ciguatera - toxin from dinoflagellates ingested by reef herbivorous fish (baracuda, grouper, etc.). GI (n/v/d), Cardiac (bradycardia,bp, block) Neurologic (paresthesias, hold/cold). Scromboid - high Histamine level in fish (tuna, mackerel, mahi mahi). Acute Allergic Reaction syndrome. Parlaytic Shellfish Poisoning – saxitoxins (neurotoxins); mussels and clams. Mild (tingling) to severe (ataxia, dysphagia, flaccid paralysis, respiratory failure). Neurotoxic Shellfish Poisoning – brevetoxins, GI and Neurologic, Respiratory (can be inhaled with ‘red tide’). Diarrheic and Amnesic Shellfish Poisoning – 2 less common forms (mussels and scallops). ANTIBIOTIC PROPHYLAXIS IS GENERALLY NOT RECOMMENDED
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
CHOLERA……….
Cholera, is a Greek word, which means the gutter of the roof. It is caused by bacteria: Vibrio cholerae, which was discovered in 1883 by Robert Koch during a diarrheal outbreak in Egypt. 2010-2014: 91 CASES IN US TRAVELERS 75% FROM CARIBBEAN 2016: ORAL VACCINE (CVD 103-HgR) VAXCHORA ENDEMIC IN 50 COUNTIRES SINGLE DOSE > 18 YRS OLD Diseases in Returning Travelers
• Fever : Malaria, Dengue ,Typhoid, nonspecific
• Diarrhea : Giardiasis, Amebiasis, bacterial, non specific
• Dermatologic : Insect bites, CLM, allergic rashes
• Non diarrheal Intestinal disorders : Hepatitis, Strongyloidosis
N Engl J Med 2006; 354:119-130 Fever in the Returned Traveler Geosentinal sites study CID 2007 44: 1560-8 ( n=6957) • Malaria 21% • Acute Diarrheal Disease 15% • Respiratory Illness 14% • Dengue 6% • Salmonella Infections 2% • Tick borne Illness 2% • 3% had vaccine preventable illness ( Hep A, Typhoid Fever, Influenza ) Causes of imported fever by region
Africa Asia Americas
Malaria 35% Unknown etiology 19% Unknown etiology 33%
Unknown etiology 25% Respiratory 13% Respiratory 16%
Respiratory 10% Dengue 12% Dengue 9%
Bacterial enteritis 5% Malaria 11% Bacterial enteritis 9%
Rickettsial 4% Bacterial Enteritis 9%, Malaria 4 % Typhoid 3%
Bottieau et al Arch Int Med 166: 1642, 2005 Skin lesions in the returning traveler
Seabathers itch
Salt water exposure Jellyfish larvae release nematocysts, inject toxin Distribution matches areas covered by bathing suit, etc. Inflammatory papules, can become vesicular or pustular MYIASIS (Maggots of Tumbu Fly) Cutaneous Larva Migrans
Most frequently on lower extremities buttocks and anogenital region, trunk, and upper extremities less often Starts as pruritic papule and develops into elevated, serpiginous, reddish-brown lesions in 2-3 days 10% of cases vesiculobullous L
Loaisis (Loa Loa) Dirofilariasis
Mediterranean, but many parts of the world (US) Dog heartworm Can be transmitted to humans by mosquitoes Cutaneous or pulmonary syndrome CUTANEOUS LEISMANIASIS Death during travel
CONTACT THE US EMBASSY OR CONSULATE
DEATH CERTIFICATE ( IN ENGLISH) NEEDED UNLESS CREMATED
SPECIAL RULES IF DEATH FROM QUARANTINABLE COMMUNICABLE DISEASE
INSURANCE SOLD FOR PURPOSES OF TRANSPORTING BODY BACK TO USA
WHERE I LIVE…WHAT COULD BE NICER ?