TRAVEL 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 to Canada and Mexico TRAVEL 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 AND 38% TO 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 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 – vs. camping • Activities – Business vs. tourism – Adventure, – 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, • Systems review • Medical history • Medication use • Vaccination history • • Contraindications to 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 – 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 • 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 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 . 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 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 ?

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 • Estrogen hormone & 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 • 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 resistant areas

Mefloquine Malarone 250mg weekly 100mg daily 250mg/100mg daily 2nd/3rd trimester (from 2000)

Alternatives include: − chloroquine 300mg weekly + 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 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 • – 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

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

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, , 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 • 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 ?