Travel Medicine Update
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Travel Medicine Update Joan Ingram ADHB and Auckland Travel Medicine Service (94 Remuera Road, 5240830) Outline • Outbreaks – Chickungunya/ Americas – Zika – Dengue – Pacific Outbreaks – Ebola – MERS – Measles – Antibiotic resistance • Good Pretravel Care Chickungunya • Alpha virus spread by A.aegypti and A.albopictus • Recent outbreaks in Africa, SE Asia and around the Indian Ocean islands then India(2005), New Caledonia ( 2011) and PNG (2012) • Current outbreaks in Tonga, American Samoa, Samoa, Caribbean and Americas • Travellers have taken home and caused outbreaks in Italy, France and Croatia • In a Dutch study 1 Chickugunya case for every 4 dengue Chickungunya • Acute febrile illness- fever, headache, rash and moderate to severe arthralgia- bilateral symmetric • Resolves in 7 to 10 days • Persistent joint pain and tenosynovitis which can be disabling and continue for up to 12 months • Severe or atypical disease in neonates, elderly, those with underlying medical conditions • Mortality <1% Chickungunya • Lymphopenia common • PCR to diagnose early • Rest, analgesics Chickungunya in Americas • First report of local transmission of Chickungunya in the Americas when in December 2013 the WHO reported local transmission in Saint Martin • Since then 850,000 cases have been reported from all Caribbean countries apart from Cuba and Brazil, El Salvador, Costa Rica, Panama, Venezuela, Colombia, Guatemala, Guyana, Suriname and French Guiana in the Americas 31 countries or territories but greatest numbers in Dominican Republic, Martinique, Guadeloupe, Haiti, and El Salvador Up to 30% of population may become infected Zika virus • Flavivirus related to yellow fever and dengue • Isolated from a sick rhesus monkey from Uganda in 1947 • Subsequent serological studies showed it in numerous African countries and Asia but outbreaks unnoticed • Outbreak on Yap Island in Federated States of Micronesia in 2007- attack rate 15/1,000 but estimated 73% of population seropositive Zika Virus • December 2013 French Polynesia especially Tahiti and Moorea- thousands of cases • March- New Caledonia 1,400 cases • Cook Islands- over 900 cases • Over 45 cases diagnosed in New Zealand since March • Fever , headache , nonpurulent conjunctivitis arthralgia and convalescent maculopapular rash • Symptoms 3- 5 days- “mild dengue” Zika in French polynesia • Although disease is usually mild during the outbreak in French Polynesia there was a 10 fold increase in Guillian Barre with 40 cases in three months instead of the usual 5 • Possibly associated with the concurrent dengue out break Dengue is increasing dramatically • Day time biting mosquito • Particularly in urban areas • Vaccine now in phase 3 trials • NS1 test positive early in illness NZ 2012 Notifiable Disease Report Outbreaks in the Pacific Great website • www.spc.int/phd/epidemics/ • Shows epidemics by country, if increasing or decreasing • In Pacific typically a single serotype of dengue circulates at a time for 4 or 5 years before being replaced by another one • E.g. dengue 3 had not circulated since 1996 but was reintroduced in 2013 • Dengue 3 outbreaks this year- Fiji >25,000 cases (15 deaths), Solomon Islands 1,800 cases, French Polynesia >2,000 cases • Dengue also in Vanuatu, Tuvalu, Tonga, Nauru Pacific Arboviral Outbreaks • All 3 are notifiable • All 3 have short incubation periods – 2-4 days and usually less than 1 week • viremia for < 5 days and clears when fever settles • PCR in first 5 days then serology • Send samples with full travel history • Dengue- 176 notifications in past 12 mo (cf 90) • Chickungunya- 12 notifications in past 12 mo (cf 0) • Zika- 45 notifications predominantly from Cook Is Ebola Virus disease Filovirus – single stranded RNA virus Pleomorphic filaments First identified in 1976 Since then sporadic outbreaks S K Gire et al. Science 2014;345:1369-1372 Published by AAAS Started in February in Gueckedou Guinea then to Conakry S K Gire et al. Science 2014;345:1369-1372 Published by AAAS Severe haemorrhagic fever Figure 3 Source: The Lancet Infectious Diseases 2004; 4:487-498 (DOI:10.1016/S1473-3099(04)01103-X) Terms and Conditions Management • Isolation and strict barrier nursing – If someone calls in get their contact details and tell them someone will call them back – Call Medical Officer of Health who will arrange transport to hospital – If some one presents put them in a separate room, don’t examine them, call Medical Officer of Health • Exclude other diagnoses • Intensive and supportive care • No proven treatment or post exposure prophylaxis Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) • June 2012 in Jeddah a patient had severe respiratory distress and renal failure- virus grown- 6th human coronavirus • Now 855 cases with 333 deaths (CFR 40%) • 723 of then in Saudi Arabia, 73 in UAE • 59 in 20 other countries • Males and older, underlying illnesses • Nosocomial transmission- 25 % HCWs • No evidence of sustained person to person transmission in the community • Most cases have visited a health care facility or have come in contact with camels or raw camel products while in Saudi Arabia • Hajj - elderly or those with chronic disease have been asked to not go this year Measles Outbreaks • PNG, Federated States of Micronesia and Solomon Islands • Philippines- >40,000 suspected and 37,000 confirmed • Think of it in returning febrile patients with rash • Ensure travellers have been vaccinated Antibiotic resistance is linked to travel NDM-1 resistance element distributed among a variety of bacteria in samples of drinking water and seepage samples around New Delhi Lancet Infectious Diseases 2011; 11: 355 Journal of Antimicrobial Chemotherapy Advance Access published May 14, 2013 • Swedish travellers – 262 enrolled – 2.4% were colonised before travel – 226 evaluable participants ESBL-PE from 68 (30%) after return • Travel to India subcontinent OR 24.8 • Asia excluding ISC OR 8.6 • Africa north of Equator OR 4.94 • Age > 65 years OR 7.38 • Diarrhoea during travel 2.4 • Other GI symptoms 2.99 • Another study 5/21 still carriers after 6 months Risks of various health problems during travel Some travellers are at higher risk • Those who return home to visit friends and relatives (VFRs) have significantly higher rates of malaria, typhoid, TB and STIs • Children particularly at risk eg Hepatitis A • If you have such patients in your practice try and give them preemptive pre-travel advice Good pre-travel care • Advice • Vaccinations • Prophylactic medication-malaria • Self treatment medication- TD, altitude 1. Advise and Discuss • Always • Sometimes – Insects – Immersion – Ingestions – Altitude – Indiscretions – Inhalation – Injury – Insurance – Injections – Immobility – Medication advice – Immigration Issues Insects • Spread many illnesses • DEET containing repellent – Remarkable safety profile – Down to 2 months of age • Permethrin impregnated nets • Vitamin B does not reduce bites • Pregnant women more attractive to mosquitoes Ingestions • No good evidence that care with oral intake reduces rates of traveller’s diarrhoea – CID 2005; 41: S531-5 • May reduce other food borne illnesses • Restaurant food more risky than that prepared in own kitchen • Alcohol hand wash makes good sense New Water Treatment • Chlorine dioxide – more potent than chlorine – minimal taste – effective against all water borne pathogens – Aqua Mira or Portable Aqua – Sensitive to sunlight Indiscretions • Travel increases the probability of casual sex • Travelling alone • HIV is global (40 million infected, most don’t know it) • Many STIs are more common in developing countries and more resistant to treatment • Condoms lower risk • Give them to most travellers Injuries • Be especially careful in countries that drive on the right hand side • Avoid travelling alone and at night, bad weather • Use helmets, seat belts etc • Avoid looking like a rich tourist • Keep valuables out of view • Speak up if concerned about driver • Flying may be safer than roads • Don’t swim alone or after drinking alcohol • Don’t feed or play with dogs or monkeys Road death rates by country Insurance • Vital for all travel • Check for exclusions • Read policy carefully to see what is covered, level of excess • Have a special policy if preexisting medical conditions, working overseas, doing “hazardous recreational activities” Injections • Travellers end up having injections: 1.5% of Canadian travellers on 1 month trip – J Travel Med 2000; 7: 259-66 • Overuse of injections in many developing countries – BMJ 2003; 327: 1075-78 • Reuse of injection equipment without sterilsation is common • Avoid any puncturing of the skin unless the equipment is sterile Immobility • Any form of travel • Risk related to duration of travel • Those with preexisting VTE risk factors are most vulnerable Immobility • Move legs frequently • Drink plenty of water (not alcohol) • Wear below knee compression stockings: incidence of DVT 19 times lower – Angiology 2001; 52:369-74 • High risk travellers can have clexane injections • Richard Beasley suggests asprin Medication Advice • Take a letter from usual Doctor about any chronic illness and usual medications • Have vital medications in two bags in case one is lost • Have a self help kit as medications overseas may be fakes. Inhalation • TB, influenza, bird flu, MERS • Dutch study showed 3.3% of travellers per year to areas of high TB endemicity are infected (2.8 per 1000 per month) – Lancet 2000; 356: 461-5 • Advise two step pre-travel mantoux testing with repeat after return or quantiferon gold for