travel’’ medicine - continuing medical education - ucsf …€¦ · · 2011-04-05travel’’...

2/25/11

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Travel Medicine

Infec/ous Diseases in Clinical Prac/ce

February 2011 Brian S. Schwartz, MD

Director, UCSF Travel Medicine and Immuniza/on Clinic

Lecture outline

1.  How to prepare your pa/ents for safe travel

2.  How to evaluate an ill returning traveler

Travelers crossing interna/onal borders

Keystone. Travel Medicine. 2008

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What do we know about travelers from the US?

Lesiure 50%

Business 15%

VFR 11%

Research/Educa7on 9%

Service Work 15%

• India • S. Africa/Thailand

• India • Ghana

• India • China

• China • India

• Hai7 • Kenya

Reason for travel and 2 most frequent des/na/ons

N=13,235

Travel related morbidity/mortality

•  20-‐70% report some illness

•  1-‐5% seek medical aVen/on

•  3% report fevers

•  0.1-‐0.01% require medical evacua/on

•  1/100,000 – death Hill DR. CID. 2006

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PREPARING THE TRAVELER Part 1

Pre-‐travel consulta/on

1.  Assessing the health of the traveler

2.  Assessing the risk of travel

3.  Preventa/ve advice

4.  Immuniza/ons/prophylaxis/self treatment

Assessing the health of the traveler

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Cardiovascular Disease 49%

Injury 22%

Infec7on 1%

Other/Unknown 6%

Cancer 6%

Suicide/Homicide 3%

Medical 14%

Exacerba/on of comorbidi/es is the predominant cause of death in US Travelers:

Hargarten SW. Annals of Emergency Medicine.1991

Asthma in adventure travelers

•  203 w/ asthma assessed pre/post travel

– 88 (43%) had asthma aVacks

– Risk factors for aVacks during travel •  Frequent bronchodilator use before travel (RR, 3.35) •  Intensive physical exer/on during treks (RR, 2.04)

– Triggers •  Trekking (43%), Exercise (41%), Pollu/on (27%), Dust (25%)

Golan Y. Annals Internal Med. 2002

Assessing the risk of travel

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Infec/ons acquired during stay in developing countries

•  20-‐70 % -‐ Traveler’s diarrhea •  3% -‐ Malaria (no chemoprophylaxis in Africa)

•  1% -‐ Influenza, Dengue •  0.5% -‐ Animal bite, PPD conversion

•  0.05% -‐ Typhoid, Hep A •  0.0001% -‐ Japanese encephali/s •  < 0.0001% -‐ Meningococcal disease , polio

Steffen R. J Trav Med. 2008

Assessing the risk of travel

•  Vaccine preventable infec/ons •  Malaria

•  Traveler's diarrhea •  Vector borne illness •  Other

Vaccine preventable diseases •  Rou/ne vaccina/on should be up to date

– Measles and mumps

–  Influenza

•  “Required” vaccines – Yellow fever: many endemic countries

– Meningococcal vaccine: Haj

•  Other vaccines “recommended”

•  Live vaccines -‐ avoid in IS/pregnant pa/ents

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How to determine risk of vaccine preventable diseases?

•  CDC Yellow Book – hVp://wwwnc.cdc.gov/travel/default.aspx

•  WHO – hVp://www.who.int/ith/en/

•  Other –  hVp://www.mdtravelhealth.com/

–  hVp://www.filortravel.scot.nhs.uk/des/na/ons.aspx

•  What do we use in clinic? – Travax™ EnCompass

Malaria •  1997-‐2006: 10,745 malaria cases in US, 54 (0.5%) fatal

•  Risk is highly variable by travel region

Freeman DO. NEJM 2008

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Recommenda/ons for malaria prophylaxis are not always the same for the whole country…

Malaria preven/on •  Low risk:

–  Insect avoidance: DEET; bednets; long sleeves; avoid being outside at dusk and dawn

– Consider chemoprophylaxis in certain persons: •  vulnerable travelers •  immigrants visi/ng friends/rela/ves •  prolonged travel (> 1 mo) •  unreliable access to medical care

•  Moderate -‐ High risk: – Chemoprophylaxis

Malaria chemoprophylaxis Drug Direc7ons Side effects

Mefloquine (Lariam™)

Weekly; start 1 week before, during and 4 weeks post

Vivid dreams, avoid if psychiatric or seizure disorder

Doxycycline Daily; start day before, during, 4 weeks post

Photosensi/vity; GI upset

Atovaquone/proguanil (Malarone™)

Daily; start day before, during, 1 week post

Expensive

Chloroquine Weekly; start day before, during, 4 weeks post

GI upset. Only effec)ve in limited areas (West of Panama canal, Hai))

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sporozoites

schizont

schizont

trophozoite

merozoites

merozoites

LIVER RBC

Hepatocyte

Lifecycle of P. falciparum

7-14d after infection

Mefloquine Doxycycline Chloroquine

Atovaquone/proguanil

Traveler’s diarrhea (TD)

•  #1 travel-‐related illness: 30-‐70% of travelers

•  Pathogens: – Bacteria 80-‐90%: ETEC, campy, shigella, salmonella – Viruses 10%: Norovirus, rotavirus

•  Course: – Bacterial and viral diarrhea lasts 3-‐5 days – Longer dura/ons suggests other diseases

Preven/on and treatment of TD

•  Avoidance: “boil it, peel it, cook or forget it” •  Prophylaxis

– Bismuth subsalicylate QID dosing – An/microbials: ciprofloxacin or rifaximin

– Probio/cs?: Studies mixed results

•  Self-‐treatment

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Self-‐treatment of TD

•  An/bio/cs – Ciprofloxacin – drug of choice outside SE Asia

•  500 mg PO BID un/l symptoms improve vs. 3 days

– Azithromycin – drug of choice for SE Asia •  500 mg PO QD x 3 days •  1000 mg PO x 1

– Rifaximin – not for invasive infec/ons •  200 mg PO TID x 3 days

•  An/-‐mo/lity agents: add in “emergency”

Vector borne illness preven/on

•  Dengue fever, chikungunya fever, ricketssial infec/ons…

•  Recommenda/ons – Long sleeve clothing, avoid high risk areas –  Insect repellents

•  DEET ~ 35% for skin, no increased benefit > 50% •  Premethrin for clothing

Other infec/ous and non-‐infec/ous risks of travel

•  Plan to swim in fresh water? – Leptospirosis – Schistosomiasis

•  Travel to High Al/tude: > 8000 x? – Common des/na/ons: Machu Picchu, Tibet, etc… – Some symptoms > 25% – Educate on acclima/za/on

– Acetazolamide prophylaxis

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Travelers Visi/ng Friends and Rela/ves (VFR)

•  Immigrants or 2nd gen persons returning to their homeland to visit friends and rela/ves – Higher degree of exposure –  Insufficient protec/on measures

•  Immigrant VFR traveler vs. tourist traveler – Malaria risk: 8.7x –  Intes/nal parasite: 3.8x – Hospitaliza/on: 8.3x

Leder K. CID. 2006

Other important topics to discuss

•  Safe sex

•  Avoidance of animals

•  Injury preven/on

•  Managing symptoms of jet lag

•  Sun exposure

Case 1: Bill •  65 year-‐old male planned a 3 week trip to Asia, leaving in 15 days

•  I/nerary: –  India (1.5 weeks) – Delhi, Jaipur, Mumbai

– Thailand (1.5 weeks) – Bangkok and resort islands

•  High end tour, hotels

•  “I love Indian and Thai food and I plan to eat where the food is the best, on the street”

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Assessing the health of the traveler

•  Underlying medical condi7ons: – GERD and Hypertension

•  Medica7ons – Omeprazole and lisinopril

•  Allergies – none

•  Immuniza7on history – Polio; Hepa))s B; born before ’57; had varicella

Recommenda/ons based on Bill’s medical issues

•  HTN – Keep meds in carry-‐on

– Bring copies of Rx

•  PPI use increase risk for traveler’s diarrhea – Avoiding high risk food, consider daily prophylaxis

•  Consider obtaining evacua/on insurance – Example: Interna)onal SOS, MEDEX

Which immuniza/ons would you recommend to Bill?

A.  Hepa//s A

B.  Hepa//s E

C.  Japanese encephali/s

D.  Typhoid

E.  A and D

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Hepa//s A

•  Transmission: –  food/water

•  Risk: –  1:4,000-‐1:16,000 per/mo abroad

•  Vaccine –  Intramuscular (inac/vated)

–  Life-‐long protec/on axer 2nd dose at 6 mo –  Ok to give up un/l departure

Victor JC. NEJM. 2007

Typhoid Fever


•  > 400 cases annually US –  Travel #1 risk factor

•  2 vaccines (50-‐80% protec/ve) –  Intramuscular (inac/vated) – booster Q2 years

–  Oral (live aVenuated) – booster Q5 years

Hepa//s E


•  Risk: – Less transmissible than Hepa//s A

•  Endemic and epidemics

•  High mortality in pregnant women

•  No vaccine available Teshale EH. CID 2010

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Other immuniza/ons to consider in travelers to Asia

•  Japanese Encephali/s

•  Hepa//s B

•  Rabies

•  Polio

http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/japanese-encephalitis.aspx

Malaria map of India

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Malaria map of Thailand

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Malaria preven/on for Bill?

•  Axer weighing risks and benefits..

•  Malarone™ for his /me in India

TD preven/on/treatment recommenda/ons for Bill?

•  Safe food/water intake

•  Prophylaxis – Rifaximin 200 mg PO QD

•  Breakthrough treatment – Azithromycin 500 mg PO QD x 3d

•  When to seek medical aVen/on – Fever > 2 days, dehydra/on, bloody diarrhea

Dupont HL. Ann Intern Med. 2005

Vector borne illness preven/on

•  Travel risk for Bill? – Dengue fever in India and Thailand – Chikungunya fever in S. India

•  Recommenda/ons – Long sleeve clothing, avoid high risk areas –  Insect repellents

•  DEET ~ 35% for skin •  Premethrin for clothing

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Yellow Fever •  Transmission: mosquito

•  1970-‐2002: 9 travelers; 8/9 died •  Risk:

– W. Africa: 50/100K; S. America: 5/100K

•  Only required vaccine •  Vaccina/on risk (↑ with age)

– Neurologic Disease (0.8/100K) – Viscerotropic Disease (0.4/100K)

Summary

•  Goal is to minimize health risk during travel

–  Iden/fy condi/ons that could worsen during travel

–  Iden/fy specifics risks of pa/ent’s travel

– Provide advice, PRN treatment, and immunize

– Consider involving a specialist in travel medicine

THE FEBRILE RETURNING TRAVELER Part 2

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Fever

•  2-‐3% of American/European travelers to developing countries

Hill DR. J Trav Med. 2000

So many diagnoses, how to narrow your DDx?

Geography

Exposures

Incubation Exam findings

Prophylaxis

Diagnosis

Geography

•  Where did they go – specifically? – Not just country but ci/es – Time of year

•  What is endemic is that region? – Use resources

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0

100

200

300

400

500

600

700

800

900

1000

Carribean C. America S. America Sub-‐Saharan Africa

South Central Asia

SE Asia

Cases

Freedman DO. NEJM. 2006.

E/ology of fever according to region traveled

Dengue

Unknown

EBV/CMV

Malaria

Rickettsia

Typhoid

Dengue

Incuba/on period?

•  Incuba/on period is from /me of exposure

•  Marked variability amongst infec/ons

•  Very helpful in making diagnosis

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Clinical Infectious Diseases 2007

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-‐7 7-‐14 14-‐21 21-‐28 28-‐35 35-‐42 >42

Prop

or7on

of D

iagnoses

Days post-‐travel

7

E/ology of fever according to interval axer travel

Wilson ME. CID. 2007.

Rickettsia

P. falciparum

P. vivax

CMV/EBV

Dengue Typhoid

Other

Malaria Other

7 14 21 28 35 42 49 0

Exposures?

•  Insect or animal exposures?

•  Fresh water exposure?

•  What did they consume?

•  Other ill travelers?

•  Sexual ac/vity?

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Specific symptoms or exam findings?

•  Symptoms – Diarrhea? – Abdominal pain? – Headache?

•  Exam findings – Rash? – Lymphadenopathy? – Arthri/s?

Prophylaxis?

•  Vaccina/ons? – Which ones?

– Timing of vaccina/ons?

•  Malaria prophylaxis? – Appropriate agents? – Taken appropriately?

What should your ini/al tes/ng include?

•  CBC w/ differen/al •  LFTs •  Blood cultures x 2 •  Thick and thin blood smear x 2

•  Urinalysis •  CXR •  Addi/onal tes/ng based on history/exam

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Case

•  55 year-‐old male returns from a 2 week trip in S. Africa with 4 days of fever.

Case /meline

21 11 13 3 14 19 18

South Africa Return to US

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Noticed lesion under waist-band, non-tender

Visit to PCP

“Red spots” on chest, arms

20

UCSF ED

February

Fevers, myalgias, fatigue

Physical Exam

•  VS. 38.5, 76, 128/70, 16, 99% RA •  Gen: rela/vely well appearing •  Exam otherwise unremarkable except…

– Lymph – 1 cm R inguinal LAD, minimal tenderness – Skin – papulovesicular rash and 1x 1 cm eschar

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Labs and Microbiology

3.8>47<214

Chem 7 – wnl

LFTS – wnl

UA -‐ wnl

Bld Cx X 2 – pending

Thick/thin smear – pending

CXR -‐ clear

Assuming that this is an infec/on what is the mode of transmission?

A.  Inges/ng contaminated food or water

B.  Mosquito

C.  Sexual contact

D.  Swimming in contaminated water

E.  Tick

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DIFFERENTIAL DIAGNOSIS?

Geography?

Incubation?

Exposures?

Specific features?

Prophylaxis?

Geography

•  Geography: Lompopo Valley, South Africa

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0

100

200

300

400

500

600

700

800

900

1000


South Central Asia

SE Asia

Cases



Dengue

Unknown

EBV/CMV

Malaria

Rickettsia

Typhoid

Dengue

Incuba/on

•  Incuba/on 3-‐11 days

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-‐7 7-‐14 14-‐21 21-‐28 28-‐35 35-‐42 >42

Prop

or7on

of D

iagnoses

Days post-‐travel



Rickettsia

P. falciparum

P. vivax

CMV/EBV

Dengue Typhoid

Other

Malaria Other

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Exposures

•  Big game hunt -‐ denied animal or insect bites

•  Denies fresh water exposure

•  Denies ea/ng uncooked food/ unfiltered water

•  Denies exposure to sick contacts

•  Denies any sexual ac/vity

Prophylaxis

•  Vaccines – Hep A, Typhoid, Yellow Fever, Rabies

•  An/-‐malarial prophylaxis – Yes -‐ Atovaquone/proguanil

Diagnos/cs

•  Bld cx x 2 – NGTD

•  CXR – clear

•  Thick/thin smear – nega/ve

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Specific exam findings

•  Eschar –  Plague, Tularemia –  Cutaneous anthrax –  Brown Recluse Spider –  Cutaneous leishmaniasis

–  RickeVsial infec/ons: •  Ricketssialpox •  Mediterranean spoVed fever

•  African /ck bite fever

•  Papulovesicular rash –  Varicella (chickenpox) –  Variola (smallpox)

– Measles –  Enterovirus infec/ons –  RickeVsial infec/ons

•  RickeVsialpox •  African /ck bite fever •  Queensland Tick Typhus

Diagnosis: African /ck-‐bite fever

•  Travel to Sub-‐Saharan Africa -‐ #2 cause of febrile illness – rickeVsial disease

•  Exposure – direct contact with wild animals

•  Incuba/on period -‐ ~ 7 days

•  Exam -‐ fever, eschar, papulovesicular rash

African Tick Bite Fever (ATBF)

•  ATBF due to infec)on with R. africae •  TransmiVed in rural sub-‐Saharan Africa by ungulate /cks

•  Southern African bont /ck – Aggressive (oxen mul/ple bites)

– Wild ungulates (giraffes, buffalo)

– 70% infected w/ R. africae

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ATBF in returning travelers from sub-‐equitorial Africa

•  Hun/ng as main purpose of travel (OR 10.18)

•  Clinical manifesta/ons: – Fever, Headache, Myalgias –  Inocula/on eschar, oxen mul/ple – Regional lymphadeni/s – Rash – maculopapular or papulovesicular

•  Treatment – Doxycycline x 7 days

Jensenius M. CID 2003; Jensenius M. Lancet Infect Dis 2003; Rauolt D.N Engl J Med 2001, 344 (20)

Case 2

•  32-‐year-‐old woman developed sudden onset of headache, high fever, and extreme fa/gue 2 days axer returning from Central Mexico

•  Complained of flushing over face and chest

•  Three days later, developed a generalized “splotchy” rash.

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Physical Exam

•  VS: 38.8, 110/65, 87, 18, 98%/RA •  GEN: fa/gued, generally uncomfortable

•  HEENT: oropharynx clear •  NECK: supple, no meningismus

•  CV: tachy no murmur

•  CHEST: clear •  ABD: benign, no HSM

Skin findings

Laboratory findings

•  CBC: 1.5 >48.9<37 •  Cr -‐ 0.9 •  AST/ALT – 124/87 •  AP, Bili, PT, PTT -‐ wnl

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Assuming that this is an infec/on, what is the mode of transmission?

A.  Inges/ng contaminated food or water

B.  Mosquito

C.  Sexual contact

D.  Swimming in contaminated water

E.  Tick

0

100

200

300

400

500

600

700

800

900

1000


South Central Asia

SE Asia

Cases



Dengue

Unknown

EBV/CMV

Malaria

Rickettsia

Typhoid

Dengue

Incuba/on

•  Arrived in Mexico 14 days ago, returned to US 5 days ago

•  Incuba/on: 5-‐9 days

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-‐7 7-‐14 14-‐21 21-‐28 28-‐35 35-‐42 >42

Prop

or7on

of D

iagnoses

Days post-‐travel



Rickettsia

P. falciparum

P. vivax

CMV/EBV

Dengue Typhoid

Other

Malaria Other

Diagnos/cs

•  Blood culture x 2 – No growth

•  Thick and thin smear – nega/ve

Diagnosis: Dengue fever

•  Travel to C. America -‐ #1 -‐ dengue fever

•  Incuba/on period – 7-‐12 days •  Unique findings– rash, leukopenia, thrombocytopenia, transamini/s

•  Dengue virus /ters -‐ IgM 11.78, IgG< 0.5

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Dengue fever: Clinical manifesta/ons

•  Dengue Fever – Severe headache – Myalgias and arthralgias – Nausea and vomi/ng – Rash: Generalized erythema -‐>maculopapular w/ petechiae

•  Dengue Hemorrhagic Fever

•  Lab abnormali/es: ↓WBC/PLT, ↑ AST/ALT

Dengue fever: Rx/preven/on

•  Treatment is suppor/ve

•  No vaccine available

•  Preven/on of mosquito exposure – Avoid endemic areas

– DEET – Premetherin treated clothing

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Summary •  Preven/on of infec/on is best

– Educa/on, immuniza/on, prophylaxis

•  DDx infec/ons of traveler is finite – Use resources

•  Detailed history and exam helps to narrow DDx –  Specific des/na/ons – Dura/on of stay (incuba/on period) – Ac/vi/es – Exposures

Ques/ons?

[email protected]

travel’’ medicine - continuing medical education - ucsf …€¦ · · 2011-04-05travel’’...

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