This presentation is a brief overview of travel- related infections I strongly encourage travelers to endemic countries to consult a travel medicine specialist at least one month prior to departure Find a travel medicine clinic: http://wwwnc.cdc.gov/travel/page/find-clinic.htm http://www.astmh.org/source/ClinicalDirectory http://www.istm.org/WebForms/SearchClinics
Hitchhiked in Africa, 1988-1989 Registered Nurse, 1992 Diploma in Clinical Tropical Medicine & Travelers’ Health, 2000 Worked in Ethiopia, 2002 Master of Public Health & Tropical Medicine, 2009Niger River, Mali, 1988
Locally Acquired Dengue - Key West, Florida, 2009—2010 (CDC, 2010) Dengue Hemorrhagic Fever - U.S.-Mexico Border, 2005 (CDC, 2007) Autochthonous Transmission of Trypanosoma cruzi, Louisiana (Dorn et al., 2007) Multifocal Autochthonous Transmission of Malaria - Florida, 2003 (CDC, 2004) Changing patterns of autochthonous malaria transmission in the United States (Zucker, 1996)
West Nile Virus Eastern Equine Encephalitis Western Equine Encephalitis St. Louis Encephalitis La Crosse Chikungunya? Vector competence of Florida mosquitoes for chikungunya virus (Richards et al., 2010) Chikungunya: a potentially emerging epidemic? (Thiboutot et al., 2010)
Primary Amebic Meningoencephalitis Deaths Associated With Sinus Irrigation Using Contaminated Tap Water (Yoder et al., 2012) The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008 (Yoder et al., 2010) Raccoon Roundworms in Pet Kinkajous - Three States, 1999 and 2010 (MMWR 2011) Raccoon Roundworm Encephalitis - Chicago, Illinois, and Los Angeles, California, 2000 (MMWR, 2002) Eosinophilic meningitis attributable to Angiostrongylus cantonensis infection in Hawaii (Hochberg et al. 2011) Parastrongylus (=Angiostrongylus) cantonensis now endemic in Louisiana wildlife (Kim et al., 2002) The finding of Angiostrongylus cantonensis in rats in New Orleans (Campbell & Little 1988) (Okay, they don’t really eat brains)
Death: Non-infectious Cardiovascular disease Drowning Motor vehicle accidents Infectious disease Malaria Most common non-fatal illness: Travelers’ diarrhea Steffen & Grieve, 2013
3000 28202500200015001000 500 428 88 18 6 1 0 Falciparum Typhoid fever Leptospirosis DHF/DSS East African Japanese malaria trypanosomiasis encephalitis Jensenius et al., 2013
Protozoan parasite Complex lifecycle Transmitted by mosquitoes Four human species Plasmodium falciparum Widespread drug resistance P. vivax P. ovale P. malariae P. knowlesi Simian malaria www.cdc.gov/malaria Vaccines in clinical trials
1,691 cases reported to CDC Species Region of Acquisition P. falciparum 58% Africa 65% P. vivax 19% West Africa 73% P. malariae 2% Asia 19% P. ovale 2% South Asia 94% Unknown 18% India 81% Americas 15% Reason for travel Visiting friends and relatives (VFR) 71% Missionaries 9% Business 8% CDC 2012
Atovaquone/proguanil (Malarone®) Daily 1-2 days before arriving in malaria-endemic area 7 days after leaving Doxycycline Daily 1-2 day before arriving 4 weeks after leaving Mefloquine Weekly 2 weeks before arriving 4 weeks after leaving CDC, 2012
35% of antimalarial drugs obtained in Southeast Asia and sub-Saharan Africa failed chemical analysis (Nayyar et al. 2012) 53% of artesunate tablets collected in Southeast Asia contained no trace of the drug (Dondorp et al., 2004) Subtherapeutic doses increase the risk of treatment failure and development of drug- resistance
Inactivated polio vaccine (IPV) Single lifetime booster for adults traveling to areas with polio transmission and who have previously received primary series Influenza Year-round transmission in the tropics Measles, mumps, rubella (MMR) 2 doses Tetanus, diphtheria, acellular pertussis (Tdap)
Ongoing wild poliovirus transmission: Afghanistan Nigeria Pakistan Vaccine-associated paralytic poliomyelitis (VAPP) 1 in 2.4 million OPV doses Vaccine-derived poliovirus (VDPV) Areas with inadequate polio vaccine coverage 2012: Somalia, Chad, Kenya, DR Congo, Yemen Importation November 2012: outbreak in Niger imported from Nigeria December 2012: wild poliovirus from Pakistan found in sewage in Cairo, Egypt WHO, 2013
Imported vaccine-associate paralytic poliomyelitis – United States, 2005 22 year old woman Religious exemption from IPV/OPV Stayed with a family in Costa Rica beginning Jan 14, 2005 Infant in the family received OPV Jan 19 Onset of symptoms March 2 Sabin strain poliovirus isolated from stool CDC, 2006 Transmission of imported vaccine-derived poliovirus in an undervaccinated community in Minnesota OPV not used in the U.S. since 2000 In 2005, 8 Amish children found to be excreting poliovirus Source not identified Alexander et al., 2009
Measles declared eliminated from the U.S. in 2000 222 cases in the U.S. in 2011 200 associated with importation from other countries 166 unvaccinated/unknown vaccination status 141 eligible to receive MMR 50 refused vaccination for personal, philosophical, or religious objections Measles in Europe 39% of cases imported to the U.S. 2001-2008 46% of cases imported to the U.S. in 2011 CDC, 2012; Parker Fiebelkorn et al., 2010
Neisseria meningitidis Meningitis Meningococcemia Transmitted by respiratory droplets Risk factors: crowding, poverty, smoking African Meningitis Belt Major epidemics every 5-10 years Hot, dry, dusty season Ends with beginning of rainy season Asymptomatic nasopharyngeal carriage Vaccine Conjugate A, C, Y, W-135 Required for Hajji Apicella, 2010
Salmonella enterica Fever Subspecies Typhi Remittent Drug resistance Step-wise Non-typhoidal Sustained Salmonella Relative bradycardia S. paratyphi Constipation/diarrhea Clinically indistinguishable from Abdominal pain typhoid Headache Fecal-oral Rose spots transmission Thielman et al., 2010
Two vaccine licensed in the U.S. Vivotif® Live attenuated oral typhoid vaccine 1 capsule every other day x 4 doses Do not take with antibiotics active against S. typhi Typhim Vi® Injectable Vi capsular polysaccharide vaccine 1 IM doseDo not prevent non-typhoidal Salmonella infections
Flavi- “yellow” Dengue Japanese encephalitis St. Louis encephalitis Tickborne encephalitis West Nile virus Yellow fever
Transmitted by mosquitoes Reservoir: forest primates Major epidemics in the U.S. Eastern seaboard, Mississippi Valley Last epidemic: New Orleans 1905 Most infections self-limiting Fever, headache, myalgias Biphasic Period of remission Period of intoxication Fulminant hepatitis Mortality 20-50% Vaughn et al., 2010
Relative bradycardia Fever without increase in heart rate Jean Charles Faget 1818-1884 New Orleans physician St Louis Cemetery No 2 New Orleans, Louisiana
International Certificate of Vaccination or Prophylaxis (ICVP) Vaccine must be administered by a provider with an official uniform stampwwwnc.cdc.gov/travel/yellow-fever-vaccination-clinics/search.htm CDC, 2012
Transmitted by mosquitoes Night-biting Most active June - November Not active during winter months Most infections asymptomatic Encephalitis: Fever, headache, lethargy Movement disorders Agitation, decreased LOC, coma Meningeal signs, seizures, focal neurological deficits 20-30% case fatality 30-50% left with residual neurological deficits CDC, 2010
Most travelers not at risk Low risk in urban areas Long stays in or frequent visits to rural/farming areas Vero cell culture vaccine: ≥17 years of age 2 doses 28 days apart Second dose at least 1 week before travel Not licensed for children in the U.S. Mouse brain vaccine 1 – 16 years of age 3 doses at 0, 7, and 30 days No longer available in the U.S. CDC, 2010
American Society of Tropical Medicine and Hygiene www.astmh.org International Society of Travel Medicine www.istm.org WHO travel and health www.who.int/topics/travel/en
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