Matthew Rollosson, RN, MPH&TM
   This presentation is a brief overview of travel-    related infections   I strongly encourage travelers to endemic   ...
   Hitchhiked in Africa,                              1988-1989                             Registered Nurse, 1992      ...
   Locally Acquired Dengue - Key West, Florida,    2009—2010 (CDC, 2010)   Dengue Hemorrhagic Fever - U.S.-Mexico    Bor...
   West Nile Virus   Eastern Equine Encephalitis   Western Equine Encephalitis   St. Louis Encephalitis   La Crosse ...
   Primary Amebic Meningoencephalitis Deaths    Associated With Sinus Irrigation Using Contaminated    Tap Water (Yoder e...
   Air travel                       Pre-existing conditions       DVT                          Sexual health   Enveno...
   Death:       Non-infectious         Cardiovascular disease         Drowning         Motor vehicle accidents      ...
3000          28202500200015001000 500                     428                                         88                 ...
   Protozoan parasite   Complex lifecycle   Transmitted by mosquitoes   Four human species       Plasmodium falciparu...
CDC 2012
1,691 cases reported to CDC  Species                         Region of Acquisition  P. falciparum      58%          Africa...
   Atovaquone/proguanil (Malarone®)       Daily       1-2 days before arriving in malaria-endemic area       7 days af...
   35% of antimalarial drugs obtained in    Southeast Asia and sub-Saharan Africa failed    chemical analysis (Nayyar et ...
   “Breakbone fever”       Fever       Rash       Arthralgia       Myalgia       Headache   Transmitted by mosquito...
CDC, 2012
Mosquitoes                          Chigger Mites    Chikungunya                        Rickettsial pox    Dengue      ...
   Repellants       Applied to skin:           DEET           Picaridin           IR3535           (Skin-So-Soft® No...
   4 – 6 weeks before travel       Accelerated schedule   Routine       Age-specific   Recommended       Destination...
   Inactivated polio vaccine (IPV)       Single lifetime booster for adults traveling to areas        with polio transmi...
   Ongoing wild poliovirus transmission:     Afghanistan     Nigeria     Pakistan   Vaccine-associated paralytic poli...
   Imported vaccine-associate paralytic poliomyelitis –    United States, 2005   22 year old woman         Religious ex...
   Measles declared eliminated from the U.S. in 2000   222 cases in the U.S. in 2011     200 associated with importatio...
   Hepatitis A   Hepatitis B   Japanese encephalitis   Meningococcal   Pneumococcal   Typhoid   Varicella   Yellow...
   Hepatitis A   Hepatitis B   Meningococcal   Pneumococcal   Varicella
   Neisseria meningitidis       Meningitis       Meningococcemia   Transmitted by respiratory droplets       Risk fac...
CDC, 2012
   Salmonella enterica              Fever       Subspecies Typhi               Remittent         Drug resistance     ...
Two vaccine licensed in the U.S. Vivotif®       Live attenuated oral typhoid vaccine       1 capsule every other day x ...
   Flavi- “yellow”   Dengue   Japanese encephalitis   St. Louis encephalitis   Tickborne encephalitis   West Nile vi...
   Transmitted by mosquitoes   Reservoir: forest primates   Major epidemics in the U.S.     Eastern seaboard, Mississi...
   Relative bradycardia       Fever without increase        in heart rate   Jean Charles Faget       1818-1884       ...
CDC, 2012
   International Certificate of Vaccination or    Prophylaxis (ICVP)   Vaccine must be administered by a provider    wit...
   Transmitted by mosquitoes       Night-biting       Most active June - November       Not active during winter month...
CDC, 2012
   Most travelers not at risk   Low risk in urban areas   Long stays in or frequent visits to    rural/farming areas   ...
   American Society of Tropical Medicine and    Hygiene       www.astmh.org   International Society of Travel Medicine ...
   Alexander, J. P., Ehresmann, K., Seward, J., Wax, G., Harriman, K., Fuller, S. et al. (2009).    Transmission of impor...
   Centers for Disease Control and Prevention. (2007). Dengue hemorrhagic fever – U.S-    Mexico border, 2005. Morbidity ...
   Dondorp, A. M., Newton, P. N., Mayxay, M., Van Damme, W., Smithuis, F. M., Yeung, S.    et al. (2004). Fake antimalari...
   Nayyar, G. M. L., Breman, J. G., Newton, P. N., & Herrington, J. (2012). Poor-quality    antimalarial drugs in Southea...
   Vaughn, D. W., Barrett, A., Solomon, T. (2010). Flaviviruses (yellow fever, dengue,    dengue hemorrhagic fever, Japan...
Congo River, 1989
Travel-related infections
Travel-related infections
Travel-related infections
Travel-related infections
Travel-related infections
Travel-related infections
Travel-related infections
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Travel-related infections

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Travel-related infections

  1. 1. Matthew Rollosson, RN, MPH&TM
  2. 2.  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
  3. 3.  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
  4. 4.  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)
  5. 5.  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)
  6. 6.  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)
  7. 7.  Air travel  Pre-existing conditions  DVT  Sexual health Envenomations/intoxications  Special needs Environment  Trauma  Altitude  Crime  Diving  Motor vehicle accidents  Heat/cold  Natural disasters  Pollution  Violence  Sunburn  Recreational water exposure Food/water  Leptospirosis Mental health  Marine animals  Culture shock  Schistosomiasis  Re-entry shock  Substance abuse
  8. 8.  Death:  Non-infectious  Cardiovascular disease  Drowning  Motor vehicle accidents  Infectious disease  Malaria Most common non-fatal illness:  Travelers’ diarrhea Steffen & Grieve, 2013
  9. 9. 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
  10. 10.  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
  11. 11. CDC 2012
  12. 12. 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
  13. 13.  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
  14. 14.  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
  15. 15.  “Breakbone fever”  Fever  Rash  Arthralgia  Myalgia  Headache Transmitted by mosquitoes Dengue hemorrhagic fever (DHF) Dengue shock syndrome (DSS) Vaccines in clinical trials
  16. 16. CDC, 2012
  17. 17. Mosquitoes Chigger Mites  Chikungunya  Rickettsial pox  Dengue  Scrub typhus  Japanese encephalitis  Lymphatic filariasis Deer flies (Chrysops)  Malaria  Loiasis  Rift Valley fever  Yellow fever Fleas  Murine typhusTicks  Plague  Babesiosis  Ehrlichiosis/Anaplasmosis Lice  Relapsing fever  Epidemic typhus  Rickettsial pox  Relapsing fever  Tick typhus  Tularemia Sandflies  LeishmaniasisBlackflies (Simulium)  Onchocerciasis Tsetse  African trypanosomiasis
  18. 18.  Repellants  Applied to skin:  DEET  Picaridin  IR3535  (Skin-So-Soft® Not-So-Good)  Applied to clothing:  Permethrin Bed nets  Insecticide treated Clothing  Cover  Light-colored CDC, 2012; Fradlin, 2008
  19. 19.  4 – 6 weeks before travel  Accelerated schedule Routine  Age-specific Recommended  Destination-specific Required  Destination-specific  Yellow fever  Meningococcal (Hajj) Jong, 2008
  20. 20.  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)
  21. 21.  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
  22. 22.  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
  23. 23.  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
  24. 24.  Hepatitis A Hepatitis B Japanese encephalitis Meningococcal Pneumococcal Typhoid Varicella Yellow fever
  25. 25.  Hepatitis A Hepatitis B Meningococcal Pneumococcal Varicella
  26. 26.  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
  27. 27. CDC, 2012
  28. 28.  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
  29. 29. 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
  30. 30.  Flavi- “yellow” Dengue Japanese encephalitis St. Louis encephalitis Tickborne encephalitis West Nile virus Yellow fever
  31. 31.  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
  32. 32.  Relative bradycardia  Fever without increase in heart rate Jean Charles Faget  1818-1884  New Orleans physician St Louis Cemetery No 2 New Orleans, Louisiana
  33. 33. CDC, 2012
  34. 34.  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
  35. 35.  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
  36. 36. CDC, 2012
  37. 37.  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
  38. 38.  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
  39. 39.  Alexander, J. P., Ehresmann, K., Seward, J., Wax, G., Harriman, K., Fuller, S. et al. (2009). Transmission of imported vaccine-derived poliovirus in an undervaccinated community in Minnesota. Journal of Infectious Diseases, 199(3), 391-397. http://jid.oxfordjournals.org/content/199/3/391.full. Apicella, M. A. (2010). Neisseria meningitidis. In G. L. Mandell, J. E. Bennett, & R. Dolin (Eds.) Mandell, Douglas, and Bennetts principles and practice of infectious diseases, (7th Ed.). Elsevier [Electronic version]. Campbell, B. G. & Little, M. D. (1988). The finding of Angiostrongylus cantonensis in rats in New Orleans. American Journal of Tropical Medicine and Hygiene, 38(3), 568-573. Centers for Disease Control and Prevention. (1994). Typhoid immunization recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 43(14), 1-7. http://www.cdc.gov/mmwr/preview/mmwrhtml/00035643.htm. Centers for Disease Control and Prevention. (2002). Raccoon roundworm encephalitis – Chicago, Illinois, and Los Angeles, California, 2000. Morbidity and Mortality Weekly Report, 50(51), 1153-1155. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5051a1.htm. Centers for Disease Control and Prevention. (2004). Multifocal autochthonous transmission of malaria – Florida, 2003. Morbidity and Mortality Weekly Report, 53(19), 412- 413. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5319a2.htm. Centers for Disease Control and Prevention. (2006). Imported vaccine-associated paralytic poliomyelitis – United States, 2005. Morbidity and Mortality Weekly Report, 55(4), 97-99. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5504a2.htm.
  40. 40.  Centers for Disease Control and Prevention. (2007). Dengue hemorrhagic fever – U.S- Mexico border, 2005. Morbidity and Mortality Weekly Report, 56(31), 785-789. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5631a1.htm. Centers for Disease Control and Prevention. (2010). Japanese encephalitis vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 59(1), 1-27. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5901a1.htm. Centers for Disease Control and Prevention. (2010). Locally acquired dengue – Key West, Florida, 2009-2010. Morbidity and Mortality Weekly Report, 59(19), 577-581. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5919a1.htm. Centers for Disease Control and Prevention. (2011). Raccoon roundworms in pet kinkajous – three states, 1999 and 2010. Morbidity and Mortality Weekly Report, 60(10), 302- 305. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6010a2.htm. Centers for Disease Control and Prevention. (2012). CDC health information for international travel 2012. New York: Oxford University Press. [Electronic version]. http://wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm. Centers for Disease Control and Prevention. (2012). Malaria surveillance – United States, 2010. Morbidity and Mortality Weekly Report, 61(Suppl. 2), 1-17. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6102a1.htm. Centers for Disease Control and Prevention. (2012). Measles – United States, 2011. Morbidity and Mortality Weekly Report, 61(15), 253-257. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6115a1.htm.
  41. 41.  Dondorp, A. M., Newton, P. N., Mayxay, M., Van Damme, W., Smithuis, F. M., Yeung, S. et al. (2004). Fake antimalarials in Southeast Asia are a major impediment malaria control: multinational cross-sectional survey on the prevalence of fake antimalarials. Tropical Medicine and International Health, 9(12), 1241-1246. Dorn, P. L., Perniciaro, L., Yabsley, M. J., Roellig, D. M., Diaz, J., & Wesson, D. (2007). Autochthonous transmission of Trypanosoma cruzi, Louisiana. Emerging Infectious Diseases, 13(4), 605-607. http://wwwnc.cdc.gov/eid/article/13/4/06-1002_article.htm. Fradin, M. S. (2008). Insect protection. In E. C. Jong & C. Sanford (Eds.) Travel and tropical medicine manual. (4th Ed.). Elsevier. [Electronic version]. Hochberg, N. S., Blackburn, B. G., Park, S. Y., Sejvar, J. J., Effler, P. V., Herwaldt, B. L.(2011). Eosinophilic meningitis attributable to Angiostrongylus cantonensis infection in Hawaii. American Journal of Tropical Medicine and Hygiene, 85(4), 685-690. http://www.ajtmh.org/content/85/4/685.long. Jensenius, M., Han. P. V., Schlagenhauf, P., Schwartz, E., Parola, P., Castelli, F. et al. (2013). Acute and potentially life-threatening tropical diseases in western travelers – a GeoSentinal multicenter study, 1996-2011. American Journal of Tropical Medicine and Hygiene, 88(2), 397-404. Jong, E. C. (2008). Immunizations for travelers. In E. C. Jong & C. Sanford (Eds.) Travel and tropical medicine manual. (4th Ed.). Elsevier. [Electronic version]. Kim, D. Y., Stewart, T. B., Bauer, R. W., & Mitchell, M. (2002) Parastrongylus (=Angiostrongylus) cantonensis now endemic in Louisiana wildlife. Journal of Parasitology, 88(5), 1024-1026.
  42. 42.  Nayyar, G. M. L., Breman, J. G., Newton, P. N., & Herrington, J. (2012). Poor-quality antimalarial drugs in Southeast Asia and sub-Saharan Africa. Lancet Infectious Diseases, 12(6), 488-496. Parker Fiebelkorn, A., Redd, S. B., Gallagher, K., Rota, P. A., Rota, J., Bellini, W. et al. (2010). Measles in the United States during the postelimination era. Journal of Infectious Diseases, 202(10), 1520-1528. http://jid.oxfordjournals.org/content/202/10/1520.long. Richards, S. L., Anderson, S. L., & Smartt, C. T. (2010). Vector competence of Florida mosquitoes for chikungunya virus. Journal of Vector Ecology, 35(2), 439-443. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076135. Steffen, R. & Grieve, S. (2013). Epidemiology: morbidity and mortality in travelers. In J. S. Keystone, D. O. Freedman, P. E. Kozarsky, B. A. Connor, & H. D. Nothdurft (Eds.) Travel medicine (3rd Ed.) Elsevier [Electronic version]. Thiboutot, M. M., Kannan, S., Kawalekar, O. U., Shedlock, D. J., Khan, A. S., Sarangan, G. et al. (2010). Chikungunya: a potentially emerging epidemic? PLoS Neglected Tropical Diseases, 4(4), e623. http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000623. Thielman, N. M., Crump, J. A., & Guerrant, R. L. (2010). Enteric fever and other causes of abdominal symptoms with fever. In G. L. Mandell, J. E. Bennett, & R. Dolin (Eds.) Mandell, Douglas, and Bennetts principles and practice of infectious diseases, (7th Ed.). Elsevier [Electronic version].
  43. 43.  Vaughn, D. W., Barrett, A., Solomon, T. (2010). Flaviviruses (yellow fever, dengue, dengue hemorrhagic fever, Japanese encephalitis, West Nile encephalitis, St. Louis endephalitis, tick-borne encephalitis). In G. L. Mandell, J. E. Bennett, & R. Dolin (Eds.) Mandell, Douglas, and Bennetts principles and practice of infectious diseases, (7th Ed.). Elsevier [Electronic version]. World Health Organization. (2013). Weekly epidemiological record, 7(88). http://www.who.int/wer/2013/wer8807.pdf. Yoder, J. S., Eddy, B. A., Visvesvara, G. S., Capewell, L., Beach, M. J. (2010). The epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008. Epidemiology and Infection, 138(7), 968-975. Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C.. et al. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-85. Zucker, J. R. (1996). Changing patterns of autochthonous malaria transmission in the United States: a review of recent outbreaks. Emerging Infectious Diseases, 2(1), 37-43. http://wwwnc.cdc.gov/eid/article/2/1/96-0104_article.htm.
  44. 44. Congo River, 1989

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