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Shelub cdc health care professional travel lecture


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Travel Medicine lecture slides

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Shelub cdc health care professional travel lecture

  1. 1. Travel Medicine and the Pre- Travel Consultation Aaron Shelub AaronShelub @aaronshelubmd Board Certified Internal Medicine Board Certified Infectious Disease Certified Yellow Fever Vaccine Provider May 8th 2012 1 CDC presentation for healthcare professionals
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  3. 3. Outline• Travelers’ Health Epidemiology• Traveler Assessment• Itinerary Review• Sources of Information• Risks to the Traveler• Common diseases of concern• Travel Vaccines• Travel Medications• Counseling 3
  4. 4. U.S. Residents Traveling Abroad*Number of Travelers (millions) 65 60 55 50 45 95 96 00 03 97 98 99 01 02 04 05 19 19 19 19 20 20 20 20 19 20 20 Year *ITA, includes travel to Canada and Mexico 4
  5. 5. International Travel 80 900 70 800 700 60 US nonresident Inbound (ITA)US Resident travel in millions Worldwide arrivals in millions 600 50 US Resident Air Outbound (ITA) 500 40 All US Resident 400 Outbound (ITA) 30 Worldwide arrivals 300 (WTO) 20 200 10 100 0 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 5
  6. 6. Where Do U.S. Residents Travel? Of the 17% who traveled outside the U.S. . . . 40 30 20% 10 0 Z I a t ad a ro p e /N x ico ric a p an /P s ia ric ea n as n s e Ja ia A Af b E Ca E u Au Me Am an er rib le S Oce Ot h Ca M idd or C 6 Source: HealthStyles Survey 2005
  7. 7. 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 1 US 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 3 2004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, 7 USDOC
  8. 8. Travelers’ Health RisksOf 100,000 travelers to a developing country for 1 month: – 50,000 will develop some health problem – 8,000 will see a physician – 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 8
  9. 9. Estimated Incidence rate per month of infections andfatal accidents among travelers to developing countries 9 Yellow book page 12 2012 version
  10. 10. Yellow book figure 1-2 Proportionate morbidity among ill travelers returning from the developing world according to region of travel. 10
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  12. 12. The Patient: Medical Issues• Age-specific issues• Underlying illness, immunosuppression• Systems review• Medical history• Medication use• Vaccination history• Allergies• Contraindications to vaccines and medications 12
  13. 13. The Patient: Other Issues• Reproductive – Pregnant – Breastfeeding – Preconception• Risk-taking behaviors 13
  14. 14. Travel Itinerary• Full itinerary – Dates, duration, stopovers – Seasonal considerations• Styles of travel – Rural vs. urban – Budget vs. luxury• Accommodation – Hotel vs. camping• Activities – Business vs. tourism – Adventure, safari – Missionary/Humanitarian/NGO – -Sexual or Medical tourism 14
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  16. 16. Travel Health Resources• CDC Travelers’ Health Website –• World Health Organization –• State Department –• International Society of Travel Medicine –• Health Information for International Travel – CDC “Yellow Book”• International Travel and Health – WHO “Green Book” 16
  17. 17. Travelers’ Health Website 17
  18. 18. Regional Destinations• Region-specific pages• Goal to move to country-specific format 18
  19. 19. Travel Notices & Announcements 19
  20. 20. Figure 2-01. Leading causes of injury death for US citizens in foreign countries, 2007–2009 Data from US Department of State. Death of US citizens abroad by non-natural causes. Washington, DC: US Department of State; 20 2010. Available from: . 2Excludes deaths of US citizens fighting wars in Afghanistan or Iraq.
  21. 21. Table 2-12. Estimated traffic death rates in the 20 countries most frequently traveled by US residents • Country reported # rate/100,000 • Mexico 22,103 20.7 • Thailand 12,492 19.6 • India 105,725 16.8 • China 96,611 16.5 • Greece 1,657 14.91Data from the US Department of Commerce. 2008 United States resident travel abroad. Washington, DC: US Department of Commerce; 2010. Availablefrom: (PDF) and World Health Organization. Global StatusReport on Road Safety: Time for Action. Geneva: WHO; 2009. Available from: .(PDF)2Deaths reported in the local population in 2007. For comparison, the number of reported traffic deaths in the United States was 42,642, with an estimatedtraffic death rate of 13.9 per 100,000
  22. 22. Infectious Disease Risks to the Traveler• Malaria • Schistosomiasis• Diarrhea • Tuberculosis• Leishmaniasis • Leptospirosis• Rabies • Polio• Dengue • Yellow Fever• Meningococcal • Measles Meningitis • JEV ETC. 22
  23. 23. Other Risks to the Traveler• Accidental injury• Environmental hazards• Crime and assault• Psychiatric problems• Animal bites, stings and envenomations• Dermatologic disorders• Altitude• ……. ETC. 23
  24. 24. Case presentation• 38 yo male with no significant pmh returns from Mexico with fever 101.3, fatigue and muscle aches.• He was camping outside and on a “vision quest”• Labs reveal wbc 2.4 and mild anemia• Feels better with IVF 24
  25. 25. Dx? 25
  26. 26. Probable Dengue Fever 26
  27. 27. Dengue Fever Risk Areas 27
  28. 28. Dengue Fever• positive-strand RNA viruses of the genus Flavivirus, family Flaviviridae• bite of an infected Aedes aegypti mosquito• World Health Organization (WHO) estimates that 50 million cases of dengue occur every year,• Infection rates (based on serology) among febrile travelers returning from dengue- endemic areas in the tropics are 3%–8% 28
  29. 29. Dengue Fever Clinical Presentation• travel  tropics and subtropics 2 weeks before symptom onset• acute febrile illness with 2 or more of the following: headache, retroorbital pain, muscle aches, joint pain, rash, hemorrhagic manifestation, or leukopenia.• Dengue shock syndrome (DSS) is defined as a syndrome in a patient who meets the criteria for DHF and has hypotension, narrow pulse pressure (≤20 mm Hg), or frank shock. 29
  30. 30. Dengue Fever dx and Rx• Dx: serologic testing for IgM anti-DENV.• Rx: Supportive care• DHF/DSS: abrupt change from fever to hypothermia, severe abdominal pain, persistent vomiting, bleeding, difficulties breathing, or altered mental status (such as irritability, confusion, lethargy)- IVF 30
  31. 31. Dengue Fever Prevention• being bitten highest during the early morning,• several hours after daybreak,• late afternoon before sunset.• insecticides to get rid of mosquitoes 31
  32. 32. Immunizations to Consider for Adult Travelers Routine Travel related Diphtheria* Hepatitis A Tetanus* Hepatitis B Pertussis* Typhoid Measles + Rabies Mumps+ Meningococcal disease Rubella + Polio Varicella Japanese encephalitis Pneumococcus Yellow Fever Influenza * Td or Tdap 32 + MMR
  33. 33. Hepatitis A• Person to person contact, contaminated water, shellfish and other foods• Shed in feces• Very common vaccine-preventable infection• Rural areas, trekking, poor sanitation = highest risk• Abrupt onset of fever, malaise, anorexia, nausea and abdominal discomfort then jaundice• No treatment 33
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  35. 35. Hepatitis A cont.• Prevention with vaccination• Havrix 0,6,12 months• Vaqta 0,6-18 months• Twinrix 0,1,6 months• Immune globulin 0.02 ml/kg 1-2 months 35
  36. 36. Hepatitis B• Contact with blood, body fluids• Risk by prevalence• 90 days incubation,• Jaundice, nausea,vomiting,abdominal pain• Progression to chronic Hep B 30-90%• No treatment• Vaccine preventative, 0,1,6 months• All unvaccinated people traveling to areas int to high prevalence 36
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  38. 38. Typhoid fever• Acute life threatening febrile illness• Bacterium Salmonella enterica serotype Typhi• Consumption of water or food contaminated by feces• 22 million cases typhoid fever, 200,000 related deaths/ year 38•
  39. 39. Typhoid Fever Cont.• Insidious fatigue,• fever low high,• HA, malaise,• anorexia,• hepatosplenomegaly,• rose colored rash 39
  40. 40. Typhoid Fever cont.• Complications: intestinal hemorrhage or perforation• Clinical dx• Rx: Empiric floroquinolone• Vaccines:Oral live attenuated, Vi capsular polysacchride vacc 40
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  42. 42. Yellow Fever• Flavirus• Vectorborne transmission• Aedes or Haemagogus spp. Mosquito• “Epidemiological silence” ≠ no risk• Non-specific flu like illness, fever,chills, HA,myalgias,n/v• 15%jaundice,hemorrhagic sx,shock multisystem failure, (case fatality hepatorenal 20-50%) 42
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  45. 45. Yellow Fever cont.• Rx= supportive only• Prevention: avoid mosquito bites, vaccinate (YF-Vax)• Several countries require proof of vaccination from all arriving travelers or• Travelers going through endemic countries. 45
  46. 46. Malaria• 1 0f 4 protozoan species genus Plasmodium• Transmitted by Anopheles mosquito• Major international public health problem• 350 – 500 million infections worldwide, 1 million deaths annually. 46
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  48. 48. Malaria Cont.• fever and influenzalike symptoms,• chills, headache, myalgias, and malaise;• symptoms at intervals• severe disease, seizures, mental confusion, kidney failure, acute respiratory disease syndrome (ARDS), coma, and death may occur. 48
  49. 49. Malaria cont.• P. falciparum = medical emergency,• clinical deterioration can occur rapidly and unpredictably.• consider malaria: patient with a febrile illness who has recently returned from a malaria- endemic country.• Smear microscopy = gold standard for malaria diagnosis. 49
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  53. 53. Malaria Cont.• seek medical evaluation as soon as possible• CDC Malaria Hotline (770-488-7788 or toll- free at 1-855-856-4713) from 9:00 am to 5:00 pm Eastern Time• Atovaquone-proguanil• .Artemether-lumefantrine 53
  54. 54. Malaria cont.Prophylaxis:Mosquito avoidanceChemoprophylaxis:Atovaquone- proguanilDoxycyclineOthers- side effect issues 54
  55. 55. Travelers’ Diarrhea• 30% to 70% of travelers• “boil it, peel, it, or forget it,” traditional• Bacterial pathogens predominant risk• most common pathogen is enterotoxigenic Escherichia coli• High-risk areas include most of Asia, the Middle East, Africa, Mexico, and Central and South America. 55
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  57. 57. Travelers Diarrhea risk factors• bouts of TD do not appear to protect against future attacks• environments where large numbers of people do not have access to plumbing or outhouses, the amount of stool contamination in the environment will be higher and more accessible to flies• poorly functioning refrigeration, which can result in unsafe food storage and an increased risk for disease. 57
  58. 58. Travelers diarrhea Sx’s and• prevention sudden onset mild cramps and urgent loose stools  severe abdominal pain, fever, vomiting, and bloody diarrhea.• alcohol-based hand cleaners (containing at least 60% alcohol) may make it easier for travelers to clean their hands before eating.• freshly cooked and served piping hot are safer than foods that may have been sitting for some time in the kitchen or in a buffet.• avoid beverages diluted with nonpotable water (reconstituted fruit juices, ice, and milk)• prevention = bismuth subsalicylate (BSS), Pepto-Bismol• 58
  59. 59. Travelers Diarrhea prevention and Rx• Lactobacillus GG and Saccharomyces boulardii, = Results are inconclusive,• Prophylactic abx = discouraged• Rx:ciprofloxacin or levofloxacin, azitrhomycinAntimotility agentsOral Rehydration Therapy 59
  60. 60. Travel Medications: Prophylaxis & Self Treatment• Malaria – chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine• Diarrhea – quinolone, azithromycin• Altitude – acetazolamide• Motion sickness – scopolamine, dimenhydrinate (Dramamine) 60
  61. 61. Patient Counseling• Sufficient time for patient education• Tailored to suit traveler• Fitness for travel – Understanding impact on existing conditions – Advisability of destinations 61
  62. 62. Travel Preparation• Travel health insurance – Medical care – Hospitalization – Evacuation• Obtaining medical care abroad• Awareness of travel notices• Hand washing and hygiene 62
  63. 63. Environmental Precautions• Air Travel• Jet Lag• Sun Protection• Extreme Heat and Cold – dehydration, heat stroke – hypothermia, frostbite• Altitude• Water recreation – Drowning, boating & diving accidents – Risk of schistosomiasis or leptospirosis – Biological and chemical contamination 63
  64. 64. Food and Water Precautions • Bottled water • Selection of foods – well-cooked and hot • Avoidance of – salads, raw vegetables – unpasteurized dairy products – street vendors – ice 64
  65. 65. Vector Precautions• Covering exposed skin• Insect repellent containing DEET 25 – 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 65
  66. 66. 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 66
  67. 67. Animal Precautions• Animal avoidance• Rabies – Specific animal threats – Medical evaluation of bites/scratches – Post exposure immunization and immunoglobulin• Envenomations – Snakes, scorpions, spiders – Maritime animals 67
  68. 68. Injury and Crime• Vehicles – Risk of road and pedestrian accidents – Night travel – Seat belts and car seats• Use of drugs and alcohol• Understanding local crime risks – Scam awareness – Situational awareness – Location avoidance 68
  69. 69. Travel Emergency Kit• Copy of medical records and extra pair of glasses• Prescription medications• Over-the counter medicines and supplies – Analgesics – Decongestant, cold medicine, cough suppressant – Antibiotic/antifungal/hydrocortisone creams – Pepto-Bismol tablets, antacid – Band-Aids, gauze bandages, tape, Ace wraps – Insect repellant, sunscreen, lip balm – Tweezers, scissors, thermometer 69
  70. 70. Post-Travel Care• Post-travel checkup – Long term travelers – Adventure travelers – Expatriates in developing world• Post-travel care – Fever, chills, sweats – Persistent diarrhea – Weight loss 70
  71. 71. Questions? 71
  72. 72. Other Resources 72
  73. 73. Journals• American Journal of Tropical Medicine and Hygiene• Bulletin of the World Health Organization• Emerging Infectious Diseases Journal• Eurosurveillance Weekly• Journal of Travel Medicine• Morbidity and Mortality Weekly Report• Tropical Medicine and International Health• Vaccine 73
  74. 74. Books• Textbook of Travel Medicine and Health, 2nd Ed. – DuPont, H.L. and Steffen R. (editors)• The Travel and Tropical Medicine Manual, 3rd Ed. – Jong, E.C., McMullen, R.• Travel Medicine – Keystone, J.S., Kozarsky, P.E., et al 74
  75. 75. WebsitesEurosurveillance www.eurosurveillance.orgTravax EnCompass www.travax.comGIDEON www.gideononline.comInternational SOS www.internationalsos.comMedical Advisory Service for Travelers Abroad (MASTA) Forces Medical Intelligence Center Intelligence Agency 75
  76. 76. Travel Insurance sites• Department of State ( )• International SOS(• MEDEX ( )• International Association for Medical Assistance to Travelers ( )• American Association of Retired Persons ( 76 )
  77. 77. Aaron Shelub MD• Aaron Shelub @aaronshelubmd•!/aaronshelubmd• shelub-md-30618 77
  78. 78. End 78
  79. 79. Picture of diseases from vacc shop 79