This document discusses travel-related infections and provides an overview by Matthew Rollosson, an RN with expertise in travel medicine. It recommends travelers consult a travel medicine specialist at least one month before departure to endemic countries. It then lists Matthew Rollosson's background and experience in travel medicine and tropical countries.

1. Matthew Rollosson, RN, MPH&TM

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.  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,
2009
Niger River, Mali, 1988

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.  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.  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.  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.  Death:
 Non-infectious
 Cardiovascular disease
 Drowning
 Motor vehicle accidents
 Infectious disease
 Malaria
 Most common non-fatal illness:
 Travelers’ diarrhea
Steffen & Grieve, 2013

9. 3000
2820
2500
2000
1500
1000
500 428
88
18 6 1
0
Falciparum Typhoid fever Leptospirosis DHF/DSS East African Japanese
malaria trypanosomiasis encephalitis
Jensenius et al., 2013

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. CDC 2012

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.  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.  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.  “Breakbone fever”
 Fever
 Rash
 Arthralgia
 Myalgia
 Headache
 Transmitted by mosquitoes
 Dengue hemorrhagic fever (DHF)
 Dengue shock syndrome (DSS)
 Vaccines in clinical trials

16. CDC, 2012

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 typhus
Ticks  Plague
 Babesiosis
 Ehrlichiosis/Anaplasmosis Lice
 Relapsing fever  Epidemic typhus
 Rickettsial pox  Relapsing fever
 Tick typhus
 Tularemia Sandflies
 Leishmaniasis
Blackflies (Simulium)
 Onchocerciasis Tsetse
 African trypanosomiasis

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.  4 – 6 weeks before travel
 Accelerated schedule
 Routine
 Age-specific
 Recommended
 Destination-specific
 Required
 Destination-specific
 Yellow fever
 Meningococcal (Hajj)
Jong, 2008

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.  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.  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.  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.  Hepatitis A
 Hepatitis B
 Japanese encephalitis
 Meningococcal
 Pneumococcal
 Typhoid
 Varicella
 Yellow fever

25.  Hepatitis A
 Hepatitis B
 Meningococcal
 Pneumococcal
 Varicella

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. CDC, 2012

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. 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 dose
Do not prevent non-typhoidal Salmonella
infections

30.  Flavi- “yellow”
 Dengue
 Japanese encephalitis
 St. Louis encephalitis
 Tickborne encephalitis
 West Nile virus
 Yellow fever

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.  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. CDC, 2012

34.  International Certificate of Vaccination or
Prophylaxis (ICVP)
 Vaccine must be administered by a provider
with an official uniform stamp
wwwnc.cdc.gov/travel/yellow-fever-vaccination-clinics/search.htm
CDC, 2012

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. CDC, 2012

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

45.  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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51. Congo River, 1989