Travel Associated Infections

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Sunanda Gaur, MD

Travelers’ Health Risks

Of 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 dieSteffen R et al. J Infect Dis 1987; 156:84-91 (ISTM)

Infectious Disease Risks to the Traveler

• Malaria• Diarrhea• Leishmaniasis• Rabies• Dengue• Meningococcal

Meningitis• Hepatitis A

• Schistosomiasis• Tuberculosis• Leptospirosis• Polio• Yellow Fever• Measles• JEV

ETC.

Diseases in Returning Travelers

• Fever : Malaria, Dengue ,Typhoid, nonspecific

• Diarrhea : Giardiasis, Amebiasis, bacterial, non specific

• Dermatologic : Insect bites, CLM, allergic rashes

• Non diarrheal Intestinal disorders : Hepatitis, Strongyloidosis

N Engl J Med 2006; 354:119-130

Fever in the Returned TravelerGeosentinal sites studyCID 2007 44: 1560-8 ( n=6957)

• Malaria 21%• Acute Diarrheal Disease 15%• Respiratory Illness 14%• Dengue 6%• Salmonella Infections 2%• Tick borne Illness 2%• 3% had vaccine preventable illness ( Hep

A, Typhoid Fever, Influenza )

Causes of imported fever by region Africa Asia Americas

Malaria 35% Unknown etiology 19% Unknown etiology 33%

Unknown etiology 25% Respiratory 13% Respiratory 16%

Respiratory 10% Dengue 12% Dengue 9%

Bacterial enteritis 5% Malaria 11% Bacterial enteritis 9%

Rickettsial 4% Bacterial Enteritis 9%, Typhoid 3%

Malaria 4 %

Bottieau et al Arch Int Med 166: 1642, 2005

Travel Health Resources

• CDC Travelers’ Health Website– www.cdc.gov/travel

• World Health Organization – www.who.int/int

• State Department – travel.state.gov

• International Society of Travel Medicine– www.istm.org

• Health Information for International Travel– CDC “Yellow Book”

• International Travel and Health– WHO “Green Book”

Travelers’ Health Websitewww.cdc.gov/travel

Traveler's Diarrhea

• In general, up to 50% of travelers develop at least one episode of diarrhea during a two week stay

• Onset usually within 2-3 days of arrival, > 90% occur within the first two weeks

• A self limiting illness with significant morbidity

Causes of Traveler’s DiarrheaCause Percent Isolation

Bacteria 50-75

Escherichia coli

Enterotoxigenic

Enteroadhesive

Enteroinvasive

5-70

5-70

?

?

Campylobacter spp. 0-30

Salmonella spp. 0-15

Shigella 0-15

Aeromonas 0-10

Plesiomonas 0-5

Other 0-5

Causes of Traveler’s DiarrheaCause Percent Isolation

Protozao

Giardia lamblia

Entamoeba histolytica

Cryptosporidium ssp.

Cyclospora cayetanensis

0-5

0-5

0-5

?

?

Viruses

Rotavirus

Enterovirus

0-20

0-20

?

No pathogen isolated 10-40

Food and Beverage Precautions

Boil it , peel it, cook it or FORGET IT !!

Food and Water Precautions

• Bottled water

• Selection of foods– well-cooked and hot

• Avoidance of – salads, raw vegetables– unpasteurized dairy products– street vendors– ice

Traveler’s Diarrhea

• Prevention : Antimicrobial prophylaxis is not recommended.

• Early self therapy is recommended• Oral rehydration• Fluoroquinolones remain drug of choice• Resistance is developing in some regions• Azithromycin ( Mexico , Thailand, Morocco ), ? preferable• Rifaximin ( non bloody stools, no fever)• Non specific agents ( Bismuth subsalycilate, loperomide)

Destination Specific VaccinesVaccine Risk Region

Yellow fever Parts of Africa and South America. (travel.state.gov)

Hepatitis B SE Asia, parts of Africa, Middle East, Pacific Islands, parts of South America

Hepatitis A All except Japan, Australia, New Zealand, north and west Europe, North America (except Mexico)

Typhoid Developing countries

Meningococcal Sub Saharan Africa

Japanese Encephalitis

Indian Subcontinent, SE Asia

Cholera Outbreak setting

Rabies South and SE Asia, Mexico, parts of South and Central America and Africa

Plague Outbreak Setting

The Meningococcal Meningitis Belt

Don’t Forget the “Routine Vaccines”

• MMR

• dT ( New dTaP )

• Varicella

• IPV

• Hepatitis B

Malaria

Malaria

MALARIA

• Plasmodium vivax*

• Plasmodium falciparum*

• Plasmodium ovale

• Plasmodium malariae

* most common

Malaria Risk

• Oceania 1: 5 ( chloroquin res Vivax)

• Sub-Saharan Africa 1:50 ( falciparum)

• South Asia 1:250 ( mainly vivax)

• SE Asia 1:2500 ( multi res falciparum)

• Mexico/Central Am 1:10,000 ( Chloroquin sens)

Malaria life cycle

Malaria

• All febrile returning travelers should be considered to have malaria until proven otherwise

• Serial blood smears (thick and thin) every 8-12 hours in the first 24 – 48 hours

• Thick smears are 10 – 40 times more sensitive than thin smears. Thin smears important for quantitation of parastemia

• Important to identify the species

Fatal Malaria

• 45 fatal cases between 1980 – 1992• 98% caused by P. falciparum• 82% acquired in Sub-Saharan Africa• Most cases were associated with lack of

chemoprophylaxis, suboptimal chemoprophylaxis, delay in seeking medical attention, and delay in diagnosis

“ABCD” of malaria reduction

– A Awareness of risk– B Bite prevention– C Chemoprophylaxis– D Diagnosis

Mosquito Bite Prevention

Vector Precautions

• Covering exposed skin• Insect repellent containing DEET 30 – 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

Malaria Prophylaxis

Drug Mefloquine

Usage In areas with chloroquine resistant Plasmodium falciparum and vivax. Highly effective

Adult Dose 22mg base (250 mg salt) orally, once/week, continue for 1 week after return

Side effects 25% mild headache, GI upset, malaise, anxiety

1/250-1/500 nightmares, irritability, depression

Comments Contraindicated in persons allergic to mefloquine. Not recommended for persons with epilepsy and other seizure disorders; with severe psychiatric disorders; or with cardiac conduction abnormalities.

Malaria Prophylaxis

Drug Doxycycline

Usage An alternative to mefloquine

Adult Dose 100 mg orally, once/day

Pediatric Dose

>8 years of age: 2mg/kg of body weight orally/day

up to adult dose of 100 mg/day

Comments Contraindicated in children < 8 years of age, pregnant women, and lactating women.

MalariaProphylaxis

Drug Chloroquine phosphate

Usage In areas with chloroquine sensitive Plasmodium flaciparum

Adult Dose 300 mg base (500 mg salt) orally, once/week

Pediatric Dose

5 mg/kg base (8.3 mg/kg (salt)) orally once/week up to maximum adult dose of 300 mg base

Comments

Malarone (Atovaquone and Proguanil Hydrochloride)

• Atovaquone - a broad spectrum antiprotozoal inhibits the parasites mitochondrial electron transport.

• Treatment with Atovaquone alone results in rapid development of resistance.

• Atovoquone and Proguanil are synergistic against multi drug resistant P. falciparum

• Several studies have demonstrated the efficacy of this combination in treatment and prophylaxis of multidrug resistant P. falciparum

• Daily dosing ( 2-3 days prior, 7 days after), high cost• Occasional headache, GI upset

Typhoid Fever

• Caused by S.typhi or S. paratyphi• In US 445 cases/year between 1967 – 1994• 72% of cases in the recent years (1985-1994) occurred in returning

travelers• Travel to Mexico and India account for >50% of cases• Fever, chills, headache, malaise, abdominal pain, and constipation

are common symptoms.• Blood cultures positive in 40-66%, bone marrow culture positive in

90%• Increasing antibiotic resistance – particularly in India – consider

Ceftriaxone or Ciprofloxacin as first line therapy

Commercially Available Typhoid Vaccines Available in the United States

DrugDrug Ty21a ViCPS

TypeType Live Attenuated Polysaccharide

RouteRoute Oral IM

Min Age of ReceiptMin Age of Receipt 6 2

No. DosesNo. Doses 4 1

Booster frequency,yBooster frequency,y 5 2

Side Side Effects(incidence)Effects(incidence)

<5% <7%

Oral Ty21a Vaccine

• Live attenuated vaccine• Enteri coated capsule – 1 cap every other day x 4 doses• Efficacy – 65%• Minimal to no side effects• Contraindicated in immune compromised individuals• Mefloquine can inhibit growth of Ty21a in vitro; delay

vaccine at least 24 hours before or after Mefloquine• Concommitant or antimicrobials may effect vaccine

efficacy

GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION

Hepatitis A Vaccine

• Inactivated Vaccine• Approved for children 2-18 years old and adults• Highly Immunogenic

– 88 – 90% seroconversion in 2 weeks– 99% seroconversion after 2nd dose

• Duration of protection – under evaluation• Indicated for:

– Foreign travel– Residence in communities with high endemicity – Patients with chronic liver disease– Homosexual/bisexual men– IVDU– Occupational risk

Yellow fever Endemic Zones

Yellow Fever Vaccine

• Live vaccine• Required if entering endemic area or going from an

endemic region to non-endemic region• Approved for children > 9 months old• Do not administer simultaneously with cholera vaccine• Under 4 months – unsafe (high incidence of post

vaccination encephalitis)• Adverse effect ( viscerotropic disease) : 1 in 2-3 million

World Distribution of Dengue 1999

Areas infested with Aedes aegyptiAreas with Aedes aegypti and recent epidemic dengue

Travel related Tick-Borne Diseases

Tick Borne Relapsing Fever

Israel, Africa, South Asia

Every 3-5 days fever episodes

African TBF Southern Africa Fever, h/a ,eschars

Mediterranean Spotted fever

Mediterranean , South Asia, E&S Africa

Similar to African TBF, more severe

TBE Central and E Europe Fever, Meningo-encephalitis

Lyme Borreliosis Europe Rash, 7th nerve palsy, aseptic meningitis

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

Post Exposure HIV prophylaxis

• Assess likelihood of exposure• Assess degree of exposure• Begin ARV prophylaxis within 12-24 hrs.• 2-3 drug combinations recommended depending

on exposure risk . To be continued for 4 weeks.• http://www.cdc.gov/mmwr/PDF/rr/rr5409.pdf or

http://www.ucsf.edu/hivcntr/hotlines/PEPline

Pre Travel Check ListRoutine immunization

Hepatitis A Immune Dose 1 Dose 2

Polio Immune One dose IPV

Meningococcal One dose Booster

Typhoid Oral 4 doses One dose IM Booster

Malaria Chloroquin Mefloquin Malarone Doxy

Diarrhea Loperamide Ciprofloxacin Azithromycin Oral rehydration

Allergy Antihistamine Epi Pen

Soft tissue infection Cefalexin bacitracin

Motion sickness/GERD Dramamine/H2 blocker

Food and water precautions Instruction

Adventure/long stay Rabies Yellow fever JE

Special problems Asthma Diabetes

Mantoux status

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

Kibera, Nairobi

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

Rabies

• Rabies in travelers – an underestimated risk• 1980 – 1997 12/36 (33%) of human rabies deaths in US have been

related to rabid animals outside the US• Canine rabies in endemic in the Indian Subcontinent, China, SE

Asia, Philippines, Latin America, Africa and the former Soviet Union• In many rabies endemic countries, only Equine RIG and older

Semple rabies vaccines are available• Equine RIG – significant risk of serum sickness• Semple type rabies vaccine is not as effective, and theoretical

danger of allergic myeloencephalitis exists• Pre-exposure prophylaxis should be considered in selected cases

Japanese Encephalitis Vaccine

• Inactivated vaccine• Efficacy = 91%• Booster every 3 years• Not approved for children under 3 years• Side effects

– Local reaction (10-25%)– Fever (10-25%)– Hypersensitivity reaction (0.6%)

• Indications– Expatriates living in Asia– Travel to endemic regions for >30 days during transmission

season, especially travel to rural areas