Travel
Associated
Infections
Sunanda Gaur, MD
Qtr
1st
0
100
Qtr
2nd
Qtr
3rd
Qtr
4th
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 die
Steffen R et al. J Infect Dis 1987; 156:84-91 (ISTM)
Infectious Disease Risks to
the Traveler
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Malaria
Diarrhea
Leishmaniasis
Rabies
Dengue
Meningococcal
Meningitis
• Hepatitis A
ETC.
Schistosomiasis
Tuberculosis
Leptospirosis
Polio
Yellow Fever
Measles
JEV
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 Traveler
Geosentinal sites study
CID 2007 44: 1560-8 ( n=6957)
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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 Website
www.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 Diarrhea
Cause
Bacteria
Percent Isolation
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 Diarrhea
Cause
Percent Isolation
Protozao
Giardia lamblia
Entamoeba histolytica
Cryptosporidium ssp.
Cyclospora cayetanensis
0-5
0-5
0-5
?
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Viruses
Rotavirus
Enterovirus
0-20
0-20
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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
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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 Vaccines
Vaccine
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”
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MMR
dT ( New dTaP )
Varicella
IPV
Hepatitis B
Malaria
Malaria
MALARIA
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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
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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
–B
–C
–D
Awareness of risk
Bite prevention
Chemoprophylaxis
Diagnosis
Mosquito Bite Prevention
Vector
Precautions
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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.
Malaria
Prophylaxis
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
Drug
Ty21a
ViCPS
Type
Live Attenuated
Polysaccharide
Route
Oral
IM
Min Age of Receipt
6
2
No. Doses
4
1
Booster frequency,y
5
2
<5%
<7%
Side Effects(incidence)
Oral Ty21a Vaccine
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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:
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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 aegypti
Areas 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, Meningoencephalitis
Lyme Borreliosis
Europe
Rash, 7th nerve palsy,
aseptic meningitis
Bloodborne and STD Precautions
• Prevalence of
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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
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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 List
Routine immunization
Hepatitis A
Immune
Dose 1
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
Dose 2
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
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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
