Montezuma’s Revenge and Other Woes of Traveling

1. Montezuma’s Revenge and Other Woes of Traveling Catherine M. Bettcher, M.D. CME Director & Assistant Professor, Department of Family Medicine, University of Michigan

2. Learning Objectives • Determine appropriate destination-specific vaccinations prior to travel • Understand how to provide malaria chemoprophylaxis • Implement strategies to prevent and manage traveler’s diarrhea • http://travel.state.gov/ • http://www.who.int/ith/en

3. Immunizations • Update routine vaccinations • Search for recommended vaccinations for the specific destination • Go to www.cdc.gov/travel

4. Hepatitis A Vaccine • Consider for all travelers • Indicated for travelers to destinations with poor sanitation • Single dose provides protection in 14-28 days • Lifelong immunity with completed vaccine series

5. Typhoid Fever Vaccine • Indicated for travelers to endemic areas in Central and South America, Asia, and Africa

6. Other Vaccines • Give one additional polio dose for travel to certain countries in Asia and Africa • Yellow fever vaccine required for endemic areas in Africa and South America • Give meningococcal vaccine for travel to countries with frequent epidemics • Assess need for vaccinations against rabies and Japanese encephalitis

7. Malaria • Severe disease among travelers • Most cases are preventable • Risk depends on geographic area, type of accommodations, season, and elevation • http://www.cdc.gov/malaria/map/

8. Prevention of Mosquito Bites • Wear light colored clothing with long pants and sleeves • Apply repellent • Sleep under netting • Apply permethrin to clothing and tents • Stay indoors between dusk and dawn

9. Repellents • DEET (4-30%) • Higher formulations offer longer lasting protection • Avoid in infants < 2 months • Avoid combinations with sunscreen • Picaridin (7-20%) • Odorless, non-sticky, non-greasy • PMD/eucalyptus plant extract (10, 65%) • Avoid in children < 3 years

10. Malaria Chemoprophylaxis • Take antimalarial prior to, during, and after travel • Check chloroquine resistance in the destination • Consider contraindications to particular antimalarials

11. Antimalarial Drugs

12. Definition of Traveler’s Diarrhea • 3 or more unformed stools in 24 hours • May have low grade fever, N/V, cramping • Occurs in people traveling outside of their homeland

13. Risk Areas

14. Other Risk Factors • Younger age • Self organized activities • Backpacking • Not staying in hotels • Not staying with friends and family

15. Causes of Traveler’s Diarrhea • Mainly bacteria, like E. coli (and Campylobacter, Shigella, and Salmonella) • Less commonly viruses (rotavirus and norovirus) • Rarely parasites (Giardia and Cryptosporidium), except in long term travelers

16. Diagnosis of Diarrhea • No need to identify pathogen • Send a stool culture if fever or blood in stools • Send O&P and tests for Giardia and Cryptosporidium if diarrhea persists for 10-14 days

17. Treatment of Diarrhea • Traveler self treats based on the symptoms • Usually resolves with hydration alone • Take bismuth subsalicyclate or loperamide as needed • Start antibiotic if moderate to severe diarrhea

18. Drug Treatment • Short course of an antibiotic shortens the duration and severity of diarrhea • Give travelers a prescription to take if needed • Fluoroquinolone indicated as first line • Azithromycin needed for travelers to Southeast Asia because of resistant Campylobacter

19. Treatment Options *preferred for children

20. Patient Advice • Wash hands with soap and water • Wash cooking utensils with soapy water • Disinfect water if camping • Drink bottled water, soft drinks without ice • Eat hot, thoroughly cooked foods • Peel fruits and vegetables

21. Prevention of Diarrhea • Choose food and drinks wisely • Taking bismuth subsalicyclate provides 65% protection • Dose: 2 oz or 2 tabs po qid during travel • Do not use prophylactic antibiotics • No evidence for probiotics • No effective vaccine

22. Take Home Points • Update immunizations • Prescribe malarial chemoprophylaxis • Eat carefully and take bismuth subsalicyclate • No medication needed for diarrhea, but one dose of antibiotic usually works • Go to CDC and AAFP website

23. References • Bazemore A, Huntington M. The pretravel consultation. Am Fam Phys 2009 Sep 15;80(6):583-90. • Boulware DR. Influence of hygiene on gastrointestinal illness among wilderness backpackers. J Travel Med. 2004 Jan-Feb;11(1):27-33. • Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006 Dec 15;43(12):1499-539 • DiCesare D, DuPont HL, Mathewson JJ, et al. A double blind, randomized, placebo-controlled study of SP-303 (Provir) in the symptomatic treatment of acute diarrhea among travelers to Jamaica and Mexico. Am J Gastroenterol. 2002 Oct;97(10):2585-8. • DuPont HL, Jiang ZD, Okhuysen PC, et al. A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea. Ann Intern Med 2005;142:805-12. • Gascón J. Epidemiology, etiology and pathophysiology of traveler's diarrhea. Digestion 2006;73 Suppl 1:102-8. • Johnson BA, Kalra MG. Prevention of malaria in travelers. Am Fam Phys 2012 May 15;85(10):973-7.

24. References • Okhuysen PC, Jiang ZD, Carlin L, Forbes C, DuPont HL. Post-diarrhea chronic intestinal symptoms and irritable bowel syndrome in North American travelers to Mexico. Am J Gastroenterol 2004 Sep;99(9):1774-8. • Pakyz AL. Rifaximin: a new treatment for travelers' diarrhea.Ann Pharmacother 2005 Feb;39(2):284-9. • Redman CA, Maclennan A, Wilson E, Walker E. Diarrhea and respiratory symptoms among travelers to Asia, Africa, and South and Central America from Scotland. J Travel Med. 2006 Jul-Aug;13(4):203-11. • Riddle MS, Sanders JW, Putnam SD, Tribble DR. Incidence, etiology, and impact of diarrhea among long-term travelers (US military and similar populations): a systemic review. Am J Trop Med Hyg 2005 Feb; 74:891-900. • Sazawal S, Hiremath G, Dhingra U, Malik P, Deb S, Black RE. Efficacy of probiotics in prevention of acute diarrhea: A meta-analysis of masked, randomized, placebo-controlled trials. Lancet Infect Dis 2006;6:374-382. • Steffen R, Hill DR, DuPont HL. Traveler’s diarrhea: a clinical review. JAMA 2015 Jan;313(1):71-80.