1 / 49

Travel Associated Infections

Travel Associated Infections. 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

gastelum
Télécharger la présentation

Travel Associated Infections

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Travel Associated Infections Sunanda Gaur, MD

  2. 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)

  3. Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis Hepatitis A Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV Infectious Disease Risks to the Traveler ETC.

  4. 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

  5. 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 )

  6. Causes of imported fever by region Bottieau et al Arch Int Med 166: 1642, 2005

  7. 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”

  8. Travelers’ Health Websitewww.cdc.gov/travel

  9. 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

  10. Causes of Traveler’s Diarrhea

  11. Causes of Traveler’s Diarrhea

  12. Food and Beverage Precautions Boil it , peel it, cook it or FORGET IT !!

  13. Food and Water Precautions • Bottled water • Selection of foods • well-cooked and hot • Avoidance of • salads, raw vegetables • unpasteurized dairy products • street vendors • ice

  14. 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)

  15. Destination Specific Vaccines

  16. The Meningococcal Meningitis Belt

  17. Don’t Forget the “Routine Vaccines” • MMR • dT ( New dTaP ) • Varicella • IPV • Hepatitis B

  18. Malaria

  19. Malaria

  20. MALARIA • Plasmodium vivax* • Plasmodium falciparum* • Plasmodium ovale • Plasmodium malariae * most common

  21. 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 ( Chloroquinsens)

  22. Malaria life cycle

  23. 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

  24. 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

  25. “ABCD” of malaria reduction • A Awareness of risk • B Bite prevention • C Chemoprophylaxis • D Diagnosis

  26. Mosquito Bite Prevention

  27. 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

  28. Malaria Prophylaxis

  29. Malaria Prophylaxis

  30. MalariaProphylaxis

  31. 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

  32. 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

  33. Commercially Available Typhoid Vaccines Available in the United States

  34. 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

  35. GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION

  36. 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

  37. Yellow fever Endemic Zones

  38. 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

  39. World Distribution of Dengue 1999 Areas infested with Aedes aegypti Areas with Aedes aegypti and recent epidemic dengue

  40. Travel related Tick-Borne Diseases

  41. 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

  42. 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

  43. Pre Travel Check List

  44. 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

  45. Kibera, Nairobi

  46. 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

  47. 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

  48. 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

More Related