In the name of God

1. In the name of God Dr. KianaShirani Assistant professor Infectious Diseases specialist

2. Infection in travelers

4. Epidemiology ofTravel-Related illness 22% to 64% of travelers report some illness; most of these problems are mild, self-limited illnesses such as diarrhea, respiratory infections, and skin disorders. Rates are significantly higher in summer.

5. Epidemiology ofTravel-Related illness Approximately 8% of travelers consult a physician either during or after a trip, but less than 1% require hospitalization. Infectious diseases account for up to 10% of the morbidity during travel but only 1% of the deaths, with malaria being the most common disease.

6. آفریقا: مالاریا-بیماریهای مننگوکوکی-اسهال مسافران-انواع عفونتهای انگلی ومایکوباکتریال-تبهای خونریزی دهنده- تب زرد-دانگ-هپاتیتها - بیماری خوابو... • جنوب شرقی آسیا:مالاریا-اسهال مسافران-هپاتیتهای ویروسی-ایدز- HTLV -بیماریهای انگلی در رابطه با غذاهای دریایی –عفونتهای تنفسی- انسفالیت ژاپنیو ... • هند:مالاریا-عفونتهای انگلی ومایکوباکتریال و قارچی-اسهال مسافران-کلرا-هپاتیت ها-عفونتهای تنفسی -آنفلوآنزا و ...

7. The most common communicable diseases in Mecca are include influenza, influenza-like illness, meningococcal disease, traveler diarrhea. مکه ومدینه: عفونتهای تنفسی فوقانی- پنومونی- عفونتهای مننگوکوکی- اسهال مسافران- هپاتیتهای ویروسی- سل- تبهای خونریزی دهنده

8. Acute respiratory tract infections Particularly so when the pilgrimage falls in the winter season. The close contact, intense congestion, shared sleeping accommodations (mainly in tents) and dense air pollution all combine to increase the risk of airborne respiratory disease transmission.

9. Upper respiratory tract infections A viral etiology of URTI is most commonly implicated at the Hajj, but bacterial super infection often follows. More than 200 viruses can cause. Influenza viruses are the most common, followed by RSV and adenoviruses.

10. Common cold • Incubation period: 1-3 days • Symptoms: sore or "scratchy" throat, nasal obstruction, rhinorrhea, Cough (rhinosinusitis) • Causes: rhinoviruses, coronaviruses, RSV, and … • Treatment: symptom therapy, rest, hydration, adrenergic agents, antihistamine, acetaminophen or NSAIDS

11. Sinusitis • Symptoms & signs: sore throat, headache, myalgias, occasionally Fever, Nasal congestion and discharge, periorbital edema, malodorous breath, nasal discharge vary from thin and mucoid to thick and purulent • The most common etiologic agents are viruses.

12. When to treat sinusitis with AB? 1.Compatible sign and symptoms lasting 10 days or more without improvement 2.Severe symptoms or signs (T>39, purulent nasal discharge, facial pain) lasting for at least 3-4 consecutive days at the beginning of illness. 3.Double sickening

13. Treatment of ABRS • AB • Saline irrigation • Intranasal corticosteroid Macrolide, antihistamine, decongestant should not be used.

14. First line: Coamoxiclav • Second line: high dose coamoxiclve, doxycycline, levofloxacin, moxifloxacin

15. Flu • incubation period : 1 to 2 days • Systemic symptoms predominate( fever, chills, shaking chills, headaches, myalgia, malaise, anorexia, In more severe cases, prostration) • The systemic symptoms usually persist for 3 days. Respiratory symptoms (dry cough, severe pharyngeal pain, nasal obstruction and discharge) are also usually present but are overshadowed by the systemic symptoms.

16. Flu The predominance of systemic symptoms is a major feature that distinguishes influenza from other viral upper respiratory infections. Fever is the most important physical finding.

17. Treatment • No studies have ever shown a benefit of antiviral therapy begun after 48 hours or more of symptoms, and the greatest effect is typically seen when therapy is started in the first 24 hours. • Oseltamivir/Zanamivir/Amantadine/Rimantadine • Precaution: droplet+ contact

18. Lower Respiratory Tract Infection Pneumonia is the leading cause of hospital admissions during Hajj; and the second leading cause of ICU admissions, with a reported mortality of 17%.

19. Pneumonia fever, chills, cough, sputum production, dyspnea, pleuritic chest pain, and new pulmonary infiltrates Outpatient treatment: Betalactam, macrolide, doxycycline, respiratory FQ

20. Lower Respiratory Tract Infection The causative agents could differ from those of CAP. In one study TB(28%) and gram-negative organisms(26%) were the most common causative organisms. Streptococcus pneumoniae was identified in (10%) patients, and atypical organisms were identified in only (6%) patients.

21. Tuberculosis The intense congestion, living in close proximity with vast crowds and the increasing percentage of elderly pilgrims are all factors magnifying tuberculosis risk. Additionally many Muslims travel from countries of high TB endemicity.

22. Pertussis One study found a high incidence of pertussis in Hajj pilgrims with an overall incidence of pertussis (1.4%) during this one-month-long pilgrimage Hajj pilgrims would therefore benefit from pertussis vaccination prior to their departure.

23. Etiology: small gr – coccobacilli • catarrhal stage: rhinorrhea, non purulent conjunctivitis with excessive lacrimation, occasional cough, low-grade fever, typically lasts 1 to 2 w • paroxysmal stage: paroxysms of coughing, uncontrollable coughing, often 10 to 15 coughs in a row in a single expiration, the face may turn red or purple, inspiratory whoop, post-tussive vomiting (1-6 W)

24. convalescent stage: The length of the cough distinguishes pertussis from other respiratory tract illnesses “cough of 100 days” cough of at least 14 days and at least one of the following symptoms: paroxysmal cough, inspiratory whoop, or post-tussive vomiting. • Treatment: macrolide, TS, FQ?

25. Face masks & vaccination To reduce the risk of RTI during the Hajj, wear surgical face masks when in crowded places and vaccination against seasonal influenza before, particularly those with pre-existing conditions (the elderly, people with chronic chest or cardiac, hepatic or renal disease and all health care workers working in the Hajj premises).

26. Influenza (pandemic) Vaccination mandatory Influenza (seasonal) Vaccination mandatory at least 2 weeks before arriving

27. The Saudi Ministry of Heaith requires from all healthcare workers working in Mecca and Medina to be vaccinated recommends influenza and pneumococcal polysaccharide vaccination for pilgrims older than 65 years and for those younger with underlying co-morbidities such as cardiovascular disease, chronic lung disease, diabetes, alcoholism, liver disease etc.

29. Age 2-23 monswith the PCV7. /PPV23 for all persons older than 2 ys who are at increased risk of developing pneumococcal infection or a serious complication of such an infection./ older than 65 ys; /anatomic or functional asplenia, CSF leak, DM, alcoholism, cirrhosis, CRF, chronic pulmonary disease (asthma), or advanced CVD;/immunocompromised( MM, lymphoma, HD, HIV, organ transplantation, use of glucocorticosteroid);/genetically susceptible (Native Americans & Alaskans);/live in nursing homes.

30. Meningoccocaldisease age annual rates per 100,000 population 0-2.9 3-9.9 10-24.9 25-120o Meningitis belt

31. Meningococcal disease During the Hajj, carrier rates for meningococcal disease rise to a level as high as 80 percent due to intense overcrowding, high humidity and dense air pollution. When rates of carriage rise to this level, the risk for meningococcal outbreaks becomes a real concern.

32. Meningococcal disease • The largest meningococcal outbreak among pilgrims occurred in 1987 with meningococcal serogroup A affecting pilgrims in Mecca and internationally.

33. Meningococcal disease • In the years 2000 and 2001, 2 large outbreaks of meningococcal serogroup W135 occurred among pilgrims and their families in Saudi Arabia and internationally. • Quadrivalent (A,C,Y, W135) meningococcal polysaccharide vaccine has eliminated future meningococcal outbreaks.

34. Treatment • Ceftriaxone • Pen G • Chloramphenicol for 10-14 days

35. Prophylaxis for: • Household contacts and sharing the same living quarters. • Daycare center or child care contacts, frequent playmates of young children • Close social contacts who were exposed to oral secretions in week before onset, such as by kissing, sharing eating utensils or toothbrushes. Chemoprophylaxis is not recommended for school, work, or transportation contacts.

36. Prophylaxis • Rifamipin: 600 mg BD for 2 days • Ciprofloxacin: 500 mg single dose • Ceftriaxone: 250 mg single IM dose

37. Vaccination college freshmen, living in dormitories, microbiologists routinely exposed to N.M; military recruits; travel to or reside in countries in which N.M is hyperendemic or epidemic; terminal complement component deficiencies; functional or anatomic asplenia, HIV infection.

38. Blood-borne diseases Muslim shave their heads. Head shaving is an important means of transmission of blood-borne disease. Illegal unlicensed barbers, shaving hair at the roadside with non-sterile blades, which are re-used on multiple scalps. We encourage all pilgrims to receive the full series of hepatitis B vaccination prior to travel to Hajj. As well, all pilgrims should avoid unlicensed barbers and seek approved licensed barber facilities.

39. Blood-borne diseases In a 1999 study which examined hepatitis serology in Hajj barbers showed that 4% of them were positive for HBsAg , 10% were HCV-positive, and 0.6% was positive for HbeAg, indicating high infectivity. use your own razor blades..!

40. Hepatitis B Countries/areas with moderate-to-high risk of infection

41. Diarrhoea Traveller’sdiarrhoea is common during the Hajj. The last study was done in 2002 showing that diarrhoea was the 3rd most common cause for hospitalization during Hajj.

42. Diarrhoea Pilgrims must be educated about self-treatment of diarrhoeal disease. Proper hydration and fluid intake is vital. The inclement conditions at the Hajj predispose to dehydration in all adults, let alone the extremes of age where dehydration is more expected.

43. Self-administered AB with an extended spectrum macrolide (azithromycin) or an oral quinolone are probably indicated for moderate to severe travelers’ diarrhea. Most pilgrims can be advised to carry a 3-day course of antibiotic therapy, an antimotility agent such as loperamide, and a thermometer.

44. Diarrhoea Significant improvement in water supply and sewage treatment has eliminated cholera outbreaks. Concerns still persist about importing cholera with pilgrims from affected countries, which will cause widespread outbreaks in Mecca.

45. Hepatitis A HAV is also common in Saudi Arabia, with 90% of adults being immune from natural infection. HAV vaccine is recommended for pilgrims from developed countries—it is probably unnecessary for those from developing countries since they are likely to be immune because of childhood exposure. Travelers can be checked for HAV IgG before administration of the vaccine, to avoid vaccination.

46. Hepatitis A Most pilgrims coming from high endemicity countries (Most) older pilgrims naturally protected → vaccination for youngers born in european countries!

47. Hepatitis A Countries/areas with moderate-to-high risk of infection

48. Malaria: no risk around Mecca-Medine-Jeddao Cholera: no cholera anymore since 1989

50. Thank you