M35: CC5: Traveler's Infections Flashcards Preview

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Flashcards in M35: CC5: Traveler's Infections Deck (24)
1

Travel and Illness

20-64% of travelers to the developing world report some health problems encountered during their trip or after return such as _ with an incidence of 30% in travelers for a 2-3 week trip ((country) > (country) > (country)).

Most of these are _ (60% of travelers with _ are better in 48 hours) but 8% of the patients are ill enough to seek medical care for the following health problems:

– _ 13%
– _ infections 10%
– _ disorders 3%
– _ illnesses 2%

However, keep in mind that the main morbidity in travelers is not from infectious diseases but from _!

diarrhea
India > North Africa > South Africa

self limiting
diarrhea

–Diarrhea
–Respiratory infections
–Skin disorders
–Febrile illnesses

accidents

2

General Travel Advice

1) Food/drinks: “Boil it, Peel it or Forget it”. Discuss the avoidance of _ and _, realizing that 90% of traveler’s make errors such as drinking beverages with _ (made from tap water), or eating _ (rinsed in tap water)

2) _ trauma

3) Sex-STI’s: Up to 40% of single travelers have _. They are at risk of acquiring (7)

1) contaminated food and water
ice cubes
salads

2) Road

3) unprotected sex
syphilis, genital herpes, gonorrhea, Chlamydia, lymphogranuloma venereum (LGV), HIV and Hepatitis B

3

General Travel Advice

4) Insect precautions are not only for _, but also to prevent acquisition of _, _, and _.

Premier biting times of most mosquito’s are at dusk and dawn ((disease) and (disease)) but some are daytime feeders ((disease) and (disease)).

Advise to use protective clothing covering all _, liberal use of _ containing insect repellants and bednetting (permethrin impregnated) unless sleeping in an airconditioned hotel.

5) Avoidance of _. Feeding monkeys puts people at risk for bites and _ infection, causing serious encephalitis. Biking and jogging make dogbites more likely with the risk of acquiring _.

6) Local Medical Care: Discuss health insurance and medical evacuation coverage. The test results from local laboratories may not always be _. Some medication sold by local pharmacies are _ and may not contain any active ingredients.

Discuss an emergency medical kit containing (5).

4) malaria
Dengue, Chikungunya, and WNV

Malaria and Japanese encephalitis
WNV, Yellow Fever

skin
DEET

5) animal bites
Herpes B
rabies

6) reliable
counterfeits

NSAIDS, antihistamines, anti-diarrheal, Oral Rehydration Salts (ORS), and antibiotics

4

General Travel Advice

7) Travelers arriving at the following high altitude destinations are at significant risk for altitude sickness: (4)

In addition, travelers who dive at their destination need to allow sufficient decompression time prior to _.

8) Swimming and rafting in fresh water lakes and rivers world wide puts travelers at risk for _ and _ while biking and jogging increase the risk of dog bites and associated _

9) Pre-existing illnesses. Ensure an own _ supply in carry-on luggage. _ stating necessity of injection paraphernalia (diabetes patients) or pain medications may be necessary to get through customs.

7) - Lima, Peru
- La Paz, Bolivia
- Lhasa, Tibet
- Mt. Kilimanjaro, Africa

flying

8) schistosomiasis and leptospirosis
rabies

9) medication
Letters

5

General Travel Advice

In order to give specific travel advice you need to know the following specifics about the

A) _: General health assessment including (6)

B) _: Details of the trip include the _ of travel, _, _ with planned and unplanned (but possible) activities.

Many travelers have a limited budget and you may have to prioritize _ while taking in consideration the _ efficacy, risk of disease acquisition and potential severity of the preventable illness.

In addition there are issues of _ (Hep B vaccine should be given in 3 doses) and _. Some expats, immigrants (refugees) and long term travelers may benefit from a post-travel evaluation, mainly for the presence of _ and _.

A) Host
age, pregnancy status, underlying health conditions, immunosuppressed state, medications and immunization history

B) Environment
season
duration
itinerary

vaccinations
vaccine

timing
availability
parasites and TB

6

General Travel Advice

Specific advice should be given to

1) _ travelers whether they can safely receive _ immunizations and whether _ vaccines are efficacious.

2) Region and season-specific advice depending on the _ of certain diseases (malaria, yellow fever, tick-borne encephalitis, Japanese encephalitis and meningococcus).

3) Health care workers need to

a. Assess their risk for acquisition of _ and the need to bring fit-tested _ and pre- and post travel _ exposure screening with either a PPD or IGRA (interferon-gamma release assay)

b. _ (required vaccination in USA)

c. Ensure availability of _ for HIV ($3000 for a 28 day supply).

4) Government regulations may require certain vaccinations before allowing entry into the country (disease)

1) Immunocompromized
live attenuated
inactivated

2) endemicity

a. TB
N95 respirators
TB

b. Hepatitis B

c. post-exposure prophylaxis (PEP)

4) Yellow Fever

7

Vaccinations

It is a great opportunity to update the standard vaccinations if indicated: (5)

Costs of the following vaccinations through the Allegheny Health Dept. (2012)

Live-attenuated vaccines (7)

Inactivated vaccines (12)

–TdaP (Tetanus, Diphteria and acellular Pertussis)
–Influenza
–Pneumovax
–Polio
–Measles

– Yellow fever $ 95
– Typhoid (oral) $ 43
– MMR $ 10
– BCG
– Influenza (Flumist) $ 25
– Polio (OPV) N/A
– Varicella $ 85

– Hepatitis A (series of 2) $146
– Hepatitis B (series of 3) $186
– Hep A/B (twinrix)(series of 3) $327
– Meningococcal $117
– Typhoid (IM) $ 58
– Rabies (series of 3) $645
– Japanese encephalitis (series of 3) $350
– Tick borne encephalitis (series of 3) $300 (not available in USA)
– Pneumococcal $ 36
– Influenza $ 10
– TdaP $ 10
– Polio (IPV) $ 36

8

Travelers’ diarrhea

Causes of traveler’s diarrhea are:

A) Bacterial 50-75%, of which half is _ followed by (3)

B) Viral 5-20%, mostly _ and _

C) Parasites 0-5%, mostly _ and _

A) E. coli
Salmonella, Campylobacter and Shigella

B) Norovirus and Rotavirus

C) Giardia and Cryptosporidium

9

If travelers experience traveler’s diarrhea the following algorithm can be used:

1) Self treatment with _ should be advocated at all times.

2) _ (_) can be used if more than 2 loose stools per 24 hours, but not in case of concomitant _ (T >38C) or _ is present in stool unless antibiotics are used also

3) _ works 50% in decreasing diarrhea

4) _ will decrease the duration of diarrhea from 3 days (untreated) to 1 day and are indicated if the diarrhea is accompanied by

a. a _ (T >38C), or
b. the presence of _ or
c. >(#) loose stools per 24 hours.

- Common antibiotics used are (5).

- Prophylactic antibiotics are generally (recommended / not recommended) for routine travelers.

1) hydration (ORS)

2) Loperamide (Imodium)
fever
blood

3) Pepto-bismuth

4) Antibiotics
a. fever
b. blood
c. 5

- fluoroquinolones, cotrimoxazole, azithromycin, doxycycline and rifaximin

- not recommended

10

Malaria

Travelers visiting friends and relatives (VFR’s) are at highest risk for getting malaria, especially in (continent) (then (continent) and lowest risk in (continent)).

They generally stay at more _ or _ places, while adapting to the lifestyle of the locals.

Former immigrants may (wrongly) believe they are _ to malaria while within years of not being exposed this protective effect has disappeared.

In addition to the preventive measures mentioned earlier (protective clothing, insect repellants with DEET and permethrin impregnated bednetting), _ is often indicated even although only 50-60% of travelers are adherent to this therapy.

Africa
SE Asia
Central/South America

rural or primitive

immune

chemopropylaxis

11

Malaria

The following choices are available for P. falciparum (4)

_ is only useful for P. vivax and P. ovale

chloroquine
Doxycycline
Mefloquine (Lariam)
Atovaquone/proguanil (Malarone)

Primaquine

12

Malaria Drugs

a. Mefloquine (Lariam)
b. Chloroquine
c. Atovaquone/proguanil (Malarone)
d. Doxycycline

Comments

i) Limited use because of widespread resistance

ii) Candida vaginitis, sun sensitivity, not for children

iii) Neuropsychiatric SE, cheaper > 7 days, discont. rate 2-5%

iv) Take with food, cheaper

i) Chloroquine

ii) Doxycycline

iii) Mefloquine (Lariam)

iv) Atovaquone/proguanil (Malarone)

13

Typhoid fever (Salmonella typhi)

This is a febrile illness characterized by _ and _ but not often with _.

It is most commonly acquired in the _ subcontinent, but also seen in _/_ and _/_.

The efficacy of the _ (_) or _ (_) vaccine lasts 3 and 5 years respectively but is only 50-70% effective.

Typhoid fever can be treated with _, _, or _ although resistance is becoming very common so empiric _ is recommended.

fever and malaise
diarrhea

Indian
Central/South America and Asia/Africa

inactivated (injection) or live attenuated (by mouth)

bactrim, amoxicillin or fluoroquinolones
ceftriaxone

14

Yellow fever

This is a _ but often _ illness (Case fatality rate 20-50%) characterized by _.

Outbreaks occur in (continent) and in (continent) (15 degrees on either side of the equator).

Only 10-30% of American travelers receive adequate Yellow fever immunization with the _ vaccine that lasts about 10 years.

About 1:100,000 vaccine recipients experience _.

Japanese encephalitis

This only affects 1:1,000,000 travelers to (continent) but has a mortality rate of 20%.

It is generally recommended when traveling _ and _ stays

rare
fatal
jaundice

South America
Africa

live-attenuated

severe side effects

South East Asia

rurally and prolonged

15

Meningococcal vaccine

Indicated for some travelers to the meningococcal belt in (continent) during the period Dec-June and especially for pilgrimage to _ where most countries require proof of vaccination before entry.

Rabies vaccine

Unvaccinated individuals need rabies _ in addition to 4 doses of the rabies _ as post-exposure prophylaxis.

Even after receiving the vaccine as pre-exposure prophylaxis, patients that are bitten by a suspected rabid animal still need _.

Africa
Mecca (Hajj)

IgG
vaccine

2 additional doses of the rabies vaccine

16

What are the causes of the symptoms of infection in returned travelers?

The last century has seen an explosion in the ability of people to travel from the United States to environments where “_” pathogens exist.

A travel history is an essential component of history-taking. It must be remembered that some infections have an incubation period of _, even to _.

Failure to ask about travel may have disastrous consequences if infections such as _ are missed.

exotic

weeks, even to months

malaria

17

Essentials of a travel history

(i) Where did you go? _ vs. _
(ii) What did you _ there?
(iii) _ did you go?
(iv) What _ did you take or did you not take?
(v) _ history (including _)

WHERE exactly has the patient been?

It is very important to determine if the patient has been in an area endemic for _, _, or where a local outbreak may be occurring (_ in many islands in the Indian Ocean)

i) Major cities vs. rural areas
ii) do
iii) When
iv) precautions
v) Immunization
childhood vaccinations

hemorrhagic fever, malaria
Chikungunya

18

WHAT exactly did the patient do?

• Eco-challenge in Borneo (_)
• Swimming in Lake Malawi (_)
• Unprotected MSM in Amsterdam (_, _, _, _)
• Beach vacation in Bermuda (_)
• Camping in rural Cambodia (_)
• Exploring food from street vendors in Bangkok (_, _, _)
• Spelunking in Mexico (_)

WHEN and for HOW LONG? Determine the _ time and _ time.

• Short exposure during travel increases the incidence of (4).

• Long exposure to the local environment or people increases the risk of _ and _ diseases such as _ or _.

Incubation Time
• Malaria (falciparum) _ days
• Typhoid fever _ days
• Viral hemorrhagic fever _ days

• leptospirosis
• schistosomiasis
• HIV, Lymphogranuloma venereum, HSV, syphilis
• cutaneous larva migrans
• Japanese encephalitis
• hepatitis A, E, typhoid fever
• histoplasmosis

exposure
incubation

influenza, diarrhea, upper respiratory infections (URI’s) or a non-travel related illness

tuberculosis and parasitic
amebic liver abscess or strongyloidiasis

• 7-90 days
• 7-21 days
• 2-21 days

19

What to evaluate in a returning traveler with fever?

A thorough physical exam is mandatory, including a neurologic exam for _ and _, the skin for any _ or _, an abdominal exam to evaluate for _ and all lymphnode stations for _.

A laboratory exam will usually include a _ with differential, liver enzymes, a thick and thin blood smear, a urine analysis, blood and stool cultures as well as an ova and parasite exam of stool.

In addition, a _ and _ may be indicated.

encephalopathy and meningismus
rashes or lesions
hepatosplenomegaly
lymphadenopathy

complete blood count (CBC)

chest Xray and abdominal ultrasound

20

Etiologies of fever for consideration in a returned traveler (7)

(i) Malaria
(ii) Malaria
(iii) Malaria
(iv) Dengue Fever
(v) Typhoid fever
(vi) Acute schistosomiasis (Katayama fever)
(vii) Leptospirosis

21

Etiologies of diarrhea for consideration in a returned traveler (3)

(i) Bacterial infections (E. coli, Salmonella, Shigella, Vibrio cholerae)
(ii) Protozoal infections (Giardia, Cryptosporidium, Entameba)
(iii) Viral infections (Norovirus, Rotavirus, etc)

22

Etiologies of confusion for consideration in a returned traveler (4)

(i) Viral encephalitis (Japanese encephalitis, West Nile virus)
(ii) Meningococcal meningitis
(iii) Typhoid fever
(iv) Malaria

23

Etiologies of jaundice for consideration in a returned traveler (4)

(i) Hepatitis A
(ii) Hepatitis B
(iii) Hepatitis E
(iv) Yellow fever

24

Returning traveler with an illness; the following common and less common (but urgent) diagnoses to consider are:

•Most common (9)

•Most urgent (all these cause a fever) (4)

– Malaria
– Infected insect bite
– Diarrhea
– Upper respiratory illness (URI)
– Dengue
– Typhoid
– Chikungunya
– Hepatitis A
– Rickettsial infection

– Malaria
– Typhoid
– Amebic liver abscess
– Viral Hemorrhagic Fever