Flashcards in M35: CC5: Traveler's Infections Deck (24)
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 _!
India > North Africa > South Africa
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
3) unprotected sex
syphilis, genital herpes, gonorrhea, Chlamydia, lymphogranuloma venereum (LGV), HIV and Hepatitis B
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).
Dengue, Chikungunya, and WNV
Malaria and Japanese encephalitis
WNV, Yellow Fever
5) animal bites
NSAIDS, antihistamines, anti-diarrheal, Oral Rehydration Salts (ORS), and antibiotics
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
8) schistosomiasis and leptospirosis
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 _.
age, pregnancy status, underlying health conditions, immunosuppressed state, medications and immunization history
parasites and TB
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)
b. Hepatitis B
c. post-exposure prophylaxis (PEP)
4) Yellow Fever
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)
– Yellow fever $ 95
– Typhoid (oral) $ 43
– MMR $ 10
– 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
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
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)
- fluoroquinolones, cotrimoxazole, azithromycin, doxycycline and rifaximin
- not recommended
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.
rural or primitive
The following choices are available for P. falciparum (4)
_ is only useful for P. vivax and P. ovale
a. Mefloquine (Lariam)
c. Atovaquone/proguanil (Malarone)
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
iii) Mefloquine (Lariam)
iv) Atovaquone/proguanil (Malarone)
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
Central/South America and Asia/Africa
inactivated (injection) or live attenuated (by mouth)
bactrim, amoxicillin or fluoroquinolones
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 _.
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
severe side effects
South East Asia
rurally and prolonged
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.
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 _.
2 additional doses of the rabies vaccine
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.
weeks, even to months
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
hemorrhagic fever, malaria
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 _.
• Malaria (falciparum) _ days
• Typhoid fever _ days
• Viral hemorrhagic fever _ days
• HIV, Lymphogranuloma venereum, HSV, syphilis
• cutaneous larva migrans
• Japanese encephalitis
• hepatitis A, E, typhoid fever
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
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
complete blood count (CBC)
chest Xray and abdominal ultrasound
Etiologies of fever for consideration in a returned traveler (7)
(iv) Dengue Fever
(v) Typhoid fever
(vi) Acute schistosomiasis (Katayama fever)
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)
Etiologies of confusion for consideration in a returned traveler (4)
(i) Viral encephalitis (Japanese encephalitis, West Nile virus)
(ii) Meningococcal meningitis
(iii) Typhoid fever
Etiologies of jaundice for consideration in a returned traveler (4)
(i) Hepatitis A
(ii) Hepatitis B
(iii) Hepatitis E
(iv) Yellow fever