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Flashcards in Travel Medicine Deck (51):
1

Key factors in determining the health risks to which travelers may be exposed are?
6

1. destinations
2. duration of visit
3. purpose of visit
4. standards of accommodation and food
5. hygiene
6. behavior of the traveler

2

Pre-Trip Recommendations
14

1. Basic medical kit
2. Analgesics (acetaminophen, aspirin, ibuprofen)
3. Antibiotic for self-treatment of diarrhea (ciprofloxacin, azithromycin)
4. Anti-diarrheals…bismuth subsalicylate(Pepto Bismol), loperamide (Imodium)
5. Antihistamines
6. Antimalarials
7. Antinausea/motion sickness (Bendadryl, Dramamine) meds
8. Sleeping medication
9. Insect repellent
10. Water purifier or tablets
11. Cold/sinus/cough medication
12. Sunscreen
13. Wound dressings
14. Antiseptic

3

Risk Assessment looking at Itinerary?
7

1. Regions visiting
2. Urban v Rural
3. Dates and lengths
4. Purpose
5. Modes of transportation
6. Activities
7. Accommodations

4

Traveler demographics
risk assessment?
5

1. Health/medical history
2. Vaccinations
3. Medications/allergies
4. Pregnancy
5. Planned surgeries/medical care

5

Environmental Precautions
8

1. Air Travel
2. Jet Lag (Melatonin?)
3. Sun Protection
4. Extreme Heat and Cold
dehydration, heat stroke
hypothermia, frostbite
5. Altitude (Lake Titicaca 12,570 feet)
6. Water recreation
7. Drowning, boating & diving accidents
8. Biological and chemical contamination

6

Food and Water Precautions
2

1. Bottled water may be best
2. Selection of foods
--well-cooked and hot

7


What foods/things to avoid?
5



Avoid
1. salads,
2. raw vegetables
3. unpasteurized dairy products
4. street vendors
5. ice

8

Determine If Pre-existing Health Status Precludes Travel:
Flying contraindications for Cardiovascular disease?
3

1. Less than 3 weeks post MI
2. Longer “wait” following complicated courses
3. ~ 2 weeks post CABG

9

Determine If Pre-existing Health Status Precludes Travel:
Flying contraindications for Pulmonary disease?
3

1. 2-3 weeks post chest tube removal
2. Pao2
3. See if patient can walk up flight of stairs or walk 50 yards as practical stress test

10

Determine If Pre-existing Health Status Precludes Travel:
Flying contraindications for Post-op?
3

1. Increased risk of DVT, especially in “economy” class seats
2. Recommended wait of 2 weeks
3. Recommend frequent movement and walking through cabin

11

Determine If Pre-existing Health Status Precludes Travel:
Severe Anemia?
3

1. Hgb
2. Recommended wait of 2 weeks
3. Recommend frequent movement and walking through cabin

12

What might flying after diving lead to?

What should we wait how long after diving before flying?

May lead to decompression illness

Should wait 12 hours after diving

13

General Recommendations for Travel Patients With Cardiopulmonary Disease
8

1. Carry all medications on board
2. Be aware of dose intervals while crossing time zones
3. Carry a recent EKG
4. Carry a pacemaker card with an EKG
5. Use airline special services: wheelchairs, trolley service, special diet, oxygen, pre boarding
6. Walk through the cabin frequently, perform in-seat range-of-motion exercises and deep breathing exercises
7. Avoid alcohol and drink plenty of fluids
8. Wear support hose

14

Vaccines up to date?
(which ones?)
11

Poliovirus
Hep A
Hep B
Meningococcal
Influenza
Tetanus, Diptheria, Pertusis
MMR
Varicella
HIB
Influenza
Pneumococcal

15

Vaccines you may need before you go?
7

Typhoid
Yellow Fever
Rabies
Japanese Encephalitis
Cholera
Tick-borne Encephalitis
Tuberculosis

16

Motion sickness prophylaxis?
3

What is the only one that works after symptoms are started?

Meclizine (OTC)
Promethazine (needs Rx)**
Transdermal scopolamine (needs Rx)

Promethazine works after symptoms started

17

What is Jet Lag?

What are the symptoms?
4

Disturbance of circadian rhythms due to crossing time barriers

Symptoms-
fatigue,
irritability,
nausea,
difficulty concentrating

18

Three helpful therapies for Jet Lag?

1. Light therapy
2. Diet therapy (Ehret-Scanlon’s Jet Lag Diet)
--Alternate high and low food intake before travel and high protein and low carb lunches before and after travel
3. Melatonin therapy

19

Problems at Your Destination Altitude Sickness:
Symptoms include headache and one or more of the following? 5

What is the pathology of altitude sickness?

Nausea
Vomiting
Fatigue
Malaise
Insomnia

Due to relative hypoxemia and delay in development of compensatory erythrocytosis

20

Problems at Your Destination
Altitude Sickness:
Acute Mountain sickness usually acclimation occurs in how many days?

2-3 days

21

Altitude sickness prevention?
5

1. Gradual ascent-300 meters/day
2. Spend a few days at intermediate altitudes (2500-3000 m)
3. Slowly ascend at > 2500 m
4. Spend an extra night for every 600-900 m if continuing to ascend. Climb high, sleep low
5. Avoid alcohol and sedative-hypnotics

22

High Altitude Pulmonary Edema (HAPE) pathology?

Who is most susceptible?

Symptoms include?
6


Signs include?

What must you have for the diagnosis?

Combination of low hypoxic ventilatory drive and over perfusion

Young physically fit males most susceptible

Weakness
Decreased exercise performance
Chest congestion
Dyspnea
Wheezing

Wheezing
Crackles (rales)
Cyanosis
Tachycardia

Must have two signs and two symptoms for diagnosis

23

How should we treat HAPE?
3

This will be on the test!

Rx-Diamox

1. Acetazolamide--125-250 mg by mouth every 8 to 12h starting 24h before ascent and continue for 2 days at altitude
2. Steroids-Dexamethasone
3. Nifedipine

24

MOA of Acetazolamide?

Mild diuretic which increases amount of excreted bicarb, which in turn increases the blood pH which in turn causes you to hyperventilate which increases oxygen saturation

25

MOA of Nifedipine?
2

1. Decreases pulmonary hypertension
2. Improves oxygen saturations

26

High Altitude Cerebral Edema (HACE) signs and symtpoms?
5

How serious is this illness?

How should we treat it? 3

1. Hallucinations
2. Focal neurologic signs
3. Seizures
4. Stupor
5. Coma

A medical emergency…

patients need
1. high flow oxygen and
2. prompt DESCENT to lower altitude
3. Dexamethasone to reduce edema

27

How should we treat stings from
Coelenterate family:
Sea urchins
Jellyfish
Anemones
Portuguese man-o-war
Release nematocysts from tentacles
?

Treat with vinegar

28

Papulovesicular rash caused by larvae of coelenterates is called what?

What is the treatment?
5

Sea bathers eruption (sea lice)

1. Shower
2. Soak affected part in vinegar
3. Discard bathing suit
4. More susceptible after initial infestation
5. Future infestations can cause severe allergic reactions

29

Signs of cholera?
4




Prevention/treatment
of Cholera? 2

1. Rice water diarrhea
2. Vomiting,
3. circulatory collapse and shock.

4. Many infections may only have milder diarrhea or be asymptomatic.

1. Simple rehydration treatment saves lives
2. Adjunct antibiotic treatment (reisistance is high)

30

Signs of Hepitis?
7





Treatment?

1. Jaundice,
2. fatigue,
3. abdominal pain,
4. loss of appetite,
5. nausea,
6. vomiting,
7. joint pain

…..30% asymptomatic


Adefovir, dipivoxil, interferons, lamivudine, entecavir, and telbivudine are drugs used for the treatment of persons with chronic hepatitis B
New treatments with high cure rate…..sofosbuvir/ledipasvir (Harvoni)

31

Typhoid caused by what?

Symtpoms?
4
Test!!!!


Treatment?
3


Where does it live? 2

How is it spread?

Salmonella typhi
Contaminated water supply

1. High fever
2. Rose colored rash*****
3. Abdominal pains
4. Diarrhea

1. Ampicillin,
2. SMX/TMP,
3. Ciprofloxocin

Lives only in humans in the intestinal tract and blood

Spread by oral/fecal route
Raw fruits & vegetables,
milk and
shellfish

CAN BE CARRIERS
Typhoid Mary

32

What is an acute viral hemorrhagic disease?

What kind of virus is it?

How is it transmitted?

Onset and symtpoms?
7



Incubation period?





What is the second phase of yellow fever clinical features?

Treatment? 3

Yellow fever

RNA virus in the Flaviviridae family

mosquitos

Onset is sudden, with
1. fever of 39 to 40 C,
2. chills,
3. headache,
4. dizziness, and
5. myalgias.
6. Faget's sign (pluse slows)
7. Severe bowel issues

Incubation period of 3-6 days

Toxic phase- hemorrhagic fever-deadly

Treatment is mainly supportive. Bleeding may be treated with
1. Calcium gluconate. Prophylaxis against GI bleeding with a
2. proton pump inhibitor or an
3. H2 blocker. (omeprazole, ranitidine)

33

Yellow Fever Vaccine
Contraindications and Precautions?
7

Immunosuppression
Thymic disorders
Age

34

Diagnosis of Malaria?
2

Thick/thin smears
Serologic tests

35

Parasitic infection caused by trematodes (parasitic freshwater worms that live in snails)?

Clinical picture includes:
3

Schistosomiasis

1. Dermatitis
2. Katayama syndrome
3. Chronic infection can cause CNS disease, colon polyps, bloody diarrhea

36

What is katayama syndrome?

fatigue, malaise, fever, cough,
hepatosplenomgaly

Clinical manifestations may not show up for several weeks post exposure

37

Schistosomiasis
Diagnosis?
3

Treatment?
2

1. Thick stool smears reveal eggs
2. Eosinophilia on peripheral blood smear
3. Serologic testing-IFA available

1. Praziquantel-quinolone
2. Oxaminiquine

38

Fish (Scombroid) Poisoning is caused by?

Illness begins when and lasts up to how many days?

Symptoms? 4

Treatment?3

Poor fish preservation causes decarboxylization of histidine to histamine

Illness begins 90 min and lasts for up to 12 hrs after ingestion

Flushing, tachycardia, nausea, vomiting

Treatment-
supportive care, antihistamines,
epinephrine

39

Non Scombroidea Fish Poisoning
pathology and transmission?

When do symtpoms occur?
What are the symtpoms? 3

Ciguatera poisoning from fish that have ingested dinoflagellates

Competitive inhibitors of Ca+ channels

Symptoms occur within 24 hours
1. GI-nausea, vomiting, diarrhea
2. Neuro-paresthesias, pruritus, tremors, fasciculations
3. Temperature reversal-burning of skin exposed to cold is classic symptom

40

Shellfish Poisoning
caused by what?

Incubation period?

How is the diagnosis made?
2

Caused by saxitoxin after algae blooms

Incubation hours to days

Diagnosis is made when two sensory & two motor symptoms are found in patients with appropriate history

1. Sensory-numbness,dizziness, paresthesia, headache,dysesthesia,pruritus

2. Motor-dysphagia, paralysis, paresis, dyspnea, diplopia, dysphonia

41

Insect infection. What is DEET?

DEET(diethyl-methyl-benzamide)
Permethrin also an option

42

Traveler's diarrhea can be caused from what?

Most commonly from different strains of what?

Prevention and Treament Drugs?
5

Can be from parasites or other organisms

Most commonly from different strains of E.coli

Prevention and treatment
1. Pepto Bismol (bismuth salicylate)
2. Loperamide
3. Ciprofloxocin
4. Azithromycin
5. fluid replacement

43

Travelers’ Diarrhea
Epidemiology-
Bacterial?
Viral?
Parasitic?


80-90%
5-10%
>10%

44

Travelers’ Diarrhea
Describe the onset and symtpoms?
7


Most symptoms resolve in how many days without treatment?

Abrupt with increasing frequency and volume of stool

1. 4-5 loose stools/day
Also
2. N/V,
3. abdominal cramping,
4. bloating,
5. fever,
6. urgency,
7. malaise.

Most resolve 1-2 days w/o treatment

45

Prevention/Avoid
what things?
3

Street vendor food/drinks
Raw/undercooked meats
Raw fruits/veggies

46

Vector Precautions?
9

1. Covering exposed skin
Insect repellent containing 2. DEET 25 – 50%
3. Treatment of outer clothing with permethrin
4. Use of permethrin-impregnated bed net
5. Use of insect screens over open windows
6. Air conditioned rooms
7. Use of aerosol insecticide indoors
8. Use of pyrethroid coils outdoors
9. Inspection for ticks

47

Rabies Vaccine pre-exposure schedule?
3

1st dose
7 days later
21 or 28 days after the first dose

48

Mosquito-borne flavivirus
The most common vaccine-preventable cause of encephalitis in Asia?

What kind of virus is it?

Incubation period?

Most pts present how?

Japanese Encephalitis

RNA virus


Incubation period: 6 to 8 days

Most asymptomatic or mild signs

49

Acute Japanese Encephalitis clinical manifestations?
4

Severe encephalitis clinical manifestations?
5

Headache,
high fever,
stiff neck,
stupor

Paralysis,
seizures,
convulsions,
coma, and
death

50

What will 45-70% of survivors have from Acute Japanese Encephalitis?

What will happen in an In utero infection?

Neuropsychiatric sequelae

Abortion of fetus

51

Without treatment, tuberculosis can be fatal. Untreated active disease typically affects the lungs, but it can spread to other parts of the body causing?
5

Pneumothorax
Bronchiectasis
Cardiac aneurysms
Meningitis
Renal failure