Travel Related Infection

Question 1

What are the unfamiliar features of imported diseases?

Answer 1

Presenting features
Isolation requirements
Diagnostic methods
Treatment
Unexpected complications

Question 2

Why are travellers vulnerable to infection?

Answer 2

Temptation to take risks e.g. food, water, animals, sex
Different epidemiology of diseases
Incomplete understanding of health hazards
Stress of travel
Refugees

Question 3

What infections are common worldwide?

Answer 3

Influenza
community acquired pneumonia
Meningococcal disease
STIs

Question 4

What climate/ environment related health problems are there?

Answer 4

Sunburn
Heat exhaustion
Fungal infections
Bacterial skin infections
Cold injury
Altitude sickness

Question 5

What methods are infections controllable by public health measures?

What infections are controllable though these measures?

Answer 5

Sanitation:

• Traveller’s diarrhoea
• Typhoid
• Giardiasis
• Amoebiasis
• Food poisoning
• Chloera

Immunisation:

• Poliomyelitis
• Diptheria

Education:

• HIV
• STDs

Question 6

What water related infection are there?

Answer 6

Schistosomiasis
Leptospirosis
Liver Flukes
Hookworms

Question 7

What arthropod borne infections are there?

Answer 7

Malaria, Dengue fever - mosquitos
Rickettsial infections - ticks
Leishmaniasis - sand flies

Question 8

What emerging infectious diseases are there?

Answer 8

Zika virus
Ebola virus
Swine Flu
Avian flu
West Nile virus

Question 9

What important tropical diseases are there?

Answer 9

• Malaria
• Typhoid
• Dengue Fever
• Schistosomiasis
• Rickettsiosis
• Viral Haemorrhagic fevers
• Zika fever

Question 10

What is the vector for malaria?

Answer 10

Female Anopheles mosquito

Question 11

What is the parasite called causing malaria?

Answer 11

Plasmodium falciparum - can potentially be severe

The benign forms of the parasite include:
•	Plasmodium vivax 
•	Plasmodium ovale 
•	Plasmodium malariae
•	Plasmodium knowlesi

Question 12

What are the symptoms of malaria?

Answer 12

Fever
Rigors
Aching
Malaise

(abdominal pain, headache dysuria, frequency, sore throat, cough, non-specific)

Question 13

What are the signs of malaria?

Answer 13

Can be none

Splenomegaly, hepatomegaly, mild jaundice

Question 14

What are the complications of malaria?

Answer 14

Cerebral malaria (encephalopathy)
Blackwater fever (dark urine, renal failure)
Pulmonary oedema
Jaundice
Severe anaemia

Question 15

How is malaria diagnosed?

Answer 15

Thick + thin blood films

Rapid antigen tests

Question 16

How is the severity of malaria assessed?

Answer 16

Complicated malaria indicated by one or more of:
•Impaired consciousness or seizures
•Hypoglycaemia
•Parasite count >2%
•Haemoglobin < 8mg/dL
•Spontaneous bleeding
•Haemoglobinuria
•Renal impairment or pH < 7.3
•Pulmonary oedema or ARDS
•Shock (algid malaria): gram negative bacteraemia

Question 17

What is the prophylaxis for malaria?

Who needs to take prophylaxis?

Answer 17

Malarone, Mefloquine, Doxcycline

All travellers going to an endemic area including children and pregnant women need to take prophylaxis

Question 18

What are the treatment options for uncomplicated Plasmodium falciparum?

Answer 18

Riamet - 3 days
or Malarone - 3 days
or Quinine - 7 days (plus doxycycline)

Question 19

What are the treatment options for complicated Plasmodium falciparum?

Answer 19

IV quinine plus oral doxycycline

Question 20

What are the treatment options for P. vivax, P. ovale, P. malariae, P. knowlesi?

Answer 20

Chloroquine - 3 days
Riamet - 3 days

NoteL add primaquine (14 days) in P. vivax and P. ovale

Question 21

What adjuvant measures are there for malaria?

Answer 21

Ventilation (if pulmonary oedema)
Maintain glucose level
Correct anaemia (blood transfusion)
Dialysis if renal failure
Exchange transfusion if high parasitaemia

Question 22

What malaria control programmes are there?

Answer 22

Drainage of stagnant water to prevent mosquito breeding sites
Larvacides against larval life stage
Mosquito killing sprays - DDT
Bed nets, mesh windows

Question 23

What is the bacterium causing typhoid fever?

Answer 23

Salmonella typhi

Salmonella paratyphi

Question 24

What are the risk factors for typhoid fevers?

Answer 24

Poor sanitation, unclean drinking water

Question 25

What are the symptoms of typhoid fever at each stage?

Answer 25

Incubation period of 7 days 4 weeks 1st week: Fever, headache, abdo discomfort, constipation, neutrophilia, confusion 2nd week: fever peaks, diarrhoea begins 3rd week (complications): intestinal bleeding, perforation 4th week: recovery 10-15% relapse

Question 26

How is typhoid fever diagnose?

Answer 26

Culture blood, urine + stool | Culture bone marrow

Question 27

What is the treatment for typhoid fever?

Answer 27

Oral azithromycin IV ceftriaxone if complicated Note: increasing ciprofloxacin resistance

Question 28

What is the vector for Dengue fever?

Answer 28

Aedes aegypti (yellow fever mosquito)

Question 29

What are the clinical features for Dengue fever?

Answer 29

``` Sudden fever Headache Severe myalgia, arthralgia Rash Haemorrhagic signs ```

Question 30

What is the diagnosis for Dengue fever?

Answer 30

Thrombocytopenia Leucopenia Elevated transaminases PCR, serology

Question 31

What is the management for Dengue fever?

Answer 31

Conservative measures: IV fluids, frozen plasma, platelets

Question 32

What are the complications of Dengue fever?

Answer 32

Dengue haemorrhage fever | Dengue shock syndrome

Question 33

What is schistosomiasis caused by?

Answer 33

A parasitic worm that lives in freshwater, the larvae grow inside freshwater snails

Question 34

What are the clinical features and progression of schistosomiasis?

Answer 34

Swimmers itch Invasive stage - cough, abdo discomfort, splenomegaly Katayma fever - fever, diarrhoea, eosinophilia Acute disease- eggs deposited in bowel (dysentery) or bladder Chronic disease

Question 35

How is schistosomiasis diagnosed?

Answer 35

clinical antibody tests ova in stools and urine

Question 36

What is the treatment for schistosomiasis?

Answer 36

Praziquantel | Prednisolone if severe

Question 37

What is the vector for Rickettsiosis? What is the bacteria responsible for it?

Answer 37

Ticks •Tick typhus (R. conorii, R. africae) * Rocky Mountain Spotted Fever (R. rickettsii) * Epidemic typhus (R. prowazekii) * Murine or endemic typhus (R. mooseri) * Scrub typhus (R. tsutsugamushi)

Question 38

What are the clinical features of Rickettsiosis?

Answer 38

Abrupt fever, rash, headache, confusion, bleeding

Question 39

What is the diagnosis for Rickettsiosis? What is the management?

Answer 39

Dx= Clinical features, serology Tx= Tetracycline, doxycycline

Question 40

What are examples of viral haemorrhagic fevers?

Answer 40

Ebola Congo-Crimea haemorrhage fever Lassa fever Marburg disease max incubation = 3 weeks

Question 41

What is the course to follow for viral haemorrhage fevers?

Answer 41

Rule out severe infections Isolation Supportive treatment

Question 42

How is Zika virus transmitted?

Answer 42

- Transmitted by daytime-biting Aedes mosquitos | - Also transmitted by sexual contact, blood transfusion

Question 43

What are the symptoms of Zika virus? What are the complications?

Answer 43

No or mild symptoms - headache, rash, fever, malaise, joint pains In pregnancy, can cause microcephaly and other neurological symptoms Can cause Guillain Barre syndrome Note, Prevention: mosquito control measures

Question 44

What is the approach to a fever in returning traveller?

Answer 44

``` Travel history Precautions taken Risks Symptoms Incubation periods ```

Question 45

What investigations can be done if traveller illness suspected?

Answer 45

* FBC * malaria films * liver function tests * stool microscopy & culture * urine analysis & culture * blood culture(s) * CXR

Question 46

What is the measures if travellers illness suspected?

Answer 46

Isolation + personal protective equipment Supportive measures Empirical Tx- Antimicrobial Specific Tx once diagnosed

Question 47

Look at the following signs on examination and the indicated disease (rash, jaundice, lymph nodes, liver, spleen)

Answer 47

* rash - typhoid, typhus, dengue * jaundice - hepatitis, malaria, Yellow fever * lymph nodes - leishmania, trypanosomiasis * liver - malaria, typhoid, amoebic abscess * spleen – visceral leishmaniasis, typhoid, malaria