Travel Health
Traveler's Diarrhea: Treatment
1) Oral rehydration 2) Bismuth-subsalicylate compounds 3) Antimotility agents > Not for children < 6 years
Required Immunizations:
Yellow fever Meningitis Polio
Zika complications
*microcephaly & Guillain-Barre syndrome* discourage pregnant women from travel to Zika endemic areas!!!!!
Pre-travel Consultation: Risk Assessment
- Destination - Departure, length of stay - Purpose of trip, planned activities - Type of accommodations - Insurance coverage, evacuation coverage
What topics should you cover in a pre-travel consultation?
- Food & water precautions - Traveler's diarrhea - Immunization - Insect precautions - Malaria prophylaxis - Special activities
Chloroquine
*- does not eradicate liver phase* but it is cheap - Start 1 weak prior, weekly while there and 4 weeks upon return
Rabies: Post-exposure prophylaxis - Previously vaccinated - Non previously vaccinated
*Clean bite wound thoroughly with soap and water* Previously vaccinated: 2 doses of vaccine at days 0 & 3 Not previously vaccinated: 4 doses of vaccine at days 0, 3, 7, 14 *plus human rabies immunoglobulin* which must be given within 7 days of first post-exposure vaccine (can be difficult to obtain during travel)
Case #6 A 30 year old female with history of hypothyroidism is traveling with her 3 month old exclusively breastfed son to Ethiopia. Her husband is a camel researcher and the family plans to move there once he is finished with his fellowship at ISU Vet Med School. Her son otherwise healthy and had birth and 2 month old routine vaccines.
*FIRST DISCOURAGE TRAVELING D/T AGE OF INFANT - AT LEAST POSTPONE UNTIL HE IS 12 MONTHS OLD AND CAN GET THE REST OF HIS VACCINES* Food and water precautions? - *YES* Traveler's diarrhea treatment? - Child: azithromycin - Mom: Ciprofloxacin Immunizations? - Mom: Hep A, Typhoid, yellow fever (have to store up breast milk cause this breast milk can't be used), influenza - Child: Hep A immun globlulin, rabies Insect precautions? - Typical Malaria prophylaxis? - Mefloquine for both
Insect Precautions
*Need DEET 25-35% for best protection* Wait to apply until 30 min after applying sunscreen
Traveler's Diarrhea: Antibiotics
*Quinolone* (single dose or 3-day regimen) Azithrymycin (3 day) for quinolone resistant areas, safe in children Rifaximin (expensive, E. coli)
Traveler's Diarrhea: Causes
1) *Bacteria* (60-8%) 2) Viral (10-20%) 3) Parasites (5-10%)
Adverse Effects for Yellow Fever Vaccine
Neurotropic - encephalitis, Guillain Barre, demyelination Viscertropic - 2-8 day onset, progresses to multi-organ involvement *only happen during first-time vaccinees*
Mefloquine
Start 1 week prior, weekly while there, and 4 weeks upon return (1 dose weekly) Does not eradicate liver phase, cheap SE: *vivid dreaming, migraine, cardiac conduction, seizures, depression, anxiety, psychosis*
Where is Yellow Fever vaccine required?
Africa & South America (and more around the equator)
Malaria Chemoprophylaxis
Chlorquine (most countries have resistance) Mefloquine Atovaquone-proguanil Doxycycline Primaquine
No fresh fruits or vegetables unless....
Boil it, cook it, peel it YOURSELF
Primaquine
Daily dosing Rarely used *must be tested for G-6PD deficiency*
Atovaquone-proguanil
Daily dosing: begin day prior, daily while there, 7 days upon return *eradicates liver & blood phases* Expensive, but well tolerated
Doxycycline
Daily dosing: start day before, daily while there, and 4 weeks upon return *doesn't eradicate liver phase* SE: GERD, esophagitis, photosensitivity, vaginal candidiasis
Food & Water Precautions
Don't drink local water Wash your hands Use hand sanitizer Do NOT: - add ice or water to your drinks - brush your teeth with tap water - open your mouth and rinse in the shower/bath
Absolute Contraindications to Yellow Fever Vaccine
Egg allergy Thymus disorders Myasthenia Gravis Immune supression (Age > 60 is relative indication)
Typhoid Prevention
Food & water precaution Immunization - Oral, LIVE (4 pills: 1 pill every other day --> lasts 5-7 years) - Injectable, KILLED (single dose --> 2-3 year duration)
Prevention of Hep A
Food & water precautions Immunization - Schedule 0, 180 days - long term immunity
Case #4 A 29 year old couple, otherwise healthy, traveling to Jamaica in June for their honeymoon that will last 10 days.
Food and water precautions? - *YES* Traveler's diarrhea treatment? - Ciprofloxacin Immunizations? - Hep A, Typhoid Insect precautions? - Typical Malaria prophylaxis? - None Pregnancy plans? - Condom use fore duration of trip plus 6 months - Postpone pregnancy plans for 6 months (ZIKA!)
Case #7 A 65 year old retired male with a past medical history significant for atrial fibrillation on warfarin, non-insulin dependent type 2 diabetes, coronary heart disease with 2 bare metal stents and depression is heading a mission trip to dig wells in Cameroon for 3 weeks. He will be sleeping in tents or with host families. This is his life long dream. He was in the military and deployed to southeast Asia 45 years ago where he received small pox vaccine. He had childhood vaccines including MMR and polio.
Food and water precautions? - *YES* Traveler's diarrhea treatment? - Ciprofloxacin Immunizations? - Hep A, Typhoid,Yellow Fever, Meningitis, Influenza, Pneumonia, TdaP, Varicell Zoster Insect precautions? - Typical plus mosquito bed net to sleep under Malaria prophylaxis? - Atovaquone-proguanil Other - Bring plenty of lancets, test strips - Consider portable INR machine & Vitamin K to reverse INR if too high or bleeding
Case #5 A 29 year old healthy female vet student will be spending 6 months in rural China 100 miles outside of Beijing studying abroad local veterinary practices on small and large animals.
Food and water precautions? - *YES* Traveler's diarrhea treatment? - Ciprofloxacin (enough for 3 bouts) Immunizations? - Hep A, Typhoid, Influenza, Rabies, Japanese Encephalitis Insect precautions? - Typical Malaria prophylaxis? - None
Case #3 A family of 4 are traveling to a resort in Cancun, Mexico to spend spring break. Parents and children (age 13 and 15 boys) are healthy other than seasonal allergies. No plans for any rural excursions.
Food and water precautions? - *yes* Traveler's diarrhea treatment? - Cipro for adults - Azithromycin for children - OR Azithromycin for everyone - OR Cipro for everyone Immunizations? - Hep A for everyone - Consider Typhoid if anyone plans to eat crazy food Insect precautions? - Typical Malaria prophylaxis? - None
Case #2 55 year old male with history of COPD well controlled on an inhaled anticholinergic will be traveling to Australia in June for 1 week to visit his son who is studying abroad in Sydney.
Food and water precautions? - None Traveler's diarrhea treatment? - None Immunizations? - Influenza, Pneumonia Insect precautions? - Typical Malaria prophylaxis? - None
Case #1 27 year old healthy male traveling to Italy for the first time during the summer to site see in Rome, Vatican City and Venice staying in 3 star hotels. He does not take any prescription medicines and has no allergies. All childhood immunizations are up to date
Food and water precautions? - None Traveler's diarrhea treatment? - None Immunizations? - TdaP Insect precautions? - Typical Malaria prophylaxis? - None
Recommended Immunizations
Hep A Hep B Typhoid Cholera Poliomyelitits Meningococcal Meningitis Japanesse Encephalitis Rabies Tick-Borne Encephalitis Influenza Pneumococcal Pneumonia Yellow Fever
Zika: - Cure - Treatment - Vaccine
NO CURE NO TREATMENT NO VACCINE
Where is Polio vaccine required?
India - requires yearly booster if you visit endemic areas (also at risk in Pakistan, Afghanistan, Nigeria)
Japanese Encephalitis Vaccine: - Indications - Schedule
Indications: travel > 1 month, high risk for environmental exposures, (can't get until > 2 months old) Schedule: 0 & 28 days
Malaria Prevention
Insect repellant Clothing Permethrin clothing Screens on windows/doors Air conditioning Mosquito bed net Restrict Outdoor activities at night
Zika Virus
Most people have mild symptoms or even asymptomatic Can be transmitted SEXUALLY! > *postpone pregnancy for 6 months after returning*
Japanese Encephalitis
Pigs, Horses, Wading birds are vectors 1/2 of survivors have long term neurological damage (Seen in India, China, Thailand, Japan & surrounding countries)
Where is meningococcal vaccine required?
Saudi Arabia for pilgrims to Hajj or Umrah (Only A, C, W, Y strains - NOT B) Also at risk in dorm situations & Sub-Saharan Africa
Rabies: indication for immunization
Travel > 1 month Children Occupational risks Schedule: 0, 7 and 21 or 28 days
Polio vaccine
Usually given at 2, 4, 6, months and 4 years
Yellow fever: duration
Valid 10 days after given Lasts lifelong, but most countries still require it every 10 years