Shelub cdc health care professional travel lecture
•Télécharger en tant que PPT, PDF•
1 j'aime•4,107 vues
Travel Medicine lecture slides
Recommandé
Contenu connexe
Tendances
Tendances (15)
En vedette
En vedette (20)
Similaire à Shelub cdc health care professional travel lecture
Similaire à Shelub cdc health care professional travel lecture (20)
Dernier
Dernier (20)
Shelub cdc health care professional travel lecture
- 1. Travel Medicine and the Pre- Travel Consultation Aaron Shelub AaronShelub @aaronshelubmd Board Certified Internal Medicine Board Certified Infectious Disease Certified Yellow Fever Vaccine Provider May 8th 2012 1 CDC presentation for healthcare professionals
- 2. 2
- 3. Outline • Travelers’ Health Epidemiology • Traveler Assessment • Itinerary Review • Sources of Information • Risks to the Traveler • Common diseases of concern • Travel Vaccines • Travel Medications • Counseling 3
- 4. U.S. Residents Traveling Abroad* Number of Travelers (millions) 65 60 55 50 45 95 96 00 03 97 98 99 01 02 04 05 19 19 19 19 20 20 20 20 19 20 20 Year *ITA, includes travel to Canada and Mexico 4
- 5. International Travel 80 900 70 800 700 60 US nonresident Inbound (ITA) US Resident travel in millions Worldwide arrivals in millions 600 50 US Resident Air Outbound (ITA) 500 40 All US Resident 400 Outbound (ITA) 30 Worldwide arrivals 300 (WTO) 20 200 10 100 0 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 5
- 6. Where Do U.S. Residents Travel? Of the 17% who traveled outside the U.S. . . . 40 30 20 % 10 0 Z I a t ad a ro p e /N x ico ric a p an /P s ia ric ea n as n s e Ja ia A Af b E Ca E u Au Me Am an er rib le S Oce Ot h Ca M idd or C 6 Source: HealthStyles Survey 2005
- 7. VFRs: Visiting Friends and Relatives • Foreign-born increased 57% since 1990 from 19.8 million to 31.1 million1 • 20% of US population are first- or second-generation immigrants • VFRs comprised ~46% of US international air travelers in 20043 1 US Census Bureau, Census 2000 Brief, The Foreign-Born Population: 2000, issued Dec 2003 (Previous: US Census Bureau, Profile of the Born Outside the United States Population 2000, issues Dec 2003??? 2 Angell & Cetron, 2005 3 2004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, 7 USDOC
- 8. Travelers’ Health Risks Of 100,000 travelers to a developing country for 1 month: – 50,000 will develop some health problem – 8,000 will see a physician – 5,000 will be confined to bed – 1,100 will be incapacitated in their work – 300 will be admitted to hospital – 50 will be air evacuated – 1 will die Steffen R et al. J Infect Dis 1987; 156:84-91 8
- 9. Estimated Incidence rate per month of infections and fatal accidents among travelers to developing countries 9 Yellow book page 12 2012 version
- 10. Yellow book figure 1-2 Proportionate morbidity among ill travelers returning from the developing world according to region of travel. 10
- 11. 11
- 12. The Patient: Medical Issues • Age-specific issues • Underlying illness, immunosuppression • Systems review • Medical history • Medication use • Vaccination history • Allergies • Contraindications to vaccines and medications 12
- 13. The Patient: Other Issues • Reproductive – Pregnant – Breastfeeding – Preconception • Risk-taking behaviors 13
- 14. Travel Itinerary • Full itinerary – Dates, duration, stopovers – Seasonal considerations • Styles of travel – Rural vs. urban – Budget vs. luxury • Accommodation – Hotel vs. camping • Activities – Business vs. tourism – Adventure, safari – Missionary/Humanitarian/NGO – -Sexual or Medical tourism 14
- 15. 15
- 16. Travel Health Resources • CDC Travelers’ Health Website – www.cdc.gov/travel • World Health Organization – www.who.int/int • State Department – travel.state.gov • International Society of Travel Medicine – www.istm.org • Health Information for International Travel – CDC “Yellow Book” • International Travel and Health – WHO “Green Book” 16
- 17. Travelers’ Health Website www.cdc.gov/travel 17
- 18. Regional Destinations • Region-specific pages • Goal to move to country-specific format 18
- 19. Travel Notices & Announcements 19
- 20. Figure 2-01. Leading causes of injury death for US citizens in foreign countries, 2007–2009 Data from US Department of State. Death of US citizens abroad by non-natural causes. Washington, DC: US Department of State; 20 2010. Available from: http://travel.state.gov/law/family_issues/death/death_600.html . 2Excludes deaths of US citizens fighting wars in Afghanistan or Iraq.
- 21. Table 2-12. Estimated traffic death rates in the 20 countries most frequently traveled by US residents • Country reported # rate/100,000 • Mexico 22,103 20.7 • Thailand 12,492 19.6 • India 105,725 16.8 • China 96,611 16.5 • Greece 1,657 14.9 1Data from the US Department of Commerce. 2008 United States resident travel abroad. Washington, DC: US Department of Commerce; 2010. Available from: http://tinet.ita.doc.gov/outreachpages/download_data_table/2008_US_Travel_Abroad.pdf (PDF) and World Health Organization. Global Status Report on Road Safety: Time for Action. Geneva: WHO; 2009. Available from: http://whqlibdoc.who.int/publications/2009/9789241563840_eng.pdf . (PDF) 2Deaths reported in the local population in 2007. For comparison, the number of reported traffic deaths in the United States was 42,642, with an estimated traffic death rate of 13.9 per 100,000
- 22. Infectious Disease Risks to the Traveler • Malaria • Schistosomiasis • Diarrhea • Tuberculosis • Leishmaniasis • Leptospirosis • Rabies • Polio • Dengue • Yellow Fever • Meningococcal • Measles Meningitis • JEV ETC. 22
- 23. Other Risks to the Traveler • Accidental injury • Environmental hazards • Crime and assault • Psychiatric problems • Animal bites, stings and envenomations • Dermatologic disorders • Altitude • ……. ETC. 23
- 24. Case presentation • 38 yo male with no significant pmh returns from Mexico with fever 101.3, fatigue and muscle aches. • He was camping outside and on a “vision quest” • Labs reveal wbc 2.4 and mild anemia • Feels better with IVF 24
- 25. Dx? 25
- 26. Probable Dengue Fever 26
- 27. Dengue Fever Risk Areas 27
- 28. Dengue Fever • positive-strand RNA viruses of the genus Flavivirus, family Flaviviridae • bite of an infected Aedes aegypti mosquito • World Health Organization (WHO) estimates that 50 million cases of dengue occur every year, • Infection rates (based on serology) among febrile travelers returning from dengue- endemic areas in the tropics are 3%–8% 28
- 29. Dengue Fever Clinical Presentation • travel tropics and subtropics 2 weeks before symptom onset • acute febrile illness with 2 or more of the following: headache, retroorbital pain, muscle aches, joint pain, rash, hemorrhagic manifestation, or leukopenia. • Dengue shock syndrome (DSS) is defined as a syndrome in a patient who meets the criteria for DHF and has hypotension, narrow pulse pressure (≤20 mm Hg), or frank shock. 29
- 30. Dengue Fever dx and Rx • Dx: serologic testing for IgM anti-DENV. • Rx: Supportive care • DHF/DSS: abrupt change from fever to hypothermia, severe abdominal pain, persistent vomiting, bleeding, difficulties breathing, or altered mental status (such as irritability, confusion, lethargy)- IVF 30
- 31. Dengue Fever Prevention • being bitten highest during the early morning, • several hours after daybreak, • late afternoon before sunset. • insecticides to get rid of mosquitoes 31
- 32. Immunizations to Consider for Adult Travelers Routine Travel related Diphtheria* Hepatitis A Tetanus* Hepatitis B Pertussis* Typhoid Measles + Rabies Mumps+ Meningococcal disease Rubella + Polio Varicella Japanese encephalitis Pneumococcus Yellow Fever Influenza * Td or Tdap 32 + MMR
- 33. Hepatitis A • Person to person contact, contaminated water, shellfish and other foods • Shed in feces • Very common vaccine-preventable infection • Rural areas, trekking, poor sanitation = highest risk • Abrupt onset of fever, malaise, anorexia, nausea and abdominal discomfort then jaundice • No treatment 33
- 34. 34
- 35. Hepatitis A cont. • Prevention with vaccination • Havrix 0,6,12 months • Vaqta 0,6-18 months • Twinrix 0,1,6 months • Immune globulin 0.02 ml/kg 1-2 months 35
- 36. Hepatitis B • Contact with blood, body fluids • Risk by prevalence • 90 days incubation, • Jaundice, nausea,vomiting,abdominal pain • Progression to chronic Hep B 30-90% • No treatment • Vaccine preventative, 0,1,6 months • All unvaccinated people traveling to areas int to high prevalence 36
- 37. 37
- 38. Typhoid fever • Acute life threatening febrile illness • Bacterium Salmonella enterica serotype Typhi • Consumption of water or food contaminated by feces • 22 million cases typhoid fever, 200,000 related deaths/ year 38 •
- 39. Typhoid Fever Cont. • Insidious fatigue, • fever low high, • HA, malaise, • anorexia, • hepatosplenomegaly, • rose colored rash 39
- 40. Typhoid Fever cont. • Complications: intestinal hemorrhage or perforation • Clinical dx • Rx: Empiric floroquinolone • Vaccines: Oral live attenuated, Vi capsular polysacchride vacc 40
- 41. 41
- 42. Yellow Fever • Flavirus • Vectorborne transmission • Aedes or Haemagogus spp. Mosquito • “Epidemiological silence” ≠ no risk • Non-specific flu like illness, fever,chills, HA,myalgias,n/v • 15%jaundice,hemorrhagic sx,shock multisystem failure, (case fatality hepatorenal 20-50%) 42
- 43. 43
- 44. 44
- 45. Yellow Fever cont. • Rx= supportive only • Prevention: avoid mosquito bites, vaccinate (YF-Vax) • Several countries require proof of vaccination from all arriving travelers or • Travelers going through endemic countries. 45
- 46. Malaria • 1 0f 4 protozoan species genus Plasmodium • Transmitted by Anopheles mosquito • Major international public health problem • 350 – 500 million infections worldwide, 1 million deaths annually. 46
- 47. 47 http://science.nationalgeographic.com/science/photos/malaria/#/malaria-parasites_1059_600x450.jpg
- 48. Malaria Cont. • fever and influenzalike symptoms, • chills, headache, myalgias, and malaise; • symptoms at intervals • severe disease, seizures, mental confusion, kidney failure, acute respiratory disease syndrome (ARDS), coma, and death may occur. 48
- 49. Malaria cont. • P. falciparum = medical emergency, • clinical deterioration can occur rapidly and unpredictably. • consider malaria: patient with a febrile illness who has recently returned from a malaria- endemic country. • Smear microscopy = gold standard for malaria diagnosis. 49
- 50. 50
- 51. 51
- 52. 52
- 53. Malaria Cont. • seek medical evaluation as soon as possible • CDC Malaria Hotline (770-488-7788 or toll- free at 1-855-856-4713) from 9:00 am to 5:00 pm Eastern Time • Atovaquone-proguanil • .Artemether-lumefantrine 53
- 54. Malaria cont. Prophylaxis: Mosquito avoidance Chemoprophylaxis: Atovaquone- proguanil Doxycycline Others- side effect issues 54 http://science.nationalgeographic.com/science/photos/malaria/#/mosquito-nets_1104_600x450.jpg
- 55. Travelers’ Diarrhea • 30% to 70% of travelers • “boil it, peel, it, or forget it,” traditional • Bacterial pathogens predominant risk • most common pathogen is enterotoxigenic Escherichia coli • High-risk areas include most of Asia, the Middle East, Africa, Mexico, and Central and South America. 55
- 56. 56
- 57. Travelers Diarrhea risk factors • bouts of TD do not appear to protect against future attacks • environments where large numbers of people do not have access to plumbing or outhouses, the amount of stool contamination in the environment will be higher and more accessible to flies • poorly functioning refrigeration, which can result in unsafe food storage and an increased risk for disease. 57
- 58. Travelers diarrhea Sx’s and • prevention sudden onset mild cramps and urgent loose stools severe abdominal pain, fever, vomiting, and bloody diarrhea. • alcohol-based hand cleaners (containing at least 60% alcohol) may make it easier for travelers to clean their hands before eating. • freshly cooked and served piping hot are safer than foods that may have been sitting for some time in the kitchen or in a buffet. • avoid beverages diluted with nonpotable water (reconstituted fruit juices, ice, and milk) • prevention = bismuth subsalicylate (BSS), Pepto-Bismol • 58
- 59. Travelers Diarrhea prevention and Rx • Lactobacillus GG and Saccharomyces boulardii, = Results are inconclusive, • Prophylactic abx = discouraged • Rx: ciprofloxacin or levofloxacin, azitrhomycin Antimotility agents Oral Rehydration Therapy 59
- 60. Travel Medications: Prophylaxis & Self Treatment • Malaria – chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine • Diarrhea – quinolone, azithromycin • Altitude – acetazolamide • Motion sickness – scopolamine, dimenhydrinate (Dramamine) 60
- 61. Patient Counseling • Sufficient time for patient education • Tailored to suit traveler • Fitness for travel – Understanding impact on existing conditions – Advisability of destinations 61
- 62. Travel Preparation • Travel health insurance – Medical care – Hospitalization – Evacuation • Obtaining medical care abroad • Awareness of travel notices • Hand washing and hygiene 62
- 63. Environmental Precautions • Air Travel • Jet Lag • Sun Protection • Extreme Heat and Cold – dehydration, heat stroke – hypothermia, frostbite • Altitude • Water recreation – Drowning, boating & diving accidents – Risk of schistosomiasis or leptospirosis – Biological and chemical contamination 63
- 64. Food and Water Precautions • Bottled water • Selection of foods – well-cooked and hot • Avoidance of – salads, raw vegetables – unpasteurized dairy products – street vendors – ice 64
- 65. Vector Precautions • Covering exposed skin • Insect repellent containing DEET 25 – 50% • Treatment of outer clothing with permethrin • Use of permethrin-impregnated bed net • Use of insect screens over open windows • Air conditioned rooms • Use of aerosol insecticide indoors • Use of pyrethroid coils outdoors • Inspection for ticks 65
- 66. Bloodborne and STD Precautions • Prevalence of – STDs – Hepatitis B – Hepatitis C – HIV • Unprotected sexual activity • Commercial sex workers • Tattooing and body piercing • Auto accidents • Blood products • Dental and surgical procedures 66
- 67. Animal Precautions • Animal avoidance • Rabies – Specific animal threats – Medical evaluation of bites/scratches – Post exposure immunization and immunoglobulin • Envenomations – Snakes, scorpions, spiders – Maritime animals 67
- 68. Injury and Crime • Vehicles – Risk of road and pedestrian accidents – Night travel – Seat belts and car seats • Use of drugs and alcohol • Understanding local crime risks – Scam awareness – Situational awareness – Location avoidance 68
- 69. Travel Emergency Kit • Copy of medical records and extra pair of glasses • Prescription medications • Over-the counter medicines and supplies – Analgesics – Decongestant, cold medicine, cough suppressant – Antibiotic/antifungal/hydrocortisone creams – Pepto-Bismol tablets, antacid – Band-Aids, gauze bandages, tape, Ace wraps – Insect repellant, sunscreen, lip balm – Tweezers, scissors, thermometer 69
- 70. Post-Travel Care • Post-travel checkup – Long term travelers – Adventure travelers – Expatriates in developing world • Post-travel care – Fever, chills, sweats – Persistent diarrhea – Weight loss 70
- 71. Questions? 71
- 72. Other Resources 72
- 73. Journals • American Journal of Tropical Medicine and Hygiene • Bulletin of the World Health Organization • Emerging Infectious Diseases Journal • Eurosurveillance Weekly • Journal of Travel Medicine • Morbidity and Mortality Weekly Report • Tropical Medicine and International Health • Vaccine 73
- 74. Books • Textbook of Travel Medicine and Health, 2nd Ed. – DuPont, H.L. and Steffen R. (editors) • The Travel and Tropical Medicine Manual, 3rd Ed. – Jong, E.C., McMullen, R. • Travel Medicine – Keystone, J.S., Kozarsky, P.E., et al 74
- 75. Websites Eurosurveillance www.eurosurveillance.org Travax EnCompass www.travax.com GIDEON www.gideononline.com International SOS www.internationalsos.com Medical Advisory Service for Travelers Abroad (MASTA) http://www.masta.org/ Armed Forces Medical Intelligence Center www.afmic.detrick.army.mil/ Central Intelligence Agency www.cia.gov/cia/publications/factbook/ 75
- 76. Travel Insurance sites • Department of State (www.travel.state.gov ) • International SOS(www.internationalsos.com) • MEDEX (www.medexassist.com ) • International Association for Medical Assistance to Travelers (www.iamat.org ) • American Association of Retired Persons ( 76 www.aarp.org )
- 77. Aaron Shelub MD • Aaron Shelub @aaronshelubmd • https://twitter.com/#!/aaronshelubmd • http://www.zocdoc.com/doctor/aaron- shelub-md-30618 77
- 78. End 78
- 79. Picture of diseases from vacc shop 79
Notes de l'éditeur
- Love travelling, Machu Pichu
- Will try to cover some of the most common diseases but not all of them.
- Source http://tinet.ita.doc.gov/view/f-2005-11-001/index.html 2009 WTO said 61 million americans traveled internationally. 5% increase since 1999. More people traveling but seeking out arease that have rarely been visited. (page 2 yellow book) Everywhere on the globe is accessible in 24 hours
- 880 Million international tourist arrivals in 2009
- This is not supposed to include travel without an overnight stay, particularly to Canada and Mexico. Notice that the specification of the regions was not completely 52% have traveled to developing countries As expected, the majority of travel is to Canada, western Europe and Mexico.
- Christie, the first bullet needs to have the reference I cited. The previous reference is in parentheses, which I think is a typo. I cannot find a source to confirm the second bullet. The paper I have cited there has this information, but I cannot confirm with the US Census reference that is included in the paper (Kip has a copy). The whole reference is Angell SY, Cetron MS. Health Disparities among Travelers Visiting Friends and Relatives Abroad. Annals of Internal Medicine, 2005; 142:1, 67-73. I have updated the 3 rd bullet and reference.
- 1/5,000 will get hep a when tavelling to developing world. Probably an acceptable risk. More severe illness such as Meningococcal Meningitis, rabies or Japanese encephalitis indicate almost no tolerance for any risk. Studies are older. Lot of studies for Travel medicine are older and difficult to do. Geosentinel 17,353 ill returned travelers seen at 31 clinical sites on 6 continents. (ITSM and CDC collaborative effort)
- Yellow book figure 1-2 Proportionate morbidity among ill travelers returning from the developing world according to region of travel. I don’t know about you but returning from south American with chronic Diarrhea doesn’t sound like fun. Fever most common from africa and southeast asia, Malaria top 3 dx from every region Dengue Most common febrile illness from every region outside Sub-Saharan africa
- Older people less strong more likely to get sick Immunosuppressed no live virus vaccines
- Joshua Tree national forest
- In web use, usually in top 5 CDC sites Primary Audiences Traveling public Health professionals advising travelers Content Areas Travel Notices & Announcements Online Yellow Book Regional Destination Pages Resources (Y.Fever Registry, Travel Med Clinics, Contact Us) Additional Topics & Special Needs Groups Diseases A-Z Traveling with Pets, Children, Special Needs Travelers Travel Industry
- Your 10x more likely to die from a traffic related injury than an infectious Disease.
- U.S. is 42,000, rate is 13.9 In 2008, 20.3 million travelers visited Mexico. From 2007 through 2009, over 280 US travelers lost their lives in motor vehicle crashes in Mexico, the nation most frequently visited by US citizens.
- Infection with 1 DENV produces lifelong immunity against reinfection with that DENV type but no long-term cross-protection against the other 3 DENV types (any cross-protection is ≤2 months). The geographic spread of dengue is similar to that of malaria, but unlike malaria, dengue is often found in populated urban and residential areas of tropical nations. Several dengue outbreaks have been detected in the continental United States since 1980, including 7 outbreaks in southern Texas along the United States-Mexico border, one outbreak in Hawaii in 2001, and 2 outbreaks in southern Florida in 2009 and 2010.
- The incubation period is typically 4–7 days (range, 3–14 days).
- Detection of DENV genomes or NS1 antigen is used primarily in the acute febrile stage of the illness (≤5 days after symptom onset), and testing for IgM anti-DENV is used primarily >5 days after fever onset. Seroconversion (negative to positive) to IgM anti-DENV from acute-phase (<5 days after fever onset) specimens to convalescent-phase (>5 days after symptom onset) specimens No specific therapeutic agents exist for dengue virus infections.
- VZV (no mention of upper age limit; approved for >=12 months) >= 13 Years of Age After the first and second doses, 10.2% and 9.5% of vaccinees, respectively, developed fever (i.e., oral temperature greater than or equal to 100 F {37.7 C}); these febrile episodes occurred throughout the 42-day period and were usually associated with intercurrent illness. After one and two doses, 24.4% and 32.5% of vaccinees, respectively, had complaints regarding the injection site; rash at the injection site at a peak of 6-20 days and 0-6 days postvaccination, respectively, developed in 3% and 1% of vaccinees, respectively; and a nonlocalized rash consisting of a median number of five lesions developed in 5.5% and 0.9% of vaccinees, respectively, and occurred at a peak of 7-21 days and 0-23 days postvaccination, respectively.
- More common vaccine preventable diseases Most travel (85%) was to Mexico,Central America,or South America In children most infection asymptomatic Case fatality 1.8% in adults>50 Igm detectable 5-10 days after exposure
- Higher dose Immune globulin for longer exposure
- All unvaccinated children and adolescents <19 vaccinate MSM, IVDA, hx of STDs, more than one sexual partner in 6 months Anyone who wants protection from Hep B should be vaccinated Accelerated vacc schedule available but probably not as effective (booster at 12 months) 1-2 doses better than 0
- Transient macular rash of rose-colored spots Hertzls sister died of typhoid fever
- Resistance to florquinolones highest on Indian Subcontinent, injectable 3 rd generation cephalosporin empiric choice here Vaccines do not protect against S.paratyphi infections (6 million cases per year) Typhoid vaccination is not 100% effective Oral live attenuated is taken every other day x 4 days, vi capsular is one 0.5ml IM shot
- Argentina Igazu falls
- Single stranded RNA virus Risk : location,season,duration exposure,occupational and recreational activities while traveling Aware of failure of local surveillance systems to detect cases, high level of immunity in population (vaccination etc.),case reports absent, low level transmission Can lead to epidemiological silence Risk in South America highest in rainy season (February – March) South America at risk for large scale epidemic Ae Aegypti in many towns and cities Remember to add yellow fever diploma to website and diplomas on walls office with posters (posters of yellow fever CDC risk areas)
- The first recorded outbreak of the disease was in 1648 in Yucatan , where the illness was termed xekik (black vomit). At least 25 major outbreaks followed. In colonial times and during the Napoleonic wars, the West Indies was a particularly dangerous posting, and both the English and French forces posted there were decimated by the &quot;Yellow Jack&quot;. Napoleon had his eye on conquering the New World, and sent his brother-in-law in command of an army to seize control of Haiti, but over 27,000 of his troops perished of the &quot;Yellow Jack&quot;, including their commander. An outbreak as far north as Philadelphia in 1793 resulted in the deaths of several thousand people and forced the administration to flee the city, including president George Washington . [25] Yellow fever epidemics in North America have caused some 100,000-150,000 deaths. [26] Wikipedia
- Anopheles gambiae is a complex of at least seven morphologically indistinguishable species of mosquitoes in the genus Anopheles . This complex was recognised in the 1960s and includes the most important vectors of malaria in sub-Saharan Africa particularly of the most dangerous malaria parasite, Plasmodium falciparum . [1] It is one of the most efficient malaria vectors known. Anopheles Mosquito Photograph by Hugh Sturrock Her abdomen full of blood that will nourish her eggs, a female Anopheles mosquito takes to the air. Her next landing may be a dangerous one—for the human who receives her bite. The female Anopheles mosquito is the only insect capable of carrying the human malaria parasit
- The invasion has begun. Microscopic magnification shows Plasmodium falciparum —the most virulent of the four malaria parasites that infect humans—destroying red blood cells in the liver. It digests a cell's hemoglobin, multiplies inside to the point of rupturing the cell, and rapidly spreads a new generation of infection. History of Malaria:
- Malaria Victim Photograph by Michael Nichols Caught in a wrenching cycle of shivering cold, high fevers, and profuse sweats, ecologist Michael Fay struggles through yet another attack of malaria at the Bomassa camp in Congo. Taking regular doses of antimalarial drugs can have long-term side effects, such as hearing loss and liver and kidney damage. So Fay, who has worked in Africa for decades, tends to wait until he feels achy and queasy before medicating himself. It's a risky approach that has twice come close to killing him.
- Microscopy can also be used to determine the species of malaria parasite and quantify the parasitemia— Testing Blood Photograph by John Stanmeyer A sample of blood seems to captivate young locals at a malaria testing center in Iquitos, Peru. The first widely known remedy—from the bark of the cinchona tree—was discovered in the region in the early 1600s. The medicine, which became known as quinine, was so promising that malaria-ravaged Europe mounted expeditions to acquire the plant. Today, scientists search for more ways to fight the disease—including the development of a vaccine—as the parasite becomes resistant to the most common course of drugs.
- Wooden Huts on River Photograph by Nic Cleave Photography/Alamy Washed garments hung to dry add splashes of color to weatherworn huts lining a river in Siem Reap, Cambodia. Poverty and weather conditions compound the problem of malaria. Outside of Africa, the majority of recorded cases of malaria are concentrated here and in eight other countries in Asia and South America.
- Clinicians who require assistance with the diagnosis or treatment of malaria should call the Travelers should be advised that this self-treatment of a possible malarial infection is only a temporary measure and that prompt medical evaluation is imperative. Atovaquone-proguanil The adult tablet contains 250 mg atovaquone and 100 mg proguanil. The pediatric tablet contains 62.5 mg atovaquone and 25 mg proguanil. Most drugs used in treatment are active against the parasite forms in the blood (the form that causes disease) and include: chloroquine atovaquone-proguanil (Malarone®) – recently became generic artemether-lumefantrine (Coartem®) mefloquine (Lariam®) quinine quinidine doxycycline (used in combination with quinine) clindamycin (used in combination with quinine) artesunate (not licensed for use in the United States, but available through the CDC malaria hotline)
- Mosquito Nets in Dormitory Photograph by John Stanmeyer Veiled in old bed nets, dormitory residents at the Kafue Boys Secondary School in Kafue, Zambia, get a small measure of protection each night. But the mosquito barriers are only as good as the fabric from which they're made. Holes in the nets, untreated material, or an exposed hand or foot during sleep increase the odds that the malaria-carrying insects will bite pyrethroid-containing insect spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body. Medications Used for Chemoprophylaxis Atovaquone-Proguanil Atovaquone-proguanil is a fixed combination of the drugs atovaquone and proguanil. Prophylaxis should begin 1–2 days before travel to malarious areas and should be taken daily, at the same time each day, while in the malarious areas, and daily for 7 days after leaving the areas (see Table 3-11 for recommended dosages). Atovaquone-proguanil is well tolerated, and side effects are rare. The most common adverse effects reported in people using atovaquone-proguanil for prophylaxis or treatment are abdominal pain, nausea, vomiting, and headache. Atovaquone-proguanil is not recommended for prophylaxis in children weighing <5 kg (11 lb), pregnant women, or patients with severe renal impairment (creatinine clearance <30 mL/min). There is a theoretical interaction between proguanil and warfarin that can increase the effect of warfarin; however, adverse events related to this theoretical interaction have not been reported. Chloroquine and Hydroxychloroquine Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present (see Maps 3-09 and 3-10 and the Yellow Fever and Malaria Information, by Country section later in this chapter). Prophylaxis should begin 1–2 weeks before travel to malarious areas. It should be continued by taking the drug once a week, on the same day of the week, during travel in malarious areas and for 4 weeks after a traveler leaves these areas (see Table 3-11 for recommended dosages). Reported side effects include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and pruritus, but generally these effects do not require that the drug be discontinued. High doses of chloroquine, such as those used to treat rheumatoid arthritis, have been associated with retinopathy; this serious side effect appears to be extremely unlikely when chloroquine is used for routine weekly malaria prophylaxis. Chloroquine and related compounds have been reported to exacerbate psoriasis. People who experience uncomfortable side effects after taking chloroquine may tolerate the drug better by taking it with meals. As an alternative, the related compound hydroxychloroquine sulfate may be better tolerated. Doxycycline Doxycycline prophylaxis should begin 1–2 days before travel to malarious areas. It should be continued once a day, at the same time each day, during travel in malarious areas and daily for 4 weeks after the traveler leaves such areas. Insufficient data exist on the antimalarial prophylactic efficacy of related compounds such as minocycline (commonly prescribed for the treatment of acne). People on a long-term regimen of minocycline who need malaria prophylaxis should stop taking minocycline 1–2 days before travel and start doxycycline instead. Minocycline can be restarted after the full course of doxycycline is completed (see Table 3-11 for recommended dosages). Doxycycline can cause photosensitivity, usually manifested as an exaggerated sunburn reaction. The risk for such a reaction can be minimized by avoiding prolonged, direct exposure to the sun and by using sunscreen. In addition, doxycycline use is associated with an increased frequency of vaginal yeast infections. Gastrointestinal side effects (nausea or vomiting) may be minimized by taking the drug with a meal or by specifically prescribing doxycycline monohydrate or the enteric-coated doxycycline hyclate, rather than the generic doxycycline hyclate, which is often less expensive. To reduce the risk for esophagitis, travelers should be advised not to take doxycycline before going to bed. Doxycycline is contraindicated in people with an allergy to tetracyclines, during pregnancy, and in infants and children aged <8 years. Vaccination with the oral typhoid vaccine Ty21a should be delayed for ≥24 hours after taking a dose of doxycycline. Mefloquine Mefloquine prophylaxis should begin ≥2 weeks before travel to malarious areas. It should be continued once a week, on the same day of the week, during travel in malarious areas and for 4 weeks after a traveler leaves such areas (see Table 3-11 for recommended dosages). Mefloquine has been associated with rare but serious adverse reactions (such as psychoses or seizures) at prophylactic doses; these reactions are more frequent with the higher doses used for treatment. Other side effects that have occurred in chemoprophylaxis studies include gastrointestinal disturbance, headache, insomnia, abnormal dreams, visual disturbances, depression, anxiety disorder, and dizziness. Other more severe neuropsychiatric disorders occasionally reported during postmarketing surveillance include sensory and motor neuropathies (including paresthesia, tremor, and ataxia), agitation or restlessness, mood changes, panic attacks, forgetfulness, confusion, hallucinations, aggression, paranoia, and encephalopathy. On occasion, psychiatric symptoms have been reported to continue long after mefloquine has been stopped. Mefloquine is contraindicated for use by travelers with a known hypersensitivity to mefloquine or related compounds (such as quinine or quinidine) and in people with active depression, a recent history of depression, generalized anxiety disorder, psychosis, schizophrenia, other major psychiatric disorders, or seizures. It should be used with caution in people with psychiatric disturbances or a history of depression. A review of available data suggests that mefloquine may be used in people concurrently on β-blockers, if they have no underlying arrhythmia. However, mefloquine is not recommended for people with cardiac conduction abnormalities. Any traveler receiving a prescription for mefloquine must also receive a copy of the FDA medication guide, which can be found at www.fda.gov/downloads/Drugs/DrugSafety/ucm088616.pdf . Primaquine Primaquine phosphate has 2 distinct uses for malaria prevention: primary prophylaxis in areas with primarily P. vivax and presumptive antirelapse therapy (terminal prophylaxis). When taken for primary prophylaxis, primaquine should be taken 1–2 days before travel to malarious areas, daily, at the same time each day, while in the malarious areas, and daily for 7 days after leaving the areas (see Table 3-11 for recommended dosages). Primary prophylaxis with primaquine obviates the need for presumptive antirelapse therapy. When used for presumptive antirelapse therapy, primaquine is administered for 14 days after the traveler has left a malarious area. When chloroquine, doxycycline, or mefloquine is used for primary prophylaxis, primaquine is usually taken during the last 2 weeks of postexposure prophylaxis. When atovaquone-proguanil is used for prophylaxis, primaquine may be taken during the final 7 days of atovaquone-proguanil, and then for an additional 7 days. Primaquine should be given concurrently with the primary prophylaxis medication. However, if that is not feasible, the primaquine course should still be administered after the primary prophylaxis medication has been completed. The most common adverse event in people with normal glucose-6-phosphate dehydrogenase (G6PD) levels is gastrointestinal upset if primaquine is taken on an empty stomach. This problem is minimized or eliminated if primaquine is taken with food. In G6PD-deficient people, primaquine can cause hemolysis that can be fatal. Before primaquine is used, G6PD deficiency MUST be ruled out by appropriate laboratory testing.
- “ boil it, peel, it, or forget it,” but studies have found that people who follow these rules still get ill. Poor hygiene practice in local restaurants is likely the largest contributor to the risk for TD. What is commonly known as “food poisoning” involves the ingestion of preformed toxins in food. In this syndrome, vomiting and diarrhea may both be present, but symptoms usually resolve spontaneously within 12 hours. ETEC leading to HUS enterotoxigenic Escherichia coli , followed by Campylobacter jejuni , Shigella spp., and Salmonella spp.
- http://www.travmed.com/health_guide/ch6.htm
- Inadequate water supplies can lead to the absence of sinks for handwashing by restaurant staff. Poor training in handling and preparation of food may lead to cross-contamination from meat, and inadequate disinfection of food preparation surfaces and utensils. In destinations in which effective food handling courses have been provided, the risk for TD has been demonstrated to decrease. It should be noted, however, that pathogens that cause TD are not unique to developing countries. The risk of TD is associated with the hygiene practices in specific destinations and the handling and preparation of food in restaurants in developed countries as well.
- oods washed in nonpotable water, such as salads. Other risky foods include raw or undercooked meat and seafood and unpeeled raw fruits and vegetables. Safe beverages include those that are bottled and sealed or carbonated. Boiled beverages and those appropriately treated with iodine or chlorine may also be safely drunk. Although food and water precautions continue to be recommended, travelers may not always be able to adhere to the advice. Furthermore, many of the factors that ensure food safety, such as restaurant hygiene, are out of the traveler’s control.
- tudies from Mexico have shown this agent (taken daily as either 2 oz of liquid or 2 chewable tablets 4 times per day) reduces the incidence of TD from 40% to 14%. BSS commonly causes blackening of the tongue and stool and may cause nausea, constipation, and rarely tinnitus. BSS should be avoided by travelers with aspirin allergy, renal insufficiency, and gout and by those taking anticoagulants, probenecid, or methotrexate. ncreasing microbial resistance to the fluoroquinolones, especially among Campylobacter isolates, may limit their usefulness in some destinations such as Thailand, where Campylobacter is prevalent. Increasing cases of fluoroquinolone resistance have been reported from other destinations. An alternative to the fluoroquinolones in this situation is azithromycin. Rifaximin has been approved to treat TD caused by noninvasive strains of E. coli . However, since it is often difficult for travelers to distinguish between invasive and noninvasive diarrhea, and since they would have to carry a back-up drug in the event of invasive diarrhea, the overall usefulness of rifaximin as empiric self-treatment remains to be determined. he safety of loperamide when used along with an appropriate antibiotic has been well established, even in cases of invasive pathogens. ORS is prepared by adding 1 packet to the appropriate volume of boiled or treated water. Travelers may find most ORS formulations to be relatively unpalatable, due to their saltiness. In most cases, rehydration can be maintained with any palatable liquid.
- Patient who wanted to go on sex tourism
- My experience in chech republic taxi driver.
- Hiker in the canyon who lost his hand