1 UNITED STATES TRAVELERS 1) 25 Million each year 2) 5 Million to developing nations a) ¼ - ½ get some illness (2.5 million) b) 1/100 – 1/1000 get serious.

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UNITED STATES TRAVELERS

1) 25 Million each year

2) 5 Million to developing nationsa) ¼ - ½ get some illness (2.5 million)

b) 1/100 – 1/1000 get serious illness (25,000 – 250,000) – malaria and filariasis

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SCOPE OF THE TRAVEL INDUSTRY

1. A trillion dollar industry

2. Over 7 million jobs

3. In developing nations, often the major

source of foreign currency

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DEFINITION OF A TRAVELER

Someone who goes from an area of the world slightly fecally contaminated to an area where contamination is moderate to severe.

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THE FECAL VENEER

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International TravelMay be Required: Yellow Fever Cholera

May be Recommended: Typhoid Plague Measles Polio Rabies Hepatitis A Hepatitis B

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Required Immunizations for Travel

A. Yellow Fever- Every 10 years for travel to areas infected with yellow fever and to rural areas endemic for yellow fever –equatorial SouthAmerica and Africa.

B. Cholera- New serotype Vibrio cholera 0139 now affecting Indian

subcontinent and Asia. For most travelers, risk remains low.- no country now requires vaccination for direct travel from

the United States.- no vaccine will protect against V. cholerae 0139.

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Yellow Fever

Attenuated live virus vaccine Administered at designated centers Only one injection required Protection afforded for 10 years Areas of risk: Equatorial Africa, Central and

South America

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Cholera Vaccines

Inactivated, parenteral

- poorly protective (50%) for only a few months

- uncomfortable side effects

- rarely recommended

Experimental

A. Inactivated oral vaccine-Whole cell (WC) and B subunit/whole cell (BS/WC)

B. Attenuated, live oral vaccine-CVD 103-HgR

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CHOLERA

Vaccine of limited usefulness Risk to U.S. travelers is low (10 cases since

1961, 7 had been vaccinated) Indicated if passing through endemic regions One injection meets international

requirements Full series of 3 shots for select patients Boosters may be required every 6 months

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Polio

The Americas have now (9/29/94) been declared polio-free!

A. Inactivated, parenteral – enhanced (elPV)- should be used in adults (≥ 18 yrs) never previously

immunized

B. Attenuated, live oral – OPV- can be used to boost previously immunized adults

- risk of paralysis 1/1.4 million with first dose;

1/41,500,000 in previously immunized

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The Global Effort to Eradicate Polio by 2000 Before vaccines, 500,000 people a year were

paralyzed or died from contracting polio.

In 1996, 400 million children were vaccinated against polio.

Since 1988, cases of polio have dropped 90 percent.

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TYPHOID

• Attenuated, live oral-Ty 21a mutant of S. Typhi (Vivotif Berna)

- well tolerated, 60-70% effective

• Inactivated, parenteral-Vi polysaccharide of S. Typhi (Typhim Vi)

- well tolerated, 64-72% effective, single dose

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Japanese B Encephalitis

Consider travel for > 1 month in rural areas (particularly with rice and pig farming) in Far East

Adverse reactions include local in≈20% and systemic in 10%

Hypersensitivity reactions in 0.01% to 1% which may occur after any dose and be delayed up to 10 days

In passive surveillance by Connaught, none of these reactions have been reported in 200,000 doses distributed

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TETANUS & DIPHTHERIA

EVERYONE SHOULD RECEIVE A PRIMARY SERIES

TETANUS-DIPHTHERIA TOXOID BOOSTER IS INDICATED EVERY 10 YEARS

TdAP

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MMR

1) Live attenuated measles, mumps, rubella

2) Two dose regimen

3) Avoid Gamma Globulin

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OTHER VACCINES

Hepatitis A – most common in developing world

Hepatitis B

Meningococcal

Rabies

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Uncommon or Unavailable Vaccines

1) Smallpox

2) Typhus

3) Anthrax

4) BCG

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Resurgence of Malaria

Risk in over 100 countries 300 million cases with 3 million deaths

annually Major problem in Africa and Oceania Marked increase in drug resistance Deaths from malaria each year = those from

AIDS in the past decade

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MALARIA

1. Prevention-mosquito control

2. Prophylaxis-depends on geography

3. Therapy-two principles

A. Decrease parasite load

B. Then eradicate parasite

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PLASMODIA

1) Falciparum-malignant

2) Vivax-has liver phase

3) Ovale-has liver phase

4) Malariae-chronic

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MALARIA-CLINICAL

1) Fever, chills, ha, myalgias, nausea

2) Diarrhea, abdominal pain, fatigue, confusion

3) Fevers become cyclic

4) Complications-DIC, splenic rupture, anemia

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MOSQUITO PROTECTION

1. DEET

2. Appropriate Clothing

3. Permethrin

4. Screens

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ANOPHELES MOSQUITO

1) Silent

2) Night Biting

3) Female

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Table 1. Drugs used in the prophylaxis of malaria

Drug Adult DoseChloroquine 300 mg base (500 mg salt)phosphate orally, once/week (Aralen*)

Hydroxychloroquine 310 mg base (400 mg salt)sulfate orally, once/week (Plaquenil*)

Malarone 250 mg Atovoquone/100 mg Proguanil, daily

Mefloquine 228 mg base (250 mg salt)(Lariam*) orally, once/week

Doxycycline 100 mg orally, once/day

Primaquine 15 mg base (26.3 mg salt) orally,_______________________________________________________________________________

The dose (250 mg for an adult) should be taken once each week for 4 weeks, followed by one dose everyother week

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HYGIENE ABROAD

a) Water Acquisition

b) Other Beverages

c) Food Precautions

d) Restaurant Evaluation

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Travelers Diarrhea – The Litany

Aztec Two Step-Delhi Belly-Rome Runs

La Turista-Greek Gallop-Sumatra Spurts

Hong Kong Dog-Turkey Trots

Cairo Crud-Montezuma’s Revenge

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Etiology of Travelers’ Diarrhea

1. E. Coli 50%

2. Shigella/Salmonella 10%

3. Campylobacter 8%

4. Viral 10%

5. Parasites 2%

6. Unknown 20%

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Infectious Doses of Enteric PathogensShigella 10-100

Campylobacter 1000-100,000

Salmonella 100,000

E. Coli 100 million

Cholera 100 million

Giardia 10-100

Amoebas 10-1000

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Travelers’ Diarrhea Precautions

1. Water Precautions

2. Food Precautions

3. Common Sense

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Water Precautions:Avoid

1. Tap water if not treated2. Ice cubes3. Fresh milk4. Bottled water with broken seal

Safe1. Bottled H²O, seal intact2. Water at facility w/purifier3. Soft drinks4. Beer & wine5. Coffee & tea if H²O boiled

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Water Precautions (2)

- Alcohol will not disinfect water- Be leery of how glassware, dishes & utensils

have been handled and washed- Don’t gargle or brush your teeth with water

you wouldn’t drink- If in doubt, draw a glass of HOT water and let

it cool, having passed through a hot water heater, it will be pasteurized

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FOOD PRECAUTIONS

Safe:

Meat and fish dishes well done & eaten hot.

Vegetables that are thoroughly cooked.

Nuts, fruits & vegetables to be peeled, shelled or skinned if purchased intact with no breaks in shell or skin.

Chinese restaurants enjoy a reputation of serving safe tasty food worldwide.

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FOOD PRECAUTIONS

Avoid:

Raw eggs Steak tartare

Raw meats Undercooked meats

Cold Platters Custards

Pastries Raw vegetables

Salads Dairy products

Raw shellfish Certain seafood

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RESTAURANT GUIDE

Presence of window and door screens

State of trash containment

Status of the Restrooms

Presence of roaches & flies

Chinese restaurants

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TRAVELERS’ DIARRHEA SYMPTOMATIC TREATMENT

1) Dietary restrictions

2) Pepto Bismol

3) Immodium

4) Lomotil

5) Lactobacillus

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Oral Therapy for Acute Diarrhea Developed in 1950’s-Glucose and electrolytes

Misconception about hypernatremia

1960’s-Coupled transport of sodium and glucose

Clinical studies with cholera showed efficacy

Subsequent studies worldwide

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TRAVELERS’ DIARRHEA PROPHYLAXIS

1) Generally not advised

2) Short trips only

3) Complications

4) Resistant organisms

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TRAVELERS’ DIARRHEA PROPHYLAXIS

1) Pepto Bismol

2) Antibiotics

a) Quinolones

b) Rifaximin

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EARLY TREATMENT OF TRAVELER’S DIARRHEA

1) Effective and proven

2) Short course – 3 Days

3) Pepto Bismol – Less effective

4) Antibiotics

a) Quinolones

b) Rifaximin

c) Azithromicin

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Special Risks of Travel

1) Motor vehicle accidents

2) Motion sickness

3) High altitude

4) Bites/stings/sun

5) Jet lag

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ACUTE MOUNTAIN SICKNESS HEADACHE WEAKNESS & LASSITUDE GI DISTRESS DIZZINESS SHORTNESS OF BREATH ANOREXIA DISTURBED SLEEP

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OTHER INFECTIOUS DISEASE RISKSa) STD’s

b) HIV

c) Schistosomiasis

d) Lepto-spirosis’

e) Dengue

f) Plague

g) Sleeping sickness

h) Parasites