Conflict of Interest Disclosure Conflict of Interest Disclosure The commercial entities with which I have relationships do not produce healthcare-related products or services relevant to the content I am planning developing or presenting for this Claire Panosian Dunavan, MD, DTM&H Claire Panosian Dunavan, MD, DTM&H content I am planning, developing, or presenting for this activity. Company Relationship Content Area HealthQuest Media, Inc. Co-owner Medical journalism; Print and broadcast products TRAVEL MEDICINE TRAVEL MEDICINE Made Practical Made Practical Current Clinical Issues in Primary Care Pri-Med West, Anaheim, CA, April 28-30, 2011 Made Practical Made Practical Claire Claire Panosian Panosian, MD, DTM&H (London) , MD, DTM&H (London) Division of Infectious Diseases Division of Infectious Diseases David Geffen School of Medicine at UCLA David Geffen School of Medicine at UCLA Once upon a time … Once upon a time … Travel to exotic Travel to exotic destinations was a destinations was a rare privilege rare privilege rare privilege … rare privilege … and (sometimes) and (sometimes) a definite hazard a definite hazard American Express Travel Poster circa 1920s Today … the world is smaller and more accessible, but medical hazards still exist. View of Earth from Apollo 11 Global Tourism Today Global Tourism Today A leading leisure activity A leading leisure activity A vital source of employment and income A vital source of employment and income In 2007: In 2007: 900 million international tourist arrivals 900 million international tourist arrivals (6.6 % (6.6 % ↑ over previous year) over previous year) USD 856 billion in monetary receipts USD 856 billion in monetary receipts
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Conflict of Interest DisclosureConflict of Interest Disclosure
The commercial entities with which I have relationships do not produce healthcare-related products or services relevant to the content I am planning developing or presenting for this
Vi capsular polysaccharideVi capsular polysaccharide 70%70%
TYPHOID FEVER: TYPHOID FEVER: A Look at Recent TrendsA Look at Recent Trends
JAMA “Typhoid Fever in the US,” 1999JAMA “Typhoid Fever in the US,” 1999--20062006
1902 patients: median age 22 yrs (11902 patients: median age 22 yrs (1--90), 90), 79% traveled overseas within 30 days of illness79% traveled overseas within 30 days of illnessyy
38% decreased susceptibility to Ciprofloxacin, 38% decreased susceptibility to Ciprofloxacin, increasing from 19% in 1999 to 54% in 2006increasing from 19% in 1999 to 54% in 2006
Patients with resistant infections more likely to report Patients with resistant infections more likely to report travel to Indian subcontinenttravel to Indian subcontinent
Countries Visited by TF Patients Countries Visited by TF Patients in 30 days before illnessin 30 days before illness
CountriesCountries No. of TravelersNo. of TravelersIndiaIndia 606 606 (47%)(47%)PakistanPakistan 126126 (10%)(10%)BangladeshBangladesh 124124 (10%)(10%)MexicoMexico 9090 (7%)(7%)PhilippinesPhilippines 5757 (4%)(4%)
P. P. falciparumfalciparum threatens 2.4 billion people threatens 2.4 billion people ––35% of the global population 35% of the global population
Taking into account the effect of Taking into account the effect of temperature and aridity, areas were temperature and aridity, areas were defined as stable (dark red areas where defined as stable (dark red areas where P. P. falciparumfalciparum annual parasite incidence (annual parasite incidence (PfPfAPIAPI))falciparumfalciparum annual parasite incidence (annual parasite incidence (PfPfAPIAPI) ) ≥0.1/1,000 persons), unstable (pink areas where ≥0.1/1,000 persons), unstable (pink areas where PfPfAPIAPI<0.1/1,000 <0.1/1,000 persons), or no risk (light grey).(8) (citation for new map) 74% of persons), or no risk (light grey).(8) (citation for new map) 74% of P. P. falciparumfalciparum cases occur in Africa, 25% in Asia, and 1% in the Americas.(1)cases occur in Africa, 25% in Asia, and 1% in the Americas.(1)
74% of PF cases in Africa, 25% in Asia,
1% in the Americas
P. P. vivaxvivax threatens 2.6 billionthreatens 2.6 billion——almost 40% of world’s populationalmost 40% of world’s population
Of 130-390 million yearly PV cases: 52 % in S. and S.E. Asia,
15 % in E Mediterranean, 13% in South America
Malaria life cycle in manMalaria life cycle in man
Plasmodium falciparum blood smear
Malaria in US ResidentsMalaria in US Residents
19971997--2006: 10,745 cases reported2006: 10,745 cases reported 60% acquired in 60% acquired in subSaharansubSaharan AfricaAfrica 14% acquired in Asia14% acquired in Asia 13% acquired in Caribbean, Central and 13% acquired in Caribbean, Central and
South AmericaSouth America____________________________________________________________________During same period, 54 fatal infectionsDuring same period, 54 fatal infections——
85% PF, 71% acquired SSA85% PF, 71% acquired SSA
(available online at www.cdc.gov)
Prevention of Malaria in TravelersPrevention of Malaria in Travelers
Insecticides (eg. deltamethrin, permethrin): Insecticides (eg. deltamethrin, permethrin): knockknock--down sprays or impregnate clothes/netsdown sprays or impregnate clothes/nets
Repellants (eg DEET, PMD, picaridin) for skinRepellants (eg DEET, PMD, picaridin) for skin
DEET based repellantsDEET based repellants–– best evidence and longest history of usebest evidence and longest history of use–– 20% DEET safe in pregnancy20% DEET safe in pregnancy–– Now sanctioned for infants > 2 monthsNow sanctioned for infants > 2 months
Antimalarials in the 21Antimalarials in the 21stst centurycenturyProphylactic RegimensProphylactic Regimens
Antimalarials in the 21Antimalarials in the 21stst centurycenturyStandStand--by Emergency Selfby Emergency Self--Treatment (SBET)Treatment (SBET)
ArtemetherArtemether--lumefantrinelumefantrine ((RiametRiamet, Co, Co--ArtemArtem))Effective, rapid parasite and fever clearance, Effective, rapid parasite and fever clearance, good safety/tolerability good safety/tolerability
AtovaquoneAtovaquone--proguanilproguanil ((MalaroneMalarone))Currently effective, good safety/tolerabilityCurrently effective, good safety/tolerability–– BUTBUT–– pending pending resistance? resistance?
Travel MedicineTravel MedicineSpecial Cases and IssuesSpecial Cases and Issues
Global Health workersGlobal Health workers
LongLong--term travelersterm travelers
ImmunosuppressedImmunosuppressed patientspatients
Unanticipated hazards in “clean” environments Unanticipated hazards in “clean” environments ((egeg norovirusnorovirus outbreaks on cruise lines)outbreaks on cruise lines)