UNITED STATES TRAVELERS

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UNITED STATES TRAVELERS

• 25 Million each year
• 5 Million to developing nations
• a) 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 Travel

• May 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 gt 1 month in rural areas
  (particularly with rice and pig farming) in Far
  East
• Adverse reactions include local in20 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

• Prevention-mosquito control
• Prophylaxis-depends on geography
• 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 Dose
• Chloroquine 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

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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-Montezumas 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 Pathogens

• Shigella 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 treated
• 2. Ice cubes
• 3. Fresh milk
• 4. Bottled water with broken seal
• Safe
• 1. Bottled H²O, seal intact
• 2. Water at facility w/purifier
• 3. Soft drinks
• 4. Beer wine
• 5. 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
• Dont gargle or brush your teeth with water you
  wouldnt 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 1950s-Glucose and electrolytes
• Misconception about hypernatremia
• 1960s-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

• Pepto Bismol
• Antibiotics
• a) Quinolones
• b) Rifaximin

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EARLY TREATMENT OF TRAVELERS DIARRHEA

• Effective and proven
• Short course 3 Days
• Pepto Bismol Less effective
• 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 RISKS

1. STDs
2. HIV
3. Schistosomiasis
4. Lepto-spirosis
5. Dengue
6. Plague
7. Sleeping sickness
8. Parasites