Transcript TRAVEL BROADENS THE MIND AND LOOSENS THE BOWELS.

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 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
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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
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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 poliofree!
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
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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
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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
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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.
2.
3.
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
Chloroquine
phosphate
(Aralen*)
Adult Dose
300 mg base (500 mg salt)
orally, once/week
Hydroxychloroquine
sulfate
(Plaquenil*)
310 mg base (400 mg salt)
orally, once/week
Malarone
250 mg Atovoquone/
100 mg Proguanil, daily
Mefloquine
(Lariam*)
228 mg base (250 mg salt)
orally, once/week
Doxycycline
100 mg orally, once/day
Primaquine
15 mg base (26.3 mg salt) orally,
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The dose (250 mg for an adult) should be taken once each week for 4 weeks, followed by one dose every
other 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.
2.
3.
4.
5.
6.
E. Coli
Shigella/Salmonella
Campylobacter
Viral
Parasites
Unknown
50%
10%
8%
10%
2%
20%
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Infectious Doses of Enteric Pathogens
Shigella
Campylobacter
Salmonella
E. Coli
Cholera
Giardia
Amoebas
10-100
1000-100,000
100,000
100 million
100 million
10-100
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)
-
-
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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
Raw meats
Cold Platters
Pastries
Salads
Raw shellfish
Steak tartare
Undercooked meats
Custards
Raw vegetables
Dairy products
Certain seafood
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RESTAURANT GUIDE

Presence of window and door screens
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State of trash containment
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Status of the Restrooms
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Presence of roaches & flies

Chinese restaurants
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TRAVELERS’ DIARRHEA
SYMPTOMATIC TREATMENT
1)
2)
3)
4)
5)
Dietary restrictions
Pepto Bismol
Immodium
Lomotil
Lactobacillus
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Oral Therapy for Acute Diarrhea

Developed in 1950’s-Glucose and electrolytes
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Misconception about hypernatremia

1960’s-Coupled transport of sodium and glucose
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Clinical studies with cholera showed efficacy
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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)
2)
3)
4)
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
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HEADACHE
WEAKNESS & LASSITUDE
GI DISTRESS
DIZZINESS
SHORTNESS OF BREATH
ANOREXIA
DISTURBED SLEEP
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OTHER INFECTIOUS DISEASE RISKS
a)
b)
c)
d)
e)
f)
g)
h)
STD’s
HIV
Schistosomiasis
Lepto-spirosis’
Dengue
Plague
Sleeping sickness
Parasites
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