Transcript In the name of God - Isfahan University of Medical Sciences

In the name of God
Dr. Kiana Shirani
Assistant professor
Infectious Diseases specialist
Infection in travelers
Epidemiology of
Travel-Related illness
22% to 64% of travelers report some illness;
most of these problems are mild, self-limited
illnesses such as diarrhea, respiratory
infections, and skin disorders. Rates are
significantly higher in summer.
Epidemiology of
Travel-Related illness
Approximately 8% of travelers consult a
physician either during or after a trip, but less
than 1% require hospitalization. Infectious
diseases account for up to 10% of the
morbidity during travel but only 1% of the
deaths, with malaria being the most common
disease.
‫• آفریقا‪ :‬ماالریا‪ -‬بیماریهای مننگوکوکی‪ -‬اسهال مسافران‪-‬‬
‫انواع عفونتهای انگلی ومایکوباکتلایر‪ -‬تبهای خونریزی‬
‫دهنده‪ -‬تب زرد‪ -‬دانگ‪ -‬هپاتیتها ‪-‬بیماری خواب و‪...‬‬
‫• جنوب شرقی آسیا‪ :‬ماالریا‪ -‬اسهال مسافران‪ -‬هپاتیتهای‬
‫ویروسی‪ -‬ایدز‪ - HTLV -‬بیماریهای انگلی در رابطه با‬
‫غذاهای دریایی – عفونتهای تنفسی‪ -‬انسفالیت ژاپنی و ‪...‬‬
‫• هند‪ :‬ماالریا‪ -‬عفونتهای انگلی ومایکوباکتلایر و قارچی‪-‬‬
‫اسهال مسافران‪ -‬کلرا‪ -‬هپاتیت ها‪-‬عفونتهای تنفسی ‪-‬‬
‫آنفلوآنزا و ‪...‬‬
• The most common communicable diseases in
Mecca are include influenza, influenza-like
illness, meningococcal disease, traveler
diarrhea.
-‫ پنومونی‬-‫ عفونتهای تنفسی فوقانی‬:‫مکه ومدینه‬
‫ هپاتیتهای‬-‫ اسهال مسافران‬-‫عفونتهای مننگوکوکی‬
‫ تبهای خونریزی دهنده‬-‫ سل‬-‫ویروسی‬
Acute respiratory tract infections
Particularly so when the pilgrimage falls in the
winter season. The close contact, intense
congestion, shared sleeping accommodations
(mainly in tents) and dense air pollution all
combine to increase the risk of airborne
respiratory disease transmission.
Upper respiratory tract infections
A viral etiology of URTI is most commonly
implicated at the Hajj, but bacterial super
infection often follows. More than 200 viruses
can cause.
Influenza viruses are the most common,
followed by RSV and adenoviruses.
Common cold
• Incubation period: 1-3 days
• Symptoms: sore or "scratchy" throat, nasal
obstruction, rhinorrhea, Cough (rhinosinusitis)
• Causes: rhinoviruses, coronaviruses, RSV, and
…
• Treatment: symptom therapy, rest, hydration,
adrenergic
agents,
antihistamine,
acetaminophen or NSAIDS
Sinusitis
• Symptoms & signs: sore throat, headache,
myalgias, occasionally Fever, Nasal congestion
and discharge, periorbital edema, malodorous
breath, nasal discharge vary from thin and
mucoid to thick and purulent
• The most common etiologic agents are
viruses.
When to treat sinusitis with AB?
1.Compatible sign and symptoms lasting 10 days
or more without improvement
2.Severe symptoms or signs (T>39, purulent
nasal discharge, facial pain) lasting for at least
3-4 consecutive days at the beginning of
illness.
3.Double sickening
Treatment of ABRS
1. AB
2. Saline irrigation
3. Intranasal corticosteroid
Macrolide, antihistamine,
should not be used.
decongestant
• First line: Coamoxiclav
• Second line: high dose coamoxiclve,
doxycycline, levofloxacin, moxifloxacin
Flu
• incubation period : 1 to 2 days
• Systemic symptoms predominate( fever, chills,
shaking chills, headaches, myalgia, malaise,
anorexia, In more severe cases, prostration)
• The systemic symptoms usually persist for 3
days. Respiratory symptoms (dry cough,
severe pharyngeal pain, nasal obstruction and
discharge) are also usually present but are
overshadowed by the systemic symptoms.
Flu
The predominance of systemic symptoms is a
major feature that distinguishes influenza
from other viral upper respiratory infections.
Fever is the most important physical finding.
Treatment
• No studies have ever shown a benefit of
antiviral therapy begun after 48 hours or more
of symptoms, and the greatest effect is
typically seen when therapy is started in the
first 24 hours.
• Oseltamivir/Zanamivir/Amantadine/Rimantadi
ne
• Precaution: droplet+ contact
Lower Respiratory Tract Infection
Pneumonia is the leading cause of hospital
admissions during Hajj; and the second
leading cause of ICU admissions, with a
reported mortality of 17%.
Pneumonia
fever, chills, cough, sputum production,
dyspnea, pleuritic chest pain, and new
pulmonary infiltrates
Outpatient treatment: Betalactam, macrolide,
doxycycline, respiratory FQ
Lower Respiratory Tract Infection
The causative agents could differ from those of
CAP.
In one study TB(28%) and gram-negative
organisms(26%) were the most common
causative
organisms.
Streptococcus
pneumoniae was identified in (10%) patients,
and atypical organisms were identified in only
(6%) patients.
Tuberculosis
The intense congestion, living in close
proximity with vast crowds and the increasing
percentage of elderly pilgrims are all factors
magnifying tuberculosis risk. Additionally
many Muslims travel from countries of high TB
endemicity.
Pertussis
One study found a high incidence of pertussis
in Hajj pilgrims with an overall incidence of
pertussis (1.4%) during this one-month-long
pilgrimage Hajj pilgrims would therefore
benefit from pertussis vaccination prior to
their departure.
• Etiology: small gr – coccobacilli
• catarrhal stage: rhinorrhea, non purulent
conjunctivitis with excessive lacrimation,
occasional cough, low-grade fever, typically lasts
1 to 2 w
• paroxysmal stage: paroxysms of coughing,
uncontrollable coughing, often 10 to 15 coughs in
a row in a single expiration, the face may turn red
or purple, inspiratory whoop, post-tussive
vomiting (1-6 W)
• convalescent stage: The length of the cough
distinguishes pertussis from other respiratory
tract illnesses “cough of 100 days”
cough of at least 14 days and at least one of
the following symptoms: paroxysmal cough,
inspiratory whoop, or post-tussive vomiting.
• Treatment: macrolide, TS, FQ?
Face masks & vaccination
To reduce the risk of RTI during the Hajj, wear
surgical face masks when in crowded places
and vaccination against seasonal influenza
before, particularly those with pre-existing
conditions (the elderly, people with chronic
chest or cardiac, hepatic or renal disease and
all health care workers working in the Hajj
premises).
Influenza (pandemic)
Vaccination mandatory
Influenza (seasonal)
Vaccination mandatory
at least 2 weeks before arriving
The Saudi Ministry of Heaith requires from all
healthcare workers working in Mecca and
Medina to be vaccinated recommends
influenza and pneumococcal polysaccharide
vaccination for pilgrims older than 65 years
and for those younger with underlying comorbidities such as cardiovascular disease,
chronic lung disease, diabetes, alcoholism,
liver disease etc.
Age 2-23 mons with the PCV7. /PPV23 for all
persons older than 2 ys who are at increased
risk of developing pneumococcal infection or a
serious complication of such an infection./
older than 65 ys; /anatomic or functional
asplenia, CSF leak, DM, alcoholism, cirrhosis,
CRF, chronic pulmonary disease (asthma), or
advanced CVD;/immunocompromised ( MM,
lymphoma, HD, HIV, organ transplantation,
use
of
glucocorticosteroid);/genetically
susceptible
(Native
Americans
&
Alaskans);/live in nursing homes.
Meningoccocal disease
age annual rates per 100,000 population
0-2.9
3-9.9
10-24.9
25-120
o Meningitis belt
Meningococcal disease
During the Hajj, carrier rates for
meningococcal disease rise to a level as high
as 80 percent due to intense overcrowding,
high humidity and dense air pollution. When
rates of carriage rise to this level, the risk for
meningococcal outbreaks becomes a real
concern.
Meningococcal disease
• The largest meningococcal outbreak among
pilgrims occurred in 1987 with meningococcal
serogroup A affecting pilgrims in Mecca and
internationally.
Meningococcal disease
• In the years 2000 and 2001, 2 large outbreaks
of meningococcal serogroup W135 occurred
among pilgrims and their families in Saudi
Arabia and internationally.
• Quadrivalent (A,C,Y, W135) meningococcal
polysaccharide vaccine has eliminated future
meningococcal outbreaks.
Treatment
• Ceftriaxone
• Pen G
• Chloramphenicol
for 10-14 days
Prophylaxis for:
• Household contacts and sharing the same living
quarters.
• Daycare center or child care contacts, frequent
playmates of young children
• Close social contacts who were exposed to oral
secretions in week before onset, such as by
kissing, sharing eating utensils or toothbrushes.
Chemoprophylaxis is not recommended for
school, work, or transportation contacts.
Prophylaxis
• Rifamipin: 600 mg BD for 2 days
• Ciprofloxacin: 500 mg single dose
• Ceftriaxone: 250 mg single IM dose
Vaccination
college freshmen, living in dormitories,
microbiologists routinely exposed to N.M;
military recruits; travel to or reside in
countries in which N.M is hyperendemic or
epidemic; terminal complement component
deficiencies; functional or anatomic asplenia,
HIV infection.
Blood-borne diseases
Muslim shave their heads. Head shaving is an
important means of transmission of bloodborne disease. Illegal unlicensed barbers,
shaving hair at the roadside with non-sterile
blades, which are re-used on multiple scalps.
We encourage all pilgrims to receive the full
series of hepatitis B vaccination prior to travel
to Hajj. As well, all pilgrims should avoid
unlicensed barbers and seek approved
licensed barber facilities.
Blood-borne diseases
In a 1999 study which examined hepatitis
serology in Hajj barbers showed that 4% of
them were positive for HBsAg , 10% were
HCV-positive, and 0.6% was positive for
HbeAg, indicating high infectivity.
use your own razor blades..!
Hepatitis B
Countries/areas with moderate-to-high risk of infection
Diarrhoea
Traveller’s diarrhoea is common during the
Hajj. The last study was done in 2002 showing
that diarrhoea was the 3rd most common
cause for hospitalization during Hajj.
Diarrhoea
Pilgrims must be educated about selftreatment of diarrhoeal disease. Proper
hydration and fluid intake is vital. The
inclement conditions at the Hajj predispose to
dehydration in all adults, let alone the
extremes of age where dehydration is more
expected.
Self-administered AB with an extended
spectrum macrolide (azithromycin) or an oral
quinolone are probably indicated for
moderate to severe travelers’ diarrhea. Most
pilgrims can be advised to carry a 3-day course
of antibiotic therapy, an antimotility agent
such as loperamide, and a thermometer.
Diarrhoea
Significant improvement in water supply and
sewage treatment has eliminated cholera
outbreaks. Concerns still persist about
importing cholera with pilgrims from affected
countries, which will cause widespread
outbreaks in Mecca.
Hepatitis A
HAV is also common in Saudi Arabia, with 90%
of adults being immune from natural
infection. HAV vaccine is recommended for
pilgrims from developed countries—it is
probably unnecessary for those from
developing countries since they are likely to
be immune because of childhood exposure.
Travelers can be checked for HAV IgG before
administration of the vaccine, to avoid
vaccination.
Hepatitis A
Most pilgrims coming from high endemicity
countries
(Most) older pilgrims naturally
protected → vaccination for youngers born in
european countries!
Hepatitis A
Countries/areas with moderate-to-high risk of infection
Malaria: no risk around Mecca-Medine-Jeddao
Cholera: no cholera anymore since 1989
Thank you