Travel and Tropical Medicine Zain Chagla

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Agenda• The infectious stuff

Malaria prophylaxis

Diarrhea

Vaccination

Zika

• Other infection prevention

• Non infectious issues

• Post travel

Syndromic management

When to refer/what to test

Some local regions with tropical stuff

Case 1• A healthy 23 year old male presents for a travel assessment

• His itinerary includes a trip to Peru direct from Toronto

• He is otherwise healthy, takes no medications

• He’s here 3 weeks before his trip, and wants to minimize interventions due to a lack of funds

The travel consult• Vaccine preventable diseases

• Malaria and other mosquito borne diseases

• Diarrhea / Food and Water Prevention

• Zika

• Sexual / Tattoo health

• Non infectious complications

Underlying medical conditions

Altitude sickness

• Prevention / Safety

Vaccine Preventable Diseases• If you remember three things to vaccinate against

Hepatitis A (Havrix/Avaxim - $66)

if no history just vaccinate, don’t check serology

Typhoid (Typhim Vi/Typherix - 40) - combined HAV (Vivaxim 106), or oral vaccine

Coverage for 3-5 years, 60% prevention

Influenza (free?)

• Hepatitis B - can combine with HAV as twinrix (fast vaccination schedule) -free?? Twinrix - $69

• These should be updated for everyone regardless of immunocompromised (avoid oral typhoid vaccine)

• Consider updating specific vaccines (MMR, Tetanus/Diphtheria/Acellular pertussis, varicella/shingles)

Yellow fever• Both preventative behavior and

passport behavior

• WHO Requirements - as of July 2016 a single lifetime vaccination

• Exemptions for immunocompromising conditions

• Border guards may not respect WHO requirements (pay or get injected)

• $164 dollars, needs to be given at a certified center, and a global vaccine shortage

Other geographical vaccines • Meningococcal vaccine (conjugated)

Hajj travellers, Sub-Saharan Africa

Consider anywhere - particularly if staying in close quarters (hosteling, military recruits, living in dorms)

• Japanese encephalitis ($237)

Southeast Asia - particularly rural setting

Consider to those spending a significant amount of time camping or spending one night camping outdoors during their travels

Live vaccine - contraindicated in immunocompromised

• Rabies

Long term travellers, particularly staying in low income settings

People doing animal work abroad (most veterinarians / techs are already vaccinated)

Dukoral

• Originally developed as a cholera vaccine

• Targets cholera toxin structurally similar to enterotoxin in enterotoxigenic E. coli

• Original studies done show some benefit (50 % for ETEC) - only about 20% of all diarrhea causes At best 10% protection

• Cochrane review - NO benefit in preventing travellers diarrhea over placebo

• Only recommendation to give in an area with an ongoing cholera outbreak

• $100

Malaria • Look up on CDC website

• Intra country variation (Some itineraries may need)

• Can avoid if SHORT trip in air conditioned hotels (i.e. airport to hotel to airport)

• No role for chloroquine given global resistance

Malaria• Malarone (Atovaquone-Proguanil) 1 tab PO daily

Start 24 hours after travel to 7 days post travel

Mild GI side effects, headache

Unclear if safe in pregnancy

Total cost for 1 month of travel (covers 5 weeks) - $170

• Doxycycline 100mg PO daily Start 24 hours prior, 4 weeks post

Contraindicated in pregnancy, young children

Side effects - GI, esophagitis, hepatotoxicity, interference with Ca/Fe, photosensitivity

Resistance in Myanmar / Burma

Total cost 1 month of travel (covers 8 weeks) - $28

• Mefloquine 250 mg PO weekly Start 1 week (+2 weeks for tolerance) prior to travel, 4 weeks post

QT prolongation, cardiac dysrhythmia, neuropsychiatric side fx

Safe in pregnancy

Second line now unless previously tolerated in past

Total cost for 1 month (covers 10 weeks) - 37

• Chloroquine - very few indications - Mexico/Central America, Dominican, Middle east

Diarrhea• Prevention is key!

• Bottled water, peeled/boiled veggies, avoid ice in drink, deep fry foods!

• Imodium prn for mild diarrhea

• Antibiotic for travellers diarrhea (mild to moderate)

Quinolone

Azithromycin (particularly India/SE Asia)

Amoxicillin/Septra

• Take Imodium with antibiotic, if no better next day repeat, if no better repeat, by day 4 should seek medical help

• D/c once feeling better

Zika • First discovered at UVRI in Entebbe (Near Kampala) Uganda nearly a

century ago

• Circulated through Africa SE Asia in 60’s --> French Polynesia 2013 Latin America

• First noted microcephaly cases in Dec 2015 French Polynesia data suggests it may have been there too

• Prior cases of Male to Female transmission noted semen isolates at 4-5 months (very low efficiency)

• Controversy of whether there is an old world/new world difference vs. all risk is the same CDC everyone is at risk, Canada - only new world

Zika• Recommendations for all

Avoid unprotected intercourse and trying to conceive for 3 months females, 6 months males, avoid travel by all pregnant women

• Recommendations for CDC - same in Africa/SE Asia

• Recommendations from CATMAT - avoid mosquitos in these areas but no overt travel ban

• Cool places you can still visit Chile (including cruise ships)

Uruguay

Hawaii

Bermuda

Seychelles

Azores (Portugal)

Mallorca

South Africa

Australia/NZ

Other safety• Sexual Health / Tattoos / Health Tourism

Huge risk of HIV, GC/CT, Syphilis up to 5-20% of travellers engage in casual sex while abroad, 50% unprotected Highest risk < 25, MSM or female

Sterilization for needles poor

Health tourism - sterilization poor, high risk of blood borne infections as well as atypical / resistant wound infections

Pack lots of OCP and condoms if needed

• Hospital based tourists Particularly in high endemic HIV settings with blood exposure consider HIV post

exposure prophylaxis (as well as HBV vaccination)

• Mosquito prevention Bed nets (all during night not just sleep), DEET spray, permethrin impregnated

clothing, long sleeves

Non infectious issues• Travel / Trauma safety

Of the leading causes of death while travelling - 50% of issues due to MI/Stroke/Arrhythmia (Basically unpreventable bad timing stuff)

Of the remaining 25% of deaths / injuries due TRAUMA

More likely to get in an MVC, more likely to be fatal

More likely to be hit by drunk drivers

More likely to drown

More likely to have MSK injuries

• If you are going to counsel on anything it is preventing trauma

• Avoid travelling at night, flashlights, avoid motorcycle based transport, seatbelts needed

Non infectious issues• Underlying medical issues

Know the nearest tertiary care facility for complex patients

Have a standing amount of home meds plus analgesia etc.

• VTE prevention

Regular walking while on plane, consider compression stockings / ASA for long haul (very little evidence)

• Altitude sickness

Acclimatization / Pre acclimatize

In most folks this is enough, occasionally can consider acetazolamide

Side effects - flushing, diuresis, dehydration

Avoid triggers (caffeine, alcohol)

Other • Copy of all itineraries including to a contact on the ground

• Having some local currency

• Consular registration

• Travel insurance - even to Quebec or USA

• Copy of all passports

• Leave all non essential cards at home

• Despite all the warnings, most people DO fine, and relax / enjoy

Case 1• A healthy 23 year old male presents for a travel assessment

• His itinerary includes a trip to Peru direct from Toronto

• He is otherwise healthy, takes no medications

• He’s here 3 weeks before his trip, and wants to minimize interventions due to a lack of funds

Case revisitedVaccines

• HepA, Typhoid, Influenza

• Yellow fever - dependent on where

(Typical tourism no, into the jungle

yes

Malaria

• No typical, yes into jungle

• Mosquito prevention for other vector

borne diseases

Diarrhea

• Cipro or Azithro

Zika - counselling on condom use

• Others

Sexual health and safety

Trauma safety

Altitude sickness - occasionally an issue for the Inca trail - Consider staying in Cusco for a while, if very susceptible low dose acetazolamide

Register with consulate

Get travel insurance

Give someone else your itinerary just incase

Summary• Infectious issues

Vaccines

Malaria

Prevention

• Non infectious

Trauma/travel safety

Altitude sickness

Consulate/Insurance

Questions?

Case 2• Your patient has a great time hiking the Inca trail, and spends a few days in

Lima before departing back to Toronto

• 2 days after returning to Toronto, he notices the onset of fatigue, lethargy, retro orbital headache, and fevers

• He comes into the office, and you note no meningismus, some faint petechie, and fever of 39.0. There is no focal neurologic symptoms otherwise

• You send off basic bloodwork - WBC 2.0, NEUTS 1.0, HEMOGLOBIN 120, PLT 10, mild elevation in LFT’s

• How would you further work this up?

Approach to the returned traveler• Is this infectious or not?

• If infectious - is this tropical or not?

• If tropical - always consider malaria if in an endemic area

Break down into syndromes

Febrile syndrome

Meningitis syndrome

Hepatitis Syndrome

Gastroenteritis syndrome

Rashes

• Consider hospitalization or urgent care for most of these, in all of those MUST RULE OUT MALARIA

Febrile Syndromes• Malaria

• Dengue

• Chikungunya

• Zika

• Salmonella typhi

• Rickettsia / Lyme

• Malaria - cyclical fever, hemolysis, liver enzyme abnormalities

Diagnose on blood smear / rapid testing

Needs inpatient assessment

• Dengue - fever, leukopenia, thrombocytopenia, retro orbital headache, occasionally frank DIC

Diagnose on serology (within 21 d of travel)

• Chikungunya - Dengue +/- arthritis

• Zika - Dengue +/- Conjunctivitis

Meningitis syndrome• Bacterial meningitis

• Viral meningitis

West Nile

Other flaviviruses

Enterovirus

• Cryptococcus (where?)

• Lyme

• HIV / Syphilis

• All should be hospitalized

Hepatitis syndrome • Hepatitis A

• Hepatitis E

• Hepatitis B / D

• Syphilis

• Leptospirosis

• Yellow fever

• CMV/EBV

• Malaria / Dengue

• All should be hospitalized

• Hepatitis A/E

Acute fulminant hepatitis with some GI symptoms - serology

• Leptospirosis - history of water sports / rodent exposure

Gastroenteritis syndrome • Typical enteric

Salmonella

Shigella

E coli

Yersinia

Campylobacter

• Typhoid

• Viral - Norwalk

• Others - Giardiasis, E. histolytica, cryptosporidiosis

• Salmonella (non typhoidal) -significant diarrhea, occasionally bacteremia

• Shigella - Bloody diarrhea

• Yersinia - abdo pain, lymphadenopathy

• Typhoid - fever, constipation, abdominal pain, hepatosplenomegaly

• Giardiasis - steatorrhea

• E histolytica - diarrhea, colitis, liver abscess

Rashes • General approach

Think of local things like vaccine preventable diseases

Infected bug bites

Allergic reactions

Other random things

Rash trivia!

Summary• Break it into non infectious vs

infectious, tropical vs. non

• Syndromic diagnosis

• If unwell do workup in hospital

• Always think malaria

Questions?