*With the exception of programs from the ACCEL series, each of which qualifies for up to 4 Category 1 CME credits.
Audio-Digest Emergency Medicine
Volume 30, Issue 08
April 21, 2013
Planning for Travel Michael J. VanRooyen, MD, MPH
Travel Infections Robert Derlet, MD
The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.
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The goal of this program is to improve the health care and safety of travelers. After hearing and assimilating this program, the clinician will be better able to:
1. Review the risks of personal injury from trauma while traveling abroad.
2. Recommend appropriate prophylactic measures based on travel destination.
3. Manage diarrheal and upper respiratory illness while abroad.
4. Assess relative risk for diseases based on geographic location.
5. Recognize symptoms of infectious diseases that present after travel abroad.
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Derlet is a consultant for McKesson and is on the Speakers’ Bureau for Forest Laboratories. Dr. VanRooyen and the planning committee reported nothing to disclose. In his lecture, Dr. Derlet presents information that is related to the off-label or investigational use of a therapy, product, or device.
Planning for Travel
Michael J. VanRooyen, MD, MPH, Professor, Harvard Medical School, Brigham and Women’s Hospital, Department of Emergency Medicine, Boston, MA
Introduction: consult Centers for Disease Control and Prevention (CDC) for specifics about travel health; travelers more likely to die from unintentional injury (eg, trauma, motor vehicle accidents) than from infectious disease; travelers compliant with water and food precautions but often do not bring along enough of their medications; travelers often fail to use seatbelts while abroad and become susceptible to serious injury from traffic accidents
Demographics of travelers: from 2010 onward; senior travelers (aged ≥65 yr) and adventure travelers represent two main groups that illustrate changing travel demographics and habits; senior travelers — baby boom generation began reaching age 65 yr in 2010; this demographic controls majority of assets and account for majority of American travelers; many senior travelers participate in high-impact activities during travel; senior travelers face unique challenges, and travel may exacerbate challenges; senior travelers may have chronic conditions and plan to visit locations with poor access to curative medical services; notoriously noncompliant with bringing adequate supply of their daily medications; challenges in preparation for senior travelers — consideration of comorbid conditions and multiple medications; decreased mobility and lack of accessibility in foreign countries; increased risk for cardiac events due to stress; limited access to health services; adventure travelers — traveling to politically unstable countries and participating in high-stakes activities (eg, adventure races, mountaineering, biking, back-country traveling); activities carry higher rate of injury, and performed in locations with limited health services and less ability to evacuate injured; motor vehicle accidents often overlooked health threat to adventure travelers; personal security issues (easily avoidable); specific disease exposures; bodily injury leads all other causes of preventable death during travel; risk for death from malaria (with proper prophylaxis) exceedingly small, compared to risk for death from injury; travelers have higher risk for death by homicide than by motor vehicle accidents in certain areas (eg, Honduras, Guatemala, Haiti); travelers often go to risky places and voluntarily participate in risky behaviors; most travel agencies or clinics do not adequately address issue of personal security; article on State Department website has publication, “A Safe Trip Abroad,” that provides useful personal security tips for travelers
Recommendations: allow 3 mo to plan trip abroad (eg, tickets, passports, visas); consult CDC for specifics on particular countries and regions; diarrhea — plan for diarrheal illness and adhere to food precautions (“boil it, cook it, peel it, or forget it”); bottled water, no salads, regular handwashing; bring some prophylaxis for diarrhea (eg, fluoroquinolone drugs); take loperamide when going to high-risk locations (contraindicated if experiencing fever or blood in stool); half of people who travel for >1 wk experience diarrheal illness; acute bacterial diarrhea or protozoal diarrhea (indolent course and more persistent than bacterial diarrhea); bring metronidazole (Flagyl) if traveling for extended time; diarrhea lasting >2 wk while taking metronidazole requires medical attention; use loperamide to treat diarrheal symptoms unless frank dysentery present; insurance — get excellent travel insurance (speaker recommends company that provides evacuation for health reasons and for political instability); transportation — exercise caution when choosing transportation while traveling; choose high-end buses; use seatbelts; do not ride on motorcycles or scooters; do not drive yourself in unfamiliar places (use official taxi services); personal safety — stay sober or drink in hotel or safe place; do not appear conspicuous or rich; protect belongings; divide cash and valuables; senior travelers — check accessibility and restrictions of desired locations before leaving; be wary of cardiac strain from altitude; ensure adequate supply of medication for chronic conditions; senior travelers should get waiver of yellow fever vaccination (do not be coerced into vaccination at border crossings); walk around during flights to prevent deep venous thrombosis (DVT); aspirin helpful for prevention of DVT; high-risk people (previous history of DVT or pulmonary embolism ([PE]) should take low molecular weight heparin; miscellaneous — make copies of important documents, leave one copy at home and stow another copy in your luggage; back-up documents in cell phone and password-protect your cell phone (get international plan); pack 1 mo ahead of time and reassess what you need before you leave; certain countries have significant restrictions on types of medications travelers can bring into country (have medical license on hand); use routine antibiotics; bring EpiPen, antibiotic eyedrops; go to biggest, best hotel in area while traveling in dangerous areas (have security, money, access to transportation)
Robert Derlet, MD, Professor Emeritus, Emergency Department, University of California, Davis, School of Medicine, Sacramento
Introduction: diarrhea and respiratory illness most worrisome health risks while traveling; death or injury from automobile or pedestrian crash another significant concern; blood banks outside of Europe and United States may not screen for hepatitis C or HIV, presenting significant risk when receiving transfusions in other countries; overall poor quality of health care in many foreign countries can lead to complications; herd immunity does not exist in many regions (high incidence of pertussis in central Africa and parts of Asia); speaker recommends updating tetanus/diphtheria/acellular pertussis (Tdap), influenza, and hepatitis B vaccinations; area-specific immunizations — yellow fever vaccination recommended for travelers going to Amazon or central Africa; check CDC website for prevalence of polio in travel destination; consider Japanese encephalitis and rabies vaccines if traveling to southeast Asia
Foodborne illness: diarrheal illness common among travelers; traveler’s diarrhea (TD) most frequently caused by Escherichia coli (E coli); E coli normally lives in gut, but certain strains cause disease; incidence of Campylobacter-associated diarrhea equivalent to incidence of diarrhea from E coli in southeast Asia; Shigella and various viruses may also be responsible for diarrheal illness in certain locales; less frequently, Giardia infection or amoebiasis may underlie diarrhea (often presents after return home due to long incubation periods); most types of E coli not harmful and considered normal flora of mammalian gut; enterotoxigenic E coli most common cause of TD worldwide; E coli that produce Shiga toxin can cause severe illness (especially in children); symptomatic treatment of TD — meta-analysis concluded that use of loperamide (Imodium) for TD safe and produces good outcomes; speaker recommends bringing antimotility medication and azithromycin (shortens course of TD); consider bringing quinolone drug, although much of E coli and Campylobacter in southeast Asia resistant to quinolones; speaker recommends bringing metronidazole for trips lasting >2 wk to treat protozoal infection; Giardia — results from ingestion of water or food contaminated with cattle manure; protozoan with low infective dose; anecdotal evidence suggests Giardia can survive >1 yr; easily treated with metronidazole; illness from infection with Giardia presents with bloating and gas several weeks after trip abroad; norovirus — gastrointestinal (GI) virus; primarily causes vomiting (hallmark of norovirus infection) with some diarrhea; only 18 virus particles necessary to infect; 10 trillion virus particles shed in stool of infected person; norovirus survives outside body, presents significant public health risk; rapid diagnostic techniques not available; previous infection not protective; can be acquired via ingestion of contaminated food or water
Respiratory illness: airplane study — studied transfer of infection when ventilation turned off; studies found that risk of acquiring respiratory virus increased when ventilation in airplane shut off just before deplaning; infectious distance depends on vehicle, ie, aerosol or droplet; respiratory infections spread by droplet include influenza, rhinovirus, adenovirus, respiratory syncytial virus, and meningitis bacteria from other passengers sitting in front, behind, or directly next to traveler; influenza, adenovirus, and tuberculosis infection from aerosols possible over larger radius; bird flu — speaker states that travelers do not require immunization for avian flu; avian flu has H5 antigen which does not allow virus to adhere to human respiratory epithelium (H1, H2, and H3 antigens do); low risk of contracting H5 bird flu unless working closely with birds or if defect in epithelium allows H5 antigen to adhere; concern that toxic genes from H5 influenza will cross over in pig or bird and infect H1 strain
Diseases of concern in Africa: malaria — disease often presents within 1 mo of infection by mosquito vector; 1% of infected people may take ≤1 yr to present with disease; parasite has complex life cycle, one phase of which occurs in human liver; doxycycline (daily prophylactic) effective against parasite in liver phase, while most other antimalarial drugs effective in red blood cell (RBC) stages; symptoms include headache, flu-like viral syndromes, abdominal pain, chest pain, nausea, weakness, sweating with fever; physicians should not rely on ‘textbook’ presentation of disease, but should test for malaria in patients who present feeling sick and have traveled in regions where malaria endemic; complications of malaria — cerebral malaria may result in altered mental status; malaria can cause renal failure, hemolytic anemia leading to blackwater fever, and acute respiratory distress syndrome (ARDS); death from malaria occurs in Europe and United States; malaria easily missed by first-world physicians; important to ask patients about travel; drug therapy — chloroquine has become obsolete for prophylaxis of malaria due to global resistance; mefloquine, atovaquone/proguanil (Maralone), or doxycycline all first-line antimalarial drugs; travelers to southeast Asia (near Burma-Thailand border) may consider acquiring artesunate compound drug from overseas vendors; side effects of mefloquine include nightmares and behavioral disturbances; speaker recommends atovaquone/proguanil or daily doxycycline along with use of mosquito nets while sleeping for prophylaxis of malaria; African tick bite fever (ATBF) — related diseases include Rocky Mountain spotted fever; caused by bacterium Rickettsia africae; increasing incidence among travelers to Africa; often missed due to ordinary appearance of tick bite; patients often do not realize they have tick bite; symptoms include fever, headache, and myalgias; difficult to distinguish from Dengue fever; speaker states that patients with fever who have traveled to Africa and had exposure should receive doxycycline; patients misdiagnosed and treated for malaria have died from their ATBF; doxycycline fairly innocuous and may be life-saving; schistosomiasis — transmission by cercaria released by water snail; important to boil and filter drinking water before use; ≥3 types of schistosomiasis-causing organisms; Schistosoma haematobium affects bladder and causes hematuria; Schistosoma mansoni and Schistosoma japonicum affect liver and cause cirrhosis; parasite enters bloodstream through legs after exposure to infected water; cirrhosis from schistosomiasis most common cause of ascites in Africa; schistosomiasis may disseminate into brain and cause seizures; treated with praziquantel; schistosomiasis endemic to parts of South America, most of tropical Africa, Mekong River delta in southeast Asia; incubation period lasts years; can be acquired after one exposure to infected water; parasite found in urine or stool
Diseases of concern in Asia: Dengue fever — found in most tropical regions of Asia and rest of world; transmitted via Aedes aegypti mosquito; virus more virulent now due to evolution of genome over past 30 yr; no effective vaccine; lives only in human reservoirs and transmitted exclusively via mosquitoes; causes severe flu symptoms for about 1 mo (eg, myalgia, high fever); treating clothes with pyrethrin useful for repelling mosquitoes when traveling through jungle; Dengue shock syndrome causes hemorrhagic fever (caused by more virulent strain); four unique strains of virus that causes Dengue fever; typhoid fever — caused by Salmonella typhosa; acquired through ingestion of infected food or water; rarely causes diarrhea; average incubation period 7 to 14 days, case reports up to 21 days; can occur once traveler returns home; symptoms include headache, nausea, malaise, and abdominal pain; differentiated from Dengue fever by relative bradycardia; treated with ceftriaxone, azithromycin, or doxycycline (resistant to quinolone drugs); patients may also have coated tongue; oral vaccine effective for 5 yr
Diseases of concern in Central and South America: hookworm — 1 billion people have hookworm; causes severe anemia (100 worms consume 20 mL of blood per day); causes low hematocrit and abdominal pain; treated with albendazole or mebendazole; often acquired when people go barefoot in endemic areas; worms acquired through skin, go through bloodstream to get to gut, where they reside; speaker once saw patient with severe hookworm infection with hematocrit of 12%; leishmaniasis — spread by bite of sandfly; can infect almost any organ system and cause multiorgan system failure; can cause malaise, fatigue, or wasting; one form affects skin and causes mucocutaneous lesions; speaker recommends treatment with amphotericin B; leishmaniasis can only be prevented by preventing sandfly bites; sandfly not exclusive to sandy areas; amebiasis — acquired anywhere, but higher risk for acquisition in Central and South America; transmitted through ingestion of infected food or water; diarrhea variable, may cause only loose stools; diagnosis made through stool analysis or serology
Dr. VanRooyen spoke at 11th Annual Clinical Decision Making in Emergency Medicine, held June 21-23, 2012, in Ponte Vedra Beach, FL, and sponsored by Mount Sinai Medical Center, Brigham and Women’s Hospital, University of Florida, Jacksonville, Mayo Clinic College of Medicine, Carolinas Medical Center, the Foundation for Education and Research in Neurologic Emergencies, Best Practices, Inc., and Emergency Medicine Practice. Dr. Derlet spoke at the 35th Annual UC Davis Winter Conference, held February 27 to March 2, 2012, in Truckee, CA, and sponsored by the University of California, Davis, School of Medicine. For future CME activities by our meeting sponsors, visit www.clinicaldecisionmaking.com for Mt. Sinai Medical Center et al, and, www.ucdmc.ucdavis.edu/cme/ for UC Davis. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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