Download LTC Joel T. Fishbain, MD, FACP

Pre-travel Counseling/Medicine
LTC Joel T. Fishbain, MD, FACP
Asst Chief, Infectious Disease Service
Walter Reed Army Medical Center
Goals and Objectives
Discuss general counseling of patients traveling
Review immunization issues related to travel
Discuss malaria prophylaxis and travel
Review the common infectious diseases and
potential diseases of travelers
 Discuss traveler’s diarrhea and self-treatment
 Review preventive measures for a variety of
diseases




Introduction
 In 2000 there were an estimated 699 million
international travelers with 50 million to lessdeveloped nations
 ~ 3 in every 4 travelers will become ill or injured
 Risk estimation
 100000 travelers to developing world in 1 month
 50K will have a health problem
 5K will have to stay in bed
 300 will be admitted to a hospital
 50 will have to be air evacuated
 1 will die
Spira A. Preparing the traveller. Lancet 2003;361:1368.
Case
 65 yo male and his wife are traveling to Kenya for 2
weeks.
 He and his wife present for pre-travel counseling.
 Now what?
Basics
 Basic health assessment
 PMHx and ongoing problems
 DM – insulin? Meds? Coumadin? aPTT?
 Itinerary
 Rural vs urban travel
 Economy vs military living
 Individual vs group
 Immunizations
 Baseline – Td, pneumovax, MMR, polio
 Based on itinerary
Basics cont’d
 Disease risk assessment
 Malaria
 Dengue
 Hepatitis A, B and E
 JEV
 Rabies
 Yellow fever
 Meningococcal
 Infectious diarrhea
 Leptospirosis
 Schistosomiasis
 Other parasites
 Heat/cold injury
 Altitude sickness
Case
 Couple is actually spending a few days in Egypt then
on to Nairobi. They will spend a few days there and
then a week in the game park.
 They will be living on the economy.
 Food and water will be provided at times.
 They have minor medical issues and have plenty of
medications.
Malaria
 Risk assessment is quite difficult
 Big difference between falciparum and vivax
 First assess risk of falcip
 Then assess chloroquine resistance
 Then assess mefloquine resistance
 Consider common side effects of medications and
drug interactions
 Consider photosensitivity issue when prescribing
doxycycline
Malaria
 Non-scientific assessment of risk
 Location of travel – rural vs urban
 Duration of exposure
 Time of day of exposure – malaria transmission is
dusk to dawn
 Living situation – b&b vs a/c hotel, bed nets yes
or no, etc.
 Season traveling and climate expected
 Altitude and coastal travel
Prophylaxis
 Personal protective measures are key
 Cover the skin with light colored, loose fitting
clothing including long sleeves and slacks (ha!).
 Bed netting or good window screens impregnated
with permethrin are important
 Insect repellents are key
 Do botanicals work?
 How about skin so soft (Avon®)?
Insect Repellents
 DEET (N,N-diethy-3-methylbenzamide) is the best
and proven product for skin insect repellents
 Deep Woods OFF! – mean complete protection for
300 minutes
 Skin-So-Soft – 22 minutes
 Citronella products – 10-20 minutes
 Repello Wristband – 0.2 minutes
 Issues that I have found important for patients
 Vehicles and method of administration important
 Military axle grease vs spray?
Fradin MS and Day JF. Comparative efficacy of … NEJM 2002;347:13.
Malaria Life Cycle
http://www.malaria.org/LIFECYCL.HTM
Blood schizonocide
Chloroquine
Mefloquine
Doxycycline
Atovaquone/proguanil?
Tissue schizonocide
Atovaquone/proguanil
Primaquine
Chemoprophylaxis for P. falciparum
 Extremely important due to the mortality of the
infection
 Must be emphasized to patients
 Assess risk
 Assess the travelers compliance, willingness to take
meds, “press” related to mefloquine, drug
interactions – beta-blocker is really a non-issue
 Assess resistance in the area
 Mefloquine resistance in Asia
 Chloroquine sensitive P. falciparum is limited
Malaria
 Med of choice to start 1-2 pills before travel
 Weeks for chloroquine/mefloquine
 Days for malarone and doxycycyline
 Continue for 4 weeks upon return due to the tissue
schizont/hypnoizite stage of all malaria.
 Unlike P. vivax, no prolonged or persistent
hypnozoite stage.
 Strongly consider primaquine for the very short trips
 Not FDA approved
 Double dose required when used for primary
prophylaxis
 Works quite well
 Check G6PD on all patients taking primaquine
Primaquine as Causal Prophylaxis
 In a 20 week, placebo controlled trial in Papua, 88%
efficacy of protection against P. falciparum and
>92% for P. vivax.
 Cough, sore throat and HA were statistically more
common with PLACEBO. O/W no adverse events
were statistically significant
Baird JK et al. Randomized, parallel placebo-controlled… CID 2001;33:1990.
 Comparison of mefloquine, primaquine and doxy
showed 94% efficacy with primaquine, 47% with
doxy and 48% with mefloquine. Predominantly P.
falcip in primaquine failures of course.
Schwartz E. Primaquine as prophylaxis… CID 1999;29:1502.
Malaria
 Med of choice to start 1-2 pills before travel
 Weeks for chloroquine/mefloquine
 Days for malarone and doxycycyline
 Continue for 4 weeks upon return due to the tissue
schizont/hypnoizite stage of all malaria.
 Unlike P. vivax, no prolonged or persistent
hypnozoite stage.
 Strongly consider primaquine for the very short trips
 Not FDA approved
 Double dose required when used for primary
prophylaxis
 Works quite well
 Check G6PD on all patients taking primaquine
Malaria Prophylaxis
 Mefloquine – once weekly starting 1-2 weeks before and
continue for 4 weeks after returning.
 CNS side effects common – dreams, etc
 Not permitted for flight status
 No consistent issues with beta-blocker interaction
 Highly effective and easy to take
 Doxycycline – daily dosing required
 Usual contraindications
 Photosensitivity
 GI upset
 Less effective than other drugs – compliance vs true drug
issue
 Required for parts of SE Asia due to increasing reports of
mefloquine resistance
Malaria Prophylaxis
 Atovaquone/proguanil – Malarone, daily use
required but no need to continue past one week
upon return
 Synergistic combination required for activity
 Very expensive
 Well tolerated – HA and GI symptoms reported
 Not indicated for P. vivax
 Very effective as treatment for uncomplicated P.
falciparum
 Highly effective as prophylaxis
Terminal Prophylaxis
 If primaquine not given for causal prophylaxis, then
consider primaquine upon return.
 Prevents relapse from hypnozoites.
 CDC recommends it for longer stays? Why?
 If you are going to prophylax vivax, then finish it.
 Vivax not lethal so many travel medicine docs don’t
worry about it.
 Check G6PD on all patients prior to administration.
Common Problems
 What about the long term stay?
 How long can you safely give malaria prophylaxis?
 What about access to health care should the
traveler become ill with or without prophylaxis?
Case
 Our travelers will be in the game parks for a week.
They will be living in hard side tents with provided
supplies.
 They don’t know if bed nets will be provided and
a/c is doubtful.
 Your assessment of their malaria risk is…..?
 Risk is mod-high and patients are non-immune.
 You would prescribe PPE and mefloquine
Case
 The patients want to know about traveler’s
diarrhea.
 How can you counsel them on prevention?
Food Borne Illness
 Prevention is key and counseling is critical to
protecting patients.
 Steaming hot food that is freshly prepared.
 Peelable fruits.
 Bottled beverages – make sure the water bottles
have not been filled from the tap.
 No ice unless assured made from purified water
(supposedly the ice with the holes is OK?).
Water Disinfection
 Consider water disinfection – tabs, boiling, special
filters (can not be recommended or confirmed by
CDC). Turbidity and contact time important.
 I consider them for very long stays, remote travel,
large group travel, very frequent travel, hiking,
camping
When Prevention Fails!
 E. coli, campylobacter (high percentage of
quinolone resistance), salmonella, shigella, viruses
most common causes of travelers diarrhea (nonpreformed toxin). Very geographic when talking
about prevalence of one agent over another.
 Affects 20-50% of travelers.
 Definition for studies - > or = 3 unformed stools in
24 hour period.
 Prevent volume depletion.
 Shorten the course of symptoms.
Adachi JA. Empirical antimicrobial therapy… CID 2000;31:1079.
Traveler’s Diarrhea
Mild
1-2 stools
Mild/absent sx
Mod
> 2 stools
Severe
Fever or bloody stools
> 6 stools
Fluids
+/- loperamide
Fluids
loperamide
Fluids
+
Fluoroquinolone
+
NO loperamide
Add fluoroquinolone
For distressing sx
Consider finding medical
Care (State Department)
Unusual Exposures
 54 yo Eco-Challenge participant came to see me one
month prior to Papua-New Guinea race. We went
through all aspects of his trip, provided mefloquine
for malaria chemoprophylaxis and self-treatment of
traveler’s diarrhea. All immunizations were
reviewed and updated appropriate for his trip.
 We forgot something!
 A week or two after his return a large number of
participants became ill with high fevers, cytopenias
and mild erythroderma rash.
 Diagnosis?
Exposures!
 Number of participants with confirmed
leptospirosis.
 We should have given doxycycline for prophylaxis.
 A marine LT and his wife were spending 3 months in
Africa and he absolutely planned on swimming in
Lake Malawi.
 What did I advise? What did I give him?
 Discussed schistosomiasis, post-exposure treatment
with praziquantel.
Other Diseases
 Dengue fever – counsel about PPE and bug
repellents irrespective of malaria.
 Other vector borne problems – hemorrhagic fevers,
etc.
 Blood borne – Hepatitis B, C, HIV (particular
concerning in trauma and transfusion in many
countries).
 STDs – particularly HIV.