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Transcript
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.