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UNITED STATES TRAVELERS 1) 25 Million each year 2) 5 Million to developing nations a) ¼ - ½ get some illness (2.5 million) b) 1/100 – 1/1000 get serious illness (25,000 – 250,000) – malaria and filariasis 1 SCOPE OF THE TRAVEL INDUSTRY 1. A trillion dollar industry 2. Over 7 million jobs 3. In developing nations, often the major source of foreign currency 2 DEFINITION OF A TRAVELER Someone who goes from an area of the world slightly fecally contaminated to an area where contamination is moderate to severe. 3 THE FECAL VENEER 4 International Travel May be Required: Yellow Fever Cholera May be Recommended: Typhoid Plague Measles Polio Rabies Hepatitis A Hepatitis B 5 Required Immunizations for Travel A. - Yellow Fever Every 10 years for travel to areas infected with yellow fever and to rural areas endemic for yellow fever – equatorial SouthAmerica and Africa. B. - Cholera New serotype Vibrio cholera 0139 now affecting Indian subcontinent and Asia. For most travelers, risk remains low. no country now requires vaccination for direct travel from the United States. no vaccine will protect against V. cholerae 0139. - 6 Yellow Fever Attenuated live virus vaccine Administered at designated centers Only one injection required Protection afforded for 10 years Areas of risk: Equatorial Africa, Central and South America 7 Cholera Vaccines Inactivated, parenteral - poorly protective (50%) for only a few months - uncomfortable side effects rarely recommended Experimental A. Inactivated oral vaccine-Whole cell (WC) and B subunit/whole cell (BS/WC) B. Attenuated, live oral vaccine-CVD 103-HgR 8 CHOLERA Vaccine of limited usefulness Risk to U.S. travelers is low (10 cases since 1961, 7 had been vaccinated) Indicated if passing through endemic regions One injection meets international requirements Full series of 3 shots for select patients Boosters may be required every 6 months 9 Polio The Americas have now (9/29/94) been declared poliofree! A. Inactivated, parenteral – enhanced (elPV) - should be used in adults (≥ 18 yrs) never previously immunized B. Attenuated, live oral – OPV - can be used to boost previously immunized adults - risk of paralysis 1/1.4 million with first dose; 1/41,500,000 in previously immunized 10 The Global Effort to Eradicate Polio by 2000 Before vaccines, 500,000 people a year were paralyzed or died from contracting polio. In 1996, 400 million children were vaccinated against polio. Since 1988, cases of polio have dropped 90 percent. 11 TYPHOID • Attenuated, live oral-Ty 21a mutant of S. Typhi (Vivotif Berna) - well tolerated, 60-70% effective • Inactivated, parenteral-Vi polysaccharide of S. Typhi (Typhim Vi) - well tolerated, 64-72% effective, single dose 12 Japanese B Encephalitis Consider travel for > 1 month in rural areas (particularly with rice and pig farming) in Far East Adverse reactions include local in≈20% and systemic in 10% Hypersensitivity reactions in 0.01% to 1% which may occur after any dose and be delayed up to 10 days In passive surveillance by Connaught, none of these reactions have been reported in 200,000 doses distributed 13 TETANUS & DIPHTHERIA EVERYONE SHOULD RECEIVE A PRIMARY SERIES TETANUS-DIPHTHERIA TOXOID BOOSTER IS INDICATED EVERY 10 YEARS TdAP 14 MMR 1) Live attenuated measles, mumps, rubella 2) Two dose regimen 3) Avoid Gamma Globulin 15 OTHER VACCINES Hepatitis A – most common in developing world Hepatitis B Meningococcal Rabies 16 Uncommon or Unavailable Vaccines 1) Smallpox 2) Typhus 3) Anthrax 4) BCG 17 Resurgence of Malaria Risk in over 100 countries 300 million cases with 3 million deaths annually Major problem in Africa and Oceania Marked increase in drug resistance Deaths from malaria each year = those from AIDS in the past decade 18 MALARIA 1. 2. 3. Prevention-mosquito control Prophylaxis-depends on geography Therapy-two principles A. Decrease parasite load B. Then eradicate parasite 19 PLASMODIA 1) Falciparum-malignant 2) Vivax-has liver phase 3) Ovale-has liver phase 4) Malariae-chronic 20 MALARIA-CLINICAL 1) Fever, chills, ha, myalgias, nausea 2) Diarrhea, abdominal pain, fatigue, confusion 3) Fevers become cyclic 4) Complications-DIC, splenic rupture, anemia 21 MOSQUITO PROTECTION 1. DEET 2. Appropriate Clothing 3. Permethrin 4. Screens 22 ANOPHELES MOSQUITO 1) Silent 2) Night Biting 3) Female 23 Table 1. Drugs used in the prophylaxis of malaria Drug Chloroquine phosphate (Aralen*) Adult Dose 300 mg base (500 mg salt) orally, once/week Hydroxychloroquine sulfate (Plaquenil*) 310 mg base (400 mg salt) orally, once/week Malarone 250 mg Atovoquone/ 100 mg Proguanil, daily Mefloquine (Lariam*) 228 mg base (250 mg salt) orally, once/week Doxycycline 100 mg orally, once/day Primaquine 15 mg base (26.3 mg salt) orally, _______________________________________________________________________________ The dose (250 mg for an adult) should be taken once each week for 4 weeks, followed by one dose every other week 24 HYGIENE ABROAD a) Water Acquisition b) Other Beverages c) Food Precautions d) Restaurant Evaluation 25 Travelers Diarrhea – The Litany Aztec Two Step-Delhi Belly-Rome Runs La Turista-Greek Gallop-Sumatra Spurts Hong Kong Dog-Turkey Trots Cairo Crud-Montezuma’s Revenge 26 Etiology of Travelers’ Diarrhea 1. 2. 3. 4. 5. 6. E. Coli Shigella/Salmonella Campylobacter Viral Parasites Unknown 50% 10% 8% 10% 2% 20% 27 Infectious Doses of Enteric Pathogens Shigella Campylobacter Salmonella E. Coli Cholera Giardia Amoebas 10-100 1000-100,000 100,000 100 million 100 million 10-100 10-1000 28 Travelers’ Diarrhea Precautions 1. Water Precautions 2. Food Precautions 3. Common Sense 29 Water Precautions: Avoid 1. Tap water if not treated 2. Ice cubes 3. Fresh milk 4. Bottled water with broken seal Safe 1. Bottled H²O, seal intact 2. Water at facility w/purifier 3. Soft drinks 4. Beer & wine 5. Coffee & tea if H²O boiled 30 Water Precautions (2) - - - Alcohol will not disinfect water Be leery of how glassware, dishes & utensils have been handled and washed Don’t gargle or brush your teeth with water you wouldn’t drink If in doubt, draw a glass of HOT water and let it cool, having passed through a hot water heater, it will be pasteurized 31 FOOD PRECAUTIONS Safe: Meat and fish dishes well done & eaten hot. Vegetables that are thoroughly cooked. Nuts, fruits & vegetables to be peeled, shelled or skinned if purchased intact with no breaks in shell or skin. Chinese restaurants enjoy a reputation of serving safe tasty food worldwide. 32 FOOD PRECAUTIONS Avoid: Raw eggs Raw meats Cold Platters Pastries Salads Raw shellfish Steak tartare Undercooked meats Custards Raw vegetables Dairy products Certain seafood 33 RESTAURANT GUIDE Presence of window and door screens State of trash containment Status of the Restrooms Presence of roaches & flies Chinese restaurants 34 TRAVELERS’ DIARRHEA SYMPTOMATIC TREATMENT 1) 2) 3) 4) 5) Dietary restrictions Pepto Bismol Immodium Lomotil Lactobacillus 35 Oral Therapy for Acute Diarrhea Developed in 1950’s-Glucose and electrolytes Misconception about hypernatremia 1960’s-Coupled transport of sodium and glucose Clinical studies with cholera showed efficacy Subsequent studies worldwide 36 TRAVELERS’ DIARRHEA PROPHYLAXIS 1) Generally not advised 2) Short trips only 3) Complications 4) Resistant organisms 37 TRAVELERS’ DIARRHEA PROPHYLAXIS 1) Pepto Bismol 2) Antibiotics a) Quinolones b) Rifaximin 38 EARLY TREATMENT OF TRAVELER’S DIARRHEA 1) 2) 3) 4) Effective and proven Short course – 3 Days Pepto Bismol – Less effective Antibiotics a) Quinolones b) Rifaximin c) Azithromicin 39 Special Risks of Travel 1) Motor vehicle accidents 2) Motion sickness 3) High altitude 4) Bites/stings/sun 5) Jet lag 40 ACUTE MOUNTAIN SICKNESS HEADACHE WEAKNESS & LASSITUDE GI DISTRESS DIZZINESS SHORTNESS OF BREATH ANOREXIA DISTURBED SLEEP 41 OTHER INFECTIOUS DISEASE RISKS a) b) c) d) e) f) g) h) STD’s HIV Schistosomiasis Lepto-spirosis’ Dengue Plague Sleeping sickness Parasites 42