Preparing the Traveler

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Stephen J. Thomas, MDDirector, Viral Diseases Branch

Walter Reed Army Institute of Research

AUG 2013

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DisclaimerThe views expressed in this presentation are those of the speaker and

do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government

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Outline

• Introduction– Dynamics of tropical disease– Example - Nipah

• Preparing the Traveler– Asking the right questions– Routine vaccinations– Travel medicine literature– Geographic distribution of threats– Vaccination– Diarrhea

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Introduction

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Understand the Dynamics of Tropical Diseases

HOST

VECTORS THREATS

Ecology / Environment

Demographics, special

populations

Circulating animal and

human pathogens

Mosquitoes, ticks, bats, birds, dogs, cats, etc.

Temperature, rainfall,

cultural & agricultural

practices, etc.

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Example - Nipah Virus

• Highly pathogenic paramyxovirus– Isolated from CSF– Sungai Nipah village

• Natural host are fruit bats

• Causes severe febrile encephalitis

• Outbreaks– Peninsular Malaysia and Singapore (1998 – 1999)– Bangladesh: 2001, 2003, 2004, 2005, 2007 and 2008– India: 2001 and 2007

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Nipah Transmission Dynamics

• Pigs crowded in pens• Pens near fruit trees• Fruit bat home destroyed • Fruit bats relocate to fruit trees• Bat fluids contain Nipah • Aerosolized virus infects pigs• Pigs infect handlers

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Preparing the TravelerAsking the Right Questions

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Asking the Right QuestionsWho, Where, When, Why and What?

• Who is the host / traveler?– Immunologic background, medical problems, etc.

• Where are they going?– Geographic region, known threats.

• When are they going?– Seasonal variations in disease threat epidemiology

• Why are they going there and what will they do?– Defines likely exposure risks– Defines required prophylaxis / PPMs

• Know what you do not know. Look it up. Seek consultation.

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Practice Evidenced Based Medicine

http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Travel%20Medicine.pdf

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Travel Medicine Resources

• U.S. Department of State– www.travel.state.gov

• MILVAX– www.vaccines.mil/QuickReference

• CIA Factbook – www.cia.gov/cia/publications/factbook

• National Center for Medical Intelligence– www.intelink.gov/my.policy

• AMEDD Virtual Library– Travax

• International Society of Travel Medicine website)– http://www.istm.org/

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US CDC

•http://wwwnc.cdc.gov/travel/

•http://wwwnc.cdc.gov/travel/yellowbook/2014/table-of-contents

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DoD On-Line Infectious Diseases Consults

• id.consult@us.army.mil• Infect.cntrl.consult@us.army.mil

• pmom.consult@us.army.mil

• Began in January 2005• 839 teleconsultations thru July 2013• 35 teleconsultations received January – July 2013• 6 teleconsultations received in July 2013• First teleconsultation received from Niger• 7.4% of all teleconsultations received in the AKO Program

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Locations Submitting Teleconsultations

Supported Facility

US, Canadian& AustralianNavy afloat

Afghanistan

Bosnia

Chad

Continental US

Egypt – MFO Sinai

Haiti Relief

Germany

Hurricane Katrina

Iraq

Italy - Sicily

Kuwait

Kyrgyzstan

Okinawa

Pakistan

Qatar

Niger

United Arab Emirates

Turkey

Djibouti

Ecuador

Morocco

Belize Philippines

Japan

Congo

Mauritania

Senegal

Papua New Guinea

Albania

Ghana

Guatemala

Botswana

Turkmenistan

Bahrain

Thailand

Guinea

Mali

Guam

Spain

Honduras

Yemen

Laos

Belgium

UkraineEl Salvador

Kenya

Bangladesh

Jordan

Saudi Arabia

Sudan

Solomon Islands

Ethiopia

Chili

http://www.cia.gov/cia/publications/factbook/reference_maps/pdf/time_zones.pdf

Peru

Nepal

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Per

cen

tag

e o

f C

onsu

ltatio

ns

99.52% of all teleconsultationsare answered in less than 24 hours

Reply Time by Percentage of Consultations

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Key Elements of the Consult• • Patient History

– When did it start– Patient symptoms now?– Getting better? Worse? Staying the same? Spreading?– Previous treatments and outcomes?– Laboratory tests results (if any)?– Your Dx / DDx– Your question

• Limitations you have in managing the patient

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Key Elements of the Consult• • Patient Demographics

– Age– Gender– Branch of service (if not MIL, state their nationality)– Identify if contractor, detainee, foreign military, etc.

• Include digital images if appropriate • PDFs of EKGs• JPEGs of radiographs• Copies of laboratory and pathology reports

• Do not send any patient identifying info(HIPAA applies)

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Preparing the TravelerRefer to the Traveler Literature

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Preparing the TravelerGeographic Distribution of Disease

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Yellow Fever

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Chikungunya

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Dengue

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Dengue

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Hepatitis A

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Hepatitis E

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HIV

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Japanese Encephalitis

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Malaria

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Malaria / Mefloquine Resistant

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Melioidosis

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Meningitis

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Middle East Respiratory Syndrome-Coronavirus

Countries Cases (Deaths)

France 2 (1)

Italy 3 (0)

Jordan 2 (2)

Qatar 2 (1)

Saudi Arabia 74 (39)

Tunisia 2 (0)

United Kingdom (UK) 3 (2)

United Arab Emirates (UAE) 6 (2)

Total 94 (47)

APRIL 2012 - Present

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Rabies

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Schistosomiasis

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Tuberculosis

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Preparing the TravelerVaccination

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Vaccination

• Confirm up to date routine vaccinations for adults– Documentation or considered susceptible

• Confirm past travel related vaccination history

• Calculate risk: benefit ratio– Disease threat versus vaccine adverse event

• Consider special populations– Pregnant, immunosuppressed, known allergic past rxns

• Remember – Diseases extinct in the US, alive and well in other locations (examples: polio, measles, etc.)

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Vaccine Preventable Diseases (Routine)

http://www.cdc.gov/vaccines/schedules/downloads/adult/mmwr-adult-schedule.pdf

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Vaccine Preventable Diseases (Traveler)

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Preparing the TravelerDiarrhea

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Risk of Traveler’s Diarrhea

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Traveler’s Diarrhea (TD)

• Attack rates range from 30% to 70% of travelers• Clinical syndrome from a variety of intestinal pathogens

– Bacterial pathogens are the predominant risk (80%–90%)– Viruses have been isolated (5%–8%), Norovirus may > %– Protozoal pathogens (10%), longer-term travelers

• Bacteria– Enterotoxigenic Escherichia coli (#1), Campylobacter jejuni, Shigella spp.,

and Salmonella spp. Enteroadherent and other E. coli species are also common. Aeromonas spp. and Plesiomonas spp. as well.

• Viral– Norovirus, rotavirus, and astrovirus.

• Protozoal– Giardia, Entamoeba histolytica and Cryptosporidium uncommon– Cyclospora (Nepal, Peru, Haiti, and Guatemala)– Dientamoeba fragilis is a low-grade but persistent pathogen

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Traveler’s Diarrhea (TD)

• Prevention– Food and beverage selection

• Wash it, boil it ,cook it, peel it: reduces, does not eliminate risk– Non-antimicrobial drugs for prophylaxis

• Bismuth subsalicylate (Pepto-Bismol)– Not in travelers w/ aspirin allergy, renal insufficiency, or gout.– Not for use with anticoagulants, probenecid, or methotrexate. – Not generally recommended for children aged <12.– Studies have not established safety for periods >3 weeks.

– Probiotics (Lactobacillus GG and Saccharomyces boulardii)• Study results are inconclusive• Insufficient information to recommend the use of bovine colostrum

– Prophylactic Antibiotics• Diarrhea attack rates are reduced by 90% or more• At this time, prophylactic antibiotics not be recommended for most• Ease of treating diarrhea versus side effects of antibiotics

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Preparing the TravelerMalaria

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Malaria

• MALARIA KILLS SERVICE MEMBERS!

• #1 threat if you are traveling to a malarious region

• Any fever in any traveler who is in or who has been to a malarious region has malaria until proven otherwise

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Marines deploy to Liberia, 44 contract malaria despite prophylaxis and PPMs

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Differences Between CIV and MIL Populations

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Differences Between CIV and MIL Populations

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Differences Between CDC and US military’s use of malaria chemoprophylaxis

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Differences Between CDC and US military’s use of malaria chemoprophylaxis

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Differences Between CDC and US military’s use of malaria chemoprophylaxis

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Preparing the TravelerVector Avoidance

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Vector Avoidance

• Mosquitoes, sand flies, chiggers, ticks

• Malaria, dengue, CCHF, scrub typhus, leishmaniasis

• Be smart, be knowledgeable, be safe– Geographic areas with known risk– Avoid man-made creation of local breeding areas– Understand feeding habits

• Protect yourself

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DoD Repellent System

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(Woodland) NSN 3740-01-516-4415 (Desert) NSN 3740-01-518-7310

•Fits on standard cot

•Set-up: throw it

•Self-supporting

•No cot or pole set needed

•Zips open and closed on both sides

•Factory-treated with permethrin – 25

washings or one year

•Has attached floor for use on ground

•Water resistant

•Flame retardant

•2 pounds

Pop-Up Bednet

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Preparing the TravelerAnimal Contact

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Dogs: Rabies, skin and soft tissue, crush

UnpredictableNot man’s best friend on deployment

1 sec.

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Defining Event

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Cats: Needle-like teeth, inoculate bacteria, deep tissue space/planes, joints

Necrotizing fasciitis is a medical and surgical emergency!

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Monkeys: Rabies, Herpes B virus

There is no cure for stupid! Stay away!

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Preparing the TravelerAdditional Risks

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Additional Concerns• Trauma

– Motor vehicle accidents– Wear a belt, helmet, 4 wheels when possible

• Water exposure– Rip tide and undertow– Infectious diseases (leptospirosis, shistosomiasis)

• Sexually transmitted infections– HIV, resistant organisms– Human trafficking

• Environment– Heat, cold, altitude

• Alcohol and drugs– Bad decisions, dangerous decisions

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Preparing the TravelerConclusion

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The Ten Commandments of Travel Medicine

• Acquire a pre-travel consultation from your provider• Wash your hands and avoid eating poop• Vaccinate• Invest in DEET, PPMs• Respect traffic, local rules• Don’t drink and do anything• Respect and believe fever• Stay away from the animals• Avoid STIs • Take your prophylaxis

• KNOW WHAT YOU DON’T KNOW!

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Preparing the TravelerBack Up Slides

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Soliciting a Detailed Medical History

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Chief Complaint

• Localizing– Focal lesion (cellulitis)– Bite (arthropod, animal, human)– Post-traumatic (altercation, vegetation)– Anatomical (CNS, GU, GI, etc.)

• Generalized and systemic– Fever, chills, rigors– Muscle and / or joint pain– Fatigue

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History of Present Illness

• Key information– Detailed chronology of illness

• Patient was well until…DATE…when…X…happened• Appearance / disappearance of signs / symptoms

– Non-specific illnesses may declare themselves• Identify patterns if they exist

– Example: patterns of fever (every 3 days)

– Incorporate important medical background of patient• Age (impacts presentation, fever curves, etc.)• Immunodeficient (HIV, medications, malignancy)

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History of Present Illness

• Key information– Incorporate activities / exposures

• Animals, arthropods, people, vegetation• Urban, rural environment exposure• Indoor or outdoor activities

– Incorporate relevant active (recent) medications• Prophylaxis, immunomodulators, OTC medications

– Incorporate relevant associated travel history

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Review of Systems

• Pertinent positives and negatives – Specifically mention if no fever– CNS: evidence of meningitis, encephalitis, any neuro– Respiratory: tracheobronchitis, pneumonia– Oropharynx: pharyngitis, bleeding gums, dentition– GI: diarrhea with blood, mucus, rice water appearance– GU: discharge, dysuria, abnormal menses– Skin: rash, location, itching, character– Extremities: localized pain, joint versus bone pain

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Past Medical/Surgical History

• Drill down on relevant pre-existing medical conditions– Immunosuppressive conditions

• Drill down on chronic or re-occurring conditions– Examples: frequent respiratory infections, meningitis

• Presence or absence of organs– Appendix, gallbladder, spleen, thymus

• Previous surgical interventions– Heart surgery (valve)– Implant of any hardware or foreign material

• Known lab / radiologic abnormalities– Examples: lung nodule/Ca++, heart block, etc.

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Medications / Immunizations

• Rx and OTC (previous antibiotics)• Immunosuppressives

– Examples – prednisone, DMARDS• Anti-pyretics (ASA, NSAIDS, acetaminophen)

– Manipulate fever curve• Prophylaxis (detailed account)

– Test understanding (especially malaria prophylaxis)• Anything which could impact absorption or metabolism of

chronic or prophylactic medications impacting their performance.

• All routine and travel specific vaccinations!

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Social History

• Activities, hobbies, occupation (defines potential exposures)– Examples: hunter, gardener, fishing

• Sexual practices– Examples: monogamous, MSM, high risk behaviors

• Drugs and alcohol– Needle based drugs, potential for cirrhosis, etc.

• Tobacco– American or foreign

• Food– OCONUS (“on economy”), imported

• Pets– Type, acquisition history, level of interface

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Family History

• First degree relatives– Immunosuppressive conditions– Recurrent infections

• Individuals sharing household– Recent medical events (including vaccinations)

• “Sick contacts”– Immunosuppressive conditions– Recent or current illness

• If yes, explore diagnosis if known • Hospitalized?

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Travel

• Where (geographic specific infections)

• When (rainy season = vectors)

• Activities during travel (urban, rural)

• Accommodations (hotel with A/C, outdoors)

• Food (hot, cold, water, hotel, street, etc.)

• Precautions (any PPM?)

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Medical History Informing Diagnosis

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Mandell et al. PPID 7th ed.

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