Travel Health in the Developing World

1
Travel Health in the Developing World

• Christopher Sanford, MD, MPH, DTMH
• Clinical Asst. Professor, Dept. of Family Med.
• Co-Director, Travel Clinic, Hall Care Center
• University of Washington Seattle, Washington, USA
• September, 2009

Amazon River, Peru
2
Overview of pre-travel encounter

• 1) Intake questions Itinerary, activities.
• Past medical history incl. immunizations.
• 2) Advised immunizations.
• 3) Malaria PPMs, medication.
• 4) Travelers diarrhea diet, carry along med.
• 5) Urban medicine cars, smog, etc.
• 6) Resources.

3
Intake questions

• Where to
• For how long
• For what purpose
• Staying in what kind of place
• Guided or not
• Previous developing world travel or not

4
Intake questions

• Past medical history
• Allergies
• History of antimalarial use if any
• Medications
• Medical problems
• History of depression, anxiety
• LMP, birth control
• None of antimalarials proven safe in pregnancy

5
Immunizations

• Review of past immunizations
• Advised recommendations
• Routine
• Required
• Recommended

6
Immunizations (cont.)

• 1. Routine
• Td (tetanus diphtheria)or Tdap within 10 years
• MMR
• Influenza
• Hepatitis B
• Polio

7
Tdap

• Give Tdap if its been over 10 years since Td.
• Then in 10 years pt gets usual Td
• Tdap is a once/life vaccine
• CDC site Adults aged 19-64 years who have not
  previously received Tdap should receive a single
  dose of Tdap if their last dose of tetanus
  toxoid-containing vaccine was administered more
  than 10 years prior

8
MMR

• 2 doses, at least 4 weeks apart

9
Influenza

• Important
• International travelers develop influenza more
  often than do folks who stay at home.
• Transmission is year-round at the equator.

10
Hepatitis B

• 3 doses at time 0, 1, and 6 months.
• A large proportion of travelers have risks.

11
Polio

• One dose as an adult on top of the usual
  pediatric series.
• If going to area with polio
• Now in about 25 countries in Africa
• And the Indian subcontinent India, Pakistan,
  Bangladesh

12
Immunizations (cont.)

• 2. Required a short list.
• Yellow fever
• tropical Africa
• tropical South America
• none in Asia

13
Yellow fever Distribution None in Asia
14
Yellow fever

• Required for entry into
• In South America
• Bolivia, and French Guiana

15
Yellow fever

• Required for entry into
• Africa
• Angola, Benin, Burkina Faso, Burundi, Cameroon,
  Central African Republic, Chad, Congo, Cote de
  Ivoire, Democratic Republic of Congo, Gabon,
  Ghana, Liberia, Mali, Mauritania (for stay over 2
  weeks), Niger, Rwanda, Sao Tome and Principe,
  Sierra Leone, and Togo.
• Not required for return to U.S. regardless of
  previous destination.

16
Meningococcal

• Required for Hajj (Muslim pilgrimage to Mecca)
• Recommended for high risk travelers
• Meningitis belt of sub-Saharan Africa
• Crowded living conditions, e.g. dorm

17

18
Immunizations (cont.)

• 3. Recommended
• Everyone Hepatitis A
• Typhoid fever
• Consider rabies
• Consider Japanese encephalitis
• Cholera No.

Rabies avoidance never hold hands with a
gorilla.
19
Hepatitis A

• Appropriate for every nation in the developing
  world.
• The most frequent vaccine-preventable disease in
  international travelers.
• 2 doses, at least 6 months apart.
• Dont give Ig to immunocompetent travelers over
  the age of one year.
• Lifetime protection.

20
Typhoid fever

• Present throughout developing world.
• Risk in increased in long-stay travelers, and
  those off the beaten path.
• Either oral (good for 5 years).
• Minimum age 6 years. 4 pills. One pill every
  other day.
• Or via injection (good for 2 years).
• Minimum age 2 years. One dose.

21
Rabies

• Three doses, over 28 days.
• Expensive.
• Rabies rare in travelers.
• Consider for prolonged stay, backpackers,
  spelunkers, others with significant risk.
• Pre-exposure series does not remove need for
  immediate post-exposure treatment.

22
Japanese encephalitis

• Spread by mosquitoes, present throughout South
  and Southeast Asia.
• Expensive
• Rare--rural only. Associated with rice and pig
  farming.
• Vaccine 3 doses over 30 d.
• Adverse effects can be delayed. Finish series
  at least ten days prior to departure.

23
Malaria

• Personal protection measures are more important
  than medications.
• DEET to skin (20-35 not 100)
• Permethrin to clothes, every 2 weeks.
• Bednet, preferably impregnated with permethrin
• Long sleeves/pants
• Also benefit for diseases other than malaria,
  (e.g. dengue.)

24

DEET
permethrin
25
Malaria medications

• There are approx. 100 countries with malaria.
  Chloroquine still effective in only a handful.
• Mexico, and Central America to west of Panama
  Canal
• Island of Hispaniola (Dominican Republic and
  Haiti)
• North Africa (prophylaxis not recommended)

26

27

28
chloroquine-sensitive areas

• chloroquine or Plaquenil once/week
• Schedule start one week before entry, take
  once/week while in malaria country, take for four
  weeks after exit.
• In US, Plaquenil is one-fifth cost of chloroquine
• Dose
• chloroquine 300 mg base 500 mg salt once/week
• Plaquenil 310 mg base 400 mg salt once/week

29
Chloroquine-resistant countries

• 3 options
• doxycycline
• mefloquine (Larium)
• atovaquone/proguanil (Malarone)

30
doxycycline

• Dose 100 mg once/day.
• Start one day prior to entry to malaria area,
  take once/day while, continue for 28 days after
  leaving malaria area.
• Cheap. Approx. 16 cents/pill.
• Side effects
• photosensitivity. Less than one percent.
• esophageal erosion. Dont swallow tablet dry

31
Mefloquine (Larium)

• 250 mg (salt) once/week. Start one week prior to
  entry into malaria area, continue once/week while
  there, continue once/week for four weeks after
  leaving malaria area.
• Price intermediate.
• Contraindications people with any type of
  psychiatric history ever (e.g., depression,
  anxiety) should not take this.

32
Mefloquine (Larium) (cont.)

• Side effects (cont.)
• No one should take this who
• Has had cardiac conduction defects
• Seizures (aside from uncomplicated febrile
  seizures in childhood)
• Doesnt want to take it.

33
Malarone (atovaquone and proguanil)

• Expensive.
• Once/day begin one day prior to entry into
  malaria area take one/day while there, continue
  once/day for 7 days after exiting malaria area.
• Only one adult strength Each tablet 250 mg
  atovaquone 100 mg proguanil
• Side effects lowest rate of the 3 drugs for
  chloroquine-resistant malaria.
• Rash, GI upset, mood changes.

34
What about carry-along standby self-treatment,
instead of prophylaxis?

• My vote no.
• You cant diagnosis malaria clinically.
  Diagnosis is only possible via laboratory exam
  (thick and thin smears of blood).
• Card diagnostic test is not yet ready for prime
  time.
• May be an option in the future.

35
An exception

• Consider carry along/standby medication for
  geographically remote traveler.
• E.g. Malarone if not taking it for prophylaxis.

36
Travelers diarrhea

• A self-limited illness in most international
  travelers.
• Duration can be shortened by antibiotics.
• Very common. Up to 50 over 2-4 weeks.

37

38

Sign with unknown significance, Korea
39
Synonyms

• Aztec two-step
• Delhi belly
• Hong Kong dog
• Montezumas revenge
• Rangoon runs
• Turista
• etc., etc., etc. (DuPont Steffen see
  bibliography lists 32 synonyms)

40
Cause of travelers diarrhea

• Usually bacterial, usually ETEC (enterotoxigenic
  E. coli). Relatively recently described EAEC
  (entero-adherent E. coli) also common
• More rare causes
• Other bacteria Shigella, Salmonella,
  Campylobacter
• Protozoan Giardia
• viral

41
Dietary strategy to reduce risk of travelers
diarrhea

• Not much evidence that eating practices reduce
  risk.
• The (relatively) safe list? Dry foods, such as
  bread.
• ? Packaged foods.
• ? Well-cooked food.
• ? Bottled anythingwater, beer, pop (if sealed).
• ? Boiled anything.

42
Steffen R, Tornieporth N, Costa Clemens SA, et
al. Epidemiology of travelers' diarrhoea details
of a global survey. J Travel Med
200411(4)231-238.

• This study adds to a growing literature that
  conventional advice on avoidance of specific food
  and drink items seems to be ineffective in
  reducing risk.
• Where one eats may be more important than what
  one eats.
• survey on TD travelers diarrhea among tourists
  to Goa (India), Mombasa (Kenya), Montego Bay
  (Jamaica), and Fortaleza (Brazil).
• 73,630 travelers (15,631 from Goa, 15,180 from
  Mombasa, 30,369 from Montego Bay, and 12,449 from
  Fortaleza)

43

• there were no differences in prohibited food
  scores between those who did and did not have TD
  travelers diarrhea
• Cumulatively, a number of other studies over the
  past 20 years that were reviewed in a plenary
  lecture at the ISTM Conference in New York in
  2003 have shown similar results.

44
The bad list things to avoid

• ?Food from street stands (street vendors).
• ?Salads. ?Raw food, such as sushi.?Buffets,
  even at nice hotels or restaurants, in which food
  sits out for several hours.
• ?Tap water.
• ?Ice. Freezing doesnt kill most of the germs
  that can give you the trots.

45
Two strategies I dont recommend

• Prophylactic antibiotics
• These can have side effects in
• and of themselves
• Pepto-Bismol
• It works you chew 2 tablets,
• four times/day, for the whole trip.
• Benefit 50-65 reduction in travelers diarrhea
• Drawbacks black tongue, weird black poop

46
Stand-by medication

• Taken only if symptoms develop
• For most of the world a fluoroquinolone (e.g.,
  ciprofloxacin, levofloxacin)
• For Southeast Asia azithromycin, one dose
  only.
• Duration without treatment 3-5 days.
• Duration with treatment 12-24 hours.
• Brunei, Burma (Myanmar), Cambodia, East Timor,
  Indonesia, Laos, Malaysia, Philippines,
  Singapore, Thailand, Vietnam

47
Travelers diarrhea caveats

• Take self-treatment medication only for normal
  diarrhea
• If blood in stool,
• Or fever,
• Or significant abdominal pain,
• Or if not better 2 days after starting
  antibiotics
• ?See a doc!

48
2nd self-treatment drug

• An antimotility drug e.g. loperamide (Imodium
  AD)
• 2 at onset of symptoms, then 1 after each loose
  BM not to exceed six/day.

49
TD carry-along med algorithm

• Pt feels good Takes nothing
• Mild diarrhea Imodium-AD only
• Watery diarrhea Imodium-AD Cipro
• Sick See doc
• Blood in stool
• Fever
• Significant abd. pain

50
Special oral rehydration solution

• -Only needed at extremes of age.
• -No need to rest
• the gut during
• recovery.

51
Should you carry more than one medication for
travelers diarrhea?

• Cipro for ETEC
• azithromycin for Campylobacter
• metronidazole (Flagyl) for Giardia
• ??
• No. These cant be distinguished without
  laboratory exam.

52

• For those with a fascination with poop and its
  aberrations, I refer you to Ericsson, DuPont, and
  Steffens 315-page Travelers Diarrhea (BC
  Decker, Hamilton, 2003).

53
Urban medicine

• Road traffic accidents
• Air pollution
• Heat illness
• Recreational pharmacology
• Psychological
• illness

54
What do U.S. travelers die from in the developing
world?

• About half heart attacks, strokes (mostly in
  the elderly).
• About 25 road traffic accidents.
• The rest drowning, falls from heights,
  homicide, suicide.
• Infectious disease only about 1.

55
Road traffic accidents

• The rate of fatalities per 100 million miles
  driven in the US is 1.1 this is similar to
  Western European rates.
• The rates in Sri Lanka and Turkey are 23 and 44,
  respectively.

56

• So does Turkey have the worst roads in the world?
• No! Turkey collects good statistics.
• In Ghana, only 10 of traffic fatalities are
  collected and tallied.

57

• So does Ghana have the worst roads in the world?
• No! Ghana has a stable government. In states
  failed or otherwise harboring complex
  humanitarian emergencies, deaths/mile traveled
  are probably much higher.

58
Tippling and driving

• The percentage of drivers with blood alcohol
  levels higher than 80 mg/dl, indicating
  impairment, has been found to be 0.4 in Denmark,
  3.4 in Franceand 21 in Accra, the capital of
  Ghana. And alarmingly, 4 of bus drivers and 8
  of truck drivers in Ghana were found to have
  blood alcohol levels above this level.
• Mock CM et al J Crash Prevent Injury Control
  2001 2(3)pp. 193-202.

59

• Seat belts are good.

60

• Helmets are good. Better still, stay off
  anything two-wheeled and motorized.

61

• Do not ride on top of a bus or in the back of an
  open truck, even if youre told the view is
  wonderful.
• Do you not want to become
• A) a missile, then
• B) a stiff

62

63

64

• Avoid the roads at night

65
Air pollution

• Mexico City was the worst city in the world in
  1992. Now its not on the top ten list.
• Nine of worst ten cities are in China.

66

Mexico City

• Total suspended particulates
• (in mcg/cubic meter)
• Stockholm 9
• Mexico City 279
• Lanzhou, China 732

Lanzhou, China
67

• Sulfur dioxide is formed by the burning of fossil
  fuels, such as oil and gas.
• Sulfur dioxide
• (in mcg/cubic meter)
• Los Angeles, California 9
• Guiyang, China 424

Guiyang, China
68
What does this bad air mean to the young, fit,
short-term traveler?

• Usually not much other than irritated eyes and a
  sore chest.

69
Who can get into trouble with heavily polluted
air?

• Those with pre-existing conditions
• Asthma
• Chronic bronchitis, emphysema
• Coronary artery disease

70

• Those with asthma carry an oral steroid
• Those with chronic bronchitis or emphysema carry
  rescue cocktail
• Additional inhaler
• Appropriate antibiotic
• Oral steroid.

71

• Dont exercise in the heat of the day
• Have a low threshold for seeking medical
  attention for symptoms not quickly relieved by
  self-treatment

72
Sex

• No glove, no love

73
security

• Wallet not in pants pocket, but around neck or
  waist in a money belt.
• Have hotel call for taxi
• Hotel safety boxes are usually safe.
• Dont take anything (camera, jewelry) that you
  would be significantly bummed if you lost

74
Security leave the laptop at home.

• Laptop
• Expensive
• Needs electricity
• Needs adaptor plug for most of developing world
• Can be damaged by humidity or rough handling
• Useless in bright sunlight
• High potential for rip-off
• Clipboard or spiral-bound notebook
• Cheap
• No need for electricity
• No adaptor plug required
• Relatively indestructible
• Not hampered by bright sunlight
• Near-zero potential for rip-off

75
photography

• If theres a guy within sight who is carrying a
  rifle or machine gun ask permission before you
  take photographs.

76
Recreational pharmacology

• A full one-third of the 2,500 US citizens who are
  arrested abroad each year are arrested on drug
  charges. A number of countries, including the
  Bahamas, the Dominican Republic, Jamaica, Mexico,
  and the Philippines, have enacted more stringent
  drug laws which impose mandatory jail sentences
  for those convicted of possessing even small
  amounts of marijuana or cocaine for personal use.
  

77
Recreational pharmacology (cont.)

• The death penalty remains an option in several
  countries, including Malaysia, Pakistan, and
  Turkey, for those caught smuggling illicit drugs.

78
Evacuation insurance

• It costs 50-75K to hire a medical jet to evac
  someone to developed world.
• Consider evac insurance
• Medex
• International SOS
• DAN (Divers Alert Network)

79
Resources

• cdc.gov
• Entire Yellow Book (Health Information for
  International Travelers) on line
• state.gov
• Crime, terrorism
• Email of travel clinic

80
Post-travel medicine Chronic travelers
diarrhea

• TD is usually an acute, self-limiting illness
  resolves within about 5 days.
• 3-10 of pts with TD will have symptoms lasting
  longer than 2 weeks.
• Up to 3 of travelers have TD lasting over 30
  days.

81
Work-up of diarrhea in the returned international
traveler.

• Diarrhea is by far the most common complaint in
  the returned international traveler.

82
TD lab work-up Step 1 (a.k.a. the routine)

• A. Stool OP (ova and parasite) x 3.
• Not more than one stool sample/day.
• B. Stool CS x 1
• C. Stool Giardia antigen
• D. Stool C. difficile if history of antibiotic
  or antimalarial use
• E. serum wbc with differential
• F. UA

83
Giardia diagnosis

• Stool OP x 3
• Stool antigen (IFA or ELISA). These tests have a
  sensitivity of 85-98 and a specificity of
  90-100.
• Not blood work.
• ELISA assays for serum antibodies against Giardia
  are not readily available.
• Because immunoglobulin G (IgG) levels remain
  elevated for long periods, they are not
  beneficial in making the diagnosis of acute
  giardiasis. Serum anti-Giardia immunoglobulin M
  (IgM) can be beneficial in distinguishing between
  acute infections and past infections.
• Pennardt, Andre Giardiasis. eMedicine, Last
  Updated Feb 4, 2008
• http//www.emedicine.com/EMERG/topic215.htm

84
What to do when your lab identifies some
protozoan you havent heard mentioned since
medical school--

• non-pathogenic
• Endolimax nana
• Entamoeba coli
• Entamoeba hartmani
• Entamoeba dispar (looks identical
• to E. histolytica)
• Iodoamoeba beutschlii
• Chilomastix mesnili
• controversial
• Blastocystis hominis (common)
• Dientamoeba fragilis
• Entamoeba polecki

B. hominis
85
TD lab work-up Step 2

• A. Lactose intolerance test
• B. d-xylose test
• If considering celiac disease sprue, add IgA
  antibodies antiendomysial, and antigliadin.
• C. thyroid function tests
• D. electrolytes, calcium
• E. Stool Cryptosporidium, Cyclospora
• F. Consider save a tube. (For acute-phase
  serum.)

86
2A) Lactose intolerance test

• Lactose intolerance is caused by deficiency of
  the enzyme lactase, which is produced by cells
  lining the small intestine.
• Three tests to evaluate this
• breath hydrogen test after oral lactose bolus
• serum glucose after oral lactose bolus
• stool acidity test (used less often)

87
sprue

• A non-specific term for chronic malabsorption
• Two types of sprue
• sprue celiac sprue celiac disease
  gluten-sensitive enteropathy
• Tropical sprue

88
2B) D-xylose test

• Lower than normal range in
• celiac disease (a.k.a. sprue, a.k.a. celiac
  sprue, a.k.a. gluten-sensitive enteropathy)

89
2B) D-xylose test (cont.)

• Urine or blood is checked after oral bolus of
  D-xylose. In sprue, absorption of D-xylose is
  decreased.
• Checking both one-hour and three-hour serum
  levels post oral bolus improves sensitivity (vs.
  checking one-hour post bolus level only.)
• Ehrenpreis ED, Salvino M, Craig RM Improving the
  serum D-xylose test for identification of
  patients with small intestinal malabsorption. J
  Clin Gastroenterol. 2001 Jul33(1) 36-40.

90
2B) D-xylose test (cont.)

• Non-specific. Lower than normal value in
• Giardia intestinalis, Crohns disease, hookworm,
  lymphatic obstruction, radiation enteropathy,
  small intestinal bacterial overgrowth, viral
  gastroenteritis, Whipples disease.

91
2B) D-xylose/celiac disease (cont.)

• IgA antibodies antiendomysial, and
  antigliadin--more specific for celiac disease
  (sprue) than D-xylose.
• Best diagnostic test for celiac disease small
  bowel biopsy. Improved symptoms and biopsy after
  gluten-free diet strongly correlated to celiac
  disease.

92
In long-term ex-pats with GI sx, consider
tropical sprue.

• Tropical sprue a poorly characterized syndrome
  of worsening intestinal symptoms with continuing
  diarrhea and steatorrhea occurs in ex-pats
  living long-term (over one year) and residents of
  tropical and sub-tropical areas. particularly
  Caribbean, southern India, and SE Asia. (From
  30? N. of equator to 30 ? South.) Rare in
  short-term travelers.
• Etiology unknown

93
Tropical sprue etiology

• ?? Combination of poor nutrition infection.
• Tropical sprue appears to be limited to certain
  geographic areas, even within the tropics. For
  example, although it is commonly observed and
  described in Puerto Rico and the Dominican
  Republic, it is not reported in Jamaica.

94
Tropical sprue (cont.)

• Sx light-colored stools, weight loss, chronic
  diarrhea.
• Iron, B12 and folic acid deficiency ? anemia.
• Prothrombin deficiency?easy bruising, prolonged
  bleeding.
• Small intestine biopsy flattened villi.

95
Tropical sprue (cont.)

• Treatment most patients improve with
  tetracycline x several months vitamin B12 and
  folic acid.
• Treatment usually results in full recovery.

96
Recap sprue vs. tropical sprue

• Sprue celiac disease celiac sprue
  gluten-sensitive enteropathy. Improves with
  gluten-free diet.
• Tropical sprue. Unknown cause. Occurs almost
  exclusively in long-term ex-pats. Improves with
  antibiotics (TCN) and vitamin supplementation.

97
TD lab work-up step 3

• (Consider involving gastroenterologist).
• Stool hemocults
• HIV
• serum gastrin
• fecal fat

98
TD lab work-up Step 4

• (Consider involving gastroenterologist).
• Endoscopy
• EGD with duodenal aspirate
• small bowel biopsy
• light
• EM
• Flex. sig. with biopsy
• Colonoscopy with biopsy

99
Post-infectious malabsorption

• A.k.a. post-infectious dysmotility syndrome,
  post-infectious irritable bowel syndrome.
• A common sequelae of TD.
• A diagnosis of exclusion.
• Usually self-limiting.
• Can evolve into permanent irritable bowel
  syndrome.

100
What to do with that positive Blastocystis
identification on stool OP?

• If patient is asymptomatic or rapidly
  improving--nothing.
• If GI sx are ongoing, and no other pathogen is
  found--consider treating (with metronidazole). A
  subset of symptomatic patients will improve.

101
Treatment of Giardiasis.

• Increasing resistance to metronidazole.
• Consider using tinidazole 2 g once. You no
  longer need to go through a compounding pharmacy
  for this.

102
Caveat regarding TD

• Not all diarrhea that begins during or
  immediately after international travel is related
  to that travel.
• No positive lab findings ? Youre fine.

103
bibliography

• DuPont HL, Steffen R (eds.) Textbook of Travel
  Medicine and Health, 2nd Ed. B.C. Decker, 2001.
  
• Ericsson, DuPont, and SteffenTravelers
  Diarrhea. BC Decker, Hamilton, 2003.
• Jong EC, Sanford C (eds.) The Travel and
  Tropical Medicine Manual, 4th ed.
  Saunders/Elsevier, 2008.
• Keystone JS, Kozarsky PE, Freedman DO, et al,
  eds Travel Medicine. Mosby, 2004.
• McLellan, SLF Evaluation of fever in the
  returned traveler. In Sanford C (guest ed.)
  Primary Care Clinics Travel medicine.
  Saunders/Elsevier Dec 2002.
• Sanford, C The Adventurous Travelers Guide to
  Health, University of Washington Press 2008.
• Sanford C. (guest editor) Primary Care Clinics
  Travel Medicine. Saunders/Elsevier, December
  2002.