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Infectious Disease > Travel medicine > Flashcards

Travel medicine Flashcards

1
Q

How may international travel upset a person’s equilibrium making them susceptible to disease?

A
  • sudden exposure to sig changes in altitude, humidity, microbial flora, sunlight, and temperature, exacerbated by stress and fatigue, may result in ill-health and an inability to achieve purpose of travel
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2
Q

What are key factors determining health risks to which travelers may be exposed?

A
  • destinations
  • duration of visit
  • purpose of visit
  • std of accommodation and food hygiene
  • behavior of traveler
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3
Q

What are some pre-trop recommendations?

A
  • basic medical kit
  • analgesics (acetaminophenm aspirin, ibuprofen)
  • abx for self-tx of diarrhea (chipper, azithro)
  • anti-diarrheals: bismuth subsalicylate (pepto), loperamide (imodium)
  • antihistamines
  • antimalarials
  • antinausea/motion sickness (benedryl, dramamine) meds
  • sleeping meds
  • insect repellent
  • water purifier or tablets
  • cold/sinus/cough med
  • sunscreen
  • wound dressings
  • antiseptic
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4
Q

Pre-travel consultation with pt?

A
  • risk assessment: itinerary
    traveler demographics, emphasis on not traveling while sick
  • discussion with pt: vaccinations, prophylaxis, specific advice about self tx (traveler’s diarrhea), pre-tx of chronic health issues
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5
Q

Medical planning: determine destination?

A
  • investigate specific risks associated with that region

- ID travel clinic that can acquire specific vaccines read

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6
Q

What enivironmental precautions should you be aware of?

A
  • air travel
  • jet lag (melatonin)
  • sun protection
  • extreme heat and cold: dehydration, heat stroke, hypothermia, frostbite
  • altitude
  • water recreation
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7
Q

Food and water precautions?

A
  • bottled water!!!
  • selection of foods: well cooked and hot
  • avoid: salads, raw veggies, unpasteurized dairy products, street vendors, ice
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8
Q

Pre-existing health status concerns?

A

Flying:
CVD: less than 3 weeks post MI, longer “wait” following complicated courses, 2 weeks post CABG

pulmonary disease: 2-3 weeks post chest tube removal, PaO2:

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9
Q

What vaccines should be up to date?

A
  • polio
  • Hep A and B
  • meningococcal
  • influenza
  • tetanus, diptheria, pertusis
  • MMR
  • Varicella
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10
Q

Vaccines you may need?

A
  • Typhoid
  • yellow fever
  • rabies
  • japanese Encephalitis
  • cholera
  • tick-borne encephalitis
  • TB
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11
Q

When should you have Hep A vaccine?

A

endemic areas- Asia, central America, Africa, Mexico, caribbean

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12
Q

Motion sickness prophylaxis?

A
  • meclizine
  • promethazine (need Rx)
  • Transdermal scopolamine (Rx)
  • most must be taken before trip
  • prometh. works after sxs start
  • drowsiness can be sig
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13
Q

Why does jet lag occur?

A
  • disturbance of circadian rhythms due to crossing time barriers
  • sxs: fatigue, irritability, nausea, difficulty concentrating
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14
Q

Destination altitude sickness sxs?

A
  • HA and one or more of the following:
  • nausea
  • vomiting
  • fatigue
  • malaise
  • insomnia
  • due to relative hypoxemia and delay in development of compensatory erythrocytosis
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15
Q

Acute mountain sickness?

A
  • usually acclimatization occurs in 2-3 days

- 30% incidence at 3000 M, 75% at 4500 M

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16
Q

Prevention of altitude sickness?

A
  • gradual ascent - 300 M/day
  • spend a few days at intermediate altitudes
  • slowly ascend at > 2500 m
  • spend an extra night for every 600-900 m if continuing to ascend, climb high and sleep low
  • avoid alcohol and sedative hypnotics
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17
Q

High altitude pulmonary edema (HAPE)

A
  • combo of low hypoxic ventilatory drive and over perfusion
  • young physically fit males most susceptible
    sxs: weakness, decreased exercise performance, chest congestion, dyspnea, wheezing
    signs: wheezing, crackles (rales), cyanosis, tachycardia
  • must have 2 signs and 2 sxs for dx
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18
Q

TX of HAPE?

A
  • Rx: Diamox aka
  • acetazolamide: mild diuretic that increases amount of excreted bicarb, which in turn increases the blood pH which in turn causes you to hyperventilate which increases O2 saturation.
  • steroids: dexamethasone
  • Nifedipine: decreases pulmonary hypertension, improves oxygen saturations
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19
Q

High altitude cerebral edema (HACE) signs and sxs?

A
  • Hallucinations
  • focal near signs
  • seizures
  • stupor
  • coma
  • MEDICAL emergency: pts need high flow O2 and prompt descent to lower altitude
  • dexamethasone to reduce edema
  • can have HACE and HAPE simultaneously
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20
Q

What are you worried about with snorkeling and diving?

A
  • stings and envenomization
  • coelenterate family:
    sea urchins, jellyfish, anemones, portuguese man-o-war
  • release nematocysts from tentacles
  • tx with vinegar
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21
Q

Tx for sea bathers eruption (sea lice)

A
  • papulovesicular rash caused by larvae of coelenterates
    Rx: shower, soak affected part in vinegar, throw away bathing suit, more susceptible after initial infestation: future infestations can cause severe allergic rxns
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22
Q

Where can you get cholera?

A
  • 0-5 cases per year in US, major cause of epidemic diarrhea throughout the developing world. Its an ongoing global pandemic in Asia, Africa, and Latin America for the last four decades
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23
Q

Sign of cholera?

A
  • rice water diarrhea
  • vomiting, circulatory collapse and shock. Many infections may only have milder diarrhea or be asymptomatic
  • prognosis: 5-50% typical cases are fatal if untx
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24
Q

Prevention of cholera?

A

routine immunization isn’t recommended for conventional travelers from US, although vaccination is approp. for aid and refugee workers to endemic areas in high risk situations

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25
Q

Prevention/tx of cholera?

A
  • natural infection and currently available vaccines offer incomplete protection of relatively short duration, no multivalent vaccines available
  • simple rehydration tx saves lives, but logistics of delivery in remote areas remains difficult during epidemic periods
  • adjunct abx tx is helpful but may be difficult b/c of growing antimicrobial resistance
  • natural reservoir in warm coastal waters makes eradication very unlikely
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26
Q

Locations of Hepatitis A and B

A
  • worldwide: can be isolated cases or epidemic

- 1.25 million chronic Hep B infections in US

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27
Q

Signs of Hepatitis?

A
  • jaundice, fatigue, abdominal pain, loss of appetite, nausea, vomiting, joint pain, 30% asymptomatic
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28
Q

Tx of Hep B?

A
  • Adefovir, dipivoxil, interferons, lamivudine, entecavir, and telbivudine used for tx of chronic Hep B
  • new txs: high cure rates -> Harvoni
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29
Q

Typhoid?

A

infection with salmonella typhi

  • 16 mill cases & 600K deaths/year
  • mainly in undeveloped countries with contaminated water supplies
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30
Q

sxs and tx of typhoid?

A
  • high fever
  • rose colored rash***
  • abdominal pains
  • diarrhea
  • tx: ampicillin, SMX/TMP, cipro
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31
Q

locations of typhoid?

A
  • greatest risk for travelers to S. Asia, developing countries in Asia, Africa, Caribbean, and Central and S. America (approx. 400 cases occur in US/ year 75% international travel)
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32
Q

Signs of typhoid?

A

high fever 103-104

  • HA, malaise, anorexia, splenomegaly, rash of flat rose-colored spots and bradycardia
  • many mild and atypical infections occur
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33
Q

Prognosis of Typhoid

A
  • life threatening if left untx
34
Q

Tx/prevention of typhoid?

A
  • vaccination recommended for those who will be traveling in rural areas
  • travelers should be cautioned that none of avail. vaccines are 100% effective
    (not a sub. for careful selection of food and drink)
  • specific antimicrobrial therapy shortens clinical course and reduces risk of death.
35
Q

How is typhoid spread?

A
  • lives only in humans in intestinal tract and blood
  • spread oral/fecal route: raw fruits and veggies, milk and shellfish
  • small number of carriers: both ill and carriers can shed bacteria in their stool
36
Q

Typhoid vaccines?

A
  • injectable: contains inactivated polysaccharide ag
    (given as single IM injection, single dose is adequate)
  • oral: live virus -> one enteric coated capsule in four doses
37
Q

How long does immunity last with typhoid vaccine?

A
  • IM: 2 years

- oral: 5 years, after 5 years get a booster

38
Q

CIS and precautions of Typhoid vaccine?

A
  • severe allergic reaction to vaccine component or following a prior dose
  • immunosuppression
  • moderate or severe acute illness: acute GI illness
  • pregnancy
  • age
39
Q

Yellow Fever

A
  • acute viral hemorrhagic disease
  • RNA virus in the Flavivridae family
  • transmitted by mosquitoes
  • found in Africa, S. American with several epidemics in the 19th century
  • 200,000 estimated cases of yellow fever/year
  • 90% of infections occur in Africa
40
Q

Signs of Yellow Fever

A
  • infection ranges from asymptomatic (5-50% of cases) to hemorrhagic fever
  • onset is Sudden with fever 39-40 C. Chills, HA, dizziness, and myalgias
  • Pulse first tachycardic - gets bradycardic (facets sign*****)
  • face will be flushed and eyes will be injected, N/V, constipation, severe prostration, restlessness, irritability are common.
41
Q

Clinical features of Yellow Fever

A
  • incubation period: 3-6 days
  • 85% of cases will have only midl sxs including:
    fever, HA, chills, back pain, N/V, loss of appetite
  • 15% will enter a second, toxic phase with recurring fever accompanied by other sxs
  • toxic phase is fatal in approx 20-50% of cases
  • surviving the infection results in life-long immunity and normally there is no permanent organ damage
42
Q

Tx of Yellow fever?

A
  • up to 20% mortality
  • tx mainly supportive
  • bleeding may be tx with Ca gluconate. Prophylaxis against GI bleeding with a proton pump inhibitor or H2 blocker
  • prevention: reduce number of mosquitoes and limit mosquito bites by using DEET mosquito netting and protective attire
43
Q

Yellow Fever vaccine recommendations?

A
  • attenuated live vaccine
  • single dose is adequate
  • lasts 10 years
  • recommended for pts traveling to affected areas over age of 9 months, people living in endemic areas b/t 9-12 months, lab personnel who might be exposed to virus or vaccine virus
  • bed netting, mosquito repellant recommended
    SEs of vaccine: HAs, fever, myalgias
44
Q

CIs and precautions for Yellow Fever vaccine?

A
  • immunosuppression
  • thymic disorders
  • age
45
Q

Malaria?

A
  • parasitic infection transmitted by mosquitoes: Plasmodium falciparum, P. Vivax, P. ovale, P. malariae
  • > 1 mill deaths/year
  • transmitted by anopheles mosquito
46
Q

signs of malaria?

A

fever, chills, sweats, HAs, muscle pains, N/V, severe malaria caused by P. falciparum - confusion, coma, neuro focal signs, severe anemia, resp. difficulties, dx by direct visualization and Ag detection

47
Q

Prophylaxis for malaria?

A
  • bed nets tx with permethrin, insecticides, and antimalarial drugs:
    Atovaquone/proguanil (malarone), cholorquine (some strains resistant), doxy (works well), Mefloquine (Larium): cause hallucinations
48
Q

Clinical manifestations of Malaria?

A
  • cyclic fevers
  • anemia: erythrocyte destruction
  • hepatosplenomegaly
  • capillary occlusion
  • intravascular hemolysis (blackwater fever)
  • dormant sporozoites.. recurrent lapses
49
Q

Dx of malaria?

A
  • thick/thin smears

- serologic tests

50
Q

Tx of malaria?

A
  • Atovaguone/proguanil (Malarone)

- Artemether/Lumefantrine (coartem)

51
Q

What is schistosomiasis?

A
  • 200 million worldwide infected

- parasitic infection caused by trematodes (parasitic freshwater worms that live in snails)

52
Q

Clinical picture of schistosomiasis?

A
  • dermatitis
  • katayama syndrome: fatigue, malaise, fever, cough, hepatosplenomegaly
  • clinical manifestations may not show up for several weeks post exposure
  • chronic infection can cause CNS disease, colon polyps, bloody diarrhea
53
Q

Dx of schistosomiasis?

A
  • thick stool smears reveal eggs
  • eosinophilia on peripheral blood smear
  • serologic testing- IFA available
54
Q

Tx of schistosomiasis

A
  • praziquantel-quinolone

- oxaminiquine

55
Q

Fish (scrombroid) poisoning

A
  • scrombroidea family: tuna, mackerel, albacore
  • poor fish preservation causes decarboxylization of histidine to histamine
  • illness begins 90 min and lasts for up to 12 hrs after ingestion
  • flushing, tachycardia, N/V
56
Q

Tx of Fish (scombroid) poisoning

A

supportive care, antihistamines, epi

57
Q

non scrombroidea fish poisoning

A
  • mainly in caribbean
  • ciguatera poisoning from fish that have ingested dinoflagellates
  • competitive inhibitors of Ca channels
  • sxs occur w/in 24 hours: Gi- nausea, vomiting, diarrhea
    neuro paresthesias: pruritus, tremors, fascicultations
  • ***temp reversal burning of skin exposed to cold is classic sx
58
Q

Shellfish poisoning?

A
  • caused by saxitoxin after algae blooms
  • incubation hours to days
  • dx made when 2 sensroy and 2 motor sxs are found in pts with approp. hx: sensory - numbness, dizziness, paresthesia, HA, dysethesia, pruritus
    motor dysphagia: paralysis, paresis, dyspnea, diplopia, dysphonia
  • mortality rate: 2-20%
59
Q

What is the biggest risk for travelers?

A
  • travelers diarrhea
60
Q

Traveler’s diarrhea?

A
  • can be from parasites or other organisms
  • most commonly from diff. strains of E. coli
  • prevention and tx:
    Pepto bismol
    loperamide
    cipro
    azithro
61
Q

Epidemiology of Travelers’ diarrhea

A

bacterial: 80-90%
viral: 5-10%
parasitic: >/10%

62
Q

Signs of travelers’ diarrhea?

A
  • onset usually w/in first week
  • abrupt with increasing frequency and volume of stool
  • 4-5 loose stools/day: also N/V, abdominal cramping, bloating, fever, urgency, malaise
  • most resolve 1-2 days w/o tx
63
Q

Cause of travelers diarrhea and what to avoid?

A
  • bacterial enteropathogens: E. coli

prevention/avoid: street vendor foods/drinks, raw/undercooked meats, raw fruits and veggies

64
Q

Prophylaxis for travelers’ diarrhea?

A
  • bismuth subsalicylate (pepto)

antibacterial and antisecretory

65
Q

Tx of travelers’ diarrhea?

A
  • replacement fluids/electrolytes: mostly clear fluids
  • antibiotics: N/V, cramping, bloody stools, fever
  • anti motility agents
  • loperamide (imodium): not for blood stool!!!! Reduces duration of diarrhea
66
Q

rabies?

A
  • caused by the rabies virus: almost always fatal
  • RNA virus: part of Rhabdoviruses
  • virus is transmitted through a bite or scratch from an infected animal. These are the most common species: raccoons, skunks, foxes, coyotes, bats
67
Q

What country has the most rabies cases?

A

India has about half of all rabies cases worldwide

68
Q

clinical features of rabies?

A
  • prodrome: HA, fever, rhinorrhea, sore throat, myalgias, GI upset, back pain, and muscle spasms
  • agitation and anxiety may result in dx of psychosis or intoxication
  • paresthesias, pain or severe itching at site may be first near sx
  • over several days symptoms progress
69
Q

Two forms of rabies?

A
  • furious/encephalitic forms: agitation, hydrophobia, extreme irritability, hyperexcitability periods fluctuate with lucidity: pt will exhibit: tachycardia, tachypnea, fever
  • dumb or paralytic rabies: similar to Guillain-Barre
  • prominent limb weakness. Consciousness initially spared

the 2 forms can overlap or progress from one to the other
- coma after one week of neuro sxs with death a few days after

70
Q

Rabies vaccine:

A

inactivated vaccine, pre-exposure vaccine should be offered to people in high risk groups
(anyone who is likely to come in contact with rabid animals
- immediate access to approp. medical care is limited

71
Q

Post-exposure vaccine is recommended for who?

A
  • all individuals who have had contact with animal (bites or abrasions) that they believe may be or which is proven to be rabid
  • unvaccinated: 4-5 doses in 2-4 weeks + RIG
  • vaccinated: 2 doses, no rabies immunoglobulin
72
Q

Rabies vaccine CIs and precautions

A
  • hypersensitivity
  • moderate or severe acute illness
  • immunocompromised and pregnant women who are exposed to rabies may receive vaccine
73
Q

What is Japanese encephalitis?

A
  • mosquito borne flavivirus
  • most common vaccine preventable cause of encephalitis in Asia
  • RNA virus
  • 35,000-50,000 cases annually (less than 1 case / year in US)
74
Q

Clinical features of JE

A
  • incubation period: 6-8 days
  • most asymptomatic or mild signs
  • acute encephalitis: HA, high fever, stiff neck, stupor
    -severe encephalitis: paralysis, seizures, convulsions, coma and death
    Neuropsychiatric sequelae: 45-70% of survivors
  • in utero infection possible: abortion of fetus
75
Q

JE vaccine

A
  • inactivated Vero Cell Culture - derived vaccine
  • recommended for those at increased risk such as: lab workers, travelers spending more than one month in endemic/epidemic areas during transmission season
  • 2 doses (days 0, 28)
76
Q

TB

A

caused by bacteria Mycobacterium tb

  • 2 types of infection: active or latent
  • respiratory transmission: it is currently estimated that 1/3 of world pop is infected with TB (doesn’t mean it is active)
  • with increased incidence of AIDS, TB #s have increased in US
77
Q

Clinical features of TB

A
  • cough, hemoptysis
  • persistent fever/night sweats
  • wt loss
  • malaise
  • adenopathy
  • pleuritic chest pain
78
Q

Complications with TB

A 
- w/o tx may be fatal.  Untx active disease typically affects the lungs but it can spread to other parts of body causing:
pneumothorax
bronchiectasis
cardiac aneurysms
meningitis
renal failure
79
Q

TB vaccine

A
  • BCG live strain
  • lasts 10 years
  • given intradermally
80
Q

Who should receive the TB vaccine?

A
  • newborns and health care workers in countries where TB prevalence is moderate to high, close contacts of pts with TB
  • in countries where prevalence is low, not recommended that health care workers get vaccine unless in close contact with pts from endemic countries
81
Q

TB vaccine CIs and precautions

A
  • hypersensitivity
  • moderate or severe acute illness
  • immunosuppression
  • pregnancy is CI
  • local skin reactions are common
82
Q

Summary of recommendations for traveling

A
  • follow recommendations for destination
  • begin vaccinations early
  • find travel clinic for immunizations
  • plan ahead if you are traveling with children or have other special needs or chronic illnesses

Infectious Disease (27 decks)

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