Travel Medicine Flashcards
_____the science of travel
medicine
Emporiatics
The main diseases facing the international
traveller are _____ and _____ especially the potentially lethal
______
traveller’s diarrhoea (relatively mild) and malaria,
Plasmodium falciparum malaria
Most cases of traveller’s diarrhoea are caused
by enterotoxigenic_____ and _____
Escherichia coli and
Campylobacter species
Enteroinvasive E. coli (a different serotype)
produces a dysentery-like illness similar to ______
Shigella
____ is contracted mainly from
contaminated water and ice used for beverages,
washing food or utensils, or cleaning teeth
Traveller’s diarrhoea
_____is endemic in at least 20 countries and thus immunisation for polio is still important.
Poliomyelitis
Infections transmitted by mosquitoes include:
malaria, yellow fever, Rift Valley fever, Japanese
B encephalitis, chikungunya and dengue fever
Malaria is a dusk-till-dawn risk only, but bites from
daytime mosquitoes can cause _____
dengue
It is important for GPs to consult a _____to obtain specific information about ‘at
risk’ countries
travel medicine database
The commonest causes of death in travellers
overseas are ____ (26%), particularly traffic
accidents, and _____ (16.9%).
trauma
homicide
Other diseases caused by poor santitation
hepatitis A,
and worm infestations such as hookworm and
schistosomiasis.
Reputable soft drinks, such as ____should be recommended for drinking.
Coca-Cola,
Traveller’s diarrhoea is a special problem in which countries:
Mexico, Nepal, India, Pakistan, South-East Asia,
Latin America, the Middle East and Central Africa
Duration of Travellers diarrhea
2 or 3 days. It is unusual for it to last longer than 5 days
Very severe diarrhoea, especially if
associated with the passing of blood or mucus, may bea feature of
Shigella sp or Campylobacter sp infections
and amoebiasis.
Most traveller’s diarrhoea is caused by:
enterotoxigenic E. coli (ETEC), Campylobacter sp, Shigella sp and Salmonella sp
The key factor in treatment of TD is
rehydration
Tx of mild diarrhea
- Maintain fluid intake—Gastrolyte.
* Antimotility agent
Examples of antimotility agents
loperamide (Imodium) ____
or
______ (Lomotil) 2 tablets
statim then 1–2 (o) 8 hourly
___is the preferred agent.
2 caps statim then 1 after each unformed stool (max. 8 caps/day)
diphenoxylate with atropine
Imodium
Shigella species
Dysentery
Salmonella species
Typhoid
Moderate diarrhoea Tx
- Attend to hydration.
- Patient can self-administer antibiotic—e.g. single dose____
- Loperamide in adults.
norfloxacin or azithromycin (especially in
India, Nepal and Thailand).
Severe diarrhoea (patient toxic and febrile) TX
• ? Admit to hospital. • Attend to hydration—use an oral hydrate solution (e.g. Gastrolyte). • Loperamide in adults. • Antibiotic: \_\_\_\_\_
norfloxacin, ciprofloxacin or
azithromycin (usually 3 days
There is increasing resistance to ____ and _____, especially in South-East Asia
doxycycline
and cotrimoxazole
Any travellers with persistent diarrhoea after visiting less-developed countries, especially India and China,may have a protozoal infection such as ____ and __
amoebiasis
or giardiasis.
______ is characterised by abdominal cramps, flatulence, and bubbly, foul-smelling diarrhoea persisting beyond 2 to
4 days
Giardiasis
Treatment
• Giardiasis: _____
• Amoebiasis: _____
tinidazole or metronidazole
metronidazole or tinidazole
Preventive advice for TD
Purify all water by boiling for 10 minutes.
Adding purifying tablets is not so reliable, but
if the water cannot be boiled some protection is provided by adding _____
Puratabs (chlorine) or iodine (2% tincture of iodine), which is more effective than chlorine—
Avoid fresh salads or raw vegetables (including watercress).
Salads or uncooked vegetables are
often washed in ______
contaminated water
Malaria:
The risk is very low in the major cities of ______ and _________
can be high in some African cities
Central and Southern America and South-East Asia but
• In humans malaria is caused by four species of plasmodium: — Plasmodium vivax and P. ovale \_\_\_\_\_\_\_ — P. falciparum —\_\_\_\_\_\_\_ — P. malariae —\_\_\_\_\_\_\_\_\_ — P. knowlesi —\_\_\_\_\_\_\_\_
tertian malaria
malignant tertian malaria
quartian malaria
presents like vivax and
falciparum
The lethal ______ is developing
resistance to chloroquine and the antifolate
malarials (Fansidar and Maloprim).
P. falciparum
Resistance is common in _____
South-East Asia,
Papua New Guinea (PNG), northern South
America and parts of Africa
Patients who have had _____ are at grave
risk from P. falciparum malaria (PFM).
splenectomies
It is recommended that _____ and _____do not travel to malarious areas
(if possible).
pregnant women and
young children
Travellers should be advised that malaria may be
prevented by following two simple rules:
1 avoid mosquito bites
2 take antimalarial medicines regularly
In order to avoid mosquito bites, travellers are advised to:
impregnate nets with ___ or ____
permethrin (Ambush) or
deltamethrin
Important considerations in malaria
prophylaxis:
Know areas of widespread chloroquine resistance:
• Asia, tropical South America (rare north of
Panama Canal), sub-Sahara, East Africa
WHO Guidelines in drug prophylaxis:
What prophylaxis:
• Accommodation in large, air-conditioned hotels in most cities of South-East Asia (dusk–dawn) for <2 weeks: ______
no prophylaxis required
WHO Guidelines in drug prophylaxis:
What prophylaxis
For low-risk travel (urban: dusk–dawn) in areas of high resistance for <2 weeks: chloroquine adequate; ______
use a treatment course of Malarone if
necessary
WHO Guidelines in drug prophylaxis:
What prophylaxis
For short- and long-term travel to rural areas of high resistance (e.g. South-East Asia including Thailand, Kenya, Tanzania, Ecuador, Venezuela, Brazil): ______
doxycycline daily alone or mefloquine (once
a week).
WHO Guidelines in drug prophylaxis:
What prophylaxis
For short- and long-term travel to rural areas of high resistance (e.g. South-East Asia including Thailand, Kenya, Tanzania, Ecuador, Venezuela, Brazil):
______) is
also very useful for short-term travel
Atovaquone and proguanil (Malarone
Drugs for Malarial Prophylaxis:
Chloroquine:
Dose (Adult)___________
Dose (Children): __________
300 mg base (2 tabs) same
day each week 1 week
before, during, 4 weeks
after exposure
5 mg base/kg up to
maximum adult dose
Only antimalarial approved for
pregnancy, Aggravates psoriasis,
Beware of retinopathy
Chloroquine
Drugs for Malarial Prophylaxis:
Doxycycline*
Dose (Adult)___________
Dose (Children): __________
100 mg each day, 2 days before, during, 4 weeks after
> 8 years only 2 mg/kg/day up to
100 m
SE: Photosensitivity reactions
Doxycycline*
Drugs for Malarial Prophylaxis:
Mefloquine
(Lariam)*
Dose (Adult)___________
Dose (Children): __________
250 mg (1 tab) same day each week, 1 week before, during, 4 weeks after
Not recommended <45 kg; >45 kg as for
adults
SE of Mefloquine:
Side effects: dizziness, ‘fuzzy’ head, blurred vision, neuropsychiatric
Beware of beta blockers
Drugs for Malarial Prophylaxis
Atovaquone+ proguanil
(Malarone)*
Dose (Adult)___________
Dose (Children): __________
250 mg / 100 mg (1 tab) with food same day each week 2 days before, during, 7 days later
Junior tablets 62.5 mg/
25 mg
11–20 kg: 1 tablet/day
21–30 kg: 2 tablets/day
31–40 kg: 3 tablets/day
>40 kg: 1 adult tab/day
Avoid in pregnant women or
women breastfeeding infants
<11 kg
Avoid in severe kidney impairment
Atovaquone+ proguanil
(Malarone)*
Drugs used for uncomplicated chloroquineresistant
malaria (presumptive breakthrough
where professional medical care
unavailable, i.e. emergency self-treatment
Artemether/ lumefantrine (Riamet)
Atovaquone/ proguanil (Malarone
if not used for prophylaxis)
All travellers should be immunised against :
tetanus, polio and diphtheria and
measles.
Protection against tetanus requires an initial
course of three injections followed by a booster every
______
10 years.
___vaccination is a legal requirement for any
travellers returning from a endemic area.
Yellow fever
______has now been eradicated from the world and therefore is no longer required
for any traveller.
smallpox vaccination
The two vaccinations that may be required
before visiting ‘at risk’ areas are____ and _______
yellow fever and
meningococcus.
Yellow fever is a serious viral infection spread by ______ mosquitoes and, like malaria, is a tropical disease
Aedes
Yellow fever vaccination, which is the only WHOrequired vaccine, is essential for travel to or through
equatorial Africa and northern parts of South America, and for re-entry to Australia from those countries
fever + bradycardia + jaundice
yellow fever
Yellow fever
One injection only is required and the
immunisation is valid for______ years
10
T or F
Yellow fever
Children aged less than 9 months should not be given this vaccine
T
It should not be given within 3 weeks of cholera vaccine.
Yellow fever
T or F
According to the WHO a certificate against yellow fever is the only certificate that should be required for international travel
T
Travellers trekking through the
Kathmandu valley of Nepal and those attending the Haj pilgrimage to Saudi Arabia are at special risk and
should have the vaccine
Meningococcal infection
There is a declining level of
antibodies to _____ in developed countries and adults are at special risk
hepatitis A
How many doses of Hep A should be givem?
1-2
________is endemic in South-East Asia, South America and other developing countries.
Vaccination is recommended, especially for people working in such countries, particularly those in the health care area or
those who may expect to have sexual or drug contact
Hepatitis B
If patients have a ‘negative’ HBV core IgG titre, then vaccination would be worthwhile : what vax?
(three doses: 0, 1
and 6 months).
______ has a high mortality rate
in pregnant women.
Hepatitis E
Hepa vax:
The usual approach for non-immunised people is to give _____ and _____
the combined hepatitis A and B vaccine (Twinrix) as a course of three injections
_________ is not required for entry into any country but is recommended for travel to third world countries where the standards of sanitation are low
Typhoid immunisation
Typhoid immunisation:
It should be considered for travellers to
smaller cities, and village and rural areas in
Africa,
Asia, Central and South America and Southern
Europe.
The parenteral (subcutaneous) vaccine can be used but the _______, which have fewer side effects, are generally preferred
single dose typhi Vi vaccine or the oral vaccine
Cholera is given as an oral vaccine (Dukoral) over\_\_\_\_\_\_\_prior to exposure. It is not recommended in children under \_\_\_\_ or \_\_\_\_\_
1 week
5 years or pregnant women.
Routine vaccination for all Australians
Tetanus, diphtheria, pertussis Hepatitis B Haemophilus influenzae Measles, mumps, rubella Influenza Pneumococcal disease Poliomyelitis Rotavirus Varic
This mosquito-borne ______infection presents a real dilemma to the traveller and doctor because it is a very severe infection (mortality rate 20–40%) with high infectivity and high prevalence in endemic
countries
flavivirus
febrile illness + vomiting + stupor
Japanese B encephalitis
__________is recommended for some
international aid workers or travellers going to
rabies-endemic areas for periods of more than 1 month or even for short periods of working with affected animals in those areas.
Rabies vaccination
T or F
The prebite vaccination does not remove the need for postexposure vaccination
T
painful bite + paraesthesia +
hydrophobia ( pain with drinking)
rabies
_______ is still prevalent in rodents in countries
such as Vietnam, Brazil, Peru, Ecuador and
Kenya.
Plague
Vaccination for plague
Two doses are given to adults (three to children <12 years) and a booster
every 6 months
The common STIs, especially prevalent in South-East Asia and Africa, are
non-specific urethritis (NSU), gonorrhoea
(especially penicillin-resistant strains), hepatitis B and syphilis
Unusual STIs such as _____, ______, ____ are more common in tropical developing
countries.
lymphogranuloma venereum, chancroid and
donovanosis
If a patient has had unprotected intercourse and is at definite risk of acquiring an STI, such as penicillin resistant gonorrhoea or NSU, the following may be appropriate:
• ceftriaxone 250 mg IM (as a single dose)
• doxycycline 100 mg (o) for 10 days or
azithromycin 1 g (o) statim
Most international airlines do not allow passengers to travel after the____ week of pregnancy and may require a doctor’s certificate after ______ weeks
36th
28
Air travel is contraindicated in the last month of pregnancy and until
the ______ day after delivery.
7th
Administration of killed or inactivated ______, _______, ________is permitted during pregnancy.
vaccines, toxoids and polysaccharides
Yellow fever vaccine is considered safe after the ____
6th month
______ is important as protection
is passed on to the child during early infancy.
Tetanus immunisation
______ can be safely given as prevention against hepatitis in pregnant women
Immunoglobin
The antimalarial drugs _____, ______, ______ may be given to pregnant women
chloroquine, quinine and proguanil
Air travel is not recommended for _______
infants of less than 7 days or premature infants.
Most vaccines__________) can safely be given in the first few weeks of life.
(diphtheria, tetanus, poliomyelitis, BCG
______ is common overseas and it is worthwhile considering it even under 12 months
Measles
____ should not be given under 12 months.
Yellow fever
vaccine
____, ___, _____may be given safely to
infants. However, as a rule young children should be
discouraged from trave
Chloroquine,
proguanil and quinine
This is the uncomfortable aftermath of a long flight in which the person feels exhausted and disoriented, and has poor concentration, insomnia and anxiety
Jet lag
On Jet lag:
The worst cases appear to be in those travelling eastbound from ______
It can occur with travel
in any direction, but the north–south flights are not so bothersome.
England to Australia.
Specific factors affecting jet lag
Duration of the flight, time of
departure, and changes in climate and culture at the
destination affect the severity of jet lag
Oral medication in a 5 mg dose close to the desired or usual bedtime decreased jet lag
Melatonin
Patients with these problems should avoid flying
or be assessed for fitness:
• upper airways congested by infection, including
_______, e.g. within 6 weeks of severe acute
respiratory illness
• acute gastroenteritis
• severe respiratory disease______
• recent_________ surgery
influenza
(COPD, chronic bronchitis, pneumothorax)
thoracic
Patients with these problems should avoid flying
or be assessed for fitness:
• cystic fibrosis • \_\_\_\_\_\_\_\_\_(people should not fly until rendered non-infective) • past history of respiratory problems while flying (dyspnoea, chest pain, confusion) • unstable heart failure • severe anaemia \_\_\_\_\_\_\_\_
pulmonary tuberculosis
below 7.5 g/dL
Patients with these problems should avoid flying
or be assessed for fitness:
- pregnancy beyond ____
- previous violent or unpredictable behaviour
- within _______days of a myocardial infarction
- within 3 days of a cerebrovascular accident
- within_____ days of major surgery
200 days (28 weeks) (up to 36 weeks if necessary)
7
5–10
Special precautions are required by travellers with
the following problems:
• Colostomy. Patients should wear a large colostomy
bag and take extra bags.
• __________. Such patients should wear
supportive stockings and exercise frequently.
__________Those with broken limbs in plaster
should be careful of swelling
Varicose veins
• Plaster casts.
Special precautions are required by travellers with
the following problems:
Those with _______ may have a
problem with X-rays at some overseas airports.
Mention it to security officials before passing
through security equipment.
________. Medication should be increased on the
day of travel.
________should discuss their therapy
and control with their doctor. They should carry
sweets.
pacemakers
- Epilepsy
- Diabetics.
Risk factors for DVT
increasing
age, clotting tendency, i.e. thrombophilia, past history
of DVT, family history of DVT, smoking, obesity,
varicose veins, dehydration, significant illness, recent
major surgery and oestrogen therapy
The main symptoms of_______ are nausea,
vomiting, dizziness, weakness and lethargy. Early
signs are pallor and drowsiness, and sudden silence
from an active, talkative child
travel sickness
Many medicines are available for travel sickness.
They include ________, ________, _______ derivatives, all of which can cause drowsiness
hyoscine, various antihistamines and
other phenothiazine
Phenothiazine derivatives that provide appropriate
anti-labyrinthine activity include
1.
2.
3`
prochlorperazine
(Stemetil), promethazine hydrochloride (Phenergan)
and promethazine theoclate (Avomine
Travel sickness:
These preventive oral preparations should ideally
be taken ______ minutes before the trip and can be
repeated _______hourly during the trip (maximum
4 tablets in 24 hours).
30–60
4–6
________ generally poses no special problems apart
from motion sickness and the possibility of injuries
in the aged
Sea travel
Those prone to sea sickness are advised to
take anti-emetics _______ minutes before sailing and for
the first _______ days at sea until they obtain their ‘sea legs
60
2
The Chief Surgeon on P & O’s
flagship recommends that elderly people should
bring the following:
• a letter from their doctor stating diagnosis and medication • a spare set of spectacles • a spare set of dentures • a walking stick (if appropriate
Forms of Altitude sickness:
1.
2.
3.
1 Acute mountain sickness (mild to severe)
2 High-altitude pulmonary oedema
3 High-altitude cerebral oedema
