This slide show was originally presented at a Parish Nurse Support Group meeting, March 5, 2013.

1. Matthew Rollosson, RN, MPH&TM

2.  This presentation is a brief overview of travel-
related infections
 I strongly encourage travelers to endemic
countries to consult a travel medicine specialist
at least one month prior to departure
 Find a travel medicine clinic:
 http://wwwnc.cdc.gov/travel/page/find-clinic.htm
 http://www.astmh.org/source/ClinicalDirectory
 http://www.istm.org/WebForms/SearchClinics

3.  Hitchhiked in Africa,
1988-1989
 Registered Nurse, 1992
 Diploma in Clinical
Tropical Medicine &
Travelers’ Health, 2000
 Worked in Ethiopia,
2002
 Master of Public Health
& Tropical Medicine,
2009
Niger River, Mali, 1988

4.  Locally Acquired Dengue - Key West, Florida,
2009—2010 (CDC, 2010)
 Dengue Hemorrhagic Fever - U.S.-Mexico
Border, 2005 (CDC, 2007)
 Autochthonous Transmission of Trypanosoma
cruzi, Louisiana (Dorn et al., 2007)
 Multifocal Autochthonous Transmission of
Malaria - Florida, 2003 (CDC, 2004)
 Changing patterns of autochthonous malaria
transmission in the United States (Zucker, 1996)

5.  West Nile Virus
 Eastern Equine Encephalitis
 Western Equine Encephalitis
 St. Louis Encephalitis
 La Crosse
 Chikungunya?
 Vector competence of Florida mosquitoes for
chikungunya virus (Richards et al., 2010)
 Chikungunya: a potentially emerging epidemic?
(Thiboutot et al., 2010)

6.  Primary Amebic Meningoencephalitis Deaths
Associated With Sinus Irrigation Using Contaminated
Tap Water (Yoder et al., 2012)
 The epidemiology of primary amoebic
meningoencephalitis in the USA, 1962-2008 (Yoder et
al., 2010)
 Raccoon Roundworms in Pet Kinkajous - Three States,
1999 and 2010 (MMWR 2011)
 Raccoon Roundworm Encephalitis - Chicago, Illinois,
and Los Angeles, California, 2000 (MMWR, 2002)
 Eosinophilic meningitis attributable to Angiostrongylus
cantonensis infection in Hawaii (Hochberg et al. 2011)
 Parastrongylus (=Angiostrongylus) cantonensis now
endemic in Louisiana wildlife (Kim et al., 2002)
 The finding of Angiostrongylus cantonensis in rats in
New Orleans (Campbell & Little 1988)
(Okay, they don’t really eat brains)

7.  Air travel  Pre-existing conditions
 DVT  Sexual health
 Envenomations/intoxications  Special needs
 Environment  Trauma
 Altitude  Crime
 Diving  Motor vehicle accidents
 Heat/cold  Natural disasters
 Pollution  Violence
 Sunburn  Recreational water exposure
 Food/water  Leptospirosis
 Mental health  Marine animals
 Culture shock  Schistosomiasis
 Re-entry shock
 Substance abuse

8.  Death:
 Non-infectious
 Cardiovascular disease
 Drowning
 Motor vehicle accidents
 Infectious disease
 Malaria
 Most common non-fatal illness:
 Travelers’ diarrhea
Steffen & Grieve, 2013

9. 3000
2820
2500
2000
1500
1000
500 428
88
18 6 1
0
Falciparum Typhoid fever Leptospirosis DHF/DSS East African Japanese
malaria trypanosomiasis encephalitis
Jensenius et al., 2013

10.  Protozoan parasite
 Complex lifecycle
 Transmitted by mosquitoes
 Four human species
 Plasmodium falciparum
 Widespread drug resistance
 P. vivax
 P. ovale
 P. malariae
 P. knowlesi
 Simian malaria www.cdc.gov/malaria
 Vaccines in clinical trials

11. CDC 2012

12. 1,691 cases reported to CDC
Species Region of Acquisition
P. falciparum 58% Africa 65%
P. vivax 19% West Africa 73%
P. malariae 2% Asia 19%
P. ovale 2% South Asia 94%
Unknown 18% India 81%
Americas 15%
Reason for travel
Visiting friends and relatives (VFR) 71%
Missionaries 9%
Business 8% CDC 2012

13.  Atovaquone/proguanil (Malarone®)
 Daily
 1-2 days before arriving in malaria-endemic area
 7 days after leaving
 Doxycycline
 Daily
 1-2 day before arriving
 4 weeks after leaving
 Mefloquine
 Weekly
 2 weeks before arriving
 4 weeks after leaving
CDC, 2012

14.  35% of antimalarial drugs obtained in
Southeast Asia and sub-Saharan Africa failed
chemical analysis (Nayyar et al. 2012)
 53% of artesunate tablets collected in Southeast
Asia contained no trace of the drug (Dondorp
et al., 2004)
 Subtherapeutic doses increase the risk of
treatment failure and development of drug-
resistance

15.  “Breakbone fever”
 Fever
 Rash
 Arthralgia
 Myalgia
 Headache
 Transmitted by mosquitoes
 Dengue hemorrhagic fever (DHF)
 Dengue shock syndrome (DSS)
 Vaccines in clinical trials

16. CDC, 2012

17. Mosquitoes Chigger Mites
 Chikungunya  Rickettsial pox
 Dengue  Scrub typhus
 Japanese encephalitis
 Lymphatic filariasis Deer flies (Chrysops)
 Malaria  Loiasis
 Rift Valley fever
 Yellow fever Fleas
 Murine typhus
Ticks  Plague
 Babesiosis
 Ehrlichiosis/Anaplasmosis Lice
 Relapsing fever  Epidemic typhus
 Rickettsial pox  Relapsing fever
 Tick typhus
 Tularemia Sandflies
 Leishmaniasis
Blackflies (Simulium)
 Onchocerciasis Tsetse
 African trypanosomiasis

18.  Repellants
 Applied to skin:
 DEET
 Picaridin
 IR3535
 (Skin-So-Soft® Not-So-Good)
 Applied to clothing:
 Permethrin
 Bed nets
 Insecticide treated
 Clothing
 Cover
 Light-colored
CDC, 2012; Fradlin, 2008

19.  4 – 6 weeks before travel
 Accelerated schedule
 Routine
 Age-specific
 Recommended
 Destination-specific
 Required
 Destination-specific
 Yellow fever
 Meningococcal (Hajj)
Jong, 2008

20.  Inactivated polio vaccine (IPV)
 Single lifetime booster for adults traveling to areas
with polio transmission and who have previously
received primary series
 Influenza
 Year-round transmission in the tropics
 Measles, mumps, rubella (MMR)
 2 doses
 Tetanus, diphtheria, acellular pertussis (Tdap)

21.  Ongoing wild poliovirus transmission:
 Afghanistan
 Nigeria
 Pakistan
 Vaccine-associated paralytic poliomyelitis (VAPP)
 1 in 2.4 million OPV doses
 Vaccine-derived poliovirus (VDPV)
 Areas with inadequate polio vaccine coverage
 2012: Somalia, Chad, Kenya, DR Congo, Yemen
 Importation
 November 2012: outbreak in Niger imported from
Nigeria
 December 2012: wild poliovirus from Pakistan found in
sewage in Cairo, Egypt
WHO, 2013

22.  Imported vaccine-associate paralytic poliomyelitis –
United States, 2005
 22 year old woman
 Religious exemption from IPV/OPV
 Stayed with a family in Costa Rica beginning Jan 14, 2005
 Infant in the family received OPV Jan 19
 Onset of symptoms March 2
 Sabin strain poliovirus isolated from stool
CDC, 2006
 Transmission of imported vaccine-derived poliovirus
in an undervaccinated community in Minnesota
 OPV not used in the U.S. since 2000
 In 2005, 8 Amish children found to be excreting poliovirus
 Source not identified
Alexander et al., 2009

23.  Measles declared eliminated from the U.S. in 2000
 222 cases in the U.S. in 2011
 200 associated with importation from other countries
 166 unvaccinated/unknown vaccination status
 141 eligible to receive MMR
 50 refused vaccination for personal, philosophical, or
religious objections
 Measles in Europe
 39% of cases imported to the U.S. 2001-2008
 46% of cases imported to the U.S. in 2011
CDC, 2012; Parker Fiebelkorn et al., 2010

24.  Hepatitis A
 Hepatitis B
 Japanese encephalitis
 Meningococcal
 Pneumococcal
 Typhoid
 Varicella
 Yellow fever

25.  Hepatitis A
 Hepatitis B
 Meningococcal
 Pneumococcal
 Varicella

26.  Neisseria meningitidis
 Meningitis
 Meningococcemia
 Transmitted by respiratory droplets
 Risk factors: crowding, poverty, smoking
 African Meningitis Belt
 Major epidemics every 5-10 years
 Hot, dry, dusty season
 Ends with beginning of rainy season
 Asymptomatic nasopharyngeal carriage
 Vaccine
 Conjugate A, C, Y, W-135
 Required for Hajji
Apicella, 2010

27. CDC, 2012

28.  Salmonella enterica  Fever
 Subspecies Typhi  Remittent
 Drug resistance  Step-wise
 Non-typhoidal  Sustained
Salmonella  Relative bradycardia
 S. paratyphi
 Constipation/diarrhea
 Clinically
indistinguishable from  Abdominal pain
typhoid
 Headache
 Fecal-oral  Rose spots
transmission
Thielman et al., 2010

29. Two vaccine licensed in the U.S.
 Vivotif®
 Live attenuated oral typhoid vaccine
 1 capsule every other day x 4 doses
 Do not take with antibiotics active against S. typhi
 Typhim Vi®
 Injectable Vi capsular polysaccharide vaccine
 1 IM dose
Do not prevent non-typhoidal Salmonella
infections

30.  Flavi- “yellow”
 Dengue
 Japanese encephalitis
 St. Louis encephalitis
 Tickborne encephalitis
 West Nile virus
 Yellow fever

31.  Transmitted by mosquitoes
 Reservoir: forest primates
 Major epidemics in the U.S.
 Eastern seaboard, Mississippi Valley
 Last epidemic: New Orleans 1905
 Most infections self-limiting
 Fever, headache, myalgias
 Biphasic
 Period of remission
 Period of intoxication
 Fulminant hepatitis
 Mortality 20-50%
Vaughn et al., 2010

32.  Relative bradycardia
 Fever without increase
in heart rate
 Jean Charles Faget
 1818-1884
 New Orleans physician
St Louis Cemetery No 2
New Orleans, Louisiana

33. CDC, 2012

34.  International Certificate of Vaccination or
Prophylaxis (ICVP)
 Vaccine must be administered by a provider
with an official uniform stamp
wwwnc.cdc.gov/travel/yellow-fever-vaccination-clinics/search.htm
CDC, 2012

35.  Transmitted by mosquitoes
 Night-biting
 Most active June - November
 Not active during winter months
 Most infections asymptomatic
 Encephalitis:
 Fever, headache, lethargy
 Movement disorders
 Agitation, decreased LOC, coma
 Meningeal signs, seizures, focal neurological deficits
 20-30% case fatality
 30-50% left with residual neurological deficits
CDC, 2010

36. CDC, 2012

37.  Most travelers not at risk
 Low risk in urban areas
 Long stays in or frequent visits to
rural/farming areas
 Vero cell culture vaccine: ≥17 years of age
 2 doses 28 days apart
 Second dose at least 1 week before travel
 Not licensed for children in the U.S.
 Mouse brain vaccine 1 – 16 years of age
 3 doses at 0, 7, and 30 days
 No longer available in the U.S.
CDC, 2010

45.  American Society of Tropical Medicine and
Hygiene
 www.astmh.org
 International Society of Travel Medicine
 www.istm.org
 WHO travel and health
 www.who.int/topics/travel/en

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51. Congo River, 1989