Chapter 117. Health Advice for International Travel (Part 7) docx

Health Advice for International Travel Part 7 Gastrointestinal Illness Decreased levels of gastric acid, abnormal gastrointestinal mucosal immunity, other complications of HIV infecti

Chapter 117 Health Advice for

International Travel

(Part 7)

Gastrointestinal Illness

Decreased levels of gastric acid, abnormal gastrointestinal mucosal immunity, other complications of HIV infection, and medications taken by HIV-infected patients make travelers' diarrhea especially problematic in these individuals Travelers' diarrhea is likely to occur more frequently, be more severe,

be accompanied by bacteremia, and be more difficult to treat Although

uncommon, Cryptosporidium, Isospora belli, and Microsporidium infections are

associated with increased morbidity and mortality in AIDS patients

The HIV-infected traveler must be careful to consume only appropriately prepared foods and beverages and may benefit from antibiotic prophylaxis for

travelers' diarrhea Sulfonamides (as used to prevent pneumocystosis) are ineffective because of widespread resistance

Other Travel-Related Infections

Data are lacking on the severity of many vector-borne diseases in HIV-infected individuals Malaria is especially severe in asplenic persons and in those with AIDS The HIV load doubles during malaria, with subsidence in ~8–9 weeks; the significance of this increase in viral load is unknown

Visceral leishmaniasis (Chap 205) has been reported in numerous HIV-infected travelers Diagnosis may be difficult, given that splenomegaly and hyperglobulinemia are often lacking and serologic results are frequently negative Sandfly bites may be prevented by evening use of insect repellents

Certain respiratory illnesses, such as histoplasmosis and coccidioidomycosis, cause greater morbidity and mortality among patients with AIDS Although tuberculosis is common among HIV-infected persons (especially

in developing countries), its acquisition by the short-term HIV-infected traveler has not been reported as a major problem

Medications

Adverse events due to medications and drug interactions are common and raise complex issues for HIV-infected persons Rates of cutaneous reaction (e.g.,

increased cutaneous sensitivity to sulfonamides) are unusually high among patients with AIDS Since zidovudine is metabolized by hepatic glucuronidation, inhibitors of this process may elevate serum levels of the drug Concomitant administration of the antimalarial drug mefloquine and the antiretroviral agent ritonavir may result in decreased plasma levels of ritonavir In contrast, no significant influence of concomitant mefloquine administration on plasma levels

of indinavir or nelfinavir was detected in two HIV-infected travelers There is a strong theoretical concern that the antimalarial drugs lumefantrine (combined with artemisinin in Coartem and Riamet) and halofantrine may interact with HIV protease inhibitors and nonnucleoside reverse transcriptase inhibitors since the latter are known to be potent inhibitors of cytochrome P450

Chronic Illness, Disability, and Travel

Chronic health problems need not prevent travel, but special measures can make the journey safer and more comfortable

Heart Disease

Cardiovascular events are the main cause of deaths among travelers and of in-flight emergencies on commercial aircraft Extra supplies of all medications should be kept in carry-on luggage, along with a copy of a recent electrocardiogram and the name and telephone number of the traveler's physician

at home Pacemakers are not affected by airport security devices, although

electronic telephone checks of pacemaker function cannot be transmitted by international satellites Travelers with electronic defibrillators should carry a note

to that effect and ask for hand screening A traveler may benefit from supplemental oxygen; since oxygen delivery systems are not standard, supplementary oxygen should be ordered by the traveler's physician well before flight time Travelers may benefit from aisle seating and should walk, perform stretching and flexing exercises, consider wearing support hose, and remain hydrated during the flight to prevent venous thrombosis and pulmonary embolism

Chronic Lung Disease

Chronic obstructive pulmonary disease is one of the most common diagnoses in patients who require emergency-department evaluation for symptoms occurring during airline flights The best predictor of the development of in-flight problems is the sea-level PaO2 A PaO2 of at least 72 mmHg corresponds to an in-flight arterial PaO2 of ~55 mmHg when the cabin is pressurized to 2500 m (8000 ft) If the traveler's baseline PaO2 is <72 mmHg, the provision of supplemental oxygen should be considered Contraindications to flight include active bronchospasm, lower respiratory infection, lower-limb deep-vein phlebitis, pulmonary hypertension, and recent thoracic surgery (within the preceding 3 weeks) or pneumothorax Decreased outdoor activity at the destination should be considered if air pollution is excessive