Chapter 117. Health Advice for International Travel (Part 9) pptx

Health Advice for International Travel Part 9 Fever Fever in a traveler who has returned from a malarious area should be considered a medical emergency because death from P.. Although

Chapter 117 Health Advice for

International Travel

(Part 9)

Fever

Fever in a traveler who has returned from a malarious area should be

considered a medical emergency because death from P falciparum malaria can

follow an illness of only several days' duration Although "fever from the tropics" does not always have a tropical cause, malaria should be the first diagnosis

considered The risk of P falciparum malaria is highest among travelers returning

from Africa or Oceania and among those who become symptomatic within the first 2 months after return Other important causes of fever after travel include viral hepatitis (hepatitis A and E), typhoid fever, bacterial enteritis, arboviral infections (e.g., dengue fever), rickettsial infections (including tick and scrub typhus and Q fever), and—in rare instances—leptospirosis, acute HIV infection,

and amebic liver abscess A cooperative study by GeoSentinel (an emerging infectious disease surveillance group established by the CDC and the International Society of Travel Medicine) showed that, among 3907 febrile returned travelers, malaria was acquired most often from Africa, dengue from Southeast Asia and the Caribbean, typhoid fever from southern Asia, and rickettsial infections (tick typhus) from southern Africa (Table 117-3) In at least 25% of cases, no etiology can be found, and the illness resolves spontaneously Clinicians should keep in mind that no present-day antimalarial agent guarantees protection from malaria and that some immunizations (notably, that against typhoid fever) are only partially protective

Table 117-3 Etiology and Geographic Distribution (Percent) of

Systemic Febrile Illness in Returned Travelers (N = 3907)

ib

CA

m

SA

m

SS

A

S

CA

SE

A

Mononucle

osis

Note: Carib, Caribbean; CAm, Central America; SAm, South America;

SSA, Sub-Saharan Africa; SCA, South Central Asia; SEA, Southeast Asia Bold type is for emphasis only

Source: Revised from Table 2 in Freedman et al, 2006 Used with

permission from the Massachusetts Medical Society

When no specific diagnosis is forthcoming, the following investigations, where applicable, are suggested: complete blood count, liver function tests, thick/thin blood films for malaria (repeated twice if necessary), urinalysis, urine and blood cultures (repeated once), chest x-ray, and collection of an acute-phase serum sample to be held for subsequent examination along with a paired convalescent-phase serum sample

Skin Diseases

Pyodermas, sunburn, insect bites, skin ulcers, and cutaneous larva migrans are the most common skin conditions affecting travelers after their return home In those with persistent skin ulcers, a diagnosis of cutaneous leishmaniasis, mycobacterial infection, or fungal infection should be considered Careful, complete inspection of the skin is important in detecting the rickettsial eschar in a febrile patient or the central breathing hole in a "boil" due to myiasis

Emerging Infectious Diseases

In recent years, travel and commerce have fostered the worldwide spread of HIV infection, led to the reemergence of cholera as a global health threat, and created considerable fear about the possible spread of severe acute respiratory syndrome (SARS) and avian influenza (H5N1) For travelers, there are more realistic concerns One of the largest outbreaks of dengue fever ever documented

is now raging in Latin America; schistosomiasis is being described in previously unaffected lakes in Africa; and antibiotic-resistant strains of sexually transmitted and enteric pathogens are emerging at an alarming rate in the developing world In addition, concerns have been raised about the potential for bioterrorism involving not only standard strains of unusual agents but mutant strains as well Time will tell whether travelers (as well as persons at home) will routinely be vaccinated against diseases such as anthrax and smallpox As Nobel laureate Dr Joshua

Lederberg pointed out, "The microbe that felled one child in a distant continent yesterday can reach yours today and seed a global pandemic tomorrow." The vigilant clinician understands that the importance of a thorough travel history cannot be overemphasized

Further Readings

Chen LH, Keystone JS: New strategies for the prevention of malaria in travelers Infect Dis Clin North Am 19:185, 2005 [PMID: 16027794]

DuPont AW, DuPont HL: Travelers' diarrhea: Modern concepts and new developments Curr Treat Options Gastroenterol 9:13, 2006 [PMID: 16423310]

Freedman DO et al (GeoSentinel Surveillance Network): Spectrum of disease and relation to place of exposure among ill returned travelers N Engl J Med 354:119, 2006 [PMID: 16407507]

Keystone JS et al: Travel Medicine Mosby, Philadelphia, 2004

Okhuysen PC: Current concepts in travelers' diarrhea: Epidemiology, antimicrobial resistance and treatment Curr Opin Infect Dis 18:522, 2005 [PMID:

16258326]

Ryan ET et al: Illness after international travel N Engl J Med 347:505,

2002 [PMID: 12181406]

Shlim DR: Update in traveler's diarrhea Infect Dis Clin North Am 19:137,

2005 [PMID: 15701551]

Sohail MR, Fischer PR: Health risks to air travelers Infect Dis Clin North

Am 19:67, 2005 [PMID: 15701547]

Wilson ME, Chen LH: Dermatologic infectious diseases in international travelers Curr Infect Dis Rep 6:54, 2004 [PMID: 14733850]

Websites of Interest: Chronic renal failure: www.kidney.org Diabetes:

www.diabetesmonitor.com/other-14.htm Dialysis: www.dialysisfinder.com Disability: www.access-able.com HIV: www.aegis.com

Bibliography

Angell SY, Behrens RH: Risk assessment and disease prevention in

travelers visiting friends and relatives Infect Dis Clin North Am 19:49, 2005 [PMID: 15701546]

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Centers for Disease Control and Prevention: Health Information for International Travel 2005–2006 HHS publication no (CDC) 92-8280

Washington, DC, Government Printing Office, 2005 (http://wwwn.cdc.gov/travel/contentYellowBook.aspx)

Connor BA: Sequelae of traveler's diarrhea: Focus on postinfectious irritable bowel syndrome Clin Infect Dis 41(Suppl 8):S577, 2005

Dondorp AM et al: Fake antimalarials in Southeast Asia are a major impediment to malaria control: Multinational cross-sectional survey on the prevalence of fake antimalarials Trop Med Int Health 9:1241, 2004 [PMID: 15598255]

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