DIAGNOSIS ETIOLOGI FOR TRAVELER ILLNESS Nurrokhman Dept of Microbiology Fac of Medicine UGM

International Travel

U.S. Residents Traveling Abroad* Source http://tinet.ita.doc.gov/view/f-2005-11-001/index.html *ITA, includes travel to Canada and Mexico

Travelers’ Health Risks Of 100,000 travelers to a developing country for 1 month: 50,000 will develop some health problem 8,000 will see a physician 5,000 will be confined to bed 1,100 will be incapacitated in their work 300 will be admitted to hospital 50 will be air evacuated 1 will die Steffen R et al. J Infect Dis 1987; 156:84-91

Deaths Related to International Travel Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

Infectious Disease Risks to the Traveler Schistosomiasis Tuberculosis Leptospirosis Polio Yellow Fever Measles JEV Malaria Diarrhea Leishmaniasis Rabies Dengue Meningococcal Meningitis ETC.

Incidence of specific illnesses while staying in developing countries Incidence rate / month 100% 100,000 Traveller’s diarrhoea 30 -80% 10,000 10% Malaria (West Africa, not taking malaria tablets) Acute respiratory infection 1% 1,000 Hepatitis A Gonorrhoea 0.1% 100 Animal bite with risk of rabies Typhoid (India, North and North-West Africa, Peru) HIV infection Puts into perspective what we should be discussing from a morbidity point of view: 1. Diarrhoea 2. Respiratory Tract Illness 3. Sexually Transmitted Disease ............ and way down the list cholera! 0.01% 10 Typhoid (other regions) Asymptomatic polio 0.001% 1 Cholera Paralytic polio

Travel Preparation Travel health insurance Medical care Hospitalization Evacuation Obtaining medical care abroad Awareness of travel notices Hand washing and hygiene

Environmental Precautions Air Travel Jet Lag Sun Protection Extreme Heat and Cold dehydration, heat stroke hypothermia, frostbite Altitude Water recreation Drowning, boating & diving accidents Risk of schistosomiasis or leptospirosis Biological and chemical contamination

Food and Water Precautions Bottled water Selection of foods well-cooked and hot Avoidance of salads, raw vegetables unpasteurized dairy products street vendors ice

Immunizations to Consider for Adult Travelers Routine Diphtheria* Tetanus* Pertussis* Measles + Mumps+ Rubella + Varicella Pneumococcus Influenza Travel related Hepatitis A Hepatitis B Typhoid Rabies Meningococcal disease Polio Japanese encephalitis Yellow Fever VZV (no mention of upper age limit; approved for >=12 months) >= 13 Years of Age After the first and second doses, 10.2% and 9.5% of vaccinees, respectively, developed fever (i.e., oral temperature greater than or equal to 100 F {37.7 C}); these febrile episodes occurred throughout the 42-day period and were usually associated with intercurrent illness. After one and two doses, 24.4% and 32.5% of vaccinees, respectively, had complaints regarding the injection site; rash at the injection site at a peak of 6-20 days and 0-6 days postvaccination, respectively, developed in 3% and 1% of vaccinees, respectively; and a nonlocalized rash consisting of a median number of five lesions developed in 5.5% and 0.9% of vaccinees, respectively, and occurred at a peak of 7-21 days and 0-23 days postvaccination, respectively. * Td or Tdap + MMR

TRAVELLER’S DIARRHOEA Affects between 30 – 50% of people in a 2 week stay Onset usually during stay - 62% in first week - day 3 the highest rate of onset Mean duration 3.2 + 0.2 days (treated) Mean duration 4.1 + 0.2 days (untreated) Duration less in older travellers Correlation between dietary indiscretions

Traveller’s diarrhoea Cause: Ingestion of contaminated FOOD AND WATER; High risk foods Seafood, Salads, Cold meat, Peeled fruit, Local water and ice Single most important message- WASH YOUR HANDS!!! Aetiology is going to vary with the season and he geographic area Comment on the fact that some medical conditions may in fact increase the chance of getting TD; Age, Children, PPI’s

Travelers’ diarrhea Very common. Up to 50% over 2-4 weeks. A self-limited illness in most international travelers. Duration can be shortened by antibiotics.

Cause of travelers’ diarrhea Usually bacterial, usually ETEC (enterotoxigenic E. coli). Relatively recently described EAEC (entero-adherent E. coli) also common More rare causes: Other bacteria: Shigella, Salmonella, Campylobacter Protozoan: Giardia viral

Traditional wisdom: The bad list: → Food from street stands (street vendors) → Salads → Raw food, such as sushi → Buffets, even at nice hotels or restaurants, in which food sits out for several hours → Tap water → Ice. Freezing doesn’t kill most of the microorganisms that can cause diarrhea.

Traditional wisdom: Dietary strategy to reduce risk of travelers’ diarrhea The (relatively) safe list: → Boiled anything. → Bottled anything—water, beer, pop (if sealed). → Dry foods, e.g. bread. → Packaged foods. → Well-cooked food. → Fruits which require peeling (oranges, bananas)

Travelers’ diarrhea caveats: Take self-treatment medication only for “normal” diarrhea If blood in stool, Or fever, Or significant abdominal pain, Or if not better 2 days after starting antibiotics—  See a doc!

2nd self-treatment drug An antimotility drug: e.g. loperamide (Imodium A-D) 2 at onset of symptoms, then 1 after each loose BM, not to exceed six/day. Contraindicated in presence of symptoms consistent with “invasive organism” (blood in stool, fever, significant abd. pain).

TD carry-along med algorithm: Pt feels good Takes nothing Mild diarrhea Imodium A-D only Watery diarrhea Imodium A-D + antibiotic Sick See doc Blood in stool Fever Significant abd. pain

Special oral rehydration solution -Only needed at extremes of age. -No need to “rest” the gut during recovery.

Should you carry more than one medication for travelers’ diarrhea? Cipro for ETEC azithromycin for Campylobacter metronidazole (Flagyl) for Giardia ?? No. These can’t be distinguished without laboratory exam.

Standard of care: Stand-by medication Taken only if symptoms develop For most of the world: a fluoroquinolone (e.g., ciprofloxacin, levofloxacin). Cipro dose: 500 mg b.i.d., stop when better (for up to 48 hours). For Southeast Asia*, and Indian subcontinent: azithromycin, one dose only (for adults, one gram once). Duration without treatment: 3-5 days. Duration with treatment: 12-24 hours. *Brunei, Burma (Myanmar), Cambodia, East Timor, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand, Vietnam

Persistent Diarrhea Post-Travel Differential Diagnosis “Typical” protozoan cause (E. histolytica, G. lamblia) Atypical presentation of “acute” pathogens, e.g. Shigella Newer pathogens: Cyclospora, Cryptosporidia, Dientameba fragilis ?Lactose intolerance Clostridium difficile diarrhea (antibiotic-related) “Unmasked” inflammatory bowel disease (IBD) or celiac disease Tropical sprue HIV-related Post infectious irritable bowel Helminths (worms or flukes) rarely cause diarrhea in travellers