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

2. International Travel

3. U.S. Residents Traveling Abroad*
Source
*ITA, includes travel to Canada and Mexico

4. 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

5. Deaths Related to International Travel
Hargarten S et al, Ann Emerg Med, :

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

7. Incidence of specific illnesses while staying in developing countries
Incidence rate / month
100%
100,000
Traveller’s diarrhoea %
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

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

9. 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

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

11. 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

12. 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 days (treated)
Mean duration days (untreated)
Duration less in older travellers
Correlation between dietary indiscretions

13. 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

14. 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.

15. 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

16. 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.

17. 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)

18. 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!

19. 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).

20. 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

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

22. 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.

23. 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: hours.
*Brunei, Burma (Myanmar), Cambodia, East Timor, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand, Vietnam

24. 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