Travel Medicine

1. Make sure travelers get up to date, timely, itinerary-specific advice from a reliable source (e.g., travel clinic, travel website).
2. When seeing patients planning travel, discuss the common, non-infectious perils of travel (e.g., accidents, safer sex, alcohol, safe travel for women).
3. In patients presenting with symptoms of infection without an obvious cause, especially those with a fever, enquire about recent travel history to identify potential sources (especially, but not exclusively, malaria).
4. Provide prevention and treatment advice and prescribe medications for common conditions associated with travel (e.g., traveler’s diarrhea, altitude sickness).
5. Ensure patients understand how to manage their chronic disease while traveling (e.g., diabetes, asthma, international normalized ratios [INRs]).
6. Use patient visits for travel advice as an opportunity to update routine vaccinations.
7. Advise patients to check insurance coverage issues especially in regard to recent changes in chronic disease and any recent treatment changes.
8. Advise patients traveling with medications to have an adequate supply, documentation of need for use, and to transport them securely (e.g., carry-on bag).

Fever in a Returning Traveler

• Use surveillance network to determine new outbreak of disease (CanTravNet, EuroTravNet, GeoSentinel)
  • Consider web algorithm (www.fevertravel.ch, KABISA, GIDEON)

Red Flags

• Rule out sepsis, eg. qSOFA - Altered mentation, RR≥22, sBP≤100
• Meningeal signs
• Bleeding sign (petechiae)
• Eschar
  • Southern Africa = Benign African tick typhus
  • South/Southeast Asia = Scrub typhus potentially fatal (look in moist areas: genitalia, perineum, under breasts)

HPI

• Exposures
  • Day-by-day itinerary, areas traveled, activities
  • Sick contact (TB)
  • Fresh water (shistosomiasis, leptospirosis)
  • Unclean water, unpasteurized milk, raw food (Traveler's diarrhea, giardiasis, nontyphoidal salmonellosis, enteric fever, shigellosis, campylobacter, hepatitis A and E, brucellosis, listeriosis)
  • Skin contact with soil - walking barefoot (Strongyloidiasis, melioidosis)
  • Farm animals
  • Sexual contact (Herpes virus, HIV, Hep A/B/C, syphilis, gonorrhea, Zika, viral hemorrhagic)
  • IVDU, tattoo, piercing (Hep B/C, HIV, CMV, malaria, babesiosis)
  • Insect bites/Animal bites
• Vaccinations and prophylaxis
• PMH including immune status (HIV), medications
• Symptoms
  • Cough, dyspnea, sore throat, abdominal pain, N/V/D

Physical Exam

• Vitals (bradycardia may be seen with Typhoid fever)
• Neuro r/o meningitis
• HEENT
• Resp
• Lymph nodes
• Abdo (enlarged liver/spleen)
• Skin (see images below)
  • Eschar (Rickettsial)
  • Rose spots of Typhoid fever
  • Dengue rash (islands of white in a sea of red)
  • Petechiae
  • Jaundice

DDx

• Malaria (Plasmodium) - leading cause of fever 21%
  • Prevent: Clothing, DEET, bed nets with permethrin
  • 7 days to months post Anopheles mosquito bite
  • Treatment/chemoprophlyaxis
    • Atovaquone/proguanil (Malarone) daily
      • Start 1 day prior, continue 7d after
      • Avoid in children <5kg
    • Mefloquine (Lariam) weekly
      • Start 3w prior, continue 4w after
      • AE: Severe intolerance in some patients
    • Chloroquine weekly
      • Start 1-2w prior, continue 4w after
      • Resistance
    • Doxycycline also option for prophylaxis (risk of sun sensitivity, and avoid in children <8yo due to teeth staining)
• Diarrhea/Fever: Nontyphoidal Salmonella, Shigella, Campylobacter, E histolytica
• Dengue, Chiungunya, Zika
  • Avoid pregnancy after return from Zika area (2 months for women, 6 months for men)
• Enteric / Typhoid fever
• Rickettsial (Spotted Rocky Mountain Fever) r/o scrub typhus
• Tuberculosis

Investigations

• CBC (anemia, lymphopenia, thrombocytopenia, eosinophilia)
• Thick and thin blood smear r/o Malaria (consider repeat q12h until three negative smears as parasitemia is cyclical)
• Liver/Renal studies
• Electrolytes
• Blood culture x2
• Urinalysis/Urine culture
• CXR
• Consider
  • ESR/CRP
  • PPD r/o TB
  • Dengue Serology
  • Widal test r/o typhoid fever
  • LP

Management

• Consider ID Consult
• If suspected life-threatening infection
  • Empiric coverage with carbapenem or ceftazidime for possible extended-spectrum beta-lactamase (ESBL)
  • Add doxycycline if suspect scrub typhus (or other rickettsial infection)
• Malaria
  • Treat severe malaria aggressively (organ dysfunction, anemia, electrolyte abnormalities, altered mental status, seizure, coma)
    • IV antimalarials (Quinidine with doxycycline or Artesunate)
  • Consider outpatient treatment if <4% parasitemia and no severe features as above
    • Chloroquine (if sensitive) 600mg base orally immediately, then 300mg base orally 6, 24, 48h (total of 1500mg base)
    • Artemisinin combintation therapy if Chlororoquine-resistant region (eg. Artemether-lumefantrine)
    • Monitor parasitemia with daily blood smears until no parasitemia

Prevention

• Avoid risky behaviours (sex, drugs), exposures (food, insect)
• Update regular vaccines
  • MMR, TdaP, flu, polio
• General travel vaccines
  • Hepatitis A/B
  • Rabies vaccine (adventure trips lasting more than 4 weeks)
• Country specific vaccines
  • Typhoid vaccine (South Asia)
  • Meningitis vaccine (Meningitis belt, Hajj)
  • Yellow fever vaccine (African, South American countries)
    • Must be given at designated clinic for official certificate
  • Japanese encephalitis vaccine (Rural Asia)
  • Antimalarials

Travel-associated Medications

Traveler's Diarrhea

• Self-limited (ETEC, campylobacter, salmonella)
• Prevention
  • Hand hygiene, peel, cook, bottled water (exposure to local tap water including ice cubes and uncooked vegetables)
  • ETEC/cholera oral vaccine [Dukoral] (prevents only 1-7%)
  • 2 bismuth subsalicylate tablets 4 times daily (prevents up to 60%)
    • Side effects: Black tongue, black stools, tinnitus, constipation
• Treatment
  • Fluid replacement +/- oral rehydration salts
  • Loperamide 4mg, then 2mg after each loose stool, max 16mg/d (stop if abdominal pain, persistent or worsening diarrhea)
  • Consider antibiotics if severe (> four unformed stools daily, fever, or blood, pus, or mucus in the stool) or high risk (child, pregnant, elderly)
    • Ciprofloxacin 500mg PO BID x 3 days
    • Azithromycin 1000mg PO x 1 in children, pregnant women, or travellers to Asia (resistance to fluoroquinolones)
      • Note: Risk of Hemolytic Uremic Syndrome in EHEC, especially in children with bloody diarrhea
  • If >10-14d, stool culture and O+P should be done for targeted therapy
• Complications
  • Post-infectious IBS (5%)
  • Reactive arthritis, Guillain-Barre syndrome (rare)

Altitude Sickness

• Gradual ascent is the surest and safest method of preventing or ameliorating symptoms
• In acute mountain sickness (above 2000m)
  • Consider symptomatic treatment (analgesic, antiemetic)
  • Consider prophylaxis, Acetazolamide 125mg PO q12h
• In High Altitude Cerebral Edema (encephalopathy and ataxia, usually above 4000m) consider immediate descent, dexamethasone and oxygen

Motion Sickness

• Nonvertiginous sense of dizziness, nausea, belching, malaise
• Treatment
  • Visual cues congruous with vestibular cues (eg. view the horizon from the deck of a ship)
  • Lying supine
  • Ginger, acupressure
  • Anticholinergic medication (care in elderly or risk of angle closure glaucoma)
    • Dimenhydrinate, diphenhydramine, transdermal scopolamine (patch 72h)

Counselling

• Refer to Travel clinic 4-6w prior to travel
  • Vaccinations may include HAV, HBV, Influenza, Measles, Polio, Rabies, Yellow Fever, Japanese Encephalitis
  • Malaria prophylaxis eg. Malarone daily 1-2 days prior until 1w after travel
• Ensure adequate medications and prescription
• Counselling on prevention of disease (mosquito bite prevention, safe sex)

Basic First Aid

• Adhesive bandages (multiple sizes) and adhesive tape
• Alcohol-based hand sanitizer
• Antiseptic wound cleanser (for example, alcohol or iodine pads)
• Blister pads or moleskin
• Disposable latex or vinyl gloves
• Gauze
• Packets of oral rehydration salts
• Safety pins and scissors
• Tensor bandages for sprains
• Thermometer
• Tweezers for removing ticks, splinters etc...

Medications

• Any prescription or over-the-counter medication you normally use
• 1% hydrocortisone cream to treat minor skin irritation, such as itching caused by bug bites or poison ivy
• Allergy medication, such as an antihistamine, or epinephrine prescribed by your doctor, such as an Epinephrine auto-injector (EpiPen®)
• Anti-diarrheal medication
• Anti-motion sickness medication
• Antifungal and antibacterial ointments or creams to apply to wounds to prevent infection.
• Pain and fever medication, such as acetylsalicylic acid (Aspirin), ibuprofen (Advil), or acetaminophen (Tylenol)
• Stomach and intestinal medication, such as antacids and laxatives
• If recommended, destination-specific medication, like those for malaria or high-altitude sickness
• If you need to use needles or syringes, take more than enough to last for your entire trip and carry a medical certificate from your health care provider explaining that the needles or syringes are for medical use.

Other items

• Mosquito net
• Water purification filter or tablets
• Adequate supply of condoms
• Ear plugs to reduce noise or stop contaminated water from entering the ear canal
• Extra pair of glasses or contacts (or a copy of your prescription)
• Sunscreen
• Insect repellent containing DEET or Icaridin

Contact card

• Name, address, phone number of emergency contact person
• Travel health insurance provider information