Montezuma s Revenge and Other Woes of Traveling Catherine

Montezuma’s Revenge and Other Woes of Traveling Catherine M. Bettcher, M. D. CME Director & Assistant Professor, Department of Family Medicine, University of Michigan

Learning Objectives l l l Determine appropriate destination-specific vaccinations prior to travel Understand how to provide malaria chemoprophylaxis Implement strategies to prevent and manage traveler’s diarrhea http: //travel. state. gov/ http: //www. who. int/ith/en

Immunizations l l l Update routine vaccinations Search for recommended vaccinations for the specific destination Go to www. cdc. gov/travel

Hepatitis A Vaccine l l Consider for all travelers Indicated for travelers to destinations with poor sanitation Single dose provides protection in 14 -28 days Lifelong immunity with completed vaccine series

Typhoid Fever Vaccine l Indicated for travelers to endemic areas in Central and South America, Asia, and Africa

Other Vaccines l l Give one additional polio dose for travel to certain countries in Asia and Africa Yellow fever vaccine required for endemic areas in Africa and South America Give meningococcal vaccine for travel to countries with frequent epidemics Assess need for vaccinations against rabies and Japanese encephalitis

Malaria l l Severe disease among travelers Most cases are preventable Risk depends on geographic area, type of accommodations, season, and elevation http: //www. cdc. gov/malaria/map/

Prevention of Mosquito Bites l l l Wear light colored clothing with long pants and sleeves Apply repellent Sleep under netting Apply permethrin to clothing and tents Stay indoors between dusk and dawn

Repellents l DEET (4 -30%) – – – l Picaridin (7 -20%) – l Higher formulations offer longer lasting protection Avoid in infants < 2 months Avoid combinations with sunscreen Odorless, non-sticky, non-greasy PMD/eucalyptus plant extract (10, 65%) – Avoid in children < 3 years

Malaria Chemoprophylaxis l l l Take antimalarial prior to, during, and after travel Check chloroquine resistance in the destination Consider contraindications to particular antimalarials

Antimalarial Drugs Medication Dose Positives Contraindications Atovaquoneproguanil (Malarone) 1 tab daily; begin 1 -2 d before travel, continue for 7 d after return Good for lastminute travelers, Well-tolerated Renal insufficiency, pregnancy Mefloquine 1 tab weekly; begin 2 wks before travel, continue for 4 wks after return Safe in pregnancy History of seizures, psychiatric conditions Doxycycline 100 mg daily; begin 1 -2 d before travel, continue for 4 wks after return Good for lastminute travelers, Inexpensive Pregnancy and young children, sun sensitivity Chloroquine 500 mg weekly; begin 1 -2 Safe in wks before travel, continue pregnancy for 4 wks after return Resistant areas

Definition of Traveler’s Diarrhea l l l 3 or more unformed stools in 24 hours May have low grade fever, N/V, cramping Occurs in people traveling outside of their homeland

Risk Areas

Other Risk Factors l l l Younger age Self organized activities Backpacking Not staying in hotels Not staying with friends and family

Causes of Traveler’s Diarrhea l l l Mainly bacteria, like E. coli (and Campylobacter, Shigella, and Salmonella) Less commonly viruses (rotavirus and norovirus) Rarely parasites (Giardia and Cryptosporidium), except in long term travelers

Diagnosis of Diarrhea l l l No need to identify pathogen Send a stool culture if fever or blood in stools Send O&P and tests for Giardia and Cryptosporidium if diarrhea persists for 10 -14 days

Treatment of Diarrhea l l Traveler self treats based on the symptoms Usually resolves with hydration alone Take bismuth subsalicyclate or loperamide as needed Start antibiotic if moderate to severe diarrhea

Drug Treatment l l Short course of an antibiotic shortens the duration and severity of diarrhea Give travelers a prescription to take if needed Fluoroquinolone indicated as first line Azithromycin needed for travelers to Southeast Asia because of resistant Campylobacter

Treatment Options Medication Dose Ciprofloxacin 500 mg po bid for up to 3 days Norfloxacin 400 mg po bid for up to 3 days Ofloxacin 200 mg po bid for up to 3 days Levofloxacin 500 mg po daily for up to 3 days Azithromycin 1000 mg po once* Rifaximin 200 mg po tid for up to 3 days *preferred for children

Patient Advice l l l Wash hands with soap and water Wash cooking utensils with soapy water Disinfect water if camping Drink bottled water, soft drinks without ice Eat hot, thoroughly cooked foods Peel fruits and vegetables

Prevention of Diarrhea l l Choose food and drinks wisely Taking bismuth subsalicyclate provides 65% protection – l l l Dose: 2 oz or 2 tabs po qid during travel Do not use prophylactic antibiotics No evidence for probiotics No effective vaccine

Take Home Points l l l Update immunizations Prescribe malarial chemoprophylaxis Eat carefully and take bismuth subsalicyclate No medication needed for diarrhea, but one dose of antibiotic usually works Go to CDC and AAFP website

References l l l l Bazemore A, Huntington M. The pretravel consultation. Am Fam Phys 2009 Sep 15; 80(6): 583 -90. Boulware DR. Influence of hygiene on gastrointestinal illness among wilderness backpackers. J Travel Med. 2004 Jan-Feb; 11(1): 27 -33. Hill DR, Ericsson CD, Pearson RD, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006 Dec 15; 43(12): 1499 -539 Di. Cesare D, Du. Pont HL, Mathewson JJ, et al. A double blind, randomized, placebo-controlled study of SP-303 (Provir) in the symptomatic treatment of acute diarrhea among travelers to Jamaica and Mexico. Am J Gastroenterol. 2002 Oct; 97(10): 2585 -8. Du. Pont HL, Jiang ZD, Okhuysen PC, et al. A randomized, double-blind, placebo-controlled trial of rifaximin to prevent travelers' diarrhea. Ann Intern Med 2005; 142: 805 -12. Gascón J. Epidemiology, etiology and pathophysiology of traveler's diarrhea. Digestion 2006; 73 Suppl 1: 102 -8. Johnson BA, Kalra MG. Prevention of malaria in travelers. Am Fam Phys 2012 May 15; 85(10): 973 -7.

References l l l Okhuysen PC, Jiang ZD, Carlin L, Forbes C, Du. Pont HL. Post-diarrhea chronic intestinal symptoms and irritable bowel syndrome in North American travelers to Mexico. Am J Gastroenterol 2004 Sep; 99(9): 1774 -8. Pakyz AL. Rifaximin: a new treatment for travelers' diarrhea. Ann Pharmacother 2005 Feb; 39(2): 284 -9. Redman CA, Maclennan A, Wilson E, Walker E. Diarrhea and respiratory symptoms among travelers to Asia, Africa, and South and Central America from Scotland. J Travel Med. 2006 Jul-Aug; 13(4): 203 -11. Riddle MS, Sanders JW, Putnam SD, Tribble DR. Incidence, etiology, and impact of diarrhea among long-term travelers (US military and similar populations): a systemic review. Am J Trop Med Hyg 2005 Feb; 74: 891 -900. Sazawal S, Hiremath G, Dhingra U, Malik P, Deb S, Black RE. Efficacy of probiotics in prevention of acute diarrhea: A meta-analysis of masked, randomized, placebo-controlled trials. Lancet Infect Dis 2006; 6: 374 -382. Steffen R, Hill DR, Du. Pont HL. Traveler’s diarrhea: a clinical review. JAMA 2015 Jan; 313(1): 71 -80.