Infectious Disease & Travel Medicine PDF Fall 2024

Infectious Disease & Travel Medicine Rachel Elbing PA-C, MPH Augsburg Physician Assistant Program Fall 2024 Objectives Special Topics in ID and Travel Medicine 1. Formulate questions for an appropriate history, ROS and physical exam in a patient presenting for a pre-travel h...

Infectious Disease & Travel Medicine Rachel Elbing PA-C, MPH Augsburg Physician Assistant Program Fall 2024 Objectives Special Topics in ID and Travel Medicine 1. Formulate questions for an appropriate history, ROS and physical exam in a patient presenting for a pre-travel health visit and in a patient with a fever following travel. 2. Compare and contrast the signs and symptoms of malaria, dengue, typhoid fever, Zika and Ebola. 3. Develop a differential diagnosis list for a patient presenting with a fever in a returned traveler. 4. Develop an evidence-based plan for a pre-travel health visit utilizing clinical tools such as the Center for Disease Control and Preventions Yellowbook including immunizations, chemoprophylaxis, and preventive health guidance. 5. Develop an evidence-based diagnostic and treatment plan for a patient presenting with fever following travel.  Travel Medicine Pre-Travel Health Fever in returned traveler Where to? Good H&P Purpose? ○ Location of travel ○ Timing of illness Patient and trip specific Exam Components details Diagnostics and Treatment  Travel Health 23yo female who plans to travel to Belize for PA rotation She is otherwise healthy Will be working at health clinically and remotely in Mayan villages Immunizations are UTD for PA school What else should be included?  Timing of pre-travel visit At least one month before leaving! ○ Takes time for certain vaccinations to be effective Vaccines, medicines, and other travel information/recommendations Travel Health - Pre-Travel Health Visit History - patient specific History - trip specific ○ PMH (chronic illness, allergies, ○ Where to? Dates, Duration, stop-overs age, immunocompromised) Consider season ○ Pregnancy, breastfeeding, ○ Purpose? preconception Business, tourism, humanitarian, ○ Medication use sexual ○ Vaccination history ○ Accomodations? ○ Allergies Hotel, camping ○ Styles of travel ○ Prior travel experience Rural vs urban ○ Risk taking behavior Luxury vs budget Transportation plans Health concerns when traveling? Accidents - leading cause of death in tourists Infectious disease ○ Diarrhea, URI, febrile illness, STIs Constipation Mental Health Underlying health conditions - cardiovascular disease Travel Recommendations: Non-vaccine preventable Dz Food Safe driving Fluids Swimming Flies Sun Sex Stress Travel Recommendations: Immunizations and chemoprophylaxis Malaria Polio Typhoid Hepatitis A/B Yellow Fever Meningitis Rabies Chickenpox, Shingles Cholera Influenza Diphtheria, Tetanus, Pertussis MMR Covid-19 Resources for you and your patients STEP (US State Department’s Smart Traveler Enrollment Program) ○ https://step.state.gov/ ○ Free service ○ Important safety information in destination and helps U.S. Embassy contact in emergency CDC Travelers’ Health Website ○ https://wwwnc.cdc.gov/travel Health information for International Travel ○ CDC “Yellow Book” ○ https://wwwnc.cdc.gov/travel/yellowbook/2024/table-of-contents  Application… 23yo female who plans to travel to Belize for PA rotation She is otherwise healthy Will be working at health clinically and remotely in Mayan villages Immunizations are UTD for PA school What else should be included?  Application… What if they were traveling to Uganda?  Fever AFTER travel 35yo female presenting with fevers, body aches, myalgias What questions would you have for her? Travel Health: Fever after travel HPI ○ Timing ○ Location of travel ○ Other sick contacts? ○ Food/Water ingestion ○ Bug prevention strategies used ○ Sexual history PMH ○ Prior vaccinations; chemoprophylaxis and adherence ○ Medications: Herbal meds ○ Chronic medical conditions ROS Physical Exam https://wwwnc.cdc.gov/travel/yellowbook/2024/posttravel-evaluation/general-approach-to- the-returned-traveler#6247 Definitions: Incubation: period between exposure to infection and appearance of first symptoms Immunoglobulins: Antibodies made to virus ○ IgM: Produced as body’s first response to new infection. Short term protection ○ IgG: Rise a few weeks after infection, then decrease and stabilize. Long-term protection ○ IgA: Also found in saliva, tears, respiratory and gastric secretions, breast milk ○ IgE: Associated with allergies, allergic disease, and parasitic infections Host: Animal or plant that acts as biologic refuse in which another organism may dwell (often parasitic infection) Vector: Living organisms that transmit infectious diseases between humans or from animal to human Infectious Diseases Other Systemic Viral Infections Zika Viral Hemorrhagic fevers Chikungunya Colorado Tick Fever Ebola Dengue Lassa fever Hantaviruses Yellow fever Protozoal Infections Malaria Gram Negative Bacteria African Trypanosomiasis American Trypanosomiasis Enteric Fever (Typhoid (Chagas) Fever) Leishmaniasis Cholera Shigellosis Campylobacter Plague Ebola: Overview Single stranded RNA virus - Filoviridae family (filament-shaped viruses) Transmission: Mucous membranes, non-intact skin, sexual intercourse, breast feeding or needlesticks Reservoir: Fruit Bats? Incubation: 2-21 days; not transmissible prior to symptoms Rare but severe illness in humans and often fatal  Ebola - Presentation Early stage: nonspecific febrile illness ○ Fever, headaches, weakness, malaise, joint pains Late stage: severe GI sx, then neurologic sx, and hypovolemic shock ○ 3-5 days after onset ○ N/V/D ○ Encephalitis - confusion, slowed cognition, atitations, seizures Hypovolemic shock develops in most patients, hemorrhagic manifestation only in 1-5% Respiratory symptoms are uncommon Ebola - Diagnosis and Treatment Diagnosis: Several modalities ○ ELISA, PCR, Virus isolation Repeat if negative and in first 3 days of illness and clinical signs persist Additional lab workup: Filoviruses infect dendritic cells and then hepatocytes and renal cells ○ Low platelets, leukopenia, transaminitis ○ DIC Treatment: Supportive (IV FLUIDS!); monoclonal antibodies Prevention: Droplet & contact precautions, avoid sexual activity or use barrier for 12 months from onset of sx Vaccine: two license vaccines available - specific populations and Ebola species (Zaire spp.)  Dengue: Overview Flavivirus family - 4 different serotypes (1,2,3,4) Transmission: Human to human via mosquito (primarily) Reservoir: Aedes mosquito (same as Zika and Chikungunya) Incubation: 7-10 days  Dengue 2nd overall cause of febrile illness in returned traveler from developing country (excluding common URIs)  Dengue - Presentation Most infected patients are asymptomatic Only 20% of people develop symptoms which can range from… ○ Dengue Fever - Mild disease ○ Dengue shock syndrome - severe hemorrhagic fever to fatal shock Febrile phase: Nonspecific - fever, chills, malaise, severe myalgias & arthralgias ○ Occasionally maculopapular rash, sore throat, conjunctival injection ○ Usually recover by day 8 Severe Dengue: Plasma leakage, hemorrhage, organ involvement ○ More common in poorly controlled diabetics ○ GI bleeding, ecchymosis, epistaxis, myocarditis, hepatitis, encephalitis ○ Shock develops  “Bone-Break Fever” Dengue thrives in poverty, where inadequate drinking water, sanitation, and surface water drainage promote mosquito breeding sites. While most people survive dengue with treatment (see below), the economic consequences can be devastating for those already living precarious lives. Taking time off to recover or to care for a sick child can mean lost wages and no food on the table. And when the disease kills, it doesn’t discriminate, as the death of a Bollywood filmmaker in 2012 drove home. A New Delhi father told Al-Jazeera at the time, “I fear for my children more from a mosquito than any terrorist attack.” - Amy Roeder, Associate Editor of Harvard Public Health - Article “Breaking Breakbone Fever”, discussing strategies for bringing dengue vaccine to countries in need - https://www.hsph.harvard.edu/magazine/magazine_article/breaking-breakbone-fever/ Where did that name come from? East Africa: Disease called Ka dinga pepo. Translated as “a cramp- like seizure caused by an evil spirit” West Indies: “dandy fever”. For the delicate gait observed in people suffering from characteristic muscle and joint pain & stiffness Philadelphia 1789: “Breakbone fever” Also “break heart fever” for fatigue and depression that can linger Dengue - Diagnosis & Treatment IgM and IgG ELISA testing; PCR or detection of specific viral protein Lab tests: ○ Leukopenia, anemia, thrombocytopenia ○ Elevated transaminases Treatment: Supportive care ○ Volume replacement ○ Transfusion ○ Vasopressors Prevention: Control of mosquitoes ○ Screen blood transfusions ○ Vaccination: Approved for children 9-16yo w/ previous h/o dengue and who live in endemic areas  Zika Virus Flavivirus family (same as Dengue) Transmission: Human to human via mosquito Sexual - vaginal, anal or oral Vertical (woman → fetus) Transfusion Reservoir: Aedes aegypti mosquito Incubation: 3-14 days Zika  Zika - Presentation Majority are asymptomatic (50-80%) Acute onset fever, maculopapular pruritic rash, nonpurulent conjunctivitis and arthralgias Commonly mistaken as Dengue or Chikungunya Complications Congenital microcephaly Guillain-Barre syndrome  Zika - Diagnosis and Treatment Viral RNA (nucleic acid testing) in patients with symptoms < 14 days IgM testing if > 14 days Trioplex RT-PCR (Zika, chikungunya, dengue) Screening for pregnant women if travel history supports Treatment: Supportive care Prevention: Environmental ○ No vaccine  Gram Negative Bacteria Typhoid fever “Enteric Enteric Fever (Typhoid Fever) fever” Cholera Shigellosis Campylobacter From of Salmonellosis - S typhi and S paratypi Plague Transmission: fecal-oral route: Organism breach the mucosal epithelium of intestines → replicate in macrophages in “Peyer patches”, mesenteric lymph nodes, and spleen → bacteremia Host: Only lives in humans Incubation: 6-30 days Typhoid fever  Typhoid fever - Presentation Prodromal phase: malaise, HA, cough, sore throat; constipation w/ abd pain 7-10 days → more ill: “Pea soup” diarrhea, abdominal distension Usually gradually improves; can relapse after 2 weeks Exam: ○ Prodrome: few physical findings ○ Later: splenomegaly, abdominal distension & tenderness, relative bradycardia, “Rose spots” Typhoid - Diagnosis and Treatment Often do NOT have leukocytosis - can have leukopenia Blood culture - 1st week of illness more sensitive; stool cultures are NOT as helpful Differential - TB, endocarditis, lymphoma, malaria, viral hepatitis Complications - occur in 30% of untreated cases ○ Intestinal hemorrhage ○ Urinary retention, pneumonia, myocarditis, meningitis Prevention: Vaccine for household contacts of carrier and travel ○ Multiple-dose oral vaccine: 5 year booster needed ○ Parenteral: 2 year booster needed ○ Appropriate waste disposal and protection of food and water supplies Treatment: antibiotics ○ Fluoroquinolones - Ciprofloxacin ○ Ceftriaxone  Malaria - “the most important parasitic disease of humans” Protozoan parasite: 4 (5?) species of the Plasmodium genus P falciparum P vivax P ovale P malariae (P knowlesi) - Monkeys  Malaria Life Cycle Transmitted by bite of infected female mosquito → Injection of sporozoites → liver → infection of hepatocytes (asymptomatic liver infection) → infect erythrocytes → cause disease in humans → some erythrocytic parasites develop in to sexual gametocytes → infect the next mosquito Malaria  Malaria - Presentation Varies by species Intermittent attacks of chills, fever, and sweating Headaches, myalgias, vomiting common Cycles of 48 hour (P vivax and P ovale) or 72 hour (P malariae) Exam: May be normal ○ Signs of anemia - why? ○ Jaundice, splenomegaly, mild hepatomegaly ○ NOT rash or lymphadenopathy - think something different  Malaria - Species specific P falciparum Southeast Asia and sub-saharan Africa In developing world: Severe malaria and deaths often in Risk is greatest w/i 2 months of return from young children travel Cerebral malaria - single Severe malaria: almost always P falciparum severe infection infection ○ Organ dysfunction Severe anemia - multiple ○ High parasite load malarial infections, intestinal ○ Neurologic sx - AMS, seizures, coma helminths, nutritional ○ Severe anemia and/or hemolysis deficiencies ○ Hypotension & shock ○ Pulmonary edema and ARDS ○ Acute kidney injury (AKI)  Malaria - Species specific P vivax & P ovale Longer incubation and can be dormant in liver Longer incubation - weeks to months after travel Not as severe as P falciparum Rotating fevers ~ 48hr cycles Headache, malaise, anorexia, nausea, vomiting, diarrhea, arthralgias, myalgias  Malaria - Diagnosis “Giemsa-stain” blood smears: thick and thin ○ Identifies intraerythrocytic parasites ○ Done at 8 hr intervals for 3 days Rapid diagnostic tests Antibodies persist for ~10yrs (difficulty with new infection) CBC - leukocytosis or leukopenia, anemia, thrombocytopenia Reticulocytosis Liver function abnormalities Malaria - Treatment & Prevention Treatment Prevention ACT = artemisinin–based Clothing, repellant, barriers combination therapies Chemoprophylaxis Non-falciparum: Chloroquine ○ Chloroquine drug of choice ○ Erythrocytic stage ○ Resistance → ACTs Safe in pregnancy Transient GI sx (take w/ P vivax & P ovale food) ○ Add Primaquine (liver stage) ○ Mefloquine if Chl. resistance P falciparum: ACTs, consider ○ Malarone hospitalization ○ Doxycycline ○ Primaquine Severe malaria ○ IV Artesunate ○ HOSPITALIZATION Disease Incubation Transmission Symptoms Diagnostics Treatment Prevention Ebola 2-21 days Mucous Early:febrile illness PCR, ELISA, Supportive Precautions membranes Late: severe GI, neuro virus isolation sx; hypovolemic shock Vaccine in DRC Dengue 7-10 days Aedes Mosquito Asymptomatic Antibody testing Supportive, Environmental Febrile phase: body PCR transfusions, (Mosquito control) aches/stiffness Virus detection pressors Severe dengue: Vaccination for plasma leakage, children in endemic hemorrhage, shock regions Zika 3-14 days Aedes Mosquito Majority asymptomatic Viral RNA Supportive Environmental Fever, rash, IgM (mosquito control) arthralgias PCR **complications Typhoid 6-30 days Fecal-oral route Prodrome viral illness Blood cultures Ceftriaxone, Immunization Human → human Abdominal pain, “pea- early in illness Fluoroquinolone soup”, splenomegaly Environmental (waste water/food) Malaria Variable based Anopheles Cycle of fever Peripheral Antimalarials Antimalarials on species - mosquito P falciparum: severe smear: “Giemsa can be months malaria Smear”