MCQs in Travel Medicine PDF 2013

MCQs in Travel Medicine MCQs in Travel Medicine Dom Colbert MD, BSc, FRCSI, CTHTM , FFTM (Glasg), FCS (ECSA) Department of International Health and Tropical Medicine, Royal College of Surgeons, Ireland, Travel Medicine Society of Ireland, College of Surgeons of East, Central and Southern Africa, Nat...

MCQs in Travel Medicine MCQs in Travel Medicine Dom Colbert MD, BSc, FRCSI, CTHTM , FFTM (Glasg), FCS (ECSA) Department of International Health and Tropical Medicine, Royal College of Surgeons, Ireland, Travel Medicine Society of Ireland, College of Surgeons of East, Central and Southern Africa, National University of Ireland, Galway Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press, 2013 The moral rights of the authors have been asserted All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer British Library Cataloguing in Publication Data Data available ISBN 978-0-19-966452-8 Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the nonpregnant adult who is not breastfeeding. DEDICATION For a new generation of travellers, my grandchildren, Dominic, Gino, Conor, Lily, Patrick, Danielle, Robert, Helena The Author’s royalties from this book are donated to AboutFace, a UKbased organization of volunteer surgeons, who care for and correct facial deformities whatever the cause in those who cannot afford it. PREFACE Travel health has expanded enormously in recent times, with over 2 billion people on the move every year. Such an expansion has brought on medical problems on a scale never before encountered, but which are now a daily challenge. Thus we are faced with preparing people of all ages, and sometimes those with indifferent health, to travel to places where strange and exotic diseases exist. Equally we are faced with the problems they bring back home. In addition to this, globalization has brought massive demographic changes, particularly in developed countries, so that ‘new’ populations and ‘new’ diseases, many of which were previously unheard of, are present at our clinics and hospitals. All this is compounded by global warming, which is allowing a variety of tropical diseases, in particular arthropod-borne diseases such as West Nile fever and dengue fever, to creep north and south from the equator into Europe, Asia, the USA, and Australia. This book addresses these problems in a practical way by challenging the reader over a wide range of topics. It encompasses the whole range of travel medicine from simple entomology to problems found in the returned traveller. Although I set out to write a short MCQ book for those preparing for exams in travel medicine, I finished by writing a small textbook of travel medicine in MCQ format. Because of this I hope the book will be of value to anyone working in travel medicine whether doctor, nurse, pharmacist, or interested healthcare worker. I also had in mind those who are responsible for the health of our growing immigrant population or who plan to work overseas, especially in the tropics. The book is designed to be easy to use. It contains almost 800 questions, each with four options as answers, only one of which is correct or is considered the best. The detailed explanations are meant to teach and challenge the reader, who is finally asked to do a self-test in chapter 19. I recognize that everyone in health care is extremely busy and has little time to spare for professional reading. However, it is my hope that the division of this book into many sub-sections will allow for a pick-up, put-down approach, in which even a 10-minute session will be beneficial. Most of all, I hope the reader will enjoy this work and share some of the excitement and thrill of exploring a fascinating and expanding field of medicine. As ever I am happy to receive and incorporate constructive comments, suggestions, and corrections from any reader. I acknowledge the patience of my wife Doreen, who has endured the neverending vagaries of a doctor’s life. I also acknowledge the professional advice of Nicola Wilson and Caroline Smith from OUP and the painstaking editorial direction of Dr Lesley Montford from Anglosphere Editing. In a special way I am indebted to my friend and distinguished colleague Dr Gerard Flaherty of the Galway Medical School, who has been so generous with his time and so sound in his advice. Dom Colbert Galway 2012 CONTENTS Abbreviations 1 Setting up a travel clinic 2 Epidemiological and geographical considerations 3 Selected arthropods 4 Common gastrointestinal worms 5 Vaccines General vaccinology Specific vaccines 6 Pre-travel consultation General Specific 7 Protecting the skin Skin and sun Insect repellents 8 Special groups Pregnancy Children The elderly Diabetics Asplenics Last-minute travellers Corporate and frequent travellers Urban versus rural holidays Missionaries and expatriates Pilgrims and mass gatherings Visiting friends and relatives Disabled travellers 9 Adventure travellers General Potable water Rafting Climate extremes Snakes and scorpions Marine envenomations and injuries War zones 10 Special activities Swimming Diving Mountain climbing 11 Fish hazards 12 Air travel General Deep venous thrombosis (DVT) Air quality Contraindications Miscellaneous Jet lag 13 Medical care overseas Accessibility and quality Medical evacuation 14 Specific medical risks for the traveller Travellers’ diarrhoea Prevention of TD Probiotics, prebiotics, and TD Skin infestations and infections Moving subcutaneous skin lesions Malaria Rapid diagnostic tests (RDTs) Retrospective diagnosis of malaria Filariasis Sexually transmitted infections (STIs) Motion sickness 15 Selected medical risks in the tropics Dengue fever Enteric fever Miscellaneous 16 The returned traveller 17 Psychiatric and behavioural problems 18 Drugs and travel Antimalarials Drugs in travellers’ diarrhoea Miscellaneous 19 Self-test Appendix: Aide mémoire chart for Leishmaniasis, Trypanosomiasis, and Filariasis Index ABBREVIATIONS ACT artemisinin combined treatment ADE antibody-dependent enhancement AGE arterial gas embolism AMS acute mountain sickness anti-HBcAg anti-hepatitis B core antigen anti-HBs hepatitis B surface antibody AP atovaquone 250 mg/proguanil 100 mg ARI acute respiratory infection ART anti-retroviral therapy AS acute strongyloidosis ATBF African tick bite fever BCG Bacille Calmette-Guerin BCR benefit-cost ratio BSS bismuth subsalicylate BTI Bacillus thuringiensis Israeli CABG coronary artery bypass graft CAP community-acquired pneumonia CBF cerebral blood flow CCF chronic congestive heart failure CDC Centres for Disease Control and Prevention CFS chronic fatigue syndrome CFU colony-forming unit CL cutaneous leishmaniasis CLM Cutaneous larva migrans CNS central nervous system CPRV chromatographically purified rabies vaccine CRFM chloroquine-resistant falciparum malaria CRP C reactive protein CSF cerebrospinal fluid CVA cerebrovascular accident CXR chest X-ray DC dendritic cells DEAC diffusely enteroadherent E. coli DEC diethylcarbamazine DEET diethyltoluamide DHA dihydroartemisinin DHF dengue haemorrhagic fever DOTS directly observed therapy strategy DV dengue virus DVT deep venous thrombosis ECS environmental control systems EHEC enterohaemorrhagic E. coli EIEC enteroinvasive E. coli EM eosinophilic meningitis ENL erythema nodosum leprosum ES exposure to symptoms ESR erythrocyte sedimentation rate ETEC enterotoxigenic E. coli FQ fluoroquinolones G6PD glucose 6-phosphate dehydrogenase GCS graduated compression stockings HAART highly active anti-retroviral treatment HACE high-altitude cerebral oedema HAPE high-altitude pulmonary oedema HAT human African trypanosomiasis HAV hepatitis A virus HBV hepatitis B virus HBeAg hepatitis B e-antigen HBsAg hepatitis B surface antigen HCT hypoxic challenge test HDCV human diploid cell vaccine HEPA high-efficiency particle air filtration HIG modern human immunoglobulin HUS haemolytic uremic syndrome HRP-2 histidine-rich protein-2 antigen ICP intracranial pressure ICT immunochromatography ID intradermal IFAT indirect immunofluorescence antibody test ILI influenza-like illness IM intramuscular INH isoniazid IPV inactivated parenteral polio vaccine ISTM International Society of Travel Medicine KCV killed cholera vaccine LF lymphatic filariasis MCV4 meningococcal conjugate vaccine MDRTB multidrug-resistant TB MI myocardial infarction ML mucocutaneous leishmaniasis MS multiple sclerosis MVA motor vehicle accident MVP mitral valve prolapse NCC neurocysticercosis NNT number of persons needed to treat NPP neuropsychiatric problems NWCL New World cutaneous leishmaniasis OC oral contraceptive OCP Oncocerciasis Control Program OCV oral cholera vaccine OPSS overwhelming post-splenectomy sepsis OPV oral poliomyelitis vaccine ORS oral rehydration solution OTC over the counter OWCL Old World cutaneous leishmaniasis PABA para-aminobenzoic acid PAM primary amoebic meningoencephalitis PaO2 pressure of oxygen in arterial blood PCEV purified chick embryo vaccine PCR polymerase chain reaction PDEV purified duck embryo vaccine PEP post-exposure prophylaxis PKDL post Kala-azar dermal leishmaniasis pLDH plasmodium lactate dehydrogenase PoEP post-exposure prophylaxis POPS pulmonary overpressurization syndrome PPD purified protein derivative PQP piperaquine PreEp pre-exposure prophylaxis PTS post-traumatic stress PUO pyrexia of unknown origin PVRV purified vero cell rabies vaccine PZQ praziquantel REAO rapid epidemiological assessment for onchocerciasis RDT rapid diagnostic test RIG rabies immune globulin RRR reporting rate ratio SADS sudden adult death syndrome SAT serum agglutination test SBET standby emergency treatment SC subcutaneous SCUBA self-contained underwater breathing apparatus SIDS sudden infant death syndrome SPF skin protection factor SR slow release STEC shiga-toxin-producing E. coli STI sexually transmitted infection TD travellers’ diarrhoea TMP-SMX trimethoprim-sulfamethoxazole TNF-α tumour necrosis factor-α TOCP tri-ortho-cresylphosphate TPE tropical pulmonary eosinophilia TQS tetanus quick sticks TT tuberculin test URI upper respiratory infection UV ultraviolet VAPP vaccine-associated paralytic poliomyelitis VFRs visiting friends and relatives VHF viral haemorrhagic fever VGIG varicella zoster immune globulin Vi parenteral typhoid vaccine VL visceral leishmaniasis VOCs volatile organic compounds VTE venous thromboembolism WHO World Health Organization WNV West Nile virus YFVA-ND yellow fever vaccine-associated neurotropic disease YFVA-VD yellow fever vaccine-associated viscerotropic disease chapter 1 SETTING UP A TRAVEL CLINIC QUESTIONS Setting up a travel medical service involves time, money, patience, and continual updating of information. Ultimately such a service cannot be viable unless there is a sufficient throughput of patients to warrant its existence. It is likely that in a multipractice clinic one practitioner will be very interested in travel medicine. Other members of the group should refer all travellers to him or her. In many countries, particularly in the UK, the practice nurse is the one who does most pre-travel consultations. However, this should be a shared responsibility between nurse and doctor so that maximum benefit is provided for both the patient and the clinic. 1. General considerations about travel clinics A. Most general practices are suitably prepared to run a travel clinic service B. A refrigerator dedicated solely to vaccine storage is a most important physical item in a travel clinic C. More than 20 patients per week are needed to warrant setting up a travel clinic D. At least two people, e.g. doctor and nurse, are needed to run a travel clinic 2. Which of the following do you consider to be the most important thing for the travel medical practitioner to have? A. Membership of a travel medical society B. Access to internet services C. A textbook of travel medicine D. A textbook of tropical medicine 3. Which of the following is the most important thing for a travel clinic to do? A. Keep permanent medical records B. Have all travel-related vaccines available C. Be familiar with the destination of the traveller D. Provide a pre-consultation form detailing all facts relevant to a particular traveller and the proposed itinerary 4. Which of these would you consider to be the most common problem when managing a travel clinic? A. Out-of-date vaccines B. Adverse reactions to vaccines C. The traveller dictating which vaccines are needed for his or her travel D. Insufficient time to give to individual travellers chapter 1 SETTING UP A TRAVEL CLINIC ANSWERS 1. B. This is the preferred option from the above. A vaccine-dedicated fridge is essential, with the temperature kept between 2 and 8°C, ideally at 5°C. A maximum/minimum thermometer should be used to monitor this. Vaccines should not be stored in the door compartments. Where vaccines are freeze-stored, e.g. varicella in North America, the temperature should be kept around −200°C. Records of vaccines stored and their expiry dates should be meticulously kept. Most family practices are not suitable to set themselves up as specialist travel clinics unless the expertise of those running them, the equipment needed, and the throughput of patients is satisfactory. While the majority of practices deal with fewer than 20 travellers per week, many consider that 10 per week is the minimum needed to warrant such a practice. 2. B. All of the above are important, but internet access to the best current medical practice in travel medicine is essential. There are numerous sites that provide this information and also give reports of current outbreaks of disease overseas. Everyone has free access to the WHO and CDC sites but there are other excellent sites dedicated to travel medicine for which a fee is payable, e.g. Travax. Lists of these sites are readily available from any local society, from the International Society of Travel Medicine (ISTM.org) or can be found in any textbook of travel medicine. 3. A. Retention of permanent records is essential. Such records will contain travellers’ itineraries, activities, medical history, immunization history, and subsequent follow-up. Keeping records in this way allows information to be transmitted years later to the subject or to other healthcare providers in other locations or in other countries. It is also necessary for insurance purposes should the need arise. Clearly the other options listed are important but not essential. 4. D. Each pre-travel consultation takes time, patience, and space. It takes a minimum of 20 minutes to complete an average consultation and much longer depending on the patient’s age, health status, intended activities, length of trip, time of year and location of the proposed travel. In addition to the other options listed the following present problems: last-minute consultations, phone calls for advice, need for up-to-date information for clinic personnel, conflicting advice from different sources, cost of vaccines (especially for family groups visiting friends and relatives), language difficulties, and vague itineraries. chapter 2 EPIDEMIOLOGICAL AND GEOGRAPHICAL CONSIDERATIONS QUESTIONS It is useful to have a good knowledge of geography and to have at least a globe or atlas in the clinic so that the patient can point out a planned itinerary. Appropriate internet facilities must be available so that information on local diseases, current outbreaks, and required immunizations can be accessed speedily. 1. Which of the following infects the largest number of people worldwide? A. Schistosomiasis B. Trypanosomiasis C. Amoebiasis D. Filariasis 2. The likelihood of a traveller becoming ill is greatest in A. India B. Thailand C. South Africa D. Argentina 3. Which of these species is the most common cause of clinical disease worldwide? A. Brucella abortus B. Brucella melitensis C. Brucella suis D. Brucella canis 4. Mortality from malaria has only been documented in A. P. falciparum, P. malariae, and P. knowlesi infections B. P. falciparum and P. vivax infections C. P. falciparum and P. ovale infections D. All five types 5. Lassa fever is named after a town in A. Nigeria B. South Africa C. China D. South America 6. Which species of malaria is confined almost exclusively to West Africa? A. P. falciparum B. P. malaria C. P. ovale D. P. vivax 7. Endemic falciparum malaria is still found in A. The Dominican Republic B. Taiwan C. Brunei D. The Maldives 8. Plasmodium knowlesi A. Is indistinguishable microscopically from P. falciparum B. Is almost always clinically similar to a P. falciparum infection C. Responds well to chloroquine D. Is most common in West Africa 9. The incidence of typhoid fever is highest in A. India B. Mexico C. Indonesia D. Mozambique 10. The infective dose of S. typhi is estimated at A. One organism B. 1000 organisms C. 100,000 organisms D. More than a million organisms 11. To eliminate the risk from ingested S. typhi A. Heat water and food to 60°C B. Keep food in the deep freeze (–21°C) C. Store all meat and dairy products in the fridge D. Treat all sewage in accordance with current regulations 12. S. typhi is most often spread to travellers apart from those visiting friends and relatives (VFRs) by A. Droplet infection B. Carriage by flies to food C. Carriage in faeces of small mammals D. Consumption of duck eggs 13. The risk of contracting falciparum malaria is greatest A. On the Kenyan coast B. In Kinshasa C. In the island resorts off Thailand D. In Nairobi 14. Cholera is still officially reported in A. Fewer than five countries B. Fewer than 10 countries C. Fewer than 20 countries D. Fewer than 100 countries 15. The most common way travellers contract leptospirosis is from A. White-water river rafting B. Ingesting leptospiral-contaminated food C. Contact with farm animals D. Hotel swimming pools 16. The most common cause of febrile jaundice in the traveller is A. Malaria B. Dengue fever C. Acute viral hepatitis D. Leptospirosis (Weil’s disease) 17. Where is the traveller most likely to contract African tick bite fever (ATBF)? A. Southern Africa B. Kenya C. Ethiopia D. West Africa 18. Apart from the required immunizations and advice, anyone planning to go on daytime safaris in Tanzania, Kenya, or Uganda should be specifically warned of the danger of contracting A. Yellow fever B. Malaria C. Human African trypanosomiasis (HAT) D. Pulmonary histoplasmosis 19. Which of the following is associated with being bitten mainly during the darker hours? A. Yellow fever B. Dengue fever C. African trypanosomiasis (sleeping sickness) D. American trypanosomiasis (Chagas disease) 20. Match the vector with the disease. Vector options may be used once, more than once, or not at all A. Malaria 1. Sandflies B. Yellow fever 2. Mosquito C. Leishmania 3. Tsetse fly D. Loa loa 4. Flea E. Dengue fever 5. Red fly (chrysops fly) F. Onchocerciasis 6. Black fly (Simulium damnosum) 21. Make the best matches for the following locations using options once, more than once, or not at all. A. South-East Asia 1. Giardiasis B. Nepal 2. Espundia C. South America 3. Altitude sickness D. Russia 4. Campylobacter 22. The most common cause of sore throat in the long-term visitor to tropical and subtropical regions is A. Viral or bacterial pharyngitis (as found in temperate climates) B. Diphtheria C. Acute HIV D. One of the viral hemorrhagic fevers 23. Chlorination as used widely in swimming pools fails to destroy A. S. typhi B. Rotavirus C. Giardial cysts D. E. coli 24. Match the diseases listed with the vectors that carry them. Options may be used once, more than once, or not at all A. Typhus 1. Mosquitoes B. Cutaneous 2. Ticks leishmaniasis C. West Nile fever 3. Fleas D. Hantavirus 4. Sandflies 25. Match the diseases listed with the vectors that carry them. Options may be used once, more than once, or not at all A. Lyme disease 1. Mosquito B. Schistosomiasis 2. Black fly C. River blindness 3. Ticks D. Rabies 4. Aquatic snails 5. Bats 26. Match the diseases listed with the vectors that carry them. Options may be used once, more than once, or not at all A. Relapsing 1. Lice fever (borreliosis) B. Chagas disease 2. Mosquitoes C. Yellow fever 3. Triatomine bugs D. Dengue fever 4. Ticks 27. Which causes the greatest number of deaths in humans? A. Sharks B. Crocodiles C. Venomous snakes D. Lions 28. Bear attacks have been reported from A. Morocco B. Nepal C. Australia D. Argentina 29. Which of these conditions is most common in urban areas?