Travel and Tropical

Medicine
Roger Thomas, MD, Ph.D,
CCFP. MRCGP

RISKS of Travel to
Developing Countries
Diarrhea

34%
(ETEC causes 30-60% of these cases)
26%
Respiratory
8%
Skin disorder
6%
Acute mountain sickness
5%
Accident and injury
3%
Illness with fever

Mortality from travel in

developing world
50% is cardiovascular (older travelers

with pre-existing cardiac condition), but

rates are not increased by travel
In younger travelers injuries are main
cause of death: accidental death rate in
15-44 year olds is 2-3 times domestic
rate (MVA, scooters, drowning)

Traffic accidents worldwide

2004
1.7 million deaths, single major cause of

death in males 15-45

> 750 US citizens die, > 25,000 injured
annually on foreign roads, some are
permanent residents abroad, (implying >
75 Canadians and > 2,500 accidents)
30 million injuries
Egypt, Kenya, India, S. Korea, Turkey,
Morocco most dangerous
Advise do not drive at night, especially
rural areas; do not drive motorbike or bike

OUTLINE
1. Take a history

2.
3.
4.
5.
6.
7.
8.

past medical history, medications, vaccinations

planned travel
unplanned excursions and sports
Bring childhood vaccinations up to date (MMR,
polio, tetanus)
Vaccinations and medications needed for trip
Ask their understanding of risks; your advice
Print off CDC data and have them read and
underline it
Malaria: prevention; diagnosis; treatment
Travellers diarrhea: prevention; diagnosis;
treatment
Helminths 9. Other

Lets begin with a 60 year old

going to Peru and Ecuador
PMH: HTN, hyperlipidemia, well
controlled; never smoker
What are his/her travel plans?
Review CDC website cdc.gov
Identify risks and prescribe

60 year old visiting Peru and

Ecuador
Update childhood vaccinations
Check for egg allergy if plan MMR, influenza,

Yellow Fever vaccines

GI risk: cholera? typhoid? Bacterial diarrhea?
Hepatitis? (Twinrix) Helminths?
Yellow Fever?
Malaria risks?
High altitude sickness risks? (he/she is going
to 3,600 meters rapidly by plane, no slow
ascent; risks begin above 2,400 meters)
PE from air travel (5/million)

60 year old visiting Peru and

Ecuador: Other risks?
Helminths such as Amebiasis, echinococcus
American trypanosomiasis (Chagas disease)
Cutaneous and mucocutaneous Leishmaniasis
Paragonimiasis (oriental lung fluke)
Brucellosis
Bartonellosis (Oroya fever) on western slopes
of Andes up to 3000 m
Louseborne typhus in mountainous areas of
Peru

28 year old veterinarian,

visiting Malawi, South Africa,
advising for WHO

PMH: LMP 6 weeks ago, rising HcG

titres, planning to be in Africa during

1st and 2nd trimesters
GI risks?
Malaria risks?
Rabies risks?
Risks to pregnancy?

Live-attenuated vaccines in
pregnancy
MMR and varicella are live-attenuated and

contrandicated in pregnancy because of

theoretical risk to fetus
However, no evidence of harm from inadvertent
rubella vaccination
226 pregnant females 1971- 1989 in US
caused subclinical infection in 1-2% of fetuses,
no evidence of congenital rubella
Motherisk found no evidence of increased
rate of fetal malformations in 94 women
vaccinated with rubella 3 months before
conception or during pregnancy

Live-attenuated vaccines in
pregnancy
No evidence of harm from

inadvertent varicella vaccination

in 362 women vaccinated during
pregnancy, no cases of congenital
varicella

Vaccines in pregnancy
No evidence of increased risk of

adverse reactions, teratogenic or

embryotoxic effects in pregnancy
All classes of maternal IgG transported
across placenta, mostly in 3 rd trimester
maternal IgG has half life of 3-4 weeks
in infant, waning after 6-12 months of
life.
Strong evidence of benefits of vaccines

Canadian Immunization Guide

Advice for pregnancy
Safe
Influenza (good idea as pregnant
women have 4 x hospitalisation rate for
influenza compared to non-pregnant due
to increased CVS volume, HR and O2
consumption)
Diptheria/tetanus
Polysaccharide meningococal vaccine
(no evidence for conjugate vaccine)
Salk poliomyelitis vaccine

Canadian Immunization Guide

Advice for pregnancy
No apparent risk, recommended in women at risk
Hepatitis B
No apparent risk, consider in high-risk situations
Hepatitis A
Pneumococcal polysaccharide
Cholera (no data)
Typhoid (no data)
Pertussis (no data)
Live Japanese encephalitis (no data)
Contraindicated (unless high risk travel unavoidable)
Yellow fever (6/million risk of visceral and 6/million risk
of cerebral complications for all vaccinees)

Malaria
Incubation: for Plasmodium falciparum: 7-14
days (up to 6 weeks)
Partial immunity from long-term residence
is against erythrocytic stages and diminishes
within 6-12 months of leaving endemic area
Clinical presentation: (clinical diagnosis is
inaccurate as malaria is a great imitator;
must do thick and thin films)
Prodrome of tiredness, malaise and aching
in the back, joints and abdomen, anorexia
and nausea and vomiting. Tender
splenomegaly. Conjunctivae suffused. Patient
febrile for 2-3 hours before paroxysm.

Malaria
Cold stage of rigors (15-60 minutes):
sudden feeling of cold and apprehension
pulse rapid and low volume
mild shivering turns into violent teeth
chattering and shaking of the whole body.
Patients try to cover themselves with
bedclothes
core temperature is high but peripheral
vasoconstriction with skin cold and goosepimpled

Malaria
Hot stage up to 104F (2-6 hours): (Ague

attack resembles the endotoxin reactions of

lobar pneumonia or pyelonephritis)
restless, unbearably hot, throws off all the
bedclothes, excited
severe throbbing headache, palpitations,
tachypnea, postural syncope
may vomit
may become confused, convulse
skin dry flushed and burning
splenomegaly may be detected first the first
time in this stage
sweating stage (2-4 hours): temperature
returns to normal and patient sleeps

WHO criteria for Severe malaria

Identify patients with severe malaria
for special treatment with one or
more of:
Cerebral malaria
Respiratory distress
Severe normocytic anemia
Renal failure
Hyperparasitemia
Pulmonary edema
Hypoglycemia
Circulatory collapse
Spontaneous bleeding
Generalised convulsions

Cerebral malaria
(encephalitis)
impairment of consciousness or

generalised convulsion followed by

coma
high fever can cause irritability,
obtundation, psychosis, and febrile
convulsions (children) so urgently
treat impairment of consciousness
may thrash or lie immobile with eyes
open or have dysconjugate gaze

Cerebral malaria
(encephalitis)
brainstem signs:
dolls eyes (in children)
may be decorticate (flexion of
elbows and wrists, supination of the
arm) suggests severe bilateral
damage to the midbrain
may be decerebrate (extension of
wrists and elbows with pronation of
the arms suggests damage to the
midbrain or the caudal diencephalon)

Cerebral malaria
(encephalitis)
children may have subtle convulsions

(nystagmoid eye movements, salivation,

shallow irregular respirations, clonic
movements of an eyebrow, finger, toe or
mouth)
with excellent care mortality is 15-20%;
death within hours for children
respiratory distress (compensation for
metabolic acidosis), laboured breathing,
intercostal recession, nasal flaring, accessory
muscles of respiration)

Malarial Anemia (defined as < 5

g/dl):
children with severe anemia usually
have acidosis (deep Kussmaul
breathing);
malarial anemia kills as many
children as cerebral malaria
(mortality = 5-15%; mortality from
acidosis = 24%; mortality from
severe anemia + acidosis = 35%)
also common in pregnant women

Jaundice and hypoglycemia in

malaria

Jaundice

1/3 of adults; associated with cerebral malaria,

acute pulmonary edema
Hypoglycemia
Anxiety, breathlessness, lightheadedness,
tachycardia, impairment of consciousness,
seizures, abnormal posturing can be
misinterpreted as due only to the malaria
Pregnant women:
cell-mediated immunity is altered to favour
survival of the fetus (more so in primigravidae),
the placenta is heavily parasitized (the parasites
adhere to chondriotin sulphate on the
syncytiotrophoblast) The peripheral blood film
may show no parasites
risk is greatest for primigravidae in areas of
unstable malaria

Chemoprophylaxis of
malaria

Causal prophylaxis: atovaquone and

primaquin act on exo-erythrocytic cycle in

liver
Schizontocides: atovaquone,
mefloquine, chloroquine, doxycycline,
proguanil act on intra-erythrocytic
parasites
Terminal prophyaxis: Primaquine acts
on latent hypnozoites in liver to prevent
relapses in P Ovale and P vivax

Chemoprophylaxis of
malaria

Mefloquine PO (Begin 1 week

before departure, continue 4 weeks

after return)
62.5 mg weekly children 3 months
5
years
125 mg weekly 6-8 years
187.5 mg 9-14 years
250 mg weekly adults

Chemoprophylaxis of malaria
Doxycycline PO 1.5mg/kg daily. Do not

use children < 12 years and pregnant or

lactating women; can begin 2 days before
enter malarious area
Pyrimethamine-dapsone (Malaquine)
PO 1 tablet = 12.5 mg pyrimethamine +
100 mg dapsone
tablet weekly children 1-5 years
1/2 tablet weekly children 6-11 years
1 tablet weekly children >11 years and
adults

Prevention of malaria
Bednets & clothes impregnated with

pyrethroids.
Cochrane review by Gamble (2006) found for
4 RCTs of treated nets vs. no nets a reduction
in relative risks:
RR
95%CI
placental malaria
0.79 0.63 to 0.98
low birth weight
0.77 0.61 to 0.98
Avoid going out at night, wear long sleeves
and long trousers (80% of bites on ankles)
Compliance with medication

Treatment of Malaria
ARTEMISINS (halve parasite

clearance time compared to

quinine, but RCTs do not show
reduction in mortality compared
to quinine)
Uncomplicated disease: artesunate
or artemether by mouth 4mg/kg x 3
days. Give each day in divided doses.
Artesunate suppositories are easy to
use. Use with second drug (e.g.
mefloquine) to prevent recrudescence)

Treatment of Malaria
Severe disease:
Artesunate: 2.4 mg/kg IV or IM; then 1.2
mg/kg IM daily.
To make artesunate: dissolve 60 g in 0.6 ml of
5% NaHCO3,
dilute to 5 ml with 5% dextrose and give IV or
IM.
Artemether: Loading dose 3.2 mg/kg IM then
maintenance 1.6
mg/kg IM. Do not give artemether IV, only
orally, by suppository
or IM. [Complete the therapy with oral
sulfadoxine/pyrimethamine]

Treatment of Malaria
QUININE
Uncomplicated disease: 10m/kg quinine SALT by
mouth three times daily x 7 days. Once parasites
eradicated, change to tetracycline 4mg/kg PO four
times daily OR doxycycline 3mg/kg PO once daily
Severe disease: starting dose: 20mg/kg quinine
SALT IV over 2-4 hours THEN 10mg/kg infused over
2 hours every 8 hours until tolerates oral
medication (sulfadxine/pyrimethamine). [If given
IM, dilute to 60mg/ml and split between sites if
volume exceeds 5ml]
Give IV doses in 500ml of 5% glucose over 4
hours
Reduce rate if cardiac arrhythmias
Pregnant women: quinine is the drug of choice.

Falciparum strains adjust to

antibiotic pressure
Treatment of malaria must take into account

local sensitivity to medications and shifts in

parasite genome due to antibiotic pressure
Zongo (Lancet 2007) showed in children older
than 6 months in a 28 day RCT in Burkina Faso
that risk of recurrent malaria was:
amodiaquine + sulfadoxine-pyrimethamine
1.7% artemether-holofantrine
10.2%

Large family going to Mexico for

daughters wedding. They are worried
about getting travellers diarrhea

Advise on risks, precautions and

treatment

TRAVELERS DIARRHEA:
PREVENTION
1.Hand washing: 30 seconds with soap

2.Boil, cook or peel, eat when piping hot.

Avoid salads, ice cubes, food vendors,

cans cooled in water (probably from a
stream), shellfish, undercooked seafood
However, most travelers commit a food
indiscretion within the first 72 hours due to
being tempted by the sight of snacks, pre-paid
buffets and the unavailability of hot food
Studies of US naval ships abroad showed the
more indiscretions ashore (salads, ice in drinks,
food vendors ) the more were on sick parade
the next day with diarrhea.

TRAVELERS DIARRHEA:
PREVENTION
3. Take a micropore filter. Cryptosporidium
can pass through a 1 micropore filter, so
needs subsequent halogenation
Chlorine is less effective in acid or alkaline
or cool water, so lengthen contact time (2
hours for Giardia, 10 minutes for bacteria).
Resistance to halogenation increases from
bacteria, viruses, protozoan cysts,
bacterial spores to parasitic ova and larvae
4. Potassium Permanganate to wash fruit and
veg
5. Kettle to boil water (boiling for 1 minute
kills even Cryptosporidium

TRAVELERS DIARRHEA:
PREVENTION
6. Pepto-bismol: 2 tablets qid reduces risk by

65% (children > 3 years: 1 tablet qid)

Indications: Prophylactic Pepto-bismol for a
short trip: Consider if immunocompromised, HIV+,
severe inflammatory bowel disease, renal failure,
poorly controlled insulin dependent diabetes. Or of
you are a conference speaker or a musical performer
who must be well at a specific time.
Contraindications:
(a) 2 tablets have the salicylate content of
one 325 mg aspirin, so contraindicated if allergy to
aspirin, bleeding disorder, taking warfarin, history of
GI bleed.
(b) If taking doxycycline: Pepto-bismol inhibits
absorption of doxycycline (an important antimalarial).

TRAVELERS DIARRHEA:
PREVENTION

7. Dukoral cholera vaccine:

provides 60% cross-over protection

against ETEC.
8. Antibiotics: considering sideeffects, best to use antibiotics for
treatment in the case of diarrhea
rather than prophylaxis

DIAGNOSIS of TRAVELLERs
DIARRHEA
On a 3 week trip the indiscreet
traveler is most likely to get diarrhea
in the first week, and will need
guidance about self-treatment.
>60% is bacterial: Most common is
E. Coli, then Shigella, Salmonella,
Campylobacter
Attack rate remains same in longterm travelers and expatriates for
several years

Diagnosis of Travellers Diarrhea by Clinical

Presentation: Watery diarrhea (60%):

Mostly enterotoxigenic E. Coli; also

Salmonella, Campylobacter, Vibrios .

Parasites such as Giardia,
Cryptosporidium, Cyclospora and
Isospora can cause watery diarrhea.
10% is viruses.
Symptoms last 3-5 days and range
from several watery stools per day to
more explosive profuse but non-bloody
diarrhea. Some may have nausea,
cramps, vomiting, low grade fever .

Diagnosis of Travellers Diarrhea by

Clinical Presentation: Dysentery (15%):

Usually Shigella. Other causes: Salmonella,

Campylobacter, Yersinia, E. Coli serotype
0157:H7, more rarely amebiasis.
Symptoms: small volume stools with
mucous, high fever, abdominal pain and
tenderness, prostration, feeling of
incomplete evacuation. Blood seen in only
50% of patients.
Treatment: Treat all bloody diarrhea with
antibiotics; fluids to prevent dehydration.

Diagnosis of Travellers Diarrhea by

Clinical Presentation: Chronic diarrhea,
lasting > 1 month (3-5%):

Usually Giardia or Campylobacter.

In many cases tests are negative and

is attributed to postinfectious lactose
intolerance and IBS.
Symptoms: vague abdominal pain,
bloating, nausea, weight loss, low
grade fever.

Treatment of Diarrhea while

Travelling
1. Oral rehydration
Severe dehydration:. WHO is glucose
based, CeraLyte is rice based. If not
available, make your own with 1 teaspoon
salt and 2 tablespoons sugar or honey in 1
L water. Continue to drink even if vomiting.
Moderate: drink 3 L water/day, add soup
+ salty crackers, avoid dairy
Mild: infants - continue usual breast
feeding/formula/ fluids

Treatment of Diarrhea while

Travelling

2. Loperamide: 2 mg. capsules: two STAT

then 1 capsule for every loose stool, max 16
mg/day reduces frequency of stools and
duration of illness by 80% due to anti-motility
and anti-secretory actions.
Young children are more susceptible to side
effects: drowsiness, vomiting and paralytic
ileus. Not approved for children < 2 years.
3. Pepto-bismol (do not exceed 16 tablets/day):
reduces diarrhea by 50% because of antiperistaltic and anti-secretary effects.

Treatment of Diarrhea while

Travelling
4. Antibiotics: If copious or bloody stools, or fever.

Ciprofloxacin 750 mg once or 500 mg bid. If unwell

continue for a total of three days.
Resistance: 90% in Thailand, 50% Nepal, 40% Egypt
Alternatives:
Levaquin 500 mg once or 500 mg daily x 3 days
Azithromycin 1000 mg once or 500 mg daily for 3
days (also effective against Shigella, Salmonella, E.
Coli, Campylobacter and typhoid fever. In Thailand
more effective against Campylobacter than
ciprofloxacin.
Flagyl 250 mg tid x 5-7 days if you consider you may
have Giardia and cannot get medical help. Do not
use with alcohol.

Treatment of Diarrhea while

Travelling
Treat all bloody diarrhea with
antibiotics.
Treat pregnant women with
ciprofloxacin, best alternative is
azithromycin.
Consider whether the rapid diarrhea
is limiting antibiotic absorption.

Returning travellers:
how many will have symptoms?
Which symptoms are most frequent?

Returned travellers
Freedmans (NEJM 2006) study of 17,353 ill
returned travellers from 30 GeoSentinel
sites in developing countries
per 1000 travellers
226
Systemic febrile illness
222
Acute diarrhea
170
Dermatologic disorder
113
Chronic diarrhea
82
Nondiarrheal GI disorder
77
Respiratory disorder
1
Death

Returned travellers: basic approach to

diagnosis

Detailed history of symptoms

if persistent fever malaria thick and thin
films and repeat in 12-24 hours
Detailed history of itinerary and
exposures
Careful physical exam
CBC, LFTs, creatinine, electrolytes (if
had diarrhea) (hepatitis Ags and Abs as
appropriate)
2 fresh stools

Investigation of prolonged
diarrhea (> 14 days)

2 fresh stools for

Parasites: Giardia, Cyclospora, Cryptosporidium,
Microsporidum, Entamoeba histolytica
Bacteria: Enteropathogenic E. Coli, Shigella,
Salmonella, Aeromonas, enteroaggreagative E.
Coli, noncholera Vibrios
If all tests negative, consider ciprofloxacin 500
mg tid x 5 days if not yet given, then flagyl 250
mg tid x 7 days
If diarrhea continues, sigmoidoscopy or upper GI
endoscopy
A few patients progress to IBS after
Campylobacter

Investigation of persistent fever

without focal disease: Blood cultures

Bacterial endocarditis
Bacterial sepsis
Bartonellosis
Brucellosis
Leptospirosis
Listeriosis
Meliodosis
Meningococcemia
typhoid

Investigation of persistent fever

without focal disease: blood or CSF for
parasites
Babesiosis
borreliae
African and American
trypanosomiasis
malaria
microfilariae
visceral leishmaniasis
loiasis

Investigation of persistent fever

without focal disease: serology

Cytomegalovirus
Epstein-Barr
viral hepatitis
Leptospirosis
Rickettsiae
viral hemorrhagic fevers
Dengue
syphilis
relapsing fever
toxoplasmosis

You are going to work as a physician in

a SubSaharan country (Sudan) for 2
years; What can you contribute?

Train health professionals

Be able to do and teach a safe C-section

and vacuum delivery

Reduce infectious disease risks by public
health interventions
Involve other experts in increasing food
production in each household
Encourage an organisation to come in and
start small loans to households to start
businesses (Gramin banks)

Sudan: Infectious Diseases: Arthropod

borne diseases
malaria (except above 2600 m)
filariasis
onchocerciasis (river blindness)
cutaneous and mucocutaeous leishmaniasis
visceral leishmaniasis
trypanosomiasis (sleeping sickness)
relapsing fever
louse- flea- and tick-borns typhus
Tungiasis
viral hemorrhagic fevers (from mosquitoes,
ticks, sand flies)
Yellow Fever

Sudan: Food and water-borne

infections
helminths
bacterial diarrhea; typhoid
hepatitis A and E
hepatitis B
cholera

Sudan: Food and water-borne

infections: Helminths
Metazoa
Flat worms
worms

Round
(nematodes)

Cestodes
Trematodes
(tape worms) (flukes)

Sudan: Food and water-borne

infections: Helminths: nematodes
(round worms)

Ascaris lumbricoides
Trichuris trichiura
Enterobius vermicularis
Stronglyoides
Ancyclostoma duodenale
Necator americanus
Trichinella spiralis
Wucheria bancrofti
Loa loa
Onchocerca volvulus

Sudan: Food and water-borne

infections: Helminths: Cestodes (tape
worms)

Taenia solium
Taenia saginata
Echinococcus granulosus
Echinococcus multilocularis

Sudan: Food and water-borne

infections: Helminths: Trematodes
(flukes)

Schistosoma haematobium, mansoni

and japonicum