2. This presentation is a brief overview of travel-
related infections
I strongly encourage travelers to endemic
countries to consult a travel medicine specialist
at least one month prior to departure
Find a travel medicine clinic:
http://wwwnc.cdc.gov/travel/page/find-clinic.htm
http://www.astmh.org/source/ClinicalDirectory
http://www.istm.org/WebForms/SearchClinics
3. Hitchhiked in Africa,
1988-1989
Registered Nurse, 1992
Diploma in Clinical
Tropical Medicine &
Travelers’ Health, 2000
Worked in Ethiopia,
2002
Master of Public Health
& Tropical Medicine,
2009
Niger River, Mali, 1988
4. Locally Acquired Dengue - Key West, Florida,
2009—2010 (CDC, 2010)
Dengue Hemorrhagic Fever - U.S.-Mexico
Border, 2005 (CDC, 2007)
Autochthonous Transmission of Trypanosoma
cruzi, Louisiana (Dorn et al., 2007)
Multifocal Autochthonous Transmission of
Malaria - Florida, 2003 (CDC, 2004)
Changing patterns of autochthonous malaria
transmission in the United States (Zucker, 1996)
5. West Nile Virus
Eastern Equine Encephalitis
Western Equine Encephalitis
St. Louis Encephalitis
La Crosse
Chikungunya?
Vector competence of Florida mosquitoes for
chikungunya virus (Richards et al., 2010)
Chikungunya: a potentially emerging epidemic?
(Thiboutot et al., 2010)
6. Primary Amebic Meningoencephalitis Deaths
Associated With Sinus Irrigation Using Contaminated
Tap Water (Yoder et al., 2012)
The epidemiology of primary amoebic
meningoencephalitis in the USA, 1962-2008 (Yoder et
al., 2010)
Raccoon Roundworms in Pet Kinkajous - Three States,
1999 and 2010 (MMWR 2011)
Raccoon Roundworm Encephalitis - Chicago, Illinois,
and Los Angeles, California, 2000 (MMWR, 2002)
Eosinophilic meningitis attributable to Angiostrongylus
cantonensis infection in Hawaii (Hochberg et al. 2011)
Parastrongylus (=Angiostrongylus) cantonensis now
endemic in Louisiana wildlife (Kim et al., 2002)
The finding of Angiostrongylus cantonensis in rats in
New Orleans (Campbell & Little 1988)
(Okay, they don’t really eat brains)
7. Air travel Pre-existing conditions
DVT Sexual health
Envenomations/intoxications Special needs
Environment Trauma
Altitude Crime
Diving Motor vehicle accidents
Heat/cold Natural disasters
Pollution Violence
Sunburn Recreational water exposure
Food/water Leptospirosis
Mental health Marine animals
Culture shock Schistosomiasis
Re-entry shock
Substance abuse
9. 3000
2820
2500
2000
1500
1000
500 428
88
18 6 1
0
Falciparum Typhoid fever Leptospirosis DHF/DSS East African Japanese
malaria trypanosomiasis encephalitis
Jensenius et al., 2013
10. Protozoan parasite
Complex lifecycle
Transmitted by mosquitoes
Four human species
Plasmodium falciparum
Widespread drug resistance
P. vivax
P. ovale
P. malariae
P. knowlesi
Simian malaria www.cdc.gov/malaria
Vaccines in clinical trials
12. 1,691 cases reported to CDC
Species Region of Acquisition
P. falciparum 58% Africa 65%
P. vivax 19% West Africa 73%
P. malariae 2% Asia 19%
P. ovale 2% South Asia 94%
Unknown 18% India 81%
Americas 15%
Reason for travel
Visiting friends and relatives (VFR) 71%
Missionaries 9%
Business 8% CDC 2012
13. Atovaquone/proguanil (Malarone®)
Daily
1-2 days before arriving in malaria-endemic area
7 days after leaving
Doxycycline
Daily
1-2 day before arriving
4 weeks after leaving
Mefloquine
Weekly
2 weeks before arriving
4 weeks after leaving
CDC, 2012
14. 35% of antimalarial drugs obtained in
Southeast Asia and sub-Saharan Africa failed
chemical analysis (Nayyar et al. 2012)
53% of artesunate tablets collected in Southeast
Asia contained no trace of the drug (Dondorp
et al., 2004)
Subtherapeutic doses increase the risk of
treatment failure and development of drug-
resistance
20. Inactivated polio vaccine (IPV)
Single lifetime booster for adults traveling to areas
with polio transmission and who have previously
received primary series
Influenza
Year-round transmission in the tropics
Measles, mumps, rubella (MMR)
2 doses
Tetanus, diphtheria, acellular pertussis (Tdap)
21. Ongoing wild poliovirus transmission:
Afghanistan
Nigeria
Pakistan
Vaccine-associated paralytic poliomyelitis (VAPP)
1 in 2.4 million OPV doses
Vaccine-derived poliovirus (VDPV)
Areas with inadequate polio vaccine coverage
2012: Somalia, Chad, Kenya, DR Congo, Yemen
Importation
November 2012: outbreak in Niger imported from
Nigeria
December 2012: wild poliovirus from Pakistan found in
sewage in Cairo, Egypt
WHO, 2013
22. Imported vaccine-associate paralytic poliomyelitis –
United States, 2005
22 year old woman
Religious exemption from IPV/OPV
Stayed with a family in Costa Rica beginning Jan 14, 2005
Infant in the family received OPV Jan 19
Onset of symptoms March 2
Sabin strain poliovirus isolated from stool
CDC, 2006
Transmission of imported vaccine-derived poliovirus
in an undervaccinated community in Minnesota
OPV not used in the U.S. since 2000
In 2005, 8 Amish children found to be excreting poliovirus
Source not identified
Alexander et al., 2009
23. Measles declared eliminated from the U.S. in 2000
222 cases in the U.S. in 2011
200 associated with importation from other countries
166 unvaccinated/unknown vaccination status
141 eligible to receive MMR
50 refused vaccination for personal, philosophical, or
religious objections
Measles in Europe
39% of cases imported to the U.S. 2001-2008
46% of cases imported to the U.S. in 2011
CDC, 2012; Parker Fiebelkorn et al., 2010
24. Hepatitis A
Hepatitis B
Japanese encephalitis
Meningococcal
Pneumococcal
Typhoid
Varicella
Yellow fever
25. Hepatitis A
Hepatitis B
Meningococcal
Pneumococcal
Varicella
26. Neisseria meningitidis
Meningitis
Meningococcemia
Transmitted by respiratory droplets
Risk factors: crowding, poverty, smoking
African Meningitis Belt
Major epidemics every 5-10 years
Hot, dry, dusty season
Ends with beginning of rainy season
Asymptomatic nasopharyngeal carriage
Vaccine
Conjugate A, C, Y, W-135
Required for Hajji
Apicella, 2010
28. Salmonella enterica Fever
Subspecies Typhi Remittent
Drug resistance Step-wise
Non-typhoidal Sustained
Salmonella Relative bradycardia
S. paratyphi
Constipation/diarrhea
Clinically
indistinguishable from Abdominal pain
typhoid
Headache
Fecal-oral Rose spots
transmission
Thielman et al., 2010
29. Two vaccine licensed in the U.S.
Vivotif®
Live attenuated oral typhoid vaccine
1 capsule every other day x 4 doses
Do not take with antibiotics active against S. typhi
Typhim Vi®
Injectable Vi capsular polysaccharide vaccine
1 IM dose
Do not prevent non-typhoidal Salmonella
infections
30. Flavi- “yellow”
Dengue
Japanese encephalitis
St. Louis encephalitis
Tickborne encephalitis
West Nile virus
Yellow fever
31. Transmitted by mosquitoes
Reservoir: forest primates
Major epidemics in the U.S.
Eastern seaboard, Mississippi Valley
Last epidemic: New Orleans 1905
Most infections self-limiting
Fever, headache, myalgias
Biphasic
Period of remission
Period of intoxication
Fulminant hepatitis
Mortality 20-50%
Vaughn et al., 2010
32. Relative bradycardia
Fever without increase
in heart rate
Jean Charles Faget
1818-1884
New Orleans physician
St Louis Cemetery No 2
New Orleans, Louisiana
34. International Certificate of Vaccination or
Prophylaxis (ICVP)
Vaccine must be administered by a provider
with an official uniform stamp
wwwnc.cdc.gov/travel/yellow-fever-vaccination-clinics/search.htm
CDC, 2012
35. Transmitted by mosquitoes
Night-biting
Most active June - November
Not active during winter months
Most infections asymptomatic
Encephalitis:
Fever, headache, lethargy
Movement disorders
Agitation, decreased LOC, coma
Meningeal signs, seizures, focal neurological deficits
20-30% case fatality
30-50% left with residual neurological deficits
CDC, 2010
37. Most travelers not at risk
Low risk in urban areas
Long stays in or frequent visits to
rural/farming areas
Vero cell culture vaccine: ≥17 years of age
2 doses 28 days apart
Second dose at least 1 week before travel
Not licensed for children in the U.S.
Mouse brain vaccine 1 – 16 years of age
3 doses at 0, 7, and 30 days
No longer available in the U.S.
CDC, 2010
38.
39.
40.
41.
42.
43.
44.
45. American Society of Tropical Medicine and
Hygiene
www.astmh.org
International Society of Travel Medicine
www.istm.org
WHO travel and health
www.who.int/topics/travel/en
46. Alexander, J. P., Ehresmann, K., Seward, J., Wax, G., Harriman, K., Fuller, S. et al. (2009).
Transmission of imported vaccine-derived poliovirus in an undervaccinated community
in Minnesota. Journal of Infectious Diseases, 199(3), 391-397.
http://jid.oxfordjournals.org/content/199/3/391.full.
Apicella, M. A. (2010). Neisseria meningitidis. In G. L. Mandell, J. E. Bennett, & R. Dolin
(Eds.) Mandell, Douglas, and Bennett's principles and practice of infectious diseases, (7th Ed.).
Elsevier [Electronic version].
Campbell, B. G. & Little, M. D. (1988). The finding of Angiostrongylus cantonensis in
rats in New Orleans. American Journal of Tropical Medicine and Hygiene, 38(3), 568-573.
Centers for Disease Control and Prevention. (1994). Typhoid immunization
recommendations of the Advisory Committee on Immunization Practices (ACIP).
Morbidity and Mortality Weekly Report, 43(14), 1-7.
http://www.cdc.gov/mmwr/preview/mmwrhtml/00035643.htm.
Centers for Disease Control and Prevention. (2002). Raccoon roundworm encephalitis –
Chicago, Illinois, and Los Angeles, California, 2000. Morbidity and Mortality Weekly
Report, 50(51), 1153-1155.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5051a1.htm.
Centers for Disease Control and Prevention. (2004). Multifocal autochthonous
transmission of malaria – Florida, 2003. Morbidity and Mortality Weekly Report, 53(19), 412-
413. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5319a2.htm.
Centers for Disease Control and Prevention. (2006). Imported vaccine-associated
paralytic poliomyelitis – United States, 2005. Morbidity and Mortality Weekly Report, 55(4),
97-99. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5504a2.htm.
47. Centers for Disease Control and Prevention. (2007). Dengue hemorrhagic fever – U.S-
Mexico border, 2005. Morbidity and Mortality Weekly Report, 56(31), 785-789.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5631a1.htm.
Centers for Disease Control and Prevention. (2010). Japanese encephalitis vaccines.
Recommendations of the Advisory Committee on Immunization Practices (ACIP).
Morbidity and Mortality Weekly Report, 59(1), 1-27.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5901a1.htm.
Centers for Disease Control and Prevention. (2010). Locally acquired dengue – Key West,
Florida, 2009-2010. Morbidity and Mortality Weekly Report, 59(19), 577-581.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5919a1.htm.
Centers for Disease Control and Prevention. (2011). Raccoon roundworms in pet
kinkajous – three states, 1999 and 2010. Morbidity and Mortality Weekly Report, 60(10), 302-
305. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6010a2.htm.
Centers for Disease Control and Prevention. (2012). CDC health information for
international travel 2012. New York: Oxford University Press. [Electronic version].
http://wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm.
Centers for Disease Control and Prevention. (2012). Malaria surveillance – United States,
2010. Morbidity and Mortality Weekly Report, 61(Suppl. 2), 1-17.
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6102a1.htm.
Centers for Disease Control and Prevention. (2012). Measles – United States, 2011.
Morbidity and Mortality Weekly Report, 61(15), 253-257.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6115a1.htm.
48. Dondorp, A. M., Newton, P. N., Mayxay, M., Van Damme, W., Smithuis, F. M., Yeung, S.
et al. (2004). Fake antimalarials in Southeast Asia are a major impediment malaria
control: multinational cross-sectional survey on the prevalence of fake antimalarials.
Tropical Medicine and International Health, 9(12), 1241-1246.
Dorn, P. L., Perniciaro, L., Yabsley, M. J., Roellig, D. M., Diaz, J., & Wesson, D. (2007).
Autochthonous transmission of Trypanosoma cruzi, Louisiana. Emerging Infectious
Diseases, 13(4), 605-607. http://wwwnc.cdc.gov/eid/article/13/4/06-1002_article.htm.
Fradin, M. S. (2008). Insect protection. In E. C. Jong & C. Sanford (Eds.) Travel and tropical
medicine manual. (4th Ed.). Elsevier. [Electronic version].
Hochberg, N. S., Blackburn, B. G., Park, S. Y., Sejvar, J. J., Effler, P. V., Herwaldt, B.
L.(2011). Eosinophilic meningitis attributable to Angiostrongylus cantonensis infection
in Hawaii. American Journal of Tropical Medicine and Hygiene, 85(4), 685-690.
http://www.ajtmh.org/content/85/4/685.long.
Jensenius, M., Han. P. V., Schlagenhauf, P., Schwartz, E., Parola, P., Castelli, F. et al.
(2013). Acute and potentially life-threatening tropical diseases in western travelers – a
GeoSentinal multicenter study, 1996-2011. American Journal of Tropical Medicine and
Hygiene, 88(2), 397-404.
Jong, E. C. (2008). Immunizations for travelers. In E. C. Jong & C. Sanford (Eds.) Travel
and tropical medicine manual. (4th Ed.). Elsevier. [Electronic version].
Kim, D. Y., Stewart, T. B., Bauer, R. W., & Mitchell, M. (2002) Parastrongylus
(=Angiostrongylus) cantonensis now endemic in Louisiana wildlife. Journal of
Parasitology, 88(5), 1024-1026.
49. Nayyar, G. M. L., Breman, J. G., Newton, P. N., & Herrington, J. (2012). Poor-quality
antimalarial drugs in Southeast Asia and sub-Saharan Africa. Lancet Infectious Diseases,
12(6), 488-496.
Parker Fiebelkorn, A., Redd, S. B., Gallagher, K., Rota, P. A., Rota, J., Bellini, W. et al.
(2010). Measles in the United States during the postelimination era. Journal of Infectious
Diseases, 202(10), 1520-1528. http://jid.oxfordjournals.org/content/202/10/1520.long.
Richards, S. L., Anderson, S. L., & Smartt, C. T. (2010). Vector competence of Florida
mosquitoes for chikungunya virus. Journal of Vector Ecology, 35(2), 439-443.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076135.
Steffen, R. & Grieve, S. (2013). Epidemiology: morbidity and mortality in travelers. In J.
S. Keystone, D. O. Freedman, P. E. Kozarsky, B. A. Connor, & H. D. Nothdurft (Eds.)
Travel medicine (3rd Ed.) Elsevier [Electronic version].
Thiboutot, M. M., Kannan, S., Kawalekar, O. U., Shedlock, D. J., Khan, A. S., Sarangan, G.
et al. (2010). Chikungunya: a potentially emerging epidemic? PLoS Neglected Tropical
Diseases, 4(4), e623.
http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000623.
Thielman, N. M., Crump, J. A., & Guerrant, R. L. (2010). Enteric fever and other causes of
abdominal symptoms with fever. In G. L. Mandell, J. E. Bennett, & R. Dolin (Eds.)
Mandell, Douglas, and Bennett's principles and practice of infectious diseases, (7th Ed.).
Elsevier [Electronic version].
50. Vaughn, D. W., Barrett, A., Solomon, T. (2010). Flaviviruses (yellow fever, dengue,
dengue hemorrhagic fever, Japanese encephalitis, West Nile encephalitis, St. Louis
endephalitis, tick-borne encephalitis). In G. L. Mandell, J. E. Bennett, & R. Dolin
(Eds.) Mandell, Douglas, and Bennett's principles and practice of infectious diseases, (7th
Ed.). Elsevier [Electronic version].
World Health Organization. (2013). Weekly epidemiological record, 7(88).
http://www.who.int/wer/2013/wer8807.pdf.
Yoder, J. S., Eddy, B. A., Visvesvara, G. S., Capewell, L., Beach, M. J. (2010). The
epidemiology of primary amoebic meningoencephalitis in the USA, 1962-2008.
Epidemiology and Infection, 138(7), 968-975.
Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C..
et al. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation
using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-85.
Zucker, J. R. (1996). Changing patterns of autochthonous malaria transmission in the
United States: a review of recent outbreaks. Emerging Infectious Diseases, 2(1), 37-43.
http://wwwnc.cdc.gov/eid/article/2/1/96-0104_article.htm.