Post on 03-Jan-2020
transcript
Julie Richards
President, ATHNA
Stanford University
julier2@stanford.edu
Post-Travel Fever: Protecting Your
Patients, Your Institution, and
Yourself
“Travel Health Catastrophes”
15 Tips for Travel Health Catastrophes Success
OMG! The Best Travel Health Catastrophes Ever
7 Ways To Keep Your Travel Health Catastrophes Growing Without Burning The Midnight Oil
The Top 10 Travel Health Catastrophes - #6 Will Blow Your Mind
The Lazy Man’s Guide to Travel Health Catastrophes
What Bill Gate Can Teach Us About Travel Health Catastrophes
Disclaimer
I have no conflicts of interest to report.
Why are we talking about this?
More U.S. students are going abroad
Overall number of Americans studying
abroad has more than tripled in the last 35
years: 304,467 in 2013-2014
More and more universities making this a
requirement
Institute of International Education Open Doors Report 2015
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More students are traveling to the U.S.
The number of students of international
students in the U.S. has grown 73% in the
last decade: 974,926 students.
They contributed $30 billion to the U.S
economy in 2014
Institute of International Education Open Doors Report 2015
Goals
Prevent unnecessary deaths
….possibly your own
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Objectives
List 3 simple interventions institutions can implement to protect the campus community
List 4 “Do Not Miss” conditions
Identify major geographic regions and illnesses associated with them
Delineate a systematic approach to getting a travel history
Describe 3 steps you can take to assess returning travelers
Travel should always
be on the radar
Identify Stakeholders
• Risk Management
• Parents/Students/Faculty
• ED
• ID
• Local Travel Clinics
• Local Health Departments
Vaden Health Center
All departments
On-line appointments
Clerical staff
Triage
Nurse visit encounter form
Provider visit encounter form
Peer health educators
Ask EVERY patient
about fever and travel
Prepare in advance: can’t
assume ED “will take care of it”.
PHD contacts
Infectious Disease
Risk Analysis Consequences
Low
Consequences
Catastrophic
Likelihood
Low
Hand, foot, and mouth
disease
P. Falciparum malaria
Rabies
Typhoid fever
Hemorrhagic dengue
Avian influenza
Japanese encephalitis
Viral hemorrhagic
fevers
Schistosomiasis
Likelihood
High
Traveler’s Diarrhea
Most dengue
Most chikungunya
P. Falciparum malaria
Rabies
Typhoid Fever
Schistosomiasis
Always ask
Is this a risk for me?
Is this a public health risk?
How much time do I have?
Realize What You Don’t Know
List is long
Some life-threatening
Life-threatening can appear benign
History of fever is important
Travel History
Patient
Destination
Activities
Patient
Chronic diseases/pregnancy
Vaccine status
Previous infections
Travel clinic visit/prophylaxis
Health Care Worker
VFR
Destinations
Countries (not just recent)
Dates
Accommodations (camping,
bednets, cruise ship, screens,
A/C)
ID profile (recent outbreaks)
Activities
Caves (spelunking-bats)
Water (bottled, boiled/tap water to
brush)
Food (raw, bush meat, unpasteurized
dairy)
Soil (night soil in bare feet)
Activities
Blood/body fluids
Hospitalizations during travel, dental
work
Animal contact (bite, scratch, lick)
Arthropods(mosq, ticks, spiders,
sandflies)
Water (fresh/salt)
Regions
Rabies
Malaria
Anopheles Mosquito
Also “great imitator”
Fever, malaise and “other”
History of fever is key
5 Types
Plasmodium falciparum
WILL KILL YOU WITHIN 72 HOURS
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
Plasmodium knowlesi
Infects RBC
• P. falciparum so deadly due to sequestration in microcirculation
• Parasitemia can be low but all stages can be sequestered – pt severely ill
• Degree of microvascular obstruction determines severity of disease
• P. knowlesi looks like malariae but kills like falciparum – both have short reproductive cycles (24 and 48 hours respectively)
Malaria: mostly P. falciparum
CDC Hotline: 855-856-4713
Dengue
CDC Dengue Clinical Case Management Course:
https://www.cdc.gov/dengue/training/cme.html
Dengue Virus: What You Need to Know:
https://www.cdc.gov/dengue/resources/factSheets/factsheet_dengue-what-you-need-to-know.pdf
Home Care for Dengue Patients:
https://www.cdc.gov/dengue/resources/factSheets/homeCareenglish.pdf
Chikungunya
Zika
US Cases: 618
Interim Guidance for Interpretation
of Zika Virus Antibody Test Results
http://www.cdc.gov/mmwr/volumes/65/w
r/mm6521e1.htm?s_cid=mm6521e1_e
MERS: Arabian Peninsula
Saudi Arabia
United Arab Emirates (UAE)
Qatar
Oman
Jordan
Kuwait
Yemen
Lebanon
Iran
Enteric Fever
Enteric Fever
• Typhoid and paratyphoid: Salmonella
enterica
• Incubation 6-30 days
• Gradual fever and abdominal pain, may
have rash, diarrhea and then
constipation
• Fatality rate of 20% in untreated cases
Schistosomiasis
Avian Flu (H5N1: multiple
countries, H7N9: China)
Incubation Periods
< 14 days
Chikungunya, dengue, encephalitis, arboviral (JE, West Nile, tickborne encephalitis), HIV, influenza, legionaellosis, leptospirosis, malaria – P. falciparum, P. vivax, spotted fever rickettsiae
14 days – 6 wks
Encephalitis; arboviral; enteric fever, HIV; leptospirosis; malaria, amebic liver abscess, hep a, hep e, schistosomiasis (Katayama syndrome)
> 6 wks
Amebic liver abscess, hep e, malaria, acute schistosomiasis, hep b, leishmaniasis – visceral, TB
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Order Sets
Traveler’s Diarrhea
• Usually treat first – do not work-up, if symptoms mild and
no fever
• Work-up Part 1 o Stool for O and P x 3 (not more than 1 stool
sample/day) o Stool C and S x 1 o Stool Giardia antigen o Stool C. difficile if history of antibiotic or antimalarial
use o Complete blood count/ differential o Urinalysis with possible culture (women more prone to
UTI with diarrhea) • Work-up Part 2
o HIV o Lactose intolerance test (3 tests) o D-xylose test (celiac sprue) o Thyroid function tests o Electrolytes, calcium o Stool for Cryptosporidium, Cyclospora (Modified AFB
stain), Entamoeba histolytica Note: must rule out malaria if diarrhea/fever and travel
to malarial area!
Fever
• Blood Smears for Malaria – repeat 12-24 hours x 2
if negative • Complete blood count/differential • Metabolic Panel • Blood Cultures • Influenza Screen • HIV antibody • Urinalysis with possible culture • Chest X-ray • Stool culture, exam for blood, fecal leukocytes, O&P • Serum for later serology • Order Dengue serology AND PCR or NS1 antigen
test. (Stanford Lab uses NS1)
• Check eosinophils, → filaria serology if eosinophilia
• Schistosomiasis/Strongyloides serology based on
exposure
• STI screening as indicated
• TB screening if stays> 6 mos and high risk of exposure
(e.g. hospital work, etc.)
• Chagas screening if in Latin America in primitive housing
Screening of Asymptomatic
Long Term Travelers (≥ 3 mos)
Summary
Screen for travel!
Get help – PHD, ID
Know what you don’t know
Get a comprehensive history
Consider incubation periods
Use the order sets
Be a patient advocate
References/Resources
CDC Yellow Book 2015 (online)
2015 International Travel Health Guide, Stuart Rose, MD and Jay S. Keystone, MD (online edition)
American Travel Health Nurses Association (www.ATHNA.org)
International Institute of Education, Open Doors Report, 2015(online)
Gideon/Fevertravel
GeoSentinal Global Surveillance Network (online)
Thank You
Julie Richards
julier2@stanford.edu