Julie Richards

President, ATHNA

Stanford University

julier2@stanford.edu

Post-Travel Fever: Protecting Your

Patients, Your Institution, and

Yourself

“Travel Health Catastrophes”

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OMG! The Best Travel Health Catastrophes Ever

7 Ways To Keep Your Travel Health Catastrophes Growing Without Burning The Midnight Oil

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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