Dr. Crum-Cianflone discusses various potential infections patients are at risk for when traveling abroad including food and drink borne illness, sexually transmitted disease, bug bites, and animal exposures, among others.
Back to Symposium Page » Welcome back, everybody. I'd like to introduce Dr Nancy Crumb, an infectious disease specialist at Scripps Mercy Hospital in San Diego. She's also a voluntary associate clinical professor at the University of San Diego, California and adjunct professor in public health and epidemiology at San Diego State University. She has a doctor grade medicine from the University of Chicago. A master's degree in public health from San Diego State University. Bastards of Arts degree from Wittenberg University. Dr. Trump serves on the Publication committee for the Clinical Infectious Disease Journal and the Journal of Infectious Diseases. She's also an editorial board member for both infectious disease in clinical practice and AIDS, Patient Care and STDs. She reviews articles for over 20 journals. Nancy, welcome. Hi, everyone. It's really wonderful to be here with you, and I'm going to talk today about travel related infectious diseases and really focus on what not to bring home. I don't really have any relevant disclosures regarding what I'm gonna talk about today, and I thought about how do you really try to summarize various infections from all over the world and what may come back with our patients? And so what I wanted to do today is to review with you the most common infections that we may see in travelers. And I'm going to do that by breaking it down into these various transmission mechanisms. So I'm going to start with bad air and then progressed through all these other things that may happen with our travelers when they're on their vacations and what they could bring home. I welcome you to chat in any questions, and I'll be taking those at the very end of the talk. So first, to start off with bad air, what could be bad in the air that someone can pick up. So I'm going to start here, and I'm gonna have cases throughout my talk today to present a few patients, and then I'm gonna ask you to think about what this could be, and then I'll be giving you an update on that particular infectious disease. So this is an 18 year old came in with fever, runny nose and cough. Three days later, a rash developed, and I'm showing you a picture on the slide of the rash that you may see it began at the patient's hairline. Progress diffuse Lee through the body and the patient states that he had been on travel to Philippines and is obviously now back in the U. S. So I wanna ask you what you think might be one of the top diagnoses of this condition. And because we are remote, I'm gonna just have you look at this list and then I'm going to kind of proceed into what ended up being the diagnosis of the case. So this turns out to be measles. And although I got to forget about measles, as you probably did for many years, we now are thinking about this condition again. And this is the world map of measles. And so even though in the United States our caseload is relatively low when people travel abroad and if they're not appropriately vaccinated, we still have to think of measles as well as mumps as a possible cost. And you can see here at the epidemiology of measles and then in the Philippines, there is high rates of measles going on throughout Africa throughout Asia, but also note that even in Europe, if you're going to just take a little easy European vacation, this is the time also, that we need to make sure that the measles vaccines are up to date. Mhm. So here's our case reported numbers in the U. S. The C. D. C. Does not have official data yet from 2020 but you could tell that we were really having a problem, particularly last year. The good news is, is this problem has actually gotten better. According to the CDC counting, there's only been 12 reported cases this year this far, so we're doing much better to assure our travelers are aware of measles A. A. Of course, with the covert epidemic, less people are traveling, more people are isolating, and that's probably also contributing to the improvement in these numbers. But I just want to bring up measles as a airborne travel related infection. So one of the things to just think about with measles is how important it is to get your MMR. If you are susceptible and non vaccinated and you are in contact with someone with measles, you have a 90% chance of coming down with measles. It's one of the highest reproductive rates of any infectious diseases. People can remain contagious for several days, and the virus can actually be in the air for up to two hours. So even if you're not directly next to a person, you could potentially get exposed if they were in that same space just before you. In terms of if you have a patient who has measles, what to do. But here are the symptoms that we want to think about, which is cough, runny nose, conjunctivitis on bond. Then the specific signs and symptoms that you want to think about are the cop lot spots that you can see in the mouth as well as the rash that usually begins at the hairline and then progresses Diffuse Lee through the body. Some people say, Well, measles, no big deal. Don't need to really worry about this. I would I would offer you really? Actually dio there's a lot of CNS possibilities of complications both acutely and longer term. In addition, we have now good data to suggest that, um, measles actually lowers your immune system and ability to respond to infections for several years after contracting measles. So it remains a new issue. Okay, in terms of the diagnosis here, um, the thing to do is to contact public health. If you see. Think someone has measles? There's an I G. M. Test. There's a PCR test available. Treatment is generally supportive. And again, prevention is key, making sure all of our patients are up to date on their MMR. And then if you have someone exposed to someone with active case of measles and they're not vaccinated, you could give him an MMR within 72 hours for protection. And if they cannot get the MMR Because this is, of course, a live vaccine, you can consider giving them immune globulin up to six days of exposure as another possibility. Okay, I'm gonna move on to case number two with the same idea of airborne travel related infectious diseases. And this is a case that I saw not long ago of a 48 year old male who quarantine himself at home and stated that his work continued as a computer programmer and he was told to just stay at home and get this giant computer project done. So he did that he literally stayed in his home, worked 15 hour days and finally the computer project was over, and he decided to leave Southern California and go to Tijuana for a vacation, So he took a vacation in Tijuana. But unfortunately, four days after returning back to Southern California from Tijuana, he started developing fevers. And then seven days into the illness, he started getting quite short of breath. So he presented to our institute with shortness of breath and cough. Um, here is his chest X ray. That was done. And so I'm going to ask you what respiratory infection this gentleman ultimately had. So we have influenza B. We have Pertussis Cove in 19 or this is too hard. So all these air possible diagnoses, of course. But it was in the summer months, and influenza would be kind of unlikely there. Although in the differential. And for Texas, although adults can get protests leading to a more chronic cough over time. Obviously the diagnosis that we're thinking about here is Cove in 19. And, of course, you do not need to leave your house to get Cove in 19. But we are seeing it in travelers, at least where I work, particularly people who are traveling in the Mexico that, at least for us, has become a risk factor. These were the numbers when I put the slide together. Of course, you all know the numbers air increasing. We've exceeded 200,000 deaths now in the United States, and unfortunately, the numbers continue to go up. So this is a diagnosis due to bad air, both in local populations as well as travelers that we want. Thio continue to think about symptoms. You guys are all probably very familiar with the symptoms that are that we're looking for the median duration from incubation of time from when you get exposed to. Actually, you start getting symptoms is five days, but can range between two and 14 days now. This next slide is a study that talks about a variety of patients who presented and what they presented with so again, a general viral illness symptoms. Sometimes patients aren't febrile right away, but become federal. If you watch him long enough, we've seen a lot of patients print predominantly, have G I symptoms upfront with nausea, vomiting and diarrhea. There's this idea of loss of taste and smell, particularly common in women and young people, but really can be found in anyone, and this is not specific to Koven but can happen in other infectious diseases. A swell, but those signs and symptoms have been shown to have predictive value in terms of patients who have Koven. Now there have been classifications systems may to define. If you have mild, moderate, severe critical cove it, of course, it can range from being completely asymptomatic to respiratory failure and death. Um, illness. Severity. Most cases are asymptomatic or mild or moderate. About 14% have severe disease requiring oxygen coming into the hospital and then critical illness and about 5% of people. And, of course, these numbers really depend on what population you're looking at. These air data from China. Our experience here is quite similar to that that most patients will have asymptomatic or mild disease, especially our young people with no co morbidity. Ease now in terms of those people who are really going to get into trouble. These are this the risk factors so far identified in terms of patients who may progress to respiratory failure and death. And so these are the groups that were very concerned about on I think you are all familiar with these, uh, specific bricks. Fact. Yes Labs site open. Ia's elevated LFTs are common inflammatory markers. Air frequently elevated and D diner being elevated and lymph a pina have been associated with mortality. So this is the list of labs that we typically get in patients who we suspect cove it. And then for some of these, like the CRP, um, and the d dime er, we do trend those over time diagnostic testing. The test of choice, of course, is the PCR that you could do on sputum or nasal differential specimens regarding serology. This has really been a big issue in the United States that trying to get a reliable I g. M I G measure has been difficult. I give you the I D. Society of America's position, paper and data on this is a link to look things up. But again, serology zehr not being commonly utilized, particularly in clinical practice because of this variation in test performance. Now, the next slide here, it really shows us what happens to people as they come into the hospital and what happens with their PCR and their I g. M and I g over time. And so this just shows you when the PCR starts to be positive, and then when it starts to sort of tail off And then when you start to provide a positive specimens for I, g. M and I g. So that data is there in your slide deck to just give you an idea. But it is really variable. It is really variable because we know our older people immune. Suppressed patients will shed the virus, at least in terms of a positive PCR a lot longer than are younger folks. In terms of radiology, you're gonna look for these ground glass peripheral infiltrates. Our radiologists have gotten really good at diagnosing Cove It, of course, other things can look like this is well and so the diagnosis is really by the PCR. Like we talked about management supportive care for those with mild or moderate disease. They should quarantine at home. People with severe critical are admitted to the hospital. We've seen a whole host off possible complications associated with covert. I've just mentioned some of those here, but hyper quick gullibility, stroke, heart attacks, heart disease, myocarditis. These were just some of the things that we're seeing in our patients that we have to really have a multidisciplinary approach, and a lot of different clinicians are often involved in their care because of all the kidney and heart and other issues that people have now, the treatment is really evolving. Over time, I give you the links for IEDs society and N I H. I would recommend going to these links as there frequently updated to get the latest data on what treatments we should be using. What are we doing at this very time? Is decks of Methodism? For approximately 10 days on, patients need to be admitted or ventilated. Ram dis severe were using again for severe patients who require hospitalization and oxygen supplementation. Whether a remedy severe really helps, once of patients already on the ventilator is still unknown will often offer it in those cases, and that's usually a five day course. Convalescent plasmas really gotten very mixed data again. I list some of the sites there to look for updated data. It can be offered again. It would be offered in patients with severe or critical covert infections, but its utility still, I think, is to be defined regarding ah, lot of other possible treatments. We no longer use hydroxy clerk. When is it through my assignar Lopez severe? Those have not been shown to be effective. There's a lot of agents to decrease side a kind storm. Those are possibly helpful and critically ill patients. But the recommendations is to really utilize those in the setting of a research study, if possible. And then anti coagulation should be considered these patients or hyper quiet example, and the guidelines are pasted there. I'm going to move on from Cove. It actually I got a couple more slides from Cove. It one is about a de escalation. This is the thing that keeps changing constantly. This is the current guidance of when patients can go out of isolation. The big point here is we're really focusing on symptoms versus repeat testing. So unless we have to repeat tests, someone because they're going to a nursing facility or some other place like that, we really want to think about that. For mild and moderate illness. At least 10 days have passed and symptoms first appeared for your severe critical patients were using 20 days, and then we consider taking them off of isolation. At that point, in terms of prevention, you guys know the the traditional ways to prevent this vaccine in the future, not clear when the vaccine will be available. I do not believe it will not be available until early next year. But of course you're hearing all the bantering back in the media of when it could be a on the right side of the slide here. Sometimes my patients say, should I and then they give you a list of things? Should I go to a hotel? Should I go on this vacation? This is the I. D. S. A guidance of what is medium low and high risk in terms of activities that you can advise your patient on. If they're thinking about doing an activity, how safe could that possibly be? Okay, so continuing to move on to bad air, these air, some other things that could be transmitted through the air after travel or during travel and people could bring home Um, if you're going to the Arabian Peninsula, you're going to still think of MERS. Uh, influenza is a big thing. Of course, This fall we're all concerned we're all asking people to get vaccinated and then finally, tuberculosis mainly an issue. If people are staying in a developing country with high rates of TV for a while. You'll want to do a pre travel TV screen and then after they get back, you wanna wait eight weeks and you want to retest them for TV? Of course, if they have symptoms consistent with TV, you're gonna do your chest X ray. You're gonna put him in isolation. You're going to collect sputum samples as well. I'm gonna move on to risky food and risky drinks and talk to you a little bit about what we have with this and traveler's diarrhea is the number one thing. I have the definitions here, but basically patients coming back with lots of loose stools, abdominal cramps, the number one organism that you're going to think about is neurotoxic genic E. Coli that accounts for the majority of the cases. In terms of further work up, we don't generally do much of further work up. If they are notably symptomatic, we wanna make sure they're hydrated. You can consider anti motility agents if they do not have bloody diarrhea or they don't have fever. Um, in terms of antibiotics, if they're having significant symptoms and I define that on this slide, then your options are Flora Quinn alone like Leave a Quinn or a Zithromax. Jason, The dozing of this is a single dose. A single dose has been shown to be as effective as a three day or longer course of treatment. Onda dozing regiments were shown there. If you do have a patient who has dysentery and is severely ill than I would preferentially used the three day course. The other thing I would say is that if you're patient is coming back from Asia from India from places where there's a lot of flora queen alone resistance, then the treatment of choice really is a zip through Miocene from those locations because we know of the issue with Quinn alone. Failures in terms of prophylaxis. If you have a patient going on a trip and they're worried or you're worried about the potential traveler's diarrhea, you can always send them with a prescription for, um, odium and a queen alone. Or is it throw Mayas? And on their trip with the instructions, don't take it unless you get significant diarrhea. But if you get significant diarrhea, consider starting these medications based on the same guidance that I list here, a self treatment so that their vacation can continue, and hopefully they won't miss too many exciting sights. Thea other infection that we worry about in the G I tract on travel is normal virus. Of course, this is transmitted Ah lot at cruise ships. We've had a lot of issues there. It's very infectious. Hand washing environmental control are the big things on if you really want to diagnosis. If someone is confirmed to have norovirus, there is a PCR, and there is a supportive care that you could give patients. But there's no specific antiviral, and there's no specific vaccine to prevent this at at the current time. But this should be on your differential. Travel related diarrhea now the most common causes of diarrhea. Um, in terms loose stools, um uh, then and they continue on and on. This is the time that you're wanting to get your oh MPs and further work up. I see a lot of patients travelers coming back a few days later with diarrhea and you get this whole work up. It's really not necessary. It's really only necessary to start thinking about these particular items when you have somebody who has chronic issues after return and this is the list of things that I would start with thinking about in terms of what to look for. Uh, this is a really good review from New England Journal of Medicine that just talks about all the different organisms that you can think of. The treatments, the diagnosis. I just put this on your slide deck. So you have this available. Okay, I'm gonna move on to another case transmitted by food for you to think about. It's a 38 year old with fevers, headache, abdominal pain and rash. Came back recently from a trip to India. At the time of his vacation, he ate lots of the local cuisine and unfortunately, he never sought pre travel guidance or vaccines. And he now is coming to your clinic saying I think something's wrong. I show you his abdominal exam here, and you might be able to see there is a rash on his abdomen with thes circular macular lesions that is present as well. So the diagnosis of this patient I'm gonna have you look at the slide here. And I think one of the key factors to think about is where are they coming back? Did they get their appropriate vaccines and what is the constitution of their their symptoms that they have? Well, this patient ends up having typhoid on Dwan. Of the key points here is the other conditions that I show you here don't really have rash. And if you want to successfully get typhoid, the place that you should go to visit is to go to India or South East Asia, not be vaccinated and eat a local cuisine. And this patient did all those things, so this would be the most commonplace to get typhoid. But as you can see on the map here, typhoid is endemic throughout much of the world. And so a typhoid vaccine prior to discharge is something that we would want to think about in terms of symptoms of typhoid sustained fevers, G. I upset either diarrhea or constipation. The more path and demonic symptoms is our signs is the rose spots. Relative bradycardia is classic for typhoid, but not always present. Uh, since this is salmonella, patients could be chronic carriers and of course, they're going to need follow up stool samples for evaluation of this in terms of the diagnosis, blood cultures and stool cultures, is what we use. I list the antibiotics that are commonly used pending sensitivity results and in terms of prevention, it's safe water, safe food and vaccination before travel. And there's an injectable, and there's an aural vaccine that could be given if you get the oral vaccine. It's good for five years. If you get the inter muscular injection, then that is good for two years. So making sure, especially if you have a frequent traveler who goes a lot of places making sure they're typhoid is up to date cholera, cholera still exist. I show you on this map where the hot spots right now in the world are for cholera. Of course, this is a patient coming back with rice, water stools. The new thing here and the reason I really include cholera. It's not because we frequently see it in our travelers, but the real reason that I included here is that there is actually a vaccine that now isn't available now. The vaccine is not something we would typically give to our travelers, but it humanitarian work in one of these locations are going to be living there for a while. Then this is something that thinking about an offer. So all the details of the vaccine are here in terms of durability and efficacy. But again, not a normal, routine travel related vaccine, but one that you could think about in terms of someone who is going to be at high risk. Hepatitis A is another, uh, infection that travelers can get. It's actually the most common travel related, uh, infection that can be prevented by vaccination. So hepatitis A here again, I show you the world map. The hot spots. As you all know, you've had hepatitis A outbreaks throughout the United States. Um, and in Southern California we've had a lot of outbreaks, especially among our homeless and drug users. So it's not just a problem. Like Cove is not just a problem overseas. It's a problem here. It home. But it is something to think about in our travelers and making sure that they do get their hepatitis A vaccine. Um, like many vaccines making sure they're vaccinated two weeks or more before travel. And then if they need to get a second dose of the vaccine for hepatitis A, that's in six months, and they can get that upon return Ideally, it would be best for them to get both injections before travel, if possible. Finally, in terms of things that people can get from eating and drinking things during their travels, this is a non traditional travel related infection slide to just show the increasing amount of studies that have shown people picking up drug resistant bacteria on their travels. And what happens is, then they come home. And if they develop a u T. I. They may not just have a simple U T I with E. Coli that spanned sensitive. They may have any E. Coli that's multi drug resistant in their urine. Or if they develop diverticulitis or some kind of bowel condition. This may not just be, let's simply give them a tradition. National antibiotics. They may need more extend expanded antibiotics because of these bad bugs that they may be picking up on their travels. So something to think about, um, kind of scary as well. Okay, so now I'm gonna walk, move on from bad air and bad food and drinks to what happens when we're not careful where we're walking or swimming. So the next case is a 38 year old has a rash on their foot recently returned from a Caribbean vacation where they walked on the beach often barefoot. So I'm gonna ask you guys that think about what you think that patient may have picked up. Here are a list of potential possibilities and I'll ask you just to take a couple minutes. Just a vote here, uh, to see what you think. Okay, so the answer here is cutaneous larva migrants, its's throughout the world. I give you the top sites here at the very first bullet. These were actually hook warms of animals, but they see human skin. They decide that might be a friendly environment, and they crawl into the skin and then start to cause what the what ends up being this creeping eruption. It's very, very itchy. The diagnosis is clinical, and although these can resolve over time, you can give them a course of al benzoyl to try to help this go away. Of course, the prevention of this is to wear shoes. Tell your travelers not to be laying on the beaches or walking on the beaches without clothing. The slide on the photo on the right of the slide shows creeping eruption of the abdomen. This patient was sunbathing. Decided to lay on the beach when their stomach for several hours and this is what they acquire now. The other thing is that I'm gonna talk about in the next few slides are not very common in terms of travelers. But, see, um, in patients. So the next one is leptospirosis, a swimming and contaminated water that's contaminated with urine of animals. This can happen, even hold in Hawaii. When you go swimming in these springs, it can really happen throughout the world. People come in with a flu like illness about 10 days after exposure. Conjunctivitis sort of fusion and calf pain. Or classic, um, they have high LFTs, low platelets. It could be diagnosed by serology. But if you think someone has leptospirosis, you should just begin treatment immediately on. That's generally with doxycycline or penicillin. Agent um, serology is just take too long to come back, and this can be a life threatening disease where people develop a renal and liver toxicity all wheel syndrome. And so if you think someone may have this, you'll want to start them on therapy. And then the results of the testing will come back later. Obviously, you also want Thio recommend to your travelers not to be getting into this water that could be contaminated. Another water related issues. Schistosomiasis again? Not very common. There's a huge list of Somalia's because called Katayama fever. And then there's chronic schistosomiasis where people have G I liver and bladder complications later in their life again. Not really that common, but something to think about, especially if they swam in fresh water, especially in places in Africa and in Asia. Those are the places that we really want to warn our patients about. Now I'm gonna move on to bug bites. There's a lot to cover in terms of bug bites. Of course, we're going to tell our travelers not to get bit by any bugs as much as they can. And so here is Case number five, where it's a 68 year old comes back from being in Kanye to your office with fevers, headaches, lethargy and diarrhea. She says she went to Kenya and she wanted to see the Big Five, and she did not unfortunately tell you about this trip. Nor did she get any pre travel counseling or vaccines. She is, in fact, very sick. She's febrile. Um, she is Taqa Kartik. And you get some basic blabs and those are shown here at the bottom of the slide. So my first question, of course, is what is the big five? And if you have traveled to Africa or you have had a patient traveling to Africa, these are the five animals that they are looking to find and photograph during their trip. Of course, there are other things that they may be looking for. Um, that is not one of the animals. It's a parasite. And so in this question, what testing would you consider ordering for this patient who's back from their trip in Africa? So let me give you just a tiny bit of time to think about this, Okay, so we'll move on to the next slide. And this is the malaria smears that you ordered. And you can see that Yes, they are positive. And although she may have wanted to see the Big Five animals, unfortunately she's picked up something else. And that's the parasite of malaria. Most of the cases in the United States travel related cases coming back. The U s have traveled to Africa. That's the primary. A place, Of course. She had a mosquito there on def. She wasn't taking malaria prophylaxis and she was not. Then she developed malaria. I think the main point I really want to dwell on in this slide is that fever, plus any other symptoms and a travel history to a malaria's area, no matter what other diagnostic tests you could consider the number one test we always want to get is malaria smears. People have fever and cough often have malaria. People who have fever and diarrhea can have malaria. Um, if you have fever you coming back from a malarial area, we want three thick and thin smears done. The thick smears is just dropping a drop of their blood on a slide and looking. If there is a parasite there, the thin slide is where you actually smear the blood across the slide. And that is the slide that you really try to determine. Is this fell sick from, or what exact species is it? If you think someone has malaria or, you know, they dio, I would recommend getting an eye de consult or, if you don't have a way to get an I D console. There is the malaria hotline for the CDC. Most deaths due to malaria are due to misdiagnosis, not thinking about it in time or not appropriately, given the treatment that they really need, depending on their species and the location they got this in terms of prevention, of course. Mosquito avoidance. There's a variety of medications that can be used to prevent malaria. I give you the link to the C. D. C malaria travelers drug place, where it gives you all the updated information. There is actually a malaria vaccine now developed. This is not, though, for travelers. This is being rolled out for Children who live in Africa. You can see the efficacy is not great. But what we do believe it will reduce malaria cases and deaths, particularly in Children in these high risk countries. Eso again not for eventually traveler, but something I think. Good to know about that. We do have a malaria vaccine now staying on the same topic of bug bites, you are now confronted with a 69 year old male who says he's going to Cape Town, South Africa, on May may go up to Uganda. Thio, see what's happening there on safari. He says he had a yellow fever vaccine at age 45 when he went to Uganda at that time and he wants to know from you. Does he need another yellow fever vaccine? So here are the choices that you can text in and that is yes, on Lee if he goes up to Uganda or no. Okay, so we're gonna go on to the next slide, and this just shows you yellow fever on Lee can be acquired to general places in the world. And that's in sub Saharan Africa and in South America. And you can see Cape Town is not a risk for yellow fever. But if he did go up to Uganda, yes, he would be at risk for potentially acquiring yellow fever. So these are the geographic areas that we want to consider when we talk to people about yellow fever vaccines. In terms of the question, um, a single dose now is thought to provide lifelong protection for most people. So we used to tell people that you need to get a yellow fever vaccine every 10 years if you're going tohave exposure But in reality, we now know that most people are protected for their life and their Onley a few people. For instance, if you're immuno suppressed around the time that you got the vaccine or you subsequently became immune suppressed that we may need to reconsider whether to give you boosters. Of course, yellow fever is a vaccine that has potential side effects, and so the benefits and risks obviously also has to be considered. But for this particular gentleman, I would tell them that they probably do not need a yellow fever vaccine, even if they go up to Uganda because they've already been vaccinated earlier in life. And if there otherwise healthy, their risk would be very lovable and a vaccine would not being indicated. Yeah, since the 24 year old who comes in with travel from Philippines. You remember that at the beginning of my slide deck, I talked about a gentleman coming in with a rash from the Philippines. Well, this is a woman that is going to the Philippines as well, but she comes back. She has this rash, and she says she got bit by lots of mosquitoes to rash began on her trunk, and she also has very severe back and joint pains as well as high fevers. I'm she has low late lets her white count is somewhat low as well. And if you check your LFTs, they would likely be elevated as well. So going on to the next slide, what do we think is the diagnosis from from this travel related exposure? So we have Danny virus. We have zika virus, we have malaria and we have measles. So I'll ask you to vote. Okay, so a lot of these things, of course you're going to think about you're going to think really about all these things. The measles rashes we talked about starts at the hairline and is diffuse and is really not related thio into mosquito bites. Malaria does not have a rash associated with it. So I would not really entertain malaria in terms of the rash. Of course, we might want to get malaria smears anyway to make sure she doesn't have a couple of things going on. But this turns out to be Danny fever very common in the Philippines in Southeast Asia, and I show you the high risk areas in the world and there are millions of people in the world that live in dang areas on. Many of our travelers will go to one of these areas, so going on to the next slide, this is break bone fever. Patients have severe muscle and backaches. They have high fevers, headaches. They developed this trunk, all diffuse rash. Um, the one thing that know about this and then all these slides I've been putting on incubation period. The other thing that's really helpful here is to think about well, when did they return? And is it long enough? Because sometimes I'll be asked by providers. Patient was in the Philippines 30 days ago and now is back and now is having fever. Well, we know the patient doesn't have Danny fever, because Danny Fever incubation is very short. Um, in terms of complications of this disease, of course, we worry about hemorrhagic complications. This is primarily in patients who have been infected with Danny once, and then they're getting Danny again a second time. Those air the people at highest risk for this severe disease, and we frequently don't see that necessarily in a traveler unless you have a patient who travels a lot diagnostics. I show their treatment is supportive. There is now a Danny vaccine available, but there are a lot of caveats. And here's where the FDA approval for the dengue vaccine is for us persons travelers. And it's really only recommended in people who are going to be living in endemic area for Danny. And it's really Onley for people who have already had Danny once. The risk here and the issue here is something called an antibody dependent enhancement, which is, if you just get the vaccine and you've never been exposed to Danny before and you go to one of these countries and get Danny, it could be a lot more severe because of this antibody dependent enhancement that happens the second time you're seeing Danny antigens. And so here is the recommendations for this vaccine again, it will not be recommended for most of our travelers who are going to permanently reside at endemic area, but I think it's something to be aware of that it does exist, and it does have kind of like the color of vaccine, a specific group of people you may think about now, other things thinking about with this this patient who has this trunk of rash got bit by mosquitoes. I always want to put in a differential. Chikungunya fever. Um, this is a virus that is now across the world, including in Asia, Africa, Central, South America and in the the very, um, the key characteristics of chicken Big Union is the severe, severe, arthritic pains that caused patients. Ah, lot of misery treatment is supporting. We do not have a vaccine for this. And the final virus that I want to talk about very quickly here is Zika virus. It has very fortunately died out through much of the world. We heard so much about Zika virus these last couple of years. But really the caseload now has significantly declined. If you do have a patient going and you're worried about Zika, go to this website. I can't give you the website here. Go up for a search for destination, put in the patient's destination and they will take you to the site of what is the risk of Zika at that area? I think this is very important to still consider for women who are pregnant or who will become pregnant or or men who will be wanting to father a child. We still want to focus on this and think about this. But the risk is much lower. So I'm not going to spend a lot of time today talking about Zika because of the fact that the epidemic has kind of burned out in many locations. Finally, there's other bug bites other than mosquitoes. Here is a sand fly bite patient was in Brazil comes back with this. Um this is Lishman Iesus. The diagnosis here with the biopsy. In this, you should send the biopsy to the C D. C. Who can do culture as well as PCR to confirm Lishman Iesus. Obviously you're going to talkto idea about the best treatment. Uh, prevention of our threat. Arthropod bites are really important. I'm not going to spend any time on this, But this is something we should console Our patients on animal exposures were gonna quickly go through this again. The risk of animal exposures is overall low. I always tell every single one of my travel patients avoid the animals. I don't care if the dog is cute. I don't care if the cat looks. I don't care if I want a picture by this monkey. Really? We want to stay away from the animals as much as we can because we don't know you could get bit. And then you're in this predicament of does the Does the animal have Rabies patients who are very high risk of getting bitten by animals or who are going to go to a different country and work with animals? Then you would recommend I would recommend pre travel three vaccine. Siri's against Rabies. Obviously, if you have a traveler who comes back and they say they've been bit by a dog and you don't know if it's rabid, then you're going to have to consider Rabies post exposure prophylaxis. And I've included the details on this slide. Okay, so finally, I'm going to just talk about sexually transmitted infections very briefly because our travelers also may be at risk for for these. So this is a 28 year old male comes to your office after being in Thailand. He was sexually active with the local people, and he comes in with penile discharge. So my next slide here is going to ask you what test would you order on him for this specific complaint off penile discharge coming home from being in Thailand. Okay, so you can really think about ordering all of these because of the fact that you want to screen him for all STDs. But the answer really is D The urethral nucleic acid amplification tests that would look for gonorrhea so pure, ethereal and your arthritis we really want to think of gonorrhea has a worldwide distribution. I show you the symptoms in the incubation there, the diagnosis and men can be a urine specimen for the nucleic acid test or a urethral swab for the nucleic acid test. If it was a woman and she was having service side IHS or period and vaginal discharge and you were concerned about gonorrhea, then it's a vaginal swab for that woman with the same nucleic acid test treatment to subtract some pluses and throw meson. Ah, The big challenge here is that there are now cases of drug resistant gonorrhea, particularly in Asia, but it's being found in other places in the United States as well as other places in the world as well. Very rare in the United States. So if you have a patient who picks up gonorrhea overseas, and they're not responding to this traditional regimen. You would get a culture and susceptibilities for gonorrhea, and then you'd have to decide based on that, how you could successfully treat that particular patient now moving on to the next slide. Um, in terms of other things that could be picked up. This is syphilis again, worldwide distribution. We think of primary syphilis, which is the painless Shankar. We think of secondary syphilis, which is this macular popular rash of the palms and soles. Of course, some patients may have no symptoms, and you diagnose them with latent. Syphilis, of course, is well, other people may come back later on with CNN s findings, ocular disease, auditory disease and headaches. And so these are things that think about, um, and in terms of the clinical diagnosis of a Shankar, it's usually make clinically. You can think of a dark field microscopy. Sometimes the RPR could be negative early on, so you would just treat that patient later on with secondary tertiary syphilis and latent syphilis. Typically, your R P R will be positive, and you'll treat them accordingly based on the treatment choices below. Finally, HIV HIV also of course, worldwide epidemiology. But we do see patients where travelers coming back from high risk areas with HIV eso something. Also in the differential diagnosis, patients can come back within 14 days of exposure with acute retroviral syndrome, which is a mono like illness. Um, you would detect this really by travel history and exposures during their trip. You we will ask them about any sexual exposures blood exposures if they're using injection drugs. A diagnosis is an HIV antigen antibody fourth generation test if you think they might be in the window period that they just got. You can also order in HIV PCR as well. Starting antiretrovirals immediately on HIV patients is now what we're recommending. I show you the guidelines there of what we're recommending. Big Harvey is probably the most commonly prescribed anti retroviral now in the United States, and then in terms of prevention, of course, you're going to talk to your patients about safe sex, condoms, etcetera. And if you do have a high risk person who is planning to engage in high risk sexual behaviors or a drug user who may be sharing needles, then pre exposure prophylaxis with either Truvada or disco V is what we're recommending in those settings. Pregnant women are at high risk of severe disease if they contract one of these infections during their travel. So people who are traveling pregnant, I think they deserve special and extra time and counseling. Off course, we would probably say, delay your trip till after your delivery. But of course, sometimes that's not possible. And so for them way want to make sure they get the counseling that they're going to need. I hear yeah, how to stay safe. So how to stay safe? A lot of the things I already covered going through the different infections that I talked about being wise, being wise about what you eat and drink. Being wise on animal contact. Which means, I would say no animal contact. Don't swim in freshwater. Don't swim in any water that could have been contaminated with animal urine. Safer. No sex andan, of course. Going to your physician or going to a travelers clinic to get advice, get placed on the appropriate prophylactic medications, for instance, against malaria and getting updated on your vaccines. Great resource is that I use, of course, is the CDC 2020 yellow book that gives you each country what to expect in terms of infectious risk. What prophylaxis should be offered with vaccines should be given. So I will end here and I will take any questions. And I really want to say it's been my pleasure to talk with you today. And, um, I hope that we'll all be able to be traveling in the near future. Most of us are staying home because of Cove it. But in the future, I hope we can all get out there and start traveling again because it's truly wonderful. As long as we protect ourselves against all these unusual things that can happen outside the United States. So thank you. Okay, so the first question I see here is a question about typhoid and Mexico being in California. People going back and forth of Mexico should be immunized against typhoid. Um, I think if they're going into the deeper parts of Mexico on bear going to be with family and friends, that's always a risk factor for typhoid. They're going to their house. They're going to eat food that maybe the people who already live there are kind of used to eating I don't think it's unreasonable to think about that in Our people are just going back and forth between Tijuana. I actually haven't seen really typhoid coming back from that kind of exposure. But if I was having someone going to spend significant amount of time deeper down south into Mexico, I would certainly give them counseling about what to drink and what not to drink and eat. Although I know that it's difficult, especially if they're staying with family and friends in those cases, I'm a considerate but local people just going back and forth to visit some family and friends. I actually haven't been vaccinating against Andi. I think the risk of that would be really low. I have one question. So let's say no yellow fever vaccine 65 to 70 years old. I'm going to Uganda for, um two on a safari. Um, that's a great question. I mean, we we do know that yellow fever side effects of yellow fever vaccine go up as people get older and so there are potential side effects of this vaccine. But if I was the clinician seeing that scenario, I would absolutely recommend yellow fever vaccination, The risk of this vaccine in that age group would be far lower than the possibility of getting yellow fever. And so I would absolutely have vaccinated that gentlemen, if he had never been vaccinated in his life. Yellow fever is often a fatal disease. This is one of these ones that is actually worse than malaria and worse than typhoid. And people do die of yellow fever. And often it's not early recognized, particularly back in the United States. Most people wouldn't have thought about that, and the mortality is very high. So in that scenario, if you are going to a yellow fever endemic area and you haven't been vaccinated, I try to find every reason to give the vaccine. If you can't get the vaccine, you really think the risk is too great. You can try toe, write them a waiver, but I try to actually either give the vaccine or talk them out of that education. Onda talk them into another part of the world that doesn't have yellow fever. Great. Thank you