Various uncommon but severe complications have been reported, especially in newborns and the elderly. Up to half of infected patients go on to develop chronic arthritis.
Arthritis is more common in patients older than 45 years of age, in those with pre-existing osteoarthritis, and in those who had severe joint pain at the time of their initial presentation. Chronic post-chikungunya pain is associated with fatigue, deconditioning, weight gain, and depression, with significant reduction in the quality of life. Multifaceted treatment can help with the various associated comorbidities. Data to guide the management of joint pain are extremely limited.
So far, there is no evidence to support the use of antiviral agents or monoclonal antibodies for treatment. Pain management is important. Short-term steroids often are advised, but supportive data are limited. For the couple percent of patients with inflammatory arthritis, methotrexate is advised, but treatment failures are more common if methotrexate is started after the first year of symptoms.
Biologic agents are not advised because of some infection risk coupled with minimal to no known benefit. What is needed for treatment? Physical therapy is critically important, and one study suggests that Pilates is helpful. Most patients improve significantly with pain control, physical therapy, and functional restoration. Rabies prevention is challenging, partly when choosing who needs pre-exposure vaccination and partly because of the cost of vaccines. In April , the World Health Organization released new guidelines. Pre-exposure prevention is suggested for travelers at higher risk of an animal bite animal workers, children, joggers, long-distance cyclists , especially when post-exposure vaccination might not be readily available.
The pre-exposure vaccine may be provided with two doses separated by a week, either with a total of two intramuscular vaccine doses or with two intradermal doses at different sites on each of the two vaccine administration days; a third dose would be given to immunocompromised patients.
What to pack in your travel medical kit (+ a healthy packing checklist)
As discussed by an expert panel, the current standard in the United States now is for four doses of post-exposure intramuscular vaccine in patients who did not receive pre-exposure vaccination days 0, 3, 7, and , but not given in the gluteal region, with immune globulin as soon as possible after the exposure but certainly within a week of the beginning of vaccination — intramuscularly and especially around the wounds. Smaller volumes of dosing may be used, and the total doses can be dropped to three with cost savings if the vaccine is given intradermally, based on reasonable effectiveness data.
Two doses of post-exposure vaccine without immune globulin are effective to boost protection in travelers who received pre-exposure vaccine. Resistance to common antimicrobials is common in many parts of the world. David Tribble from Uniformed Services University of the Health Sciences in Bethesda, MD, reviewed bacterial resistance to antimicrobials in south and southeast Asia and the relevance of antimicrobial resistance to travelers. Multi-resistant Enterobacteriaceae , Staphylococcus aureus even to vancomycin , and Salmonella Typhi are common, with risk of travelers developing resistant urinary tract infection and difficult-to-treat systemic infections.
Even asymptomatic travelers can transmit resistant germs to relatives and colleagues after returning from their travel. Laura Nellums from London reviewed the impact of antimicrobial resistance in migrants after reminding her large audience that Alexander Fleming predicted antibiotic overuse and resistance in his Nobel Prize lecture 75 years ago.
Worldwide, according to Regina LaRocque from Harvard, 35 billion daily doses of antibiotics are used each year , and antibiotics are essential to the practice of modern medicine. However, antibiotic resistance accounts for as many deaths as influenza, HIV, and tuberculosis combined. Multi-resistant gram-negative organisms are especially prevalent in Asia.
Even in the United States, it is the first not repeated use of an antibiotic that increases the risk of developing resistance. Thus, prevention of antimicrobial resistance can focus on avoiding unnecessary initial prescription of antibiotics. At least some travelers regain their pre-trip microbiome pattern and lose resistant germs over the three months following travel.
With concern for Zika and other travel-related illnesses, Lin Chen and colleagues at a hospital in Cambridge, MA, retrospectively reviewed pre-visit screening for a history of travel outside the United States within the 30 days of the medical visit. Overall, 5, patients had traveled, mostly to Latin America; were of reproductive age and had been to a Zika-endemic area.
Of the patients who had traveled and were hospitalized, 41 had symptoms compatible with Zika such as fever, arthralgia, or rash ; two of them were confirmed Zika-positive. Attention to pre-visit screening and Zika testing might have identified many other patients either with acute Zika infection or at risk of future consequences of Zika infection.
A research group from an experienced Swiss travel clinic randomized patients with gastrointestinal symptoms and blastocystis-positive stool tests to receive metronidazole or placebo. There was no difference in outcomes between the two groups. As with previous studies, these new data suggest that blastocystis is unlikely pathogenic in human intestines. Obviously, the impact of travel extends far beyond infections. Clearly, changing climates are associated with changing risks of infection. Participants thought about wise stewardship of environmental resources in tangible ways.
There were no printed programs for the meeting, reducing paper consumption. Each participant received a commemorative mug at the beginning of the conference, and no cups were provided during meals and breaks. One day of the conference featured only plant-based snacks and meals. Conference participants were tangibly reminded that travel offers positive value and that behavioral choices can mitigate some of the negative environmental consequences of travel.
Reprints Share. Highlights of the 5th International Conference on Travel Medicine. Keywords vaccine. Malaria Artesunate has proven effectiveness in treating severe malaria. Wild poliomyelitis disease is currently exported only by Pakistan and Afghanistan; nevertheless, wild virus and circulating vaccine-derived polioviruses are still present in Nigeria, Guinea, Lao People's Democratic Republic, Madagascar and Myanmar, justifying a booster dose of inactivated poliovirus vaccine if a primary polio vaccination has been administered more than 10 years before; and a complete vaccine series for unvaccinated individuals 42 , A booster polio vaccine dose is advisable even if travel plans exclude those countries, but extend to neighboring places where the virus can reemerge during the long trip.
Cholera vaccines are rarely prescribed for travelers, except during outbreaks, due to their short-term protection. However, the disease remains endemic in countries of Africa, Southeast Asia as well as Haiti. Outbreaks emerged unpredictably 44 , as in Tanzania in 45 and Haiti in after an earthquake However, additional evidence is required to support the recommendation for its use for this indication 48 - Additionally, food and water safety precautions must be followed because of the limited efficacy of some vaccines and against other agents transmitted by the oral route, such as bacteria and viruses causing diarrhea, hepatitis E, worms, and protozoa.
Advisors must consider the consequences of TD, in addition to the growing antibiotic resistance associated with TD 51 , 52 , particularly in those treated with antimicrobials 53 , For that reason, antimicrobials should be restricted to severe disease incapacitating or bloody diarrhea. RWT must be instructed to recognize symptoms of severe diarrhea and to carry antimicrobials for self-administration. Azithromycin is currently the preferred antibiotic because of the widespread resistance to quinolones, particularly in Southeast and South Asia and especially related to Campylobacter spp.
Quinolones and rifaximin are considered alternatives in some guidelines, but must be avoided in dysenteric diarrhea. Loperamide can be used as combined therapy.
If symptoms do not improve in h, patients must seek medical attention Travelers must learn that oral rehydration and salt intake are essential, and carry rehydration packages or learn to produce an oral rehydration fluid with salt and sugar. The recent widespread increase in the incidence of measles, mumps, and pertussis underscores the need for RWT to be up-to-date with routine immunization to protect themselves and the people at their destination Even though the risk of acquiring disease for travelers is considered low 61 , it is a devastating disease. The disease course is often fulminant, which makes the prognosis worse in travelers to remote areas with limited or delayed access to qualified medical care For those going to the African meningitis belt and areas around Rift Valley and Great Lakes, MCV4 vaccine is recommended because of the increased disease prevalence 59 , RWT planning to be in close contact with local populations, including activities in schools or hospitals, or living under crowded conditions, should consider vaccination 61 , 64 , Those with underlying conditions, such as asplenia or other immune deficiencies related to immunoglobulin or complement deficiency, should also be vaccinated because of the increased risk of invasive disease Influenza vaccine can be recommended; however, efficacy may be limited considering the varied viruses circulating across hemispheres.
Advice includes avoiding crowded, enclosed spaces, close contact with individuals with respiratory infections, and washing hands frequently Travelers going to avian flu risk areas in Asia or Southeast Asia should avoid exposure to wild birds and poultry 67 , During trips to the Arabian Peninsula, travelers must avoid contact with camels and their products, such as raw milk, urine or undercooked meat because of the Middle East respiratory syndrome coronavirus Immediate access to appropriate medical care is usually limited, and availability of rabies vaccine and rabies immunoglobulin RIG is uncertain or products are ineffective Most injured travelers in those countries 70 will need to access a neighboring place or their home country to start or continue proper care Therefore, rabies pre-exposure prophylaxis is strongly recommended.
These diseases affect people exposed to lake and river waters. RWT frequently engage in activities in close contact with nature in wild and rural areas. Therefore, advice must include the risks of bathing in fresh water, mainly in areas wherein schistosomiasis is endemic. Considering the unpredictability of risk areas in some countries, screening of possibly exposed travelers on return must be considered Leptospirosis has a worldwide distribution, with a higher incidence in tropical climates, especially after flooding.
Chemoprophylaxis is not generally prescribed; however, those taking doxycycline for malaria prevention will additionally be protected against leptospirosis. Awareness of leptospirosis risk factors will increase chances of early appropriate treatment for this potentially lethal disease Traveling has historically been an important risk factor for acquisition and spread of sexually transmitted infections STIs.
RWT, even those with a partner, need advice about STIs, condom use, and hepatitis B vaccination, and to come for screening after return if they have engaged in casual sex during the trip Medication should cover any preexisting medical conditions and general medications like pain and fever relievers, pre-packed rehydration salts, antacids, decongestants, antihistamines, motion sickness medication, and saline eye and nose drops Narcotic or psychotropic substances are subject to international laws, and lists with the amounts of those medicines allowed by each country must be checked before traveling Travelers must carry medicines in the original containers with clear labels, along with copies of all medical prescriptions in the language spoken at destination or, minimally, in English RWT frequently engage in activities such as scuba diving, climbing and trekking at altitude which require alertness and fine motor coordination.
Such activities can impact some infectious disease prophylactic decisions, such as prescription of mefloquine in those planning activities such as scuba diving or doxycycline for those planning heavy sun exposures These situations require a detailed discussion and more complex planning regarding malaria prophylaxis, sometimes requiring use of different drugs over the trip.
RWT are people embarking on long touristic adventures including risky places, with poorly predicted schedules at the time of consultation. Travel advice for RWT comprises an extensive range of travel medicine expertise. Adherence to malaria prophylaxis among Peace Corps Volunteers in the Africa region, Travel Med Infect Dis. Special infectious disease risks of expatriates and long-term travelers in tropical countries.
Part II: Infections other than malaria. J Travel Med. Part I: Malaria. Visiting relatives and friends VFR , pregnant, and other vulnerable travelers. Infect Dis Clin North Am. General practitioners' perception of risk for travelers visiting friends and relatives. Prevention of malaria in long-term travelers. Illness in long-term travelers visiting geosentinel clinics. Emerg Infect Dis. The respect of recommendations provided in an international travelers' medical service: Far from the cup to the lips.
Intent-to-adhere and adherence to malaria prevention recommendations in two travel clinics. Compliance with long-term malaria prophylaxis in British expatriates. Bauer IL. Educational issues and concerns in travel health advice: Is all the effort a waste of time? Travel clinic consultation and risk assessment. Jungwirth D, Haluza D. Information and communication technology and the future of healthcare: Results of a multi-scenario Delphy survey. Health Informatics J. Problems and risks of unsolicited e-mails in patient-physician encounters in travel medicine settings.
Behrens RH, Carroll B. Travel trends and patterns of travel-associated morbidity. Determinants of compliance with anti-vectorial protective measures among non-immune travellers during missions to tropical Africa. Malar J. Imported malaria : Trends and perspectives. Bull World Health Organ. Immunization in travel medicine. Prim Care. In : Centers for Disease Control and Prevention.
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- Society and the State in Interwar Japan (Nissan Institute Routledge Japanese Studies Series).
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The global threat of counterfeit drugs: Why industry and governments must communicate the dangers. PLoS Med. Schlagenhauf P, Petersen E. Standby emergency treatment of malaria in travelers: Experience to date and new developments. Expert Rev Anti Infect Ther. Guidelines for malaria prevention in travelers from the United Kingdom. London: Public Health England; Updated 22 August ; [Internet]; acessed on: 08 September Genton B, D'Acremont V. Malaria prevention in travelers.
Sensitivity and specificity of dipstick tests for the rapid diagnosis of malaria in non-immune travelers. J Clin Microbiol. Jelinek T. Malaria self-testing by travellers: Opportunities and limitations. Yellow fever vaccine booster doses: Recommendations of the advisory committee on immunization practices, June 19 th Country list. Yellow fever vaccination requirements and recommendations; malaria situation; and other vaccination requirements, Current recommendations for the Japanese encephalitis vaccine.
J Chin Med Assoc. Pavli A, Maltezou HC. Travel-acquired Japanese encephalitis and vaccination considerations. J Infect Dev Ctries. Japanese Encephalitis. In: Centers for Disease Control and Prevention.
International Travel and Health. Japanese encephalitis. Dengue virus seroconversion in travelers to dengue-endemic areas. Am J Trop Med Hyg. Macnamara FN. Zika virus: a report on three cases of human infection during an epidemic of jaundice in nigeria. Tang BL. Zika virus as a causative agent for primary microencephaly: The evidence so far. Arch Microbiol. N Engl J Med. Weaver SC, Lecuit M. Chikungunya virus and the global spread of a mosquito-borne disease. J Assoc Physicians India. Personal protection measures against mosquitoes, ticks, and other arthropods. Med Clin North Am. Prospects for dengue vaccines for travelers.
Clin Exp Vaccine Res. Prevention of sexual transmission of Zika virus. Martin LB. Vaccines for typhoid fever and other salmonelloses. Curr Opin Infect Dis. Gautret P, Wilder-Smith A. Vaccination against tetanus, diphtheria, pertussis and poliomyelitis in adult travellers. The Green Book. Information for public health professionals on immunization. Immunization against infectious disease: poliomyelitis.
Cholera cases report by year and by continent.
Traveler's First-Aid Kit | Johns Hopkins Medicine
Cholera United Republic of Tanzania. Epidemiological Update. Holmgren J, Svennerholm AM. Vaccines against mucosal infections. Curr Opin Immunol. Jelinek T, Kollaritsch H. Vaccination with dukoral against travelers' diarrhea ETEC and cholera. Expert Rev Vaccines. Vaccines for viral and bacterial pathogens causing acute gastroenteritis: Part II: Vaccines for Shigella , Salmonella , enterotoxigenic E.
Hum Vaccin Immunother. Import and spread of extended-spectrum beta-lactamase-producing Enterobacteriaceae by international travellers COMBAT study : a prospective, multicentre cohort study. Lancet Infect Dis. ESBL-producing Enterobacteriaceae in travellers: doctors beware.