Principles of Ambulatory Medicine, 7th Edition

Chapter 41

International Medicine: Care of Travelers and Foreign-Born Patients

Stephen D. Sears

Nathaniel W. James IV

Care of Travelers

International travel is increasing in popularity. Americans are visiting exotic locales and trekking to increasingly remote regions of the world. It is now estimated that 25 to 40 million Americans travel by air to foreign countries each year. Many others take boats, cruises, or cars to Canada and Mexico. Of these millions, it is estimated that 4 to 8 million journey to developing areas of the world where they encounter infectious diseases that are uncommon in developed countries. Malaria, schistosomiasis, yellow fever, polio, typhoid fever, and amebiasis are just a few of the diseases that are more prevalent in tropical developing countries. Many travelers make little or no provision for the prevention of illness while traveling. This is unfortunate because the overall attack rate for several infectious diseases is much higher in international travelers than it is in comparable populations that remain at home (1). This fact is well illustrated by the results of a study of Swiss travelers that found that three-fourths had at least one symptom of infectious illness while traveling; of the 16,500 travelers surveyed in this study, more than 30% had at least one episode of a diarrheal illness. In a followup study, not only were travelers found to have illnesses while traveling, but almost one-third became ill within a month of returning home. Another study of 2,000 travelers returning to the United Kingdom found that 43% became ill during or shortly after their journeys (2). In another review, 75% of travelers did not take sufficient basic precautions against infection (3).

These studies offer a small glimpse into the medical problems of travelers. Even so, there is no reliable measurement of the amount or severity of disease encountered by the traveler. Only a portion of the most dramatic cases of illness in travelers, such as malaria, Lassa fever, or African trypanosomiasis, are usually reported to public health authorities. For instance, outbreaks of leptospirosis (4) and coccidiomycosis (5) only came to light well after the travel-related exposures. Additionally, new illnesses such as severe acute respiratory syndrome (SARS) and avian influenza emphasize the need for global surveillance and a continued review of updated reports on emerging infections. At present, there is no mechanism for obtaining accurate surveillance data on the occurrence of illness in American travelers, nor are there data on significant risk factors for acquiring infectious diseases. This lack of data hampers scientific investigation of interventional strategies in travelers. Even so, significant progress has been made in the prevention of malaria, traveler's diarrhea, and diseases for which immunizations exist.

To prevent unnecessary illness, it is imperative that travelers undertake appropriate pretrip health planning. When approached by a person about to embark upon an international journey, it is important for the clinician to ascertain several key aspects of the proposed trip. Where are you going? Where will you stay? What is the purpose of your trip? Where will you be eating? In restaurants or in private homes? Is sex with other travelers or local residents likely? With this information, one can categorize the types and magnitude of risk. A business person staying for a short time in a first-class hotel in a large city in a developing country has different risks than does a college student who will be living in villages in several developing countries. Most travelers fit somewhere between these two extremes, and a travel consultation must be individualized to fit the traveler's lifestyle, itinerary, medical history, use of medications, allergies, and previous immunizations.

There are several sources for current recommendations. Immunizations, malaria prevention, food and water safety, diarrhea, schistosomiasis, and a number of general health hazards are topics that should be discussed with the traveler. Two useful resources that are updated yearly provide practical information on these issues: Health Information for International Travel, published by the U.S. Public Health Service (available from the Centers for Disease Control and Prevention, Atlanta, GA 30333) and Vaccination

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Certificate Requirements for International Travel and Health Advice to Travelers
, published by the World Health Organization (WHO) (available from WHO Publication Center, 49 Sheridan Ave., Albany, NY 12210). Other valuable resources include the International Association for Medical Assistance to Travelers (IAMAT, 1623 Military #279, Niagara Falls, NY 14304-1745, telephone 716-754-4883), which provides information on tropical diseases and a list of English-speaking physicians overseas, and the Centers for Disease Control and Prevention (CDC) Traveler's Information Hotline (404-332-4559; will fax current information on all regions).

Additionally, travel medicine websites have proliferated. At least 65 websites cover a variety of topics, including consumer advice, professional societies, outbreak updates, traveling with chronic illnesses, epidemiology of infectious diseases, and consumer products. For a partial listing, see Table 41.1.

Immunizations

Vaccines are now available against a number of the major viral and bacterial diseases encountered in developing areas. For patients traveling to these areas, it is necessary to administer travel-specific vaccines and to update primary vaccines (Table 41.2). Immunizations can be broadly separated into those that are legally required and those that are recommended. Legally required vaccinations are public health measures that certain countries demand before entry, to benefit the country as a whole, whereas recommended immunizations are designed to benefit only the patient. No vaccines are legally required to enter or return to the United States. However, many countries have strict entry requirements, and travelers who arrive without proper vaccination certificates may be denied entry, quarantined, or possibly vaccinated at the point of entry. Therefore, it is important to determine what vaccines are required before beginning a journey (6).

Currently, the only legally required vaccination is for yellow fever, and each country has its own requirements. In the past, smallpox and cholera vaccinations were required by many countries, but in 1980, the WHO declared the global eradication of smallpox, and on January 1, 1982, smallpox was deleted from the list of diseases subject to regulation. Although cholera vaccination is not endorsed by the WHO for entry into any country, some local authorities may still require proof of cholera vaccination, especially if the traveler is arriving from endemic areas.

Yellow Fever

Yellow fever, once almost controlled, has made a dramatic resurgence (7). Although generally rare in travelers, two yellow fever deaths in Americans visiting the Amazon Basin were recently reported. Yellow fever vaccine, containing a live attenuated strain of the yellow fever virus, is one of the most important and effective vaccines. It is required by some countries before travelers are allowed

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entrance, particularly when areas to be visited are endemic for yellow fever and when travelers have recently left a country endemic for yellow fever. If yellow fever exists in the country of destination, the traveler should be vaccinated regardless of the regulations of the country (Figs. 41.1 and 41.2).

TABLE 41.1 Travel-Related Websites

 

Website

Authoritative travel medicine recommendations

   CDC Yellow Book

http://www.cdc.gov/travel/yb/outline.htm

   CDC Travel's Health

http://www.cdc.gov/travel/index.htm

   CDC Travel Notices

http://www.cdc.gov/travel/outbreaks.htm

   Health Canada Online

http://www.hc-sc.gc.ca

   Pan American Health Organization

http://www.paho.org/

Databases for travel medicine practitioners

   American Society of Travel Medicine and Hygiene

http://www.astmh.org

   The Medical Letter

http://www.medicalletter.com

   Shoreland's Travel Health Online

http://www.tripprep.com

Consumer websites

 

   Medical Advisory Services for Travelers Abroad

http://www.masta.org

   International Society of Travel Medicine

http://www.istm.org

   Travax Pre Travel Advice

http://www.shoreland.com

Medical assistance for overseas travelers

   International Association for Medical Assistance to Travelers

http://www.iamat.org

   International Federation of Red Cross and Red Crescent Societies

http://www.ifrc.org

   U.S. State Department

http://www.state.gov

   World Health Organization

http://www.who.int/en/

CDC, Centers for Disease Control and Prevention.

TABLE 41.2 Vaccines and Immune Globulin for International Travel

Vaccine/Immune Globulin

Patient Age

Route

Dose

Booster

Comments

Yellow fever

> 9 mo

s.c.

0.5 mL

0.5 mL q10yr

May be required.

Cholera

6 mo–4 yr

s.c. or i.m

0.2 mL

0.2 mL q6mo

May be required.

 

5–10 yr

 

0.3 mL

0.3 mL q6mo

Limited efficacy.

 

>10 yr

 

0.5 mL

0.5 mL q6mo

 

Typhoid parenteral

< 10 yr

s.c.

0.25 mL

0.25 mL q3yr

Local reactions common.

 

>10 yr

 

0.50 mL

0.5 mL q3yr

 

Typhoid oral (TY21a)

> 1 yr

Oral

1 dose q.o.d.×4

Repeat series q5yr

Keep refrigerated, avoid antibiotics.

Typhoid parenteral (ViCPS)

≥2 yr

i.m.

0.5 mL

2 yr

Well tolerated.

Poliomyelitis

 

 

 

 

 

   OPV

All ages

Oral

3 doses

1 dose pretravel

IPV is preferable for adults.

   IPV

All ages

s.c.

3 doses

1 dose q10yr

 

Japanese encephalitis

< 3 yr

s.c.

0.5 mL

1 dose at 1 and 4 yr

Delayed allergic reactions.

 

> 3 yr

 

1.0 mL

 

 

Hepatitis A

 

 

 

 

 

   Havrix

2–17 yr
> 17 yr

i.m.
i.m.

0.5 mL×2
1 mL×2

6–12 mo then 10 yr
6–12 mo then 10 yr

Consider screening for anti-HAV in frequent travelers.

   Vaqta

2–17 yr

i.m.

0.5 mL×2

6–12 mo then 10 yr

 

 

> 17 yr

i.m.

1 mL×2

6–12 mo then 10 yr

 

Immune globulin (short term <3 mo)

< 23 kg
23–45 kg
> 45 kg

i.m.

0.5 mL
1.0 mL
2.0 mL



Immune globulin is used for prophylaxis of hepatitis A; consider screening for anti-HAV in frequent travelers.

Tetanus-diphtheria

>7 yr

i.m.

3 doses

1 dose q10yr

Always use combined vaccine.

Mennomune

>2 yr

i.m.

0.5 mL

Unclear

For specific areas of travel.

Menactra

>3 yr

i.m.

0.5 mL

Unclear

For specific areas of travel.

Rabies

All ages

i.m.

1.0 mL (3 doses)

1 dose q2yr

Still requires postexposure treatment.

 

 

i.d.

0.1 mL (3 doses)

1 dose q2yr

i.d. only approved for HDCV.

Hepatitis B

All ages

i.m.

1.0 mL (3 doses)

Unclear

Protection lasts 5–7 yr.

OPV, oral polio vaccine; IPV, inactivated polio vaccine; HDCV, human diploid cell vaccine.

The vaccine is nontoxic and induces long-lasting immunity. Although the yellow fever vaccine is quite safe, there have been recent reports of rare adverse effects. Therefore, the vaccine should only be given to travelers who will be at risk for yellow fever. Mild reactions occur in 1% to 5% of patients. These include mild headache, myalgia, low-grade fever, or other minor symptoms 5 to 10 days after inoculation.

Because yellow fever vaccine is a live attenuated virus, it could pose a risk to pregnant women, although teratogenicity has not been encountered. Pregnant women who must travel to areas endemic for yellow fever should be vaccinated. It is presumed that the unknown but small risk to the fetus is less than the risk to the mother. If at all possible, the trip should be postponed until after delivery. The vaccine is contraindicated in immunocompromised patients, including patients with acquired immunodeficiency syndrome with CD4 counts below 200. Because the vaccine strain is grown in chick embryo culture, it should not be given to travelers with known hypersensitivity to eggs. Yellow fever immunization is also discouraged in children younger than 9 months of age because of neurotoxicity in infants.

Yellow fever vaccine is available only through official yellow fever vaccine centers; locations of these centers can be obtained by calling the local health department. The dose of vaccine is 0.5 mL subcutaneously. It must be given within 1 hour of reconstitution and should be stored at 41°F (5°C) until it is reconstituted. The vaccine gives solid immunity for at least 10 years. If it is contraindicated for a traveler to receive yellow fever vaccine for any of the above reasons, a detailed letter explaining the contraindications should be provided to the traveler.

Cholera

Since January 1991, more than a million cases of cholera have occurred in South and Central America, and cholera occurs in nearly all developing countries. Additionally, a new cholera epidemic erupted in India in 1992 with a

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non-01 Vibrio cholerae strain (0-139) and has spread rapidly (8). Even so, the risk to travelers remains low, especially for those who use caution in food and water acquisition. In 1973, the World Health Assembly recommended discontinuing required vaccination against cholera. By 1992, all countries had officially discontinued this requirement, but a few in Africa still have unofficial requirements at certain border crossings for travelers coming from areas endemic for cholera. Thus, there is still some possibility of difficulty at borders unless a certificate of vaccination is obtained. Unless the vaccine is legally required, the killed whole cell injectable vaccine is discouraged because it causes excessive local inflammation and is not warranted considering the low risk.

 

FIGURE 41.1. Yellow fever endemic zone in Africa. (From 

Centers for Disease Control and Prevention. Health Information for International Travel, 2003–2004, DHHS, Atlanta, GA

, with permission.)

Travelers in countries outside the United States may wish to take one of the new safe oral cholera vaccines if they travel to high-risk areas. Two recently developed vaccines for cholera are licensed and available in other countries

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(Dukoral from Biotec AB and Mutacol from Berna). Both vaccines appear to provide somewhat better immunity and have fewer side effects than the parenteral vaccine. Of note, no vaccines presently provide protection against the 0-139 strain. For travelers following usual tourist routes and using standard precautions in countries endemic for cholera, the estimated attack rate is less than 1 per 100,000 returning travelers, but recent studies in Japanese travelers suggest that the rate of cholera infection may be much higher than previously assumed (9). The estimated rates are likely

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to be significantly underestimated because many cholera episodes may be not be distinguished from other episodes of traveler's diarrhea, and being treated overseas, they may not be reported to the CDC. Nonetheless, rather than recommend immunization routinely, clinicians should emphatically instruct travelers to areas endemic for cholera not to eat uncooked vegetables, to use caution with undercooked seafood, and always to drink boiled water or bottled beverages. With the continued increases in the worldwide prevalence of cholera coupled with reported antibiotic resistance, the new oral vaccines may become a recommended strategy for travelers in the future (10).

 

FIGURE 41.2. Yellow fever endemic zone in the Americas. (From 

Centers for Disease Control and Prevention. Health Information for International Travel, 2003–2004, DHHS, Atlanta, GA

, with permission.)

Typhoid Fever

Typhoid fever remains a danger for high-risk travelers; more than 70% of the 2,445 cases reported to the CDC in the United States between 1985 and 1994 occurred after international travel (11). Areas with the greatest risk are parts of South America and the Indian subcontinent, although the risk is present in almost all developing countries. Salmonella typhi is transmitted by the ingestion of fecally contaminated food and water. Typhoid vaccination, although not legally required, is recommended for travelers who are likely to stray off the usual tourist route, stay in small villages, and eat local food. With the increasing prevalence of antimicrobial resistance to S. typhi, vaccination takes on even greater significance.

Typhoid vaccines have been available for over 100 years. Two vaccines currently are licensed for protection against typhoid fever: a live attenuated oral vaccine (Ty21a), and a newly licensed capsular polysaccharide parenteral vaccine (ViCPS, Typhim Vi). The older heat-phenol-inactivated parenteral vaccine has been discontinued. The efficacy of these vaccines is 60% to 70% depending on the degree of subsequent exposure. Ty21a is a mutant of S. typhi that produces enough endotoxin to be immunogenic and nonpathogenic and has limited replication. Ty21a is taken as four separate doses over 7 days; it must be refrigerated and is well tolerated, although abdominal cramps sometimes occur with the vaccine. The capsules may be difficult for some to swallow, are contraindicated in children younger than 6 years, and have a theoretical risk in pregnancy, immunocompromised patients, or those with altered gastrointestinal (GI) function. Antibiotics should not be taken during the week that the oral vaccine is being administered.

Typhim Vi is composed of purified Vi (Virulence) antigen, the capsular polysaccharide produced by S. typhi. Primary vaccination with ViCPS consists of one 0.5-mL (25-mg) dose given intramuscularly with boosters every 2 to 3 years. It is safe for immunocompromised travelers, is well tolerated, and is not affected by concurrent antibiotics. The vaccine is not recommended for children younger than 2 years of age because of poor immunogenicity at this age.

Polio

Paralytic poliomyelitis had been eradicated from the Americas (12), and in developing countries outside the Americas polio rates are falling, but travelers should still be protected. Travelers who have previously completed a primary series with either the Sabin (oral, live) or Salk (parental, inactivated) vaccine should have a booster dose if they have not previously received a booster as an adult. A history of at least three doses of oral polio vaccine (OPV, Sabin) or four doses of inactivated polio vaccine (IPV, Salk) with IPV boosters each 5 years until age 18 is evidence of adequate primary immunization. Such fully immunized people need only one dose of polio vaccine before traveling to high-risk areas. If a traveler is only partially immunized, the primary series should be completed.

Adults who require a primary series should receive IPV. Recently, a new IPV of enhanced potency has been released (eIPV). IPV is preferred in adults because the risk of OPV-associated paralysis is somewhat higher in adults than in children. If children are not already vaccinated, they should receive a primary series. New guidelines for primary polio immunization with eIPV rather than OPV have just been released. If an unimmunized adult traveler does not have time to complete a primary IPV series before departure, a single dose of OPV may offer reasonable protection. On return, primary immunization with IPV should be completed. Live (OPV) vaccine should not be given routinely to women known to be pregnant, although teratogenicity has not been shown. If the risk of polio is significant and the pregnant woman is unimmunized, primary vaccination with IPV would be prudent. Because OPV is a live virus, immunocompromised patients and their families should not receive OPV; instead they should be immunized with IPV. Table 41.2 summarizes information regarding dosages for polio vaccines.

Tetanus and Diphtheria

Tetanus occurs worldwide but is slightly more common in the tropics. Many adults may not be protected against tetanus (13), so it is important to keep tetanus immunization up to date in travelers. Boosters must be given every 10 years regardless of age. Travelers, if they injure themselves, are less likely to seek medical help, so adequate pretravel immunization becomes more important. Diphtheria is endemic in many developing countries and is currently epidemic in the countries of the former Soviet Union. Most cases occur in unimmunized or partially immunized people. Therefore, routine immunization with tetanus-diphtheria rather than with tetanus toxoid alone should be given. For primary immunization, patients

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older than 7 years should receive three doses of tetanus-diphtheria. (Before age 7, the primary immunizing agent is the diphtheria-pertussis-tetanus combination.) The first doses are 1 to 2 months apart and the third 6 to 12 months later. Local reactions may occur within 12 to 48 hours after vaccination. Severe local reactions can occur in adults if the booster is given within a short time of the previous vaccine. The only contraindication to tetanus-diphtheria is a history of hypersensitivity reactions after immunization.

Varicella

A live attenuated vaccine against varicella virus (chickenpox) was released in the mid-1990s. Varicella occurs worldwide, is highly contagious, and can be severe in adults. The primary series in childhood is a single dose of vaccine, and in those older than 12 years, it is two doses given 1 month apart. Long-term travelers should be immune; if immune status is not known, serologic testing may be indicated. The vaccine is contraindicated in pregnant women and those with compromised immunity.

Hepatitis A

Hepatitis A (HA) continues to be an important risk for travelers to many areas of the developing world and is the most common vaccine-preventable disease of travelers. Although the risk is less for people who travel on ordinary tourist routes and stay for short periods, it may be considerable for those who bypass the tourist routes and stay for extended periods. HA illness may be asymptomatic but can also be severe, with jaundice and significant morbidity. Protection against HA is strongly recommended for international travelers to developing areas (14). Although immune globulin provides passive protection against HA for a few months and is safe and effective, HA vaccine (active immunization) is generally preferred for most travelers. Two vaccines are licensed, Havrix (SKF) and Vaqta (Merck), and both prevent approximately 90% of expected HA infections. A new combination vaccine for HA and hepatitis B (HB) is also available (see Hepatitis B). Travelers to HA-endemic areas should ideally receive the first dose of vaccine at least 1 month before travel. Recent evidence suggests that vaccine is protective even when given immediately before a trip, although protective antibodies may not be measurable. Immune globulin is less expensive and is still a reasonable choice for travelers making only one trip who need limited (up to 3 months) HA protection. For travelers leaving immediately, administering both immune globulin and HA vaccine is both safe and effective.

The recommended schedules for both Havrix and Vaqta include a primary immunization for all patients and a booster in 6 to 12 months for patients 2 to 18 years of age. A booster for travelers over 18 ensures optimal long-term protection. The dosage of immune globulin may be based on weight, but for adults injection of 2 mL for stays of less than 3 months is adequate in practice. HA vaccines are well tolerated and adverse events are rare. The only side effect of immune globulin is muscle soreness at the injection site. Immune globulins for intramuscular injection prepared in the United States carry no risk of transmission of human immunodeficiency virus (HIV) or other infectious agents, but those produced in developing countries should not be used. Pregnancy is not a contraindication to immune globulin. Screening for anti-HA virus in frequent travelers should also be considered.

Hepatitis B

HB vaccination is now recommended for all infants and adolescents. Although the risk of HB is generally low for the routine traveler, this may be an opportunity to provide this important vaccine. Health care workers who are likely to have contact with blood or secretions from patients in areas endemic for HB should receive the HB vaccine. Travelers who will live for more than 6 months in countries with a high prevalence of HB antigenemia should also be strongly considered for vaccination. The prevalence of HB virus carriers is 5% to 15% in sub-Saharan Africa and Southeast Asia, including China and Indonesia, and 1% to 5% in North Africa, South Central Asia, and Southern Europe. Because HB can be transmitted through sexual contact, travelers should be counseled appropriately when going to endemic areas. Vaccination or HB immune globulin prophylaxis may be appropriate for people who are likely to have sexual contacts. Primary adult vaccination consists of three intramuscular doses of 1 mL of vaccine. The first two doses are given 1 month apart, and the third dose should be given 6 months later. This is often difficult in travelers, and accelerated vaccine schedules have been defined and may be useful for travelers with high exposure risks (see additional details in Chapter 18). A combination vaccine (Twinrix, GlaxoSmithKline) may be given to travelers who need to be protected against HA and HB, as long as there is time to provide two doses (1 month apart) before departure. It is not approved for children.

Rabies

Rabies remains uncontrolled in many areas of the developing world, but the risk to short-term travelers is low (15). Rabies transmission occurs when the rabies virus is introduced into open cuts or wounds, usually through the bite of an infected animal, so counseling on avoidance of animal bites and avoiding street dogs is essential. Pre-exposure rabies prophylaxis, which consists of three inoculations of human diploid cell killed virus vaccine (HDCV), purified chick embryo cell vaccine (PCEC), or rabies vaccine adsorbed (RVA) (1 mL intramuscularly on days 0, 7, and 21 or 28) is appropriate for long-term travelers who will

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live in endemic areas. People who anticipate animal exposure, such as veterinarians, animal handlers, and laboratory workers, should be vaccinated and should also receive a booster dose of vaccine (1 mL) every 2 years. Children are especially at risk because of the increased likelihood of contact with stray dogs. The new vaccines (HDCV, PCEC, and RVA) are more immunogenic and cause fewer reactions than the old duck embryo vaccine. Occasional local reactions and rare systemic reactions such as headaches, myalgias, and dizziness may occur. Vaccine from animal brain tissue is still being used in some developing countries, so if travelers require rabies vaccine, they should be sure to obtain the HDCV, PCEC, or RVA.

The HDCV may also be administered to travelers by the intradermal route (0.1 mL on days 0, 7, and 21 or 28) if the three-dose series is completed 30 days or more before departure. The PCEC and RVA should not be administered intradermally. If there is not sufficient time before departure, one of the intramuscular rabies vaccine should be used. Intradermal rabies vaccine is as immunogenic as intramuscular vaccine, but because the dose is one-tenth of the intramuscular dose, it is less costly. The HDCV should not be administered by the intradermal route when chloroquine or mefloquine, which may interfere with the immune response to the HDCV, is being used.

Pregnancy is not a contraindication to pre-exposure prophylaxis. If the previously vaccinated traveler is exposed to rabies, he or she should still seek medical help for postexposure immunization (see Chapter 18). Any animal bite should be thoroughly cleansed with soap and water to help reduce the risk of rabies.

Tuberculosis

Tuberculosis (TB) continues to be a worldwide health problem, but the risk to the short-term traveler is small. Mycobacterium tuberculosis is primarily a respiratory pathogen contracted by inhaling droplet nuclei, but unpasteurized milk products can also spread the disease. Travelers who will be spending extended periods in TB endemic areas should have a tuberculin skin test before departure. Bacillus Calmette-Guérin (BCG) vaccine use is controversial, and most U.S. experts do not recommend it. Periodic skin tests in long-term travelers are recommended to detect subclinical infections.

Measles, Mumps, Rubella, and Influenza

In most developing and developed countries other than the United States, measles, mumps, and rubella remain uncontrolled. Therefore, children should receive routine immunizations against these diseases before travel. Adolescents and adults who have neither had these diseases nor been immunized against them are at risk of becoming infected while traveling. People born after 1957 should have a booster dose of vaccine if they have not already received it. Rubella vaccine is indicated for females of child-bearing age without serologic evidence of prior rubella infection (see Chapter 18).

Certain travelers may benefit from pretrip vaccination with influenza and pneumococcal vaccine. Influenza causes morbidity and mortality throughout the world and poses a risk to unvaccinated travelers. Influenza vaccination should be considered for high-risk travelers who did not receive influenza vaccine the previous fall if they are traveling to the tropics (where influenza occurs throughout the year), traveling in large tourist groups (which may include persons from areas of the world where influenza viruses are circulating), or traveling to the Southern Hemisphere during April through September. Increasing penicillin resistance in pneumococci throughout the world is also of concern, and pneumococcal vaccine should be given to patients at increased risk. Chapter 18 contains details regarding risk groups, dosages, and schedules for these vaccines.

Japanese Encephalitis

Japanese encephalitis is a mosquito-borne viral encephalitis that occurs in epidemics in much of Asia, including China, and endemically in the tropical areas of Southeast Asia. The risk to short-term travelers and those who confine their travel to urban centers is low. People at greatest risk are those living for prolonged periods in endemic or epidemic areas (Fig. 41.3). A vaccine to protect against Japanese encephalitis is now available in the United States (16). The vaccine (JE-VAX, Japanese encephalitis vaccine, inactivated; distributed by Connaught Laboratories) should be considered for patients planning long-term residence in endemic areas and for travelers visiting rural farming areas or sleeping in unscreened rooms in endemic or epidemic areas. It is especially recommended for people staying more than 1 month in an endemic country. Japanese encephalitis vaccine is associated with a 10% to 20% rate of side effects, including fever, headache, myalgias, and malaise. Serious allergic reactions have also been documented, which may be delayed up to 1 week after immunization. Even so, the vaccine is immunogenic, efficacious, and safe and has been used to vaccinate millions of people. Vaccinees should be observed for 30 minutes after immunization and should be warned about the possibility of delayed allergic reaction. The primary series consists of three subcutaneous injections at weekly intervals, with boosters at 1 and 4 years, and the initial series should be completed at least 3 weeks before departure.

Meningococcal Meningitis

Meningococcal meningitis occurs throughout the developing world, often in devastating epidemics (17). Although

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cases in American travelers are rare, vaccine may be indicated for persons going to countries with high rates of infection. Areas where pretravel immunization has been recommended in the past include Northern India, Nepal, and Kenya. Risk is seasonal in the meningitis belt of Sahel (sub-Saharan Africa), including the dry inland regions of west African countries. Vaccine is required for entry into Saudi Arabia for pilgrims traveling to Mecca for the Hajj. Although meningococcal meningitis epidemics have occurred in Latin America, the prevalent type has been B, a serotype not covered by the vaccine. Two vaccines available for use in the United States are the A, C, Y W-135 Quadrivalent vaccine (Menomune, Connaught) and the newly released conjugated polysaccharide quadrivalent vaccine (Menactra) (18). The dose of vaccine is 0.5 mL given subcutaneously, with boosters recommended between 3 and 5 years.

 

FIGURE 41.3. Reported Japanese encephalitis cases by endemic countries and regions of Southeast Asia where viral transmission is proven or suspected, 1986–2000. (From 

Halstead SB, Tsai TF. Japanese encephalitis vaccines. In: Plotkin SA, Orenstein WA, eds. Vaccines, 4th ed. Philadelphia: W.B. Saunders, 2004

, with permission.)

Miscellaneous Vaccines: Typhus, Plague, Lyme, Anthrax, and Tick-borne Encephalitis

Typhus vaccine is no longer available, and the disease poses little risk except for those working with louse-infected refugees. Anecdotal cases of typhus have been reported in travelers to remote areas and empiric treatment with doxycycline is effective and curative.

Plague exists in certain rural areas in Africa, Asia, and North and South America. Vaccination is not recommended for most travelers, but if the traveler will have direct contact with wild rodents in plague-enzootic areas, vaccination may be considered. Local and systemic reactions after plague vaccine are common. Instead of vaccination, travelers considered to be at high risk for plague due to unavoidable exposures in epidemic areas should consider short-term antibiotic prophylaxis with tetracycline (500 mg twice daily) or doxycycline (100 mg daily). Trimethoprim-sulfamethoxazole (TMP-SMZ) can be substituted in children.

Lyme disease is found in temperate regions of Europe, Asia, and the United States and is generally not transmitted in the tropics (seeChapter 38). A recently licensed vaccine has been withdrawn, but because of genospecies diversity of the infectious agent, Borrelia burgdorferi, it was not likely to be efficacious outside North America. Avoiding tick habitats, using repellants, and checking daily for ticks is the recommended strategy to avoid exposure.

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Tick-borne encephalitis (spring–summer encephalitis) is a viral infection of the central nervous system occurring in western and central Europe, including the countries of the former Soviet Union. Transmission is from infected ticks, but infection can be acquired by consuming unpasteurized dairy products. Effective vaccines are available in Europe but are not licensed in the United States. Available data do not support their use in travelers.

Anthrax vaccine is produced from a culture filtrate of Bacillus anthracis and has been licensed since 1970. Its use is controversial and is confined to military personnel.

Timing of Vaccines

Many travelers see a physician just before their departure. In this situation, all active immunizations can be given concurrently. The simultaneous administration of injectable cholera and yellow fever vaccine may rarely be associated with lower than expected antibody levels to both vaccines. The clinical relevance of this is unknown because injectable cholera vaccine is almost never given. Simultaneous administration of multiple vaccines produces good antibody responses to all the antigens. However, when it is possible, multiple vaccinations should be spread out over time, and all should be completed by 1 week before arrival in a developing country to decrease the likelihood of reactions and to ensure that adequate antibody levels have been attained (19). When vaccines are administered concurrently, they should be given with separate syringes at different body sites. Killed vaccines can be given at the same time as immune globulin. With certain live attenuated vaccines (especially measles, mumps, rubella), passively acquired antibody may interfere with replication of the vaccine virus and poses the possibility of decreasing the efficacy of the vaccine. Therefore, if possible, live virus vaccines should be given at least 14 days before the administration of immune globulin and probably 3 months after administration. Immune globulin does not interfere with yellow fever or OPV, both of which are live.

Malaria Prophylaxis

Malaria is a potentially fatal parasitic disease caused by infection of red blood cells (RBCs) with Plasmodium species. It is usually transmitted by Anopheles mosquitoes but can be acquired from transfused blood and intravenous drug use. Malaria tends to be more severe in “immunologically virgin” travelers than in residents of endemic areas. The disease is characterized by high fevers, chills, sweats, myalgias, and headache with no obvious focal signs or symptoms of infection. Malaria exists worldwide. The risk of contracting malaria varies from country to country and from season to season depending on local conditions such as rainfall, altitude, and mosquito density. Because malaria is almost totally preventable in travelers, there should be no deaths in travelers caused by malaria. Each year, however, American travelers still die because of inadequate protection against malaria. Prevention of malaria requires minimizing mosquito contact and taking appropriate prophylactic medicine (20).

To avoid mosquito exposure, travelers should sleep in screened rooms and under mosquito nets. Anopheles mosquitoes feed predominantly from dusk to dawn. Therefore, travelers who must be out during this time should try to cover the body with clothing and use insect repellent on exposed areas. Long-sleeved shirts, long-legged trousers, and occasionally a face net should be worn if at all possible. Mosquito repellent containing N,N-diethyl-m-toluamide (DEET, 20% to 40%) should be applied to exposed skin. Use of 100% DEET is not recommended and can be toxic for children. Outdoor nighttime activity should be avoided whenever possible. Permethrin, a repellant and insecticide of low toxicity, can be applied to bed nets, clothing, and tents. Permethrin has been shown to decrease clinical malaria cases in African children when applied to bedding. It is available in most pharmacies and sporting goods stores (21).

Even with appropriate mosquito protection, travelers may get bitten by malarious mosquitoes. It is therefore necessary to take an appropriate chemoprophylactic drug (Table 41.3) when traveling to a malarious area. Malaria chemoprophylaxis should preferably begin 1 to 2 weeks before travel and should continue for 4 weeks after leaving the malarious areas. Before deciding on a chemoprophylactic regimen, it is important to obtain recent information regarding country-specific malaria risk. The CDC maintains up to date information that is available by calling 707-488-7788. Regardless of the chemoprophylaxis used, it is still possible to contract malaria. Symptoms of malaria can develop as early as 1 week after initial exposure and as late as several months after departure from a malarious area.

In selecting the appropriate chemoprophylactic agents, several factors must be taken into consideration. The most important consideration is whether the traveler will be at risk of acquiring chloroquine-resistant Plasmodium falciparum (CRPF) malaria.

For travel to malarious areas where CRPF has not been reported or is at a very low level (e.g., Central America), once weekly chloroquine phosphate, 500 mg of the phosphate salt (300-mg base), should be taken. Chloroquine is usually well tolerated, but a few people may experience mild side effects, including itching, nausea, and disorientation. Side effects can be minimized by taking the drug with meals or in divided twice weekly doses. As an alternative, the related compound hydroxychloroquine may be better tolerated. Amodiaquine, another related compound (not available in the United States), should not be used because of associated hepatotoxicity and bone marrow depression. When chloroquine is used for prolonged periods at high dosages, as in the therapy of rheumatoid arthritis, it may be associated with a severe retinopathy.

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This serious side effect is extremely rare when chloroquine is used at the low dosages for malaria chemoprophylaxis. The risk of retinopathy appears to increase after a cumulative dosage of 100 g of base, and periodic retinal examinations should be considered in travelers who have taken this much chloroquine. Chloroquine is safe in pregnant and lactating women and should be recommended to pregnant women traveling to malaria endemic zones.

TABLE 41.3 Drugs Used in the Prophylaxis of Malariaa

Drugs

Adult Dosage

Pediatric Dosage

Chloroquine phosphate (Aralen)

500 mg salt orally, once/wk

5 mg/kg base (8.3 mg/kg salt) orally, once/wk, up to a maximal dose of 300 mg base

Hydroxychloroquine sulfate (Plaquenil)

400 mg salt orally, once/wk

5 mg/kg base (6.5 mg/kg salt) orally, once/wk, up to a maximal adult dose of 310 mg base

Mefloquine

228 mg base (250 mg salt) orally, once/wk

15–19 kg: ¼ tablet/wk
20–30 kg: ½ tablet/wk
31–45 kg: ¾ tablet/wk
>45 kg: 1 tablet/wk

Doxycycline

100 mg orally, once/day

> 8 yr of age: 2 mg/kg of body weight orally/day, up to adult dose of 100 mg/day

Atovoquine/Proguanil (Malarone)

250 mg/100 mg daily, 1–2 days, before and for 7 days after entering malaria area

10–20 kg: ¼ tablet
21–30 kg: ½ tablet
31–45 kg: ¾ tablet

Primaquine

30 mg base (52.6 mg salt) orally, daily

0.6 mg/kg base (1.0 mg/kg salt) up to adult dose orally, daily

For presumptive therapy: pyrimethamine-sulfadoxine (Fansidar)

3 tablets (75 mg pyrimethamine and 1500 mg sulfadoxine orally as a single dose)

5–10 kg: ½ tablet
11–20 kg: 1 tablet
21–30 kg: 1.5 tablets
31–45 kg: 2 tablets
>45 kg: 3 tablets

aSee text for indications according to geographic region and Plasmodium species.

Most malaria endemic areas now have strains of P. falciparum that are resistant to chloroquine, and travelers to these areas (Figs. 41.4 and41.5) are at risk of contracting chloroquine-resistant malaria if chloroquine alone is used for chemoprophylaxis.

Chemoprophylaxis Against Chloroquine-Resistant Malaria

For travel to areas of risk where CRPF exist, three efficacious options exist, which are listed below. Although all three of these regimens are effective, Malarone is becoming increasingly the first choice followed by mefloquine and then doxycycline in special situations. Additionally, there are new recommendations for the use of Primaquine for primary prophylaxis in special situations.

Atovaquone/Proguanil (Malarone)

Atovaquone/proguanil is a fixed combination of the two drugs atovoquone and proguanil. Atovaquone/proguanil primary prophylaxis should begin 1 to 2 days before travel to malarious areas and should be taken at the same time each day while in the malarious area and for 7 days after leaving such areas. The most common adverse effects reported in persons using atovaquone/proguanil prophylaxis are abdominal pain, nausea, vomiting and headache. Atovaquone/proguanil should not be used in children weighing less than 11 kg, in pregnant women, in women with breast feeding infants weighing less than 11 kg or in patients with severe renal impairment.

Mefloquine (Lariam and Generic Brands)

Mefloquine primary prophylaxis should begin 1 to 2 weeks before travel to malarious areas. It should be taken once a week on the same day of the week during travel in malarious areas and for 4 weeks after the traveler leaves such areas. Mefloquine has been associated with rare serious adverse reactions such as psychosis or seizures at prophylactic doses. These reactions are more frequent with higher dosages used for treatment. Other side effects that may occur with prophylactic doses include gastrointestinal disturbances, headache, insomnia, abnormal dreams, visual disturbances, depression, anxiety disorder, and dizziness. Mefloquine is contraindicated for frequent use in travelers with active depression or a history of psychosis or seizures. It should be used with caution in persons with psychiatric disturbances if at all. Although it appears that mefloquine is safe for individuals on beta blockers, it should not be recommended for persons with cardiac conduction abnormalities. Mefloquine resistance is increasing and either doxycycline or Malarone can be used by travelers to these areas (the borders of Thailand with Burma and Western Cambodia and Eastern Burma (Fig. 41.6).

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FIGURE 41.4. Malaria endemic countries in the Americas 2002. (From 

Centers for Disease Control and Prevention. Health Information for International Travel, 2003–2004, DHHS, Atlanta, GA

, with permission.)

 

FIGURE 41.5. Malaria endemic countries in Africa, the Middle East, Asia and the South Pacific 2002. (From 

Centers for Disease Control and Prevention. Health Information for International Travel, 2003–2004, DHHS, Atlanta, GA

, with permission.)

Doxycycline (Many Brand Names and Generic)

Primary prophylaxis with doxycycline should begin 1 to 2 days before travel to malarious areas. It should be continued once a day, the same time each day during travel in malarious areas and daily for 4 weeks after leaving such areas. There is insufficient data that related compounds such as minocycline and other tetracyclines are effective against malaria. Persons on long term regimens of minocycline for acne should stop taking the minocycline 1 to 2 days prior to travel and start doxycycline instead. Doxycycline can cause photo sensitivity usually manifested as an exaggerated sunburn type reaction. The risk of such a reaction can be minimized by avoiding prolonged direct exposure to sun and by using sunscreens (Chapter 118). Additionally, doxycycline use is associated with an increased frequency of Candida vaginitis in women. GI side effects including nausea and vomiting may be minimized by taking the drug with a meal. To reduce the risk of esophagitis, travelers should be advised to not take doxycycline before going to bed.

Primaquine

In rare instances and after consultation with malaria experts such as those available through the CDC malaria hotline, primaquine may be used for primary prophylaxis to

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travel areas with or without chloroquine resistant P. falciparum. This use should generally be reserved for travelers unable to take any of the other chemoprophylactic regimens indicated for their region of travel. Prior to taking primaquine the traveler must have a documented level of glucose 6-phosphate dehydrogenase (G6PD) in the normal range. Primaquine primary prophylaxis should begin 1 to 2 days before travel to malarious areas, be taken daily at the same time each day while in the malarious area and daily for 7 days after leaving such areas. Of note, the CDC no longer recommends chloroquine/proguanil (Paludrine) as a preventive option for persons traveling to areas withchloroquine-resistant P. falciparum. Although not yet approved, recent evidence suggests that azithromycin 250 mg daily may also be an effective and safe agent for chloroquine resistant P. falciparum prophylaxis (22).

 

FIGURE 41.6. Mefloquine resistant malaria. (From 

Centers for Disease Control and Prevention. Health Information for International Travel, 2003–2004, DHHS, Atlanta, GA

, with permission.)

Chemoprophylaxis for Infants, Children, and Adolescents

Infants, children, and adolescents of any age can contract malaria. Therefore, children traveling to malaria risk areas should take an antimalarial drug. In the United States antimalarial drugs are available only in tablet form and may taste quite bitter. Pediatric dosages should be carefully calculated according to body weight and should never exceed adult dosages. Pharmacists can pulverize tablets and prepare gelatin capsules for each measured dose (Table 41.3).

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Chemoprophylaxis during Pregnancy

Malaria infection in pregnant women can be more severe than in nonpregnant women. Malaria can increase the risk for adverse pregnancy outcomes including prematurity, abortion, and stillbirth. For these reasons and because no chemoprophylactic regimen is completely effective, women who are pregnant or are likely to become pregnant should be advised to avoid travel to areas with malaria transmission if possible. If travel to malarious areas cannot be deferred, the use of an effective chemoprophylactic regimen is essential.

Changing Prophylactic Medications

The medications recommended for prophylaxis against malaria have different modes of action that affect the parasite at different stages of the life cycle. Thus, if the medication needs to be changed because of side effects prior to the completion of a full course, there are some special considerations. If a traveler starts prophylaxis with a medication such as mefloquine or doxycycline and then changes to atovaquone/proguanil during or after travel, the standard duration of therapy would be insufficient. The atovaquone/proguanil should be continued for 4 weeks after the switch or 1 week after returning, whichever is longer. In situations where malaria chemoprophylaxis is complex or involves pregnant women or small infants, it is best to consider calling the CDC malaria hotline (770-488-7788) for up-to-date guidance.

Travelers who decide to take chloroquine alone in areas of chloroquine resistant P. falciparum should take with them a treatment supply (three tablets) of pyrimethamine-sulfadoxine (Fansidar). These travelers are at risk of chloroquine resistant P. falciparum and should be advised to take the Fansidar promptly if they have a febrile illness and can not obtain medical care (Table 41.3). Mefloquine should not be used for self-treatment because of the likelihood of dosage-dependent side effects.

Routine malaria prophylaxis with chloroquine or mefloquine does not prevent delayed attacks of malaria from Plasmodium vivax orPlasmodium ovale because these species have an extraerythrocytic chronic liver phase that is not eradicated by these two agents.Primaquine is an 8-aminoquinolone drug that is effective against the chronic liver forms of vivax and ovale malaria. For travelers with minimal mosquito exposure and short stays in endemic areas, primaquine is not routinely indicated. However, primaquine prophylaxis should be considered in travelers who have had extended stays in areas endemic for either P. vivax or P. ovale malaria and who have had significant mosquito exposure. Primaquine, 15 mg of base daily for 14 days, is usually given during the last 2 weeks of chloroquine chemoprophylaxis. Primaquine can cause hemolysis in people with G6PD deficiency and has several other potential side effects, such as headache, nausea, vomiting, and gastrointestinal distress. Before treatment with this drug, the patient's G6PD status should be determined.

Food and Water

The traveler should learn the mantra for food and water safety: “boil it, cook it, peel it, or forget it.” Food and water are the most common vehicles for the introduction of infectious agents into the body. It is best for the traveler to the developing world to consider any uncookedfood and any product containing unpasteurized milk as possibly contaminated and therefore not safe to consume. Meats can harbor pathogens such as Trichinella spiralis and Taenia solium and Taenia saginata. Raw or undercooked freshwater fish and crustaceans can transmit liver flukes and tapeworms. Even after foods have been cooked, it is imperative that food is properly stored. Food held at ambient temperatures is a medium in which bacterial pathogens can multiply rapidly. Creamy desserts are often vehicles for Salmonella and staphylococcal food poisoning and should be avoided in areas with poor refrigeration (see Chapter 35). Fruits that can be peeled are safe as long as they are peeled by the consumer just before eating. The traveler should be wary of cheese products made from unpasteurized milk as possible sources of Brucella and other enteric pathogens. Salads should be avoided because lettuce and leafy vegetables are difficult to clean properly and often harbor infectious parasite eggs, cysts, and bacteria.

Although water may be safe in hotels in large cities, only water that has been adequately boiled or chlorinated should be considered safe to drink. If the traveler is uncertain about the purity of the water, it should be boiled. Routine chlorination may not kill all parasites. In areas where purified water is not available or where hygiene and sanitation are poor, travelers are advised to drink only the following beverages: those that use boiled water, such as hot tea or coffee; canned or bottled carbonated beverages, including carbonated bottled water and soft drinks; and beer or wine.

Boiling is by far the most reliable method of making water safe to drink. If the water contains sediment or floating matter, it should be strained with a cloth before boiling or chemical treatment. The water should be boiled vigorously for at least 10 minutes to kill cysts, viruses, and bacteria and then allowed to cool to room temperature. If boiling is not possible, water can be chemically disinfected with tincture of iodine or tetraglycine hydroperiodide tablets. The purification tablets can be purchased from a pharmacy or a sporting goods store. The traveler should follow the manufacturer's instructions. If the water is cloudy, the number of tablets should be doubled. If the water is extremely cold, it should be allowed to warm up before the tablets are added. Tincture of iodine should be used as follows. Per quart or liter of water, for clean water, use 5 drops and let sit

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30 minutes. For cloudy or cold water, use 10 drops and let sit several hours.

Water may also be adequately purified by the use of small portable water filters that are available in sporting goods stores. These remove all water-borne parasitic and bacterial agents and some remove viruses. The water can be consumed immediately after treatment.

It should be remembered that where water may be contaminated, ice (as well as containers for drinking) should also be considered contaminated. If at all possible, boiled or bottled water should be used for making ice, rinsing drinking vessels, and brushing teeth. If boiled or bottled water is unavailable, the hot water tap can be used as a last resort. Although many infectious agents do not grow at these temperatures, hot tap water is by no means completely safe.

Diarrhea

Diarrhea is the most common illness among travelers to developing countries, occurring in 30% to 60%, and it affects the enjoyment of the trip for many people. Most cases do not pose a serious health threat; however, some episodes are severe and may lead to dehydration. Cases occur when fecally contaminated food or water is ingested, so the precautions mentioned above for food and water should be followed. Even with good personal hygiene and avoidance of suspect food and water, the attack rate for traveler's diarrhea remains high. Approximately 70% of episodes are caused by bacterial agents, with more than 50% caused by enterotoxigenic Escherichia coli. Less common etiologies include protozoa and viruses, but no organism is found in 10% to 40% of cases (Table 41.4). Because the causative agents can be assumed to be bacterial three fourths of the time, several strategies to prevent bacterial diarrhea or to treat it early have been studied (23).

Prophylaxis

A consensus conference on traveler's diarrhea held at the National Institutes of Health (NIH) recommended against the routine use of prophylactic antimicrobials (24). The potential risk of adverse reactions to the prophylactic agent was thought to outweigh the benefits. Although routine prophylaxis was not thought to be appropriate, it was also concluded that some travelers may wish to consult with their physician and may elect to use prophylactic antimicrobial agents for travel under special circumstances, once the risks and benefits are clearly understood. The antimicrobials that have been used in this way include ciprofloxacin (250 or 500 mg/day), norfloxacin (400 mg/day), ofloxacin 300 mg/day, levofloxacin 500 mg/day, doxycycline (100 mg/day with meals), and TMP-SMX (one double-strength tablet daily), continued for 2 days after departure from a developing country. Global resistance is increasing and quinolones are generally preferred (25). If prophylaxis is used, it should be limited to less than 3 weeks, and the quinolones listed are preferred in most cases because of the excellent coverage for the enteric pathogens, with consequent high efficacy rates (prevents more than 95% of expected illness) and low rate of adverse reactions. If doxycycline is being used for another indication (e.g., malaria prophylaxis or acne), additional antidiarrheal prophylaxis is not needed; because of possible photosensitivity, people taking doxycycline should wear hats and garments that prevent sun exposure.

TABLE 41.4 Common Causes of Traveler's Diarrheaa

Bacteria

Protozoa

Viruses

(50%–70%)

(0%–20%)

(0%–20%)

Escherichia coli

Giardia

Rotavirus

Campylobacter

Entamoeba

Calicivirus

Salmonella

Cryptosporidia

Enterovirus

Shigella

Cyclospora

 

aNo organism found (10%–40%).

Pepto-Bismol, anonprescriptionproductcontainingbismuth subsalicylate, can also prevent approximately 65% of diarrhea episodes; the dosage is two tablets four times a day with meals. Pepto-Bismol turns the tongue and stools black, and it may cause tinnitus.

Examples of travelers who would benefit from prophylaxis are those with pre-existing medical conditions (e.g., cardiovascular disease) that would place the person at great risk if diarrhea and even mild dehydration develop. Prophylaxis is also sometimes appropriate for people who will be at high risk for a very limited time (e.g., volunteers in a refugee camp for less than 3 weeks).

Treatment

Most cases of diarrhea are self-limited and may require only rest and replacement of fluids and salts. This can best be accomplished with oral rehydration solution (ORS; e.g., CeraLyte, Cera Products, Inc., Columbia, MD), but certain home-available fluids (e.g., juices, soups) can also be used. Especially when diarrhea is severe, ORS should be used because it contains a complete formulation to replace the needed electrolytes in the appropriate concentrations. The traveler should drink a volume of ORS to approximate the volume of diarrhea losses, although an exact balance of intake and output is not necessary. If no commercial ORS is available, a similar solution can be made by adding one-half teaspoon salt, one-half teaspoon baking soda, and 4 tablespoons sugar to 1 pint (500 mL) water. (If baking soda is not available, 1 teaspoon salt should be used.) The electrolyte concentrations of fluids for sweat replacement

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(e.g., Gatorade) are not equivalent to ORS. Any ORS remaining after 24 hours should be discarded because there is a chance of bacterial contamination.

TABLE 41.5 Chemoprophylaxis and Treatment of Traveler's Diarrhea

Drug

Dose

Prophylaxis

 

   Bismuth subsalicylate

Two 262 mg tablets chewed q.i.d. with meals and at bedtime

   Quinolone antibiotics

 

      Norfloxacin

400 mg/day

      Ciprofloxacin

500 mg/day

      Ofloxacin

300 mg/day

      Levofloxacin

500 mg/day

      Doxycycline

100 mg/day

Treatment

 

   Loperamide

4 mg loading dose, then 2 mg after each loose stool, to a maximum of 16 mg/day

   Quinolone antibiotics

 

      Norfloxacin

400 mg b.i.d. for up to 3 days

      Ciprofloxacin

500 mg b.i.d. for up to 3 days

      Ofloxacin

300 mg b.i.d. for up to 3 days

      Levofloxacin

500 mg/day for up to 3 days

      Azithromycin

1,000 mg single dose or 500 mg/day for 3 days

      Rifaximin

200 mg t.i.d. for 3 days

Early antimicrobial treatment with ciprofloxacin (250 or 500 mg twice daily), levofloxacin (500 mg daily), norfloxacin (400 mg twice daily), doxycycline (100 mg twice daily), or TMP-SMX (one double-strength tablet twice daily) will shorten the episode caused by susceptible strains of bacteria (Table 41.5). Generally, the drug should be started soon after diarrhea begins and continued for 3 days, although a single dose of ciprofloxacin (500 mg) or levofloxacin (500 mg) has been shown to be effective (26). Recently, campylobacter resistant to quinolones has been increasing in prevalence. Preliminary studies suggest that azithromycin 500 mg daily may be effective therapy for this organism and for traveler's diarrhea in general. If the illness is thought to be shigellosis on the basis of signs and symptoms (blood in the stool, fever, and severe cramps), one of the quinolones for 5 days is the regimen of first choice; the second choice would be TMP-SMX for 5 days. Most shigellae are resistant to tetracyclines and sulfa, however. A new approach to the treatment of traveler's diarrhea has been the development of antimicrobial agents that are poorly absorbed. Rifaximin (Xifaxan, 200 mg by mouth twice a day for 3 days) is a nonabsorbable locally active agent effective against enteric pathogens. Early studies with rifaximin look highly promising.

Antimotility drugs such as diphenoxylate/atropine (Lomotil) and loperamide (Imodium) may provide temporary relief when diarrhea is especially inconvenient, such as during a long bus trip or other emergent situations. There continues to be concern that dysentery can be prolonged if antimotility drugs are used, and these agents should be used with care (if at all) with fever or dysentery because of potential clinical deterioration with an invasive bacterial pathogen. They have been used together with antimicrobial agents such as the quinolones to provide more rapid relief than might occur with the antimicrobial alone; however, the improvement is marginal. If loperamide (no prescription needed), which does not cause atropine-like side effects, is used, the dose is two 2-mg tablets after each voluminous watery stool.

Bismuth subsalicylate (Pepto-Bismol) is also helpful, although large amounts are needed to significantly reduce diarrhea. The dosage is 30 mL liquid (or two tablets) every half hour to 1 hour, up to eight doses in 24 hours. Precautions with this drug include complications caused by the salicylates it contains and by the fact that it binds tetracyclines. Kaopectate, Entero Vioform, and Streptotriad are not efficacious and should not be used.

The choices among the modalities described above should be based on the patient's symptoms. Fluid replacement should be encouraged for any episode of diarrhea and is all that is necessary in mild cases. For diarrhea of moderate severity (two to three unformed stools per day, no fever, no symptoms of frank dysentery, e.g., severe crampy pain or bloody stools), nonspecific symptomatic therapy may be all that is needed. Either bismuth subsalicylate or loperamide is useful. Antimicrobial agents should be used only for moderately severe to severe illness (more than four unformed stools per day, mild fever, dysentery). Some travel experts advocate taking antimicrobial agents at the first sign of diarrhea to minimize the length of the illness episode. Balancing adverse drug effects with symptomatic relief is the goal.

For diarrhea that is very severe, is associated with repeated vomiting, or does not improve after several days, the traveler should be advised to consult a physician rather than attempt self-treatment. A doctor should also be consulted if there is blood in the stool; if there is a fever higher than 101°F (38.3°C), especially if accompanied by shaking chills; or if antimicrobial therapy does not provide rapid improvement.

Finally, in preparation for possible diarrhea, the traveler should be reminded that toilet tissue is difficult to find in many developing countries and that it is prudent to take a supply. Chapter 35 contains additional information regarding the pathogenesis, epidemiology, and treatment of diarrheal illnesses.

Schistosomiasis

Schistosomiasis is one of the world's major public health problems. Three predominant species exist (Schistosoma

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mansoni, S. japonicum
, and S. haematobium) and are found worldwide (Fig. 41.7). Although few travelers are aware of schistosomiasis, it is a common disease in much of the developing world (27). After infection, the disease may lie dormant until it causes problems later in life. People contract schistosomiasis by wading or swimming in fresh or estuary water that harbors the snail vector of this trematode parasite. The cercariae (larval stage) can penetrate the skin and pass into the bloodstream without causing any symptoms at the time. Symptoms that may occur with schistosomiasis depend on the stage of the infection. Sometimes, there may be a rash at the site where the cercariae invaded, but this is uncommon. About 4 or 5 weeks after infection, an episode of fever, cough, and general malaise may occur. Still later (6 months to several years), more severe complications may occur, usually related to liver or urinary tract disease.

 

FIGURE 41.7. Geographic distribution of Schistosomasis. (From 

Centers for Disease Control and Prevention. Health Information for International Travel, 2003–2004, DHHS, Atlanta, GA

, with permission.)

In recent years, severe cases of schistosomiasis have occurred in Americans after river rafting in Ethiopia and after swimming in fresh water in Kenya. Although treatment has improved with the advent of praziquantel, it is better to advise travelers to avoid fresh water contact in endemic areas and thereby prevent disease acquisition. For a returning traveler who has been exposed to fresh water in a schistosome-endemic area, screening tests, including a complete blood count (CBC) and specific serology, may be useful. This is particularly important in a patient with unexplained systemic symptoms. Eosinophilia in the peripheral blood may be present during the initial stages of the parasitic infection, although it is not a constant finding in late chronic infections. Positive serology indicates likely exposure, especially in the nonimmune traveler. If serology is positive, a further laboratory evaluation including urinalysis and stool examination for ova should be undertaken, recognizing that the acute syndrome described above may occur before there is detectable egg excretion. Proven or strongly suspected acute schistosomal infection requires treatment with praziquantel (Biltricide), which

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is effective in early schistosomal infection. This drug is supplied in 600-mg tablets, scored so that they can be broken into four 150-mg units. Treatment is accomplished in 1 day by giving a single dose of 40 mg/kg for S. mansoni or S. haematobium and three doses (20 mg/kg each) 4 to 6 hours apart for S. japonicum.

 

FIGURE 41.8. World distribution of dengue, 1996. (From 

Centers for Disease Control and Prevention. Health Information for International Travel, 2003–2004, DHHS, Atlanta, GA

, with permission.)

Dengue

In recent years the incidence of dengue fever has increased dramatically in most of the countries in the Caribbean (Fig. 41.8). Dengue fever is a mosquito-borne viral illness transmitted by Aedes aegypti mosquitoes. It also occurs in parts of tropical Asia, Africa, and the Pacific (28). Dengue fever is characterized by sudden onset of high fevers, severe frontal headaches, joint and muscle pains, and a general feeling of malaise. In addition, many patients have nausea, vomiting, and a maculopapular rash that typically appears 3 to 5 days after the onset of fever. The rash may spread from the trunk to the arms, legs, and face and generally is benign and self-limited, although prolonged convalescence is often seen. Most dengue is subclinical or nonspecific in presentation, but it may also present as a severe and fatal hemorrhagic disease, called dengue hemorrhagic fever. Currently, there is no specific treatment for dengue and vaccines are not available. Travelers to areas where dengue is endemic therefore need to take precautions to avoid mosquito bites (see Malaria Prophylaxis, above). Unlike the Anopheles mosquito (malaria vector), which is a nocturnal biter, the Aedes mosquitoes (dengue) are out and feeding during the day. In addition, Aedes are well adapted to an urban environment, breeding in trees, cans, and wells near human dwellings. Because increasing numbers of travelers have become ill with dengue, precautions to avoid mosquito exposure need to be rigorously followed when endemic areas are visited (29).

 

FIGURE 41.9. Time zones (jet lag typically occurs when five or more zones are crossed). GMT, Greenwich meridian time. (From 

Walker E, Williams G, Raeside F, et al. ABC of health travel, 5th ed. London: BMJ Publishing Group, 1997

, with permission.)

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Miscellaneous Health Concerns

Human Immunodeficiency Virus-Infected Traveler

Infection with HIV should not preclude travel. However, health risks for the HIV-infected traveler require special considerations (30). The efficacy of vaccination, the risks of live virus vaccines, the risk of acquiring enteric infections, and the late expression of latent infections such as TB, malaria, and fungal diseases require careful pretrip counseling (for details on HIV infection, see Chapter 39). HIV-infected travelers can receive the usual vaccines if the CD4 count is above 200, but live vaccines should not be given if the count is lower (31).

Air Travel and Jet Lag

Recent studies suggest an increased risk of venous thromboses in air travelers. Prevention by stretching and walking during flights should be encouraged. Cabin pressure is generally maintained at altitudes of approximately 8,000 feet, which lowers the PaO2 to between 60 and 70 mmHg in healthy travelers. Individuals with chronic lung disease may need supplemental oxygen. Those with recent myocardial infarction or significant underlying cardiovascular compromise should generally avoid travel unless absolutely necessary (32).

Jet lag seems to be nearly universal for travelers traversing several time zones (Fig. 41.9), although some seem to be more affected than others. Traveling eastward is associated with increased jet lag compared with traveling west. More than simple travel fatigue, jet lag occurs when the body's physiologic clock has not yet adjusted to the new time zone. Symptoms include sleepiness during the daytime, lying awake and hungry at night, and often a feeling that one's thinking processes are not quite normal. Several days to a week are usually needed to recover completely from jet lag.

Although time is the only cure, a few suggestions seem to help. Patients should be advised to avoid overeating and excess alcohol ingestion during air travel and to keep a light snack handy for middle of the night hunger. Before a long trip, travelers can adjust by going to bed 1 hour earlier or later for each time zone crossed. Also, they should be advised to try to schedule a day of rest after passing six or more time zones before proceeding with their business or vacation. Travelers should be encouraged to adjust to local times for eating and sleeping as soon as possible after arrival. Taking a mild sleeping medication before bed for 2 or 3 days may also help to get back on schedule (see

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also Chapter 7). Melatonin, a hormone produced in the pineal gland from tryptophan, is a potent modulator of circadian rhythms and has been investigated as a prophylactic agent for jet lag (33). Melatonin has a hypnotic effect and is presently marketed in the United States as a dietary supplement and is not regulated for purity and concentration by the Food and Drug Administration (FDA). Using melatonin for jet lag remains controversial because of concern about long-term safety and efficacy. Proponents of melatonin suggest a dosage of 3 to 5 mg taken on an eastward trip at 3:00 a.m. “destination time” for 3 days before departure and at bedtime for 4 nights after arrival. For westward journeys, 3 to 5 mg should be taken at local bedtime for 4 days. Melatonin preparations are available without prescription. For short-term use such as for jet lag, it appears safe.

Accidents

The major cause of serious morbidity and leading cause of mortality in travelers to the developing world is accidents, especially involving motor vehicles (34). In many developing countries vehicles are in disrepair, drivers are inexperienced, and common sense rules for driving are not followed. Other major accidents include drowning, electric shocks, and trauma associated with dangerous sports (hang gliding, whitewater rafting). Injury prevention strategies should be part of routine travel advice (35). Defensive driving is a must. In developing areas, roads are generally not as well built as in developed areas, road hazards are common, and often animals sleep in the roads at night. Compounding the problems of accidental trauma is the usual lack of a developed emergency medicine infrastructure. Many countries have no formal emergency transport system, and hospital supplies are often lacking. Blood is often not available or not carefully screened, and quality control is not available. For serious trauma, it is often best to arrange transport to a medical facility in or operated by a developed nation.

Injectable Medications and Blood Transfusions

Travelers should be advised to avoid, if possible, receiving any injectable medication or blood transfusions when traveling in the developing world. Both HB and HIV can be readily transmitted by this route because needles and syringes may not always be sterilized properly. In addition, blood in most developing countries is not routinely screened for HIV (and may also not be screened for HB).

Motion Sickness

Travelers with a history of motion or sea sickness can attempt to avoid these symptoms by taking one of the antihistamines useful for this problem or ginger root derivatives (36). There are a number of medications available for symptom control, but in a recent study of whale watchers in the North Sea, meclizine, cyclizine, diphenhydramine, and ginger root (given as candy or in a 250-mg tablet) were found to have equivalent efficacy (37). Chapter 89 contains further details.

Swimming and Bathing

Swimming in contaminated water may result in eye, ear, skin, and some intestinal infections. Wading, washing, and swimming should be avoided in water that is likely to be infested with the snail hosts of schistosomiasis (see above) or with human sewage or with animal urine that may contain Leptospira. Generally, only chlorinated pools should be considered safe places to swim in developing countries. Ocean beaches may be safe, if not contaminated by sewage, but bathers should be advised to wear light shoes to protect against exposure to coral and other contact hazards.

Insects

The bites, stings, and contact of some insects cause unpleasant reactions. Many insects, such as mosquitoes, can bite and transmit disease without the traveler being aware of the bite. Insect repellents, protective clothing, and mosquito netting, which prevent the bite of insects, are the best prevention for some communicable diseases, particularly malaria (see Malaria Prophylaxis). The same personal protection measures used against mosquitoes will protect against ticks and biting flies. Travelers therefore should take a supply of insect repellent cream, lotion, or spray and permethrin.

Sunburn

Sunburn is a particular hazard in tropical and high-glare environments. Sunshades, sunscreens (see Chapter 118), broad-brimmed hats, and protective clothing are important preventive measures. Many sunscreen lotions must be reapplied after bathing or heavy perspiration. For maximal protection, travelers should apply all sunscreen products before going outside. A small percentage of people who take the tetracycline antibiotics (including doxycycline) may develop an exaggerated burn after exposure to the sun; this may be important if this antibiotic is being taken daily for diarrhea or malaria prevention.

High Altitude

High altitudes can be a problem for people with pre-existing heart or lung disease, and portable oxygen may be advisable for these situations. Rapid exposure to altitudes more than 8,000 feet above sea level can cause serious medical problems. The incidence and severity of mountain sickness are related to the altitude, rate of ascent, and

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prior acclimatization. Initial symptoms include dizziness, headache, extreme fatigue, chilliness, nausea, and vomiting. More severe symptoms may also occur, most commonly difficulty in concentrating, extreme shortness of breath, and more severe headache. In most people, symptoms are mild and clear within 24 to 48 hours. If symptoms persist or are severe, a return to lower altitude may be required. Administration of oxygen generally relieves acute symptoms. Preventive measures include adequate rest before travel, avoidance of alcohol and tobacco, and decreased physical activity at high altitude.

The carbonic anhydrase inhibitor acetazolamide (Diamox) has been shown to reduce the time needed for acclimatization to high altitudes. It is prescribed at a dosage of 125 to 250 mg two to three times a day beginning 1 day before ascent and continued for 2 to 3 days after ascent. Dexamethasone is also effective in minimizing altitude sickness. In a recent report, both acetazolamide and dexamethasone (2 mg four times a day or 4 mg twice daily) were effective and reasonably well tolerated, although depression after dexamethasone withdrawal has been observed. Nifedipine may prevent high altitude pulmonary edema but has not been shown clearly to prevent or treat altitude sickness (38). Although acetazolamide is considered the drug of choice for the prevention of high altitude sickness, the definitive treatment consists of moving to a lower altitude as soon as possible. Acetazolamide should not be used by sulfa-allergic people.

Snakes and Scorpions

Poisonous snakes live in many developing countries, although most travelers will never see them unless they visit a zoo. If travelers will be walking through brush or jungle or will be walking at night, they should wear good-quality leather boots that cover the ankle. Not all snake bites are poisonous and not all poisonous snake bites are fatal, but immediate treatment by a physician is essential. If possible, the traveler should bring the snake for identification.

Scorpion bites are painful but seldom dangerous, except possibly to infants. Exposure to bites can be avoided by sleeping under mosquito netting and shaking clothing and shoes before putting them on.

Contact with marine life in tropical seas can be associated with minor discomfort such as sea bathers’ eruption or may be more serious with exposure to jelly fish toxins, bites of sea snails, or lion fish. Most marine hazards are avoided by using good judgment and common sense while swimming, snorkeling, and diving.

Medicines

If travelers are taking prescribed medications, they should obtain an adequate supply before leaving and keep all medications in their luggage. Many medications are sold without prescription overseas. However, the traveler should be cautious about purchasing these medicines. Although medicines made by recognized pharmaceutical companies are generally of high quality, the quality of other medicines may not be guaranteed. The traveler should be advised not to self-medicate, because many medicines have serious side effects.

Pregnant Women and Children

Some medications used commonly in travelers should not be given to pregnant women, in particular doxycycline (impairs tooth development in the infant) and Fansidar (see Malaria Prophylaxis, above) (39). Travel late in pregnancy may precipitate labor. In fact, many airlines do not allow air travel during the final month. Women prone to vaginal yeast infections, especially if antibiotics are taken, may want to take antifungal agents.

Immunizations recommended for children are, in general, the same as those recommended for adults (Table 41.2), except that yellow fever vaccine is not usually required for children younger than 1 year of age (40). Routine infant vaccinations are even more important for children traveling to developing countries because diphtheria, whooping cough, polio, and measles are common (41). The dosages of medicines have to be adjusted for children. This is especially important for malaria medications. Because children may be restless on long airline trips, some parents are tempted to sedate their children. This is discouraged, however, because children may react adversely to sedatives.

Sexually Transmitted Diseases

Engaging in casual sex may be more common in travelers than previously recognized (42). The risk of contracting sexually transmitted diseases (STDs) is high in some parts of the world. Very importantly, HIV infection has become a global health problem. In addition to the risk of HIV infection, sexually transmitted pathogens such as penicillinase-producing Neisseria gonorrhoeae are becoming increasingly common. Likewise, less common pathogens such as chancroid and lymphogranuloma venereum and HB are more common in certain areas. To reduce the risk of sexually transmitted infections, travelers need to be discriminating in sexual relations and avoid multiple partners, anonymous partners, prostitutes, and people who have had multiple sexual partners (43). If a traveler chooses to have sexual relations, condoms should always be used during intercourse.

Miscellaneous Infections

Many people experience a traveler's cold during a trip. These are thought to be caused by infection with respiratory viruses to which the traveler has no immunity. Travelers should bring their favorite cold remedy and an extra box of tissues with them. Erythromycin is sometimes used

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for travel-related respiratory infection, but its efficacy is unknown. Fungal infections, especially jock itch (tinea cruris) and athlete's foot (tinea pedis), may also be more common, especially in hot humid environments. Travelers should wear clean dry socks, or sandals when possible, and use antifungal powders and ointments as needed.

In recent years, American cutaneous leishmaniasis has also occurred sporadically in people who have visited the area endemic for this disease (southern Texas to northern Argentina, chiefly Mexico and Central America). The etiologic agents are protozoa of the Leishmaniaspecies, which are inoculated by female sandflies that inhabit forested lowlands. The skin lesion of American cutaneous leishmaniasis evolves over weeks to months from a papule to a nodule to an ulcer with raised indurated borders that eventually heals with a scar. Diagnosis requires identification of organisms in skin scrapings or biopsied tissue. Using insect repellent and wearing long sleeves and trousers are usually effective in preventing sandfly bites.

Long-Term Travelers

Recommendations for long-term travelers are generally the same regarding food and water, immunizations, and malaria prophylaxis. However, the need for certain interventions may increase. For example, the reasons for immunizing short-term travelers against HB, typhoid, rabies, meningitis, or Japanese encephalitis may not be compelling, but the benefit for a long-term traveler will be greater because the duration of time at risk is greater. Hence, the need for complete immunizations for endemic diseases of the area should be stressed. With recommendations for universal HB protection for infants, the importance of this vaccine for young travelers living overseas should be stressed. Furthermore, travelers may be willing to avoid fresh garden salads for short times, but long-term residents may choose to grow their own garden or find safe vegetables.

The commonly used antimalarials (chloroquine, mefloquine, and Malarone) can all be used safely for several years if indicated; therefore, long duration of stay is not a contraindication for these drugs, although the cost of long-term usage must be discussed when choosing an antimalarial.

If the traveler hires people to work in the house, these employees should be screened medically before starting work. The examination should include a chest radiograph to rule out active TB and stool analysis to rule out fecal parasites and S. typhi.

Medical Emergencies

Becoming ill overseas can be frightening and challenging. If the traveler becomes seriously ill or injured while traveling, the U.S. consulate can provide advice on where to go for help. In addition, the International Association for Medical Assistance to Travelers publishes a book listing English-speaking physicians (call 716-754-4883). Also, local Rotary or Lions Clubs can be helpful.

International Traveler's Health Kit

The following is a suggested first aid and health kit that represents the minimal necessary equipment for the traveler to the developing world (items can be obtained from various travel catalogs and suppliers):

  • International Immunization Card with documentation of vaccines received
  • Appropriate medication for malaria prophylaxis
  • Mosquito repellent
  • Water purification tablets, tincture of iodine, or water filters
  • Oral rehydration salt packets (available in the United States from CERA Products, Columbia, MD, 410-997-2334, and Jianas Brothers, Kansas City, MO, 816-421-2880).
  • Antimicrobial medication for treatment or prevention of diarrhea as arranged with the traveler's physician
  • Imodium or Lomotil, if indicated
  • Sunscreen
  • Adhesive bandages (for blisters)
  • A spare pair of glasses or at least the lens prescription
  • Any prescription medication the traveler takes regularly
  • Legible copies of prescriptions for medications
  • The traveler's favorite cold remedy
  • Fever thermometer
  • Aspirin or acetaminophen (paracetamol in most other countries)
  • Astringent or antiseptic
  • Antifungal powder
  • Toilet paper

Posttravel Screening

Most people who acquire viral, bacterial, or parasitic infections in developing countries become ill within 6 weeks after returning, but certain infectious diseases, such as malaria and schistosomiasis, may not manifest themselves until later. The traveler should be advised to seek medical help for any unexplained symptoms during the 12 months after the end of a trip. When an unexplained late illness occurs, it is necessary to identify all of the developing countries that the traveler visited to know which infectious disease risks he or she encountered.

For travelers who stay for long periods in the developing world, it is prudent to provide routine screening on arrival home (44). This should include a CBC with differential, liver function tests, TB skin test, stool examination for occult blood, urinalysis, and stool examination for ova and parasites. If these tests all are normal, the traveler has probably not acquired a serious unrecognized infectious

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disease, but post-trip surveillance for another 6 months is still warranted.

Care of Foreign-Born Patients

Each year thousands of individuals are admitted to the United States temporarily under nonimmigrant visas, indefinitely as permanent resident aliens, or indefinitely as refugees. Thousands more cross secretly into the United States as undocumented aliens. Some undocumented aliens file claims for asylum, which may be approved or denied; most remain indefinitely as illegal immigrants. The illegal immigrant population has grown from an estimated 3.5 million in 1990 to an estimated 11 million in March 2005 (45,46). The rate of growth of the illegal immigrant population has averaged 500,000 per year since 1990 but has increased recently to between 700,000 and 800,000 per year (46).

Rising immigration and mobility is bringing health care professionals across the United States into increasing contact with foreign-born patients. This has generated a growing need for health care professionals and the health care system to adapt in order to address language, knowledge, and cultural barriers. It means health care professionals must increasingly consider geographic medicine in the approach to primary care and the differential diagnosis of disease. This section briefly examines these issues and offers recommendations for a systematized approach to health screening of foreign-born patients, with special emphasis on refugees and asylees, who may have a greater number of both physical and psychiatric issues than the foreign-born population as a whole.

Official Designations

As defined by the Immigration and Nationality Act (INA) of 1952, an alien is any person not a citizen or national of the United States. Apermanent resident alien is any alien lawfully permitted to reside permanently in the United States. Permanent resident alien is sometimes used synonymously with immigrant. However, the INA broadly defines an immigrant as any alien in the United States who is not admitted under a temporary (nonimmigrant) visa (47). This definition includes illegal immigrants. Care must be taken to distinguish the correct intention of the term “immigrant” within the context of how it is used.

For practical purposes, a refugee is an alien who is unable or unwilling to return to his or her own country of nationality because of persecution, or a well-founded fear of persecution, based upon race, religion, nationality, membership in a particular social group, or political opinion (47). Refugees must be classified as such prior to entering the United States. Every year the Congress and the President set a proposed ceiling for refugee admissions to the United States. Actual refugee admissions may or may not reach this goal. In fiscal year (FY) 2003, the refugee ceiling was set at 70,000 but only 28,300 were admitted. This is an historic low when compared to the more than 100,000 refugees per year who were admitted to the United States in the years following the end of the Vietnam conflict in 1975 (47).

An asylee is any alien residing in the United States who claims asylum on grounds of persecution, or fear thereof, and who is granted asylum. The only difference between a refugee and an asylee is the country from which the claim for protection is made. In FY 2003, of 87,516 claims for asylum, 11,434 were approved, allowing 15,470 individuals to be granted asylum in the United States (48). Those not granted asylum face possible deportation.

Vietnamese Amerasians are defined as aliens born in Vietnam after January 1, 1962, and before January 1, 1976, who were fathered by a U.S. citizen. Under the second Amerasian Homecoming Act of 1987, Vietnamese Amerasians and their spouses, children, parents, or guardians became eligible for permanent resident alien visas (47).

Permanent resident aliens, refugees, and asylees reside legally in the United States. They may be legally employed. Following 1 year of continuous residence in the United States, refugees and asylees are eligible to adjust to permanent resident alien status. Upon adjustment of status, refugees and asylees are counted as permanent resident aliens in the fiscal year in which their status was adjusted. For example, in FY 2003, 705,827 aliens were granted permanent resident alien status; 358,411 of these were new arrivals in FY 2003 and 347,416 were already residing in the United States under other status. In FY 2003, 34,496 refugees and 10,431 asylees adjusted their status to that of permanent resident alien (47).

After living for 5 years in the United States, permanent resident aliens age 18 or older may apply for United States citizenship. This process requires taking a U.S. history and civics examination in English, with few exceptions. Children with valid permanent resident alien cards automatically become citizens if either parent obtains citizenship.

Following the terrorist attacks of September 11, 2001, the U.S. Immigration and Naturalization Service (INS) was reorganized on March 1, 2003, as the U.S. Citizenship and Immigration Services (USCIS) under the U.S. Department of Homeland Security (DHS). The USCIS is one bureau under DHS involved with administering U.S. immigration law. Foreign-born patients applying for adjustment of status may need to have USCIS medical forms completed as part of their application. These forms need to be completed by a USCIS-designated Civil Surgeon.

Unofficial Patient Categories Relevant to Health Care

In addition to official designations recognized by the USCIS, patients fall into one or more unofficial, but more

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medically relevant
patient categories, based upon similarities in their health care needs or specific vulnerabilities.

Refugees

From a medical perspective there are characteristics that distinguish refugees from other nonrefugee immigrants. These characteristics do not vanish or resolve when their status is adjusted to permanent resident alien or they become a citizen. To the health care professional, refugee patients are special in many ways. They fit into a broad category of patients who share a common refugee experience. Many are victims of physical and psychological trauma. Many have been subjected to systematized abuse or torture. All have experienced forced displacement, loss of their homeland, villages, communities, and personal belongings. Most have been separated from loved ones, have lost family members to war or disease, or have no knowledge of their relatives’ condition or whereabouts. Many have experienced the humiliation of life in refugee camps. They are likely to originate from developing parts of the world, disrupted by recent conflict, where modern medicine and public health improvements have never been accessible or have been disrupted. Often the overseas physical examination required for U.S. entry accounts for all of their contact with modern health care. They arrive in the United States with the clothes on their backs, possibly some photographs, and little more.

As a category of patients, refugees have many similar unmet health care needs. Immunization series need to be started and completed. Chronic conditions need to be identified and managed. Many need orientation to the concept of primary health care. Those who have suffered physical trauma need reconstructive surgery and rehabilitation. Posttraumatic stress disorder (PTSD), depression, limited English proficiency, employment requirements, resettlement into substandard housing, and transportation problems can complicate adjustment to life in America. Parents often worry about loss of control over their children who seem to acculturate too quickly into a society often viewed as liberal and devoid of culturally appropriate role modeling.

The U.S. Department of Health and Human Services, Administration for Children and Families, Office of Refugee Resettlement (ORR) oversees services for refugees and disbursement of funds designated for refugee cash assistance (RCA) and refuge medical assistance (RMA). RMA funds reimburse state Medicaid programs for which refugees are automatically eligible for a limited period of time. Federally subsidized, often church-affiliated, refugee resettlement programs, in conjunction with state refugee coordinators, help on the local level with case workers, housing applications, school enrollment, and job acquisition.

The greatest numbers of refugees resettled in the United States in recent years have arrived from Southeast Asia (Cambodia, Vietnam, and Laos) between 1975 and 1990. The Soviet occupation of Afghanistan in 1987 displaced millions of Afghans. Soviet style communism resulted in a trickle of refugees from Hungary, Poland, Bulgaria, Romania, Czechoslovakia, and the former Soviet Union. Serbs, Croats and other refugees from the former Yugoslavia arrived during and following the Balkan conflict. Civil wars in Africa have displaced thousands of people from Ethiopia, Eritrea, Somalia, Sudan, Democratic Republic of Congo (Zaire), Uganda, and Rwanda, among other countries.

Each source of refugees has its own characteristics and, within countries of origin, smaller subsets can be defined. While Cambodian refugees are very homogeneous in culture and experience, other sources of refugees are more ethnically diverse or share other common experience. The Kampuchea (or Khmer) Krom from the south of modern day Vietnam, constitute an ethnically distinct group of people who identify more with Cambodia than Vietnam. Vietnamese “boat people” and re-education camp detainees lived through special circumstances that make them somewhat distinct from other Vietnamese refugees. The Somali Bantu, a more recently resettled subset of Somali refugees are ethnically, physically, and culturally distinct from other Somalis. They were imported as slaves from Mozambique and Zanzibar by Arab slave traders in the 18th century and have remained marginalized within Somali society ever since. Sudanese refugees can be broadly divided into Christians and Muslims and further divided by tribal affiliation.

Secondary Migrant Refugees

Once resettled in the United States, many refugees migrate secondarily, once or more than once, in search of relatives, friends, clan members, ethnic cluster sites, jobs, or better living conditions. This secondary migration disconnects refugees from RCA programs, Medicaid, contact with case workers, housing, schools, and other programs established on their behalf. Health care they receive along the way becomes fragmented. Overseas medical records, carefully guarded in transit to the United States, are often lost. Records of tuberculosis screening and treatment, immunizations, and other care received in the United States are difficult or impossible to reconstruct. These “secondary migrants” must depend upon their own ingenuity to re-enroll in school and jobs. They must find their own way back onto Medicaid rolls and into the health care system. Many become dependent upon local general assistance programs and city shelters. Secondary migrants are refugees with additional issues that can complicate their health care management.

Asylum Seekers and Asylees

People seeking asylum may need medical evidence of injury or torture that can be used to make a case for asylum

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before a judge. They may also need psychiatric evidence of PTSD or other psychological sequelae of their past or present situation. Clinicians may be asked by lawyers, often working pro bono, to evaluate a person seeking asylum and to render a formal medical or psychiatric opinion. Asylum seekers may or may not be allowed to work legally at the time of their application so the ability to afford a medical evaluation may be a complicating factor. As a general rule, they are not eligible for ORR services and assistance. Financial concerns and preoccupation with satisfying the requirements of their application for asylum may outweigh concerns regarding comorbidities or preventive health care. Addressing unrelated findings such as uncontrolled high blood pressure or suspected diabetes may have to be deferred.

From a health care perspective, asylees are similar to refugees. They are eligible for ORR services and assistance. Access to services, usually available to refugees through refugee resettlement programs, can vary from state to state.

Vietnamese Amerasians

The precipitous collapse of South Vietnam on April 30, 1975 placed many thousands of Vietnamese Amerasian young people under a reunified, communist Vietnam. Their American features, once regarded favorably under the former regime, became reminders of the American occupation. Families with Amerasian children feared reprisals. Many Amerasian children were marginalized and left to fend for themselves on the streets, uneducated and stigmatized as “Dust of Life” or half-breeds. Following implementation of the second Amerasian Homecoming Act, in conjunction with the Orderly Departure Program (ODP), they became “Golden Children,” the ticket for safe transit out of Vietnam for America, not just for themselves, but for their immediate family. In many cases the “immediate family” was financially arranged. This became apparent when many Amerasian young people moved away from their “families” shortly after arriving in the United States. Discriminated against in Vietnam and foreign in America, these youth without a country, many in poor health and beyond the age of being able to matriculate easily into schools, have struggled physically and psychologically to survive. Few have been reunited with their biological fathers. Technically, Vietnamese Amerasians are not refugees. Yet, from a health care perspective they share much in common with Vietnamese refugees. Additionally, they have suffered in other ways placing them at additional risk for PTSD, depression, and failure to acculturate and succeed in America.

Lost Boys and Girls of Sudan

Thousands of young boys left their homes in southern Sudan in 1987 to avoid enslavement and conscription. They wandered thousands of miles, becoming known as “The Lost Boys of Sudan,” and many died of disease and starvation. In 2001, 4000 of these boys were resettled to the United States. The CDC recommends presumptive treatment for schistosomiasis and strongyloidiasis for this population and for other Sudanese with similar exposure risk (49).

Illegal Immigrants

Illegal immigrants keep a low profile in order to avoid the U.S. immigration justice system. They avoid circumstances where they may be questioned in order to complete forms and applications. Hospital clinics that offer uncompensated care are inaccessible if high barrier patient registration processes or Medicaid denial letters are required. With few exceptions for emergency services, illegal immigrants are not eligible for health benefits under Medicaid. Most work “under the table” and receive no employer-sponsored health benefits.

Migrant Farm Workers

Migrant or seasonal farm workers are a mixture of citizens, permanent resident aliens, non-immigrants working under an H-2A visa, and illegal aliens. Most migrant workers earn wages that are less than 100% of federal poverty guidelines. Eighty-five percent of migrant workers are minorities. Most are Hispanic, while others come from Haiti, Jamaica, Thailand, Laos, and other countries (50,51). Alien migrant workers are generally ineligible for Medicaid. Migrant workers who are eligible for Medicaid may not be able to meet state residency requirements due to high mobility. Few state-sponsored Medicaid programs have reciprocity agreements with other states. Mobility also contributes to the fragmentation of health care and the health care record (52). A Federal, nationwide network of migrant health centers is capable of meeting only approximately 20% of the health needs of this population (50).

Communication across Cultures

As health care practitioners, learning about geographic medicine is relatively easy and an extension of basic training in medicine. Learning effective communication across cultures can be another matter. This requires attention to accurate language interpretation, elimination of knowledge deficits, and sensitivity to cultural differences.

Language

Of all the barriers to communication across cultures, the language barrier is the most obvious and the most important to address. This is accomplished through use of a skilled language interpreter and acquisition of triadic

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interviewing skills by the practitioner (53). The Joint Commission on Accreditation of Health Care Organizations (JCAHO) identifies a patient's ability to access culturally and linguistically appropriate services as not just a right but a matter of quality and safety (54). The Health Plan Employers Data and Information Set (HEDIS 3.0) now considers availability of an interpreter as a quality measure (55). Standards for interpreters are becoming clearer and go beyond the mere ability to translate (56). Increasingly, interpreters are professionals who are either full-time employees of hospitals or who contract their services through formal vendor agreements. The Health Insurance Portability and Accountability Act (HIPAA) of 1996, has driven expectations around confidentiality. There is an increasing expectation that interpreters will have some training in medical terminology, and that they will be professional in their interactions with patients both inside the examination room and in the community at large. Hospitals and medical offices that accept federal health care reimbursement are required to provide interpreters.

Professional, gender-concordant interpreters present for the medical encounter are generally preferred over other means of providing language interpretation (55). Interpreters who are present in the examination room are better able to engage through eye contact and nonverbal cues, than telephonic translators. Utilization of fulltime hospital-employed interpreters may not be associated with longer visit times (57). As a general rule of thumb, young children should not be medical interpreters. They lack sufficient education and sophistication around matters of confidentiality. They may be uncomfortable discussing medical conditions. Their native language and English language development are likely to be imperfect. A patient's own child is likely to be uncomfortable in the examination room and the patient is unlikely to disclose relevant confidential information. On the other hand, a mature adult child may be comfortable accompanying their parent and be the person with whom the patient is most comfortable as an interpreter (55).

The evolution of telephone language lines has helped make interpreters readily available anywhere and at any time of the day or night. Language line services provide trained interpreters for most major languages without prior appointment. Minority dialects may be an exception. With some language lines it may be possible to make prior arrangements for unusual languages or dialects by appointment. In small communities, or under special circumstances involving very private conversations, language lines may be a preferable alternative to having an interpreter in the examination room. If a language line is used, the patient should be introduced to the interpreter using age, sex, and clinical context (examination room, trauma room, etc.) and it should be explained that names are not to be used. If necessary, time should be spent to discuss the patient's concerns about confidentiality and the measures that are in place to protect it. The use of high quality speaker phones with preprogrammed dialing enhances the use of language lines. At registration desks in busy waiting rooms, dual handset telephones may work better. Some of the larger language line services include CyraCom International (http://www.cyracom.net), LanguageLine Services (http://www.languageline.com), and Pacific Interpreters (http://www.pacificinterpreters.com).

Being able to access translated written materials such as brochures, educational materials, and informed consents documents can be very helpful but may have some limitations. Translating documents can be complicated and expensive. Back translation is necessary to ensure accuracy. Translated materials have to be kept up to date. Multiple documents are difficult to catalog, access, and keep in stock. Native language illiteracy also may be a factor. The Immunization Action Coalition (http://www.immunize.org/vis/index.htm) has obtained funding for the translation, cataloging, and Internet distribution of vaccine information statements (VIS) in many languages. The continued expansion of high speed Internet access, electronic medical record systems, and computers in examination rooms makes accessing translated materials via the Internet an increasingly practical solution. Computer systems have the flexibility to offer language-appropriate narrated video clips that, in the future, could help explain procedures, disease management, and more (for example, see Healthy Roads Media at http://www.healthyroadsmedia.org/).

Knowledge about Health Care Practices

Foreign-born patients may lack familiarity with Western, scientific approaches to health and illness. Instead, they may adhere to their own, deeply rooted, culture-bound health beliefsinterventions, and practices. Western-trained health care professionals may regard these as curiosities and with skepticism. But, this is a two-way street, as foreign-born patients often regard Western health beliefs, interventions, and practices with equal skepticism.

Depending upon the extent of a patient's exposure to Western, scientific explanations of health and illness, culture-bound health beliefs may explain states of wellness or illness in terms of natural or supernatural balance or disturbance. Earth, wind, fire, and water may be viewed as the elements of life. Wellness may be seen as a state of harmony between these elements and the balance of opposing forces such as hot and cold, as in the principle of yin and yang. Illness may be explained on the basis of a “bad wind” that has entered the body, feeling “hot,” or as the result of being possessed by a spirit or demon (58,59). Members of many cultures turn to traditional healers who possess special knowledge of these principles to seek cures and remedies based upon them (60,61). Patients may believe that if they feel well or do not have pain that nothing can be wrong. This can complicate explanations of

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screening tests or interventions for sub-clinical disease. In interactions with Western-trained practitioners, patients may feel a sense of embarrassment if they disclose adherence to a belief system that may be viewed as primitive or unscientific. Nevertheless, adherence to traditional beliefs tends to be strong. Patients are apt to question the ability of Western-trained health care practitioners who are not indoctrinated in their belief system, fearing the practitioner will be incapable of understanding and treating their condition. This perception is likely to be reinforced by the practitioner who resorts to too many questions, questions that are too personal, unfamiliar physical examinations that invade privacy, laboratory testing, and deferral of treatment pending the outcome of testing. Phlebotomy or radiograph imaging may be perceived as injurious within the health belief system of many patients. The patient may expect an injection or have another preconceived notion of appropriate treatment that should be offered at the time of the visit.

Culture-bound health interventions have evolved as traditional or folk remedies that have as their basis the restoration of natural order and the state of well-being. Examples include acupuncture, cupping (Fig. 41.10), coining (Fig. 41.11), pinching, taping, massage, ceremonies to exorcise evil spirits, consumption of herbal tea or alcohol, and inhalation of steam from herbal brews:

 

FIGURE 41.10. Cupping. Cambodian refugee adolescent with fever, sore throat, and tonsillar exudate. Portland, Maine 1997. Photographer: Maine Medical Center Audiovisual Department.

 

FIGURE 41.11. Coining, tattoo, and amulet. Cambodian adult male. Emergency Department, Maine Medical Center, Portland, Maine ~1994. Photographer: Maine Medical Center Audiovisual Department.

Coining can be a social event usually at the home of the sick person, who is the center of attention. Adult family members and close friends may participate. A small amount of green Tiger Balm oil or other lubricant is applied to skin and rubbed using the edge of a coin until a red bruise is raised. This is repeated until a symmetrical pattern of bruises is created, usually on the neck, trunk, arms, and/or abdomen. The process is thought to help release heat from the body, thereby, reestablishing the harmonic balance of hot and cold. This practice is common in Cambodian culture and is performed on both adults and children.

Cupping is performed in much the same way and for the same reasons. The difference is that a small glass cup is pressed over a small lighted candle balanced on the skin until it extinguishes. This creates a perfectly circular suction ecchymosis. This approach might be taken on a level surface such as the forehead of a recumbent patient. An alternative approach employs a preheated cup, sealed to the skin with gentle pressure and allowed to cool.

A Vietnamese patient seen in the office with a red vertical streak in the center of the bridge of the nose between the eyes has been repeatedly pinching the skin to relieve headache, “fever” or dizziness. “Fever” in this sense does not necessarily correlate with febrile.

White adhesive tape impregnated with aromatic extracts and possibly combined with a salicylate is applied to the temples to relieve headache or to the back or joints to relieve pain in Asian cultures. The practice may extend to other Asian cultures.

Cambodian women traditionally believe it is important to build a fire under the bed and to remain on the

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bed consuming hot spicy food for weeks following the delivery of a new baby. Failure to do this may result in the perception that healing will never be complete and future complaints of pelvic pain, backaches, and other complications may ensue, requiring expensive medical evaluations.

Diarrhea, fever of malaria, and many other ailments may be treated with moxibustion, the burning of skin as a counterirritant, by the application of a glowing stick, burning cotton ball, or other moxa. Moxibustion sticks are available in Asian markets in America.

The concept of primary care, prevention, and screening for diseases such as cancer at the hands of a Western health care professional may not be understood by patients who have never had this luxury and for whom Western health care was only accessible in cases of dire emergency (62). Preventive health care may take the form of a tattoo or wearing of an amulet (Fig. 41.11). Uvulectomy, the removal of the uvula at birth or infancy to prevent throat infections may be seen in some African cultures (63). The risks from exposure to tobacco smoke, alcohol, and environmental substances such as lead in homes or mercury in fish may be poorly understood or unknown (64). Culture-bound health practices are distinguished from culture-bound health interventions because they appear to have no purpose in the prevention or treatment of specific maladies. They tend to be rooted in cultural, folk, or religious beliefs or fads. Included in this category are ritual tribal scarring, cosmetic scarring, modern day piercing, and tattoos (Fig. 41.11). Tattoos in this category should be distinguished from those applied for preventative health purposes. The practice of “female circumcision,” also referred to as female genital mutilation, has drawn much attention with the recent influx of Somali populations in which the practice is nearly universal (65). The procedure is traumatic, disfiguring, and has potential for long term medical and psychiatric consequences.

Culture

Cultural differences between practitioner and patient may necessitate implementing special accommodations in order to promote a context within which communication is possible. Certain taboos may exist that can impact the doctor-patient relationship. For instance, Muslim women likely will not allow an examination by a male practitioner except in an emergency and may even feel uncomfortable being in the same room with him unless her father, husband, or brother accompanies her.

Gestures or other nonverbal body language may be perceived as disrespectful. The Asian patient will not appreciate the practitioner who assumes a slouched posture or exposes the bottom of the foot toward the patient. Patting the head of little Asian children is considered an impropriety, despite good intentions. To heap praise upon a newborn may, in some Asian cultures, be perceived by the new parents as potentially calling the attention of evil spirits to the child. The Asian patient who does not make eye contact with the health care professional may be adhering to traditional norms of respect that can be misinterpreted as disinterest or passivity. Likewise, the Asian patient may tend to agree with or defer to the health care professional since to do otherwise may be considered discourteous. Contrary to Western belief that bad news should be communicated directly to an individual by laying out the facts, other cultures believe that bad news should be communicated through a trusted family member or friend or not be communicated at all. Patients from Somali Muslim cultures may adhere to the belief that only God can make predictions and that for a doctor to do so, as in predicting someone will succumb to a cancer, is improper.

Differences among cultures are complex and no one practitioner can be expected to comprehend the nuances of each. Numerous books, guides, accounts, and Internet sources are available that provide interesting insight into different cultures, some from a medical perspective (see EthnoMed, http://www.ethnomed.org/). However, no one source can possibly prepare the practitioner for each possibility. While some generalizations about culture may be accurate, others are not. Mitigating factors may involve the patient's membership within a national, ethnic, social, economic, educational, family, gender, or religious group. For this reason, practitioners should rely upon their own sense of what constitutes respect for the patient. When uncertain, it is best to ask.

Names

Practitioners and support staff should be careful to record names and birth dates as accurately as possible. Many Southeast Asian cultures invert the name after arriving in the United States so that Nguyen Van Thong in Vietnam becomes Thong Van Nguyen in the United States. This can be a source of confusion, duplicate registrations, and denial of claims. In this example it is best to think in terms of the family name and given name instead of last name and first name. Computer renditions and written records can avoid confusion by representing all names in the format family name, given name. Somali names can be very similar and, in fact, the family name can sometime be the same as the given name.

Dates of Birth

Overseas, dates of birth are usually recorded in Day-Month-Year format. These dates can easily be misinterpreted in the United States so that, for example, 12-05-1981 on overseas documents or as written by the patient translates incorrectly to December 5, 1981 and correctly to May 12, 1981. Different cultures approach birthdays differently. Vietnamese children are considered to be age one at birth and the age increments on the lunar New Year.

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As simple and inconsequential as these issues may seem, errors can lead to registration errors, denial of claims and inaccurate child growth charts, and immunization record errors. Many refugee patients do not have official records of birth and often birth dates are recorded using the first day of the first month with an estimated year of birth (for example 01/01/1945).

Holidays

Some holidays may have direct medical relevance, most notably the Muslim holy month of Ramadan, during which able-bodied adults must fast from sun up to sun down. Some individuals interpret this to include medications and injections such as flu shots and insulin and they will not permit these injections during their fast.

Overseas Medical Examination

All refugees and overseas applicants for a U.S. immigrant visa must undergo a medical examination prior to embarking for the United States. The standards for this screening are established by the U.S. CDC, National Center for Infectious Diseases, Division of Quarantine and published at the website for this organization (http://www.cdc.gov/ncidod/dq/index.htm). “Panel Physicians” designated by the U.S. Department of State administer the exam. Documentation is on U.S. Department of State form DS-2053 (formerly OF-157). A supplement to form DS-2053 is sometimes used to document immunizations. The overseas medical examination seeks to identify physical or mental health problems of public health significance. Health problems are designated as Class A or Class B conditions. Class A conditions are those that potentially may preclude immigration to the United States; Class B conditions are those that are of sufficient public health concern that they be brought to the attention of consular authorities. Active TB, a positive HIV test, infectious syphilis, or other active STD are among the Class A conditions. TB screening is by chest radiograph. Those with suspected or confirmed active pulmonary TB or positive tests for syphilis are required to be fully treated before being allowed to travel to the United States. These conditions, once treated, are considered Class B conditions. HIV disease does not automatically preclude U.S. immigration. Additional information regarding the overseas medical examination can be obtained from the Division of Quarantine website.

Initial Health Evaluation in the United States

Entering the United States

Quarantine officials located at U.S. ports of entry review the overseas medical examination and directly notify state public health officials of the need to conduct medical followup for conditions of public health significance on a case by case basis. Compared to nonrefugee immigrants, refugees, because of disrupted medical care due to conflict, dislocation, deprivation, and life in refugee camps, are considered to be at greater risk for TB. Consequently state public health officials are notified of all new refugee arrivals for purposes of additional TB surveillance in the form of tuberculin skin testing. If a refugee migrates secondarily within the United States the public health system may lose contact with the patient, increasing the risk of disrupted treatment and follow-through.

There are no standard guidelines or requirements for health care followup of refugees, asylees, and other immigrants beyond those that cover specific diseases and conditions of public health significance. All immigrants should undergo a complete and thorough health screening examination and have the option of establishing primary health care shortly after arrival in the United States. In addition to being at greater risk from TB, refugees and asylees are more likely than other immigrant populations to have other undiagnosed or inadequately managed health problems. Problems of growth and development, congenital disorders, rheumatic heart disease, and other conditions may have never been previously addressed.

Existing Medical Records

The initial health-screening examination should start with a careful review of any overseas health documents. The patient should have a copy of the DS-2053 and supplement to form DS-2053 (immunization record) and may have other overseas medical records. These and other health records that have been generated as a consequence of public health or other health intervention after U.S. arrival should be reviewed and copied to the medical record. This might include tuberculin skin test results, additional chest radiograph reports, TB clinic records, and immunization records among others. If other health professionals have seen the patient in the United States it is important to obtain records of what was done to avoid duplication and because it may be difficult for the refugee or immigrant patient to communicate medical detail. Care should be taken to construct the health history of the patient and to record it properly.

Medical History

The medical history should be obtained using generally accepted standards. Software programs such as MICROMEDEX (http://www.micromedex.com) are helpful in being able to rapidly identify some overseas medications the patient may already be taking. Additional helpful information includes migration history and information on accompanying family members and on those left behind. Refugees may have suffered war-related physical trauma, emotional trauma, or torture. Documentation of this information may be helpful in directing future therapeutic interventions. Languages and dialects, both written and spoken, should be documented. Literacy, years

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of education, and work experience may be predictors of ability to adjust to life in the United States. If appropriate, family planning options should be explored since there may be differences between what is available in the United States and what was available overseas.

Physical Examination

Despite conscientious attempts to minimize communication barriers, most valuable screening data may derive from objective findings. Refugees and asylees frequently have had no prior access to health care and may be unable to communicate an accurate past medical history. For these reasons the physical examination should be comprehensive. It should include height, weight, hearing, and vision assessment. A pelvic examination should be done for women, and it should include cervical cancer, gonorrhea, and chlamydia screening. This is particularly true for refugee girls and women who may be victims of rape as a war crime or in refugee camps, and who may be unable to verbalize these atrocities. All physical examination findings should be carefully documented including any scars or deformities acquired as a consequence of battle, land mine, torture, or other injury. No part of the examination should be “deferred” unless a language, knowledge, cultural, permission, or other barrier warrants. Deferred components of the exam should be rescheduled with appropriate interpreters, clinicians, and time for explanations. Same-sex practitioners will reduce anxiety and may be a prerequisite for achieving the cooperation of the patient.

Screening Laboratory Tests

The decision to obtain screening laboratory and other studies should follow generally accepted guidelines for other age and sex-matched patients. Since reliable family histories of diabetes and coronary disease are often unobtainable for refugee and asylee patients, it is reasonable in these patients to routinely screen with a fasting blood sugar and lipid panel. Additional testing should be included based upon geographic prevalence of disease, decision support, or cost-effectiveness considerations. Other routine screening tests to consider in new arrivals, particularly refugees and asylees, include a CBC and differential, sickle prep, varicella antibody, hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), hepatitis C antibody (HCAb), rapid plasma reagin (RPR), and stool for ova and parasites (O&P) (66).

Common Health Problems

Tuberculosis

Screening for TB begins with the overseas medical examination that is intended to reduce the likelihood that a patient with active pulmonary TB will board a plane or enter the United States. Overseas TB screening is not done for all visa applicants and is only done for those older than age 15. Therefore it is possible that a person coming to the United States on a temporary visa will have had no TB screening. Subsequent cases of active pulmonary TB have been identified in this group. Rarely, someone who has been screened for TB will arrive in the United States with active pulmonary TB. The CDC requires a purified protein derivative (PPD) skin test upon arrival in the United States for all new refugee arrivals. Induration of 10 mm or greater constitutes a positive PPD skin test in this population (67). Prior BCG vaccination should be ignored in interpreting a positive PPD skin test in a foreign-born patient. Although prior BCG vaccination is causes a positive PPD skin test for variable periods of time following immunization. A positive PPD skin test cannot be attributed reliably to vaccination.

Patients with latent TB infection identified by PPD skin test are usually asymptomatic, are not infectious, and do not pose an immediate public health risk. They should undergo an additional chest radiograph, history, and physical examination. Patients without evidence of active disease should receive prophylactic therapy to reduce the 5% to 10% lifetime risk of reactivation of TB, according to established guidelines. Directly observed therapy is preferred but generally impractical. Isoniazid (INH), 300 mg daily for 9 months is the currently recommended regimen (see Chapter 34).

If patients are determined to have active pulmonary or extrapulmonary disease, they should be treated at designated TB clinic and reported to public health authorities (67). Most states have TB control programs that oversee TB treatment. Other mycobacterial diseases, including leprosy may occur with greater prevalence in refugees and immigrants.

Hepatitis B

Hepatitis B is more prevalent in developing countries than in the United States. Sixty percent of Southeast Asian patients may have one or more serologic marker for hepatitis B. In parts of Southeast Asia, hepatitis B carrier prevalence approaches 15% (68). Serologic screening for HBsAg is important to identify carriers and should be done even for the rare patient who has received hepatitis B immunization overseas. The high prevalence of HBsAb positivity may also makes routine screening for this marker more cost effective than blanket immunization. Refugee and immigrant patients who lack both markers should be considered for immunization, realizing that they are more likely to associate closely with others in whom the prevalence of hepatitis B is high.

HBsAg carrier patients require careful counseling. They may easily misunderstand the implications of this finding or even confuse a discussion about hepatitis B virus infection with HIV disease. Diagnosis of hepatitis B may stigmatize the patient in ways that are poorly understood by the practitioner. These patients should also undergo additional

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initial screening to assess their risk of progression of their disease and for hepatocellular carcinoma. This should include hepatitis B virus DNA and E antigen and antibody, hepatitis C antibody, hepatitis delta antigen and antibody, and alanine aminotransferase (ALT). Either hepatitis A IgG antibody testing or hepatitis A vaccine should be considered. Patients should be monitored periodically to determine their eligibility for treatment (see Chapter 47). No clear evidence exists for screening patients with chronic hepatitis for hepatocellular carcinoma, although obtaining α-fetoprotein (AFP) levels and hepatic ultrasound at 6-month intervals has been suggested for such patients with early cirrhosis.

Anemia

Anemia is common in refugee patients. Reversible causes include general nutritional factors and iron deficiency. Chronic net iron loss and subsequent anemia occurs when menses, hookworm disease, schistosomiasis, or a combination of these is present in the face of dietary iron deficiency. Treatment of parasites and iron repletion through supplements or a normal diet should correct the anemia. Persistently low mean corpuscular volume (MCV) in the setting of normal iron studies should prompt hemoglobinopathy screening. The most common nonreversible cause of anemia in Southeast Asian refugees is β-thalassemia, hemoglobin E, or a combination of the two conditions. Sickle cell trait may occur with greater prevalence in new arrivals, particularly from West Africa. Patients identified as having sickle trait or one or more other hemoglobinopathy should be considered for genetic counseling.

Parasites

Asymptomatic parasitosis is common in newly arrived patients from tropical or subtropical countries and screening with stool samples for O&P should be considered for this subset of patients. The standard practice of ordering three stool samples for O&P should be reconsidered if there are concerns about communicating instructions properly. If necessary, obtain one sample at a time until three or more studies, sufficient to achieve reasonable sensitivity, have been competed. Many isolates are nonpathogenic amoebae, but when these are found, others, possibly pathogenic, are likely. If a sample is positive for a treatable parasite, the patient should be treated and testing should be repeated after several weeks. Eosinophilia, in the absence of other explanations, should prompt consideration of possible tissue helminthes or luminal helminthes in the tissue phase. Strongyloidiasis may account for persistent occult eosinophilia.

Empiric treatment with albendazole, 200 mg twice daily for 5 days has been suggested as a cost-effective alternative to O&P testing and management of common parasites in adults (69). The CDC has issued algorithms for the empiric treatment of strongyloidiasis, schistosomiasis, and other intestinal parasites in the Lost Boys and Girls of Sudan and for other Sudanese with similar exposure risk (Southern Sudanese). These recommendations include higher doses of albendazole and are summarized on the CDC website (http://www.cdc.gov/ncidod/dq/lostboysandgirlssudan/index.htm). Albendazole, unlike mebendazole, is readily absorbed from the gut. It is generally safe and is effective treatment for many tissue helminthes or luminal helminthes in tissue or luminal phase. Persistent eosinophilia following treatment should prompt further analysis for persistent tissue helminthes, and may require assistance from the CDC Division of Parasitic Diseases (770-488-7775). Patients whose urine dipstick tests detect hematuria should undergo microscopic examination for schistosomes, which can be readily managed with praziquantel.

Syphilis

Although a test for syphilis is mandatory for refugees and immigrants age 15 or older and is included as part of the routine overseas medical examination, additional testing detects cases missed during the overseas medical examination or acquired since the exam was administered. A positive test for syphilis in a patient who previously tested negative should prompt treatment and further investigation for possible HIV disease, other STDs, and screening of children who may not have been tested previously. Routine screening for HIV disease in newly arrived foreign-born patients is hampered by informed consent requirements.

Immunization Delay

Delayed immunizations need to be updated according to the recommendations of the Advisory Committee for Immunization Practices (ACIP) (http://www.cdc.gov/nip/recs/adult-schedule.pdf). It is common for refugees and asylees to have no knowledge or record of prior immunizations. Immunizations should be updated at the time of the overseas medical examination and documented on the supplement to form DS-2053, but often are not, depending upon availability of immunization products or other factors. Unless documentation of prior immunizations can be obtained, immunization series should be restarted and completed. Careful documentation of all immunizations should be provided to the refugee and immigrant patient since proof of immunization will be required when the patient applies for adjustment of citizenship status with the USCIS. It can be very difficult to obtain an accurate history of prior varicella infection. Given the cost of this vaccine and the need for two doses of vaccine in patients older than the age of 13, it may be cost-effective to routinely perform varicella serologic testing for all new refugee and immigrant patients.

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Other Health Problems

Hypertension, diabetes, gout, malignancy, and many other health problems may be detected on routine screening of foreign-born patients. In some cases a prior diagnosis may have been established and the patient may have been treated. They may arrive in the United States on a dwindling supply of medications that usually must be changed in order to incorporate more readily available drugs. Alternatively they may have had inadequate, sporadic, or no treatment at all for these health problems. Dental problems are very common (70). Appropriate followup, workup, and referral to specialists and dentists must be coordinated.

Posttraumatic Stress Disorder and Depression

Refugees are both victims and survivors. They are all escapees, displaced from their homeland. Many have been directly or tangentially involved with war, imprisonment, rape, execution of family members, torture, ethnic cleansing or other atrocities. Often refugees from the same country share strikingly similar histories. Some have lived for years in refugee camps. Children have been born and raised in these camps and have never known a normal existence. Other refugees have been luckier, having fled encroaching fighting to live with relatives or on their own in a neighboring country. Arrival in America marks the end of one chapter and the beginning of another. New challenges include learning English, surviving economically, enduring life in problematic and sometimes dangerous neighborhoods, acculturating and yet holding onto old values and culture. Health care professionals should be watchful for symptoms and signs of PTSD and depression in this population. Despite amazing survival capacity and a propensity to maintain a thick veneer, many do become overwhelmed. Cambodian patients may refer to “thinking too much” as an explanation for sleeplessness or sadness. Disrupted work attendance, decreased interest in family matters, family violence, withdrawal, lack of motivation, gambling, and substance abuse may be possible clues to mental health problems (71,72). Standardized instruments have been studied and validated in the screening for PTSD and depression but are not widely available in a variety of languages (73).

Parents who are having trouble coping have little reserve for their children and often can be of little help for them with homework, school activities, or general questions about growing up. Children acculturate rapidly, too rapidly according to their parents, and after a few years may have trouble conversing with parents who do not learn English. Cambodian youth, for example, may use “Khmerican,” an admixture of Khmer and American English, half of which their parents cannot understand (74).

Physical Trauma

Physical trauma as a consequence of fighting, land mines, and torture are encountered in refugee patients, including children and adolescents. These injuries may impact the ability to work or attend school. Awareness, documentation of the extent of these injuries, and prompt attention to rehabilitation is important in order to maximize functional ability.

Anticipatory Guidance

Refugee and immigrant patients must begin to take an active role in preventive health care. This may not begin to happen with the first visit for reasons already presented. Additional regular visits should be scheduled to afford the refugee and immigrant patient the opportunity to become familiar with our health care system and to establish a trusting relationship with their practitioner. Often refugee and immigrant patients must return at two and six months after the initial exam in order to complete immunization series. These are good opportunities to see how they are adjusting and to reinforce use of smoke detectors, child safety seats, and seat belts. Fire egress, particularly from upper story, low-income apartments where many family members may live in crowded conditions, should be discussed. Personal preventive health measures such as stopping smoking, reducing passive smoke exposure, and the need for cancer screening examinations such as mammography need to be introduced. Family planning and STD prevention should be discussed at appropriate opportunities. Adolescents should be monitored for adjustment to school, peer-groups, and use of free time. Usual adolescent concerns related to driving, fights, guns, gang involvement, substance abuse, early sexual activity, and Internet access also apply to refugee and immigrant youth.

Specific References

For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.

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