Health Guide Chapter 22 (Travemed.

com)
Guide to the Evaluation of Post-Travel Illness
Review the Itinerary & Associated Disease Risks
Reviewing the travelers' itinerary suggests possible disease riskand eliminates others. Malaria, for
example, may occur in a traveler returned from Africabut only if the traveler had visited an endemic
area.

The Destination Advisor lists the most common diseases endemic in each country. If outbreaks are
occurring, that will also be noted (or found on the Travel Health Service link for that country).

Disease Incubation Period

Some diseases become symptomatic a few days after exposure; in others, symptoms appear weeks to
months later. Knowing the incubation periods of various illnesses can help determine the diagnosis.

How long after return from an endemic area did the traveler become ill?

>>>Go to Incubation Periods for Select Infections with Fever to select illnesses based on their
incubation period.

What are the Traveler's Symptoms?

The most common symptoms of a travel-related infectious disease are:

Fever (the most important symptom)

Abdominal pain

Diarrhea

Weight loss

Fatigue

Cough or shortness of breath

Skin rash

Review the Traveler's Immunization Status

If the traveler has been fully vaccinated against certain diseases they can probably be eliminated from
consideration. Not all vaccines, however, are 100% protective. The typhoid vaccine, e.g., provides
about 60% protection.
The Post-Travel Medical Checklist
Travel to a particular country doesn't necessarily mean exposure to a disease endemic in that country;
a knowledge of the traveler's activities in that country is essential.

Questions to ask the traveler include the following:

What countries did you visit and for how long in each? What specific geographic areas did you
visit in each country? Did you visit disease-endemic areas? (For example, in Thailand, malaria
occurs only in certain forested border areas, not in the cities.)

What were your arrival and departure dates? When did you return home?

When did you get sick? Date you first noted your symptoms?

What symptom(s) brought you to the doctor?

Did you receive any vaccinations prior to departure? Have you been previously immunized
against diseases such as hepatitis A or typhoid? Are your routine immunizations up-to-date?

Please list all the vaccines you received during the past 10 years.

Did you travel in rural areas of tropical/semitropical countries or did you stay exclusively in
urban areas and stay in high-end, air-conditioned hotels. Did you stay exclusively in a resort?

Were you on a cruise ship?

Were you visiting friends or family?

Did you take insect-bite prevention measures (e.g., use DEET skin repellents, sleep under a
bednet)?

Did you adhere to your malaria prophylaxis schedule (if prescribed)?

Did you adhere to safe food and drink guidelines? Did you eat snails, crabs, prawns, raw fish, or
inadequately cooked or raw exotic foods made from beef, pork, bear, walrus, or fish? Did you
use a water filter or purifier? Drink only bottled water or beverages?

Did you get sick during your trip? If you were in a group, did others get sick? Did you self-treat
for diarrhea or other illness? Did you have an illness with fever while abroad.

Were you treated in a clinic, a doctor's office, or in your hotel? Were you hospitalized? Where?

What was your diagnosis, if any? Were any tests done? Were you treated with medications.
Which ones? Did you get any shots? Did the medical personnel use sterile equipment?

Did you receive any intravenous fluids, IV medications or blood transfusions?

What was the exposure of the traveler to the following:

Unsafe food and drink - Did you eat undercooked or raw meat or fish (e.g., sushi); cold food and
salads from buffets or salad bars; street vendor food not well-cooked? Did you drink tap water or
untreated water from lakes, streams or ponds? Did you consume unpasteurized dairy products
(e.g., raw milk, cheese)? Did you handle freshly slaughtered animals?

Camping in rural forested or brushy areas; walking/hiking in brushy, forested areas.

Insect and animals bites - Were you bitten by mosquitoes, flies, or ticks? Were you bitten by a dog
or other animal?

Walking barefoot on beaches or moist soil.

Freshwater swimming, wading, or bathing. Canoeing or rafting in lakes, rivers or streams.

Unprotected sex with a new partner. Did you have same-sex contact?

Recreational drug use (especially by injection), tattooing, body piercing, or surgical procedures.

People with infectious diseases. Did you work in a hospital or refugee camp? Did you have
contact with sick people with respiratory illnesses, such as tuberculosis?

In view of the traveler's symptoms, itinerary, and disease incubation periods, which disease(s) seems
likely?

Laboratory Tests & Imaging Studies

Testing may include microscopy, cultures, biochemical tests, including serology, and polymerase
chain reaction. The laboratory tests commonly available to evaluate post-travel illness include:

Complete blood count to screen for anemia, eosinophilia, elevated or decreased white blood cell
count and/or low platelets.

Travel-related infections causing eosinophilia include intestinal parasites, nematodes

(roundworms), cestodes (tapeworms), and trematodes (flukes). The most common are are
nematodes causing cutaneous larva migrans. Eosinophilia is commonlyn seen with filariasis and
schistosomiasis

Thick and thin blood films to screen for malaria (3 times over 24 hours)

Dip stick malaria assay, if available

Urinalysis and urine culture

Blood cultures

Stool culture. Smear for fecal leukocytes

 Cultures of other body fluid/tissues

Microscopic examination of stool for ova and parasites

Liver function tests

HIV test. Suspect HIV when the WBC count is low, especially low total lymphocyte count

Serology testing (e.g., dengue, brucellosis, leishmaniasis, amebiasis or other parasites, etc.). PCR
testing.

Imagingstudies: Chest x-ray or other plain films, ultrasound, CT and MRI

TRAVELLERS DIARRHEA (CDC)

Tingkat prevalensi = 30 70% (tergantung tujuan dan musim). TD sebenarnya bisa dicegah dengan
rekomendasi boil it, cook it, peel it, or forget it, tapi pada kenyataan sangat sedikit yang
mengikutinya. Salah satu faktor resiko tersering = poor hygiene practice in local restaurants.

Etiologi = Bakteri (80 90%), virus (5 8%), protozoa (10% terdiagnosis in long term travelers)

DD = food poisoning (diare dan muntah bisanya sembuh spontan dalam 12 jam)

Agen Infeksius

Bakteri = Entero-toxigenic E.coli, Campylobacter jejuni, Shigella sp, Salmonella sp.

Viral = norovirus, rotavirus, astrovirus
Protozoa = Giardia intestinalis, Entamoeba hystolitica

Prevalensi

1. Low risk = U.S, Canada, Australia, Japan, New Zeland

2. Intermediate risk = Afrika selatan, eastern Europe
3. High risk = Asia, Middle East, Africa, Mexico, Central & South America

Resiko

In environments where large numbers of people do not have access to plumbing

or latrines, the amount of stool contamination in the environment will be higher and
more accessible to flies. Inadequate electrical capacity may lead to frequent blackouts
or poorly functioning refrigeration, which can result in unsafe food storage and an
increased risk for disease. Lack of safe water may lead to contaminated foods and
drinks prepared with such water; inadequate water supply may lead to shortcuts in
cleaning hands, surfaces, utensils, and foods such as fruits and vegetables. In addition,
handwashing may not be a social norm and could be an extra expense, thus there may
be no handwashing stations in food preparation areas. In destinations in which effective
food handling courses have been provided, the risk for TD has been demonstrated to
decrease. However, even in developed countries, pathogens such as Shigella sonnei
have caused TD linked to handling and preparation of food in restaurants.

Manifes Klinis
Bakteri & Viral

Onset tiba-tiba, gejala mulai dari mild cramps dan urgent loose tools, sampai ke
severe abdominal pain, fever, vomiting, bloody diarrhea (pada norovirus paling
mencolok gejala muntah2)
Inkubasi 6 72 jam
Untreated bacterial: sembuh dalam 3 7 hari, viral : 2 3 hari

Protozoal

Gejala bertahap (mulai 2 5 stools/day)

inkubasi 1 2 minggu (jarang muncuk di 1 minggu awal travel)
Untreated : bertahan minggu bulan persistent travellers diarrhea (Suspicion
for giardiasis should be particularly high when upper gastrointestinal symptoms
predominate. Untreated, symptoms may last for months, even in immunocompetent
hosts. The diagnosis can often be made through stool microscopy, antigen detection,
or immunofluorescence. However, as Giardia infects the proximal small bowel, even
multiple stool specimens may fail to detect it, and a duodenal aspirate may be
necessary for definitive diagnosis.Management = dietary modif (gangguan
malabsorpsi), probiotik (terutama pada anak), antimicrobial)

Managemen (medscape)

Antibiotik = E.coli Salmonella - Shigella (cotrimoksasol 80-400mg 2 x 1 (5 days)),

Caampylobacter (Eritromycin 250 mg 3 x 1 (5 days)) perpendek durasi sakit &
shedding), Entamoeba hystolitica - Giardia (metronidazol 500 mg 2 x 1 (5 days))
Rehidrasi
a) Minimal/No dehirasi = 120 140 ml air tiap muntah/BAB cair
b) Mild moderate = 50 100 ml/kgBB tiap 3 4 jam (oralit), 120 140 ml air tiap
muntah/BAB
c) Severe = 20 ml/kgBB sampai perfusi + mental status improve (RL IV/NS) , 120
40 ml air tiap muntah/BAB

(American Family Physician, aafp.org)

Table 1.

Noninflammatory vs. Inflammatory Diarrheal Syndromes

Factor Noninflammatory Inflammatory
Etiology Usually viral, but can be bacterial or Generally invasive or toxin-producing
parasitic bacteria
PathophysiologyMore likely to promote intestinal secretion
More likely to disrupt mucosal integrity,
without significant disruption in the which may lead to tissue invasion and
intestinal mucosa destruction
History and Nausea, vomiting; normothermia; Fever, abdominal pain, tenesmus, smaller
examination abdominal cramping; larger stool volume;stool volume, bloody stool
findings nonbloody, watery stool
Laboratory Absence of fecal leukocytes Presence of fecal leukocytes
findings
Common Enterotoxigenic Escherichia coli, Salmonella (non-Typhi species), Shigella
pathogens Clostridium perfringens, Bacillus cereus Campylobacter, Shiga toxinproducing
 Staphylococcus aureus, Rotavirus, coli, enteroinvasive E. coli, Clostridium
Norovirus, Giardia, Cryptosporidium, difficile, Entamoeba histolytica, Yersinia
Vibrio cholerae
Other Generally milder disease Generally more severe disease
Severe fluid loss can still occur, especially
in malnourished patients

Table 3.

Clinical Features of Acute Diarrhea Caused by Select Pathogens

Pathogen Fever Abdomin Nausea, Fecal evidenceBloodyHeme-
al pain vomiting, or
of inflammation
stool positive
both stools
Bacterial
Campylobacter CommonCommon Occurs Common Occurs Variable
Clostridium difficile Occurs Occurs Not common Common Occurs Occurs
Salmonella CommonCommon Occurs Common Occurs Variable
Shiga toxinproducing Not Common Occurs Not common CommonCommon
Escherichia coli common
Shigella CommonCommon Common Common Occurs Variable
Vibrio Variable Variable Variable Variable Variable Variable
Yersinia CommonCommon Occurs Occurs Occurs Occurs
Parasitic
Cryptosporidium Variable Variable Occurs None to mild Not Not common
common
Cyclospora Variable Variable Occurs Not common Not Not common
common
Entamoeba histolytica Occurs Occurs Variable Variable Variable Common
Giardia Not Common Occurs Not common Not Not common
common common
Viral
Norovirus Variable Common Common Not common Not Not common
common

Treatment of Acute Diarrhea

Table 4.

Summary of Antibiotic Therapy for Acute Diarrhea

Organism Therapy Preferred Alternativ Comments
effectiv medication e
eness medicatio
ns
Bacterial
Campylobacter Proven in Azithromycin Erythromyci Consider
dysentery (Zithromax), n, 500 mg prolonged
and sepsis, 500 mg once per four times treatment if the
possibly day for 3 to 5 per day for 3 patient is
effective days to 5 days immunocomprom
in enteritis Ciprofloxaci ised
n (Cipro),
500 mg
twice per
day for 5 to7
days
Clostridium difficile Proven Metronidazole Vancomycin If an
(Flagyl), 500 mg , 125 mg antimicrobial
three times per four times agent is causing
day for 10 days per day for the diarrhea, it
10 days should be
discontinued if
possible
Enteropathogenic/enteroin Possible Ciprofloxacin, TMP/SMX
vasive Escherichia coli 500 mg twice DS, 160/800
per day for 3 mg twice
days per day for 3
days
Enterotoxigenic E. coli Proven Ciprofloxacin, TMP/SMX Enterotoxigenic
500 mg twice DS, 160/800 E. coli is the
per day for 3 mg twice most common
days per day for 3 cause of traveler's
days diarrhea
Azithromyci
n, 500 mg
per day for 3
days
Salmonella, non-Typhi Doubtful Options for In addition to
species in severe patients with
enteritis; disease: severe disease, it
proven in Ciprofloxaci is appropriate to
severe n, 500 mg treat patients
infection, twice per younger than 12
 sepsis, or day for 5 to months or older
dysentery 7 days than 50 years,
TMP/SMX and patients with
DS, 160/800 a prosthesis,
mg twice valvular heart
per day for 5 disease, severe
to 7 days atherosclerosis,
malignancy, or
uremia
Azithromyci Patients who are
n, 500 mg immunocomprom
per day for 5 ised should be
to 7 days treated for 14
days
Shiga toxinproducing E. Controver No treatment No The role of
coli sial treatment antibiotics is
unclear; they are
generally avoided
because of their
association with
hemolytic uremic
syndrome
Antimotility
agents should be
avoided
Shigella Proven in Ciprofloxacin, Azithromyci Use of
dysentery 500 mg twice n, 500 mg TMP/SMX is
per day for 3 twice per limited because
days, or 2-g day for 3 of resistance
single dose days
TMP/SMX Patients who are
DS, 160/800 immunocomprom
mg twice ised should be
per day for 5 treated for 7 to 10
days days
Ceftriaxone
(Rocephin),
2- to 4-g
single dose
Vibrio cholerae Proven Doxycycline, Azithromyci Doxycycline and
300-mg single n, 1-g single tetracycline are
dose dose not
Tetracycline recommended in
, 500 mg children because
four times
 per day for 3 of possible tooth
days discoloration
TMP/SMX
DS, 160/800
mg twice
per day for 3
days
Yersinia Not Options for
needed in severe
mild disease:
disease or Doxycycline
enteritis, combined
proven in with an
severe aminoglycos
disease or ide
bacteremia TMP/SMX
DS, 160/800
mg twice
per day for 5
days
Ciprofloxaci
n, 500 mg
twice per
day for 7 to
10 days
Protozoal
Cryptosporidium Possible Therapy may Option for Highly active
not be necessary severe antiretroviral
in disease: therapy, which
immunocompete Nitazoxanid achieves immune
nt patients with e (Alinia), reconstitution, is
mild disease or 500 mg adequate to
in patients with twice per eradicate
AIDS who have day for 3 intestinal disease
a CD4 cell count days (may in patients with
greater than 150 offer longer AIDS
cells per mm3 treatment
for
refractory
cases in
patients with
AIDS)
Cyclospora or Isospora Proven TMP/SMX DS,
160/800 mg
twice per day for
 7 to 10 days
AIDS or
immunosuppress
ion: TMP/SMX
DS, 160/800 mg
twice to four
times per day for
10 to 14 days,
then three times
weekly for
maintenance
Entamoeba histolytica Proven Metronidazole, Tinidazole If the patient has
750 mg three (Tindamax), severe disease or
times per day for 2 g per day extraintestinal
5 to 10 days, for 3 days, infection,
plus plus including hepatic
paromomycin, paromomyci abscess, serology
25 to 35 mg per n, 25 to 35 will be positive
kg per day in 3 mg per kg
divided doses per day in 3
for 5 to 10 days divided
doses for 5
to 10 days
Giardia Proven Metronidazole, Tinidazole, Relapses may
250 to 750 mg 2-g single occur
three times per dose
day for 7 to 10
days
Microsporida Proven Albendazole
(Albenza), 400
mg twice per
day for 3 weeks