418
Articles
Travel Medicine for the Primary Care Physician ALEX STUDEMEISTER, MD, San Jose, California
ravel medicine has become an important aspect of priMore than 8 million Americans travel to developing countries each year,1 and of these a quarter have at least one illness develop during their sojourn.2 Travelers are at risk of acquiring a number of preventable infections, such as travelers' diarrhea, viral hepatitis A, and malaria (Table 1).2-' Sources of information are available that describe in detail prophylactic measures and immunizations for travelers (Table 2). The following is an overview of vaccinations and prophylactic regimens that can be readily provided by primary care physicians. T
mary care.
General Recommendations Before traveling to underdeveloped areas, each patient should be instructed on preventive measures against travelers' diarrhea. Consideration should also be given to the need for vaccinations and malaria chemoprophylaxis. Patients with any significant chronic illness should have a complete medical evaluation in advance and consider taking along a medical summary, a list of medications with written prescriptions, and any relevant studies, such as a copy of an electrocardiogram. A first-aid kit consisting of adhesive strips and gauzes, insect repellent, aspirin, antacid, antibiotic ointment, sun-guard lotion, lip balm, antimotion sickness medication, thermometer, extra glasses, and moleskin may be useful. Table 3 lists the methods of administering commonly used vaccines. Yellow fever and cholera vaccines, with proper documentation in the International Certificates of Vaccination, are required to gain entry into certain countries. Meningococcal vaccination is required for entry into Saudi Arabia. More than three vaccinations should not be given simultaneously because of the possibility of increased side effects. On theoretic grounds, live vaccines-measles, mumps, rubella, yellow fever, oral poliovirus-should be avoided in immunocompromised persons and during pregnancy. Details regarding vaccination requirements and administration can be obtained from the publication, Health Information for International Travel. 8
Travelers' Diarrhea Acute diarrhea, which in most cases is a mild illness lasting less than a week, occurs in 20% to 50% of travelers to developing countries.8 Enterotoxigenic Escherichia coli is the most frequently identified cause of travelers' diarrhea; other causes include Salmonella, Shigella, Campylobacter, and Giardia species, Entamoeba histolytica, and viruses.
Elderly persons and patients with achlorhydria, gastric resection, or immune deficiency are at increased risk for travelers' diarrhea. Travelers can protect themselves by drinking only bottled beverages or purified water. Boiling is the most reliable way to purify water. Bringing the water to boil should be adequate, except at high altitudes, where it should be boiled for several minutes. Alternatively, 5 drops of tincture of iodine can be added per quart (or liter) of clear water 30 minutes before drinking. Cold or turbid water requires 10 drops and a delay preferably of several hours before it is drunk. Portable water filters may offer some protection, but they have not been extensively tested and the Centers for Disease Control (CDC) make no specific recommendations regarding their use. Travelers should not consume ice, uncooked food, unpasteurized milk, and fruit that cannot be peeled. The use of antibiotics, such as doxycycline (100 mg daily), double-strength trimethoprim-sulfamethoxazole (once a day), and norfloxacin (400 mg daily), and of bismuth subsalicylate (2 oz or two tablets four times a day) is effective in preventing travelers' diarrhea.8 9 These preventive measures are not recommended for the average traveler, however, because of the benign nature of the illness and the risk of side effects from prophylactic antimicrobials. Prophylaxis should be considered for persons at high risk for acquiring travelers' diarrhea who may have substantial morbidity from this illness. Travelers' diarrhea usually resolves without specific therapy. Bismuth subsalicylate and antimotility agents, such as loperamide hydrochloride and diphenoxylate hydrochloride, may provide temporary relief in mild cases (Table 4). Fluid therapy consisting of juices, caffeine-free soft drinks, and soup or an oral replacement solution as recommended by the United States Public Health Service (Table 5) should be part of the treatment of any diarrheal illness. Travelers to underdeveloped areas may benefit from early, self-treatment of travelers' diarrhea, especially if diarrhea is associated with fever and blood or mucus in the stools. Treatment with three- to five-day regimens of the combination drug trimethoprim and sulfamethoxazole, trimethoprim alone, doxycycline, and ciprofloxacin (Table 4) may be effective.8'10 Fluoroquinolones have the advantage of a broad spectrum of activity that includes Campylobacter species. The combination of sulfamethoxazole-trimethoprim and loperamide is also effective therapy.tI If diarrhea persists for more than three days, further medical evaluation should be carried out promptly to rule out intestinal parasites and other causes of diarrhea.
(Studemeister A: Travel medicine for the primary care physician. West J Med 1991 Apr; 154:418-422) From the Department of Medicine, Section of Infectious Diseases, San Jose Medical Group, San Jose, Califomia. Reprint requests to Alex Studemeister, MD, Department of Medicine, Section of Infectious Diseases, San Jose Medical Group, 45 S 17th St, San Jose, CA 95112.
THE WESTERN JOURNAL OF MEDICINE
APRIL 1991
o
THI
o
154
4
o
Vaccinations Against Enteric Pathogens
ABBREVIATIONS USED IN TEXT CDC = Centers for Disease Control HAV = hepatitis A virus HDCV = human diploid cell [rabies] vaccine OPV = oral poliovirus vaccine
TABLE 1.-Frequency of Infections in US Travelers Infection
Cases_100.000 Travelers
Travelers' diarrhea ......... 30,200 Viral hepatitis A ........... 300 Malaria ..................
Articles
Travel Medicine for the Primary Care Physician ALEX STUDEMEISTER, MD, San Jose, California
ravel medicine has become an important aspect of priMore than 8 million Americans travel to developing countries each year,1 and of these a quarter have at least one illness develop during their sojourn.2 Travelers are at risk of acquiring a number of preventable infections, such as travelers' diarrhea, viral hepatitis A, and malaria (Table 1).2-' Sources of information are available that describe in detail prophylactic measures and immunizations for travelers (Table 2). The following is an overview of vaccinations and prophylactic regimens that can be readily provided by primary care physicians. T
mary care.
General Recommendations Before traveling to underdeveloped areas, each patient should be instructed on preventive measures against travelers' diarrhea. Consideration should also be given to the need for vaccinations and malaria chemoprophylaxis. Patients with any significant chronic illness should have a complete medical evaluation in advance and consider taking along a medical summary, a list of medications with written prescriptions, and any relevant studies, such as a copy of an electrocardiogram. A first-aid kit consisting of adhesive strips and gauzes, insect repellent, aspirin, antacid, antibiotic ointment, sun-guard lotion, lip balm, antimotion sickness medication, thermometer, extra glasses, and moleskin may be useful. Table 3 lists the methods of administering commonly used vaccines. Yellow fever and cholera vaccines, with proper documentation in the International Certificates of Vaccination, are required to gain entry into certain countries. Meningococcal vaccination is required for entry into Saudi Arabia. More than three vaccinations should not be given simultaneously because of the possibility of increased side effects. On theoretic grounds, live vaccines-measles, mumps, rubella, yellow fever, oral poliovirus-should be avoided in immunocompromised persons and during pregnancy. Details regarding vaccination requirements and administration can be obtained from the publication, Health Information for International Travel. 8
Travelers' Diarrhea Acute diarrhea, which in most cases is a mild illness lasting less than a week, occurs in 20% to 50% of travelers to developing countries.8 Enterotoxigenic Escherichia coli is the most frequently identified cause of travelers' diarrhea; other causes include Salmonella, Shigella, Campylobacter, and Giardia species, Entamoeba histolytica, and viruses.
Elderly persons and patients with achlorhydria, gastric resection, or immune deficiency are at increased risk for travelers' diarrhea. Travelers can protect themselves by drinking only bottled beverages or purified water. Boiling is the most reliable way to purify water. Bringing the water to boil should be adequate, except at high altitudes, where it should be boiled for several minutes. Alternatively, 5 drops of tincture of iodine can be added per quart (or liter) of clear water 30 minutes before drinking. Cold or turbid water requires 10 drops and a delay preferably of several hours before it is drunk. Portable water filters may offer some protection, but they have not been extensively tested and the Centers for Disease Control (CDC) make no specific recommendations regarding their use. Travelers should not consume ice, uncooked food, unpasteurized milk, and fruit that cannot be peeled. The use of antibiotics, such as doxycycline (100 mg daily), double-strength trimethoprim-sulfamethoxazole (once a day), and norfloxacin (400 mg daily), and of bismuth subsalicylate (2 oz or two tablets four times a day) is effective in preventing travelers' diarrhea.8 9 These preventive measures are not recommended for the average traveler, however, because of the benign nature of the illness and the risk of side effects from prophylactic antimicrobials. Prophylaxis should be considered for persons at high risk for acquiring travelers' diarrhea who may have substantial morbidity from this illness. Travelers' diarrhea usually resolves without specific therapy. Bismuth subsalicylate and antimotility agents, such as loperamide hydrochloride and diphenoxylate hydrochloride, may provide temporary relief in mild cases (Table 4). Fluid therapy consisting of juices, caffeine-free soft drinks, and soup or an oral replacement solution as recommended by the United States Public Health Service (Table 5) should be part of the treatment of any diarrheal illness. Travelers to underdeveloped areas may benefit from early, self-treatment of travelers' diarrhea, especially if diarrhea is associated with fever and blood or mucus in the stools. Treatment with three- to five-day regimens of the combination drug trimethoprim and sulfamethoxazole, trimethoprim alone, doxycycline, and ciprofloxacin (Table 4) may be effective.8'10 Fluoroquinolones have the advantage of a broad spectrum of activity that includes Campylobacter species. The combination of sulfamethoxazole-trimethoprim and loperamide is also effective therapy.tI If diarrhea persists for more than three days, further medical evaluation should be carried out promptly to rule out intestinal parasites and other causes of diarrhea.
(Studemeister A: Travel medicine for the primary care physician. West J Med 1991 Apr; 154:418-422) From the Department of Medicine, Section of Infectious Diseases, San Jose Medical Group, San Jose, Califomia. Reprint requests to Alex Studemeister, MD, Department of Medicine, Section of Infectious Diseases, San Jose Medical Group, 45 S 17th St, San Jose, CA 95112.
THE WESTERN JOURNAL OF MEDICINE
APRIL 1991
o
THI
o
154
4
o
Vaccinations Against Enteric Pathogens
ABBREVIATIONS USED IN TEXT CDC = Centers for Disease Control HAV = hepatitis A virus HDCV = human diploid cell [rabies] vaccine OPV = oral poliovirus vaccine
TABLE 1.-Frequency of Infections in US Travelers Infection
Cases_100.000 Travelers
Travelers' diarrhea ......... 30,200 Viral hepatitis A ........... 300 Malaria ..................
