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

Other

Staphylococcus aureus, Rotavirus,

coli, enteroinvasive E. coli, Clostridium
Norovirus, Giardia, Cryptosporidium, difficile, Entamoeba histolytica, Yersinia
Vibrio cholerae
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 evidenceBloodyHemeal pain vomiting, or
of inflammation
stool positive
both
stools

Bacterial
Campylobacter
Clostridium difficile
Salmonella
Shiga toxinproducing
Escherichia coli
Shigella
Vibrio
Yersinia
Parasitic
Cryptosporidium

Occurs
Not common
Occurs
Occurs

Common
Common
Common
Not common

Occurs Variable
Occurs Occurs
Occurs Variable
CommonCommon

Common
Variable
Occurs

Common
Variable
Occurs

Occurs Variable
Variable Variable
Occurs Occurs

Variable Variable Occurs

None to mild

Cyclospora

Variable Variable Occurs

Not common

Entamoeba histolytica
Giardia

Occurs Occurs Variable

Not
Common Occurs
common

Variable
Not common

Not
Not common
common
Not
Not common
common
Variable Common
Not
Not common
common

Variable Common Common

Not common

Viral
Norovirus

CommonCommon
Occurs Occurs
CommonCommon
Not
Common
common
CommonCommon
Variable Variable
CommonCommon

Treatment of Acute Diarrhea

Not
Not common
common

Table 4.
Summary of Antibiotic Therapy for Acute Diarrhea
Organism
Therapy Preferred
Alternativ
effectiv
medication
e
eness
medicatio
ns

Bacterial
Campylobacter

Proven in
dysentery
and sepsis,
possibly
effective
in enteritis

Azithromycin
(Zithromax),
500 mg once per
day for 3 to 5
days

Clostridium difficile

Proven

Metronidazole
(Flagyl), 500 mg
three times per
day for 10 days

Enteropathogenic/enteroin
vasive Escherichia coli

Possible

Ciprofloxacin,
500 mg twice
per day for 3
days

Enterotoxigenic E. coli

Proven

Ciprofloxacin,
500 mg twice
per day for 3
days

Salmonella, non-Typhi
species

Doubtful
in
enteritis;
proven in
severe
infection,

Erythromyci
n, 500 mg
four times
per day for 3
to 5 days
Ciprofloxaci
n (Cipro),
500 mg
twice per
day for 5 to7
days
Vancomycin
, 125 mg
four times
per day for
10 days

TMP/SMX
DS, 160/800
mg twice
per day for 3
days
TMP/SMX
DS, 160/800
mg twice
per day for 3
days
Azithromyci
n, 500 mg
per day for 3
days
Options for
severe
disease:
Ciprofloxaci
n, 500 mg
twice per

Comments

Consider
prolonged
treatment if the
patient is
immunocomprom
ised

If an
antimicrobial
agent is causing
the diarrhea, it
should be
discontinued if
possible

Enterotoxigenic
E. coli is the
most common
cause of traveler's
diarrhea

In addition to
patients with
severe disease, it
is appropriate to
treat patients
younger than 12

sepsis, or
dysentery

day for 5 to
7 days
TMP/SMX
DS, 160/800
mg twice
per day for 5
to 7 days

Shiga toxinproducing E.
coli

Controver
sial

No treatment

Shigella

Proven in
dysentery

Ciprofloxacin,
500 mg twice
per day for 3
days, or 2-g
single dose

Vibrio cholerae

Proven

Doxycycline,
300-mg single
dose

months or older
than 50 years,
and patients with
a prosthesis,
valvular heart
disease, severe
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
No
The role of
treatment
antibiotics is
unclear; they are
generally avoided
because of their
association with
hemolytic uremic
syndrome
Antimotility
agents should be
avoided
Azithromyci Use of
n, 500 mg
TMP/SMX is
twice per
limited because
day for 3
of resistance
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
Azithromyci Doxycycline and
n, 1-g single tetracycline are
dose
not
Tetracycline recommended in
, 500 mg
children because
four times

Yersinia

Not

needed in
mild
disease or
enteritis,
proven in
severe
disease or
bacteremia

Protozoal
Cryptosporidium

Possible

Therapy may
not be necessary
in
immunocompete
nt patients with
mild disease or
in patients with
AIDS who have
a CD4 cell count
greater than 150
cells per mm3

Cyclospora or Isospora

Proven

TMP/SMX DS,
160/800 mg
twice per day for

per day for 3 of possible tooth

days
discoloration
TMP/SMX
DS, 160/800
mg twice
per day for 3
days
Options for

severe
disease:
Doxycycline
combined
with an
aminoglycos
ide
TMP/SMX
DS, 160/800
mg twice
per day for 5
days
Ciprofloxaci
n, 500 mg
twice per
day for 7 to
10 days
Option for
severe
disease:
Nitazoxanid
e (Alinia),
500 mg
twice per
day for 3
days (may
offer longer
treatment
for
refractory
cases in
patients with
AIDS)

Highly active
antiretroviral
therapy, which
achieves immune
reconstitution, is
adequate to
eradicate
intestinal disease
in patients with
AIDS

Entamoeba histolytica

Proven

Giardia

Proven

Microsporida

Proven

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
Metronidazole,
750 mg three
times per day for
5 to 10 days,
plus
paromomycin,
25 to 35 mg per
kg per day in 3
divided doses
for 5 to 10 days

Metronidazole,
250 to 750 mg
three times per
day for 7 to 10
days
Albendazole
(Albenza), 400
mg twice per
day for 3 weeks

Tinidazole
(Tindamax),
2 g per day
for 3 days,
plus
paromomyci
n, 25 to 35
mg per kg
per day in 3
divided
doses for 5
to 10 days
Tinidazole,
2-g single
dose

If the patient has

severe disease or
extraintestinal
infection,
including hepatic
abscess, serology
will be positive

Relapses may
occur