The Traveler in the ED: Initial Evaluation
Authors: Gary D. Hals, MD, PhD, Attending Physician, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, Columbia, SC; Danielle Davis, MD, Resident Physician, Department of Emergency Medicine, Palmetto Richland Memorial Hospital, Columbia, SC.
Peer Reviewer: Fredrick M. Abrahamian, DO, FACEP, Associate Professor of Medicine, David Geffen School of Medicine at University of California–Los Angeles; Direct or of Education, Department of Emergency Medicine, Olive View–UCLA Medical Center, Sylmar, CA.
During a busy shift the nurse brings a chart and states: "Another patient with a feverbut this one has an interesting twist. She just got back from Africa." Emergency physicians are very comfortable and well trained to evaluate patients of all ages with fever or other signs of infection. However, this familiar comfort quickly evaporates when evaluating the same symptoms in a patient with history of international travel. One's first impulse is likely to be to reach for the nearest text that describes exotic infections. Few emergency physicians see this type of patient on a regular enough basis not to feel that impulse. Further, possible climate change may allow the spread of vectors and diseases (e.g., Dengue fever from infected mosquitoes) northward and bring diseases U.S. physicians are not used to treating across our borders.1 The recent diagnosis of nine cases of cutaneous leishmaniasis (endemic in Mexico) in north Texas patients without travel histories is another example.2
This article will help provide the tools needed to approach the ill international traveler in the ED. First, the important historical points unique to these patients's evaluation will be discussed. Next, an overview of the major diseases will be provided by geographical region to help one focus on what disease to consider based on the exact travel history of each patient.
Travel is part of our world today. This article will be followed later this year by several more dealing with the traveler in the ED. We plan a comprehensive review of diseases typical to the tropics as well as more common diseases encountered during travel, such as STDs. Finally, because patients don't present with a diagnosis but with symptoms, we will address the approach to a symptomatic traveler in a future issue.
Travel is part of our world and ED physicians, be they rural or urban, need to be familiar with these "uncommon" diseases. It is hoped this and the future issues, along with their very helpful tables, will prove useful to our readers.
Sandra M. Schneider, MD, FACEP, Editor
Introduction
Every year increasing numbers of Americans leave the United States, traveling for a variety of reasons; business, tourism, aid work, immigrants visiting home, etc. According the Centers for Disease Control (CDC) more than 60 million U.S. residents traveled abroad in 2005 alone (includes Canada and Mexico). This number has increased from just over 50 million in 1995. With just over 300 million people living in the United States, this represents 20% of the population undergoing international travel yearly. Larger numbers of people are also traveling to the United States from other countries (visiting friends and relatives), and often they do not come with the same preventative immunizations as we are accustomed to in U.S. citizens. Recent government travel statistics show that in 2004 these visiting friends and relatives accounted for nearly 50% of U.S. international travelers.3
While travel to developed countries such as Canada may not increase the risk of illness, a significant number of travelers journey to exotic/tropical destinations where risk of disease is heightened. Exact numbers may vary yearly, but approximately 50% of U.S. international travel is to developing countries. A large number of these travelers are at risk for travel-related illness. Between 15% and 70% of people traveling from industrialized countries to developing countries become ill as a result,4 and at least 8% will seek medical care5; approximately 1 in 100,000 will die as a result.6 A specific study of 784 U.S. travelers found that 64% experienced at least one travel-related illness.7 These illnesses arise from a variety of sources: contaminated food or water, insect bites, infected humans or animals. Common symptoms of travel-related illness vary widely and include diarrhea, fever, rash, and respiratory illness.
Efficient evaluation of the ill traveler requires a systematic approach. One must obtain the appropriate history; locations visited, time spent at each, pre-travel immunization history, etc. Likewise one must be aware of the diseases that are common in the specific geographic areas, and the incubation times of these conditions. The next sections will discuss these topics in detail.
General Guidelines for Evaluation
When evaluating an ill traveler in the ED, there are several important points that one must address that are unique to these cases. (See Table 1.) Perhaps the most important point to remember is that illness after travel does not necessarily equate with travel-related illness. In other words, certain diseases are common, and the patient with fever and abdominal pain who thinks he may have visceral leishmaniasis may only be suffering from a urinary tract infection. Certainly one must screen the patient for more exotic conditions when indicated, but they may not be present. One should not forget to examine for standard disorders as well. When travel-related illnesses are present though, the screening process used is essential to being able to diagnose these challenging diseases. One should also remember that sexually transmitted diseases can be travel-related, and to consider acute HIV seroconversion in the evaluation of febrile illness.
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The act of obtaining the travel history can be more problematic than one would expect. Unfortunately not all patients will think to bring it up, and this is more likely to occur as time since travel passes. Given that incubation times of some infections can be months instead of days (i.e., malaria, rabies, trypanosomiasis, visceral leishmaniasis) obtaining the history of travel can be essential to accurate diagnosis. As seen in Table 2, incubation times for some important diseases can be up to several months. Thus, one should inquire about international travel at least a year prior to the ED visit,8 which may be longer than one initially would think relevant.
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Surprisingly, just remembering to obtain the travel-related history is often overlooked by ED physicians. One study found that a travel history was recorded in only 2% of ED patients although the number of patients with potential for travel-related illness was actually 5.3%.9 Another study gave ED physicians clinical scenarios describing acute presentations of imported diseases, but missing a travel history. They found that only 16% of physicians obtained the relevant travel history and thus the correct diagnosis was reached in only 22% of the cases.10
Pre-travel Vaccinations
There are several historical points that are necessary to obtain from ill travelers. Perhaps the best point to begin is with pre-travel vaccination and prophylaxis history. One may overlook this information when focusing on presenting symptoms and other details. Likewise, normal childhood vaccination history may also be useful. There are several pre-travel immunizations available, including hepatitis A and B, yellow fever, typhoid, meningococcus, rabies, and Japanese encephalitis. While most of these vaccines are recommended for travel to certain areas, yellow fever vaccine is required for legal entry into sub-Saharan Africa and tropical South America. Proof of yellow fever vaccination < 10 days prior to travel must be carried with the traveler. Vaccination is also required by many other countries if one passes through these endemic areas during travel. Meningococcal vaccine is also required for entry into Saudi Arabia during the Hajj (pilgrimage to Mecca required by Muslim religion to be performed once in their lifetime). Other immunizations are available, but are often covered in standard childhood vaccination series (i.e., diphtheria, measles, tetanus). Be aware that, with the exception of typhoid vaccine (50-80% efficacy), all of the pre-travel vaccinations are considered highly effective. Also be aware that HIV-positive patients may not be able to receive some pre-travel vaccines and therefore may be at increased risk for these infections (e.g., yellow fever).
Lastly, one should ask about prophylactic medications used, such as anti-malarial drugs, and any medications taken during travel. Antibiotic use during travel is of particular concern as several antibiotics can suppress (but not cure) malaria: azithromycin, doxycycline, quinolones, and clindamycin. Remember that these and other medications are available over the counter in some other countries. Obviously the symptoms prompting use of medications during travel are also of prime concern.
Geography
Locations visited are clearly important as the geographic area visited helps to narrow the list of possible infections to those endemic to the area. (See Tables 3 and 4.) The type of travel, urban vs. rural, is also important. "Extreme travel" or adventure travel is a relatively new term that describes what some travelers have been doing for decades: "journeying to remote destinations or participating in unusual high-risk activities during travel, generally far off the beaten path."11 While not a new concept, certainly these trips have become much more popular recently. Those visiting more remote locations are often more likely to be exposed to local human and insect populations, both of which can be sources of infection. These travelers are at particular risk for diarrheal illnesses, with a documented incidence of greater than 50%11 compared to 4–15% for standard travelers.12
Incubation Times
Dates of travel are also essential to obtain so the physician can cross-reference with incubation times for various diseases and thus determine which illnesses are possible. The amount of time spent at the destination and length of time since return can help narrow the differential. For example, if a patient does not develop symptoms until 1 month after travel to an area where dengue fever is endemic, then dengue fever is unlikely to be the diagnosis as the incubation time is between 2-7 days, which is one of the shortest for travel-related disease. Table 2 summarizes incubation periods of common travel-related infections. It is rare for a pathogen to cause an acute febrile illness associated with travel if the trip occurred over one year prior to fever.8 Thus, the travel history should focus on the past year. The dates of travel are also important as some diseases are seen seasonally. For example, meningococcal meningitis is most common in sub-Saharan during the dry season (November to February). It is also important to note that many diseases can have variable incubation times. Malaria, rabies, amebic liver abscess, hepatitis B, acute HIV, and schistosomiasis can all have incubation times anywhere from fewer than 2 weeks to more than 2 months.
Specific Exposures
Food, water, animals, insects, and humans can all be a potential source of infection for travelers. (See Table 5.) Patients with gastrointestinal symptoms should be asked about any exposures to untreated water, raw foods, and unpasteurized milk. Mosquitoes are carriers of dengue fever, malaria, and yellow fever. Tick bites can transmit typhus and borreliosis, and animal contact can cause Q fever, brucellosis, anthrax, rabies, or plague. Lastly, one should remember other humans as potential sources of hemorrhagic fevers (Lassa, Ebola), viral hepatitis, typhoid, sexually transmitted illness, or meningococcal disease. Remember to ask about travel companions who may have developed symptoms either during travel or after return, besides exposure to native populations. Some patients may be reluctant to offer information on sexual encounters during travel, but this data should be discussed specifically as it may hold the key to diagnosis.
Specific Region of Travel
The location(s) visited during travel are of prime importance as each area of the world has certain diseases that are endemic to that region. Table 3 provides a summary of major geographic regions and common endemic diseases, and Table 4 gives results from a study indicating the frequency of diseases documented in travelers to specific regions. Be aware that many diseases occur sporadically and at times may be found in regions they are not listed under in Table 3 or 4. Also, just because a disease is listed under a region does not imply that the risk of contracting that disease in all countries of that region is equal. In some cases the risk may only be high in one or two countries of a region, or only in a specific area of a particular country. For example, malaria is endemic in Africa but the risk in North Africa is limited to only southern Egypt, while the risk is highest in Sub-Saharan Africa. In addition, the lists of countries in each region are not complete for Europe, South America, or the South Pacific, but are limited to more common destinations.
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Africa
The area of sub-Saharan Africa is referred to in many places in this and other articles. By way of clarification, sub-Saharan Africa includes Southern, Western, Eastern, and Central Africa. In other words, sub-Saharan Africa includes every country in Africa except the North African countries of Algeria, Egypt, Libya, Morocco, Tunisia, and Western Sahara.
The primary risk for infection in North Africa is from contaminated food and/or water. Thus the most common disease reported is traveler's diarrhea. Typhoid fever, hepatitis A, amebiasis, and various intestinal parasites also are reported. Vector-borne infections also occur, but the risk of malaria is limited to only a few areas (rural areas of the Nile delta, and southern Egypt near the Sudan border). The risk of other vector-borne illnesses (dengue fever, filariasis, and leishmaniasis) is also low. HIV infections rates are relatively low for Africa (< 0.5%) but hepatitis B rates are between 2-7% and hepatitis C rates in Egypt are higher (15%). Animal bites are high risk as rabies is endemic. Cases of avian influenza (H5N1) in poultry and humans were first reported in 2006, with human deaths occurring in Egypt (47 cases, 20 deaths as of March 2008).
Central Africa is composed of Angola, Cameroon, Central African Republic, Chad, Congo, Zaire (Democratic Republic of Congo), Equatorial Guinea, Gabon, Sudan, and Zambia. Travelers to these areas are at increased risk for vector-borne illness, especially malaria. In fact, malaria is the most common cause of fever in travelers returning from this region. Further, the majority of infections are from Plasmodium falciparum, which causes a more dangerous form of malaria. Outbreaks of yellow fever, as well as cases of trypanosomiasis, dengue fever, filariasis, leishmaniasis, typhus, plague, viral hemorrhagic fevers (Ebola, Lassa, Marburg), and African tick-bite fever have all been reported in recent years. The risk of meningococcal disease is primarily during the dry season (December to June). Contaminated food and water cause traveler's diarrhea, as well as cholera, hepatitis A, typhoid, and amebiasis. Nearly 800 cases of polio were reported in Nigeria in 2005. HIV, tuberculosis, and hepatitis B infection rates are high in the local populations. One should remember that in this region, the majority of HIV infection occurs through heterosexual contact. The avian influenza virus (H5N1) has been found in poultry with at least one human case reported in 2006.
Southern Africa consists of Botswana, Lesotho, Namibia, South Africa, Swaziland, and Zimbabwe. Like central Africa, the risk of vector-borne illness is high, with malaria and African tick-bite fever among the more common infections reported by visitors to the area. Access to clean food and water can reduce risk of traveler's diarrhea and hepatitis A. While most of the population is vaccinated, polio made a comeback in Namibia in 2006. Those spending longer periods of time here are at high risk of HIV (up to 34% of adults are infected in some areas), hepatitis B, tuberculosis, schistosomiasis, and intestinal parasites. Rabies is also endemic; over 30 deaths were reported in South Africa in 2006, with most resulting from dog bites.
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Asia
East Asian countries include China, Hong Kong, Japan, Macau, Mongolia, North/South Korea, and Taiwan. Risk of infection in these countries varies widely, with rural areas generally being higher risk than urban regions of the same country. Traveler's diarrhea and generic respiratory infections are the most common problems reported. Malaria and Japanese encephalitis are found during the rainy season in China, Japan, and the Koreas, but pose little risk to urban travelers. Dengue fever outbreaks have occurred in China, Hong Kong, and Taiwan. Leishmaniasis and filariasis are limited to rural, coastal areas of China and South Korea. Hepatitis A risk is relatively high in most areas except Japan. Tuberculosis is relatively common, with rates of multi-drug resistant cases most common in parts of China (as high as 10% of cases). HIV infection rates are low in most areas, but hepatitis B is endemic in all but Japan. Hepatitis C is especially common in Mongolia and less so in mainland China. Rabies is prevalent in China and Mongolia (not in Japan or Taiwan), and a reported 2545 people in China died from rabies in 2005.15 Avian influenza (H5N1), plague, and hantaviruses have all be problematic in China and Korea in recent years. Schistosomiasis is limited to the Yangtze River and its tributaries in China.
South Asia is made of Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. The most common diseases reported by travelers are traveler's diarrhea, malaria, and typhoid fever. Japanese encephalitis occurs seasonally in rural areas (mostly lower elevations) except for Afghanistan. Leishmaniasis is found in rural India (especially eastern areas), Nepal, Bangladesh, and Pakistan. Filariasis is present in India, Sri Lanka, and Bangladesh. Dengue fever risk is low, except during outbreaks. Hepatitis A is common in this region and infection in travelers is common. Cholera and typhoid outbreaks occur in India and Bangladesh, again mostly in rural areas. While HIV infection rates are relatively low, rates are on the rise in some areas in India. Tuberculosis infection is quite high for the region, as is hepatitis B. Rabies cases are mostly from dog bites. Plague and anthrax are all endemic as well. The risk of meningococcal disease occurs year-round, mostly in India and Nepal. Avian influenza (H5N1) is also found in poultry from India and Pakistan, but as of March 2008 only 1 death has been reported (Pakistan).
Southeast Asia consists of Brunei, Myanmar (Burma), Cambodia, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand, East Timor, and Vietnam. Traveler's diarrhea, dengue fever and respiratory infections are the most commonly reported problems. Mosquito-borne diseases are common in these areas, and include dengue fever, Japanese encephalitis, and malaria. The malaria risk is year-round, but the risk of Japanese encephalitis is usually only high during the rainy season. Hepatitis A is common throughout the region. Amebiasis and typhoid fever also occur. SARS outbreaks occurred in 2003, mostly in Singapore and Vietnam. Avian influenza (H5N1) cases, including several human cases, have been primarily in Vietnam, Cambodia, Indonesia, and Thailand. Hepatitis B and C are common, as is HIV in high risk populations (sex trade workers, IV drug users). Rabies risk is localized to rural areas with large numbers of dogs.
Middle East countries include Bahrain, Cyprus, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates, and Yemen. As with most regions of the world, traveler's diarrhea is the most common complaint. Malaria risk is limited to localized areas of Iran, Iraq, Oman, Saudi Arabia, Syria, and Turkey. Outbreaks of dengue fever appeared in Saudi Arabia and Yemen in 2002. Leishmaniasis is relatively common, and risk of hepatitis A is high in most areas. Meningococcal outbreaks have occurred in Saudi Arabia during the Hajj pilgrimage, and meningococcal vaccine is required only during these periods. Hepatitis B is common throughout the region, while HIV rates are thought to be relatively low. Tuberculosis is high in Iraq, but lower in the rest of the areas. Rabies is pervasive, mostly from dog bites. Avian influenza (H5N1) has been found in poultry in Turkey, Iraq, and Israel with human deaths reported from Turkey and Iraq in 2006.
Europe
Common destinations in Western Europe are Austria, Belgium, Denmark, Finland, France, Germany, Greece, Greenland, Iceland, Ireland, Italy, Norway, Spain, Sweden, Switzerland, and the United Kingdom. As in North America, risk of infectious diseases here are low in most cases. Leishmaniasis occurs in countries bordering the Mediterranean. Other than Greenland, the risk of hepatitis A is low, as is the risk of traveler's diarrhea. Likewise, tuberculosis risks are only slightly higher than for North America. Rabies is found here but human cases are rare. HIV prevalence is a little higher than for North America, but is greater in high-risk groups. Avian influenza (H5N1) has been found in bird populations, but no human cases have been reported as of March 2008.
Eastern European countries commonly visited include Albania, Bulgaria, Czech Republic, Georgia, Hungary, Lithuania, Macedonia, Poland, Romania, Russia, Serbia, and Ukraine. Unlike Western Europe, access to clean food and water is variable as is use of childhood immunizations. As a result, diphtheria and measles outbreaks have occurred in recent past, and hepatitis A risk is high in most countries. Tick-borne encephalitis is endemic, but mostly seen during summer months in the southern areas. Lyme disease occurs in most of the former Soviet Union, and a West Nile virus outbreak was seen in Romania in 1999. Tuberculosis rates are high for the entire region, and multi-drug resistant cases are as high as 14% in Estonia, Lithuania, Russia, and Uzbekistan. Hepatitis B rates are moderate (2-7 % of population), while hepatitis C rates are lower except (< 4%) for Romania (up to 10%). HIV rates are thought to be between 1 and 5%, with clusters in high-risk populations. Rabies infections are rising in many countries. Hantaviruses are endemic, but sporadic. Avian influenza (H5N1) is found in local bird populations, and 8 human cases (5 deaths) were documented by March 2008.
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South/Central America
Central America consists of Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama. Traveler's diarrhea (E. coli, Giardia, Cryptosporidia, and Entamoeba histolytica) and dengue fever are the most common infections reported. Risk for malaria is low, limited mostly to rural areas, and is due to Plasmodium vivax in more than 50% of cases. Dengue fever occurs in outbreaks, and so far West Nile virus infection has been limited to Mexico. Hepatitis A is high in most areas, and hepatitis B risk is moderate. There is also moderate risk for tuberculosis (risk is highest in Guatemala, Nicaragua, and Honduras). A cholera outbreak occurred in the early 1990s involving the entire region (Central and South America). Leptospirosis outbreaks have been documented from those bathing in contaminated water.
Common destinations in South America include: Argentina, Chile, Uruguay, Bolivia, Brazil, Columbia, Ecuador, Galapagos Islands, Peru, and Venezuela. Primary infections found in temperate regions (Uruguay, Chile, Argentina) include: traveler's diarrhea, tuberculosis, hepatitis A (higher risk), leishmaniasis (Argentina), typhoid fever (Chile), and leptospirosis. The only yellow fever risk is in northern Argentina. The tropical regions of South America present the highest risk to the traveler with dengue fever, malaria, and traveler's diarrhea being the most common infections reported. Malaria risk is highest in rural areas (northern Peru, Columbia, Surinam, and Guyana). No malaria risk exists for Uruguay or the Falkland Islands. Dengue fever outbreaks are increasing with time, while yellow fever remains sporadic (Bolivia, Brazil, Columbia, Ecuador, Peru, and Venezuela). Chagas' disease (American trypanosomiasis) was more common in the past, especially in rural Brazil, but efforts to curb risks have been successful. The cholera epidemic began in Peru in 1991 and killed an estimated 10,000 people in Peru alone. Cholera is still present, but cases are sporadic. Hepatitis A risks are high throughout, but cholera risks have been limited to Brazil, Columbia, and Ecuador. Tuberculosis rates are generally moderate, but are high in Peru, Ecuador, and Bolivia. Hepatitis B rates are greater than 8% in Peru, northern Brazil, and 2-7% in Columbia and Venezuela. Hepatitis D outbreaks have occurred in the Amazon basin. Rabies risk results more from bats (vampire bats) than from dogs. Plague cases still occur, with most found in Peru. Leptospirosis is found throughout tropical regions.
Australia/South Pacific
Primary tourist destinations in this region include: Australia, Samoa, Fiji, Guam, Micronesia, New Zealand, Papua New Guinea, Solomon Islands, Tahiti, Tonga, and Wake Island. Risks vary in this region, with Australia and New Zealand being lowest risk for most infections. Risks are higher in the smaller islands. Malaria exists on Papua New Guinea, Vanuatu, and the Solomon Islands. Dengue fever occurs in epidemics in northern Australia and most of the islands. Japanese encephalitis has been documented in Papua New Guinea and northern Australia. Filariasis is common on most islands. Hepatitis A risk is high for the islands as well. Likewise, tuberculosis risk is high for the islands, but low on Australia and New Zealand. HIV is found throughout, but risks are highest on Papua New Guinea and nearby islands.
Traveler within the United States
Many of us forget that there are areas of the United States where unusual diseases are endemic. Therefore, when obtaining a history of travel, one should also question patients about travel within the United States.
Hantavirus, once largely felt to be confined to the southwestern United States, is now reported in 30 of the southern 48 states. It still remains more concentrated, however, in the states of Arizona, New Mexico, and surrounding areas. Plague (both bubonic and pneumonic) is endemic in rural parts of New Mexico, Arizona, Colorado, California, Oregon, and Nevada. West Nile virus, originally primarily in New York and surrounding states, has now been found in 39 states. Currently the only states without cases of West Nile are Arizona, Utah, Nevada, Oregon, Alaska, and Hawaii. Coccidiomycosis is endemic in California and also found in Arizona, Nevada, New Mexico, Texas, and Utah. Echinococcus, often associated with "third-world" countries, is found in Utah, Arizona, New Mexico, California, Alaska, as well as North Dakota, South Dakota, Minnesota, Iowa, Nebraska, Montana, and Wyoming. Lyme disease is spread primarily by the deer tick (although other species may spread it as well). They are found primarily in two locationsin the northeast from Pennsylvania to Massachusetts, and in the upper midwest in Wisconsin and Minnesota. New York has the highest number of Lyme disease cases, particularly in Winchester and Suffolk counties. Another tick-related disease, Ehrlichiosis, is seen seasonally from April to September in a variety of states, but is prevalent in New York, Minnesota, and Rhode Island.
Common Diseases
There are a handful of important diseases that the provider should keep in mind when seeing a recent traveler. These include leptospirosis, meningococcal disease, amebiasis, influenza, rabies, brucellosis, plague, and tuberculosis (particularly multiple drug resistant strains). These diseases are relatively widespread in the tropical and non-tropical areas of the world, including areas of the United States. These will be dealt with in a future issue on common travel-related diseases.
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Emergency physicians are very comfortable and well trained to evaluate patients of all ages with fever or other signs of infection. However, this familiar comfort quickly evaporates when evaluating the same symptoms in a patient with history of international travel.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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