Felicia Spadini, APRN, MSN, NP-C

The frequency and scale of global travel has led to unprecedented opportunity for rapid spread of emerging and reemerging diseases. Providers not only need to take measures to protect their patients from health risks, but they must also consider measures to protect the community at large. Clinicians need to be aware of the current health concerns in order to protect the residents in the communities where travelers will be visiting, as well as the residents in the communities to which travelers will be returning.

In order to minimize the spread of nonendemic diseases from region to region and to offer solid pretravel counseling, clinicians should be familiar with resources that identify known and emerging health threats by geographic distribution.

The CDC offers 2 excellent resources that are accessible to health care professionals, travel professionals, and laypersons. The first is the

CDC Health Information for International Travel: The Yellow Book

. The second is the CDC Travelers’ Health Website (cdc.gov/travel).

Alternatively, there are proprietary software platforms that provide similar information. Such services are not free, but they may simplify and accelerate the process of locating pertinent travel health information by location.

The health needs of travelers vary based on destination, length of stay, planned activities, age and current health status of the traveler, and pregnancy status. Health risks vary according to whether international travel is for business, tourism, family, or humanitarian reasons.

Multiple factors must be taken into account, including costs, because many travel health—related expenses are unlikely to be covered by insurance. Clinicians should be able to help patients prioritize their health concerns, but they should also realize that patients with complex itineraries or preexisting health conditions may require more extensive and personalized planning efforts. In addition, patients who have a complex health history, have young children, or are currently pregnant may need to be referred to a travel medicine specialist.

These consultations offer clinicians an opportunity to advise patients regarding methods for limiting common travel health hazards and minimizing the risks of contracting illnesses while traveling. It is an opportunity to update routine vaccinations and to provide vaccine recommendations based on travel destination. The pretravel health visit is also the time to discuss disease prophylaxis and self-treatment of common travel illnesses. Clinicians should discuss strategies to avoid food and waterborne illnesses, sexually transmitted infections, mosquito-borne infections, and respiratory tract infections.

If travel health—related costs are an issue, now is also the time to help patients prioritize their health concerns to get maximum benefits within their budget.

Routine Immunizations to Update Before Travel

Finally, clinicians should be aware that Menactra and Menveo, the standard meningococcal vaccines, are only safe for patients up to age 55 years. Travelers 56 years and older should receive Menomune instead.

Patients should bring their vaccine records to the pretravel consultation. Routine vaccines that should be completed or brought up-to-date before travel include

type b, hepatitis B, human papillomavirus, influenza, measles/mumps/rubella, meningococcal, pneumococcal, polio, rotavirus, tetanus/diptheria/pertussis, varicella, and zoster. For the most part, routine vaccines follow standard US immunization schedules and are covered by health insurance. Therefore, the zoster and pneumococcal vaccines will not be necessary unless the travelers meet the age and health requirements set by the Advisory Committee on Immunization Practices.

The one exception is the meningococcal vaccine. For travelers going to high-risk destinations, the meningococcal vaccine should be administered every 3 to 5 years. And for those attending the Hajj (the annual pilgrimage by Muslims to Mecca), proof of meningococcal vaccine is required in order to be issued a visa. Travelers need a valid International Certificate of Vaccination or Prophylaxis documenting that they were given the meningococcal vaccine 10 or more days prior to, and within 3 years of, travel in order to enter Saudi Arabia.

Patients requiring travel health vaccines for yellow fever, rabies, or Japanese encephalitis may need to be referred to a travel health specialist because many standard health care settings are not equipped to administer them. Additionally, vaccines for cholera and tick-borne encephalitis are not available in the United States. The travel-related vaccines that are more readily available are hepatitis A and typhoid. Hepatitis A is administered as a 2-dose series, with the second dose approximately 6 months after the initial dose. The typhoid vaccine may be given orally or intramuscularly (IM). IM typhoid is inactivated, and one dose given 2 weeks prior to travel offers protection for 2 years. Oral typhoid is a live vaccine and requires 4 doses over 7 days; it should be given at least 1 week prior to travel, and a booster is required every 5 years if typhoid remains a concern. Travelers should know that neither typhoid vaccine (IM or oral) is 100% effective, so they should maintain caution when eating and drinking.

Patients who do not complete vaccines requiring a series (such as hepatitis A or B) should be counselled that they may pick up where they left off and that the series does not need to be restarted.

Altitude sickness is caused by hypoxemia secondary to decreased air pressure. It is caused by climbing mountains or traveling to high-altitude areas, such as Colorado. This consists of 3 distinct syndromes: acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE). Both HACE and HAPE are rare but can be fatal. HACE presents with drowsiness, altered mental status, and ataxia. HAPE presents with breathlessness, weakness, and cough. Both require descent to a lower altitude to prevent death. AMS is much more common and not fatal, and presents with head ache, fatigue, nausea, and pallor. The condition usually resolves as the body acclimates to the altitude—generally within 24 to 72 hours.

There are medications to help prevent altitude illness, but providers should stress that proper altitude acclimation remains paramount to avoiding altitude illness. Acetazolamide and dexamethasone are used to help prevent AMS and HACE. Acetazolamide acidifies the blood, causing an increase in respiration and oxygenation. Dosing at 125 mg every 12 hours begins the day before increased altitude. Acetazolamide, however, should be avoided by travelers who are allergic to sulfa drugs. Dexamethasone at 4 mg every 6 hours is an alternative form of treatment.

Malaria continues to pose a very serious risk of morbidity and mortality. Travelers visiting malaria-endemic countries should be counseled regarding chemoprophylaxis and malaria transmission to reduce their risk of contracting the disease. Malaria is a concern for travelers visiting certain areas of Africa, Latin America, the Caribbean, Asia, Southeast Asia, the Middle East, Eastern Europe, and the South Pacific. Malaria is transmitted via a bite from an infected female

Clinicians should warn that chemoprophylaxis is only part of avoiding illness and that proper mosquito-bite prevention is essential to limiting the risk for mosquito-borne illnesses. Risk levels vary with the season and type of travel planned. Travelers in low-cost, rural settings face a higher risk than do those staying in air-conditioned hotels. Therefore, mosquito repellants (eg, DEET) and other strategies to avoid mosquito bites should be researched and considered.

When choosing an antimalarial drug, multiple factors should be considered, including cost, length of travel, daily versus weekly administration, resistance, and adverse effects. There are currently 5 different antimalarial medications, and each has pros and cons that should be considered on a case-by-case basis.

The Table provides the pros, cons, and dosage overviews of 5 prophylactics available to travelers.

Traveler’s diarrhea (TD) is defined as 3 or more loose stools per day with or without cramping and abdominal pain. It is one of the most common travel ailments—affecting 30% to 70% of travelers. TD may be caused by bacteria, viruses, or protozoa, but bacterial TD accounts for 80% to 90% of cases. The standard incubation period for viral and bacterial causes is 6 to 12 hours and for most protozoal pathogens, 1 to 2 weeks. To date, the best antibiotics for empiric treatment of bacterial TD are ciprofloxacin and azithromycin. It should be noted that bacterial resistance to ciprofloxacin is becoming more common and that neither antibiotic will treat protozoal or viral pathogens. For children younger than 18 years, azithromycin remains first-line therapy.

Motion sickness refers to vestibular disturbances caused by the movement during car, train, sea, or air travel. Women and children (aged 2 to 12 years) are most commonly affected. Treatment mainstays include antihistamines such as Benadryl, Dramamine, meclizine, promethazine, and cyclizine. The scopolamine patch (transdermal) is an alternative for patients who do not want to take daily oral medication. Other options include prochlorperazine and metoclopramide. For children with motion sickness, Dramamine and Benadryl are considered first-line treatment.

In the past decades, many illnesses have emerged or reemerged that may be spread by international travelers. Two new respiratory illness caused by coronavirus and characterized by severe pneumonia are Middle East Respiratory Virus (MERS) and Severe Acute Respiratory Syndrome (SARS). New strains of influenza A have also caused global concern, and both H1N1 and H5N1 have caused significant morbidity and mortality.

Several mosquito-transmitted illnesses, such as malaria, West Nile virus, and dengue fever, have long presented serious health risks for travelers, but new mosquito-borne illnesses have also emerged, such as chikungunya and Zika virus. In the aftermath of the 2010 earthquake in Haiti, a new strain of cholera that appears related to strains from Africa and Asia appeared. This strain has now spread to the Dominican Republic, Cuba, and parts of Mexico.

Although rare in the Western Hemisphere, polio continues to circulate in some regions of the world. Recently, polio has been identified in Pakistan, Syria, Somalia, Iraq, Cameroon, and Equatorial Guinea. Finally, measles outbreaks continue throughout the world due to lack of vaccination.

When a patient presents with an illness that may be related to travel, the clinician should consider factors such as severity of illness, vaccine record, past medical history, type of travel, accommodations and activities, insect bites, animal bites, exposure to freshwater from lakes or rivers, source of drinking water, and known exposure to illness. Febrile illnesses should be viewed as highly suspicious, especially with respiratory illness, rash, and/or nervous system involvement.

Clinicians have many facets to consider during the travel health visit. Travelers should be made aware of known health risks specific to their destination to ensure the safest travel possible. Clinicians should advise travelers regarding recommended vaccines, chemoprophylaxis, and self-treatment options. They must also stress the importance of common wellness measures, such as clean drinking water, mosquito protection, sun protection, condom use, and safe eating practices. Travelers should be directed to reputable travel health resources and encouraged to take an active part in preparing and protecting themselves during their travels.

Felicia Spadini is a board-certified nurse practitioner. She began her career as a registered nurse in emergency medicine and then worked in the cardiothoracic stepdown unit for several years as a certified diabetes resource nurse and a certified wound/skin care nurse. As a nurse practitioner, she has worked in the retail health care setting since graduating in 2013. Her passion is research and providing education for peers and patients alike.

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CDC Health Information For International Travel The Yellow Book 2016

Sotir A, LaRocque R. travel epidemiology. In:Brunette G, ed.

Chen L, Hochberg N, Magill A. the pre-travel consultation. In:Brunette G, ed.

MacNeil J, Meyer S. meningococcal disease. In:Brunette G, ed.

Newton A, Routh R, Mahon B. typhoid and paratyphoid fever. In:Brunette G, ed.

Hackett P, Shlim D. altitude illness. In:Brunette G, ed.

Arguin P, Tan K. malaria. In:Brunette G, ed.

Youngster I, Barnett E. interactions among travel vaccines & drugs. In:Brunette G, ed.

Connor B. self-treatable conditions: travelers’ diarrhea. In:Brunette G, ed.

Erskine S. self-treatable conditions: motion sickness. In:Brunette G, ed.

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Articles

The frequency and scale of global travel has led to unprecedented opportunity for rapid spread of emerging and reemerging diseases. 

Travel Health

Varicella-zoster virus (VZV) is a herpesvirus that causes 2 related but separate clinical illnesses. Primary exposure to VZV causes varicella infection (chickenpox). Once chickenpox resolves, VZV resides latent in neurons within the regional ganglia and may re-emerge at any time to cause herpes zoster infection (shingles).

The incidence of chickenpox in the United States has decreased significantly since universal varicella vaccination began in 1995.

However, herpes zoster infection remains very common, with almost 1 of 3 individuals in the United States developing it in their lifetime.

Primary care providers should be able to diagnose both conditions and begin treatment promptly for uncomplicated infections. Moreover, clinicians should be able to recognize patients with signs and symptoms of severe VZV infection, as well as those at high risk for developing complications, and refer them to appropriate specialists.

Following exposure, chickenpox has an incubation period ranging from 10 to 21 days.

Clinical illness starts with a short prodromal period of fever and malaise followed by the hallmark pruritic vesicular rash.

The lesions associated with the rash form crusts in about 6 days and then fall off after 1 to 2 weeks. Once the lesions have crusted, the individual is no longer considered contagious.

Usually, chickenpox confers lifelong immunity, although rare cases of reinfection have been reported.

Humans are the only VZV reservoir, so chickenpox can only be transmitted from patient to patient.

It is highly contagious and may be transmitted via respiratory droplets and vesicular fluids; less commonly, the virus may become airborne.

Transmission of chickenpox is also possible from infected mother to her fetus in utero and to her newborn during birth.7 If an immunized individual develops breakthrough varicella infection, transmission to others is possible but uncommon.

In healthy children, chickenpox is generally a mild, self-limiting illness that requires only symptomatic management. Typical symptoms include fever, malaise, and pruritic vesicular rash that starts on the head and face and spreads to the rest of the body.

However, in certain populations, varicella may cause significant morbidity and mortality. Groups at increased risk for complications include unvaccinated adolescents and adults, neonates, immunocompromised individuals, and pregnant women. Common serious complications from chickenpox include encephalitis, hepatitis, varicella pneumonia, and infection.

Additionally, maternal VZV infection during the first or second trimesters of pregnancy may lead to the fetus developing congenital varicella syndrome, which can cause severe birth defects.

Mild varicella-like syndrome (MVLS), also called breakthrough varicella, is a milder version of varicella infection that develops occasionally when vaccinated patients are exposed to wild-type

VZV. Breakthrough infection may be caused by a failure to develop an effective immune response to the vaccine or by immunity diminishing over time.

Although the symptoms of MVLS are mild, the infected individual is still contagious to susceptible individuals.

Complications from chickenpox include secondary bacterial skin infection, meningitis, encephalitis, cerebellar ataxia, pneumonia, glomerulonephritis, myocarditis, ocular disease, adrenal insufficiency, sepsis, and death.

Additionally, grave complications may develop if chickenpox is contracted during pregnancy, the most common of which is the aggressive varicella pneumonia, characterized by diffuse infiltration that often compromises both lungs and rapidly causes respiratory failure.

The fetus is also at risk of developing congenital varicella syndrome, which has a 30% mortality rate and can result in multiple birth defects. Common abnormalities caused by congenital varicella syndrome include mental retardation, microcephaly, hydrocephalus, seizures, limb hypoplasia or paresis, cataracts, optic nerve atrophy, micropthalmos, nystagmus, stenotic bowel, scarring, and low birth weight. Neonatal chickenpox may also cause severe disease and has a high mortality rate.

Groups considered to be at high risk for complications include immunocompromised patients, unvaccinated adults, pregnant women, and adolescents older than 12 years. For immunocompetent patients, oral valacyclovir or acyclovir are the treatments of choice. Immunocompromised patients should receive intravenous acyclovir. For greatest benefit, treatment should be started within 24 hours of development of rash. Regardless of age, treatment

should be initiated for any patient that presents with varicella-related complications such as encephalitis, hepatitis, or varicella pneumonia.

The treatment for chickenpox varies widely based on the patient’s age and overall state of health. In general, symptomatic management is all that is required for immunocompetent children up to 12 years old. Recommended treatment for this group includes acetaminophen, antihistamines, and trimming fingernails to help discourage secondary skin infections.

Due to concerns of Reye syndrome, salicylates should be avoided with children and adolescents.

Following exposure to VZV, pregnant women who have never received varicella vaccination and show no serologic proof of past VZV infection have a 96-hour window to receive post-exposure prophylaxis.

In the United States, the only FDA-approved product for passive immunity is VariZIG, which is used to prevent or attenuate varicella infection.

For pregnant women who develop varicella infection despite prophylaxis, there is no evidence that it prevents congenital varicella syndrome.19 VariZIG may also be used prophylactically in newborns who have been exposed to VZV to prevent or attenuate varicella infection.

When chickenpox is suspected, primary care providers should obtain vaccine history. If the patient has received 1 or 2 doses of vaccine, infection will likely be mild.

For patients older than 12 years, oral antivirals should be initiated within 24 hours of rash onset.

Patients should be advised that they are highly contagious until the lesions have crusted over, which usually takes 7 to 10 days.

They should be counseled to avoid unvaccinated individuals, immunocompromised individuals, newborns, and pregnant women since these groups have the greatest risk of complications.9 If an immunocompromised patient develops chickenpox, the individual should be closely monitored for prolonged fevers, extensive rashes, confusion, or other signs of distress.6 If chickenpox is suspected in a newborn, prompt referral for monitoring and treatment is warranted.

In general, once an individual has had chicken pox, immunity is conferred for life.

However, after varicella infection, the individual may develop shingles at any age.

Herpes zoster infection (shingles) is the reactivated illness caused by latent VZV. It can occur in individuals at any age, but is more likely to affect those 50 years and older.

It manifests as a pruritic vesicular rash that is typically unilateral and confined to a single dermatome. The rash associated with herpes zoster infection may be accompanied by acute neuritis, which may cause significant pain. The neuralgia can start days before the rash appears and can last for weeks after the rash resolves.

Although there are multiple risk factors that contribute to VZV reactivation, the single greatest risk factor for developing shingles is being 60 years or older.

Other major risk factors for reactivation of VZV include physical trauma, female gender, depression, and various conditions that lead to host immunocompromise such as chronic lung disease, autoimmune disease, cancer,kidney disease, HIV infection, solid organ transplant, bone marrow transplant, inflammatory bowel disease, rheumatoid arthritis, and immunosuppressive medications

The exact mechanism and pathway of VZV from chickenpox to latency and then to reactivated herpes zoster infection is uncertain

However, it is clear that decreased cell-mediated immunity contributes to reactivation. Therefore, primary risk factors for developing shingles are conditions that decrease cell-mediated immunity such as increased age and immunocompromise arising secondary to illness or medications.

Herpes zoster infection is far less contagious than chickenpox. An individual with shingles cannot transmit shingles to another individual. However, they may transmit chicken pox to susceptible individuals.

Herpes zoster infection is transmitted via vesicular fluids and, less commonly, the virus may become airborne.

Complications in Immunocompetent Patients

For immunocompetent patients, the most common complication of herpes zoster infection is postherpetic neuralgia. It is characterized by pain that recurs in the area of the initial outbreak for months to years after the infection has resolved. Patients older than 60 years account for half of the cases of postherpetic neuralgia.

In addition to nerve-related pain, there are several other serious neurologic complications which may develop from herpes zoster infection including aseptic meningitis, myelitis, peripheral motor neuropathy, encephalitis, Guillain-Barré syndrome, and stroke syndromes.

Shingles infection in the eyes may cause herpes zoster opthalmicus or acute retinal necrosis, which are grave ophthalmic disorders that can result in permanent vision loss.

Patients with shingles lesions on the nose (Hutchinson’s Sign) are considered high risk for developing herpes zoster opthalmicus.

Clinicians should consider all patients with eye or nose involvement emergent because early detection and treatment are paramount for preserving vision.

Finally, there is Ramsay Hunt Syndrome, an optic complication which may involve multiple cranial nerves and result in facial paralysis, ear pain, vertigo, tinnitus, and taste disturbances.

Herpes zoster infection during pregnancy is not associated with congenital varicella syndrome. However, the mother may transmit chickenpox to her newborn during birth, and very rarely, the mother may transfer the virus to the fetus in utero.

Complications in Immunocompromised Patients

In general, the immunocompromised, such as transplant recipients and HIV-positive patients, are at greatest risk of developing severe complications from herpes zoster infection.

In those patients, herpes zoster infection may even become a life-threatening syndrome with multi-organ involvement. Disseminated herpes zoster infection often involves multiple dermatomes and presents bilaterally.

It leads to rapidly progressing pneumonia, hepatitis, and encephalitis that often progresses to death even with treatment.

Oral antiviral therapy is recommended for any patient without contraindications. Treatment should be initiated up to 72 hours after rash appears.

Antivirals are prescribed to lessen the severity and duration of illness, prevent post-herpetic neuralgia and reduce the risk of transmission.

Medications suitable for treatment of shingles are acyclovir, valacyclovir, and famciclovir. However, the second-generation antivirals, valacyclovir and famciclovir, are

preferred because of greater bioavailability and less frequent dosing.

Depending on the severity of neuritis and pain, patients may be treated with a range of pain medications. For mild pain, OTC acetaminophen or nonsteroidal anti-inflammatory drugs may suffice. Moderate to severe pain generally requires prescription pain medications such as tramadol, codeine, oxycodone, or morphine.

Adjunct medications such as glucocorticoids and tricyclic antidepressants are not recommended for initial treatment of shingles related pain since there is not enough evidence to support their use.

Pregnant women with herpes zoster infection are not considered high risk and are treated similar to other immunocompetent patients.

Postherpetic neuralgia is the most common complication of herpes zoster infection.

Current treatments for moderate to severe recurrent pain include amitriptyline, nortriptyline, desipramine, pregabalin, gabapentin, and valproic acid.

Topical capsaicin may also be used to augment any of these medications or as an alternative to systemic therapy.

For intractable pain, opioids may be prescribed. Other methods to control postherpetic neuralgia are intrathecal glucocorticoids, botulinim toxin injections, cryotherapy, and even surgery.

Severe complications from herpes zoster infection, such as those that involve cranial nerves and affect the eyes and ears, require early diagnosis and treatment with intravenous antivirals and ophthalmic steroids.

Additionally, immunocompromised individuals are at much greater risk of morbidity and mortality, and generally require hospitalized care where they may receive intravenous antiviral therapy as well as close monitoring for life-threatening complications.

When shingles is suspected, the primary care provider should obtain vaccine history. Previously vaccinated individuals tend to have milder infections and fewer complications than patients who have not been vaccinated.

Treatment with oral antivirals should be initiated within 72 hours of rash onset. If pain is present, pain-control measures should also be initiated.

Immunocompromised patients, as well as those with face or eye involvement, should be considered emergent and promptly referred to appropriate specialist.

Patients with shingles should be counseled that they are contagious until the rash has crusted over and that they can spread chickenpox to susceptible individuals.

Appropriate patients older than 50 years should be advised to receive the shingles vaccine to prevent or attenuate herpes zoster infection. Patients should also be counseled that past history of herpes zoster infection is not a contraindication to receiving the shingles vaccine. Providers should stay abreast of new vaccines since HZ/su may soon become available.

1. CDC. Varicella. CDC website. cdc.gov/vaccines/pubs/pinkbook/downloads/varicella.pdf. Accessed May 3, 2016.

2. CDC. Evolution of varicella surveillance — selected states, 2000-2010. MMWR Morb Mortal Wkly Rep. 2012; 61(32):609-612. CDC website. cdc.gov/mmwr/preview/mmwrhtml/mm6132a2.htm. Accessed May 3, 2016.

3. Straus SE, Ostrove JM, Inchauspé G, et al. NIH conference. Varicella-zoster virus infections. Biology, natural history, treatment, and prevention. Ann Intern Med. 1988;108(2):221-237.

4. Heininger U, Seward JF. Varicella. Lancet. 2006;368(9544):1365-1376.

5. Martin KA, Junker AK, Thomas EE, Van Allen MI, Friedman JM. Occurrence of chickenpox during pregnancy in women seropositive for varicella-zoster virus. J Infect Dis. 1994;170(4):991-995.

6. Leclair JM, Zaia JA, Levin MJ, Congdon RG, Goldmann DA. Airborne transmission of chickenpox in a hospital. N Engl J Med. 1980;302(8):450-453.

7. Enright AM, Prober CG. Herpesviridae infections in newborns: varicella zoster virus, herpes simplex virus, and cytomegalovirus. Pediatr Clin North Am. 2004;51(4):889-908.

Varicella-zoster virus (VZV) is a herpesvirus that causes 2 related but separate clinical illnesses.

Felicia Spadini, APRN, MSN, NP-C

Articles

Travel Health

Treating Chickenpox and Shingles in Contemporary Clinics