Winter 2021 Issue
Volume 13 | Number 1
Stan Grogg, DO, FACOP, FAAP
Certificate in Travel Medicine
Barbara C Grogg, APRN-CNP
Certificate in Travel Medicine
A family comes to your office for a travel consultation. The couple with a 2 y/o and 6 y/o will be taking a cruise in the Caribbean. Which advice is the most pertinent to prevent mosquito transmitted disease?
One cannot pick up a medical journal without finding an article about Zika virus. Previously, travelers to tropical areas including some parts of the Caribbean were concerned about malaria, which is transmitted by the Anopheles species of mosquito and is known as the dusk to dawn (nighttime) feeding mosquito. (1) Now evidence indicates that the Aedes aegypti and Aedes albopictus mosquitoes, daytime and nighttime feeding mosquitoes, carry the Zika, Chikungunya and dengue. (2) Thus we must be use antimosquito techniques both day and night.
Although mosquitoes can transmit several illnesses, this article will concentrate on some of the most common and dangerous types giving travel concerns: Malaria, Yellow Fever, West Nile Virus, Dengue, Chikungunga and Zika. (3) In addition to a limited discussion of locations and symptoms of each of the diseases, proper mosquito protection will be stressed.
Before discussing the mosquito-borne diseases, the most important dialogue should be the prevention of mosquito and other insect bites, no matter where one travels, even in the USA. The American Academy of Pediatrics (AAP) has published the following recommendations:
Bug Safety (AAP) (8).
The CDC reports, “every year, millions of US residents travel to countries where malaria is present. About 1,500 cases of malaria are diagnosed in the United States annually, mostly in returned travelers to sub-Saharan Africa have the greatest risk of both getting malaria and dying from their infection. However, all travelers to countries where malaria is present (Fig. 1) may be at risk for infection”. (4) Healthcare providers as well as the public can access the CDC website to determine if the travel itinerary is one in which malaria is a concern. (5) People who develop malaria are typically very sick with high fevers, shaking chills, and flu-like illness. Although malaria can be a deadly disease, illness and death from malaria can usually be prevented. (6) Protection against malaria includes use of the following: prophylactic malaria medications, insect repellent, wearing long-sleeved clothing, and bednets. (9) Presently, there is no vaccine for malaria. The CDC website has a information educating travlers about malaria. https://www.cdc.gov/malaria/travelers/index.html. (4)
Fig. 1: Where malaria is found (from CDC (7)
There is no specific treatment for yellow fever; care is based on symptoms. Steps to prevent yellow fever virus infection include using insect repellent, wearing protective clothing, and receiving the specific vaccine for the disease. Presently there is a shortage of yellow fever vaccine in the USA and is expected to continue through 2018. This vaccine may be required to enter many countries thus receiving this vaccine if the traveler is required to have the international travel card with yellow fever documentation should be done well ahead of travel. (10,11) Fig. 2 and 3.
Fig. 2. Yellow fever vaccine recommendations in Africa (from CDC)
Fig 3. Yellow fever in South America (from CDC)
West Nile Virus
According to the CDC, “West Nile virus (WNV) is most commonly transmitted to humans by mosquitoes. You can reduce your risk of being infected with WNV by using insect repellent and wearing protective clothing to prevent mosquito bites. There are no medications to treat or vaccines to prevent WNV infection. Fortunately, most people infected with WNV will have no symptoms. About 1 in 5 people who are infected will develop a fever with other symptoms. Less than 1% of infected people develop a serious, sometimes fatal, neurologic illness”. WNV is found in all continental USA. (12) Fig. 4. About 1 in 5 people who are infected will develop a fever with other symptoms such as headache, body aches, joint pains, vomiting, diarrhea, or rash. Most people with this type of West Nile virus disease recover completely, but fatigue and weakness can last for weeks or months. (12)
Fig. 4. WNV is found in all 48 continental states (from CDC)
CDC states, “With more than one-third of the world’s population living in areas at risk for infection, dengue virus is a leading cause of illness and death in the tropics and subtropics. As many as 400 million people are infected yearly. Dengue is caused by any one of four related viruses transmitted by mosquitoes. There are not yet any vaccines to prevent infection with dengue virus and the most effective protective measures are those that avoid mosquito bites. When infected, early recognition and prompt supportive treatment can substantially lower the risk of medical complications and death. Although dengue rarely occurs in the continental United States, it is endemic in Puerto Rico and in many popular tourist destinations in Latin America, Southeast Asia and the Pacific islands.” (13) Fig. 5.
Fig. 5. Dengue risk distribution in the Americas and the Caribbean (from CDC)
The principal symptoms of dengue are high fever and at least two of the following:
Generally, younger children and those with their first dengue infection have a milder illness than older children and adults. (14) For initial treatment of Dengue, use acetaminophen and not NASIDS because of possible bleeding disorders. (15)
The CDC indicates, "The most common symptoms of chikungunya virus infection are fever and joint pain. Other symptoms may include headache, muscle pain, joint swelling, or rash. Outbreaks have occurred in countries in Africa, Asia, Europe, and the Indian and Pacific Oceans. In late 2013, chikungunya virus was found for the first time in the Americas on islands in the Caribbean. There is a risk that the virus will be imported to new areas by infected travelers. There is no vaccine to prevent or medicine to treat chikungunya virus infection. Acetaminophen rather than Ibuprofen should be used for the joint pain because of the associated hemorrhagic disease that can occur with Chikungunya. Travelers can protect themselves by preventing mosquito bites. When traveling to countries with chikungunya virus, use insect repellent, wear long sleeves and pants, and stay in places with air conditioning or that use window and door screens” (16). The disease is found in many parts of the world. (Fig. 6)
Fig. 6. Distribution of Chikungunga fever (from CDC)
The CDC has developed 5 facts about Zika Virus. (17) A summary of the five facts are as follows:
Fig. 7. Zika Virus distribution. (from CDC)
Fig. 8. Symptoms of Zika (from CDC (19)
In conclusion, prior to travel to areas with mosquito or other insects with transmissible diseases, a family should consult with their pediatrician or healthcare provider to discuss avoidance of harmful mosquito diseases. Vaccines are available for some such as Yellow Fever and prophylactic medications are recommended for some such as malaria. All healthcare professionals and patients should become familiar with the CDC’s travel site for up to date information on travel health. https://wwwnc.cdc.gov/travel.
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