Screening Asymptomatic Returned Travelers

Michael Libman
http://wwwnc.cdc.gov/travel/yellowbook/2016/post-travel-evaluation/screening-asymptomatic-
returned-travelers

Screening dipandang sbg secondary prevention prevention, yaitu upaya untuk

mengidentifikasi penyakit yg tersembunyi maupun health risk
Recommendations for screening the asymptomatic traveler are necessarily based on
opinion and common sense, rather than convincing evidence. The following may serve
as a general guideline.
For the asymptomatic short stay (<3–6 months) traveler, the yield of screening is low
and should be directed by specific risk factors revealed in the history. A history of
prolonged (>2 weeks) digestive symptoms during travel can suggest protozoal infection.
Exposure to fresh water in a region endemic for schistosomiasis, especially in Africa,
merits serologic screening, with the addition of stool and urine examination in the case
of high-intensity exposure. Serology for Strongyloides should be considered in those
who have a high risk of skin exposure to soil likely to be contaminated with human feces,
usually those with a history of frequently walking barefoot outdoors. A sexual history
should be obtained. Work in a health care setting or other area at high risk for TB may
merit screening.

Post-Travel Health Consultation

Dr Peter A. Leggat
School of Public Health and Tropical Medicine James Cook University & Visiting
Professor School of Public Health University of the Witwatersrand
It is important to develop policies in travel medicine
l Policy and procedures, including
– Policy of follow-up of travelers
– Policy on notifiable diseases
– Policy on reporting adverse reactions
– Policy on “eradication” treatment
Policy on follow-up of travelers
Do you see travellers
l Symptomatic on return?
l Symptomatic whilst aboard?
l Asymptomatic abroad and asymptomatic now?
 l To complete immunization courses?
Policy on reporting notifiable diseases and adverse reaction
l Is it a notifiable disease? Early liaison concerning suspected cases and formal
notification to public health units
l Keep a list of notifiable diseases and reporting forms
l Document and report any possible serious adverse reactions to immunisations and
chemoprophylaxic and other medications experienced by traveller whilst abroad
l Is the traveler part of a clinical trial?
Eradication Policy
l Do you prescribe empiric “eradication” treatment?
l If so, what groups of travelers?
Eradication “Treatment”
l Malaria - primaquine (check G6PD deficiency), (tafenoquine)
l Deworming agent for soil transmitted “roundworms” (consider strongyloides)
l Deworming agent for “flatworms”- praziquantel
l Deworming agent for filariasis - albendazole
l Antiprotozoal agent - giardiasis
l Others (?)
Groups where eradication treatment may be considered
l Medium to long term travelers or overseas workers
l Those travellers at high risk of infection
l Those where diagnosis suggestive but investigations inconclusive
l Where required by authorities-refugees
l Even when on preventive measures!
Post-travel Consultation
Screening History
l Are they symptomatic now or have been?
l Risk assessment - leading to specific history of possible exposures, e.g.
schistosomiasis, zoonotic disease, sexual history, recently been diving, have they been
bitten?
l Is there correspondence in relation to treatment abroad?
 l Travel history can be important in terms of working out possible incubation period
and differential diagnosis
l Prophylaxis and compliance - was the prophylaxis appropriate?
l Could it be a pre-existing condition?
l Could it be related to an occupational/recreational exposure?
Screening Examination
l Post-travel physical examination for most short term travelers is usually unremarkable
for disease, but may be useful for assessment of injuries
l Signs of “tropical” disease can be subtle and can be missed unless specifically looked
for, e.g. rashes, eschar, jaundice
l Abnormalities unrelated to travel
l When sending specimens to lab, document current medications, history, what you
think
l Liaise with lab if unsure what tests available
l Stool microscopy M/C/S, O/C/P-most diarrhoeal disease bacterial>>parasitic>viral
l Urine tests-dipstick urinalysis, “terminal” urine for ova of S. haematobium
l Full Blood Count and differential- eosinophilia, anaemia, thrombocytopenia
l Rapid tests, e.g. Immunochromographic tests (ICT)-often used for initial screening for
malaria, Bancroftian filariasis, (dengue), etc
l Serological investigations, e.g. schistosomiasis, filariasis
l Blood films for malaria
l HIV/STI serology
l TB screening-useful if you can compare with pre-travel
Look for the “spot” diagnosis
l Hookworms and cutaneous larva migrans: tracking lesions on the foot (or other body
areas in contact with sand/soil)
l Leishmaniasis: non-healing skin ulcers/lesions, especially on exposed areas and been
to endemic areas
l Eschars-may be associated with rickettsial infectious such as scrub typhus
l Skin infection: bacterial and fungal (ask for occupational and recreational
history)
Does the traveler have diarrhea
 l Most travelers’ diarrhea is brief, self-limiting and non-inflammatory (about 4 days in
duration)
l About 20% of travelers have fever and/or bloody diarrhea
l Enterotoxigenic Escherichia Coli is probably the most frequent pathogen in about 40-
75 of cases
Does the traveler have fever?
l Possible serious infectious disease causes in travelers returning from tropical regions:
– Malaria-great mimicker
– Hepatitis A
– Enteric fever (incl typhoid)
– Dengue fever
Has the traveler been injured abroad?
l Need to document extent of injuries
l Are they covered by any insurance or superannuation policy?
l Arrange for any further treatment and follow-up
l Liaise with airlines if further travel required
l Arrange for assessment for rehabilitation as necessary