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10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023
| Contributor Information
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Image from Vecteezy.com. Free stock photos by Vecteezy.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
So much has changes since early 2020. The impact of coronavirus disease 2019 (COVID-19) brought tremendous change economically and with travel. Although COVID-19 remains in the post-pandemic mix of illness considerations, travel has resumed and is expected to reach pre-pandemic numbers in the coming years. With this resumption, a renewed awareness of travel diseases for the traveler and the healthcare provider must follow.
The global COVID-19 pandemic heightened awareness of travel-associated illnesses unlike anything in the past century. More recently, the declaration of the end of the Ebola outbreak in Uganda as of January 2023 highlighted yet another outbreak milestone,[1] although 2 small outbreaks of Marburg remain active (Tanzania, Equatorial Guinea).[2] Increased inquiry regarding not only travel history and exposures during travel (foreign or domestic) but also the social, environmental, and medical circumstances that impact the risk of acquiring and spreading disease are essential.[2] Navigating vaccine-preventable disease outbreaks, such as polio, yellow fever, Ebola, measles, and cholera to following ongoing global disease outbreak news, awareness of current state, and potential travel-related exposures matter. In addition, respiratory viral outbreaks (i.e. COVID-19, MERS, avian influenza, SARS, influenza, etc.) should remain in consideration.
This slideshow provides essential information regarding 10 common health conditions associated with global travel that you should know.
Image from Our World in Data. [Creative Commons Attribution 4.0 International (CC BY 4.0).]
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Malaria
Malaria is caused by the parasite Plasmodium, transmitted via the bite of infected female Anopheles mosquitoes.[3,4] Infection may also occur through blood transfusions, organ transplantation, needle sharing, and congenital transmission.[4]
In 2021, there were an estimated 247 million cases with estimated deaths of 619,000 globally.[5] There are 5 Plasmodium parasite species that cause malaria in humans and 2 of these species – P. falciparum and P. vivax – pose the greatest threat.[6] The African region continues to bear a disproportionately high share of the global burden (95% of malaria cases; 96% of malaria deaths).[5,6] In late June 2023, local transmission of P vivax was identified in Florida and Texas.
Micrograph depicting a malaria parasite (blue, right) attaching to a human red blood cell (red, left) from NIAID via Flickr. Inset: Higher magnification view of the attachment point. [Creative Commons Attribution 2.0 Generic (CC BY 2.0).]
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Plasmodium parasites multiply in the human liver and then infect red blood cells.[5,6] Malaria signs and symptoms (s/s) include fever/chills, headache, vomiting, myalgia, and anemia; the incubation period ranges from 7 to 30 days after the mosquito bite.[6] Left untreated, P. falciparum malaria can progress to severe illness and death within 24 hours.[6] However, symptoms may be delayed up to months after exposure.[3,4]
Clinicians should suspect malaria in anyone with fever and/or s/s who recently traveled to malaria-endemic areas or who received a blood transfusion while in an endemic area.[6] Increasing chemoprophylaxis resistance informs optimal antimalarial agent selection for travelers and physicians alike.[7]
Image of a healthcare worker reading a child's rapid diagnostic malarial test. Image from the US Centers for Disease Control and Prevention (CDC) | Nelli Westercamp. (Public domain).
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Parasite-based diagnostic testing (either microscopy or a rapid diagnostic test) confirms the diagnosis.[5,6]Travelers to endemic regions should use specific malaria prevention measures (e.g., protective clothing, insect repellents, insecticide-treated bed nets, region specific antimalarial agents).[7]
For treatment, artemisin-based combination therapy are usually most effective; Chloroquine can be used for P. vivax in areas still sensitive; Primaquine is added to treatment of P. vivax and P. ovale to prevent relapse.[5,7]
Malaria vaccination (R21/Matrix-M, Mosquirix RTS/S) have shown significant reduction in malaria and severe malaria; it acts against P falciparum.[8] In children who completed large-scale clinical trials, the vaccines prevented about 4 in 10 cases of malaria over a 4-year period.[8]
Map of dengue cases from the past 90 days as of June 7, 2023 from the CDC via healthmap.org. (Public domain).
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Dengue
Dengue is a febrile illness transmitted by Aedes mosquitoes—the same species that transmits Zika, yellow fever, and chikungunya (CHIKV) viruses.[9] There are 4 serotypes, meaning it is possible to be infected 4 times.[9] Nearly half of the world's population, about 4 billion people, live in areas with a risk of dengue.[9,10]
Of the approximate 400 million cases of dengue annually, 1 in 4 are symptomatic, and of those, 1 in 20 develop severe dengue.[10,11]
Images from (top) Giri S, Agarwal MP, Sharma V, Singh A. Cases J. 2008;1(1):204 (CC BY 2.0). PMID: 18831758, PMCID: PMC2566568; and (bottom) Lee C, Jang EJ, Kwon D, Choi H, Park JW, Bae GR. Ann Occup Environ Med. 2016;28:16. (CC BY 4.0). PMID: 27057314, PMCID: PMC4823875.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Patients with dengue commonly present with high fever, and/or headache, nausea, vomiting, rash, and muscle/joint pain.[11] Symptoms typically develop within 2 weeks of exposure (incubation: 4-10 days) and last up to 7 days.[11] Rarely, severe dengue may be associated with dengue hemorrhagic fever—with bleeding from the gums and other mucosa, severe abdominal pain, persistent vomiting, and respiratory difficulty—or dengue shock syndrome, both of which may be fatal.[11] (The top image reveals subconjunctival hemorrhages in a dengue patient with acute liver failure. The bottom images show a confluent maculopapular rash with islands of sparing in the lower extremities of a different dengue patient).
CYD-TDV (Dengvaxia), licensed in 2015, is currently approved by regulatory authorities in about 20 countries.[45] The World Health Organization (WHO) recommends vaccination for persons (9-45) living in areas where dengue is highly endemic who have a confirmed prior dengue infection.[45,48] Treatment remains supportive. Employing routine mosquito avoidance behaviors remains essential.[45,48] Future control measures include the Sterile Insect Technique (SIT) and other methodologies.[47]
Image from Lutz C, Erken M, Noorian P, Sun S, McDougald D. Front Microbiol. 2013;4:375. [Open access.] PMID: 24379807, PMCID: PMC3863721.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Cholera
Cholera, an acute diarrheal infection, is caused by ingestion of contaminated food or water with the bacterium Vibrio cholerae.[13] Globally, there are an estimated 1.3 to 4.0 million cases per year and up to 143,000 cholera-related deaths.[14] The bacterium releases a toxin that increases the release of water from intestinal cells, resulting in severe diarrhea. The main reservoirs for V cholerae are humans and aquatic/marine sources (e.g., brackish water, estuaries).[13,15]
The image depicts interactions between V cholerae with other organisms and the environment.
Cholera infection is often asymptomatic or mild (acute watery diarrhea only), but a small percentage produces severe disease characterized by sudden, profuse watery diarrhea ("rice-water stools") and vomiting that can lead to profound hypotension, dehydration, and shock; muscle cramps; and tachycardia.[50,51] Left untreated, death can occur within hours.[50,51]
The gold standard of diagnostic testing is isolation and identification of V cholerae serogroup O1 or O139 by stool culture.[16] In resource-austere areas, antigen-based rapid diagnostic tests are available, but do not provide toxin detection, susceptibility, or subtyping. Without stool testing, it is almost impossible to distinguish cholera from other conditions that cause acute watery diarrhea.[16] Travelers should always take basic safety and hygiene precautions with food and drinking water,[14,15] even if vaccinated.
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
The image is a model for the role of biofilm in V cholerae intestinal colonization. CT = cholera toxin.
Severe cholera can cause acute renal failure, severe electrolyte imbalances, coma, and death. Rehydration is the cornerstone of therapy including electrolytes (e.g., WHO-recommended oral rehydration therapy).[14,15] Antibiotics (e.g.doxycycline) reduce fluid requirements and the duration of illness are generally reserved for severe cases.[17] Zinc supplementation reduces severity and duration of illness in children (<5 y).[14]
CVD 103-HgR, a live, attenuated, single-dose oral cholera vaccine is available globally (US: Vaxchora, PaxVax; Global: Orochol, Mutacol)[15]; additionally, three 2-dose vaccines are WHO pre-qualified (Dukoral, Shanchol, Euvichol-Plus/Euvichol).[15,16] Vaccines offer incomplete protection, require up to 2 weeks, and may last 2-3 years. The CDC does not recommend routine cholera vaccination for US travelers visiting areas that do not have active cholera transmission.[15] Vaccination should not replace standard prevention and control measures. Ongoing surveillance of and vigilance in monitoring diarrheal outbreaks are crucial for minimizing cholera epidemics.[14,15]
Image from the CDC.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Tuberculosis
Tuberculosis (TB) is a global disease caused by Mycobacterium tuberculosis (Mtb), a slow-growing, rod-shaped aerobic bacterium.[18] in 2021, an estimated 10.6 million people fell ill with TB with 1.6 million associated deaths, and the 13th leading cause of death globally.[19] Approximately ¼ of the global population have been infected with TB with <10% becoming symptomatic. In 2021, the largest number of new TB cases occurred in Southeast Asian (46%), Africa (23%) and the Western Pacific (18%). Two thirds of the global total are from Bangladesh, China, the Democratic Republic of the Congo, India, Indonesia, Nigeria, Pakistan, and the Philippines.[19]
TB mainly affects the lungs (70%-80%)—in active disease, the upper lobes are most often involved[20]—but it can also affect the kidney, brain, spine, and other organs.[18] TB is primarily an airborne disease; transmission occurs when an actively infected person coughs, sneezes, or spits, propelling MTB into the air.[18] Common s/s of active lung TB are cough with sputum/blood, chest pain, weakness, weight loss, fever/chills, and night sweats.[18,19] Latent TB is typically asymptomatic and noninfectious[18,19]; active disease may develop years later when the person's immune system becomes compromised.[19]
Image from the CDC via Wikimedia Commons. (Public domain).
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Diagnostic tests include rapid molecular diagnostic tests (e.g. Xpert MTB/RIF ultra and Treunat), tuberculin skin test (TST), interferoongamma release assay (IGRA), imaging studies (e.g., chest x-ray [CXR] [shown]), and sputum examination/cultures.[18] Travelers should avoid close contact with, or prolonged exposure to, known TB patients in crowded, enclosed environments; if avoidance is not possible, travelers should undergo a TST or interferon-gamma release assay (IGRA) test before leaving the United States.[18] If the test result is negative, repeat the TST/IGRA test 8-10 weeks after the travelers return.[18]
TB is most often treatable and curable; however, it can be fatal if left untreated. Inadequately treated disease has resulted in growing rates of drug-resistant disease.[19] Active drug-sensitive TB disease requires a multidrug treatment regimen that can take 4, 6, or 9 months depending on the regimen.[18,19]
In areas with endemic TB, the Bacille Calmette-Guérin (BCG) vaccine is often given to infants and children to prevent TB – but does so outside the lungs.[19] Therefore, clinical evaluation and CXR are most helpful in people who previously received the BCG vaccine.
Map showing an equatorial distribution of areas with risk of Zika infection as of July 25. 2022 from the CDC.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Zika Virus
Zika virus, another Aedes mosquito spread virus, was identified in Uganda in 1947 and is increasingly present in many equatorial countries[21,22]—a total of 86 countries have reported evidence of mosquito-transmitted Zika infection.[22] After the 2015-2016outbreaks in the Americas, including limited local transmission in Florida and Texas through 2017, no local mosquito-borne Zika virus transmission has been reported in the continental United States.[23]
The most common signs and symptoms of Zika virus infection are fever, rash, joint pain, and conjunctivitis.[21,22] They typically begin within days after an individual has been bitten by an infected mosquito, are usually mild, and last 2 days to 1 week. Cases are most commonly managed without hospitalization and with supportive care.[21,22]
Micrograph from Flickr | NAID (CC BY 2.0). Palmar rash image from Medscape.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
The left image is a transmission electron microscope image of negative-stained, Fortaleza-strain Zika virus (red), isolated from a patient with microcephaly in Brazil. The right image demonstrates a Zika virus–associated rash on a patient's hand. According to the WHO, Zika virus is a cause of microcephaly and congenital and neurologic disorders, including Guillain-Barré syndrome (GBS).[21,22]
Because Zika infection during pregnancy can cause severe birth defects,[21,22] pregnant women should consider postponing travel to any area where the Zika virus is active or employ appropriate mosquito precautions.[21]
Image from the CDC.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Measles
Measles, or rubeola, is a highly contagious, airborne disease caused by a single-stranded, enveloped RNA virus (family Paramyxoviridae)) that can lead to severe complications and death.[24,25]
Despite global setbacks in surveillance and immunization effort during the COVID-19 pandemic, global vaccination efforts decreased measles deaths from 761,000 (2000) to 128,000 (2021) mostly among unvaccinated or under-vaccinated children.[25] Measles cases in the United States were 121 in 2022, down from a peak of 1,274 in 2019.[26] Most US measles cases result from travelers who become infected in endemic areas and then bring the disease back home and infect the unvaccinated.[24,26] Despite having safe and cost-effective vaccination, measles remains a leading cause of death among young children globally [24,26]
Images from the CDC.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Initial s/s of measles, which appear 10-12 days after infection, are high fever, coryza, conjunctivitis, cough, and Koplik spots (left image).[24,25] A rash appears about 2 weeks later (first on the face/upper neck, gradually spreading downward [right image]).[24,25] The diagnosis is commonly clinical, but laboratory identification and confirmation by serologic testing for measles-specific IgM/IgG titers, viral isolation from oropharyngeal/nasopharyngeal swabs, or detection of measles RNA by RT-PCR assay are necessary for public health and outbreak control.[24,27]
Measles can be a serious illness even in previously healthy children, and inpatient care may be required. Complications that tend to affect children younger than 5 years and adults older than 20-30 years, particularly those who are malnourished and/or immunocompromised, include middle ear infections (7%-9%), severe diarrhea (8%)/dehydration, pneumonia (1%-6%), blindness, and encephalitis.[24,25]
Image from the CDC.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
No specific antiviral measles therapy exists, but supportive care to prevent complications includes good nutrition, adequate fluid intake, and rehydration with a WHO-recommended oral solution for fluid losses.[25] Those with uncomplicated measles infection generally recover well; antibiotics are recommended for treating pneumonia and eye/ear infections.[25] The WHO also recommends two doses of vitamin A supplements 24 hours apart for all children with measles to reduce the risk of complications.[24,25]
Routine, safe, effective pediatric measles vaccination (highly effective for prevention) and mass immunization campaigns in countries with high case/death rates are key public health strategies for reducing global measles deaths.Postexposure prophylaxis to reduce the risk of developing measles or ameliorate its s/s includes receiving the vaccine within 72 hours of, or taking serum Ig within 6 days after, viral exposure.[24]
Image from the CDC.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Chikungunya Virus Disease
CHIKV, an RNA alphavirus (family Togaviridae), is the third disease in this series spread via the bite of infected female Aedes (aegypti/ albopictus) mosquitoes.[28,29] Outbreaks have occurred in Africa, Asia, Europe, and islands in the Indian and Pacific Oceans (shown).[30] In 2013, CHIKV disease was found for the first time in the Americas, in the Caribbean, with a peak in cases in 2014 (>1.1 million)[30]; in 2015, CHIKV became a nationally notifiable condition in the United States.[30] No local acquired cases have been identified (US) since 2015; 36 travel-associated cases were identified in 2021.[30]
Dengue, Zika and CHIKV have similar symptoms. Fever and arthralgia are the main s/s of CHIKV; headache, myalgia, and rash may also be present.[28,29] Most s/s resolve quickly, but arthralgia may persist for months. Serious complications are uncommon.[28,29] Those at risk for more severe disease include perinatally infected newborns, older adults (≥65 y), and people with comorbidities (e.g., diabetes, heart disease).[28,29]
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
The image shows a rash on the foot of a patient with CHIKV infection in the Philippines.
Serologic studies (e.g., enzyme-linked immunosorbent assays [ELISA]) may confirm the presence of IgM and IgG anti-CHIKV antibodies.[66] Use serologic and virologic testing (e.g., RT-PCR assay) for samples collected during week 1 after s/s onset.[30] Differentiating CHIKV from dengue can be a clinical challenge due to s/s overlap.[28-30] However, therapy remains supportive for both diseases (e.g., rest, adequate hydration, antipyretics/analgesics).[28-30]
Key elements of prevention and infection control are eliminating mosquito breeding grounds (including both natural habitats and plastic containers) and avoiding Aedes mosquito bites (e.g., wearing permethrin-treated clothing; using insect repellents that contain N,N-diethyl-meta-toluamide [DEET], picaridin, oil of lemon eucalyptus/p-menthane 3,8-diol [PMD]; using window/door screens and bed nets; outdoor activity).[66]
Image of a child in Nepal receiving an oral polio vaccine from the CDC | Adam Bjork, Phd. (Public domain).
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Polio
Polio (poliomyelitis) is caused by poliovirus types 1, 2, and 3.[31] Poliovirus is an enterovirus that is transmitted by the fecal-oral or oral-oral route. Primarily affecting children, this acute infection involves the oropharynx, GI tract, and the central nervous system (1:200).[31,32]
The incubation period for polio is 3-6 days for nonparalytic polio. For paralytic polio, the incubation period prior to the onset of paralysis is 7-21 days.[33] The three basic patterns of infection are subclinical, nonparalytic, and paralytic. Most polio cases are subclinical; patients may be asymptomatic (72%) or have minor s/s (24%) (eg, low-grade fever, pharyngitis, headache, neck/back stiffness, limb pain).[32,33] Fewer than 1% of polio cases result in permanent limb paralysis (usually the legs).[32] Among those paralyzed, 5-10% die from respiratory failure.[32] Post-polio syndrome (weakening of previously unaffected/affected muscles) may develop in 25%-40% patients up to 15-40 years after the initial infection.[33]
Image from the CDC.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
There is no cure for polio, only preventive measures.[32] Diagnostic tests for polio include viral isolation by cultures of throat washings, stool samples, or cerebrospinal fluid (CSF); spinal tap and CSF examination; and serologic measurement of antibodies to the polio virus.[34]
Polio immunization is over 90% (2 doses) or 99% (3 doses) effective.[32] Consider vaccination for (1) travelers to polio-endemic or high-risk regions, (2) laboratory workers who may be exposed to polioviruses, and (3) clinicians with exposure to infected people or their close contacts.[71]
As a result of a massive global vaccination campaign since the late 1980s, wild-type cases have decreased by 99% with only 6 reported wild poliovirus cases in 2021.[32] However, despite the progress in eradicating polio globally, outbreaks still occur, usually in groups of unvaccinated people and those travelling to endemic regions.[31]
Adapted images from the CDC.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Yellow Fever
Yellow fever, named for the jaundice that affects some patients,[36] results from a single-stranded RNA arbovirus[37] (genus Flavivirus) that is transmitted to humans via the bite of infected Aedes or Haemagogus mosquitoes.[36,37] The vectors acquire the virus by feeding on infected primates and then transmit it to other primates. Yellow fever has three transmission cycles (sylvatic [jungle], intermediate [savannah], urban)[36-38] and three disease stages (infection, remission, intoxication).[36-38]
As of 2023, 34 African and 13 countries in Central/South America are endemic. (shown).[36,37] Most infected persons are asymptomatic or have only a mild illness (incubation, 3-6 days) that improves 3-4 days after the initial onset. Early s/s include sudden fever/chills, severe headache, back pain, myalgias, nausea/vomiting, and fatigue/weakness.[36,37] After a brief remission of hours to a day, about 12% of patients develop a more severe form of the disease that is characterized by high fever, jaundice, bleeding, and, eventually, shock with multisystem organ failure. Half of these patients die within 7-10 days.[36,37]
Images from the CDC (micrograph) and the CDC | James Gathany (inset).
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Micrograph: Yellow fever virus particles. Inset: An A aegypti mosquito feeding.
Yellow fever is difficult to diagnose during the early stages; it can be confused with severe malaria, dengue or other hemorrhagic fevers, leptospirosis, viral hepatitis, and other conditions including poisoning.[36] Diagnostic tests include serology and viral isolation or nucleic acid amplification.[36,37] Treatment for yellow fever is supportive including managing dehydration, respiratory failure, and fever[36,37]; antibiotics should be used to treat concurrent bacterial infections.[36]
Precautions to take when traveling to endemic areas include vaccination and vector control, such as sleeping in screened housing, using mosquito repellents (e.g., insect repellents containing DEET, picaridin, IR3535, or oil of lemon eucalyptus), and wearing clothing that fully covers the body.[38] The live-attenuated vaccine against yellow fever achieves 99% immunity within 30 days.[37] The vaccine should be administered at least 10 days before travel to endemic areas.[36,37]
Image from Caronna R, Boukari AK, Zaongo D, et al. BMC Gastroenterol. 2013;13:102. (CC BY 2.0). PMID: 23782915, PMCID: PMC3691877.
10 Travel Diseases You Need to Know
Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Typhoid Fever
Typhoid fever, a life-threatening condition, most often results from infection with the bacterium Salmonella enterica serotype Typhi (ie, S typhi).[38,39] The disease is transmitted through contaminated food or water, moving from the intestines into the bloodstream and then to other parts of the body, including the lymph nodes, gallbladder, liver, and spleen.[40,41] The intraoperative specimen above shows multiple typhoid ileal perforations.
Annually, an estimated 11-21 million people become ill from typhoid with 200,000 associated deaths.[42] Illness is more common in developing nations in South-East Asia, Africa, the Americas, and the Western Pacific.[39] Diagnosed cases of typhoid fever (350) and paratyphoid fever (90) are mostly acquired during international travel.[42]
Typhoid fever manifests 1-2 weeks after the bacterium has been ingested (incubation: 6-30 days) and is characterized initially by fever and abdominal pain.[38,43] As the disease progresses, fever rises and severe diarrhea develops. Small red spots may appear on the chest and abdomen of some patients.[38]
Image from Sejvar J, Lutterloh E, Naiene J, et al. PLoS One. 2012;7(12):e46099. [Open access.] PMID: 23226492, PMCID: PMC3513310.
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Bret A Nicks, MD, MHA, FACEP | June 13, 2023 | Contributor Information
Blood cultures are the mainstay for diagnosis of typhoid fever; the sensitivity increases with multiple blood cultures.[38] The diagnostic yield of bone marrow cultures increases to about 80% of cases. Blood cultures are best obtained during week 1 of a patient's illness; stool and urine cultures are usually not positive until later in the disease course.[38] In resource austere settings, the diagnosis is often made from the clinical course.[38]
Treatment includes antibiotics, although resistance has been increasing (e.g., fluoroquinolones, azithromycin); in such cases, third-generation cephalosporins are used.[38,39,44,45] Patients with signs of typhoid fever within 60 days of returning from an endemic area or who have consumed food prepared by a known S typhi carrier should receive empiric broad-spectrum antibiotics prior to diagnostic confirmation, followed by more specific antibiotics once typhoid fever is verified. IV fluid and electrolytes may also be given.[38,39,43] Vaccines are available for those in endemic areas (since 2017). Although helpful, typhoid vaccines are not 100% effective, therefore safe eating and drinking habits are recommended.[40,41]
In 2015, an MDR strain of S typhi, H58, emerged from South Asia and spread globally.[44,45] In 2016, H58 mutated, becoming an extensively drug-resistant (XDR) strain identified during an outbreak in Pakistan. Carbapenems should be used for patients with suspected severe or complicated typhoid fever who have traveled to Pakistan.[46]
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Bret A Nicks, MD, MHA, FACEP
Professor, Emergency Medicine
Director, Masters of Healthcare Leadership
Director, EM Administrative and Leadership Fellowship
Director, EM Global Health Fellowship
Wake Forest Baptist Health
Winston-Salem, NC
Disclosure: Bret A Nicks, MD, MHA, FACEP, has disclosed no relevant financial relationships.
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