What’s happening What’s happening out there?out there?

Global Shifts in DiseaseGlobal Shifts in Disease

Musings of Paul Van Caeseele, MDMusings of Paul Van Caeseele, MDApril 25, 2008April 25, 2008

ObjectivesObjectives

Bird’s eye view of what’s going on Select diseases emerging and

reemerging Introduction to some of the drivers

affecting disease and travel around the world

Learn something that will broaden thoughts of what travel medicine could encompass

Reemergence of Reemergence of Vaccine Preventable Vaccine Preventable Disease & Other Old Disease & Other Old

FriendsFriends In the last few years, we’ve witnessed In the last few years, we’ve witnessed

outbreaks of well-suppressed VPD’soutbreaks of well-suppressed VPD’s Diphtheria (Russia, 1993-96)Diphtheria (Russia, 1993-96) Measles Measles MumpsMumps

Resurgence of dormant diseases or Resurgence of dormant diseases or common diseases with twistscommon diseases with twists

Diphtheria, USSR, 1993-Diphtheria, USSR, 1993-9696

Huge jump in Huge jump in cases due to cases due to collapse of collapse of Soviet Soviet infrastructureinfrastructure

>130,000 >130,000 cases over 4 cases over 4 yearsyears

>4000 deaths >4000 deaths that decadethat decade

Vitek & Wharton, 1998

MeaslesMeasles WhatWhat

Sporadic measles appearing in limited outbreaksSporadic measles appearing in limited outbreaks Most begin with an importationMost begin with an importation

Ontario limited outbreakOntario limited outbreak Most propagated due to inadequate vaccine coverage, i.e Most propagated due to inadequate vaccine coverage, i.e

less than two doses MMR, killed vaccine onlyless than two doses MMR, killed vaccine only More noted in adolescent to adult age groups (atypical to More noted in adolescent to adult age groups (atypical to

historical 5-10 year age group)historical 5-10 year age group) Larger European outbreakLarger European outbreak

>250 cases associated with anthroposophic (naturalistic) >250 cases associated with anthroposophic (naturalistic) schoolsschools

““mobile communities” felt to be the sourcemobile communities” felt to be the source Mostly noted in childhood age groups due to low Mostly noted in childhood age groups due to low

vaccination ratevaccination rate So What?So What?

Measles leading cause of death due to “respiratory Measles leading cause of death due to “respiratory disease” in the third worlddisease” in the third world

AnthroposophyAnthroposophy A spiritual philosophy based on A spiritual philosophy based on

the teachings of Rudolph the teachings of Rudolph Steiner (1861-1925)Steiner (1861-1925)

Believes in the existence of an Believes in the existence of an objectively experienced objectively experienced spiritual world that can be spiritual world that can be accessed with proper inner accessed with proper inner developmentdevelopment Mysticism meets ScienceMysticism meets Science

Very active movement in many Very active movement in many areas, including schools, with areas, including schools, with >900 Steiner/Waldorf schools >900 Steiner/Waldorf schools worldwideworldwide

MumpsMumps WhatWhat

Large outbreak across Large outbreak across Canada (& others) Canada (& others)

>1200 cases in 2007, mostly >1200 cases in 2007, mostly in NS, NB, AB in NS, NB, AB

Mostly 20-29 year olds with Mostly 20-29 year olds with incomplete immunity, highly incomplete immunity, highly social and highly mobile, social and highly mobile, often non-adherentoften non-adherent

Only 8% had two doses of Only 8% had two doses of vaccinevaccine

Also in Ireland, Australia, Also in Ireland, Australia, England, USAEngland, USA

So what?So what? High incidence of orchitis High incidence of orchitis

and hearing lossand hearing loss Appreciable rate of Appreciable rate of

encephalitis and mortalityencephalitis and mortality

FlavivirusesFlaviviruses

Mosquito-borne viruses that includeMosquito-borne viruses that include West Nile VirusWest Nile Virus Yellow Fever VirusYellow Fever Virus Japanese Encephalitis VirusesJapanese Encephalitis Viruses Dengue VirusesDengue Viruses

Increasing due to increasing travel, Increasing due to increasing travel, trade, urbanization, inattention to trade, urbanization, inattention to control programscontrol programs

Dengue feverDengue fever Still a major concernStill a major concern

50-100 million infections per year50-100 million infections per year Mosquito born virus cases “break-bone fever”Mosquito born virus cases “break-bone fever”

Frequently asymptomaticFrequently asymptomatic May be complicated by diatheses, hepatitis, MTCTMay be complicated by diatheses, hepatitis, MTCT Second time around at risk for DHF – Dengue Second time around at risk for DHF – Dengue

Hemorrhagic Fever (mortality 1-50%)Hemorrhagic Fever (mortality 1-50%) Many tropical beaches at risk nowadaysMany tropical beaches at risk nowadays More frequently diagnosed than malaria in More frequently diagnosed than malaria in

travelers from South America and Asiatravelers from South America and Asia Australian travelers 10X more likely to have Australian travelers 10X more likely to have

Dengue coming from AsiaDengue coming from Asia

Peteresen & Marfin, 2005

Skin infectionsSkin infections

Remain a common problemRemain a common problem 10-23.4% of travelers return with skin 10-23.4% of travelers return with skin

problemproblem 8-18% of these are infections8-18% of these are infections11

Some specific likelihoodsSome specific likelihoods Belize – cutaneous myiasis (Belize – cutaneous myiasis (Dermatobium hominis)Dermatobium hominis) Rickettsial – South Africa & ZimbabweRickettsial – South Africa & Zimbabwe Leishmania - ColumbiaLeishmania - Columbia <18 years more likely to have CLM & dog bites<18 years more likely to have CLM & dog bites >65 more likely to have rickettsial disease or >65 more likely to have rickettsial disease or

cellulitiscellulitis2121

1. Schleucher et al, 2008

2. Lederman et al, 2008

New DangersNew Dangers

Staphylococcus aureusStaphylococcus aureus Reports of returned travelers with Reports of returned travelers with

recurrent skin infectionsrecurrent skin infections MRSA sometimes culturedMRSA sometimes cultured Panton-Valentine Leukocidin (PVL) Panton-Valentine Leukocidin (PVL)

positive strains not uncommonpositive strains not uncommon11

Cytotoxin causing tissue necrosis Cytotoxin causing tissue necrosis and WBC destructionand WBC destruction

Increasingly prevalent in CanadaIncreasingly prevalent in Canada Seen in CA-MRSA, usually native strainsSeen in CA-MRSA, usually native strains

Schleucher et al, 2008

Series #1Series #1

Following a report of imported MRSA in Following a report of imported MRSA in Ireland, Scottish group reportedIreland, Scottish group reported 14 cases of recurrent or moderately severe 14 cases of recurrent or moderately severe

cutaneous cutaneous All associated with travel, non hospital-associatedAll associated with travel, non hospital-associated Some persisted for >3 yearsSome persisted for >3 years

Noted that antibiotics commonly used in Noted that antibiotics commonly used in travel prophylaxis (or empiric treatment) travel prophylaxis (or empiric treatment) were ineffectivewere ineffective Doxycycline and ciprofloxacin resistance noted in Doxycycline and ciprofloxacin resistance noted in

somesomeHelgason et al, 2008

Series #2Series #2

German study also noted thatGerman study also noted that Panton-Valentine Leukocidin-positive Panton-Valentine Leukocidin-positive

MRSA isol.MRSA isol. Mostly imported and associated withMostly imported and associated with

Travel to MediterraneanTravel to Mediterranean Travel to Middle EastTravel to Middle East

Some also no recent travel but did have Some also no recent travel but did have family from the Mediterraneanfamily from the Mediterranean

Maier et al, 2005

MRSA ContinuedMRSA Continued

One Danish Study found evidence of One Danish Study found evidence of importation of strainsimportation of strains11

Usually skin and soft tissue infectionsUsually skin and soft tissue infections Highly associated with arrival from Balkan Highly associated with arrival from Balkan

refugee camps, travel to Mediterranean or refugee camps, travel to Mediterranean or Middle EastMiddle East

Evidence of transmission in familiesEvidence of transmission in families They were able to eradicate effectivelyThey were able to eradicate effectively

Hajj only carry MRSA 1.6% of the timeHajj only carry MRSA 1.6% of the time22

1. Larsen et al, 2008

2. Memish et al, 2006

Invasive MRSA Rates in Europe, Invasive MRSA Rates in Europe, 20042004

Bioquell, 2008

Implications: MRSAImplications: MRSA No longer just a hospital-acquired infectionNo longer just a hospital-acquired infection There may be a future for services targeted at There may be a future for services targeted at

the highest risk travelersthe highest risk travelers Athletes, especially wrestlers, football playersAthletes, especially wrestlers, football players

Early detection and segregationEarly detection and segregation General hygiene and equipment cleaningGeneral hygiene and equipment cleaning

ImmunocompromisedImmunocompromised Tropical travel would predictably be higher risk Tropical travel would predictably be higher risk

(SSTI)(SSTI) Bring empiric topical antibiotics/disinfectants for Bring empiric topical antibiotics/disinfectants for

injuries as a routine? (similar to contact lenses)injuries as a routine? (similar to contact lenses) Often routinely included in “adventure” travel first aid Often routinely included in “adventure” travel first aid

kitskitsBenjamin et al,

2007

Clostridium difficileClostridium difficile: : What now?What now?

Increasing virulence and presence locallyIncreasing virulence and presence locally One third to one half of local cases are One third to one half of local cases are

community acquired – suggests higher carriage community acquired – suggests higher carriage ratesrates

No stats on presence in returned travelers, and No stats on presence in returned travelers, and it is still a low probabilityit is still a low probability

Increasing numbers of reports of Increasing numbers of reports of C. difficileC. difficile in returned travelers with persistent in returned travelers with persistent diarrheadiarrhea Severe cases marked by loperamide and Severe cases marked by loperamide and

(multiple) courses of antibacterial use(multiple) courses of antibacterial use Colectomy reported, deaths uncommonColectomy reported, deaths uncommon

So what?So what? Tweaks to advice on management of diarrhea Tweaks to advice on management of diarrhea

may become necessarymay become necessary

Chikungunya VirusChikungunya Virus Means “that which bends up” (Makonde) Means “that which bends up” (Makonde)

or “walking hunchbacked”or “walking hunchbacked” Mosquito borne virus causing explosive Mosquito borne virus causing explosive

onset disease with fever, severe onset disease with fever, severe arthralgia, hemorrhagic disease (25%)arthralgia, hemorrhagic disease (25%)

““inactive” for 20 yearsinactive” for 20 years Prolonged joint pain isProlonged joint pain is

very commonvery common Usually self-resolvesUsually self-resolves Co-circulates with Dengue,Co-circulates with Dengue,

often under or mis-diagnosedoften under or mis-diagnosed

Chikungunya Chikungunya DistributionDistribution

The distributorThe distributor AedesAedes spp. spp. Works during the Works during the

dayday

Her sales areaHer sales area

Confirmed Sales: Confirmed Sales: RéunionRéunion

2005-2006 epidemic on the Isle of 2005-2006 epidemic on the Isle of RéunionRéunion Population 750,000, cases ~218,000 Population 750,000, cases ~218,000

(29%)(29%)

Eurosurveillance, 2006

The International The International ConcernConcern

No vaccineNo vaccine AedesAedes exists in many other areas of exists in many other areas of

the world and could gain a footholdthe world and could gain a foothold Some mortality possibleSome mortality possible

(more virulent?)(more virulent?)

Chikungunya Market Chikungunya Market CollapseCollapse

Good news: the travel advisory is over Good news: the travel advisory is over as of December 2007as of December 2007 Still a low risk and typically self-resolving Still a low risk and typically self-resolving

diseasedisease Daytime mosquito prevention works Daytime mosquito prevention works

(repellent, light coloured clothing, etc.)(repellent, light coloured clothing, etc.) Bad news: it will be backBad news: it will be back

Still going moderately strong in India, Still going moderately strong in India, Indonesia and Sri Lanka (Italy in late Indonesia and Sri Lanka (Italy in late 2007)2007)

What is a shift?What is a shift?

Most of what we have discussed could Most of what we have discussed could easily fall into predictable cyclical or easily fall into predictable cyclical or sporadic activitysporadic activity

ShiftShift A change or move (outside of the norm)A change or move (outside of the norm) A systematic change as something evolvesA systematic change as something evolves May be of different types, for exampleMay be of different types, for example

ClinicalClinical Demographic/EpidemiologicDemographic/Epidemiologic GeographicGeographic GeneticGenetic

Death rates due to VPD Death rates due to VPD in USin US

Death Rates Compared in Death Rates Compared in USUS

Ausubel et al, 2001

Travel EconomicsTravel Economics

Travel trends affected byTravel trends affected by Strength of local currency vs. costs (oil)Strength of local currency vs. costs (oil) Safety abroad (SARS, war, etc.)Safety abroad (SARS, war, etc.)

Demand for “high-risk” Demand for “high-risk” 11 or adventure travel or adventure travel DemographicsDemographics

More singles (MSM and young adults)More singles (MSM and young adults) More grandparents (some with grandchildren) More grandparents (some with grandchildren)

(denture ventures)(denture ventures) More large familiesMore large families2,32,3

““Conscious” tourismConscious” tourism Ecotourism and geotourismEcotourism and geotourism

1. Valerio et al, 2005

2. World Travel Trends Report, 2006-7

3. Statistics Canada, 1997

Economic Impacts?Economic Impacts? For us in Travel HealthFor us in Travel Health

More retirement age travel (more co-morbidity 24-More retirement age travel (more co-morbidity 24-35%)35%)

15% Thai backpackers >55y15% Thai backpackers >55y11

More immunocompromised also travel – dialysis cruises More immunocompromised also travel – dialysis cruises (2004 - >18,000), transplant patients (2004 - ~1800)(2004 - >18,000), transplant patients (2004 - ~1800) 2 2, etc., etc.

Phase advance (eastward jet lag) longer recovery timePhase advance (eastward jet lag) longer recovery time33

IM Needle length adjustments for body mass (1-1.5”) IM Needle length adjustments for body mass (1-1.5”) 11

More adventure and backcountry travel (more More adventure and backcountry travel (more exposure to harsh environments)exposure to harsh environments)

More pediatric considerations in bothMore pediatric considerations in both In generalIn general

Much more travel, much more “risky” travelMuch more travel, much more “risky” travel1. Reed, 2007

2. CIHI, 2006

3. Brendel et al, 1990

Other Hazards: Habits of Other Hazards: Habits of the Polar Fox, the Polar Fox, AlopexlagopusAlopexlagopus

Verhoeven et al, 2007

Conscious TourismConscious Tourism GeotourismGeotourism

““tourism that sustains or enhances the geographic tourism that sustains or enhances the geographic character of a place”character of a place” (environmental, cultural, (environmental, cultural, heritage and well-being) heritage and well-being) 11

EcotourismEcotourism An ecotourist is one with “ceaseless expectations for An ecotourist is one with “ceaseless expectations for

unique, authentic travel experiences that preserve unique, authentic travel experiences that preserve the ecological and cultural environment”the ecological and cultural environment”11

““Germophobic”Germophobic” One marketing study indicates an increased One marketing study indicates an increased

awareness of germs (80% are concerned, 55% wash awareness of germs (80% are concerned, 55% wash hands more, 27% bring own sheets/towels/sanitizers, hands more, 27% bring own sheets/towels/sanitizers, n=2500)n=2500)22

Movement in the industry to accommodate Movement in the industry to accommodate these travelersthese travelers

1. National Geographic Society, 2002

2. Hotel Industry News, Oct 2007

Medical TourismMedical Tourism Increasing awareness of health-driven tourismIncreasing awareness of health-driven tourism

Medical Tourism (750 K Americans/yr projected)Medical Tourism (750 K Americans/yr projected) Travel across borders to receive health careTravel across borders to receive health care Canada third largest consumer based on indirect reportsCanada third largest consumer based on indirect reports Surgical procedures (Plastic and Dental) seem to Surgical procedures (Plastic and Dental) seem to

predominatepredominate Reproductive TourismReproductive Tourism

Assisted reproduction and IVFAssisted reproduction and IVF 16% in one US Clinic were Canadian patients16% in one US Clinic were Canadian patients22

Not all countries adequately screen, and ovarian Not all countries adequately screen, and ovarian hyperstimulation can be dangerous (one fatality in Ireland)hyperstimulation can be dangerous (one fatality in Ireland)

Transplantation TourismTransplantation Tourism Foreign travel to receive transplantsForeign travel to receive transplants

1. Patel et al, 2007

2. Leigh, 2005

Companion AnimalsCompanion Animals Because pets are people tooBecause pets are people too Increasing interest in their travel-acquired Increasing interest in their travel-acquired

diseasedisease Increasingly brought on travelIncreasingly brought on travel Small animal travel increasingly importantSmall animal travel increasingly important Imported pathogens/diseases may be poorly Imported pathogens/diseases may be poorly

recognized here and pose a risk for:recognized here and pose a risk for: Autochthonous transmissionAutochthonous transmission Zoonotic transmissionZoonotic transmission

Decreasing vet skill in diagnosingDecreasing vet skill in diagnosing Reflexive antiparasitics Reflexive antiparasitics Increasingly urban practiceIncreasingly urban practice

1. Deplazes, 2006

2. Irwin, 2002

Some Veterinary Some Veterinary ExamplesExamples

Increasingly immunocompromised animalsIncreasingly immunocompromised animals Aged or on immunosuppressive therapyAged or on immunosuppressive therapy

GiardiaGiardia Affects canines as well as humansAffects canines as well as humans Gastrointestinal disease very common in canine Gastrointestinal disease very common in canine

petspets High rates of High rates of Giardia Giardia carriage, even in well-caredcarriage, even in well-cared

Heartworm (Heartworm (Dirofilaria)Dirofilaria) Travel to high-risk areas a well known riskTravel to high-risk areas a well known risk Transmitted by mosquitoes Transmitted by mosquitoes

Canine BabesiosisCanine Babesiosis Cause of refractory anemia, frequently mistaken Cause of refractory anemia, frequently mistaken

for autoimmunefor autoimmune Also Echinococcus, Brucellosis, Lyme, etc.Also Echinococcus, Brucellosis, Lyme, etc.

Way out ThereWay out There

One author suggest that One author suggest that xenotransplantation may be the xenotransplantation may be the wave of the futurewave of the future11

Animal organs in humans in foreign Animal organs in humans in foreign countriescountries

Potential for “xenoses” Potential for “xenoses”

1. Graczyk et al, 2005

Climate Change: What’s Climate Change: What’s HappeningHappening

Is it real? Is it real? Average temperatures worldwide riseAverage temperatures worldwide rise

0.6º C rise in last 100 years0.6º C rise in last 100 years Rising faster (3º C in the next 100 years)Rising faster (3º C in the next 100 years)

Average sea level risingAverage sea level rising Risen Risen >>3 inches since 19613 inches since 1961 Projected to rise another 7.1 to 23.2 Projected to rise another 7.1 to 23.2

inches by 2100inches by 210011

25% of US coastal houses and resorts are 25% of US coastal houses and resorts are anticipated to be submerged by 2060anticipated to be submerged by 206022

1. Intergovernmental Panel on Climate Change report, 2007

2. Heinz Centre for Science, Economics and Environment, 2000

Climate Change & HealthClimate Change & Health

WHO now recognizes climate change as a WHO now recognizes climate change as a danger to human healthdanger to human health Not as a sole determinant, but importantNot as a sole determinant, but important Recognizes these examplesRecognizes these examples

Hurricane Katrina, 2005Hurricane Katrina, 2005 2003 European Heat Wave (22-45 K)2003 European Heat Wave (22-45 K) Cholera in BangladeshCholera in Bangladesh Malaria in East AfricaMalaria in East Africa Droughts in numerous locationsDroughts in numerous locations

Least resourced areas will be least able to copeLeast resourced areas will be least able to cope By 2030, attributable excess risk outcomes will By 2030, attributable excess risk outcomes will

likely doublelikely double

WHO, April 2008

Natural Disasters in Canada, 1900-Natural Disasters in Canada, 1900-20022002

Etkin et al, 2004

Insect Vectors and Warmer Insect Vectors and Warmer WeatherWeather

Increase in malaria?Increase in malaria? AnophelesAnopheles do not breed or develop well below 16º do not breed or develop well below 16º

C or above 40º C (Dengue limited by winter C or above 40º C (Dengue limited by winter temperatures <10º C)temperatures <10º C)

A 3º C rise in average global temperatures (by A 3º C rise in average global temperatures (by 2100) could lead to 50-80 million more cases of 2100) could lead to 50-80 million more cases of malariamalaria11

Higher altitudes (Asia, Central Africa, Latin Higher altitudes (Asia, Central Africa, Latin America) now seeing more mosquito born disease America) now seeing more mosquito born disease due to presumed influence of warmingdue to presumed influence of warming22

Other Insect vectorsOther Insect vectors Black-legged Ticks moving north in Scandinavia, Black-legged Ticks moving north in Scandinavia,

expected to do the same in North Americaexpected to do the same in North America33

1. Martens et al, 1995

2. Epstein et al, 1998

3. Epstein, 2005

Projected Ranges of Projected Ranges of Ixodes scapularisIxodes scapularis in Canadain Canada

Ogden et al, 2005

Areas vulnerable to malaria in the Areas vulnerable to malaria in the African HighlandsAfrican Highlands

Patz & Lindsay, 1999

Probable Endemic Malaria in US Probable Endemic Malaria in US and Canada, 1882and Canada, 1882

Reiter, 2001

Hot Weather EffectsHot Weather Effects

Heat wavesHeat waves Particularly bad in urban setting (heat island)Particularly bad in urban setting (heat island) Kill or hospitalize thousandsKill or hospitalize thousands

Chicago 1995, Europe 2003Chicago 1995, Europe 2003

Other effectsOther effects Enhances smog, dust, mold and pollen Enhances smog, dust, mold and pollen

persistence (elevated COpersistence (elevated CO22 also exacerbates) also exacerbates)11

Higher rates of asthmaHigher rates of asthma More urban violenceMore urban violence22

Changes in migration of birds, bats and other Changes in migration of birds, bats and other animalsanimals

1. Epstein, 2005

2. Health Canada, Nov 2005

Water: Too much or too Water: Too much or too littlelittle

Too muchToo much Flooding and excess rain linked to (w. other factors)Flooding and excess rain linked to (w. other factors)11

Greater mosquito populations = MalariaGreater mosquito populations = Malaria More standing water = Diarrhea, cholera, schistosomiasisMore standing water = Diarrhea, cholera, schistosomiasis More rodentia = Plague, HantavirusMore rodentia = Plague, Hantavirus

Coastal risesCoastal rises 200 million at risk from coastal storms (13/20 megacities)200 million at risk from coastal storms (13/20 megacities)

Too littleToo little Drought (affects local economies and food prod.)Drought (affects local economies and food prod.) Forest fires (deforestation and smoke)Forest fires (deforestation and smoke) Water crises (violence)Water crises (violence)

>1.7 billion live in water stressed conditions>1.7 billion live in water stressed conditions Projected to rise to 5 billion by 2025Projected to rise to 5 billion by 2025

Patz and Kovnats, 2005

Peter, 2007

Implications for Us?Implications for Us? Changing trends in & geography of diseaseChanging trends in & geography of disease

Shifting malaria & vector borne disease regionsShifting malaria & vector borne disease regions Potential for many regions to be in seasonal crisesPotential for many regions to be in seasonal crises

More early warning systemsMore early warning systems El Niño and other weather pattern monitoring can be El Niño and other weather pattern monitoring can be

predictive for some regions and diseasespredictive for some regions and diseases Malaria (SA), plague, Hantavirus, (cholera), dengueMalaria (SA), plague, Hantavirus, (cholera), dengue Heat waves in Europe, AsiaHeat waves in Europe, Asia

Measures to mitigate warming (Greenhouse Measures to mitigate warming (Greenhouse gases?)gases?) Preserve forests and greeneryPreserve forests and greenery

On a more personal note…On a more personal note… Prairies and North expected to be hit hardPrairies and North expected to be hit hard No Health Plan works for all climatesNo Health Plan works for all climates

El Niño El Niño Affected Affected Weather Weather

Patterns in Patterns in Dec-Feb Dec-Feb and Jun-and Jun-

AugAug

Patz & Kovats, 2002

The Walk Away MessageThe Walk Away Message

The last century was very interestingThe last century was very interesting The next century may be even more The next century may be even more

interestinginteresting We’ll have this talk again in 100 We’ll have this talk again in 100

yearsyears

Thank youv.3