key: cord-0826263-nysj3d5q authors: Sandrock, Christian; Aziz, Shahid R. title: Travel/Tropical Medicine and Pandemic Considerations for the Global Surgeon date: 2020-05-08 journal: Oral Maxillofac Surg Clin North Am DOI: 10.1016/j.coms.2020.05.001 sha: a44108a4a701c30c77f9d63dd9cefdaf8015c93c doc_id: 826263 cord_uid: nysj3d5q International travel goes hand-in-hand with medical delivery to underserved communities. The global health care worker (HCW) can be exposed to a wide range of infectious diseases during their global experiences. A pre-travel risk assessment visit and all appropriate vaccinations and education are performed. Universal practices of water safety, food safety, and insect avoidance will prevent a majority of travel related infections and complications. Region specific vaccinations will further reduce illness risk.. An understanding of common travel related illness signs and symptoms is helpful. Lastly, emerging pathogens that can cause a pandemic, such as SARS-CoV-2, should be understood to avoid healthcare worker infection and spread in the workplace and when returning home. International travel is often required for medical delivery to underserved communities. This travel requires preparation to prevent infectious diseases at the location of travel as well as disease that can occur upon return [1, 2] . Only a minority of illness will occur during travel, requiring a premature return to the home country [2, 3] . Most of the illnesses will be minor and can be cared for locally. A recent study of 100,000 travelers (of all types) to the developing world, roughly 300 will undergo hospitalization, 50 will be air evacuated and 1 will die [4, 5] . Surprisingly, a majority of mortality and morbidity associated with travel remain cardiovascular disease and trauma sustained from motor vehicle accidents, not infectious diseases [4, 5] Recent literature suggest that infectious diseases account for less than 5% of travel associated mortality among travelers and healthcare workers [2, 6] . Mostly importantly, these infectious diseases are largely preventable and a well prepared HCW will largely have uneventful travel allowing them to provide the maximal care to their patients. This chapter will focus on the basic generic preparation, prevention, and treatment of infectious diseases for the global healthcare worker. A traveler maybe exposed to a wide range of infectious diseases during their global experiences [6] . These infections can come from the environment, community members, or most importantly, the local healthcare system. As such, the list of potential etiologic agents is very broad and hard to differentiate and most importantly, varies widely from location to location [1, 2] . In general, travel-associated infections are acquired via enteral, respiratory, vector-borne, and/or sexual exposures. The most common travel related infections fall into gastrointestinal, febrile, and dermatologic illnesses [3] .. Thus, preparing for all diseases globally is an impossible task. Preparation must include reviewing the local epidemiology of the country visited. Even in these circumstances, local epidemiology can vary greatly given population migration, weather, vector growth, healthcare and public health infrastructure, and emerging pathogen presence. Thus, travel medicine must be tailored to the location. A few generic preparation actions can apply globally and in many cases, a few diseases (e.g. Malaria, tuberculosis) can appear frequently across locations. In these cases, a broad preparation plan of education, vaccination, and basic disease preparation will provide care in most cases, with a few adjustments to complement the local epidemiology. At least one month prior to travel, an evaluation should be performed by a travel medicine or primary care physician[1] (Box 1). The pretravel evaluation should include: • A review of all underlying medication conditions • Pregnancy or potential pregnancy upon return home • Allergy review and plans to assess allergies at location of travel (e.g. medications) • A review of the location for all vaccinations required • A plan to take sufficient supplies of current medications as equivalent drugs may not be available in travel destinations. • An evacuation plan and review of travel insurance Updates on needed prevention should be obtained via the Centers for Disease Control and Prevention (https://wwwnc.cdc.gov/travel). Specific country based information and travel medicine guidance is found here. The evaluation should tailor the risks of the traveler, including comorbidities, to the location (Boxes 1 and 2, Table 1 ) [1] [2] [3] . At the end of the session, a pre-trip prevention plan should include vaccinations, medication supplies, water and food education, and an evacuation plan should illness occur (this will include obtaining evacuation insurance). In most locations (not active war zone), bottled water or soft drinks should be present. If traveling to remote areas, clean water sources should be planned [1, 7] . Travelers who have poor access to clean and safe water should purify water in the following ways [8] (Table 2 ): •Boiling for 3 minutes followed by cooling to room temperature. Do not add ice to speed cooling. •Adding two drops of 5 percent sodium hypochlorite (bleach) to a quart of water and let sit for 30 minutes. •Adding five drops of Kncture of iodine per quart of water and let sit for 30 minutes •Compact water filters with iodine impregnation can remove parasitic, bacterial and viral pathogens. Non-drinking water exposure Swimming in fresh water can lead to multiple parasitic diseases. In areas of high schistosomiasis (Asian, sub saharan Africa), fresh water exposure should be avoided, including short exposures such as rafting and boat rides [9] . . Avoid walking barefoot or in loose-fitting footwear on beaches, on soil, or in water that may be contaminated with human or canine feces. Such exposure may lead to contact with Strongyloides larvae. Acquisition of the larvae can cause cutaneous larva migrans, hookworm, or strongyloidiasis [2, 9] . Thus, limiting fresh water contact and wearing closed toes shoes becomes essential in areas of high prevalence. As with water safety, food safety is essential in regions where sanitation and personal hygiene is poor. Hands should always be washed before eating with appropriately treated water. Infections transmissible by contaminated food and water include travelers' diarrhea, parasitic infection, and hepatitis A and E [10] . Raw foods rinsed with tap water should be avoided. While chlorination may kill most viral and bacterial pathogens, the protozoal cysts of Giardia lamblia and Entamoeba histolytica and oocysts of Cryptosporidium survive and thus can be transmitted easily [8, 10] .. . Basic advice for travelers should include food choices of thoroughly cooked and served hot, fruits that the traveler peels just prior to eating, and pasteurized dairy products only [8, 10] .. . Condiments on the table should be avoided as they can be contaminated. The old adage "cook it, boil it, peel it, or forget it" is the best advice for food protection broadly. Global surgery often requires travel to regions with high rates of vector-borne diseases, The HCW should take action to reduce risk of bites from sandflies, ticks, and other mosquito species [11] [12] [13] [14] . Basic measures should include: • Avoiding outdoor exposure between dusk and dawn (peak Anopheles mosquitoes feed) • Reducing the amount of exposed skin with clothing • Wearing clothing impregnated with insecticide (e.g pyrethrins). They are protective for about 3 washes or 3 weeks. • Sleeping within bed nets treated with insecticide. These are protective for approximately 3 washes • Staying in well-screened or air-conditioned rooms • For exposed skin, wearing appropriate insecticide. This ideally is N,N-diethyl-mtoluamide (DEET), picaridin, ethyl butylacetylaminopropionate (IR3535), and oil of lemon eucalyptus (OLE) Regarding insect repellent, DEET (30 to 50%) is generally protective for at least 4 hours, although lower percentage preparations provide a shorter duration of protection [11] .. Picaridin, a synthetic repellant, has similar protection at 20% concentration when compare to DEET (35% concentration) for up to 8 hours. IR3535 (15% or higher) is protective for 8 hours and OLE in is an effective repellant and can be used in children >3 years but has not been tested for efficacy or safety [12] [13] [14] .. As a global HCW, exposure to bodily fluids and contaminated fomites is common. As such, personal protective equipment (PPE) is paramount for the prevention of disease in both health care workers and their patients [15] [16] [17] . . Healthcare systems themselves can become a nidus for drug resistance and emerging infections. As such, the most effective preventive measures in the community include [15] [16] [17] [18] [19] :: • performing hand hygiene frequently with an alcohol-based hand rub if your hands are not visibly dirty or with soap and water if hands are dirty-20 second vigorous wash is recommended prior to rinsing • Wearing a surgical mask and face shield for contact and any procedures with bodily fluids (standard and contact precautions) • When limited with mask, avoiding touching face, eyes, and mouth • Practicing respiratory hygiene by coughing or sneezing into a bent elbow or tissue and then immediately discarding tissue and/or cleaning sleeve of shirt or skin at elbow with a disinfectant • Masking all patients if they have respiratory symptom. In resource limited settings, using a cloth mask is appropriate. Precautions to be implemented by health care workers caring for patients include using PPE appropriatelyspecifically in how to put on, remove, and dispose of it. Taking these simple measures will protect the global health care worker from developing a healthcare associated infection while also protecting their patients in difficult resource limited settings. For Maxillofacial Surgery/Head and Neck Surgery-appropriate PPE include [15] [16] [17] [18] [19] :: Worldwide, the prevalence of multi-drug resistant bacteria (MDR) is rising rapidly [20, 21] . . Exposure to MDR is occurs largely though foodborne or water contact. MDR strains have been identified in nontyphoidal Salmonella, Shigella spp, and V. cholerae [21] . Gram-negative bacteria (GNB), such as Klebsiella pneumoniae and other Enterobacteriales, Acinetobacter baumannii, and Pseudomonas aeruginosa are the most common bacteria found worldwide [21] [22] [23] . Treatment options for health care workers become limited for both their patients and themselves if they acquire disease in many developing countries. As a result, antibiotic treatment choices must be very tailored to the local epidemiology, and given the high rates of resistance, the use of personal protective equipment and sterile technique becomes essential in protecting both staff and patients. The guidelines for recommended vaccinations for travel greatly vary based on the local epidemiology. However, despite this, a number of basic vaccinations including yellow fever, meningococcus, typhoid, Hepatitis A, Hepatitis B, polio, and influenza [24] [25] [26] . Box 2 and Table 1 include the major vaccines that are recommended for travel to developing countries as well as some regional recommendations. However, as local epidemiology changes, up to date country specific vaccine requirements can be found at the United States Centers for Disease Control and Prevention (https://wwwnc.cdc.gov/travel) [24] [25] [26] . . Malaria is the most classic disease associated with travel [2] . Malaria is found worldwide and is common in most developing countries with varying prevalence and incidence. P. falciparum is the most common species to cause severe disease, with vivax and malariae rarely causing severe or respiratory based symptoms [27] . Most cases can be mild and present both during travel and upon return [28] . All forms of malaria need treatment, but severe malaria requires rapid treatment due to the potential for rapid decline and death within 24 hours of onset [27] . Malaria severity is often based on the parasite load, with less severe cases having 1-2% parasitemia and severe disease with 5-10% (5% in low incidence regions and 10% in high incidence regions) with signs of organ damage [29] . The most common presentation is fever, headache, malaise, chest and joint pain, and weight loss. More severe cases progress with abdominal pain, jaundice, splenomegaly, and progress to the severe symptoms of altered consciousness with or without seizures, respiratory distress or ARDS, hypotension and heart failure, metabolic acidosis, renal failure with hemoglobinuria ("blackwater fever"), hepatic failure, coagulopathy, severe anemia, and hypoglycemia [27] [28] [29] Cerebral malaria with encephalopathy and seizures carry the worst prognosis, which is not part of this patient's presentation [27] [28] [29] Artemisinin-based combination therapies for the treatment of uncomplicated malaria caused by the P. falciparum parasite is the recommended mainstay [30, 31] . By combining 2 active ingredients with different mechanisms of action, combination therapy is the most effective antimalarial medicines available today. Artemisinin and its derivatives must not be used as oral monotherapy, as this promotes the development of artemisinin resistance. In low transmission areas, a single low dose of primaquine should be added to the antimalarial treatment in order to reduce transmission of the infection [30, 31] . P. vivax infections should be treated with an ACT or chloroquine in areas without chloroquine-resistant P. vivax. Parenteral therapy is preferred for rapid treatment [30, 31] There are two major classes of drugs available by IV administration: the cinchona alkaloids (quinine and quinidine) and the artemisinin derivatives (artesunate, artemether and artemotil) [30, 31] Based on clinical trials, artesunate is superior for treatment of severe falciparum malaria when compared to quinine [29] [30] [31] Additional support with blood transfusions can be considered in cases of altered consciousness, high output heart failure, respiratory distress, and/or high density parasitemia [29] [30] [31] . Exchange transfusion is additionally an option to reduce parasite load. Blood transfusion and exchange transfusion are largely supportive and have not been shown to reduce mortality [29] [30] [31] . Thus they should not delay the onset of therapy with artesunate or quinine. In rare cases, non-faciparum malaria can cause severe disease, and these cases, treatment is identical with artesunate or quinidine. Although bacterial pathogens predominate as the cause of travelers' diarrhea, viral and parasitic agents are also possible sources. Enteropathogenic Escherichia coli, Salmonella spp, Campylobacter jejuni, and Shigella spp constitute a majority of the worldwide causes of gastrointestinal disease [32] . Hepatitis A, rotavirus and the parasites Entamoeba histolytica, Cryptosporidium parvum, and Giardia lamblia are the most common non-bacterial causes worldwide [8, 32] . Up to 25% of individuals can have an infection with more than one organism. Overall, the incidence of travelers' diarrhea is approximately 20-40% but varies greatly based on destination of travel, but the risk varies considerably based on destination of travel [8, 10] . . Mexico. Moderate risk regions include Caribbean Islands, South Africa, Central and East Asia (including Russia and China), Eastern Europe, and the Middle East. Risk of travelers' diarrhea is highest during the first week of travel and then progressively decreases with time. High risk activities include buying food from street vendors, traveling to visit friends and relatives, and staying in "all-inclusive" lodgings [8, 10] . The symptoms of travelers' diarrhea depend upon the microbial etiology [8] . The classic findings of enterotoxigenic Escherichia coli include malaise, anorexia, and abdominal cramps followed by the sudden onset of watery diarrhea [8, 10] . Nausea and vomiting also may occur. A low grade fever is variable. Most episodes of travelers' diarrhea occur between 4 and 14 days after arrival. . The illness is generally self-limited with symptoms lasting for approximately 1-5 days. The development of chronic gastrointestinal symptoms, and in particular irritable bowel syndrome, has been reported in a sizable minority of patients following travelers' diarrhea. Avoidance is the ideal therapy -only utilize known safe facilities ( hotel, hospital etc); never eat or drink from so-called "street vendors." Once ill, acute management includes fluid replacement and rest [32] . Antimicrobial therapy shortens the disease duration to about one day and antimotility agents may limit symptoms to a period of hours. Antibiotic treatment is reasonable for travelers with severe diarrhea, which is characterized by fever and blood, pus, or mucus in the stool, or for travelers with diarrhea that substantially interferes with the ability to work [10, 32] . Antimicrobial choice depends on the region of travel but includes azithromycin, trimethoprim/sulfamethoxazole, ciprofloxacin (or another fluoroquinolone), A restricted diet (eg, beginning with only clear liquids to match diarrheal losses during the acute phase of diarrhea) is often recommended [10] . Arthropod-borne encephalitis viruses represent a significant public health problem throughout most of the world and are found in all locales. They come from a wide range of families such as Flaviviridae, Togaviridae, Bunyaviridae, and Reoviridae and are highly adapted to particular reservoir hosts and region [35] ; Kaiser, 2008. Spread occurs through an infected arthropod bite (usually mosquito or tick) and are spread from animal to animal. The mosquito or tick becomes infected when feeding on the blood of the viremic animal, replicates in the mosquito or tick tissue, and ultimately infects the salivary glands. The mosquito or tick transmits the virus to a new host when it injects infective salivary fluid while taking a blood meal. As a group, these viruses are found worldwide, but each specific virus has a regional presence. In North America, West Nile, St. Louis encephalitis, and La Crosse encephalitis viruses predominate [33, 34] . Venezuelan equine encephalitis virus is of concern in Central and South America, while Japanese encephalitis virus affects persons living or traveling to parts of Asia [35] . Dengue is a rare cause of encephalitis throughout the tropical world [36] . Table 3 outlines the major arthropod borne viral diseases. Selected encephalitis infections are reviewed in the following sections. Dengue viruses are spread through the Aedes species (Ae. aegypti or Ae. albopictus) mosquito. These are the same species of mosquitoes that also spread Zika, chikungunya, and other arthropod-borne viral encephalitis [36] [37] [38] [39] . Dengue is common in more than 100 countries around the world with over 400 million cases reported. Mild symptoms of dengue include a rash, nausea, aches, joint pain, and fever. Given the non-specific findings, dengue can be confused with other illnesses that cause fever, aches and pains, or a rash. For mild disease, symptoms of dengue typically last 2-7 days [36] [37] [38] [39] . . Most people will recover after about a week. However, a minority of people progress to severe disease, especially in individuals who have had a prior infection with dengue. This includes the classic signs of hemorrhagic fever including abdominal pain, jaundice, mucosal bleeding and eventually hepatic, renal, and respiratory failure [36] . The diagnosis of dengue virus infection is established via serology or reverse-transcription polymerase chain reaction (RT-PCR) . While mild disease is self limiting, treatment of severe disease is largely supportive. Prevention of arthropod bites through covering and insecticides (DEET) is the primary way to avoid dengue. The EEE viruses (family Togaviridae, genus Alphavirus) consists of classic EEE virus found in North America and the Caribbean and Madariaga virus in South and Central America [40] [41] [42] . EEE virus is associated with severe clinical disease. In North America, wild birds and Culiseta melanura, a mosquito that is found in swampy moist areas maintain the EEE virus. However, Culiseta melanura mosquitoes rarely bite humans, thus some Aedes, Coquillettidia, and Culex species are responsible for transmission to humans. Although infections can occur throughout the year, peak incidence is in August and September in North America, January and February in South America [40] . The incubation period is usually 4 to 10 days after the mosquito bite. The illness often begins with a prodrome lasting several days, with fever, headache, nausea, and vomiting [41] . A minority of people will progress to encephalitis but universally, disease is severe. Once neurologic symptoms begin, Patients decline rapidly and progress to a coma or stupor. Seizures, and focal neurologic signs, including cranial nerve palsies, develop in approximately one-half of the patients. The diagnosis of EEE can be made by demonstration of immunoglobulin M (IgM) antibody by capture immunoassay of CSF, a fourfold rise in serum antibody titers against EEE virus, or isolation of virus from or demonstration of viral antigen or genomic sequences in tissue, blood, or CSF. Treatment is supportive. As with other arthropodborne viruses, prevention focuses primarily upon avoiding mosquito bites [40] [41] [42] . WEE viruses (family Togaviridae, genus Alphavirus) are a complex of closely related viruses found in North and South America [35] . Spread is through Culex mosquitoes family, and thus, as flooding and increase standing water occur, regional outbreaks can occur. Incubation is about seven days from a bite, followed by the onset of a headache, vomiting, stiff neck, and backache [35] . Restlessness, irritability, and seizures are common in children. Although rare in adults and older children, neurologic sequelae are relatively common in infants. The diagnosis of WEE can be made by demonstration of immunoglobulin M (IgM) antibody by capture immunoassay of CSF, a fourfold rise in serum antibody titers against WEE virus, or isolation of virus from or demonstration of viral antigen or genomic sequences in tissue, blood, or CSF. Treatment is supportive [35] . WNV is a member of the flavivirus genus and belongs to the Japanese encephalitis antigenic complex of the family Flaviviridae. [33, 43] skin rash (on the trunk of the body), and swollen lymph glands predominate [33, 43] . Severe disease (also called neuroinvasive disease, such as West Nile encephalitis or meningitis or West Nile poliomyelitis) include headache, high fever, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, and paralysis. It is estimated that approximately 1 in 150 persons infected with the West Nile virus will develop a more severe form of disease. Diagnosis is through antibody testing (IgM and IgG) in the serum with an appropriate 4 fold rise in titer or isolation of the virus in the CSF by RT-PCR [33, 43] . Care is supportive. For those who develop neurologic disease, sequelae often persist. There is no vaccine at this time in humans. Zika is spread mostly by the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus) [34, 44, 45] . Zika can be passed from a pregnant woman to her fetus. Infection during pregnancy can cause certain birth defects and thus prevention, both with mosquito bites and with sexual transmission is essential [34, 44, 45] . Pregnant women are recommended to prevent mosquito bites and sexual exposure to Zika during and after travel. If traveling without male partner, wait 2 months after return before becoming pregnant. For male partners with a pregnant partner, condoms must be used or abstain from sexual activity during pregnancy. Returning travelers should avoid being bitten for 2-3 months (viremic period) as this can establish disease elsewhere [34, 44, 45] . Chikungunya virus is an arthropod-borne alphavirus transmitted by mosquitoes that predominately infects humans and non-human primates [36, [46] [47] [48] . Chikungunya virus has spread from its origin in West Africa to Asia, Europe, islands in the Indian and Pacific Oceans, and in the Americas. Infected travelers can import chikungunya virus into new areas, where local transmission can occur if competent mosquitoes are present. In Africa, chikungunya virus transmission occurs in cycles involving humans, Aedes and other mosquitoes, and animals (nonhuman primates and perhaps other animals) [36, [46] [47] [48] . Outside Africa, major outbreaks are sustained by mosquito transmission among susceptible humans. Transmission via maternal-fetal route and blood products have been described but unlike Zika and WNV, transmission through transplantation has not occurred. Incubation lasts from period of 3 to 7 days followed by an acute infection with fever and malaise [36, [46] [47] [48] . Polyarthralgia often begins 2-5 days after onset of fever and commonly involves multiple joints. The arthralgia is usually bilateral and symmetric, associated with morning stiffness, and involves the distal more than proximal joints. Skin manifestations include macular or maculopapular rash. For most individuals, the duration of acute illness is usually 7 to 10 days how ever the inflammatory arthritis can persist for weeks, months, or years [36, [46] [47] [48] . The chronic manifestations usually involve joints affected during the acute illness and can be relapsing or unremitting and incapacitating. Severe complications (including meningoencephalitis, cardiopulmonary decompensation, acute renal failure, and death) have been described with greater frequency among patients older than 65 years and those with underlying co-morbidities. The diagnosis of chikungunya is established by detection of chikungunya viral RNA by RT-PCR or serology [36, [46] [47] [48] . Testing for dengue, Zika and Ross River Valley virus infection should also be considered as they present similarly. There is no known treatment of chikungunya other than supportive care [36, [46] [47] [48] . Treatment of arthritis with non-steroidal anti-inflammatories is recommended. Rickettsia cause a wide range of human diseases across all continents. Rickettsial diseases are transmitted by ticks with few exceptions: Rickettsia prowazekii is transmitted by a louse, rickettsialpox and scrub typhus is transmitted by mites, and R. felis is transmitted by cat fleas [49] . The number of species of rickettsia are large and important differences exist in the epidemiology, clinical features, and diagnostic methods [49] [50] [51] [52] . However, the antimicrobial treatment is similar across all Rickettsia. Table 4 outlines the major Rickettsial diseases and they range from African spotted fever to Rocky mountain fever and scrub typhus [49] . The various clinical illnesses that are seen in association with the individual Rickettsia vary significantly in severity. Some, such as African Tick Fever, can be self-limiting with minimal symptoms. However, others, such as Rocky Mountain Spotted Fever, can progress rapidly if not treated and recognized. However, a few features due exist in common with all of them including [53] : • Rickettsial infections cause fever, headache, and intense myalgias. • Rickettsial are arthropod-borne; known or potential exposure to ticks or mites is an important clue to their early diagnosis. • A Rash and/or a localized eschar occur in most patients. After suspecting a rickettsial disease in a patient with a rash and fever, clinical diagnosis can be achieved in four basic ways: serology, polymerase chain reaction detection of DNA in blood or tissue samples, immunologic detection in tissue samples, and isolation of the organism [49] [50] [51] [52] [53] . Often this is difficult in the field and immediate treatment without a diagnosis is often recommended. The preferred treatment of choice is doxycycline, even for pregnant women and children given the high rate of success. Alternatively, chloramphenicol can be used in adults. The route of administration will depend upon the severity of disease, but most patients can be treated as outpatients with oral therapy. The hemorrhagic fever viruses include wide number of geographically distributed viruses found worldwide, including Ebola and Marburg viruses, Rift Valley Fever, Crimean Congo hemorrhagic fever, Lassa fever, yellow fever, and dengue fever [54] [55] [56] . Ebola and Marburg viruses are in the family Filoviridae. Although any of the many VHF can cause severe disease in a traveler, Marburg and Ebola virus serve as a classic template for VHFs and will be largely discussed here. Marburg virus has a single species while Ebola has four different species that vary in virulence in humans [55, 57] . Transmission appears to occur through contact with nonhuman primates and infected individuals [58] . Settings for transmission have occurred in vaccine workers handling primate products, nonhuman primate food consumption, nosocomial transmission, and laboratory worker exposure [57] . . The use of VHF in bioterrorism has also been postulated, largely based on its high contagiousness in aerosolized primate models. The exact reservoir for the virus was initially felt to be with wild primates, but recently bats have been labeled as the reservoir, passing the infection onto nonhuman primates in the wild [57] . . and pathophysiology, with morality being the only major difference between them [55] . Initial incubation period after exposure to the virus is 5-7 days, with clinical disease beginning with the onset of fever, chills, malaise, severe headache, nausea, vomiting, diarrhea, and abdominal pain [58] . Disease onset is abrupt, and over the next few days, symptoms worsen to include prostration, stupor and hypotension. Shortly thereafter, impaired coagulation occurs with increased conjunctival and soft tissue bleeding. In some cases, more massive hemorrhage can occur in the gastrointestinal and urinary tract, and in rare instances, alveolar hemorrhage can occur [58] . The onset of maculopapular rash on the arms and trunk also appears classic and may be a very distinctive sign [55] . Along with the bleeding and hypotension, multi-organ failure occurs eventually leading to death. Reports of outbreaks and cases have largely occurred in developing countries where critical care resources are more limited [57] . . Case fatality rates have reached 80-90% in the recent outbreak of Marburg outbreak in Angola, but Ebola case fatality rates appear lower at 50% [58] . The diagnosis of VHF becomes extremely important in order to initiate supportive care before the onset of shock, alert and involve the public health department, and to institute infection control measures [55, 56, 59] . However, diagnosis is difficult outside of the endemic area. VHF should be suspected in cases of an exposed laboratory worker, an acutely ill traveler from an endemic area (i.e central Africa), or in the presence of some classic clinical findings with increasing cases within the community suggesting a bioterror attack [55] . Outside of travel or laboratory exposure, the presence of a high fever, malaise and joint pain, conjunctival bleeding and bruising, confusion, and progression to shock and multi-organ failure should raise suspicion of a VHF, particularly if multiple cases are presenting in the community [56] . Laboratory diagnosis includes antigen testing by enzyme-linked immunosorbent assay or viral isolation by culture, but these tests are only performed by the CDC currently. As no specific therapy is available, patient management includes supportive care, including a lung protective strategy with low -tidal volume ventilation if ARDS appears as part of the disease course. In a few cases in a Zaire out break in 1995, whole blood with IgG antibodies against Ebola may have improved outcome, although analysis showed these patients were likely to survive anyhow. Although transmission appears to spread by droplet route, airborne precautions are recommended with respiratory protection with an N-95 or PAPR and placement of the patient in a respiratory isolation room [60] . Equipment should be dedicated to that individual, and all higher risk procedures should be done with adequate, full PPE. Any suspected case of VHF should immediately involve the public health officials and infection control department, as public health interventions and outbreak investigation will be paramount to reduce spread of disease [59] . If exposure to a HCW occurs, there is no specific post exposure prophylaxis, and infection control and occupational health should be involved with potential quarantine measures for exposed individuals [59] . Other Emerging Viral Pathogens Coronaviruses are important human and animal pathogens and the source of approximately 30% of all respiratory tract infections worldwide. However, coronaviruses are a major source of emerging pathogens given their RNA genome, ability to adapt to multiple hosts, and the frequent contact between wildlife, domesticated animals, humans. In 2003, a rapid progressive respiratory illness originating in China spread to multiple countries with over 8000 cases and a case fatality ratio of almost 10% [61] . . This disease was termed Severe Acute Respiratory Syndrome (SARS) and a novel coronavirus was determined to be the etiologic (Severe Acute Respiratory Syndrome-coronavirus-1 (SARS-CoV-1)) In September 2012, a case of novel coronavirus infection was reported involving a man in Saudi Arabia who was admitted to a hospital with pneumonia and acute kidney injury [62] . This case was followed by multiple clusters of infections in the Arabian peninsula and this outbreak was indeed related to a coronavirus (betacoronavirus) which is different but closely related to the other human betacoronaviruses (e.g. SARS). In fact, this virus's lineage was closely related to bat coronaviruses. Within 12 months, over 2400 confirmed cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) had spread to over North Africa, Europe. Asia, and North America [61, 62] . . At the end of 2019, another acute respiratory syndrome was described in Wuhan, a city in the Hubei Province of China [63, 64] . . Likewise, this coronavirus is a betacoronavirus in the same subgenus but different class as the SARS virus. Based on the viral taxonomy, this virus was named Severe Acute Respiratory Syndrome-coronavirus-2 (SARS-CoV-2). This virus spread rapidly throughout China and with increasing cases worldwide leading to an active pandemic. By May 2020, over 1 million cases have been identified on 6 continents with over 100,000 deaths [63, 64] . While cases of SARS-CoV-1 and MERS-CoV have all but disappeared, SARS-CoV-2 and subsequent disease from this virus (coronavirus disease 2019 (COVID-19)) are actively overwhelming hospitals and healthcare systems in North America, Asia, Europe, and the Middle East, thus altering the mobility and response of global healthcare workers. Person-to-person spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is thought to occur mainly via respiratory droplets, resembling the spread of influenza[17, 61, 62] .. With droplet transmission, virus released in the respiratory secretions when a person with infection coughs, sneezes, or talks and can infect via direct contact with the mucous membranes. The infection also occurs through the touch of an infected surface with subsequent touch to the eyes, nose, or mouth (fomite spread) [65] . . SARS-CoV-2 has been detected in non-respiratory specimens, including stool, blood, and ocular secretions, but the role of these sites in transmission is unknown. Most importantly, spread through droplet mechanisms can be aerosolizied when undergoing aerosol generating procedures such as intubation, bronchoscopy, tracheostomy, manipulation of the sinus and airway with surgery, and invasive and non-invasive mechanical ventilation [60, 64, [66] [67] [68] . This is important for any global healthcare worker undergoing these procedures so that they have the appropriate personal protective equipment required for the given procedure to reduce transmission. The incubation period for COVID-19 is thought to be within 14 days following exposure, with a median of 5.2 days[17, 63, 64, 68] . COVID-19 ranges from mild to severe. Mild disease with no pulmonary involvement remains for approximately 80% of cases. Pneumonia appears to be the most frequent serious manifestation of infection, characterized primarily by fever, cough, dyspnea, and bilateral infiltrates on chest imaging [63, 68] .. Other findings such as upper respiratory tract symptoms, myalgias, diarrhea, and smell or taste disorders, are also common. Severe disease (eg, with dyspnea, hypoxia, or >50 percent lung involvement on imaging within 24 to 48 hours) occurs in 14% [63, 68] .. More critical disease (eg, with respiratory failure, shock, or multiorgan dysfunction) was reported in 5%. The overall case fatality rate appears to be 1-2% but a large number of minimal to asymptomatic carries suggest that this case fatality rate may be lower. Co-morbidities of cardiovascular disease, hypertension, diabetes, and immunosuppression appear to increase the likelihood of severe disease [63, 68] .. Male gender appears to be associated with a worse outcome along with various abnormal laboratory values: Lymphopenia, elevated liver enzymes, lactate dehydrogenase (LDH), inflammatory markers (eg, C-reactive protein [CRP], ferritin, D-dimer (>1 mcg/mL) and prothrombin time (PT), troponin, and creatine phosphokinase (CPK). However, older age is perhaps most associated with increased mortality. In China, fatality rates were 8% among those aged 70 to 79 years and 15% among those 80 years or older [63, 68] .. This is in contrast to the 2.3 percent case fatality rate among all other ages. It is also becoming apparent that some infected individuals become hypercoagulable, increasing the risk of embolic stroke or pulmonary embolism [63, 68] .. • PPE should include face shield, goggles, N-95 or equivalent mask, surgical mask, gloves, and gowns. Confirm if your destination will have these and if not, ensure that they are being secured with the team prior to travel. • All PPE should be stored away from sunlight and in a low humidity area. Check all expiration on PPE prior to departure Arrival care • All workers coming from a high area pf prevalence who test negative prior to departure should self-quarantine for 14 days prior to working. This will ensure that disease is not spread to another area of lower prevalence, including patients • If symptoms consistent with COVID-19 develop on arrival or during work, being isolation away from workers and patients • If available, obtain a nasal swab for SARS-CoV-2 RNA by RT-PCR. Many developing countries will not have the resources to test. This case, isolation until symptom free for greater than 72 hours and at least 1 week from the onset of symptoms will allow for a return to work. A mask should be worn for the next 7 days when working. • For workers performing high risk procedures (e.g. intubation, surgical manipulation of the upper airway, bronchoscopy), screening of all patients prior to surgery should be performed. This should include symptoms screening and any individual with symptoms consistent with COVID-19 should have surgery delayed. • If possible, have local hospital perform screening by testing with RT-PCR. As this is limited in developing countries, for patients who cannot receive testing but have no symptoms, appropriate PPE should be worn. This includes airborne precautions for any intubation or surgical procedure involving the airway and sinuses (PPE to include N-95 mask, face shield hoodie, gown, and gloves). • Patients with unkown tests should have procedure performed in OR with a delay of over 1 hour between cases to allow for over 12 air cycles. • If a local healthcare system has patients with active COVID-19, these patients should be cohorted and placed in droplet precautions (face shield, surgical mask, gown, gloves). If aerosol procedures are going to be performed, airborne precautions should be used during the procedure and for 1 hour after (12 air cycle changes in room roughly) • Health care worker teams should monitor symptoms and wear a mask when unable to keep a >3 meter distance from each other. • Intubations should be done in a rapid sequence manner. All patients should be orally intubated preferably with a skilled operator and video assisted if possible. Nasal intubations should be avoided. Bag valve mask use shodl be avoided and the patient, once intubated should be placed on the ventilator immediately without bag insufflation. Post -Trip preparations [6] • Upon return, all workers will have to quarantine for 14 days unless coming from a region with no cases. • Returning to work should be held off until 14 days. • Avoiding family is recommended for 14 days as well given travel from a high prevalence region. If the returning traveler becomes febrile, the etiology of this fever is largely unknown and if coming from areas of emerging pathogens, the evaluation and treatment can be difficult [6, 70] . While bacterial pathogens constitute most cases, the breadth of agents that can cause disease is enormous, with many having direct impacts on public health systems and the community [60] . . Many of these cases require further epidemiological and diagnostic testing which can take time and resources in order to determine the larger impact of one ill traveler [6] . Often these patients will not be isolated and tested for these pathogens upon admission, and they will additionally undergo higher risk aerosolizing procedures that will increase the likelihood for disease transmission [60, 69, 70] . . This puts both HCWs and other patients at risk for acquiring disease as experienced during the SARS-CoV-2 pandemic, the H1N1 pandemic, and other outbreaks of highly contagious disease [59, 60] . Therefore, a standardized approach, with early isolation and testing of these cases, can reduce the likelihood of disease transmission of an emerging pathogen within the ICU. Figure 1 outlines an approach to early isolation, testing, and involvement of institutional infection control and public health in cases of acute febrile illness in an returning healthcare worker. Upon admission, the patient should undergo initial diagnostic testing as discussed earlier. If an etiologic agent is identified on initial screening and clinical findings (i.e gram positive diplococci with a lobar pneumonia on x-ray), targeted treatment is performed with appropriate isolation based on pathogen. However, if agent is not easily identified in a patient with acute febrile illness and possibly pneumonia, patients should be placed in isolation and further diagnostic testing should be performed based on epidemiologic risk. Isolation should most likely be droplet, but based on specific epidemiological clues or high risk procedures, airborne isolation may be instituted [59, 67] . . Involvement of institutional infection control, microbiology, and public health should be started as early as possible [67, 69, 70] . . Usually this is performed after the common agents have been eliminated and a suspicious high risk pathogen is suspected [59] . Hospital based infection control will assist in isolation and HCW protection, and the hospital based microbiology laboratory should be notified of suspected pathogens, allowing for worker protection and targeted testing of samples [67, 69, 70] . . Finally, public health involvement will allow a broader viral testing, including additional agents, subtyping, and resistance testing as well as rapid laboratory testing, epidemiological investigation, case definition, and community prevention. Finally, higher risk procedures should be limited in these cases. Appropriate PPE should be worn by HCWs at all time, and if worn properly, disease transmission is low risk [67, 69, 70] . . Most cases during the SARS and avian influenza epidemic appeared to have occurred when HCWs did not wear the appropriate PPE. The global surgeon may be exposed to a large number of pathogens though travel, including community exposure and healthcare contact. All global medical travel should begin with a pre-travel visit where risk is assessed and all appropriate vaccinations and education are performed. Routine universal practices with clean water, food access, and insect avoidance will prevent a majority of travel related infections and complications. An understanding of the basic illness of malaria, traveler's diarrhea, arthropod-borne viral infections, tick borne illnesses, hemorrhagic fever will provide protection. Lastly, emerging pathogens that can cause a pandemic, such as SARS-CoV-2, should be understood to avoid healthcare worker infection and spread in the workplace and when returning home. Medical Considerations before International Travel Spectrum of disease and relation to place of exposure among ill returned travelers The burden of illness in international travelers Assessment of travellers who return home ill Preparing the traveller Fever in travellers returning from the tropics Travel medicine considerations for North American immigrants visiting friends and relatives Traveler's diarrhea: a clinical review Schistosomiasis presenting in travellers: a 15 year observational study at the Hospital for Tropical Diseases Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea Multiple activities of insect repellents on odorant receptors in mosquitoes Our new tests identify what works and what doesn't against the bugs that can spread the virus and other serious diseases Insect repellents: historical perspectives and new developments The efficacy of repellents against Aedes, Anopheles, Culex and Ixodes spp. -a literature review Strategies to prevent surgical site infections in acute care hospitals: 2014 update Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews Infection prevention in the operating room anesthesia work area Antimicrobial Resistance in the Tropics Antibiotic resistance in travellers' diarrhoeal disease, an external perspective What and how should we tell travellers about antimicrobial resistance? Antimicrobial resistance in the 21st century: a multifaceted challenge Preventing diseases in round-the-world travelers: a contemporary challenge for travel medicine advice Vaccines for International Travel Malaria: An Update Therapy of uncomplicated falciparum malaria in Europe: MALTHER -a prospective observational multicentre study Treatment of malaria in the United States: a systematic review The treatment of malaria Guidelines for the prevention and treatment of travelers' diarrhea: a graded expert panel report West Nile virus in the Americas Zika Virus Medically important arboviruses of the United States and Canada Chikungunya and dengue viruses in travelers Dengue fever Eastern equine encephalitis in Latin America Clinical and neuroradiographic manifestations of eastern equine encephalitis Successful management of severe neuroinvasive eastern equine encephalitis West Nile virus: review of the literature An update on Zika virus infection Zika Virus Chikungunya infection in travelers Chikungunya fever: an epidemiological review of a re-emerging infectious disease Chikungunya virus and the global spread of a mosquitoborne disease Rickettsiae and rickettsial infections: the current state of knowledge Diagnosis and management of tickborne rickettsial diseases: Rocky Mountain spotted fever, ehrlichioses, and anaplasmosis--United States: a practical guide for physicians and other health-care and public health professionals Rickettsioses and the international traveler Update on tick-borne rickettsioses around the world: a geographic approach Diagnosis and Management of Tickborne Rickettsial Diseases: Rocky Mountain Spotted Fever and Other Spotted Fever Group Rickettsioses, Ehrlichioses, and Anaplasmosis -United States Viral Hemorrhagic Fevers Other than Ebola and Lassa Ebola Virus Disease: Epidemiology, Clinical Features, Management, and Prevention Lassa Fever: Epidemiology, Clinical Features, Diagnosis, Management and Prevention Knowledge and beliefs about Ebola virus in a conflict-affected area: early evidence from the North Kivu outbreak Ebola virus disease: a highly fatal infectious disease reemerging in West Africa Intensive Care Unit Preparedness During Pandemics and Other Biological Threats Acute febrile respiratory illness in the ICU: reducing disease transmission Severe acute respiratory syndrome Middle East Respiratory Syndrome Clinical Characteristics of Coronavirus Disease 2019 in China A Novel Coronavirus from Patients with Pneumonia in China Detection of SARS-CoV-2 in Different Types of Clinical Specimens Transmission of SARS and MERS coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination Severe febrile respiratory illnesses as a cause of mass critical care Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Care of the critically ill and injured during pandemics and disasters: groundbreaking results from the Task Force on Mass Critical Care Illness in the Returned International Traveler Approach to early isolation, testing, and involvement of institutional infection control and public health in cases of acute febrile illness in a returning healthcare worker Box 1: Basic pre-travel appointment checklist • Review all underlying medical conditions and comorbidities • Review all travel locations • Determine medication limitations at destination. If medication is unavailable, purchase supply of medications for travel • Review medication and environmental allergies and take appropriate remedy Determine highest risk activity on travel where infection is greatest (e.g altitude illness, fresh water exposure, personal travel safety and seatbelts) risk area (e.g. SARS-CoV-2 or Zika virus) • Determine home limited activities (e.g. sexual activity, travel, avoidance of pregnancy) based on risk of transmission of disease General vaccines and prophylaxis required for global travel Routine Vaccinations • Influenza • Hepatitis B • Hepatitis A • Pneumococcal (If over age 65 years) • Meningococcal (if age 14-25 years) • Measles, Mumps, Rubella • Haemophilus influenzae type b • Polio • Tetanus, diptheria, pertussis • Varicella • Zoster Specialized Vaccinations • Typhoid • Rabies • Cholera (all areas of active disease)