David R Shlim’s research while affiliated with Jackson Hole Center For Preventive Medicine and other places

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Publications (71)


Christian European/Asian pilgrimages
Sacred journeys and pilgrimages: health risks associated with travels for religious purposes
  • Literature Review
  • Full-text available

August 2024

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97 Reads

Journal of Travel Medicine

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Robert Steffen

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Harunor Rashid

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[...]

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Background Pilgrimages and travel to religious Mass Gatherings (MGs) are part of all major religions. This narrative review aims to describe some characteristics, including health risks, of the more well known and frequently undertaken ones. Methods A literature search was conducted using keywords related to the characteristics (frequency of occurrence, duration, calendar period, reasons behind their undertaking and the common health risks) of Christian, Muslim, Hindu, Buddhist and Jewish religious MGs. Results About 600 million trips are undertaken to religious sites annually. The characteristics varies between religions and between pilgrimages. However, religious MGs share common health risks, but these are reported in a heterogenous manner. European Christian pilgrimages reported both communicable diseases, such as norovirus outbreaks linked to the Marian Shrine of Lourdes in France, and noncommunicable diseases (NCD). NCD predominated at the Catholic pilgrimage to the Basilica of Our Lady of Guadalupe in Mexico, which documented 11 million attendees in one week. The Zion Christian Church Easter gathering in South Africa, attended by about 10 million pilgrims, reported mostly motor vehicles accidents. Muslim pilgrimages, such as the Arbaeen (20 million pilgrims) and Hajj documented a high incidence of respiratory tract infections, up to 80% during Hajj. Heat injuries and stampedes have been associated with Hajj. The Hindu Kumbh Mela pilgrimage, which attracted 100 million pilgrims in 2013, documented respiratory conditions in 70% of consultations. A deadly stampede occurred at the 2021 Jewish Lag BaOmer MG. Conclusion Communicable and NCD differ among the different religious MGs. Gaps exists in the surveillance, reporting, and data accessibility of health risks associated with religious MGs. A need exists for the uniform implementation of a system of real-time monitoring of diseases and morbidity patterns, utilising standardised modern information-sharing platforms. The health needs of pilgrims can then be prioritised by developing specific and appropriate guidelines.

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Health Problems in Travellers to Nepal Visiting CIWEC Clinic in Kathmandu — A GeoSentinel Analysis

February 2021

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71 Reads

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6 Citations

Travel Medicine and Infectious Disease

Background Nepal has always been a popular international travel destination. There is limited published data, however, on the spectrum of illnesses acquired by travellers to Nepal. Methods GeoSentinel is a global data collection network of travel and tropical medicine providers that monitors travel-related morbidity. Records for ill travellers with at least one confirmed or probable diagnosis, were extracted from the GeoSentinel database for the CIWEC Clinic Kathmandu site from January 1, 2009 to December 31, 2017. ResultsA total of 24,271 records were included. The median age was 30 years (range: 0–91); 54% were female. The top 3 system-based diagnoses in travellers were: gastrointestinal (32%), pulmonary (16%), and dermatologic (9%). Altitude illness comprised 9% of all diagnoses. There were 278 vaccine-preventable diseases, most frequently influenza A (41%) and typhoid fever (19%; S. typhi 52 and S. paratyphi 62). Of 64 vector-borne illnesses, dengue was the most frequent (64%), followed by imported malaria (14%). There was a single traveller with Japanese encephalitis. Six deaths were reported. Conclusions Travel lers to Nepal face a wide spectrum of illnesses, particularly diarrhoea, respiratory disease, and altitude illness. Pre-travel consultations for travellers to Nepal should focus on prevention and treatment of diarrhoea and altitude illness, along with appropriate immunizations and travel advice.


What will travel medicine look like in the COVID-19 pandemic era?

August 2020

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33 Reads

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13 Citations

Journal of Travel Medicine

Travel medicine has virtually stopped in light of the coronavirus pandemic. It is worth contemplating how travel medicine will be affected by the ongoing pandemic when international travel starts to become more possible. How will we advise patients, and utilize the coming vaccines that may be available? Travel medicine practices are well-suited to play a major role in advising travelers in the pandemic era.



The Use of Acetazolamide for the Prevention of High Altitude Illness

January 2020

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27 Reads

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17 Citations

Journal of Travel Medicine

Background Modern travel means that many travellers can arrive abruptly to high-altitude destinations without doing any trekking or climbing. Airports in high-altitude cities mean that travellers can go from sea level to over 3350–3960 m (11 000–13 000 feet) in a matter of hours, putting themselves at risk for high-altitude illness (HAI). Methods Acetazolamide has been shown to be an effective way to help prevent HAI on such itineraries. The risk of HAI on rapid arrival to altitudes over 3350 m (11 000 feet) has been shown to range from 35% to nearly 50%. The risk can be higher for high-altitude trekking. This risk is far higher than most travel medicine risks and is on a par with the risk of travellers’ diarrhea in high risk destinations. Result The use of prophylactic acetazolamide in a dosage of 125 mg every 12 h is highly effective at diminishing the risk of HAI. Conclusion Travel medicine practitioners should become comfortable with assessing the risk of HAI and determining when it is appropriate to offer acetazolamide prophylaxis to prevent HAI.


FIGURE 1. Transmission cycle of Japanese encephalitis virus*
Seroprotection rates and geometric mean titers among children aged 14 months-17 years in the Philippines before and after a booster dose of inactivated Vero cell culture-derived Japanese encephalitis vaccine administered 11 months after the second dose of a 2-dose primary series
Japanese Encephalitis Vaccine: Recommendations of the Advisory Committee on Immunization Practices

July 2019

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86 Reads

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100 Citations

MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control

This report updates the 2010 recommendations from the CDC Advisory Committee on Immunization Practices (ACIP) regarding prevention of Japanese encephalitis (JE) among U.S. travelers and laboratory workers (Fischer M, Lindsey N, Staples JE, Hills S. Japanese encephalitis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2010;59[No. RR-1]). The report summarizes the epidemiology of JE, describes the JE vaccine that is licensed and available in the United States, and provides recommendations for its use among travelers and laboratory workers. JE virus, a mosquitoborne flavivirus, is the most common vaccine-preventable cause of encephalitis in Asia. JE occurs throughout most of Asia and parts of the western Pacific. Approximately 20%–30% of patients die, and 30%–50% of survivors have neurologic, cognitive, or behavioral sequelae. No antiviral treatment is available. Inactivated Vero cell culture–derived JE vaccine (Ixiaro [JE-VC]) is the only JE vaccine that is licensed and available in the United States. In 2009, the U.S. Food and Drug Administration (FDA) licensed JE-VC for use in persons aged ≥17 years; in 2013, licensure was extended to include children aged ≥2 months. Most travelers to countries where the disease is endemic are at very low risk for JE. However, some travelers are at increased risk for infection on the basis of their travel plans. Factors that increase the risk for JE virus exposure include 1) traveling for a longer period; 2) travel during the JE virus transmission season; 3) spending time in rural areas; 4) participating in extensive outdoor activities; and 5) staying in accommodations without air conditioning, screens, or bed nets. All travelers to countries where JE is endemic should be advised to take precautions to avoid mosquito bites to reduce the risk for JE and other vectorborne diseases. For some persons who might be at increased risk for JE, the vaccine can further reduce the risk for infection. The decision about whether to vaccinate should be individualized and consider the 1) risks related to the specific travel itinerary, 2) likelihood of future travel to countries where JE is endemic, 3) high morbidity and mortality of JE, 4) availability of an effective vaccine, 5) possibility (but low probability) of serious adverse events after vaccination, and 6) the traveler’s personal perception and tolerance of risk. JE vaccine is recommended for persons moving to a JE-endemic country to take up residence, longer-term (e.g., ≥1 month) travelers to JE-endemic areas, and frequent travelers to JE-endemic areas. JE vaccine also should be considered for shorter-term (e.g., <1 month) travelers with an increased risk for JE on the basis of planned travel duration, season, location, activities, and accommodations and for travelers to JE-endemic areas who are uncertain about their specific travel duration, destinations, or activities. JE vaccine is not recommended for travelers with very low-risk itineraries, such as shorter-term travel limited to urban areas or outside of a well-defined JE virus transmission season.




Agents available for the management of TD
Medications for the prevention and treatment of travellers' diarrhea

April 2017

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440 Reads

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46 Citations

Journal of Travel Medicine

Background: . Travellers' diarrhea (TD) remains one of the most common illnesses encountered by travellers to less developed areas of the world. Because bacterial pathogens such as enterotoxigenic Escherichia coli (ETEC), enteroaggregative E. coli , Campylobacter spp. and Shigella spp. are the most frequent causes, antibiotics have been useful in both prevention and treatment of TD. Methods.: Results of trials that assessed the use of medications for the prevention and treatment of TD were identified through PubMed and MEDLINE searches using search terms 'travellers' diarrhea', 'prevention' and 'treatment'. References of articles were also screened for additional relevant studies. Results.: Prevention of TD with antibiotics has been recommended only under special circumstances. Doxycycline, trimethoprim-sulfamethoxazole, fluoroquinolones and rifaximin have been used for prevention, but at present the first three antibiotics may have limited use secondary to increasing resistance, leaving rifaximin as the only current option. Bismuth subsalicylate (BSS) (Pepto-Bismol tablets) is also an option for prophylaxis. Treatment with antibiotics has been recommended for moderate to severe TD. Azithromycin is the drug of choice, especially in Asia where Campylobacter is common. Fluoroquinolone antibiotics continue to be effectively used in Latin America and Africa where ETEC is predominant. BSS and loperamide (LOP) also are effective as standalone treatments. LOP may be used alone for treatment of mild TD or in conjunction with antibiotics for treatment of TD. Conclusions: . Historically, antibiotic prophylaxis has not been routinely recommended and has been reserved for special circumstances such as when a traveller with an underlying illness cannot tolerate TD. Antibiotics with or without LOP have been useful in shortening the duration and severity of TD. Emerging antibiotic resistance, limited new antibiotic alternatives and faecal carriage of antibiotic-resistant bacteria by travellers may prompt a re-evaluation of classic recommendations for treatment and prevention of TD with antibiotics.



Citations (53)


... Numerous examples of analyses of specific diseases, specific destinations, and specific patient characteristics are cited below. 32 Recent work has demonstrated that the time from the beginning of an outbreak until its detection and public reporting has been reduced as informal source surveillance has blossomed. ...

Reference:

Non-traditional infectious disease surveillance systems
Health Problems in Travellers to Nepal Visiting CIWEC Clinic in Kathmandu — A GeoSentinel Analysis
  • Citing Article
  • February 2021

Travel Medicine and Infectious Disease

... At that time, several authors began questioning the future of travel medicine and how COVID-19 would change travelers' behavior, especially for travelers at higher risk of severe disease, such as those with older age and underlying conditions [4,5]. During times of crisis, it has been described that travelers adapt their behavior according to their personality traits and in response to the perceived risks [3,6]. ...

What will travel medicine look like in the COVID-19 pandemic era?
  • Citing Article
  • August 2020

Journal of Travel Medicine

... AMS and/or HACE or when the ascent rate cannot be regulated and/or pre-acclimatization is not possible 211,212 . Acetazolamide promotes acclimatization by stimulating the ventilatory drive and excretion of bicarbonate to counteract the resulting respiratory alkalosis 213,214 . For AMS prophylaxis, acetazolamide should be started 8-24 h before ascending to high altitude and continued for 48 h at the target destination [215][216][217] . ...

The Use of Acetazolamide for the Prevention of High Altitude Illness
  • Citing Article
  • January 2020

Journal of Travel Medicine

... Japanese encephalitis virus (JEV) belongs to the Flavivirus genus which is recognized as a significant group of mosquito-borne viruses. JEV predominantly circulates in the southeastern and southern regions of Asia [1,2], with occasional cases reported in northern Australia and parts of the Western Pacific [3][4][5][6]. Nevertheless, the effects of global warming and urbanization have facilitated the spread of JEV to additional locations such as Australia, Pakistan, and Saipan [7][8][9]. Notably, JEV infects individuals across all age groups, with children serving as the most affected hosts, while adults who were exposed to the pathogen during childhood possess natural immunity. ...

Japanese Encephalitis Vaccine: Recommendations of the Advisory Committee on Immunization Practices

MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control

... As a reminder, there is also no proof that the current PEP schedules without rabies immunoglobulins recommended by the World Health Organization, 4 which are virtually 100% protective, necessarily reach 100% seroconversion rate at Day 7. While we fully agree with our colleagues that for a completely vaccine-preventable and practically 100% lethal disease such as rabies a PEP schedule with a failure rate of 1% or higher would be unacceptable, 1 we would like to point out that in the current context of at-risk populations having difficulties in accessing rabies PrEP and/or timely PEP, 5 we should take into account limitations of both our studies 1,2 and thoroughly investigate the ID dose-sparing schedules before cautioning against their use. While public health bodies and health practitioners from highincome countries might feel reticent to adopt off-label dosesparing regimens and choose to use the more reassuring twovisit intramuscular schedules, 5 low-resource settings, where most rabies cases occur, might not always have the luxury of this choice. ...

Preventing Rabies: The New WHO Recommendations and Their Impact on Travel Medicine Practice
  • Citing Article
  • November 2018

Journal of Travel Medicine

... Specifically, these are the two most effective oral antimicrobial treatment strategies for campylobacteriosis, the most common cause of bacterial enteritis globally. 3,4 Although antimicrobials are not advised for treatment for uncomplicated gastroenteritis, antimicrobial therapy is advised for patients with severe symptoms, dysentery, persistent infections, and patients that are immunocompromised or pregnant. In a recent scoping review of 17 studies that described the risk of AMR Campylobacter, all studies described an elevated risk of drug resistance in individuals who reported foreign travel. ...

Medications for the prevention and treatment of travellers' diarrhea

Journal of Travel Medicine

... Additionally, mosquitoes are important vectors of diseases like Dengue, Yellow Fever, and West Nile virus [86,87]. Typhoid, schistosomiasis, and cryptosporidiosis are among the waterborne illnesses that are expanding around the world as a result of tainted water sources [98][99][100][101]. Rabies, brucellosis, leptospirosis, and Japanese encephalitis are among the major zoonoses in India; outbreaks are usually connected to inadequate sanitation and tainted food or water [102][103][104]. ...

Infectious Diseases Related To Travel
  • Citing Chapter
  • June 2015

... These arrays are assumed to be interrelated with the spread of HEV genotypes, modes of transmission, basics of viral septicity, prevalence of disease, as well as medical indications of the infection. According to WHO and Center for Diseases Control (CDC), the clinical characteristics and epidemiology of HEV infection are principally resolute by the prime genotype, in particular, hosts and the area as illustrated by two expressions of hepatitis E infection that are associated with geographic dispersal (Table 1). 1, 10,11 In developing countries, the epidemiology of HEV infection indicates low seroprevalence in people under 15 years of age; however, it rises rapidly between the ages of 15 and 30 years. The incidence is variable among developing countries with reported outbreaks affecting thousands of people, specifically during flooding or monsoons with a mortality rate of 0.5-3%. ...

Infectious Diseases Related To Travel
  • Citing Chapter
  • September 2013

... The causative agent of human shigellosis, Shigella is a genus of gram-negative bacteria that cause diarrhoea and dysentery, being a major cause of moderate-to-severe diarrhoea in sub-Saharan Africa 39 . Annually, Shigella is estimated to cause 600,000 deaths from 80 to 165 million cases worldwide 40 . In the developing world, S. flexneri is the predominant cause of shigellosis, with S. sonnei being the predominant strain in industrialised countries 40 . ...

Infectious Diseases Related to Travel

... The expedition doctor who prefers reading textbooks should consider the focused manual, Expedition and Wilderness Medicine, by Hudson and Knox, [11] the practical and comprehensive Oxford Handbook of Expedition and Wilderness Medicine, edited by Johnson et al., [8] or the definitive encyclopaedia in the field, Auerbach's Wilderness Medicine. [9] Scenario resolution Realising you have bitten off a little more than you can chew, you make two worthwhile investments: the electronic copy of an expe- dition and wilderness medicine textbook, and a hands-on course with an experienced company. ...

Expedition and wilderness medicine
  • Citing Chapter
  • May 2015