Who Wants to Be . . .

Conference Quiz

Who wants to be a millionaire? If it’s you, you probably won’t reach that goal by reading about travel medicine. But, who wants to be a good travel medicine provider? If that’s you, read on! Americans know that quizzes are fun, whether in an effort to gain wealth or merely to avoid being the “weakest link.” Educators also are well aware that we can learn from tests and quizzes. In an effort to stimulate your current awareness of important news in the field, Travel Medicine Advisor Update is pleased to provide this annotated trivia quiz stemming from items that came up at the recent meeting of the American Society of Travel Medicine and Hygiene in Atlanta.

1. In what Asian nation has Plasmodium vivax re-emerged as a problem for American travelers?

a. India

b. Thailand

c. Uzbekistan

The correct answer is c. India has long offered both falciparum and vivax malaria as significant risks for travelers. Outside urban areas, Thailand continues to be endemic for malaria. Recently, however, malaria has been increasingly identified in travelers to the south of Uzbekistan near the Tajik border. There were 7 cases in 1999 and 46 in 2000. So far, all malaria in Uzbekistan has been due to P vivax, and chloroquine offers adequate chemoprophylaxis. From a session led by Monica Parise of the CDC on 11-12-01.

2. Which malaria chemoprophylaxis regimen is linked to a higher risk of overall adverse events among these 3 regimens?

a. Mefloquine

b. Atovaquone-proguanil

c. Chloroquine-proguanil

d. None of the above

The correct answer is d. The overall incidence of side effects is about equal with mefloquine and atovaquone-proguanil even though severe neuropsychiatric reactions are more common with mefloquine. (See also Clin Infect Dis. 2001;33:1015-1021) Similarly, chloroquine-proquanil was linked to more gastrointestinal symptoms than was atovaquone-proguanil, but the overall incidence of adverse effects was about equal between these 2 combinations. (See also Lancet 2000;356:1888-1894) From a session led by Monica Parise of the CDC on 11-12-01.

3. How many cases of malaria are imported into the United States each year?

a. 50

b. 250

c. 1500

d. 10,000

The best answer is c. In addition, there have been 115 malaria deaths in travelers following their arrival into the United States since 1963. Most, if not all, deaths would have been prevented by the use of appropriate chemoprophylaxis and/or prompt diagnosis and therapy after symptoms began. From a session led by Robert Newman of the CDC on 11-12-01.

4. Atovaquone-proguanil:

a. is effective as treatment of all forms of P vivax malaria.

b. should be avoided in children weighing less than 11 kg.

c. is available in adult and pediatric sizes of tablets.

The correct answer is c. This combination therapy does not kill vivax or ovale hypnozoites and does not obviate the need for primaquine following successful treatment of P vivax. There are good data emerging that atovaquone-proguanil is both safe and effective in children weighing from 5 kg to 11 kg. The pediatric-sized pills contain one fourth as much medication as the adult pills. Again, from Monica Parise’s 11-12-01 session.

5. Individuals traveling to visit friends and relatives are:

a. more likely to die of malaria than nonimmune travelers.

b. more likely to get pretravel advice from a travel medicine specialist.

c. only 20% as likely to take chemoprophylaxis as other travelers to the same area.

The correct answer is again c. Attention must be paid to these “VFR” travelers. From a presentation by Jay Keystone on 11-12-01.

6. Meningococcal vaccine:

a. is useful for individuals going to Mecca on a Hajj.

b. prevents all common types of meningococcal meningitis.

c. prevents the development of a carrier state.

The correct answer is a. Meningococcal vaccine is indeed useful and required for pilgrims visiting Saudi Arabia. The quadrivalent A-C-Y-W135 vaccine prevents most of the travel-related cases of this disease but is ineffective against the serotype B. Vaccination prevents disease, but vaccinated travelers can become carriers and spread organisms to family members after they return from their pilgrimages. In a report from Singapore by Annelies Wilder-Smith on 11-12-01.

7. Which of the following diseases occurs in or near Afghanistan?

a. Crimean-Congo hemorrhagic fever

b. West Nile encephalitis

c. Leishmaniasis

d. Malaria

e. All of the above

The correct answer is e. Steve Berger of Gideon^© fame reviewed diseases endemic to Afghanistan and surrounding areas on 11-12-01.

8. What is true about the ASTMH-certifying exam in tropical medicine and travelers’ health?

a. Nonphysicians will soon be able to sit for the exam.

b. Approximately 100 people have taken the test.

c. Almost everyone who takes the test passes.

The correct answer is a. Details are being worked out so that non-physician licensed health care providers can take the test. More than 500 people have taken the test, and the pass rate is 64%.

9. Who said, “While keeping in mind the realities we can nevertheless be confident that malaria is well on its way toward oblivion”?

a. Steve Hoffman, 2001

b. Louis Miller, 1985

c. PF Russell, 1955

The correct answer is c. Russell was a leading malariologist through the middle part of the 20th century. Unfortunately, malaria eradication efforts failed, and Russell’s optimistic predictions did not come true. Steve Hoffman discussed this on 11-13-01 during his presidential address. Who is Louis Miller? A leading malaria researcher at the NIH. How are you doing on the quiz? If you were a millionaire, would you contribute some of your wealth to pushing malaria toward oblivion? More resources and energy must be devoted to the effort.

10. Brucellosis can present as fatigue in returned travelers. What is not true about this condition?

a. It is only caused by one species.

b. It is associated with unpasteurized dairy products—often goat cheese in the Americas.

c. Fever and back pain can be presenting complaints.

The correct answer is a (since different species are common in different geographical areas). From a case presentation by David Freedman on 11-14-01.

11. Multiple church youth groups doing construction work in Mexico have developed respiratory illnesses. What is true about these outbreaks?

a. They are due to Coccidiomycosis.

b. They are associated with flooding and stagnant water.

c. Rapid initiation of antimicrobial therapy is required to prevent death.

d. Masks should be avoided when working in dusty areas.

The correct answer is a. These infections seem to be associated with dust that is inhaled during times of dryness. When returned travelers present with flu-like symptoms after visiting Mexico, one should consider fungal causes. This was similarly important after the Spring Break outbreak of histoplasmosis in Mexico. From a CDC report presented on 11-14-01.

12. Concerned about dive-bombing flies leaving larvae in eyes of tourists in Barbados? If so:

a. consider a diagnosis of sheep fly infestation.

b. consider getting diagnostic help from www.dpd.cdc.gov/dpdx/default.htm.

c. realize that removal of larvae will likely be curative.

d. All of the above

The correct answer is d. From a fascinating case report (Levett PN et al. A case of human external ophthalmomyiasis in Barbados, abstract 818).

13. Sleepy, or still enthused about this quiz? What is true about African sleeping sickness?

a. Of 30 cases in US travelers in the past 34 years, 7 were reported in 2000.

b. An increased incidence has also been reported in European travelers.

c. Since 1990, 14 of 15 US cases have been found in travelers to game parks in or near Tanzania.

d. Effective free medicines are available from the CDC at 404-639-3670.

e. All of the above

Once again, the correct answer is “all of the above.” From a CDC report on 11-14-01.

14. How many people work at WHO?

The joking answer of former US President Jimmy Carter during a session on the eradication of dracunculiasis on 11-15-01 was “about 50%.”

15. How have you done on this quiz? All correct answers? Learning something about pretravel malaria prevention counsel? Reminded of clinical presentations of brucellosis, fungal infections, and sleeping sickness in travelers? Enthused about learning more? To stay up-to-date, you can:

a. keep reading Travel Medicine Advisor Update.

b. stay in touch with the American Society of Tropical Medicine and Hygiene at www.astmh.org.

c. check out the International Society of Travel Medicine at www.istm.org.

d. go to next year’s ASTMH meeting in Denver, Colo, in November.

e. All of the above

Answer e could be correct. The choices are yours.

Published: February 2002