Before you go go….

Don’t leave yourself hanging like a yo-yo…

Abinash Virk, MD Division of Infectious Diseases

Before you go….

• Get to know the country – Culture – Electricity – Money – Healthcare access – Food • Get a medical / dental tune up – Avoid preventable medical urgencies / emergencies – Take plenty of supplies • Meds • Visit the travel clinic – Specific advise – Vaccines – Meds • Malaria • TD • Altitude • HIV PEP (if needed) – HCW advise – Med Kit

Health problems in American Travelers

Motion sick 5% Trauma 5% AMS 6% Fever 3% Skin prob.

8% TD Resp illness Skin prob.

AMS Motion sick Trauma Fever Resp illness 26% TD 46%

Hill, DR. JTM 2000; 7:259–266

Visit to the travel clinic

• Minimum 6 weeks but best 6 months prior to leaving • Bring details of your itinerary – Impact on vaccine-preventable disease and malaria risk • Know details of planned activities • Bring your prior vaccine records

Malaria Yellow Fever

Pre-travel advice

RISK ASSESSMENT ADVISE & EDUCATION Insect precautions Ingestion - food/water Injuries Immobility - DVT

Indiscretions - STD/HIV

Immersion

Insurance Air evacuation

Altitude sickness

Safety

IMMUNIZATIONS PRESCRIPTIONS

Pre-travel advice

VACCINATIONS

•

Always

- routine •

Often

- Hep A ADVISE & EDUCATION •

Sometimes

•Hep B •Yellow fever •Meningococcal •JEV •Polio •Rabies PRESCRIPTIONS •Cholera

Hepatitis A & B risk areas

3-20/1000 travelers/1month

Hep A Vaccine

• Inactivated • 20-25 yrs after 2 doses • Safe 80-240/100,000 travelers/1month

Hep B Vaccine

• Inactivated • 3 dose schedule • Safe

Geographic distribution of Yellow Fever

Yellow fever Vaccine

• Live attenuated viral • Minimum 10 days before entry • Not for immunocompromised, thymoma • Rare risk of viscerotropic disease Required vaccine

Geographic distribution of meningococcal Required vaccine

Meningococcal Vaccine

• HCW in Africa; Hajj • Quadrivalent – A, C, Y, W-135 •New conjugated - better • Safe

Geographic distribution of Japanese Encephalitis Virus

JEV Vaccine

• If staying > 4-6 weeks • Takes 24 - 40 days to complete • Rare anaphylaxis • Current shortage

Geographic distribution of Polio

Geographic distribution of Rabies

Rabies Pre-exposure Vaccine

• If staying > 4-6 weeks • Takes 21 - 28 days to complete • Precludes need for RIG post-bite • Current vaccine shortage

Geographic distribution of Typhoid

Typhoid Vaccine

• Oral – live attenuated bacterial • Injectable – inactivated • Safe

Geographic distribution of Cholera

Cholera Vaccine

• Oral – live attenuated bacterial • Not available in US • Risk is rare

Pre-travel advice

RISK ASSESSMENT ADVISE & EDUCATION IMMUNIZATIONS PRESCRIPTIONS

Therapy Treatment Prophylaxis Geographic location traveling to What species is present

INSECT REPELLENTS

• •

DEET (N,N-diethylmetatoluamide)

- available under many brand names such as – OFF ®, Cutter ® and Repel ®.

– 40 years use, 8 billion human applications – Only 50 cases of serious effects – “Normal use of DEET does not present a health concern to the general U.S. population” • EPA, 1998

Picaridin

- available as Bayrepel®, Hepidanin®, and Autan Repel® or

Cutter® Advanced

. – Each application lasts for 2-4 hours in the concentration that is available in the US. – Frequent application is required

Permethrin

• Synthetic version of natural pyrethrum insecticide from flowers (Chrysanthemum) • Applied to clothing/fabric • Repeated washings • Extremely safe and effective • Works on mosquitoes and ticks

Bed nets

• Available in many sizes, shapes • Permethrin treated • Lightweight, inexpensive • Protect against all insect bites (vs antimalarial meds!) • Night-time feeding

P. falciparum

malaria chemoprophylaxis MEFLOQUINE CHLOROQUINE DOXYCYCLINE MALARONE

Formulation Tablets Efficacy Dosing Frequency Safety 90-100% Weekly Yes Pregnancy use Yes # Side Effects Dreams, sleep problems, 1% neuropsch. rxn Schedule Cost

+ 4 wks

$10/week Tablets and suspension No

(except CQ sensitive areas)

Weekly Yes Tablets 77-99% Daily Yes Tablets 99% Daily Yes Yes No No Bitter taste. Hearing / eye AE with prolonged use (months/years) Acidic pill, increases sensitivity to sun, yeast infections (women) Diarrhea, some sleep trouble.

+ 4 wks

$10/week

+ 4 wks

~0.25cents/day

+ 7 days

$5/day

Close the loop for Malaria

Recognizing signs / symptoms of malaria and what to do:

• • •

The most common symptoms of malaria:

–

fever, chills, flu-like symptoms, and headache

– Other symptoms can occur

If symptoms occur while on malaria pills &

still traveling :

– Seek immediate medical attention such as emergency room – Be sure to tell the doctor which malaria pills you are taking. – halofantrine, quinine and quinidine should not be taken if you are taking mefloquine for malaria prevention

If symptoms occur after your return to the US

: – Seek immediate medical attention such as emergency room – Inform the MD regarding your area of recent travel – Ask to be tested for malaria – Continue taking your malaria pills until further instructions.

Stand-by Malaria Treatment (SBMT)

• Taking a treatment course for self-treatment of malaria whether or not on malaria prophylaxis – Considered for areas with poor access to healthcare • Controversial – Requires understanding of disease, diagnosis and treatment – Can result in inappropriate use or undertreatment • Most often recommended SBMT – Malarone (if not on Malarone for prophylaxis) – Artemisinin combination treatment (not available for SBMT in US)

Geographic distribution of TD incidence (%) Risk increases as duration of stay increases

4 40 26 50 34 26 10 41 40 26 50 25

Kollaritsch et al. Eur J Epidemiology 1989

TD Etiology

• • • •

Bacteria

–

E coli (enterotoxigenic)

–

Campylobacter jejuni

Parasites

–

Giardia lamblia

Viral

–

Rotavirus

–

Adenovirus Multiple pathogens Trekking, longer India

Reinthaler, FF et al. JTM 1998; 5:65-72.

Travelers Diarrhea (TD) impact

• 30-60% get TD • 20 -30% confined to bed • 40% change schedule • <1% hospitalized • Rare deaths • Wasted: – time (vacation, business) – money “Travel broadens the mind but loosens the bowels”

Prevention of Traveler’s diarrhea

•

“Cook it, peel it, boil it or forget it” – do it!

• Primary prevention (generally not recommended) Prevention Major side effects

Antibiotics (%) Rifaximin (%) 0.01 0 BSS (%) 0

Minor side effects

Protection 3 90 few 72 1 65

Ericsson, CD. Infec Dis Clin of NA. 1998;12(2):285-303 DuPont, H. L. et. al. Ann Intern Med 2005;142:805-812

Take Antibiotics for TD self-treatment

• Fluoroquinolones – Ciprofloxacin – Levofloxacin Single dose vs 3-day course  Antibiotic Treatment for TD  Cipro/loperamide >> 3 days Ciprofloxacin > Single dose Cipro • Azithromycin – Especially for areas where Campy is more • Rifaximin – Not as effective for invasive diarrhea such as Campylobacter or shigella

Health care delivery overseas • Need to consider

– Management of needlestick exposure • Confirm anti-HBsAb prior to travel • Consider carrying HIV PEP for needlestick exposure • Have source patient check for HBV, HCV and HIV – Respiratory-borne illnesses • TB – Carry & use an N-95 mask prn – PPD or QuantiFERON Gold after return • Viral – Hand hygiene

Travel medical Kit

• • •

Over-the-Counter Medications and Supplies Prescription Medications and Supplies

– Antibiotic for TD, antimalarial, Acetazolamide (for AMS if needed) – Epi-pen™ – Nausea and anti-emetics – Sleeping pills – Routine medications – Pain medications

Simple First Aid Kit

– Adhesive bandages of various sizes (for blisters etc.) Gauze swabs, adhesive tape – Antiseptic powder, solution or wipes – Nonadhesive dressings (such as Telfa® or Melolin®) – Small scissors (place in check-in baggage because of airport security) – Thermometer – Tweezers to remove splinters and ticks – IV fluids, syringes and needles

Conclusions

• Plan ahead • Get details of your itinerary – helps keep you healthy • Give yourself time to complete vaccinations • Be an informed traveler: – Less likely to inadvertently expose yourself to disease – More likely to be able to handle unforeseen problems

Which

one

of the following immunizations would be

contraindicated

in an HIV positive patient traveling to Africa with a CD-4 count of 20?

76%

1.

2.

3.

4.

5.

Injectable Influenza Injectable typhoid Yellow fever meningococcal Hepatitis A

10% 6% 4% 4% 1 2 3 4 5