Transcript Pre-travel Preparation
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