primary care medical care for international travel

MEDICINE FOR INTERNATIONAL TRAVEL Carl Dirks, MD 1

CASE PRESENTATION 24 y/o medical student presents after visiting Belize with malaise, wt loss and loose stools for 3 days. Spent time with friends in a local village, time in jungle, swam in ocean. Drank local water and ate home cooked meals. No Dysentery, no night sweats, no rashes/skin breaks identiﬁed. No insect bites noted 2

TOPICS Pre-travel planning Post travel care Immunizations Selected disease topics Immunoprophylaxis Resources Medical care abroad 3

US-INTERNATIONAL TRAVELERS 65 Number of Travelers (millions) 60 55 50 45 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year 4

% 0 10 20 30 40 C an ad a Eu ro pe A us /N Z M ex ic o C or S A m er ic a Ja pa n O ce an ia /P I O th er A COUNTRIES si a DESTINATION A fr ic a C ar ib be an M id dl e Ea s t 5

Of 100,000 travelers to a developing country for 1 month: 50,000 will develop some health problem 8,000 will see a physician 5,000 will be conﬁned to bed 1,100 will be incapacitated in their work 300 will be admitted to hospital 50 will be air evacuated 1 will die Steffen R et al. J Infect Dis 1987; 156:84-91 6

P R E - T R AV E L P L A N N I N G 7

PRE-TRAVEL PLANNING Get patient in the ofﬁce! activities planned When will you be vaccine history traveling? allergies (travel meds, Where? immunizations) country good H/P region (urban rural) pregancy status/plan accommodations (hotel, breast feeding tent) Behavior risk 8

TRAVEL HEALTH KIT Personal Prescriptions antacid Antimalarial Epi-Pen (with hx medications allergy) OTC antidiarrheals insect repellant (DEET) antibiotic for diarrhea sunscreen allergy meds oral re-hydration Note to self- laxative ﬁrst aid items wife’s migraine regimen!!! 9

I M M U N I Z AT I O N S http://blog.wired.com/photos/uncategorized/2007/03/26/syringe.jpg 10

IMMUNIZATIONS Review traditional Diptheria Rotavirus vaccine needs Tetanus Inﬂuenza national immunization Pertussis HPV program Measles Pneumococcal http://www.cdc.gov/ Mumps Meningococcal vaccines/ Rubella HIB Varicella Hepatitis A/B Polio 11

Recommended Adult Immunization Schedule, by Vaccine and Age Group · UNITED STATES OCTOBER 2006 – SEPTEMBER 2007 Age group 19–49 years 50–64 years >65 years L Vaccine L 1-dose Td booster every 10 yrs Tetanus, diphtheria, pertussis (Td/Tdap)1,* Substitute 1 dose of Tdap for Td Human papillomavirus (HPV)2 3 doses (females) Measles, mumps, rubella (MMR)3,* 1 or 2 doses 1 dose Varicella4,* 2 doses (0, 4–8 wks) 2 doses (0, 4–8 wks) Influenza5,* 1 dose annually 1 dose annually Pneumococcal (polysaccharide)6,7 1–2 doses 1 dose Hepatitis A8,* 2 doses (0, 6 –12 mos, or 0, 6 –18 mos) Hepatitis B9,* 3 doses (0, 1–2, 4–6 mos) Meningococcal10 1 or more doses *Covered by the Vaccine Injury Compensation Program. NOTE: These recommendations must be read with the footnotes (see reverse). For all persons in this category who meet the age Recommended if some other risk factor is requirements and who lack evidence of immunity present (e.g., on the basis of medical, (e.g., lack documentation of vaccination or have occupational, lifestyle, or other indications) no evidence of prior infection) This schedule indicates the recommended age groups and medical indications for routine administration of currently licensed vaccines for persons aged >19 years, as of October 1, 2006. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory Committee on Immunization Practices (www.cdc.gov/nip/publications/acip-list.htm). Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available at www.vaers.hhs.gov or by telephone, 800-822-7967. Information on how to file a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400. Additional information about the vaccines in this schedule and contraindications for vaccination is also available at www.cdc.gov/nip or from the CDC-INFO Contact Center at 800-CDC-INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week. Recommended Adult Immunization Schedule, by Vaccine and Medical and Other Indications · UNITED STATES OCTOBER 2006 – SEPTEMBER 2007 13

ADDITIONAL IMMUNIZATIONS Region focused immunization Belize 14

TYPHOID FEVER - 2 VACCINE OPTIONS oral Ty21a vaccine consists of four capsules, one taken every other day Must be completed one week prior to exposure Primary vaccination with ViCPS consists of one 0.5- mL (25-µg) dose administered intramuscularly. Must be completed two weeks prior to exposure 15

RABIES Pre-exposure vaccine- 3 doses, risk stratiﬁed administration choices Other prevention tips for patient example? 16

HEPATITIS A/B Hepatitis A (required worldwide except NA, Japan, Australia, NZ, and “developed” Europe)- Vaccine , also Ig available schedule based on vaccine brand/type HAVRIX 0,6 - 12 VAQTA 0, 6 - 18 17

HEP A CDC.gov Immunity conferred at 4 weeks after ﬁrst dose of vaccine in 96-100% of patients 18

HEP B Hepatitis B (Africa, Southeast Asia, Middle East, South and Western Paciﬁc Islands, interior Amazon River Basin, Haiti, Dominican Republic) Schedule- 0-1- 6 mos 19

COMBINED HEP A/B OPTIONS Combined vaccine - TWINRIX (A/B) accelerated schedule 0, 7, 21 days 20

PICK A BAG TO BOARD PLANE 21

M E D I C A L C A R E D U R I N G T R AV E L 23

MEDICAL COVERAGE ABROAD Concerns- Commercial insurance coverage spotty, lots of qualiﬁers possible pre-existing exclusions Medicare does not cover medical evacuations 24

DEATHS RELATED TO INTERNATIONAL TRAVEL Cardiovascular Medical Injury Homicide/Suicide Infectious Disease Other N = 2463 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626 25

INJURY DEATHS DURING INTERNATIONAL TRAVEL Motor Vechicle Drowning Air Crash Homicide/Suicide Poisoning Other N = 601 Hargarten S et al, Ann Emerg Med, 1991. 20:622-626 26

MEDICAL COVERAGE ABROAD Resources/Solutions US consolate Travel Insurance Evacuation companies JCAHO approved facilities 27

http://travel.state.gov/travel/tips/health/health_1185 International SOS www.internationalsos.com MEDEX www.medexassist.com policies, clinic access, evacuation/repatriation International Association for Medical Assistance for travelers www.iamat.org free membership- providor network - english speaking physicians 28

SPECIFIC DISEASE TOPICS http://www.fehd.gov.hk/safefood/library/fphposter/je_df.html 29

TRAVELER’S DIARRHEA 30-50% of travelers to affected regions Fairly abrupt onset Loose, watery, or semi- formed stools gaseousness abdominal cramping dantastisk- ﬂickr.com vomiting 30

TRAVELER’S DIARRHEA Self Limited course 3-4 days high fevers/dysentery- suggest further eval 31

TRAVELER’S DIARRHEA POTENTIAL COMPLICATIONS High Fever/Dysentery- falls out of “typicality” Postinfectious complications Reactive arthritis GBS Post Infectious IBS (up to 3% of TD patients) 32

TRAVELER’S DIARRHEA PREVENTION good food/drink choices (!street vendors) Pepto-Bismol 2 tablets QID (40%>14%) ﬂouroquinolones - not CDC guideline appr. campylobacter resistance increasing (Thailand + Nepal) Peterrieke-ﬂickr.com 33

TRAVELER’S DIARRHEA TREATMENT antibiotics- cipro, levaquin (3Days) azithromycin- useful in allergies or ﬂouroquinolone resistance Bismuth SS - 1oz/2 tablets Q 30 min for 8 doses loperamide - antimotility rehydration 34

PROTOZOA Giardia intestinalis- metronidazole, tinidazole, nitazoxanide cryptosporidiosis- nitazoxanide, if needed (self limited) cyclosporiasis - Bactrim amebiasis- ﬂagyl, then luminal agent- iodoquinol or paromomycin 35

WHO Oral Rehydration Solution Ingredient Amount Measurement NaCl 3.5g/L 1/2 tsp KCl 1.5 g/L 1 1/4 tsp Glucose 20 g/L 2 Tbsp NaHCO3 3 g/L 1/2 tsp H20 1.0 g 1 liter 36

DENGUE FEVER mosquito vector (Ae. aegypti)- avoidance primary deterrant sudden onset fevers, severe frontal HA, joint, muscle pain nausea, vomiting, maculopapular rash 3-5 days after fever 1% progress to dengue hemorrhagic fever (5% mortality) serological testing (IgG, IgM)- can cross react with other ﬂavivirus (west nile, yellow fever, japanese encephalitis) 0-5 days, then 6-30 days - CDC dengue center supportive care 37

YELLOW FEVER countries have included yellow fever immunization restrictions for entry Need to seek out Yellow Fever Vaccine clinic 38

MALARIA Highest prevalence around equator Cental/south america, Dominican republic and haiti, Africa, Asia, Eastern Europe, South Paciﬁc Fever, ﬂu symptoms, anemia, jaundice, CNS symptoms can occur 7 days after exposure, or months after chemo exposure 39

RED = Chloroquine- Resistant PINK - Chloroquine sensitive 40

CHEMOPROPHYLAXIS specific resistance confirmation of utmost importance mefloquine or chloroquine - 1-2 weeks prior to travel doxy, Malarone, or primaquine 1-2 days prior to travel continue 4 weeks after travel- chloro, meflo, doxy continue 7 days after travel - malarone, primaquine USE THE TOOLS FROM CDC 41

OTHER INFECTION NOTES 42

NON-INFECTIOUS TOPICS DVT/PE Jet Lag Motion Sickness Altitude illness Diving risk - diving-Air travel (wait 12 hours) 43

CRUISE SHIP ILLNESSES Norovirus Clostridium Perfringens salmonella Cyclospora enterotoxigenic e. Coli Trichinella Shigella Legionnaires Vibrio regional exposures Staph aureus 44

POST TRAVEL CARE review travel history, incubation periods, use of appropriate chemoprophylaxis Risk of malaria should be aggressively evaluated referral to ID/tropical medicine specialist may be required 45

POST TRAVEL MOST COMMONS GI illness 10% Skin Lesions/rashes 8% Resp infections 5-13% fever 3% 46

Resources for providers 47

primary care medical care for international travel

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