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  • Ask about traveler’s diarrhea rx
  • More sophisticated travelers are concerned with vaccines. Although many think that they only need to get “required” shots. Some realize that they need to get prescriptions. Few understand other risks.
  • 100,000 travelersto developing world x 1 month50% will develop a health problem8 % will need to see a physician1% will not be able to return to work50 will need to be air lifted out1 traveler will die
  • insurance
  • PLUG TCA:Forms make life much easier. We have on line forms that travelers complete before the visit.
  • More sophisticated travelers are concerned with vaccines. Although many think that they only need to get “required” shots. Some realize that they need to get prescriptions. Few understand other risks.
  • Almost as good a protection as an actual disease.Measles, rubella and YF 90-95% effective, mumps and varicella 80-85% effective within 2 weeks.
  • This is why it is improtant to administer live vaccines the same day or space them 4 weeks apart.
  • Grown in culture then inactivated with heat or chemicals. Inactivated vaccines are made either from the whole or a portion of the bacteria or virus or from its toxin. Therefore, the virus or the bacteria cannot replicate within the body. Can be given at any time. There is little cellular response and dosing must be repeated to boost immunity.
  • Influenza: year round in the tropics, April-Sept in the Southern Hemisphere, Nov-March in the Northern hemisphere. Tetanus: pediatric dose has more diphtheria and pertussis antigenMMR: live vaccinePolio: list of countries on CDC, boost once; and boost those who had polioPneumonia: single revaccination if more than 5 yrs for immunocompromised or competent if first dose is under 65Varicella: (1350 plaque units) disease of temperate climate and more prevalent in developing worldShingles: has 18,700-60,000 plaque unitsMANY WOULD INCLUDE HEPATITIS VACCINES but we will talk about these a little later.
  • Influenza: year round in the tropics, April-Sept in the Southern Hemisphere, Nov-March in the Northern hemisphere. Tetanus: pediatric dose has more diphtheria and pertussis antigenMMR: live vaccinePolio: NEXT SLIDElist of countries on CDC, boost once; and boost those who had polioPneumonia: single revaccination if more than 5 yrs for immunocompromised or competent if first dose is under 65Varicella: (1350 plaque units) disease of temperate climate and more prevalent in developing worldShingles: has 18,700-60,000 plaque unitsMANY WOULD INCLUDE HEPATITIS VACCINES but we will talk about these a little later.
  • We will talk about meningitis vaccine later because it is required only for pilgrimages.
  • Hemorrhagic fever arbovirus with monkey reservoir.
  • Immunity persists for probably 20 years
  • Dreaded complications which are very rare. Some countries require but vaccine may be recommended for other countries. Requirements change. Need to asses risk of disease vs risk from vaccine. YEL-AND: associated neurological disease, The onset of illness is3–28 days after vaccination, and almost all cases were in first-time vaccine recipients. YEL-AND is rarely fatal. The incidence of YEL-AND in the United States is 0.8 per 100,000 doses administered. The rate is higher in people aged ≥60 years, with a rate of 1.6 per 100,000 doses in people aged 60–69 and 2.3 per 100,000 doses in people aged ≥70 years.YEL-AVD: associated viscerotropic disease; severe illness similar to wild type; 0.4 cases per 100,000 doses of vaccine administered. The rate is higher for people aged ≥60 years, with a rate of 1.0 per 100,000 doses in people aged 60–69 years and 2.3 per 100,000 doses in people aged ≥70 years.
  • Prednisone 20mg or more and not intraarticular, topical, inhaled. If >1 month has passed since high-dose steroids (≥20 mg per day ofprednisone or equivalent for >2 weeks) have been used. However, aftershort-term (<2 weeks) therapy with daily or alternate-day dosing of ≥20 mgof prednisone or equivalent, some experts will wait 2 weeks beforeadministering measles vaccine.Can be given to younger children down to 6 m.o.
  •  
  • Hepatitis A: Can affect travelers on standard itineraries: the workershighly effective after 1 dose and can be given at any time prior to departure2 doses confer full immunity probably for lifeCDC “All susceptible people traveling for any purpose, frequency, or duration to countries with high or intermediate hepatitis A endemicity should be vaccinated or receive immunoglobulin (IG) before departure. Providers also may consider its administration to travelers to any destination. ”
  • Hepatitis BHepatitis B vaccination should be administered to all unvaccinated people traveling to areas with intermediate or high prevalence of chronic hepatitis B (hepatitis B surface antigen prevalence ≥2%). RisksSex: increased in travel as all risk takingTattoos, body piercing, injections, blood transfusions
  • Typhoid fever is an acute, life-threatening febrile illness caused by the bacterium Salmonella enterica serotype TyphiHumans are the only source of these bacteria;Both typhoid vaccines protect 50%–80% of recipients;Oral: Vivotif: live attenuated; 6y.o. and olderInjectable: Typhim Vi 2 y.o. and older
  • Menveo and Menactra are for 2-55protect against meningococcal disease caused by serogroups A, C, Y, and W-135. Approximately 7–10 days are required after vaccination for development of protective antibody levels. Travelers may need boosters every 3 yearsMenomuneis licensed for use among people aged ≥2 years but can be given to younger if needed
  • O, 3 days with PrEP0,3, 7, and 14 after the first vaccination. RIG should not be given >7 days after the start of the postexposure vaccine series. Human RIG is manufactured by plasmapheresis of blood from hyperimmunized volunteers. The manufactured quantity of human RIG falls short of worldwide requirements, and it is not available in many developing countries. Equine RIG or purified fractions of equine RIG have been used effectively in some developing countries where human RIG might not be available. If necessary, such heterologous products are preferable to no RIG.
  • Human RIG is manufactured by plasmapheresis of blood from hyperimmunized volunteers. The manufactured quantity of human RIG falls short of worldwide requirements, and it is not available in many developing countries. Equine RIG or purified fractions of equine RIG have been used effectively in some developing countries where human RIG might not be available. If necessary, such heterologous products are preferable to no RIG.
  • 16 y.o.
  • Malaria: choice of rx: resistance in certain parts of the world (THAILAND), doxy because of ricketsial infections; cost/contraindications/pregnancyDoxycycline also can prevent some additional infections (e.g., Rickettsiae and leptospirosis) and so it may be preferred by people planning to do lots of hiking, camping, and wading and swimming in fresh water
  • Malaria: choice of rx: resistance in certain parts of the world (THAILAND), doxy because of ricketsial infections; cost/contraindications/pregnancyDoxycycline also can prevent some additional infections (e.g., Rickettsiae and leptospirosis) and so it may be preferred by people planning to do lots of hiking, camping, and wading and swimming in fresh water
  • 80-85% bacteria10% parasites5% viral
  • Cipro resistance in Asia : campylobacterRifaximine can be used if not dysentery or invasive diseaseCan be used as prophylaxis
  • Cipro resistance in Asia : campylobacterRifaximin can be used if not dysentery or invasive diseaseCan be used as prophylaxis
  • HAPE HACE AMSAcute mountain sickness (AMS) affects up to 40% of travelers at moderate altitudes (up to 10,000 feet) and >50% of trekkers on popular high-altitude routes.
  • Acetazolamide (Diamox)—Acetazolamide has been shown to reduce susceptibility to AMS and the incidences of HAPE and HACE. This is the drug of choice for preventing AMS and is about 75% effective. Acetazolamide works through several mechanisms: (1) It forces the kidneys to excrete bicarbonate, acidifying the blood. Standard dosage: 125 to 250 mg every 12 hours, or 500 mg daily of the slow-release preparation (Diamox-SR). Start acetazolamide 24 hours before starting your ascent and continue it for 3 days at the higher altitude. Side effects include frequent urination (polyuria) and a tingling sensation of the face and lips (paresthesia).
  • More sophisticated travelers are concerned with vaccines. Although many think that they only need to get “required” shots. Some realize that they need to get prescriptions. Few understand other risks.
  • Video
  • Recommendations constantly change
  • Recommendations constantly change
  • Recommendations constantly change
  • Northern Ghana but not in Dec thru May
  • No YFNot a meningitis belt
  • No YFNot a meningitis belt
  • Ask about traveler’s diarrhea rx
  • Ask about traveler’s diarrhea rx

Transcript

  • 1. TRAVEL MEDICINE PLUSES AND MINUSESAlla Kirsch, MDCertificate in Travel HealthPresident and Medical Director at Travel Clinics of AmericaFamily physician in private practice in Cleveland, Ohiowww. TravelClinicsof America.comAKirsch@TravelClinicsofAmerica.com
  • 2. Hypothetical Cases 52 y.o. healthy businessman  Leaving for Ghana in 10 days  Staying for 5 days in 5-star hotel  No immunizations since childhood 20 y.o. healthy woman  Leaving in 6 weeks for India where she was born  Staying with family in rural India for 2 months  Has been in the U.S. for 15 years  Immunizations are up to date
  • 3. ObjectivesIntroduction to Travel Medicine  Emphasis on immunizations  Prescriptions and traveler education  The business of travel medicine  Resources and help  Discuss hypothetical cases
  • 4. Why? > 10 million U.S. residents per year  Businessmen  Tourists  Immigrants going home (VFR’s)  Students  Missionaries  Adoptions  Medical travel  Military
  • 5. Why? Many fail to get pre-travel care Rely on travel agents Important service to the community Interesting and healthy patients Lucrative if done properly
  • 6. Why?Care by untrained physicians No prescriptions Wrong prescriptions Inadequate vaccination Excessive vaccination No additional traveler education
  • 7. What is travel medicine? Risk Assessment Immunizations Prescriptions Advice on illness prevention Post-travel care
  • 8. Risks100,000 travelers to developing countries x 1 mo. 50% will develop a health problem 8 % will need to see a physician 1% will not be able to return to work 50 will need to be air lifted out 1 traveler will die
  • 9. Health Risks Traveler’s diarrhea 20-60% Respiratory infection 5-20% Malaria (without prophylaxis) 2% Hepatitis A 0.03-0.3% Animal bites with rabies risk 0.3%
  • 10. Pre-Travel ConsultationRisk Assessment: collect information Itinerary  Duration  Accommodations  Season  Reasons for travel Medical information  Past medical history  Immunization history  Allergies  Special health needs e.g. pregnancy, children
  • 11. What is travel medicine? Risk Assessment Immunizations Prescriptions Advice on illness prevention Post-travel care
  • 12. Vaccines Live attenuated vaccines Inactivated Vaccines
  • 13. Live Vaccines Attenuated (weakened) form of wild, or disease causing, virus or bacterium Must replicate in the body to produce immune response Infer an immune response similar to natural infection Usually effective with one dose within 2 weeks, except oral vaccines
  • 14. Live Vaccines Viral  Measles, mumps, rubella  Varicella  Oral polio  Influenza (intranasal)  Rotavirus  Yellow fever  Small pox (vaccinia) Bacterial  Oral typhoid  BCG
  • 15. Live Vaccines Precautions Contraindicated in certain groups Circulating antibody can interfere with immune response Fragile and must be stored carefully; damage from heat and light Severe reactions can occur
  • 16. Inactivated Vaccines Cannot replicate Require multiple doses Antibody titer wanes with time because response is humoral not cellular Little interference from circulating antibodies
  • 17. Inactivated Vaccines Whole cell  Viral  Hepatitis A  Influenza  Polio  Rabies  Bacterial  Typhoid  Cholera  Plague  Pertussis Fractional (accelular, recombinant)  Viral  Hepatitis B  HPV  Bacterial  Acellular pertussis  HIB Toxoids  Diphtheria  Tetanus
  • 18. Vaccine Timing Can be given on the same day Separate live vaccines by 28 days PPD on same day or in 28 days if given live vaccines Boosters: no need to restart series except oral typhoid Do not given earlier than scheduled (4- day grace period) Immunoglobulin cannot be given with live vaccines but ok with inactivated
  • 19. Vaccines for TravelDecision depends • International requirements • Efficacy of vaccine • Severity of disease • Cost of vaccine • Risk the traveler
  • 20. Pre-Travel ConsultationImmunizations: Provider recommends Ultimate decision is with the traveler
  • 21. Vaccines for Travel• Routine• Required• Recommended
  • 22. Routine Influenza Tetanus (Tdap vs Dtap) MMR Polio Pneumonia Varicella HPV Shingles
  • 23. Polio Boosters Are Recommended forTravelers Visiting the Following Countries: Afghanistan Djibouti Nepal Angola Equatorial Guinea Niger Armenia Eritrea Nigeria Azerbaijan Ethiopia Pakistan Bangladesh Gabon Russia Benin Gambia Rwanda Bhutan Georgia Senegal Burkina Faso Ghana Sierra Leone Burundi Guinea Somalia Cameroon Guinea-Bissau Sudan and South Central African India Sudan Republic Iran Tajikistan Chad Kenya Tanzania China Kazakhstan Togo Congo Kyrgyzstan Turkmenistan Côte d’Ivoire Liberia Uzbekistan Democratic Mali Uganda Republic of the Mauritania Zambia Congo (DRC) Namibia http://wwwnc.cdc.gov/travel/notices/in-the-news/polio- outbreaks.htm
  • 24. Routine Influenza Tetanus (Tdap vs Dtap) MMR Polio Pneumonia Varicella HPV Shingles
  • 25. Required Vaccines Yellow fever Meningitis  Saudi Arabia requirement  Hajj pilgrimage
  • 26. Yellow Fever Disease Disease:  Hemorrhagic fever  Spread by mosquitoes  Africa and South America  Rural disease
  • 27. YF vaccine Live vaccine Efficacy 98-99% Mandated by WHO Approved YF vaccine centers Yellow Card (International Certificate of Vaccination and Immunization) Interval every 10 yrs per international rules 10 days before arrival
  • 28. Yellow Fever Vaccine Adverse reactions  Mild  YEL-AND  YEL-AVD
  • 29. YF vaccine Contraindications and precautions to yellow fever vaccine administrationCONTRAINDICATIONS Allergy to vaccine component Age <6 months 3 Symptomatic HIV infection or CD4 T-lymphocytes <200/mm (or <15% 1 of total in children aged <6 years) Thymus disorder associated with abnormal immune-cell function Primary immunodeficiencies Malignant neoplasms Transplantation Immunosuppressive and immunomodulatory therapiesPRECAUTIONS Age 6–8 months Age ≥60 years 3 Asymptomatic HIV infection and CD4 1 T-lymphocytes 200–499/mm (or 15%–24% of total in children aged <6 years) Pregnancy Breastfeeding Source: http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/yellow-fever.htm
  • 30. Recommended Travel Vaccines Hepatitis A Hepatitis B Typhoid Meningitis Rabies Japanese Encephalitis
  • 31. Hepatitis A• Risks: fecal oral route•All unvaccinated travelers toany destination for anypurpose• Schedule: •0 and 6 mo.“All susceptible people traveling for any purpose, frequency, or durationto countries with high or intermediate hepatitis A endemicity should bevaccinated or receive immunoglobulin (IG) before departure. Providersalso may consider its administration to travelers to any destination. ”CDC
  • 32. Hepatitis B• Risks: body fluids•All unvaccinated travelers tohigh risk areas• Schedules: •0, 1 and 6 mo. •0, 1, 3 wks and 12 mo.“Hepatitis B vaccination should be administered to all unvaccinatedpeople traveling to areas with intermediate or high prevalence ofchronic hepatitis B (hepatitis B surface antigen prevalence ≥2%).” CDC
  • 33. Combined Hepatitis A & B Twinrix Schedules: • 0, 1 and 6 mo. • 0, 1, 3 wks and 12 mo.
  • 34. Typhoid Life-threatening febrile illness Risks: fecal-oral route
  • 35. Typhoid Vaccine Oral  Vivotif  Live attenuated  6 y.o. and older  Effective for 5 yrs Injectable  Typhim Vi  Inactivated  2 y.o. and older  Effective for 2 yrs
  • 36. Meningitis Serious disease Sub-Saharan Africa meningitis belt Highest risk: dry season Dec-June Required: Hajj every 3 yrs
  • 37. Meningitis Vaccine Vaccines  Conjugate (MenACWY) (Menveo and Menactra)  Polysaccharide (MPVS4) (Menomune)
  • 38. Rabies Risks  Mammals  Bats  Children  No pet immunization Fatal disease Pre-exposure schedule (PrEP) 0, 7, 21-28d
  • 39. Rabies Vaccine Post –exposure w/PrEP  2 boosters  0, 3 days  No RIG Post –exposure  RIG ASAP  4 shots in immunocompetent  0,3,7 and 14 days  5 shots in immunocompromised  0,3,7,14 and 28 days
  • 40. Rabies Vaccine RIG  $$$$  Difficult to find  Needs to be given ASAP but no longer than 7 days after starting post-exposure series
  • 41. Japanese Encephalitis Vaccine• Very rare in travelers• Rural, mosquito borndisease• Only Ixiatro available now• 2 shots 28 days apart• Booster in 1 yr if at risk
  • 42. What is travel medicine? Risk Assessment Immunizations Prescriptions Advice on illness prevention Post-travel care
  • 43. Prescriptions Malaria prophylaxis Traveler’s diarrhea Altitude illness
  • 44. Malaria Transmitted by infected female Anopheles mosquitoes Sxs develop 2 weeks to 1 year after the bite Sxs: fever, h/a, myalgias, anemia, ARF
  • 45. Malaria Prophylaxis Vaccine Avoidance of bites  Repellents with DEET  Permethrin  Clothing  Netting Medications
  • 46. Malaria Prophylaxis Atovaquone/Proguanil (Malarone)  Yes: well tolerated, daily, 7 days post travel  No: $$$, pregnancy Mefloquine (Larium)  Yes: $$, weekly, pregnancy  No: psychiatric, CV, seizures, resistance, late plans Doxycycline  Yes: $, daily, other infections  No: pregnancy, children < 8 y.o, sun, yeast inf., GI Chloroquine  Yes: weekly, pregnancy  No: resistance, psoriasis, late plans
  • 47. Traveler’s Diarrhea Up to 60% risk for 2 wk travel 10% IBS 80% bacterial Campylobacter resistance in Asia
  • 48. Traveler’s DiarrheaPrevention  Hand hygiene  “Boil it, peel it, or forget it” easy to teach but impossible to doTreatment  Fluids  Loperamide (Imodium)  Pepto-Bismal  Antibiotics
  • 49. Traveler’s Diarrhea Antibiotics  Ciprofloxacin  Azithromycin  Rifaximin
  • 50. Altitude Illness 40-50% risk at over 8, 000 feet Altitude illness  AMS- acute mountain sickness  HAPE- high altitude pulmonary edema  HACE- high altitude cerebral edema
  • 51. Altitude Illness AMS sxs  H/a  Fatigue  Nausea  Insomnia  Dizziness Prophylaxis  Acetazolamide (Diamox) 125mg BID
  • 52. What is travel medicine? Risk Assessment Immunizations Prescriptions Advice on illness prevention Post-travel care
  • 53. Advice on illness prevention Accidents number #1 risk Crime Food and water risks Bites: insects, snakes, animals Fresh water swimming DVT’s Temperature extremes Evacuation insurance
  • 54. Resources Center for Disease Control (CDC) World Health Organization (WHO) The Immunization Action Coalition U.S. Department of State International Society of Travel Medicine  Certificate in Travel Health Paid subscriptions ( e.g. TravelCare)
  • 55. Business of Travel Medicine Knowledge  Learn travel medicine: ISTM, alone, TCA  New developments Mechanics  Yellow fever vaccine center  Vaccine buying, storing  Forms  Educational materials
  • 56. Business of Travel Medicine Generating Income  Business models  Insurance:  Money lost on vaccines  No insurance:  Fair mark-up on vaccines  Paid for the consult  Becomes a cash practice add-on  Must market to be successful
  • 57. Business of Travel Medicine Adding travel medicine to a practice options:  Do it alone  Steep learning curve  Significant time and possibly money expenditure  Buy a franchise  $25-100,000 to purchase  Join the only Independent physicians’ network  Travel Clinics of America  $495 to join  Includes  CME education  Business set up  Vaccine discounts  Marketing  Accounting
  • 58. Case #1 52 y.o. healthy businessman  Leaving for Ghana in 10 days  Staying for 5 days in 5-star hotel  No immunizations since childhood
  • 59. Case #1: CDChttp://wwwnc. cdc.gov/travel/destinations/ghana.htm
  • 60. Case #1: CDC Recommendations or Vaccination or Disease Requirements for Vaccine- Preventable DiseasesRoutine Recommended if you are not up- to-date with routine shots, such as measles/mumps/rubella (MMR) vaccine, diphtheria/pertussis/tetanus (DPT) vaccine, poliovirus vaccine, etc. Our traveler: MMR, Tdap, flu
  • 61. Case #1: CDCHepatitis A or immune globulin Recommended for all(IG) unvaccinated people traveling to or working in countries with an intermediate or high level of hepatitis A virus infection (see map) where exposure might occur through food or water. Cases of travel-related hepatitis A can also occur in travelers to developing countries with "standard" tourist itineraries, accommodations, and food consumption behaviors.Our traveler: Hepatitis A
  • 62. Case #1: CDCHepatitis B Recommended for all unvaccinated persons traveling to or working in countries with intermediate to high levels of endemic HBV transmission (see map), especially those who might be exposed to blood or body fluids, have sexual contact with the local population, or be exposed through medical treatment (e.g., for an accident).Our traveler: short but frequenttravel: encourage Hepatitis B
  • 63. Case #1: CDCTyphoid Recommended for all unvaccinated people traveling to or working in West Africa, especially if staying with friends or relatives or visiting smaller cities, villages, or rural areas where exposure might occur through food or water.Our traveler: not enough time; noTyphoid vaccine
  • 64. Case #1: CDCPolio Recommended for adult travelers who have received a primary series with either inactivated poliovirus vaccine (IPV) or oral polio vaccine (OPV).Our traveler: Polio
  • 65. Case #1: CDCYellow Fever Requirements: Required upon arrival for all travelers ≥9 months of age.Our traveler: Yellow fever
  • 66. Case #1: CDCMeningococcal (meningitis) Recommended if you plan to visit countries that experience epidemics of meningococcal disease during December through June (see map).Our traveler: offer Meningitis
  • 67. Case #1: CDCRabies Recommended for travelers spending a lot of time outdoors, especially in rural areas… Our traveler: No rabies vaccine
  • 68. Case #1 Prescriptions  Antimalarial  Self-rx for traveler’s diarrhea EducationOur traveler: Rx: Malarone, Cipro Discussion or TCA video
  • 69. Case #2 20 y.o. healthy woman  Leaving in 6 weeks for India where she was born  Staying with family in RURAL India for 2 months  Has been in the U.S. for 15 years  Immunizations are up to date
  • 70. Case #2 For India  Required: none  Routine: Tdap, MMR. polio, flu  Recommended: hep A, hep B, typhoid, rabies, Japanese encephalitis
  • 71. Case #2 Our traveler  Routine:  Tdap: had before college  MMR: had x 2  polio  influenza  Recommended:  hep A: had one dose 2 yrs ago  hep B: had as a child  typhoid  rabies: pt refuses because of $; document  Japanese encephalitis: pt refuses because of $
  • 72. Case #2 Prescriptions  Antimalarial  Self-rx for traveler’s diarrhea Education: DEET, DVT, food & waterOur traveler: Rx: doxycycline, Cipro Discussion or TCA traveler ed video
  • 73. Complexities Pregnant Young Old Immunosupressed Complicated PMH Long term travelers Multiple destinations VFR’s (Visting Friends and Relatives) Last minute travel
  • 74. Why you should consider TM: Important service to the community Interesting, healthy, fun patients Lucrative if done properly Do it alone or get help such asTravel Clinics of America
  • 75. Contact information:Alla Kirsch, MDAKirsch@TravelClinicsofAmerica.comwww. TravelClinicsof America.com