1. TRAVEL MEDICINE
PLUSES AND MINUSES
Alla Kirsch, MD
Certificate in Travel Health
President and Medical Director at Travel Clinics of America
Family physician in private practice in Cleveland, Ohio
www. TravelClinicsof America.com
AKirsch@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. Objectives
Introduction 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. Risks
100,000 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 Consultation
Risk 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 Travel
Decision depends
• International requirements
• Efficacy of vaccine
• Severity of disease
• Cost of vaccine
• Risk the traveler

20. Pre-Travel Consultation
Immunizations:
 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 for
Travelers 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 administration
CONTRAINDICATIONS
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 therapies
PRECAUTIONS
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 to
any destination for any
purpose
• Schedule:
•0 and 6 mo.
“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. ”
CDC

32. Hepatitis B
• Risks: body fluids
•All unvaccinated travelers to
high risk areas
• Schedules:
•0, 1 and 6 mo.
•0, 1, 3 wks and 12 mo.
“Hepatitis 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%).” 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 born
disease
• 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 Diarrhea
Prevention
 Hand hygiene
 “Boil it, peel it, or forget it” easy to teach
but impossible to do
Treatment
 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: CDC
http://wwwnc. cdc.gov/travel/destinations/ghana.htm

60. Case #1: CDC
Recommendations or
Vaccination or Disease Requirements for Vaccine-
Preventable Diseases
Routine 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: CDC
Hepatitis 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: CDC
Hepatitis 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 frequent
travel: encourage Hepatitis B

63. Case #1: CDC
Typhoid 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; no
Typhoid vaccine

64. Case #1: CDC
Polio 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: CDC
Yellow Fever Requirements: Required upon
arrival for all travelers ≥9 months
of age.
Our traveler: Yellow fever

66. Case #1: CDC
Meningococcal (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: CDC
Rabies 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
 Education
Our 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 & water
Our 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 as
Travel Clinics of America

75. Contact information:
Alla Kirsch, MD
AKirsch@TravelClinicsofAmerica.com
www. TravelClinicsof America.com