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141 Cards in this Set
- Front
- Back
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What is Travel Medicine (Emporiatrics)?
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• A subspecialty focusing on preventing the diseases/injuries likely to be encountered by travelers and caring for ill returning travelers.
• Risk assessment & Management • Traveler’s diarrhea prevention and treatment • Malaria prevention • Travel Vaccination • Other: |
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What is Travel Medicine?
Other: |
Other:
Altitude sickness Motion sickness Jetlag Safety issues Special needs travelers (VFR, Pregnancy, Infants, Diabetics) , Adoption, Medical evacuation |
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Travel Medicine Components
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• Traveler’s Diarrhea Prevention/Treatment
• Malaria Prophylaxis • Travel Vaccination |
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Travel Medicine Objectives
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Objectives
• Review the prevention and treatment of traveler’s diarrhea • Discuss non-pharmacologic and pharmacologic malaria prevention • Identify the indications for common travel vaccines |
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New CDC Yellow Book Features
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• Pre-Travel Consultation: risk assessment, risk communication, risk management
• Post-Travel Consultation • Select Destinations /Travel Itineraries • Infectious Diseases Related to Travel • Yellow Fever /Malaria Tables • Special Traveler Populations: Children, Special Needs, Immigrants/Refugees • Appendices: – A. Practice of Travel medicine – B. Electronic Resources – C. Travel Vaccine Summary Table |
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Watch Out For “VFR” Travelers
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• VFR = Visiting Friends and Relatives
• VFRs often spent childhood at destination so more comfortable with perceived risk (unfortunately, often a false sense of security) • Immunity to malaria and travelers diarrhea is quickly lost with residence in a developed country • VFRs as likely to get sick as a non-native—perhaps even more likely due to absence of precautions • VFR Travelers are unlikely to seek travel consultation, take malaria meds or use as much care with food selection • Much of the imported malaria in the U.S. is due to visits back home (may fail to take prophylaxis since malaria may have been less of an issue in their childhood). |
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Traveler’s Diarrhea
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Traveler’s Diarrhea
3+ unformed stools in 24 h with at least one of the following : fever N/V cramps tenesmus or bloody stools (dysentery) Occurs in up to 55% of travelers from a developed country visiting a less-developed country, usually within the first two weeks |
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Traveler’s Diarrhea should be distinguished from Transition Bowel!
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• It is normal when traveling to develop irregular bowel habits for a while –like irritable bowel syndrome—during adjustment
• No need to treat with antibiotics • May have loose stools or constipation, excess gas (w/o hydrogen sulfide smell) but these symptoms are not associated with illness • Unfamiliar spicy or high fiber foods may contribute to problem • Some change undoubtedly related to change in bacterial flora • True traveler’s diarrhea gives repeated bouts of loose stools and sense of being physically ill (cramping) • Post Travel IBS: many returning travelers with persisting diarrhea s/p TD also have IBS symptoms w/ negative culture and O&P • Parasitic infections, like giardia, also make the patient feel ill: gassy diarrhea, “eggy” or “purple” burp |
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T.D. Epidemiology
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• RISK FACTORS:
Gastric surgery Suppressed gastric acidity: H2 blockers Proton Pump Inhibitors Previous High Susceptibility |
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Traveler’s Diarrhea Microbiology BACTERIA:
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most TD is bacterial!
Enterotoxigenic E. coli (ETEC) #1 Salmonella (need lg inoculum) Shigella Campylobacter jejuni (some drug resist in Asia) Vibrio parahaemolyticus Yersinia |
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Traveler’s Diarrhea Microbiology VIRUSES:
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Rotavirus
Norovirus (cruise ships) |
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Traveler’s Diarrhea Microbiology PARASITES
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Giardia (gas, rotten eggs)
Entameba histolytica Cryptosporidium |
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Traveler’s Diarrhea Prevention Safe Food
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hot cooked foods,
fruits you peel yourself, carbonated beverages, beer, fresh bread |
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Traveler’s Diarrhea Prevention Unsafe food
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street vendor fare,
ice, salads, fruit you don’t peel yourself, uncooked vegetables, un-pasteurized dairy, tap water, pastry icing table condiments (e.g. guacamole) |
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Traveler’s Diarrhea Prevention
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“Boil It, Cook It, Peel It or Forget It”
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Traveler’s Diarrhea Active Intervention:
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treatment of food/ water
Food disinfection by cooking, boiling, baking Avoid contamination after cooking—eat while hot |
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Traveler’s Diarrhea Prophylaxis
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• CDC doesn’t recommend TD prophylaxis except in unusual circumstances
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Reasons not to prophylax for TD with antibiotics:
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1.non-fatal self-limited illness for most
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Reasons not to prophylax for TD with antibiotics:
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2.provides false sense of security
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Reasons not to prophylax for TD with antibiotics:
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3.cost and toxicity of drugs
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Reasons not to prophylax for TD with antibiotics:
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4.resistance problem exacerbated
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Reasons not to prophylax for TD with antibiotics:
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5.effective therapy readily available
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When To Prophylax for T.D.
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Consider for those unable to afford 24-48 h illness e.g. high-profile speakers, 3d diving trip, diplomatic missions
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When To Prophylax for T.D.
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Consider for high risk patients e.g. immune compromised, leukemia, chronically ill, reduced gastric acid
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Traveler’s Diarrhea Treatment: “Poo Pack”
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Loperamide hydrochloride (Imodium A/D) 2 mg
Adults: one after each loose stool (max: 8 mg/d) for symptom relief but avoid with dysentery! You do not wish to slow the bowel with an invasive organism. Stop in 48h if ineffective. Avoid in Children (esp. if <6y). |
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Traveler’s Diarrhea Treatment: “Poo Pack”
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ADD ANTIBIOTIC IF ILL BUT ONLY A SINGLE DOSE IS USUALLY NEEDED (Stop when diarrhea stops!):
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Rifaximin (Xifaxan)
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• Broad-spectrum nonabsorbable Rifamycin-derivative for travelers’ diarrhea caused by non-invasive E.coli
• Approved by FDA for patients 12 years of age or older (5/25/04)—marketed Autumn 2004 • Non-systemic: treats only GI tract (<.4% absorbed) so less likely to cause drug reactions, interactions • Side effects similar to that of placebo (flatulence 11%), HA (9.7%), abdominal pain (7%) , tenesmus (7%) • Safe, no clinically significant resistance • Rifaximin 200mg TID x 3d equally effective to Cipro regimen but recommend completion of course. • Not for diarrhea w/ fever or blood in stool or diarrhea from other pathogens; discontinue if diarrhea persists > 24-48h |
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Persistent Diarrhea (> 7 days)
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• Sometimes diarrhea persists in spite of Cipro Rx
• Possible antibiotic (quinolone) resistance, esp. SE Asia and India where azithromycin is better 1st choice (quinolone-resistant Campylobacter in Thailand) • Parasitic infections (Ameba, Giardia) respond to metronidazole or tinidazole 2g or nitazoxanide • Cryptosporidia diarrhea: self-limited 7-14d if healthy; Rx Nitazoxanide (Alinia) approved for children ages 1-11 and adults • Pseudomembranous Colitis Rx metronidazole • R/O Inflammatory Bowel Disease, Immunosuppression |
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Nitazoxanide (Alinia)
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• Indications: diarrhea due to Giardia or Cryptosporidium parvum
• Adults: 500 mg q 12h x 3d taken w/ food • Pediatric: 1-3y: 100 mg q 12h w/ food x 3d, 4-11 y: 200 mg q 12h w/ food x 3d • Available as suspension 100 mg/5ml (60 ml) or 500 mg adult tablets • Side effects: GI upset, anorexia, HA, dizziness, eye/urine discoloration, increased creatinine/ALT |
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Tinidazole (Tindamax)
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• Indications: Giardiasis, Intestinal amebiasis and amebic liver abscess
• Preferred over metronidazole as better tolerated and shorter course • Good second-line diarrhea drug if antibiotics don’t work • Giardiasis: adult 2g single dose; pediatric >3y 50 mg/kg (max:2g) single dose • Amebiasis: adult 2g qd x 3d; pediatric >3y 50 mg/kg/d (max:2g) x 3d (3-5 d for liver abscess) • Like metronidazole, has the advantage of treating pseudomembranous colitis caused by Clostridium difficile (often from excessive use of antibiotics) • Available as 250 mg and 500 mg tablets • Must avoid alcohol during and 3d after use; avoid 1st TM • Potentiates oral anticoagulants, lithium, phenytoin • Side effects: GI upset, abdominal pain, metallic taste, anorexia, constipation, dizziness, HA, transient leukopenia Rare: seizures, peripheral neuropathy, contraindicated in breast feeding |
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Pediatric Traveler’s Diarrhea
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• Risk greatest <3y (31% attack rate in first 2 weeks travel) and young children get sicker and take longer to recover
• Increase breast feeding frequency but decrease duration—no bowel rest • Consider lactobacillus Rx–helpful in rotavirus trials but unclear for TD • Treat diaper dermatitis with A+D w/ zinc ointment or Aquaphor • Is there fever? Remember malaria and meningitis may also present w/ diarrhea in children |
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Malaria Prevention in Travelers
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• Malaria risk greater than ever: up to 30,000 world travelers infected/year—over 1000/yr in U.S.A.
• #1 life-threatening infectious disease for travelers: 4% -20% mortality P. falciparum • Risk greatest in Africa (W>E) and Oceania (PNG, Solomons) • Global Resurgence due to chloroquine-resistant P. falciparum (CRPF) and mosquito resistance to insecticides |
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Problems in Malaria Prevention
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• Malaria risk greater than ever: up to 30,000 world travelers infected/year—over 1000/yr in U.S.A.
• #1 life-threatening infectious disease for travelers: 4% -20% mortality P. falciparum • Risk greatest in Africa (W>E) and Oceania (PNG, Solomons) • Global Resurgence due to chloroquine-resistant P. falciparum (CRPF) and mosquito resistance to insecticides |
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Pre-Travel Malaria Counseling Goals
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• Identify high risk travelers by itinerary
• Identify appropriate prophylaxis option by patient characteristics and region to be visited—benefits should outweigh risk • Recommend insect repellents and treated bed nets to prevent bites • Ensure best medical option both affordable and tolerable, and directions for its use are well understood—esp. need to continue when back home • Coach about importance of early diagnosis and treatment if febrile illness occurs after exposure |
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Chloroquine (Aralen): Central America, Haiti
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• 500 mg (300 mg base) once weekly starting one week prior to departure and continuing x 4 weeks after return
• Reliable only in Central America, Hispaniola (Haiti), Mid-East —elsewhere varying degrees of resistance • Inhibits heme polymerase • Side effects: GI upset, itching (esp. blacks), psoriasis exacerbation, intradermal HDCRV interference, safe for retina at prophylactic doses (avoid if diseased) • Safe in pregnancy; avoid with seizures, retinopathy • Pediatric dosing based on 5mg/kg base weekly (6.3mg/kg salt) • Dangerous to children in overdose; Nivaquine syrup 6mg/ml available outside U.S. • Resistance mostly in P. falciparum—but also P. vivax in Indonesia/PNG and increasing worldwide |
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Mefloquine (Lariam): best long-term option
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• CDC’s recommendation for most areas with CRPF; resistance in Thai border areas (rare elsewhere)
• Dose: 250 mg weekly starting one week prior to travel, weekly in area of risk and weekly x 4 weeks afterwards (half-life 21d) # = wks+5; convenient for long trips • Cost: $10/tab but most effective (95%) in E. Africa • Side effects: vivid dreams, insomnia, GI upset (take with water), dizziness, seizures, panic, hallucinations, cardiac conduction problems • Contraindications: avoid in seizure disorders, past history of psychosis or depression, cardiac conduction defects (avoid use w/ quinine, quinidine, halofantrine)—beta-blockers and calcium channel blockers now ok; avoid in pilots unless tolerance already “proven” • Relative Contraindications: 1st trimester pregnancy (ok 2nd, 3rd TM w/consent), airline pilots or tasks involving fine motor coordination, infants (<5 kg?) • Many refuse it out of fear of neuropsychiatric reactions! Especially Europeans |
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Mefloquine Neuro-Psych Scare
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• Myth: mefloquine causes severe side effects in most users [although up to ¼ said to have at least a few psych effects in 2/02 Consumer Reports issue]
• Screen carefully for past depression, panic, psychosis • Vivid dreams, insomnia common • Severe neuropsych reactions (hallucinations, psychosis) are rare at weekly dose but definitely may occur with treatment doses • Women more at risk (2x?) despite similar serum levels • 75% of adverse reactions occur within first 3 doses so it is reasonable to try 2-3 weeks ahead of departure |
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Primaquine phosphate (PQ)
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• “Causal” Anti-malarial: eradicates liver hypnozoite phase of P. vivax and ovale, preventing later relapses— “eliminates cause.”
• Alternative trip prophylaxis: Primaquine 0.5 mg base/kg (30 mg base) daily during trip and for 1 week post return; take w/ food; 85-95% effective (non-approved in U.S. but recommended by CDC as alt. option if others can’t be used) • Terminal prophylaxis: 30 mg base (two 15 mg tabs) qd x 14 d • Option for long-term higher risk residents returning after probable P.vivax exposure—will prevent relapse • Terminal treatment of P. vivax/ovale also—same dose as above • Must R/O G6PD deficiency before use (hemolysis risk); avoid in pregnancy since fetus can’t be tested for G6PD • Tafenoquine 100-400mg weekly (load 400mg/d x 3d) is a primaquine-related drug w/ great potential for weekly chemoprophylaxis—same restrictions apply |
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“Causal” Antimalarials
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• Get at the root “cause” of malaria: the early liver stage (after the sporozoite enters the liver but before the “blood stage” starts)
• Primaquine and Tafenoquine can eradicate early liver malaria and also kill the persistent hypnozoites of P. vivax and ovale (only primaquine is currently approved for terminal treatment/prophylaxis)—ideally used w/ chloroquine to cover any blood stage parasitemia • Malarone (atovaquone/proguanil) will eradicate early liver malaria but won’t kill vivax and ovale hypnozoites • Although causal anti-malarials are recommended for 7 days after exposure stops, as little as 3 days may be sufficient |
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Malaria Self Treatment Options
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• If > 24h from medical care with fever 38+C, consider stand-by self-administered anti-malarial Rx (different from what is already being used as chemoprophylaxis)
• Must continue prophylactic regimen (if any) and get medical care ASAP • Malarone (atovaquone/proguanil) usual best choice!: 4 tabs daily (2 tabs 2x/d w/ food) for 3 days • Fansidar (pyrimethamine-sulfadoxine) 3 tabs no longer reliable due to resistance problems (?obsolete) • Lariam (mefloquine) 250 mg 3 tabs followed 12h later by 2 tabs or 1250 mg in 24H –frequent neuropsychiatric problems at treatment dose • Overseas: Coartem or Riamet (artemether/lumefantrine) or LapDap (chlorproguanil/dapsone) are new African self-treatment options—not licensed or available in U.S. |
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Standard Self-Treatment of Uncomplicated Malaria 2010
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• Chloroquine Sensitive : Chloroquine 600 mg base , 300 mg 6h later, 300 mg qd for next 2d (Central America, Haiti parts of Mid-East only) #5
• Chloroquine Resistant: Malarone (atovaquone/proguanil) 2 tabs bid x 3 d (#12)—use alternative Rx if already taking Malarone for prophylaxis • Vivax / Ovale Terminal Treatment: Primaquine 30 mg base (two 15 mg tablets) q d x 14 d |
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Overseas Malaria Prophylactic Regimens often recommended locally but less effective or problematic
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• Maloprim (not the same as Malarone!)
• Proguanil (daily)/Chloroquine (weekly) • Chloroquine in chloroquine-resistant areas • Homeopathic Anti-Malarials e.g. Demal 200 (Blue Turtle Pharmaceuticals) unproven • Artemisinin tea or pharmaceutical derivatives (insufficient half-life) • Papaya leaf tea (unproven) |
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Maloprim or Deltaprim
Pyrimethamine [aka Daraprim] 12.5 mg and Dapsone 100mg combination |
• Weekly prophylaxis regimen overseas GlaxoSmithKline UK
• Used for affordable malaria prevention in many developing countries • Not available or approved in U.S. (withdrawn in Europe 1988 due to hematological side effects) but still widely recommended in Africa • Dapsone may cause agranulocytosis, thrombocytopenia in susceptible patients—monitor CBC regularly if used • Maloprim ay be easily confused with Malarone (atovoquone/proguanil) |
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Proguanil (Paludrine) w/ Chloroquine
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• Proguanil 200mg daily plus weekly chloroquine 300 mg base (w/ 4 wk tail) is a popular British regimen for Africa but is less effective than other agents
• Now less effective even in W. Africa and no longer recommended by CDC as no more effective than treated bed nets (about 50% protection)—should be phased out • Proguanil is unavailable in U.S. • Savarine is fixed chloroquine 100mg /proguanil 200 mg French combination taken daily • Safe in Pregnancy (B) but less effective –best given w/ folate • Side effects: GI upset, mouth ulcers • Mechanism: dihydrofolate reductase inhibitor |
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Malaria Prevention Conclusions
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• No regimen guarantees 100% protection against malaria so avoid mosquito bites
• Malaria ABCs A: Be aware of malaria risk; B: Avoid being bitten; C: Take chemoprophylaxis; D: Seek diagnosis /treatment if fever develops 1 week or more after entering risk area and up to 3m (falciparum) or 1 year (other species) after departure. • Mefloquine: best for long trips and pregnancy; neuropsychiatric issues hinder its use • Malarone: best option for short-term travel; $ • Overseas, ignore advice re regimens there |
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TRAVEL VACCINATION
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• Safe, effective way to reduce morbidity from travel diseases
• Contact with unvaccinated population = loss of “herd” immunity and increased disease risk • Procrastination a major problem: ideally see patients 1+ month before travel • Often not covered by insurance • Three vaccine categories: recommended, required and routine |
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Live Vaccines
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Avoid in immunocompromised patients and in pregnancy
Give together or 4 weeks apart |
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LIVE VACCINE LIST
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• Measles-Mumps-Rubella (MMR)
• Flu-Mist • Oral Typhoid (Vivotif Berna) • Varicella (Varivax) • Yellow Fever |
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Cholera USP Vaccine (off market)
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• Killed bacterial vaccine w/ bad local reactions
• Vibrio cholera El Tor strain: 50 % effective x 6 months ( ineffective against Asian Bengal strain) NO LONGER AVAILABLE U.S. • Series: two .5 ml doses IM 1 wk-1m apart (0, 1) • Boost every 6 months • Cholera vaccines no longer required by WHO ( rarely requested at border crossings in central Africa but not formally required) • Most travelers don’t need—consider newer cholera vaccines only for refugee camp workers and those w/ known high risk • Avoid giving within 3 weeks of Yellow Fever |
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Oral Cholera Vaccine: 2 choices outside of U.S. (available in Canada)
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• Mutacol (live oral cholera vaccine CVD-HgR) available in Canada, Europe, Latin America
– Single oral dose live attenuated cholera vaccine-but only for travelers at risk • Dukoral (oral beta-subunit cholera vaccine) two dose killed vaccine also protects against traveler’s diarrhea secondary to ETEC (halves the risk). – Contains inactivated Vibrio cholerae bacteria serogroup 01 and recombinant cholera toxin B subunit (part of toxin) – Children 2-6 need 3 doses; adults/older kids need 2 doses – Add granules to 150 ml water (discard half for children 2- 6) and then add vaccine suspension, drink on empty stomach – Doses 1-6 weeks apart (at least a week prior to going) – Boost every 2 years |
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Obsolete Japanese Encephalitis Vaccine
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Obsolete Japanese Encephalitis Vaccine
JE-Vax (Biken—Sanofi, Pasteur) Manufacture ceased 2005; Supplies to run out 2011 all stock has expired now • Three 1.0 ml SC doses: 0,7, 30d (0, 7, 14 d short course); formalin-inactivated mouse brain vaccine—last dose must be 10+ days before departure (delayed reactions) • 1ml > 3y, 0.5ml < 3y, avoid under 1 year of age • Risk of delayed urticaria (.6%), anaphalaxis, angioedema— observe for 30 min (10d access to care); Expensive at $100/shot ($300) contains thimerisol • Contraindications: urticaria hx, pregnancy, < 1yr age • May give booster dose after 2 years if risk indicates |
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New Japanese Encephalitis Vaccine: Ixiaro (made by InterCell/marketed by Novartis)
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New Japanese Encephalitis Vaccine: Ixiaro (made by InterCell/marketed by Novartis)
• Vero-cell culture inactivated vaccine to replace JE-Vax (approved March 2009) better tolerability • Adults 17+ years old (pregnancy category B); still must use JE-Vax for children—but this expired 5/11 • 96% seroconversion by 4 weeks (99% Ab later) • Duration and need for boosters still unknown • 2 dose 0.5 ml IM deltoid series given 28 days apart • HA, injection site pain and myalgias but apparently less risk of delayed urticaria • $195 x 2 = $390 cost; No 10d wait period to travel • No thimerosol but contains protamine sulfate |
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No Current JE option for U.S. children
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Japanese encephalitis vaccine for U.S. children poses challenges
Marc Fischer, M.D., FAAP and Gordon E. Schutze, M.D., FAAP AAP News July 2011 Vol 32(7): 8 • ACIP recommendations for use of Japanese encephalitis (JE) vaccine are available from the CDC at www.cdc.gov/mmwr/preview/mmwrhtml/rr5901a1.htm. • Ixiaro product information is available from the FDA at www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm179132.htm. • Information about the pediatric safety and immunogenicity trial with Ixiaro is available from the National Institutes of Health at http://clinicaltrials.gov/ct2/show/NCT01047839?term=Japanese+encephalitis&rank=26. • In addition, a list of the five U.S. clinical trial sites and contact information is available from the CDC at www.cdc.gov/ncidod/dvbid/jencephalitis/children.htm. • More information about the use of Ixiaro in children is available by calling Novartis Medical Communications at 877-683-4732 or e-mailing vaccineinfo.us@novartis.com . • A partial list of international travelers’ health clinics in Asia that administer JE vaccines to children is available from the CDC at www.cdc.gov/ncidod/dvbid/jencephalitis/children.htm. |
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Other JE Vaccines in Asia
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• JE vaccines available at international traveler’s health clinics in Asia include:
– inactivated mouse brain-derived vaccine manufactured in South Korea, – live attenuated SA 14-14-2 vaccine manufactured in China, or – inactivated Vero cell culture-derived vaccine manufactured in Japan. • All approved for pediatric use but not FDA approved, dosing varies by vaccine type/ |
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Measles/Mumps/Rubella (MMR) Vaccine-live
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• Live attenuated vaccine—chick embryo cell
• Routine MMR #2 if not already given to patient born after 1956 Single SC injection • Give 2 weeks before or 3m after immune globulin • Suppresses PPD x 6weeks after (same day OK) • Contraindicated in pregnancy (avoid conception x 30d), active TB, egg allergy; HIV+ benefits > risk, but avoid if immune compromised • Infants: administer to 12m old if traveling (revaccinate at 12-15 m if MMR#1 @ 6-12m) |
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Meningococcal Quadrivalent Vaccines
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• Menomune quadrivalent A, C, Y, W-135 polysaccharide vaccine (MPVS4) —0.5 ml SC deltoid (polysaccharide vaccines have shorter duration of protection); approved for ages >2 years (best option for > 55yrs); boost q3-5yrs
• Menactra quadrivalent conjugate vaccine (MCV4, 2005) approved for ages 2-55 y 0.5 ml IM deltoid; avoid in latex allergy • Menveo quadrivalent conjugate vaccine (MCV4, 2010) approved for ages 2-55y same dose as above • Indications – Hajj (Pilgrims to Mecca) required by Saudi Arabia – Travel to Sub-Saharan Africa meningitis belt Dec-June dry season (serogroup A outbreaks) – Incoming University Students (esp. Dorm Residents) – Medical/mission work in developing world (particularly Africa) • Neither vaccine protects against serogroup B • Menactra and Menveo conjugate vaccines will give longer immunity than Menomune polysaccharide vaccine |
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Inactivated Polio Vaccine: IPV
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• Wild polio eradicated in the Western Hemisphere but still a concern in Eastern Hemisphere
• PAIN countries: Pakistan, Afganistan, India, Nigeria (and other African countries); Nepal, Indonesia also • Current epidemic in tropical Africa • IPOL Types 1, 2, 3 inactivated poliovirus 0.5 ml • Non-immunized adults: IPV 0.5 ml IM or SC three deltoid doses 1m apart or 0,1-2,6 m • Immunized adults: single IPV booster as adult (travelers to Sub-Saharan Africa, India) • Pregnancy Cat. C (IPV); avoid OPV (no longer in U.S.) with live typhoid vaccine |
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Polio Outbreak
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• Kano State, Nigeria refused polio vaccination: none given since 8/03
• Polio has since spread from Nigeria throughout Africa and then on to Yemen, India, and Indonesia |
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Rabies Pre-Exposure Vaccine
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• Rabies Human Diploid Cell Vaccine (HDCV) = Imovax
• Rabies Purified Chick Embryo Cell Vaccine (PCEC) = RabAvert • Pre-exposure regimen: – 1 ml IM deltoid on days 0, 7, 21 or 28 or (previously) – .1 ml (HDCV) ID 0, 7, 21 or 28d (if ID immunization completed 1m prior to malaria prophylaxis w/ chloroquine or mefloquine) • Intradermal (ID) rabies vaccine ($250+) much less expensive than IM ($400+) but no longer marketed for pre-exposure in U.S. • Intra-dermal vaccine was never used post-exposure in U.S. but is often still used post- exposure overseas • One 1ml of IM vaccine = 10 doses of ID vaccine |
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Rabies Vaccine
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• Booster injection or check serology q 2 yrs
• Post-exposure treatment still necessary (1shot & repeat in 3 days) (but no rabies immune globulin needed) • May give in pregnancy if necessary • Indications: animal workers, spelunkers, long-term residents and their children • 50,000 cases rabies in world/y—over half U.S. rabies due to foreign dog exposure: DON’T PET! • Dog bites in Asia, Africa, Central and S. America all high risk—questionable longer asymptomatic period in Indian dogs (>10 d) so recommend treating as wild animal bites |
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Tick Borne Encephalitis Vaccine
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• FSME Tick Borne Encephalitis (TBE) Vaccine Inactivated (Immuno AG, Vienna) .5ml dose @ 0, 1-3, 9-12m (boost q 3y)
• Encepur TBE Vaccine Inactivated (Chiron Behring, Germany) 0, 7, 21d (rapid) vs. 0, 28d and 3rd dose at 1y (boost 3-5y) • Not available in U.S.– can be obtained in Europe • Indicated for E. Europe and Russia (including far east) adventure travelers |
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Typhoid Vaccine—2 options
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• Vivotif Berna oral live attenuated vaccine four capsules 1 qod 2+w before departure (keep refrigerated); available again; avoid w/in 24h of antibiotics or w/ hot liquids, avoid in children < 6y, avoid in pregnancy; boost every 5 yrs
• Typhim Vi capsular polysaccharide vaccine single dose; boost q 2y ok in children >2y • Both vaccines only provide about 70% protection (lower sero-conversion than most other vaccines) • Older typhoid inactivated bacterial vaccine (painful) 2 injections 1m apart now discontinued in U.S. • Indicated: 3+ wk travel, or primitive conditions, any travel to sub-Saharan Africa, India (highest risk), Indonesia |
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Tetanus and diphtheria (Td)
or Tetanus, Diphtheria, Activated Pertussus (Tdap) |
• Routine Td every 10 years – q 5 yrs with contaminated wounds (0.5 ml IM deltoid)
• Primary course Td (>7y): 0, 1-2, 6m • Children: should have 3 doses DTP prior to travel • Diphtheria risk to travelers in Russia and the Ukraine • Defer in 1st trimester pregnancy overseas except if risk warrants (commonly given in pregnancy overseas) • Tdap (Boostrix) one time booster is designed to boost waning pertussis (whooping cough) immunity in 10-64 y/o (expanded) • Tdap (Adacel) one-time booster for 11-64y, protecting both the patient and any pediatric contacts from pertussis—don’t confuse with pediatric vaccine (6wks-7yrs) DTaP (Tripedia) • Tdap: Avoid in latex allergy, Avoid giving w/in 2 years of Td |
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Varicella Vaccine (live) = Varivax
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• Varivax live attenuated varicella vaccine should be considered if no history of chicken pox (Varicella)
• Check Varicella Ab if uncertain • Adult (>13y): 2 SC deltoid doses .5 ml @ 0, 4-8 weeks • Child (12m-12y): 2 SC deltoid doses .5 ml @ 0, 4-8 weeks (new recommendation) avoid salicylates for 6 weeks due to risk of Reyes syndrome • Avoid in active TB, neomycin allergy, immune deficiency, pregnancy/lactation, <12m • Same PPD concerns as measles • U.S. born 1965- 1980 usually assume most will be immune (unless HCW or pregnant) only 2.6-2.8% susceptible |
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Yellow Fever Vaccine—Live
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• Tropical S. America and Africa: vaccine required for entry into many endemic zone countries and by some outside countries too
• Aedes aegypti mosquito virus > 20% mortality • Attenuated live virus vaccine– egg origin • One .5 ml dose SC, booster q 10 years • Avoid in egg allergy, pregnancy (exceptions made), immunocompromised (splenectomy ok), infants < 6-9 m (encephalitis /YF neurotropic disease risk), bad thymus • Yellow Fever Vaccine-Associated Viscerotropic Disease 2001 (23 cases—often fatal) 65+ |
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Vaccines in Pregnancy
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• Avoid all live vaccines (YF, MMR, FluMist, Varivax, BCG, Oral Typhoid) except in unusual circumstances with Yellow Fever when justified by risk
• Tetanus-diphtheria if indicated • Hepatitis A—use immune globulin instead • Hepatitis B if at risk of infection • Influenza (inactivated) safe anytime in pregnancy • JE-Vax only if at significant risk • Meningitis (Menomune) if indicated • Polio (inactivated) if indicated • Rabies if indicated • Typhoid (Typhim Vi) if indicated |
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Traveler’s Diarrhea Treatment: “Poo Pack”
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Loperamide hydrochloride (Imodium A/D) 2 mg
Adults: one after each loose stool (max: 8 mg/d) for symptom relief but avoid with dysentery! You do not wish to slow the bowel with an invasive organism. Stop in 48h if ineffective. Avoid in Children (esp. if <6y). |
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Traveler’s Diarrhea Treatment: “Poo Pack”
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ADD ANTIBIOTIC IF ILL BUT ONLY A SINGLE DOSE IS USUALLY NEEDED (Stop when diarrhea stops!):
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Antibiotics
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Cipro 500mg BID x 1-3D prn #6
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Antibiotics
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Azithromycin (Zithromax) 500mg one qd x 1-3d #3 (best for quinolone-resistant areas like SE Asia and India)
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Antibiotics
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Rifaximin (Xifaxan) 200 mg 3x/d for 3 days #9
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Tinidazole (Tindamax)
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• Indications: Giardiasis, Intestinal amebiasis and amebic liver abscess
• Preferred over metronidazole as better tolerated and shorter course • Good second-line diarrhea drug if antibiotics don’t work • Giardiasis: adult 2g single dose; pediatric >3y 50 mg/kg (max:2g) single dose • Amebiasis: adult 2g qd x 3d; pediatric >3y 50 mg/kg/d (max:2g) x 3d (3-5 d for liver abscess) • Like metronidazole, has the advantage of treating pseudomembranous colitis caused by Clostridium difficile (often from excessive use of antibiotics) • Available as 250 mg and 500 mg tablets • Must avoid alcohol during and 3d after use; avoid 1st TM • Potentiates oral anticoagulants, lithium, phenytoin • Side effects: GI upset, abdominal pain, metallic taste, anorexia, constipation, dizziness, HA, transient leukopenia Rare: seizures, peripheral neuropathy, contraindicated in breast feeding |
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Pediatric Traveler’s Diarrhea
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• Supervise food intake--same rules as adults
• Remember rehydration w/ Pedialyte, Ceralyte or other oral rehydration solution 5cc-2oz. Q 15m w/ spoon or syringe (important under 3y and critical < 6m) Sports drinks ok for older kids—have too much sugar for infants • Azithromycin 5-10 mg/kg/d daily for up to 3 days—10d suspension life 100mg/5ml or 200 mg/5 ml Children > 8y: 250 mg qd x 1-3d NO GOOD STUDIES • Loperamide avoid under 2y, 2-6y use rarely 1mg/5ml soln., Safest if >60# use 1/2 adult dose or 1 mg and stop after 48 h if not helping (risk of ileus, megacolon under 2y) CDC discourages use in kids—emphasizes rehydration instead • Home remedies: green bananas, boiled rice gruel • Avoid Pepto-Bismol (salicylates) due to Reyes risk • Avoid clioquinol (Enterovioform) overseas due to neurologic reactions • Avoid prochlorperazine (Compazine) in kids due to EPS • Rifaxamin (Xifaxan) non-absorbable antibiotic only approved for children >12 years |
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Malaria Prophylaxis Menu of Options
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Chloroquine, Mefloquine, Doxycycline, Malarone. Primaquine
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Proguanil (Paludrine) w/ Chloroquine
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• Proguanil 200mg daily plus weekly chloroquine 300 mg base (w/ 4 wk tail) is a popular British regimen for Africa but is less effective than other agents
• Now less effective even in W. Africa and no longer recommended by CDC as no more effective than treated bed nets (about 50% protection)—should be phased out • Proguanil is unavailable in U.S. • Savarine is fixed chloroquine 100mg /proguanil 200 mg French combination taken daily • Safe in Pregnancy (B) but less effective –best given w/ folate • Side effects: GI upset, mouth ulcers • Mechanism: dihydrofolate reductase inhibitor |
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TRAVEL VACCINATION
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• Safe, effective way to reduce morbidity from travel diseases
• Contact with unvaccinated population = loss of “herd” immunity and increased disease risk • Procrastination a major problem: ideally see patients 1+ month before travel • Often not covered by insurance • Three vaccine categories: recommended, required and routine |
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Tick Borne Encephalitis Vaccine
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• FSME Tick Borne Encephalitis (TBE) Vaccine Inactivated (Immuno AG, Vienna) .5ml dose @ 0, 1-3, 9-12m (boost q 3y)
• Encepur TBE Vaccine Inactivated (Chiron Behring, Germany) 0, 7, 21d (rapid) vs. 0, 28d and 3rd dose at 1y (boost 3-5y) • Not available in U.S.– can be obtained in Europe • Indicated for E. Europe and Russia (including far east) adventure travelers |
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Typhoid Vaccine—2 options
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• Vivotif Berna oral live attenuated vaccine four capsules 1 qod 2+w before departure (keep refrigerated); available again; avoid w/in 24h of antibiotics or w/ hot liquids, avoid in children < 6y, avoid in pregnancy; boost every 5 yrs
• Typhim Vi capsular polysaccharide vaccine single dose; boost q 2y ok in children >2y • Both vaccines only provide about 70% protection (lower sero-conversion than most other vaccines) • Older typhoid inactivated bacterial vaccine (painful) 2 injections 1m apart now discontinued in U.S. • Indicated: 3+ wk travel, or primitive conditions, any travel to sub-Saharan Africa, India (highest risk), Indonesia |
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Tetanus and diphtheria (Td)
or Tetanus, Diphtheria, Activated Pertussus (Tdap) |
• Routine Td every 10 years – q 5 yrs with contaminated wounds (0.5 ml IM deltoid)
• Primary course Td (>7y): 0, 1-2, 6m • Children: should have 3 doses DTP prior to travel • Diphtheria risk to travelers in Russia and the Ukraine • Defer in 1st trimester pregnancy overseas except if risk warrants (commonly given in pregnancy overseas) • Tdap (Boostrix) one time booster is designed to boost waning pertussis (whooping cough) immunity in 10-64 y/o (expanded) • Tdap (Adacel) one-time booster for 11-64y, protecting both the patient and any pediatric contacts from pertussis—don’t confuse with pediatric vaccine (6wks-7yrs) DTaP (Tripedia) • Tdap: Avoid in latex allergy, Avoid giving w/in 2 years of Td |
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Varicella Vaccine (live) = Varivax
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• Varivax live attenuated varicella vaccine should be considered if no history of chicken pox (Varicella)
• Check Varicella Ab if uncertain • Adult (>13y): 2 SC deltoid doses .5 ml @ 0, 4-8 weeks • Child (12m-12y): 2 SC deltoid doses .5 ml @ 0, 4-8 weeks (new recommendation) avoid salicylates for 6 weeks due to risk of Reyes syndrome • Avoid in active TB, neomycin allergy, immune deficiency, pregnancy/lactation, <12m • Same PPD concerns as measles • U.S. born 1965- 1980 usually assume most will be immune (unless HCW or pregnant) only 2.6-2.8% susceptible |
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Vaccines in Pregnancy
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• Avoid all live vaccines (YF, MMR, FluMist, Varivax, BCG, Oral Typhoid) except in unusual circumstances with Yellow Fever when justified by risk
• Tetanus-diphtheria if indicated • Hepatitis A—use immune globulin instead • Hepatitis B if at risk of infection • Influenza (inactivated) safe anytime in pregnancy • JE-Vax only if at significant risk • Meningitis (Menomune) if indicated • Polio (inactivated) if indicated • Rabies if indicated • Typhoid (Typhim Vi) if indicated |
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Travel Medicine
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• Traveler’s Diarrhea Prevention/Treatment
• Malaria Prophylaxis • Travel Vaccination Objectives • Review the prevention and treatment of traveler’s diarrhea • Discuss non-pharmacologic and pharmacologic malaria prevention • Identify the indications for common travel vaccines • Traveler’s Diarrhea Prevention/Treatment • Malaria Prophylaxis • Travel Vaccination Objectives • Review the prevention and treatment of traveler’s diarrhea • Discuss non-pharmacologic and pharmacologic malaria prevention • Identify the indications for common travel vaccines • Traveler’s Diarrhea Prevention/Treatment • Malaria Prophylaxis • Travel Vaccination Objectives • Review the prevention and treatment of traveler’s diarrhea • Discuss non-pharmacologic and pharmacologic malaria prevention • Identify the indications for common travel vaccines |
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What is Travel Medicine (Emporiatrics)?
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• A subspecialty focusing on preventing the diseases/injuries likely to be encountered by travelers and caring for ill returning travelers.
• Risk assessment and management (avoiding extremes of excessive caution and excessive complacency). • One size does not fit all: Avoid the Procrustian bed approach! • Traveler’s diarrhea prevention and treatment • Malaria prevention • Travel Vaccination • Other: Altitude sickness, Motion sickness, Jetlag, Safety issues, Special needs travelers (VFR, Pregnancy, Infants, Diabetics) , Adoption, Medical evacuation |
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Contacting the CDC
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• CDC-INFO Contact Center 800-CDC-INFO or cdcinfo@cdc.gov
• CDC Malaria Hotline 770-488-7788 or 770-488-7100 (after hours) • Travel Notices: cdc.gov/travel/notices (public health focus) • CDC Malaria Risk Map www.cdc.gov/malaria/features/risk_map.htm |
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10 Commandments of Travel Medicine
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• Consult thy health care provider in time
• Know thy destination • Thou shalt take thy malaria pills as directed • Thou shalt prevent insect bites • Thou shalt eat wisely • Thou shalt not go swimming in unchlorinated fresh water • Thou shalt wear thy shoes • Thou shalt make new friends but be careful • Thou shalt be prepared for adventures/altered plans • Thou shalt be prepared for emergencies Dr. Elaine Jong |
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Watch Out For “VFR” Travelers
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• VFR = Visiting Friends and Relatives
• VFRs often spent childhood at destination so more comfortable with perceived risk (unfortunately, often a false sense of security) • Immunity to malaria and travelers diarrhea is quickly lost with residence in a developed country • VFRs as likely to get sick as a non-native—perhaps even more likely due to absence of precautions • VFR Travelers are unlikely to seek travel consultation, take malaria meds or use as much care with food selection • Much of the imported malaria in the U.S. is due to visits back home (may fail to take prophylaxis since malaria may have been less of an issue in their childhood). |
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Traveler’s Diarrhea
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Traveler’s Diarrhea
3+ unformed stools in 24 h with at least one of the following : fever, N/V, cramps, tenesmus, or bloody stools (dysentery) Occurs in up to 55% of travelers from a developed country visiting a less-developed country, usually within the first two weeks |
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Traveler’s Diarrhea should be distinguished from Transition Bowel!
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• It is normal when traveling to develop irregular bowel habits for a while –like irritable bowel syndrome—during adjustment
• No need to treat with antibiotics • May have loose stools or constipation, excess gas (w/o hydrogen sulfide smell) but these symptoms are not associated with illness • Unfamiliar spicy or high fiber foods may contribute to problem • Some change undoubtedly related to change in bacterial flora • True traveler’s diarrhea gives repeated bouts of loose stools and sense of being physically ill (cramping) • Post Travel IBS: many returning travelers with persisting diarrhea s/p TD also have IBS symptoms w/ negative culture and O&P • Parasitic infections, like giardia, also make the patient feel ill: gassy diarrhea, “eggy” or “purple” burp |
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T.D. Epidemiology
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• RISK FACTORS:
Gastric surgery Suppressed gastric acidity: H2 blockers Proton Pump Inhibitors Previous High Susceptibility |
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Traveler’s Diarrhea Microbiology
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BACTERIA: most TD is bacterial!
Enterotoxigenic E. coli (ETEC) #1 Salmonella (need lg inoculum) Shigella Campylobacter jejuni (some drug resist in Asia) Vibrio parahaemolyticus Yersinia |
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Traveler’s Diarrhea Microbiology
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VIRUSES: Rotavirus, Norovirus (cruise ships)
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Traveler’s Diarrhea Microbiology
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PARASITES: Giardia (gas, rotten eggs), Entameba histolytica, Cryptosporidium
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Traveler’s Diarrhea Prevention
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• Behavioral Intervention: careful selection of food and water
SAFE: hot cooked foods, fruits you peel yourself, carbonated beverages, beer, fresh bread |
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Traveler’s Diarrhea Prevention
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UNSAFE: street vendor fare, ice, salads, fruit you don’t peel yourself, uncooked vegetables, un-pasteurized dairy, tap water, pastry icing and table condiments (e.g. guacamole)
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Traveler’s Diarrhea Prevention
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“Boil It, Cook It, Peel It or Forget It”
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Traveler’s Diarrhea
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Active Intervention: treatment of food/ water
Food disinfection by cooking, boiling, baking Avoid contamination after cooking—eat while hot |
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Traveler’s Diarrhea
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Disinfect water by boiling 3 minutes--BEST
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Traveler’s Diarrhea
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Chemical disinfection of water (15h for crypto!)
chlorine bleach 5% tincture of iodine 2% tetraglycine hydroperiodide tablets (Potable Aqua) |
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Traveler’s Diarrhea
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Filter Pumps —often clog, often fail for Crypto
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Traveler’s Diarrhea Prophylaxis
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• CDC doesn’t recommend TD prophylaxis except in unusual circumstances
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When To Prophylax for T.D.
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Consider for those unable to afford 24-48 h illness e.g. high-profile speakers, 3d diving trip, diplomatic missions
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When To Prophylax for T.D.
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Consider for high risk patients e.g. immune compromised, leukemia, chronically ill, reduced gastric acid
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Contraindication to Prophylaxis
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Stay > 3 weeks
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Prophylaxis Options
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Bismuth subsalicylate 2 tablets qid (65% reduction)
Ciprofloxacin 500 mg daily (or other quinolone) Rifaximin 200 mg daily -74 % protection (Dupont et al. Annals Int. Med 6/05) Older drugs no longer used: SMZ-TMP DS one daily, Doxycycline 100 mg daily |
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Traveler’s Diarrhea Treatment: “Poo Pack”
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Loperamide hydrochloride (Imodium A/D) 2 mg
Adults: one after each loose stool (max: 8 mg/d) for symptom relief but avoid with dysentery! You do not wish to slow the bowel with an invasive organism. Stop in 48h if ineffective. Avoid in Children (esp. if <6y). |
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Traveler’s Diarrhea Treatment: “Poo Pack”
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ADD ANTIBIOTIC IF ILL BUT ONLY A SINGLE DOSE IS USUALLY NEEDED (Stop when diarrhea stops!):
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Azithromycin Off Label Alternative
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• Zithromax 500 mg qd x 1-3 days for adults (or 1000 mg x 1 dose)
• Zithromax 250 mg qd x 1-3d for older children • Zithromax 100 mg or 200mg/5ml susp. for younger children (10mg/kg/d) > 6mo. • Best for S.E. Asia (e.g. Thailand) and India • Appears safe in pregnancy (category B[m]) but transmitted to breast milk |
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Food Poisoning
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• Bacterial toxins found in held over, repeatedly reheated foods (street vendors, buffet tables, open bowls of dipping sauces, condiments)
• Acute N/V +/- D usually 1-6h after ingestion, symptoms x 24h • Unresponsive to antibiotics • Odansetron 4 mg PO (preferred) or promethazine suppositories (adults only) and rehydration with clear liquids • “First you’re afraid you are going to die, then you’re afraid you will not.” |
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Food Poisoning and Bacterial Enterotoxins
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• Staphylococcus aureus enterotoxin: stimulates adenylate cyclase causing n/v soon after ingestion; heat stable
• Bacillus cereus enterotoxin: common cause of food poisoning from reheated rice in Chinese restaurants; heat stable Unlike traveler’s diarrhea (usual incubation > 8h), GI symptoms (N+V+/D-+) occur within 1-6h of ingestion |
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Tinidazole (Tindamax)
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• Indications: Giardiasis, Intestinal amebiasis and amebic liver abscess
• Preferred over metronidazole as better tolerated and shorter course • Good second-line diarrhea drug if antibiotics don’t work • Giardiasis: adult 2g single dose; pediatric >3y 50 mg/kg (max:2g) single dose • Amebiasis: adult 2g qd x 3d; pediatric >3y 50 mg/kg/d (max:2g) x 3d (3-5 d for liver abscess) • Like metronidazole, has the advantage of treating pseudomembranous colitis caused by Clostridium difficile (often from excessive use of antibiotics) • Available as 250 mg and 500 mg tablets • Must avoid alcohol during and 3d after use; avoid 1st TM • Potentiates oral anticoagulants, lithium, phenytoin • Side effects: GI upset, abdominal pain, metallic taste, anorexia, constipation, dizziness, HA, transient leukopenia Rare: seizures, peripheral neuropathy, contraindicated in breast feeding |
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Insect Bite Prevention
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DEET containing insect repellant (17-35%) 35%=6h
N,N diethyl-m-toluamide apply to skin at dusk—not on clothes/gear Now considered safe in children > 2months or 2nd, 3rd TM pregnancy @ 35% ; apply to skin after sunscreen use if using both Picaridin (BayRepel) insect repellent (20%) safe, reasonable duration, not approved for children < 2 Permethrin-impregnated bed nets Long light-colored sleeves and trousers Window screens Avoid or reduce activity after dusk Mosquito coils Unproven: B vitamins (thiamine), ultrasound, wrist bands, Demal 200 (homeopathic prophylaxis) —these don’t work reliably and should not be relied upon! |
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Doxycycline: cheapest but least convenient option
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• Dose: 100mg daily starting 1-2 d prior to travel, daily during risk period and daily for 4 weeks after
• Best cheap alternative to mefloquine for CRPF; Best for Thailand-Myanmar (Burma) and Thai-Cambodia border areas of mefloquine-resistance • Side effects: photosensitivity (3%), esophagitis (take w/ water and keep upright), monilia, BCP interaction • Contraindications: pregnancy, children < 8 yrs, allergy Interaction: antagonized by Dilantin and seizure meds • Mechanism: ribosomal inhibition (pre- and erythrocytic phases) Safe for long-term chemoprophylaxis • No resistance reported but compliance poorer due to long post-trip regimen and side effects |
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Atovaquone and Proguanil (Malarone)
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• New causal option for CRPF prophylaxis—best for short trips of under 30 days (or brief forays into malarious areas) as it is fairly expensive
• Adults: 250 mg/100 mg qd (daily) regimen w/ 1 week tail • Pediatric tablet (¼ adult dose) 62.5mg/25mg: ½ ped-tab qd (5-8 kg), ¾ tab qd (8-11 kg), 1qd (11-20kg), 2qd (21-30kg), 3qd (31-40kg), 1 adult tab if > 40 kg • Side effects: GI upset, mouth ulcers (from proguanil) • Costly but effective (near 100%) in trials—rare resistance in Africa • Best option for epilepsy patients • Start 1-2 d prior to risk period and continue for only 1 week after departure (causal for P. falciparum only) • Expense: $5/day! Usually trips < 1month (but longer trips ok) • Adult Self Treatment Dose: 4 tabs/d (or 2 tabs bid w/ food) x 3 days (use if fever > 38C and more than 24 h from care, after at least one week in risk area) |
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German/Swiss/Austrian Approach
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• Chemoprophylaxis for highest-risk destinations
• Sub-Saharan Africa—excepting most of South Africa • Papua New Guinea/Papua (Irian Jaya) /Solomons • North India (monsoon season)—debated • Outbreak Areas (these change w/ time: Punta Cana resort area in D.R., Lombok 12/01) • Self Treatment only for low-risk sites e.g. Malarone • South India • South-east Asia • Central and South America |
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Coartem Self-Treatment: Use 3d for travelers
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• Coartem =Artemether 20 mg and Lumefantrine (Benflumetrol) 120 mg (Novartis)
• Artemisin combination therapy (ACT) • Two Day Rx: 4 tabs @dx, then @ 8, 24, 48h (less resistant areas, partially immune or native patient) • Three Day Rx: 4 tabs @dx, then @8h then BIDx2d (resistant areas, non-immune patient and travelers) • >95% cure rates, no increased QT problems • Can be used in small children (5-10 kg) • Well-tolerated; good “standby” 3 day Rx for traveler |
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Dengue Fever
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• Flaviviruses (RNA), DEN 1-4
• Vector: Aedes aegypti mosquito • Classic Dengue: 2-7d incubation w/ sudden onset of HA, fever, arthralgias, conjunctivitis, eyelid puffiness, facial flushing, palmar erythema, n/v, lymphadenopathy and rash lasting 1-5d after fever (supportive treatment) • Dengue Hemorrhagic Fever/Shock Syndrome: initial course followed by hypotension, tachycardia, petechiae, GI hemorrhage and renal failure (hydration essential) 5% mortality |
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TRAVEL VACCINATION
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• Safe, effective way to reduce morbidity from travel diseases
• Contact with unvaccinated population = loss of “herd” immunity and increased disease risk • Procrastination a major problem: ideally see patients 1+ month before travel • Often not covered by insurance • Three vaccine categories: recommended, required and routine |
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Hepatitis A Vaccine
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• Two main options equivalent and interchangeable
• Havrix, Vaqta : adult and pediatric (1-18) doses • Available in U.S. since 1995 – essential recommended vaccine for most travelers to developing countries!!! • Single dose HAV given IM deltoid 4wks prior gives 98-100% protection (give up till departure if necessary) • Single booster dose 6-12 m later for long-term immunity • Approved for children over 1 year of age (IG public health option for children in daycare) • Now recommended for all U.S. children > 1year 5/06 • Pediatric dose: 1-18 y: 720 EL.U. IM • Adult dose >18y : 1440 EL.U. IM |
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Hepatitis A Immune Globulin
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• Blood product: Cohn-Oncley preparation is safest (only option in U.S.) otherwise theoretical risk hep. C/ HIV
• Passive immunity only to Hepatitis A (essentially rendered obsolete by Hepatitis A vaccine) • Safe in pregnancy, small children < 1y • Given IM in buttocks just before travel • Pediatric dose: .02 mg/kg < 3m, .06 mg/kg > 3m travel • Adult dose (>100#): 2 cc IM <3m, 5 cc IM >3m (repeat q 5m) • Consider for children < 1y for public health reasons only—they don’t get that sick but may infect adults |
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Hepatitis B Vaccine
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• Recombinant Hepatitis B surface antigen
• Recombivax, Engerix-B, Comvax (Hep B/HIB) in pediatrics • Dose: 0, 1, 6 months 0.5 ml IM deltoid 10+yr • Accelerated Engerix-B regimens: 0, 1, 2 m w/ 12m booster or 0, 7, 21 days w/12 m booster (65% seroprotection on day 28 increasing to 99% month 13) • Pregnancy precaution but safe– noninfectious HBsAg • Indicated for long-term (6+m) travel or any anticipated sexual or body fluid exposure • Highest risk: China, Sub-Saharan Africa • Now a standard pediatric vaccination in much of the world |
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Hepatitis A+B Vaccine Combination
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• Twinrix Hepatitis A/B Vaccine (SKB)
• 3 doses: 0, 1, 6 months or 0, 1, 2 w/ 12 m booster • 1 cc IM deltoid adult dose • For adults >18y—no pediatric option now • Vaccine Formulation: adult Hepatitis A antigen 720 EI. U. (ped dose) HBsAg 20mcg Dose volume 1 ml Accelerated off label option: 0, 7, 21 d (83 % HBAb 1m) w/ booster in 12 m 93% Hepatitis A antibody present after 1st dose |
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Hepatitis Vaccine Indications
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• Hepatitis A: any travel to a developing country—fecal-oral risk from water or food
• Hepatitis B: long-term travel (4-6+m) or any sexual/body fluid exposures or IV drug abuse likely; any medical work; homosexuals (Hepatitis D always assoc. with B) • Hepatitis C: no vaccine available; parenteral • Hepatitis E: vaccine in development; fecal-oral spread in South Asia with highest risk during pregnancy (20% third TM mortality) |
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Influenza Vaccine
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• Fluogen, Flushield, Fluzone
• Flu occurs year round rather than seasonally in the tropics and seasons reversed in southern hemisphere (some exceptions) • Consider vaccination for elderly, ill and diabetic travelers (inactivated so cannot cause flu!) • Adult: 0.5 ml IM deltoid x 1 (give 1 month before flu season) • Pediatric: 6m-8y 2 doses 1m apart for 1st immunization then one dose/y (dose: .25 ml 6-35m, .5ml > 3y) • Avoid in egg allergy, active neurological disorder • Nasal live (cold-adapted) flu vaccine (FluMist) approved for healthy patients 2-49 yrs old |
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Cold-Adapted Live Intra-nasal Influenza Vaccine (FluMist)
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• Trivalent (AAB) nasal vaccine —cold-adapted virus can grow only in nasopharynx but not in lung
• 0.5 ml total dose, half is sprayed into each nostril with the patient upright • 87% efficacy • Indicated only for healthy non-pregnant individuals ages 2-49 thus far (FDA approved summer 2003) • More expensive: cost is $46 wholesale and at least $60 to patient |
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Japanese Encephalitis
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• Virus transmitted in Asia by Culex night-feeding mosquitoes
• 10-15, 000 deaths/yr out of > 50,000 reported cases. Most cases sub-clinical but up to 30% fatality rate in those with clinical encephalitis. • Encephalitis survivors often have permanent neurologic sequelae! • However quite rare in American travelers so vaccination only recommended for expatriates and longer-term (>1m) travelers. |
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Japanese Encephalitis Vaccine
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• Consider for 1+ m travel in rural Asia esp. summers ( May-September)
• Average reported risk: only 1 case per year in American travelers • Viral disease transmitted by Culex night-feeding mosquitoes • Rare in U.S. tourists but high morbidity (50%)/mortality (30%); Rec. for long term stays or long-term expatriates living in Asia |
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Current 3 options for obtaining JE vaccine for U.S. children
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• Enroll in the ongoing JE-VC (IXIARO) pediatric clinical trial at one of five U.S. sites: The study is open-label and all enrollees receive two doses of JE-VC administered 28 days apart. A third study visit is required at 56 days after the subject receives the first dose of vaccine. Additional information is available at the NIH clinical trials webpage.
• Use JE-VC (IXIARO) off-label: JE-VC is FDA-licensed for use in adults ≥17 years of age. Because it is a licensed product, a healthcare provider can purchase the product and choose to use it off-label in children <17 years of age. Data from the one completed pediatric study have been published (Kaltenbock et al. Vaccine 2010;28:834-9). The manufacturer is currently studying a 6µg/0.5mL dose (regular adult dose) for children ≥3 years of age and a 3µg/0.25mL dose (half adult dose) for children aged 2 months through 2 years. For additional data and information regarding the use of JE-VC in children, healthcare providers can contact NovartisMedical Communications at 1-877-683-4732 or vaccineinfo.us@novartis.com. • Obtain Non-FDA approved JE vaccine in Asia, usually by referring to clinic there |
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Tick Borne Encephalitis Vaccine
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• FSME Tick Borne Encephalitis (TBE) Vaccine Inactivated (Immuno AG, Vienna) .5ml dose @ 0, 1-3, 9-12m (boost q 3y)
• Encepur TBE Vaccine Inactivated (Chiron Behring, Germany) 0, 7, 21d (rapid) vs. 0, 28d and 3rd dose at 1y (boost 3-5y) • Not available in U.S.– can be obtained in Europe • Indicated for E. Europe and Russia (including far east) adventure travelers |
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Typhoid Vaccine—2 options
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• Vivotif Berna oral live attenuated vaccine four capsules 1 qod 2+w before departure (keep refrigerated); available again; avoid w/in 24h of antibiotics or w/ hot liquids, avoid in children < 6y, avoid in pregnancy; boost every 5 yrs
• Typhim Vi capsular polysaccharide vaccine single dose; boost q 2y ok in children >2y • Both vaccines only provide about 70% protection (lower sero-conversion than most other vaccines) • Older typhoid inactivated bacterial vaccine (painful) 2 injections 1m apart now discontinued in U.S. • Indicated: 3+ wk travel, or primitive conditions, any travel to sub-Saharan Africa, India (highest risk), Indonesia |
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Tetanus and diphtheria (Td)
or Tetanus, Diphtheria, Activated Pertussus (Tdap) |
• Routine Td every 10 years – q 5 yrs with contaminated wounds (0.5 ml IM deltoid)
• Primary course Td (>7y): 0, 1-2, 6m • Children: should have 3 doses DTP prior to travel • Diphtheria risk to travelers in Russia and the Ukraine • Defer in 1st trimester pregnancy overseas except if risk warrants (commonly given in pregnancy overseas) • Tdap (Boostrix) one time booster is designed to boost waning pertussis (whooping cough) immunity in 10-64 y/o (expanded) • Tdap (Adacel) one-time booster for 11-64y, protecting both the patient and any pediatric contacts from pertussis—don’t confuse with pediatric vaccine (6wks-7yrs) DTaP (Tripedia) • Tdap: Avoid in latex allergy, Avoid giving w/in 2 years of Td |
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Varicella Vaccine (live) = Varivax
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• Varivax live attenuated varicella vaccine should be considered if no history of chicken pox (Varicella)
• Check Varicella Ab if uncertain • Adult (>13y): 2 SC deltoid doses .5 ml @ 0, 4-8 weeks • Child (12m-12y): 2 SC deltoid doses .5 ml @ 0, 4-8 weeks (new recommendation) avoid salicylates for 6 weeks due to risk of Reyes syndrome • Avoid in active TB, neomycin allergy, immune deficiency, pregnancy/lactation, <12m • Same PPD concerns as measles • U.S. born 1965- 1980 usually assume most will be immune (unless HCW or pregnant) only 2.6-2.8% susceptible |
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Live Vaccines in Pregnancy - YF, MMR, FluMist, Varivax, BCG, Oral Typhoid
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• Avoid all live vaccines except in unusual circumstances with Yellow Fever when justified by risk
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Vaccines in Pregnancy - Tetanus-diphtheria
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if indicated
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Vaccines in Pregnancy -
Hepatitis A |
use immune globulin instead
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Vaccines in Pregnancy -
Hepatitis B |
Use if at risk of infection
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Vaccines in Pregnancy -
Influenza A(inactivated) |
safe anytime in pregnancy
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Vaccines in Pregnancy -Typhoid (Typhim Vi)
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if indicated
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Vaccines in Pregnancy -
• Meningitis (Menomune) |
if indicated
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Vaccines in Pregnancy -
• Polio (inactivated) |
if indicated
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Vaccines in Pregnancy -
Rabies |
if indicated
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Vaccines in Pregnancy -
JE-Vax |
only if at significant risk
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