Transcript Pre-travel Preparation

Before you go-go….
Don’t leave yourself hanging like a yo-yo…
Abinash Virk, MD
Division of Infectious Diseases
Before you go….
• Get to know
the country
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Culture
Electricity
Money
Healthcare
access
– Food
• Get a medical
/ dental tune
up
– Avoid
preventable
medical
urgencies /
emergencies
– Take plenty of
supplies
• Meds
• Visit the travel
clinic
– Specific advise
– Vaccines
– Meds
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Malaria
TD
Altitude
HIV PEP (if
needed)
– HCW advise
– Med Kit
Health problems in American Travelers
Motion sick
5%
AMS
6%
Trauma
5%
Fever
3%
TD
Resp illness
Skin prob.
AMS
Motion sick
Trauma
Fever
Skin prob.
8%
Resp illness
26%
TD
46%
Hill, DR. JTM 2000; 7:259–266
Visit to the travel clinic
• Minimum 6 weeks but best 6 months prior to leaving
• Bring details of your itinerary
– Impact on vaccine-preventable disease and malaria risk
• Know details of planned activities
• Bring your prior vaccine records
Malaria
Yellow Fever
Pre-travel advice
RISK ASSESSMENT
ADVISE & EDUCATION
Insect precautions
Ingestion - food/water
Injuries
Immobility - DVT
Indiscretions - STD/HIV
Immersion
Insurance
Air evacuation
Altitude sickness
Safety
IMMUNIZATIONS
PRESCRIPTIONS
Pre-travel advice
VACCINATIONS
•Always - routine
•Often - Hep A
•Sometimes
•Hep B
•Yellow fever
•Meningococcal
ADVISE & EDUCATION
•JEV
•Polio
•Rabies
PRESCRIPTIONS
•Typhoid
•Cholera
Hepatitis A & B risk areas
3-20/1000 travelers/1month
Hep A Vaccine
• Inactivated
• 20-25 yrs after 2 doses
• Safe
80-240/100,000 travelers/1month
Hep B Vaccine
• Inactivated
• 3 dose schedule
• Safe
Geographic distribution of Yellow Fever
Required vaccine
Yellow fever Vaccine
• Live attenuated viral
• Minimum 10 days before entry
• Not for immunocompromised,
thymoma
• Rare risk of viscerotropic disease
Geographic distribution of meningococcal
Required vaccine
Meningococcal Vaccine
• HCW in Africa; Hajj
• Quadrivalent – A, C, Y, W-135
•New conjugated - better
• Safe
Geographic distribution of Japanese Encephalitis Virus
JEV Vaccine
• If staying > 4-6 weeks
• Takes 24 - 40 days to complete
• Rare anaphylaxis
• Current shortage
Geographic distribution of Polio
Geographic distribution of Rabies
Rabies Pre-exposure Vaccine
• If staying > 4-6 weeks
• Takes 21 - 28 days to complete
• Precludes need for RIG post-bite
• Current vaccine shortage
Geographic distribution of Typhoid
Typhoid Vaccine
• Oral – live attenuated bacterial
• Injectable – inactivated
• Safe
Geographic distribution of Cholera
Cholera Vaccine
• Oral – live attenuated bacterial
• Not available in US
• Risk is rare
Pre-travel advice
IMMUNIZATIONS
RISK ASSESSMENT
ADVISE & EDUCATION
PRESCRIPTIONS
Geographic location traveling to
Therapy
Prophylaxis
Treatment
What species is present
INSECT REPELLENTS
• DEET (N,N-diethylmetatoluamide) - available
under many brand names such as
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OFF ®, Cutter ® and Repel ®.
40 years use, 8 billion human applications
Only 50 cases of serious effects
“Normal use of DEET does not present a health concern
to the general U.S. population”
• EPA, 1998
• Picaridin - available as Bayrepel®, Hepidanin®,
and Autan Repel® or Cutter® Advanced.
– Each application lasts for 2-4 hours in the concentration
that is available in the US.
– Frequent application is required
Permethrin
• Synthetic version of natural
pyrethrum insecticide from flowers
(Chrysanthemum)
• Applied to clothing/fabric
• Repeated washings
• Extremely safe and effective
• Works on mosquitoes and ticks
Bed nets
• Available in many sizes,
shapes
• Permethrin treated
• Lightweight, inexpensive
• Protect against all insect
bites (vs antimalarial meds!)
• Night-time feeding
P. falciparum malaria chemoprophylaxis
MEFLOQUINE CHLOROQUINE DOXYCYCLINE MALARONE
Formulation
Tablets
Tablets
Tablets
77-99%
99%
Weekly
Tablets and
suspension
No (except CQ
sensitive areas)
Weekly
Efficacy
90-100%
Dosing
Frequency
Safety
Daily
Daily
Yes
Yes
Yes
Yes
Yes
No
No
Pregnancy use Yes #
Side Effects
Schedule
Cost
Dreams, sleep
problems, 1%
neuropsch. rxn
<2, wkly
+ 4 wks
$10/week
Bitter taste. Hearing / Acidic pill, increases
Diarrhea, some
eye AE with prolonged sensitivity to sun, yeast sleep trouble.
use (months/years)
infections (women)
<1, wkly
+ 4 wks
$10/week
<2days, daily <2d, daily
+ 7 days
+ 4 wks
~0.25cents/day
$5/day
Close the loop for Malaria
Recognizing signs / symptoms of malaria and what to do:
• The most common symptoms of malaria:
– fever, chills, flu-like symptoms, and headache
– Other symptoms can occur
• If symptoms occur while on malaria pills & still traveling:
– Seek immediate medical attention such as emergency room
– Be sure to tell the doctor which malaria pills you are taking.
– halofantrine, quinine and quinidine should not be taken if you are
taking mefloquine for malaria prevention
• If symptoms occur after your return to the US:
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Seek immediate medical attention such as emergency room
Inform the MD regarding your area of recent travel
Ask to be tested for malaria
Continue taking your malaria pills until further instructions.
Stand-by Malaria Treatment (SBMT)
• Taking a treatment course for self-treatment of
malaria whether or not on malaria prophylaxis
– Considered for areas with poor access to healthcare
• Controversial
– Requires understanding of disease, diagnosis and
treatment
– Can result in inappropriate use or undertreatment
• Most often recommended SBMT
– Malarone (if not on Malarone for prophylaxis)
– Artemisinin combination treatment (not available for SBMT
in US)
Geographic distribution of TD incidence (%)
Risk increases as duration of stay increases
10
41
4
50
40
40
26
50
26
25
34
26
Kollaritsch et al. Eur J Epidemiology 1989
TD Etiology
• Bacteria
– E coli (enterotoxigenic)
– Campylobacter jejuni
• Parasites
– Giardia lamblia
Trekking, longer
India
• Viral
– Rotavirus
– Adenovirus
• Multiple pathogens
Reinthaler, FF et al. JTM 1998; 5:65-72.
Travelers Diarrhea (TD) impact
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30-60% get TD
20 -30% confined to bed
40% change schedule
<1% hospitalized
Rare deaths
Wasted:
– time (vacation, business)
– money
“Travel broadens the mind but loosens the bowels”
Prevention of Traveler’s diarrhea
• “Cook it, peel it, boil it or forget it” – do it!
• Primary prevention (generally not recommended)
Prevention
Antibiotics (%)
Major side effects
0.01
Rifaximin
(%)
0
BSS (%)
Minor side effects
3
few
1
Protection
90
72
65
0
Ericsson, CD. Infec Dis Clin of NA. 1998;12(2):285-303
DuPont, H. L. et. al. Ann Intern Med 2005;142:805-812
Take Antibiotics for TD self-treatment
• Fluoroquinolones
– Ciprofloxacin
– Levofloxacin
Single dose vs 3-day course
Antibiotic Treatment for TD
Cipro/loperamide >> 3 days Ciprofloxacin > Single
dose Cipro
• Azithromycin
– Especially for areas where Campy is more
• Rifaximin
– Not as effective for invasive diarrhea such as
Campylobacter or shigella
Health care delivery overseas
• Need to consider
– Management of needlestick exposure
• Confirm anti-HBsAb prior to travel
• Consider carrying HIV PEP for needlestick exposure
• Have source patient check for HBV, HCV and HIV
– Respiratory-borne illnesses
• TB
– Carry & use an N-95 mask prn
– PPD or QuantiFERON Gold after return
• Viral
– Hand hygiene
Travel medical Kit
• Over-the-Counter Medications and Supplies
• Prescription Medications and Supplies
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Antibiotic for TD, antimalarial, Acetazolamide (for AMS if needed)
Epi-pen™
Nausea and anti-emetics
Sleeping pills
Routine medications
Pain medications
• Simple First Aid Kit
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Adhesive bandages of various sizes (for blisters etc.) Gauze swabs, adhesive tape
Antiseptic powder, solution or wipes
Nonadhesive dressings (such as Telfa® or Melolin®)
Small scissors (place in check-in baggage because of airport security)
Thermometer
Tweezers to remove splinters and ticks
IV fluids, syringes and needles
Conclusions
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Plan ahead
Get details of your itinerary – helps keep you healthy
Give yourself time to complete vaccinations
Be an informed traveler:
– Less likely to inadvertently expose yourself to disease
– More likely to be able to handle unforeseen problems
Which one of the following immunizations
would be contraindicated in an HIVpositive patient traveling to Africa with a
CD-4 count of 20?
76%
1.
2.
3.
4.
5.
Injectable Influenza
Injectable typhoid
Yellow fever
meningococcal
Hepatitis A
10%
4%
1
6%
2
4%
3
4
5