Transcript TRAVEL MEDICINE IN THE HIV

EMPORIATRIC MEDICINE
AND THE HIV-INFECTED
TRAVELER
NY/NJ AETC Stuart Haber, MD
ISSUES FOR ALL TRAVELERS
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Generally want at least 4-6 week lead time prior to
departure to assess travel needs, especially vaccines and
need for malaria chemoprophylaxis
Get list of medical clinics from IAMAT
www.iamat.org
Bring 30-35% DEET spray where biting insects are
anticipated
Avoid piercings and tatoos, acupuncture, even shaving by a
barber in many of these developing areas
Be cautious of motor vehicle travel
Swim only in chlorinated water
Health insurance: both international insurance(try credit
card companies, yellow pages, internet) and air ambulance
insurance: www.airambulancedirectory.com
NY/NJ AETC Stuart Haber, MD
SPECIFIC PRECAUTIONS FOR
ENTERITIS
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Developing countries: especially important in
patients with severe immunosuppression
Food and waterborne diseases:same precautions
for all travelers regardless of HIV serostatus
If you can’t boil it, peel it, cook it, then forget it!!
No tap water, ice cubes. Bottled water, including
for brushing teeth!
Portable water purifiers ( with absolute one
micron filter)
NY/NJ AETC Stuart Haber, MD
TRAVELER’S DIARRHEA
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If traveler’s diarrhea is severe: must seek medical attention
(gi bleeding, fever, vomiting, prostration)
Enterotoxigenic E. coli probably no different in it’s
presentation, but Salmonella, Campylobacter, Shigella can
be worse in HIV+ people
Occasional microsporidia(J Travel Med 1999 Dec;6(4):2237), enteroaggregative E. coli(CID 2001 Jun
15;32(12):1706-9), and Cryptosporidia
Other causes of enteritis eg,Cyclospora, Isospora belli,
helminths, C. difficile, tropical sprue
Treatment for uncomplicated disease:cipro 500mg BID for
three to seven days with first day imodium.
NY/NJ AETC Stuart Haber, MD
SELF-MEDICATION FOR OTHER
AILMENTS
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Options of self-medication: for
respiratory tract infection, sinusitis,
otitis media,UTI, cellulitis
NY/NJ AETC Stuart Haber, MD
INTERNATIONAL SCREENING OF
TRAVELERS FOR HIV INFECTION
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Primarily aimed for those with extended
stays: work visas, students
Approximately 50 countries may block
entry of HIV+ travelers
Check with consular office(s) or go to
www.travelstate.gov/hivtestingreqs.html
Our own calls to Brazilian, Canadian, and
British consulates did not bear out any
refusal to have HIV+ travelers in their
nation for short-term stay. However, longterm stay decided on case by case basis.
NY/NJ AETC Stuart Haber, MD
TIMING OF HAART ACROSS
TIME ZONES
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Take more doses in the period than less.
East to West: extra dose of Nukes,
viramune and PIs at bedtime
West to East: extra dose next morning
Efavirenz doesn’t need an extra dose (G.
Moyle, personal comm.)
Viread has long intracellular half-life and
may not need an extra dose
Debatable what to do with indinavir with
respect to risk of nephrolithiasis
NY/NJ AETC Stuart Haber, MD
DRUG AND MEDICAL CARE
ISSUES
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Adequacy of supply of medications,
including need for refrigeration and
avoidance of damp places
Adequacy of medical care in
destination, especially important in
prolonged stays-consult with IAMAT
Avoid if possible, new medication
changes just prior to travel
NY/NJ AETC Stuart Haber, MD
MALARIA PREVENTION
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Same precautions and prophylaxis with all travelers
Review itinerary on www.cdc.gov malaria site
Disease presentation not different in HIV, except more
severe in HIV-positive pregnant women
Mosquito bite prevention with 30-35% DEET, bed netting,
permethrin spray, and avoidance of dusk to dawn exposure
Drug interactions: mefloquine had variable effects on
ritonavir, with decrease in Cmax, Cmin, AUC. Despite
strong inhibition of CYP3A4, mefloquine levels were not
affected by ritonavir (Khaliq et al, 7th Conf on Retro,
abstract 92, 2000)
Malarone: Proguanil AUC increased possibly via CYP 2D6,
Atovaquone AUC may be decreased in presence of
Ritonavir, mechanism unknown (Karp, Current Inf Dis Rep
2001, 3:50-8)
Despite these observations, there are currently no dose
adjustments recommended at this time.
Measure patient’s glucose-6-phosphate
dehydrogenase
NY/NJ AETC Stuart Haber, MD
level prior to trip (possible need for primaquine)
MALARIA TREATMENT
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Quinidine:AUC increased by ritonavir via CYP3A4
inhibition. Quinidine reserved for severe malaria
and decrease in maintenance rate of drug
required. Quinine probably increased to lesser
extent and should be avoided (risk of prolonged
QT interval with Torsades de pointes)
Treat non-severe malaria with malarone 4
pills/day for three days, or with lariam (increased
risk of seizures).
Self-treatment not generally advised
NY/NJ AETC Stuart Haber, MD
VACCINE ISSUES IN HIV+
TRAVELER
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Potential exposure to pathogen
Potential increase in side effects to
vaccine
Potential decreased efficacy of
vaccine
NY/NJ AETC Stuart Haber, MD
VACCINES
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In most developing areas of world, following
vaccine-preventable illnesses are addressed:
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Measles
Hepatitis A
Typhoid Fever
Influenza
Yellow fever
Hepatitis B
Polio
Japanese encephalitis
Rabies
Cholera
Meningococcus
NY/NJ AETC Stuart Haber, MD
VACCINES
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Killed (inactivated): Hepatitis A,
Inactivated Polio (IPV), Rabies,
Japanese encephalitis
Live (attenuated): MMR, Yellow fever,
oral Typhoid
Subunit: Hepatitis B
Polysaccharide: Pneumococcal,
Meningococccal, Typhoid Vi
Split antigen: Influenza
NY/NJ AETC Stuart Haber, MD
MEASLES VACCINE
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Increased prevalence of disease in SE Asia, Africa
(especially sub-Saharan) based on W.H.O. data on measles
in children
Worse disease with increased morbidity and mortality in
HIV-infected people with pneumonitis and also encephalitis.
Increased risk of vaccine side effects in severely
immunosuppressed: one known death in patient with AIDS
and deaths in other immunosuppressed recipients.
Vaccine considered safe in adults if T-helper count >200
&/or T-helper % >14%
If immune serum globulin prescribed to prevent Hep A,
separate injections by at least two weeks
Role of measuring serum IgG measles antibody
Use of gammaglobulin if inadequate antibody in AIDS, dose
suggested is 15 ml IM. IVIG may also be okay.
NY/NJ AETC Stuart Haber, MD
NY/NJ AETC Stuart Haber, MD
YELLOW FEVER
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Mosquito-borne disease in tropical South America and SubSaharan Africa
Severity of illness from flu-like illness to severe hepatitis
and hemorrhagic fever with a classic biphasic illness
Fatality rate of severe disease ranges from 20% to 65%
Not known if HIV influences presentation of illness
Asymptomatic HIV+ recipients of vaccine without adverse
effects
Lower antibody titers in HIV+ children
Consider measurement of antibody titer after vaccination
Vaccine not recommended in symptomatic HIV-positive
adults, certainly not if T-helper count <200.
NY/NJ AETC Stuart Haber, MD
GLOBAL DISTRIBUTION OF
YELLOW FEVER, 1996
NY/NJ AETC Stuart Haber, MD
YELLOW FEVER
Options to taking vaccine:
1. Avoiding areas of transmission altogether
2. If in an area of potential exposure, meticulously
avoiding mosquito bites
3. Vaccine waiver letter-this may not be accepted at
border. Need to arrange this with consulate prior
to leaving USA
4. Distinguish requirements of country from actual
zones of endemicity
NY/NJ AETC Stuart Haber, MD
HEPATITIS A
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Vaccine response is lower in HIV+ patients, with
dramatically low response rate in patients with <200
cells/mm3(Kemper et al, JID 2003 April 15; 187(8):132731)
Know if measurable IgG prior to travel. However, actual
protective titer against infection is unknown.
Generally, if less than one month prior to travel, give
immune serum globulin with option of starting Hepatitis A
vaccine series at same time. There are no current
recommendations for an accelerated schedule.
Dose of immune serum globulin: 0.02 ml/kg body weight
IM for trip less than three months. If longer trip, give 0.06
ml/kg IM.
Prolonged viral shedding reported in HIV+ patients with
acute Hep A
NY/NJ AETC Stuart Haber, MD
HEPATITIS B
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Know immune status prior to travel
Risk to international travelers
generally low
Must warn susceptible patients of
sexual risk of acquisition
Consider extra doses of vaccine if
patient a non-responder (Rey et al
Vaccine 2000 Jan 18; 18(13):11615)
NY/NJ AETC Stuart Haber, MD
MENINGOCOCCUS
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Endemic to sub-Sahara Africa during
the dry season, occasional epidemics
reported elsewhere
Vaccine required for annual Hajj in
Mecca
Very scant information on HIV and
disease. No mention on efficacy of
vaccine in HIV infection
NY/NJ AETC Stuart Haber, MD
JAPANESE ENCEPHALITIS
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Caused by a flavivirus, transmitted by mosquito
Endemic to rural areas of SE Asia, varies often with season
Most cases are subclinical. Symptomatic disease presents
as an acute encephalitis-- seizures, paralysis, coma,
death; prolonged recovery in survivors and permanent
brain injury in some
It is a rare disease of travelers
Killed vaccine recommended for travelers with prolonged
stays in endemic areas
Vaccine occasionally causes severe allergic reaction
requiring emergent care
One study demonstrating reduced antibody titers in HIV+
children vaccinated with JE vaccine
Alteration in presentation of illness in HIV-infected people
not known
NY/NJ AETC Stuart Haber, MD
POLIO
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Most world transmission currently in
south Asia and sub-Sahara Africa
Only inactivated polio vaccine (IPV)
available in the USA
Usually give one adult dose, unless
primary series never done or
completed
NY/NJ AETC Stuart Haber, MD
OTHER VACCINES
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Typhoid: two vaccines available: one live and one
killed-use only the latter in HIV+ patients.
Typhim Vi has lower antibody response rate in
patients with less than 200 CD4+ T lymphs
(Vaccine 1999 Aug 6;17(23-24):2941-45)
Influenza-year-round endemicity in the tropics
and April - September in southern hemisphere.
No recommendations on revaccinating prior to
travel
Diptheria/Tetanus
Pneumococcus
NY/NJ AETC Stuart Haber, MD
PENICILLIUM MARNEFFEI
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Fungal infection endemic to SE Asia,
acquired by inhaling spores
Opportunistic infection in AIDS
Chronic illness with fever, weight loss,
anemia, generalized lymphadenopathy,
hepatomegaly, umbilicated papules. Other
organ systems can also be involved.
Diagnosis:bone marrow, skin lesion, blood
culture
Treatment: Ampho B, followed by
itraconazole
NY/NJ AETC Stuart Haber, MD
NY/NJ AETC Stuart Haber, MD
VISCERAL LEISHMANIASIS
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Protozoan parasite transmitted by sandflies
90% world cases acquired in India, Bangladesh,
Sudan, Nepal, Brazil; and also endemic in
Mediterranean countries
Typically a chronic illness with prolonged
incubation period. Typically have
hepatosplenomegaly, fevers, weight loss
In AIDS, worse cytopenias, and atypical
presentations: pleuropulmonary, GI
Serologic tests less sensitive in AIDS
Lower treatment response in AIDS
HAART and secondary prophylaxis improves
survival
NY/NJ AETC Stuart Haber, MD
TUBERCULOSIS
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Know PPD status prior to trip
Repeat PPD after return, especially
after prolonged trip.
Risk of acquisition might be much
higher in health care setting
NY/NJ AETC Stuart Haber, MD
APPROACH TO THE RETURNING
HIV-POSITIVE TRAVELER
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Review dates and itinerary
More aggressive evaluation of asymptomatic
patient if visit to developing areas was prolonged
For symptomatic patients, check incubation
periods for the more common diseases of
travelers:
Short (less than one week):bacterial diarrhea,
Cryptosporidium, hemorrhagic fevers
Medium (up to one month): Giardia,
Entamoeba, Malaria, Salmonella typhi,
leptospirosis
Long: Malaria, Visceral leishmaniasis, viral
hepatitis, amoebic liver abscess, Schistosomiaisis
NY/NJ AETC Stuart Haber, MD
EOSINOPHILIA
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May see this anyway in HIV-infected
persons
However, in setting of travel to
indigenous areas, helminthic
infections should be looked for in
fecal smears
NY/NJ AETC Stuart Haber, MD
SUMMARY
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Precautions generally same for HIV and non-HIV infected
travelers
Decisions regarding live vaccines are very weighted to
patient’s immune status
May anticipate lower response to all vaccines and hence
increased risk of disease
Incomplete information currently on need for dose or drug
changes for malaria prevention in patients taking ritonavir
Patients taking proper precautions and not severely
immunocompromised should do well.
Sometimes, travel itinerary should be modified to avoid
potential exposures
Differential diagnosis of illness in returning HIV-positive
traveler can be very broad both in short term and long term
follow-up
NY/NJ AETC Stuart Haber, MD