Transcript “What Shots Do I Need?”An approach to pre

“What Shots Do I Need?”
An approach to pre-travel counseling
Omar A. Khan, MD MHS
[email protected]
Disclosure
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No drug company has given me massive
amounts of money to promote this talk (or
any other)
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No other conflicts of interest
Overview
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Much of the advice herein applies to the
developing (“tropical”) setting where
diseases of sanitation, poverty and
environment are more common than in
industrialized settings
Focus today is on pre-travel counseling, not
on Dx and Rx of tropical diseases
Overview
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So the short version, for those who have patients only
traveling to Western Europe (and yes, you can leave
after the section on Air Travel) --
– Look to the right when crossing the road
– Don’t confuse soccer and football
– Avoid getting jealous at their long vacations (remember
how much they pay in taxes and for gas)
– Learn to drive stick and to get out of the fast lane in
Germany
– Avoid debates on who has the better health care system.
Unfortunately, you will probably lose the argument…
Overview
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Common travel risks
Common conditions
Travel counseling framework
What to vaccinate for
What to prophylax against
Special situations
Resources
Travel risks
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Travel statistics
– Increasing people travel each year
– Destinations becoming more exotic
– Most illness during travel is diarrheal
– 2nd most common illness is non-tropical, e.g. DVT, MI, etc. So
make sure general preventive care is UTD
– Travel-related deaths only 1-4%
– >50% deaths during travel are from chronic disease issues
(CV– MI, CVA etc.)
– Remainder: MVA, drowning, falls, accidents
Travel risks
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Travel statistics
– Over 700 million trips internationally each year (2004)
– Over 28 million Americans travel abroad each year (2005)
 Western Europe 40%
 Eastern Europe 4%
 Caribbean 18%
 South America 9%
 Central America 7%
 Africa 2%
 Middle East 4%
 Asia 19%
 Australia 2%
Travel risks
– For every 100,000 travelers to developing
countries:
– 50,000 will have a health problem.
– 8,000 will have to visit a physician.
– 5,000 will have to stay in bed.
– 1,100 will be completely incapacitated.
– 300 will be hospitalized.
– 50 will be air evacuated.
– 1 will die.
Travel risks
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Un/Common infectious travel-related conditions
(per month of stay in developing country)
Diarrheal (30%)
 Respiratory (2%)
 Malaria (2%)
 Hep A (0.5%)
 Gonorrhea (0.5%)
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Travel risks
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The most common concerns remain, predominantly,
conditions they could have acquired anywhere
Multiple (hundreds of) uncommon conditions abound
which are impossible to cover in pre-travel counseling
Their being uncommon still means general principles
will likely cover them
The most exotic stuff is also the least likely, so don’t
worry too much about Ebola
Why include travel counseling in primary care?
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More people traveling
Resources available
Referral for unusual scenarios
Reimbursable
Patients see it as a primary care issue, and so
should we: spans adult, pediatric, emergency,
and ob/gyn areas
Good way to keep up on the literature if
working in global health oneself
Approach to travel counseling
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Assessment of Risk based on
– Not only on countries of travel, but subregions
– Also on what the participant will do there
General preventive principles
 Specific concerns
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Typical travel counseling questions
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Where are you going?
What is the purpose of travel?
How long will you be there for?
Will you be in the city or the country?
Hotel, home, or camping?
Form an assessment of awareness and of
risk
Travel counseling questions
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Have you seen your other relevant
doctors (e.g. coumadin clinic, cardiologist,
pulmonologist, dentist?)
Make a follow-up (cancelable)
appointment a couple of days after the
traveler returns to address any concerns
Travel Advice
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Be careful
Have fun
But not too much fun
Travel Advice
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Choose an appropriate
travel companion
Travel Advice
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And leave the furs at
home
Coding for US physicians*
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Code 99403 for a preventive medicine counseling visit
lasting approximately 45 minutes.
Also bill the vaccine administration code 90471 for one
vaccine and 90472 for each additional vaccine.
– E.g., if you administer three vaccines, you would code
90471 once and 90472 twice.
– If the patient is under 8 years of age, you should submit
90465 and, when appropriate, 90466, instead
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Code separately for the actual vaccine products: e.g.,
90717 for yellow fever and the appropriate code from
90690-90693 for typhoid.
*Talk to your coder or bus. mgr. My ref: AAFP/ FPM Oct. 2005
General Preventive Principles
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Plan ahead: figure out medical and other
backup resources
Leave copies of itinerary with family/physician
Consider travel insurance
In the plane:
Hydrate, ambulate, avoid alcohol
 Anxiolytic?
 Melatonin?
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General Preventive Principles
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Boil water/milk and avoid iced drinks
Peel fruit/vegetables
NEVER trust tap water
– Boiled > ‘bottled’ > ‘purified’ >‘filtered’
– Yes, even for brushing, especially for
kids
Avoid mosquitoes
Don’t walk barefoot on the beach
Don’t swim if the lake says ‘Bilharziafree’. It’s not.
Backyard ‘bottling plant’ in Beijing
Filtering the water in Pakistan
General Preventive Principles
Reiterate common-sense advice which
would apply here as well:
– Don’t have unprotected sex
– Wear your seat belt
– Avoid bats, rodents, wild dogs and other
carriers
– Seek medical care if sick
– Use the travel insurance you’ve paid for if
you’re really sick
Yes, OK, but what shots do I need?
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To figure this out, need to know:
– A) the distribution of diseases in the area traveled
to (see www.cdc.gov/travel)
– B) the likelihood of contracting those disease (see
resources at the end)
– C) what can actually be prevented safely for this
particular traveler
– Don’t go overboard- visitors to the US don’t worry
unduly about our major public health issues….HIV,
TB, hepatitis, road traffic accidents, tobacco, etc.
Yes, OK, but what shots do I need?
Maybe none if you’re careful!
 Very few mandated vaccinations:
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– Yellow fever vaccination before entering and
when coming from a YF endemic country
(even if in transit)
– YFV vaccination certificate is valid for 10
years
– Meningococcal vaccination before going on
the Muslim pilgrimage (Hajj) to Saudi Arabia
Yes, OK, but what shots do I need?
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CDC on the Yellow Fever vaccine
– < 1/3 of those traveling to endemic areas
get it
– ‘All those who have got YF in the last 10
years have died’
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CDC on Malaria
– >50% ask about it, but less than half that
follow the advice.
Yellow Fever Vaccine
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Attenuated virus
Good for 10 years
Get stamped yellow certificate to show when entering a
YFV-endemic country, or when entering any country
after having been to YFV area
Given at approved clinics (see list at
www.cdc.gov/travel)
YFV in pregnancy “INDICATED IF EXPOSURE CANNOT
BE AVOIDED” CDC Yellow Book
HIV – avoid YFV but can give if high risk and CD4 >200
Avoid mosquitoes!
Yellow Fever Areas
Hajj
Hajj
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2 M Muslims from 140 countries annually to Saudi
Arabia
Crowding = ID and non-ID risks
Facilities are generally sanitary and reasonable standard
Req: Flu, pneumococcal (for >65) and meningococcal
(>3 wks and <3 yrs prior to travel)
Rec: Hep A, Hep B, Typhoid
Cipro prophylaxis prior to return home has been
suggested but not implemented (for meningitis)
www.saudiembassy.net has more information on annual
requirements.
No, they do not accept requests to lower oil prices.
Specific concerns (brief overview to prepare your
patients for what they might face)
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Food/Water-Borne- Diarrhea, Typhoid, Hepatitis
Insect-Borne- Malaria, Dengue
Respiratory- Viral, bacterial, TB
Injuries- Mind the gap, and the rickshaw
STDs+blood-borne- Just (don’t) do it: gonorrhea,
syphilis, HIV, hepatitis
Other- e.g., Schisto, Typhoid, CLM
Water-Borne: examples of intestinal parasites
Ascariasis
How can you stay mad at this face?
Hookworm
Water-Borne: examples
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Intestinal parasites
All transmitted, generally, by fecal-oral transmission
(except hookworms whuch also go through skin)
Worldwide distribution
– Hookworms (Necator and Ancylostoma spp.)
 (A. caninum also causes CLM - addressed later)
– Tapeworms:
 Taenia saginata: Beef tapeworm
 Taenia solium: Pork tapeworm and cysticercosis
 Echinococcus: cystic hydatid disease
– Roundworms:
 Ascaris and Trichuris spp.
Water-Borne: examples
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Viruses
– Self-limiting; ORS/ORT adequate
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Bacteria
– All transmitted, generally, by fecal-oral
transmission (except hookworms which also go
through skin)
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Parasites
– Entamoeba histolytica (amebiasis)
Water-Borne: examples
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Bacteria
– ETEC, Campylobacter, Cholera, Shigella,
Salmonella (in kids and adults)
– Among kids, those old enough to crawl are at
highest risk of catching
– Youngest at highest risk of dehydration
Water-Borne: prevention
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But none of that really matters much for pretravel
General principles:
– Most watery and non-bloody diarrhea is self-limiting;
use ORS/ORT to avoid dehydration
– Bloody diarrhea, generally, can be considered treatable
with antimicrobials
– Use basic prevention principles mentioned earlier
– Continue breastfeeding
Water-Borne: treatment
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All-purpose empiric treatment regimens:
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Bacterial: Ciprofloxacin (for adults), macrolide e.g. azithro for kids
Amebiasis, Giardia: Metronidazole (no alcohol)
Worms: Mebendazole (Vermox). Not in <2 y.o. or BF
Stay away from antimotility agents in general (e.g. loperamide)
May consider advance prescription if sufficient risk is
present
Counsel to only take IF appropriate sx develop, NOT as
malaria-style chemoprophylaxis
See Vaccines section
Vectors and their diseases
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Aquatic snails: Schistosomiasis (Bilharziasis)
Blackflies: Onchocerciasis (River blindness)
Fleas (via rats, to humans): Plague
Mosquitoes: Dengue, yellow fever (Aedes); Malaria,
lymphatic filariasis (Anopheles); Japanese encephalitis,
filariasis, West Nile fever (Culex)
Sandflies: Leishmaniasis (concern in Middle East)
Tsetse flies: African trypanosomiasis (sleeping sickness)
Triatomine bugs: American trypanosomiasis/Chagas’
disease
Ticks: Lyme; borreliosis; Q fever; encehpalitis; tularemia;
Crimean-Congo hemorrhagic fever
Insect-Borne
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Malaria by far the most common
– Transmitted by night-biting mosquitoes
– Average of 40 cases in returned US travelers
– Worldwide
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Dengue
– Transmitted by day-biting mosquitoes
Malaria map- Western hemisphere
Malaria map: Eastern hemisphere
Insect-Borne: prevention
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Repellents: DEET-type most common; avoid
ingestion or contact with mucus membranes
Long sleeves
Bednets: excellent protection esp. when
impregnated with repellent
Locally available resources:
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Coils (pyrethroid-impregnated)
Mats
Sprays/insecticides (“Flit”, etc.)
Air conditioning cuts risk
A very fancy bednet
Insect-Borne: prophylaxis for malaria
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Recommended only for malaria (P. falciparum, vivax,
ovale, malariae)
Present in 100+ countries (but not in all cities of those
countries)
12-15000 travelers get malaria annually
Fever within 10 weeks of return from endemic area
should cause concern
Fever less than 7 days of first possible exposure is almost
never malaria
Falciparum malaria is the most dangerous and has the
most resistance
Insect-Borne: prophylaxis for malaria
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All the quinine derivatives should be used with care with
other Q-T prolongers
Chloroquine: 1 week prior to travel through 4 weeks after
return. OK for breastfeeding, pregnant, young kids.
Problems: may worsen psoriasis
Mefloquine (Lariam): 1 week prior to travel through 4
weeks after return. OK for BF; limits on kids and
pregnancy. Problems: psychiatric or convulsive disorders
Doxycycline: 1 day prior to travel through 4 weeks after
return. NO to BF/kids/pregnancy. Problems: sunburn;
vaginal yeast infections; liver dysfunction
Atovaquone/proguanil (Malarone): 1 day prior to travel
through 7 days after return. Unknown for
kids/BF/pregnancy.
Insect-Borne: prophylaxis for malaria
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If considering Primaquine (anti-relapse Rx against P.
ovale and P. vivax): consult with CDC or travel clinic.
Many contraindications: G6PD deficiency, pregnancy,
lactation
Suggested Algorithm for Pediatric Malaria
Chemoprophylaxis
No
Chloroquine Resistant Area
CQ
YES
Mefloquine Resistant Area,
Seizures or psychiatric disease
YES
Doxycycline (>8 years)
Malarone (>11 Kg)
No
MFQ (>5 Kg)
Insect-Borne: treatment
Chemprophylaxis does not usually apply to
treatment of other vector-borne diseases
 Rx should be carried out in consultation
with appropriate resources (whether incountry or on return) so will not be covered
here
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Japanese Encephalitis (ever reported)
Dengue (ever reported)
Respiratory
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Unprecedented levels
of pollution can be
reliably expected to
trigger reactive airway
disease in those with a
predisposition
Respiratory
Ten most polluted cities in
the world:
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Linfen, China
Tianying, China
Sukinda, India
Vapi, India
La Oroya, Peru
Dzerzhinsk, Russia
Norilsk, Russia
Chernobyl, Ukraine
Sumgayit, Azerbaijan
Kabwe, Zambia
Respiratory
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Ten cleanest cities in the world
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Calgary
Honolulu
Helsinki
Ottawa
Minneapolis
Oslo
Stockholm
Zurich
Respiratory
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Unprecedented levels of pollution can be reliably
expected to trigger reactive airway disease in those
with a predisposition
Carry inhaled medications and antihistamines/
decongestants
Influenza vaccination is recommended year-round
Much of the developing world has TB, but as long as
patient is not directly exposed to active TB, risk should
be low
Similar decision-making applies abroad when
distinguishing viral from bacterial process (sinusitis,
bronchitis, pneumonia)
Injuries
>2 million killed in traffic accidents
worldwide each year
 Seat belts, and their usage, is spotty at
best
 Unless very familiar with the local driving
situation, do not drive
 Unless wishing to be very familiar with the
afterlife, do not take the bus…
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Before….
After.
Injuries
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Other tourist injuries (less common)
involve violence (muggings, carjackings)
and natural accidents (falls, drownings)
STDs
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Sexual tourism is real
Latex condoms are reasonably
safe but high-risk sex should be
discouraged
Risk of HIV and hepatitis (B
and C in this case) may be
much higher than in the US
In addition, gonorrhea,
chlamydia, syphilis are more
common
– (Unless you’re from Baltimore)
Other
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Other- e.g., Schisto, Typhoid, Cutaneous
Larva Migrans
– Specific risks exist at the individual country
level but do not warrant chemoprophylaxis
– E.g.
Avoid swimming in schisto (bilharzia) areas
 Avoid walking barefoot in the beach
 Follow safe hygiene practices
 Communicate above to kids as well
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CLM eruption
Things aren’t always what they seem….
21 y.o FEMALE BACK
FROM A MEXICAN
VACATION 3 DAYS
EARLIER PRESENTED
WITH PAINLESS
LINEAR AND
SERPIGINOUS LESIONS
ON HER LEGS. SHE
HAD NO SYSTEMIC
COMPLAINTS. SHE HAD
BEEN LYING ON THE
BEACH.
THE DIAGNOSIS IS:
It’s not cutaneous larva migrans….
• PHYTOPHOTODERMATITIS CAUSED BY
PHOTOSENSITIZING PSORALEN-CONTAINING
COMPOUNDS IN THE LIME PEEL.
• LIME WEDGES STUCK ON HER BEER GLASS -> LIME
SKIN PSORALENS DRIPPED DOWN THE SIDE OF THE
GLASS WITH WATER CONDENSATION AND DRIPPED
ON HER LEG = LOCAL SUNBURN!
Vaccines
Vaccines and the diseases they prevent
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Anthrax
Diphtheria
Hepatitis A
Hepatitis B
H. influenzae b
(Hib)
Human
Papillomavirus
(HPV)
Influenza (Flu)
Japanese
Encephalitis (JE)
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Measles
Meningococcal
Monkeypox
(sort of)
Mumps
Pertussis
Pneumococcal
Poliomyelitis
Rabies
Rotavirus
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Rubella (German
Measles)
Shingles (Herpes
Zoster)
Tetanus (Lockjaw)
Tuberculosis
Typhoid
Varicella
(Chickenpox)
Yellow Fever
The common vaccines: Don’t forget…
…the vaccines of childhood in the US
 …boosters when appropriate for
tetanus/diphtheria
 …the flu shot
 Meningococcus, Hep A/B, Rotavirus
 Influenza
 Age-related:
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– Pneumococcus, Zostavax, Gardasil
The common vaccines: Don’t forget…
KEY
Range of ages
High-risk
groups
The common vaccines: Don’t forget…
KEY
Range of ages
High-risk
groups
You can’t vaccinate kids against everything…
The less common vaccines
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Hepatitis A (if unvaccinated as child), IM
– Inactivated virus
– Preferably given 2 weeks prior to travel
– Approved for children over 1 year old
– TwinRix= Hep A + Hep B
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Typhoid
– CDC recommends > 3 weeks in endemic area or high risk
– Oral (Vivotif), live attenuated, 4 doses:
 6 years and over
 Must be able to swallow pills
– Parenteral (Typhim Vi), polysaccharide, 1 dose:
 2 years and over
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Yellow Fever (discussed earlier)
The really uncommon vaccines
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Japanese Encephalitis: inactivated live virus; only if traveling
to JE-endemic areas; not < 1 y.o.
Rabies: India relatively high risk. Expensive vaccination.
Post-exposure vaccination/Ig is recommended
Anthrax: only for high-risk occupations e.g. military
Cholera: killed; not generally recommended; only partial,
transient protection
‘Pigbel’ (enteritis necroticans): inactivated C. perfringens
given to kids in Pacific islands eg Papua New Guinea
Lyme disease: LymeRix pulled in 02
You don’t always need vaccines
Vaccines and prophylaxis in the pipeline
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ETEC
Parainfluenza
RSV
Dengue
Schistosomiasis
Shigella
…..and, wishfully, HIV and malaria
+ New meds for malaria
Special populations
Young children
 Pregnant women
 Immunocompromised individuals
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Special populations: Young children
No travel in the first week of life
 No travel to malaria-endemic areas
 Chloroquine is OK (weight dosed)*
 Mefloquine (Lariam) OK after 5 kg*
 Doxycycline – not under 8 years of age
 Atovaquone/proguanil (Malarone)- not
under 11 kg
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*Bitter.
Special populations: Pregnant women
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WHO recommends no travel after 32 weeks
Airline may have specific requirements
Carry letter from FP/OB verifying dates and
condition
Pre-travel consultation and communication with
the obstetric provider (if not the same as the
family physician) is recommended
Special populations: Pregnant women
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No live vaccines, e.g. Yellow fever, MMR, BCG
Malaria:
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Avoid travel to malaria-endemic areas
Chloroquine is OK
Mefloquine is OK in trimesters 2 and 3
Avoid pregnancy for 3 months after mefloquine is
stopped, and 1 week after doxycycline is stopped
Special populations: Immunocompromised (e.g. HIV+)
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In general, vaccination is safe in asymptomatic
individuals
Careful with live vaccines
 E.g., yellow fever and measles vaccine
should be given in asymptomatic but not
symptomatic
Be especially careful of infections e.g. diarrheal
illnesses (crypto), tuberculosis
What to pack
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Meds in hand luggage (e.g. insulin); check with airlines
about needles/liquids
Emergency kit items suggestions
– Bandage, tape, scissors
– Thermometer
– Prophylactic meds, condoms, OCPs
– Water purification
– Insect repellent
– Anifungal cream
– Antipyretic, decongestant, antihistamine
– Med list / conditions/ Allergies in Red
– Epi Pen if needed
– Condition-specific supplies
Getting sick abroad
Refer to list of approved providers
 US Embassy
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– if you’re in Libya or Iran, good luck
– if you’re in Cuba, mention Michael Moore to
get free care?
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See treatment center (immediately if
febrile and in a malarial area)
Biased observations
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Basic counseling can be provided by the majority of
family physicians
Consultation is available from other FPs and travel
medicine specialists (who are usually, but not
always, ID physicians)
General prevention, common sense, and being up to
date on the US vaccination schedule (and yellow
fever, if needed) is the most important
Malaria prophylaxis is second
Selected vaccination is next (Hep A and Typhoid are
the only ones most people should consider; even
then, they may not be needed)
Final recommendations
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Keep the CDC travel website on bookmarks
Keep a ready list of countries and vaccination
requirements/malaria recommendations
Keep price list of vaccines (insurance does not
usually cover the non-schedule ones), as well
as a list of pharmacies which carry them
Final recommendations
Patient Links
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CDC www.cdc.gov/travel
WHO www.who.int/ith
International SOS 215-245-4707
www.internationalsos.com Med-evac / medical insurance
Medjet Assist 800-963-3538 www.medjetassist.com
US Dept. of State
www.travel.state.gov/travel/warnings.html travel
warnings, consular information sheets, public
announcements
References
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www.CDC.gov/travel
International Travel & Health, World Health Organization
Control of Communicable Diseases Manual. American Public Health
Organization/WHO.
Possick SE. Ann Intern Med. 2004. Evaluation and Management of the
Cardiovascular Patient Embarking on Air Travel.
Gendreau MA. NEJM. 2002. Responding to Medical Events During
Commercial Airline Flights
Keystone JS, et al. Travel Medicine. Mosby; 2004
Air travel and transportation of patients: a guide for physicians, 2nd edition.
Jong EC and McMullen R, eds. The Travel and Tropical Medicine Manual.
Saunders/Elsevier.
ASTMH’s list of travel clinic and trop med/ travel health courses:
www.astmh.org
PROMED www.promedmail.org-daily /postings of disease outbreaks
worldwide
ISTM: International Society of Travel Medicine www.istm.org
UVM/FAHC Travel Clinic
Closing thoughts:
Choose your destinations wisely