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BELGIANCONSENSUS MEETINGon TRAVEL MEDICINE

June 20, 2014

Belgian Scientific Study Group on Travel

Medicine

Pr. A. Van Gompel (ITG)Pr. F. Jacobs (Hôp. Erasme, ULB)

Pr. P. Lacor (UZ-Brussel) Dr. Ph. Leonard (CHU-ULg)

Pr. W. Peetermans (U.Z. - K.U.Leuven) Pr. S. Callens(UZ.- U.Gent) Dr. S.Quoilin (iph.fgov.be)

Dr.P. Soentjens (Belgian Defence)Pr. B. Vandercam (CHU. St. Luc, UCL)

Pr. Y. Van Laethem (CHU. St. Pierre, ULB)PART 2 version 05/11/2014

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REPORTBELGIAN CONSENSUS MEETING on TRAVEL MEDICINE

June 20, 2014 – PART 2

2014

• The consensus meeting was chaired by A. Van Gompel• Secretary of the meeting was Y, Van Laethem• A preliminary PowerPoint, prepared by A. Van Gompel,

was presented• The discussion and recommendations of the

meeting are included in this finale presentation.• The ESSENTIAL SLIDES (pdf-version) & the

CONSENSUS BROCHURE (in Dutch and French) highlighting the proposals for changes will been sent to all participants. May be used for teaching.

• These documents will serve as a proposal for approval by the governmental Belgian Health Council – section Vaccinations, on 26-06-2014

• Responsable final redaction : A. Van Gompel

PART 1• 1.a - Vaccination for Yellow Fever• 1.b - Malaria

PART 2• 2.A - Other vaccinations• 2.B - TD, other infections, …., • 2.C - VARIA

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Basic Vaccinations - Tetanus-diphteria-pertussis- Poliomyelitis- Measles mumps rubella

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Tetanus-Diphtheria-Pertussis

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Primovaccinatie met dTp(a) ? In de bijsluiter wordt de primovaccinatiemet het dTp(a)-vaccin niet vermeld.Ook de aanbeveling van de HogeGezondheidsraad vermelden daaroverniets.Een studie uit 2007 onderzocht bijvolwassenen ouder dan 40 jaar die devoorbije 20 jaar geen tetanus of difterievaccinhadden gekregen of waarvan devaccinatiestatus onbekend was, de efficiëntievan dTp(a) en dTp(a)-IPV-vaccins.Eén maand na de toediening van 3 dosissen,bedroeg het niveau van beschermendeantistoffen 99%. Bij gebrek aan dT kan dTp(a) dus worden gebruikt voor primovaccinatie. Indien ook bescherming tegen polio nodig is, kan dTp(a)-IPV gebruikt worden

Primovaccination avec le dTp(a) ?

Ni la notice, ni les recommandations duConseil Supérieur de la Santé ne mentionnentla possibilité d’une primovaccinationavec le dTp(a).Cependant, une étude publiée en2007 a montré chez 99% des vaccinésl’obtention de taux séroprotecteurscontre le tétanos et la diphtérie après uneprimovaccination à l’aide du dTp(a) (3doses), chez des adultes de plus de 40ans (en absence de données vaccinalesou avec un dernier rappel datant de plusde 20 ans).En cas d’indisponibilté du dT, par exemple lors d’une rupture de stock, l’administration du dTp(a) pourrait donc être utilisé en primovaccination. En cas de nécessité d’une protection contre la poliomyélite, dTp(a)-IPV peut être utilisé,

Theeten H et al, Primary vaccination of adults with reduced antigen-content diphtheria-tetanusacellular pertussis or dTpa-inactivated poliovirus vaccines compared to diphtheria-tetanus-toxoid vaccines. Current medical research and opinion. Vol. 23, n° 11, 2007 : 2729-2739.

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POLIO

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POLIO

• SEARO/WHO South-East Asia: Press release 26 March 2014 :

WHO South-East Asia Region certified polio-free

2014

• WHO Polio Eradication Initiative http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

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WHO 29-04-2014

WHO 29-04-2014

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2014

http://www.who.int/mediacentre/news/statements/2014/polio-20140505/en/

WHO 05-05-2014

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• …… declared the international spread of wild poliovirus in 2014 a Public Health Emergency of International Concern (PHEIC).

• …… the Committee’s advice – for ‘States currently exporting wild

polioviruses’ and – for ‘States infected with wild poliovirus but not

currently exporting’ ….. • …. issued them as Temporary

Recommendations under the IHR (2005) to reduce the international spread of wild poliovirus, effective 5 May 2014

• reassessment of this situation in 3 months

WHO 05-05-2014

ECDC 28/05/2014

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(= PHEIC).

ECDC 28/05/2014

since august 2014 also Equatorial Guinea

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Imovax Polio ®

Revaxis ® & Boostrix IPV ® =also Polio

Clearly mention that this is polio-vaccination

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Travel Vaccinations

1. Hepatitis A 2. Hepatitis B 3. Typhoid fever4. Rabies5. Meningococcal meningitis6. Japanese encephalitis7. TBE - FSME

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HEPATITIS A

Immunodepressed traveler should – if possible - receive the complete series

(2 / 3 doses) before leave(+ antibodytiter)

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Results: • The final study population consisted of

53 patients treated with • TNFi (n 15),TNFi & MTX (n 21) or MTX (n 17)

months after the 1st dose % of the patients that had attained seroprotection

1  10%6  33%months after the 2nd dose1  83%6  72%

at month 24 86%

Conclusions: • Two doses of hepatitis A vaccine at a 6-

month interval provided protection for most immunosuppressed RA patients.

• A single dose does not seem to afford sufficient protection to this group of patients.

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HEPATITIS B

Immunodepressed …..

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INFLUENZA

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TYPHOID FEVER

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Cochrane 2014

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Cochrane 2014

IDSA 2012 conference poster 251 2012

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2012

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MENINGOCOCCAL MENINGITIS

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Promedmail 20 May 2014• The new vaccine MenAfriVac® is manufactured by

Serum Institute of India Ltd. and was developed for the meningitis belt through the Meningitis Vaccine Project, a partnership between WHO and PATH, funded by the Bill & Melinda Gates Foundation.

• …… since the introduction of the meningococcal A conjugate vaccine in countries of the African meningitis belt in 2010, the WHO noted a decrease in the number of cases of meningitis; in fact, the number of cases in 2013 was the lowest recorded during the epidemic season in the last 10 years (http://www.who.int/csr/don/2013_06_06_menin/en/).

• In addition, Neisseria meningitidis serogroup A was noted to be no longer the predominant pathogen.

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Lancet 2014

CID_13

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LID 2012

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RABIES

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2013

From 31- 05 - 2013 on:no booster after 1 year or later is advisedanymore for at least 20-30 yearsafter the basic series of 3 shots (1-7-21/28) in persons with normal immunity

2012

Accelerated schedule off label

• Accelerated schedules (D1, D4, D8) • not licenced = off label• To be discussed with the client

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NECTM 5 Bergen Norway 2014 Jelinek LECTURE & POSTER

accelerated pre-exposure purifiedChick-embryo cell-culture rabies

vaccine for travelers

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2014

The percentages of subjects with RVNA levels ≥ 0.5 IU/mL at7 days after the last active vaccination were

100% (R/JE-Acc) and 99% (R-Conv).

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As expected, a faster decrease in RVNA antibody titers was observed inthe accelerated group than in the 2 conventional schedule groups(Figure 2A).

Irrespective of vaccination regimen, strong short-term immune responsesup to day 57 were observed, with percentages of subjects with adequateantibody titers above 95% at all time points in all groups as soon as 2weeks after the first vaccination (Figure 2B).

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TO DOWNLOAD http://www.sbimc.org/1-Rabies-Soentjes.pdf

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TO DOWNLOAD http://www.sbimc.org/1-Rabies-Soentjes.pdf

Future

accelerated & intradermal rabies vaccination

(Soentjes et al. ,,,)

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JAPANESE ENCEPHALITIS

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Accelerated schedule off label

• Accelerated schedules (D1, D8) • not licenced = off label• To be discussed with the client

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NECTM 5 Bergen Norway 2014 Jelinek LECTURE & POSTER

accelerated JE vaccine for travelers

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Former slides

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Japanese encephalitis (Ixiaro®)

• 2013 : Ixiaro from the age of 2 months on• CISTM 13 Maastricht : “Based on modeled

data, we expect protection to last for at least 4 years in 95% of vaccinees”

2013

Japanese encephalitis (Ixiaro®)

• The standard scheme requires 2 injections, separated by one month. Afterwards, the traveler remains boostablewhich means that a booster dose can be given after 12-24 months – (later boosters ? 3-5 years ?)

• When the patient was vaccinated with Jevax® previously the consensus meeting gives the advice to use two doses of Ixiaro® when Jevax® dates from five years back or more.

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TBE FSME

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2013 2014

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PART 1• 1.A - Vaccination for Yellow Fever• 1.B - Malaria

PART 2• 2.A - Other vaccinations• 2.B - TD, other infections, …., • 2.C - VARIA

2014

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Quid role in travel medicine ?

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Racecadotril Tiorfix& Aanpak in de eerste lijn van acute diarree bij het kind

RECENTE INFORMATIE OKTOBER 2012

• Racecadotril (Tiorfix®; hoofdstuk 3.6.4.) is een antidiarreïcum dat in het buitenland gecommercialiseerd is sinds 1993;

• het gaat om een inhibitor van de enkefalinasen (enzymen verantwoordelijk voor de afbraak van bepaalde endogene opioïden, de enkefalines), vooral ter hoogte van de darmmucosa.

• Racecadotril heeft een perifere werking met vermindering van de intestinale hypersecretie.

• De posologie vermeld in de Samenvatting van de Kenmerken van het Product (SKP) is bij volwassenen 100 mg, gevolgd door 100 mg 3 maal per dag, en bij het kind ouder dan 3 maanden 1,5 mg/kg, 3 maal per dag.

• De voornaamste ongewenste effecten zijn secundaire obstipatie en hoofdpijn.• Racecadotril is gecontra-indiceerd bij aanwezigheid van koorts en bloederige of

slijmerige ontlasting (acute dysenterie). • In de vergelijkende studies met loperamide (een opiaatderivaat en remmer van de

intestinale peristaltiek) hadden beide behandelingen een gelijkaardige doeltreffendheid, waarbij de diarree-episode slechts met een paar uur verkortte.

• Men moet voor ogen houden dat de aanpak van acute diarree vooral gebaseerd is op rehydratiemaatregelen, en dat antidiarreïca slechts een zeer beperkte plaats hebben, vooral bij jonge kinderen. De vormen voor gebruik bij kinderen zijn voorschriftplichtig.

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Le racécadotril ( Tiorfix®; chapitre 3.6.4.) est un antidiarrhéique commercialisé à l’étranger depuis ‘93;

• il s’agit d’un inhibiteur des enképhalinases (des enzymes responsables de la dégradation de certains opioïdes endogènes, les enképhalines) particulièrement au niveau de la muqueuse intestinale.

• Le racécadotril exerce une activité périphérique en diminuant l’hypersécrétion intestinale.

• La posologie mentionnée dans le Résumé des Caractéristiques du Produit (RCP) est chez l’adulte de 100 mg suivie de 100 mg 3 x par jour, et chez l’enfant âgé de plus de 3 mois de 1,5 mg/kg, 3 x par jour.

• Ses principaux effets indésirables consistent en de la constipation secondaire et des céphalées.

• Le racécadotril est contre-indiqué en présence de fièvre et de selles glaireuses ou sanglantes (dysenterie aiguë).

• Dans les études comparatives avec le lopéramide (un dérivé des opiacés, freinateur du transit intestinal), les deux traitements avaient une efficacité comparable, ne diminuant que de quelques heures l’épisode diarrhéique.

• Il faut garder à l’esprit que la prise en charge de la diarrhée aiguë repose avant tout sur des mesures de réhydratation, et que les antidiarrhéiques n’ont qu’une place très limitée, en particulier chez les jeunes enfants. Les formes de racécadotril destinées à l’usage chez l’enfant sont soumises à prescription.

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Chikungunya

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Eurosurveillance, Volume 19, Issue 28, 17 July 2014

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Dengue

New WHO map

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Hajj

19/09 – 12/10 2014

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Kingdom of Saudi Arabia Ministry of Health

Health Regulations for travellers to Saudi Arabia for Umrah &

Pilgrimage (Hajj)-1435 (2014).

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No change of the advice in 2014

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Former slides

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2012

http://www.who.int/wer/2013/wer8832.pdf

Varia– Hajj 2013

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Varia– Hajj

MEKKA http://www.hajinformation.com/main/p3001.htm -

• meningococcal vaccine remain obligatory• influenza vaccine remain imperatively

advised

2013

General advice for Mecca pilgrims -required/recommended vaccines• Vaccination with a tetravalent, conjugated ACYW135

meningococcal vaccine is required to obtain a visa.

• Available vaccines in Belgium: Nimenrix® and Menveo®

• The unconjugated 4-valent meningococcal vaccine is not available anymore in pharmacy (July 2013) – it might still be available in the travel clinics and be used in pilgrims

• It remains unclear if children till the age of 2 years are obliged to be vaccinated, but it correct to vaccinate also the little children – on the other hand, see further : children under 12 yrs are discouraged to come to Mecca.

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General advice for Mecca pilgrims -required/recommended vaccines• Incompletely vaccinated individuals should update

their vaccine status.• Vaccination against the seasonal flu is

recommended when available (around mid-September, the pilgrimage starts October 4th).

• Pneumococcal vaccine for the known risk groups• Hepatitis A vaccination is recommended,

depending on age and medical history.• For journeys exceeding 3 weeks stay, a

vaccination against typhoid fever may be advisable.

2013 = 2014

… & Mers

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Promedmail - Morocco 19-6-2014• Advice not to go on the Hadj … !!

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Because of the MERS-Cov : The Saudi Ministry of Health

recommends that people• aged over 65 years and • those with chronic diseases (e.g. heart disease, kidney disease,

respiratory disease, diabetes) and • pilgrims with immune deficiency (congenital and acquired), • malignant and • terminal illnesses, • pregnant women and • children aged under 12 years

planning to come for Hajj and Umra this year, to postpone the performance of the Hajj and Umra for their own safety.

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http://www.who.int/ith/updates/20140603/en/

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Ebola

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Schistosomiasis

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CDCLetter EID sept 2014 In press

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PART 1• 1.a - Vaccination for Yellow Fever• 1.b - Malaria

PART 2• 2.A - Other vaccinations• 2.B - TD, other infections, …., • 2.C - VARIA

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Deep Venous Thrombosis

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Itchy skin problems during travel

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2014 A division of “Outdoor Medicine” (Nl) in Belgiumwww.outdoormedicine.org & www.awls.be

Future links with travel medicine ? (cfr ISTM & Wilderness Medical Society in the US)

Commitment travel clinics waiting lists & capacity last

minute travelers ?

- Waiting time max 2 weeks ? - Ability to help as soon as

possible last minute travelers ?

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Varia – NEW BOOKS Handboek vaccinatiesDeel B Infectieziekten

en vaccinaties

• Rudy Burgmeijer, Karel Hoppenbrouwers, Fons Van Gompel (red.)

• Autumn 2013.

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END

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