MEDICINE FOR INTERNATIONAL TRAVEL

Carl Dirks, MD

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CASE PRESENTATION

24 y/o medical student presents after visiting Belize with malaise, wt loss and loose stools for 3 days.

Spent time with friends in a local village, time in jungle, swam in ocean.

Drank local water and ate home cooked meals.

No Dysentery, no night sweats, no rashes/skin breaks identified.

No insect bites noted

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TOPICS

Pre-travel planning

Immunizations

Immunoprophylaxis

Medical care abroad

Post travel care

Selected disease topics

Resources

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US-INTERNATIONAL TRAVELERS

45

50

55

60

65

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Num

ber o

f Tra

vele

rs (m

illio

ns)

Year

4

DESTINATION COUNTRIES

0

10

20

30

40

Canad

a

Europe

Aus/NZ

Mexico

C or S Ameri

caJa

pan

Ocean

ia/ PI

Other Asia

Africa

Caribbea

n

Middle Eas

t

%

5

Of 100,000 travelers to a developing country for 1 month:50,000 will develop some health problem

8,000 will see a physician5,000 will be confined to bed

1,100 will be incapacitated in their work300 will be admitted to hospital

50 will be air evacuated1 will die

Steffen R et al. J Infect Dis 1987; 156:84-91

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P R E - T R AV E L P L A N N I N G

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PRE-TRAVEL PLANNING

Get patient in the office!

When will you be traveling?

Where?

country

region (urban rural)

accommodations (hotel, tent)

activities planned

vaccine history

allergies (travel meds, immunizations)

good H/P

pregancy status/plan

breast feeding

Behavior risk

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TRAVEL HEALTH KIT

Personal Prescriptions

Antimalarial medications

OTC antidiarrheals

antibiotic for diarrhea

allergy meds

laxative

antacid

Epi-Pen (with hx allergy)

insect repellant (DEET)

sunscreen

oral re-hydration

first aid itemsNote to self-

wife’s migraine regimen!!!

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I M M U N I Z AT I O N S

http://blog.wired.com/photos/uncategorized/2007/03/26/syringe.jpg10

IMMUNIZATIONS

Review traditional vaccine needs

national immunization program

http://www.cdc.gov/vaccines/

Diptheria Rotavirus

Tetanus Influenza

Pertussis HPV

Measles Pneumococcal

Mumps Meningococcal

Rubella HIB

Varicella Hepatitis A/B

Polio

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Recommended Adult Immunization Schedule, by Vaccine and Age GroupUNITED STATES · OCTOBER 2006–SEPTEMBER 2007

Vaccine Age group 19–49 years 50–64 years >65 years

Tetanus, diphtheria,pertussis (Td/Tdap)1,*

Human papillomavirus (HPV)2

Measles, mumps, rubella (MMR)3,*

Influenza5,*

Pneumococcal (polysaccharide)6,7

Hepatitis A8,*

Hepatitis B9,*

Meningococcal10

Varicella4,*

1 or 2 doses

1 dose annually1 dose annually

3 doses (0, 1–2, 4–6 mos)

1 or more doses

!

!

This schedule indicates the recommended age groups and medical indications for routine administration of currently licensed vaccines for persons aged >19 years, as of October 1, 2006. Licensedcombination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory Committee onImmunization Practices (www.cdc.gov/nip/publications/acip-list.htm).

Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available atwww.vaers.hhs.gov or by telephone, 800-822-7967.Information on how to file a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400.Additional information about the vaccines in this schedule and contraindications for vaccination is also available at www.cdc.gov/nip or from the CDC-INFO Contact Center at 800-CDC-INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week.

2 doses (0, 4–8 wks) 2 doses (0, 4–8 wks)

1 dose

1–2 doses

1-dose Td booster every 10 yrs

2 doses (0, 6–12 mos, or 0, 6–18 mos)

1 dose

3 doses (females)

Recommended Adult Immunization Schedule, by Vaccine and Medical and Other IndicationsUNITED STATES · OCTOBER 2006–SEPTEMBER 2007

Vaccine

Indication

Tetanus, diphtheria,pertussis (Td/Tdap)1,*

Human papillomavirus (HPV)2

Measles, mumps, rubella (MMR)3,*

Influenza5,*

Pneumococcal (polysaccharide)6,7

Hepatitis A8,*

Hepatitis B9,*

Meningococcal10

Varicella4,*

1 dose 1 dose 1 dose

!

!

*Covered by the Vaccine Injury Compensation Program. NOTE: These recommendations must be read with the footnotes (see reverse).

For all persons in this category who meet the agerequirements and who lack evidence of immunity(e.g., lack documentation of vaccination or haveno evidence of prior infection)

Recommended if some other risk factor is present (e.g., on the basis of medical,occupational, lifestyle, or other indications)

*Covered by the Vaccine Injury Compensation Program. NOTE: These recommendations must be read with the footnotes (see reverse).

For all persons in this category who meet the agerequirements and who lack evidence of immunity(e.g., lack documentation of vaccination or haveno evidence of prior infection)

Recommended if some other risk factor is present (e.g., on the basis of medical,occupational, lifestyle, or other indications)

Contraindicated

2 doses (0, 4–8 wks) 2 doses

1–2 doses 1–2 doses

3 doses for females through age 26 yrs (0, 2, 6 mos)

Pregnancy

Congenital immunodeficiency,

leukemia,11

lymphoma, generalized malignancy,

cerebrospinal fluidleaks; therapy with alkylating agents,antimetabolites,

radiation, or high-dose, long-termcorticosteroids

Diabetes, heart disease,

chronic pulmonary disease,chronic alcoholism

Chronic liverdisease,

recipients of clotting factorconcentrates

Asplenia11

(including elective

splenectomy and terminal complement component

deficiencies)

Kidney failure, end-stage renal

disease, recipients ofhemodialysis

Human immunodeficiency

virus (HIV)infection3,11

Healthcare workers

1–2 doses

1 or 2 doses

2 doses (0, 6–12 mos, or 0, 6–18 mos) 2 doses (0, 6–12 mos, or 0, 6–18 mos)2 doses

3 doses (0, 1–2, 4–6 mos) 3 doses (0, 1–2, 4–6 mos)

Substitute 1 dose of Tdap for Td

1-dose Td booster every 10 yrsSubstitute 1 dose of Tdap for Td

1 doseannually1 dose annually 1 dose annually

Approved by the Advisory Committee on Immunization Practices,

the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians,

and the American College of Physicians

Department of Health and Human ServicesCenters for Disease Control and Prevention

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ADDITIONAL IMMUNIZATIONS

Region focused immunization

Belize

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TYPHOID FEVER - 2 VACCINE OPTIONS

oral Ty21a vaccine consists of four capsules, one taken every other day

Must be completed one week prior to exposure

Primary vaccination with ViCPS consists of one 0.5-mL (25-µg) dose administered intramuscularly.

Must be completed two weeks prior to exposure

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RABIES

Pre-exposure vaccine- 3 doses, risk stratified administration choices

Other prevention tips for patient example?

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HEPATITIS A/B

Hepatitis A

(required worldwide except NA, Japan, Australia, NZ, and “developed” Europe)- Vaccine , also Ig available

schedule based on vaccine brand/type

HAVRIX 0,6 - 12

VAQTA 0, 6 - 18

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HEP A

Immunity conferred at 4 weeks after first dose of vaccine in 96-100% of patients

CDC.gov

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HEP B

Hepatitis B

(Africa, Southeast Asia, Middle East, South and Western Pacific Islands, interior Amazon River Basin, Haiti, Dominican Republic)

Schedule- 0-1- 6 mos

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COMBINED HEP A/B OPTIONS

Combined vaccine - TWINRIX (A/B)

accelerated schedule 0, 7, 21 days

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P I C K A B A G T O B O A R D P L A N E

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M E D I C A L C A R E D U R I N G T R AV E L

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MEDICAL COVERAGE ABROAD

Concerns-

Commercial insurance coverage spotty, lots of qualifiers

possible pre-existing exclusions

Medicare does not cover

medical evacuations

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DEATHS RELATED TO INTERNATIONAL TRAVEL

CardiovascularMedicalInjuryHomicide/SuicideInfectious DiseaseOther

N = 2463

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

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INJURY DEATHS DURING INTERNATIONAL TRAVEL

Motor VechicleDrowningAir CrashHomicide/SuicidePoisoningOther

N = 601

Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

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MEDICAL COVERAGE ABROAD

Resources/Solutions

US consolate

Travel Insurance

Evacuation companies

JCAHO approved facilities

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http://travel.state.gov/travel/tips/health/health_1185

International SOS www.internationalsos.com

MEDEX www.medexassist.com

policies, clinic access, evacuation/repatriation

International Association for Medical Assistance for travelers

www.iamat.org

free membership- providor network - english speaking physicians

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http://www.fehd.gov.hk/safefood/library/fphposter/je_df.html

S P E C I F I C D I S E A S E T O P I C S

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TRAVELER’S DIARRHEA30-50% of travelers to affected regions

Fairly abrupt onset

Loose, watery, or semi-formed stools

gaseousness

abdominal cramping

vomiting

dantastisk- flickr.com

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TRAVELER’S DIARRHEA

Self Limited course 3-4 days

high fevers/dysentery-suggest further eval

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TRAVELER’S DIARRHEAPOTENTIAL COMPLICATIONS

High Fever/Dysentery- falls out of “typicality”

Postinfectious complications

Reactive arthritis

GBS

Post Infectious IBS (up to 3% of TD patients)

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TRAVELER’S DIARRHEAPREVENTION

good food/drink choices (!street vendors)

Pepto-Bismol 2 tablets QID (40%>14%)

flouroquinolones - not CDC guideline appr.

campylobacter resistance increasing (Thailand + Nepal)

Peterrieke-flickr.com

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antibiotics- cipro, levaquin (3Days)

azithromycin- useful in allergies or flouroquinolone resistance

Bismuth SS - 1oz/2 tablets Q 30 min for 8 doses

loperamide - antimotility

rehydration

TRAVELER’S DIARRHEATREATMENT

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PROTOZOA

Giardia intestinalis- metronidazole, tinidazole, nitazoxanide

cryptosporidiosis- nitazoxanide, if needed (self limited)

cyclosporiasis - Bactrim

amebiasis- flagyl, then luminal agent- iodoquinol or paromomycin

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Ingredient Amount Measurement

NaCl 3.5g/L 1/2 tsp

KCl 1.5 g/L 1 1/4 tsp

Glucose 20 g/L 2 Tbsp

NaHCO3 3 g/L 1/2 tsp

H20 1.0 g 1 liter

WHO Oral Rehydration Solution

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DENGUE FEVERmosquito vector (Ae. aegypti)- avoidance primary deterrant

sudden onset fevers, severe frontal HA, joint, muscle pain

nausea, vomiting, maculopapular rash 3-5 days after fever

1% progress to dengue hemorrhagic fever (5% mortality)

serological testing (IgG, IgM)- can cross react with other flavivirus (west nile, yellow fever, japanese encephalitis)

0-5 days, then 6-30 days - CDC dengue center

supportive care

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YELLOW FEVER

countries have included yellow fever immunization restrictions for entry

Need to seek out Yellow Fever Vaccine clinic

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MALARIA

Highest prevalence around equator

Cental/south america, Dominican republic and haiti, Africa, Asia, Eastern Europe, South Pacific

Fever, flu symptoms, anemia, jaundice, CNS symptoms

can occur 7 days after exposure, or months after chemo exposure

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RED = Chloroquine-Resistant

PINK - Chloroquine sensitive

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CHEMOPROPHYLAXIS

specific resistance confirmation of utmost importance

mefloquine or chloroquine - 1-2 weeks prior to travel

doxy, Malarone, or primaquine 1-2 days prior to travel

continue 4 weeks after travel- chloro, meflo, doxy

continue 7 days after travel - malarone, primaquine

USE THE TOOLS FROM CDC

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OTHER INFECTION NOTES

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NON-INFECTIOUS TOPICS

DVT/PE

Jet Lag

Motion Sickness

Altitude illness

Diving risk -

diving-Air travel (wait 12 hours)

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CRUISE SHIP ILLNESSES

Norovirus

salmonella

enterotoxigenic e. Coli

Shigella

Vibrio

Staph aureus

Clostridium Perfringens

Cyclospora

Trichinella

Legionnaires

regional exposures

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POST TRAVEL CARE

review travel history, incubation periods, use of appropriate chemoprophylaxis

Risk of malaria should be aggressively evaluated

referral to ID/tropical medicine specialist may be required

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POST TRAVEL MOST COMMONS

GI illness 10%

Skin Lesions/rashes 8%

Resp infections 5-13%

fever 3%

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Resources for providers

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