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“What Shots Do I Need?” An approach to pre-travel counseling. Omar A. Khan, MD MHS [email protected] Disclosure. No drug company has given me massive amounts of money to promote this talk (or any other) No other conflicts of interest. Overview.

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What shots do i need an approach to pre travel counseling l.jpg

“What Shots Do I Need?”An approach to pre-travel counseling

Omar A. Khan, MD MHS

[email protected]


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Disclosure

  • No drug company has given me massive amounts of money to promote this talk (or any other)

  • No other conflicts of interest


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Overview

  • 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


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Overview

  • 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…


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Overview

  • Common travel risks

  • Common conditions

  • Travel counseling framework

  • What to vaccinate for

  • What to prophylax against

  • Special situations

  • Resources


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Travel risks

  • 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


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Travel risks

  • 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%


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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.


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Travel risks

  • 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

  • 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


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Why include travel counseling in primary care?

  • 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


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Approach to travel counseling

  • Assessment of Risk based on

    • Not only on countries of travel, but sub-regions

    • Also on what the participant will do there

  • General preventive principles

  • Specific concerns


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Typical travel counseling questions

  • 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


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Travel counseling questions

  • 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


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Travel Advice

  • Be careful

  • Have fun

  • But not too much fun


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Travel Advice

  • Choose an appropriate travel companion


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Travel Advice

  • And leave the furs at home


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Coding for US physicians*

  • 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

  • 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


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General Preventive Principles

  • 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

  • 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 ‘Bilharzia-free’. It’s not.




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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


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Yes, OK, but what shots do I need?

  • 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.


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Yes, OK, but what shots do I need?

  • Maybe none if you’re careful!

  • Very few mandated vaccinations:

    • 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


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Yes, OK, but what shots do I need?

  • 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’

  • CDC on Malaria

    • >50% ask about it, but less than half that follow the advice.


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Yellow Fever Vaccine

  • 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!




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Hajj

  • 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.


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Specific concerns (brief overview to prepare your patients for what they might face)

  • 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


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Water-Borne: examples of intestinal parasites for what they might face)

Ascariasis


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How can you stay mad at this face? for what they might face)

Hookworm


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Water-Borne: examples for what they might face)

  • 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.


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Water-Borne: examples for what they might face)

  • Viruses

    • Self-limiting; ORS/ORT adequate

  • Bacteria

    • All transmitted, generally, by fecal-oral transmission (except hookworms which also go through skin)

  • Parasites

    • Entamoeba histolytica (amebiasis)


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Water-Borne: examples for what they might face)

  • 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


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Water-Borne: prevention for what they might face)

  • But none of that really matters much for pre-travel

  • 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


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Water-Borne: treatment for what they might face)

  • All-purpose empiric treatment regimens:

    • 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


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Vectors and their diseases for what they might face)

  • 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


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Insect-Borne for what they might face)

  • Malaria by far the most common

    • Transmitted by night-biting mosquitoes

    • Average of 40 cases in returned US travelers

    • Worldwide

  • Dengue

    • Transmitted by day-biting mosquitoes


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Malaria map- Western hemisphere for what they might face)


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Malaria map: Eastern hemisphere for what they might face)


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Insect-Borne: prevention for what they might face)

  • 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:

    • Coils (pyrethroid-impregnated)

    • Mats

    • Sprays/insecticides (“Flit”, etc.)

    • Air conditioning cuts risk


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A very fancy bednet for what they might face)


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Insect-Borne: prophylaxis for malaria for what they might face)

  • 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


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Insect-Borne: prophylaxis for malaria for what they might face)

  • 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.


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Insect-Borne: prophylaxis for malaria for what they might face)

  • If considering Primaquine (anti-relapse Rx against P. ovale and P. vivax): consult with CDC or travel clinic. Many contraindications: G6PD deficiency, pregnancy, lactation


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Suggested Algorithm for Pediatric Malaria Chemoprophylaxis for what they might face)

No

Chloroquine Resistant Area

CQ

YES

No

Mefloquine Resistant Area,

Seizures or psychiatric disease

MFQ (>5 Kg)

YES

Doxycycline (>8 years)

Malarone (>11 Kg)


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Insect-Borne: treatment for what they might face)

  • Chemprophylaxis does not usually apply to treatment of other vector-borne diseases

  • Rx should be carried out in consultation with appropriate resources (whether in-country or on return) so will not be covered here


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Japanese Encephalitis (ever reported) for what they might face)


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Dengue (ever reported) for what they might face)


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Respiratory for what they might face)

  • Unprecedented levels of pollution can be reliably expected to trigger reactive airway disease in those with a predisposition


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Respiratory for what they might face)

  • Ten most polluted cities in

    the world:

    • Linfen, China

    • Tianying, China

    • Sukinda, India

    • Vapi, India

    • La Oroya, Peru

    • Dzerzhinsk, Russia

    • Norilsk, Russia

    • Chernobyl, Ukraine

    • Sumgayit, Azerbaijan

    • Kabwe, Zambia


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Respiratory for what they might face)

  • Ten cleanest cities in the world

    • Calgary

    • Honolulu

    • Helsinki

    • Ottawa

    • Minneapolis

    • Oslo

    • Stockholm

    • Zurich


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Respiratory for what they might face)

  • 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)


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Injuries for what they might face)

  • >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…. for what they might face)


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After. for what they might face)


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Injuries for what they might face)

  • Other tourist injuries (less common) involve violence (muggings, carjackings) and natural accidents (falls, drownings)


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STDs for what they might face)

  • 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)


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Other for what they might face)

  • 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 for what they might face)


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Things aren’t always what they seem…. for what they might face)

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:


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It’s not cutaneous larva migrans…. for what they might face)


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  • 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!


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Vaccines PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.


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Vaccines and the diseases they prevent PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

  • Rubella (German Measles)Shingles (Herpes Zoster)Tetanus (Lockjaw)TuberculosisTyphoidVaricella (Chickenpox)Yellow Fever

  • MeaslesMeningococcalMonkeypox(sort of)

    MumpsPertussis

    PneumococcalPoliomyelitisRabiesRotavirus

  • AnthraxDiphtheriaHepatitis AHepatitis BH. influenzae b (Hib) Human Papillomavirus (HPV)Influenza (Flu)Japanese Encephalitis (JE)


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The common vaccines: Don’t forget… PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

  • …the vaccines of childhood in the US

  • …boosters when appropriate for tetanus/diphtheria

  • …the flu shot

  • Meningococcus, Hep A/B, Rotavirus

  • Influenza

  • Age-related:

    • Pneumococcus, Zostavax, Gardasil


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The common vaccines: Don’t forget… PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.


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The common vaccines: Don’t forget… PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.


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You can’t vaccinate kids against everything… PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.


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The less common vaccines PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

  • 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

  • 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

  • Yellow Fever (discussed earlier)


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The really uncommon vaccines PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

  • 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


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You don’t always need vaccines PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.


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Vaccines and prophylaxis PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL. in the pipeline

  • ETEC

  • Parainfluenza

  • RSV

  • Dengue

  • Schistosomiasis

  • Shigella

  • …..and, wishfully, HIV and malaria

  • + New meds for malaria


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Special populations PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

  • Young children

  • Pregnant women

  • Immunocompromised individuals


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Special populations: Young children PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

  • 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

*Bitter.


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Special populations: Pregnant women PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

  • 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


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Special populations: Pregnant women PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

  • No live vaccines, e.g. Yellow fever, MMR, BCG

  • Malaria:

    • 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


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Special populations: Immunocompromised (e.g. HIV+) PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

  • 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


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    What to pack PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

    • 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


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    Getting sick abroad PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

    • Refer to list of approved providers

    • US Embassy

      • if you’re in Libya or Iran, good luck

      • if you’re in Cuba, mention Michael Moore to get free care?

    • See treatment center (immediately if febrile and in a malarial area)


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    Biased observations PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

    • 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)


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    Final recommendations PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

    • 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


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    Final recommendations PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.


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    Patient Links PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

    • 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


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    References PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

    • 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


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    Closing thoughts: PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

    Choose your destinations wisely


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