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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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Presentation Transcript
slide2

Disclosure

  • No drug company has given me massive amounts of money to promote this talk (or any other)
  • No other conflicts of interest
slide3

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
slide4

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…
slide5

Overview

  • Common travel risks
  • Common conditions
  • Travel counseling framework
  • What to vaccinate for
  • What to prophylax against
  • Special situations
  • Resources
slide6

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
slide7

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%
slide8

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.
slide9

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%)
slide10

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
slide11

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
slide12

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
slide13

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
slide14

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
slide15

Travel Advice

  • Be careful
  • Have fun
  • But not too much fun
slide16

Travel Advice

  • Choose an appropriate travel companion
slide17

Travel Advice

  • And leave the furs at home
slide18

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

slide19

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?
slide20

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.
slide23

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
slide24

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.
slide25

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
slide26

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.
slide27

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!
slide30

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.
slide31

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
slide34

Water-Borne: examples

  • 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.
slide35

Water-Borne: examples

  • 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)
slide36

Water-Borne: examples

  • 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
slide37

Water-Borne: prevention

  • 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
slide38

Water-Borne: treatment

  • 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
slide39

Vectors and their diseases

  • 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
slide40

Insect-Borne

  • 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
slide43

Insect-Borne: prevention

  • 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
slide46

Insect-Borne: prophylaxis for malaria

  • 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
slide47

Insect-Borne: prophylaxis for malaria

  • 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.
slide48

Insect-Borne: prophylaxis for malaria

  • If considering Primaquine (anti-relapse Rx against P. ovale and P. vivax): consult with CDC or travel clinic. Many contraindications: G6PD deficiency, pregnancy, lactation
slide49

Suggested Algorithm for Pediatric Malaria Chemoprophylaxis

No

Chloroquine Resistant Area

CQ

YES

No

Mefloquine Resistant Area,

Seizures or psychiatric disease

MFQ (>5 Kg)

YES

Doxycycline (>8 years)

Malarone (>11 Kg)

slide50

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 in-country or on return) so will not be covered here
slide53

Respiratory

  • Unprecedented levels of pollution can be reliably expected to trigger reactive airway disease in those with a predisposition
slide54

Respiratory

  • 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
slide55

Respiratory

  • Ten cleanest cities in the world
    • Calgary
    • Honolulu
    • Helsinki
    • Ottawa
    • Minneapolis
    • Oslo
    • Stockholm
    • Zurich
slide56

Respiratory

  • 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)
slide57

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…
slide60

Injuries

  • Other tourist injuries (less common) involve violence (muggings, carjackings) and natural accidents (falls, drownings)
slide61

STDs

  • 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)
slide62

Other

  • 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
slide64

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:

slide66

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!
slide68

Vaccines and the diseases they prevent

  • 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)
slide69

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:
    • Pneumococcus, Zostavax, Gardasil
slide73

The less common vaccines

  • 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)
slide74

The really uncommon vaccines

  • 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
slide76

Vaccines and prophylaxis in the pipeline

  • ETEC
  • Parainfluenza
  • RSV
  • Dengue
  • Schistosomiasis
  • Shigella
  • …..and, wishfully, HIV and malaria
  • + New meds for malaria
slide77

Special populations

  • Young children
  • Pregnant women
  • Immunocompromised individuals
slide78

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

*Bitter.

slide79

Special populations: Pregnant women

  • 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
slide80

Special populations: Pregnant women

  • 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
slide81

Special populations: Immunocompromised (e.g. HIV+)

  • 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
slide82

What to pack

  • 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
slide83

Getting sick abroad

  • 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)
slide84

Biased observations

  • 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)
slide85

Final recommendations

  • 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
slide88

Patient Links

  • 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
slide89

References

  • 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
slide90

Closing thoughts:

Choose your destinations wisely

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