HIV Case studies Brazil Videoteleconference

1. HIV Case studiesBrazilVideoteleconference Dominique Tessier, md, ccfp, fcfp Medical director Medisys Travel Health Clinics Post-exposure prophylaxis clinics Hôpital Saint-Luc, CHUM Dominique Tessier, md, ccfp, fcfp

2. Objectives • Identify specific risks issues for hiv positive travellers • Recognize indications and contra-indications to immunizations for HIV positive individuals • Identify pro and cons of drug holidays Dominique Tessier, md, ccfp, fcfp

3. Anthony, 33 years old, HIV + Men having sex with men (MSM) HIV positive since 1999 CD4 at 230 Viral load at 11,237 Dominique Tessier, md, ccfp, fcfp

4. Anthony, 33 years old, HIV + • Wants to do a religious retreat in the North of Brazil for 3 months. • Wants to stop all his medications to purify his body. • Not sure about receiving immunizations. • Comes for your advise. CD4 at 230 viral load at 11,237 Dominique Tessier, md, ccfp, fcfp

5. Anthony, 33 years old, HIV + • Vaccines? • Anti-malarials? • First Aid Kits? • Recommendations CD4 at 230 Viral load at 11,237 Dominique Tessier, md, ccfp, fcfp

6. Individualisation of recommendations requires time and knowledge of • Questions to ask Anthony? Dominique Tessier, md, ccfp, fcfp

7. Individualisation of recommendations requires time and knowledge of • Where, Why, When, How, How long • Type of Travel • Activities • Health status • Special needs • Experience • Fears and beliefs • Budget Dominique Tessier, md, ccfp, fcfp

8. Evaluation of the potential risks • Medical exam • Previous Immunizations • Vector precautions • Cardiopulmonary problems • Allergies • HIV or other test required • Psychological evaluation • Age related specificities • Handicaps Dominique Tessier, md, ccfp, fcfp

9. Estimated monthly incidence of health problems per 100 000 travellers to developing countries WHO 2001 Dominique Tessier, md, ccfp, fcfp

10. Travel considerations: HIV+ • Restrictions on crossing international borders, • Vaccination requirements,effectiveness and safety • Increased susceptibility to infections • Accessibility of health care • Medical evacuation • Travel counselling regarding: • Food and water and self-treatment of travellers' diarrhea • Vector protection • Sun protection • Safety • Sexual and body fluids protection Dominique Tessier, md, ccfp, fcfp

11. Restrictions on crossing international borders • A number of countries screen for evidence of HIV infection and can deny entry to seropositive individuals. • Unofficial list of entry requirements may be obtained from: www.hwc.ca/hpb/lcdc. • Such requirements may change without notification • Verification with consulate recommended Dominique Tessier, md, ccfp, fcfp

12. Strategies to increase adherence during travel • For HIV + individuals in general, what can be done to help them with adherence? Dominique Tessier, md, ccfp, fcfp

13. Strategies to increase adherence during travel • Information on risks and possible side effects • Realistic choice of medications • Contract with patient • Good counseling • Collaboration from co-traveler • Establish specific strategies for specific situations • Consider trial with candies Dominique Tessier, md, ccfp, fcfp

14. A pill counter can facilitate adherence Dominique Tessier, md, ccfp, fcfp

15. Potential complications • Toxicity to be monitored: • Hematologic: anemia, neutropenia, thrombocytopenia, pancytopenia • Hepatic: elevation of enzymes • Neurological: neuropathies • Renal: stones • Cardio-vascular; metabolic syndrome • Drug Interactions • cytochrome P 450: induction or inhibition Dominique Tessier, md, ccfp, fcfp

16. HIV Travelers and Drug Holidays Photo DT Tibet 2000 Dominique Tessier, md, ccfp, fcfp

17. Susceptibility to infections • Many infections encountered by travelers are associated with increased morbidity and mortality in HIV+ persons. • These individuals are also more likely to have adverse reactions to drugs used to treat infection.2 Dominique Tessier, md, ccfp, fcfp

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19. Vaccination is the most effective strategy for Travel Medicine practitioners Dominique Tessier, md, ccfp, fcfp

20. Vaccination is one of the greatest public health achievements in the United states during the 20th century. Immunizations have • eradicated smallpox; • eliminated poliomyelitis in the Americas; • controlled measles, rubella, tetanus, diphtheria, haemophilus influenzae type b, and other infectious diseases » David SATCHERAssistant SECRETARY For HEALTH AND, Surgeon GENERALU.S. Public Health Service, Department of Health and Human Services AUGUST 3, 1999 Dominique Tessier, md, ccfp, fcfp

21. Immunizations and immunosuppression General information Regarding HIV and Travel Health Information for International Travel CDC’s « The Yellow book » http://www.cdc.gov/travel/hivtrav.htm Dominique Tessier, md, ccfp, fcfp

22. Vaccination requirements • Yellow fever: • Required for international travel in some countries. • Recommended in many other countries • Contra-indicated if immunosuppressed Dominique Tessier, md, ccfp, fcfp

23. Yellow Fever Vaccine • Disease’s case-fatality rate is more than 60% in non-immune adults • Vaccine • Almost total efficacy • Excellent tolerance • Rare contra-indications • True allergy to egg protein • Cellular immunodeficiency Dominique Tessier, md, ccfp, fcfp

24. Yellov Fever endemic zone in Africa Dominique Tessier, md, ccfp, fcfp

25. Yellow Fever endemic zone in the Americas Dominique Tessier, md, ccfp, fcfp

26. Vaccinations Requirements, Effectiveness and Safety Severely immunocompromised travellers • should be recommended to change his-her itinerary or • to strictly follow mosquito physical precautions if trip unavoidable • should be aware that, in the face of an epidemic, he or she could be denied entry in some countries if not immunized. Dominique Tessier, md, ccfp, fcfp

27. Fatal Yellow fever in traveler returning from Venezuela, 1999 • 48 yearl old male from California • 10 day trip from September 16 to 26 • first symptoms September 28 • died on October 4 Dominique Tessier, md, ccfp, fcfp

28. YELLOW FEVER VACCINE-ASSOCIATED DEATH - SPAIN 26 Oct 2004 A 26-year-old woman from Onuba died from yellow fever stemming from a post-vaccination reaction. The woman was admitted to Hospital because of fever and multi-organ failure, having had, in addition to fever, malaise, vomiting, and diarrhea during the previous days. The patient was also vaccinated for diphtheria and tetanus. Dominique Tessier, md, ccfp, fcfp

29. Yellow Fever in Brazil - Federal District/Brasilia • A young male farmer, age 22, died of YF in the Federal district of Brasilia. Although the population of the district has a high rate of vaccination with YF vaccine (>90%), the deceased refused vaccination on two previous occasions. Dominique Tessier, md, ccfp, fcfp

30. Reaction to Yellow Fever Vaccine Linked to Several Recent Deaths • In 1996 and 1999, 2 U.S. and 2 European unvaccinated travelers to areas where YF is endemic died of YF viral infection (1,8). • The risk for YF in unvaccinated travelers probably is increasing because potential YF transmission zones are expanding to include urban areas with large populations of susceptible humans and abundant competent mosquito vectors. Dominique Tessier, md, ccfp, fcfp

31. Vaccines to be generally avoided in immunocompromised Tuberculosis (BCG) : no exception • Severe complications have been reported after immunization with live vaccines in immuno-suppressed hosts. MeaslesMumpsRubella: • Only if no immunosuppression Varicella: • not recommended • Immunize close contacts Dominique Tessier, md, ccfp, fcfp

32. Vaccines to be generally avoided in immunocompromised • Yellow fever: • only if strong indication • Oral polio (Sabin): • use injectable vaccine (Salk) • Avoid for close contacts • Typhoid: • use injectable vaccine (Typhim Vi), not oral (Vivotif) Dominique Tessier, md, ccfp, fcfp

33. Vaccines to be avoided in immunocompromised • BCG no exception • MMR only if no immunosuppression • Oral cholera not usually recommended • Varicella immunize close contacts • Yellow fever only if strongly indicated and no severe immunosuppression • Oral typhoid use injectable vaccine • Polio (OPV) use injectable vaccine (IPV) avoid for close contacts Dominique Tessier, md, ccfp, fcfp

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35. Vaccines considered safe for immunosuppressed • Diphtheria and Tetanus • Hepatitis A, B and A & B • Hib • Influenza • Japanese encephalitis rare indications • Meningococcal • Pertussis prefer acellular • Polio, inactivated • Pneumococcal • Rabies pre or post exposure Dominique Tessier, md, ccfp, fcfp

36. Vaccinations Requirements, Effectiveness and Safety Some severely immunocompromised individuals may respond poorly to immunization. Other strategies may thus be needed to protect them such as: • Passive immunization with specific immunoglobulins • Preventive medication • Rapid treatment. Dominique Tessier, md, ccfp, fcfp

37. Increased morbidity and mortality. Hepatitis A. • Up to 25% of HIV+ adult patient with hepatitis A will require hospitalization. • Increased prevalence of fulminant hepatitis. • Pre-existing liver disease increases the risk of fulminant hepatitis and fatality. • Persistent infection does not occur. Dominique Tessier, md, ccfp, fcfp

38. Increased morbidity and mortality. Hepatitis A. • All HIV+ seronegative individuals for hepatitis A or B should be offered the vaccine or, if severely immunosuppressed, immunoglobulins (Hepatitis A protection). • Hepatitis A immunization should be a priority for patients with hepatitis B or C co-infection. Dominique Tessier, md, ccfp, fcfp

39. Rabies in the World • Only 20 countries, mostly islands, are reported « rabies free ». • Dog are often the vectors. • Highest incidence in asia, with over 33,000 cases of human rabies per year, the majority, estimated 30,000, in india . Photo DT Acapulco 1995 Dominique Tessier, md, ccfp, fcfp

40. Prescribing medications • Malaria • Diarrhoea • Altitude sickness • Motion sickness • Special needs Dominique Tessier, md, ccfp, fcfp

41. Photo DT Iquitos Dominique Tessier, md, ccfp, fcfp

42. Travellers’ diarrhea Dominique Tessier, md, ccfp, fcfp

43. Boil it, peel it, cook it or forget it: easy to remember, impossible to follow. • The majority of travellers will make a “faux-pas” with food and water within 48 hours. Dominique Tessier, md, ccfp, fcfp

44. Travellers’ diarrhea • Usually a minor problem with a high potential of • Uncomfort • Complications in HIV+ Photo DT Lhassa, Tibet 2000 Dominique Tessier, md, ccfp, fcfp

45. Travellers’ diarrhea • Anthony has a chronic diarrhea when he takes his medication • How can he recognize if he gets an infection during his trip? Dominique Tessier, md, ccfp, fcfp

46. Travellers’ diarrhea • Anthony has a chronic diarrhea when he takes his medication • How can he recognize if he gets an infection during his trip? • An increase in number of passages per day (double of usual) • A change in texture Dominique Tessier, md, ccfp, fcfp

47. Travellers’ diarrhea • A diet rich in fibers (psyllium) can help normalize the stools. Dominique Tessier, md, ccfp, fcfp

48. Travellers’ diarrhea When there is evidence of a possible infection persisting after usual treatment, a culture and 3 search for parasites should be done. Dominique Tessier, md, ccfp, fcfp

49. First aid kit Dominique Tessier, md, ccfp, fcfp

50. Dominique Tessier, md, ccfp, fcfp