Presentation Transcript

1. INTERNATIONAL TRAVEL MEDICINE:Vaccines AND More…….

   George A. Fisher, PA-C, MPA, DFAAPA October 23, 2013
2. International Travel Medicine OBJECTIVES Learn the main resources for educational and preventive guidance on regional disease risk Be familiar with the primary vaccines associated with international travel Understand preventive measures for travel to developing countries
3. International Travel Medicine Resources www.WHO.int/en/ www.CDC.gov Definitions: Developed Countries Developing Countries Immunizations Malaria Prophylaxis “Rest of the Story”
4. Developed Country Developing Country
5. Geographical Regions Equator Tropic of Cancer Tropic of Capricorn Subtropics
6. International Travel Medicine Common Vaccines Tetanus (Td, Tdap) Adults Dose – 0.5 mL IM Frequency – One Tdap then Td every 10 years Pediatrics Birth to 6 Months: Tdap @ 2 mos, 4 mos, 6 mos, 15-18 mos, 4-6 years 7 to 18 years old: Tdap @ 7-10 years, 11-12 years, 13-18 years Polio Adults Dose – 0.5 mL IM (over the age of 35 years) Pediatrics Birth to 6 months: IPV @ 2 mos, 4 mos, 6-18 mos, 4-6 years
7. International Travel Medicine Common Vaccines (cont) Hepatitis A Adults Dose – 1.0 mL IM Frequency – Two doses 6 months apart Pediatrics Any child over 12 months – Two 0.5 mL doses 6 to 18 months apart Immune Globulin Dosage Length of stay < 3 mos - 0.02 mL/kg IM > 3 mos – 0.06 mL/kg IM (repeat every 4 to 6 months) Pediatrics under 12 months Recommended since Hepatitis A is not approved for this age group.
8. International Travel Medicine Common Vaccines (cont) Hepatitis B Adults Dose – 1.0 mL IM Frequency – Three doses: Today, 1 month, 6 months Pediatrics Frequency: At birth, 1-2 mos, final dose 6 – 18 months of age Accelerated Schedule (Emergency Responders/Disaster) Normal dose at 0, 7, and 21-30 days One booster at 12 months to promote long-term immunity Combination Hepatitis A and Hepatitis B Follow dosing schedule of Hepatitis B (not for peds < 12 mos) Can administer on accelerated schedule as Hepatitis B
9. International Travel Medicine Common Vaccines (Cont) Meningitis Adults Menigococcal conjugate (MCV4) (19 through 55 years of age) Meningococcal polysaccharide (MSPV4) since 1970 (56 years and older) Dose: 0.5 mL IM with booster every 5 years All Adolescents (MCV4) One dose 11-12 years, booster given at 16 – 18 years Pediatrics (MCV4) 9 mos through 10 years 2-dose primary series ( 2 mos apart) with booster every 5 years
10. International Travel Medicine YELLOW FEVER Aedes Aegypti Etiology: Virus Vector: Incubation: 3-6 days Locations: Central America South America Africa Last US: New Orleans 1907
11. International Travel Medicine Jungle Cycle Urban Cycle Most common form of transmission Human - Aedes Aegypti - Human Most common form in rain forests Monkey - Aedes Aegypti - Human
12. International Travel Medicine Yellow Fever – Initial Phase Yellow Fever - Toxic Phase After short period of symptom remission High Fever (plus return of initial symptoms) Bleeding (nose, gums) Black vomitus/Petechiae Deepening jaundice Hypotension/Shock/Metabolic acidosis/Arrhrthmia Fever & chills Severe headache Back pain Nausea Fatigue Weakness
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14. International Travel Medicine Yellow Fever Vaccine Government controlled In US, only available in designated clinics International Certificate of Vaccination valid 10 days after vaccination Should not donate blood for 14 days following vaccination – potential to transmit virus through blood products Adult 0.5 mL SQ reconstituted solution- 10 year booster Pediatric Minimum age – 9 Months 0.5 mL SQ reconstituted solution – 10 year booster
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16. International Travel Medicine TYPHOID FEVER Life-threatening bacterial infection Salmonella Typhi (lives only in humans) 400 cases per year in US 70% from international travel 12.5 million persons per year in developing countries
17. International Travel Medicine TYPHOID FEVER - Transmission Infected persons carry bacteria in bloodstream and intestinal tract Carriers – recover from Typhoid Fever but carry bacteria Infected persons and carriers shed S. Typhi in feces Eating food/drinking beverages handled by person shedding S. Typhi S. Typhi contaminating water used for drinking or washing food
18. International Travel Medicine TYPHOID FEVER - Symptoms High fever – 103 to 104 degrees Weakness Headache Stomach pains/Loss of appetite Some cases – Rash with flat, rose-colored spots
19. International Travel Medicine TYPHOID FEVER - Treatment Control fever Antibiotics Ampicillin Trimethoprim-Sulfamethoxazole Ciprofloxacin Stool culture
20. International Travel Medicine TYPHOID FEVER - Prevention Vaccination Typhim Vi – injectible Adult dose 0.5 mL IM, booster every two years Pediatric dose 0.5 mL IM, booster every two years Vivitof - oral Do not administer oral typhoid until at least 3 days after taking antibiotics Adult dose 1 capsule every other day (4 capsules) repeat in 5 years Pediatric dose Do not administer to younger than 6 years of age 1 capsule every other day (4 capsules) repeat in 5 years Good handwashing Bottled or boiled water Eat cooked foods Avoid raw fruits and vegetables Avoid ice or flavored ice treats (popcicles) Avoid good and beverages from street vendors
21. International Travel Medicine Japanese Encephalitis Flavivirus Closely related to West Nile and St. Louis encephalitis viruses Transmission Culex species mosquito Cycle mostly between vertebrate hosts (pigs and wading birds) Humans are incidenta or dead-end hosts (not high enough blood concentrations)
22. International Travel Medicine Japanese Encephalitis Geographical Region Primarily Asia Rural agricultural areas, rice production & flooding irrigation Temporate areas Seasonal (human disease is summer and fall) Subtropics and Tropics Year-round with peaks in rainy season Disease Less than 1% of people infected develop clinical illness Incubation 5 -15 days Initial Sx: fever, H/A, vomiting Few days: neurological Sx, weakness, seizures common in children
23. International Travel Medicine Japanese Encephalitis Treatment Supportive Rest, fluids and pain relievers (often hospitalization) Prevention Insect repellant Use of proper protective clothing Reduce exposure during peak biting hours Vaccine Recommended for: More than one month in endemic areas Short-term travelers with extensive outdoor activities Travelers to an area with ongoing JE outbreak Vaccine NOT recommended for travelers restricted to urban areas or outside well-defined JE transmission season
24. International Travel Medicine Japanese Encephalitis Vaccine IXIARO (JE-VC) new in 2009 and studied less than 5000 recipients Contains protamine sulfate (known to cause allergic reactions in some people No studies on pregnant women have been conducted Approved for people 17 years and older May 2013 approved for 2 months of age to 17 years Dose 2-dose series, spaced 28 days apart Second dose given at least 1 week prior to travel Ages 2 months to less than 3 years = 0.25 mL IM Ages 3 years and older = 0.5 mL IM
25. International Travel Medicine Rabies Viral disease of mammals transmitted through saliva Bites of rabid animals Scratches with saliva exposure Commonly in dogs, raccoons, skunks, foxes, coyotes, bats Prophylaxis vaccination depends upon type of travel plans (potential exposure) and history of endemic disease
26. International Travel Medicine Rabies Pre-Exposure Prophylaxis Vaccines: Human Diploid Cell Vaccine (HDCV) Purified Chick Embryo Cell Vaccine PCECV) Approved for adults and children Adults administered in deltoid (never glutteal) Infants and younger children administered in thigh (never glutteal) Dosage Three 1 mL IM doses on days 0, 7, and 21 or 28 Booster is exposure potential dependent and required when serologic testing demonstrates antibody titer is below acceptable level. Antibody titer screened either every 6 or 24 months.
27. International Travel Medicine Rabies Post-Exposure Prophylaxis: NOT VACCINATED Wound cleansing Vaccines: Human Diploid Cell Vaccine (HDCV) Purified Chick Embryo Cell Vaccine PCECV) Dosage Four 1 mL IM doses on days 0,3, 7, and 14 Human Rabies Immune Globulin (HRIG) Dosage: 20 IU/kg body weight Full dose infiltrated around and into the wound(s) Remainder of dose IM, distant from vaccine site
28. International Travel Medicine Rabies Post-Exposure Prophylaxis: PreviouslyVaccinated Wound cleansing Vaccines: Human Diploid Cell Vaccine (HDCV) Purified Chick Embryo Cell Vaccine PCECV) Dosage Two 1 mL IM doses on days 0 and 3 Human Rabies Immune Globulin (HRIG) Should not be administered
29. International Travel Medicine Influenza All international travelers should be encouraged to participate in the seasonal inflenza vaccinination program. Vaccine is effective globally
30. International Travel Medicine Tuberculosis Mycobacterium tuberculosis causative organism Opportunistic disease (co-infection with HIV) Spread by respiratory droplet Prevention Bacille Calmette Guerin (BCG) Vaccine More effective in protecting newborns than older children or adults Discontinued in UK
31. International Travel Medicine Tuberculosis Screening Tests Mantoux Tuberculin Skin Test (TST) PPD – Purified Protein Derivative Interferon-Gamma Release Assays (IGRA) Measure how the immune system reacts to bacteria that cause TB QuantiFERON TB Gold T-SPOT 6X more predictive of LTBI than PPD
32. International Travel Medicine Tuberculosis – Positive PPD High Risk Groups (equal to or greater than 5mm) HIV infected persons Recent contacts of a known positive TB case Fibrotic changes on CXR consistent with old TB Patients with organ transplants Persons who are immunio-suppressed for other reasons > 15 mg/day prednisone for 30 days or more
33. International Travel Medicine Tuberculosis – Positive PPD High Risk Groups (equal to or greater than 10mm) Recent arrivals (< 5 yrs from high prevelance countries) Injection drug users Residents/employees of high risk congregate settings Correctional facilities Nursing homes Hospitals (other healthcare facilities) Homeless shelters Mycobacteriology lab personnel Children less than 4 years, or children exposed to adults in high risk categories
34. International Travel Medicine Tuberculosis – Positive PPD Persons with no known risk factors A positive test is equal to or greater than 15mm
35. International Travel Medicine Tuberculosis – Positive Screening Test All persons with positive screening tests must be evaluated for active Tuberculosis Chest X-ray History of symptoms Latent Tuberculosis Infection (LTBI) The presence of M. tuberculosis organism without symptoms or radiographic evidence of TB disease
36. International Travel Medicine Malaria Transmission Parasite spread through female anopheles mosquito Strains Plasmodium ovale Plasmodium vivax Plasmodium malariae Plasmodium faciparum
37. International Travel Medicine Malaria Prophylaxis Vector control Reduce exposure Insect repellant Protective clothing/netting Avoid high biting periods
38. International Travel Medicine Malaria Prophylaxis Chemoprophylaxis Malarone (Atovaquone 250mg + Proguanil 100mg) One tablet QD Start 1-2 days prior to travel Continue for 7 days after departure from exposure area Larium (meflaquine HCL 250mg) One tablet Q week Start 1-2 weeks prior to travel Continue for 4 weeks after departure from exposure area Doxycycline (100mg) One tablet QD Start 1-2 days prior to travel Continue for 30 days after departure from exposure area
39. International Travel Medicine Other Medical Issues Plenty of rest/fluids Take adequate personal medications Exercises for DVT prevention while traveling Have International Record of Immunization available Travel Insurance Most plans do not cover medical evacuation Most plans do not cover repatriation of remains
40. Questions?