TRAVEL MEDICINE : TRAVEL MEDICINE MAJ Christine Lettieri
Dewitt Army Community Hospital
The Capital Conference
4 June 2007
Overview : Overview Risk Assessment
Resources
Immunizations
Malaria Prophylaxis
Traveler’s Diarrhea
Resources : Resources Center for Disease Control www.cdc.gov/travel
World Health Organization International Travel and Health
www.who.int/int
International Society of Travel Medicine
www.istm.org
Assessing the Risk : Assessing the Risk Where?
What time of year?
Type of lodging?
Planned activities?
Contact with local residents?
Immunizations : Immunizations Routine
Recommended
Required
Routine Immunizations : Routine Immunizations Tetanus (Tdap or Td) booster
- > 5 years
MMR
- Indicated for those without 2 doses
or + titers
Inactivated Polio (IPV)
-Single booster for travel to India, Nigeria,
Pakistan, Egypt, Niger, and Somalia
Routine Immunizations : Routine Immunizations Varicella -Women of childbearing age - 1 dose to age 13
- 2 doses > 13
Pneumovax - > age 65 - Chronic medical conditions
Influenza -All travelers -November to March in Northern Hemisphere
-April to September in Southern Hemisphere
Recommended Vaccinations : Recommended Vaccinations Hepatitis A
-Nearly all international locations
-New Pediatric recommendations
-Initial dose >4 weeks prior
-Booster at 6-12/18 months
-Mild side effects
Hepatitis A : Hepatitis A Immunoglobulin
-<2 weeks prior to travel
-Allergy to vaccine
-Children < age 2
-Pregnant patients
Twinrix (Hepatitis A and B) -Series- 0,1,6 months
-Accelerated series- 0, 1, 3 weeks with booster at 12 months
Hepatitis B : Hepatitis B Endemic in South America, Africa, SE Asia, South Pacific
Close contact with locals
Extended stay
Potential need for medical treatment
Series- 0, 1, 6 months
Accelerated series- 0,1,2, 12 months
Side effects- Injection site soreness, headaches
Japanese Encephalitis : Japanese Encephalitis India, China, Korea, Japan, SE Asia
Recommended for:
-Outdoor activities
-Endemic areas
0, 7, 30 days
Accelerated series- 0, 7, 14 days
Consider booster > 2 years
Side effects- Fever, headache, vomiting, angioedema, urticaria
Typhoid Fever : Typhoid Fever Endemic in Central and South America, India, Africa
Oral or IM route
50-80% immunity
Side effects- Nausea, vomiting, fever, abdominal cramping
Rabies : Rabies Endemic in:
-India
-China
-SE Asia
-The Philippines
-Indonesia
-Latin America
-Africa -Former USSR
Rabies Vaccinations : Rabies Vaccinations Who? -Prolonged stay in endemic region
-Remote areas
-Close animal contact
-Difficulty reporting
Series- 0, 7, 21 or 28 days
No booster shot for travelers
Required Vaccinations : Required Vaccinations Yellow Fever
Meningococcal during Mecca
Yellow Fever : Yellow Fever Endemic in equatorial Africa and South America
Yellow Fever : Yellow Fever Live attenuated vaccine
Side effects- Headaches, myalgias, fever, encephalitis
Booster every 10 years
Proof of vaccine >10 days
Special considerations
-Elderly
-Pregnancy
-Other live vaccines- same day or >28
days
Meningococcal Vaccine : Meningococcal Vaccine Endemic in Sub-Saharian Africa
Required for pilgrims to Mecca
MCV4 (Menactra)
MPSV4 (Menomune)
Single dose
Booster in 3-5 years for MPSV4
? Length of protection for MCV4
Malaria : Malaria Female Anopheles mosquito
Plasmodium vivax, ovale, falciparum, malariae
> 270 million cases worldwide
Over 1 million deaths
1,500 US cases annually
Malaria Transmission : Malaria Transmission Sporozoites in mosquito saliva
Liver
RBCs
Dormant liver stage- P. ovale, vivax
Malaria Prevention : Malaria Prevention Limit potential exposure -Avoid nighttime outdoor activities -Minimize exposed skin -DEET (30-50%) insect repellant -Insecticides -Room fans -Mosquito bed nets -Permethrin
Malaria Chemoprophylaxis : Malaria Chemoprophylaxis
Traveler’s Diarrhea : Traveler’s Diarrhea Fecally contaminated food and water
Etiology
-Bacteria- 85%
-Parasites-10%
-Viruses- 5%
Risk Areas
Traveler’s Diarrhea : Traveler’s Diarrhea Clinical Presentation:
-Abrupt onset of loose stools
-Abdominal cramping -Rectal urgency
Typically self limited
Traveler’s Diarrhea : Traveler’s Diarrhea Equal rates in males and females
Young > old
High risk travelers -Immunosuppressed -Inflammatory bowel disease -H2 blockers, PPIs, antacids
Preventive Measures : Preventive Measures Avoid street vendors
Avoid buffets
Avoid raw or undercooked meat and seafood
Avoid eating raw fruits and vegetables
Avoid tap water, ice, and unpasteurized dairy products
Prophylactic Measures : Prophylactic Measures Lactobacillus
Bismuth Subsalicylate
Antibiotics
Prophylaxis- Bismuth Subsalicylate : Prophylaxis- Bismuth Subsalicylate 2 oz or 2 tablets 4 times/day
Decreased incidence- 14-40%
Mild side effects
Avoid:
-Aspirin allergy
-Renal insufficiency
-Gout
-Certain medications- MTX, anticoagulants
-Children
Prophylaxis- Antibiotics : Prophylaxis- Antibiotics Effective- 4-40%
Fluoroquinolones
Rifaximin (Xifaxan)
Not recommended for routine use
Increased risk of resistant pathogens
False sense of security
Consider in special situations
Treatment : Treatment Antibiotics
Bismuth Subsalicylate
Antimobility agents
Oral rehydration therapy
Antibiotic Treatment : Antibiotic Treatment Consider antibiotics- > 3 stools in 8 hr period, fever, blood in stool
Fluoroquinolones
Azithromycin
Rifaximin- E. Coli
1-3 day treatment
Avoid Sulfa medications, doxycycline
Traveler’s Diarrhea : Traveler’s Diarrhea Bismuth subsalicylate -1 oz every 30 minutes x 8 for 2
days
Anti-motility agents -Symptomatic relief
-Adjunct to antibiotics with fever, bloody diarrhea
Oral Rehydration Therapy
Summary : Summary Advance planning
Travel assessment
Immunization status
Malaria chemoprophylaxis
Traveler’s Diarrhea
References : References “Antibiotic Treatment for Travelers’ Diarrhea”, Cochrane Database
“Prevention of Malaria in Travelers” American Family Physician, August 2003.
“Travel Immunizations” American Family Physician, July 2004.
“Travelers’ Diarrhea”, CDC
“Travelers’ Diarrhea”, Travelers’ Health: Yellow Book, Health Information for International Travel, 2005-2006.
CDC Travel Web site