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