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Christy Beneri, DO Assistant Professor of Clinical Pediatrics SUNY Stony Brook January 27, 2011 Nothing to disclose 1. Review current travel advice and immunizations based on travel locations 2. Recognize possible infections in returning travelers 3. Better identify the need for referrals to travel medicine experts Globally, >750 million people traveled internationally in 20041 • About 4% are children • About 8% of travelers seek medical care while abroad or on returning home • 22-64% of travelers to the developing world report health problems Nationally, >64 million trips outside the US, a 21% increase since 19972 1. Long S et al. Principles and Practices of Pediatric Infectious Diseases. 2003. Chapter 9;79-86 2. Yellow Book 2010 In one study 1,254 travelers departing from Boston Logan International Airport completed a survey. The survey revealed that: • 38% traveling to low-low/middle income countries and 62% to upper-middle or high income countries • 54% of traveler’s to LLMI countries pursued advice prior to travel • Most sighted reason for not seeking advice was lack of concern regarding health problems related to trip LaRocque et al. J of Trav Med. 2010;17(6):387-391 Web based data collection, 17,353 ill returned travelers at 31 clinical sites on six continents Individual diagnoses put into syndrome groups and examined for all regions together • 226 per 1000 had systemic febrile illness, 222 acute diarrhea, 170 dermatologic disorder, 113 chronic diarrhea and 77 respiratory disease Freedman et al. NEJM. 2006;354(2):119-30 FEBRILE ILLNESS IS MOST LIKELY FROM AFRICA AND SOUTHEAST ASIA. MALARIA IS AMONG THE TOP THREE DIAGNOSES FROM EVERY REGION. OVER THE PAST DECADE DENGUE HAS BECOME THE MOST COMMON FEBRILE ILLNESS FROM EVERY REGION OUTSIDE SUBSAHARAN AFRICA. IN SUB-SAHARAN AFRICA, RICKETTSIAL DISEASE IS SECOND ONLY TO MALARIA AS A CAUSE OF FEVER. RESPIRATORY DISEASE IS MOST LIKELY IN SOUTHEAST ASIA. ACUTE DIARRHEA IS DISPROPORTIONATELY SEEN IN TRAVELERS FROM SOUTH CENTRAL ASIA. Freedman et al. NEJM. 2006;354(2):119-30 Yellow Book 2010 With the extent of international travel, physicians need to be knowledgeable on the travel advice they give to patients Appropriate travel advice avoids mishaps including injury and illness during travel and ensures a good memorable travel experience Should at least occur 4-6 weeks prior to travel Review entire trip itinerary • Destinations, time/duration of travel, accommodations, planned activities, exposures to insects/animals Review patient’s current and past medical history Review immunization history, medications, and allergies Remember to include children of immigrants returning to their home countries to visit relatives and friends Requires skill, time, knowledge base and comfort, helps when you have been there Vaccinations- required, recommended, routine Malaria Prophylaxis Other Insect/Vector Borne Risks Travelers’ Diarrhea Other Destination Risks – water, food and safety precautions Routine Immunizations Required Immunizations Recommended Immunizations While immunization rates have increased over the past several years, a significant number remain unimmunized Many vaccine preventable diseases are endemic in most of the world Therefore, children should be brought up to date with routine immunizations Accelerated dosing schedules may be used Vaccine Earliest Age for 1st Dose Min. Interval between Doses Combined Hepatitis A and B* 1 year Hepatitis A DTaP IPV OPV* Hib Hepatitis B 1 year 6 weeks 6 weeks birth 6 weeks birth PCV7 6 weeks 1 wk, 2 wks between 2nd and 3rd doses (booster after 1 yr) 6 mos 4 wks, 6 mos between 3rd and 4th doses 4 wks 4 wks 4 wks (booster after 1 yr) 4 wks, 8 wks between 2nd and 3rd doses (give 3rd dose > 16 wks after 1st dose) 4 wks, 8 wks between 3rd and 4th doses Measles 6 mos followed by MMR at 12 mos and at 4-6 years of age 4 wks Varicella 12 months *Only outside US 4 wks if > 13 y/o 3 mos if < 13 y/o Polio • In the US, OPV is not available; IPV can be given as young as six weeks • Do not give OPV to patients with immunodeficiencies MMR • Infants between 6-12 months traveling to a measles endemic area should receive 1 dose of measles (or MMR) vaccine prior to travel Hepatitis A • Most cases are imported into the U.S. by travelers from Mexico and Central America • Infants < 12 months of age should receive Hepatitis A IG (0.02 ml/kg IM for travel <3 months or 0.06 ml/kg IM for travel > 3 months) Influenza • Seasonal influenza vaccines for all travelers 6 months of age and older Pertussis • Tdap booster should be given starting at 11 years of age Polio • For previously immunized adult travelers to polio-endemic areas (Africa, Asia), consider vaccination with an additional dose of IPV • Only 1 lifetime booster of IPV is necessary Typhoid vaccines • Asia, Africa, Central and South America, Caribbean • Contraindications: hypersensitivity, malignancies • Precautions: pregnancy Oral vaccine (Ty21a) • Live attenuated vaccine • > 6 y/o; provides 5 years of immunity • Do not take concurrently with proguanil, mefloquine, or chloroquine (antimalarials) • Adverse effects: abdominal pain, N,/V, F, HA, rash Typhoid IM vaccine (ViCPS) • Purified, killed capsular polysaccharide vaccine • > 2 y/o; provides 2 years of immunity • Adverse effects: F, HA, local reaction Type of vaccine Live attenuated Killed Route Oral Intramuscular Minimum age of receipt Age >6 yrs Age >2 yrs # of doses 4 1 Booster frequency 5 2 Adverse effects (incidence) <5 % <7% Rabies Vaccine • Travelers with occupational risk, outdoor • • • • travelers Vaccine series: 3 IM doses of 1 ml (0, 7, and 21 or 28 days) Human diploid cell vaccine or purified chick embryo cell vaccine If bitten by potentially rabid animal, 2 additional doses are needed but no RIG Wash area with soap and water Japanese Encephalitis Virus • Arboviral infection transmitted by Culex mosquitos • F, HA, N/V, meningitis/encephalitis • About 50% have neurologic abnormalities and fatality rate is 25% JE vaccine • Recommended for all travelers > 12 m/o traveling to endemic areas for > 1 month (rural East Asia, SE Asia) • 3 doses given over 2-4 weeks; give last dose at least 10 days before travel and observe for 30 min after each dose • Duration of immunity unknown (Yellow Book, 2008) Meningococcal Vaccine (MCV) • IM Quadrivalent conjugate vaccine (A, C, Y, W-135) • Most common serogroups in US: B, C, Y • Most common serogroups in sub-Saharan Africa: A, C, W-135 • Protects against meningococcemia and meningitis • Required for travelers to Hajj and the meningitis belt from December – June • MCV is preferred over MPSV4 for children 2 through 10 years of age Meningococcal Vaccine (MCV) • Contraindications: hypersensitivity, previous GBS • Adverse effects: injection site reactions, hypersensitivity (rare) The Meningitis Belt Yellow fever • Arboviral infection transmitted by Aedes and Haemogogus mosquitos • F, HA, N/V, myalgia, photophobia and restlessness, myocardial dysfunction and fulminant hepatitis YF Vaccine • Live attenuated • International certificate of vaccination for all entering travelers • Effective after 10 days; booster required every 10 yrs • Contraindications: egg allergy, immunosuppression; Cautions: pregnancy, elderly • Adverse effects: F, HA, rash; vaccine-associated encephalitis syndrome (rare: 0.5-4 per 1000 infants); vaccine-associated viscerotropic disease (CDC, Division of Vector-Borne Infectious Diseases, 2005) Malaria Dengue Infection occurs via infected female Anopheles mosquito Most commonly caused by Plasmodium species • • • • A P. falciparum – most lethal and drug resistant P. vivax – Central America, Indian subcontinent P. ovale – western sub-Saharan Africa P. malariae worldwide leading cause of death in children under 5 500 million infections and > 1 million deaths annually Highest Risk of Disease • Young children • Pregnant women • Those without prior exposure Lower Risk of Disease • Air-conditioned housing • Screened housing No vaccine available Clinical presentation • F, HA, myalgias, malaise; anemia, jaundice • P. falciparum: seizures, mental confusion, renal failure, coma, death Symptoms may present 7 days after exposure to several months after return from an endemic area Personal protective measures • Bed nets * • Clothing that covers most of the body • Insect repellant: DEET Use > 30% DEET Not for infants < 2 m/o Apply to your hands first before applying to young children • Insecticide (permethrin) coated clothing and bed nets Country specific and altitude specific Dependent on patient’s medical history Chemoprophylaxis is not 100% effective Started prior to travel, during travel, and after return Chloroquine sensitive areas • Central America, Argentina, parts of the Middle East • Chloroquine Chloroquine resistant areas • All other areas • Mefloquine • Atovaquone/proguanil • Doxycycline • Primaquine Drug of choice where parasites are sensitive Adverse effects • GI, HA, dizziness, blurred vision, insomnia Caution: may worsen psoriasis May be used in children of any weight Avoid in resistant areas (Thailand, Myanmar, Cambodia) Adverse effects • GI, HA, insomnia, abnormal dreams, visual disturbances • Rare: reversible neuropsychiatric reaction, seizures Contraindications • Psychiatric disorders, seizures Caution: history of psych disorders, cardiac conduction disorders Daily dosing Take with food Adverse effects • GI, HA Contraindications • Severe renal impairment (Cr Cl < 30 ml/min) • Infants < 5 kg • Pregnant women Daily dosing Adverse effects • GI, photosensitivity, candidal vaginitis Contraindications • G6PD deficiency (fatal hemolysis) – exclude prior to use • Pregnancy, lactation Transmitted by Aedes mosquitoes Endemic and epidemic in Asia, Latin America, and Africa 159 cases per 1,000 travelers to Southeast Asia during epidemic years Outbreaks have occurred in southern Texas and Hawaii (CDC, 2005) Classic dengue fever – asymptomatic to mild systemic illness • Estimated 100 million cases annually • Acute F, HA (retro-orbital), myalgia, arthralgia, V, abdominal pain, rash • 1% progress to dengue hemorrhagic fever (DHF) DHF and dengue shock syndrome (DSS) • Increased vascular permeability on 3rd-7th day of illness • Hepatitis, myocarditis, neurologic symptoms; shock Treatment: rest, hydration, supportive care One of the most common illnesses affecting travelers; 9-40% of all children Highest rates, longest duration, and greatest severity in children < 3 y/o Etiologies • Bacteria 80-85% • Parasites 10% • Viruses 5% Pathogens are isolated 30-60% of the time Enterotoxigenic E. coli (ETEC) • Most common cause worldwide • Large inoculum Enteroaggregative E. coli (EAEC) Salmonella, Campylobacter, Shigella,Vibrio Parasites: Giardia, Cryptosporidium, Entamoeba Viruses: rotavirus, norovirus (Yellow Book, 2008) Less common than travelers’ diarrhea Ingestion of pre-formed toxins V > D Usually resolves within 12-18 hours Avoid raw fruits and vegetables Avoid undercooked meat and seafood Avoid street vendors Avoid tap water, ice, and unpasteurized dairy products Use safe water sources (bottled, boiled, filtered, or chemically treated [iodine tablets]) • Drinking • Toothbrushing • Food preparation Encourage breastfeeding for as long as is feasible Use a clean water supply for powdered formula Frequent handwashing/hand sanitizer use Bring prepackaged foods Oral rehydration solution packets are the treatment of choice IV fluids for severe dehydration Antimotility agents are not recommended in children • Toxic megacolon, extrapyramidal symptoms, salicylate toxicity “There is little evidence for the use of antimicrobial agents in pediatric travelers’ diarrhea” Azithromycin may be used in children traveling to areas with fluoroquinolone resistance (India, Thailand) • 10 mg/kg/d for 3 days 3 day course of ciprofloxacin (20-30 mg/kd/d) may be given in children with moderate to severe or bloody diarrhea Stauffer WM, et al. J Travel Med 2002;9:141–150. If travelers’ diarrhea does not respond to a course of antimicrobial treatment, other possible causes of diarrhea need to be investigated Studies on probiotics (e.g. Lactobacillus, Saccharomyces) are inconclusive Assemble prior to travel Prescription items • Prescription medications, antimalarial prophylaxis Nonprescription items • First aid supplies • Thermometer • Analgesics/antipyretics • Sun protection • DEET • Oral rehydration packets • Water purification tablets • Antihistamine Disturbance of body & environmental rhythms resulting from rapid change in time zones. Insomnia, irritability. Usually more severe after eastward travel. Take short naps, remain hydrated, avoid alcohol and pursue activities in daylight upon arrival. Dietary supplement Melatonin 2-3 mg started on the first night of travel for 1-5 days has been reported to facilitate transition. Ambien started the first night of travel for up to 3 days. Rapid exposure to >8,000 ft (2500 mt) Headache, fatigue, nausea, anorexia, insomnia, dizziness The most preventive measure is pre-acclimatization by a 2-4 day period with gradual ascent. Preventative Rx: Acetazolamide (carbonic anhydrase inhibitor) starting 1-2 days before ascent and continuing at high altitude for 48 hrs. Children: 5 mg/kg/d in 2-3 divided doses Rare cross-reactivity to sulfa drug allergy Rx: descent, O2 supplementation, dexamethasone 4mg q6h +/- diamox 250-500 q 12 Cholinergic blocker scopolamine Patch or oral formulation Transderm Scop is applied to skin behind ear 6-8 hrs before exposure and changed q 3 days. Oral Scopace is taken 1 hour before exposure. Dramamine or Meclizine are alternatives Avoid swimming in lakes and streams Appropriate use of seat belts and car seats (should accompany the family) Counsel adolescents about STIs, sharing needles, acupuncture, and tattoos • In one study of British travelers, 6% contracted STIs during their travel Consider travel insurance Advance planning Pre-travel assessment includes • Providing vaccines and prophylactic medications • A whole lot more! Travel advice should be tailored to the traveler No preventive measures are 100% effective CDC: www.cdc.gov/travel WHO International Travel and Health: www.who.int/ith The International Society for Tropical Medicine: www.istm.org Travax: www.travax.scot.nhs.uk CDC Health Information for International Travel (The Yellow Book), 2008 Travmed: www.travmed.com 37 Research Way E. Setauket, NY 11733 (631) 444-KIDS