Download Travel Medicine (Powerpoint presentation)

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
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