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HIV Case studies
Brazil
Videoteleconference
Dominique Tessier, md, ccfp, fcfp
Medical director
Medisys Travel Health Clinics
Post-exposure prophylaxis clinics
Hôpital Saint-Luc, CHUM
December 2004
Dominique Tessier, md, ccfp, fcfp
Objectives
• Identify specific risks issues for hiv
positive travellers
• Recognize indications and contraindications to immunizations for HIV
positive individuals
• Identify pro and cons of drug holidays
December 2004
Dominique Tessier, md, ccfp, fcfp
Anthony, 33 years old, HIV +
Men having sex with men (MSM)
HIV positive since 1999
CD4 at 230
Viral load at 11,237
December 2004
Dominique Tessier, md, ccfp, fcfp
Anthony, 33 years old, HIV +
Wants to do a religious retreat in the North
of Brazil for 3 months.
Wants to stop all his medications to purify
his body.
Not sure about receiving immunizations.
Comes for your advise.
CD4 at 230
viral load at 11,237
December 2004
Dominique Tessier, md, ccfp, fcfp
Anthony, 33 years old, HIV +
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Vaccines?
Anti-malarials?
First Aid Kits?
Recommendations
CD4 at 230
Viral load at 11,237
December 2004
Dominique Tessier, md, ccfp, fcfp
Individualisation of recommendations
requires time and knowledge of
•Questions to ask Anthony?
December 2004
Dominique Tessier, md, ccfp, fcfp
Individualisation of recommendations
requires time and knowledge of
•Where, Why, When, How, How long
•Type of Travel
•Activities
•Health status
•Special needs
•Experience
•Fears and beliefs
•Budget
December 2004
Dominique Tessier, md, ccfp, fcfp
Evaluation of the potential risks
•Medical exam
•Previous Immunizations
•Vector precautions
•Cardiopulmonary problems
•Allergies
•HIV or other test required
•Psychological evaluation
•Age related specificities
•Handicaps
December 2004
Dominique Tessier, md, ccfp, fcfp
Estimated
monthly
incidence of
health
problems per
100 000
travellers to
developing
countries
WHO 2001
December 2004
Dominique Tessier, md, ccfp, fcfp
Travel considerations: HIV+
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Restrictions on crossing international borders,
Vaccination requirements,effectiveness and safety
Increased susceptibility to infections
Accessibility of health care
Medical evacuation
• Travel counselling regarding:
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Food and water and self-treatment of travellers' diarrhea
Vector protection
Sun protection
Safety
Sexual and body fluids protection
December 2004
Dominique Tessier, md, ccfp, fcfp
Restrictions on crossing
international borders
A number of countries screen for evidence of HIV
infection and can deny entry to seropositive
individuals.
Unofficial list of entry requirements may be obtained
from:
www.hwc.ca/hpb/lcdc.
Such requirements may change without notification
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Verification with consulate recommended
December 2004
Dominique Tessier, md, ccfp, fcfp
Strategies to increase adherence
during travel
• For HIV + individuals in general, what
can be done to help them with adherence?
December 2004
Dominique Tessier, md, ccfp, fcfp
Strategies to increase adherence
during travel
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Information on risks and possible side effects
Realistic choice of medications
Contract with patient
Good counseling
Collaboration from co-traveler
Establish specific strategies for specific
situations
• Consider trial with candies
December 2004
Dominique Tessier, md, ccfp, fcfp
A pill counter can facilitate
adherence
December 2004
Dominique Tessier, md, ccfp, fcfp
Potential complications
• Toxicity to be monitored:
– Hematologic: anemia, neutropenia,
thrombocytopenia, pancytopenia
– Hepatic: elevation of enzymes
– Neurological: neuropathies
– Renal: stones
– Cardio-vascular; metabolic syndrome
• Drug Interactions
– cytochrome P 450: induction or inhibition
December 2004
Dominique Tessier, md, ccfp, fcfp
HIV Travelers and Drug Holidays
Photo DT Tibet 2000
December 2004
Dominique Tessier, md, ccfp, fcfp
Susceptibility to infections
• Many infections encountered by
travelers are associated with increased
morbidity and mortality in HIV+
persons.
• These individuals are also more likely
to have adverse reactions to drugs used
to treat infection.2
December 2004
Dominique Tessier, md, ccfp, fcfp
December 2004
Dominique Tessier, md, ccfp, fcfp
Vaccination is the most effective
strategy for Travel Medicine
practitioners
December 2004
Dominique Tessier, md, ccfp, fcfp
Vaccination is one of the greatest public
health achievements in the United states
during the 20th century.
Immunizations have
– eradicated smallpox;
– eliminated poliomyelitis in the Americas;
– controlled measles, rubella, tetanus, diphtheria,
haemophilus influenzae type b, and other
infectious diseases »
David SATCHER
Assistant SECRETARY For HEALTH AND, Surgeon GENERAL
U.S. Public Health Service, Department of Health and Human Services
AUGUST 3, 1999
December 2004
Dominique Tessier, md, ccfp, fcfp
Immunizations and immunosuppression
General information Regarding HIV and Travel
Health Information for International Travel
CDC’s « The Yellow book »
http://www.cdc.gov/travel/hivtrav.htm
December 2004
Dominique Tessier, md, ccfp, fcfp
Vaccination requirements
• Yellow fever:
– Required for
international travel in
some countries.
– Recommended in many
other countries
– Contra-indicated if
immunosuppressed
December 2004
Dominique Tessier, md, ccfp, fcfp
Yellow Fever Vaccine
• Disease’s case-fatality rate is more
than 60% in non-immune adults
• Vaccine
– Almost total efficacy
– Excellent tolerance
• Rare contra-indications
– True allergy to egg protein
– Cellular immunodeficiency
December 2004
Dominique Tessier, md, ccfp, fcfp
Yellov Fever
endemic zone in
Africa
December 2004
Dominique Tessier, md, ccfp, fcfp
Yellow Fever
endemic zone in
the Americas
December 2004
Dominique Tessier, md, ccfp, fcfp
Vaccinations Requirements,
Effectiveness and Safety
Severely immunocompromised travellers
• should be recommended to change his-her
itinerary or
• to strictly follow mosquito physical precautions
if trip unavoidable
• should be aware that, in the face of an epidemic,
he or she could be denied entry in some
countries if not immunized.
December 2004
Dominique Tessier, md, ccfp, fcfp
Fatal Yellow fever in traveler returning
from Venezuela, 1999
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48 yearl old male from California
10 day trip from September 16 to 26
first symptoms September 28
died on October 4
December 2004
Dominique Tessier, md, ccfp, fcfp
YELLOW FEVER VACCINEASSOCIATED DEATH - SPAIN
26 Oct 2004
A 26-year-old woman from Onuba died from yellow
fever stemming from a post-vaccination reaction. The
woman was admitted to Hospital because of fever and
multi-organ failure, having had, in addition to fever,
malaise, vomiting, and diarrhea during the previous
days.
The patient was also vaccinated for diphtheria and
tetanus.
December 2004
Dominique Tessier, md, ccfp, fcfp
Yellow Fever in Brazil - Federal
District/Brasilia
• A young male farmer, age 22, died of
YF in the Federal district of Brasilia.
Although the population of the district
has a high rate of vaccination with YF
vaccine (>90%), the deceased refused
vaccination on two previous occasions.
December 2004
Dominique Tessier, md, ccfp, fcfp
Reaction to Yellow Fever Vaccine
Linked to Several Recent Deaths
• In 1996 and 1999, 2 U.S. and 2 European
unvaccinated travelers to areas where YF is
endemic died of YF viral infection (1,8).
• The risk for YF in unvaccinated travelers
probably is increasing because potential YF
transmission zones are expanding to include
urban areas with large populations of
susceptible humans and abundant competent
mosquito vectors.
December 2004
Dominique Tessier, md, ccfp, fcfp
Vaccines to be generally avoided in
immunocompromised
Tuberculosis (BCG) : no exception
– Severe complications have been reported after
immunization with live vaccines in immunosuppressed hosts.
MeaslesMumpsRubella:
– Only if no immunosuppression
Varicella:
– not recommended
– Immunize close contacts
December 2004
Dominique Tessier, md, ccfp, fcfp
Vaccines to be generally avoided
in immunocompromised
• Yellow fever:
– only if strong indication
• Oral polio (Sabin):
– use injectable vaccine (Salk)
– Avoid for close contacts
• Typhoid:
– use injectable vaccine (Typhim Vi), not
oral (Vivotif)
December 2004
Dominique Tessier, md, ccfp, fcfp
Vaccines to be avoided in
immunocompromised
 BCG
 MMR
 Oral cholera
 Varicella
 Yellow fever
 Oral typhoid
 Polio (OPV)
December 2004
no exception
only if no immunosuppression
not usually recommended
immunize close contacts
only if strongly indicated
and no severe immunosuppression
use injectable vaccine
use injectable vaccine (IPV)
avoid for close contacts
Dominique Tessier, md, ccfp, fcfp
December 2004
Dominique Tessier, md, ccfp, fcfp
Vaccines considered safe for
immunosuppressed
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Diphtheria and Tetanus
Hepatitis A, B and A & B
Hib
Influenza
Japanese encephalitis rare indications
Meningococcal
Pertussis prefer acellular
Polio, inactivated
Pneumococcal
Rabies pre or post exposure
December 2004
Dominique Tessier, md, ccfp, fcfp
Vaccinations Requirements,
Effectiveness and Safety
Some severely immunocompromised
individuals may respond poorly to
immunization.
Other strategies may thus be needed to protect
them such as:
 Passive immunization with specific
immunoglobulins
 Preventive medication
 Rapid treatment.
December 2004
Dominique Tessier, md, ccfp, fcfp
Increased morbidity and mortality.
Hepatitis A.
• Up to 25% of HIV+ adult patient with
hepatitis A will require hospitalization.
• Increased prevalence of fulminant
hepatitis.
• Pre-existing liver disease increases the
risk of fulminant hepatitis and fatality.
• Persistent infection does not occur.
December 2004
Dominique Tessier, md, ccfp, fcfp
Increased morbidity and mortality.
Hepatitis A.
• All HIV+ seronegative individuals for
hepatitis A or B should be offered the
vaccine or, if severely immunosuppressed,
immunoglobulins (Hepatitis A protection).
• Hepatitis A immunization should be a
priority for patients with hepatitis B or C
co-infection.
December 2004
Dominique Tessier, md, ccfp, fcfp
Rabies in the World
• Only 20 countries, mostly
islands, are reported
« rabies free ».
• Dog are often the vectors.
• Highest incidence in asia,
with over 33,000 cases of
human rabies per year, the
majority, estimated 30,000,
in india .
Photo DT Acapulco 1995
December 2004
Dominique Tessier, md, ccfp, fcfp
Prescribing medications
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Malaria
Diarrhoea
Altitude sickness
Motion sickness
Special needs
December 2004
Dominique Tessier, md, ccfp, fcfp
December 2004
Dominique Tessier, md, ccfp, fcfp
Photo DT Iquitos
Travellers’
diarrhea
December 2004
Dominique Tessier, md, ccfp, fcfp
Boil it, peel it, cook it or forget it: easy
to remember, impossible to follow.
• The majority of
travellers will
make a “fauxpas” with food
and water within
48 hours.
December 2004
Dominique Tessier, md, ccfp, fcfp
Travellers’ diarrhea
• Usually a minor
problem with a
high potential of
– Uncomfort
– Complications in
HIV+
Photo DT Lhassa, Tibet 2000
December 2004
Dominique Tessier, md, ccfp, fcfp
Travellers’ diarrhea
• Anthony has a chronic diarrhea when
he takes his medication
– How can he recognize if he gets an
infection during his trip?
December 2004
Dominique Tessier, md, ccfp, fcfp
Travellers’ diarrhea
• Anthony has a chronic diarrhea when
he takes his medication
– How can he recognize if he gets an
infection during his trip?
• An increase in number of passages per day
(double of usual)
• A change in texture
December 2004
Dominique Tessier, md, ccfp, fcfp
Travellers’ diarrhea
• A diet rich in fibers
(psyllium) can help
normalize the stools.
December 2004
Dominique Tessier, md, ccfp, fcfp
Travellers’ diarrhea
When there is evidence
of a possible infection
persisting after usual
treatment, a culture
and 3 search for
parasites should be
done.
December 2004
Dominique Tessier, md, ccfp, fcfp
First aid kit
December 2004
Dominique Tessier, md, ccfp, fcfp
December 2004
Dominique Tessier, md, ccfp, fcfp
Re-used needles
December 2004
Dominique Tessier, md, ccfp, fcfp
Trauma:
car accidents, sport injuries
December 2004
Dominique Tessier, md, ccfp, fcfp
Sexual counselling
December 2004
Dominique Tessier, md, ccfp, fcfp
• Hiv-Infected Traveler Precautions
Health information for international
Travel, 1999–2000:
• Safety of vaccines for hiv-Infected
Persons. CDC
December 2004
Dominique Tessier, md, ccfp, fcfp
December 2004
Dominique Tessier, md, ccfp, fcfp
Photo DT Tibet 2000