Travel Medicine. Tonya Gray, MD

Transcription

1 Travel Medicine Tonya Gray, MD

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4 Where are North Iowans Going South Africa 15 Tanzania 13 Haiti, Egypt 12 Zambia 10 Peru, India 9 Kenya 8 French Polynesia/Tahiti/Bora Bora, Nicaragua, Colombia, Thailand, Argentina, Germany 3 Suriname, France, Nepal, Namibia, Spain, Romania, Uganda, Burma, Cambodia, Turkey, Mali, Zimbabwe, Dominican Republic, Malaysia/Phillipines, Congo, Guyana 2 United Arab Emirates, Panama, West Africa/Togo, Jamaica, Italy, Bhutan, Kuwait, Madagascar, Costa Rica, Austria, Paraguay, Liberia, Malawi,Japan, South Korea, Taiwan, Belize, Bolivia, Chile, New Guinea, Australia, Israel, Puerto Rico 1 Ghana, Ecuador 6 Mexico, Indonesia, China, Guatemala, Honduras, Afghanistan, Vietnam 5 Brazil, Botswana 4

5 Pre Travel Consultation Goal: Effectively and efficiently prepare the traveler with information, vaccinations, and medications to reduce the risk of illness and injury related to travel minutes in length 4-6 weeks prior to travel Anyone can benefit, regardless of destination. Most important for those visiting low income nations.

6 Risk Assessment: Itinerary Countries and regions to be visited Rural vs Urban Dates and length of travel Modes of transportation Planned and possible activities Types of accommodations Purpose of travel Visiting Friends and Relatives (VFR)

7 Risk Assessment: Traveler Age Vaccine history Medical and surgical history Medication and allergies Pregnancy/breastfeeding Previous testing, preventative care

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11 Risk Communication and Management Information Immunizations Medications

12 Information Jet lag Motion sickness Sun protection- SPF at least 15, apply before DEET, protect against UV A and B STD prevention DVT prophylaxis- walk often, calf exercises, graduated compression stockings if increased risk of VTE Injury prevention Insect bite avoidance Fresh water avoidance State Department website Traveler s Insurance Altitude sickness

13 Injury prevention 100,000 travelers 50,000 experience a health problem 8,000 need to see a doctor 300 admitted to a hospital 20 need evacuated 1 dies #1 cause of death (50%) cardiovascular problems Injuries (13% of deaths) #1 MVA #2 Drowning or Violence (Homicide)

14 Freshwater avoidance

15 US Department of State Travel.state.gov Location of US Embassy USembassy.gov Find a doctor or hospital Crime and security information Localized hot spots Health and medical information Drug penalties Sign up for STEP. CDC app SmartTraveler

16 Health Insurance Check with current policy Most insurances do not cover evacuation Bring insurance card and claim form Medicare does not cover travel Check with AARP, travel agent

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18 Immunizations MMR Tetanus/pertussis Polio Hepatitis A and B Influenza Varicella/Zoster Meningitis Yellow Fever Typhoid Japanese Encephalitis Rabies Cholera Pneumonia

19 Meningitis Belt

20 Typhoid Injectable Typhim For ages 2 and over 2 years protection 90% of cases in the US are in travelers Recommend for Africa, Asia, Latin America Live vaccine Oral Vivotif: take 1 capsule every 2 days for 8 days For ages 6 and over 5 years protection Cannot open/chew capsules or take with antibiotics

21 Japanese Encephalitis Asia and Western Pacific Longer duration of travel (> 1 month) Rural areas

22 Rabies 60,000 deaths/yr worldwide 95% due to dog bites India #1 Rabies IG and vaccine Monkey bite: herpes B virus Valacyclovir 1gm Q8 14 days

23 Yellow Fever Requirements: protect country from importation of yellow fever virus Recommendations: protect the traveler from contracting yellow fever virus Countries set own requirement 1. No requirement 2. Vaccination mandatory for all travelers from all countries 3. Vaccination required only from travelers entering from countries with risk of YF.

24 Yellow Fever

25 To Become a YF Certified Uniform Stamp Holder Physician must be designated by the state health department course Take online 2010 CDC Yellow Fever Need a stamp # to purchase vaccine. YF VAX from Sanofi is the only product available in the US. Currently a shortage. Submit to IDPH 10 additional things State department gives physician name to CDC, who adds it to registry. Not transferable.

26 Yellow Fever Applying physician must provide the following information: A statement that each physician who provides yellow fever vaccine accepts responsibility for seeing and providing a pre-vaccine medical examination to each person requesting the Yellow Fever vaccine.

27 Yellow Fever Vaccine Reactions Mild adverse effects 5-10% Last 5-10 days Fever, HA, backache, myalgias, injection site inflammation Severe adverse effects 1. Hypersensitivity and anaphylactic reaction a. 1.8/100,000 b. Monitor for 15 minutes

28 Yellow Fever Vaccine Reactions 2. YEL-AND (yellow fever associated neurologic ds) 0.8/100, YEL-AVD (yellow fever associated viscerotropic ds) 0.4/100,000 days) 3-28 days after vaccine (ave 14 Meningoencephalitis, GBS Most recover completely 0-8 days (ave 4 days) Resembles yellow fever 50-65% fatal

29 Yellow Fever Most infections are asymptomatic or flu-like illness for which most people recover completely % develop jaundice/hemorrhagic fever 20-50% of those cases result in death Risk of developing yellow fever during a 2 week stay West Africa: 50/100,000 South America 5/100,000

30 Yellow Fever Contraindications History of acute hypersensitivity reaction to prior dose or component (eggs, gelatin, latex) Thymus disorder Infant less than 6 months Immunosuppression Precautions Asymptomatic HIV CD4 over 200 Pregnancy/breastfeeding Adults age 60 and over Infants 6-8 months Moderate to severe acute illness

31 Yellow Fever International Certificate of Vaccination Yellow Card Valid 10 days after administration for the lifetime of person vaccinated WHO adopted recommendation to remove 10 year booster requirement as of June Uncertain if countries will adopt this change. ACIP has adopted this change February Medical Waiver Give signed, dated, stamped letter on letterhead stating vaccine contraindicated on medical grounds. Receiving country usually honors waiver but is not required to do so. Consider checking with that country s embassy in Washington DC.

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33 Medications Malaria prophylaxis Traveler s diarrhea Altitude sickness Motion sickness

34 Altitude sickness Acute mountain sickness Headache and nausea Those traveling above 8000 ft Ascend slowly Acetazolamide 125 mg BID for 3 days Start day before ascent

35 Insect Bites Yellow Fever Malaria Zika Dengue 20-30% DEET to exposed skin (or 20% picaridin) Daytime and nighttime feeders Permethrin treated bed nets and clothing Chikungunya West Nile Japanese Encephalitis

36 Malaria

37 Malaria Malarone (atovaquone-proguanil) mg tab per day, start 1-2 days before entering malaria area until 7 days after return Mefloquine 250 mg tablet every week, start 1 week before entering malaria area and continue for 4 weeks upon return. Least side effects but most expensive Doxycycline 100mg per day, start 1-2 days before entering malaria area until 4 weeks after return effects pregnancy Inexpensive but psychiatric side Can be used in all trimesters of Inexpensive but side effects photosensitivity, yeast infections, nausea illnesses Also protects against tick-borne Must be over 8 yrs of age Give test dose. Do not use in SE Asia Could use chloroquine or hydroxychloroquine for travel to Mexico, Central America west of Panama Canal, and Haiti/Dominican Republic

38 Malaria Symptoms may occur from 1 week to 1 year after the mosquito bite. Alert doctor if fever, chills, headache, arthralgias

39 Traveler s Diarrhea Prevention Use of PPI increases risk Hand washing: reduces risk 30% Pepto Bismol: Reduces risk 50-65% 80-90% bacterial in origin CDC app Can I Eat This 2 tabs QID Avoiding unbottled water, ice, raw foods, street vendors hasn t been shown to make a difference

40 Traveler s Diarrhea Treatment Treatment Postinfectious Irritable Bowel Syndrome Rehydration Mild: Imodium day up Severe: Azithromycin: 500mg per to 3 days Ciprofloxacin 500 mg tablet, repeat 12 hours later Rifampin 200 mg TID for 3 days

41 Post Travel Approach to Fever in the Returning Traveler NEJM, February 9, 2017 Malaria most common serious infection seen in returning travelers and remains main cause of death. CDC Malaria hotline

42 Coding and reimbursement Bill based on time Z71.89 Other specified counseling Z23 Vaccine codes Chronic illness codes Not often covered

43 Resources CDC travel website CDC Yellow Book Travel Medicine, Jay Keystone ISTM International Society of Travel Medicine

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