Outline QUIZ QUIZ QUIZ QUIZ 3/9/2015. What is the most common clinical illness in travelers to tropical and semitropical

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1 Outline Elaine Rosenblatt MSN, FNP BC Certificate in Travel Health Clinical Professor School of Nursing UW Madison March 10, 2015 Traveling when immunosuppressed What to expect at the travel health visit What immunizations you might need How to prevent and treat travelers diarrhea How to prevent malaria Other health concerns Jet Lag High Altitude Motion Sickness How to Prevent Blood Clots (DVTs) Travel Medications to Take QUIZ What is the most frequent vaccinepreventable disease among travelers going to countries of lower hygiene standards? A. Hepatitis A B. Influenza C. Hepatitis B D. Typhoid QUIZ What is the most common clinical illness in travelers to tropical and semitropical regions? A. Diarrhea B. Hepatitis A C. Typhoid D. Dengue fever QUIZ What is the most common cause of morbidity and mortality in travelers 50 years and older? A. Malaria B. Rabies C. Cardiovascular disease D. Accidents QUIZ What is the most common cause of morbidity and mortality in travelers under 50 years of age? A. Malaria B. Rabies C. Cardiovascular disease D. Accidents 1

2 CAUSES OF DEATH WHILE TRAVELING Cardiovascular (heart attack, stroke) 49% Accidents (auto, motorcycle) 22% Medical illnesses 13.7% Infectious diseases 1.0% Key Points: Be Prepared See a travel health specialist, when possible, at least 2 3 months before traveling Know your insurance coverage as many of the vaccines are expensive Be up to date on influenza, pneumonia and other routine vaccines Pack needed medications and supplies for the trip plus at least 1 week Carry a list of your medications generic and brand names and dose Key Points: Travel Smartly and Safely Check your insurance coverage before traveling Consider evacuation insurance Know where to go for medical assistance abroad Leave jewelry and other expensive items at home Dress inconspicuously Travel in pairs or groups at night Carry wallet in the front pocket, purse straps across the shoulder Be aware of travel advisories When Travelers are Immunosuppressed May be at greater risk of developing a disease That disease may cause a complication or exacerbation of your underlying disease Avoid live vaccines Killed/Inactivated vaccines not a problem but there may not be as effective When Travelers are Immunosuppressed Greater risk for Food and water bourne illnesses such as Salmonella sp, Cryptosporidium parvum, Isospora belli, Microsporidia, and Cyclospora sp Respiratory infections: pneumonia, influenza and tuberculosis Take precautions to prevent insect bites, particularly sandflies, reduviid bugs, scabies When Travelers are Immunosuppressed Precautions for preventing malaria, foodand water bourne diseases and insectbourne diseases generally don t differ from immumocompetent travelers Travelers with solid organ transplants: avoid traveling until after 1 year post transplant 2

3 OUTPATIENT VISIT Obtain a thorough trip and medical history Review required/recommended vaccines Set a schedule for immunizations depending upon amount of time before trip and interactions between vaccines Learn about common health problems you may encounter: Travelers diarrhea Altitude Sickness Malaria Jet Lag Sun exposure Safety and security STI s Sterile syringes Pre Travel Assessment Countries to be visited: medical risks and administrative border requirements Purpose of travel: business vs pleasure Length of travel: longer trips increase risks Accommodations: staying with a family, camping, hotels, VFR s (visiting friends and family) Transportation: biking, renting cars Pre Travel Assessment Traveler s age: very old and very young at increased risk, as well as year olds Health of traveler: assess for preexisting diseases that might increase risk, smoking Medications/Allergies: potential contraindications Immunization status: previous vaccinations Immunizations Required to gain entry 1) Yellow Fever 2) Meningococcal for Saudi Arabia for pilgrimages Recommended to decrease risk against specific diseases (e.g. meningococcal, typhoid, hepatitis, rabies and Japanese encephalitis) Routine immunizations: childhood or adult always keep up to date (e.g.diphtheria tetanus pertussis, influenza, pneumovax, MMR) Yellow Fever Discuss pros and cons of travel to a yellow fever area with travel health specialist: consider your health status, age, level of risk (where traveling and for how long) Live, attenuated vaccine; contraindicated if immunosuppressed Side effects: sore arm, flu like symptoms Carried by a daytime mosquito: use personal protection measures 3

4 Yellow Fever, cont. Required if going to at risk areas and for administrative purposes (crossing at risk borders) Administered at official yellow fever centers Need to have a officially validated WHO yellow book Medical waivers available if can t get the vaccine Effective 10 days after administration Duration of immunity: 10 years, but in June 2016 will become lifetime immunity once received one dose Meningococcal Vaccine Required for: Saudi Arabia during pilgrimages Recommended for: International travel to endemic areas (Sub Sahara Africa) Effective vaccine and well tolerated Effective 10 days after vaccination Meningococcal Meningitis Vaccine Three types, each only effective against types A, C, Y and W 135, but with different age indications: Menactra: conjugate: age 9 months 55 years Booster 5 years if at risk Menveo: conjugate: age 2 months 55 years Booster 5 years if at risk Menomune: polysaccharide: age 2 and older Booster dose at 3 years if at risk Hepatitis A Transmission Contaminated food and water; Person to person Recommendations International travelers to high risk areas Anyone with ongoing contact with children adopted from countries where hepatitis A is common 4

5 Hepatitis A Vaccine Give at least 2 weeks before at risk, best if can get both dose before leaving Booster 6 to 12 months later Do not restart series if you are late in getting your second dose Side effects: sore arm Hepatitis B Transmission Sexual contact; contaminated needles, syringes; and other instruments (e.g., tattooing, body piercing, acupuncture); blood and blood products Risk Behavior driven as well as destination specific Education on preventing risks essential Hepatitis B Vaccine for Travelers If: Long term traveler (>6 months,?> 3 months) Frequent short term traveler High risk behavior profile (sex, drugs) Occupational exposure: healthcare worker, military, aid worker, missionary Close contact with locals (e.g., VFR children) Adventure traveler Accident prone Hepatitis B cont. Schedule: First 2 doses 1 month apart, 3rd dose 5 months after 2nd Accelerated: 0, 7, 21 days or 0, 14, 28 days with booster at 1 year; or 0, 1, 2 months with booster at 1 year Side effects: sore arm No need to restart series if you are late in getting a dose Twinrix: Hepatitis A&B Recommended for at risk who are age 18 or older At 0, 1, 6 months Accelerated schedule 0, 7, 21 days with a booster at 1 year Appropriate if never had the hepatitis A or B series 5

6 Typhoid Transmission Contaminated food and water Risk Highest risk for those going off the usual tourist routes and those returning to visit family and friends Rates higher in travelers to Indian subcontinent, Peru, Northwest Africa (excluding Tunisia), Mexico Typhoid Vaccine: Live Oral Avoid if immunosuppressed 1 pill every other day for 4 doses Duration of protection 5 years Refrigerate Side effects: gastrointestinal, flu like symptoms Complete at least 1 week before trip Antibiotic use before, during and after will interfere with effectiveness Typhoid Vaccine, cont. Killed injectable Duration of protection 2 years Side effects: local reaction, flu like symptoms Takes 2 weeks to obtain immunity Both vaccines approximately 50 80% effective Polio Vaccine Injectable (inactivated, Salk, IPV) One time booster recommended for adults for international travel (India and most countries in Africa; no polio in the Americas) 6

7 Rabies: Human Diploid Cell Vaccine (HDCV) High risk groups need to receive pre exposure series (veterinarians, animal handlers, trappers, those visiting and living in endemic countries for >30 days, certain lab workers) Side effects: local reaction, fever Rabies: Pre exposure Given as 3 doses: day 0, 7, 21 to 28 Still need to avoid contact with animals and get post exposure treatment after cleaning the wound (2 injections day 0,3) Rabies: Post exposure If you didn t receive pre exposure treatment: Rabies immune globulin (HRIG) with as much at the injury site as is possible Give at day 0, 3, 7, 14 Consider 5 th dose at day 28 for patients who are immunosuppressed, or you have a high suspicion that this may be a significant rabies exposure Japanese Encephalitis Mosquito borne viral encephalitis If in endemic rural areas for > 30 days, less than 30 days if more intense exposure Mostly Asia and India Still need to use good personal protection measures, especially at dusk 7

8 Japanese Encephalitis Vaccine: Ixiaro Inactivated vaccine 2 dose schedule: day 0 and 28 days Most commonly reported adverse events were headache, muscle pain and pain, swelling, and tenderness at the injection site Travelers Diarrhea 30 70% of travelers on a 2 week trip will develop diarrhea 40% of those have to alter their itinerary 25% are confined to bed 3% have persistent gastrointestinal problems Etiology Bacterial 85% Parasitic 5 15% Viral <5% Traveler s Diarrhea (TD) The best protection against TD is careful choice of food and drink. The following recommendations may help prevent TD: 1. Restrict your diet to cooked food and fruits that can be peeled. 2. Avoid food from street vendors. 3. Avoid unpasteurized dairy products. Traveler s Diarrhea cont. 4. Use purified carbonated beverages when possible. You can drink bottled water, soda, beer or wine. Avoid tap water and ice cubes. 5. Use heated beverages when possible. 6. Avoid brushing teeth when water is suspected to be contaminated. Boil it, Cook it, Peel it or Forget it Water Purification Filters: best against bacteria, protozoa. Viruses too small for most filters. Best to get pore size <1 micron Chemical disinfection: chlorine, iodine Bring water to a boil. Getting the water to boil takes longer at higher altitudes. Travelers Diarrhea Self treatment: Non antibiotic Oral rehydration solutions Bismuth containing compounds (pepto bismol) Antimotility agents, e.g. Imodium. Do not use if fever or bloody stools 8

9 Travelers Diarrhea Self treatment: Antibiotics Antibiotic +/ loperamide Quinolones: maximum 3 days for adults Azithromycin: maximum 3 days for children and adults Use in areas of campylobacter resistance, and for pregnant women Rifaximin (Xifaxan: nonabsorbable gi antibiotic): twice daily for 3 days if over age 12 No coverage for campylobacter, shigella and salmonella Travelers Diarrhea See a healthcare provider if symptoms persist after 3 days of antibiotic treatment, sooner if high fever, significant abdominal pain, bloody diarrhea. Malaria World s most important parasitic disease # 1 infectious disease in the world million cases/yr; 1 million deaths/yr Parasite transmitted by mosquitoes Female anopheles mosquito Highest risk from dusk to dawn Use personal protection measures Malaria Six species of the genus plasmodium affect humans: falciparum (may be life threatening) vivax Ovale (divided into 2 species) Malarial knowlesi P. falciparum parasite causes most severe morbidity and mortality responsible for 40 60% of world s malaria responsible for 95% of deaths from malaria Hoffman Am 1992;76:1327. Personal Protection Measures Wear long sleeved shirts and long trousers Apply insect repellent containing no more than 30 35% DEET, or use 20% or greater Picaridin At dusk, spray aerosolized insecticides (such as those containing pyrthrins) in living and sleeping areas Sleep in a screened or air conditioned room Use bednetting of good quality with small mesh that is not damaged and preferably impregnated with permethrin Pretreat clothing with permethrin 9

10 How to Choose the Malaria Medication That s Best for You Individual factors: health problems, medications, if medical resources available at destination, length of stay, previous experience with antimalarials Region visited: defines the predominant malaria species and drug sensitivity. Evaluate benefits and drawbacks of each medication, including cost Malarious Areas: Chloroquine Sensitive Central America north of the Panama Canal Haiti Dominican Republic Middle East Prophylaxis of Malaria Start before trip, take during trip and continue after trip Mefloquine (Lariam) Doxycycline Malarone Chloroquine phosphate (Aralen) Prophylaxis of Malaria Adult Doses DRUG Chloroquine phosphate (Aralen and generic) 300 mg base (500 mg salt) Hydroxychloroquine sulfate (Plaquenil) 310 mg base (400 mg salt) ADULT DOSE Orally once/week starting 1 week before trip and continuing for 4 weeks after Orally, once/week starting 1 week before trip and continuing for 4 weeks after Prophylaxis of Malaria Adult Doses DRUG Atovaquone 250 mg/proguanil hydrochloride 100 mg (Malarone) Doxycycline 100 mg (many brand names and generic) Mefloquine (Lariam and generic) 228 mg base (250 mg salt) ADULT DOSE 1 tablet orally daily starting 2 days before trip and continuing for 7 days after 100 mg orally daily starting 2 days before trip and continuing for 28 days after Orally once a week starting 1 week before trip and continuing for 4 weeks after Side Effects Chloroquine: itching, gastrointestinal side effects. Less gastrointstinal side effects if taken with meals Doxycycline: sun sensitivities, yeast vaginitis in some woman, gastrointestinal side effects. Best taken with food. Malarone: upset stomach 10

11 Side Effects Mefloquine: gastrointestinal, neurological (insomnia, dizziness) and occasionally, nightmares and other psychological side effects. Best taken with food and away from alcohol. Do not use if you have a history of seizures, psychiatric disorder, arrhythmias secondary to cardiac conduction defects, or previous problem with the drug. Insect bourne Diseases Malaria Dengue fever Japanese Encephalitis Leishmaniasis Scabies Chagas disease Yellow Fever Lyme Tick bourne encephalitis Chikungunya Jet Lag: Prevention Diet: no scientific data, but helpful to minimize alcohol, smoking and caffeine in flight Light exposure during daytime Short acting hypnotics, first 3 nights at new location Melatonin Melatonin Induces sleepiness Use of commercial preparations is controversial because of lack of standardization and impurities Usual dose is 3 5 mg taken at the following times: For eastbound travel at local bedtime for 6 nights after arrival For westbound travel: at local bedtime for 4 nights after arrival Altitude Sickness Ascend slowly: 2 3 days at 2500 m before ascending, then 2 days per 1000 m Prophylaxis with Acetazolamide 125 mg twice daily, beginning 24 hours before ascent and continuing for at least 48 hours after ascent or while at high altitude, or start when symptoms start and treat for 2 3 days at altitude. Caution with allergies to sulfa and penicillin Acute Mountain Sickness: headache, nausea, fatigue, insomnia Motion sickness Best taken minutes before at risk OTC antihistamines: cyclizine (Marezine), dimenhydrinate (Dramamine), diphenhdramine (Benedryl), meclizine (Bonine), Sea Band, ginger candy Prescription: transderm scopolamine patch Side effects of medications: dizziness, drowsiness 11

12 Motion sickness, cont. Eat lightly before and during travel. Limit alcohol intake. Sit in most stable section of moving vehicle (over the wings on an airplane; front seat of car; near the front of trains; amidships, on deck if possible; and just forward of the midsection on buses) Face forward and look out a window, keeping your eyes fixed on the horizon or a stationary point in the distance. DVT s and Travel Possible increased risk if: Flying for more than 6 hrs at a time Older and/or overweight Have had recent surgery Malignancy On estrogen containing medications Immune suppressed Have a history of previous dvt s Have had a recent serious illness Pregnancy Preventing Blood Clots (DVT s) While Traveling Minimize alcohol intake, No smoking Increase non alcoholic fluid intake (1 litre per 6 8 hrs flying time) Take regular short walks and perform regular leg exercises Don t sit for prolonged periods with legs crossed or the back of your legs pressed tightly against the front of the seat No evidence to support use of aspirin Consider using compression stockings (20 30 mm Hg) Prescriptions Current prescriptions for all medications including OTC Enough supplies plus 1 week Food/Drug Interactions Storage of medications with temperature changes Carry a record of what medications you take as well as your allergies Travel Health Kit Anti diarrheal Anti malarial Antibiotic Antipyretic/analgesic Antihistamines Cold preparations First aid kit including bandages Sunscreen Antacids Laxatives Motion sickness medication Sedative/hypnotic Condoms/birth control Water purifier tablets/filter Hand sanitizer Emergency Resources International Association for Medical Assistance to Travelers (IAMAT) 417 Center St Lewiston, NY International Medic Alert 2323 Colorado Ave Turlock, CA State Department 12

13 Helpful Websites CDC: International Society of Medicine: Travel Health Information Service: Shoreland's Health Care : WHO: 13