Travel Medicine Today

Transcription

1 Travel Medicine Today Marvin J. Bittner MD April 28, 2018 Disclosures Member, Speaker s Bureau, Sanofi Pasteur This presentation does not reflect the views of any organization with which I am affiliated Off label use, but supported in medical literature. Indeed, CDC endorses several off label uses. Marvin J. Bittner MD MSc 1

2 Objectives Identify major classes of issues that need attention in a pre-travel consultation, such as Traveler s diarrhea Malaria Immunizations Marvin J. Bittner MD MSc 2

3 Root s life came to a sudden end three weeks later, due to a crocodile attack while on a wildlife tour of the Limpopo River. He was in the lead dugout canoe when a 13-foot crocodile followed him and tipped it over. It then leapt out of the water, grabbed Root by his neck and shoulders, pulled him under and drowned him. The crocodile which ended Root's life was never found. Parts of his body were found a few days later and cremated. Marvin J. Bittner MD MSc 3

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10 A generally healthy 15-year-old boy who will visit family in south India takes doxycycline for acne. Empiric antimicrobial for travelers diarrhea? A. Azithromycin B. Levofloxacin C. Trimethoprim-sulfamethoxazole D. None. Doxycycline will prevent it Marvin J. Bittner MD MSc 10

11 Choosing antimicrobial for travelers diarrhea Resistance limits use: Doxycycline, trimethoprim-sulfamethoxazole Levofloxacin once daily, no methyl xanthine inhibition (unlike ciprofloxacin) Rifaximin costly Azithromycin if under 18 or going to south Asia or southeast Asia Mostly off label but evidence-based Travelers diarrhea Biggest determinant of risk: destination country Most common etiology: E. coli 50% resolved in 2-3 days without treatment No vaccine in the US Approach: risk reduction, empiric treatment Marvin J. Bittner MD MSc 11

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13 Loperamide 2 mg for mild diarrhea 1-2 unformed stools/24 hr No concerning symptoms (blood in stool, pus in stool, fever, running behind in fluids, persistence) Fear of exacerbation not borne out Unlike diphenoxylate with atropine: not controlled substance, no anticholinergic, over the counter Marvin J. Bittner MD MSc 13

14 Key points about travelers diarrhea E. coli #1 cause Careful eating Loperamide for 1-2 unformed stools Worse: levofloxacin usually Medical evaluation if pus, blood, fever, extensive fluid loss, persistence A traveler headed for Puerto Rico asks about insect avoidance measures. Advice? A. No malaria there... so none needed B. Avon Skin So Soft on skin C. Citronella candles in room D. Permethrin on clothes Marvin J. Bittner MD MSc 14

15 What a day! I must have spread malaria across half the country! I really heard it when this mosquito cartoon came out. Numerous readers wrote to remind me that it s the female that does the biting, not the male. I knew this. Of course, it s perfectly acceptable that these creatures wear clothes, live in houses, speak English. Zika virus Brazil 2015: Saw increase in Zika virus, microcephaly. 80% subclinical; OR fever, rash, eye, joint Spread: Aedes, sex CDC Pregnant: Postpone travel to Zika areas Men: Condoms if have traveled there Insect avoidance Marvin J. Bittner MD MSc 15

16 Zika virus, 4/18 (CDC) Zika extent, Western hemisphere, 4/18 (CDC) Zika extent, Eastern hemisphere, 4/18 (CDC) Marvin J. Bittner MD MSc 16

17 Malaria... not the only insect-borne disease Spread by Aedes (bites during day) Zika virus, emerged in the Americas. Dengue in much of the tropics. Chikungunya fever, not just in India. African sleeping sickness. Tsetse fly. Bites through thin fabric, not repelled by DEET. Wear dull colors, heavier fabric Insect avoidance DEET. 3M s Ultrathon has longer duration. Picaridin, IR3535, lemon oil of eucalyptus Long clothing Treat clothing with permethrin (Permanone) Malaria spread by female Anopheles evenings and night; stay indoors Screens, nets Marvin J. Bittner MD MSc 17

18 Countries with malaria, western hemisphere, 2015 Marvin J. Bittner MD MSc 18

19 Countries with malaria, eastern hemisphere, 2015 Malaria prophylaxis drug selection Is malaria present? If so, is it chloroquine-resistant? If so, what are the traveler s preferences? Previous drug use Health issues Attitude toward adverse events, costs Marvin J. Bittner MD MSc 19

20 Mefloquine resistance Marvin J. Bittner MD MSc 20

21 Healthy, nonpregnant 25-year-old medical student on one-week service trip to Nicaragua with expected malaria risk. Drug for prophylaxis? A. Atovaquone-proguanil (Malarone) B. Chloroquine C. Doxycycline D. Mefloquine E. Primaquine Chloroquine preferred if no resistance Relatively inexpensive Start 2 wk before arrival, take weekly, continue 4 wk after departure Take on a full stomach Theoretical interaction with quinolones Supply issues Marvin J. Bittner MD MSc 21

22 Primaquine almost never used Need to test for G6PD deficiency before use Nonetheless... Excellent for Plasmodium vivax So-called radical cure eliminates hepatic organisms Doxycycline Least costly Daily Start 1-2 days before arrival, continue during travel, continue 4 wk after departure Concerns Photosensitivity: Use sunblock Esophagitis: Take with full glass of water, upright for 30 min Marvin J. Bittner MD MSc 22

23 Mefloquine Weekly Start 2 wk before arrival, continue during trip, continue 4 wk after departure Contraindicated: seizure disorder, conduction disorder, psychiatric disorder,fine coordination/spatial discrimination needed (pilot) OK in pregnancy Concern: dreams. Controversy: psychosis Adverse reaction to mefloquine associated with ethanol ingestion. Can Med Assoc J 1995;152:515 Week 1. Mef 250 mg. Ok Week 2. Mef 250 mg. Ok Week 3. Mef 250 mg + Whisky 500 ml. Hallucinations, paranoid delusions, suicidal ideation. Week 4. Mef 250 mg + Whisky 500 ml. Ditto. Subsequently. Mef 250 mg + no whisky. OK. Marvin J. Bittner MD MSc 23

24 Atovaquone-proguanil (Malarone) Daily. Start 1-2 days before arrival, continue 7 days after departure Generally well tolerated Generally most expensive... but now generic Marvin J. Bittner MD MSc 24

25 Key points about malaria Itinerary, activity to assess risk Mosquito avoidance measures may prevent dengue, chikungunya, Zika, African sleeping sickness Repellent, long clothing, indoors, screens & nets, permethrin, room spray Chloroquine if no resistance If doxycycline, full glass of water & upright 30 min Marvin J. Bittner MD MSc 25

26 A generally healthy 40-year-old man is planning a business trip to the city of Rio de Janeiro. He asks about yellow fever vaccine; your refrigerator has none. Now? A. Order more yellow fever vaccine B. Insect avoidance measures are adequate C. Advise him to cancel the trip D. Elsewhere to get an investigational French yellow fever vaccine E. No yellow fever in the city of Rio Yellow Fever Vaccine Recommendations, Brazil, cdc.gov/travel (accessed 4/8/18) Marvin J. Bittner MD MSc 26

27 Yellow Fever Brazil Spring 2018 Increased extent, includes city of Rio US-licensed vaccine supplies exhausted Expect more US-licensed vaccine late 2018 French vaccine Stamaril available as investigational drug at limited number of clinics, see cdc.gov/travel cdc.gov/travel Marvin J. Bittner MD MSc 27

28 Immunizations and Travel Recent changes: yellow fever, hepatitis A, polio, cholera, shingles Up to date on routine vaccines Enteric illness Hepatitis A Beyond Canada, Western Europe, Japan, Singapore, Australia: Typhoid Special situations Hepatitis A (ACIP 2/18) Infants 6-11 months Traveling outside US where hepatitis A vaccine advised Need vaccine Ordinarily, hepatitis A vaccine given at 12 mo Marvin J. Bittner MD MSc 28

29 Polio (CDC 3/18) Asia: Afghanistan, Pakistan, Syria Africa: Nigeria, Democratic Republic of the Congo WHO requirement for long-term travelers (> 4 wk) May need proof of immunization between 4 wk and 12 mo before departure Marvin J. Bittner MD MSc 29

30 [or name & contact info of facility] [4 wk to 12 mo after date of vaccination] A generally healthy 55-year-old woman is planning a trip to India. This is a tour focusing on tourist spots and high quality hotels. What should you advise about cholera vaccine? A. No longer available in the US B. Will need to order it for your refrigerator C. Only 50% effective, not advised D. Low risk itinerary, not advised Marvin J. Bittner MD MSc 30

31 Cholera (CDC 3/18) West Africa: Nigeria, Chad East Africa: South Sudan, Somalia, Ethiopia, Kenya, Tanzania Central Africa: Uganda, Rwanda, Burundi Southern Africa: Mozambique, Malawi, Zimbabwe, Republic of the Congo, Angola Asia: Bangladesh, India, Yemen Americas: Haiti Marvin J. Bittner MD MSc 31

32 Cholera Vaccine Not Generally Recommended (CDC 3/18) Mainly Visiting friends and relatives Humanitarian aid work Key to prevention Hand hygiene Food and water precautions Cholera Vaccine Considerations(CDC 3/18) Intensity of transmission Rarity of severe cholera Risk factors for exposure (eg, aid work in outbreak) Risk factors for poor outcomes (access to care, medical conditions) Ability to adhere to food and water precautions Marvin J. Bittner MD MSc 32

33 45-year-old man, 1-week business trip to Tokyo, no history of chickenpox, shingles, or varicella vaccine. Advice? A. Varicella vaccine, 1 dose B. Varicella vaccine, 2 doses 30 days apart C. Shingles vaccine, 1 dose D. Varicella titer E. No lab test or vaccine indicated Marvin J. Bittner MD MSc 33

34 No history of varicella or vaccine 80% are immune despite no history If time, varicella titer If vaccine needed, 1 dose of varicella vaccine followed by another after 30 days Zoster (source: CDC) Marvin J. Bittner MD MSc 34

35 Shingrix (recombinant zoster vaccine) 2 doses im 2-6 mo apart age > 50 At least 8 wk after Zostavax (zoster live vaccine) or Varivax (chickenpox vaccine) Not contraindicated in immune compromise but efficacy not studied. No problem in low-dose immune suppression (< 20 mg/da prednisone or topical/inhaled) Indicated if history of zoster, but wait til acute stage resolves Need not screen for VZV immunity; but if negative, give varicella vaccine Recent changes: Key points Yellow fever: Brazil outbreak; shortage; use Stamaril clinics Hepatitis A as young as 6 mo for travelers Polio may be required; check for updates Cholera vaccine available, but appropriate for high risk, especially aid workers & visiting friends and relatives Shingles recombinant vaccine age >50 Marvin J. Bittner MD MSc 35

36 12 wk pregnant, 1-wk business trip to Buenos Aires. Last Tdap 3 yr ago. When to revaccinate with Tdap? A. Unknown. Probably lasts 10 yr B. Not needed. If tetanus vaccine indicated, use Td C. 27 to 36 weeks gestation D. Immediately post partum Marvin J. Bittner MD MSc 36

37 Tetanus-diphtheria-acellular pertussis Developments Pertussis peak 2012 Minimal risk from too frequent Tdap CDC 2012 recommendations Once in every adult 19 and older, regardless of interval since last tetanus Every pregnancy Meningitis belt, more risk Dec.-Jun. Marvin J. Bittner MD MSc 37

38 Routine adult immunizations All ages Tetanus-diphtheria-acellular pertussis Annual influenza Younger Meningococcal Human papillomavirus Older Pneumococcal Shingles Enterically transmitted Hepatitis A Routinely given at 12 mo Low threshold for travelers 0, 6 months Variant regimens with Twinrix (w hep B) Typhoid Off the beaten track Choice: oral or im Marvin J. Bittner MD MSc 38

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40 Special situations Rabies Japanese encephalitis Hepatitis B Key Messages Not just which country trip and traveler Careful eating, loperamide, levofloxacin Malaria: Present? Resistance? Yellow fever: More disease, less vaccine Hepatitis A: 6 mo for travelers Cholera: Friends & relatives, aid work Shingles: Recombinant vaccine, age > 50 Marvin J. Bittner MD MSc 40

41 Key Spanish Phrase DON-deh es-tah ell BAHN-yo Marvin J. Bittner MD MSc 41