The Pretravel Consultation CIINC April 12 Archive Presentation

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Today's Presenter
Gary W. Brunette, MD, MS Medical
Epidemiologist Travelers Health Team, CCID,
Centers for Disease Control and Prevention
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THE PRE-TRAVEL CONSULTATION

• Gary W. Brunette, MD, MS
• Travelers Health Team
• Division of Global Migration and Quarantine
• Centers for Disease Control and Prevention

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Outline

• Travelers Health Epidemiology
• Traveler Assessment
• Itinerary Review
• Sources of Information
• Risks to the Traveler
• Travel Vaccines
• Travel Medications
• Counseling

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U.S. Residents Traveling Abroad
ITA, includes travel to Canada and Mexico
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Travelers Health Risks

• Of 100,000 travelers to a developing country for
  1 month
• 50,000 will develop some health problem
• 8,000 will see a physician
• 5,000 will be confined to bed
• 1,100 will be incapacitated in their work
• 300 will be admitted to hospital
• 50 will be air evacuated
• 1 will die
• Steffen R et al. J Infect Dis 1987 15684-91

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The Patient Medical Issues

• Age-specific issues
• Underlying illness, immunosuppression
• Systems review
• Medical history
• Medication use
• Vaccination history
• Allergies
• Contraindications to vaccines and medications

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The Patient Other Issues

• Reproductive
• Pregnant
• Breastfeeding
• Preconception
• Risk-taking behaviors

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Travel Itinerary

• Full itinerary
• Dates, duration, stopovers
• Seasonal considerations
• Styles of travel
• Rural vs. urban
• Budget vs. luxury
• Accommodation
• Hotel vs. camping
• Activities
• Business vs. tourism
• Adventure, safari
• Missionary/Humanitarian/NGO

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Travelers Health Websitewww.cdc.gov/travel
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Deaths Related to International Travel
N 2463
Hargarten S et al, Ann Emerg Med, 1991. 20622-626
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Infectious Disease Risks to the Traveler

• Schistosomiasis
• Tuberculosis
• Leptospirosis
• Polio
• Yellow Fever
• Measles
• JEV

• Malaria
• Diarrhea
• Leishmaniasis
• Rabies
• Dengue
• Meningococcal Meningitis

ETC.
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Immunizations for Adult Travelers

• Routine immunizations
• Required immunizations for travel
• Recommended immunizations for travel

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Routine Immunizations

• Diphtheria
• Tetanus
• Pertussis
• Measles
• Mumps
• Rubella
• Varicella
• Pneumococcus
• Influenza

Td or Tdap MMR
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Imported Disease

• Measles in the U.S., 1997-2005
• 925 cases reported
• 74 imported or linked to imported cases
• Typhoid Fever in the U.S., 1999-2003?
• 1140 cases reported
• 74 imported or linked to imported cases

97-01 Papania.JID.2004189S61. 02-03 MMWR.
200453713. 04 MMWR. 2005541229. 05 CDC,
unpublished
? Lynch. WHO. 2005.
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Required Immunizations for Travel

• Yellow Fever
• Meningococcal

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Yellow Fever

• Viral disease transmitted via bite of Aedes
  mosquito
• Ranges in severity up to severe hepatitis and
  hemorrhagic fever
• Risk to US travelers of illness and death
• 0.5 and 0.05 per 100,000, respectively

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Distribution of Yellow Fever
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Yellow Fever Vaccine

• Indicated for travel to endemic countries in S.
  America and Africa, or where required for entry
• Relatively safe, effective vaccine
• 0.5 ml of reconstituted vaccine administered
  subcutaneously
• Booster required every 10 years

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Yellow Fever Vaccine

• Recent recognition of Severe Adverse Events
  (SAEs) following vaccination
• Viscerotropic
• Risk 3-5 cases per million doses
• Neurologic
• Risk 5 cases per million doses
• All cases in first time vaccinees
• Risk is higher in travelers over 60 years
• 18 cases per million doses
• Thymus disease is also associated with a higher
  risk

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Meningococcal Meningitis

• Bacterial infection transmitted via the
  respiratory route
• Five major serogroups A, B, C, Y, W-135
• Outbreaks in Africa during dry season (December
  to June)
• Associated with crowding conditions

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Distribution of Meningococcal Disease
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Meningococcal Vaccine

• Indicated for travel to endemic countries, or
  where required for entry
• Tetravalent vaccines (A, C, Y, W-135)
• conjugate vaccine (MCV4)
• Ages 11-55
• polysaccharide vaccine (MPSV4)
• Ages 2-10 and 55
• High efficacy, few side effects

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Recommended Immunizations for Travel

• Hepatitis A
• Hepatitis B
• Typhoid
• Japanese encephalitis
• Polio
• Rabies

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Hepatitis A

• Viral infection transmitted via fecal-oral route
• Contamination of food and water
• Person to person
• Ranges in severity from a mild illness to
  severely disabling disease lasting months

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Distribution of Hepatitis A
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Hepatitis A Vaccine

• Indicated for travel to areas of intermediate to
  high risk of disease
• Two hepatitis A vaccines (inactivated)
• HAVRIX (0, 6-12)
• VAQTA (0, 6-18)
• Lifelong protection
• High efficacy, few side effects
• TWINRIX combined Hep A, Hep B vaccine
• Usual dosing 0, 1, 6 months
• Accelerated dosing 0, 7, 21, 365 days

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Hepatitis B

• Transmitted via bloodborne route
• Sexual contact
• Transfusions, surgical or dental procedures
• Shared injection needles
• Ranges in severity from no symptoms to fulminant
  hepatitis
• Risk determined by behavior and prevalence of
  chronic infections at destination.

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Distribution of Hepatitis B
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Hepatitis B Vaccine

• Indicated for travel to areas with intermediate
  to high levels of transmission
• Two recombinant vaccines
• Recombivax
• Engerix B
• Dosing 0, 1, 6 months
• High efficacy, few side effects

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Typhoid

• Transmission via fecal-oral route, usually
  contaminated food or water
• Acute, life-threatening febrile illness
• 22 million cases and 200,000 related deaths occur
  worldwide each year

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Distribution of Typhoid
Source sanofi pasteur MSD
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Typhoid Vaccine

• Indicated for travel to areas where there is a
  recognized risk of exposure to S. Typhi
• Two administration routes
• Oral live attenuated vaccine 4 doses
• Protection for 5 years
• Injectable Vi polysaccharide vaccine 1 dose
• Protection for 2 years
• Protection from S. Typhi but not S. Paratyphi

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Japanese Encephalitis

• Transmitted via bite of Culex mosquito
• 50,000 cases and 15,000 deaths reported each year
  
• Up to 50 of survivors have significant
  neurologic sequelae

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Distribution of Japanese Encephalitis
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Japanese Encephalitis Vaccine

• Indicated for extended stays in areas where JE is
  endemic or epidemic, and for travelers whose
  activities include trips into rural farming areas
  
• Dosing 0, 7, 30 days, booster at 2 years
• Production has ceased on current inactivated
  mouse brain-derived vaccine
• Inactivated cell culture-derived vaccine
  currently in FDA approval process

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Polio

• Acute viral infection acquired by fecal-oral or
  oral transmission
• Ranges from acute flaccid paralysis, to
  quadriplegia, respiratory failure and death
• High transmission areas are India, Pakistan,
  Afghanistan, Nigeria.

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Distribution of Polio
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Polio Vaccine

• Indicated for travel to areas where polio is
  endemic
• Inactivated polio vaccine (IPV)
• Adult patients require one booster

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Rabies

• Acute, progressive, fatal encephalomyelitis
• Transmission via animal bite or scratch
• dogs, monkeys, bats, etc.
• 40,000 deaths per year

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Distribution of Rabies
Source World Health Organization
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Rabies Vaccine

• Indications
• long-term travelers in high risk countries
• occupational risks
• lower threshold to vaccinate children
• Pre-exposure prophylaxis
• 3 doses 0, 7, and 21 or 28 days
• intramuscular injection in deltoid
• Post-exposure immunization
• even when pre-exposure received
• HRIG administered (if no PEP)

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Travel MedicationsProphylaxis Self Treatment

• Malaria
• chloroquine, atovaquone/proguanil (Malarone),
  doxycycline, mefloquine (Lariam), primaquine
• Diarrhea
• quinolone, azithromycin
• Altitude
• acetazolamide
• Motion sickness
• scopolamine, dimenhydrinate (Dramamine)

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Patient Counseling

• Sufficient time for patient education
• Tailored to suit traveler
• Fitness for travel
• Understanding impact on existing conditions
• Advisability of destinations

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Travel Preparation

• Travel health insurance
• Medical care
• Hospitalization
• Evacuation
• Obtaining medical care abroad
• Awareness of travel notices
• Hand washing and hygiene

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Environmental Precautions

• Air Travel
• Jet Lag
• Sun Protection
• Extreme Heat and Cold
• dehydration, heat stroke
• hypothermia, frostbite
• Altitude
• Water recreation
• Drowning, boating diving accidents
• Risk of schistosomiasis or leptospirosis
• Biological and chemical contamination

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Food and Water Precautions

• Bottled water
• Selection of foods
• well-cooked and hot
• Avoidance of
• salads, raw vegetables
• unpasteurized dairy products
• street vendors
• ice

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Vector Precautions

• Covering exposed skin
• Insect repellent containing DEET 25 50
• Treatment of outer clothing with permethrin
• Use of permethrin-impregnated bed net
• Use of insect screens over open windows
• Air conditioned rooms
• Use of aerosol insecticide indoors
• Use of pyrethroid coils outdoors
• Inspection for ticks

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Bloodborne and STD Precautions

• Prevalence of
• STDs
• Hepatitis B
• Hepatitis C
• HIV
• Unprotected sexual activity
• Commercial sex workers
• Tattooing and body piercing
• Auto accidents
• Blood products
• Dental and surgical procedures

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Animal Precautions

• Animal avoidance
• Rabies
• Specific animal threats
• Medical evaluation of bites/scratches
• Post exposure immunization and immunoglobulin
• Envenomations
• Snakes, scorpions, spiders
• Maritime animals

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Injury and Crime

• Vehicles
• Risk of road and pedestrian accidents
• Night travel
• Seat belts and car seats
• Use of drugs and alcohol
• Understanding local crime risks
• Scam awareness
• Situational awareness
• Location avoidance

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Travel Emergency Kit

• Copy of medical records and extra pair of glasses
• Prescription medications
• Over-the counter medicines and supplies
• Analgesics
• Decongestant, cold medicine, cough suppressant
• Antibiotic/antifungal/hydrocortisone creams
• Pepto-Bismol tablets, antacid
• Band-Aids, gauze bandages, tape, Ace wraps
• Insect repellant, sunscreen, lip balm
• Tweezers, scissors, thermometer

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Post-Travel Care

• Post-travel checkup
• Long term travelers
• Adventure travelers
• Expatriates in developing world
• Post-travel care
• Fever, chills, sweats
• Persistent diarrhea
• Weight loss

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FINISH
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Travel Health Resources

• CDC Travelers Health Website
• www.cdc.gov/travel
• World Health Organization
• www.who.int/int
• State Department
• travel.state.gov
• International Society of Travel Medicine
• www.istm.org
• Health Information for International Travel
• CDC Yellow Book
• International Travel and Health
• WHO Green Book

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Journals

• American Journal of Tropical Medicine and Hygiene
• Bulletin of the World Health Organization
• Emerging Infectious Diseases Journal
• Eurosurveillance Weekly
• Journal of Travel Medicine
• Morbidity and Mortality Weekly Report
• Tropical Medicine and International Health
• Vaccine

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Books

• Textbook of Travel Medicine and Health, 2nd Ed.
• DuPont, H.L. and Steffen R. (editors)
• The Travel and Tropical Medicine Manual, 3rd Ed.
• Jong, E.C., McMullen, R.
• Travel Medicine
• Keystone, J.S., Kozarsky, P.E., et al

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Websites

• Eurosurveillance
• www.eurosurveillance.org
• Travax EnCompass
• www.travax.com
• GIDEON
• www.gideononline.com
• International SOS
• www.internationalsos.com
• Medical Advisory Service for Travelers Abroad
  (MASTA)
• http//www.masta.org/
• Armed Forces Medical Intelligence Center
• www.afmic.detrick.army.mil/
• Central Intelligence Agency
• www.cia.gov/cia/publications/factbook/

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Thank You...From Atlanta!