What

1
Whats New in Travel Medicine?

• Gregory Juckett, MD, MPH
• Professor of Family Medicine
• Director, WVU International Travel Clinic
• West Virginia University
• gjuckett_at_hsc.wvu.edu

2
Resources/Recommendations

• New Travel Programs and Web Support
• New CDC Yellow Book 2010 Edition
• Special Case Travelers VFR
• New Approaches to Travelers Diarrhea
• New Recommendations for Malaria Prevention
• New Travel Vaccines Tdap, Menactra (meningitis),
  Ixiaro (Japanese encephalitis), H1N1 (Swine
  flu)

3
Free Web Travel Information Sources
Full Listing CDC Yellow Book Appendix B

• www.cdc.gov/travel CDC Travel Info (best)
• www.tripprep.com Shorelands Travel Health
  Online
• www.mdtravelhealth.com/ MD Travel Health
• www.who.int/ith/en World Health Organization
  Intl Travel
• www.astmh.org American Society of Trop.
  Medicine
• www.travel.state.gov U.S. State Dept.
  (202-647-5222)
• www.iamat.org Int. Assoc. Med. Assist. To
  Travelers
• www.promedmail.org Pro-MED program for monitoring
  emerging disease
• www.healthmap.org/en Health Map --Global Disease
  Alert
• www.medletter.com Medical Letter (Travel Health
  Summary)
• www.fallingrain.com Altitude Finder
• www.odci.gov/cia/publications/pubs.html CIA
  (select World Fact Book)

Travel Subscription Services e.g. Shoreland
TRAVAX Encompass, CultureGrams, SOS Travel Care,
and Gideon are even more useful but entail an
annual fee
4
CDC Health Information for International Travel
2010www.cdc.gov/travel/index.htmU.S. Government
Printing Office
New, Improved! Now has popular
destination-specific recommendations.
The Yellow Book
5
New CDC Yellow Book Features

• Pre-Travel Consultation risk assessment, risk
  communication, risk management
• Post-Travel Consultation
• Select Destinations /Travel Itineraries
• Infectious Diseases Related to Travel
• Yellow Fever /Malaria Tables
• Special Traveler Populations Children, Special
  Needs, Immigrants/Refugees
• Appendices
• A. Practice of Travel medicine
• B. Electronic Resources
• C. Travel Vaccine Summary Table

6
Contacting the CDC

• CDC-INFO Contact Center 800-CDC-INFO or
  cdcinfo_at_cdc.gov
• CDC Malaria Hotline [phone] or 770-488-7100
  (after hours)
• Travel Notices cdc.gov/travel/notices (public
  health focus)
• CDC Malaria Risk Map www.cdc.gov/malaria/features/
  risk_map.htm

7
CDC Malaria Interactive Mapwww.cdc.gov/malaria/fe
atures/risk_map.htm
Search Feature Country and City
8
Computer Travel Information Services
(all entail an annual fee)

• SOS Travel Care www.internationalsos.com
• Shoreland TRAVAX www.shoreland.com and Shoreland
  TRAVAX Encompass (online) www.travax.com
• Exodus Software www.exodus.ie
• Tropimed www.tropimed.com
• Travel Medicine Advisor (online) www.ahcmedia.com
  or orders_at_ahcmedia.com

9
Other Subscription Sites ( fee)

• Gideon (for diagnosing the ill returning
  traveler) www.gideononline.com
• CultureGrams (concise 4 page cultural summary by
  country) www.culturegrams.com
• VaxisEHR from Travis Medical (electronic health
  record) www.vaxisehr.com/travel

10
Watch Out For VFR Travelers

• VFR Visiting Friends and Relatives
• VFRs often spent childhood at destination so more
  comfortable with perceived risk (unfortunately,
  often a false sense of security)
• Partial immunity to malaria and travelers
  diarrhea is quickly lost with residence in a
  developed country
• VFRs as likely to get sick as a
  non-nativeillness perhaps even more likely due
  to absence of precautions
• VFR Travelers are unlikely to seek travel
  consultation, take malaria meds or use as much
  care with food selection
• Much of the imported malaria in the U.S. is due
  to visits back home (may fail to take prophylaxis
  especially since malaria may have been less of an
  issue in their childhood).

11
Travelers Diarrhea3 unformed stools
in 24 h with at least one of the following
fever, N/V, cramps, tenesmus, or bloody stools
(dysentery)Occurs in up to 55 of travelers from
a developed country visiting a less-developed
country, usually within the first two weeks
12
Travelers Diarrhea Poo-Pak

• Loperamide hydrochloride (Imodium A/D) 2 mg
• Adults one after each loose stool (max 8 mg/d)
  for symptom relief but avoid with dysentery!
  You do not wish to slow the bowel with an
  invasive organism. Stop in 48h if ineffective.
  Reserve for older children (gt6y)
• ADD ANTIBIOTIC (IF ILL) FOR UP TO THREE DAYS
• 1. Ciprofloxacin (Cipro) 500mg one q 12h x
  1-3d prn (other quinolones work as well) or
• 2. Azithromycin (Zithromax Tri-Pak) 500mg one
  q d x 1-3d (best for children/pregnancy
  quinolone-resistant areas like SE Asia and India
  alternative to Cipro) or
• 3. Rifaximin (Xifaxan) 200 mg 3x/d for 3 days

Rifaximin not helpful for invasive organisms
Only diarrhea with illness needs to be
treated with antibiotics!
13
Azithromycin Off Label Alternative

• Zithromax 500 mg qd x 1-3 days for adults (or
  1000 mg x 1 dose)
• Zithromax 250 mg qd x 1-3d for older children
• Zithromax 100 mg or 200mg/5ml susp. for younger
  children (10mg/kg/d) gt 6mo.
• Best for S.E. Asia (e.g. Thailand) and India
• Appears safe in pregnancy (category Bm) but
  transmitted to breast milk

14
New Therapy Rifaximin (Xifaxan)

• Broad-spectrum nonabsorbable Rifamycin-derivative
  for travelers diarrhea caused by non-invasive
  E.coli
• Approved by FDA for patients 12 years of age or
  older (5/25/04)marketed Autumn 2004
• Non-systemic treats only GI tract (lt.4
  absorbed) so less likely to cause drug reactions,
  interactions
• Side effects similar to that of placebo
  (flatulence 11), HA (9.7), abdominal pain (7)
  , tenesmus (7)
• Safe, no clinically significant resistance
• Rifaximin 200mg TID x 3d
• Not ideal for diarrhea w/ fever or blood in
  stool discontinue if diarrhea persists gt 24-48h

15
TD Option2 Tinidazole (Tindamax)

• Good second-line diarrhea drug if antibiotics
  dont work
• Indications Giardiasis, Intestinal amebiasis and
  amebic liver abscess
• Better than metronidazole as well tolerated and
  shorter course (more expensive in U.S.)
• Giardiasis adult 2g single dose
• Amebiasis adult 2g qd x 3d
• Like metronidazole, has the advantage of treating
  pseudomembranous colitis caused by Clostridium
  difficile (often from excessive use of
  antibiotics)
• Available as 250 mg and 500 mg tablets
• Must avoid alcohol during and 3d after use avoid
  1st TM
• Potentiates oral anticoagulants, lithium,
  phenytoin
• Side effects GI upset, abdominal pain, metallic
  taste, anorexia, constipation, dizziness, HA,
  transient leukopenia Rare seizures, peripheral
  neuropathy

16
No pooping or smoking allowed!
17
World Malaria Risk
18
Insect Bite Prevention

• DEET containing insect repellant (35) 6h
  protection
• N,N diethyl-m-toluamide apply to skin at
  dusknot on clothes/gear
• Now considered safe in children gt 2months or
  2nd, 3rd TM pregnancy _at_ 35 apply to skin after
  sunscreen use if using both avoid gt50 DEET
  products
• Picaridin containing insect repellent (20)
  safe, reasonable duration, not approved for
  children lt 2
• Permethrin-impregnated bed nets
• Long light-colored sleeves and trousers
• Window screens
• Avoid or reduce activity after dusk
• Mosquito coils
• Unproven B vitamins (thiamine), ultrasound,
  wrist bands, Demal 200 (homeopathic prophylaxis)
  these dont work reliably and should not be
  relied upon!

19
Global Dengue Risk
Common cause of febrile illness in returning
travelers Prevention is only available strategy
20
Malaria Prophylaxis Menu of Options
GENERIC TRADE MANUFACTURER DOSE FREQUENCY
Chloroquine Aralen Sanos 300 mg base 500 mg salt weekly
Mefloquine Lariam Roche 250 mg salt weekly
Doxycycline Vibramycin Pfizer 100 mg daily
Atovaquone Proguanil Malarone Glaxo 250mg /100 mg daily
Primaquine (use only if others unacceptable) 30 mg base qd 52.6 mg salt 2-15 mg tabs daily
G6PD testing necessary
21
TRAVAX Costa Rica Old vs. New Malaria Maps
22
India TRAVAX Map risk stratification
23
Atovaquone/Proguanil (Malarone) Malaria
Prophylaxis

• Newest anti-malarial drug for prophylaxis
• Adult (250/100) and Pediatric (62.5/25) doses
• Well-Tolerated (take w/ food)
• Expensive
• Best for short trips (1-4 weeks) into malarious
  regions
• Best options for patients w/ seizure disorders
• Daily prophylaxis dosing with 1 week tail

24
Chloroquine (Aralen) Central America, Haiti

• 500 mg (300 mg base) once weekly starting one
  week prior to departure and continuing x 4 weeks
  after return
• Reliable only in Central America, Hispaniola
  (Haiti), Mid-East elsewhere varying degrees of
  resistance
• Side effects GI upset, itching (esp. blacks),
  psoriasis exacerbation, intradermal HDCRV
  interference, safe for retina at prophylactic
  doses (avoid if diseased)
• Safe in pregnancy avoid with seizures,
  retinopathy
• Pediatric dosing based on 5mg/kg base weekly
  (6.3mg/kg salt)
• Dangerous to children in overdose Nivaquine
  syrup 6mg/ml available outside U.S.
• Resistance mostly in P. falciparumbut also P.
  vivax in Indonesia/PNG and increasing worldwide

25
Mefloquine (Lariam) best long-term option

• CDCs recommendation for most areas with CRPF
  resistance in SE Asiaesp. Thai border-- areas
  (rare resistance elsewhere)
• Dose 250 mg weekly starting one week prior to
  travel, weekly in area of risk and weekly x 4
  weeks afterwards (half-life 21d) wks5
  convenient for long trips
• Cost 10/tab
• Side effects vivid dreams, insomnia, GI upset
  (take with water), dizziness, seizures, panic,
  hallucinations, cardiac conduction problems
• Contraindications avoid in seizure disorders,
  past history of psychosis or depression, cardiac
  conduction defects (avoid use w/ quinine,
  quinidine, halofantrine)beta-blockers and
  calcium channel blockers now ok avoid in pilots
  unless tolerance already proven
• Relative Contraindications 1st trimester
  pregnancy (ok 2nd, 3rd TM w/consent), airline
  pilots or tasks involving fine motor
  coordination, infants (lt5 kg?)
• Many refuse it out of fear of neuropsychiatric
  reactions!

26
Mefloquine Resistance in SE Asia
In red areas, use doxycycline or Malarone not
mefloquine
27
Doxycycline cheapest but least convenient option

• Dose 100mg daily starting 1-2 d prior to travel,
  daily during risk period and daily for 4 weeks
  (28d) after
• Best cheap alternative to mefloquine for
  resistant malaria Best for SE Asian areas of
  mefloquine-resistance
• Side effects photosensitivity (3), esophagitis
  (take w/ water and keep upright), monilia, BCP
  interaction
• Contraindications pregnancy, children lt 8 yrs,
  allergy Interaction antagonized by Dilantin
  and seizure meds
• Mechanism ribosomal inhibition (pre- and
  erythrocytic phases) Safe for long-term
  chemoprophylaxis
• No resistance reported but compliance poorer due
  to long post-trip regimen and side effects

28
Malaria Self Treatment Options

• If gt 24h from medical care with fever 38C,
  consider stand-by self-administered anti-malarial
  Rx (different from what is already being used as
  chemoprophylaxis)
• Must continue prophylactic regimen (if any) and
  get medical care ASAP
• Malarone 250/100 (atovaquone/proguanil) usual
  best choice! 4 tabs daily with food for 3 days
  (12) 60-70
• Coartem (artemether/lumefantrine) 4 tabs _at_dx,
  then 4_at_8h then 4 BID x 2d (24) Novartis sells
  for 69
• Chloroquine phosphate 600 mg base , 300 mg 6h
  later, 300 mg q d for next 2d (Central America,
  Haiti)
• Fansidar (pyrimethamine-sulfadoxine) 3 tabs no
  longer reliable due to resistance
• Lariam (mefloquine) 250 mg 3 tabs followed 12h
  later by 2 tabs or 1250 mg in 24H frequent
  neuropsychiatric problems at treatment dose

29
Coartem Self-Treatment of Malaria
Now licensed in U.S. (2009) and commonly used for
self-treatment in Africa

• Artemether 20 mg and Lumefantrine 120 mg
  (Novartis)
• Riamet (marketed in Europe) Coartem
• Three Day Rx 4 tabs _at_dx, then _at_8h then BIDx2d
  (dose for resistant areas, non-immune patient)
• gt95 cure rates, no increased QT problems
• Can be used in small children (5-10 kg)
• Well-tolerated good standby Rx for traveler

30
Malaria Prevention Summary

• No regimen guarantees 100 protection against
  malaria so avoid mosquito bites
• Malaria ABCs A Be aware of malaria risk
  B Avoid being bitten C Take chemoprophylaxis
  D Seek diagnosis /treatment if fever develops 1
  week or more after entering risk area and up to
  3m (falciparum) or 1 year (other species) after
  departure.
• Mefloquine best for long trips and pregnancy
  neuropsychiatric issues hinder its use
• Malarone best option for short-term travel
• Overseas, ignore advice re regimens there

31
TRAVEL VACCINATION

• Safe, effective way to reduce morbidity from
  travel diseases
• Three vaccine categories recommended, required
  and routine
• Contact with unvaccinated population loss of
  herd immunity and increased disease risk
• Procrastination a major problem ideally see
  patients gt1 month before travel
• Often not covered by insurance

32
Live Vaccines

• Avoid in immunocompromised patients and in
  pregnancy
• Give together or 4 weeks apart
• LIVE VACCINE LIST
• Measles-Mumps-Rubella (MMR)
• Flu-Mist (and new H1N1 live vaccine)
• Oral Typhoid (Vivotif Berna)
• Varicella (Varivax)
• Yellow Fever

33
Hepatitis A Vaccine

• Two main options equivalent and interchangeable
• Havrix, Vaqta adult (gt19) and pediatric (18 and
  under) doses
• Available in U.S. since 1995 essential
  recommended vaccine for most travelers to
  developing countries!!!
• Single dose HAV given IM deltoid 4wks prior gives
  98-100 protection (give up till departure if
  necessary)
• Booster dose 6 -12 m later for long-term immunity
• Approved for children over 1 year of age (IG
  public health option for younger children in
  daycare)
• Now recommended for all U.S. children gt 1 year
  5/06
• Pediatric Doses 2-18 y 720 EL.U. IM, gt18y 1440
  EL.U. IM

34
Hepatitis B Vaccine

• Recombinant Hepatitis B surface antigen
• Recombivax, Engerix-B, Comvax (Hep B/HIB) in
  pediatrics
• Dose 0, 1, 6 months 0.5 ml IM deltoid 10yr
• Accelerated Engerix-B regimens 0, 1, 2 m w/ 12m
  booster or 0, 7, 21 days w/12 m booster (65
  seroprotection on day 28 increasing to 99 month
  13)
• Pregnancy precaution but safe noninfectious
  HBsAg
• Indicated for long-term (6m) or frequent travel
  or any anticipated sexual or body fluid exposure
• Highest risk China, Sub-Saharan Africa
• Now a standard pediatric vaccination in much of
  the world

Assume students will be sexually-active overseas!!
35

Patpong District, Bangkok
36
Hepatitis AB Vaccine Combination

• Twinrix Hepatitis A/B Vaccine (SKB)
• 3 doses 0, 1, 6 months or 0, 1, 2 w/ 12 m
  booster
• 1 cc IM deltoid adult dose
• For adults gt18 years old
• Vaccine Formulation adult
• Hepatitis A antigen 720 EI. U. (ped dose)
• HBsAg 20mcg
• Dose volume 1 ml
• Accelerated off label option 0, 7, 21 d (83
  HBAb 1m) w/ booster in 12 m
• 93 Hepatitis A antibody present after 1st dose

37
Influenza Seasonal Flu Vaccine

• Flu occurs year round rather than seasonally in
  the tropics and seasons reversed in southern
  hemisphere (some exceptions)
• Consider vaccination for elderly, ill and
  diabetic travelers (inactivated so cannot cause
  flu!)
• Adult 0.5 ml IM deltoid x 1 (give 1 month before
  flu season)
• Pediatric 6m-8y 2 doses 1m apart for 1st
  immunization then one dose/y (dose .25 ml 6-35m,
  .5ml gt 3y)
• Avoid in egg allergy, active neurological
  disorder
• Nasal live (cold-adapted) flu vaccine (FluMist)
  approved for healthy patients 5-49 yrs old

38
H1N1 Swine Flu Vaccine

• Still a concern for travelers vaccine is
  expiring
• 4 manufacturers 3 killed and 1 live vaccine
  options (no adjuvant in this years vaccine)
• May be given at same time as seasonal flu
• One dose for adults and children gt10years
• Children lt10 y need 2 doses (21-28d apart)
• Recommended for 5 target groups first pregnant
  women, caregivers/contacts for children lt 6
  months, health care workers, everyone 6 m-24y
  old, 25-64 y with health problems (do not give if
  lt 6m)
• Multi-dose vials contain thimerosol (not in
  single dose)

39
Japanese Encephalitis

• Virus transmitted in Asia by Culex night-feeding
  mosquitoes
• 10-15, 000 deaths/yr out of gt 50,000 reported
  cases. Most cases sub-clinical but up to 30
  fatality rate in those with clinical
  encephalitis.
• Encephalitis survivors often have permanent
  neurologic sequelae
• However much less common in American travelers
  so vaccination recommended for expatriates and
  longer-term (gt1m) travelers.

40
Arboviruses of the World
ARBO Arthropod borne
TBE
JE
YF
YF
Tick-Borne Encephalitis (Red) Japanese
Encephalitis (Blue)
Yellow Fever (Yellow))
41
Japanese Encephalitis Map
42
Seasonal Risk of Japanese Encephalitis
Sanofi will cease manufacture of JE-Vax Summer
2005supplies to run out 2009. New JE Vaccine
is Ixiaro (Intercell)
43
Japanese Encephalitis Vaccine (Obsolete) JE-Vax
(Biken)

• Consider for 1 m travel in rural Asia (esp.
  May-September) Risk up to 15,000 per month of
  travel
• Rare in U.S. tourists but high morbidity
  (50)/mortality (30) Recommended for long term
  stays
• Three 1.0 ml SC doses 0,7, 30d (0, 7, 14 d short
  course) formalin-inactivated mouse brain
  vaccinelast dose must be 10 days before
  departure (delayed reactions incl. anaphylaxis)
• 1ml gt 3y, 0.5ml lt 3y, avoid under 1 year of age
• Risk of delayed urticaria (.6), anaphalaxis,
  angioedema observe for 30 min (10d access to
  care) Expensive
• Contraindications urticaria hx, pregnancy, lt 1yr
• May give booster dose after 2 years if risk
  indicates
• Manufacture ceased 2005 (supplies to run out this
  year) but only JE vaccine approved for children
  (1-17)

44
New Japanese Encephalitis Vaccine Ixiaro
(made by
InterCell/marketed by Novartis)

• Vero-cell culture inactivated vaccine to replace
  JE-Vax (approved March 2009) better tolerability
• Adults 17 years old (pregnancy category B)
  still must use JE-Vax for children
• 96 seroconversion by 4 weeks (99 Ab later)
• Duration and need for boosters still unknown
• 2 dose 0.5 ml IM deltoid series given 28 days
  apart
• HA, injection site pain and myalgias but
  apparently less risk of delayed urticaria
• 195 x 2 390 cost No 10d wait period to
  travel
• No thimerosol but contains protamine sulfate

45
Meningococcal Quadrivalent Vaccines

• Menomune quadrivalent A, C, Y, W-135
  polysaccharide vaccine (MPVS4) 0.5 ml SC deltoid
  (polysaccharide vaccines have shorter duration of
  protection) approved for ages gt2 years (best
  option for gt 55yrs) boost q3-5yrs
• Menactra quadrivalent conjugate vaccine (MCV4,
  2005) approved for ages 2-55 y 0.5 ml IM
  deltoid avoid in latex allergy
• Menveo quadrivalent conjugate vaccine (MCV4,
  2010) approved for ages 11-55y (applying for
  2-11) same dose as above
• Indications
• Hajj (Pilgrims to Mecca) required by Saudi Arabia
• Travel to Sub-Saharan Africa meningitis belt
  Dec-June dry season (serogroup A outbreaks)
• Incoming University Students (Dorm Residents)
• Medical/mission work in developing world
• Neither vaccine protects against serogroup B
• Menactra and Menveo conjugate vaccines will give
  longer immunity (10 years) than Menomune
  polysaccharide vaccine

46
Meningitis Belt
African Meningitis Belt
47
Inactivated Polio Vaccine IPV

• Wild polio eradicated in the Western Hemisphere
  but still a concern in Africa, India, Afganistan,
  Pakistan, Nepal
• Current epidemic in Africa began in 2003
• IPOL Types 1, 2, 3 inactivated poliovirus 0.5 ml
• Non-immunized adults IPV 0.5 ml IM or SC three
  deltoid doses 1m apart or 0,1-2,6 m
• Immunized adults single IPV booster as adult
  (travelers to Sub-Saharan Africa, India)
• Avoid in pregnancy, avoid OPV (no longer in U.S.)
  with live typhoid vaccine

48
Polio Outbreak

• Kano State, Nigeria refused polio vaccination
  none given since 8/03
• Polio has since spread from Nigeria throughout
  Africa and then on to Yemen, India, and Indonesia

49
Rabies Pre-Exposure Vaccine

• Rabies Human Diploid Cell Vaccine (HDCV) Imovax
  (now available again)
• Rabies Purified Chick Embryo Cell Vaccine (PCEC)
  RabAvert
• Pre-exposure regimen 1 ml IM deltoid on days 0,
  7, 21 (or 28) or .1 ml (HDCV only) ID 0, 7, 21
  (or 28) d
• EXPENSIVE!!! ID (250) much less expensive than
  IM (700) but no longer available in U.S.
• Advantages Peace of Mind for expats and their
  children living in high risk developing
  countrieschildren should be highest priority as
  they play with animals and may not report an
  exposure.

50
50,000 cases rabies in world/yover half U.S.
rabies due to foreign dog exposure DONT PET
Animals!
High Risk
High Risk
High Risk
Free
World Rabies Risk Map
51
Rabies Pre-Exposure Vaccine

• Given at 0, 7, and 21 (or 28) days
• Cost is about 700
• Booster injection or check serology q 2 yrs if
  high risk for exposure
• Post-exposure treatment if vaccinated 2 doses at
  0, 3 days to boost immune response
  (no Rabies Immune Globulin needed)
• May give in pregnancy if necessary
• Indications long-term travelers (expats) and
  their children, animal workers, spelunkers
• Post-Exposure Rabies Vaccine in previously
  unvaccinated patients now only 4 (not 5) doses
  0, 3, 7 and 14 days (plus Rabies Immune Globulin
  RIG)

52
Typhoid Vaccine2 options

• Vivotif Berna oral live attenuated vaccine four
  capsules 1 qod 2w before departure (keep
  refrigerated) available again avoid w/in 24h of
  antibiotics or w/ hot liquids, avoid in
  pregnancy boost every 5 yrs (for healthy
  adults and children gt6y)
• Typhim Vi capsular polysaccharide vaccine single
  dose boost q 2y adults and children gt2y
• Both vaccines only provide about 70 protection
  (lower sero-conversion than most other vaccines)
• Older typhoid inactivated bacterial vaccine
  (painful) 2 injections 1m apart
  now discontinued in U.S.
• Indications 3 wk travel or primitive
  conditions, any travel to sub-Saharan Africa,
  India (highest risk), Indonesia can still get
  typhoid but milder illness

53
Tetanus and diphtheria (Td)Tetanus, Diphtheria,
Activated Pertussus (Tdap)

• Routine Td every 10 years q 5 yrs with
  contaminated wounds (0.5 ml IM deltoid)
• Primary course Td (gt7y) 0, 1-2, 6m
• Children should have 3 doses DTP prior to travel
• Diphtheria risk to travelers in Russia and the
  Ukraine
• Pertussus (Whooping Cough) protection with Tdap
• Defer in 1st trimester pregnancy overseas except
  if risk warrants (commonly given in pregnancy
  overseas)
• Tdap (Boostrix, GSK) one time booster is designed
  to boost waning pertussis (whooping cough)
  immunity in 10-64 y/o
• Tdap (Adacel, SP) one-time booster for 11-64y,
  protecting both the patient and any pediatric
  contacts from pertussisdont confuse with
  pediatric vaccine (6wks-7yrs) DTaP (Tripedia)
• Tdap Avoid in latex allergy, Avoid giving w/in 2
  years of Td (increased reaction)

54
Varicella Vaccine (live) Varivax

• Varivax live attenuated varicella vaccine should
  be considered if no history of chicken pox
  (Varicella)
• Check Varicella Ab if uncertain
• Adult (gt13y) 2 SC deltoid doses .5 ml _at_ 0, 4-8
  weeks
• Child (12m-12y) Now 2 SC deltoid doses
  .5 ml _at_0, 4-8 weeks (new recommendation)
  avoid salicylates for 6 weeks due to risk of
  Reyes syndrome
• Avoid in active TB, neomycin allergy, immune
  deficiency, pregnancy/lactation, lt12m
• Same PPD concerns as measles (false negative x
  6w)
• U.S. born 1965- 1980 usually assume most patients
  will be immune (unless health care workers or
  pregnant) only 2.6-2.8 gen. population
  susceptible

55
Yellow Fever VaccineLive

• Tropical S. America and Africa vaccine required
  for entry into many endemic zone countries and by
  some outside countries as well (consult Yellow
  Book)
• Aedes aegypti mosquito virus gt 20 mortality
• Attenuated live virus vaccine egg origin
• One .5 ml dose SC, booster q 10 years
• Avoid in egg allergy, pregnancy (exceptions
  made), immunocompromised (splenectomy ok), thymus
  disorders
• Infants lt 6-9 m (encephalitis /YF neurotropic
  disease) use in 6-9m old only if going to area w/
  outbreak
• Yellow Fever Vaccine-Associated Viscerotropic
  Disease (may be fatal) 65 and thymus disorders

56
Yellow Fever Distribution
CDC Yellow Fever Information 404-498-1648
57
Vaccines in Pregnancy
Avoid travel after 36 weeks gestation
Prefer to give most after 1st TM due to possible
febrile response, Risk vs. Benefit Consideration

• Avoid all live vaccines (YF, MMR, FluMist,
  Varivax, BCG, Oral Typhoid) except in unusual
  circumstances e.g. Yellow Fever when justified by
  risk of outbreak
• Tetanus-diphtheria if indicated
• Hepatitis Ause immune globulin instead
• Hepatitis B if at risk of infection
• Influenza (inactivated) if at risk during season
  (post 1st TM best)
• Ixiaro only if at significant risk
• Meningitis (Menomune) if indicated
• Polio (inactivated) if indicated
• Rabies if indicated
• Typhoid (Typhim Vi) if indicated

Malaria Mefloquine after the first TM (even
during 1st TM if unable to defer travel)
Treated Bed nets DEET 35 Chloroquine also OK
but only if no CRPF in area
58
REMEMBER the largest cause of mortality in
(older) U.S. travelers is death secondary to
pre-existing conditions e.g. MI, stroke The 1
cause of death in younger travelers is
accidents!!!
59
Wowthat headdress would make a great souvenir
Wow! That head would make a great souvenir!
(Not Me)
Avoid costly cultural misunderstandings!