Travel Medicine Christy Beneri, DO Assistant Professor of Clinical Pediatrics SUNY Stony Brook January 27, 2011
Transcript
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Christy Beneri, DO Assistant Professor of Clinical Pediatrics
SUNY Stony Brook January 27, 2011
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Nothing to disclose
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1. Review current travel advice and immunizations based on
travel locations 2. Recognize possible infections in returning
travelers 3. Better identify the need for referrals to travel
medicine experts
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Globally, >750 million people traveled internationally in
2004 1 About 4% are children About 8% of travelers seek medical
care while abroad or on returning home 22-64% of travelers to the
developing world report health problems Nationally, >64 million
trips outside the US, a 21% increase since 1997 2 1. Long S et al.
Principles and Practices of Pediatric Infectious Diseases. 2003.
Chapter 9;79-86 2. Yellow Book 2010
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In one study 1,254 travelers departing from Boston Logan
International Airport completed a survey. The survey revealed that:
38% traveling to low-low/middle income countries and 62% to
upper-middle or high income countries 54% of travelers to LLMI
countries pursued advice prior to travel Most sighted reason for
not seeking advice was lack of concern regarding health problems
related to trip LaRocque et al. J of Trav Med.
2010;17(6):387-391
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Web based data collection, 17,353 ill returned travelers at 31
clinical sites on six continents Individual diagnoses put into
syndrome groups and examined for all regions together 226 per 1000
had systemic febrile illness, 222 acute diarrhea, 170 dermatologic
disorder, 113 chronic diarrhea and 77 respiratory disease Freedman
et al. NEJM. 2006;354(2):119-30
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FEBRILE ILLNESS IS MOST LIKELY FROM AFRICA AND SOUTHEAST ASIA.
MALARIA IS AMONG THE TOP THREE DIAGNOSES FROM EVERY REGION. OVER
THE PAST DECADE DENGUE HAS BECOME THE MOST COMMON FEBRILE ILLNESS
FROM EVERY REGION OUTSIDE SUB- SAHARAN AFRICA. IN SUB-SAHARAN
AFRICA, RICKETTSIAL DISEASE IS SECOND ONLY TO MALARIA AS A CAUSE OF
FEVER. RESPIRATORY DISEASE IS MOST LIKELY IN SOUTHEAST ASIA. ACUTE
DIARRHEA IS DISPROPORTIONATELY SEEN IN TRAVELERS FROM SOUTH CENTRAL
ASIA. Freedman et al. NEJM. 2006;354(2):119-30 Yellow Book
2010
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With the extent of international travel, physicians need to be
knowledgeable on the travel advice they give to patients
Appropriate travel advice avoids mishaps including injury and
illness during travel and ensures a good memorable travel
experience
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Should at least occur 4-6 weeks prior to travel Review entire
trip itinerary Destinations, time/duration of travel,
accommodations, planned activities, exposures to insects/animals
Review patients current and past medical history Review
immunization history, medications, and allergies Remember to
include children of immigrants returning to their home countries to
visit relatives and friends
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Requires skill, time, knowledge base and comfort, helps when
you have been there Vaccinations- required, recommended, routine
Malaria Prophylaxis Other Insect/Vector Borne Risks Travelers
Diarrhea Other Destination Risks water, food and safety
precautions
While immunization rates have increased over the past several
years, a significant number remain unimmunized Many vaccine
preventable diseases are endemic in most of the world Therefore,
children should be brought up to date with routine immunizations
Accelerated dosing schedules may be used
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VaccineEarliest Age for 1st DoseMin. Interval between Doses
Combined Hepatitis A and B*1 year1 wk, 2 wks between 2nd and 3rd
doses (booster after 1 yr) Hepatitis A1 year6 mos DTaP6 weeks4 wks,
6 mos between 3rd and 4th doses IPV6 weeks4 wks OPV*birth4 wks Hib6
weeks4 wks (booster after 1 yr) Hepatitis Bbirth4 wks, 8 wks
between 2nd and 3rd doses (give 3rd dose > 16 wks after 1st
dose) PCV76 weeks4 wks, 8 wks between 3rd and 4th doses Measles 6
mos followed by MMR at 12 mos and at 4-6 years of age4 wks
Varicella12 months4 wks if > 13 y/o 3 mos if < 13 y/o *Only
outside US
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Polio In the US, OPV is not available; IPV can be given as
young as six weeks Do not give OPV to patients with
immunodeficiencies MMR Infants between 6-12 months traveling to a
measles endemic area should receive 1 dose of measles (or MMR)
vaccine prior to travel
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Hepatitis A Most cases are imported into the U.S. by travelers
from Mexico and Central America Infants 3 months)
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Influenza Seasonal influenza vaccines for all travelers 6
months of age and older Pertussis Tdap booster should be given
starting at 11 years of age
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Polio For previously immunized adult travelers to polio-endemic
areas (Africa, Asia), consider vaccination with an additional dose
of IPV Only 1 lifetime booster of IPV is necessary
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Typhoid vaccines Asia, Africa, Central and South America,
Caribbean Contraindications: hypersensitivity, malignancies
Precautions: pregnancy
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Oral vaccine (Ty21a) Live attenuated vaccine > 6 y/o;
provides 5 years of immunity Do not take concurrently with
proguanil, mefloquine, or chloroquine (antimalarials) Adverse
effects: abdominal pain, N,/V, F, HA, rash Typhoid IM vaccine
(ViCPS) Purified, killed capsular polysaccharide vaccine > 2
y/o; provides 2 years of immunity Adverse effects: F, HA, local
reaction
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Type of vaccineLive attenuatedKilled RouteOralIntramuscular
Minimum age of receiptAge >6 yrsAge >2 yrs # of doses41
Booster frequency52 Adverse effects (incidence)
Japanese Encephalitis Virus Arboviral infection transmitted by
Culex mosquitos F, HA, N/V, meningitis/encephalitis About 50% have
neurologic abnormalities and fatality rate is 25% JE vaccine
Recommended for all travelers > 12 m/o traveling to endemic
areas for > 1 month (rural East Asia, SE Asia) 3 doses given
over 2-4 weeks; give last dose at least 10 days before travel and
observe for 30 min after each dose Duration of immunity
unknown
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(Yellow Book, 2008)
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Meningococcal Vaccine (MCV) IM Quadrivalent conjugate vaccine
(A, C, Y, W-135) Most common serogroups in US: B, C, Y Most common
serogroups in sub-Saharan Africa: A, C, W-135 Protects against
meningococcemia and meningitis Required for travelers to Hajj and
the meningitis belt from December June MCV is preferred over MPSV4
for children 2 through 10 years of age
Yellow fever Arboviral infection transmitted by Aedes and
Haemogogus mosquitos F, HA, N/V, myalgia, photophobia and
restlessness, myocardial dysfunction and fulminant hepatitis YF
Vaccine Live attenuated International certificate of vaccination
for all entering travelers Effective after 10 days; booster
required every 10 yrs Contraindications: egg allergy,
immunosuppression; Cautions: pregnancy, elderly Adverse effects: F,
HA, rash; vaccine-associated encephalitis syndrome (rare: 0.5-4 per
1000 infants); vaccine-associated viscerotropic disease
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(CDC, Division of Vector-Borne Infectious Diseases, 2005)
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Malaria Dengue
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Infection occurs via infected female Anopheles mosquito Most
commonly caused by Plasmodium species P. falciparum most lethal and
drug resistant P. vivax Central America, Indian subcontinent P.
ovale western sub-Saharan Africa P. malariae A worldwide leading
cause of death in children under 5 500 million infections and >
1 million deaths annually
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Highest Risk of Disease Young children Pregnant women Those
without prior exposure Lower Risk of Disease Air-conditioned
housing Screened housing No vaccine available
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Clinical presentation F, HA, myalgias, malaise; anemia,
jaundice P. falciparum: seizures, mental confusion, renal failure,
coma, death Symptoms may present 7 days after exposure to several
months after return from an endemic area
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Personal protective measures Bed nets * Clothing that covers
most of the body Insect repellant: DEET Use > 30% DEET Not for
infants < 2 m/o Apply to your hands first before applying to
young children Insecticide (permethrin) coated clothing and bed
nets
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Country specific and altitude specific Dependent on patients
medical history Chemoprophylaxis is not 100% effective Started
prior to travel, during travel, and after return
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Chloroquine sensitive areas Central America, Argentina, parts
of the Middle East Chloroquine Chloroquine resistant areas All
other areas Mefloquine Atovaquone/proguanil Doxycycline
Primaquine
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Drug of choice where parasites are sensitive Adverse effects
GI, HA, dizziness, blurred vision, insomnia Caution: may worsen
psoriasis
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May be used in children of any weight Avoid in resistant areas
(Thailand, Myanmar, Cambodia) Adverse effects GI, HA, insomnia,
abnormal dreams, visual disturbances Rare: reversible
neuropsychiatric reaction, seizures Contraindications Psychiatric
disorders, seizures Caution: history of psych disorders, cardiac
conduction disorders
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Daily dosing Take with food Adverse effects GI, HA
Contraindications Severe renal impairment (Cr Cl < 30 ml/min)
Infants < 5 kg Pregnant women
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Daily dosing Adverse effects GI, photosensitivity, candidal
vaginitis Contraindications G6PD deficiency (fatal hemolysis)
exclude prior to use Pregnancy, lactation
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Transmitted by Aedes mosquitoes Endemic and epidemic in Asia,
Latin America, and Africa 159 cases per 1,000 travelers to
Southeast Asia during epidemic years Outbreaks have occurred in
southern Texas and Hawaii
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(CDC, 2005)
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Classic dengue fever asymptomatic to mild systemic illness
Estimated 100 million cases annually Acute F, HA (retro-orbital),
myalgia, arthralgia, V, abdominal pain, rash 1% progress to dengue
hemorrhagic fever (DHF) DHF and dengue shock syndrome (DSS)
Increased vascular permeability on 3 rd -7 th day of illness
Hepatitis, myocarditis, neurologic symptoms; shock Treatment: rest,
hydration, supportive care
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When outdoors or in a building that is not well screened, use
insect repellent on uncovered skin. Always apply sunscreen before
insect repellent. DEET, picaridin (KBR 3023), oil of lemon
eucalyptus/PMD, or IR3535. Always follow the instructions on the
label when you use the repellent. Protect longer against mosquito
bites when they have a higher concentration (%) of the active
ingredient. However, concentrations above 50% do not offer a marked
increase in protection time. Products with less than 10% of an
active ingredient may offer only limited protection, often just 1-2
hours. The American Academy of Pediatrics approves the use of
repellents with up to 30% DEET on children over 2 months old.
Protect babies less than 2 months old by using a carrier draped
with mosquito netting with an elastic edge for a tight fit.American
Academy of Pediatrics
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One of the most common illnesses affecting travelers; 9-40% of
all children Highest rates, longest duration, and greatest severity
in children < 3 y/o Etiologies Bacteria 80-85% Parasites 10%
Viruses 5%
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Pathogens are isolated 30-60% of the time Enterotoxigenic E.
coli (ETEC) Most common cause worldwide Large inoculum
Enteroaggregative E. coli (EAEC) Salmonella, Campylobacter,
Shigella, Vibrio Parasites: Giardia, Cryptosporidium, Entamoeba
Viruses: rotavirus, norovirus
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(Yellow Book, 2008)
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Less common than travelers diarrhea Ingestion of pre-formed
toxins V > D Usually resolves within 12-18 hours
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Avoid raw fruits and vegetables Avoid undercooked meat and
seafood Avoid street vendors Avoid tap water, ice, and
unpasteurized dairy products Use safe water sources (bottled,
boiled, filtered, or chemically treated [iodine tablets]) Drinking
Toothbrushing Food preparation
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Encourage breastfeeding for as long as is feasible Use a clean
water supply for powdered formula Frequent handwashing/hand
sanitizer use Bring prepackaged foods
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Oral rehydration solution packets are the treatment of choice
IV fluids for severe dehydration Antimotility agents are not
recommended in children Toxic megacolon, extrapyramidal symptoms,
salicylate toxicity
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There is little evidence for the use of antimicrobial agents in
pediatric travelers diarrhea Azithromycin may be used in children
traveling to areas with fluoroquinolone resistance (India,
Thailand) 10 mg/kg/d for 3 days 3 day course of ciprofloxacin
(20-30 mg/kd/d) may be given in children with moderate to severe or
bloody diarrhea Stauffer WM, et al. J Travel Med
2002;9:141150.
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If travelers diarrhea does not respond to a course of
antimicrobial treatment, other possible causes of diarrhea need to
be investigated Studies on probiotics (e.g. Lactobacillus,
Saccharomyces) are inconclusive
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Assemble prior to travel Prescription items Prescription
medications, antimalarial prophylaxis Nonprescription items First
aid supplies Thermometer Analgesics/antipyretics Sun protection
DEET Oral rehydration packets Water purification tablets
Antihistamine
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Disturbance of body & environmental rhythms resulting from
rapid change in time zones. Insomnia, irritability. Usually more
severe after eastward travel. Take short naps, remain hydrated,
avoid alcohol and pursue activities in daylight upon arrival.
Dietary supplement Melatonin 2-3 mg started on the first night of
travel for 1-5 days has been reported to facilitate transition.
Ambien started the first night of travel for up to 3 days.
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Rapid exposure to >8,000 ft (2500 mt) Headache, fatigue,
nausea, anorexia, insomnia, dizziness The most preventive measure
is pre-acclimatization by a 2-4 day period with gradual ascent.
Preventative Rx: Acetazolamide (carbonic anhydrase inhibitor)
starting 1-2 days before ascent and continuing at high altitude for
48 hrs. Children: 5 mg/kg/d in 2-3 divided doses Rare
cross-reactivity to sulfa drug allergy Rx: descent, O2
supplementation, dexamethasone 4mg q6h +/- diamox 250-500 q 12
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Cholinergic blocker scopolamine Patch or oral formulation
Transderm Scop is applied to skin behind ear 6-8 hrs before
exposure and changed q 3 days. Oral Scopace is taken 1 hour before
exposure. Dramamine or Meclizine are alternatives
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Avoid swimming in lakes and streams Appropriate use of seat
belts and car seats (should accompany the family) Counsel
adolescents about STIs, sharing needles, acupuncture, and tattoos
In one study of British travelers, 6% contracted STIs during their
travel Consider travel insurance
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Advance planning Pre-travel assessment includes Providing
vaccines and prophylactic medications A whole lot more! Travel
advice should be tailored to the traveler No preventive measures
are 100% effective
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CDC: www.cdc.gov/travelwww.cdc.gov/travel WHO International
Travel and Health: www.who.int/ith www.who.int/ith The
International Society for Tropical Medicine:
www.istm.orgwww.istm.org Travax:
www.travax.scot.nhs.ukwww.travax.scot.nhs.uk CDC Health Information
for International Travel (The Yellow Book), 2008 Travmed:
www.travmed.com
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1/6/11: Yellow fever northern Uganda 12/6/10: Chikungunya fever
Asia and Indian Ocean 12/7/10: Dengue C/S America, Asia and Africa
10/22/10: Polio Russia, Tajikistan, Central Asia 1/12/11:
Legionnaires disease Cozumel, Mexico
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CDC. General recommendations on immunization: recommendations
of the ACIP. MMWR 2006;55(RR15):148. CDC Health Information for
International Travel, 2008. Freedman DO, et al. Spectrum of disease
and relation to place of exposure among ill returned travelers. N
Engl J Med 2006; 354:11930. International travel issues for
children, Textbook of Pediatric Infectious Diseases, 5 th Ed.,
Feigin RD, et al. 2004. Protection of travelers, Principles and
Practice of Pediatric Infectious Diseases, 3 rd Ed., Long SS, et
al. 2008. Schwartz E, et al. Seasonality, Annual Trends, and
Characteristics of Dengue among Ill Returned Travelers, 19972006.
EID. 14, No. 7, July 2008, 1081-8. Stauffer WM, et al. Traveling
with infants and young children. J Travel Med. 2002; 9:14150.
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