Pre-Travel Health

Travelers diarrhea prevention mantra

-Boil it -cook it -peel it -or forget it

Controversies with Traveler's Diarrhea and antibiotics

-concern about data suggesing an increase in carriage of antibiotic ressisant bacteria in travelres -Consider stratifation of diarhes symptoms (mild-moderate do not need it0 -Prescrption for self treatment may still be approprate for remote destinations, limited or no access to medical care

What is the schedule for twinrix

0, 1, 6 months

What is the accelerated schedule

0, 7, 21 days with a booster at 1 year OR other schedules similar to hep B accelerated schedules

Typhoid injectable

0.5 IM

Meninococcal vaccine: route of admin

0.5 mL IM in deltoid

Meninococcal vaccine: adminstartion route

1 mL IM preferably given at least 2 week before at risk

Typhoid vaccine schedule

1 pill every other day for 4 doses

Cosider screening before vaccinating for Hep B if:

1) Individuals from highly endemic areas 2) Homosexually active males 3) Illicit injectable drug users 4) Previous recipients of factor VIII or IX concentrates 5) High risk health care workers

What are the side effects of Typhoid Vaccine?

1) Local reaction 2) Flu-like sx

What are the side effects of Rabies (HDCV) vaccine?

1) Local reaction 2) fever

Insect bourne diseases

1) Malaria 2) Dengue fever 3) JEV 4) Leishmaniasis 5) Scabies 6) Zika 7) Chagas' disease 8) Yellow fever 9) Lyme 10) tick -bourne encephalitis 11) Chikuncunya

Other than travelr's diarrhea and malaria what other teaching might patients need?

1) Medical alert (penicillin allergy) 2) Sun protection 3) EPI kit (Her Bee stin) 4) Motion sickness 5) High altitude 6) Medical resources/insurance/evacuation insurance 7) Medical supplies to bring 8) Saftey issuee, including safe sex

Prophylaxis of Malaria

1) Mefloquine (Lariam ) 2) Doxycycline 3) Malarone 4) Chloroquine phosphate

Malorne adverse effects

1) Mouth ulcers 2) GI effects

Patient instructions after the vaccine?

1) No eating or drinking for 60 minutes before or after administration 2) No antibiotics within 14 days before administration

Outpatient visit, what should you do?

1) Obtain a thorough history 2) Review required/recommended vaccines 3) Set a schedule for immunizations depending upon amount of time before trip and interaction between vaccines 4) Do teach and provide informaiton to take home on common medical problems patient may encounter

Traveler's Diarrhea Self-treatment: Non-antibiotic

1) Oral rehydration solutions 2) Bismuth-containing compounds (pepto bismol), 3 and older 3) Antimotality agens (ex, imodium in 3 and older, do not use if fever or bloody stools)

Choroquine adveres

1) Pruritus 2) GI side effects 3) Less GI side effects if taken with meals AVOID if hx of seizures

What is cholera vaccine adverse reactions?

1) Tiredness 2) Headache 3) Abdominal pain 4) Nausea 5) Vomiting 6) Appetite loss 7) Diarrhea

Prescription for motion sickness?

1) Transderm scopolamine patch 2) scopolamine pills (Scopace)

What are some common medical problems patient may encounter?

1) Traveler's diarrhea 2) Malaria 3) Sun exposure 4) STI's 5) Altitude sickness 6) Jet lag 7) Saftey security 8) Sterile syringes

Water purification: Chemical disinfeciotn

1) chlorine and iodine

Acute Mountain sickness

1) headache 2) Nausea 3) Fatigue 4) insomnia

Japanese Encephalitis: reccommendation

1) if in endemic RURAL areas for more than 30 days 2) less than 30 days if during out break 3) JEV tranmission season and plan substaial time outdoors

Yellow fever: precautions

1) immunosuppressed 2) age 60 and older if naiive to vaccine

Typhoid vaccine

1) live oral (Ty21a) (pill form)

Hep B vaccine: Recommendaitons

1) long-term traveler (greater than 6 months, (greater than 3 months with shared clincial decision making) 2) Frequent short-term traveler 3) High-risk behaivor profile (sex, drugs) 4) Occupational exposure (healthcare worker, miliatry, aid worker, missionary) 5) Close contact with locals (ex. VFRs, children) 6) Adveture traveler 7) Accident prone

At the visit you should asses

1) medications they are one 2) Health problems and how they feel tody 3) Pregnancy/breast feeding status 4) Timein rural/Urban 5) WHat other activitied will they be doing 6) Lodging and eating conditions 7) Will their work include medical work or working with children? 8) Status of their routine immunization (Tdap, MMP, influenza) and any travel immunizations they've had 9) ask them if there are any specific areas/teaching they would like you to cover

How to prevent DVT while traveling

1) minimize alcohol and no smoking 2) INcrease non-alcoholic fluid intake (1 liter 6-8 hours flying time) 3) Take regular short walks and perform regular leg exercises 4)Do not sit for prolonged periods with legs crossed or the back of your legs pressed tightly agains the front of the sea

Yellow fever: Contraindiacions?

1) pregnant 2) breastfeeding 3) HIV+ 4) Anaphylactic allergy to eggs 5) Greater than 9 months of age 6) history of thymus problems 7_ Immunosuppress (recent radiation therapy or medications )

Cholera vaccine: ACIP recommendation as of June 2016

1) reccommend for a defined subpopulation of high risk travelers 2) Assess the individual traveler's risk factors and travel plans 3) Vaccine is NOT routinely recommended for most travelers due to low risk of cholera

Doxycycline adverse effects

1) sun sensitivities 2) Yeast vaginitis in woman 3) Gastrointestinal side effects (Best taken with food)

What does the risk of JEV vary with?

1) the season 2) destination 3) duration 4) Activities undertaken while traveling

Yellow fever: booster dosing

1) women pregenen when the received thei inital doe of vaccine (one additional dose prior to their next at risk travel for yellow fever virus infeciton_ 2) Individuals who receivet a hematopoitic stem cell transplant after dose and SUFFICIENTLY immunocompotent (revaccinate proir to their next at risk travel) 3) Individuals who were HIV-infected with last dose (administer doase every 10 years if they continue to be at risk) 4) Travelers who receiverd at least 10 years previously 5) Travelers who plan to spend a prolonged period of time in endemic areas or those traveling to highly endemic areas (such as west africa during peak transmission)

Hep B acclerated schedule

1)0,7, 21 days OR 2) 0,14, 28 days with booster at 1 year OR 3) 0,1,2 months with booster at 1 year

Adult dosage

1.0 mL begins age 20 (HEPLISAV-B is 0.5 mL)

Meninococcal vaccine: effective after how many days?

10 days after vaccinaiotn

What is the schedule of Ixiaro?

2 dose schedul: 1) 2 months- 2 years of ages: 0.25 mL IM day 0 and 28 2) 3 years of age and older: 0.5 mL IM day 0 and 28 - give at least 3 weeks before going

Typhoid vaccine (how long does it take to gain immunity)

2 weeks

What does WHO recommend?

2-dose ID rabies preexposure prophylaxis day 0 and 7 (not approved by CDC

Malaria

World's most important parasitic disease in th world -parasite transmitted by mosquitoes (female anopheles mosquito) -HIGHEST RISK= dusk to dawn -Use personal protection measures

What is the most common causes of morbitity and mortality in travelers under age 50?

accidents

Vaxchora is used in

adulta 18-64 yo traveling to cholera-affected areas

Yellow fever: effective

after 10 days of administration

What is Ixiaro indicated for?

age 2 months and older

Hep B geographic distribution

all over the world

Ty21a should be completed how soon before a trip

at least 1 week before trip

After the immunization patients should still,,,,

avoid contact with animals and get post-exposure treatment after cleaning the wound (2 infections day 0,3)

Ty21a antibiotic use

before, during, and after will interfere with effective ness!!!

Motion sickness

best taking 30-60 minutes before risk 1) cyclizine 2) Dimenhydrinate 3) diphenhdramine 4) meclizine 5) "Sea Band" 6) Ginger candy

What is the duration of protection from cholera

beyond 3-6 months is not know at this time

Meninococcal vaccine: for travel

booster every 5 years if at risk

Both injectatble and Ty21a

both 50-80% effective

Water purtication

bring water to boid (takes longer at altitudes above 2000 m)

Yellow fever: transmition

carried by a day time mosquito (use personal protection measures0

Hep B: What to do if patient comes in late

do not restart the series

Booster for Ixiaro indicated for

dose at 11 months if at risk for ages 14 months and older

What should patient do if symptoms last longer than 3 days?

see a health care provider (after 3 days of treatment, bloody diarrhea)

What is the general rule for travlers?

see people when possible AT LEAST 3-4 weeks before they leave

Hep A side effects

sore arm

Yellow fever: side effects

sore arm, flu like

Polio vaccine

stay tuned to periodic outbreaks and country guidlines

Traveler's Diarrhea (TD)

the best protection against TD is careful choice of food and drink. Follow these recommendations: 1) Restrict your diet to cooked food and fruits that can be peeled 2) Avoid food from street vendors 3) Avoid unpasteurized dairy products 4) Use purified carbonated beveraage when possible, avoid tap water and ice cubes 5) Use heated beverages when posible 6) Avoid brushing teeth when water is suspected to be contaminated

JEV still need what?

to use good personal protection measures

What is the controversy of reneed for titers?

traditionally high risk groups get titer drawn every 6-24 months depending on risk -boosters given if titer <1:5

Polio vaccine

use injectable (inactivated, Salk, IPV)

Yellow fever: administer how soon after drawing up

within 60 minutes after carefuly drawing up

Polio booser

(0.5 mL) recommedned for adults for international travel to risk countries (no polio in americas)

New Hep B vaccine

(HEPLISAV-B) day 0 and 1 month but only indicated for age 18 and older

Altitude sickness prophylaxisis

1) Acetazolide 125-250 mg twice daily, beging 24 hours ascent and continue 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

What are the common risk factors for travel-related illnesses?

1) Ages: -20-29 -Elderly and very young 2) Chronic GI, immunosuppression, pulmonary, or endocrine illnesses 3) Life-style while abroad -living with indigenous populations -sleepnig in tents or boarding houses 4) Prolonged stay in areas with poor sanitation 5) Tobacco smoking 6) VFR's (Visiting friends nad relatives) 7) Work or study in tropics

Prescriptions for traveling

1) All current Rx for all medicaitons influned OTC 2) Enough supplies plus 1 week 3) Food/drug interaactions 4) Storage of medications with temperature changes 5) Carry a record of what medications you take as well as your allergies

Travel health kit

1) Anit-diarrheal 2) Anti-malarial 3) Anitbiotic 4) Antipyretic/analgesic 5) Antihistamines 6) Cold preparations 7) First aid kit-including bandages 8) Sunscreen 9) Thermometer 10) Antacids 11) Laxatives 12) Motion sickness 13) Sedative/hypnotic 14) Condoms 15) Water purifier tablets/filter 16) Hand sanitizer

Malariuos areas : with chloroquine-resistan P. falciparum

1) Central america north of the panama canal 2) Haiti 3) Dominican republic 4) Middle east

Hep A: transmission

1) Contaminated food/water 2) Person to person

Pre-travel assessment

1) Countries to be visited 2) Purpose of travel (buisness vs. pleasure) 3) Length of travel (longer trips = bad) 4) Accomodations (staying with family, camping, hotels, VFR's, areas with poor sanitation 5) Transportaion 6) Travelers age (very old, yound, and 20-25) 7) Health of travelers (preexisting diseases) 8) Mediccations/allergies (potenital contradictions) 9) Immunization status (previous vaccines)

Hep B (what patients require one more vaccine)

1) Dialysis 2) Immunosuppressed patient

Jet lag: Prevention

1) Diet (no scientific date,but helpful to minimize alcohol, smoking and caffeine in flight 2) Light exposure during daytime 3) Short-acting hypnotics 4) Melatonisn

What are the side effects of motion sickness medications?

1) Dizziness 2) Drowsiness

What should you avoid Ty21a in?

1) HIV+ 2) Immunosuppressed 3) GI disease or children greater than 6 years of age

Hep A vaccine: brands

1) Havrix 2) Vaqta -both equally effective and are interchangable

What are some adverse effects of Ixiaro?

1) Headache 2) Muscle pain 3) Pain 4) swelling 5) tenderness (at ijection site)

Risk of Typoid

1) Highest risk for those going off the usual tourist routes and those returning to visit family and friends 2) Rates higher in travelers to Indian subcontinent, Peru, Northwest Africa (excluding Tunisia), Mexico

Hep A recommendations?

1) INternational travelers to high risk areas (new can start at 6 months of age!) 2) Anyone with ongoing contact with children adopted from countries where hep A is common

Yellow fever: waiting time

30 minutes after vaccination

Travelers Diarrhea

30-70% of travelers on a 2 week trip with develop diarrhea -concerns about resistance to antibiotics

What is the duration of Typoid Vaccine?

5 years

Boosters Hep A vaccine

6 to 12 months later -no need to restart the series if late

Polio geographic location

Nigeria and pakastain

Are there any recommendations for reimmunization with cholera

No formal recommendations at this time

Hep B Side effects

Sore arm

Typhoid: Geographic distribution

South america, africa, and asia (highest in india and thailand)

Japenese Encephalitis geogrophy

Southeast asia

Geographic distribution of yellow fever

Southern hemisphere

What is twinrix recommended for?

Age 18 or older

Hep A: Geographic Distribution

All over tbh

Measles

All over the world

Traveler's Diarrhea Self-Treatment: antibiotics

Antibiotic +/- lopermide 1) Azitromycin: single doese, max 3 days -use in areas of campylbacter resstance and for children and pregnant women 2) Quinolones: single dose, max 3 days 3) Rifaximin: 3 times daily for 3 days

What is the most common cause of death while traveling?

Cardiovascular

What should patients be educated on?

Avoiding potential exposrues

Cautions of acetalozimide

Caution with allergies to sulfa and penecilling

What is the most common cause of morbitiy and mortality in travelers 50 years and older?

CV diases

WHat is one thing considered for DVT

Compression stockings (20-30mm HG)

Typhoid transmission

Contaminated food and water

Advers effects of Mefloquine

DO NOT USE IF PATISION HAS HISTORY OF 1) Seizures 2) psychiatric disorder 3) arrhythmias 4) secondary to cardiac conduction defects 5) previous problem with drug

Acclerated schedule of Ixiaro?

Day 0 and 7

Stamaril

During a yellow fever shortage: stamaril was european version of US yellow fever vaccine available under FDA experimental protocal -fractional dose not FDA or ACIP approved

Hep B: what is essential

Education on risks -behaivor driven as well as destination specific

Water purification

Filters are the best agains bacteria and protosoa -viruses are too small for most filters :(

Hep B schedule

First 2 does 1 month apart 3ed dose 5 months after 2nd

What is the most frequent vaccine-preventable disease among travelers going to countries of lower hygiene standards?

Flu

Rabies: post exposure

IF patient didnt receive pre-exposure treatment: 1) Rabies immun globuin (HRIG) 20 IU/kg with as much at the injury site as possible 2) 1 mL IM day 0,3,7,14 3) Consider a 5th dose at day 28 fr patients who are immunosuppressed or you have a high suspicion that this may be a significant rabies exposure

Rabies pre-exposure schedule

IM -1 mL days 0, 7, 21, 28 -need at least 3 weeks

Hep B: Administration route

IM in to deltoid in 3 doses

What are the side effects of Ty21a?

GI, flu-like sx

Adult formulation Hep A

Havrix and Vaqta age 19 and older

Twinrix

Hep A and B

Meninococcal vaccine

Highly efficaious and well tolerated -Conjugate vaccine effective against types: --A, C, Y, and W-135

Urban vs Rura

IF greater in rural= may need rabies and therefor start at least 3-4 weeks early

Meninococcal vaccine: Reccomended for

International travel to endemic areas (Sub-Sahara Africa)

JEV vaccine name

Ixiaro

Vaxchora

Live attenuated oral vaccine

Meninococcal vaccine: 2 brand

Menactra and Menvo (age 2 months and older)

Japenses encephalitis: Transmission

Mosqito borne viral encephalitis

What are the areas of worry with JEV

Mostly asia and india

Hep A and pregnancy

Ok to use in pregnancy

What parasiste with cause most severe morbidity and mortality

P.falciparum

What is some prophylaxis measures for malaria?

Personal protection measures 1) Wear long-sleeved shirts and long trousers 2) Apply insect repellent containing no more than 30-35% DEET or use 20% or greater Picaridin 3) At dusck, spray aerosolized insecticides (sucha as those containing pyrthrinins) in living and sleeping areas 4) Sleep in a screened or air-conditioned room 5) Use Bednetting of good quality with small mesh that is not damaged and preferable impregnated with permethrin 6) Pretreat clothign with permethrin

Typhoid vaccine (storage)

Refrigerate

Meninococcal vaccine: Required for

Saudi arabia during Hajj and other pilgrimages

How long on the trip? (6 months)

So need hep B and therefore needed to get stated at least 4-5 weeks before going

Have they traveled before

They may be up-to-date on some of their immunizations if they have traveled before

What is the most common clinical illness in travelers to tropical and semi-tropical regions?

Traveler's diahhrea

Cholera vaccine name

Vaxchora

Rabies geographic location

found in upper africa and southern asian countries

Rabies: Human Diploid Cell Vaccine (HDCV) should be given pre-exposure to...

high-risk groups: 1) Veterinarians 2) Animal handlers 3) Trappers 4) those visiting and living in endemic countries greater than 30 days 5) certain lab workers

Yellow fever: Required

if going to at risk areas and for adminitstrative purposes (crossing at risk borders)

Polio: what should you asses?

if primary series was done 1) IPV series 0.5 SQ 2) IM at 0,6-8 weeks later, 6-12 months after second

Ixiaro

inactive vero cell-derived JE vaccine (IC51)

What is increasing in typhoid

increasing drug resistance

Twinrix: for traveler

leaving soon best to give antigens

Yellow fever: duration of immunity

lifespan

Yellow fever: vaccine

live attenuated vaccine -0.5 SQ in arm

Meningitis Belt

mid africa belt

Yellow fever: What do you need to administer

official validated WHO yellow book

Yellow fever: Administrations

official yellow fever centers

Typoid injectable duration

protection for up to 2 years

Vaxchora is prepared how?

reconstitued in purified bottle of water and then add active component