Beneri DO Assistant Professor of Clinical Pediatrics SUNY Stony Brook January 27 2011 Nothing to disclose Objectives 1 Review current travel advice and immunizations based on travel locations ID: 904279
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Slide1
Travel Medicine
Christy Beneri, DOAssistant Professor of Clinical PediatricsSUNY Stony BrookJanuary 27, 2011
Slide2Nothing to disclose
Slide3Objectives
1. Review current travel advice and immunizations based on travel locations2. Recognize possible infections in returning travelers3. Better identify the need for referrals to travel medicine experts
Slide4Today’s Travelers
Globally, >750 million people traveled internationally in 20041About 4% are childrenAbout 8% of travelers seek medical care while abroad or on returning home22-64% of travelers to the developing world report health problems
Nationally, >64 million trips outside the US, a 21% increase since 19972
1. Long S et al. Principles and Practices of Pediatric
Infectious Diseases. 2003. Chapter 9;79-86
2. Yellow Book 2010
Slide5Today’s Travelers
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 countries54% of traveler’s 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
Slide6Today’s Travler
Web based data collection, 17,353 ill returned travelers at 31 clinical sites on six continentsIndividual diagnoses put into syndrome groups and examined for all regions together226 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
Slide7Today’s Traveler
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
Slide8Pre-travel Counseling
With the extent of international travel, physicians need to be knowledgeable on the travel advice they give to patientsAppropriate travel advice avoids mishaps including injury and illness during travel and ensures a good memorable travel experience
Slide9Pre-travel Counseling
Should at least occur 4-6 weeks prior to travelReview entire trip itinerary Destinations, time/duration of travel, accommodations, planned activities, exposures to insects/animals
Review patient’s current and past medical historyReview immunization history, medications, and allergies
Remember to include children of immigrants returning to their home countries to visit relatives and friends
Slide10Travel Consultation
Requires skill, time, knowledge base and comfort, helps when you have been thereVaccinations- required, recommended, routine
Malaria ProphylaxisOther Insect/Vector Borne Risks
Travelers’ DiarrheaOther Destination Risks – water, food and safety precautions
Slide11Vaccinations
Routine Immunizations Required Immunizations Recommended Immunizations
Slide12Routine
ImmunizationsWhile immunization rates have increased over the past several years, a significant number remain unimmunizedMany vaccine preventable diseases are endemic in most of the worldTherefore, children should be brought up to date with routine immunizations
Accelerated dosing schedules may be used
Slide13Acceleration of
Routine Vaccine Schedule for Travel
Vaccine
Earliest Age for 1st Dose
Min. Interval between Doses
Combined Hepatitis A and
B*
1 year
1
wk, 2 wks between 2nd and 3rd doses
(booster after 1 yr)
Hepatitis A
1 year
6
mos
DTaP
6 weeks
4 wks, 6
mos
between 3rd and 4th doses
IPV
6 weeks
4 wks
OPV*
birth
4 wks
Hib
6 weeks
4 wks (booster after 1 yr)
Hepatitis B
birth
4 wks, 8 wks between 2nd and 3rd doses
(give 3rd dose
>
16 wks after 1st dose)
PCV7
6 weeks
4 wks, 8 wks between 3rd and 4th doses
M
easles
6
mos followed by MMR at 12 mos and at 4-6 years of age4 wksVaricella12 months4 wks if > 13 y/o3 mos if < 13 y/o
*Only outside US
Slide14Routine
ImmunizationsPolioIn the US, OPV is not available; IPV can be given as young as six weeksDo not give OPV to patients with
immunodeficienciesMMRInfants between 6-12 months traveling to a measles endemic area should receive 1 dose of measles (or MMR) vaccine prior to travel
Slide15Routine
ImmunizationsHepatitis AMost cases are imported into the U.S. by travelers from Mexico and Central AmericaInfants < 12 months of age should receive Hepatitis A IG (0.02 ml/kg IM for travel <3 months or 0.06 ml/kg IM for travel > 3 months)
Slide16Routine
ImmunizationsInfluenzaSeasonal influenza vaccines for all travelers 6 months of age and olderPertussis
Tdap booster should be given starting at 11 years of age
Slide17Recommended
ImmunizationsPolioFor previously immunized adult travelers to polio-endemic areas (Africa, Asia), consider vaccination with an additional dose of IPVOnly 1 lifetime booster of IPV is necessary
Slide18Wild Poliovirus Transmission in 2008
Slide19Recommended
ImmunizationsTyphoid vaccinesAsia, Africa, Central and South America, CaribbeanContraindications: hypersensitivity, malignancies
Precautions: pregnancy
Slide20Typhoid vaccine
Oral vaccine (Ty21a)Live attenuated vaccine> 6 y/o; provides 5 years of immunityDo not take concurrently with proguanil
, mefloquine, or chloroquine (
antimalarials)Adverse effects: abdominal pain, N,/V, F, HA, rashTyphoid
IM vaccine (ViCPS)Purified, killed capsular polysaccharide vaccine
> 2 y/o; provides 2 years of immunityAdverse effects: F, HA, local reaction
Slide21Typhoid vaccine
Type of vaccine
Live attenuated
Killed
Route
Oral
Intramuscular
Minimum age of receipt
Age >6 yrs
Age >2 yrs
#
of doses
4
1
Booster frequency
5
2
Adverse effects (incidence)
<5
%
<7%
Slide22Recommended
ImmunizationsRabies VaccineTravelers with occupational risk, outdoor travelersVaccine series: 3 IM doses of 1 ml (0, 7, and 21 or 28 days)
Human diploid cell vaccine or purified chick embryo cell vaccineIf bitten by potentially rabid animal, 2 additional doses are needed but no RIG
Wash area with soap and water
Slide23Geographic Distribution of Rabies
Slide24Recommended
ImmunizationsJapanese Encephalitis Virus Arboviral infection transmitted by
Culex mosquitos
F, HA, N/V, meningitis/encephalitisAbout 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 doseDuration of immunity unknown
Slide25Geographic Distribution of Japanese Encephalitis
(Yellow Book, 2008)
Slide26Required
ImmunizationsMeningococcal Vaccine (MCV)IM Quadrivalent conjugate vaccine (A, C, Y, W-135)Most common
serogroups in US: B, C, YMost common serogroups in sub-Saharan Africa: A, C, W-135
Protects against meningococcemia and meningitisRequired for travelers to Hajj and the meningitis belt from December – June
MCV is preferred over MPSV4 for children 2 through 10 years of age
Slide27Required
ImmunizationsMeningococcal Vaccine (MCV)Contraindications: hypersensitivity, previous GBSAdverse effects: injection site reactions, hypersensitivity (rare)
Slide28The Meningitis Belt
Slide29Meningococcal Infection
Slide30Required ImmunizationsYellow feverArboviral infection transmitted by
Aedes and Haemogogus
mosquitosF, HA, N/V, myalgia, photophobia and restlessness, myocardial dysfunction and
fulminant hepatitisYF VaccineLive attenuated
International certificate of vaccination for all entering travelersEffective after 10 days; booster required every 10 yrsContraindications: egg allergy,
immunosuppression; Cautions: pregnancy, elderlyAdverse effects: F, HA, rash; vaccine-associated encephalitis syndrome (rare: 0.5-4 per 1000 infants); vaccine-associated
viscerotropic disease
Slide31Global Distribution of Yellow Fever
(CDC, Division of Vector-Borne Infectious
Diseases, 2005)
Slide32Infections Transmitted by Arthropods
Malaria Dengue
Slide33Malaria
Infection occurs via infected female Anopheles mosquitoMost commonly caused by Plasmodium speciesP. falciparum
– most lethal and drug resistantP. vivax – Central America, Indian subcontinentP. ovale
– western sub-Saharan AfricaP. malariaeA worldwide leading cause of death in children under 5
500 million infections and > 1 million deaths annually
Slide34Global Distribution of Malaria
Slide35Malaria
Highest Risk of DiseaseYoung childrenPregnant womenThose without prior exposureLower Risk of Disease Air-conditioned housingScreened housing
No vaccine available
Slide36Malaria
Clinical presentationF, HA, myalgias, malaise; anemia, jaundiceP. falciparum: seizures, mental confusion, renal failure, coma, deathSymptoms may present 7 days after exposure to several months after return from an endemic area
Slide37Malaria
Personal protective measuresBed nets *Clothing that covers most of the bodyInsect repellant:
DEETUse > 30% DEET
Not for infants < 2 m/oApply to your hands first before applying to young childrenInsecticide (permethrin
) coated clothing and bed nets
Slide38Malaria Chemoprophylaxis
Country specific and altitude specificDependent on patient’s medical historyChemoprophylaxis is not 100% effectiveStarted prior to travel, during travel, and after return
Slide39Malaria Chemoprophylaxis
Chloroquine sensitive areasCentral America, Argentina, parts of the Middle EastChloroquineChloroquine resistant areas
All other areasMefloquineAtovaquone/proguanilDoxycycline
Primaquine
Slide40Chloroquine
Drug of choice where parasites are sensitiveAdverse effectsGI, HA, dizziness, blurred vision, insomniaCaution: may worsen psoriasis
Slide41Mefloquine
May be used in children of any weightAvoid in resistant areas (Thailand, Myanmar, Cambodia)Adverse effectsGI, HA, insomnia, abnormal dreams, visual disturbancesRare: reversible neuropsychiatric reaction, seizures
ContraindicationsPsychiatric disorders, seizuresCaution: history of psych disorders, cardiac conduction disorders
Slide42Atovaquone
/proguanilDaily dosingTake with foodAdverse effectsGI, HAContraindicationsSevere renal impairment (Cr Cl < 30 ml/min)
Infants < 5 kgPregnant women
Slide43Primaquine
Daily dosingAdverse effectsGI, photosensitivity, candidal vaginitisContraindications
G6PD deficiency (fatal hemolysis
) – exclude prior to usePregnancy, lactation
Slide44Dengue Viruses
Transmitted by Aedes mosquitoesEndemic and epidemic in Asia, Latin America, and Africa159 cases per 1,000 travelers to Southeast Asia during epidemic years
Outbreaks have occurred in southern Texas and Hawaii
Slide45Global Distribution of Dengue, 2005
(CDC, 2005)
Slide46Dengue Viruses
Classic dengue fever – asymptomatic to mild systemic illnessEstimated 100 million cases annuallyAcute F, HA (retro-orbital), myalgia, arthralgia, V, abdominal pain, rash1% progress to dengue hemorrhagic fever (DHF)DHF and dengue shock syndrome (DSS)
Increased vascular permeability on 3rd-7th
day of illnessHepatitis, myocarditis, neurologic symptoms; shockTreatment: rest, hydration, supportive care
Slide47Prevent Insect Bites
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.
Slide48Travelers’ Diarrhea
One of the most common illnesses affecting travelers; 9-40% of all childrenHighest rates, longest duration, and greatest severity in children < 3 y/oEtiologiesBacteria 80-85%Parasites 10%Viruses 5%
Slide49Enteric Pathogens
Pathogens are isolated 30-60% of the timeEnterotoxigenic E. coli (ETEC)Most common cause worldwide
Large inoculumEnteroaggregative
E. coli (EAEC)Salmonella, Campylobacter, Shigella, Vibrio
Parasites: Giardia, Cryptosporidium, Entamoeba
Viruses: rotavirus, norovirus
Slide50Areas of Risk for Travelers’ Diarrhea
(Yellow Book, 2008)
Slide51Toxic Gastroenteritis
Less common than travelers’ diarrheaIngestion of pre-formed toxinsV > DUsually resolves within 12-18 hours
Slide52Preventive Measures
Avoid raw fruits and vegetablesAvoid undercooked meat and seafoodAvoid
street vendorsAvoid tap water, ice, and unpasteurized dairy products
Use safe water sources (bottled, boiled, filtered, or chemically treated [iodine tablets])DrinkingToothbrushing
Food preparation
Slide53Preventive Measures in Infants/Toddlers
Encourage breastfeeding for as long as is feasibleUse a clean water supply for powdered formulaFrequent handwashing/hand sanitizer useBring prepackaged foods
Slide54Travelers’ Diarrhea: Treatment
Oral rehydration solution packets are the treatment of choiceIV fluids for severe dehydrationAntimotility agents are
not recommended in childrenToxic megacolon
, extrapyramidal symptoms, salicylate
toxicity
Slide55Travelers’ Diarrhea: Treatment
“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 days3 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;9:141–150.
Slide56Travelers’ Diarrhea: Treatment
If travelers’ diarrhea does not respond to a course of antimicrobial treatment, other possible causes of diarrhea need to be investigatedStudies on probiotics (e.g. Lactobacillus, Saccharomyces) are inconclusive
Slide57Travel Medical Kit
Assemble prior to travelPrescription itemsPrescription medications, antimalarial prophylaxisNonprescription items
First aid suppliesThermometerAnalgesics/antipyretics
Sun protectionDEETOral rehydration packets
Water purification tabletsAntihistamine
Slide58Jet-Lag
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.
Slide59Altitude Sickness
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
Slide60Motion Sickness
Cholinergic blocker scopolaminePatch or oral formulationTransderm 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
Slide61Other Preventive Measures
Avoid swimming in lakes and streamsAppropriate use of seat belts and car seats (should accompany the family)Counsel adolescents about STIs, sharing needles, acupuncture, and tattoosIn one study of British travelers, 6% contracted STIs during their travel
Consider travel insurance
Slide62Conclusions
Advance planningPre-travel assessment includesProviding vaccines and prophylactic medicationsA whole lot more!Travel advice should be tailored to the traveler
No preventive measures are 100% effective
Slide63Travel Advice Resources
CDC: www.cdc.gov/travelWHO International Travel and Health: www.who.int/ith
The International Society for Tropical Medicine: www.istm.org
Travax: www.travax.scot.nhs.uk
CDC Health Information for International Travel (The Yellow Book), 2008Travmed:
www.travmed.com
Slide64Recent CDC Travel Precautions
1/6/11: Yellow fever northern Uganda12/6/10: Chikungunya fever Asia and Indian Ocean12/7/10: Dengue C/S America, Asia and Africa10/22/10: Polio Russia, Tajikistan, Central Asia
1/12/11: Legionnaire’s disease Cozumel, Mexico
Slide65References
CDC. General recommendations on immunization: recommendations of the ACIP. MMWR 2006;55(RR15):1–48. 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; 354:119–30. “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, 1997–2006.
EID. 14, No. 7, July 2008, 1081-8.Stauffer WM, et al. Traveling with infants and young children. J Travel Med.
2002; 9:141–50.
Slide66Pediatric Infectious Diseases Clinic
@ Stony Brook University Medical CenterTravel Medicine
37 Research WayE. Setauket, NY 11733
(631) 444-KIDS