Docstoc

TRAVEL MEDICINE - PowerPoint

Document Sample
TRAVEL MEDICINE - PowerPoint Powered By Docstoc
					TRAVEL MEDICINE
       MAJ Christine Lettieri
 Dewitt Army Community Hospital
     The Capital Conference
           4 June 2007
             Overview
   Risk Assessment
   Resources
   Immunizations
   Malaria Prophylaxis
   Traveler’s Diarrhea
               Resources
   Center for Disease Control
       www.cdc.gov/travel
   World Health Organization
    International Travel and Health
       www.who.int/int
   International Society of Travel
    Medicine
       www.istm.org
       Assessing the Risk
   Where?
   What time of year?
   Type of lodging?
   Planned activities?
   Contact with local residents?
     Immunizations
 Routine
 Recommended

 Required
     Routine Immunizations
   Tetanus (Tdap or Td) booster
    - > 5 years
   MMR
    - Indicated for those without 2 doses
    or + titers
   Inactivated Polio (IPV)
    -Single booster for travel to India, Nigeria,
    Pakistan, Egypt, Niger, and Somalia
     Routine Immunizations
   Varicella
      -Women of childbearing age
      - 1 dose to age 13
      - 2 doses > 13
   Pneumovax
      - > age 65
      - Chronic medical conditions
   Influenza
      -All travelers
      -November to March in Northern Hemisphere
      -April to September in Southern Hemisphere
    Recommended Vaccinations
   Hepatitis A
    -Nearly all international locations
    -New Pediatric recommendations
    -Initial dose >4 weeks prior
    -Booster at 6-12/18 months
    -Mild side effects
              Hepatitis A
   Immunoglobulin
      -<2 weeks prior to travel
      -Allergy to vaccine
      -Children < age 2
      -Pregnant patients
   Twinrix (Hepatitis A and B)
      -Series- 0,1,6 months
      -Accelerated series- 0, 1, 3 weeks with
      booster at 12 months
               Hepatitis B
   Endemic in South America, Africa, SE Asia,
    South Pacific
   Close contact with locals
   Extended stay
   Potential need for medical treatment
   Series- 0, 1, 6 months
   Accelerated series- 0,1,2, 12 months
   Side effects- Injection site soreness,
    headaches
     Japanese Encephalitis
   India, China, Korea, Japan, SE
    Asia
   Recommended for:
    -Outdoor activities
    -Endemic areas
   0, 7, 30 days
   Accelerated series- 0, 7, 14
    days
   Consider booster > 2 years
   Side effects- Fever, headache,
    vomiting, angioedema,
    urticaria
           Typhoid Fever
   Endemic in Central and South
    America, India, Africa
   Oral or IM route
   50-80% immunity
   Side effects- Nausea, vomiting,
    fever, abdominal cramping
                  Rabies
   Endemic in:
    -India
    -China
    -SE Asia
    -The Philippines
    -Indonesia
    -Latin America
    -Africa
    -Former USSR
       Rabies Vaccinations
   Who?
      -Prolonged stay in endemic region
      -Remote areas
      -Close animal contact
      -Difficulty reporting

   Series- 0, 7, 21 or 28 days
   No booster shot for travelers
     Required Vaccinations
   Yellow Fever
   Meningococcal during Mecca
              Yellow Fever




   Endemic in equatorial Africa and South America
             Yellow Fever
   Live attenuated vaccine
   Side effects- Headaches, myalgias, fever,
    encephalitis
   Booster every 10 years
   Proof of vaccine >10 days
   Special considerations
       -Elderly
       -Pregnancy
       -Other live vaccines- same day or >28
        days
    Meningococcal Vaccine
   Endemic in Sub-Saharian Africa
   Required for pilgrims to Mecca
   MCV4 (Menactra)
   MPSV4 (Menomune)
   Single dose
   Booster in 3-5 years for MPSV4
   ? Length of protection for MCV4
Malaria
       Female Anopheles
        mosquito
       Plasmodium vivax,
        ovale, falciparum,
        malariae
       > 270 million cases
        worldwide
       Over 1 million
        deaths
       1,500 US cases
        annually
      Malaria Transmission
   Sporozoites in
    mosquito saliva
   Liver
   RBCs
   Dormant liver
    stage- P. ovale,
    vivax
       Malaria Prevention
   Limit potential exposure
       -Avoid nighttime outdoor
       activities
       -Minimize exposed skin
       -DEET (30-50%) insect repellant
       -Insecticides
       -Room fans
       -Mosquito bed nets
       -Permethrin
    Malaria Chemoprophylaxis
Medication    Dose                Contraindications
Chloroquine   500mg 1/ week, 2
              weeks prior- 4
              weeks after
Mefloquine    250mg 1/week, 2     Seizure disorders,
(Lariam)      weeks prior-4       cardiac conduction
              weeks after         abnormalities,
                                  psychosis
Doxycycline   100mg 1/day, 2      Pregnancy, children
              days prior- 4 weeks <8
              after
Atovaquone/   1/day, 2 days prior- Pregnancy, severe
Proguanil     one week after       renal failure
(Malarone)
Primaquine    26.3mg 1/day for    G-6PD deficiency
              14 days after
        Traveler’s Diarrhea
 Fecally
  contaminated
  food and water
 Etiology

 -Bacteria- 85%
 -Parasites-10%
 -Viruses- 5%
 Risk Areas
         Traveler’s Diarrhea
   Clinical Presentation:
       -Abrupt onset of loose stools
       -Abdominal cramping
       -Rectal urgency
   Typically self limited
       Traveler’s Diarrhea
   Equal rates in males and females
   Young > old
   High risk travelers
      -Immunosuppressed
      -Inflammatory bowel disease
      -H2 blockers, PPIs, antacids
      Preventive Measures
   Avoid street vendors
   Avoid buffets
   Avoid raw or undercooked meat and
    seafood
   Avoid eating raw fruits and
    vegetables
   Avoid tap water, ice, and
    unpasteurized dairy products
    Prophylactic Measures
   Lactobacillus
   Bismuth Subsalicylate
   Antibiotics
Prophylaxis- Bismuth Subsalicylate
   2 oz or 2 tablets 4 times/day
   Decreased incidence- 14-40%
   Mild side effects
   Avoid:
    -Aspirin allergy
    -Renal insufficiency
    -Gout
    -Certain medications- MTX,
    anticoagulants
    -Children
    Prophylaxis- Antibiotics
   Effective- 4-40%
   Fluoroquinolones
   Rifaximin (Xifaxan)
   Not recommended for routine use
   Increased risk of resistant pathogens
   False sense of security
   Consider in special situations
            Treatment
   Antibiotics
   Bismuth Subsalicylate
   Antimobility agents
   Oral rehydration therapy
       Antibiotic Treatment
   Consider antibiotics- > 3 stools in 8
    hr period, fever, blood in stool
   Fluoroquinolones
   Azithromycin
   Rifaximin- E. Coli
   1-3 day treatment
   Avoid Sulfa medications, doxycycline
       Traveler’s Diarrhea
   Bismuth subsalicylate
       -1 oz every 30 minutes x 8 for 2
      days
   Anti-motility agents
       -Symptomatic relief
       -Adjunct to antibiotics with fever,
       bloody diarrhea
   Oral Rehydration Therapy
            Summary
   Advance planning
   Travel assessment
   Immunization status
   Malaria chemoprophylaxis
   Traveler’s Diarrhea
              References
   “Antibiotic Treatment for Travelers’
    Diarrhea”, Cochrane Database
   “Prevention of Malaria in Travelers”
    American Family Physician, August 2003.
   “Travel Immunizations” American Family
    Physician, July 2004.
   “Travelers’ Diarrhea”, CDC
   “Travelers’ Diarrhea”, Travelers’ Health:
    Yellow Book, Health Information for
    International Travel, 2005-2006.
   CDC Travel Web site