“What Shots Do I Need?” An approach to pre-travel counseling Omar A. Khan, MD MHS [email protected].

““What Shots Do I Need?”What Shots Do I Need?”An approach to pre-travel counselingAn approach to pre-travel counseling

Omar A. Khan, MD MHSOmar A. Khan, MD MHS

[email protected]@jhu.edu

No drug company has given me No drug company has given me massive amounts of money to promote massive amounts of money to promote this talk (or any other)this talk (or any other)

No other conflicts of interestNo other conflicts of interest

DisclosureDisclosure

Much of the advice herein applies to Much of the advice herein applies to the developing (“tropical”) setting the developing (“tropical”) setting where diseases of sanitation, poverty where diseases of sanitation, poverty and environment are more common and environment are more common than in industrialized settingsthan in industrialized settings

Focus today is on pre-travel counseling, Focus today is on pre-travel counseling, not on Dx and Rx of tropical diseasesnot on Dx and Rx of tropical diseases

OverviewOverview

So the short version, for those who have patients So the short version, for those who have patients only traveling to Western Europe (and yes, you can only traveling to Western Europe (and yes, you can leave after the section on Air Travel) --leave after the section on Air Travel) --– Look to the right when crossing the road Look to the right when crossing the road – Don’t confuse soccer and footballDon’t confuse soccer and football– Avoid getting jealous at their long vacations Avoid getting jealous at their long vacations

(remember how much they pay in taxes and for gas)(remember how much they pay in taxes and for gas)– Learn to drive stick and to get out of the fast lane in Learn to drive stick and to get out of the fast lane in

GermanyGermany– Avoid debates on who has the better health care Avoid debates on who has the better health care

system. Unfortunately, you will probably lose the system. Unfortunately, you will probably lose the argument…argument…

OverviewOverview

Common travel risksCommon travel risks Common conditionsCommon conditions Travel counseling frameworkTravel counseling framework What to vaccinate forWhat to vaccinate for What to prophylax againstWhat to prophylax against Special situationsSpecial situations ResourcesResources

OverviewOverview

Travel statisticsTravel statistics– Increasing people travel each yearIncreasing people travel each year– Destinations becoming more exoticDestinations becoming more exotic– Most illness during travel is diarrhealMost illness during travel is diarrheal– 22ndnd most common illness is non-tropical, e.g. DVT, MI, most common illness is non-tropical, e.g. DVT, MI,

etc. So make sure general preventive care is UTDetc. So make sure general preventive care is UTD– Travel-related deaths only 1-4%Travel-related deaths only 1-4%– >50% deaths during travel are from chronic disease >50% deaths during travel are from chronic disease

issues (CV– MI, CVA etc.)issues (CV– MI, CVA etc.)– Remainder: MVA, drowning, falls, accidentsRemainder: MVA, drowning, falls, accidents

Travel risksTravel risks

Travel statisticsTravel statistics– Over 700 million trips internationally each year (2004)Over 700 million trips internationally each year (2004)– Over 28 million Americans travel abroad each year Over 28 million Americans travel abroad each year

(2005)(2005) Western Europe 40%Western Europe 40% Eastern Europe 4%Eastern Europe 4% Caribbean 18%Caribbean 18% South America 9%South America 9% Central America 7%Central America 7% Africa 2%Africa 2% Middle East 4%Middle East 4% Asia 19%Asia 19% Australia 2%Australia 2%


– For every 100,000 travelers to developing For every 100,000 travelers to developing countries: countries:

– 50,000 will have a health problem. 50,000 will have a health problem. – 8,000 will have to visit a physician. 8,000 will have to visit a physician. – 5,000 will have to stay in bed. 5,000 will have to stay in bed. – 1,100 will be completely incapacitated. 1,100 will be completely incapacitated. – 300 will be hospitalized. 300 will be hospitalized. – 50 will be air evacuated. 50 will be air evacuated. – 1 will die.1 will die.


Un/Common infectious travel-related Un/Common infectious travel-related conditions (per month of stay in developing conditions (per month of stay in developing country)country)

Diarrheal (30%)Diarrheal (30%) Respiratory (2%) Respiratory (2%) Malaria (2%)Malaria (2%) Hep A (0.5%)Hep A (0.5%) Gonorrhea (0.5%)Gonorrhea (0.5%)


The most common concerns remain, The most common concerns remain, predominantly, conditions they could have predominantly, conditions they could have acquired anywhereacquired anywhere

Multiple (hundreds of) uncommon conditions Multiple (hundreds of) uncommon conditions abound which are impossible to cover in pre-abound which are impossible to cover in pre-travel counselingtravel counseling

Their being uncommon still means general Their being uncommon still means general principles will likely cover themprinciples will likely cover them

The most exotic stuff is also the least likely, so The most exotic stuff is also the least likely, so don’t worry too much about Eboladon’t worry too much about Ebola


More people travelingMore people traveling Resources availableResources available Referral for unusual scenariosReferral for unusual scenarios ReimbursableReimbursable Patients see it as a primary care issue, Patients see it as a primary care issue,

and so should we: spans adult, pediatric, and so should we: spans adult, pediatric, emergency, and ob/gyn areasemergency, and ob/gyn areas

Good way to keep up on the literature if Good way to keep up on the literature if working in global health oneselfworking in global health oneself

Why include travel counseling in primary Why include travel counseling in primary care?care?

Assessment of Risk based onAssessment of Risk based on– Not only on countries of travel, but sub-Not only on countries of travel, but sub-

regionsregions– Also on what the participant will do Also on what the participant will do

therethere General preventive principlesGeneral preventive principles Specific concernsSpecific concerns

Approach to travel counselingApproach to travel counseling

Where are you going?Where are you going? What is the purpose of travel?What is the purpose of travel? How long will you be there for?How long will you be there for? Will you be in the city or the Will you be in the city or the

country? Hotel, home, or camping? country? Hotel, home, or camping?

Form an assessment of awareness Form an assessment of awareness and of risk and of risk

Typical travel counseling questionsTypical travel counseling questions

Have you seen your other relevant Have you seen your other relevant doctors (e.g. coumadin clinic, doctors (e.g. coumadin clinic, cardiologist, pulmonologist, dentist?)cardiologist, pulmonologist, dentist?)

Make a follow-up (cancelable) Make a follow-up (cancelable) appointment a couple of days after appointment a couple of days after the traveler returns to address any the traveler returns to address any concernsconcerns

Travel counseling questionsTravel counseling questions

Be carefulBe careful Have funHave fun But not too much funBut not too much fun

Travel AdviceTravel Advice

Choose an Choose an appropriate travel appropriate travel companioncompanion


And leave the furs And leave the furs at homeat home


Code Code 9940399403 for a preventive medicine counseling for a preventive medicine counseling visit lasting approximately 45 minutes. visit lasting approximately 45 minutes.

Also bill the vaccine administration code Also bill the vaccine administration code 9047190471 for for one vaccine and one vaccine and 9047290472 for each additional vaccine. for each additional vaccine. – E.g., if you administer three vaccines, you would E.g., if you administer three vaccines, you would

code 90471 once and 90472 twice. code 90471 once and 90472 twice. – If the patient is under 8 years of age, you should If the patient is under 8 years of age, you should

submit 90465 and, when appropriate, 90466, insteadsubmit 90465 and, when appropriate, 90466, instead Code separately for the actual vaccine products: Code separately for the actual vaccine products:

e.g., 90717 for yellow fever and the appropriate e.g., 90717 for yellow fever and the appropriate code from 90690-90693 for typhoid. code from 90690-90693 for typhoid.

Coding for US physicians*Coding for US physicians*

*Talk to your coder or bus. mgr. My ref: AAFP/ FPM Oct. *Talk to your coder or bus. mgr. My ref: AAFP/ FPM Oct. 20052005

Plan ahead: figure out medical and other Plan ahead: figure out medical and other backup resourcesbackup resources

Leave copies of itinerary with Leave copies of itinerary with family/physicianfamily/physician

Consider travel insuranceConsider travel insurance In the plane: In the plane:

Hydrate, ambulate, avoid alcoholHydrate, ambulate, avoid alcohol Anxiolytic?Anxiolytic? Melatonin?Melatonin?

General Preventive PrinciplesGeneral Preventive Principles

Boil water/milk and avoid iced drinksBoil water/milk and avoid iced drinks Peel fruit/vegetablesPeel fruit/vegetables NEVER trust tap water NEVER trust tap water

– Boiled > ‘bottled’ > ‘purified’ Boiled > ‘bottled’ > ‘purified’ >‘filtered’>‘filtered’

– Yes, even for brushing, especially Yes, even for brushing, especially for kidsfor kids

Avoid mosquitoesAvoid mosquitoes Don’t walk barefoot on the beachDon’t walk barefoot on the beach Don’t swim if the lake says Don’t swim if the lake says

‘Bilharzia-free’. It’s not. ‘Bilharzia-free’. It’s not.


Backyard ‘bottling plant’ in BeijingBackyard ‘bottling plant’ in Beijing

Filtering the water in PakistanFiltering the water in Pakistan

Reiterate common-sense advice which Reiterate common-sense advice which would apply here as well:would apply here as well:

– Don’t have unprotected sex Don’t have unprotected sex – Wear your seat belt Wear your seat belt – Avoid bats, rodents, wild dogs and Avoid bats, rodents, wild dogs and

other carriers other carriers – Seek medical care if sickSeek medical care if sick– Use the travel insurance you’ve paid for Use the travel insurance you’ve paid for

if you’re really sickif you’re really sick


To figure this out, need to know:To figure this out, need to know:– A) the distribution of diseases in the area A) the distribution of diseases in the area

traveled to (see www.cdc.gov/travel)traveled to (see www.cdc.gov/travel)– B) the likelihood of contracting those disease B) the likelihood of contracting those disease

(see resources at the end)(see resources at the end)– C) what can actually be prevented safely for C) what can actually be prevented safely for

this particular travelerthis particular traveler– Don’t go overboard- visitors to the US don’t Don’t go overboard- visitors to the US don’t

worry unduly about our major public health worry unduly about our major public health issues….HIV, TB, hepatitis, road traffic issues….HIV, TB, hepatitis, road traffic accidents, tobacco, etc.accidents, tobacco, etc.

Yes, OK, but what shots do I need?Yes, OK, but what shots do I need?

Maybe none if you’re careful! Maybe none if you’re careful! Very few Very few mandatedmandated vaccinations: vaccinations:

– Yellow fever vaccination before entering Yellow fever vaccination before entering and when coming fromand when coming from a YF endemic a YF endemic country (even if in transit)country (even if in transit)

– YFV vaccination certificate is valid for 10 YFV vaccination certificate is valid for 10 yearsyears

– Meningococcal vaccination before going Meningococcal vaccination before going on the Muslim pilgrimage (Hajj) to Saudi on the Muslim pilgrimage (Hajj) to Saudi ArabiaArabia


CDC on the Yellow Fever vaccine CDC on the Yellow Fever vaccine – < 1/3 of those traveling to endemic < 1/3 of those traveling to endemic

areas get itareas get it– ‘‘All those who have got YF in the last All those who have got YF in the last

10 years have died’10 years have died’ CDC on Malaria CDC on Malaria

– >50% ask about it, but less than half >50% ask about it, but less than half that follow the advice. that follow the advice.


Yellow Fever VaccineYellow Fever Vaccine

Attenuated virusAttenuated virus Good for 10 yearsGood for 10 years Get stamped yellow certificate to show when Get stamped yellow certificate to show when

entering a YFV-endemic country, or when entering entering a YFV-endemic country, or when entering any country after having been to YFV areaany country after having been to YFV area

Given at approved clinics (see list at Given at approved clinics (see list at www.cdc.gov/travel)www.cdc.gov/travel)

YFV in pregnancy “INDICATED IF EXPOSURE YFV in pregnancy “INDICATED IF EXPOSURE CANNOT BE AVOIDED” CANNOT BE AVOIDED” CDC Yellow BookCDC Yellow Book

HIV – avoid YFV but can give if high risk and CD4 HIV – avoid YFV but can give if high risk and CD4 >200 >200

Avoid mosquitoes!Avoid mosquitoes!

Yellow Fever AreasYellow Fever Areas

HajjHajj

HajjHajj 2 M Muslims from 140 countries annually to 2 M Muslims from 140 countries annually to

Saudi ArabiaSaudi Arabia Crowding = ID and non-ID risksCrowding = ID and non-ID risks Facilities are generally sanitary and reasonable Facilities are generally sanitary and reasonable

standardstandard Req: Flu, pneumococcal (for >65) and Req: Flu, pneumococcal (for >65) and

meningococcal (>3 wks and <3 yrs prior to meningococcal (>3 wks and <3 yrs prior to travel)travel)

Rec: Hep A, Hep B, TyphoidRec: Hep A, Hep B, Typhoid Cipro prophylaxis prior to return home has been Cipro prophylaxis prior to return home has been

suggested but not implemented (for meningitis)suggested but not implemented (for meningitis) www.saudiembassy.net has more information on www.saudiembassy.net has more information on

annual requirements.annual requirements. No, they do not accept requests to lower oil No, they do not accept requests to lower oil

prices.prices.

Food/Water-BorneFood/Water-Borne- - Diarrhea, Typhoid, Diarrhea, Typhoid, HepatitisHepatitis

Insect-BorneInsect-Borne- - Malaria, Dengue Malaria, Dengue RespiratoryRespiratory- - Viral, bacterial, TBViral, bacterial, TB InjuriesInjuries- - Mind the gap, and the rickshawMind the gap, and the rickshaw STDs+blood-borneSTDs+blood-borne- - Just (don’t) do it: Just (don’t) do it:

gonorrhea, syphilis, HIV, hepatitisgonorrhea, syphilis, HIV, hepatitis OtherOther- - e.g., Schisto, Typhoid, CLMe.g., Schisto, Typhoid, CLM

Specific concerns (brief overview to prepare Specific concerns (brief overview to prepare your patients for what they might face)your patients for what they might face)

Water-Borne: examples of intestinal Water-Borne: examples of intestinal parasitesparasites

AscariasisAscariasis

How can you stay mad at this face?How can you stay mad at this face?

HookworHookwormm

Intestinal parasitesIntestinal parasites All transmitted, generally, by fecal-oral transmission All transmitted, generally, by fecal-oral transmission

(except hookworms whuch also go through skin)(except hookworms whuch also go through skin) Worldwide distributionWorldwide distribution

– Hookworms (Necator and Ancylostoma spp.)Hookworms (Necator and Ancylostoma spp.) (A. caninum also causes CLM - addressed later)(A. caninum also causes CLM - addressed later)

– Tapeworms: Tapeworms: Taenia saginata: Beef tapewormTaenia saginata: Beef tapeworm Taenia solium: Pork tapeworm and cysticercosisTaenia solium: Pork tapeworm and cysticercosis Echinococcus: cystic hydatid diseaseEchinococcus: cystic hydatid disease

– Roundworms:Roundworms: Ascaris and Trichuris spp. Ascaris and Trichuris spp.

Water-Borne: examplesWater-Borne: examples

VirusesViruses– Self-limiting; ORS/ORT adequate Self-limiting; ORS/ORT adequate

BacteriaBacteria– All transmitted, generally, by fecal-oral All transmitted, generally, by fecal-oral

transmission (except hookworms which transmission (except hookworms which also go through skin)also go through skin)

ParasitesParasites– Entamoeba histolytica (amebiasis)Entamoeba histolytica (amebiasis)


BacteriaBacteria– ETEC, Campylobacter, Cholera, Shigella, ETEC, Campylobacter, Cholera, Shigella,

Salmonella (in kids and adults)Salmonella (in kids and adults)– Among kids, those old enough to crawl Among kids, those old enough to crawl

are at highest risk of catching are at highest risk of catching – Youngest at highest risk of dehydrationYoungest at highest risk of dehydration


But none of that really matters much for pre-But none of that really matters much for pre-traveltravel

General principles:General principles:– Most watery and non-bloody diarrhea is self-Most watery and non-bloody diarrhea is self-

limiting; use ORS/ORT to avoid dehydrationlimiting; use ORS/ORT to avoid dehydration– Bloody diarrhea, generally, can be considered Bloody diarrhea, generally, can be considered

treatable with antimicrobialstreatable with antimicrobials– Use basic prevention principles mentioned earlierUse basic prevention principles mentioned earlier– Continue breastfeedingContinue breastfeeding

Water-Borne: preventionWater-Borne: prevention

All-purpose empiric treatment regimens:All-purpose empiric treatment regimens:– Bacterial: Ciprofloxacin (for adults), macrolide e.g. azithro for Bacterial: Ciprofloxacin (for adults), macrolide e.g. azithro for

kidskids– Amebiasis, Giardia: Metronidazole (no alcohol)Amebiasis, Giardia: Metronidazole (no alcohol)– Worms: Mebendazole (Vermox). Not in <2 y.o. or BFWorms: Mebendazole (Vermox). Not in <2 y.o. or BF– Stay away from antimotility agents in general (e.g. Stay away from antimotility agents in general (e.g.

loperamide)loperamide)

May consider advance prescription if sufficient risk is May consider advance prescription if sufficient risk is presentpresent

Counsel to only take IF appropriate sx develop, NOT Counsel to only take IF appropriate sx develop, NOT as malaria-style chemoprophylaxisas malaria-style chemoprophylaxis

See Vaccines sectionSee Vaccines section

Water-Borne: treatmentWater-Borne: treatment

Aquatic snailsAquatic snails: Schistosomiasis (Bilharziasis): Schistosomiasis (Bilharziasis) BlackfliesBlackflies: Onchocerciasis (River blindness): Onchocerciasis (River blindness) FleasFleas (via rats, to humans): Plague (via rats, to humans): Plague MosquitoesMosquitoes: Dengue, yellow fever (Aedes); Malaria, : Dengue, yellow fever (Aedes); Malaria,

lymphatic filariasis (Anopheles); Japanese lymphatic filariasis (Anopheles); Japanese encephalitis, filariasis, West Nile fever (Culex)encephalitis, filariasis, West Nile fever (Culex)

SandfliesSandflies: Leishmaniasis (concern in Middle East): Leishmaniasis (concern in Middle East) Tsetse fliesTsetse flies: African trypanosomiasis (sleeping : African trypanosomiasis (sleeping

sickness)sickness) Triatomine bugsTriatomine bugs: American trypanosomiasis/Chagas’ : American trypanosomiasis/Chagas’

diseasedisease TicksTicks: Lyme; borreliosis; Q fever; encehpalitis; : Lyme; borreliosis; Q fever; encehpalitis;

tularemia; Crimean-Congo hemorrhagic fevertularemia; Crimean-Congo hemorrhagic fever

Vectors and their diseasesVectors and their diseases

Malaria by far the most commonMalaria by far the most common– Transmitted by night-biting mosquitoesTransmitted by night-biting mosquitoes– Average of 40 cases in returned US Average of 40 cases in returned US

travelers travelers – WorldwideWorldwide

DengueDengue– Transmitted by day-biting mosquitoesTransmitted by day-biting mosquitoes

Insect-BorneInsect-Borne

Malaria map- Western hemisphereMalaria map- Western hemisphere

Malaria map: Eastern hemisphereMalaria map: Eastern hemisphere

Repellents:Repellents: DEET-type most common; avoid DEET-type most common; avoid ingestion or contact with mucus ingestion or contact with mucus membranesmembranes

Long sleevesLong sleeves Bednets:Bednets: excellent protection esp. when excellent protection esp. when

impregnated with repellentimpregnated with repellent Locally available resources:Locally available resources:

– CoilsCoils (pyrethroid-impregnated) (pyrethroid-impregnated)– MatsMats– Sprays/Sprays/insecticides (“Flit”, etc.)insecticides (“Flit”, etc.)– Air conditioningAir conditioning cuts risk cuts risk

Insect-Borne: preventionInsect-Borne: prevention

A very fancy bednetA very fancy bednet

Recommended only for malaria (Recommended only for malaria (P. falciparum, P. falciparum, vivax, ovale, malariaevivax, ovale, malariae))

Present in 100+ countries (but not in all cities of Present in 100+ countries (but not in all cities of those countries)those countries)

12-15000 travelers get malaria annually12-15000 travelers get malaria annually Fever within 10 weeks of return from endemic Fever within 10 weeks of return from endemic

area should cause concernarea should cause concern Fever less than 7 days of first possible exposure is Fever less than 7 days of first possible exposure is

almost never malariaalmost never malaria Falciparum malaria is the most dangerous and has Falciparum malaria is the most dangerous and has

the most resistancethe most resistance

Insect-Borne: prophylaxis for malariaInsect-Borne: prophylaxis for malaria

All the quinine derivatives should be used with care with All the quinine derivatives should be used with care with other Q-T prolongersother Q-T prolongers

ChloroquineChloroquine: 1 week prior to travel through 4 weeks : 1 week prior to travel through 4 weeks after return. OK for breastfeeding, pregnant, young kids. after return. OK for breastfeeding, pregnant, young kids. Problems: may worsen psoriasisProblems: may worsen psoriasis

Mefloquine (Lariam)Mefloquine (Lariam): 1 week prior to travel through 4 : 1 week prior to travel through 4 weeks after return. OK for BF; limits on kids and weeks after return. OK for BF; limits on kids and pregnancy. Problems: psychiatric or convulsive disorderspregnancy. Problems: psychiatric or convulsive disorders

DoxycyclineDoxycycline: 1 day prior to travel through 4 weeks after : 1 day prior to travel through 4 weeks after return. NO to BF/kids/pregnancy. Problems: sunburn; return. NO to BF/kids/pregnancy. Problems: sunburn; vaginal yeast infections; liver dysfunctionvaginal yeast infections; liver dysfunction

Atovaquone/proguanil (Malarone)Atovaquone/proguanil (Malarone): 1 day prior to travel : 1 day prior to travel through 7 days after return. Unknown for through 7 days after return. Unknown for kids/BF/pregnancy. kids/BF/pregnancy.


If considering If considering Primaquine Primaquine (anti-relapse Rx (anti-relapse Rx against P. ovale and P. vivax): consult with against P. ovale and P. vivax): consult with CDC or travel clinic. Many contraindications: CDC or travel clinic. Many contraindications: G6PD deficiency, pregnancy, lactationG6PD deficiency, pregnancy, lactation


Suggested Algorithm for Pediatric Malaria Suggested Algorithm for Pediatric Malaria ChemoprophylaxisChemoprophylaxis

Chloroquine Resistant Area CQNo

YES

Mefloquine Resistant Area, Seizures or psychiatric disease

YES

Doxycycline (>8 years) Malarone (>11 Kg)

NoMFQ (>5 Kg)

Chemprophylaxis does not usually Chemprophylaxis does not usually apply to treatment of other vector-apply to treatment of other vector-borne diseasesborne diseases

Rx should be carried out in Rx should be carried out in consultation with appropriate consultation with appropriate resources (whether in-country or on resources (whether in-country or on return) so will not be covered herereturn) so will not be covered here

Insect-Borne: treatmentInsect-Borne: treatment

Japanese Encephalitis (ever reported)Japanese Encephalitis (ever reported)

Dengue (ever reported)Dengue (ever reported)

Unprecedented Unprecedented levels of pollution levels of pollution can be reliably can be reliably expected to trigger expected to trigger reactive airway reactive airway disease in those with disease in those with a predispositiona predisposition

RespiratoryRespiratory

Ten most polluted cities inTen most polluted cities inthe world:the world:

– Linfen, ChinaLinfen, China– Tianying, ChinaTianying, China– Sukinda, IndiaSukinda, India– Vapi, IndiaVapi, India– La Oroya, PeruLa Oroya, Peru– Dzerzhinsk, RussiaDzerzhinsk, Russia– Norilsk, RussiaNorilsk, Russia– Chernobyl, UkraineChernobyl, Ukraine– Sumgayit, AzerbaijanSumgayit, Azerbaijan– Kabwe, ZambiaKabwe, Zambia


Ten cleanest cities in the worldTen cleanest cities in the world– Calgary Calgary – Honolulu Honolulu – Helsinki Helsinki – OttawaOttawa– MinneapolisMinneapolis– Oslo Oslo – StockholmStockholm– ZurichZurich


Unprecedented levels of pollution can be reliably Unprecedented levels of pollution can be reliably expected to trigger reactive airway disease in expected to trigger reactive airway disease in those with a predispositionthose with a predisposition

Carry inhaled medications and antihistamines/ Carry inhaled medications and antihistamines/ decongestantsdecongestants

Influenza vaccination is recommended year-roundInfluenza vaccination is recommended year-round Much of the developing world has TB, but as long Much of the developing world has TB, but as long

as patient is not directly exposed to active TB, risk as patient is not directly exposed to active TB, risk should be lowshould be low

Similar decision-making applies abroad when Similar decision-making applies abroad when distinguishing viral from bacterial process distinguishing viral from bacterial process (sinusitis, bronchitis, pneumonia)(sinusitis, bronchitis, pneumonia)


>2 million killed in traffic accidents >2 million killed in traffic accidents worldwide each yearworldwide each year

Seat belts, and their usage, is spotty at Seat belts, and their usage, is spotty at bestbest

Unless very familiar with the local Unless very familiar with the local driving situation, do not drivedriving situation, do not drive

Unless wishing to be very familiar with Unless wishing to be very familiar with the afterlife, do not take the bus… the afterlife, do not take the bus…

InjuriesInjuries

Before….Before….

After.After.

Other tourist injuries (less common) Other tourist injuries (less common) involve violence (muggings, involve violence (muggings, carjackings) and natural accidents carjackings) and natural accidents (falls, drownings)(falls, drownings)

InjuriesInjuries

STDsSTDs

Sexual tourism is realSexual tourism is real Latex condoms are Latex condoms are

reasonably safe but high-reasonably safe but high-risk sex should be risk sex should be discourageddiscouraged

Risk of HIV and hepatitis (B Risk of HIV and hepatitis (B and C in this case) may be and C in this case) may be much higher than in the USmuch higher than in the US

In addition, gonorrhea, In addition, gonorrhea, chlamydia, syphilis are chlamydia, syphilis are more common more common – (Unless you’re from (Unless you’re from

Baltimore)Baltimore)

Other- Other- e.g., Schisto, Typhoid, Cutaneous e.g., Schisto, Typhoid, Cutaneous Larva MigransLarva Migrans– Specific risks exist at the individual country Specific risks exist at the individual country

level but do not warrant chemoprophylaxislevel but do not warrant chemoprophylaxis– E.g.E.g.

Avoid swimming in schisto (bilharzia) areasAvoid swimming in schisto (bilharzia) areas Avoid walking barefoot in the beachAvoid walking barefoot in the beach Follow safe hygiene practicesFollow safe hygiene practices Communicate above to kids as wellCommunicate above to kids as well

OtherOther

CLM eruptionCLM eruption

21 y.o FEMALE BACK 21 y.o FEMALE BACK FROM A MEXICAN FROM A MEXICAN VACATION 3 DAYS VACATION 3 DAYS EARLIER PRESENTED EARLIER PRESENTED WITH PAINLESS LINEAR WITH PAINLESS LINEAR AND SERPIGINOUS AND SERPIGINOUS LESIONS ON HER LEGS. LESIONS ON HER LEGS. SHE HAD NO SYSTEMIC SHE HAD NO SYSTEMIC COMPLAINTS. SHE HAD COMPLAINTS. SHE HAD BEEN LYING ON THE BEEN LYING ON THE BEACH. BEACH. THE DIAGNOSIS IS:THE DIAGNOSIS IS:

Things aren’t always what they seem….Things aren’t always what they seem….

It’s not cutaneous larva migrans….It’s not cutaneous larva migrans….

• PHYTOPHOTODERMATITIS CAUSED BY PHOTOSENSITIZING PSORALEN-CONTAINING COMPOUNDS IN THE LIME PEEL.

• LIME WEDGES STUCK ON HER BEER GLASS -> LIME SKIN PSORALENS DRIPPED DOWN THE SIDE OF THE GLASS WITH WATER CONDENSATION AND DRIPPED ON HER LEG =

LOCAL SUNBURN!

VaccinesVaccines

AnthraxAnthraxDiphtheriaDiphtheriaHepatitis AHepatitis AHepatitis BHepatitis BH. influenzaeH. influenzae b b (Hib) (Hib) Human Human Papillomavirus Papillomavirus (HPV)(HPV)Influenza (Flu)Influenza (Flu)Japanese Japanese Encephalitis (JE)Encephalitis (JE)

Vaccines and the diseases they preventVaccines and the diseases they prevent

MeaslesMeaslesMeningococcalMeningococcalMonkeypoxMonkeypox(sort of)(sort of)MumpsMumpsPertussisPertussisPneumococcalPneumococcalPoliomyelitisPoliomyelitisRabiesRabiesRotavirusRotavirus

Rubella (German Rubella (German Measles)Measles)Shingles (Herpes Shingles (Herpes Zoster)Zoster)Tetanus Tetanus (Lockjaw)(Lockjaw)TuberculosisTuberculosisTyphoidTyphoidVaricella Varicella (Chickenpox)(Chickenpox)Yellow FeverYellow Fever

……the vaccines of childhood in the USthe vaccines of childhood in the US ……boosters when appropriate for boosters when appropriate for

tetanus/diphtheriatetanus/diphtheria ……the flu shotthe flu shot Meningococcus, Hep A/B, RotavirusMeningococcus, Hep A/B, Rotavirus InfluenzaInfluenza Age-related: Age-related:

– Pneumococcus, Zostavax, GardasilPneumococcus, Zostavax, Gardasil

The common vaccines: Don’t forget…The common vaccines: Don’t forget…


KEY

Range of ages

High-risk

groups


KEY

Range of ages

High-risk

groups

You can’t vaccinate kids against You can’t vaccinate kids against everything…everything…

Hepatitis A (if unvaccinated as child), IMHepatitis A (if unvaccinated as child), IM– Inactivated virusInactivated virus– Preferably given 2 weeks prior to travel Preferably given 2 weeks prior to travel – Approved for children over 1 year oldApproved for children over 1 year old– TwinRix= Hep A + Hep BTwinRix= Hep A + Hep B

TyphoidTyphoid– CDC recommends > 3 weeks in endemic area or high risk CDC recommends > 3 weeks in endemic area or high risk – Oral (Vivotif), live attenuated, 4 doses: Oral (Vivotif), live attenuated, 4 doses:

6 years and over6 years and over Must be able to swallow pillsMust be able to swallow pills

– Parenteral (Typhim Vi), polysaccharide, 1 dose: Parenteral (Typhim Vi), polysaccharide, 1 dose: 2 years and over2 years and over

Yellow Fever (discussed earlier)Yellow Fever (discussed earlier)

The less common vaccinesThe less common vaccines

Japanese Encephalitis: inactivated live virus; only if Japanese Encephalitis: inactivated live virus; only if traveling to JE-endemic areas; not < 1 y.o.traveling to JE-endemic areas; not < 1 y.o.

Rabies: India relatively high risk. Expensive Rabies: India relatively high risk. Expensive vaccination. Post-exposure vaccination/Ig is vaccination. Post-exposure vaccination/Ig is recommendedrecommended

Anthrax: only for high-risk occupations e.g. militaryAnthrax: only for high-risk occupations e.g. military

Cholera: killed; not generally recommended; only Cholera: killed; not generally recommended; only partial, transient protectionpartial, transient protection

‘‘Pigbel’ (enteritis necroticans): inactivated C. Pigbel’ (enteritis necroticans): inactivated C. perfringens given to kids in Pacific islands eg Papua perfringens given to kids in Pacific islands eg Papua New GuineaNew Guinea

Lyme disease: LymeRix pulled in 02Lyme disease: LymeRix pulled in 02

The really uncommon vaccinesThe really uncommon vaccines

You don’t always need vaccinesYou don’t always need vaccines

ETECETEC ParainfluenzaParainfluenza RSVRSV DengueDengue SchistosomiasisSchistosomiasis ShigellaShigella ……..and, wishfully, HIV and malaria..and, wishfully, HIV and malaria + New meds for malaria + New meds for malaria

Vaccines and prophylaxisVaccines and prophylaxis in the n the pipelinepipeline

Young childrenYoung children Pregnant womenPregnant women Immunocompromised individualsImmunocompromised individuals

Special populationsSpecial populations

No travel in the first week of lifeNo travel in the first week of life No travel to malaria-endemic areasNo travel to malaria-endemic areas Chloroquine is OK (weight dosed)*Chloroquine is OK (weight dosed)* Mefloquine (Lariam) OK after 5 kg*Mefloquine (Lariam) OK after 5 kg* Doxycycline – not under 8 years of ageDoxycycline – not under 8 years of age Atovaquone/proguanil (Malarone)- not Atovaquone/proguanil (Malarone)- not

under 11 kgunder 11 kg

Special populations: Young childrenSpecial populations: Young children

*Bitter.*Bitter.

WHO recommends no travel after 32 WHO recommends no travel after 32 weeksweeks

Airline may have specific requirementsAirline may have specific requirements Carry letter from FP/OB verifying dates Carry letter from FP/OB verifying dates

and conditionand condition Pre-travel consultation and Pre-travel consultation and

communication with the obstetric communication with the obstetric provider (if not the same as the family provider (if not the same as the family physician) is recommendedphysician) is recommended

Special populations: Pregnant womenSpecial populations: Pregnant women

No live vaccines, e.g. Yellow fever, MMR, No live vaccines, e.g. Yellow fever, MMR, BCGBCG

Malaria:Malaria:– Avoid travel to malaria-endemic areasAvoid travel to malaria-endemic areas– Chloroquine is OKChloroquine is OK– Mefloquine is OK in trimesters 2 and 3 Mefloquine is OK in trimesters 2 and 3 – Avoid pregnancy for 3 months after Avoid pregnancy for 3 months after

mefloquine is stopped, and 1 week after mefloquine is stopped, and 1 week after doxycycline is stoppeddoxycycline is stopped

Special populations: Pregnant womenSpecial populations: Pregnant women

In general, vaccination is safe in In general, vaccination is safe in asymptomatic asymptomatic individualsindividuals

Careful with live vaccinesCareful with live vaccines E.g., yellow fever and measles E.g., yellow fever and measles

vaccine should be given in vaccine should be given in asymptomatic but not symptomaticasymptomatic but not symptomatic

Be especially careful of infections e.g. Be especially careful of infections e.g. diarrheal illnesses (crypto), tuberculosisdiarrheal illnesses (crypto), tuberculosis

Special populations: Immunocompromised (e.g. Special populations: Immunocompromised (e.g. HIV+) HIV+)

Meds in hand luggageMeds in hand luggage (e.g. insulin); check with airlines (e.g. insulin); check with airlines about needles/liquidsabout needles/liquids

Emergency kit items suggestionsEmergency kit items suggestions– Bandage, tape, scissorsBandage, tape, scissors– ThermometerThermometer– Prophylactic meds, condoms, OCPsProphylactic meds, condoms, OCPs– Water purificationWater purification– Insect repellentInsect repellent– Anifungal creamAnifungal cream– Antipyretic, decongestant, antihistamineAntipyretic, decongestant, antihistamine– Med list / conditions/ Med list / conditions/ Allergies in RedAllergies in Red– Epi Pen if neededEpi Pen if needed– Condition-specific suppliesCondition-specific supplies

What to packWhat to pack

Refer to list of approved providersRefer to list of approved providers US Embassy US Embassy

– if you’re in Libya or Iran, good luckif you’re in Libya or Iran, good luck– if you’re in Cuba, mention Michael if you’re in Cuba, mention Michael

Moore to get free care?Moore to get free care? See treatment center (immediately See treatment center (immediately

if febrile and in a malarial area)if febrile and in a malarial area)

Getting sick abroadGetting sick abroad

Biased observationsBiased observations

Basic counseling can be provided by the Basic counseling can be provided by the majority of family physiciansmajority of family physicians

Consultation is available from other FPs and Consultation is available from other FPs and travel medicine specialists (who are usually, travel medicine specialists (who are usually, but not always, ID physicians)but not always, ID physicians)

General prevention, common sense, and being General prevention, common sense, and being up to date on the US vaccination schedule up to date on the US vaccination schedule (and yellow fever, if needed) is the most (and yellow fever, if needed) is the most importantimportant

Malaria prophylaxis is secondMalaria prophylaxis is second Selected vaccination is next (Hep A and Selected vaccination is next (Hep A and

Typhoid are the only ones most people should Typhoid are the only ones most people should consider; even then, they may not be needed)consider; even then, they may not be needed)

Final recommendationsFinal recommendations

Keep the CDC travel website on Keep the CDC travel website on bookmarksbookmarks

Keep a ready list of countries and Keep a ready list of countries and vaccination requirements/malaria vaccination requirements/malaria recommendationsrecommendations

Keep price list of vaccines (insurance Keep price list of vaccines (insurance does not usually cover the non-schedule does not usually cover the non-schedule ones), as well as a list of pharmacies ones), as well as a list of pharmacies which carry themwhich carry them

Final recommendationsFinal recommendations

CDC www.cdc.gov/travelCDC www.cdc.gov/travel WHO www.who.int/ith WHO www.who.int/ith International SOS 215-245-4707 International SOS 215-245-4707

www.internationalsos.com Med-evac / medical www.internationalsos.com Med-evac / medical insurance insurance

Medjet Assist 800-963-3538 Medjet Assist 800-963-3538 www.medjetassist.com www.medjetassist.com

US Dept. of State US Dept. of State www.travel.state.gov/travel/warnings.html travel www.travel.state.gov/travel/warnings.html travel warnings, consular information sheets, public warnings, consular information sheets, public announcementsannouncements

Patient LinksPatient Links

www.CDC.gov/travelwww.CDC.gov/travel International Travel & Health, World Health OrganizationInternational Travel & Health, World Health Organization Control of Communicable Diseases Manual. American Public Health Control of Communicable Diseases Manual. American Public Health

Organization/WHO. Organization/WHO. Possick SE. Possick SE. Ann Intern Med. 2004. Ann Intern Med. 2004. Evaluation and Management of Evaluation and Management of

the Cardiovascular Patient Embarking on Air Travel. the Cardiovascular Patient Embarking on Air Travel. Gendreau MA. Gendreau MA. NEJMNEJM. 2002. Responding to Medical Events During . 2002. Responding to Medical Events During

Commercial Airline Flights Commercial Airline Flights Keystone JS, et al. Keystone JS, et al. Travel Medicine.Travel Medicine. Mosby; 2004 Mosby; 2004 Air travel and transportation of patients: a guide for physicians, 2Air travel and transportation of patients: a guide for physicians, 2ndnd

edition. edition. Jong EC and McMullen R, eds. Jong EC and McMullen R, eds. The Travel and Tropical Medicine The Travel and Tropical Medicine

ManualManual. Saunders/Elsevier.. Saunders/Elsevier. ASTMH’s list of travel clinic and trop med/ travel health courses: ASTMH’s list of travel clinic and trop med/ travel health courses:

www.astmh.orgwww.astmh.org PROMED www.promedmail.org-daily /postings of disease outbreaks PROMED www.promedmail.org-daily /postings of disease outbreaks

worldwideworldwide ISTM: International Society of Travel Medicine www.istm.orgISTM: International Society of Travel Medicine www.istm.org UVM/FAHC Travel ClinicUVM/FAHC Travel Clinic

ReferencesReferences

Closing thoughts: Closing thoughts: Choose your destinations wiselyChoose your destinations wisely

“What Shots Do I Need?” An approach to pre-travel counseling Omar A. Khan, MD MHS [email protected].

Documents

n travel statistics

n africa

n caribbean

n gonorrhea

n australia

n asia

n respiratory

n malaria