Travel Medicine for the Primary Care Provider

Transcription

1 Travel Medicine for the Primary Care Provider Minnesota Academy of Physician Assistants 2016 Joyce L. Sanchez, MD, FACP Assistant Professor of Medicine Divisions of General Internal Medicine & Infectious Diseases

2 No Disclosures

3 Objectives Become familiar with how to counsel patients regarding malaria prophylaxis and insect precautions traveler's diarrhea and food/water precautions travel vaccinations

4 Case 1 A healthy 23 year old woman will be going to Cambodia next month to work for an NGO for one year. After an orientation in Phnom Phen, she will be assigned to work the rest of the year in a small rural village, to be determined. Is malaria chemoprophylaxis recommended? A. Yes B. No C. Show me where to look it up!

5 Resources Travax Comprehensive and up to date resource Vaccine requirements and recommendations Customizable itinerary (multiple countries) Requires yearly subscription The CDC s Health Information for Travelers Published every 2 years The yellow book home

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7 Travax

8 Case 1 cont What would you prescribe for malaria prophylaxis? A. Atovaquone-proguanil B. Doxycycline C. Mefloquine D. Chloroquine

9 Malaria prophylaxis Atovaquoneproguanil Doxycycline Mefloquine Chloroquine Dosing 1 tablet daily 1 tablet daily 1 tablet weekly 1 tablet weekly Schedule 2 days before, daily, 1 wk after return 2 days before, daily, 4 wks after return 2 wks before, daily, 4 wks after return 1 2 wks before, wkly, 4 wks after return Pros Minimal side effects Antibiotic, diarrhea Weekly Weekly Cons Diarrhea, sleep trouble, Cannot miss Gastric acid, sun sens, yeast inf, Cannot miss Neuropsych Seizure threshold Dreams Bitter taste, ear/eye problems with chronic use Cost $215/mo $100/mo $40/mo $40/mo

10 Case 1 cont How about presumptive anti relapse treatment with primaquine? Yes No What do you mean by anti relapse treatment?

11 P. vivax P. ovale

12 Malaria presumptive anti relapse therapy Since she is going to be spending a year in Cambodia, we would consider presumptive antirelapse therapy (PART) using primaquine. Before primaquine is used, G6PD deficiency MUST be ruled out by appropriate laboratory testing.

13 Case 2 A 20-year-old premed student is leaving in one week to spend the summer hiking and camping in Austria, Germany, and Switzerland. He asks your advice about decreasing his risk for acquiring tick-borne encephalitis (TBE).

14 Which of the following is the best advice for lowering the risk for tick-borne encephalitis? A. Use insect repellent containing DEET B. Yellow fever vaccination for cross-protection because TBE and yellow fever are both flaviviruses C. Single dose of doxycycline after exposure D. No concern is necessary because the countries on the itinerary have no risk factors

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16 Insect Repellants DEET: 20 to 50% concentration 8 hours Mosquitoes, ticks, chiggers, fleas, gnats, flies Picaridin: at least 20% only ½ as protective 8 hours Mosquitoes and ticks Lemon eucalyptus extract: 30% 4 5 hours Mosquitoes and ticks

17 Insect Repellents Permethrin soak

18 Other Insect Precautions Long sleeved shirts, long pants, hat Remain in screened or air conditioned areas during the peak biting period for malaria (dusk and dawn). Use bed nets treated with permethrin, if not sleeping in an air conditioned or well screened room. Spray rooms with products effective against flying insects, such as those containing pyrethroid.

19 Case 3 A 33 year old man develops copious diarrhea while diving with his family in the Philippines. What is the preferred treatment for this patient? A. Azithromycin 1000 mg once B. Ciprofloxacin 500mg BID x3 days C. Levofloxacin 500mg once D. Rifaximin 200 mg TID x 3 days E. Oral fluids only

20 Traveler s Diarrhea: Treatment Moderate severe diarrhea (>= 5 stools/day) Persistent diarrhea >48 hours Quinolones in South/Central America, Africa Azithromycin in Southeast Asia Also preferred in children and in pregnancy Quinolone resistant Campylobacter Bloody stools or fever SEEK ATTENSION!

21 An ounce of prevention Soap and water. If not available, use an alcoholbased gel (at least 60% alcohol). Bottled or boiled water, drinks in cans or bottles Avoid tap water, fountain drinks, ice cubes, freshsqueezed juices Beware street vendors, open markets, buffets Food: steaming hot! Raw fruits/vegetables: need to peel NO dairy products, unless pasteurized

22 Case 4 A 30 year old Muslim man is going on a pilgrimage to Mecca (including the Hajj) with his father. He thinks he needs some vaccines before he goes. He was born and raised in Minnesota and received all childhood vaccinations. He has never traveled outside the US before. Does he need the meningococcal vaccine? A. Yes B. No C. Remind me where to look it up

23 Meningitis Meningitis Belt Greatest risk: dry season (Dec. June) Risk of travelers 0.4/100,000 Hajj pilgrimage to Saudi Arabia associated with outbreaks Hajj pilgrims must have had the meningococcal vaccine 3years and 10 days before arriving in Saudi Arabia. static/yellowbook/2016/map_3 11.pdf

24 Case 5 A 68 year old man is going on vacation for 1 week in the mountains of Peru visiting Machu Picchu and 1 week in the jungle of the Amazon basin in Puerto Maldonado. He has hypertension, for which he takes an Losartan/HCTZ, and a baby aspirin daily. He is up to date on routine immunizations for his age group. What vaccines would you recommend? A. Typhoid B. Hepatitis A C. Yellow fever D. A and B E. All of the above

25 Typhoid fever

26 Typhoid Vaccines Live, attenuated Inactivated Route Oral IM Dosage QOD, 4 doses over 1 week once Duration 5 years 2 years Pros Duration Immunosuppressed Children > 2 years Last minute trips Cons Refrigeration Inactivated by antibiotics Duration

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28 Hepatitis A Vaccine Anyone >1 year old traveling anywhere outside of U.S. and Canada Western Europe Scandinavia Japan Australia and New Zealand Inactivated Hep A virus (Havrix or Vaqta ) Two dose series: Day 0 and Month 6 Combined with Hepatitis B (Twinrix ) Three dose series: Day 0, Months 1 and 6

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31 Yellow Fever Vaccine Live attenuated Revaccination every 10 years required by WHO CONTRAINDICATIONS Allergy to vaccine component Age <6 months Symptomatic HIV infection CD4 <200/mm3 PRECAUTIONS Age 6 8 months Age 60 years Asymptomatic HIV infection CD /mm3 Thymus disorder associated with abnormal immune cell function Primary immunodeficiencies Pregnancy Breastfeeding Malignant neoplasms Immunosuppressive drugs

32 Yellow Fever Vaccine In persons 60 years of age, discuss risk/benefits: Risks: Neurologic or viscerotropic disease? Benefits: Ongoing outbreaks? Medical exemption letter?

33 Yellow Fever Vaccine Yellow fever associated neurotropic disease (YEL AND) Encephalitis, Guillian Barre, Bell s Palsy Rarely fatal Yellow fever associated viscerotropic disease (YEL AVD) Mimics severe yellow fever infection 50% or greater fatality rate

34 Yellow Fever Vaccine Incidence of YEL AVD is 0.4:100,000 doses Rate is higher for people aged 60 years years 1:100,000 doses 70 years 2.3:100,000 doses Per Yellow Book: For a 2 week stay, the risks for illness and death for an unvaccinated traveler in: South America are 5:100,000 and 1:100,000, respectively West Africa are 50:100,000 and 10:100,000, respectively

35 Case 5 cont Your patient asks about altitude sickness prevention. How would you counsel him? A. Prescribe acetazolamide B. Stay hydrated C. Avoid alcohol and caffeinated drinks D. Seek urgent medical attention if he becomes confused, short of breath or has a severe headache E. All of the above

36 Altitude sickness Higher risk: > 8 9,000 feet Common locations Machu Picchu, Peru: just under 8,000 ft Cusco, Peru: 11,000 ft Kilimanjaro, Tanzania: 19,000 ft Tibet, China: 13,000 ft Quito, Ecuador: 9,450 ft La Paz, Bolivia: 14,000 ft

37 Altitude sickness Prevention Avoiding increasing sleeping height by over 1000 ft/night after 10,000 ft Acetazolamide Start day before and for 2 days after arrival SE: numbness/tingling in fingers and mouth altered taste of carbonated beverages

38 References Travax. Comprehensive and up to date resource, requires yearly subscription. CDC Traveler s Health Yellow Book. ofcontents.aspx CDC Traveler s Health. The practice of travel medicine: Guidelines by the Infectious Diseases Society of America (IDSA). International Society of Travel Medicine Body of Knowledge for the Practice of Travel Medicine.

39 Questions?