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

1. “What Shots Do I Need?”An approach to pre-travel counseling Omar A. Khan, MD MHS Okhan.jhsph@jhu.edu

2. Disclosure • No drug company has given me massive amounts of money to promote this talk (or any other) • No other conflicts of interest

3. Overview • Much of the advice herein applies to the developing (“tropical”) setting where diseases of sanitation, poverty and environment are more common than in industrialized settings • Focus today is on pre-travel counseling, not on Dx and Rx of tropical diseases

4. Overview • So the short version, for those who have patients only traveling to Western Europe (and yes, you can leave after the section on Air Travel) -- • Look to the right when crossing the road • Don’t confuse soccer and football • Avoid getting jealous at their long vacations (remember how much they pay in taxes and for gas) • Learn to drive stick and to get out of the fast lane in Germany • Avoid debates on who has the better health care system. Unfortunately, you will probably lose the argument…

5. Overview • Common travel risks • Common conditions • Travel counseling framework • What to vaccinate for • What to prophylax against • Special situations • Resources

6. Travel risks • Travel statistics • Increasing people travel each year • Destinations becoming more exotic • Most illness during travel is diarrheal • 2nd most common illness is non-tropical, e.g. DVT, MI, etc. So make sure general preventive care is UTD • Travel-related deaths only 1-4% • >50% deaths during travel are from chronic disease issues (CV– MI, CVA etc.) • Remainder: MVA, drowning, falls, accidents

7. Travel risks • Travel statistics • Over 700 million trips internationally each year (2004) • Over 28 million Americans travel abroad each year (2005) • Western Europe 40% • Eastern Europe 4% • Caribbean 18% • South America 9% • Central America 7% • Africa 2% • Middle East 4% • Asia 19% • Australia 2%

8. Travel risks • For every 100,000 travelers to developing countries: • 50,000 will have a health problem. • 8,000 will have to visit a physician. • 5,000 will have to stay in bed. • 1,100 will be completely incapacitated. • 300 will be hospitalized. • 50 will be air evacuated. • 1 will die.

9. Travel risks • Un/Common infectious travel-related conditions (per month of stay in developing country) • Diarrheal (30%) • Respiratory (2%) • Malaria (2%) • Hep A (0.5%) • Gonorrhea (0.5%)

10. Travel risks • The most common concerns remain, predominantly, conditions they could have acquired anywhere • Multiple (hundreds of) uncommon conditions abound which are impossible to cover in pre-travel counseling • Their being uncommon still means general principles will likely cover them • The most exotic stuff is also the least likely, so don’t worry too much about Ebola

11. Why include travel counseling in primary care? • More people traveling • Resources available • Referral for unusual scenarios • Reimbursable • Patients see it as a primary care issue, and so should we: spans adult, pediatric, emergency, and ob/gyn areas • Good way to keep up on the literature if working in global health oneself

12. Approach to travel counseling • Assessment of Risk based on • Not only on countries of travel, but sub-regions • Also on what the participant will do there • General preventive principles • Specific concerns

13. Typical travel counseling questions • Where are you going? • What is the purpose of travel? • How long will you be there for? • Will you be in the city or the country? Hotel, home, or camping? • Form an assessment of awareness and of risk

14. Travel counseling questions • Have you seen your other relevant doctors (e.g. coumadin clinic, cardiologist, pulmonologist, dentist?) • Make a follow-up (cancelable) appointment a couple of days after the traveler returns to address any concerns

15. Travel Advice • Be careful • Have fun • But not too much fun

16. Travel Advice • Choose an appropriate travel companion

17. Travel Advice • And leave the furs at home

18. Coding for US physicians* • Code 99403 for a preventive medicine counseling visit lasting approximately 45 minutes. • Also bill the vaccine administration code 90471 for one vaccine and 90472 for each additional vaccine. • E.g., if you administer three vaccines, you would code 90471 once and 90472 twice. • If the patient is under 8 years of age, you should submit 90465 and, when appropriate, 90466, instead • Code separately for the actual vaccine products: e.g., 90717 for yellow fever and the appropriate code from 90690-90693 for typhoid. *Talk to your coder or bus. mgr. My ref: AAFP/ FPM Oct. 2005

19. General Preventive Principles • Plan ahead: figure out medical and other backup resources • Leave copies of itinerary with family/physician • Consider travel insurance • In the plane: • Hydrate, ambulate, avoid alcohol • Anxiolytic? • Melatonin?

20. General Preventive Principles • Boil water/milk and avoid iced drinks • Peel fruit/vegetables • NEVER trust tap water • Boiled > ‘bottled’ > ‘purified’ >‘filtered’ • Yes, even for brushing, especially for kids • Avoid mosquitoes • Don’t walk barefoot on the beach • Don’t swim if the lake says ‘Bilharzia-free’. It’s not.

21. Backyard ‘bottling plant’ in Beijing

22. Filtering the water in Pakistan

23. General Preventive Principles Reiterate common-sense advice which would apply here as well: • Don’t have unprotected sex • Wear your seat belt • Avoid bats, rodents, wild dogs and other carriers • Seek medical care if sick • Use the travel insurance you’ve paid for if you’re really sick

24. Yes, OK, but what shots do I need? • To figure this out, need to know: • A) the distribution of diseases in the area traveled to (see www.cdc.gov/travel) • B) the likelihood of contracting those disease (see resources at the end) • C) what can actually be prevented safely for this particular traveler • Don’t go overboard- visitors to the US don’t worry unduly about our major public health issues….HIV, TB, hepatitis, road traffic accidents, tobacco, etc.

25. Yes, OK, but what shots do I need? • Maybe none if you’re careful! • Very few mandated vaccinations: • Yellow fever vaccination before entering and when coming from a YF endemic country (even if in transit) • YFV vaccination certificate is valid for 10 years • Meningococcal vaccination before going on the Muslim pilgrimage (Hajj) to Saudi Arabia

26. Yes, OK, but what shots do I need? • CDC on the Yellow Fever vaccine • < 1/3 of those traveling to endemic areas get it • ‘All those who have got YF in the last 10 years have died’ • CDC on Malaria • >50% ask about it, but less than half that follow the advice.

27. Yellow Fever Vaccine • Attenuated virus • Good for 10 years • Get stamped yellow certificate to show when entering a YFV-endemic country, or when entering any country after having been to YFV area • Given at approved clinics (see list at www.cdc.gov/travel) • YFV in pregnancy “INDICATED IF EXPOSURE CANNOT BE AVOIDED” CDC Yellow Book • HIV – avoid YFV but can give if high risk and CD4 >200 • Avoid mosquitoes!

28. Yellow Fever Areas

29. Hajj

30. Hajj • 2 M Muslims from 140 countries annually to Saudi Arabia • Crowding = ID and non-ID risks • Facilities are generally sanitary and reasonable standard • Req: Flu, pneumococcal (for >65) and meningococcal (>3 wks and <3 yrs prior to travel) • Rec: Hep A, Hep B, Typhoid • Cipro prophylaxis prior to return home has been suggested but not implemented (for meningitis) • www.saudiembassy.net has more information on annual requirements. • No, they do not accept requests to lower oil prices.

31. Specific concerns (brief overview to prepare your patients for what they might face) • Food/Water-Borne- Diarrhea, Typhoid, Hepatitis • Insect-Borne- Malaria, Dengue • Respiratory- Viral, bacterial, TB • Injuries- Mind the gap, and the rickshaw • STDs+blood-borne- Just (don’t) do it: gonorrhea, syphilis, HIV, hepatitis • Other- e.g., Schisto, Typhoid, CLM

32. Water-Borne: examples of intestinal parasites Ascariasis

33. How can you stay mad at this face? Hookworm

34. Water-Borne: examples • Intestinal parasites • All transmitted, generally, by fecal-oral transmission (except hookworms whuch also go through skin) • Worldwide distribution • Hookworms (Necator and Ancylostoma spp.) • (A. caninum also causes CLM - addressed later) • Tapeworms: • Taenia saginata: Beef tapeworm • Taenia solium: Pork tapeworm and cysticercosis • Echinococcus: cystic hydatid disease • Roundworms: • Ascaris and Trichuris spp.

35. Water-Borne: examples • Viruses • Self-limiting; ORS/ORT adequate • Bacteria • All transmitted, generally, by fecal-oral transmission (except hookworms which also go through skin) • Parasites • Entamoeba histolytica (amebiasis)

36. Water-Borne: examples • Bacteria • ETEC, Campylobacter, Cholera, Shigella, Salmonella (in kids and adults) • Among kids, those old enough to crawl are at highest risk of catching • Youngest at highest risk of dehydration

37. Water-Borne: prevention • But none of that really matters much for pre-travel • General principles: • Most watery and non-bloody diarrhea is self-limiting; use ORS/ORT to avoid dehydration • Bloody diarrhea, generally, can be considered treatable with antimicrobials • Use basic prevention principles mentioned earlier • Continue breastfeeding

38. Water-Borne: treatment • All-purpose empiric treatment regimens: • Bacterial: Ciprofloxacin (for adults), macrolide e.g. azithro for kids • Amebiasis, Giardia: Metronidazole (no alcohol) • Worms: Mebendazole (Vermox). Not in <2 y.o. or BF • Stay away from antimotility agents in general (e.g. loperamide) • May consider advance prescription if sufficient risk is present • Counsel to only take IF appropriate sx develop, NOT as malaria-style chemoprophylaxis • See Vaccines section

39. Vectors and their diseases • Aquatic snails: Schistosomiasis (Bilharziasis) • Blackflies: Onchocerciasis (River blindness) • Fleas (via rats, to humans): Plague • Mosquitoes: Dengue, yellow fever (Aedes); Malaria, lymphatic filariasis (Anopheles); Japanese encephalitis, filariasis, West Nile fever (Culex) • Sandflies: Leishmaniasis (concern in Middle East) • Tsetse flies: African trypanosomiasis (sleeping sickness) • Triatomine bugs: American trypanosomiasis/Chagas’ disease • Ticks: Lyme; borreliosis; Q fever; encehpalitis; tularemia; Crimean-Congo hemorrhagic fever

40. Insect-Borne • Malaria by far the most common • Transmitted by night-biting mosquitoes • Average of 40 cases in returned US travelers • Worldwide • Dengue • Transmitted by day-biting mosquitoes

41. Malaria map- Western hemisphere

42. Malaria map: Eastern hemisphere

43. Insect-Borne: prevention • Repellents: DEET-type most common; avoid ingestion or contact with mucus membranes • Long sleeves • Bednets: excellent protection esp. when impregnated with repellent • Locally available resources: • Coils (pyrethroid-impregnated) • Mats • Sprays/insecticides (“Flit”, etc.) • Air conditioning cuts risk

45. A very fancy bednet

46. Insect-Borne: prophylaxis for malaria • Recommended only for malaria (P. falciparum, vivax, ovale, malariae) • Present in 100+ countries (but not in all cities of those countries) • 12-15000 travelers get malaria annually • Fever within 10 weeks of return from endemic area should cause concern • Fever less than 7 days of first possible exposure is almost never malaria • Falciparum malaria is the most dangerous and has the most resistance

47. Insect-Borne: prophylaxis for malaria • All the quinine derivatives should be used with care with other Q-T prolongers • Chloroquine: 1 week prior to travel through 4 weeks after return. OK for breastfeeding, pregnant, young kids. Problems: may worsen psoriasis • Mefloquine (Lariam): 1 week prior to travel through 4 weeks after return. OK for BF; limits on kids and pregnancy. Problems: psychiatric or convulsive disorders • Doxycycline: 1 day prior to travel through 4 weeks after return. NO to BF/kids/pregnancy. Problems: sunburn; vaginal yeast infections; liver dysfunction • Atovaquone/proguanil (Malarone): 1 day prior to travel through 7 days after return. Unknown for kids/BF/pregnancy.

48. Insect-Borne: prophylaxis for malaria • If considering Primaquine (anti-relapse Rx against P. ovale and P. vivax): consult with CDC or travel clinic. Many contraindications: G6PD deficiency, pregnancy, lactation

49. Suggested Algorithm for Pediatric Malaria Chemoprophylaxis No Chloroquine Resistant Area CQ YES No Mefloquine Resistant Area, Seizures or psychiatric disease MFQ (>5 Kg) YES Doxycycline (>8 years) Malarone (>11 Kg)

50. Insect-Borne: treatment • Chemprophylaxis does not usually apply to treatment of other vector-borne diseases • Rx should be carried out in consultation with appropriate resources (whether in-country or on return) so will not be covered here