**The Pre-Travel Health Consultation**

**April 12, 2007**

Judy Schmidt: Good afternoon and welcome to Current Issues in
Immunization, a CDC net conference. I'm Dr. Judy Schmidt in the National
Center for Immunization and Respiratory Diseases at the Centers for
Disease Control and Prevention in Atlanta, Georgia. And I'll be the
moderator for today's session April 12, 2007.

Net conference technology allows us to present materials instantaneously
via the internet. To participate in today's program you need a telephone
connection and a separate internet connection.

The learning objectives for today's session are

-   List a recent immunization recommendation made by the Advisory
    Committee on Immunization Practices or a ACIP and

-   Describe an emerging immunization issue.

International travel health is a frequently requested topic and we are
pleased to bring this session to you today. We will cover the pre-travel
consultation with focus on immunizations for travel. A question and
answer session will follow.

Please note the following instructions - if you have technical trouble
please dial star zero on your telephone. If you'd like to ask a
question, please press star one on the telephone.

CE credit is available only through the CDC ATSDR Training and
Continuing education online system at www.cdc.gov/phtnonline. You must
have a verification code specific to today's program to apply for
continuing education credits. This code will be revealed during the
course of the program. **Continuing education credit for this activity
will expire on May 14, 2007.**

CDC, our planners and presenters wish to disclose that they have no
financial interests or other relationships with the manufacturers of
commercial products or suppliers or supporters of commercial services.

Presentations will not include a discussion of any unlicensed or
investigational products.

Today's presenter is Dr. Gary Brunette, who is a medical epidemiologist
on the Travel Health Team at CDC. He has much to cover today, so I'll
ask him to begin his content now - Gary.

Gary Brunette: Thank you. For all travelers whether a tourist or
business traveler, persons returning to their countries of origin to
visit friends and relatives, missionaries or aid workers, an important
step in their travel preparations is a visit to their primary care
provider or to a travel medicine specialist.

In my mind this is as important as booking the air tickets or arranging
their accommodations. These are all activities that help ensure a
successful trip.

It is my hope to provide an overview of some of the issues covered
during the pre-travel consultation. We first need to discuss why travel
medicine is fast becoming a well recognized subspecialty. We will look
at some of the data related to travel health epidemiology. We then need
to review the important elements of the patient risk assessment, a
review of the patient's health and a review of the intended itinerary.

We will look at some the sources of information available to patient and
provider. And we'll briefly outline some of the major risks faced by the
traveler. We will then discuss the elements of patient risk management -
vaccines, medication and counseling.

Many people are surprised by the number of Americans who travel abroad
each year. This graph from ITA shows the number of U.S residents who
traveled abroad from 1995 to 2005. You'll notice the general upward
trend, the reaction to the events of 2001 and the subsequent resurgence
in numbers for 2004 and 2005.

In 2005 over 60 million Americans traveled outside the country. When you
look at all international arrivals around the world, in 2005 there were
more than 800 million international trips.

This slide examines travelers' (?) health risks, it can be seen that
approximately 50% of travelers will experience some health problem while
abroad. Eight percent will need to be seen by a physician, and 5% will
be confined to bed. Three hundred in 100,000 will be admitted to
hospital, 50 in 100,000 will require air evacuation and one in 100,000
will die while traveling abroad.

What can be done to prevent this? One important step is for the traveler
to consult with a medical provider while in the planning stages of their
trip, preferably four to six weeks before the departure. And this brings
us to a close examination of the pre-travel consultation.

The first step of the consultation is the risk assessment. This is an
individualized evaluation of the patient's health, their medical issues,
their travel plans and an evaluation of their particular attitude
towards risk that is their likely behavior patterns while traveling, and
the level of security that they're comfortable with.

Firstly looking at the medical issues, this is careful examination of
the patient's health and how it might be affected by travel. There are
age-specific risks associated with travel.

For example, the very young and old have a different risk profile to
certain infectious diseases - certain medical histories such as
underlying illness maybe exacerbated.

Immunosuppression will among other things increase the risk of certain
infection. Therefore careful history systems review, medication use and
vaccination history is required. Allergies and contraindications to
vaccines and medications are an important consideration.

Pregnancy breast feeding and conception plans has serious implications
when deciding on the sickness of the patient for travel, their
advisability of the itinerary, the vaccines and medications they can
receive, and the special counseling they will require.

The provider often needs to access the potential risk taking behaviors
of the patient. Again, special counseling maybe required. Also
medications and vaccinations not offered to regular travelers may be
suggested.

An important part of the risk assessment is a careful evaluation of the
proposed travel plans. A detailed and full itinerary is required
including dates of travel, duration, and all locations to be visited,
including all stopovers.

There's a vast difference in individual traveling styles. Is the patient
a backpacker or luxury tourist? Will their trip be confined to major
cities or will they spend time in rural environments? Do they intend to
hike and camp or will they be staying in hotels and resorts? Are they
there to conduct business? To participate adventurous activities or will
they possibly be part of a humanitarian effort in difficult
circumstances? All this information needs to be factored into the risk
assessment.

Both providers and patients need to be aware of some of the resources
available to them. The Travelers Health team at the CDC maintains a
comprehensive website aimed at meeting the informational needs of the
traveling public.

It is usually ranked in the top five CDC sites in web use. The primary
audiences are the traveling public and health professionals advising
travelers. There's a wide range of content areas such as travel notices
and announcements, the online Yellow Book, regional destination pages,
and disease information.

The Web site also provides current information about situations that may
impact the health of travelers. CDC issues different types of notices
for international travelers. They're described both the level of risks
for the traveler and recommended preventive measures to take at each
level of risk.

There are four levels - in the news, outbreak notices, travel health
precaution, and travel health warning.

This pie chart summarizes the major causes of death in international
travelers. You will observe that the greatest single cause of death,
almost 50% of all deaths in overseas travelers is cardiovascular
problems indicated by the blue slide.

Deaths related to medical causes, indicated in green, are ranked next at
approximately 25%. Injuries, in red, are the cause approximately 20% of
deaths. It should be noted that motor vehicle accidents and drowning are
the largest causes of injury deaths in travelers.

The high risks of motor vehicle accidents is particularly relevant in
the developing world where tourists are 4 to 5 times more likely to be
involved in trauma than locals. Wounds sustained in these countries are
at higher risk of turning septic, and emergency medical services are
often rudimentary.

Somewhat surprisingly to some people is that infectious diseases
indicated in yellow are a minor contributing factor. That being said it
should be remembered that many infectious diseases are preventable,
either with prophylactic medication or vaccinations.

This slide lists some of the infectious diseases that could affect
travelers. This is by no means a complete list, but it does represent
the diseases which travel medicine providers need to be aware of.

Each of these diseases has a particular epidemiology, and a reasonably
defined geographic range. Some are preventable with medication, others
with vaccine, and some are only prevented with personal protective
measures. It therefore behooves the practitioner to become familiar with
these details.

Immunizations play an important part in the risk management of the
individual traveler. These can be divided into three categories - the
three R's of travel immunization - Routine immunizations - Required
immunizations for travel, and Recommended immunizations for travel.

It is not always straight forward to categorize vaccines. Many vaccines,
which historically were offered only to specific groups, are now
routinely provided. Therefore certain age cohorts will have received
these vaccines and others not - hepatitis A is an example.

In addition a traveler's age will often determine whether they are
likely to have a history of a disease. For example, certain age cohorts
are more likely to have a history of measles or hepatitis A.

These vaccines could be placed in different categories depending on the
patient. It should also be kept in mind that not all vaccines are
available in many countries. Providers should ensure that all travelers
are up to date with their routine immunizations, including an annual
influenza vaccination. The pre-travel consult is often a unique
opportunity to do this.

The adult population over sixty in the U.S has very low vaccination
rates for Tdap. A number of older travelers have died from diphtheria
contracted abroad, and pertussis is also widespread. This would impact
those travelers who have chronic diseases even more. It is therefore
very important to check the immune status of older patients. If there is
no history of vaccination they may require the full series to generate
an adequate titer.

The Advisory Committee on Immunizations Practices or ACIP recommends
that adults 19 through 64 years of age receive a single dose of Tdap to
replace a single dose Td for booster immunization against tetanus
diphtheria and pertussis.

Tdap may be given at an interval less than ten years, since receipt of
last tetanus toxoid-containing vaccine in order to protect against
pertussis.

Influenza is now the most common vaccine preventable disease. Travelers
should be aware that influenza season in the southern hemisphere is from
around June to October, and in the tropics it is transmitted year round.
It is recommended that travelers receive flu vaccine when available in
the U.S, and until it expires, which is typically June of the year after
its availability.

This slide emphasis the fact that while many diseases are no longer
common in the U.S, variable rates of vaccination in other countries
especially in the developing world mean that these diseases can still be
a significant risk to travelers. Again, the importance of travelers
being current on all their routine immunizations needs to be stressed.

Yellow fever is a required vaccine for entry into many countries, and
the CDC's Yellow Book and Travelers' Health Web site have a country by
country list of vaccination requirements as well as the CDC's
recommendation for each of those countries.

As was mentioned earlier meningococcal vaccine was recently added as a
requirement for pilgrims traveling to the Hajj in Saudi Arabia.

The Travelers' Health Web site or the State departments Web sites can
always be accessed to view the latest requirements.

Yellow fever is a viral disease that is transmitted to humans through
the bite of infected mosquitoes. Illness ranges in severity from an
influenza like syndrome to severe hepatitis and hemorrhagic fever.

The case fatality rate of yellow fever in Africa is highly variable, but
approximates 20%. Infants and children are at greatest risk of severe
disease.

In South America yellow fever occurs most frequently in young men who
are exposed through their work to mosquito vectors in forested areas.

A traveler's risk of acquiring yellow fever is determined by various
factors including immunization status, location of travel, season;
duration of exposure, occupational and recreational activities while
traveling, and the local rate of virus transmission at the time of
travel.

As can be seen from these maps, the disease occurs only in sub-Saharan
Africa and tropical South America where it is endemic, and
intermittently epidemic.

Only a small proportion of yellow fever cases is recognized and
officially reported, because low level transmission may not be detected
by public health surveillance systems in many of these countries. This
epidemiologic silence does not equate to absence of risk and should not
lead to travel without the protection of vaccination.

Yellow fever transmission in rural West Africa is seasonal. With
elevated risks during the two to four months that the rainy ends and the
dry begins, usually from July to October.

In Brazil the risk of infection is highest during the rainy season from
January through March. The incidence of yellow fever in South America is
lower than that in Africa however, it is important to note that four of
the six cases of yellow fever reported among travelers from the United
States and Europe in 1996 to 2002 acquired yellow fever in South
America. All six cases were fatal and occurred in unvaccinated
travelers.

Yellow fever is preventable by relatively safe effective vaccines. For
all eligible persons, a single injection of .5 milliliters of
reconstituted vaccine should be administered subcutaneously, a booster
dose is required every ten years.

Reactions to yellow fever vaccine are generally mild. Since 1992 six
cases of encephalitis among adult recipients of the vaccine had been
reported to VAERS. In addition ten cases of autoimmune neurologic
disease were reported. All cases were in first time vaccine recipients.

The risk for this syndrome is estimated to be approximately 0.5 per
100,000 doses distributed.

Since 1996 12 cases of this viscerotropic disease had been reported in
the United States. And an additional 24 suspected cases had been
identified worldwide. Seven or 58% of the U.S cases have been fatal. All
cases reported have occurred in primary vaccinees.

Crude estimates of the incidence are estimated at 0.3 to 0.5 cases per
100,000 doses of vaccine distributed.

This frequency appears to be higher for people older than 60 years of
age. The estimated rate in this group is approximately 1.8 cases per
100,000 doses. A history thymus disease has recently been identified as
a contraindication to yellow fever vaccine.

Meningococcal disease is an acute bacterial infection characterized by
sudden onset with fever, intense headache; nausea, vomiting, stiff neck,
and frequently a rash with pink macules that develop petechiae.

Formally, the case fatality ratio exceeded 50% but early diagnosis,
modern therapy, and supportive measures have lowered the case-fatality
rate to about 10% in developed countries. Eleven to 19% of survivors
have long term sequelae. The five major meningococcal serogroups
associated with disease are A, B, C, Y and W-135.

Sporadic cases and outbreaks of meningococcal disease occur throughout
the world. In the sub-Saharan African meningitis belt, which extends
from Mali to Ethiopia, peaks of meningococcal disease occur regularly
during the dry season from December through June.

In 2000 an epidemic occurred in Saudi Arabia in association with the
Hajj pilgrimage.

Travelers to sub-Saharan Africa may be at risk from the meningococcal
disease. Travelers to the meningitis belt during the dry season should
be advised to receive the vaccine.

There are two vaccines licensed in U.S, both vaccines protect against
meningococcal disease caused by the serogroups A, C, Y and W-135.

MCV4 or Menactra is recommended for persons aged 11 to 55 years. It
offers long term protection, but because it can only be given before age
55 it is important to provide travelers with this vaccine before they
reach that age.

MPSV4 is the recommended vaccine among persons aged 2 to 10 years and
over 55 years. But it is also a suitable alternative for the
intermediate age range.

Vaccination against meningococcal disease is not a requirement for
travel to any country except Saudi Arabia, where travels to Mecca during
the annual Hajj and Umrah for pilgrimage must have proof of vaccination.

Recommended travel vaccines include hepatitis A, hepatitis B, typhoid.
Depending on the travel destination and the planned activities of the
vaccinations may be recommended as well, such as Japanese encephalitis,
polio, and rabies.

Hepatitis A is a viral infection of the liver caused by the hepatitis A
virus. Hepatitis A virus is shed in the feces of persons with
infections. Transmission can occur through direct person-to-person
contact or through exposure to contaminated water and foods.

Hepatitis A infection may be asymptomatic or its clinical manifestations
may range in severity from a mild illness lasting one to two weeks to a
severely disabling disease lasting several months.

Hepatitis A infection is common throughout the developing world where
infections most frequently are acquired during young childhood and
usually are asymptomatic or mild.

In developed countries hepatitis A infection is less common, but
community wide outbreaks still occur in some areas.

Hepatitis A vaccine, immune globulin, or both are recommended for all
susceptible persons traveling to or working in countries with an
intermediate or high endemicity of hepatitis A infection. Two monovalent
vaccines are currently licensed in the United States for persons at
least 12 years of age. Both vaccines are inactivated vaccines which
offer long term immunity.

Twinrix is a combined hepatitis A, hepatitis B vaccine which consists of
three doses given at 0, 1, and 6 months. The FDA has recently approved
an accelerated schedule for Twinrix, which consists of three doses given
at 0, 7, 21 days followed by a booster dose at 12 months.

Hepatitis B is cause by the hepatitis B virus. Hepatitis B is
transmitted through activities that involve contact with blood or blood
derived fluids. Such activities can include unprotected sex, shared
needles; work in healthcare fields, blood transfusions or having dental
and medical procedures or cosmetic procedures such as tattooing or body
building.

The clinical manifestations of hepatitis B infection range in severity
from no symptoms to fulminate hepatitis. The risk of hepatitis B
infections for international travelers is generally low except for
certain travelers in countries where the prevalence of chronic hepatitis
B infection is high or intermediate, as indicated on this map.

Hepatitis B vaccine should be administered to all unvaccinated persons
traveling to areas with intermediate or high levels of endemic
transmission. Regardless of destination, all persons who might engage in
practices that might put them at risk for hepatitis B infection during
travel should receive the vaccine if previously unvaccinated.

Two monovalent vaccines are currently licensed in the United States. The
usual schedule of primary vaccinations consists of three intramuscular
doses. As mentioned before, an accelerated schedule for Twinrix is
available for travelers who will depart before a regular vaccination
schedule can be completed. Hepatitis B vaccines have been shown to be
very safe for persons of all ages.

Typhoid fever is an acute life-threatening febrile illness cause by the
bacteria Salmonella enterica (serovar) Typhi. An estimated 22 million
cases of typhoid fever and 200,000 related deaths occur worldwide each
year.

Approximately 400 cases of typhoid fever are reported in United States
each year, most of these are associated travel.

Risk is greatest for travelers to South Asia and developing countries in
Asia, Africa, the Caribbean, and Central and South America. Travelers to
South Asia are at greatest risk for infections that are multi-drug
resistant.

Travelers who are visiting friends or relatives and who maybe less
likely to eat only safe foods and beverages are at greater risk.

The CDC recommends typhoid vaccination for travelers to areas where
there is a recognized risk of exposure to S. Typhi. Vaccination is
particularly recommended for those who will be traveling in smaller
cities, villages and rural areas off the usual tourist itineraries where
food and beverage choices may be limited.

While immunization is recommended, travelers should be cautioned as none
of the available typhoid vaccines is 100% effective. Nor do they provide
cross protection against other common causes of gastrointestinal
infections.

Typhoid vaccination is not a substitute for careful selection of food
and drink. Two vaccines are currently available in the United States; an
oral live attenuated vaccine and a polysaccharide vaccine for
intramuscular use.

Primary vaccination with the oral vaccine consists of four capsules, one
taken every other day. Primary vaccination with the injectable
polysaccharide consists of one 0.5 ml dose administered intramuscularly.

Specific antimicrobial therapy shortens the clinical course of typhoid
fever and reduces the risk of death. Persons who may have been exposed
and who develop symptoms of typhoid fever should seek medical care.

Japanese encephalitis virus is mosquito-born flaviviral virus
transmitted in an enzootic cycle between Culex mosquitoes and vertebrate
hosts.

The majority of human infections are asymptomatic and only about 1 in
250 infected persons develop clinical disease. From 35,000 to 50,000
cases of JE are reported to the World Health Organization each year
resulting in an estimated 10,000 to 15,000 deaths annually. In addition
30% to 50% of survivors have significant neurological sequelae. Children
are at greatest risk for infection in endemic areas.

Immunity to Japanese encephalitis from previous vaccination or naturally
acquired immunity reduces the risk of illness. Although most adults
living in endemic areas have acquired immunity, adult visitors to these
areas are at risks for infection.

JE transmission occurs in rural agricultural locations where flooding
irrigation is practiced. In many areas of Asia these ecological
conditions may occur near or occasionally within urban areas.

Transmission is seasonal and occurs in the summer and autumn in the
temperate regions of China, Japan, Korea and eastern Russia. Elsewhere
seasonal patterns of disease may be extended or vary with the rainy
season and irrigation practices.

Thus the risk of JE transmission varies by season and geographic area.
The risk to short term travelers and those who confine their travels to
urban centers is very low.

Expatriates and travelers living prolonged periods in rural areas where
JE is endemic or epidemic are at greater risk.

Travelers with extensive outdoor, evening, nighttime exposure in rural
areas such as might be experienced while bicycling, camping, working
outdoors or sleeping in unscreened structures without bed nets, maybe at
high risk even if their trip is brief.

Vaccination should be considered for persons who plan to live in areas
where JE is endemic or epidemic, and for travelers who activities
include trips into rural farming areas. Short term travelers, especially
those who visits are restricted to major urban areas are at lower risk
of infection and generally do not require the vaccine.

And inactivated mouse brain derived JE vaccine, JE -VAX, has been
licensed for use in the U.S since 1992. Production of this vaccine was
discontinued in 2006, but stockpiles of the vaccine will be available
for use for several more years.

And inactivated cell cultured derived JE vaccine has been evaluated in
the United States and will likely be approved for use in the next few
years.

Due to the possibilities of late adverse reactions to the vaccine, the
last dose must be administered at least ten days before the patient is
due to depart. The patient is also required to remain in the clinic for
30 minutes off a dose in case of a possible allergic reaction.

Poliomyelitis is acute viral infection that involves the
gastrointestinal tract and occasionally the central nervous system. It
is acquired by fecal-oral or oral transmission.

Because of polio eradication efforts the number of countries where
travelers are at risk for polio has decreased dramatically. Most of the
world's population resides in areas considered free of wild polio virus
circulation.

Vaccination is recommended for all travelers to polio endemic or
epidemic areas. As of November 2006 these areas include Africa, South
Asia, South East Asia, and the Middle East.

A person is considered to be fully immunized if he or she has received a
primary series of at least three doses of inactivated poliovirus vaccine
(IPV), three doses of live oral poliovirus (OPV) or four doses of any
combination of IPV and OPV.

Adults who are traveling to areas where poliomyelitis cases are still
occurring and who are unvaccinated, incompletely vaccinated or whose
vaccination status is unknown should receive IPV. Two doses of IPV
should be administered four to eight weeks apart, and a third dosage
should be administered 6 to 12 months after the second.

Adults who are traveling to areas where polio cases are occurring, and
who have received a primary series, should receive another dose of IPV
before departure.

Rabies is an acute progressive fatal encephalomyelitis caused by
neurotropic viruses. The disease is almost always transmitted by an
animal bite that inoculates the virus into wounds.

All mammals are believed to be susceptible, but the reservoirs are
carnivores and bats. Although dogs are the main reservoir in developing
countries the epidemiology of the disease differs significantly from one
region or country another to warrant the medical evaluation of all
mammal bites.

Rabies is found in all continents except Antarctica. In certain areas of
the world canine rabies remains highly endemic, including parts of
Africa, Asia and Central and South America.

Preexposure of vaccination maybe recommended for international travelers
based on the local incidence of rabies in the country to be visited, the
availability of appropriate antirabies biologicals and the intended
activity and duration of stay of the traveler.

Preexposure vaccination does not eliminate the need for additional
medical attention after a rabies exposure, but simplifies post exposure
prophylaxis in populations at risk by eliminating the need for rabies
immune globulin and by decreasing the number of doses of vaccine
required.

Travelers should be advised that any animal or scratch should receive
prompt local treatment by thorough cleansing of the wound with copious
amounts of soap and water. This local treatment will substantially
reduce the risk of disease.

Travelers who might have been exposed to rabies should be advised to
always contact local health authorities immediately for advice about
postexposure prophylaxis.

Another important aspect of risk management is the provision of
appropriate medications to the international traveler. An assessment of
the patient's risk for exposure to malaria is essential. If any risk
exists travelers should be placed on a prophylactic regimen, the choice
of which depends on the travel destination and the known epidemiology of
the disease in these locations. Consideration needs to be given to the
species of plasmodium present, the resistance to medications, and the
expected compliance of the patient.

For those travelers who maybe unable to get urgent medical care
consideration should be given to a self treatment regimen. Travelers to
the developing world would benefit from a short course of antibiotic
products for self administration in the event of persistent diarrhea.

Certain travelers may also benefit from medication to prevent the
symptoms of altitude sickness and motion sickness.

The third and last component of the patient's risk management is
counseling. This is an extremely important element of the consultation
and may require substantial amount time.

Counseling should always be tailored to suit the individual traveler and
will be based on the risk assessment completed earlier.

For those patients with existing health problems it is important that
they understand the impact that travel risks and stresses may put on
their conditions. They need to be advised on how to maintain their
current health status and may require help with planning their trip.

Travelers may also need counseling on the advisability of their
itinerary - for example - pregnant women may wish to avoid certain areas
with a malaria risk. Elderly travelers may be advised to make a change
in destination in order to avoid the required yellow fever vaccination.

As part of a traveler's preparation for their trip abroad they may need
to be advised on the importance of adequate medical insurance,
especially for hospitalizations and emergency evacuations.

Depending on their destination and risk factors they may require advice
on how to obtain medical care abroad. In certain circumstances care may
be prearranged. Travelers should also be advised to be aware of travel
notices placed on the CDC and state department Web sites.

Finally the importance of hand washing and maintaining good hygiene
should be stressed.

We will now examine a number of slides which outline precautions that
travelers can take to ensure their own health starting with
environmental precaution.

Long distance air travel is associated with certain risks such as DVTs
and jet lag. Patients can be advised on how to prevent or manage this.

Travelers to countries with extreme environmental conditions should be
advised on sun protection, the extremes of heat and cold and how to
avoid dehydration and heating injuries or hyperthermia and frost bite -
the possibility of altitude sickness.

Water recreation can pose a substantial risk, especially the risk of
accidental injury or death. Certain bodies of water should be avoided
due to parasitic infections or to contamination.

Food and Water Precautions - diarrhea is a common ailment in travelers,
especially those to the developing world. Travelers should be advised to
drink only bottled water and to select foods carefully and choose
well-cooked items that are still hot.

Many items should be avoided if possible. Salads and raw vegetables may
have been washed in contaminated water. Unpasteurized dairy products may
have a risk for diseases such as brucellosis.

Street vendors often have suboptimal hygiene standards, and ice is
usually prepared with local tap water.

Vector Precautions - patients should always be advised that prophylactic
medications and vaccinations should be considered the last line of
defense in the prevention of many vector-borne diseases.

The efficacy of medications and vaccines is never 100%. Personal
protective measures are essential in preventing these diseases. All
these measures are designed to prevent the vector from biting the
traveler.

Bloodborne and STD Precaution - depending on the risk profile of the
traveler, the provider may wish to discuss the risks associated with
unprotected sexual activities.

The traveler also needs to be aware of the risks associated with
bloodborne infections. Particular advice may be given regarding
automobile accidents and the possible requirement for surgery and blood
products. Elective dental and surgical procedures should be avoided in
certain countries. And tattooing and body piercing also pose a risk for
bloodborne disease.

Animal Precautions - in areas with a risk of rabies, patients should be
advised to avoid all animals, including domestic animals. While certain
species of animal are often associated with rabies, any bite or scratch
from any animal should be medically evaluated and postexposure
immunization and immunoglobulin should be considered.

Travelers also need to be aware of the risk of envenomation from snakes,
spiders and marine animals.

We have earlier discussed the risk of motor vehicle accidents. Travelers
should also be aware of the risks to pedestrians, and should avoid night
travel where possible.

Seat belts and infant car seats should always be used. Travelers should
be aware of the risks associated with local crime activity, and should
be encouraged to maintain their situation or awareness. They may also be
targeted for scams and violent crime.

Travelers should be advised to pack a travel emergency kit, the contents
of which will be determined by their particular travel plans. Factors
such as duration of travel and access to medical providers and
pharmacies should be taken into account.

These kits should contain a copy of any relevant medical records, extra
glasses and enough of their prescription medications in their original
containers to last the duration of the trip.

In addition the traveler should decide which of those items in his
medical chest at home would be beneficial to have close at hand while
traveling abroad. Consideration could be given to pain medications, cold
and flu medications, to creams or ointments and to basic first aid
supplies. Always remember the importance of sun screen, lip balm and
insect repellants.

It is usually not required for all travelers to have a checkup on their
return. A post travel checkup would be suggested for any long term
travelers, adventure travelers, or for expatriates returning off an
extended period abroad.

Any traveler returning with fever, chills, sweat, persistent diarrhea or
weight loss needs to be evaluated.

It is very important for all providers to be aware that any fever in a
traveler returning from an endemic area should be considered malaria
until proven otherwise.

That is all, thank you.

Judy Schmidt: And thank you Gary. This finishes the formal presentation,
we now like to invite our listeners to call in and ask questions. We ask
you to restrict your questions to the content discussed today.

Please tell us your name, your first name is fine, and where you're
from.

Our operator will now give directions for the discussion segment of the
conference, and I will follow her instructions with similar CE
information.

Coordinator: Thank you. If you would like to ask a question, please
press star one, you will be prompted to record your first and your last
name.

To withdraw your request, press star two - one moment.

Judy Schmidt: And while we are waiting for question, I would like to
provide continuing education credits for you. For CE credits, go to
www.cdc.gov/phtnonline

The course number is E-V-0378 and the verification code is
**C-R-187-F.** Remember the CE credit expires on **May 14, 2007.**

Dr. Brunette has invited two of his colleagues from the travel health
team to join him to answer your questions. You will hear the voices of
either Dr. Christie Reed, or Dr. Phyllis Kozarsky during the question
and answer session.

We are now ready for our first question.

Coordinator: Our first question comes from (Sue), your line is open.

(Sue): Yes my question is efficacy of subsequent doses of the
polysaccharide vaccines, the typhoid polysaccharide and the
meningococcal polysaccharide vaccine for like Dose 2 and 3. How
effective are those?

Phyllis Kozarsky: This is Phyllis Kozarsky -- they're not the typical
booster effect that one sees in other vaccines such as the conjugate
vaccines, but they are given as essentially a primary vaccine again
after waning of immunity. And they are - they just seem to be\-- as
efficacious as they had been after the first dosing.

Judy Schmidt: Okay, thank you. Do we have our next question? And we will
repeat the question for you - I know some of you are having trouble
hearing the questions.

Coordinator: Our next question comes from Connie, your line is open.

(Connie): Okay can you please repeat the accelerated dose for Twinrix.
And if a patient can not get a second dose, how much protection can you
get from just one dose before he travels?

Christie Reed: The accelerated schedule would be to have the injection
on the day of visit, the second injection a week later - day 7, and then
a third injection day 21.

Twinrix has combined hepatitis A and hepatitis B so that the normal two
dose series of hepatitis A is divided over three doses.

So in order to give adequate protection for the hepatitis A component
you would want the person to have had at least two doses of the Twinrix
before travel.

Coordinator: Our next question comes from (Cheryl), your line is open.

(Cheryl): I would just like to know if there is an accelerated schedule
for the hepatitis B, since you have one for the Twinrix.

Judy Schmidt: Okay accelerated schedule for hepatitis B.

Christie Reed: Yes, there is an accelerated schedule and it is the same
schedule for the Twinrix, it would be 0, 7 days and 21 days.

What's important to know is that the FDA recently approved the
accelerated dose for the Twinrix. It would be an off label use to use
the accelerated dose for hepatitis B that way, but it is commonly used
in order to provide protection for the traveler.

In either scenario which has been accelerated, wether its Twinrix or
hepatitis B, you would also want an additional dose at a year. So
that'll be 365 days from the first dose.

Coordinator: Our next question comes from (Renee), your line is open.

(Renee): Hi, I think part of my question has been answered already it
pertains to the accelerated schedule that's now being used or
recommended for Twinrix.

Now if I understand the 0, 7 and 21 days schedule, which includes a
booster, would only provide in terms of the hep A antigen - that only
provides - will two doses would provide the amount of protection that's
found with the regular 0, 1 , 6 schedule for hepatitis A or?

> Christie Reed: Let me clarify that for you. Hepatitis A is normally
> two doses, 0 and 6 months. That's at six to nine to twelve months.
> Hepatitis B is a three dose series. So in the Twinrix what they've
> done is divide the dose of hepatitis A and split it out over the three
> doses. So to give your traveler at least the equivalent of a single
> dose of hepatitis A - you would need at least two doses of the
> Twinrix.

Christie Reed: But you will still be on an accelerated schedule - you
actually end up with four doses, because you have the 0, 7, 21, and then
you have the booster dose at a year.

(Renee): Right and okay, and so then that would equate to the full two
doses.

Christie Reed: --Yes, that would equate.

Coordinator: Our next question comes from (Debra), your line is open.

(Debra): Yes I had a question about what he said that in some cases both
hepatitis A and IG are needed. I needed some clarification on that. I
didn't think we were doing that anymore.

Phyllis Kozarsky: I think that some people are doing that.What is
realized is that it does take some time after the hepatitis A vaccine to
develop sufficient antibodies.

However some people feel that because there's an incubation period of
several weeks for the hepatitis A virus- that for example, if you were
traveling today and you got the hepatitis A vaccine, and if you were
exposed to hepatitis A virus tomorrow, that you would have ample time to
develop antibodies during the incubation period of hepatitis A virus in
order to prevent clinical disease, just by having the vaccine and not
immune globulin.

However there have been some breakthroughs where people have developed
clinical disease, and therefore, the CDC still recommends that if you
have imminent travel, that is, within a two week period of time, that
people still want to consider giving immune globulin along with the
hepatitis A vaccine to give immediate coverage.

Christie Reed: And there's another scenario; the hepatitis A vaccine is
only licensed for 1 year and above. So if you have an infant or child
who is less than 1 year the hepatitis A vaccine is not available and
immune globulin can provide coverage for approximately three months for
that infant.

(Debra): Okay so in other words the only instance that you would use IG,
is if you had somebody who was under 1 year of age and perhaps on a
personal case of immediate travel and would only be the first dose of
hep A... Is that correct?

Phyllis Kozarsky: Instead of the first - instead of hepatitis A vaccine?

(Debra): He was saying that they were using them both together.

Phyllis Kozarsky: Yes, some people do use them both together with the
first dose of Hepatitis A for imminent travel.

Coordinator: Our next question comes from Sheila, your line is open.

(Sheila): Thank you. On the discussion of meningococcal vaccines, the
revaccination was stated as two years for both the polysaccharide and
the conjugate - it was my understanding that the conjugate is a one time
only - there are no current recommendations for revaccination with that.
And the interval for revaccination with the polysaccharide I thought was
five years.

Could you please straighten me out?

Christie Reed: Yes, you are correct, and the new conjugate vaccine has
an interval listed as at least five years-- and it is expected to be
life long; however, the studies have not been done long enough to
demonstrate that, so the current recommendation is five years.

The polysaccharide vaccine recommendations have been within the three to
five range, and in past we have leaned more towards the three, although
there's current understanding that it is approximately five years for
the polysaccharide.

(Sheila): Okay I'm sorry I really am confused in routine vaccination
purposes. For a conjugate vaccine there is no reimmunization, so I don't
understand why for the meningococcal conjugate vaccine you're making a
statement of a five year revaccination.

Phyllis Kozarsky: I think in general what we like to say is that with an
older polysaccharide vaccine the recommendation now is reimmunize at
five years, and with the newer vaccine it is not known. Right now it's
recommended that you just give a single dose - yes that's correct.

Coordinator: Our next question comes from (Debbie), your line is open.

Judy Schmidt: We are not hearing (Debbie). Does she have a mute button,
or maybe there's a little glitch here, maybe we should go on to the next
question.

Coordinator: Okay. Our next question comes from Katie, your line is
open.

(Katie): Yes, you discussed the typhoid, can you explain with your oral
typhoid , when to use and when not to use.

Phyllis Kozarsky: I think for some people it's just preference of what
they'd rather have, an oral vaccine or an additional shot. The oral
vaccine, as you're aware, is live; so you cannot use it in anyone who is
immunocompromised, or it's not recommended for children under 6 years of
age.

It's just a matter of preference since the efficacy seems to be about
the same. Some people have some GI problems with it, but most people
don't have any complaints. So it's a matter health care provider and
traveler preference.

Christie Reed: It's - to add onto that - also interval if the travel is
eminent - the shot is a single dose, the tablets are four tablets, need
to be taken every other day and the recommendation is that it be
completed a week before travel.

(Katie): Also can you tell us how to obtain a copy of the slides that
were demonstrated today?

Judy Schmidt: Sure, the slides will be posted on the Web site; you will
be able to just look at the slides, or you will be able to have a
complete replay of the entire session. The slides by themselves will be
posted first within the next two days, and then you'll see the complete
session with audio in the next couple of weeks.

Coordinator: Our next question comes from (Jan), your line is open.

(Jan): You actually just answered my question about looking at and
printing out the slides. Thank you.

Coordinator: This is (Carol), your line is open.

(Carol): My question concerns the recommendations for an adult booster
dose of polio. The question has arisen about adults who were adults
already when polio vaccine came out in the 50s or 60s - received it in
all series then, and this there sometime - if we have adults that had a
childhood series, and adult booster and then it's been 10, 15, 20 years
since their last polio.

Judy Schmidt: Okay, so you want us to elaborate then on the adult polio
regimens for international travel.

Christie Reed: And you put your finger on it - the recommendation for
adult's booster is the assumption that they had primary series as a
child - it's the time interval.

So an adult that would have had a vaccine series in the 1960s, it's a
goal to give a booster before they travel again, it's that interval of
time since their primary series that's been the major consideration.

Is that okay?

(Carol): Okay is there any time limit that is considered too long ago?
Is it 20 years or?

Christie Reed: No, you would just give a single dose of a booster if the
person has a history of a primary series in the past.

(Carol): Okay, so if we have a 17 year old, say that their last dose was
at 5 - that hasn't been long enough that they need a booster, or they
do?

Christie Reed: The recommendation has more typically been if the person
is over 20 to 25. Again if someone were going to go to an area that is
highly endemic, it is not a problem to give an additional booster if
there is a question.

Coordinator: Your next question is from (Teresa), your line is open.

(Teresa): Thank you. My question rather than the accelerated hepatitis B
dosing, is about a prolonged administration schedule of the hepatitis B.
If someone gets interrupted or forgets to get to their doses, or in our
instance international business travelers don't get back to the
corporate clinic to do the hepatitis B on the regular schedule.

Is there any harm in prolonging it till when they do return?

Judy Schmidt: Okay, basically you're asking about maximum intervals
between doses of hepatitis B and how that affects the international
traveler?

(Teresa): Yes, when are they covered or how long can it be expanded,
rather than the typical 0, 1, 6 months to be effective.

Christie Reed: Inactivated vaccines such as hepatitis B, once they're
begun, they can be picked up and continued, you don't have to start
again. So these are minimum intervals that are prescribed not maximum.
So if someone's had a history of an initial hepatitis B you would just
resume the schedule.

(Teresa): At any point and time?

Christie Reed: Mm-hm.

(Teresa): Thank you.

Coordinator: Our next question comes from (Angela), you line is open.

(Angela): Yes we'd like to know if there's an accelerated schedule for
the Japanese encephalitis.

Judy Schmidt: Is there an accelerated schedule for the Japanese
encephalitis?

Phyllis Kozarsky: I'm not sure that I know it off the top of my head
either, it's probably a vaccine separated at least by a week - that's my
guess.

And we've had very, very little use for it. I think we were recommending
it for people who were going over to aid after the Tsunami, and I'm
not - I'm not particularly clear of whether we use it much more
frequently than in the event of, you know, an emergency - we try not to.

But if you'd like to contact us we can look that up specifically for
you.

Judy Schmidt: Okay, we have time for one more question.

Coordinator: Our last question comes from (Connie).

(Connie): Hi yes, I just had question getting back to the Twinrix
(filler), the schedule or the Twinrix on the regular schedule, actually
as well.

And whether - the information that I have previously is that, if
somebody starts on the Twinrix, they want to take the hep B vaccine for
the second dose, rather than the combined, and then follow up with
Twinrix for the third, that that is okay - is that correct?

Judy Schmidt: Okay you're talking about mix and match with Twinrix and
monovalent hepatitis B.

(Connie): Yes correct.

Phyllis Kozarsky: People will do that again, this is not one of the FDA
approved ways of administering that vaccine, but it has been used that
way.

Judy Schmidt: Thank you. That's really all the time we have left for
today. And for CE credits, I will remind you to - that the net
conference number is EV0378 and the verification code is **CR187F**.
Remember that CE credits expire on **May 14 2007.**

The online system is easy to use and it's a good way to keep track of
all the CE credit you earn from CEC training programs. If you're having
any difficulty or are new to the system, you can get assistance by
phoning 1-800-41-TRAIN, that's 4-4-6-3-9-1-2-9-2, during business hours
from 8 am to 4:30 pm eastern time.

To get of by email, contact CE at cdc.gov. If you're unable to ask a
question during today's net conference or you have other questions, you
can contact us at our email question and answer service at
nipinfo@cdc.gov. If a question's related to today's net conference
please write the word net conference in the subject line.

You can also ask questions by calling CDC's hotline at 1-800-CDC-INFO.
This is a general hotline service that receives all public health
related questions including immunizations. The hotline is staffed 24
hours a day, 7 days a week.

I'd like to thank you for joining us today, and I want to thank our
travel health team experts, especially our presenter Dr. Gary Brunette.

Please join us again, and goodbye.

END