# Presentation: 501348

## Gary W. Brunette, MD, MS    

**Gary W. Brunette, MD, MS****    **
**Medical Epidemiologist     **
**Traveler’s Health Team, CCID, **
**Centers for Disease Control and Prevention**

**Today's  Presenter**

## THE PRE-TRAVEL CONSULTATION

- Gary W. Brunette, MD, MS
- Travelers’ Health Team
- Division of Global Migration and Quarantine
- Centers for Disease Control and Prevention

## Outline

- Travelers’ Health Epidemiology
- Traveler Assessment
- Itinerary Review
- Sources of Information
- Risks to the Traveler
- Travel Vaccines
- Travel Medications
- Counseling

## U.S. Residents Traveling Abroad*

***ITA, includes travel to Canada and Mexico**

## Travelers’ Health Risks

- Of 100,000 travelers to a developing country for 1 month:
**50,000 will develop some health problem **
**8,000 will see a physician**
**5,000 will be confined to bed**
**1,100 will be incapacitated in their work**
**300 will be admitted to hospital**
**50 will be air evacuated**
**1 will die**
- Steffen R et al. J Infect Dis 1987; 156:84-91

## The Patient: Medical Issues

- Age-specific issues
- Underlying illness, immunosuppression
- Systems review
- Medical history
- Medication use
- Vaccination history
- Allergies
- Contraindications to vaccines and medications

## The Patient: Other Issues

**Reproductive**
**Pregnant**
**Breastfeeding**
**Preconception**
**Risk-taking behaviors**

## Travel Itinerary

**Full itinerary**
- Dates, duration, stopovers
- Seasonal considerations
**Styles of travel**
- Rural vs. urban
- Budget vs. luxury
**Accommodation**
- Hotel vs. camping
**Activities**
- Business vs. tourism
- Adventure, safari
- Missionary/Humanitarian/NGO

## Travelers’ Health Websitewww.cdc.gov/travel

## Deaths Related to International Travel

**Deaths Related to International Travel**

- N = 2463

- Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

## Infectious Disease Risks to the Traveler

- Malaria
- Diarrhea
- Leishmaniasis
- Rabies
- Dengue
- Meningococcal Meningitis

- Schistosomiasis
- Tuberculosis
- Leptospirosis
- Polio
- Yellow Fever
- Measles
- JEV

- ETC.

## Immunizations for Adult Travelers

**Routine immunizations**
**Required immunizations for travel**
**Recommended immunizations for travel**

## Routine Immunizations

**Diphtheria***
**Tetanus***
**Pertussis***
**Measles +**
**Mumps+**
**Rubella +**
**Varicella**
**Pneumococcus**
**Influenza**

*** Td or Tdap**
**+ MMR**

## Imported Disease

**Measles in the U.S., 1997-2005***
- 925 cases reported
- 74% imported or linked to imported cases
**Typhoid Fever in the U.S., 1999-2003******
- 1140 cases reported
- 74% imported or linked to imported cases

***97-01: Papania.JID.2004;189:S61.**
** ****02-03: MMWR. 2004;53:713.**
** ****04: MMWR. 2005;54:1229.**
** ****05: CDC, unpublished**

**** **Lynch. WHO. 2005.**

## Required Immunizations for Travel

**Yellow Fever**
**Meningococcal**

## Yellow Fever

**Viral disease transmitted via bite of *****Aedes***** mosquito **
**Ranges in severity up to severe hepatitis and hemorrhagic fever**
**Risk to US travelers of illness and death**
**0.5 and 0.05 per 100,000, respectively**

## Distribution of Yellow Fever

**Distribution of Yellow Fever**

## Yellow Fever Vaccine

**Indicated for travel to endemic countries in S. America and Africa, or where required for entry**
**Relatively safe, effective vaccine**
**0.5 ml of reconstituted vaccine administered subcutaneously**
**Booster required every 10 years**

## Yellow Fever Vaccine

**Recent recognition of Severe Adverse Events (SAEs) following vaccination**
**Viscerotropic**
**Risk ~3-5 cases per million doses**
**Neurologic**
**Risk ~5 cases per million doses**** **
**All cases in first time vaccinees**
**Risk is higher in travelers over 60 years**
**~18 cases per million doses**
**Thymus disease is also associated with a higher risk**

## Meningococcal Meningitis

**Bacterial infection transmitted via the respiratory route**
**Five major serogroups: A, B, C, Y, W-135**
**Outbreaks in Africa during dry season (December to June) **
**Associated with crowding conditions**

## Distribution of Meningococcal Disease

## Meningococcal Vaccine

**Indicated for travel to endemic countries, or where required for entry**
**Tetravalent vaccines (A, C, Y, W-135)**
**conjugate vaccine (MCV4)**
**Ages 11-55**
**polysaccharide vaccine (MPSV4)**
**Ages 2-10 and >55**
**High efficacy, few side effects**

## Recommended Immunizations for Travel

**Hepatitis A**
**Hepatitis B**
**Typhoid **
**Japanese encephalitis **
**Polio**
**Rabies**

## Hepatitis A

**Viral infection transmitted via ****fecal-oral route**
**Contamination of food and water**
**Person to person**
**Ranges in severity from a mild illness to severely disabling disease lasting months**

## Distribution of Hepatitis A

## Hepatitis A Vaccine

**Indicated for travel to areas of intermediate to high risk of disease**
**Two hepatitis A vaccines (inactivated)**
**HAVRIX (0, 6-12)**
**VAQTA (0, 6-18)**
**Lifelong protection**
**High efficacy, few side effects**
**TWINRIX: combined Hep A, Hep B vaccine**
**Usual dosing:  0, 1, 6 months**
**Accelerated dosing: 0, 7, 21, 365 days**

## Hepatitis B

**Transmitted via bloodborne route**
**Sexual contact**
**Transfusions, surgical or dental procedures**
**Shared injection needles**
**Ranges in severity from no symptoms to fulminant hepatitis **
**Risk determined by behavior and prevalence of chronic infections at destination.**

## Distribution of Hepatitis B

## Hepatitis B Vaccine

**Indicated for travel to areas with intermediate to high levels of transmission **
**Two recombinant vaccines**
**Recombivax **
**Engerix B **
**Dosing: 0, 1, 6 months**
**High efficacy, few side effects**

## Typhoid

**Transmission via fecal-oral route, usually contaminated food or water**
**Acute, life-threatening febrile illness **
**22 million cases and 200,000 related deaths occur worldwide each year**

## Distribution of Typhoid

- Source: sanofi pasteur MSD

## Typhoid Vaccine

**Indicated for travel to areas where there is a recognized risk of exposure to *****S. *****Typhi **
**Two administration routes:**
- Oral live attenuated vaccine: 4 doses
- Protection for 5 years
- Injectable Vi polysaccharide vaccine: 1 dose
- Protection for 2 years
**Protection from *****S. *****Typhi but not *****S. *****Paratyphi**

## Japanese Encephalitis

**Transmitted via bite of***** Culex***** mosquito**
**50,000 cases and 15,000 deaths reported each year **
**Up to 50% of survivors have significant neurologic sequelae **

## Distribution of Japanese Encephalitis

## Japanese Encephalitis Vaccine

**Indicated for extended stays in areas where JE is endemic or epidemic, and for travelers whose activities include trips into rural farming areas **
**Dosing: 0, 7, 30 days, booster at 2 years **
**Production has ceased on current inactivated mouse brain-derived vaccine**
**Inactivated cell culture-derived vaccine currently in FDA approval process **

## Polio

**Acute viral infection acquired by fecal-oral or oral transmission **
**Ranges from acute flaccid paralysis, to quadriplegia, respiratory failure  and death **
**High transmission areas are India, Pakistan, Afghanistan, Nigeria.**

## Distribution of Polio

## Polio Vaccine

**Indicated for travel to areas where polio is endemic**
**Inactivated polio vaccine (IPV)**
**Adult patients require one booster**

## Rabies

**Acute, progressive, fatal encephalomyelitis **
**Transmission via animal bite or scratch**
**dogs, monkeys, bats, etc.**
**40,000 deaths per year**

## Distribution of Rabies

- Source: World Health Organization

## Rabies Vaccine

**Indications:**
**long-term travelers in high risk countries**
**occupational risks**
**lower threshold to vaccinate children**
**Pre-exposure prophylaxis**
**3 doses: 0, 7, and 21 or 28 days**
**intramuscular injection in deltoid**
**Post-exposure immunization**
**even when pre-exposure received**
**HRIG administered (if no PEP)**

## Travel Medications:Prophylaxis & Self Treatment

**Malaria**
**chloroquine, atovaquone/proguanil (Malarone), doxycycline, mefloquine (Lariam), primaquine**
**Diarrhea**
**quinolone, azithromycin**
**Altitude**
**acetazolamide**
**Motion sickness**
**scopolamine, dimenhydrinate (Dramamine)**

## Patient Counseling

**Sufficient time for patient education**
**Tailored to suit traveler**
**Fitness for travel**
**Understanding impact on existing conditions**
**Advisability of destinations**

## Travel Preparation

**Travel health insurance**
**Medical care**
**Hospitalization**
**Evacuation**
**Obtaining medical care abroad**
**Awareness of travel notices**
**Hand washing and hygiene**

## Environmental Precautions

**Air Travel**
**Jet Lag**
**Sun Protection**
**Extreme Heat and Cold**
- dehydration, heat stroke
- hypothermia, frostbite
**Altitude**
**Water recreation**
- Drowning, boating & diving accidents
- Risk of schistosomiasis or leptospirosis
- Biological and chemical contamination

## Food and Water Precautions

**Bottled water**
**Selection of foods**
**well-cooked and hot**
**Avoidance of **
**salads, raw vegetables**
**unpasteurized dairy products**
**street vendors**
**ice**

## Vector Precautions

**Covering exposed skin**
**Insect repellent containing DEET 25 – 50%**
**Treatment of outer clothing with permethrin**
**Use of permethrin-impregnated bed net**
**Use of insect screens over open windows**
**Air conditioned rooms **
**Use of aerosol insecticide indoors**
**Use of pyrethroid coils outdoors**
**Inspection for ticks**

## Bloodborne and STD Precautions

**Prevalence of**
**STDs **
**Hepatitis B**
**Hepatitis C**
**HIV**** **
**Unprotected sexual activity**
**Commercial sex workers**
**Tattooing and body piercing**
**Auto accidents **
**Blood products**
**Dental and surgical procedures**

## Animal Precautions

**Animal avoidance**
**Rabies**
**Specific animal threats**
**Medical evaluation of bites/scratches**
**Post exposure immunization and immunoglobulin**
**Envenomations**
**Snakes, scorpions, spiders**
**Maritime animals**

## Injury and Crime

**Vehicles**
**Risk of road and pedestrian accidents**
**Night travel**
**Seat belts and car seats**
**Use of drugs and alcohol**
**Understanding local crime risks**
**Scam awareness**
**Situational awareness**
**Location avoidance**

## Travel Emergency Kit

**Copy of medical records and extra pair of glasses**
**Prescription medications**
**Over-the counter medicines and ****supplies**
- Analgesics
- Decongestant, cold medicine, cough suppressant
- Antibiotic/antifungal/hydrocortisone creams
- Pepto-Bismol tablets, antacid
- Band-Aids, gauze bandages, tape, Ace wraps
- Insect repellant, sunscreen, lip balm
- Tweezers, scissors, thermometer

## Post-Travel Care

**Post-travel checkup**
**Long term travelers**
**Adventure travelers**
**Expatriates in developing world**
**Post-travel care**
**Fever, chills, sweats**
**Persistent diarrhea**
**Weight loss**

## FINISH

**FINISH**

## Travel Health Resources

- CDC Travelers’ Health Website
- _[www.cdc.gov](http://www.cdc.gov/travel)__[/travel](http://www.cdc.gov/travel)_
- World Health Organization
- _[www.who.int/int](http://www.who.int/int)_
- State Department
- _[travel.state.gov](http://www.travel.state.gov/)_
- International Society of Travel Medicine
- _[www.istm.org](http://www.istm.org/)_
- Health Information for International Travel
- CDC “Yellow Book”
- International Travel and Health
- WHO “Green Book”

## Journals

**American Journal of Tropical Medicine and Hygiene**
**Bulletin of the World Health Organization**
**Emerging Infectious Diseases Journal**
**Eurosurveillance Weekly **
**Journal of Travel Medicine**
**Morbidity and Mortality Weekly Report**
**Tropical Medicine and International Health**
**Vaccine**

## Books

**Textbook of Travel Medicine and Health, 2****nd**** Ed.**
- DuPont, H.L. and Steffen R. (editors)
**The Travel and Tropical Medicine Manual, 3****rd**** Ed.**
- Jong, E.C., McMullen, R.
**Travel Medicine**
- Keystone, J.S., Kozarsky, P.E., et al

## Websites

**Eurosurveillance**
**	****	****	**_[www.eurosurveillance.org](http://www.eurosurveillance.org/)_
**Travax EnCompass**
**	****	****	**_[www.travax.com](http://www.travax.com/)_
**GIDEON**
**	****	****	**_[www.gideononline.com](http://www.gideononline.com/)_
**International SOS**
**	****	****	**_[www.internationalsos.com](http://www.internationalsos.com/)_
**Medical Advisory Service for Travelers Abroad (MASTA)**
**	****	****	**_[http://](http://www.masta.org/)__[www.masta.org](http://www.masta.org/)__[/](http://www.masta.org/)_
**Armed Forces Medical Intelligence Center**
**	****	****	**_[www.afmic.detrick.army.mil](http://www.afmic.detrick.army.mil/)__[/](http://www.afmic.detrick.army.mil/)_
**Central Intelligence Agency**
**	****	****	**_[www.cia.gov/cia/publications/factbook](http://www.cia.gov/cia/publications/factbook/)__[/](http://www.cia.gov/cia/publications/factbook/)_

## Thank You...From Atlanta!