Preventing Global

Travel Associated

Infections

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100

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Sunanda Gaur, MDProfessor Of Pediatrics

Rutgers Robert Wood Johnson

Medical School

Global Travel (US)

Over 68 million Americans traveled abroad in 2014, a record number, up 10 percent from 2013. ( U.S. Department of Commerce)

20% of US population are first- or second-generation immigrants

Long-distance travel, especially to Asia and Africa, has increased disproportionately

Travel frequency is also increasing for persons with comorbid conditions, those traveling for business, or those visiting friends and relatives (VFR)

As many as 35-40% of travelers going abroad indicate that visiting friends and relatives was the main purpose for their trip—a total of nearly 10 million travelers per year

Ann Intern Med. 2013;158:456-468

3

GeoSentinel Surveillance Network ( ISTM & CDC ) (2007–2011)

Approximately 3% have vaccine preventable illness

( Hep A, Typhoid Fever, Influenza)

www.istm.org/geosentinal

Ann Intern Med. 2013;158:456-468

Children and International Travel

• US Office of Travel and Tourism Industries (2011): 8% of 60 million international travelers

were children

• Children presenting ill after international travel were less likely to have received pre-travel

medical services

• Children were more likely to be hospitalized due to travel related illnesses

• Children often belong to the VFR (Visiting Friends and Relatives) group.

• VFR group children tend to be younger ( < 5yrs), present late to pre-travel care, have

travelled for longer duration, refuse vaccines

• Approximately 60% of children travelling to the “tropics” develop a travel associated illness.

Hagmann S et al, Journal of Pediatric Infectious Disease Society, Vol2,No. 4,pp327-34,2013.

Newman- Klee et al. Am J trop Med Hyg 2007;77(4) 764-769

Destination Specific Vaccines

Vaccine Risk Region

Yellow fever Parts of Africa and South America. Check

requirement

Hepatitis B SE Asia, parts of Africa, Middle East, Pacific

Islands, parts of South America for longer

stays

Hepatitis A All except Japan, Australia, New Zealand,

north and west Europe, North America

(excluding Mexico)

Typhoid South Asia, Africa, SE Asia

Meningococcal Sub Saharan Africa, Haj

Japanese Encephalitis Indian Subcontinent, SE Asia

Cholera Outbreak setting

Rabies South and SE Asia, Mexico, parts of South

and Central America and Africa

Don’t Forget the “Routine Vaccines”

• MMR (can start at 6 months)

• DTaP or TdaP (accelerate if needed, 4wk interval)

• Varicella

• IPV (accelerate if needed, 4wk interval)

• Hepatitis B

• Hepatitis A

The Meningococcal Meningitis Belt

• Mostly Type A or W

• Dry season Nov-May

• Routine vaccine in US at

ages 11-12 yrs, booster

16 yrs

• For younger children who

travel age-appropriate

formulation and series of

Menactra or Menveo

(A,C,W, Y)

GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION

Hepatitis A Prevention for Travelers

• Vaccine indicated for travel to countries with high or intermediate endemicity

• 2-doses, 6-18 months apart

• Highly Immunogenic vaccine

– 88-90% seroconversion in 2 weeks (one pre travel dose acceptable,

complete after return)

– 99% seroconversion after 2nd dose

• Duration of protection – Not established( likely 15-25 years or more)

• Children <12 months, or allergic to a vaccine component

– single dose of IGIM (0.02 mL/kg) - effective protection for up to 3 months.

• Older adults, immunocompromised people, and people with chronic liver

disease traveling to an area in < 2 weeks ( Vaccine + IGIM).

Yellow fever Endemic Zones

Yellow Fever Vaccine

• Live virus vaccine

• Required if entering endemic area or going from an endemic region to non

endemic region

• Approved for children > 9 months old

• Do not administer simultaneously with cholera vaccine

• Under 4 months – unsafe (high incidence of post vaccination encephalitis)

• Fulminant Hepatitis in elderly

Rabies

• Rabies in travelers – an underestimated risk

• 1980 – 1997 12/36 (33%) of human rabies deaths in US have been related to rabid animals

outside the US

• Canine rabies in endemic in the Indian Subcontinent, China, SE Asia, Philippines, Latin

America, Africa and the former Soviet Union

• In many rabies endemic countries, only Equine RIG and older nerve tissue rabies vaccines

are available

• Equine RIG – significant risk of serum sickness

• Nerve Tissue type rabies vaccine is not as effective, and theoretical danger of allergic

myeloencephalitis exists

• Pre-exposure prophylaxis with HDCV or PCEC vaccine should be considered in selected

cases

Japanese Encephalitis Vaccine

• Inactivated vaccine

• Efficacy = 91%

• Booster every 3 years

• Not approved for children under 3 years

• Side effects– Local reaction (10-25%)

– Fever (10-25%)

– Hypersensitivity reaction (0.6%)

• Indications– Expatriates living in Asia

– Travel to endemic regions for >30 days during transmission season, especially travel to rural areas

Oral Ty21a Vaccine

• Live attenuated vaccine

• Enteric coated capsule – 1 cap every other day x 4 doses

• Efficacy – 65%

• Minimal to no side effects

• Contraindicated in immune compromised individuals

• Mefloquine can inhibit growth of Ty21a in vitro; delay vaccine at least 24

hours before or after Mefloquine

• Concomitant oral antimicrobials may effect vaccine efficacy

Typhoid Vaccines Available in the United States

Drug Ty21a ViCPS

Type Live Attenuated Polysaccharide

Route Oral IM

Min Age of Receipt 6 2

No. Doses 4 1

Booster frequency,y 5 2

Side Effects(incidence) <5% <7%

VFR and Increased Infectious Disease Risk

• In 2011, 55% of imported malaria cases in US occurred among VFRs

• GeoSentinel Surveillance Network : VFRs are 8 X more likely to be diagnosed with

malaria than tourist travelers

• in 2011, 59% of those with severe malaria were VFRs, (mostly from West Africa).

• 66% of typhoid cases occur in VFRs, mostly from South Asia and Latin America

• A recent Canadian study : 94% of typhoid cases in Quebec were in VFRs, mostly from

the Indian subcontinent

• VFR children aged <15 years are at highest risk for hepatitis A, and many are

asymptomatic

• Tuberculosis, hepatitis B, cholera, and measles, occur more commonly in VFRs

http://wwwnc.cdc.gov/travel/yellowbook/2016/advising-travelers-with-specific-needs/immigrants-returning-home-

to-visit-friends-relatives-vfrs

Why are VFR at increased risk ?

• Lack of awareness of risk. Many VFRs assume they are immune; In those who left their

countries of origin years ago, immunity may have waned ….

• Less than 30% have a pre-travel health care encounter

• Financial barriers to pre-travel health care

• Cultural and language barriers with health care providers

• Lack of trust in the medical system

• Last-minute travel plans and longer trips

• Travel to higher-risk destinations, such as staying in homes and living the local lifestyle that

often includes lack of safe food and water and bed net use

• Divergent health beliefs

Spread the Word. Make a Difference.

Destination India

A Word-of-Mouth Travel Health Awareness Project for Asian Indians in New Jersey, New

York, and Connecticut

Travel Health Awareness Program

20

• Develop & implement word-of-mouth travel health education to

Asian Indian adults living in New Jersey, New York & Connecticut

• Measure Travel Health Awareness pre/post program

92% of consumers trust

recommendations

from people they know

84% of those consumers will take

action based on recommendations

from people they know

—SOURCE: Nielsen Trust in Advertising

HealthTalkers Spread the word!

HealthTalkers Feel Great About Participating!

© HealthTalker, LLC 2015 – All rights reserved.

BUILD THE MOVEMENT EDUCATE AND PREPARE ENGAGE THE MOVEMENT MOTIVATE & ENCOURAGE

• Identify advocates

• HealthTalker Invitations

• EHR - HealthTalker is a

Practice Fusion Partner

• Patient Panels

• Etc.

• Welcome emails to new

HealthTalkers

• Welcome Kit with:

• Member Guide

• Education Materials

• Disease Awareness Center

41 2 3

• Private Portal:

MyHealthTalker.com

• Shareable Content

• Share Tools

• Education tools

• Facts

• Social Media

• Community Management and

engagement

• Encouragement Emails

• Knowledge sharing

Health Talker Meningococcal Vaccine Case Study

Objectives

– Engage consumers to spread the word about being protected

from Meningococcal disease.

– Spread the word that a booster dose is required to stay protected.

– Measure the market impact of the HealthTalker Program using independent

third party research.

• Recruited moms (mostly) between the ages 35-54 who had children 10-18 years

old ( 2013-14)

• Once engaged, participants were provided the tools and resources they needed in

order to share information with others via in-person conversations and online

1,377HealthTalkers

recruited in 10

weeks

20.6Conversations lasted

on average 20.6

minutes

79%Conversations occurred

with moms aged 35-54

28Average number of primary

conversations per

HealthTalker

56%Intent to ACT:

See their physician

303,539Total number

of conversations*

HealthTalker Case Study

26

100,000+Additional PreTeens

& Teens Protected

(attributable to Health

Talker)

5:1Returned ROI in

excess of 5:1

Market impact measurement by an independent, 3rd party market research

organization. The manufacturer provided all sales call data, individual marketing

interventions, PR campaigns, paid and organic search, digital display advertising and

sales promotion. Conversation data was captured directly from the HealthTalkers.

The HealthTalker Movement was measured 4 times during the length of the program

(19 month) using a sophisticated mixed method analytics and econometric modeling of

the sales and marketing data provided by the manufacturer, and government provided

utilization data ( Zip code specific)

MEASURE, MEASURE AND MEASURE AGAIN!

HealthTalker Case Study

27

Conversation Starters - Fact Cards

ndiQ2: Imagine you are preparing for a trip to India. Check the

topics you think about while planning.

94%

93%

74%

67%

59%

50%

45%

32%

29%

28%

0 0.25 0.5 0.75 1

Airline Tickets

Passport/Visa

Trip Itinerary

Money Exchange

Preventing Diarrhea

Malaria Medication

Lodging

Typhoid Vaccine

Hepatitis A

Travel Medical Insurance

Baseline Awareness Survey. N = 310

ndiQ3: For your trip to India, when would you visit a health care

provider to discuss your trip?.

Executive Summary

35%

34%

21%

10%

0 0.1 0.2 0.3 0.4

Not at all

4-6 weeks before my trip

1-2 weeks before my trip

3 or more months before my trip

Baseline Awareness Survey

ndiQ4: If your doctor recommended it, which vaccines would you

consider receiving for your trip?

Executive Summary

52%

50%

41%

32%

31%

30%

18%

0 0.15 0.3 0.45 0.6

Typhoid

Hepatitis A

Hepatitis B

None

Measles

Yellow Fever

Rabies

Baseline Awareness Survey

Kibera, Nairobi