TRAVEL HEALTH

PEARLS FOR THE BUSY CLINICIAN

DR. KRISTIAN LOBBAN, MD, CCFP, MBA, BSC

CERTIFICATE IN TRAVEL HEALTH™

MICHAEL MACDONALD, BSC PHARM

CERTIFICATE IN TRAVEL HEALTH™

DISCLOSURES

We work in a private travel clinic where we are funded by Costco Wholesale Canada Ltd.

Costco has provided no funding towards this presentation.

We have no pharmaceutical affiliations and receive no pharmaceutical funding.

Travel health recommendations are constantly changing, given the ever changing geographical distribution of

infectious diseases, changes in vaccine recommendations, etc. These slides are up to date as of Nov 29, 2019, and

recommendations should be used cautiously, in case of any changes in guidelines or disease distribution, since these

slides were written on Nov 29, 2019.

PRE-TRAVEL ASSESSMENT - A BRIEF OVERVIEW

1. Health Background

PMHx, Meds, Allergies

?Asthma/COPD/OSA: (pollution, exertion, altitude, etc)

?Immunocompromised (incr’d risk infection/cannot use live vaccines, etc.)

?DVT RF’s

?Cardiac conditions/CVD- (incr’d risk for certain activities – diving, altitude, etc.)

?Pregnant/Breastfeeding – many meds/vaccines contraindicated

Immunization history

ROUTINE VACCINATIONS!!! & travel vaccines

Prior travel experience / level of risk tolerance

PRE-TRAVEL ASSESSMENT – A BRIEF OVERVIEW

2. Trip Details:

Urban vrs rural

Reason for travel

Work, volunteering, VFR, etc.

Travel style

Roughing it → High end

Modes of transportation

MVCs= largest cause of death amongst travelers (CDC, 2018)

Accommodations

Special activities

Altitude , diving, caving, extreme sports, contact with animals ….

SPECIAL POPULATIONS-VISITING FRIENDS & RELATIVES (VFR)

CDC Definition: “An immigrant, ethnically and racially distinct from the majority population of the

country of residence (a higher-income country) who returns to his or her home country (lower

income country) to visit friends or relatives” (CDC, 2018)

VFRs experience higher rates of infectious disease than other travelers (CDC, 2018)

Ex. Malaria (8x), typhoid, TB, Hep A, STIs, etc. (CDC, 2018)

Consider in depth travel assessment given increased risks

SPECIAL POPULATIONS: IMMUNOCOMPROMISED TRAVELERS

Higher risk of infection

Cannot use live vaccines, and inactivated vaccines ↓ efficacy

Make sure they have travel insurance and evacuation insurance

Consider baseline TB skin test (CDC, 2018)

Consider an in depth travel health assessment given increased risks

SPECIAL POPULATIONS: LONG TERM TRAVELLERS

Ensure health insurance and provide list of legitimate hospitals/clinic in area, +/- evacuation insurance

Bring medications from Canada (higher % of counterfeit in certain countries abroad)

Malaria prevention and TREATMENT dose if needed

Ensure long term compliance

Consider baseline TB test (CDC, 2018)

Monitor for psychiatric illness (CDC, 2018)

Consider in-depth travel assessment given increased risks

HEPATITIS A VACCINES

Havrix

Havrix (age 19+): 1ml IM (1440 units) @ 0, 6-12 months

Havrix Junior (Age 1-18): 0.5ml IM (720 units) @ 0, 6-12 months

Avaxim

Avaxim (Age 12+): 0.5ml IM (160 units) @ 0, 6-36mon

Avaxim-Pediatric: (Age: 1-12): 0.5ml IM (80 units) @ 0, 6-36 mon

Further boosters not generally recommended (CDC, 2018).

Pregnancy: thought to be low risk (but no studies), but risk should be weighed against risk of infection/exposure to hep A (CDC, 2018)

HEPATITIS B VACCINES

Engerix

Engerix B (20 years+): 1ml IM at 0, 1, 6 months

Engerix B Jr (0-19): 0.5ml IM 0, 1, 6 months

• Ideally all 3 before travel (CDC, 2018)

Accelerated (4 doses):

Age 0-10: 0.5ml IM @ 0, 1, 2, 12 months

Age 11+: 1ml IM @ 0, 1, 2, 12 months

HEPATITIS B VACCINES

Recombivax HB (regular dosing)

Age 0-19: 0.5ml IM @ 0, 1, 6 months

Age 20+: 1ml IM @ 0, 1, 6 months

Recombivax HB (adolescent accelerated dosing)

Age 11-15: 1ml IM @ 0, 4-6 months

HEPATITIS A & B VACCINE (TWINRIX)

Ages 19+ years

Twinrix adult (1ml) regular schedule: 1ml dose IM @ 0, 1, 6 months

Twinrix adult (1ml) rapid schedule: 1ml dose IM @ 0, 7, 21 and 365 days

Age ≤ 18 years

Twinrix Jr (0.5 ml) regular schedule: 0.5ml IM @ 0, 1, 6 months (1-18 years old)

Twinrix adult (1ml) alternative schedule: 1 ml @ 0, 6 months (1-15 years ONLY)

TYPHOID FEVER

Highest risk: Southern Asia (India, Pakistan, Bangladesh) (CDC, 2018)

High risk: Africa and SE Asia

Lower risk: East Asia, South America, Caribbean

TYPHOID VACCINES

Vivotif (oral live attenuated vaccine): take 1 capsule on days 1, 3, 5, & 7

Age 6+, repeat q5years

Do not give if immunocompromised/pregnant or within 72 hours of taking antibiotics/antimalarials (CDC, 2018)

Space by 8 hours with taking Dukoral

TyphimVi (inactivated capsular polysaccharide vaccine): 0.5ml IM as a single dose

Age 2+, repeat q2years

Pregnancy: not studied (risks vrs benefit) (CDC, 2018)

Complete at least 2 weeks before travel (CDC, 2018)

INFLUENZA

One of the most important recommendations for any of your traveling patients!

Transmission year round in tropical/ sub-tropical regions

Ideally should get no later than 2 weeks before departure

JAPANESE ENCEPHALITIS

Vaccine recommended for (CDC, 2018):

> 1 month in endemic area during JE transmission season

< 1 month in endemic area during JE transmission season if plan to travel outside of an urban area / activities put at

increased risk (rural, agricultural, camping, hiking, trekking, etc.)

Traveling to an area with active JE outbreak

Travelers to endemic areas with uncertain destinations/activities/duration of travel

JAPANESE ENCEPHALITIS

Ixiaro (Regular vaccine series):

Age 3+: 0.5ml IM at 0, 28 days

Age 2mo-2yrs: 0.25ml IM 0, 28d

Ixiaro (Rapid Series): 0, 7 days (off-label, not studied in children) (CDC, 2018).

Booster: 1 year after primary series if ongoing risk of exposure (CDC, 2018)

No studies in pregnancy, so should be deferred, unless risks of exposure outweigh potential risks of vaccination

(CDC, 2018)

Series should be completed at least 1 week before potential exposure (CDC, 2018)

POLIOMYELITIS

Some countries still have cases of wild-polio virus (WPV) and/or vaccine-derived polio virus (VDPV)

Currently 3 countries still have WPV: Nigeria, Afghanistan, Pakistan (CDC, 2018)

Many countries still have VDPV, so important to check status of VDPV for each country

Consider vaccination if traveling to a country that BORDERS a country with WPV/VDPV (CDC, 2018)

POLIO VACCINE RECOMMENDATIONS

Imovax Polio: 0.5mls subcut

Adults who are unvaccinated/incomplete/unknown vaccine status traveling to country with WPV/VDPV

3 doses of Imovax Polio vaccine @ 0, 2, 6-12mon (CDC, 2018)

Adults who were fully vaccinated as children traveling to country with WPV/VDPV

Should receive a single lifetime dose of Imovax Polio (CDC, 2018)

*Consider bordering countries as well (CDC, 2018)

POLIO VACCINE RECOMMENDATIONS FOR CHILDREN

Children receive 5 doses of IPV in NS, if travel before 5 doses complete, needs to be looked at on a case by case

basis if travel to area of WPV/VDPV

Country may require documentation of polio vaccines on ICVP (International Certificate of Vaccination

or Prophylaxis)

This depends on individual country requirements

Even if not required, consider for long-term travelers

MENINGOCOCCAL DISEASE

Epi: worldwide, highest= meningitis belt of sub-Saharan Africa

Highest transmission in the meningitis belt: Dry Season (Dec-June) up to 1,000 cases per 100,000 population

(CDC, 2018)

MENINGOCOCCAL DISEASE

Hajj/Umrah pilgrimage to Saudi Arabia also associated with outbreaks (CDC, 2018)

Required to provide documentation of quad meningitis vaccine for visa to enter SA for Pilgrimage

Should be documented on an ICVP within the last 8 years for conjugate vaccine (Menactra/Menveo) but the CDC recommends

q5years (CDC, 2018).

MENINGOCOCCAL DISEASE

MENACTRA (MenACWY-D conj)

9 mon-23mon: 0.5ml IM, 2 doses, 3 months apart

2-55yrs: 0.5ml IM, 1 dose

MENVEO (MenACWY-CRM conj)

2-7mon: 0.5ml IM, 4 total doses @ 0, 2, 4, 10-13 months

7-23mon: 0.5ml IM, 2 total doses at least 3 months apart, 2nd dose should be after 12 months of age

2-55yrs: 0.5ml IM, 1 dose

MENINGOCOCCAL DISEASE

For all: Booster q5 years if continued risk (CDC, 2018)

If immunocompromised depends on each individual medical condition…

RABIES

BIT BY ANYTHING WHEN TRAVELING URGENTLY TO THE HOSPITAL

Consider evac insurance

Wound mgmt.:

Immediately thoroughly clean wound with ++soap/water/iodine then to hospital (CDC, 2018).

No treatment, so prevention is key!

PREEXPOSURE IMMUNIZATION FOR RABIES

Imovax Rabies (HDCV): 1.0ml IM, 3 doses, 0, 7, 21-28d

RabAvert (PCEC): 1.0ml IM, 3 doses, 0, 7, 21-28d

No booster required for most travelers who received 3 dose pre-exposure series as above (CDC, 2018)

Booster may be required for travelers in high risk categories (CDC, 2018).

If 3 doses cannot be given before travel, do not start the series (CDC, 2018)

Post-exposure vaccination not contraindicated in pregnancy, pre-exposure could be considered if risk is great

(CDC, 2018)

CHOLERA

Dukoral offers good protection against cholera (85%) (CDC, 2018)

Consider for refuge/aid workers in developing countries or in countries with active outbreak (CDC, 2018)

CHOLERA

Dukoral

Age 6+: 2 doses, 1 week apart

Age 2-6: 3 doses, 1 week apart

Finish at least 1 week before travel

Booster: 1 dose

For Cholera protection:

Booster q2years, if >5 years since initial series, repeat initial series (CDC, 2018)

For ETEC coverage:

Booster q3months, if >5 years since initial series, repeat initial series (CDC, 2018)

YELLOW FEVER

Yellow fever vaccine

Must be administered by a practitioner with a special license through Health Canada and documented on

an ICVP (“yellow card”)

Many contraindications to vaccination reviewed by trained professional - medical “contraindication to vaccination” document can

be given

>9 months of age, incr risks of vaccine >age 60

Vaccine must be given at least 10 days before travel

Many countries require proof of vaccination to YF to apply for visa or entry to country

VERY IMPORTANT to review itinerary (even a layover in an at risk country)

There is currently a world-wide shortage of the YF vaccines - fractionated doses are being given (1/3-1/5 dose)

Fractionated doses are considered protective for up to 1 year only (Government of Canada, 2019).

YELLOW FEVER

International Certificate of Vaccination or Prophylaxis (ICVP)

“Yellow Card”

Effective July 11, 2016, the ICVP for yellow fever vaccination will be valid for life (CDC, 2018)

Travelers with yellow cards issued before July 11, 2016 should have a yellow fever vaccine provider review their yellow card, to ensure

ongoing validity and/or to reissue a new ICVP

YF vaccine must be given either at the same time OR ≥28days before or after other live vaccines

Be mindful when giving MMRs

YF VACCINATION CENTRES IN NOVA SCOTIA

(Government of Canada, 2019)

ROUTINE VACCINATIONS

Tetanus

MMR

Varicella

Pneumovax

Shingles

Gardasil

TRAVELER’S DIARRHEA

Probiotics ?benefit but more studies needed (CDC, 2018)

BSS (Pepto Bismol): 524mg QID can reduce TD occurrence by 50% (CDC, 2018)

Contraindications: children <12, ASA allergy, duration >3 weeks, renal insufficiency, gout, on MTX/probenecid/anticoagulants

(CDC, 2018).

INTERVENTION TREATMENT DOSE

Azithromycin -Adult dosing: 500mg OD for 1-3 days = preferred antibiotic

-Peds dosing: 10mg/kg/day OD for 1-3 days (max 500mg OD)

(CDC, 2018)

Ciprofloxacin 750mg OD x 1-3 days, no longer routinely recommended, worldwide

resistance

(Diemert, 2006).

TRAVELERS DIARRHEA TREATMENT

When to treat TD?

● Counsel to hold off self-treatment with mild symptoms

● 2-3 loose BMs in 24 hour period AND functional impairment, start abx

(Diemert, 2006)

● Red Flags: Symptoms worsen or don’t improve within 24 hours, rash, dehydration,

fever, abdominal pain, blood in stool, etc seek medical attention (Diemert,

2006)

MALARIA: EPIDEMIOLOGY

In 2015, 1,513 cases/ 11 deaths of malaria in US travelers (CDC, 2018)

85% acquired in Africa (CDC, 2018)

THERE IS NOW MALARIA IN THE DOMINICAN REPUBLIC!!

This includes Punta Cana and Santo Domingo!!!

MALARIA: PROPHYLAXIS – ADULT

Drug Dosage Usage

Malarone

(Atovaquone-proguanil

250-100mg)

1 tablet daily, start 1-2 days before exposure and

continue until 7 days after exposure

All areas (CDC, 2018)

Doxycycline 100 mg daily, start 1-2 days before exposure and

continue until 4 weeks after exposure

All areas (CDC, 2018)

Chloroquine 500 mg weekly, start 1-2 weeks before exposure

and continue until 4 weeks after exposure

Only in areas with chloroquine-sensitive

malaria (CDC, 2018)

Mefloquine 250 mg weekly, start ≥ 2 weeks before exposure

and continue until 4 weeks after exposure

Only in areas with mefloquine-sensitive

malaria (CDC, 2018)

MALARIA: PROPHYLAXIS – PEDIATRIC

Drug Dosage Usage

Malarone Jr

(Atovaquone-

proguanil 62.5 mg-25

mg)

5–8 kg: 1/2 pediatric tablet

8–10 kg: 3/4 pediatric tablet

10–20 kg: 1 pediatric tablet

20–30 kg: 2 pediatric tablets

30–40 kg: 3 pediatric tablets

40+ kg: 1 adult tablet

Daily, start 1-2 days before exposure, stop 7 days after exposure

All areas (CDC, 2018)

Doxycycline ≥8 years of age: 2.2 mg/kg (up to adult dose of 100 mg/day)

Daily, start 1-2 days before exposure, stop 4 weeks after exposureAll areas (CDC, 2018)

Chloroquine 5 mg/kg base (8.3 mg/kg salt)

(up to maximum adult dose of 300 mg base).

Weekly, start 1-2 weeks before exposure, stop 4 weeks after

exposure

Only in areas with chloroquine-sensitive

malaria (CDC, 2018)

Mefloquine ≤9 kg: 4.6 mg/kg base (5 mg/kg salt)

9–19 kg: 1/4 tablet

19–30 kg: 1/2 tablet

30–45 kg: 3/4 tablet

>45 kg: 1 tablet

Weekly, start ≥ 2 weeks before exposure, stop 4 weeks after

exposure

Only in areas with mefloquine sensitive

malaria (CDC, 2018)

MALARIA PROPHYLAXIS: PEDIATRIC

MALARIA: PROPHYLAXIS – CI & ADRS

Drug Contraindications Adverse Effects

Malarone

(Atovaquone-proguanil

250-100mg)

-Pregnancy and breastfeeding

infant <5kg

-CrCl < 30 mL/min

(CDC, 2018)

-Well tolerated

(CDC, 2018)

Doxycycline -Pregnancy and breastfeeding

-Children aged < 8 years

(CDC, 2018)

-Photosensitivity

-Candida vaginitis

-Gastric/esophageal irritation

(CDC, 2018)

Chloroquine

-Retinal or visual field changes

-Epilepsy

(CDC, 2018)

-Minor: GI, HA, dizziness, blurred vision, pruritus

-Retinal damage, auditory changes muscle weakness or

atrophy

-Neuropsychiatric (e.g. seizures, psychosis, encephalopathy [1

in 13,000 travelers])

-long term use requires monitoring for retinal toxicity

(CDC, 2018)

MALARIA: PROPHYLAXIS – CI & ADRS

Drug Contraindications Adverse Effects

Mefloquine -Depression (active/recent)*

-GAD

-Schizophrenia

-Epilepsy

-Cardiac conduction abnormalities

(CDC, 2018)

-FDA Black box warning for neuropsychiatric disturbances (1

in 6,000-10,000 travelers)

-Disabling neuropsychological problems (e.g. insomnia,

nightmares, irritability, depression [1 in 200-500 travelers])

-Others including neurological (e.g. vertigo, tinnitus), cardiac

(e.g. sinus bradycardia, sinus arrhythmia, QTc prolongation)…

(CDC, 2018)

*any history of depression in Europe (CDC, 2018)

ZIKA

Current CDC recommendations re: pregnancy (As of Nov 29, 2019)

If only the MALE travels:

Do not become pregnant until 3 months after return from Zika risk area/onset of Zika symptoms/date of Zika diagnosis (CDC, 2019)

If only the FEMALE travels:

Do not become pregnant until 2 months after return from Zika risk area/onset of Zika symptoms/date of Zika diagnosis (CDC, 2019)

If BOTH partners travel:

Do not become pregnant until 3 months after return from Zika risk area/onset of Zika symptoms/date of Zika diagnosis (CDC, 2019)

As most asymptomatic, follow the above recommendations whether symptomatic during travel or

not (CDC, 2019)

ALTITUDE

We didn’t have time to discuss this today, but please do not forgot to ask about altitude for ALL ITINERARIES!

CONTACT INFORMATION

Dr. Kristian Lobban

taylorkm@dal.ca

Michael MacDonald

mdonald@dal.ca

CATMAT. Statement on Travellers' Diarrhea. Government of Canada, 1 May 2015, https://www.canada.ca/en/public-health/services/catmat/statement-travellers-diarrhea.html#a51.

CDC. “Travellers Diarrhea.” Centers for Disease Control and Prevention, CDC, 24 June 2019, https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea.

CDC. “Zika Virus”. Centers for Disease Control and Prevention, CDC, 04, June 2019, https://www.cdc.gov/zika/index.html

CDC (2018). CDC Yellow Book 2018. New York, N.Y.. Oxford University Press. Pages 48-54, 56-62, 94, 153-156, 183-187, 187-193,, 214-223, 233-252, 261-266, 278-282, 287-293, 342-349, 352-356, 557-571, 584-588, 602-606.

Diemert, David J. “Prevention and self-treatment of traveler's diarrhea.” Clinical microbiology reviews vol. 19,3 (2006): 583-94. doi:10.1128/CMR.00052-05

Government of Canada. (2019, November 15). Interim Canadian recommendations for the use of fractional dose of yellow fever vaccine during a vaccine shortage. Retrieved from https://www.canada.ca/en/public-health/services/publications/diseases-conditions/interim-

recommendations-fractional-dose-yellow-fever-vaccine-shortage.html

Government of Canada. (2019, November 20). Yellow Fever Vaccination Centres in Nova Scotia. Retrieved from: https://www.canada.ca/en/public-health/services/travel-health/yellow-fever/vaccination-centres-canada-nova-scotia.html

Mark S. Riddle, Bradley A. Connor, Nicholas J. Beeching, Herbert L. DuPont, Davidson H. Hamer, Phyllis Kozarsky, Michael Libman, Robert Steffen, David Taylor, David R. Tribble, Jordi Vila, Philipp Zanger, Charles D. Ericsson, Guidelines for the

prevention and treatment of travelers’ diarrhea: a graded expert panel report, Journal of Travel Medicine, Volume 24, Issue suppl_1, April 2017, Pages S63–S80, https://doi.org/10.1093/jtm/tax026

Robert Steffen, Francesco Castelli, Hans Dieter Nothdurft, Lars Rombo, N. Jane Zuckerman, Vaccination against Enterotoxigenic Escherichia coli, a Cause of Travelers' Diarrhea, Journal of Travel Medicine, Volume 12, Issue 2, 1 March 2005,

Pages 102–107, https://doi.org/10.2310/7060.2005.12207

Stefan H F Hagmann, John C Christenson, Philip R Fischer, on behalf of the Pediatric Interest Group, International Society of Travel Medicine, Travelers’ diarrhea in children: a blind spot in the expert panel guidelines on prevention and treatment,

Journal of Travel Medicine, Volume 25, Issue 1, 2018, tax075, https://doi.org/10.1093/jtm/tax07

William M. Stauffer, Robert J. Konop, Deepak Kamat, Traveling with Infants and Young Children. Part III: Travelers' Diarrhea, Journal of Travel Medicine, Volume 9, Issue 3, 1 May 2002, Pages 141–150, https://doi.org/10.2310/7060.2002.23197

Z.D. Jiang, H.L. DuPont, Etiology of travellers’ diarrhea, Journal of Travel Medicine, Volume 24, Issue suppl_1, April 2017, Pages S13–S16, https://doi.org/10.1093/jtm/tax003

REFERENCES