What’s New in Travel
Medicine?
Gregory Juckett, MD, MPH
Professor of Family Medicine
Director, WVU International Travel Clinic
West Virginia University
gjuckett@hsc.wvu.edu
Resources/Recommendations
• New Travel Programs and Web Support
• New CDC Yellow Book 2010 Edition
• Special Case Travelers: VFR
• New Approaches to Traveler’s Diarrhea
• New Recommendations for Malaria
Prevention
• New Travel Vaccines: Tdap, Menactra
(meningitis), Ixiaro (Japanese
encephalitis), H1N1 (“Swine” flu)
Free Web Travel Information Sources
Full Listing CDC Yellow Book Appendix B
• www.cdc.gov/travel
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CDC Travel Info (best)
www.tripprep.com Shoreland’s Travel Health Online
www.mdtravelhealth.com/ MD Travel Health
www.who.int/ith/en World Health Organization Int’l Travel
www.astmh.org American Society of Trop. Medicine
www.travel.state.gov U.S. State Dept. (202-647-5222)
www.iamat.org Int. Assoc. Med. Assist. To Travelers
www.promedmail.org Pro-MED program for monitoring emerging disease
www.healthmap.org/en Health Map --Global Disease Alert
www.medletter.com Medical Letter (Travel Health
Summary)
www.fallingrain.com Altitude Finder
www.odci.gov/cia/publications/pubs.html CIA (select
World Fact Book)
Travel Subscription Services e.g. Shoreland TRAVAX Encompass, CultureGrams,
SOS Travel Care, and Gideon are even more useful but entail an annual fee
CDC Health Information for
International Travel 2010
www.cdc.gov/travel/index.htm
U.S. Government Printing Office
New, Improved! Now has
popular destinationspecific recommendations.
“The Yellow Book”
New CDC Yellow Book Features
• Pre-Travel Consultation: risk assessment,
risk communication, risk management
• Post-Travel Consultation
• Select Destinations /Travel Itineraries
• Infectious Diseases Related to Travel
• Yellow Fever /Malaria Tables
• Special Traveler Populations: Children,
Special Needs, Immigrants/Refugees
• Appendices:
– A. Practice of Travel medicine
– B. Electronic Resources
– C. Travel Vaccine Summary Table
Contacting the CDC
• CDC-INFO Contact Center 800-CDC-INFO or
cdcinfo@cdc.gov
• CDC Malaria Hotline 770-488-7788 or 770488-7100 (after hours)
• Travel Notices: cdc.gov/travel/notices
(public health focus)
• CDC Malaria Risk Map
www.cdc.gov/malaria/features/risk_map.htm
CDC Malaria Interactive Map
www.cdc.gov/malaria/features/risk_map.htm
Search Feature: Country and City
Computer Travel Information Services
(all entail an annual fee)
• SOS Travel Care www.internationalsos.com
• Shoreland TRAVAX www.shoreland.com and
Shoreland TRAVAX Encompass (online)
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www.travax.com
Exodus Software www.exodus.ie
Tropimed www.tropimed.com
Travel Medicine Advisor (online) www.ahcmedia.com
or orders@ahcmedia.com
Other Subscription Sites ( fee)
• Gideon (for diagnosing the ill returning
traveler) www.gideononline.com
• CultureGrams (concise 4 page cultural
summary by country)
www.culturegrams.com
• VaxisEHR from Travis Medical (electronic
health record) www.vaxisehr.com/travel
Watch Out For “VFR” Travelers
• VFR = Visiting Friends and Relatives
• VFRs often spent childhood at destination so more comfortable
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with perceived risk (unfortunately, often a false sense of
security)
Partial immunity to malaria and travelers diarrhea is quickly lost
with residence in a developed country
VFRs as likely to get sick as a non-native—illness perhaps even
more likely due to absence of precautions
VFR Travelers are unlikely to seek travel consultation, take
malaria meds or use as much care with food selection
Much of the imported malaria in the U.S. is due to visits back
home (may fail to take prophylaxis especially since malaria may
have been less of an issue in their childhood).
Traveler’s Diarrhea
3+ unformed stools in 24 h with at least one
of the following : fever, N/V, cramps,
tenesmus, or bloody stools (dysentery)
Occurs in up to 55% of travelers from a
developed country visiting a less-developed
country, usually within the first two weeks
Traveler’s Diarrhea “Poo-Pak”
• Loperamide hydrochloride (Imodium A/D) 2 mg
Adults: one after each loose stool (max: 8 mg/d) for symptom relief but
avoid with dysentery! You do not wish to slow the bowel with an invasive
organism. Stop in 48h if ineffective. Reserve for older children (>6y)
ADD ANTIBIOTIC (IF ILL) FOR UP TO THREE DAYS:
1. Ciprofloxacin (Cipro) 500mg one q 12h x 1-3d prn
(other quinolones work as well) or
2. Azithromycin (Zithromax Tri-Pak) 500mg one q d x
1-3d (best for children/pregnancy; quinolone-resistant
areas like SE Asia and India; alternative to Cipro) or
3. Rifaximin (Xifaxan) 200 mg 3x/d for 3 days
Rifaximin not helpful for invasive organisms
Only diarrhea with illness needs to be treated with antibiotics!
Azithromycin Off Label Alternative
• Zithromax 500 mg qd x 1-3 days for
adults (or 1000 mg x 1 dose)
• Zithromax 250 mg qd x 1-3d for older
children
• Zithromax 100 mg or 200mg/5ml susp.
for younger children (10mg/kg/d) > 6mo.
• Best for S.E. Asia (e.g. Thailand) and India
• Appears safe in pregnancy (category
B[m]) but transmitted to breast milk
New Therapy: Rifaximin (Xifaxan)
• Broad-spectrum nonabsorbable Rifamycin-derivative
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for travelers’ diarrhea caused by non-invasive E.coli
Approved by FDA for patients 12 years of age or older
(5/25/04)—marketed Autumn 2004
Non-systemic: treats only GI tract (<.4% absorbed)
so less likely to cause drug reactions, interactions
Side effects similar to that of placebo (flatulence
11%), HA (9.7%), abdominal pain (7%) , tenesmus
(7%)
Safe, no clinically significant resistance
Rifaximin 200mg TID x 3d
Not ideal for diarrhea w/ fever or blood in stool;
discontinue if diarrhea persists > 24-48h
TD Option#2: Tinidazole (Tindamax)
• Good second-line diarrhea drug if antibiotics don’t work
• Indications: Giardiasis, Intestinal amebiasis and amebic liver
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abscess
Better than metronidazole as well tolerated and shorter course
(more expensive in U.S.)
Giardiasis: adult 2g single dose
Amebiasis: adult 2g qd x 3d
Like metronidazole, has the advantage of treating
pseudomembranous colitis caused by Clostridium difficile (often
from excessive use of antibiotics)
Available as 250 mg and 500 mg tablets
Must avoid alcohol during and 3d after use; avoid 1st TM
Potentiates oral anticoagulants, lithium, phenytoin
Side effects: GI upset, abdominal pain, metallic taste, anorexia,
constipation, dizziness, HA, transient leukopenia Rare: seizures,
peripheral neuropathy
No pooping or smoking allowed!
World Malaria Risk
Insect Bite Prevention
DEET containing insect repellant (35%)
=6h protection
N,N diethyl-m-toluamide apply to skin at dusk—not on clothes/gear
Now considered safe in children > 2months or 2nd, 3rd TM pregnancy @ 35% ; apply
to skin after sunscreen use if using both; avoid >50% DEET products
Picaridin containing insect repellent (20%) safe,
reasonable duration, not approved for children < 2
Permethrin-impregnated bed nets
Long light-colored sleeves and trousers
Window screens
Avoid or reduce activity after dusk
Mosquito coils
Unproven: B vitamins (thiamine), ultrasound, wrist
bands, Demal 200 (homeopathic prophylaxis) —these
don’t work reliably and should not be relied upon!
Global Dengue Risk
Common cause of febrile
illness in returning travelers:
Prevention is only available
strategy
Malaria Prophylaxis Menu of Options
GENERIC
TRADE
MANUFACT
URER
Chloroquine
Aralen
Sanos 300 mg base =
500 mg salt
weekly
Mefloquine
Lariam
Roche 250 mg salt
weekly
Doxycycline
Vibramycin Pfizer 100 mg
daily
Atovaquone
Proguanil
Malarone
daily
Primaquine
(use only if
others
unacceptable)
G6PD
testing
necessary
DOSE
Glaxo 250mg /100 mg
30 mg base qd;
=52.6 mg salt
FREQUENCY
2-15 mg
tabs
daily
TRAVAX
Costa Rica Old vs. New Malaria Maps
India TRAVAX Map: risk stratification
Atovaquone/Proguanil
(Malarone) Malaria Prophylaxis
• Newest anti-malarial drug for prophylaxis
• Adult (250/100) and Pediatric (62.5/25) doses
• Well-Tolerated (take w/ food)
• Expensive
• Best for short trips (1-4 weeks) into malarious
regions
• Best options for patients w/ seizure disorders
• Daily prophylaxis dosing with 1 week “tail”
Chloroquine (Aralen):
Central America, Haiti
• 500 mg (300 mg base) once weekly starting one week prior to
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departure and continuing x 4 weeks after return
Reliable only in Central America, Hispaniola (Haiti), Mid-East —
elsewhere varying degrees of resistance
Side effects: GI upset, itching (esp. blacks), psoriasis
exacerbation, intradermal HDCRV interference, safe for retina
at prophylactic doses (avoid if diseased)
Safe in pregnancy; avoid with seizures, retinopathy
Pediatric dosing based on 5mg/kg base weekly (6.3mg/kg salt)
Dangerous to children in overdose; Nivaquine syrup 6mg/ml
available outside U.S.
Resistance mostly in P. falciparum—but also P. vivax in
Indonesia/PNG and increasing worldwide
Mefloquine (Lariam):
best long-term option
• CDC’s recommendation for most areas with CRPF; resistance in
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SE Asia—esp. Thai border-- areas (rare resistance elsewhere)
Dose: 250 mg weekly starting one week prior to travel, weekly
in area of risk and weekly x 4 weeks afterwards (half-life 21d)
# = wks+5; convenient for long trips
Cost: $10/tab
Side effects: vivid dreams, insomnia, GI upset (take with
water), dizziness, seizures, panic, hallucinations, cardiac
conduction problems
Contraindications: avoid in seizure disorders, past history of
psychosis or depression, cardiac conduction defects (avoid use
w/ quinine, quinidine, halofantrine)—beta-blockers and calcium
channel blockers now ok; avoid in pilots unless tolerance
already “proven”
Relative Contraindications: 1st trimester pregnancy (ok 2nd, 3rd
TM w/consent), airline pilots or tasks involving fine motor
coordination, infants (<5 kg?)
Many refuse it out of fear of neuropsychiatric reactions!
Mefloquine Resistance in SE Asia
In “red”
areas, use
doxycycline
or Malarone
—not
mefloquine
Doxycycline:
cheapest but least convenient option
• Dose: 100mg daily starting 1-2 d prior to travel, daily
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during risk period and daily for 4 weeks (28d) after
Best cheap alternative to mefloquine for resistant
malaria; Best for SE Asian areas of mefloquineresistance
Side effects: photosensitivity (3%), esophagitis (take
w/ water and keep upright), monilia, BCP interaction
Contraindications: pregnancy, children < 8 yrs, allergy
Interaction: antagonized by Dilantin and seizure meds
Mechanism: ribosomal inhibition (pre- and erythrocytic
phases) Safe for long-term chemoprophylaxis
No resistance reported but compliance poorer due to
long post-trip regimen and side effects
Malaria Self Treatment Options
• If > 24h from medical care with fever 38+C, consider
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stand-by self-administered anti-malarial Rx (different
from what is already being used as chemoprophylaxis)
Must continue prophylactic regimen (if any) and get
medical care ASAP
Malarone 250/100 (atovaquone/proguanil) usual best
choice!: 4 tabs daily with food for 3 days (#12) $6070
Coartem (artemether/lumefantrine) 4 tabs @dx, then
4@8h then 4 BID x 2d (#24) Novartis sells for $69
Chloroquine phosphate 600 mg base , 300 mg 6h
later, 300 mg q d for next 2d (Central America, Haiti)
• Fansidar (pyrimethamine-sulfadoxine) 3 tabs no longer reliable due to resistance
• Lariam (mefloquine) 250 mg 3 tabs followed 12h later by 2 tabs or 1250 mg in 24H
–frequent neuropsychiatric problems at treatment dose
Coartem Self-Treatment of Malaria
Now licensed in U.S. (2009) and commonly used for self-treatment in Africa
• Artemether 20 mg and Lumefantrine 120 mg
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(Novartis)
Riamet (marketed in Europe) = Coartem
Three Day Rx: 4 tabs @dx, then @8h then BIDx2d
(dose for resistant areas, non-immune patient)
>95% cure rates, no increased QT problems
Can be used in small children (5-10 kg)
Well-tolerated; good “standby” Rx for traveler
Malaria Prevention Summary
• No regimen guarantees 100% protection
against malaria so avoid mosquito bites
• Malaria ABCs A: Be aware of malaria risk;
B: Avoid being bitten; C: Take
chemoprophylaxis; D: Seek diagnosis
/treatment if fever develops 1 week or more
after entering risk area and up to 3m
(falciparum) or 1 year (other species) after
departure.
• Mefloquine: best for long trips and pregnancy;
neuropsychiatric issues hinder its use
• Malarone: best option for short-term travel; $
TRAVEL VACCINATION
• Safe, effective way to reduce morbidity
from travel diseases
• Three vaccine categories:
recommended, required and routine
• Contact with unvaccinated population =
loss of “herd” immunity and increased
disease risk
• Procrastination a major problem: ideally
see patients >1 month before travel
• Often not covered by insurance
Live Vaccines
Avoid in immunocompromised patients and in
pregnancy
Give together or 4 weeks apart
LIVE VACCINE LIST
• Measles-Mumps-Rubella (MMR)
• Flu-Mist (and new H1N1 live vaccine)
• Oral Typhoid (Vivotif Berna)
• Varicella (Varivax)
• Yellow Fever
Hepatitis A Vaccine
• Two main options equivalent and interchangeable
• Havrix, Vaqta : adult (>19) and pediatric (18 and
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under) doses
Available in U.S. since 1995 – essential recommended
vaccine for most travelers to developing countries!!!
Single dose HAV given IM deltoid 4wks prior gives 98100% protection (give up till departure if necessary)
Booster dose 6 -12 m later for long-term immunity
Approved for children over 1 year of age (IG public
health option for younger children in daycare)
• Now recommended for all U.S. children > 1 year 5/06
• Pediatric Doses: 2-18 y 720 EL.U. IM, >18y 1440
EL.U. IM
Hepatitis B Vaccine
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Recombinant Hepatitis B surface antigen
Recombivax, Engerix-B, Comvax (Hep B/HIB) in pediatrics
Dose: 0, 1, 6 months 0.5 ml IM deltoid 10+yr
Accelerated Engerix-B regimens: 0, 1, 2 m w/ 12m booster or
0, 7, 21 days w/12 m booster (65% seroprotection on day 28
increasing to 99% month 13)
Pregnancy precaution but safe– noninfectious HBsAg
Indicated for long-term (6+m) or frequent travel or any
anticipated sexual or body fluid exposure
Highest risk: China, Sub-Saharan Africa
Now a standard pediatric vaccination in much of the world
Assume students will be sexually-active overseas!!
Patpong District,
Bangkok
Hepatitis A+B Vaccine Combination
• Twinrix Hepatitis A/B Vaccine (SKB)
• 3 doses: 0, 1, 6 months or 0, 1, 2 w/ 12 m
booster
• 1 cc IM deltoid adult dose
• For adults >18 years old
• Vaccine Formulation: adult
Hepatitis A antigen 720 EI. U. (ped dose)
HBsAg
20mcg
Dose volume
1 ml
Accelerated off label option: 0, 7, 21 d (83 %
HBAb 1m) w/ booster in 12 m
93% Hepatitis A antibody present after 1st
dose
Influenza “Seasonal Flu” Vaccine
• Flu occurs year round rather than seasonally in the
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tropics and seasons reversed in southern hemisphere
(some exceptions)
Consider vaccination for elderly, ill and diabetic
travelers (inactivated so cannot cause flu!)
Adult: 0.5 ml IM deltoid x 1 (give 1 month before flu
season)
Pediatric: 6m-8y 2 doses 1m apart for 1st
immunization then one dose/y (dose: .25 ml 6-35m,
.5ml > 3y)
Avoid in egg allergy, active neurological disorder
Nasal live (cold-adapted) flu vaccine (FluMist)
approved for healthy patients 5-49 yrs old
H1N1 “Swine Flu” Vaccine
• Still a concern for travelers; vaccine is expiring
• 4 manufacturers: 3 killed and 1 live vaccine
options (no adjuvant in this year’s vaccine)
• May be given at same time as seasonal flu
• One dose for adults and children >10years
• Children <10 y need 2 doses (21-28d apart)
• Recommended for 5 target groups first:
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pregnant women, caregivers/contacts for children < 6
months, health care workers, everyone 6 m-24y old,
25-64 y with health problems (do not give if < 6m)
Multi-dose vials contain thimerosol (not in single dose)
Japanese Encephalitis
• Virus transmitted in Asia by Culex night-
feeding mosquitoes
• 10-15, 000 deaths/yr out of > 50,000 reported
cases. Most cases sub-clinical but up to 30%
fatality rate in those with clinical encephalitis.
• Encephalitis survivors often have permanent
neurologic sequelae
• However much less common in American
travelers so vaccination recommended for
expatriates and longer-term (>1m) travelers.
Arboviruses of the World
ARBO= Arthropod borne
TBE
JE
YF
YF
Tick-Borne Encephalitis (Red)
Japanese Encephalitis (Blue)
Yellow Fever (Yellow))
Japanese Encephalitis Map
Seasonal Risk of Japanese Encephalitis
Sanofi will cease manufacture of JE-Vax Summer 2005—supplies
to run out 2009. New JE Vaccine is Ixiaro (Intercell)
Japanese Encephalitis Vaccine (Obsolete)
JE-Vax (Biken)
• Consider for 1+ m travel in rural Asia (esp. May-September)
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Risk up to 1:5,000 per month of travel
Rare in U.S. tourists but high morbidity (50%)/mortality
(30%); Recommended for long term stays
Three 1.0 ml SC doses: 0,7, 30d (0, 7, 14 d short course);
formalin-inactivated mouse brain vaccine—last dose must be
10+ days before departure (delayed reactions incl. anaphylaxis)
1ml > 3y, 0.5ml < 3y, avoid under 1 year of age
Risk of delayed urticaria (.6%), anaphalaxis, angioedema—
observe for 30 min (10d access to care); Expensive
Contraindications: urticaria hx, pregnancy, < 1yr
May give booster dose after 2 years if risk indicates
Manufacture ceased 2005 (supplies to run out this year) but
only JE vaccine approved for children (1-17)
New Japanese Encephalitis
Vaccine: Ixiaro
(made by InterCell/marketed by Novartis)
• Vero-cell culture inactivated vaccine to replace JE•
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Vax (approved March 2009) better tolerability
Adults 17+ years old (pregnancy category B); still
must use JE-Vax for children
96% seroconversion by 4 weeks (99% Ab later)
Duration and need for boosters still unknown
2 dose 0.5 ml IM deltoid series given 28 days apart
HA, injection site pain and myalgias but apparently
less risk of delayed urticaria
$195 x 2 = $390 cost; No 10d wait period to travel
No thimerosol but contains protamine sulfate
Meningococcal Quadrivalent Vaccines
• Menomune quadrivalent A, C, Y, W-135 polysaccharide vaccine
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(MPVS4) —0.5 ml SC deltoid (polysaccharide vaccines have
shorter duration of protection); approved for ages >2 years
(best option for > 55yrs); boost q3-5yrs
Menactra quadrivalent conjugate vaccine (MCV4, 2005)
approved for ages 2-55 y 0.5 ml IM deltoid; avoid in latex
allergy
Menveo quadrivalent conjugate vaccine (MCV4, 2010) approved
for ages 11-55y (applying for 2-11) same dose as above
Indications
– Hajj (Pilgrims to Mecca) required by Saudi Arabia
– Travel to Sub-Saharan Africa meningitis belt Dec-June dry season
(serogroup A outbreaks)
– Incoming University Students (Dorm Residents)
– Medical/mission work in developing world
• Neither vaccine protects against serogroup B
• Menactra and Menveo conjugate vaccines will give longer
immunity (10 years) than Menomune polysaccharide vaccine
Meningitis
African Meningitis
Belt
Belt
Inactivated Polio Vaccine: IPV
• Wild polio eradicated in the Western
Hemisphere but still a concern in Africa, India,
Afganistan, Pakistan, Nepal
• Current epidemic in Africa began in 2003
• IPOL Types 1, 2, 3 inactivated poliovirus 0.5 ml
• Non-immunized adults: IPV 0.5 ml IM or SC
three deltoid doses 1m apart or 0,1-2,6 m
• Immunized adults: single IPV booster as adult
(travelers to Sub-Saharan Africa, India)
• Avoid in pregnancy, avoid OPV (no longer in
U.S.) with live typhoid vaccine
Polio Outbreak
• Kano State, Nigeria
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refused polio
vaccination: none
given since 8/03
Polio has since spread
from Nigeria
throughout Africa and
then on to Yemen,
India, and Indonesia
Rabies Pre-Exposure Vaccine
• Rabies Human Diploid Cell Vaccine (HDCV) =
Imovax (now available again)
• Rabies Purified Chick Embryo Cell Vaccine (PCEC) =
RabAvert
• Pre-exposure regimen: 1 ml IM deltoid on days 0, 7,
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21 (or 28) or .1 ml (HDCV only) ID 0, 7, 21 (or 28) d
EXPENSIVE!!! ID ($250+) much less expensive than
IM ($700+) but no longer available in U.S.
Advantages: “Peace of Mind” for expats and their
children living in high risk developing countries—
children should be highest priority as they play with
animals and may not report an exposure.
50,000 cases rabies in world/y—over half U.S. rabies
due to foreign dog exposure: DON’T PET Animals!
High
Risk
High
Risk
High
Risk
Free
World Rabies Risk Map
Rabies Pre-Exposure Vaccine
• Given at 0, 7, and 21 (or 28) days
• Cost is about $700
• Booster injection or check serology q 2 yrs if
high risk for exposure
• Post-exposure treatment if vaccinated: 2 doses
at 0, 3 days to boost immune response
(no Rabies Immune Globulin needed)
• May give in pregnancy if necessary
• Indications: long-term travelers (expats) and
their children, animal workers, spelunkers
• Post-Exposure Rabies Vaccine in previously
unvaccinated patients now only 4 (not 5) doses: 0, 3,
7 and 14 days (plus Rabies Immune Globulin RIG)
Typhoid Vaccine—2 options
• Vivotif Berna oral live attenuated vaccine four
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capsules 1 qod 2+w before departure (keep
refrigerated); available again; avoid w/in 24h of
antibiotics or w/ hot liquids, avoid in pregnancy;
boost every 5 yrs (for healthy adults and children >6y)
Typhim Vi capsular polysaccharide vaccine single
dose; boost q 2y; adults and children >2y
Both vaccines only provide about 70% protection
(lower sero-conversion than most other vaccines)
Older typhoid inactivated bacterial vaccine (painful)
2 injections 1m apart now discontinued in U.S.
Indications: 3+ wk travel or primitive conditions, any
travel to sub-Saharan Africa, India (highest risk),
Indonesia; can still get typhoid but milder illness
Tetanus and diphtheria (Td)
Tetanus, Diphtheria, Activated Pertussus (Tdap)
• Routine Td every 10 years – q 5 yrs with contaminated wounds
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(0.5 ml IM deltoid)
Primary course Td (>7y): 0, 1-2, 6m
Children: should have 3 doses DTP prior to travel
Diphtheria risk to travelers in Russia and the Ukraine
Pertussus (Whooping Cough) protection with Tdap
Defer in 1st trimester pregnancy overseas except if risk
warrants (commonly given in pregnancy overseas)
Tdap (Boostrix, GSK) one time booster is designed to boost
waning pertussis (whooping cough) immunity in 10-64 y/o
Tdap (Adacel, SP) one-time booster for 11-64y, protecting both
the patient and any pediatric contacts from pertussis—don’t
confuse with pediatric vaccine (6wks-7yrs) DTaP (Tripedia)
• Tdap: Avoid in latex allergy, Avoid giving w/in 2 years of Td (increased reaction)
Varicella Vaccine (live) = Varivax
• Varivax live attenuated varicella vaccine should be
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considered if no history of chicken pox (Varicella)
Check Varicella Ab if uncertain
Adult (>13y): 2 SC deltoid doses .5 ml @ 0, 4-8 weeks
Child (12m-12y): Now 2 SC deltoid doses
.5 ml @0, 4-8 weeks (new recommendation) avoid
salicylates for 6 weeks due to risk of Reyes syndrome
Avoid in active TB, neomycin allergy, immune
deficiency, pregnancy/lactation, <12m
Same PPD concerns as measles (false negative x 6w)
U.S. born 1965- 1980 usually assume most patients
will be immune (unless health care workers or
pregnant) only 2.6-2.8% gen. population susceptible
Yellow Fever Vaccine—Live
• Tropical S. America and Africa: vaccine required for
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entry into many endemic zone countries and by some
outside countries as well (consult Yellow Book)
Aedes aegypti mosquito virus > 20% mortality
Attenuated live virus vaccine– egg origin
One .5 ml dose SC, booster q 10 years
Avoid in egg allergy, pregnancy (exceptions made),
immunocompromised (splenectomy ok), thymus
disorders
Infants < 6-9 m (encephalitis /YF neurotropic disease)
use in 6-9m old only if going to area w/ outbreak
Yellow Fever Vaccine-Associated Viscerotropic
Disease (may be fatal) 65+ and thymus disorders
Yellow Fever Distribution
CDC Yellow Fever Information 404-498-1648
Vaccines in Pregnancy
Prefer to give most after 1st TM due to possible febrile
response, Risk vs. Benefit Consideration
Avoid travel
after 36 weeks
gestation
• Avoid all live vaccines (YF, MMR, FluMist, Varivax,
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BCG, Oral Typhoid) except in unusual circumstances
e.g. Yellow Fever when justified by risk of outbreak
Tetanus-diphtheria if indicated
Hepatitis A—use immune globulin instead
Hepatitis B if at risk of infection
Influenza (inactivated) if at risk during season (post
1st TM best)
Malaria: Mefloquine after
Ixiaro only if at significant risk
the first TM (even during
st TM if unable to defer
Meningitis (Menomune) if indicated 1travel)
+ Treated Bed
Polio (inactivated) if indicated
nets + DEET 35%
Rabies if indicated
Chloroquine also OK but
only if no CRPF in area
Typhoid (Typhim Vi) if indicated
REMEMBER: the largest cause of
mortality in (older) U.S. travelers is
death secondary to pre-existing
conditions e.g. MI, stroke
The #1 cause of death in younger
travelers is accidents!!!
Wow—
that
headdress
would
make a
great
souvenir
Wow!
That
head
would
make a
great
souvenir!
(Not Me)
Avoid costly cultural
misunderstandings!