Download - HIV Case studies Brazil Videoteleconference
December 2004 Dominique Tessier, md, ccfp, fcfp
HIV Case studiesBrazil
Videoteleconference
Dominique Tessier, md, ccfp, fcfp
Medical director
Medisys Travel Health Clinics
Post-exposure prophylaxis clinics
Hôpital Saint-Luc, CHUM
December 2004 Dominique Tessier, md, ccfp, fcfp
Objectives
• Identify specific risks issues for hiv positive travellers
• Recognize indications and contra-indications to immunizations for HIV positive individuals
• Identify pro and cons of drug holidays
December 2004 Dominique Tessier, md, ccfp, fcfp
Anthony, 33 years old, HIV +
Men having sex with men (MSM)HIV positive since 1999
CD4 at 230Viral load at 11,237
December 2004 Dominique Tessier, md, ccfp, fcfp
Anthony, 33 years old, HIV +Wants to do a religious retreat in the North of Brazil
for 3 months.Wants to stop all his medications to purify his body.Not sure about receiving immunizations.Comes for your advise.
CD4 at 230viral load at 11,237
December 2004 Dominique Tessier, md, ccfp, fcfp
Anthony, 33 years old, HIV +
• Vaccines?• Anti-malarials?• First Aid Kits?• Recommendations
CD4 at 230
Viral load at 11,237
December 2004 Dominique Tessier, md, ccfp, fcfp
Individualisation of recommendations requires time and knowledge of
•Questions to ask Anthony?
December 2004 Dominique Tessier, md, ccfp, fcfp
Individualisation of recommendations requires time and knowledge of
•Where, Why, When, How, How long•Type of Travel•Activities •Health status•Special needs•Experience•Fears and beliefs•Budget
December 2004 Dominique Tessier, md, ccfp, fcfp
Evaluation of the potential risks
•Medical exam•Previous Immunizations•Vector precautions•Cardiopulmonary problems•Allergies•HIV or other test required•Psychological evaluation•Age related specificities•Handicaps
December 2004 Dominique Tessier, md, ccfp, fcfp
Estimated monthly incidence of health problems per 100 000 travellers to developing countriesWHO 2001
December 2004 Dominique Tessier, md, ccfp, fcfp
Travel considerations: HIV+• Restrictions on crossing international borders,• Vaccination requirements,effectiveness and safety• Increased susceptibility to infections• Accessibility of health care • Medical evacuation
• Travel counselling regarding: • Food and water and self-treatment of travellers' diarrhea• Vector protection• Sun protection• Safety• Sexual and body fluids protection
December 2004 Dominique Tessier, md, ccfp, fcfp
Restrictions on crossing international borders
A number of countries screen for evidence of HIV infection and can deny entry to seropositive individuals.
Unofficial list of entry requirements may be obtained from: www.hwc.ca/hpb/lcdc.
Such requirements may change without notification
• Verification with consulate recommended
December 2004 Dominique Tessier, md, ccfp, fcfp
Strategies to increase adherence during travel
• For HIV + individuals in general, what can be done to help them with adherence?
December 2004 Dominique Tessier, md, ccfp, fcfp
Strategies to increase adherence during travel
• Information on risks and possible side effects• Realistic choice of medications• Contract with patient• Good counseling• Collaboration from co-traveler• Establish specific strategies for specific
situations• Consider trial with candies
December 2004 Dominique Tessier, md, ccfp, fcfp
A pill counter can facilitate adherence
December 2004 Dominique Tessier, md, ccfp, fcfp
Potential complications
• Toxicity to be monitored:– Hematologic: anemia, neutropenia,
thrombocytopenia, pancytopenia
– Hepatic: elevation of enzymes
– Neurological: neuropathies
– Renal: stones– Cardio-vascular; metabolic syndrome
• Drug Interactions– cytochrome P 450: induction or inhibition
December 2004 Dominique Tessier, md, ccfp, fcfp
HIV Travelers and Drug Holidays
Photo DT Tibet 2000
December 2004 Dominique Tessier, md, ccfp, fcfp
Susceptibility to infections
• Many infections encountered by travelers are associated with increased morbidity and mortality in HIV+ persons.
• These individuals are also more likely to have adverse reactions to drugs used to treat infection.2
December 2004 Dominique Tessier, md, ccfp, fcfp
December 2004 Dominique Tessier, md, ccfp, fcfp
Vaccination is the most effective strategy for Travel Medicine practitioners
December 2004 Dominique Tessier, md, ccfp, fcfp
Vaccination is one of the greatest public health achievements in the United states during the 20th century.
Immunizations have – eradicated smallpox; – eliminated poliomyelitis in the Americas;– controlled measles, rubella, tetanus, diphtheria,
haemophilus influenzae type b, and other infectious diseases »
David SATCHERAssistant SECRETARY For HEALTH AND, Surgeon GENERALU.S. Public Health Service, Department of Health and Human Services AUGUST 3, 1999
December 2004 Dominique Tessier, md, ccfp, fcfp
General information Regarding HIV and Travel
Health Information for International Travel
CDC’s « The Yellow book »http://www.cdc.gov/travel/hivtrav.htm
Immunizations and immunosuppression
December 2004 Dominique Tessier, md, ccfp, fcfp
Vaccination requirements
• Yellow fever: – Required for
international travel in some countries.some countries.
– Recommended in many Recommended in many other countriesother countries
– Contra-indicated if Contra-indicated if immunosuppressedimmunosuppressed
December 2004 Dominique Tessier, md, ccfp, fcfp
Yellow Fever Vaccine
• Disease’s case-fatality rate is more than 60% in non-immune adults
• Vaccine – Almost total efficacy– Excellent tolerance
• Rare contra-indications– True allergy to egg protein– Cellular immunodeficiency
December 2004 Dominique Tessier, md, ccfp, fcfp
Yellov Fever endemic zone in Africa
December 2004 Dominique Tessier, md, ccfp, fcfp
Yellow Fever endemic zone in the Americas
December 2004 Dominique Tessier, md, ccfp, fcfp
Vaccinations Requirements, Effectiveness and Safety
Severely immunocompromised travellers• should be recommended to change his-her
itinerary or • to strictly follow mosquito physical precautions
if trip unavoidable• should be aware that, in the face of an epidemic,
he or she could be denied entry in some countries if not immunized.
December 2004 Dominique Tessier, md, ccfp, fcfp
Fatal Yellow fever in traveler returning from Venezuela, 1999
• 48 yearl old male from California
• 10 day trip from September 16 to 26
• first symptoms September 28
• died on October 4
December 2004 Dominique Tessier, md, ccfp, fcfp
YELLOW FEVER VACCINE-ASSOCIATED DEATH -
SPAIN26 Oct 2004
A 26-year-old woman from Onuba died from yellow fever stemming from a post-vaccination reaction. The woman was admitted to Hospital because of fever and multi-organ failure, having had, in addition to fever, malaise, vomiting, and diarrhea during the previous days.
The patient was also vaccinated for diphtheria and tetanus.
December 2004 Dominique Tessier, md, ccfp, fcfp
Yellow Fever in Brazil - Federal District/Brasilia
• A young male farmer, age 22, died of YF in the Federal district of Brasilia. Although the population of the district has a high rate of vaccination with YF vaccine (>90%), the deceased refused vaccination on two previous occasions.
December 2004 Dominique Tessier, md, ccfp, fcfp
Reaction to Yellow Fever Vaccine Linked to Several Recent Deaths
• In 1996 and 1999, 2 U.S. and 2 European unvaccinated travelers to areas where YF is endemic died of YF viral infection (1,8).
• The risk for YF in unvaccinated travelers probably is increasing because potential YF transmission zones are expanding to include urban areas with large populations of susceptible humans and abundant competent mosquito vectors.
December 2004 Dominique Tessier, md, ccfp, fcfp
Vaccines to be generally avoided in immunocompromised
Tuberculosis (BCG) : no exception– Severe complications have been reported after
immunization with live vaccines in immuno-suppressed hosts.
MeaslesMumpsRubella: – Only if no immunosuppression
Varicella: – not recommended– Immunize close contacts
December 2004 Dominique Tessier, md, ccfp, fcfp
Vaccines to be generally avoided in immunocompromised
• Yellow fever:– only if strong indication
• Oral polio (Sabin): – use injectable vaccine (Salk)– Avoid for close contacts
• Typhoid: – use injectable vaccine (Typhim Vi), not
oral (Vivotif)
December 2004 Dominique Tessier, md, ccfp, fcfp
Vaccines to be avoided in immunocompromised
BCG no exception MMR only if no immunosuppression Oral cholera not usually recommended Varicella immunize close contacts Yellow fever only if strongly indicated
and no severe immunosuppression
Oral typhoid use injectable vaccine Polio (OPV)use injectable vaccine (IPV)
avoid for close contacts
December 2004 Dominique Tessier, md, ccfp, fcfp
December 2004 Dominique Tessier, md, ccfp, fcfp
Vaccines considered safe for immunosuppressed
• Diphtheria and Tetanus• Hepatitis A, B and A & B• Hib• Influenza• Japanese encephalitis rare indications• Meningococcal• Pertussis prefer acellular• Polio, inactivated• Pneumococcal• Rabies pre or post exposure
December 2004 Dominique Tessier, md, ccfp, fcfp
Vaccinations Requirements, Effectiveness and Safety
Some severely immunocompromised individuals may respond poorly to immunization.
Other strategies may thus be needed to protect them such as:
Passive immunization with specific immunoglobulins
Preventive medication Rapid treatment.
December 2004 Dominique Tessier, md, ccfp, fcfp
Increased morbidity and mortality. Hepatitis A.
• Up to 25% of HIV+ adult patient with hepatitis A will require hospitalization.
• Increased prevalence of fulminant hepatitis.
• Pre-existing liver disease increases the risk of fulminant hepatitis and fatality.
• Persistent infection does not occur.
December 2004 Dominique Tessier, md, ccfp, fcfp
Increased morbidity and mortality. Hepatitis A.
• All HIV+ seronegative individuals for hepatitis A or B should be offered the vaccine or, if severely immunosuppressed, immunoglobulins (Hepatitis A protection).
• Hepatitis A immunization should be a priority for patients with hepatitis B or C co-infection.
December 2004 Dominique Tessier, md, ccfp, fcfp
Rabies in the World
• Only 20 countries, mostly islands, are reported « rabies free ».
• Dog are often the vectors.• Highest incidence in asia,
with over 33,000 cases of human rabies per year, the majority, estimated 30,000, in india .
Photo DT Acapulco 1995
December 2004 Dominique Tessier, md, ccfp, fcfp
Prescribing medications
• Malaria
• Diarrhoea
• Altitude sickness
• Motion sickness
• Special needs
December 2004 Dominique Tessier, md, ccfp, fcfpPhoto DT Iquitos
December 2004 Dominique Tessier, md, ccfp, fcfp
Travellers’ diarrhea
December 2004 Dominique Tessier, md, ccfp, fcfp
Boil it, peel it, cook it or forget it: easy to remember, impossible to follow.
• The majority of travellers will make a “faux-pas” with food and water within 48 hours.
December 2004 Dominique Tessier, md, ccfp, fcfp
Photo DT Lhassa, Tibet 2000
Travellers’ diarrhea
• Usually a minor problem with a high potential of– Uncomfort– Complications in
HIV+
December 2004 Dominique Tessier, md, ccfp, fcfp
Travellers’ diarrhea
• Anthony has a chronic diarrhea when he takes his medication– How can he recognize if he gets an
infection during his trip?
December 2004 Dominique Tessier, md, ccfp, fcfp
Travellers’ diarrhea
• Anthony has a chronic diarrhea when he takes his medication– How can he recognize if he gets an
infection during his trip?• An increase in number of passages per day
(double of usual)• A change in texture
December 2004 Dominique Tessier, md, ccfp, fcfp
Travellers’ diarrhea
• A diet rich in fibers (psyllium) can help normalize the stools.
December 2004 Dominique Tessier, md, ccfp, fcfp
When there is evidence of a possible infection persisting after usual treatment, a culture and 3 search for parasites should be done.
Travellers’ diarrhea
December 2004 Dominique Tessier, md, ccfp, fcfp
First aid kit
December 2004 Dominique Tessier, md, ccfp, fcfp
December 2004 Dominique Tessier, md, ccfp, fcfp
Re-used needles
December 2004 Dominique Tessier, md, ccfp, fcfp
Trauma: car accidents, sport injuries
December 2004 Dominique Tessier, md, ccfp, fcfp
Sexual counselling
December 2004 Dominique Tessier, md, ccfp, fcfp
• Hiv-Infected Traveler Precautions
Health information for international Travel, 1999–2000:
• Safety of vaccines for hiv-Infected Persons. CDC
December 2004 Dominique Tessier, md, ccfp, fcfpPhoto DT Tibet 2000