field and medicine preparation - the eagleson institute
TRANSCRIPT
Field and Travel Medicine Preparation
1
T. Warner Hudson, MD FACOEM, FAAFPMedical Director, Occupational and Employee Health
UCLA Health System and CampusJune, 2013
Real World Examples
• UC faculty drown• Faculty MI• Nicaragua research• Trans Pak injury• Monkey pox DRC research• Dive Control Board – Scientific diving• White Mountain Research Station
Sea of Cortez Baja Mexico
Preparation is Important• March 31, 2000 | From Associated Press• University of California officials flew to San Diego on Thursday to
accompany back to campus the survivors of a Sea of Cortes boating accident that killed at least four researchers. Searchers off Bahia de Los Angeles, Mexico, on Thursday morning recovered the body of the expedition's leader, world‐renowned scorpion expert Gary Polis, 53, chairman of the UC Davis environmental sciences department.
• The surviving researchers returned to Sacramento on Thursday evening after being interviewed in San Diego by U.S. Coast Guard investigators, university officials said.
• The Mexican navy and the U.S. Coast Guard continued searching for Shigeru Nakano, 37, of Kyoto University in Japan, who was missing and presumed dead.
• The researchers were part of a UC Davis‐sponsored expedition of about 20 people studying the spiders and scorpions that inhabit small islands in the Sea of Cortes, also known as the Gulf of California.
Nicaragua Research ‐ Refugio Bartola
Travel/Field Work Pre Outline
• Pre‐travel/field work preparation• During travel• Post travel issues
Antarctica‐ Cold and Rescue Issues
Travel/Field Med Elements 1• Pre‐travel/field work preparation
– Resources, insurance, vendor partners, roles and responsibilities
– Education, training, structure, oversight– Questionnaires, registration– Risk assessment, health, itinerary, and work– Medical visits
• Personal health and medications• Vaccines • Chemoprophylaxis‐malaria, TD, etc • Risk reduction advice: insect repellents, cooked food, purified water, sunscreen, jet lag, traffic, pollution, personal safety, etc.
Know your clinics
Travel/Field Med Elements 2
• During Travel– Injuries, exposures , and health events–Compliance with risk reduction advice –Medical kit use, when to call for help, ability to access medical care at destination
– Emergency medical evacuation decisions
Travel/Field Med Elements 3
• Post travel issues–Know when to check back with health care provider
–Concerns about high risk exposures during travel
–Care for onset of new travel‐related health issues
UC’s Travel ProgramRoles & Responsibilities
University of CaliforniaiJET Intelligent Risk
Systems(Technology/Security Advisory Services)
Mercer
ACE USA
Europ Assistance-USA
(Travel Assistance Services)
iJET Intelligent Risk Systems
(Security Assistance Services)
UC Occ. & Employee Health
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UCOP Overview of UC Travel Program
• Risk Management ServicesTravel Insurance TechnologyBlanket coverage for faculty, students, regents, other college participants and traveling companions.
• 24-Hour Business Travel Accident Protection
• Accident Protection for sports and other sponsored activities
• Global Medical Expense Benefits while traveling outside the U.S.
•Travel-related non-medical benefits including Lost Baggage, Personal Property, Trip Cancellation and Trip Delay Benefits.
• Dedicated UC Travel Risk Hotline
• Crisis hotline and security assistance center to secure immediate assistance while traveling
• A secure, web-based system for tracking global threats, accessing location based risk intelligence and other travel related information
• Automated security alerts for travelers
• Custom location risk assessments for international campus and study abroad locations
• Incident management team support and briefs during crisis events (Cairo, Japan, Haiti)
• On the ground security assistance in the event of a potentially life-threatening situation while traveling
• Emergency Medical Services including medical referrals, payments, emergency transportation, evacuation or repatriation
• Emergency Travel Services
• Trip Information Services
University of California White Mountain Research Station
WMRS Summit Mountain Lab14,246’
UC Service Overview
• Medical Preparation• Medical Assistance• Travel Assistance• Security Assistance• Personal Assistance• Customized Services:
• Dedicated 800# with UC specific protocols & procedures
• Custom communication tools/monthly reports• Extended service process for non-insured services• iJET website portal & travel management system
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What I’ve been doing at UCLA• Pre‐Travel medical visits
– Is the trip for work?– Where ‐ countries, cities, rural, duration– What are you doing there?– Pre‐send (e‐mail) the briefs– Bring immunization records to clinic visit– Visit – 30 minutes MD, 30 min. RN– Vaccines, meds, DEET, permethryn, etc.– Review need to register trip and update profile, 1‐800 #
– In country clinics/hospitals
Portals and Partner info
• Intro letter• Briefs – Health, trip, Immunization, security• Register trip• Update profile• Medical visit 1‐2 months before travel
Pre –Travel & Field Work
• UC Field Operation Planner Review• Pre‐medical visit questionnaire• Pre‐travel information pushes
Osorno Volcano Chile
UC Field Planning Guide
• Handout
Avian Influenza A H7N9 Virus
Avian Influenza A (H7N9) Virus
H7N9
CDC Scientist Harvests H7N9 Virus Grown for Sharing with Partner Laboratories
PPE Caring for Chinese H7N9 Patient
Shanghai Live Chicken Market April 2, 2013
Poultry Feather Removal Machine
Case Ages: H7N9 vs. H5N1 in China
MERS CoV as of June 7, 201(see MMWR June 14, 2013)
• 55 individuals; all cases linked to Saudi Arabia (40), Qatar, Jordan, UAE, • 56% mortality 31 deaths • Many clusters are healthcare associated• Patients who should be evaluated for MERS CoV infection
– A person with an acute respiratory infection, which may include fever (≥ 38°C , 100.4°F) and cough; AND
– suspicion of pulmonary parenchymal disease (e.g., pneumonia or acute respiratory distress syndrome based on clinical or radiological evidence of consolidation); AND
– history of travel from the Arabian Peninsula or neighboring countries* within 14 days; AND
– not already explained by any other infection or etiology, including all clinically indicated tests for community‐acquired pneumonia** according to local management guidelines.
• Use the SARS guidelines for airborne, contact +standard precautions http://www.cdc.gov/sars/infection/
MERS CoV Continuing
Travel/Field Medicine Issues at Home:Giant African Snails: Angiostrongylus cantonensis
Eosinphilic Meningitis
International SOS Approach
ISOS Health Assessment
ISOS Managed Preparation Process
ISOS Medical Risk Maps
ISOS Security Maps
Once the trip is booked:
• International SOS identifies the risk rating, sends
the faculty member a Pre‐Trip Email containing
medical & security information for the destination,
along with a link to a Travel Ready form.
• Traveler may also complete e‐learningmodules
relevant to the location and upload specific
medical data to be used by MDs in an emergency
• Information can be viewed via Mobile Apps
ISOS Approach: Preparation: Faculty (and students)
Pushed Kenya Alert for IPV
ISOS Preparation: Faculty ‐ Pre‐Trip Email w/ Trip Specific Details & Link to Travel Ready Form ‐ Example 1
My College
Preparation: Faculty ‐ Pre‐Trip Email ‐ Example 2
My College
Preparation: Faculty ‐ Traveler opens the Travel Ready form and completes
Questions can be customized
to meet school’s needs.
My College
Typical “Travel Ready” questions include• Faculty/Employee contact information or emergency contact details• Faculty name and phone number• Passport number and expiration date, visa details• Country of travel visa or residential permit details• Name, full address and telephone number of contacts or locations(s) to be
visited• Brief description of activities to be performed• Hotel name, address, phone number if booked outside the corporate
travel agency• Compliance questions related to university security or medical policies• Emergency contact numbers• Security measures taken prior to travel such as registration with the
embassy or transportation to/from airport.• Medical visit and vaccinations completed
Preparation: Faculty – Traveler also captures medical information & details to be used in case of medical emergency & completes relevant
e‐learning modules
Direct links to online learning and emergency record
Preparation: All information can be viewed via downloaded Membership App
Preparation: Travelers can call into an Alarm Center 24hours a day to speak to a medical or security specialist with any concerns, issues or questions
Receives notification that a traveler has booked a trip with an increased risk rating, and is out of compliance until the Travel Ready form is submitted
Dashboard compliance reporting is available to managers
Preparation: Security / Risk / Manager
Preparation: Security / Risk / Manager – Notification of Travel & Approval
My College
Decision can be made directly
through email or via handheld to approve travel
Manager can request additional information and details of the trip as well as make a decision on whether to approve the trip.
Medical Questionnaire Program
1. Destination Medical Risk
International SOS Country Rating
Client / International SOS Site Rating
2. Participant Medical Risk
Highest risk positive answer to confirms overall risk rating
Each question risk‐rated
3. Matrix drives need for further action
Dhole just polished off a cheetal
Sample Screen Shot: Destination• Medical risk rating will be defined either by country or site
Sample Screen Shot: Questions• Participant can track progress. 40 questions ~ 5 minutes
Results from 2010 Online Questionnaire Program
Program Highlights
1. 5 minute questionnaire identifies known medical issues, linked to medical risk of assignment location
2. Automated risk-rated System triggers whether follow- up is required
3. If required, contacted by nurse for further discussion
4. Outcomes:
1. Proceed
2. Recommended to physician for health exam
Program Results
68% no follow up required, 10% medical director review, 4% required exam
“Saves”: questionnaire program identifies and positively intervenes to limit or prevent a failed assignment – 1.5% of cases
Examples:1. 50y assigned to Mid-east, severe ankle fracture, about to take flight2. 58y assigned to Central America, IDDM, cancer, obese, no treatment for 2 yrs
Value of a Critical Intervention - $12,000Value of a Save - $500,000
© 2011 AEA International Holdings Pte. Ltd. For permission to reprint contact International SOS.52
Case Outcome Activity
No Follow Up required76%
No Restrictions32
Critical Interventions
28
Saves3
Follow up Required by Medical Staff
24%
Outcome
Outcome By Country Medical Risk
94108
35 39
0
17
56
0
0
12
0
20
40
60
80
100
120
140
Low medical Risk Moderate Medical Risk High Medical Risk Extreme Medical Risk
Save
Critical Int
Pass
• Travel exposure and risks are monitored at all times via hand held
device or workstation.
• Managers are immediately informed as to likely exposure to any
medical or security event.
• Communication channels are effective between traveler and
manager in times of emergency
• Managers are able to account for travelling faculty at all times
Outcomes
6 feet in front of our jeep ‐ India
Response: Global Medical Assistance Worldwide medical assistance services to manage the risks to your
expatriates and international travelers, including:
• Pre‐trip information and advice
• Hospital, doctor, dentist, specialist referrals
• Hospital and medical expense guarantee of payment
• Dispatch of doctors, specialists, medication & medical equipment
• Medical evacuations and repatriations
• Medical case management and monitoring throughout incident
• Repatriation of mortal remains
• Crisis centre support
• World class, 24 / 7 / 365 medical assistance, information and analysis
Response: Global Travel Assistance • Legal Referral
• Emergency Message Transmission
• Lost Passport, Visa advice and assistance
• Compassionate Visit or Family Travel assistance
• Emergency Personal Cash
• Return of Unaccompanied Minors
• Arrangement of Ground transportation for accompanying family members
Response: Global Security Assistance • Worldwide security assistance services to manage the risks to your
expatriates and international travelers, including:
• Access to 24‐hour security crisis centers across the world providing security assistance, information and analysis
• 200 medical, security and intelligence analysts providing real‐time updates and data
• Web / email based security information and advice. Country & city specific reports including recent risk changes
• Referrals to vetted security providers
• Incident response teams in place for crisis support
• Security evacuation and assistance
• Offering enhanced through alliance with Control Risks Group
What you expect
What you get ‐ Falklands
Growing Traveler Medical Issues• Aging travelers ‐ Vaccine safety & effectiveness, more health problems, more medications, more adventurous
• Immunocompromised – vaccines, travel meds and their meds, exacerbations of condition, travel related infections may worsen condition, exposure risk heightened
• Mental health ‐More meds, few at site resources• Disabled – More ADA travel to non ADA places• Expectations ‐For top tier responses and care• Complexity ‐Insurance vs. program responses vs. Employer vs. self responsibility
Pre‐travel Medical Visits
• Review travel plans– Registered , field planner, and read materials?– Complete detailed itinerary including excursions– Site review, housing, transport – Work ‐ what, who, animals, hazards, safety– Medical and safety what ifs preparation
• Kits, supplies, qualifications• Calls for help to medical or security service• On site, local near, local distant, remote medical resources
South India
Barbados
Pre‐travel Medical Visits cont’d• History
– conditions, surgeries, dental, allergies, glasses/contacts, fitness, current medications
• Vaccine history review ‐> vaccines scheduled• Travel medications prescribed pre , during, in case
– Sleep, anti‐diarrhea, malaria, , high altitude, BBP PEP*, routine antibiotics, anti‐nausea, antiseptics, B virus
• Other supplies– Clothing – coverage, colors, permethryn – DEET, water, sun block, nausea, first aid supplies, injections/IV, butterflies, Dermabond, sutures, condoms
• Special medical clearances – dive, maritime, Antarctica, radiation
• Other advice points – MVAs, STDs**, food/water, DVT stockings
Marine Medicine
Medicine for Mariners Marine Medical Kits
Travelers with Chronic Health Conditions
• Is the underlying medical condition in stable control?• Does medical condition present a contraindication to or
decrease the effectiveness of vaccines, malaria drugs, and management of travelers’ diarrhea?
• Do recommended travel health measures present a risk for destabilization of the underlying condition, through direct pathophysiology or drug‐drug interactions?
• Do specific health hazards at destination present a risk of exacerbation of underlying condition or cause anillness of increased severity in the IC traveler?
CDC. Health Information for International Travel 2012. Chapter 8. Jong EC, Freedman DO
Mysore market
ASMA Medical Conditions Guidelines• TABLE IV. CARDIOVASCULAR CONTRAINDICATIONS TO• COMMERCIAL AIRLINE FLIGHT.• 1. Uncomplicated myocardial infarction within 2–3 weeks• 2. Complicated myocardial infarction within 6 weeks• 3. Unstable angina• 4. Congestive heart failure, severe, decompensated• 5. Uncontrolled hypertension• 6. CABG within 10–14 days• 7. CVA within 2 weeks• 8. Uncontrolled ventricular or supraventricular tachycardia• 9. Eisenmenger syndrome• 10. Severe symptomatic valvular heart disease
Magdalena Island in Strait of Magellan off Southern Tip of Chile’s Tierra del Fuego
No significant immune compromise
• Corticosteroid therapy <20 mg per day prednisolone or equivalent
• HIV infec on with >500 CD4 lymphocytes• >3 months a er cancer chemotherapy, status in remission >2 years post bone marrow transplant, no graft‐ versus‐host disease, not being treated with immunosuppressive drugs
• Autoimmune disease not being treated with immunosuppressive drugs
CDC. Health Information for International Travel 2012. Chapter 8. Jong EC, Freedman DO
Vaccine Decisions
• Influenza ‐ seasonal, H5N1, H7N9• Typhoid – oral or shot?• Yellow Fever• Meningococcal• JEV• Rabies pre‐exposure• TBE• Cholera
Diving
Vaccines
• Routine – Td/TdaP, IPV, MMR, varicella, Influenza, hepatitis A and B, zoster, HPV
• Special –Typhoid, Yellow Fever, JEV, rabies, TBE, cholera
• TB testing –before and after
Conveniently labeled tree
Travel ImmunizationsRoutine or StandardChildhood immunizations
Age‐appropriate vaccine boosters regardless of travel Required for Travel Yellow Fever Meningococcal A,C,Y,W‐135 required for Saudi Arabia
during the Hajj No requirements for Cholera or Smallpox Recommended for Travel Based on geographic itinerary & risk of exposure Activities planned during travel Individual traveler’s underlying health
Yellow Fever Vaccine• Yellow fever (YF)
– Transmitted by Aedes aegypti & related mosquito species in jungles and urban areas
– Equatorial Africa and South American countries• Certificate of YF Vaccination
– Administered at yellow fever vaccination centers – careful completing...international date format, etc.
– Required for entry into many endemic‐zone countries– Vaccination may be required by selected countries outside the endemic zone for travelers arriving from an endemic‐zone country—even if only in transit
– Certificate valid from 10 days to 10 years after vaccination– Vaccination waiver must be obtained before departure– WHO SAGE group recommends end to YF boosters 5/17/13*
YF Africa
Rock Python ‐ Nargahole
YF South America
Yellow fever (map 236). Territory size shows the proportion of worldwide cases of yellow fever found there, 1995–2004. Data source: World Health Organization, 2004. Human Resources for
Health.
YF Vaccine and Health conditions• YF‐VAX (Yellow Fever Vaccine)‐ live attenuated virus vaccine, administered by SQ injection
• Adults and children >9 months to 60 or 65 years• Few, generally mild side effects, such as mild headache, myalgia, or low‐grade fever
• May use in Pregnancy if risk of natural infec on outweighs theoretical risks of the vaccine
• May use during Corticosteroid treatment if daily treatment dose is 20 mg or less
• May use in persons with HIV infec on if CD4 cell count is >200
YF Vaccine Adverse Events• Yellow fever vaccine (YFV)
– contains live a enuated 17D strain YF virus – 2‐5% vaccine recipients: fever, headache, muscle aches 5‐14 days post vaccination
– <1/1 million doses: immediate hypersensitivity reaction due to egg allergy
• Yellow fever vaccine‐associated neurotropic disease (YEL‐AND) – Young age < 6 months considered a significant risk factor– May occur 7‐21 days post vaccination– Neurologic signs, CSF pleocytosis, increased CSF protein– Estimated rate 1/8 million doses
Yellow fever vaccine‐associated viscerotropic disease (YEL‐ AVD)
• 13 cases reported / >100 million doses (1996‐2002) = VERY RARE• Incidence rate inaccurate because of incomplete surveillance in some countries
where YF vaccine is used• Fever, myalgia, arthralgia, increased liver enzymes & bilirubin,
thrombocytopenia, disseminated intravascular coagulation, lymphopenia, rhabdomyolysis, hyptoension, oliguria
• AKA “febrile mul ple organ system failure”• Male: Female ra o approximately 2: 1• May occur 2‐5 days after receiving YF vaccine• All cases reported to date occurred among persons receiving their first YF
vaccine dose• Advanced age over 65 years old appear to be a risk factor• 3.5/100,000 recipients aged 65‐74 years• 9.1/100,000 recipients aged >75 years• CDC and WHO have stated that no change in vaccine practices or indications is
warranted based on these limited data
Malaria Tips• CDC ‐ Choosing Drugs to Prevent Malaria• Drug ‐ drug interactions, CIs, allergies• DEET, premethryn clothes, long sleeves/pants, netting
• Any fever 7d ‐3 months after malaria area exposure began (1 yr if took prophy) could be malaria
• Means usually traveler is back home• P falciparum can be fatal w/i 24 hrs of fever onset untreated
• Young children, pregnant women, IC and elderly at risk of severe disease
• P knowlsei (monkey malaria) rain forests SE Asia, China, Indonesia, Phillippines
RDTs and SBET
• Controversial self Dx and Rx• RDTs‐many FPs and FNs; not for ovale or malariae
• SBET ‐ Possible use with medical advisor• SBET ‐ only if no way to get to treatment if unwell + fever w/I 24 hrs onset
• RDTs Maltha PLOS ONE Jan 2013• SBET E.Peterson Medscape 2012
Malaria Map
Meningococcal Map
Meningococcal Vaccines• POLYSACCHARIDE VACCINE: Meningococcal capsular polysaccharides• MPSV4: Menomune–A/C/Y/W‐135, Meningococcal Polysaccharide Vaccine,
Groups A, C, Y, W‐135 Combined• CONJUGATE VACCINES: Meningococcal capsular polysaccharides covalently linked
to carrier proteins• C‐conjugate: Used in UK and most of Europe, Canada, Brazil, and
Australia• MCV4: Menactra, Meningococcal (Groups A, C, Y, W‐135)• Polysaccharide Diphtheria Toxoid Conjugate Vaccine
New‐ Feb 2010• MenACWY‐CRM: Menveo, Meninogococcal (Groups A, C, Y, W‐135)
Polysaccharide CRM197 Conjugate Vaccine• MMWR. March 12, 2010. Vol.59, No.9. page 273
Meningococcal Conjugate Vaccine Boosters
• Administer first dose of MCV4 or MenACWY‐ CRM at age 11 or 12 years
• ◦ Give a booster dose at 16 years of age• Administer 1 dose at age 13 through 15 years if not
previously vaccinated• ◦ A 1‐time booster dose is recommended, preferably at or
after 16 through 18 years of age• ◦ Healthy persons who receive their first routine dose of
vaccine at or after age 16 years do not need a booster• ◦ Revaccinate every 5 years as long as the person remains at
increased risk• CDC. MMWR Morb Mortal Wkly Rep. January 28, 2011. Vol.
60, No.3, pages 72‐76.
Rabies: Pre‐Exposure Immunization• Pre‐exposure rabies vaccines are administered by a series of three injections:
– 1st first dose given at any time– 2nd dose given 7 days later– 3rd dose given 21 or 28 days after the first dose
• Booster rabies vaccine recommended – every 2 years for those who continue to be at increased risk of contracting rabies to
maintain protective antibody levels. – People who work with live rabies virus in laboratory settings should be tested every 6
months to ensure that they have adequate antibody levels, and receive boosters prn.• Post‐exposure rabies vaccine ‐Number of doses required is determined by the previous
immunization status of the individual– Previously unvaccinated people receive vaccine IM at 0, 3, 7, and 14 days. For adults
the vaccine is given in the deltoid area; for children, it may be given in the anterolateral of the thigh. In addition to rabies vaccine, these people also receive rabies immune globulin (HRIG) at the same time as the first dose of the vaccine to provide rapid protection that persists until the vaccine works.
– Previously vaccinated people should receive 2 doses IM; t he first immediately, the other 3 days later. RIG is unnecessary and should not be given. An immunized person is anyone who has received a complete series of vaccine, or a person who has received a pre‐exposure or post‐exposure series of any rabies vaccine who has an adequate rabies antibody level.
HDCV = Human diploid cell vaccine (IMOVAX® Rabies, Rabies VaccineHuman Diploid Cell; Sanofi Pasteur Inc.)PCEC = Purified chick embryo cell (RabAvert®;
Chiron Corp.)
Rabies: Post‐Exposure Treatment • Immediate, vigorous washing and/or flushing of wound or point of
contact; application of ethanol, iodine; postpone suturing• Immediate administra on of rabies immune globulin (HRIG ) and/or
rabies vaccine, depending on pre‐exposure vaccination status• If possible, the full dose of HRIG should be thoroughly infiltrated in the
area around and into the wounds. Any remaining volume should be injected intramuscularly at a site distant from vaccine administration.
• HRIG should never be administered in the same syringe or in the same anatomical site as the first vaccine dose. However, subsequent doses of vaccine in the four‐dose series can be administered in the same anatomic location where the HRIG dose was administered.
• An ‐tetanus toxin, antimicrobials, and other drugs to control other infections
CDC. Use of a reduced (4‐dose) vaccine schedule for postexposure to prevent human rabies:recommendations of the ACIP. MMWR 2010; 59 (No.RR‐5902):1‐8.
Travel Vaccines in US• Hepatitis A (Havrix, Vaqta)• Combined Hepatitis A and Hepatitis B (Twinrix)• Japanese encephalitis (Ixiaro)• Meningococcal conjugate ACYW‐135 (MCV4)• (Menactra, Menveo)*• Meningococcal polysaccharide (MPSV4) (Menomune)*• Polio inactivated (Ipol) (adult booster) • Rabies (Imovax, RabAvert)• Typhoid capsular polysaccharide (Typhim Vi)• Typhoid oral, live‐attenuated (Vivotif)• Yellow fever, live‐attenuated (YF‐Vax)** May be required for entry into a
country
(Source: CDC Health Information for International Travel 2012, Table C‐1.Travel vaccine summary.)
Travel Vaccines Available Outside US
• Cholera– Dukoral (Crucell, the Netherlands)– Vaccine available in Canada– Shancol (Shantha Biotechnics, India)– mORCVAX (Vabiotech, Vietnam)
• Tick‐borne Encephalitis– FSME‐IMMUN (Baxter, Austria) Adult vaccine available in Canada– Encepur (Novartis, Germany)
• Japanese encephali s– JE‐MB inactivated (manufactured in South Korea)– SA 14‐14‐2 live attenuated (manufactured in China)– JE‐VC inactivated (manufactured in Japan)
Travel vaccines included in foreignRoutine immunization programs
• Hepatitis B• Universal WHO childhood vaccine initiative• Japanese encephali s• Childhood immunization in China, Japan, South Korea,
Thailand, (India)• Tick borne encephali s• Routine immunization schedule in Austria, Finland,
Germany, Latvia• Some countries recommend vaccine for general popula on in
endemic areas, and occupational high risk groups• Bacillus Calme e‐Guérin (BCG)• Childhood immunization against TB in many countries
TBE Map
TBE Vaccination Schecule
VACCINATION AGE VACCINATION SCHEDULES
CONVENTIONAL ACCELERATED
FSME-IMMUM3
ENCEPUR4
Primary series (3 doses)
≥1 year 0, 1–3 months, 6–15 months5
0, 14 days, 5–12 months5
0, 7, 21 days
First booster
≥1 year 3 years 3 years 12–18 months
Subsequent boosters
<50 years 5 years 5 years 5 years
≥50 years 3 years 3 years 3 years
1Modified from Rendi-Wagner P. Advances in vaccination against tick-borne encephalitis. Expert Rev Vaccines. 2008 Jul;7(5):589-96.2No TBE vaccines are licensed or available in the United States.3Different formulation and dose for children aged1–15 years.4Different formulation and dose for children aged 1–11 years.5Recommended interval for the third dose varies by country and vaccine.
JEV• JE virus is a mosquito‐borne flavivirus & an important cause
of vaccine‐preventable encephalitis in Asia & western Pacific• 20‐30% of patients die and no treatment available• 30‐50% of survivors have neurologic or psychiatric sequelae• Risk for JE is low for most travelers• Peak transmission May through October• Trip factors: destination, duration, season, & activities• Children & older adults (>50 years of age) are at highest risk of
disease
CDC. Japanese encephalitis vaccines: recommendations of the AdvisoryCommittee on Immunization Practices (ACIP). MMWR 2010; 59 (no.RR‐1).
JEV MAP
JEV Deaths Map
Vero cell culture‐derived JapaneseEncephalitis Vaccine (JE‐VC)
• JE‐VC licensed in 2009 by FDA for use in persons aged >17 years.
• JE‐VC primary series consists of 2 doses administered 28 days apart.
• Booster dose of JE‐VC is recommended if the primaryseries of JE‐VC was administered >1 year AND there is a new potential for JE virus exposure.
• A 2‐dose primary series of JE‐VC is recommended if a JE‐MB primary series was administered >1 year AND there is a new potential for JE virus exposure
CDC Recommendations for use of a booster dose of inactivated Vero cell culture derived Japanese encephalitis vaccine—Advisory Committee on Immunization
Practices, 2011. MMWR 2011; 60 (20);661‐663.
Travel Vaccines Available Outside the US• Cholera• Dukoral (Crucell, the Netherlands) Vaccine available in
Canada• Shancol (Shantha Biotechnics, India)• mORCVAX (Vabiotech, Vietnam)• Tick‐borne Encephalitis• FSME‐IMMUN (Baxter, Austria) Adult vaccine available
in Canada• Encepur (Novartis, Germany)• Japanese encephali s• JE‐MB inactivated (manufactured in South Korea)• SA 14‐14‐2 live attenuated (manufactured in China)• JE‐VC inactivated (manufactured in Japan)
General Approach to Immunocompromised Travelers
• Vaccinate if possible• Select malaria chemoprophylaxis• Drug/drug interac ons• Drug dosage adjustments to treatment regimens • Empiric self‐treatment regimens for travelers’ diarrhea &
common travel‐associated ailments • Educate on risk reduction behaviors• Iden fy medical resources at des na on(s)
Adapted from: Ericsson CD, Travelers with pre‐existing medical conditions. Int J of Antimicrobial Agents 2003: 21:181‐188.
Map of countries with HIV restrictions http://www.hivtravel.org/Default.aspx?pageId=142
Medications
• Anti‐diarrhea – Cipro• Malarial prophy and treatment• Anti ‐nausea• High altitude• Antibiotics – URI, wounds, UTI, STDs, flu• BBP PEP• Rabies post exposure?• B virus post exposure
Worldwide HIV Prevalence
AIDS in Africa Maps
Worldwide TB Incidence
Surprises at night – Mala Mala
Medical Events
• Call to service• Who decides?
– Connecting with patient’s specialists
• Treat on site• Transport to higher level in country• Medical evacuation
– To near country higher capability– Transport home – when, how, who
Medical Kits• Training – qualified and trained• Cell phone• Remote locator devices• Kits – specific to needs• Special kits – marine, Gamow bag, etc.• Sutures, needles• Prescription meds• Non ‐ prescription meds• Use – when to call help, when to go locally• Understand some use like BBP PEP = evacuation
Remote Locator Devices
• Personal Locator Beacon (PLB)• Emergency Position Indicating Radio Beacons (EPIRBs)
• SPOT Satellite Messanger
Personal Locator Beacons
•Personal Locator Beacon (PLB)
•Emergency Position Indicating Radio Beacons (EPIRBs)
•SPOT Satellite Messenger
http://www.adventuremedicalkits.com/custom‐medical‐kits.php
Adventure Medical
Field Suture and Syringe Kits
Medex High Altitude Handbook
Post ‐ travel Medical Visits• STDs• TB• Diarrhea• Febrile illnesses• Malaria• Skin illnesses• Dengue, chicangunya• Parasites• When to see ID
Resources
• ITSM http://www.istm.org/• CDC Yellow book
http://wwwnc.cdc.gov/travel/page/yellowbook‐2012‐home.htm
• International SOS http://www.internationalsos.com/en/• Shoreland Travax
https://www.travax.com/scripts/Login/Login.asp?ReturnUrl=%2f
• High Altitude Handbook http://www.altitude.org/altitude_handbook.php
• National Travel Health Network and Centre http://www.nathnac.org/pro/index.htm
ISTM Journal
Q & A and discussion