1. Travel and International Vaccines Michael Martin, MD Inova Fairfax Hospital

2. CONTINUITY CLINIC The Pre-Travel Consultation Epidemiological Data Risk Assessment Advice to reduce exposure to health risks Immunization Chemoprophylaxis Advice for Self Treatment

3. CONTINUITY CLINIC The Pre-Travel Consultation -Risk Assessment- Itinerary Itinerary Reason for travel Reason for travel Duration, style and season of travel Duration, style and season of travel Medical history Medical history Immunization history Immunization history Allergies Allergies Special health needs Special health needs

4. CONTINUITY CLINIC Risk Management Must be individualized by: Must be individualized by: Specific Itinerary Specific Itinerary Class of Travel Class of Travel Acceptable risk to patient Acceptable risk to patient Outcome of disease if acquired Outcome of disease if acquired Ability of patient to pay Ability of patient to pay

5. CONTINUITY CLINIC Travel Immunization Update of routine vaccination Update of routine vaccination Required vaccines Required vaccines International Health Regulations International Health Regulations Medically recommended Medically recommended According to risk According to risk Patient tolerance of risk Patient tolerance of risk Risk may be behavior related Risk may be behavior related

6. CONTINUITY CLINIC Routine Immunizations Tetanus/diphtheria/pertussis Tetanus/diphtheria/pertussis 5 year tetanus booster in select cases (not available in location where traveling) 5 year tetanus booster in select cases (not available in location where traveling) Measles Measles 2 lifetime doses if born after 1956 2 lifetime doses if born after 1956 Polio Polio 1 adult dose for endemic countries 1 adult dose for endemic countries Pneumococcal Pneumococcal Varicella Varicella Consider for long-stay travelers Consider for long-stay travelers

7. CONTINUITY CLINIC “Any traveler who wants to reduce the risk for influenza infection should consider influenza vaccination, preferably at least 2 weeks before departure. In particular, person at high risk for complications of influenza who were not vaccinated with influenza vaccine before travel if they plan to “Any traveler who wants to reduce the risk for influenza infection should consider influenza vaccination, preferably at least 2 weeks before departure. In particular, person at high risk for complications of influenza who were not vaccinated with influenza vaccine before travel if they plan to Travel to the tropics, Travel to the tropics, Travel with organized tourist groups at any time of year, Travel with organized tourist groups at any time of year, Travel to the Southern Hemisphere during April-September.” Travel to the Southern Hemisphere during April-September.”

8. CONTINUITY CLINIC HIGH RISK COUNTRIES: Pakistan, India, Afghanistan, Nigeria (based on 2008 data) DISTRIBUTION OF POLIO

9. CONTINUITY CLINIC Medically Recommended Immunizations Hepatitis A Hepatitis A Typhoid Typhoid Hepatitis B Hepatitis B Meningococcal Meningococcal Rabies Rabies Japanese Encephalitis Japanese Encephalitis

10. CONTINUITY CLINIC Distribution of Hepatitis A

11. CONTINUITY CLINIC Hepatitis A Vaccine Killed virus, 2 brands equivalent Killed virus, 2 brands equivalent Almost 100% protection 1 month after 1 st dose Almost 100% protection 1 month after 1 st dose 90-95% after 2 weeks 90-95% after 2 weeks Use of Ig for imminent departures (<2 weeks) in compromised hosts ( or over 40 yo) Use of Ig for imminent departures (<2 weeks) in compromised hosts ( or over 40 yo) Booster: 6-18 months; long term protection Booster: 6-18 months; long term protection

12. CONTINUITY CLINIC Question When examining the vaccine records of a 3 year old child you are seeing in continuity clinic, you notice that at the age of one, she had hepatitis A administered, but no booster was given. What do you do? When examining the vaccine records of a 3 year old child you are seeing in continuity clinic, you notice that at the age of one, she had hepatitis A administered, but no booster was given. What do you do? A. Forget the whole thing, immunizations drive you crazy B. Restart the series now (meaning give an additional 2 doses) C. Do not restart, give the booster dose only

13. CONTINUITY CLINIC Answer: C, Give the Booster In the case of interrupted series, do not restart the vaccination! In the case of interrupted series, do not restart the vaccination! Late boosters: effective even at 5 years of age Late boosters: effective even at 5 years of age

14. CONTINUITY CLINIC Distribution of Hepatitis B

15. CONTINUITY CLINIC Hepatitis B Vaccine Risk: highly behavior driven Risk: highly behavior driven All stays in any highly endemic country All stays in any highly endemic country Short stays in low endemic country if sexually active, needle exposure (dental, tattooing, body piercing, acupuncture), adventure travel Short stays in low endemic country if sexually active, needle exposure (dental, tattooing, body piercing, acupuncture), adventure travel Licensed regimens: Licensed regimens: 0, 1, 6 months or 0,1,2,12 months 0, 1, 6 months or 0,1,2,12 months Brands interchangeable Brands interchangeable

16. CONTINUITY CLINIC Quick Review of Hepatitis B Approximately one third of infected persons do not have a readily identifiable risk factor Approximately one third of infected persons do not have a readily identifiable risk factor Person-to-person spread of HBV can occur in settings involving interpersonal contact over extended periods, such as when a chronically infected person resides in a household Person-to-person spread of HBV can occur in settings involving interpersonal contact over extended periods, such as when a chronically infected person resides in a household

17. CONTINUITY CLINIC Question At room temperature, how long can the Hepatitis B virus survive? At room temperature, how long can the Hepatitis B virus survive? A. 1 week B. 2 weeks C. 2 months D. 6 months E. To infinity and beyond!

18. CONTINUITY CLINIC Answer: D, 6 months Hepatitis B virus can survive when stored for 15 years at -20°C, for 24 months at -80°C, for 6 months at room temperatures, and for 7 days at 44°C Hepatitis B virus can survive when stored for 15 years at -20°C, for 24 months at -80°C, for 6 months at room temperatures, and for 7 days at 44°C

19. CONTINUITY CLINIC Distribution of Typhoid

20. CONTINUITY CLINIC Typhoid Vaccine Vaccine Live oral and killed injectable polysaccharide Live oral and killed injectable polysaccharide 70% efficacy (both vaccines) 70% efficacy (both vaccines) Duration of protection 2-7 years Duration of protection 2-7 years Vi-polysaccharide single dose Vi-polysaccharide single dose Well tolerated; 2 year protection Well tolerated; 2 year protection Vi=virulence antigen which is the capsular polysaccharide isolated from specimens in blood culture Vi=virulence antigen which is the capsular polysaccharide isolated from specimens in blood culture

21. CONTINUITY CLINIC Typhoid Vaccine (oral) Live attenuated Ty21a enteric coated Live attenuated Ty21a enteric coated No field efficacy trials in non-endemics No field efficacy trials in non-endemics Efficacy at least 70% Efficacy at least 70% 4x1 capsule at 2 day intervals 4x1 capsule at 2 day intervals Multiple difficulties: Multiple difficulties: Refrigeration, antibiotics, lost capsules Refrigeration, antibiotics, lost capsules Boosters – totally unclear Boosters – totally unclear

22. CONTINUITY CLINIC Required Vaccines Yellow Fever Yellow Fever Live virus administered at licensed centers Live virus administered at licensed centers May be required if arriving from infected areas May be required if arriving from infected areas Meningococcal Meningococcal Cholera Cholera No longer used! No longer used!

23. CONTINUITY CLINIC Distribution of Yellow Fever

24. CONTINUITY CLINIC Yellow Fever Live attentuated 17D virus Live attentuated 17D virus Egg eaters can have vaccine!!! Egg eaters can have vaccine!!! WHO licensed centers WHO licensed centers Must be given > 10 days before entry Must be given > 10 days before entry Primary: single dose Primary: single dose Booster – every 10 years Booster – every 10 years Required if arriving from transmission risk areas Required if arriving from transmission risk areas

25. CONTINUITY CLINIC Yellow what? Arboviruses (arthropod-borne viruses) are spread by mosquitoes, ticks, or sandflies and produce 4 principal clinical syndromes: Arboviruses (arthropod-borne viruses) are spread by mosquitoes, ticks, or sandflies and produce 4 principal clinical syndromes: (1) central nervous system (CNS) infection (including encephalitis, aseptic meningitis, or myelitis) (2) an undifferentiated febrile illness, often with rash (3) acute polyarthropathy (4) acute hemorrhagic fever, usually accompanied by hepatitis. Infection with some arboviruses produces congenital malformations and spontaneous abortion or, in the prenatal period, congenital perinatal illness -Western and Eastern Equine Encephalitis, St Louis Encephalitis, Powassan, California Encephalitis (primarily La Crosse virus), Colorado Tick Fever, Dengue, Japanese Encephalitis, Venezuelan Equine Encephalitis, Yellow Fever, and West Nile Encephalitis

26. CONTINUITY CLINIC Balancing Risks Yellow fever has a 50% fatality rate! Yellow fever has a 50% fatality rate! Africa 1:250 in epidemic areas, 1:4000 endemic area Africa 1:250 in epidemic areas, 1:4000 endemic area South America: 1:20,000 South America: 1:20,000 Vaccine adverse effects: Vaccine adverse effects: 18 vaccine related deaths and 37 severe cases of neurotropic or viscerotropic disease 1996-2005 18 vaccine related deaths and 37 severe cases of neurotropic or viscerotropic disease 1996-2005 Disturbing but rare events: Disturbing but rare events: Used since 1937, 50 million doses given in year 2000 Used since 1937, 50 million doses given in year 2000 Risk estimates: anaphylaxis 1 in 250,000, neurotropic disease 1 in 8 million; viscerotropic disease 1 in 400,000 based on US data (1:30,000 for age >65 years old) Risk estimates: anaphylaxis 1 in 250,000, neurotropic disease 1 in 8 million; viscerotropic disease 1 in 400,000 based on US data (1:30,000 for age >65 years old)

27. CONTINUITY CLINIC Incidence of Meningococcal Disease

28. CONTINUITY CLINIC Meningococcal Disease by Serogroup

29. CONTINUITY CLINIC Meningococcal Vaccine A,C,Y, W135 polysaccharide (MPSV4 Menomune) A,C,Y, W135 polysaccharide (MPSV4 Menomune) Primary – single dose Primary – single dose Booster: 3-5 years, less for children under 4 Booster: 3-5 years, less for children under 4 A,C,Y,W135 conjugate (MCV4; Menactra) A,C,Y,W135 conjugate (MCV4; Menactra) All adolescents from age 11 – routine All adolescents from age 11 – routine FDA approved for 2-55 years old FDA approved for 2-55 years old Booster not known, at least 10 years Booster not known, at least 10 years Preparation of choice – Guillain-barre data Preparation of choice – Guillain-barre data

30. CONTINUITY CLINIC Suggested Indications Little data in travelers; known low risk Little data in travelers; known low risk Tavelers anywhere within the classical African meningitis belt during the dry season (Dec-June) Tavelers anywhere within the classical African meningitis belt during the dry season (Dec-June) Individuals anticipating close contact with local populations and traveling to certain epidemic prone African countries south of the meningitis belt Individuals anticipating close contact with local populations and traveling to certain epidemic prone African countries south of the meningitis belt Health care workers traveling to any of the above countries Health care workers traveling to any of the above countries Traveling to any area experiencing a current epidemic Traveling to any area experiencing a current epidemic

31. CONTINUITY CLINIC Japanese B Encephalitis Mouse-brain killed virus vaccine Mouse-brain killed virus vaccine Primary – days 0,7,30 or 0,7,14 Primary – days 0,7,30 or 0,7,14 Full protection 1 month later Full protection 1 month later Boosters: 3 years but not clear Boosters: 3 years but not clear Side effects: delayed urticaria Side effects: delayed urticaria In season; long stay in rural farming areas, travel to epidemic area or hot spots, adventure travel In season; long stay in rural farming areas, travel to epidemic area or hot spots, adventure travel Risk is low to travelers, but liability is real Risk is low to travelers, but liability is real

32. CONTINUITY CLINIC So you are thinking, “Yea, great Dr. Martin, I will remember all of that 2 months from now when I see a patient who is traveling…..” DO NOT FRET……. HELP IS ON THE WAY

33. CONTINUITY CLINIC