2. December 2004Dominique Tessier, md, ccfp, fcfp HIV Case studies Brazil Videoteleconference Dominique Tessier, md, ccfp, fcfp Medical director Medisys Travel Health Clinics Post-exposure prophylaxis clinics Hôpital Saint-Luc, CHUM

3. December 2004Dominique 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

4. December 2004Dominique Tessier, md, ccfp, fcfp Anthony, 33 years old, HIV + Men having sex with men (MSM) HIV positive since 1999 CD4 at 230 Viral load at 11,237

5. December 2004Dominique 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 230 viral load at 11,237

6. December 2004Dominique Tessier, md, ccfp, fcfp Anthony, 33 years old, HIV + Vaccines? Anti-malarials? First Aid Kits? Recommendations CD4 at 230 Viral load at 11,237

7. December 2004Dominique Tessier, md, ccfp, fcfp Individualisation of recommendations requires time and knowledge of Questions to ask Anthony?

8. December 2004Dominique 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

9. December 2004Dominique 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

10. December 2004Dominique Tessier, md, ccfp, fcfp Estimated monthly incidence of health problems per 100 000 travellers to developing countries WHO 2001

11. December 2004Dominique 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

12. December 2004Dominique 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

13. December 2004Dominique Tessier, md, ccfp, fcfp Strategies to increase adherence during travel For HIV + individuals in general, what can be done to help them with adherence?

14. December 2004Dominique 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

15. December 2004Dominique Tessier, md, ccfp, fcfp A pill counter can facilitate adherence

16. December 2004Dominique 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

17. December 2004Dominique Tessier, md, ccfp, fcfp HIV Travelers and Drug Holidays Photo DT Tibet 2000

18. December 2004Dominique 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

19. December 2004Dominique Tessier, md, ccfp, fcfp

20. December 2004Dominique Tessier, md, ccfp, fcfp Vaccination is the most effective strategy for Travel Medicine practitioners

21. December 2004Dominique Tessier, md, ccfp, fcfp Vaccination is one of the greatest public health achievements in the United states during the 20 th century. Immunizations have –eradicated smallpox; –eliminated poliomyelitis in the Americas; –controlled measles, rubella, tetanus, diphtheria, haemophilus influenzae type b, and other infectious diseases » David SATCHER Assistant SECRETARY For HEALTH AND, Surgeon GENERAL U.S. Public Health Service, Department of Health and Human Services AUGUST 3, 1999

22. December 2004Dominique 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

23. December 2004Dominique Tessier, md, ccfp, fcfp Vaccination requirements Yellow fever: some countries. –Required for international travel in some countries. –Recommended in many other countries –Contra-indicated if immunosuppressed

24. December 2004Dominique 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

25. December 2004Dominique Tessier, md, ccfp, fcfp Yellov Fever endemic zone in Africa

26. December 2004Dominique Tessier, md, ccfp, fcfp Yellow Fever endemic zone in the Americas

27. December 2004Dominique 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.

28. December 2004Dominique 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

29. December 2004Dominique Tessier, md, ccfp, fcfp YELLOW FEVER VACCINE- ASSOCIATED DEATH - SPAIN 26 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.

30. December 2004Dominique 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.

31. December 2004Dominique 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.

32. December 2004Dominique 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

33. December 2004Dominique 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)

34. December 2004Dominique Tessier, md, ccfp, fcfp Vaccines to be avoided in immunocompromised  BCGno exception  MMRonly if no immunosuppression  Oral choleranot usually recommended  Varicellaimmunize close contacts  Yellow feveronly if strongly indicated and no severe immunosuppression  Oral typhoid use injectable vaccine  Polio (OPV)use injectable vaccine (IPV) avoid for close contacts

35. December 2004Dominique Tessier, md, ccfp, fcfp

36. December 2004Dominique 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

37. December 2004Dominique 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.

38. December 2004Dominique 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.

39. December 2004Dominique 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.

40. December 2004Dominique 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

41. December 2004Dominique Tessier, md, ccfp, fcfp Prescribing medications Malaria Diarrhoea Altitude sickness Motion sickness Special needs

42. December 2004Dominique Tessier, md, ccfp, fcfp Photo DT Iquitos

43. December 2004Dominique Tessier, md, ccfp, fcfp Travellers’ diarrhea

44. December 2004Dominique 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.

45. December 2004Dominique Tessier, md, ccfp, fcfp Photo DT Lhassa, Tibet 2000 Travellers’ diarrhea Usually a minor problem with a high potential of –Uncomfort –Complications in HIV+

46. December 2004Dominique 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?

47. December 2004Dominique 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

48. December 2004Dominique Tessier, md, ccfp, fcfp Travellers’ diarrhea A diet rich in fibers (psyllium) can help normalize the stools.

49. December 2004Dominique 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

50. December 2004Dominique Tessier, md, ccfp, fcfp First aid kit

51. December 2004Dominique Tessier, md, ccfp, fcfp

52. December 2004Dominique Tessier, md, ccfp, fcfp Re-used needles

53. December 2004Dominique Tessier, md, ccfp, fcfp Trauma: car accidents, sport injuries

54. December 2004Dominique Tessier, md, ccfp, fcfp Sexual counselling

55. December 2004Dominique Tessier, md, ccfp, fcfp Hiv-Infected Traveler Precautions Health information for international Travel, 1999–2000: Safety of vaccines for hiv-Infected Persons. CDC

56. December 2004Dominique Tessier, md, ccfp, fcfp Photo DT Tibet 2000