1. Getting Ready for a Travel: vaccines and Beyond
Dawd S. Siraj, MD, MPH&TM
Professor of Medicine
Director of the International Travel Clinic
Division of Infectious Diseases
University of Wisconsin-Madison

2. Objectives
Look at the overview of disease in different geographic locations that are pertinent to travelers.
Review vaccine recommendation prior to an International Trip
emphasize advices for getting ready prior to an International trip

3. 13% of US population is foreign born
In 2004
16% of adult US residents spent at least one night outside of us.
62 million trips outside of US (24% increase from 1995)
13% of US population is foreign born
46% of travels to visit families and friends
VFRs comprised around 46% of US International air travelers
Life has not been as comfortable and as easy it is today. What used to be a life time adventure now middle class individuals can circle the world in 24hrs or less.
2004 Profile of U. S. Resident Travelers Visiting Overseas Destinations Reported From: Survey of International Air Travelers, Office of travel and tourism Industries, USDOC

4. Travelers’ Health Website www.cdc.gov/travel

5. Medical problems in travelers
Among travelers to the tropics and sub-tropics,
up to 75% of short term travelers report some health impairments while traveling
5% required medical attention,
0.3% (3/1000) will require hospital admission.
% require medical evacuation and
One in 100,000 dies.
With all the enriching experiances that travel bring, there are many potentially avoidable health and health related problems that can be encountered in a new environment.
To fulfil the demand of this seg of population, travel medicine field evolved in to existance and is growing.
Travel medicine, is a new field, dealing with the well being of travellers.

7. Traveler’s diarrhea (TD)
Is an infectious diarrhea acquired while traveling.
30-70% of travelers on a 2-week trip will develop diarrhea:
40% of those will have to alter their itinerary
25% will be confined to bed
1-3% will have persistent GI problems
TD is an infectious diarrhea acquired while traveling, attributable to flaws in hygiene and sanitation infrastructure.
Steffen R, et al. JAMA. 1999;281:

9. Treatment of Traveler’s Diarrhea Algorithm
Mild, or nuisance diarrhea
Fluids (ORS), plus antimotility agents (loperamide), bismuth-subsalicylate
For hours
Antibiotic
In addition, travelers should carry an antimotility agent and an antibiotic for self-treatment of TD. Important aspect of treatment includes fluid replacement. This is more important in children who loose an extensive amount of fluid and electrolyte when they develop Td.
Dysentery or moderate
To severe illness

11. Immunizations Specific for Foreign Travel
Required
Yellow Fever
Meningococcal disease
Recommended
Hepatitis A and B
Typhoid Fever
Japanese Encephalitis
Rabies
Routine
MMR Td
Polio
Varicella
Influenza
pneumococcal
in addition to the travel related advices, Travel clinics are this is an excellent opportunity to update routine vaccines like MMR, Td. Polio, flu, pneumonia, varicella

13. Hepatitis A Vaccine Three vaccines licensed in US
Havrix, Vaqta and Twinrix
Inactivated vaccine for >1 years old
95% are immune in four weeks after one dose of the vaccine, and persists for at least 6 to 12 months.
Two doses provide long-term immunity.
As the Incubation period is 2-6 weeks, vaccine, which starts activity in about 2-3 weeks might protect even the short notice travelers.
Intramuscular immune globulin
in persons who require immediate immunity and
children too young to receive the vaccine

15. Typhoid fever vaccines
an oral, live, attenuated vaccine (Vivotif Berna vaccine) and
a total of four capsules,
one taken every other day.
The capsules should be kept refrigerated (not frozen),
This regimen should be completed 1 week before potential exposure.
not be administered to children <6 years of age
A Vi capsular polysaccharide vaccine (ViCPS) (Typhim Vi- Aventis Pasteur) for intramuscular use.
not recommend the vaccine for infants <2 years of age
One dose gives protection for 3 years. .

17. Immunogenicity data reveals that the first three doses of the accelerated Twinrix schedule provide equivalent protection to the first two doses in the standard Twinrix schedule. The first three doses of the accelerated Twinrix schedule provide equivalent protection to the first dose in the standard monovalent hepatitis A vaccine series and the first two doses in the standard monovalent hepatitis B vaccine series

18. Insect Related Diseases
Flies
Common Fly
gastrointestinal disease
trachoma
Myiasis
Sand Fly
leshmaniasis
Tsetse Fly
sleeping sickness
Mosquitoes
malaria
Yellow Fever
Dengue
Rift Valley Fever
Japanese Encephalitis
West Nile & others
Ticks
rickettsioses
Reduvid Bugs
Chaga’s Disease

19. Malaria 4 species of malaria
P.falciparum (36-38%)
P.vivax (50-52%)
P.ovale (3-5%)
P.malariae (2-4%)
More than 30,000 travelers from industrialized countries acquire malaria annually.
P. knowlesi- monkey malaria causing human diseases in Indonesia.
Approximately 90 percent of P. falciparum infections are acquired in sub-Saharan Africa, and 90 percent of travelers who are infected begin to have symptoms within one month after their return. In contrast, more than 70 percent of cases of malaria due to P. vivax infection are acquired in Asia or Latin America, and only 50 percent of travelers infected with P. vivax begin to have symptoms within one month after their return; in approximately 2 percent, fever develops more than one year afterward.

20. Areas Where Malaria Is Endemic.
Figure 1. Areas Where Malaria Is Endemic. Data are from the World Health Organization and from the Centers for Disease Control and Prevention.5, 6
Freedman DO. N Engl J Med 2008;359:

21. Life cycle of Malaria parasite
In the liver, reproduce by binary fission and yield 10,000-30,000 in 8-20 days.

22. Three Different Sites of Action of Antimalarial Drugs.
F N Engl J Med 2008;359:

23. The 3% in Canada were actually relapses for which the medication is not designed to protect from.

24. All travelers to malarious areas must understand that malaria is a serious disease and personal protection is crucial. By CDC estimates, 90% of all fatalities secondary to malaria are preventable with proper prophylaxis, treatment and diagnosis.

25. Malaria in returning travelers
However, if you really ignore precautions:
Summer 2003: American troops in Liberia for 2 weeks
Of the 157 troops who spent at least one night ashore, 69 became infected
an attack rate of 44 %
By blood levels, <5% taking prophylaxis correctly

26. Malaria in returning travelers
1,402 cases of imported malaria in US in 2000
Six deaths
most taking no prophylaxis, inappropriate prophylaxis, or taking inappropriately
Falciparum malaria:
MOST COMMON CAUSE of infectious disease death in travelers
90% of F.M is imported from Africa

30. Prevention of Insect Related Diseases
DEET- repellant
>28% in concentration
Permethrine
Cloths,shoes, socks, trousers,
Mosquito netting- Insecticide treated ones
Also protects against other insect born illnesses like
Yellow Fever Vaccine
Japanese encephalitis
Dengue
leishmaniasis
(Doxycycline will also prevent tick borne diseases)

32. Yellow fever vaccine rash, urticaria, or asthma
Doses
Volume
Comments
Primary: 1
0.5 mL
Booster
1 dose every 10 years
Immediate hypersensitivity
rash, urticaria, or asthma
incidence <1 case per 131,000 vaccinees
occur principally in persons with histories of egg allergy
Serious Adverse events
Associated neurotropic disease (AND)- 3-5/million
Associated viscerotropic disease (AVD)- 2-3/million
Live attenuated
vaccine

35. Japanese encephalitis
Incubation period days
Fever, headache, myalgia, GI disturbance, seizure, ataxia and coma
1/250 (1/25 in adults) become symptomatic
If symptomatic
30-40% case fatality
50% will have neurodeficit
Prevention
Insect repellants
vaccine

36. IXIARO (cell-derived inactivated vaccine)
Approved in January 2009 in USA for 2months or older
Immunogenic after two doses given 4 weeks apart (0.5 cc IM doses)
Neutralizing immunity lasting 12 months in 83% of vaccine recipients
Pregnancy category B

38. Dengue fever Incubation period- 4-7 days (3-14)
Fever, headache, myalgia, rash, GI symptoms
DHF- fever plus
Spontaneous bleeding (petechiae/ mucosal)
Capillary leak/hemoconcentration, Hct >44%
Prevention
DEET and Permethrine
Vaccine
>5 years away
Maculopapular rash. 98% of all DHF are second time infections. 5-20% of all second infections lead to DHF.

39. Meningococcal meningitis
Potentially fatal acute bacterial infection caused by Neisseria meningitidis
Five serotypes: A, B, C, Y, W-135.
A and C most commonly associated with epidemics in sub Saharan Africa.
Epidemics in dry season- November to June.

41. Meningococcal vaccine
Quadrivalent vaccine (A,C, Y & W-135)
Polysaccharide and conjugate vaccines.
Highly efficacious.
Conjugated vaccine
More immunogenic
Approved for ages 9 month-55 years
booster every 5 years
Menactra-9month to 2 years- give two doses 3 months apart
>2 years- one dose pre travel
Booster every 5 years for >7 years old and 3 years after for all <7 years old.

42. Rabies Central nervous system infection by RNA rhabdovirus.
Virus in the saliva of rabid animals.
Dogs remain to be the main vector in developing countries
Cats, monkey, tigers, rabbit, squirrels
Bats are the main vectors in USA
Foxes, raccoon dog in Europe, Alaska, Canada and former Soviet Union
Convulsion, coma, and encephalitis leading almost inevitably to death. In USA, <3 deaths/year. In us, 15,000-40,000 individuals receive prophylaxis annually. Is highly neurotropic and travel by retrograde axoplasmic flow from the periphery to the CNS.

43. Rabies
Mexico, Colombia, Ecuador, El Salvador, Guatemala, India, Nepal, Peru, the Philippines, Sri Lanka, Thiland, and Viet Nam are highly endemic. In India alone 40,000-50,000 persons contract rabies and die annually

44. Rabies Vaccines
Cell culture vaccines are safest and immunogenic. All are inactivated viruses
Given as three injections in days 0, 7, and 21 or 28.
PCEC (Chick Embryo culture vaccine),
HDCV ( Human Diploid Cell Vaccine) and
RVA (Rabies Vaccine Adsorbed)
PCEC- chicken embryonic fibroblasts, RVA- fetal rhesus lung cells.
Semple vaccine (derived from monkey brain) which is given in developing countries is the one with lower protection and is associated with a high rate of severe side effects including neurological problems (given by abd. Injections). HDCV has also ID version of vaccine.

45. Post Exposure prophylaxis
Proper wound care and Td vaccine
Previously immunized
Needs two more doses of the vaccine at day 0 and 3
No pre-exposure prophylaxis
4 doses of vaccine-days 0, 3, 7 and 14.
RIG at a dose of 20IU/kg
Infiltrate dose around wound as much as possible

46. Travel Emergency Kit Copy of medical records Prescription medications
Over-the counter medicines and supplies
Analgesics
Decongestant, cold medicine,
Pepto-Bismol tablets, antacid
Band-Aids, gauze bandages, tape, Ace wraps
Insect repellant, sunscreen, lip balm
Tweezers, scissors, thermometer
Travelers Evacuation Insurance

47. Post-Travel Care
Post-travel care
Fever, chills
Persistent diarrhea