1. Travel Medicine Updates Rushabh Shah Regis University PharmD Candidate Class of 2014 7/18/13

2. Outline Travelers’ Health Epidemiology Traveler Assessment Risk to the traveler Travel Disease Updates Malaria Japanese Encephalitis Typhoid Rabies Future Research Hepatitis C

3. US Residents Traveling Abroad 1.US Department of Commerce: Office of Travel and Tourism Industries tinet.ita.doc.gov/outreachpages/download_data_table/2011_US_travel_Abroad.pdf

4. Where do US Residents Travel? 1.US Department of Commerce: Office of Travel and Tourism Industries tinet.ita.doc.gov/outreachpages/download_data_table/2011_US_travel_Abroad.pdf

5. Travelers Assessment Age Specific Issues Underlying Illness, immunosuppression Systems Review Medical History Medication Use Vaccination History Allergies Contraindication to vaccines and medications Reproductive Pregnant Breast-feeding Preconception

6. Infectious Disease Risks to the Traveler Malaria Diarrhea Rabies Meningococcal Meningitis Measles Tuberculosis Typhoid Fever Polio Yellow Fever Japanese Encephalitis

7. Malaria Disease spread through Mosquito bites Most common P. falciparum and P. vivax Symptoms High Fever Shaking Chills Flu- like illness Prevention Prevent Mosquito bites Medications Malarone Chloroquine Mefloquine Primaquine Doxycycline Hydroxychloroquine (Second Line) 1. Malaria. CDC resources page Center for disease Control. http://wwwnc.cdc.gov/travel/diseases/malariahttp://wwwnc.cdc.gov/travel/diseases/malaria

8. Dosing ScheduleReasons to Consider this Medication Reasons to Avoid this Medication Cost (July 2013)- 7 Day trip Malarone (Atovaquone - proguanil) 1 Tab (250mg/100mg) DAILY Begin 1-2 Days Prior to travel Stop after 7 days of leaving such area - Last Minute Traveler - Short Trip - Well Tolerated - Pregnancy/Breastfee ding - Renal Impairment (CrCl<30 mL/min) $110.49 for quantity of 15 Chloroquine Phosphate 500 mg Once WEEKLY Begin 1-2 Weeks Prior to travel Stop after 4 Weeks of leaving such area - Long Trip- Resistance - Last minute travelers $26.66 for quantity of 7 Mefloquine250 mg Once WEEKLY Begin ≥2 Weeks Prior to travel Stop after 4 Weeks of leaving such area - Long Trip - Pregnancy - Resistance - Psychiatric Conditions - Cardiac Conduction Abnormalities - Last Minute Travelers $50.51 for quantity of 8 1. Malaria. CDC resources page Center for disease Control. http://wwwnc.cdc.gov/travel/diseases/malariahttp://wwwnc.cdc.gov/travel/diseases/malaria

9. Dosing Schedule Reasons to Consider this Medication Reasons to Avoid this Medication Cost (July 2013) Primaquine (26.3 mg primaquine phosphate=15 mg primaquine base) 30 mg (Base) 2 tablets DAILY Begin 1-2 Days Prior to travel Stop after 7 days of leaving such area - Most effective for P. vivax - Last Minute Travelers - Short Trip - G6PD Deficiency - Expensive Test - Pregnancy/ Breastfeeding - Upset Stomach $44.15 quantity of 30 Doxycycline100 mg DAILY Begin 1-2 Days Prior to travel Stop after 4 Weeks of leaving such area - Last Minute Traveler - Pregnancy - Children<8 Years Old - Increased Sun Exposure - Upset Stomach - Back-order $75.42 quantity of 30 1. Malaria. CDC resources page Center for disease Control. http://wwwnc.cdc.gov/travel/diseases/malariahttp://wwwnc.cdc.gov/travel/diseases/malaria

10. Malaria Future Research Malaria RTS,S (Mosquirix) Phase III Trial Infants 6-12 weeks, protects against P.falciparun 33% fewer episodes of clinical and severe malaria over 12 months of follow up No increase in Serious Adverse Events Long term efficacy 1. Malaria Vaccine. http://www.malariavaccine.org/about-overview.phphttp://www.malariavaccine.org/about-overview.php

11. Typhoid Fever Spread through contaminated food and water Symptoms High fever Weakness Stomach Pain Headache Loss of Appetite Vaccines Inactivated IM Injection (Typhim Vi) 1 Dose, 2 weeks prior to travel Booster dose needed every 2 years Live, Weakened, Oral Vaccine (Vivotif) 4 doses, 1 week prior to travel Booster dose needed every 5 years 1. Typhoid Fever. CDC resources page Center for disease Control. http://wwwnc.cdc.gov/travel/diseases/typhoidhttp://wwwnc.cdc.gov/travel/diseases/typhoid

12. Japanese Encephalitis Disease spread through mosquito bites Symptoms Fever Headache Vom iting Difficulty moving Prevent mosquito bites Vaccine IXIARO® *Change in Recommendation* ≥2 months to <3 years old- 0.25mL IM ≥3 Years old- 0.5mL IM 2 doses (Day 1; 28 Days after dose 1), 7 days prior to travel 1. Japanese Encephalitis. CDC resources page Center for disease Control. http://wwwnc.cdc.gov/travel/diseases/japanese-encephalitis

13. Rabies Viral disease that causes acute encephalitis in warm- blooded animals Symptoms Malaise Headache Fever Violent Movement Uncontrolled excitement Depression Vaccine Preventive Exposure 3 doses (0,7, 21 or 28) Post-Exposure, Not Vaccinated 4 doses (0,3,7,14) Post Exposure, Vaccinated 2 doses (0,3) 1. Rabies. CDC resources page Center for disease Control http://wwwnc.cdc.gov/travel/diseases/rabieshttp://wwwnc.cdc.gov/travel/diseases/rabies

14. Future Research Hepatitis C Multi- antigen DNA vaccine covering Hepatitis C virus genotypes 1a and 1b and antigen NS3/4A as well as NS4B/5A Phase I/IIA clinical study Strong NS3- specific interferon-Γ (IFN-Γ) Robust CD4 and CD8 T cell proliferation Induction of polyfunctional T cells HIV AIDSVAX/RV144 Targeted GP120 1.Hepatitis C Vaccine. http://ir.inovio.com/2013-01-09-Inovio-Pharmaceuticals-to-Initiate-Clinical- Trial-for-its-Hepatitis-C-Therapeutic-Vaccine-INO-8000-Later-this-Yearhttp://ir.inovio.com/2013-01-09-Inovio-Pharmaceuticals-to-Initiate-Clinical- Trial-for-its-Hepatitis-C-Therapeutic-Vaccine-INO-8000-Later-this-Year 2.Thai Phase III HIV Vaccine Clinical Trial. www.hivresearch.org/research.php?ServiceID=13www.hivresearch.org/research.php?ServiceID=13 3.N Engl J Med (366) 1275-1286. April 5, 2012

15. Travel Medicine Rushabh Shah Regis University PharmD Candidate Class of 2014 Acknowledgment to Dr. Christy Harmon

16. Questions?

17. Citations US Department of Commerce: Office of Travel and Tourism Industries tinet.ita.doc.gov/outreachpages/download_data_table/2011_US_travel_Abroad.pdf Accessed July 16, 2013 Malaria. CDC resources page Center for disease Control. http://wwwnc.cdc.gov/travel/diseases/malaria Accessed July 16,2013. http://wwwnc.cdc.gov/travel/diseases/malaria Japanese Encephalitis. CDC resources page Center for disease Control. http://wwwnc.cdc.gov/travel/diseases/japanese-encephalitis Accessed July 16,2013. http://wwwnc.cdc.gov/travel/diseases/japanese-encephalitis Typhoid Fever. CDC resources page Center for disease Control. http://wwwnc.cdc.gov/travel/diseases/typhoid Accessed July 16,2013. http://wwwnc.cdc.gov/travel/diseases/typhoid Rabies. CDC resources page Center for disease Control. http://wwwnc.cdc.gov/travel/diseases/rabies Accessed July 16,2013. http://wwwnc.cdc.gov/travel/diseases/rabies Malaria Vaccine. http://www.malariavaccine.org/about-overview.php Accessed July 16, 2013http://www.malariavaccine.org/about-overview.php Hepatitis C Vaccine. http://ir.inovio.com/2013-01-09-Inovio-Pharmaceuticals-to-Initiate- Clinical-Trial-for-its-Hepatitis-C-Therapeutic-Vaccine-INO-8000-Later-this-Year. Accessed July 16, 2013http://ir.inovio.com/2013-01-09-Inovio-Pharmaceuticals-to-Initiate- Clinical-Trial-for-its-Hepatitis-C-Therapeutic-Vaccine-INO-8000-Later-this-Year Thai Phase III HIV Vaccine Clinical Trial. www.hivresearch.org/research.php?ServiceID=13www.hivresearch.org/research.php?ServiceID=13 Haynes B.F., Gilbert P.B., McElrath M.J., et. al. Immune- Corraletes Analyses of an HIV-1 Vaccine Efficacy Trial. N Engl J Med (366) 1275-1286. April 5, 2012