21. Travelers Flashcards
Travel vacations should be documented on the International Certificate of Vaccination or Prophylaxis (ICVP) card, sometimes called the ___
Yellow Card
T/F: Medications and medical supplies should be packed in check in luggage
False - carry on luggage
CDC’s Health Information for International Travel on the CDC website is also known as the ____
Yellow Book
Traveler’s diarrhea is very common but if blood is mixed in with the stool, it is classified as ___
Dysentery (often with fever, considered severe)
T/F: more than 80% of Traveler’s diarrhea cases are viral
False - bacterial
What is the primary pathogens for traveler’s diarrhea?
E.coli
others: Campylobacter jejuni, Shigella species, and Salmonella species
Define persistent traveler’s diarrhea
≥ 14 days
Prophylaxis for traveler’s diarrhea
Bismuth subsalicylate (BSS) - pepto bismol
reduces incidence by 50%
Bismuth subsalicylate is often used for traveler’s diarrhea ppx. Which patients should NOT use this as ppx?
Aspirin allergy
Pregnancy
Renal insufficiency
Gout
Ulcer
Pt on anticoagulants, probenecid, methotrexate
Abx ppx for traveler’s diarrhea is typically not recommended unless at high risk (e.g immunosuppressed, significant comorbidities) or performance reasons (e.g. professional athlete). If abx ppx indicated, what is typically used?
Rifaximin (preferred)
Alt: azithromycin and rifamycin
Primary antimotility drug used for acute TD is ___
loperamide (Imodium A-D)
4mg after first loose stool and 2mg after each subsequent loose stool
Max dose 16mg/day by Rx or 8mg/day by OTC
What dose of loperamide is typically used for acute diarrhea
4mg after first loose stool and 2mg after each subsequent loose stool
Max dose 16mg/day by Rx or 8mg/day by OTC
What is the max dose of loperamide per day
Max dose 16mg/day by Rx or 8mg/day by OTC
Up to 2 days
MOA loperamide
Decreases urgency and frequency of bowel movements - helps people to continue travel activities
Patient has diarrhea and has been taking loperamide. At what point should they consult a provider?
If symptoms remain after 48hrs
Bismuth subsalicylate is FDA approved for OTC use in children ___ yo but has been used off label in younger children ___ yo as long as they had no recent or current viral infections (d/t risk of ____)
≥12yo
≥3 yo
Reye’s syndrome
Bismuth subsalicylate is another treatment option of traveler’s diarrhea. Can reduce stools based by ~40%. What are side effects/warnings?
Black tongue/stools
Risk of Reye’s syndrome in children
Salicylate toxicity
Which option is preferred for treatment of traveler’s diarrhea in both children and adults: loperamide or bismuth subsalicylate
Loperamide (greater reduction in # of diarrheal stools passed and shortened duration of acute diarrhea)
For moderate and severe traveler’s diarrhea, abx may be used. Which ones are preferred?
Moderate: Azithromycin or a quinolone (if low resistance, rifaximin alternative
Severe: azithromcyine, quinolone or rifximin alternatives
Which abx is preferred for severe traveler’s diarrhea and dysentery?
Azithromcyin
Which abx cannot be used to treat infections in which invasive pathogens such as Campylobacter jejuni and Salmonella are suspected?
Rifaximin and rifamycin
W
Typhoid fever is caused by ____
Salmonella typhi
__ are the only source Salmonella typhi and spread through ____
Humans
food or water contaminated by feces of someone with either an acute infection or from a chronic, asymptomatic carrier
S/sx of typhoid fever
Fatigue and increasing fever over 3-4 days
HA, malaise, anorexia, rash, and enlargement of the liver/spleen.
Intestinal hemorrhage or perforation can occur 2-3 weeks later and be fatal
What are some typhoid vaccine examples
Vivotif - oral, life-attenuated vaccine
Typhim Vi - inactivated IM injection
The oral typhoid vaccine (Vivotif) should be completed ___ prior to travel while the IM vaccine (Typhim Vi) must be given____ before the expected exposure
≥ 1 week
≥2 weeks
Cholera is a bacterial infection caused by ___
Vibrio cholerae
The most common symptom of cholera is ___
watery stools, referred to “rice-water stools”
Recommended vaccine for cholera
Live-attenuated vaccine (Vaxchora) - single, oral liquid dose at least 10 days before travel, approved in ages 2-64yo
What is the CDC recommendation for polio vaccination?
Single lifetime booster dose of inactivated poliovirus vaccine at least 4 weeks prior to travel for adults who have previously completed polio vaccine series and traveling to regions where poliovirus is circulating
Most people in US received polio vaccine but may need to get a booster dose if traveling to which countries?
Afghanistan, Myanmar (Burma) Guinea, Laos, Nigeria, Madagascar, Pakistan, and Ukraine
What types of travelers are at highest risk of hep A?
People from developed countries who travel to developing countries
Travel Vaccine: Inactivated Vaccine list
Hepatitis A (Havrix, VAQTA)
Hepatitis B (Engerix-B, Heplisav-B, Recombivax HB)
Hepatitis A/B (Twingrix)
Japanese encephalitis (Ixiaro)
Meningococcus (Menactra, Menveo, Menquadfi)
Polio (IPOL)
Typhoid-IM (Typhin Vi)
Travel Vaccines: Live Vaccine list
Cholera-PO (Vaxchora)
Typhoid-PO (Vivotif)
Yellow fever-SC (YF-VAX)
Note: live vaccines typically avoided in people who are immunocompromised
Hepatitis B is transmitted through ___
contact with contaminated blood or other body fluids
The 3 dose hepatitis B vaccine takes ___ to complete
6 months
Hepatitis B vaccination is extremely important for travels who plan to _____
receive medical care
Volunteer to provide medical work
Unprotected sexual encounters with new partners
Piercings/tattoos
If a traveler is unable to receive all 3 doses of hep B vaccine before departure, what is the recommendation?
Administer as many doses as possible before departure and complete series upon return
In instances of high risk, an accelerated series can be administered; when a 3 dose accelerated series is used, a booster dose is required at 1 year for long-term immunity
S/sx of meningococcal meningitis
fever, severe and unrelenting HA, nausea, stiff neck (nuchal rigidity) and mental status changes
How is dx of meningococcal meningitis made?
Lumpar puncture
How is meningitis spread
By respiratory secretions
High risk regions for meningitis
Meningitis belt of Afria during the dry season (Dec-June)
Gov of Saudi Arabia requires vaccination for travel during annual Hajj and Umrah pilgrimages
Current recommendations include only the quadrivalent vaccines for meningitis: ___
Menactra
Menveo
MenQuadfi
The quadrivalent vaccines for meningitis only cover which bacterial types?
ACWY
No recommendations to use serogroup ___ meningococcal vaccines for travelers
B
Insects that transmit disease are ___
vectors
A ___ is any place (such as an animal, insect, soil, or plant) in which the disease lives and can multiply
Reservoir
The primary insects that transmit infections to travelers are ___, which transmit diseases such as ___
Mosquitos
Japanese encephalitis, yellow fever, dengue, malaria, and Zika virus
To avoid insect bites, it is recommended to use proper application of mosquito repellents containing ____ on exposed skin.
You can also use ___ to treat clothing, gear, and bed nets but do NOT apply directly on skin
20-50% DEET (also protects against ticks)
Permethrin
____ is transmitted by Aedes aegypti and Aedes albopictus mosquitoes
Dengue
Severe dengue can include what s/sx
shock, severe bleeding, or organ failure
Treatment for dengue
Supportive, no specific meds to treat degue infections
Protection from mosquito bites is essential
___ is a live-attenuated recombinant vaccine recommended to only those wtih a past dengue infection
Dengvaxia
Japanese encephalitis is transmitted by ___
mosquitoes
___ vaccine is recommended for travelers who are planning extended exposure to the outdoors (e.g. camping) or who plan to spend at least 1 month in endemic areas during Japanese encephalitis virus transmission season
Ixiaro
Malaria is transmitted by ___
the Anopheles mosquito
Once in a human host, it multiplies first in the liver and then into RBCs, multiplying and destroying them
Classic s/sx of malaria
shaking, chills, high fever, flu-like illness
____ is the most common of 4 human malaria species
Plasmodium vivax
4 species include P. flalciparum, P. malariae, P. ovale, P. vivax
Which malaria species causes 50% of malaria cases in India and is becoming increasingly resistant to malaria drugs?
P. vivax
Which malaria species is the most deadly
P. falciparum
Malaria drugs cause nausea - what are some ways to help with that?
take with sufficient water, food, or milk
Malaria quick start ppx regimens (1-2 days prior to travel, best for when traveling with short notice)
Doxycycline (Doryx, Vibramycin) - stop 4 weeks after travel (preferred in hiking/camping)
Atovaquone/Proguanil (Malarone) - stop 1 week after travel (good coverage)
Primaquine - stop 1 week after travel (most effective again P. vivax, do NOT use in G6PD deficiency)
What are some common things among malaria ppx drugs for quick starts
Daily regimens
Avoid in pregnancy
Cause nausea, take with food, milk, water
Which malaria ppx drugs must be started 1-2 weeks prior to travel?
Chloroquine
Mefloquine
Typical malaria ppx regimen with chloroquine
Start 1-2 weeks prior to travel
Stop 5 weeks after travel
weekly dosing
Typical malaria ppx regimen with mafloquine
Start ≥2 weeks prior to travel
Stop 4 weeks after travel
Weekly dosing
Side effects for chloroquine
Retinal toxicity/visual changes - contraindicated if previous hx
Others: exacerbation of psoriasis, serious skin rash,
blue-grey skin pigmentation (rare with short-term use)
When is primaquine NOT used
G6PD deficiency (Requires screening prior to use d/t risk of hemolytic anemia)
Pregnancy/breastfeeding
When is mefloquine NOT used
Underlying psychiatric conditions
Seizures
Arrhythmias
Which malaria ppx medication requires a loading dose 3 days before travel?
Tafenoquine (Arakoda)
LD taken daily for 3 days, weekly dosing
Which malaria ppx meds cannot be used in G6PD deficiency?
Primaquine
Tafenoquine
Yellow fever is caused by ____ and transmitted by ___
Virus
mosquitoes
___ cannot be used in yellow fever d/t increased risk of bleeding
Aspirin and other NSAIDs
___ vaccine i available to prevent yellow fever and stop transmission
Live-attenuated vaccine (YF-VAX)
When patients get the yellow fever vaccine, they receive a ICVP (yellow card). At what point is that yellow card considered valid?
10 days after date of vaccination
single dose of vaccine provides life-long protection and adequate for most travelers
YF-VAX is contraindicated ____
with hypersensitivity to eggs and in people who are severely immunocompromised
T/F: Yellow fever vaccine is recommended for all travelers
False - only in travelers at high risk of exposure or who require proof of vaccination to enter a country
Zika virus is transmitted primarily by ____
the Aedes species mosquito
Sexual and possible blood transfusion-associated transmission have been reported
The most pressing concern with Zika virus arose in 2016 when Brazil observed a marked increase in the number of infants born with ____
microcephaly
T/F: There is no vaccine for Zika virus
True
What can reduce transmission risk for Zika virus?
Avoiding mosquito bites and using condoms during sexual contact with people with possible Zika virus infection
CDC recommends against pregnant women traveling to any area with ongoing transmission of Zika virus (birth defects)
What helps reduce risk of DVT/PE prevention in traveling patients?
Compression stockings
Walk around
Perform lower leg exercising when sitting
Primary ppx med for acute mountain sickness
Acetazolamide (Diamox) 125mg BID, started day before (preferred) or on the day of sscent
Higher doses are used for treatment
What are side effects of acetazolamide
Polyuria
Photosensitivity
Others: taste alteration, risk of dehydration, urticaria, and possibility of severe skin rashes
Acetazolamide is contraindicated with __ allergy
Sulfa
