21. Travelers Flashcards by Yerin M

Travel vacations should be documented on the International Certificate of Vaccination or Prophylaxis (ICVP) card, sometimes called the ___

Yellow Card

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T/F: Medications and medical supplies should be packed in check in luggage

False - carry on luggage

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CDC’s Health Information for International Travel on the CDC website is also known as the ____

Yellow Book

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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)

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T/F: more than 80% of Traveler’s diarrhea cases are viral

False - bacterial

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What is the primary pathogens for traveler’s diarrhea?

E.coli
others: Campylobacter jejuni, Shigella species, and Salmonella species

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Define persistent traveler’s diarrhea

≥ 14 days

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Prophylaxis for traveler’s diarrhea

Bismuth subsalicylate (BSS) - pepto bismol
reduces incidence by 50%

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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

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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

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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

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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

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What is the max dose of loperamide per day

Max dose 16mg/day by Rx or 8mg/day by OTC
Up to 2 days

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MOA loperamide

Decreases urgency and frequency of bowel movements - helps people to continue travel activities

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Patient has diarrhea and has been taking loperamide. At what point should they consult a provider?

If symptoms remain after 48hrs

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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

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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

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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)

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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

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Which abx is preferred for severe traveler’s diarrhea and dysentery?

Azithromcyin

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Which abx cannot be used to treat infections in which invasive pathogens such as Campylobacter jejuni and Salmonella are suspected?

Rifaximin and rifamycin

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Typhoid fever is caused by ____

Salmonella typhi

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__ 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

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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

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