Travelers with Additional Considerations Flashcards
what are key patient education points for immunocompromised travelers?
develop a plan in case of illness;
food & water precautions;
multidrug-resistant organisms;
medications;
sun protections;
bring a travel health/first aid kit
what are Health conditions & treatments that do not require specialized immunization precautions at the pretravel visit regaridng cancer history?
Received last chemotherapy treatment ≥3 months previously and malignancy in remission.
what are Health conditions & treatments that do not require specialized immunization precautions at the pretravel visit regaridng corticosteroid treatment?
Short- or long-term daily or alternate-day therapy with <20 mg of prednisone or equivalent.
Maintenance steroids at physiologic doses (replacement therapy).
Steroid inhalers or topical steroids (i.e., skin, ears, or eyes).
Intraarticular, bursal, or tendon steroid injections.
> 1 month since high-dose (≥20 mg/day of prednisone or equivalent for ≥2 weeks) steroid use.1
what are Health conditions & treatments that do not require specialized immunization precautions at the pretravel visit regaridng Hematopoietic stem cell transplant recipients or CAR-T cell recipients?
Meets all criteria: >2 years posttransplant; not on immunosuppressive drugs; no evidence of ongoing malignancy; and without graft-versus-host disease.
if HIV infection CD4 count is greater than 200/ml, which live vaccines are ok to get?
Ebola (consider), MMR (recommended), Varicella (consider),
Yellow fever (precautions if 200-499; not precaution if >500)
what are Health conditions & treatments that do not require specialized immunization precautions at the pretravel visit regaridng Multiple sclerosis or autoimmune disease (e.g., inflammatory bowel disease, rheumatoid arthritis, systemic lupus erythematosus)?
Not receiving immunosuppressive or immunomodulatory drug therapy, although definitive data are lacking.
if HIV infection CD4 count less than 200/ml, OR severe immunosupporession, which live vaccine is ok to get?
Ebola (consider)
if asplenia, which live vaccines are ok to get?
which is contraindicated?
BCG, cholera, Ebola, MMR, Typhoid, Varicella, Yellow Fever;
live attenuated influenza vaccine is contraindicated
if you have renal failure, which live vaccines is precaution or have other considerations?
live flu - precaution;
yellow fever - other considerations - varying degrees of immune deficit might be present and providers should carefully weigh vaccine risks and benefits before deciding to vaccinate
if HIV infection CD4 count is greater than 200/ml, which live vaccines are contraindication?
BCG, live flu, typhoid Ty21a
if HIV infection CD4 count is greater than 200/ml, which non-live vaccines are “recommended”?
hep A, B, flu, meningococcal, zoster recombinant (RZV), PCV 13 followed by 23, or PCV 20
if asplenia, which non-live vaccines are “recommended”?
haemophilus influenzae type b (Hib);
flu
meningococcal conjugate, meningococcal group B, PCV
for renal failure patient, which vaccine is ‘recommended”?
Hep B, flu, PCV
what is the concern of asplenia for immunization?
response might be diminished
what is the advise for asplenic travelers?
if develop fever, initiate broad-spectrum AB self-treatment;
avoid travel to where lacking immediate access to high-standard medical care;
Many clinicians advise a 3-month delay after immune reconstitution of HIV treatments (usually 6 months after initiation of antiretroviral therapy) if possible, before immunizations are administered because?
in order to maximize the immune response to vaccination.
which postvaccination serologic testing after 1 month is needed for HIV infection people?
Hep A
for HIV who does not respond to recombinant HepB vaccine, which vaccine is recommended?
adjuvanted vaccine Heplisav-B 2 doses - 87% effective
if you get periodic doses of IV immunoglobulin, when do you need to get MMR and varicella vaccine?
14 days before next scheduled immunoglobulin
patients with complement deficiencies can receive any live or inactivated vaccine. true or false
true
is glatiramer acetate and interferon therapy for MS immunosuppresive meds?
no - can have live vaccine
when do you vaccinate before immunosuppression treatment?
non-live 2 weeks before; and live 4 weeks before
for people with MS receiving disease-modifying therapy or nataluzimab, what do you need to consider when pt require yellow fever vaccine?
consult with neurologist;
not fully studied with these meds
HSCT recipients needs to begin complete revaccination with standard childhood vaccines. when should it be done?
6 months after;
MMR 24 months after only if the recipient is immunocompetent
what is recommended wait time for HSCT recipient to travel?
2 years
for solid organ transplant recipients, what is recommended wait time for travel?
1 year
A variety of medications and biologic agents compromise the immune system. Regard anyone taking which medications as severely immunocompromised?
alkylating agents - cyclophosphamide;
antimetabolites - 6-mercaptopurine, azathioprine, methotrexate;
biologic agents - B cell-depleting agents, lymphocyte-depleting agents;
cancer chemotherapeutic agents;
high dose corticosteroids - 2mg/kg or 20mg prednisoneq qd for 2 weeks;
transplant-related immunosuppressive drugs - azathioprine, belatacept, cyclosporine, everolimus, mycophenolate mofetil, prednisone, sirolimus, tacrolimus;
tumer necrosis factor blockers - adalimumab, certolizumab pegol, etanercept, golimumab, infliximab
how long to wait after high dose steroid treatment to get live vaccine?
1 months
waiting period after cancer chemotherapy, radiation therapy, and highly immunosuppressive medications (except lymphocyte-depleting agents and organ transplant immunosuppression) is for live vaccine?
3 months
lymphocyte-depleting agents (alemtuzumab, rituximab), the waiting time is for live vaccine?
6 months ~ 1 year
what is Hep B vaccine dose for immunocompromised patient and dialysis patients?
3 dose of 40 ug Recombivax HB 0, 1, 6 months; OR
4 dose of 40 ug Engerix B 0, 1, 2, 6 months
Heplisav-B - 2 dose 1 month apart 18 years and older
what is rabies vaccine dose for immunocompromised patient?
3 dose series 0, 7, 21 or 28 days
For postexposure rabies prophylaxis, all severely immunocompromised people should generally receive rabies vaccine at days …. plus human rabies immune globulin, regardless of previous vaccination history.
days 0, 3, 7, 14, and 28,
JYNNEOS is a live, attenuated, nonreplicating, virus-derived vaccine that is indicated for first responders participating in smallpox or monkeypox outbreaks. Unlike the live, replication-competent smallpox vaccine (ACAM2000), JYNNEOS is not contraindicated for use in immunocompromised people and should be safe. true / false
true
is Tick-Borne Encephalitis vaccine safe for immunocompromised people?
yes
YF vaccination is contraindicated in people with a history of a — disorder associated with abnormal immune cell function (e.g., myasthenia gravis or thymoma)
thymus
Additional doses of YF vaccine are recommended, however, for some people who might not have as robust or sustained immune response to YF vaccine. which patients?
People who received HSCT after receiving a dose of YF vaccine
People infected with HIV when they received their last dose of YF vaccine should receive a dose every 10 years if they continue to be at risk for YF and if their current CD4+ T-lymphocyte counts do not indicate precautions or contradictions.
what is the indication of zoster vacccine for immunocompromised regardless of travel plan?
all if 19 years and over
– is contraindicated in close contacts and caregivers of severely immunocompromised people who require a protected environment.
live flu
which routine three live vaccines should be administered to susceptible household contacts and other close contacts of immunocompromised patients when indicated?
MMR, rotavirus, varicella
Some older maintenance regimens for HIV have been noted to interact with drugs used for malaria chemoprophylaxis.
what are the interactions?
chloroquine, mefloquine, primaquine –> protease inhibitors (PIs)
AP –> Efavirenz can lower serum levels of AP
primaquine –> Efavirenz can increase production of hemotoxic primaquine metabolites
In organ transplant recipients, which medication might be the most appropriate malaria prophylactic agent?
AP - because other antimalarials can interact with calcineurin inhibitors and mTor inhibitors (cyclosporine, everolimus, sirolimus, tacrolimus).
which TD meds are active against several enteric bacterial pathogens and are not known to have major interactions with highly active antiretroviral therapy (HAART) drugs?
Fluoroquinolones, rifaximin, and rifamycin SV;
Macrolide antibiotics can, however, interact with HAART drugs.
Travelers with liver disease should consider avoiding direct exposure to salt water because ?
the risk for Vibrio spp. exposure, and all immunocompromised people should avoid raw seafood.
Geographically focal infections that pose an increased risk for severe outcomes for immunocompromised people include …>
visceral leishmaniasis and inhaled fungal infections such as Talaromyces marneffei (formerly Penicillium marneffei) in Southeast Asia,
coccidioidomycosis/Valley Fever and histoplasmosis in the Americas.
what is the Air Carrier Access Act (ACAA)?
to ensure that people with disabilities are treated without discrimination in a way consistent with the safe carriage of all air passengers.
for disability travelers - A medical certificate (a written statement from the traveler’s health care provider saying that the traveler can complete the flight safely without requiring extraordinary medical care or endangering other travelers) might be required in specific situations include…
Examples of specific situations include a person intending to travel with a possible communicable disease, a person requiring a stretcher or oxygen, or a person whose medical condition can be reasonably expected to affect the operation of the flight.
what is the airline obligation to meet certain accessibility requirements for disability reuqests assistance?
carriers must provide access to the aircraft door (preferably by a level entry bridge), an aisle seat, and a seat with removable armrests.
However, aircraft with <30 seats generally are exempt from these requirements.
Any aircraft with >60 seats must have an onboard wheelchair, and personnel must help move the onboard wheelchair from a seat to the lavatory area upon request. Only wide-body aircraft with ≥2 aisles are required to have fully accessible lavatories.
what is not responsbility of airline personnel for disability support?
feeding, visiting the lavatory, or dispensing medication to travelers.
Airlines might require up to 48 hours advance notice and 1-hour advance check-in, however, for certain accommodations that require preparation time for services (if they are available on the flight) - which servcies are they?
medical oxygen for use on board,
carriage of an incubator,
hook-up for a respirator to the aircraft electrical power supply,
accommodation for a passenger who must travel in a stretcher,
transport of a battery-powered wheelchair on an aircraft with <60 seats,
provision by the airline of hazardous material packaging for batteries used in wheelchairs or other assistive devices,
accommodation for ≥10 people with disabilities who travel as a group,
or provision of an onboard wheelchair for use on an aircraft that does not have an accessible lavatory.
The ACAA rules do require a sign language interpreter to ensure that a passenger with hearing loss receives all pertinent information. true / false
false
what do you need to check if you are traveling with chronic illnesses?
- carry copies of all RXs
- any med restrictions exist?
- access to quality care?
- provider letter - medical conditions, meds, any equipment required
- travel health kit
- med assis company to store your med hx
- smart traveler enrollment program
- stay hydrated, wear loose-fitting clothing, walk and stretch at regular intervals
- medical alert bracelet or carry medical info on your person
in cancer patient, what would be the contraindication of airline travel?
- severe anemia (Hgb <8.5 g/dL)
- cardiovascular, GI, or pulmonary/respiratory complications
- cerebral edema due to intracranial tumor
what is contradindcation for airline travel when you have cardiovascular and other circulatory disorders?
- unstable angina
- uncontrolled arrhythmia
- severe or decompensated CHF
- uncontrolled hypertension
- post-acute coronary syndrome
- Eisenmenger syndrome
- severe and symptomatic valvular heart disease
how long do you need to wait after CABG (coronary artery bypass graft procedure) until air travel?
minimum 10 days
how long do you need to wait for air travel after Post–percutaneous coronary intervention (elective)?
min. 2 days
how long do you need to wait for air travel after Post–percutaneous pacemaker or implanted defibrillator placement?
min 2-3 days
how long do you need to wait for air travel after post-sickle cell crisis?
min 10 days
how long do you need to wait for air travel after cerebral vascular accident (CVA)
10-14 days
how long do you need to wait for air travel after Post–TIA (transient ischemic attack)?
3 days
how long do you need to wait for air travel after Post–cranial surgery?
7-14 days
what is contradindcation for airline travel when you have CNS and PNS disorders?
- unstable neurologic process
- poorly controlled seizure disorder
what is contradindcation for airline travel when you have GI disorders?
- bowel obstruction
- active or recurrent GI bleed
- uncompensated liver failure
- post-major abdominal surgery (min. 10-14 days)
- post-colonoscopy (min 24 hours)
- post-laparoscopic surgery (min 3-5 days)
what is contradindcation for airline travel when you have respiratory tract disorders?
- severe or labile asthma
- bullous lung disease
- active lower respiratory tract infection
- post-major chest surgery - 10-14 days
- post-PTX (spontaneous) - min 7 days after full inflation before travel
- post-PTX (traumatic) - min 14 days
- severe pulmonary hypertension
- supplemental oxygen requirements: high, rapidly fluctuating or increasing
what are vaccinations recommendation for diatetes for travel?
influenza, pneumococcal, hep B
what are vaccinations recommendation for GI disorders for travel?
Influenza, pneumococcal, Hep A & B
what are vaccinations recommendations for renal failure and chronic renal insufficiency?
influenza, pneumococcal, hep B
which malaria med is not recommended for people with cardiac conduction abnormalities?
mefloquine
which malaria meds and vaccine are not recommended for patients with myasthenia gravis?
mefloquine and chloroquine;
yellow fever generallyl contraindicated
which malaria med should be used with caution with chronic liver disease?
mefloquine
which malaria med is contraindicated if CrCl <30 ml/min?
Atovaquone-proguanil
for renal failure and chronic renal insufficiency patients, what test should be screened before departure?
HIV, hep C and hep B status
Chronic kidney disease can predisose patients to increased risk of … and …
DVTs and altitude sickness
what are the main risks for anaphylaxis in adults?
medications and stinging insect venom
what are main risks for anaphylaxis in children and adolescents?
food and stinging insect venom
what is included in allergy self-care management plan?
ask about airline allergy polices in advance;
written emergency action plan;
keep epinephrine on you;
share action plan with guides;
medical bracelet
what are meds to treat alcohol use disorder?
acamprosate;
disulfiram;
naltrexone
what meds are used to treat opioid use disorder?
buprenorphine and methadone - opioid agonists, reduce cravings and withdrawal symptoms and block the effect of other opioids (e.g. heroin);
naltrexone -block the effect of opioids
