Travelers

Travel Vaccines should be documented on:

International Certificate of Vaccination or Prophylaxis (ICVP, aka yellow card)

Diseases from international travel can be spread through:

Food and water

blood and bodily fluids

transmitted through insects

CDC’s Health Information for International Travel (Yellow Book)

Located on CDC website, and contains travel information, including travel health insurance recommendations

Travel’s Diarrhea Symptoms

ranging from mild cramps and frequent loose stools to severe abdominal pain, fever, and vomiting

If blood is mixed in with the stool in Traveler’s Diarrhea along with systemic symptoms such as fever, it is considered to be:

Dysentery and is classified as severe

Primary pathogen that causes Traveler’s Diarrhea

E.coli - majority of cases are bacterial

Traveler’s Diarrhea Prevention Strategies

Only eat food that is cooked and served hot. AVOID buffet foods 

Use bottled water or boil for about 1 minute, AVOID ice 

Wash hands OFTEN

Traveler’s Diarrhea Medication Prophylaxis

Bismuth subsalicylate (Pepto-Bismol) PO 4 times daily

Antibiotics (rifaximin) are ONLY used if there is a high risk of complications from TD

Treatment of Traveler’s Diarrhea: Mild Symptoms

Hydration (with increased with fluid and salt intake)

Loperamide or Pepto-Bismol

Treatment of Traveler’s Diarrhea: Moderate Symptoms

Hydration (with increased with fluid and salt intake)

Loperamide ± antibiotics (azithromycin or a quinolone, rifaximin as alternative)

Treatment of Traveler’s Diarrhea: Severe Symptoms

Hydration (with increased with fluid and salt intake)

Antibiotics ± loperamide

Azithromycin is preferred

Quinolones or rifaximin are alternatives

Loperamide Mechanism of Action

decreases the frequency and urgency of bowel movements

Loperamide Dosing

4mg after the first loose stool, 2mg after each subsequent loose stool, up to a max dose of 16mg/day (Rx) or 8mg/day (OTC) 

Can be used for up to TWO DAYS - see a provider if no improvement

Bacteria that causes typhoid fever

Salmonella typhi

Typhoid fever is spread through:

food or water that has been contaminated by the feces of someone with either an acute infection or a chronic, asymptomatic carrier

Typhoid fever Prevention

Vaccinations (only 50-80% effective)

Safe food and water precautions

Washing hands frequently

Vivotif

Live-attenuated oral vaccine for typhoid fever

Typhim Vi

inactivated, intramuscular injection

Vivotif Timing

Should be completed >1 week before traveling

Typhim Vi Timing

Should be given > 2 weeks before the expected exposure

Bacteria that causes cholera

Vibrio cholerae

Most common symptom of cholera

rice-water stools

Cholera Prevention Strategies

Live-attenuated vaccine (Vaxchora)

Food and water precautions

Common Travel Vaccines (Inactivated ones)

Hepatitis A (Havrix, VAQTA)

Hepatitis B (Engerix-B, Heplisav-B)

Hepatitis A/B (Twinrix)

Japanese encephalitis (Ixiaro)

Meningococcus (Menveo, MenQuadfi)

Polio (IPOL)

Typhoid-IM (Typhim Vi)

Common Travel Vaccines (live vaccines)

Cholera-PO (Vaxchora)

Typhoid-PO (Vivotif)

Yellow fever-subQ (YF-VAX)

Hepatitis B is spread through:

contaminated blood or other body fluids

Meningococcal Meningitis Symptoms

fever, severe and unrelenting headache, nausea, stiff neck (nuchal rigidity), and mental status changes

Meningococcal Meningitis Diagnosis

Made through lumbar puncture

Meningococcal Meningitis Prevention

Vaccination (Menveo and MenQuadfi)

Insects that transmit disease

Vectors

Any place (such as an animal, insect, soil, or plant) in which the disease lives and can multiply

Reservoir

Primary insects that transmit disease

Mosquitoes

Diseases that are commonly spread with mosquitoes

Japanese encephalitis

Yellow fever

dengue

malaria

Zika virus

Ways to prevent insect bites

Apply mosquito repellents containing 20-50% DEET on exposed skin

Use permethrin to treat clothing, gear and bed nets (do NOT apply directly to skin)

Sleep in enclosed areas, and wear long sleeves and pants

Most common Malaria species

P. vivax

P. falciparum

P. vivax Special considerations

causes about 50% of malaria cases in India and is becoming resistant to malaria drugs

P. falciparum Special Considerations

most deadly species

Malaria Prophylaxis Daily Regimens

Doxycycline - stop 4 weeks after travel

Atovaquone/Proguanil - stop 1 week after travel

Primaquine - stop 1 week after travel

ALL should be started 1-2 days before travel

Primaquine Special Considerations

not to be used in G6PD deficiency (CDC requires screening prior to use)

Doxycycline, Atovaquone/Proguanil, and Primaquine Special Considerations

DO NOT USE IN PREGNANCY 

causes nausea, so take with food

Malaria Prophylaxis Weekly Regimens

Chloroquine - start 1-2 weeks before travel, stop 4 weeks after travel

Mefloquine - start >2 weeks before travel, stop 4 weeks after travel

Chloroquine Side Effects

retinal toxicity/visual changes

Mefloquine Special Considerations

NOT USED IN: underlying psychiatric conditions, seizures, arrhythmias

Malaria Weekly Regimen Special Considerations

SAFE for pregnancy and children

Yellow Fever Special Considerations

Do not use aspirin or other NSAIDs due to increased risk of bleeding

Zika Infection and Pregnancy

Zika infection leads to infants born with microcephaly and other birth defects

Altitude Sickness Prophylaxis

acetazolamide 125mg BID, started the day before 

Acetazolamide Side effects

Polyuria, photosensitivity, taste alteration

CONTRAINDICATED in patients with a sulfa allergy