NAPLEX: Travelers

Sources for medication for Travling

1. CDC: Yellow Book

2. International Society of Travel Medicine (ISTM) Guidelines

What should traveler's have when they leave the U.S?

1. A list of medical conditions and medications (Rx + OTC)

2. Travel vaccines documented on the International Certificate of Vaccination or Prophylaxis (ICVP) "Yellow Card"

3. Rx medications stored in original containers.

4. All medication and medical supply should be in carry-on luggage.

Live Travel Vaccines

Cholera PO

Typhoid PO

Yellow Fever SC

Common Food and Water diseases while traveling

*Travelers Can't Poop in Their Home*

-Traveler's Diarrhea

-Cholera

-Polio

-Typhoid Fever

-Hepatitis A

Traveler's Diarrhea

cause

onset

duration

- 80-90% bacterial (E. coli)

- Onset 6-72h

- Can last 3-7 days

Traceler's diarrhea prevention

non med and med

"boil it, cook it, peel it, or forget it"

hand hygiene

meds:

bismuth subsalicylate (pepto bismol) if no CI

abx if high risk

Traveler's Diarrhea Prophylaxis

- Pepto-Bismol (Any patient)*

- Rifaxamin (High risk patients)

When should Pepto-Bismol be avoided?

In patients with ASA allergy, pregnancy, renal insufficiency, gout or if taking anticoagulants.

>16 years old to avoid Reye's syndrome

Traveler's Diarrhea Treatment

Treatment:

Mild: Loperamide PRN

Moderate: Loperamide ± antibiotics

Severe: Antibiotics ± loperamide

**Azithromycin 1,000mg x1 dose**

What antibiotics are used to treat Traveler's Diarrhea

Azithromycin (Preferred)

Quinolones

Rifaxamin

Loperamide dosing for TD

4mg after first loose stool, then 2 mg after each subsequent loose stool.

Max: 8mg/day OTC or 16mg/day Rx

When is Loperamide contraindicated?

Children under 2 and if diarrhea is bloody

Typhoid Fever

cause

sx

where commonly occurs

-Caused by Salmonella typhi

-Presents has headache, malaise, anorexia, spleen/liver enlargement, rash

-Africa, Southeast Asia, Caribbean, Central/South America

Typhoid Fever Vaccines

1. Typhim VI

-IM injection ≥2 weeks before travel

-2 years old+

-Revaccinate every 2 years

2. Vivotif

-Live

-Oral Capsule ≥1 week before travel

-6 years old+

-Revaccinate every 5 years

-Store in refrigerator

Cholera

Caused by vibrio cholerae

-"Rice-water stools"

-Africa, Southeast Asia, Haiti

Cholera Vaccine

Vaxchora

-Oral liquid, Live

-Given ≥10 days before travel

-Patients aged 18-64 years

Polio

-Usually vaccinated in childhood

-Single, lifetime booster dose

-Proof of vaccination may be required

-Found in Afghanistan, Myanmar, Guinea, Laos, Nigeria, Madagascar, Pakistan and Ukrain

Polio Vaccine

IPOL

-IM injection

-Given ≥4 weeks before travel

-Single booster dose for previously vaccinated adults

Hepatitis A

cause

causes what

-Caused by Hepatitis A Virus

-Can cause jaundice, nausea, asymptomatic

-Acute, self-limiting

Hepatitis A Vaccines

Vaccines: all inactivated

Havrix (IM)

VAQTA (IM)

Twinrix (IM) - Hep A & B

Diseases from blood and bodily fluid

Hepatitis B

Meningococcal meningitis

hep b causes what if chronic?

cirrhosis, liver failure, liver cancer

who is hep b rec'd for?

if plan to

-receive medical care

-provide medical work

-have unprotected sex

-get piercings/tattoos

Hepatitis B Vaccines

which and how given?

Vaccines:

Engerix-B (IM)

Recombivax HB (IM)

Twinrix (IM) - Hepatitis A & B

-3 dose series over 6 months

Meningococcal meningitis

cause

where

transmission

required for which countries

when can you get it?

-Neisseria meningitidis

- Seasonal in African endemic zone (Dec-June)

-Transmitted through oral/nasal (coughing, kissing)

-Required for Saudi Arabian Hajj and Umrah pilgrimage

-Must be given <3 years ago & >10 days before for pilgramge

Meningococcal Meningitis Vaccine

Vaccines

Menquadfi (IM)

Menveo (IM)

Both Quadrivalent

-Serotypes ACWY

Meningococcal meningitis Classic Triad

Nuchal rigidity (stiff neck)

Headache

Fever

Diseases from Insect Bites (Travel)

*insects Make You Destroy Japanese Zoos*

Malaria

Yellow Fever

Dengue

Japanese Encephalitis

Zika Virus

Prophylactic Measures against bug bites

-20%-50% DEET

-SPF first, then DEET

-Permethrin-treated clothing, gear, bed nets - do not let touch skin

-Minimized exposed skin

Dengue Fever

transmissions

sx

vaccine?

treatment?

-Transmitted by mosquitoes

-75% asymptomatic

-5% Severe bleeding/organ failure, shock

-No vaccine so prevent bites

supportive care

Malaria

transmission

sx

4 species

-parasite transmitted by Anopheles mosquito

-High fever, shaking, chills, flu-like

- Four species:

1. Plasmodium falciparum (most deadly)

2. Plasmodium malariae

3. Plasmodium ovale

4. Plasmodium vivax (50% of cases in India and becoming more resistant)

Malaria Prophylaxis Quick Start

when initiated?

drug treatment plans (start/stop)

how taken?

avoid in?

side effect

1-2 days prior to travel

Atovaquone/proguanil (Malarone):

-Stop 1 week after travel

Doxycycline (Doryx, Vibramycin):

-Stop 4 weeks after travel

-Causes photosensitivity

Avoid in children <8

Primaquine:

-Most effective against P. vivax

-Stop 1 week after travel

-Avoid in G6PD deficiency

All:

-Taken daily

-Avoid in pregnancy

Malaria Prophylaxis Advanced Start

when start

treatment plans (start/stop)

side effects

avoid in who

how taken?

1-2 weeks prior to travel

Chloroquine:

-Start: 1-2 weeks before

-Stop: 4 weeks after

-Renal toxicity/Visual changes

Mefloquine (Lariam):

-Start: ≥2 weeks before

-Stop: 4 weeks after

-Avoid in patients with psych, seizures or arrhythmias

Both:

-Taken Weekly

-Safe in pregnancy, children

Japanese Encephalitis

sx

where is highest risk?

who should get vaccine?

-Usually asymptomatic, can lead to encephalitis

-Highest risk in rural areas of agriculture or

-Higher risk with those who are planning on extended outdoor stays (hiking, etc)

Japanese Encephalitis Vaccine

Ixiaro (IM, inactivated)

- patients aged > 2 months

- extended exposure to outdoors or >/= 1 month in area

Yellow Fever

where found? do they require?

symptoms are similar to?

ci in?

avoid use with (drug interaction)

-Found more in tropical areas

-Similar symptoms to influenza

-High risk areas require "Yellow Card", valid 10 days after vaccine

-CI with egg allergy, severely immunocompromised

-Risk of serious adverse effects

-Avoid concurrent use of NSAIDs due to increased risk of bleeding

Yellow Fever Vaccine

YF-Vax (SC, Live)

-Given ≥10 days before travel

-1 dose, but some countries require booster q10 years

Zika Virus

transmitted by

what causes?

-Transmitted mainly by Aedes mosquito

-Sexual and blood transfusion-associated transmission as well as mosquito

-Infant microcephaly (small head)

is there a vaccine for zika? other prevention?

no vaccine yet

avoid unprotected sex and mosquito bites

Treatment for altitude sickness

when start?

ci?

side effects?

Diamox (acetazolamide)

-Start day prior to travel

-CI with sulfa allergy

-Polyuria and photosensitivity