immunizations american academy of family physicians旅游免疫接种美国家庭医生学院课件

Travel Immunizations Support for this program is made possible by the AAFP Foundation through a grant from Pfizer Inc. Travel Immunizations Developed for AFMRD by Gail Colby, M.D. and Wendy Biggs, M.D. Midland Family Medicine Residency 2010 Ehab Molokhia, MD and Gerald Liu, MD University of South Alabama Family Medicine Residency Updated 2012 Travel Immunizations Competencies Medical knowledge List the 2 vaccines that are required for travel List the geographic areas at risk for yellow fever List 3 contraindications for yellow fever vaccine Recite the severe side effects of yellow fever vaccination Travel Immunizations Competencies Medical knowledge Define the “Meningitis Belt” State the vaccine required for the annual pilgrimage to Mecca (Hajj) Describe how typhoid is acquired Explain how rabies vaccination changes the post-exposure treatment Travel Immunizations Competencies Patient care Recognize returning travelers may have acquired an illness on the trip Assess immunization status of patients who will travel Travel Immunizations Competencies Interpersonal communication Advise patient to obtain necessary immunizations before travel Counsel patients on malaria risks and need for prophylaxis Systems-based practice Access on-line travel health information from Center for Disease Control and Prevention (CDC) Travel Immunizations Travel Immunizations In 2004: 763,000,000 crossed international borders Important considerations Prior immunizations Health needs Locations/Exposures Haiti - Photo by Tim Elzinga, M.D. Madrid and Paris Photos by Wendy Biggs, M.D. Travel Immunizations Mr. M, a 45-year-old Muslim man, visits your office in September. He was born in Dearborn, Michigan and attended public school there. He is going on pilgrimage to Mecca with his father in November. He thinks he needs some vaccines before he goes. What vaccines does he need? CaseCase Travel Immunizations How Do You Know What Vaccines are Needed for Travel? The CDCs Health Information for Travelers Published every 2 years The “yellow book” Can search online at /travel/yellowbook/search.aspx Travel Immunizations Travel Immunizations Required Yellow Fever Meningococcal Recommended Polio Tetanus/Diphtheria/Pertussis Influenza Measles Hepatitis A/B Typhoid Rabies Japanese Encephalitis Tick-borne Encephalitis Travel Immunizations Does Mr. M need Yellow Fever Vaccine? Case Travel Immunizations Yellow Fever Mosquito-borne hemorrhagic fever 200,000 cases per year, 90% in Africa Indigenous case fatality rates vary 20-60% Rare fatalities in travelers since vaccine introduction Travel Immunizations .au/map2.gif Yellow Fever 3 stages Infection (3-4 days) Fever, malaise, leukopenia Remission (48 hours) Abatement of symptoms 15% progress Intoxication Return of symptoms, Organ dysfunction, hemorrhage Yellow Feaver Travel Immunizations Yellow Fever Disease Transmission From primates or humans Mosquito vector Disease Prevention Avoid mosquito bites DEET Clothing Mosquito nets Eliminate standing water Vaccination Photo from . Image in public domain. Photo by James Gathany. Travel Immunizations Yellow Fever Vaccine Live-attenuated vaccine Developed in 1936 Seroconversion 95% Single 0.5ml subcutaneously Revaccination at 10-year intervals required by World Health Organization Protection from one vaccine, however, may last 30 or more years Travel Immunizations Yellow Fever Vaccine Contraindications Age 55 years old MenACWY-CRM (Menveo) 11-55 years old Licensed for use in 2010 Travel Immunizations Meningococcal Disease Revaccination If high-risk (epidemic area or travel) If vaccine given at 2-6 years old Repeat after 3 years, then every 5 years If vaccine given 6 years old Repeat every 5 years Travel Immunizations Since he is going on Hajj to Mecca, Mr. M needs Meningococcal Vaccine. He could receive any of the three Meningococcal Vaccines available. Menveo or Menactra are preferred Conjugated vaccines Give better immune response Case Travel Immunizations Does he need additional vaccines? Possibly How would you know? 1)Need to review Mr. Ms immunization status 2)Need to know recommended vaccines Case Travel Immunizations To attend public school, Mr. M had primary series of immunizations recommended 40 years ago Most likely diphtheria/tetanus/pertussis, polio, measles, mumps, rubella (or had disease documented) His age implies varicella immunity (born prior to 1966) He cannot recall his last tetanus booster CaseCase Travel Immunizations Recommended Vaccines for Travel Tetanus/Diphtheria/ Pertussis Influenza Polio Measles Hepatitis A Hepatitis B Typhoid Rabies Japanese Encephalitis Tick-borne Encephalitis Travel Immunizations Tetanus Omnipresent in the environment worldwide Agricultural areas exposure to animal excrement Approximately 290,000 people died from tetanus in 2006 Most in Asia, Africa and South America Vaccination provides 10 years of protection Booster 10 years since last dose or if wound occurs and vaccination is greater than 5 years old Travel Immunizations Polio Fecal-oral or oral transmission Global Polio Eradication Initiative (GPEI) Goal to eradicate polio Wild polio virus: India, Nigeria, Pakistan, Afghanistan Most cases of polio from these countries 2 vaccines worldwide: IPV and OPV Only IPV in U.S. Still OPV in other parts of the world Rare cases of vaccine associated paralytic poliomyelitis Vaccine recommended if traveling to endemic area and incomplete series Travel Immunizations Measles 20,000,000 cases globally each year Almost every country Travel guidelines closely match general immunization guidelines Immunity for travel: 6-11 months old 1 dose required (does not count in U.S.) 12 months old 2 doses required Laboratory evidence of immunity Born before 1957 Physician-diagnosed case of measles Travel Immunizations Hepatitis A Worldwide prevalence Fecal/oral transmission Associated poor hygiene or sanitation Symptoms include Jaundice Fatigue Abdominal pain Anorexia Nausea Photo from . Image in public domain. Travel Immunizations Hepatitis A Adults often contract from asymptomatic children Incubation 28 days (range 15-50 days) Viral shedding 2 weeks before to 1 week after symptoms Usually self-limited disease Travel Immunizations Hepatitis A Vaccine Inactivated Hep A virus (Havrix or Vaqta) Combined with Hepatitis B (Twinrix) Travel vaccine indications Anyone 1 year old traveling anywhere outside of U.S. and Canada Western Europe Scandinavia Japan Australia and New Zealand Travel Immunizations Hepatitis A Vaccine Dose at 0 and booster at 6-12 months (Havrix) Dose at 0 and booster at 6-18 months (Vaqta) If using Twinrix (combination Hep A and Hep B) 0, 1, 6 months 0, 7 days, 21-30 days and 12 months (4-dose accelerated series) Travel Immunizations Hepatitis A For healthy patients 40 years old, one dose before travel confers adequate protection Consider immunoglobulin treatment for patients Leaving in less than two weeks Older Immunocompromised Chronic medical conditions Under 12 months of age Travel Immunizations Hepatitis B Transmitted by blood and body fluids Travelers generally low risk except: Injuries that occur while traveling Sexual contact Drug injection Piercings or tattoos Recommended for travel to intermediate/high risk areas Travel Immunizations Hepatitis B Vaccine Indications International travel to endemic areas X /travel/yellowbook/2010/chapter-2/hepatitis-b.aspx Travel Immunizations Hepatitis B Vaccine (Engerix- B) Ideally 6 months or greater before travel Doses at 0,1 and 6 months If 6 months before travel, consider accelerated vaccine series 0, 7, 21-28 days and a booster at 12 months Travel Immunizations Twinrix Inactivated Hepatitis A with Recombinant Hepatitis B Indicated for 18 years old and older 3-dose series 0, 1, 6 months Better choice if both vaccines are indicated Travel Immunizations Influenza Risk depends on timing and destination Tropics: year round risk Temperate climates: risk generally April-September Avian subtype risks Visiting poultry farms Visiting open markets where live poultry are present Eating undercooked poultry products (eggs, meat, etc.) Preventative measures include Hygiene: washing hands Annual vaccination Travel Immunizations Typhoid Fever Typhoid fever acute life-threatening illness Caused by Salmonella typhi Humans only source Acquired through fecal contamination of food and water 22,000,000 cases worldwide/year 200,000 deaths Travel Immunizations Typhoid Southeast Asia 6-30 times more common Highest risk of drug resistance Africa, Caribbean, Central and South America Length of stay = increased risk /images/Map_Typhoid.gif Travel Immunizations Typhoid Incubation period: 6-30 days Headache, malaise, fever up to 104 degrees F Increasing in severity Low-grade septicemia “Rose spots” on trunk Serious complications (2-3 weeks) Hepatosplenomegaly Intestinal hemorrhage/perforation No definitive test Clinical diagnosis Rose spots on the chest in a patient with typhoid Photo from . Image in public domain. Travel Immunizations Typhoid Treatment Oral rehydration Antibiotics Ciprofloxacin if no resistance (7-10 days) 3rd generation cephalosporin (10-14 days) Azithromycin Steroids in severe cases Travel Immunizations Typhoid Prevention Avoid contaminated food and water Hygiene Local cuisine Vaccine(s) 2 available Photo from . Image in public domain. Travel Immunizations Typhoid Vaccines Vivotif Oral, live-attenuated Ages 6 and older 50-80% protection 4 pills one every other day Completed 1 week before potential exposure Revaccination every 5 years Typhim Vi Capsular polysaccharide (IM) Ages 2 and older 50-80% protection Single 0.5ml injection 2 weeks before exposure Booster every 2 years Travel Immunizations Rabies Found globally Consider vaccination If potential exposure to wild animals (especially dogs) Prolonged exposure where endemic /Travel/Images/Rabies_World_2005.JPG Travel Immunizations Rabies Vaccine Pre-exposure prophylaxis Series of 3 at 0, 7 and 21-28 days 2 vaccines available in U.S. Imovax Rabavert Outside U.S. many other vaccines Expense limits use Travel Immunizations Rabies Vaccine Post-exposure Rabies Immunoglobulin (RIG) plus vaccine RIG days 0, 4 Vaccine days 0, 3, 7,14 If had vaccine No RIG needed Vaccine days 0 and 3 Travel Immunizations Japanese Encephalitis Virus (JEV) Geographic distribution in Southeast Asia. Map from Most common cause of encephalitis in Southeast Asia Carried by mosquitoes Risk Little risk in urban areas Mostly rural areas Not recommended for short-term travel to urban area Travel Immunizations Japanese Encephalitis Incubation 5-15 days Most infections asymptomatic 1% develop clinical disease Headache, fever, vomiting, diarrhea Most recover in 1 week 1:300 severe symptoms with 30% fatality Mental status changes Focal neurological deficits Parkinsonian syndrome Seizures (especially children) Travel Immunizations Japanese Encephalitis 2 vaccines in U.S. (Multiple vaccines available in Southeast Asian countries) Inactivated Vero cell culture (JE-VC) For people over 17 years old Duration of protection unknown Need for boosters undetermined Pregnancy Category B Inactivated mouse brain cell culture (JE-MB) Production stopped 2006 Stockpile only for children 17 years old Booster 2 years after primary series if needed Travel Immunizations Tick-borne Encephalitis Endemic to Europe and Russia Biphasic illness Febrile illness that remits Returns as neuro-invasive disease Risk in unvaccinated 1/10,000 person-months Only 5 known cases in US in last decade No vaccines available in US, but are in Canada and Europe Image in public domain. Photo taken by James Gathany. Travel Immunizations Since he is going to Saudi Arabia, what additional vaccines does Mr. M need? CaseCase Travel Immunizations In addition to meningococcal vaccine, Mr. M needs Hepatitis A and B (Twinrix) Tdap Influenza He does not need measles, typhoid, rabies or encephalitis vaccines CaseCase Travel Immunizations Case Does Mr. M need anything for malaria? Case Travel Immunizations Malaria 350,000,000 - 500,000,000 cases/year 1,000,000 - 3,000,000 deaths/year Mostly sub-Saharan Africa X /wmr2005/maps/map3.gif Travel Immunizations Malaria 1500 imported cases to US/year Probably under-reported 6 deaths/year Risk assessment Location, season, elevation, duration Military Travelers visiting friends or relatives Pregnancy Travel Immunizations /wiki/File:Symptoms_of_Malaria.png. Image is in the pubic domain. Symptoms of MalariaSymptoms of Malaria Travel Immunizations Malaria NO VACCINE Have to treat with chemoprophylaxis Travel Immunizations Malaria Prevention Clothing Insect repellant Mosquito netting Chemoprophylaxis Atovaquone/proguanil (Malarone) Primaquine Chloroquine Mefloquine Doxycycline Netting image originally posted to Flickr by Tjeerd Wiersma at /photos/76396789N00/2808846. Permission to re-use when credit given. Travel Immunizations Malaria Multiple regimens, multiple meds Start before, end after Important to plan ahead with your doctor or travel clinic Recommendations at CDC yellowbook /travel/yellowbook/2010/ chapter-2/malaria.aspx Pregnancy Chloroquine/mefloquine only Travel Immunizations Mr. M does NOT need malaria prophylaxis CaseCase Travel Immunizations Travelers Responsibilities 4-6 weeks before travel see provider Get necessary immunizations Check CDC for up to date recommendations () Check travel notices for outbreak information (/travel/notices.aspx) Travel Immunizations Travelers Responsibilities Travel health kit Prescription medications and over-the-counter medications Advice available at: /travel/yellowbook/2010/chapter- 2/travel-health-kits.aspx Commercial pre-assembled health kits American Red Cross: Adventure Medical Kits: Chinook Medical Gear: Travel Medicine, Inc.: Wilderness Medicine Outfitters: Travel Immunizations Physicians Responsibilities Know some basic travel medicine advice Hepatitis A and B for trips to Mexico/Caribbean Prevention techniques Clean water Mosquito prevention How to access the CDC website for travel advice (/travel) International Society of Travel Medicine () for those more interested Travel Immunizations Summary Medical knowledge Yellow fever and meningococcal vaccines are required for travel into some countries Yellow fever is endemic to Sub-Saharan Africa and South America Travelers to those regions should be re-vaccinated every 10 years Contraindications for