EMPORIATRIC MEDICINE AND THE HIV-INFECTED TRAVELER - PowerPoint PPT Presentation

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EMPORIATRIC MEDICINE AND THE HIV-INFECTED TRAVELER

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Title: TRAVEL MEDICINE IN THE HIV-INFECTED TRAVELER Author: stuart haber Last modified by: Nicole Mandel Created Date: 6/22/2003 1:29:33 PM Document presentation format – PowerPoint PPT presentation

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Title: EMPORIATRIC MEDICINE AND THE HIV-INFECTED TRAVELER


1
EMPORIATRIC MEDICINE AND THE HIV-INFECTED TRAVELER
2
ISSUES FOR ALL TRAVELERS
  • Generally want at least 4-6 week lead time prior
    to departure to assess travel needs, especially
    vaccines and need for malaria chemoprophylaxis
  • Get list of medical clinics from IAMAT
    www.iamat.org
  • Bring 30-35 DEET spray where biting insects are
    anticipated
  • Avoid piercings and tatoos, acupuncture, even
    shaving by a barber in many of these developing
    areas
  • Be cautious of motor vehicle travel
  • Swim only in chlorinated water
  • Health insurance both international
    insurance(try credit card companies, yellow
    pages, internet) and air ambulance insurance
    www.airambulancedirectory.com

3
SPECIFIC PRECAUTIONS FOR ENTERITIS
  • Developing countries especially important in
    patients with severe immunosuppression
  • Food and waterborne diseasessame precautions for
    all travelers regardless of HIV serostatus
  • If you cant boil it, peel it, cook it, then
    forget it!!
  • No tap water, ice cubes. Bottled water, including
    for brushing teeth!
  • Portable water purifiers ( with absolute one
    micron filter)

4
TRAVELERS DIARRHEA
  • If travelers diarrhea is severe must seek
    medical attention (gi bleeding, fever, vomiting,
    prostration)
  • Enterotoxigenic E. coli probably no different in
    its presentation, but Salmonella, Campylobacter,
    Shigella can be worse in HIV people
  • Occasional microsporidia(J Travel Med 1999
    Dec6(4)223-7), enteroaggregative E. coli(CID
    2001 Jun 1532(12)1706-9), and Cryptosporidia
  • Other causes of enteritis eg,Cyclospora, Isospora
    belli, helminths, C. difficile, tropical sprue
  • Treatment for uncomplicated diseasecipro 500mg
    BID for three to seven days with first day
    imodium.

5
SELF-MEDICATION FOR OTHER AILMENTS
  • Options of self-medication for respiratory tract
    infection, sinusitis, otitis media,UTI, cellulitis

6
INTERNATIONAL SCREENING OF TRAVELERS FOR HIV
INFECTION
  • Primarily aimed for those with extended stays
    work visas, students
  • Approximately 50 countries may block entry of
    HIV travelers
  • Check with consular office(s) or go to
    www.travelstate.gov/hivtestingreqs.html
  • Our own calls to Brazilian, Canadian, and British
    consulates did not bear out any refusal to have
    HIV travelers in their nation for short-term
    stay. However, long-term stay decided on case by
    case basis.

7
TIMING OF HAART ACROSS TIME ZONES
  • Take more doses in the period than less.
  • East to West extra dose of Nukes, viramune and
    PIs at bedtime
  • West to East extra dose next morning
  • Efavirenz doesnt need an extra dose (G. Moyle,
    personal comm.)
  • Viread has long intracellular half-life and may
    not need an extra dose
  • Debatable what to do with indinavir with respect
    to risk of nephrolithiasis

8
DRUG AND MEDICAL CARE ISSUES
  • Adequacy of supply of medications, including need
    for refrigeration and avoidance of damp places
  • Adequacy of medical care in destination,
    especially important in prolonged stays-consult
    with IAMAT
  • Avoid if possible, new medication changes just
    prior to travel

9
MALARIA PREVENTION
  • Same precautions and prophylaxis with all
    travelers
  • Review itinerary on www.cdc.gov malaria site
  • Disease presentation not different in HIV, except
    more severe in HIV-positive pregnant women
  • Mosquito bite prevention with 30-35 DEET, bed
    netting, permethrin spray, and avoidance of dusk
    to dawn exposure
  • Drug interactions mefloquine had variable
    effects on ritonavir, with decrease in Cmax,
    Cmin, AUC. Despite strong inhibition of CYP3A4,
    mefloquine levels were not affected by ritonavir
    (Khaliq et al, 7th Conf on Retro, abstract 92,
    2000)
  • Malarone Proguanil AUC increased possibly via
    CYP 2D6, Atovaquone AUC may be decreased in
    presence of Ritonavir, mechanism unknown (Karp,
    Current Inf Dis Rep 2001, 350-8)
  • Despite these observations, there are currently
    no dose adjustments recommended at this time.
  • Measure patients glucose-6-phosphate
    dehydrogenase level prior to trip (possible need
    for primaquine)

10
MALARIA TREATMENT
  • QuinidineAUC increased by ritonavir via CYP3A4
    inhibition. Quinidine reserved for severe malaria
    and decrease in maintenance rate of drug
    required. Quinine probably increased to lesser
    extent and should be avoided (risk of prolonged
    QT interval with Torsades de pointes)
  • Treat non-severe malaria with malarone 4
    pills/day for three days, or with lariam
    (increased risk of seizures).
  • Self-treatment not generally advised

11
VACCINE ISSUES IN HIV TRAVELER
  • Potential exposure to pathogen
  • Potential increase in side effects to vaccine
  • Potential decreased efficacy of vaccine

12
VACCINES
  • In most developing areas of world, following
    vaccine-preventable illnesses are addressed
  • Measles
  • Hepatitis A
  • Typhoid Fever
  • Influenza
  • Yellow fever
  • Hepatitis B
  • Polio
  • Japanese encephalitis
  • Rabies
  • Cholera
  • Meningococcus

13
VACCINES
  • Killed (inactivated) Hepatitis A, Inactivated
    Polio (IPV), Rabies, Japanese encephalitis
  • Live (attenuated) MMR, Yellow fever, oral
    Typhoid
  • Subunit Hepatitis B
  • Polysaccharide Pneumococcal, Meningococccal,
    Typhoid Vi
  • Split antigen Influenza

14
MEASLES VACCINE
  • Increased prevalence of disease in SE Asia,
    Africa (especially sub-Saharan) based on W.H.O.
    data on measles in children
  • Worse disease with increased morbidity and
    mortality in HIV-infected people with pneumonitis
    and also encephalitis.
  • Increased risk of vaccine side effects in
    severely immunosuppressed one known death in
    patient with AIDS and deaths in other
    immunosuppressed recipients.
  • Vaccine considered safe in adults if T-helper
    count gt200 /or T-helper gt14
  • If immune serum globulin prescribed to prevent
    Hep A, separate injections by at least two weeks
  • Role of measuring serum IgG measles antibody
  • Use of gammaglobulin if inadequate antibody in
    AIDS, dose suggested is 15 ml IM. IVIG may also
    be okay.

15
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16
YELLOW FEVER
  • Mosquito-borne disease in tropical South America
    and Sub-Saharan Africa
  • Severity of illness from flu-like illness to
    severe hepatitis and hemorrhagic fever with a
    classic biphasic illness
  • Fatality rate of severe disease ranges from 20
    to 65
  • Not known if HIV influences presentation of
    illness
  • Asymptomatic HIV recipients of vaccine without
    adverse effects
  • Lower antibody titers in HIV children
  • Consider measurement of antibody titer after
    vaccination
  • Vaccine not recommended in symptomatic
    HIV-positive adults, certainly not if T-helper
    count lt200.

17
GLOBAL DISTRIBUTION OF YELLOW FEVER, 1996
18
YELLOW FEVER
  • Options to taking vaccine
  • Avoiding areas of transmission altogether
  • If in an area of potential exposure, meticulously
    avoiding mosquito bites
  • Vaccine waiver letter-this may not be accepted at
    border. Need to arrange this with consulate prior
    to leaving USA
  • Distinguish requirements of country from actual
    zones of endemicity

19
HEPATITIS A
  • Vaccine response is lower in HIV patients, with
    dramatically low response rate in patients with
    lt200 cells/mm3(Kemper et al, JID 2003 April 15
    187(8)1327-31)
  • Know if measurable IgG prior to travel. However,
    actual protective titer against infection is
    unknown.
  • Generally, if less than one month prior to
    travel, give immune serum globulin with option of
    starting Hepatitis A vaccine series at same time.
    There are no current recommendations for an
    accelerated schedule.
  • Dose of immune serum globulin 0.02 ml/kg body
    weight IM for trip less than three months. If
    longer trip, give 0.06 ml/kg IM.
  • Prolonged viral shedding reported in HIV
    patients with acute Hep A

20
HEPATITIS B
  • Know immune status prior to travel
  • Risk to international travelers generally low
  • Must warn susceptible patients of sexual risk of
    acquisition
  • Consider extra doses of vaccine if patient a
    non-responder (Rey et al Vaccine 2000 Jan 18
    18(13)1161-5)

21
MENINGOCOCCUS
  • Endemic to sub-Sahara Africa during the dry
    season, occasional epidemics reported elsewhere
  • Vaccine required for annual Hajj in Mecca
  • Very scant information on HIV and disease. No
    mention on efficacy of vaccine in HIV infection

22
JAPANESE ENCEPHALITIS
  • Caused by a flavivirus, transmitted by mosquito
  • Endemic to rural areas of SE Asia, varies often
    with season
  • Most cases are subclinical. Symptomatic disease
    presents as an acute encephalitis--? seizures,
    paralysis, coma, death prolonged recovery in
    survivors and permanent brain injury in some
  • It is a rare disease of travelers
  • Killed vaccine recommended for travelers with
    prolonged stays in endemic areas
  • Vaccine occasionally causes severe allergic
    reaction requiring emergent care
  • One study demonstrating reduced antibody titers
    in HIV children vaccinated with JE vaccine
  • Alteration in presentation of illness in
    HIV-infected people not known

23
POLIO
  • Most world transmission currently in south Asia
    and sub-Sahara Africa
  • Only inactivated polio vaccine (IPV) available in
    the USA
  • Usually give one adult dose, unless primary
    series never done or completed

24
OTHER VACCINES
  • Typhoid two vaccines available one live and one
    killed-use only the latter in HIV patients.
  • Typhim Vi has lower antibody response rate in
    patients with less than 200 CD4 T lymphs
    (Vaccine 1999 Aug 617(23-24)2941-45)
  • Influenza-year-round endemicity in the tropics
    and April - September in southern hemisphere. No
    recommendations on revaccinating prior to travel
  • Diptheria/Tetanus
  • Pneumococcus

25
PENICILLIUM MARNEFFEI
  • Fungal infection endemic to SE Asia, acquired by
    inhaling spores
  • Opportunistic infection in AIDS
  • Chronic illness with fever, weight loss, anemia,
    generalized lymphadenopathy, hepatomegaly,
    umbilicated papules. Other organ systems can also
    be involved.
  • Diagnosisbone marrow, skin lesion, blood culture
  • Treatment Ampho B, followed by itraconazole

26
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27
VISCERAL LEISHMANIASIS
  • Protozoan parasite transmitted by sandflies
  • 90 world cases acquired in India, Bangladesh,
    Sudan, Nepal, Brazil and also endemic in
    Mediterranean countries
  • Typically a chronic illness with prolonged
    incubation period. Typically have
    hepatosplenomegaly, fevers, weight loss
  • In AIDS, worse cytopenias, and atypical
    presentations pleuropulmonary, GI
  • Serologic tests less sensitive in AIDS
  • Lower treatment response in AIDS
  • HAART and secondary prophylaxis improves survival

28
TUBERCULOSIS
  • Know PPD status prior to trip
  • Repeat PPD after return, especially after
    prolonged trip.
  • Risk of acquisition might be much higher in
    health care setting

29
APPROACH TO THE RETURNINGHIV-POSITIVE TRAVELER
  • Review dates and itinerary
  • More aggressive evaluation of asymptomatic
    patient if visit to developing areas was
    prolonged
  • For symptomatic patients, check incubation
    periods for the more common diseases of
    travelers
  • Short (less than one week)bacterial diarrhea,
    Cryptosporidium, hemorrhagic fevers
  • Medium (up to one month) Giardia, Entamoeba,
    Malaria, Salmonella typhi, leptospirosis
  • Long Malaria, Visceral leishmaniasis, viral
    hepatitis, amoebic liver abscess,
    Schistosomiaisis

30
EOSINOPHILIA
  • May see this anyway in HIV-infected persons
  • However, in setting of travel to indigenous
    areas, helminthic infections should be looked for
    in fecal smears

31
SUMMARY
  • Precautions generally same for HIV and non-HIV
    infected travelers
  • Decisions regarding live vaccines are very
    weighted to patients immune status
  • May anticipate lower response to all vaccines and
    hence increased risk of disease
  • Incomplete information currently on need for dose
    or drug changes for malaria prevention in
    patients taking ritonavir
  • Patients taking proper precautions and not
    severely immunocompromised should do well.
  • Sometimes, travel itinerary should be modified to
    avoid potential exposures
  • Differential diagnosis of illness in returning
    HIV-positive traveler can be very broad both in
    short term and long term follow-up
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