preventing global travel associated...
TRANSCRIPT
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Preventing Global
Travel Associated
Infections
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Sunanda Gaur, MDProfessor Of Pediatrics
Rutgers Robert Wood Johnson
Medical School
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Global Travel (US)
Over 68 million Americans traveled abroad in 2014, a record number, up 10 percent from 2013. ( U.S. Department of Commerce)
20% of US population are first- or second-generation immigrants
Long-distance travel, especially to Asia and Africa, has increased disproportionately
Travel frequency is also increasing for persons with comorbid conditions, those traveling for business, or those visiting friends and relatives (VFR)
As many as 35-40% of travelers going abroad indicate that visiting friends and relatives was the main purpose for their trip—a total of nearly 10 million travelers per year
Ann Intern Med. 2013;158:456-468
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GeoSentinel Surveillance Network ( ISTM & CDC ) (2007–2011)
Approximately 3% have vaccine preventable illness
( Hep A, Typhoid Fever, Influenza)
www.istm.org/geosentinal
Ann Intern Med. 2013;158:456-468
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Children and International Travel
• US Office of Travel and Tourism Industries (2011): 8% of 60 million international travelers
were children
• Children presenting ill after international travel were less likely to have received pre-travel
medical services
• Children were more likely to be hospitalized due to travel related illnesses
• Children often belong to the VFR (Visiting Friends and Relatives) group.
• VFR group children tend to be younger ( < 5yrs), present late to pre-travel care, have
travelled for longer duration, refuse vaccines
• Approximately 60% of children travelling to the “tropics” develop a travel associated illness.
Hagmann S et al, Journal of Pediatric Infectious Disease Society, Vol2,No. 4,pp327-34,2013.
Newman- Klee et al. Am J trop Med Hyg 2007;77(4) 764-769
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Destination Specific Vaccines
Vaccine Risk Region
Yellow fever Parts of Africa and South America. Check
requirement
Hepatitis B SE Asia, parts of Africa, Middle East, Pacific
Islands, parts of South America for longer
stays
Hepatitis A All except Japan, Australia, New Zealand,
north and west Europe, North America
(excluding Mexico)
Typhoid South Asia, Africa, SE Asia
Meningococcal Sub Saharan Africa, Haj
Japanese Encephalitis Indian Subcontinent, SE Asia
Cholera Outbreak setting
Rabies South and SE Asia, Mexico, parts of South
and Central America and Africa
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Don’t Forget the “Routine Vaccines”
• MMR (can start at 6 months)
• DTaP or TdaP (accelerate if needed, 4wk interval)
• Varicella
• IPV (accelerate if needed, 4wk interval)
• Hepatitis B
• Hepatitis A
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The Meningococcal Meningitis Belt
• Mostly Type A or W
• Dry season Nov-May
• Routine vaccine in US at
ages 11-12 yrs, booster
16 yrs
• For younger children who
travel age-appropriate
formulation and series of
Menactra or Menveo
(A,C,W, Y)
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GEOGRAPHIC DISTRIBUTION OF HEPATITIS A VIRUS INFECTION
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Hepatitis A Prevention for Travelers
• Vaccine indicated for travel to countries with high or intermediate endemicity
• 2-doses, 6-18 months apart
• Highly Immunogenic vaccine
– 88-90% seroconversion in 2 weeks (one pre travel dose acceptable,
complete after return)
– 99% seroconversion after 2nd dose
• Duration of protection – Not established( likely 15-25 years or more)
• Children <12 months, or allergic to a vaccine component
– single dose of IGIM (0.02 mL/kg) - effective protection for up to 3 months.
• Older adults, immunocompromised people, and people with chronic liver
disease traveling to an area in < 2 weeks ( Vaccine + IGIM).
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Yellow fever Endemic Zones
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Yellow Fever Vaccine
• Live virus vaccine
• Required if entering endemic area or going from an endemic region to non
endemic region
• Approved for children > 9 months old
• Do not administer simultaneously with cholera vaccine
• Under 4 months – unsafe (high incidence of post vaccination encephalitis)
• Fulminant Hepatitis in elderly
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Rabies
• Rabies in travelers – an underestimated risk
• 1980 – 1997 12/36 (33%) of human rabies deaths in US have been related to rabid animals
outside the US
• Canine rabies in endemic in the Indian Subcontinent, China, SE Asia, Philippines, Latin
America, Africa and the former Soviet Union
• In many rabies endemic countries, only Equine RIG and older nerve tissue rabies vaccines
are available
• Equine RIG – significant risk of serum sickness
• Nerve Tissue type rabies vaccine is not as effective, and theoretical danger of allergic
myeloencephalitis exists
• Pre-exposure prophylaxis with HDCV or PCEC vaccine should be considered in selected
cases
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Japanese Encephalitis Vaccine
• Inactivated vaccine
• Efficacy = 91%
• Booster every 3 years
• Not approved for children under 3 years
• Side effects– Local reaction (10-25%)
– Fever (10-25%)
– Hypersensitivity reaction (0.6%)
• Indications– Expatriates living in Asia
– Travel to endemic regions for >30 days during transmission season, especially travel to rural areas
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Oral Ty21a Vaccine
• Live attenuated vaccine
• Enteric coated capsule – 1 cap every other day x 4 doses
• Efficacy – 65%
• Minimal to no side effects
• Contraindicated in immune compromised individuals
• Mefloquine can inhibit growth of Ty21a in vitro; delay vaccine at least 24
hours before or after Mefloquine
• Concomitant oral antimicrobials may effect vaccine efficacy
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Typhoid Vaccines Available in the United States
Drug Ty21a ViCPS
Type Live Attenuated Polysaccharide
Route Oral IM
Min Age of Receipt 6 2
No. Doses 4 1
Booster frequency,y 5 2
Side Effects(incidence) <5% <7%
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VFR and Increased Infectious Disease Risk
• In 2011, 55% of imported malaria cases in US occurred among VFRs
• GeoSentinel Surveillance Network : VFRs are 8 X more likely to be diagnosed with
malaria than tourist travelers
• in 2011, 59% of those with severe malaria were VFRs, (mostly from West Africa).
• 66% of typhoid cases occur in VFRs, mostly from South Asia and Latin America
• A recent Canadian study : 94% of typhoid cases in Quebec were in VFRs, mostly from
the Indian subcontinent
• VFR children aged <15 years are at highest risk for hepatitis A, and many are
asymptomatic
• Tuberculosis, hepatitis B, cholera, and measles, occur more commonly in VFRs
http://wwwnc.cdc.gov/travel/yellowbook/2016/advising-travelers-with-specific-needs/immigrants-returning-home-
to-visit-friends-relatives-vfrs
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Why are VFR at increased risk ?
• Lack of awareness of risk. Many VFRs assume they are immune; In those who left their
countries of origin years ago, immunity may have waned ….
• Less than 30% have a pre-travel health care encounter
• Financial barriers to pre-travel health care
• Cultural and language barriers with health care providers
• Lack of trust in the medical system
• Last-minute travel plans and longer trips
• Travel to higher-risk destinations, such as staying in homes and living the local lifestyle that
often includes lack of safe food and water and bed net use
• Divergent health beliefs
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Spread the Word. Make a Difference.
Destination India
A Word-of-Mouth Travel Health Awareness Project for Asian Indians in New Jersey, New
York, and Connecticut
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Travel Health Awareness Program
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• Develop & implement word-of-mouth travel health education to
Asian Indian adults living in New Jersey, New York & Connecticut
• Measure Travel Health Awareness pre/post program
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92% of consumers trust
recommendations
from people they know
84% of those consumers will take
action based on recommendations
from people they know
—SOURCE: Nielsen Trust in Advertising
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HealthTalkers Spread the word!
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HealthTalkers Feel Great About Participating!
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© HealthTalker, LLC 2015 – All rights reserved.
BUILD THE MOVEMENT EDUCATE AND PREPARE ENGAGE THE MOVEMENT MOTIVATE & ENCOURAGE
• Identify advocates
• HealthTalker Invitations
• EHR - HealthTalker is a
Practice Fusion Partner
• Patient Panels
• Etc.
• Welcome emails to new
HealthTalkers
• Welcome Kit with:
• Member Guide
• Education Materials
• Disease Awareness Center
41 2 3
• Private Portal:
MyHealthTalker.com
• Shareable Content
• Share Tools
• Education tools
• Facts
• Social Media
• Community Management and
engagement
• Encouragement Emails
• Knowledge sharing
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Health Talker Meningococcal Vaccine Case Study
Objectives
– Engage consumers to spread the word about being protected
from Meningococcal disease.
– Spread the word that a booster dose is required to stay protected.
– Measure the market impact of the HealthTalker Program using independent
third party research.
• Recruited moms (mostly) between the ages 35-54 who had children 10-18 years
old ( 2013-14)
• Once engaged, participants were provided the tools and resources they needed in
order to share information with others via in-person conversations and online
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1,377HealthTalkers
recruited in 10
weeks
20.6Conversations lasted
on average 20.6
minutes
79%Conversations occurred
with moms aged 35-54
28Average number of primary
conversations per
HealthTalker
56%Intent to ACT:
See their physician
303,539Total number
of conversations*
HealthTalker Case Study
26
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100,000+Additional PreTeens
& Teens Protected
(attributable to Health
Talker)
5:1Returned ROI in
excess of 5:1
Market impact measurement by an independent, 3rd party market research
organization. The manufacturer provided all sales call data, individual marketing
interventions, PR campaigns, paid and organic search, digital display advertising and
sales promotion. Conversation data was captured directly from the HealthTalkers.
The HealthTalker Movement was measured 4 times during the length of the program
(19 month) using a sophisticated mixed method analytics and econometric modeling of
the sales and marketing data provided by the manufacturer, and government provided
utilization data ( Zip code specific)
MEASURE, MEASURE AND MEASURE AGAIN!
HealthTalker Case Study
27
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Conversation Starters - Fact Cards
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ndiQ2: Imagine you are preparing for a trip to India. Check the
topics you think about while planning.
94%
93%
74%
67%
59%
50%
45%
32%
29%
28%
0 0.25 0.5 0.75 1
Airline Tickets
Passport/Visa
Trip Itinerary
Money Exchange
Preventing Diarrhea
Malaria Medication
Lodging
Typhoid Vaccine
Hepatitis A
Travel Medical Insurance
Baseline Awareness Survey. N = 310
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ndiQ3: For your trip to India, when would you visit a health care
provider to discuss your trip?.
Executive Summary
35%
34%
21%
10%
0 0.1 0.2 0.3 0.4
Not at all
4-6 weeks before my trip
1-2 weeks before my trip
3 or more months before my trip
Baseline Awareness Survey
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ndiQ4: If your doctor recommended it, which vaccines would you
consider receiving for your trip?
Executive Summary
52%
50%
41%
32%
31%
30%
18%
0 0.15 0.3 0.45 0.6
Typhoid
Hepatitis A
Hepatitis B
None
Measles
Yellow Fever
Rabies
Baseline Awareness Survey
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Kibera, Nairobi