Preparing HIV+ Patients for Travel I have nothing to disclose Greg - PDF document

10/28/2016 Disclosures Preparing HIV+ Patients for Travel  I have nothing to disclose Greg Melcher, M.D. Professor of Clinical Medicine Division of Infectious Diseases UCSF  Learning Objectives Approach to Traveler Health  Develop an approach to the evaluation of the  Assessment 4-6 weeks prior to departure HIV+ traveler  Medical history  Understand the role of immune suppression  Specific itinerary in modifying pre-travel vaccination recommendations  Activities  Understand how to use various pre-travel  Accommodations and food plans resources to tailor recommendations 1

10/28/2016 HIV+ female, CD4 550 HIV+ female, CD4 550  24 yo female plans 3 month trip to Brazil  Veterinary tech  Medications: ABC/3TC/DTG, BCPs  Up to date with MMR, Prevnar-13, Pneumovax, Tdap, Influenza, Hepatitis A & B  Winter season, living in group camp in rural Amazon river basin  Food prepared in group kitchen by program staff http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised.mission_disaster/brazil?s_c id=ncezid-dgmq-travel-single-002. Accessed 29 Sep 2016 Q1: Which of the following indicated HIV+ female, CD4 550 vaccines should not be administered to this patient?  Hepatitis A  Hepatitis B  Rabies  Typhoid oral (Ty21a)**  Yellow fever http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised.mission_disaster/brazil?s_cid= ncezid-dgmq-travel-single-002. Accessed 29 Sep 2016. 2

10/28/2016 HIV+ female, CD4 550 Q2: Which ART regimen has the lowest risk Malaria Risk for drug-drug interactions with malaria prophylaxis?  Abacavir/ lamivudine/ dolutegravir**  Tenofovir/ emtricitabine/ rilpivirine  Tenofovir/ emtricitabine/ efavirenz  Abacavir/ lamivudine/ darunavir/ ritonavir  Tenofovir/ emtricitabine/ darunavir/ cobicistat http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/yellow-fever-malaria- information-by-country/brazil#4751. Accessed 29 Sep 2016. HIV+ female, CD4 550 Travelers’ Diarrhea  Three or more unformed stools in a 24 hr period  Vectorborne illness risk in Brazil during travel or up to 7 days after  Dengue virus  Oral rehydration plus anti-motility agent such as  Chikungunya virus loperamide  Zika virus  Severe non-bloody diarrhea  Azithromycin 1 gram  American trypanosomiasis (Chagas  Ciprofloxacin or levofloxacin 500 mg disease) Freedman DO et al. N Engl J Med 2016;375:247-60. 3

10/28/2016 In-Office Interventions Specific Itinerary-related Topics  Administer appropriate vaccinations  Vectorborne disease personal protection  Design malaria prophylaxis (if indicated)  Altitude sickness  Counsel on general traveler advice  Bloodborne and sexually transmitted  Food and water precautions infections  Oral rehydration  Respiratory illnesses including  Self-treatment for severe diarrhea tuberculosis  Mosquito protection  Rabies and other zoonotic infections  Swimming and water exposure hazards Specific Itinerary-related Topics CDC Website Counseling Topics  Medical care abroad  Provide medical condition letter  Research health care facilities  Discuss medical evacuation insurance  Healthy traveler packing list http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised.mission_disaster/brazil?s_cid=nc ezid-dgmq-travel-single-002. Accessed 4 Oct 2016 4

10/28/2016 HIV+ male, CD4 142 HIV+ male, CD4 142  62 yo male plans trip to participate in the Hajj  Up to date for MMR, Pneumovax, Prevnar-  AIDS diagnosed 14 years ago 13, Tdap, Influenza, Hepatitis A & B  Pneumocystis jiroveci pneumon ia  Tour group with planned meals and hotels,  PMH: hyperlipidemia, hypertension adventurous eater  Planned excursions to Cairo, the Nile delta and  Medications: TDF/FTC, DRV/r, TMP/S, lisinopril, Red Sea coast atorvastatin  Viral load undetectable Q3: Which one of the following vaccines is HIV+ male, CD4 142 indicated and safe for HIV+ patients, AIDS/CD4 < 200 mm 3  Yellow fever vaccine  Zoster vaccine  Meningococcal conjugate vaccine**  Live typhoid (Ty21a) vaccine  Measles-Mumps-Rubella (MMR) vaccine 5

10/28/2016 Saudi Arabia Vectorborne Dengue Fever in Africa and Middle East Illnesses http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised/saudi-arabia?s_cid=ncezid- http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/dengue. Accessed 4 Oct dgmq-travel-single-002. Accessed 5 Oct 2016. 2016 Map of Saudi Arabia Egypt Vectorborne Illnesses http://wwwnc.cdc.gov/travel/destinations/clinician/immune_compromised/egypt?s_cid=ncezid-dgmq- www.mapsofworld.com. Accessed 4 Oct 2016. travel-single-002. Accessed 5 Oct 2016. 6

10/28/2016 HIV+ male, CD4 142 HIV+ male, CD4 142  Vaccination recommendations  Patient inquires about risk for schistosomiasis  Typhoid Vi vaccine while in Egypt  Meningococcal conjugate vaccine  Acquired by swimming or bathing in fresh water  Counseling for avoidance of vector-borne rivers and lakes and zoonotic illnesses  Cercariae forms penetrate intact skin  Endemic areas include the Nile River valley and  General pre-travel counseling lakes but not the delta region or the Red Sea  General post-travel counseling Post-Travel Evaluation References  Advise patients to seek evaluation post-travel  Freedman DO, Chen LH, Kozarsky PE. Medical Considerations  Fever before International Travel. N Engl J Med 2016;375:247-60.  Chronic diarrhea  Freedman DO, Kotton CN. Immunocompromised Travelers. In:  New rash Centers for Disease Control and Prevention. CDC health information for international travel 2016. New York: Oxford  Most common diseases University Press, 2016:622-33.  Malaria  http://wwwnc.cdc.gov/Travel. Accessed 29 Sep 2016.  Typhoid  Freedman DO, Weld LH, Kozarsky PE, et al. Spectrum of Disease  Dengue and Relation to Place of Exposure among Ill Returned Travelers.  Rickettsial infections N Engl J Med 2006;354:119-30.  Diarrhea Freedman DO et al. N Engl J Med 2006;354:119-30 7