December 2004 Dominique Tessier, md, ccfp, fcfp

HIV Case studiesBrazil

Videoteleconference

Dominique Tessier, md, ccfp, fcfp

Medical director

Medisys Travel Health Clinics

Post-exposure prophylaxis clinics

Hôpital Saint-Luc, CHUM

December 2004 Dominique Tessier, md, ccfp, fcfp

Objectives

• Identify specific risks issues for hiv positive travellers

• Recognize indications and contra-indications to immunizations for HIV positive individuals

• Identify pro and cons of drug holidays

December 2004 Dominique Tessier, md, ccfp, fcfp

Anthony, 33 years old, HIV +

Men having sex with men (MSM)HIV positive since 1999

CD4 at 230Viral load at 11,237

December 2004 Dominique Tessier, md, ccfp, fcfp

Anthony, 33 years old, HIV +Wants to do a religious retreat in the North of Brazil

for 3 months.Wants to stop all his medications to purify his body.Not sure about receiving immunizations.Comes for your advise.

CD4 at 230viral load at 11,237

December 2004 Dominique Tessier, md, ccfp, fcfp

Anthony, 33 years old, HIV +

• Vaccines?• Anti-malarials?• First Aid Kits?• Recommendations

CD4 at 230

Viral load at 11,237

December 2004 Dominique Tessier, md, ccfp, fcfp

Individualisation of recommendations requires time and knowledge of

•Questions to ask Anthony?

December 2004 Dominique Tessier, md, ccfp, fcfp

Individualisation of recommendations requires time and knowledge of

•Where, Why, When, How, How long•Type of Travel•Activities •Health status•Special needs•Experience•Fears and beliefs•Budget

December 2004 Dominique Tessier, md, ccfp, fcfp

Evaluation of the potential risks

•Medical exam•Previous Immunizations•Vector precautions•Cardiopulmonary problems•Allergies•HIV or other test required•Psychological evaluation•Age related specificities•Handicaps

December 2004 Dominique Tessier, md, ccfp, fcfp

Estimated monthly incidence of health problems per 100 000 travellers to developing countriesWHO 2001

December 2004 Dominique Tessier, md, ccfp, fcfp

Travel considerations: HIV+• Restrictions on crossing international borders,• Vaccination requirements,effectiveness and safety• Increased susceptibility to infections• Accessibility of health care • Medical evacuation

• Travel counselling regarding: • Food and water and self-treatment of travellers' diarrhea• Vector protection• Sun protection• Safety• Sexual and body fluids protection

December 2004 Dominique Tessier, md, ccfp, fcfp

Restrictions on crossing international borders

A number of countries screen for evidence of HIV infection and can deny entry to seropositive individuals.

Unofficial list of entry requirements may be obtained from: www.hwc.ca/hpb/lcdc.

Such requirements may change without notification

• Verification with consulate recommended

December 2004 Dominique Tessier, md, ccfp, fcfp

Strategies to increase adherence during travel

• For HIV + individuals in general, what can be done to help them with adherence?

December 2004 Dominique Tessier, md, ccfp, fcfp

Strategies to increase adherence during travel

• Information on risks and possible side effects• Realistic choice of medications• Contract with patient• Good counseling• Collaboration from co-traveler• Establish specific strategies for specific

situations• Consider trial with candies

December 2004 Dominique Tessier, md, ccfp, fcfp

A pill counter can facilitate adherence

December 2004 Dominique Tessier, md, ccfp, fcfp

Potential complications

• Toxicity to be monitored:– Hematologic: anemia, neutropenia,

thrombocytopenia, pancytopenia

– Hepatic: elevation of enzymes

– Neurological: neuropathies

– Renal: stones– Cardio-vascular; metabolic syndrome

• Drug Interactions– cytochrome P 450: induction or inhibition

December 2004 Dominique Tessier, md, ccfp, fcfp

HIV Travelers and Drug Holidays

Photo DT Tibet 2000

December 2004 Dominique Tessier, md, ccfp, fcfp

Susceptibility to infections

• Many infections encountered by travelers are associated with increased morbidity and mortality in HIV+ persons.

• These individuals are also more likely to have adverse reactions to drugs used to treat infection.2

December 2004 Dominique Tessier, md, ccfp, fcfp

December 2004 Dominique Tessier, md, ccfp, fcfp

Vaccination is the most effective strategy for Travel Medicine practitioners

December 2004 Dominique Tessier, md, ccfp, fcfp

Vaccination is one of the greatest public health achievements in the United states during the 20th century.

Immunizations have – eradicated smallpox; – eliminated poliomyelitis in the Americas;– controlled measles, rubella, tetanus, diphtheria,

haemophilus influenzae type b, and other infectious diseases »

David SATCHERAssistant SECRETARY For HEALTH AND, Surgeon GENERALU.S. Public Health Service, Department of Health and Human Services AUGUST 3, 1999

December 2004 Dominique Tessier, md, ccfp, fcfp

General information Regarding HIV and Travel

Health Information for International Travel

CDC’s « The Yellow book »http://www.cdc.gov/travel/hivtrav.htm

Immunizations and immunosuppression

December 2004 Dominique Tessier, md, ccfp, fcfp

Vaccination requirements

• Yellow fever: – Required for

international travel in some countries.some countries.

– Recommended in many Recommended in many other countriesother countries

– Contra-indicated if Contra-indicated if immunosuppressedimmunosuppressed

December 2004 Dominique Tessier, md, ccfp, fcfp

Yellow Fever Vaccine

• Disease’s case-fatality rate is more than 60% in non-immune adults

• Vaccine – Almost total efficacy– Excellent tolerance

• Rare contra-indications– True allergy to egg protein– Cellular immunodeficiency

December 2004 Dominique Tessier, md, ccfp, fcfp

Yellov Fever endemic zone in Africa

December 2004 Dominique Tessier, md, ccfp, fcfp

Yellow Fever endemic zone in the Americas

December 2004 Dominique Tessier, md, ccfp, fcfp

Vaccinations Requirements, Effectiveness and Safety

Severely immunocompromised travellers• should be recommended to change his-her

itinerary or • to strictly follow mosquito physical precautions

if trip unavoidable• should be aware that, in the face of an epidemic,

he or she could be denied entry in some countries if not immunized.

December 2004 Dominique Tessier, md, ccfp, fcfp

Fatal Yellow fever in traveler returning from Venezuela, 1999

• 48 yearl old male from California

• 10 day trip from September 16 to 26

• first symptoms September 28

• died on October 4

December 2004 Dominique Tessier, md, ccfp, fcfp

YELLOW FEVER VACCINE-ASSOCIATED DEATH -

SPAIN26 Oct 2004

A 26-year-old woman from Onuba died from yellow fever stemming from a post-vaccination reaction. The woman was admitted to Hospital because of fever and multi-organ failure, having had, in addition to fever, malaise, vomiting, and diarrhea during the previous days.

The patient was also vaccinated for diphtheria and tetanus.

December 2004 Dominique Tessier, md, ccfp, fcfp

Yellow Fever in Brazil - Federal District/Brasilia

• A young male farmer, age 22, died of YF in the Federal district of Brasilia. Although the population of the district has a high rate of vaccination with YF vaccine (>90%), the deceased refused vaccination on two previous occasions.

December 2004 Dominique Tessier, md, ccfp, fcfp

Reaction to Yellow Fever Vaccine Linked to Several Recent Deaths

• In 1996 and 1999, 2 U.S. and 2 European unvaccinated travelers to areas where YF is endemic died of YF viral infection (1,8).

• The risk for YF in unvaccinated travelers probably is increasing because potential YF transmission zones are expanding to include urban areas with large populations of susceptible humans and abundant competent mosquito vectors.

December 2004 Dominique Tessier, md, ccfp, fcfp

Vaccines to be generally avoided in immunocompromised

Tuberculosis (BCG) : no exception– Severe complications have been reported after

immunization with live vaccines in immuno-suppressed hosts.

MeaslesMumpsRubella: – Only if no immunosuppression

Varicella: – not recommended– Immunize close contacts

December 2004 Dominique Tessier, md, ccfp, fcfp

Vaccines to be generally avoided in immunocompromised

• Yellow fever:– only if strong indication

• Oral polio (Sabin): – use injectable vaccine (Salk)– Avoid for close contacts

• Typhoid: – use injectable vaccine (Typhim Vi), not

oral (Vivotif)

December 2004 Dominique Tessier, md, ccfp, fcfp

Vaccines to be avoided in immunocompromised

BCG no exception MMR only if no immunosuppression Oral cholera not usually recommended Varicella immunize close contacts Yellow fever only if strongly indicated

and no severe immunosuppression

Oral typhoid use injectable vaccine Polio (OPV)use injectable vaccine (IPV)

avoid for close contacts

December 2004 Dominique Tessier, md, ccfp, fcfp

December 2004 Dominique Tessier, md, ccfp, fcfp

Vaccines considered safe for immunosuppressed

• Diphtheria and Tetanus• Hepatitis A, B and A & B• Hib• Influenza• Japanese encephalitis rare indications• Meningococcal• Pertussis prefer acellular• Polio, inactivated• Pneumococcal• Rabies pre or post exposure

December 2004 Dominique Tessier, md, ccfp, fcfp

Vaccinations Requirements, Effectiveness and Safety

Some severely immunocompromised individuals may respond poorly to immunization.

Other strategies may thus be needed to protect them such as:

Passive immunization with specific immunoglobulins

Preventive medication Rapid treatment.

December 2004 Dominique Tessier, md, ccfp, fcfp

Increased morbidity and mortality. Hepatitis A.

• Up to 25% of HIV+ adult patient with hepatitis A will require hospitalization.

• Increased prevalence of fulminant hepatitis.

• Pre-existing liver disease increases the risk of fulminant hepatitis and fatality.

• Persistent infection does not occur.

December 2004 Dominique Tessier, md, ccfp, fcfp

Increased morbidity and mortality. Hepatitis A.

• All HIV+ seronegative individuals for hepatitis A or B should be offered the vaccine or, if severely immunosuppressed, immunoglobulins (Hepatitis A protection).

• Hepatitis A immunization should be a priority for patients with hepatitis B or C co-infection.

December 2004 Dominique Tessier, md, ccfp, fcfp

Rabies in the World

• Only 20 countries, mostly islands, are reported « rabies free ».

• Dog are often the vectors.• Highest incidence in asia,

with over 33,000 cases of human rabies per year, the majority, estimated 30,000, in india .

Photo DT Acapulco 1995

December 2004 Dominique Tessier, md, ccfp, fcfp

Prescribing medications

• Malaria

• Diarrhoea

• Altitude sickness

• Motion sickness

• Special needs

December 2004 Dominique Tessier, md, ccfp, fcfpPhoto DT Iquitos

December 2004 Dominique Tessier, md, ccfp, fcfp

Travellers’ diarrhea

December 2004 Dominique Tessier, md, ccfp, fcfp

Boil it, peel it, cook it or forget it: easy to remember, impossible to follow.

• The majority of travellers will make a “faux-pas” with food and water within 48 hours.

December 2004 Dominique Tessier, md, ccfp, fcfp

Photo DT Lhassa, Tibet 2000

Travellers’ diarrhea

• Usually a minor problem with a high potential of– Uncomfort– Complications in

HIV+

December 2004 Dominique Tessier, md, ccfp, fcfp

Travellers’ diarrhea

• Anthony has a chronic diarrhea when he takes his medication– How can he recognize if he gets an

infection during his trip?

December 2004 Dominique Tessier, md, ccfp, fcfp

Travellers’ diarrhea

• Anthony has a chronic diarrhea when he takes his medication– How can he recognize if he gets an

infection during his trip?• An increase in number of passages per day

(double of usual)• A change in texture

December 2004 Dominique Tessier, md, ccfp, fcfp

Travellers’ diarrhea

• A diet rich in fibers (psyllium) can help normalize the stools.

December 2004 Dominique Tessier, md, ccfp, fcfp

When there is evidence of a possible infection persisting after usual treatment, a culture and 3 search for parasites should be done.

Travellers’ diarrhea

December 2004 Dominique Tessier, md, ccfp, fcfp

First aid kit

December 2004 Dominique Tessier, md, ccfp, fcfp

December 2004 Dominique Tessier, md, ccfp, fcfp

Re-used needles

December 2004 Dominique Tessier, md, ccfp, fcfp

Trauma: car accidents, sport injuries

December 2004 Dominique Tessier, md, ccfp, fcfp

Sexual counselling

December 2004 Dominique Tessier, md, ccfp, fcfp

• Hiv-Infected Traveler Precautions

Health information for international Travel, 1999–2000:

• Safety of vaccines for hiv-Infected Persons. CDC

December 2004 Dominique Tessier, md, ccfp, fcfpPhoto DT Tibet 2000