BELGIAN CONSENSUS MEETING - Institute of Tropical Medicine ... · “Salmonella typhi” – but a...

BELGIANCONSENSUS MEETINGon TRAVEL MEDICINE

May 31, 2013

Belgian Scientific Study Group on Travel

Medicine

Pr. A. Van Gompel (ITG)Pr. F. Jacobs (Hôp. Erasme, ULB)

Pr. P. Lacor (UZ-Brussel) Dr. Ph. Leonard (CHU-ULg)

Pr. W. Peetermans (U.Z. - K.U.Leuven) Pr. S. Callens(UZ.- U.Gent) Dr. S.Quoilin (iph.fgov.be)

Dr.P. Soentjens (Belgian Defence)Pr. B. Vandercam (CHU. St. Luc, UCL)

Pr. Y. Van Laethem (CHU. St. Pierre, ULB)PART 2 other vaccinations & varia - version 23-08-13

REPORTBELGIAN CONSENSUS MEETING on TRAVEL MEDICINE

May 31, 2013 – PART 2

2013

• The consensus meeting was chaired by A. Van Gompel• Secretary of the meeting was Y, Van Laethem• A preliminary PowerPoint, prepared by A. Van Gompel,

was presented• The discussion and recommendations of the

meeting are included in this finale presentation.• The ESSENTIAL SLIDES (pdf-version) & the

CONSENSUS BROCHURE (in Dutch and French) highlighting the proposals for changes will been sent to all participants. May be used for teaching.

• These documents will serve as a proposal for approval by the governmental Belgian Health Council – section Vaccinations, on 10-10-2013

• Responsable final redaction : A. Van Gompel

PART 1• 1.a - Vaccination for Yellow Fever• 1.b - Malaria

PART 2• 2.A - Other vaccinations• 2.B - TD, other infections, …., • 2.C - VARIA

2013

cumulative risk assessment –a long tradition in Belgium

To emphasize the lifelong protection• Polio (1 booster >10 years after complete basic vaccination series)• Hepatitis A (after complete vaccination series if not immune

compromised)• Hepatitis B (if once a titer of 10 IU/ml after complete vaccination

series & if not immune compromised)• MMR (after 2 doses)• Yellow fever (cave legal/administrative problems)To emphasize the lifelong boostability• Rabies (after a complete basic series of injections 1-7-21/28)

2013

,,,hence it is worth the investment by the traveler ,,,

PART 1• 1.A - Vaccination for Yellow Fever• 1.B - Malaria


2013

Basic Vaccinations

- Tetanus-diphteria-pertussis- Poliomyelitis- Measles mumps rubella

Tetanus-Diphteria-Pertussis

Tetanus-Diphteria2013

• Small detail has been changed:

"Gezinnen met een kinderwens en in geval van een zwangerschap"

werd de "en" vervangen door een "of".

"Gezinnen met een kinderwens of in geval van een zwangerschap"

Polio• WHO Polio Eradication Initiative

http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

2013

2011

2012

2012

measles-mumps-rubella

measles-mumps-rubella

– Travelers born after 1-1-1970 (formerly 1960) who had no proven clinical measles or received no or only one vaccine shot require measles vaccination.

– Two doses lifetime are needed for optimal protection.

– Early vaccination – from the age of 6 months on - is actually advised for many European destinations because of measles outbreaks (the dose given before the age of 12 months will not count for the final complete series of “2 doses”)

2012

Mumps

• Never 100 % protective (2 doses : 90 %)• Quid students, electives, etc going to

another university ? • No rationale / place for third dose MMR

2013

• Wat het wetenschappelijk onderbouwd antwoord zou moeten zijn op de opmars van bof onder de gevaccineerde populatie, is nog onduidelijk.

• In de Verenigde Staten is enige ervaring opgedaan met het toedienen van een derde dosis MMR-vaccin tijdens een uitbraak in Orange County, New York, in 2010-2011. Maar de onderzoekers berichtten zelf nogal terughoudend over het effect van hun interventie: “While the use of a third dose of MMR vaccine may have been effective in limiting the size and duration of the outbreak, this finding should not support the routine use of a third dose of mumps vaccine in national vaccinations programs” 56.

• Mocht het ooit tot een aanbeveling komen om in bepaalde situaties of universeel een derde dosis toe te dienen, dan ziet het er niet naar uit dat we moeten vrezen voor meer, andere, of ernstiger postvaccinale verschijnselen dan na de eerste of tweede dosis 57.

- op heden werd door geen autoriteit hierover een beslissing genomen - het gaat nog maar over een beperkt aantal studies met nog net iets teveel “zou” en “wellicht” – een dergelijke upscaling vraagt wel om bekeken te worden in al zijn aspecten – het is nog te vroeg, maar het lijkt wel een mogelijke piste

No rationale / place for third dosis MMR

Travel Vaccinations

1. Hepatitis A 2. Influenza3. Typhoid fever4. Rabies5. Meningococcal meningitis6. Japanese encephalitis7. TBE - FSME

2013

HEPATITIS A

HEPATITIS A• Outbreak of Hepatitis A Virus Infection in

Travelers Returning from Egypt – Eurosurveillance 2013 Hepatitis A tourists Denmark,

UK, Germany, NL, Norway & Sweden returning from Egypt, Nov 12 to March 13

– ECDC_RRA_HAV_travellers_from_Egypt_30_04_2013_EWRS

2013

…the Association of Danish Travel Agents and Tour Operators wrote a special announcement to all its members encouraging them to pay extra attention to inform customers to contact their own doctor for vaccination advice before travelling to Egypt.

INFLUENZA

• Returning travellers with fever are at intermediate risk for influenza, with an incidence between 5 and 15% in febrile travellers returning from subtropical and tropical regions

• Influenza was a frequent cause of fever among these febrile returning travellers (30%).

• Cases occurred throughout the year. • The likelihood of PCR proven influenza increased with higher

probability as estimated on clinical grounds.• The RDTi studied here was of limited use because of a low

sensitivity (20%) in comparison with a meta-analysis study showing a pooled sensitivity of 62.3%.

• The use of this RDTi seemed to lower cost of management and decrease antibiotic use, but these trends were not statistically significant.

CISTM-13-Maastricht

TYPHOID FEVER

TYPHOID FEVER

• Stock rupture of the inactivated vaccine against typhoid fever

• Vivotif ® is again available in the pharmacy (since the end of july 2013)

2013

Message on the ITM-website• We are momentarily dealing with a stock rupture of the vaccine against

typhoid fever in Belgium (and also in the surrounding European countries). This vaccine will probably remain unavailable until early June.

• Some background information about the effectiveness of the vaccine against typhoid fever and about other measures to reduce the risk of typhoid fever:

• In Belgium, the national advice concerning the vaccination against typhoid fever is that vaccination is recommended for:

– Adventurous journeys. – Journeys in the tropics or subtropics for more than 3 weeks.

• The vaccine against typhoid fever (Typhim, Typherix, Vivotif) protects about 60-70% during 3 years against the main cause of typhoid fever, caused by “Salmonella typhi” – but a significant part of the cases of typhoid fever are caused by “Salmonella paratyphi A,B,C”, against which the vaccine provides little to no protection.

• Elimination of the (sometimes very low) risk is impossible, unlike in the case of, for example, malaria prevention and prevention by vaccination against yellow fever and hepatitis A.

• The only reliable alternative to reduce the risk of typhoid fever is to apply the hygienic measures as well as possible. These measures are thoroughly explained in the paragraphs concerning the prevention of traveler’s diarrhea (typhoid fever and paratyphoid fever are transmitted in the same way) in our brochure “How to travel and stay healthy".

IDSA 2012 conference poster 251

RABIES

2013

From 31- 05 - 2013 on:no booster after 1 year or later is advisedanymore for at least 20-30 yearsafter the basic series of 3 shots (1-7-21/28) in persons with normal immunity

2012

2013

France : Haut ConseilSP 2013 02 22 vaccinations contre la rage recommandations

• ? Rabique Pasteur 2.5 IU Sanofi-Aventis• ? Verorab® (Sanofi Pasteur MSD (SPMSD)

2013

FORMER SLIDES

RABIES • The postexposure rabies

management remains the responsibility of the WIV/IPH/ISP.

• After the postexposure rabies vaccination series, the same longterm (lifelong) boostability is present.

2011

NL: http://www.health.belgium.be/eportal/Aboutus/relatedinstitutions/SuperiorHealthCouncil/publications/factsheetsvaccination/index.htm?fodnlang=nl#.UfI__tLDCIA

FR: http://www.health.belgium.be/eportal/Aboutus/relatedinstitutions/SuperiorHealthCouncil/publications/factsheetsvaccination/index.htm?fodnlang=fr#.UfJASdLDCIA

• For category I exposures, no prophylaxis is required;

• For category II, immediate vaccination is recommended;

• For category III, immediate vaccination and administration of rabies immunoglobulin are recommended.

• For categories II and III, thorough washing and flushing (for about 15 minutes, if possible) with soap or detergent and copious amounts of water of all bite wounds and scratches should be done immediately, or as early as possible.Where available, an iodine-containing, or similarly viricidal, topical preparation should be applied to the wound.

• When it is impossible to complete post-exposure prophylaxis with the same CCV, another CCV should be used instead. However, since no study has been done yet on vaccine immunogenicity following changes in the route of vaccine administration (for example, from intramuscularto intradermal) during post-exposure prophylaxis,such changes should be the exception.

MENINGOCOCCAL MENINGITIS

FORMER SLIDES

2011

( )

JAPANESE ENCEPHALITIS

Japanese encephalitis (Ixiaro®)

• 2013 : Ixiaro from the age of 2 months on• CISTM 13 Maastricht : “Based on modeled

data, we expect protection to last for at least 4 years in 95% of vaccinees”

2013

FORMER SLIDES

8. Japanese encephalitis (Ixiaro®)

• The standard scheme requires 2 injections, separated by one month. Afterwards, the traveler remains boostablewhich means that a booster dose can be given after 12-24 months – (later boosters ? 3-5 years ?)

• When the patient was vaccinated with Jevax® previously the consensus meeting gives the advice to use two doses of Ixiaro® when Jevax® dates from five years back or more.

2011

Clinical Infectious Diseases Advance Access published July

9, 2012

2012

TBE FSME

http://www. itg.be/itg/Uploads/MedServ/

FSME%20kaart.pdf

2012FSME

This map is not a FSME-TBE-map BUT shows only the geographical distribution of ticks capable to transmit FSME-TBE

http://www.itg.be/itg/Uploads/MedServ/FSME2.jpg

FORMER SLIDES

2007FSME

PART 1• 1.A - Vaccination for Yellow Fever• 1.B - Malaria


2013

Traveler’s diarrhea • Azithromycin Does Not Increase

Cardiovascular Mortality in the General Population

• The excess cardiovascular mortality previously observed with azithromycin use is attributable to the infection being treated, not the antibiotic, a New England Journal of Medicine study finds.

• Using Danish registries, researchers compared 1.1 million episodes of azithromycin use with either 1.1 million episodes of no antibiotic use or 7.4 million episodes of penicillin V use among adults.

• The risk for cardiovascular death was roughly three times higher with current azithromycin use than with no antibiotic use. However, cardiovascular death rates did not differ between azithromycin and penicillin. This indicates, the authors write, that "the increased risk ... observed in the comparison with no antibiotic use was entirely attributable to the risk of death associated with acute infection" or some other risk factor in patients receiving antibiotics.

• The authors add that while previous research showed a link between azithromycin and cardiovascular mortality in a higher-risk (Medicaid) population, the current study "shows that this effect is not present in the general population."

• NEJM commentators still highlight the potential risk for QT prolongation with use of macrolides and emphasize caution in their use for patients with preexisting cardiovascular conditions.

2013

Journal Watch - Amy Orciari Herman

FORMER SLIDES

Traveler’s diarrhea • Azithromycine ?

2012

RESULTS• During 5 days of therapy, patients taking azithromycin, as compared

with those who took no antibiotics, had an increased risk of cardiovascular death (hazard ratio, 2.88; 95% confidence interval [CI], 1.79 to 4.63; P<0.001) and death from any cause (hazard ratio, 1.85; 95% CI, 1.25 to 2.75; P=0.002).

• Patients who took amoxicillin had no increase in the risk of death during this period.

• Relative to amoxicillin, azithromycin was associated with an increased risk of cardiovascular death (hazard ratio, 2.49; 95% CI, 1.38 to 4.50; P=0.002) and death from any cause (hazard ratio, 2.02; 95% CI, 1.24 to 3.30; P=0.005), with an estimated 47additional cardiovascular deaths per 1 million courses; patients in the highest decile of risk for cardiovascular disease had an estimated 245 additional cardiovascular deaths per 1 million courses.

• The risk of cardiovascular death was significantly greater with azithromycin than with ciprofloxacin but did not differ significantly from that with levofloxacin.

CONCLUSIONS• During 5 days of azithromycin therapy, there was a small absolute

increase in cardiovascular deaths, which was most pronounced among patients with a high baseline risk of cardiovascular disease.

2012

the vaccine failed to protect travellers against ETEC and all cause TD …….

The dermal LT antigen delivery resulted in frequent local rash with some local events persisting for up to 6 months.

CISTM – 13 - MAASTRICHT

The trial vaccine showed no protective efficacy, although delivery of LT bytranscutaneous immunization was demonstrated through the immune response against LT.

Very low rates of LT ETEC strains were observed in travelers to India with moderate to severe TD.

CISTM – 13 - MAASTRICHT

Quid role in travel medicine ?

Racecadotril Tiorfix& Aanpak in de eerste lijn van acute diarree bij het kind

RECENTE INFORMATIE OKTOBER 2012

• Racecadotril (Tiorfix®; hoofdstuk 3.6.4.) is een antidiarreïcum dat in het buitenland gecommercialiseerd is sinds 1993;

• het gaat om een inhibitor van de enkefalinasen (enzymen verantwoordelijk voor de afbraak van bepaalde endogene opioïden, de enkefalines), vooral ter hoogte van de darmmucosa.

• Racecadotril heeft een perifere werking met vermindering van de intestinale hypersecretie.

• De posologie vermeld in de Samenvatting van de Kenmerken van het Product (SKP) is bij volwassenen 100 mg, gevolgd door 100 mg 3 maal per dag, en bij het kind ouder dan 3 maanden 1,5 mg/kg, 3 maal per dag.

• De voornaamste ongewenste effecten zijn secundaire obstipatie en hoofdpijn.• Racecadotril is gecontra-indiceerd bij aanwezigheid van koorts en bloederige of

slijmerige ontlasting (acute dysenterie). • In de vergelijkende studies met loperamide (een opiaatderivaat en remmer van de

intestinale peristaltiek) hadden beide behandelingen een gelijkaardige doeltreffendheid, waarbij de diarree-episode slechts met een paar uur verkortte.

• Men moet voor ogen houden dat de aanpak van acute diarree vooral gebaseerd is op rehydratiemaatregelen, en dat antidiarreïca slechts een zeer beperkte plaats hebben, vooral bij jonge kinderen. De vormen voor gebruik bij kinderen zijn voorschriftplichtig.

Le racécadotril ( Tiorfix®; chapitre 3.6.4.) est un antidiarrhéique commercialisé à l’étranger depuis ‘93;

• il s’agit d’un inhibiteur des enképhalinases (des enzymes responsables de la dégradation de certains opioïdes endogènes, les enképhalines) particulièrement au niveau de la muqueuse intestinale.

• Le racécadotril exerce une activité périphérique en diminuant l’hypersécrétion intestinale.

• La posologie mentionnée dans le Résumé des Caractéristiques du Produit (RCP) est chez l’adulte de 100 mg suivie de 100 mg 3 x par jour, et chez l’enfant âgé de plus de 3 mois de 1,5 mg/kg, 3 x par jour.

• Ses principaux effets indésirables consistent en de la constipation secondaire et des céphalées.

• Le racécadotril est contre-indiqué en présence de fièvre et de selles glaireuses ou sanglantes (dysenterie aiguë).

• Dans les études comparatives avec le lopéramide (un dérivé des opiacés, freinateur du transit intestinal), les deux traitements avaient une efficacité comparable, ne diminuant que de quelques heures l’épisode diarrhéique.

• Il faut garder à l’esprit que la prise en charge de la diarrhée aiguë repose avant tout sur des mesures de réhydratation, et que les antidiarrhéiques n’ont qu’une place très limitée, en particulier chez les jeunes enfants. Les formes de racécadotril destinées à l’usage chez l’enfant sont soumises à prescription.

PART 1• 1.a - Vaccination for Yellow Fever• 1.b - Malaria


2013

http://www.who.int/wer/2013/wer8832.pdf

Varia– Hajj 2013

Varia– Hajj

MEKKA http://www.hajinformation.com/main/p3001.htm -

• meningococcal vaccine remain obligatory• influenza vaccine remain imperatively

advised

2013

General advice for Mecca pilgrims -required/recommended vaccines• Vaccination with a tetravalent, conjugated ACYW135

meningococcal vaccine is required to obtain a visa.

• Available vaccines in Belgium: Nimenrix® and Menveo®

• The unconjugated 4-valent meningococcal vaccine is not available anymore in pharmacy (July 2013) – it might still be available in the travel clinics and be used in pilgrims

• It remains unclear if children till the age of 2 years are obliged to be vaccinated, but it correct to vaccinate also the little children – on the other hand, see further : children under 12 yrs are discouraged to come to Mecca.

http://www.hajinformation.com/main/p3001.htm2013

General advice for Mecca pilgrims -required/recommended vaccines• Incompletely vaccinated individuals should

update their vaccine status.• Vaccination against the seasonal flu is

recommended when available (around mid-September, the pilgrimage starts October 4th).

• Hepatitis A vaccination is recommended, depending on age and medical history.

• For journeys exceeding 3 weeks stay, a vaccination against typhoid fever may be advisable.

Because of the MERS-Cov : The Saudi Ministry of Health

recommends that • people aged over 65years and • those with chronic diseases (e.g. heart disease, kidney

disease, respiratory disease, diabetes) and • pilgrims with immune deficiency (congenital and

acquired), • malignant and • terminal illnesses, • pregnant women and • children aged under 12 years

planning to come for Hajj and Umra this year, to postpone the performance of the Hajj and Umra for their own safety.

Varia – see Promedmail.org

• MERS-CoV (Middle East Respiratory Syndrome Coronavirus)

• H7n9 - China

2013

Varia – Joint Symposium 2013

Varia – NEW BOOKS 2013

Varia – NEW BOOKS

• KEYSTONE

2013

Varia – NEW BOOKS Handboek vaccinatiesDeel B Infectieziekten

en vaccinaties

• Rudy Burgmeijer, Karel Hoppenbrouwers, Fons Van Gompel (red.)

• Autumn 2013.

2013

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