The medical letter on drugs and therapeutics november 24 2014

The Medical Letter ® on Drugs and Therapeutics Objective Drug Reviews Since 1959 Volume 56 ISSUE ISSUE No 1433 1456 November 24, 2014 IN THIS ISSUE Vaccines for Travelers p 115 Volume 56 Important Copyright Message FORWARDING OR COPYING IS A VIOLATION OF U.S AND INTERNATIONAL COPYRIGHT LAWS The Medical Letter, Inc publications are protected by U.S and international copyright laws Forwarding, copying or any distribution of this material is prohibited Sharing a password with a non-subscriber or otherwise making the contents of this site available to third parties is strictly prohibited By accessing and reading the attached content I agree to comply with U.S and international copyright laws and these terms and conditions of The Medical Letter, Inc For further information click: Subscriptions, Site Licenses, Reprints or call customer service at: 800-211-2769 Published by The Medical Letter, Inc • A Nonprofit Organization The Medical Letter publications are protected by US and international copyright laws Forwarding, copying or any other distribution of this material is strictly prohibited For further information call: 800-211-2769 The Medical Letter ® on Drugs and Therapeutics Objective Drug Reviews Since 1959 Volume 56 ISSUE ISSUE No November 24, 2014 Take CME exams IN THIS ISSUE 1433 1456 Vaccines for Travelers Volume 56 Patients planning to travel to other countries should be up to date on routine immunizations and, depending on their destination, duration of travel, and planned activities, may also need to receive certain travelspecific vaccines Common travel vaccines are listed in Table on page 117 More detailed advice for travelers is available from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/travel Guidelines for routine adult immunization are discussed in a separate issue.1 Table Low-Risk Areas for Hepatitis A & B* Hepatitis A1 Hepatitis B2 Immunocompromised or pregnant patients should generally not receive live vaccines, although the benefit might outweigh the risk in some situations.2 Injectable or intranasal live vaccines not administered simultaneously should be administered  ≥4 weeks apart * All other areas are intermediate to high risk; vaccination is indicated Regions with a low or very low level of hepatitis A endemicity (KH Jacobsen and ST Wiersma Vaccine 2010; 28:6653) Countries with a low prevalence (40 years old, immunosuppressed patients, and those with chronic liver disease or other chronic medical conditions who will be traveling to an endemic A series started with one hepatitis B vaccine may be completed with another An interrupted series can be completed without being restarted 115 Published by The Medical Letter, Inc • A Nonprofit Organization The Medical Letter ® INFLUENZA Influenza may be a risk in the tropics year-round, in temperate areas of the Southern Hemisphere from April to September, and in temperate areas of the Northern Hemisphere from October to March Outbreaks have occurred on cruise ships and on organized group tours in any latitude or season.7 The US Advisory Committee on Immunization Practices (ACIP) recommends routine annual influenza vaccination for everyone ≥6 months old who does not have a specific contraindication, including pregnant women.8 Travelers should consider being vaccinated before going to the Southern Hemisphere during influenza season or to the tropics in any season, or when traveling in a group with persons from the Southern Hemisphere during their influenza season.9 Northern Hemisphere influenza vaccine is usually available in the US from August until the end of June In some years, the vaccine formulations are the same in both hemispheres If they are different, high-risk patients from the Northern Hemisphere who travel to the Southern Hemisphere during that region’s influenza season could also consider being vaccinated on arrival because the Southern Hemisphere influenza vaccine is rarely available in the Northern Hemisphere JAPANESE ENCEPHALITIS Japanese encephalitis is an uncommon but potentially fatal mosquito-borne viral disease that occurs in rural Asia, especially near pig farms and rice paddies It is usually seasonal (May-October), but may occur yearround in tropical regions The attack rate in travelers has been very low.10 Vaccination is recommended for travelers who expect a long stay (≥1 month) in endemic areas or heavy exposure to mosquitoes (such as adventure travelers) during the transmission season Vaccination should also be considered for travelers spending 12 months may be required to receive a dose of the polio vaccine that is available in that country (either IPV or oral polio vaccine) between weeks and 12 months before their departure from the polio-infected country.20 RABIES Rabies is highly endemic in many parts of Africa, Asia (particularly India, Pakistan, Bangladesh, and Bali, Indonesia), and Central and South America, but the risk to travelers is generally low.21 Pre-exposure vaccination against rabies is recommended for travelers with an occupational risk of exposure, for those (especially children) visiting endemic areas where immediate access to medical treatment, particularly rabies immune globulin, tends to be limited, and for outdoor-adventure travelers.22 The vaccines available in the US (Imovax; RabAvert) are similar After exposure to a potentially rabid animal, patients who received pre-exposure vaccination should promptly receive additional doses of vaccine Without preexposure vaccination, the ACIP recommends human rabies immune globulin (RIG) plus doses of vaccine given over 14 days; immunosuppressed patients should receive doses of vaccine (over 28 days).23 One retrospective study found that some patients did not develop adequate antibody levels after doses of vaccine.24 According to the CDC, cell culture rabies vaccines available outside the US are acceptable alternatives to FDA-approved vaccines; neural tissue vaccines have high rates of serious adverse effects and should be avoided RIG is a blood product, and its purity and potency may be less reliable, if it is available at all, in developing countries Purified equine rabies immune globulin is available in some developing countries and has been used effectively, with a low incidence of adverse reactions TETANUS, DIPHTHERIA, AND PERTUSSIS Previously unimmunized children should receive or (preferably) doses of pediatric diphtheria, tetanus, The Medical Letter ® and acellular pertussis vaccine (DTaP) before travel An accelerated schedule can be used beginning at age ≥6 weeks, with the second and third doses given weeks after the previous dose The fourth dose is given ≥6 months after the third; the child must be at least 12 months old Adults with an uncertain history of primary vaccination should receive doses of a tetanus and diphtheria toxoid vaccine The first doses should be administered at least weeks apart and the third 6-12 months after the second One of the doses (preferably the first) should contain protein components of acellular pertussis combined with diphtheria and tetanus toxoids (Tdap) to also provide protection against pertussis Two Tdap vaccines (Adacel; Boostrix) are available and are recommended by the ACIP for use in all adults, including those ≥65 years old.25 A booster dose of inactivated adsorbed (aluminumsalt-precipitated) tetanus and diphtheria toxoid (Td) vaccine is recommended every 10 years for adults All persons ≥11 years old who have completed a primary childhood series and have not yet received Tdap vaccine should receive a single dose, which can be given regardless of the interval since the last Td to provide pertussis protection before travel TYPHOID Typhoid vaccine is recommended for travelers going to areas where there is an increased risk of typhoid fever, especially if they expect a long stay or will be visiting friends or relatives or traveling outside routine tourist destinations.26,27 The risk is highest in southern Asia Other risk areas are East and Southeast Asia, Central and South America, the Caribbean, and Africa A live attenuated oral vaccine (Vivotif) is available for adults and children ≥6 years old It is taken every other day as a single capsule (at least hour before eating) for a total of capsules, beginning no later than weeks before departure; it provides protection for about years The capsules must be refrigerated Antibiotics should be avoided for at least 24 hours before administration of the first capsule and for week after administration of the last capsule A purified capsular polysaccharide parenteral vaccine (Typhim Vi) for adults and children ≥2 years old is given at least weeks before departure A combined hepatitis A/typhoid vaccine (Vivaxim – Sanofi Pasteur) is available in Canada Vol 56 (1456) November 24, 2014 YELLOW FEVER Yellow fever vaccine (YF-Vax), a single-dose live attenuated vaccine prepared in eggs, should be given at least 10 days before travel to endemic areas, which include tropical South America and sub-Saharan Africa.28 Some countries require an International Certificate of Vaccination or Prophylaxis as proof of vaccination against yellow fever, or a physician’s waiver letter, from all entering travelers; other countries require evidence of vaccination from travelers coming from or traveling through endemic or infected areas, including brief airport transits An updated list of countries requiring proof of yellow fever vaccination is available at www.cdc.gov/travel In the US, the vaccine is available only from providers certified by state health departments According to the World Health Organization, a single dose of the vaccine is sufficient to confer life-long immunity, but more data documenting the duration of immunity after vaccination are needed Boosters are recommended every 10 years by the ACIP and may be necessary for travel to countries that require a certificate of vaccination.29,30 Yellow fever vaccine-associated viscerotropic disease, a severe systemic illness that can cause fatal organ failure, has been reported rarely It has occurred only in first-time recipients Vaccine-associated neurologic disease (encephalitis, Guillain-Barré syndrome, Bell’s palsy) has also occurred almost exclusively in firsttime recipients; the risk is increased in infants and travelers >60 years old.31,32 Caution is advised for travelers ≥60 years old who are receiving the vaccine for the first time and for those with asymptomatic HIV infection and moderate immune suppression (CD4 counts 200-499 cells/mm3) A small case series study found a significant increase in relapse rates among travelers with multiple sclerosis who received yellow fever vaccine.33 There have been case reports of vaccine-associated neurologic disease in breast-fed infants of recently vaccinated women.34 The vaccine is contraindicated in infants 1 year old.36 TICKBORNE ENCEPHALITIS (TBE) — TBE occurs in temperate areas of Europe and Asia; the risk area extends from eastern France to northern Japan, and from northern Russia to Albania.37,38 The risk of infection is greatest from April to November Humans acquire the disease through the bite of an infected tick or, rarely, from eating unpasteurized dairy (mostly goat) products Immunization is recommended only for travelers who will spend extensive time outdoors in rural areas Two inactivated cell culture-derived vaccines are available in Europe (Encepur – Novartis, Germany; FSME-Immun – Baxter, Austria); they are usually given in doses over 6-15 months, but the second dose can be administered weeks after the first if a rapid immune response is required Encepur can also be given over weeks (0, 7, and 21 days) Two inactivated TBE vaccines are also available in Russia (TBE-Moscow; EnceVir); they are usually given in doses 5-7 months apart, but a rapid schedule of EnceVir at and 1-2 months can be used in emergency situations ■ Adult immunization Treat Guidel Med Lett 2014; 12:39 General recommendations on immunization - recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep 2011; 60(2):1 RM Klevens et al The evolving epidemiology of hepatitis A in the United States: incidence and molecular epidemiology from population-based surveillance, 2005-2007 Arch Intern Med 2010; 170:1811 S Iwarson et al Excellent booster response to years after a single primary dose of an inactivated hepatitis A vaccine J Travel Med 2004; 11:120 Centers for Disease Control and Prevention CDC Health Information for International Travel 2014 The Yellow Book Chapter 3, Hepatitis A Available at: www.cdc.gov/travel/yellow book/2014/chapter-3-infectious-diseases-related-to-travel/ hepatitis-a Accessed November 13, 2014 DF Johnson et al Hepatitis B and C infection in international travelers J Travel Med 2013; 20:194 R Steffen Influenza in travelers: epidemiology, risk, prevention, and control issues Curr Infect Dis Rep 2010; 12:181 Influenza vaccine for 2014-2015 Med Lett Drugs Ther 2014; 56:97 Centers for Disease Control and Prevention (CDC) Use of northern hemisphere influenza vaccines by travelers to the southern hemisphere MMWR Morb Mortal Wkly Rep 2009; 58:312 10 SL Hills et al Japanese encephalitis in travelers from non-endemic countries, 1973-2008 Am J Trop Med Hyg 2010; 82:930 11 E Mirzaian et al Mosquito-borne illnesses in travelers: a review of risk and prevention Pharmacotherapy 2010; 30:1031 12 A new Japanese encephalitis vaccine (Ixiaro) Med Lett Drugs Ther 2009; 51:66 13 Use of Japanese encephalitis vaccine in children: recommendations of the advisory committee on immunization practices, 2013 MMWR Morb Mortal Wkly Rep 2013; 62:898 14 PA Gastañaduy et al Measles - United States, January 1-May 23, 2014 MMWR Morbid Mortal Wkly Rep 2014; 63:496 120 Vol 56 (1456) November 24, 2014 15 HQ McLean et al Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep 2013; 62(RR-4):1 16 AC Cohn et al Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep 2013; 62(RR-2):1 17 A new conjugate meningococcal vaccine (Menveo) Med Lett Drugs Ther 2010; 52:59 18 JR MacNeil et al Use of MenACWY-CRM vaccine in children aged through 23 months at increased risk for meningococcal disease: recommendations of the Advisory Committee on Immunization Practices, 2013 MMWR Morb Mortal Wkly Rep 2014; 63:527 19 Meningococcal group B vaccine Med Lett Drugs Ther 2014 (in press) 20 GS Wallace et al Interim CDC guidance for polio vaccination for travel to and from countries affected by wild poliovirus MMWR Morb Mortal Wkly Rep 2014; 63:591 21 C Malerczyk et al Imported human rabies cases in Europe, the United States, and Japan, 1990 to 2010 J Travel Med 2011; 18:402 22 CE Rupprecht and RV Gibbons Clinical practice Prophylaxis against rabies N Engl J Med 2004; 351:2626 23 CE Rupprecht et al Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the Advisory Committee on Immunization Practices MMWR Recomm Rep 2010; 59(RR-2):1 24 M Uwanyiligira et al Rabies postexposure prophylaxis in routine practice in view of the new Centers for Disease Control and Prevention and World Health Organization recommendations Clin Infect Dis 2012; 55:201 25 Prevention and treatment of pertussis Med Lett Drugs Ther 2012; 54:73 26 MF Lynch et al Typhoid fever in the United States, 1999-2006 JAMA 2009; 302:859 27 JA Whitaker et al Rethinking typhoid fever vaccines: implications for travelers and people living in highly endemic areas J Travel Med 2009; 16:46 28 JE Staples et al Yellow fever vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep 2010; 59(RR-7):1 29 World Health Organization Yellow fever vaccination Weekly epidemiological record 2013; 20:208 Available at www.who.int/ wer/2013/wer8820.pdf?ua=1 Accessed November 13, 2014 30 Collaborative group for studies on yellow fever vaccines Duration of post-vaccination immunity against yellow fever in adults Vaccine 2014; 32:4977 31 RE Thomas et al How many published cases of serious adverse events after yellow fever vaccination meet Brighton Collaboration diagnostic criteria? Vaccine 2013; 31:6201 32 RE Thomas et al The safety of yellow fever vaccine 17D or 17DD in children, pregnant women, HIV+ individuals, and older persons: systematic review Am J Trop Med Hyg 2012; 86:359 33 MF Farez and J Correale Yellow fever vaccination and increased relapse rate in travelers with multiple sclerosis Arch Neurol 2011; 68:1267 34 S Kuhn et al Case report: probable transmission of vaccine strain of yellow fever virus to an infant via breast milk CMAJ 2011; 183:E243 35 RC Charles and ET Ryan Cholera in the 21st century Curr Opin Infect Dis 2011; 24:472 36 Cholera vaccines: WHO position paper Wkly Epidemiol Rec 2010; 85:117 37 A Banzhoff et al Protection against tick-borne encephalitis (TBE) for people living in and travelling to TBE-endemic areas Travel Med Infect Dis 2008; 6:331 38 U Kunze Is there a need for a travel vaccination against tickborne encephalitis? 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Call us at 800-211-2769 or 914-235-0500 or e-mail us at: custserv@medicalletter.org Questions start on next page The Medical Letter ® Online Continuing Medical Education DO NOT FAX OR MAIL THIS EXAM To take CME exams and earn credit, go to: medicalletter.org/CMEstatus Issue 1456 Questions (Correspond to questions #101-110 in Comprehensive Exam #71, available January 2015) Live vaccines: a generally should not be used in immunocompromised patients b can be given simultaneously c should be given at least weeks apart if not given simultaneously d all of the above A 49-year-old woman with cirrhosis is leaving next week on a 2-week trip to Africa She has not been vaccinated previously against hepatitis A Which of the following would you recommend she receive before her trip? a only an initial dose of hepatitis A vaccine b only a 0.02-mL/kg IM dose of immune globulin c both an initial dose of hepatitis A vaccine and a 0.02-mL/kg IM dose of immune globulin d she doesn’t need any prophylaxis because Africa is considered a low-risk area for hepatitis A acquisition A healthy 21-year old woman is planning a one-week trip to Spain for spring break She has not been vaccinated previously against hepatitis A or B You should tell her: a she should be vaccinated against hepatitis A because Spain is a high-risk country for hepatitis A acquisition b hepatitis B vaccination is required for all travelers to Spain c she should consider being vaccinated against hepatitis B if she might engage in risky behaviors such as getting a tattoo or having unprotected sexual contact with a new partner while on vacation d none of the above Influenza vaccination should be considered for persons traveling: a to the tropics in any season b to the Southern Hemisphere from April to September c in a group with persons from the Southern Hemisphere during their influenza season d all of the above A mother asks you whether her 4-year-old daughter should receive Ixiaro before traveling to Hong Kong You should tell her that: a Ixiaro is not approved for use in children