BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE June

5/11/2014
BELGIAN
CONSENSUS MEETING
on TRAVEL MEDICINE
June 20, 2014
Belgian
Scientific Study
Group on Travel
Medicine
PART 2
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)
version 05/11/2014
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2014
REPORT
BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE
June 20, 2014 – PART 2
• 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 26-06-2014
• Responsable final redaction : A. Van Gompel
2014
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
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2014
Basic Vaccinations
- Tetanus-diphteria-pertussis
- Poliomyelitis
- Measles mumps rubella
2014
Tetanus-Diphtheria-Pertussis
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2014
Medasso / ITG Gezondheidsadviezen voor reizigers Uitgave 2014-2015
Medasso / IMT Conseils de santé pour voyageurs Edition 2012-2013
2014
Medasso / ITG Gezondheidsadviezen voor reizigers Uitgave 2014-2015
Medasso / IMT Conseils de santé pour voyageurs Edition 2012-2013
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2014
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2014
2014
Primovaccinatie met
dTp(a) ?
In de bijsluiter wordt de primovaccinatie
met het dTp(a)-vaccin niet vermeld.
Ook de aanbeveling van de Hoge
Gezondheidsraad vermelden daarover
niets.
Een studie uit 2007 onderzocht bij
volwassenen ouder dan 40 jaar die de
voorbije 20 jaar geen tetanus of difterievaccin
hadden gekregen of waarvan de
vaccinatiestatus onbekend was, de efficiëntie
van dTp(a) en dTp(a)-IPV-vaccins.
Eén maand na de toediening van 3 dosissen,
bedroeg het niveau van beschermende
antistoffen 99%.
Bij gebrek aan dT kan dTp(a) dus worden
gebruikt voor primovaccinatie.
Indien ook bescherming tegen polio nodig is,
kan dTp(a)-IPV gebruikt worden
Primovaccination avec le
dTp(a) ?
Ni la notice, ni les recommandations du
Conseil Supérieur de la Santé ne mentionnent
la possibilité d’une primovaccination
avec le dTp(a).
Cependant, une étude publiée en
2007 a montré chez 99% des vaccinés
l’obtention de taux séroprotecteurs
contre le tétanos et la diphtérie après une
primovaccination à l’aide du dTp(a) (3
doses), chez des adultes de plus de 40
ans (en absence de données vaccinales
ou avec un dernier rappel datant de plus
de 20 ans).
En cas d’indisponibilté du dT, par exemple lors
d’une rupture de stock, l’administration du
dTp(a) pourrait donc être utilisé en
primovaccination.
En cas de nécessité d’une protection contre la
poliomyélite, dTp(a)-IPV peut être utilisé,
Theeten H et al, Primary vaccination of adults with reduced antigen-content diphtheria-tetanusacellular pertussis or
dTpa-inactivated poliovirus vaccines compared to diphtheria-tetanus-toxoid vaccines.
Current medical research and opinion. Vol. 23, n° 11, 2007 : 2729-2739.
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POLIO
2014
POLIO
• WHO Polio Eradication Initiative
http://www.polioeradication.org/Dataandmo
nitoring/Poliothisweek.aspx
• SEARO/WHO South-East Asia: Press
release 26 March 2014 :
WHO South-East Asia Region certified
polio-free
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WHO 29-04-2014
WHO 29-04-2014
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WHO 05-05-2014
http://www.who.int/mediacentre/news/statements/2014/polio-20140505/en/
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WHO 05-05-2014
• …… declared the international spread of wild
poliovirus in 2014 a Public Health Emergency
of International Concern (PHEIC).
• …… the Committee’s advice
– for ‘States currently exporting wild
polioviruses’ and
– for ‘States infected with wild poliovirus but not
currently exporting’ …..
• …. issued them as Temporary
Recommendations under the IHR (2005) to
reduce the international spread of wild
poliovirus, effective 5 May 2014
• reassessment of this situation in 3 months
ECDC 28/05/2014
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ECDC 28/05/2014
(= PHEIC).
since august 2014 also Equatorial Guinea
2014
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Imovax Polio ®
Revaxis ®
&
Boostrix IPV ®
=
also Polio
Clearly mention
that this is
poliovaccination
2014
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2014
Travel Vaccinations
1.
2.
3.
4.
5.
6.
7.
Hepatitis A
Hepatitis B
Typhoid fever
Rabies
Meningococcal meningitis
Japanese encephalitis
TBE - FSME
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HEPATITIS A
Immunodepressed traveler should – if
possible - receive the complete series
(2 / 3 doses) before leave
(+ antibodytiter)
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Results:
• The final study population consisted of
53 patients treated with
• TNFi (n 15),TNFi & MTX (n 21) or MTX (n 17)
months after the 1st dose
% of the patients that had attained seroprotection
1 6 months after the 2nd dose
1 10%
33%
6 72%
at month 24
86%
83%
Conclusions:
• Two doses of hepatitis A vaccine at a 6month interval provided protection for most
immunosuppressed RA patients.
• A single dose does not seem to afford
sufficient protection to this group of
patients.
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HEPATITIS B
Immunodepressed …..
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2014
Medasso / ITG Gezondheidsadviezen voor reizigers Uitgave 2014-2015
Medasso / IMT Conseils de santé pour voyageurs Edition 2012-2013
2014
INFLUENZA
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TYPHOID FEVER
Cochrane 2014
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Cochrane 2014
2012
IDSA 2012 conference poster 251
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2012
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MENINGOCOCCAL
MENINGITIS
Promedmail 20 May 2014
• The new vaccine MenAfriVac® is manufactured by
Serum Institute of India Ltd. and was developed for the
meningitis belt through the Meningitis Vaccine Project,
a partnership between WHO and PATH, funded by the
Bill & Melinda Gates Foundation.
• …… since the introduction of the meningococcal A
conjugate vaccine in countries of the African
meningitis belt in 2010, the WHO noted a decrease in
the number of cases of meningitis; in fact, the
number of cases in 2013 was the lowest recorded
during the epidemic season in the last 10 years
(http://www.who.int/csr/don/2013_06_06_menin/en/).
• In addition, Neisseria meningitidis serogroup A was
noted to be no longer the predominant pathogen.
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Lancet 2014
CID_13
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LID 2012
2014
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2014
RABIES
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2012
2013
From 31- 05 - 2013 on:
no booster after 1 year or later is advised
anymore for at least 20-30 years
after the basic series of 3 shots (1-7-21/28)
in persons with normal immunity
2014
Accelerated schedule off label
• Accelerated schedules (D1, D4, D8)
• not licenced = off label
• To be discussed with the client
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NECTM 5 Bergen Norway 2014
Jelinek LECTURE & POSTER
accelerated pre-exposure purified
Chick-embryo cell-culture rabies
vaccine for travelers
2014
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2014
2014
The percentages
of subjects with
RVNA levels ≥
0.5 IU/mL at
7 days after the
last active
vaccination were
100% (R/JE-Acc)
and
99% (R-Conv).
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As expected, a faster
decrease in RVNA
antibody titers was
observed in
the accelerated group
than in the 2 conventional
schedule groups
(Figure 2A).
2014
Irrespective of
vaccination regimen,
strong short-term
immune responses
up to day 57 were
observed, with
percentages of subjects
with adequate
antibody titers above
95% at all time points in
all groups as soon as 2
weeks after the first
vaccination (Figure 2B).
2014
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2014
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TO DOWNLOAD
http://www.sbimc.org/1-Rabies-Soentjes.pdf
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TO DOWNLOAD
http://www.sbimc.org/1-Rabies-Soentjes.pdf
2014
Future
accelerated & intradermal rabies
vaccination
(Soentjes et al. ,,,)
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JAPANESE ENCEPHALITIS
2014
Accelerated schedule off label
• Accelerated schedules (D1, D8)
• not licenced = off label
• To be discussed with the client
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NECTM 5 Bergen Norway 2014
Jelinek LECTURE & POSTER
accelerated JE vaccine for
travelers
2014
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2014
2014
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2014
2014
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2014
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Former slides
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2013
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”
2011
Japanese encephalitis (Ixiaro®)
• The standard scheme requires 2
injections, separated by one month.
Afterwards, the traveler remains boostable
which 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.
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2014
TBE FSME
2013
2014
40
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2014
Medasso / ITG Gezondheidsadviezen voor reizigers Uitgave 2014-2015
Medasso / IMT Conseils de santé pour voyageurs Edition 2012-2013
41
5/11/2014
2014
Medasso / ITG Gezondheidsadviezen voor reizigers Uitgave 2014-2015
Medasso / IMT Conseils de santé pour voyageurs Edition 2012-2013
42
5/11/2014
2014
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
2014
Medasso / ITG Gezondheidsadviezen voor reizigers Uitgave 2014-2015
Medasso / IMT Conseils de santé pour voyageurs Edition 2012-2013
43
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2013
Quid role in travel medicine ?
2013
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.
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2013
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.
2014
Chikungunya
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Eurosurveillance, Volume 19, Issue 28, 17 July 2014
2014
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Dengue
New WHO map
2014
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Hajj
19/09 – 12/10 2014
2014
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Kingdom of Saudi Arabia Ministry of
Health
Health Regulations for travellers to
Saudi Arabia for Umrah &
Pilgrimage (Hajj)-1435 (2014).
2014
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No change of the advice in
2014
Former slides
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2012
2013
Varia– Hajj
http://www.who.int/wer/2013/wer8832.pdf
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2013
Varia– Hajj
MEKKA
http://www.hajinformation.com/main/p30
01.htm • meningococcal vaccine remain obligatory
• influenza vaccine remain imperatively
advised
2013 = 2014
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.
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2013 = 2014
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 midSeptember, the pilgrimage starts October 4th).
• Pneumococcal vaccine for the known risk groups
• 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.
2014
… & Mers
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2014
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2014
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Promedmail - Morocco 19-6-2014
• Advice not to go on the Hadj … !!
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Because of the MERS-Cov :
The Saudi Ministry of Health
recommends that people
2013
• aged over 65 years 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.
2014
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2014
http://www.who.int/ith/updates/2014
0603/en/
2014
Ebola
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2014
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Schistosomiasis
2014
Medasso-Headlines Gezondheidsadviezen voor reizigers Uitgave 2014-2015
Medasso-Headlines Conseils de santé pour voyageurs Edition 2012-2013
2014
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2014
CDC
Letter
EID sept 2014
In press
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2014
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
2014
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2014
Deep Venous Thrombosis
Medasso-Headlines Gezondheidsadviezen voor reizigers Uitgave 2014-2015
Medasso-Headlines Conseils de santé pour voyageurs Edition 2012-2013
2014
Itchy skin problems during travel
Medasso / ITG Gezondheidsadviezen voor reizigers Uitgave 2014-2015
Medasso / IMT Conseils de santé pour voyageurs Edition 2012-2013
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A division of “Outdoor Medicine” (Nl) in Belgium
www.outdoormedicine.org & www.awls.be
2014
Future links with travel medicine ?
(cfr ISTM & Wilderness Medical Society in the US)
2014
Commitment travel clinics
waiting lists & capacity last
minute travelers
?
- Waiting time max 2 weeks ?
- Ability to help as soon as
possible last minute travelers ?
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2013
Varia – NEW BOOKS
Handboek vaccinaties
Deel B Infectieziekten
en vaccinaties
• Rudy Burgmeijer,
Karel Hoppenbrouwers,
Fons Van Gompel
(red.)
• Autumn 2013.
2014
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END
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