HIV/AIDS News & Information

Travelers’ Diarrhea
Travelers’ diarrhea occurs worldwide and is most prevalent in travelers visiting developing countries. It is characterized by the onset of watery diarrhea usually within one week of travel. The most common associated symptoms include abdominal cramping, sometimes followed by bloody stools and vomiting. Fever is unusual and is recorded in 1%—10% of cases. Incidence is high among young adults, presumably attributed to an adventurous life-style and ingestion of higher volumes of contaminated food.

Chemoprophylaxis. Bismuth subsalicylate preparations (two tablets chewed four times a day) are effective in prevention and treatment of travelers’ diarrhea. Taking bismuth subsalicylate will cause passage of black stools, which can be confused with malena. The usual prophylaxis dose of bismuth subsalicylate is approximate to taking 3 to 4 adult aspirins, and hence, this regimen must be avoided by patients on oral anticoagulants. Patients should be advised to rinse their mouths after chewing tablets to avoid black coating of the tongue.

Antimicrobial prophylaxis is not recommended for every traveler. The protective efficacy of an antimicrobial is variable and depends on both the agent used and the duration of treatment. Protection is limited to the time of administration. In addition, individuals are at risk of acquiring diarrhea after the discontinuation of the antibiotic. Antimicrobial prophylaxis can also give a false sense of security and delay physician evaluation and medical treatment when needed.

Antimicrobial prophylaxis should be considered for immunocompromised patients in whom enteric infections are associated with a significant morbidity. These patients should be advised to seek prompt medical evaluation if symptoms do not improve. Daily prophylactic quinolones (ciprofloxacin 500 mg once a day or norfloxacin 400 mg once a day) are recommended for immunocompromised travelers for trips lasting less than three weeks.

Self-treatment. Most cases of diarrhea can be adequately treated with over-the-counter antidiarrheal medications and fluid replacement. Stringent dietary adjustments are no longer recommended since diarrhea can be controlled faster with available therapy. Fluids and bland foods are suggested only if the diarrhea continues despite treatment. Milk, fruits, and red meat should be added only when diarrhea stops.
Symptomatic therapy with bismuth subsalicylate (1 ounce every half-hour for a total of 8 ounces) is effective at least 50% of the time. Loperamide (4 mg loading dose, then Loperamide 2 mg after each loose stool, up to 16 mg/day) is a faster-acting, effective alternative.

Antimicrobial agents have been shown to limit the course of diarrhea and provide considerable relief of symptoms. Trimethoprim and sulphamethoxazole combinations are no longer the preferred agents in view of worldwide resistance. Fluroquinolones (ciprofloxacin 500 mg twice a day or generic norfloxacin 400 mg twice a day for three days) are the most effective antibiotics for treatment of travelers’ diarrhea. A 3-day course of a quinolone for self-therapy can be prescribed for traveling patients. Unless patients are traveling in the winter months, when Campylobacter jejuni diarrhea (for which 3-day quinolone treatment is recommended) is more common, travelers should take one dose of antibiotic and reevaluate themselves after 12 hours. If unformed stools are still passed, the 3-day course has to be completed.

A logical approach to treatment of travelers’ diarrhea would be to use bismuth subsalicylate or canadian loperamide for mild (1-2 stools/day) or moderate diarrhea (>3 stools/ day) with no distressing symptoms. For worsening diarrhea with distressing symptoms, the quinolones can be used.

Malaria
Malaria is prevalent in many parts of the world and is becoming increasingly chloroquine resistant. More than 3 million deaths due to malaria are reported annually. A substantial incidence of the disease has been reported in US travelers who did not receive appropriate prophylaxis. Malaria is characterized by high fever with chills. Travelers should be advised to seek prompt medical attention if these symptoms occur up to a year after foreign travel.

Currently, three medications are available for prophylaxis against malaria (Table 3). Chloroquine is recommended for travel to Mexico, Central America, and a few parts of the Middle East where the malarial parasite is still chloroquine sensitive. Canadian Mefloquine is the drug of choice for travel to areas with chloroquine-resistant malaria. Nausea and dizziness, often reported side-effects of mefloquine, can be avoided by taking the drug before sleep. Some patients cannot take cheap mefloquine. Patients who have a seizure disorder or are taking drugs which delay cardiac conduction, like quinidine and beta-blockers, should avoid mefloquine. Canadian Doxycycline is a reasonable alternative to mefloquine for such patients. A recent study on Indonesian soldiers demonstrated comparative efficacy of mefloquine and doxycycline. Although canadian mefloquine is taken just once a week, generic doxycycline has to be taken every day. Generic Doxycycline should not be used by pregnant women during their entire pregnancy, children under 8 years of age, and travelers with a known hypersensitivity to doxycycline. Cheap Doxycycline can cause significant photosensitivity.

TABLE 3—Chemoprophylaxis for Malaria

Drug	Dosing regimen	Precautions
Chloroquine	500 mg PO once a week. Start one week before travel and continue for four weeks after return.	Ocular side effects. G6PD deficiency.
Mefloquine	250 mg PO once a week. Start one week before travel and continue for four weeks after return.	Avoid in patients with seizures, psychiatric disorders, patients on cardiac drugs like quinidine, propranolol.
Doxycycline	100 mg PO QD. Start one day before travel and continue for four weeks after return.	Avoid in pregnancy, children under eight years of age. Photosensitivity.

Insect Repellants. The appropriate use of insect repel-lants is one way of reducing the incidence of malaria. DEET (N, N-diethyl-3-methylbenzamide) is an effective repellant. Repellants containing 25%-30% DEET provide adequate protection. The American Academy of Pediatrics recommends that repellants used on children should not contain more than 10% DEET to avoid neurotoxicity. The repellant must be applied lightly on the skin, and the directions for use in the label of the repellant container should be followed. Permethrin, a synthetic pyrethroid, is an effective insecticide that can be applied to clothing but not to the skin. A combination of DEET, which is applied to the skin, and permethrin, which is applied to clothing or window screens, significantly reduces mosquito bites.

Commonly Used Vaccines
An immunization history is an essential part of a traveler’s evaluation (Table 4). Hepatitis A, typhoid fever, and yellow fever are some of the diseases that can cause significant morbidity and mortality during travel to disease-prevalent areas. Current, childhood and adolescent routine immunization recommendations do not include vaccinations against such diseases. In addition to vaccination, information about food and water precautions should be discussed with the traveler.

TABLE 4 — Vaccinations for Travel

Vaccine/lmmune-ghbluin	Dosing Schedule	Comments*	Booster Interval
Hepatitis A vaccines	Havrix®Adults:1440 El U IM Vaqta®: Adults 50 units IM	Inactivated Havrix ® contains 2 phenoxyethanol as preservative. For both vaccines, the most common side effects are mild problems that usually disappear within one to two days.	Adults: 6 to 12 months later
Immunoglobulin for hepatitis A	<3 months: 0.02 ml/Kg-IM >3 months: 0.06 ml/Kg-IM	Avoid concurrent live vaccines.	Repeat every five months
Hepatitis В (Engerix BR)	Accelerated: three doses at 0, 30 and 60 days Standard: three doses at 0,1 and 6 months	Teenagers may not need vaccination as hepatitis В vaccination has been included in the childhood immunization program.	Accelerated: 12 months Standard: Not known
Yellow fever	0.5 ml SC at least 10 days before travel	Live attenuated virus. Avoid in pregnant patients, patients with severe egg allergy, and immuno-suppressed patients.	Repeat every 10 years
Typhoid fever	Oral: One capsule every other day, four doses. Injectable: ViCPS vaccine, one dose IM Inactivated (heat-phenol) injectable: two doses, four weeks apart	Oral: live attenuated strain ty21a strain. Avoid in acute febrile or CI illness. VICPS: VICPS vaccine contains phenol- caution in patients with thrombocytopenia, coagulopathies, pregnancy (Category C), immunocompromised states. Inactivated: Reactions following vaccination like fever, myalgias and soreness at injection site are more common than the single dose ViCPS vaccine.	Oral: five years ViCPS: two years Heat-phenol inactivated: three years
Polio	Unvaccinated: three doses IM or SC, one month apart. Completed vaccination: one booster dose	Enhanced-potency inactivated poliovirus vaccine preferred in adults pregnancy (Category C), Avoid in patients with hypersensitivity to neomycin, streptomycin or polymixin B.
Cholera	Two doses IM or SC, one or more weeks apart	Limited efficacy—50%. Give at least three weeks after yellow fever vaccine.	Six months
Meningococcus	One dose SC	Needed for travel to Saudi Arabia.	None but three years later in high risk groups

IM = intramuscular, SC = subcutaneous
*Allergic reactions can occur due to the vaccine component. History of allergic reactions to vaccines should be evaluated prior to vaccination.

Hepatitis A
Hepatitis A is highly endemic throughout the developing world but rarely seen in developed countries such as the United States, Canada, countries in northern and western Europe, Japan, Australia, and New Zealand. Hepatitis A vaccines and immunoglobulins afford excellent protection and are well tolerated.

There are two hepatitis A vaccines currently available in the United States, HAVRIX® and VAQTA®. Both are inactivated vaccines. HAVRIX® contains 2-phe-noxyethanol as a preservative. The common side effects of both vaccines are mild and usually disappear within one to two days.

Vaccine Dosage:
HAVRIX®: Adults: Two doses—1440 Elisa Unit (EL.U.) with the second dose administered 6 to 12 months after the first dose.

VAQTA®: Adults: Two doses—50 unit (U) with the second dose administered 6 months later.

Children over the age of two years can receive the vaccination, and multiple regimens are available for children and adolescents. Travelers are considered to be protected four weeks after receiving the initial vaccine dose. The vaccine is estimated to afford protection for about 20 years with the booster dose.

Short-term visitors, children less than two years old, and travelers seen within two weeks of the departure date should receive immunoglobulin.

Yellow Fever
Yellow fever is a viral disease transmitted to humans by mosquito bites. Symptoms range from fever, chills, headache, and vomiting to jaundice, internal bleeding, and kidney failure. Yellow fever has been reported in unvaccinated visitors to endemic areas. Hence, vaccination is strongly recommended. Many African and South American countries require yellow fever vaccination for entry. In general, even when not required, travelers to tropical Africa and South America should consider yellow fever vaccination.

The vaccination is contraindicated in infants less than four months of age, immunocompromised patients, persons severely allergic to eggs, and pregnant women, who should be advised not to travel to an endemic area. In addition to the vaccine, travelers should use measures to reduce exposure to mosquitoes and protect themselves from mosquito bites. No serious vaccine-related, adverse experiences were observed during clinical trials.

Typhoid Fever
Typhoid fever is a common bacterial infection of the developing world. Typhoid fever is transmitted through contaminated food and/or water, or directly between people. Symptoms of typhoid include high fever, sometimes with chills, coated tongue, headaches, tiredness, loss of appetite, and constipation. Following the food and water precautions closely can reduce the incidence of typhoid fever significantly. One oral vaccine and two injectable vaccines are available. These vaccines provide protection with a 70%-90% efficacy rate.

The oral vaccine consists of four capsules taken every other day over a seven-day period. Protection starts five days after the last dose, and protection lasts about five years. Reactions are rare and include nausea, vomiting, abdominal cramps, and skin rash. In order to maximize the efficacy of oral typhoid vaccine, concomitant use of antibiotics should be avoided; all the four doses should be taken on empty stomach; and the capsules should be refrigerated. A new, one-dose, injectable ViCPS vaccine is now available, which is better tolerated than the old, killed vaccine.

Cholera
Cholera is an acute diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae. The infection is often mild or without symptoms, but sometimes it can be severe. Approximately 1 in 20 infected persons has severe disease characterized by profuse watery diarrhea and vomiting, often with leg cramps.

The risk of cholera to US travelers who follow food and water precautions is low, and the vaccine is only about 50% effective. As a result, the vaccine is used infrequently even when traveling to areas where epidemics have been reported. Cholera vaccine is not recommended for infants under six months old or for pregnant women.

Meningococcal Meningitis
Meningitis is a bacterial disease characterized by headaches, stiff neck, fever, and a typical rash. Sporadic meningococcal outbreaks have been reported in many underdeveloped countries due to overcrowding. Visitors to areas of high meningitis occurrence are strongly rec ommended to receive the vaccination. Haj pilgrims to Saudi Arabia are required to be vaccinated against meningococcal meningitis. A tetravaccine is available and affords reasonable protection.

Other Vaccinations
A complete immunization history should be elicited. Travelers should have been immunized against hepatitis B, poliovirus, MMR, diphtheria, and tetanus. Unvaccinated and partially vaccinated persons should receive appropriate vaccinations before traveling. About 10% of the polio cases between 1975 and 1984 were among US citizens returning from foreign travel. Enhanced potency inactivated poliovirus vaccine is preferred for adults. Unvaccinated adults should receive three doses of the polio vaccine, four weeks apart. If travel is unavoidable within the three-month period, two doses, four weeks apart or at least one dose should be given and the series completed on return. Vaccinated adults over the age of 50 or patients who are on immunosuppressive medications should be considered for polio booster vaccinations.

In addition, certain travelers may need protection against Japanese В encephalitis and rabies. Since rabies vaccination does not afford complete protection but only decreases the number of post-exposure vaccination doses, travelers should be cautioned against contact with dogs in areas with high rabies incidence. For diseases such as dengue fever, no vaccines are available, and limiting mosquito bites either with repellants or other measures is the only option available.

Tick-borne encephalitis is prevalent in Europe and the former Soviet Union. Risk of transmission to routine travelers is low. Travelers planning to camp in the woods or explore remote areas should, in addition to vaccination, use protective clothing that covers the arms and legs, use repellants, and inspect the body daily for ticks, complying with instructions for removing attached ticks.

Infections such as anthrax can be acquired abroad due to ingestion of contaminated meat, inhalation of aerosols containing anthrax spores, or cutaneous exposure to contaminated wool or ftir. A killed vaccine is available for people with occupational hazards, but is not routinely recommended for travelers. The vaccine series consists of three doses given two weeks apart, with booster doses at 6 months and then on an annual basis.

Epidemics of plague have occurred sporadically. Vaccination, which consists of three injections over six months, is recommended for biologists and workers in plague endemic areas.

Diabetic Traveler
Vaccine recommendations are not different for the diabetic traveler. During long flights, hypoglycemia may occur due to inappropriate dosages. Glucometers and insulin pumps are known to malfunction at high altitudes. The traveling diabetic should carry twice the amount of medications and supplies and pack half of them in the carry-on bag. A snack box containing fruit juices, crackers, and glucose tablets is an essential part of the diabetic’s hand luggage. Using charts and schedules to adjust insulin doses during travel has not been found to be effective. An individualized insulin regimen coupled with simplified advice to inform the airlines about diabetes, monitor blood glucose frequently, and carry carbohydrates to avoid hypoglycemia can be helpful during air travel.

Travelers with HIV
The care of an immunocompromised traveler is complex and has to be addressed carefully. Benefits of the travel should be weighed against the potential health risks. Primary care physicians taking care of HIV patients should advise continued compliance to anti-retroviral therapy; warn against the likelihood of developing other diseases, both opportunistic and sexually transmitted; and refer the patients to a travel medicine consultant as soon as travel plans are discussed or at least eight weeks prior to travel. Health and evacuation insurance and access to reliable health services abroad should be discussed.

Some countries may require HIV testing results. In addition to obtaining information from the respective embassies, travelers can log on to the Centers for Disease Control (CDC) travel information site on the World Wide Web at http://www.cdc.gov/travel or the US Department of State site at http://travel.state.gov to obtain entry requirements confidentially.
Canadian Pharmacy prednisone

Vaccinations for the HIV Patient. Routine vaccinations include Pneumococcal vaccine, Hepatitis В series and the yearly influenza vaccine. Generally, live vaccines must be avoided in patients with CD4 counts of less than 200 cells/mm. Hepatitis A vaccines, killed cholera vaccine, inactivated typhoid vaccines, and polyvalent meningococcal vaccine can be administered safely. Live viral vaccines, such as oral polio vaccine, MMR, yellow fever vaccine, and live cholera vaccine should not be administered to HIV patients with CD4 counts of less than 200 cells/mm. The efficacy of vaccines against rabies, plague, Japanese encephalitis, and tick-borne encephalitis in the compromised traveler are not clear.

Chemoprophylaxis for malaria should be used as it is for immunocompetent travelers. However, drug interactions with protease inhibitors and other new anti-retrovi-rals are continually increasing in number, and drug interactions should always be considered before prescribing any medication.

Enteric Infection in the HIV-infected Traveler. Salmonella typhimurium, which causes diarrhea with acute bac-teremic febrile illness, is more common in HIV-infected patients and has a high mortality in developing countries. Common protozoal infections due to Giardia and Entamoeba species are not significantly affected by HTV infection. However, coinfection with helminthic infection can cause severe disseminated disease. Strongyloidiasis, schistosomiasis, and cysticercosis have all affected the HTV traveler and must be considered by the primary care physician when caring for a returned HTV patient with worsening or new symptoms.

Food and water precautions should be strictly adhered to. Bottled water that meets European Union standards, and water that has been treated by distillation, ozonization, or reverse osmosis can be considered safe. Patients with CD4 counts of less than 500 cells/mm on trips of less than three weeks can be placed on daily quinolone prophylaxis. HIV patients developing bloody diarrhea or fever with diarrhea, however, should be advised to seek prompt medical attention.

Patients should be advised to avoid activities that can increase their chances of infection by additional subtypes of HTV, which can accelerate HTV disease progression. Leishmaniasis and trypanosomiasis are emerging as opportunistic infections in addition to the list of already well-known opportunistic infections. Use of insect repel-lants can reduce the incidence, but patients must be advised to get medical advice if new symptoms occur.

Conclusion
Each year, millions of people travel for business and pleasure. Although traveling is an exciting and informative experience, it also brings certain challenges and risks. International travel, especially to developing countries, can expose people to infectious diseases that are not commonly seen in the United States.

The medical concerns of travelers can be as varied as their itineraries: The need for preventative medications and immunization; the proper way to handle acute and chronic medical illness; the information and documentation that should be taken while traveling; and ways to seek medical assistance abroad are among the varied concerns.
Canadian Pharmacy

The international traveler should seek medical advice at least four to six weeks prior to his or her departure date. Planning may start even earlier for trips that cover many different countries or that last for extended periods. Travelers with complex medical problems also have reason to plan earlier, and such patients may be referred to a travel medicine specialist. Taking time to plan ahead can help minimize the risks associated with international travel.