Travelers’ Health, Summer, 2018 - Transcript

Moderator: Haley McCalla
Presenters: Kelly Holton; Gary Brunette, MD
Date: May 22, 2018, 1:00pm EST

>> Good afternoon, everyone. My name is Haley McCalla from CDC’s Office of Public Health Preparedness and Response, Division of Emergency Operations. And I’d like to welcome you all to today’s epic webinar on Travelers’ Health. Today we will hear from CDC’s Kelly Holton and Dr. Gary Brunette. If you don’t wish for your participation to be recorded, please exit at this time. You can earn continuing education by completing this webinar. Please follow the instructions linked in the webinar invitation that you received. The course access code is EPIC0522 with all letters capitalized. To repeat, the course access code to receive continuing education is EPIC0522 in all caps. Today’s webinar is interactive. To make a comment, click the chat button on your screen and then enter your thoughts. To ask a question, please use the Q&A button. The Q&A session will begin after the presentation. We will now transition to our presenters, Kelly Holton and Dr. Gary Brunette. Kelly Holton is the chief communications officer for CDC’s Travelers’ Health Branch. Ms. Holton has worked for CDC since 2000, spending the past ten years focused on travelers’ health. Ms. Holton has led leadership roles in many public health emergencies, including H1N1 influenza, the earthquakes in Haiti and Japan, H7N9 influenza, Middle East respiratory syndrome, Ebola, and most recently Zika. Dr. Gary Brunette joined The Centers for Disease Control in 2006. He’s a captain in the US Public Health Service and a fellow of the Faculty of Travel Medicine at the Royal College of Physicians and Surgeons in Glasgow. He is currently the chief of the Travelers’ Health Branch. He is also the editor-in-chief of CDC’s Yellow Book, which provides health information for international travel. Thank you both so much for joining us today. Please begin.

>> Good afternoon. Thank you very much for having us. We certainly appreciate the opportunity to talk to you today about travelers’ health. So what we’d like to cover in the course of the next 45 minutes is to increase your awareness of the importance of travel health concerns, to teach travelers some steps they can take before travel and how to stay healthy during travel, and also to learn a little bit more about the resources that CDC offers to both travelers and their clinicians. So the mission of the CDC’s Travelers’ Health Branch is to reduce the illness and injury in US residents traveling internationally or living abroad. The branch is engaged in a number of different activities. We study and monitor illness and injury amongst travelers. We monitor disease outbreaks around the world and other health threats that may affect travelers. And then we provide health advice, including vaccine recommendations and requirements. We deliver health communications and education to a variety of ordinances in different formats, and Kelly will be talking to you about that a little bit later. And we develop and distribute event-specific advice during emergency responses. So this is an interesting slide. The red line indicates the time it took for people to circumnavigate the world. So in 1850 it took about a year to circumnavigate the globe. But over the course of the next 150 years, you can see that time decreased until about the 1950’s when one could get from any place on the globe to another in a matter a day or two. At the same time, the green line indicates the world population. And from 1850’s we were down to less than a 1 billion people, and the steady increase over the next 150 years, we’re now sitting over 6 or 7 billion people. Next slide, please. So this is another indication of the interactivity between places on the globe and how people can move from one place to another in just a matter of days. These are airline routes back in 2012 which indicate the different connections of flights between different parts of the world. Next slide, please. People are sometimes surprised to hear how many US travelers actually leave the country every year. And currently we are over 80 million US residents who travel abroad each year. The great majority do go down south to Mexico. And we have a sizable proportion that travel up to Canada. But there are also a number of people who travel to other destinations around the world. Next slide, please. So US residents travel around the world for many different reasons. The most common one is for leisure, for tourism. And that’s around 55%. We also have about a quarter of US residents who travel to visit friends and relatives. So those are people who were born in another country, have moved and settled in the United States, and now are returning to their country of origin to say with friend or relatives. And one of the reasons we select these people out or point them out is that it has been noted and observed that they are at higher risk for some travel-related illnesses. There are also other reasons for travel. We have business travel. And business travel can vary greatly. You are sometimes having executive travel to smart hotels in major cities or other people who are traveling in the mining industry who might be at remote locations. People travel for education, for humanitarian aide, for religion and healthcare. Next slide, please. So I wanted to discuss some of the topics that we are hearing at the moment. This is a selection of health — of headlines from recent publications. And you can see Brazil, yellow fever outbreak in Brazil is mentioned; measles in Europe; Zika virus; and even the increase in vector-borne diseases in the US. Something that wasn’t mentioned or isn’t mentioned is the recent reports about Ebola in the Democratic Republic of Congo. Next slide, please. So I thought I’d take a couple of minutes just to mention some important diseases that travelers and clinicians should be aware of. One of these is measles. This is a highly contagious disease. And here in the US we have very high rates of vaccination. And so we don’t see a lot of cases originating in the US; it’s very rare. Most of the measles cases result from importations — people who have traveled abroad who have been infected and bring it back and then spread it to their local community. So just about everywhere else in the world there isn’t the same level of vaccination for measles. And so we see measles activity across the globe and occasionally measles outbreaks even in popular tourist destinations like western Europe or the Far East and so forth. So the advice here is that travelers should be up-to-date with all their routine vaccinations, including measles. And even infants six months of age or older should be up-to-date with their measles vaccination. Malaria is a very important disease for travelers. Symptoms for malaria can take a while to appear. They might be within 7 to 30 days, but some species of malaria can actually hibernate in the body for up to a year. And so people might only develop symptoms a year after returning from travel. Malaria occurs across Africa, Central America, parts of the Caribbean, Asia, even in Eastern Europe and the South Pacific. And we do have outbreaks occurring in different areas. At the moment there’s a small outbreak in South Africa, another one in Brazil and Cypress. And we do post travel notices on our website about these outbreaks. Every year about 1,700 cases of malaria are imported into the United States by travelers. And we see about five deaths occurring in travelers. So it’s very important that travelers protect themselves if they’re traveling anywhere with a risk of malaria. Thank you. This is a map showing the geographical distribution of malaria. And you can see it’s mainly in the tropical areas throughout the world. Another disease is dengue. One of the problems with dengue is it does not have a vaccine or medicine to treat the disease. And so people really rely on preventing mosquito bites to prevent getting the disease. So symptoms for dengue usually start about four to seven days after the bite. And the disease lasts for three to ten days. Many people with dengue only have a very mild illness, but there is a form of dengue that can cause severe symptoms and include intense stomach pain; repeated vomiting; bleeding from the gums; and even death. Dengue has spread in many part of the world over recent decades, and we’ve seen increased numbers of cases in the Caribbean, Central and South America, West Africa, Pacific islands, Australia, etc. Next slide, please. So this is, again, the geographic distribution of dengue. You’ll see it’s very similar to that of malaria throughout most of the tropical regions of the world. Next slide, please. Yellow fever is a very concerning disease. About 15% of people who get yellow fever can develop serious illness, which leads to bleeding, shock, organ failure, and sometimes death. Travelers to certain parts of South America and Africa are at risk, but travelers can protect themselves from this disease by getting a yellow fever vaccination and preventing mosquito bites. I think many of you are familiar with the yellow graphic at the bottom of this page. This is the international certificate of vaccination and prophylaxis that people carry to show that they have been vaccinated against yellow fever. Next slide, please. So we do have some yellow fever activity at the moment. In Brazil there’s been an ongoing outbreak. And we’ve seen a number of cases in unvaccinated travelers from Europe who’ve contracted yellow fever, and we’ve had some deaths associated with this. Because of this outbreak, there’s an expanded list of areas where yellow fever vaccination is recommended. You can see on the map that the yellow section is where yellow fever vaccine is usually recommended. But along the coast now we have additional areas where vaccine is recommended. So all of Espirito Santo, Parana State, Santa Catarina, Rio Grande do Sal; and also in Sao Paulo and Rio de Janeiro States, including the cities and all the coastal areas in those province states; and also a number of cities in the Bahia State. Next slide, please. So for the last year, there has been a yellow fever vaccine shortage in the US. There were problems with the production of the yellow fever vaccine called YF Vax that was licensed for use in the US. We ran out of stock in July 2017, actually. And in order to cover the shortfall, the FDA allowed the use of an alternative vaccine, an equivalent vaccine that is produced in Europe called Stamaril that was allowed to be imported and distributed throughout the United States. Because of the requirements of using an alternative vaccine, the number of clinics supplying vaccine has been reduced from about 4,000 clinics before to around 250 clinics currently. And so it’s important that travelers plan ahead in order to get these vaccines. And they might need to be prepared to drive some distance from home. If you look at the map on the right, this indicates where yellow fever clinics currently exist. And this map can be accessed from the CDC Travelers’ Health website. Next slide, please. So you would have heard a lot about Zika a years ago. And the message today is Zika is still a risk. There’s still Zika in many countries — in Africa, Asia, the Caribbean, Central and North America, South America, and the Pacific islands. The virus is spread by infected mosquitoes but can also be spread through sex or blood transfusions. It is also passed from a pregnant woman to a fetus. Again, there’s no vaccine or medicine to prevent or treat Zika. So how does one prevent Zika? So firstly, it is important that pregnant women do not travel to an area with risk of Zika. And if the partner of a pregnant woman travels to areas where there is risk of Zika, the couple should use condoms or not have sex for the rest of the pregnancy. At the moment CDC is updating our guidance on planning pregnancy when traveling to areas with Zika. And if you access the link below, you will get the latest information as it appears. So at the moment, we are expecting new information to appear shortly. So in order to prevent Zika — and this applies to other diseases as well that are spread by mosquitoes — we recommend that people use an insect repellant with active ingredients such as DEET or picaridin; we suggest that they wear long-sleeved shirts and long pants; and sleep in places with air-conditioning and window and door screens to keep mosquitoes outside. It is also very useful to use a bed net. Because some people can return to the US after being infected with Zika and not knowing it, being asymptomatic, we recommend that people use insect repellant for three weeks to avoid the risk of spreading the disease to local mosquitoes. It is also important to prevent the sexual transmission of Zika. And we suggest the use of condoms every time you have sex while traveling or after you return home. We’ve all heard about the problems of traveler’s diarrhea when out of the country. This is certainly the most common travel-related illness. The prevention here is to select safe food and water choices and also to hand wash regularly, especially before eating. Travelers can also take bismuth subsalicylate or Pepto-Bismol. The treatment for traveler’s diarrhea includes food replacement, which is very important to prevent dehydration. People can also take Pepto-Bismol or loperamide to treat the symptoms of traveler’s diarrhea. And sometimes providers can provide antibiotics to travelers to take by themselves if they do experience serious diarrhea. Typically they are prescribed three tablets, and often just one dose is sufficient to end the travelers’ diarrhea. So I’ve been talking about infectious diseases, but it’s important to note that most deaths in US travelers overseas are not caused by infectious diseases — that actually makes up less than 1% of all deaths. Over 50% of deaths are caused by accidental injuries, and that includes motor vehicle accidents and drownings. Environmental hazards are also a concern. So cold weather, and hot weather, and sun. People traveling to high elevations should be aware of altitude sickness. People might also be bitten, or stung, or poisoned. We often underestimate the psychiatric problems associated with travel. Travel can sometimes be stressful and people might experience psychiatric problems. People might also get skin or soft tissue infections. And then we always have to be alert about crime or assault. Next slide. So I’d like to talk next about some of the preventative actions that travelers can take and how clinicians can help their travelers stay safe while traveling. So one of the most important things is to — for all travelers — to have a pre-travel medical visit. We recommend that travelers see a provider — so that’s either their doctor or a nurse or pharmacist — at least four to six weeks before their trip. And we recommend that they see a provider who understands the implications of travel to — around the world. Travelers should also make note to tell their provider about any upcoming travel so that this can be discussed. The provider then will asses the risk of any given travel. And this is a combination of the person, the traveler, their health history and so forth, and then what type of travel they’re going to be doing. And I’ll talk a bit about that in the next few slides. So the importance of seeing a provider is that they can provide vaccines that are needed, they can provide the proper medications that travelers might need, and a experienced travel medicine provider will know what counseling and advice is important for that particular itinerary. So as mentioned, the individual traveler has to be taken into account. So all travel medicine consultations are individualized. The provider needs to take into account the age of the patient, the traveler, underlying illnesses, what medications they use, their vaccination history and so forth. And then they need to asses the patients in terms of their traveler itinerary. And there are different variables here that are important to convey to the provider. So they need to understand the full itinerary — the dates, the duration, where travelers will be stopping, what time of year they’re traveling because obviously there’s seasonal considerations with certain diseases. Style of travel varies dramatically. Some people are going to cities, urban areas, and other people will be traveling out into rural or remote areas. Some people travel on a budget and might be staying in very rudimentary accommodations, while other people are traveling to expensive resorts or accommodations. And then, again, the activities during travel play an important role in the type of risks that might be experienced. So business versus tourism, adventuresome travel, and so forth. Next slide, please. So in travel medicine we talk about the three R’s: Routine immunizations, required immunizations, and recommended immunizations. So routine immunizations are those immunizations that are — that everyone gets. And the pre-travel consult offers an opportunity to make sure that adults are up-to-date with all their routine immunizations. I mentioned measles earlier, but this also includes the annual influenza vaccine. Required immunizations, this is where countries have a requirement that you have a vaccination in order for you to enter their country. So yellow fever is required for entry into certain countries around the world. And meningococcal vaccine and polio vaccine are required for all travelers or travelers from certain countries who are going to Saudi Arabia for the Hajj pilgrimage. Next slide, please. Depending on the itinerary and the activities, there are other recommended immunizations that might be offered to travelers. And these depend on the particular circumstances. You’ll see that yellow fever is a recommended vaccine. And I mentioned in the previous slide that it was also a required vaccine for certain countries. It’s important to recognize that a requirement is — a country can have an entry requirement, so in order to get through customs and board in, in that country, you need to show vaccination. But CDC’s recommendations for travelers might vary. So for example, in Brazil, there’s a lot of yellow fever risk, but Brazil does not have a requirement for you to have a yellow fever vaccine to enter the country; however, we would strongly recommend that travelers to Brazil have yellow fever vaccine. And you can see some of the other vaccines that would be considered. Next slide. So these are some of the medications that would be considered for travelers, depending on their itinerary. Malaria should always be considered to any country where there’s a possible risk for malaria. And the medication provided can be either prophylaxis or self-treatment. So the provider can give prophylactic medicine, which means medication to prevent the disease. And this is typically taken before travel, during travel, and for a certain period after you return. And that helps to prevent infection. Sometimes providers might choose to give a dose — a course of cell treatment to travelers. So if they are in areas where they cannot get medicine treatment quickly, they are able to self-treat and then proceed to medical evaluation. There are a number of different vaccines — not vaccines — medications that can be offered, but there are considerations here. Some of these vaccines — excuse me, some of these medications have resistance issues and cannot be used in certain areas. There are cost variables. And also, the dosing varies. Some are weekly doses and some are daily doses. And so all that needs to be taken into consideration. I mentioned earlier that Pepto-Bismol and loperamide can be taken to treat the symptoms of traveler’s diarrhea. But also antibodies can be provided to treat severe diarrhea, and these are for quinolones and azithromycin. Again, resistant issues are important, and it’s important for a provider to evaluate which of these antibodies to provide. Anyone traveling to a higher altitude could be at risk for altitude sickness and acetazolamide might be recommended. Many people are troubled by motion sickness, and again, medication can be provided for that. So a couple of the recommendations that we provide to people about choosing water and food safely. Firstly, drinks should be bottled. For the most part we shouldn’t be using local water supply. The selection of food is important. Choose well cooked and hot foods or foods that you can peel yourself. Avoid salads, and raw vegetables, and pasteurized dairy products; food from street vendors; and ice because often ice is made from tap water. Again hand washing is an important preventative measure. Next slide, please. So we’ve talked about the transmission of a number of diseases through bite insects or mosquitoes, and it’s important to prevent the bites of these vectors. So some of the things you can do in the outdoors is use an insect repellent, use clothing that covers exposed skin. You can also treat clothing with permethrin, or you can use pyrethroid oils which repel insects in the area that they’re set up in. When indoors you can stay in rooms with air-conditioning or window screens, and you can also use Bennett’s that have been impregnated with permethrin. Next slide, please. We are concerned about animal bites and scratches mainly because of infection at the site of the bite but also because there are some very serious diseases, like rabies. We are also concerned about envenomations or poisonings from things like snakes, scorpions, spiders, and so forth, and even marine animals. So the advice here is travelers should avoid all animals, even pets. And if you are bitten, scratched, or stung, it’s important to get medical care right away. Next slide. So I mentioned that accidents play an important role in the health of travelers, and here are some safety precautions: Always wear a helmet when using a motorcycle; wear seatbelts; drink responsibly; stay alert when you’re in crowds; be very aware of local laws and customs; and understand the local crime risks at the destination you’re traveling to. So this indicates what I mentioned earlier about the leading causes of injury/death. Road traffic accidents are high, drowning is high, and so forth. Next slide, please. So I’m going to hand over now to Kelly Holton, who will finish the presentation. Thank you very much.

>> Thanks Gary. And hello everybody. I’m glad to be talking to you today. So Gary has talked a lot about some of the risks that can be associated with travel. So now I want to talk to you about developing an emergency plan before you go. So you put a lot of effort into planning a trip, and so one of our pieces of advice is that you put some effort into thinking about your health before you go. So that might be in getting a pre-travel consultation but also to think about how you would deal with an emergency. So one of the first things you should do is look up the US embassy or consulate in the destination that you’re going to and make sure you have that contact information that you take with you on the trip. Because they would be able to help you in the event of an emergency. It’s also a good idea to think about and research how to get healthcare in the country where you going because their system may not work anything like the way ours does here. We recommend that you leave a copy of your passport, your credit cards, and your itinerary with a trusted friend or relative and make arrangements to check in with that person regularly. You can also enroll in the State Department’s Smart Traveler Enrollment Program. We have the website here. This allows the US Department of State to find you in case of an emergency. So that might be an emergency at home with a member of your family and they need to contact you or if something is going on in the country that you’re visiting. It’s also a good idea to think about what would happen if you get sick or hurt while you’re traveling and to bring some items with you that would help you. So we have some detailed recommendations on our website about packing a health kit. You want to bring items that are used to prevent and treat common injuries and illnesses. Include any prescription medications that you take on a day-to-day basis or ones that have been prescribed to you for your trip especially. And you want to bring enough for your trip and some extra ones just in case you get delayed. And you might think, “Well, I’ll just buy something like Tylenol when I get there,” but the thing is that it might have another name or it might be — might not be available in that country, or you might be in a place where there’s a problem with counterfeit medications. It’s really better to bring your own with you. And then to know when to get medical help. So if you have diarrhea and a high fever, you want to seek medical attention — or if you have bloody diarrhea. If you have fever or flu-like illness and you’re in a place where malaria is a risk, you want to get medical attention. If you have an animal bite or scratch, even if it doesn’t seem serious, because of the risk of rabies you would want to get medical attention. And then if you’re in an accident or have a serious injury or sexual assault. So travel insurance is a really important consideration. Sometimes people overlook it because they’re already paying a lot for their trip, but it’s a good idea to first find out if your health insurance that you have in the United States covers you while you are abroad. And then you can consider, depending on your circumstances, supplemental travel health insurance and medical evacuation insurance. And that’s different from trip insurance that would pay if you needed to cancel your trip for some reason. These are specific to health and can really help you in the event of an emergency or if you just need medical care while you’re abroad. One thing that’s important to know is that you will more than likely have to pay out-of-pocket at the time you get treated abroad and then file insurance claims afterward no matter if you’re using your regular insurance or a special policy. So we wanted to talk a little bit about when to get care after travel. Most travel-related illnesses are going to present soon after your trip, but incubation periods do vary from weeks to years. And Gary was talking about malaria earlier and how long it can take for those symptoms to show up. And some things don’t have any symptoms at all. Some of the common post-travel symptoms are fever, skin and soft tissue infections, and then traveler’s diarrhea that persists. It’s really important, before I go on, just when you do talk to your doctor if you’re having issues after travel to give them information about your travel, your full itinerary, and really help them understand how your symptoms might be connected to your travel history. Okay. We have a number of resources that I wanted to share with you that can help you make your healthy travel preparations. So first of all, the yellow book or Health Information for International Travel is a book that we publish every two years. It’s available on our website. I’ve got the website there. It can also be purchased from Oxford University Press, who is the publisher, and major booksellers. We’ve got a print edition and an e-book. And then it is also available as a mobile app. This is a medical reference book that’s mostly intended for providers, but it is a great resource and really provides the foundation for everything else that we do in Traveler’s Health. And then our Traveler’s Health website, which is It’s really kind of the hub for everything that we have. You will find a copy of the yellow book on our site. We also have our destination pages that I’ll talk a little bit more about in a minute, a disease directly of many travel-related diseases so you can learn about those, and fact sheets and recommendations on all sorts of topics. So one of the things we do is monitor outbreaks around the world that are — that could affect travelers. So we’re looking for things that are unusual in a given destination. So we have three different levels of travel notices. Our level one is a watch where we’re recommending the people be aware of something but to follow the normal precautions we recommend for that destination. So the measles notices that we have posted right now are all level one — just want to raise awareness. And then level two is called an alert. And in that case we are recommending the travelers practice some sort of enhanced precaution. So all of the Zika notices that we have posted right now fall into that category, especially because of our recommendation that pregnant women avoid traveling. And then our level three is reserved for the most serious situations, and that’s a recommendation to avoid nonessential travel. An example of that one is the Ebola outbreak in west Africa in 2014 where we made these recommendations. But for the most part we are trying to encourage people to travel and to keep their health in mind and not recommending against travel. So on our destination pages we have every country in the world, plus a few places that aren’t countries but are kind of separate from the country they’re associated with. We’ve got a version of every destination page for clinicians and one for travelers. They include information about the vaccines and medications that are recommended for that destination and then advice about food and water safety, bug bite prevention, road safety — all kinds of travel health topics you can find there. We do have the health kit packing list from the kits that I was talking about before, any current travel notices that are posted for that destination, and then some information about when to seek care after travel. We also have print materials for travelers. So if you — depending on what kind of topic you’re looking for, we have things that can be ordered from our warehouse through the web link on this slide. So everything we have is available in English and in Spanish. These are available free of charge. And if you don’t want to have it shipped to you, they are also available for download there on the site. We have a couple of mobile apps. So Can I Eat This? is to help people make safe food and water choices when they’re traveling abroad. This app is being updated right now, so we have it taken offline but hope that it will be back up really soon. So want to go ahead and tell you that one’s out there. And then we have TravWell, which is really a planning tool. It allows you to build a vaccine record, to set reminders for next doses of vaccines, or a reminder of when to take your malaria medicine on the right schedule. It has an interactive packing list feature and several others — a place to store copies of your documents, that kind of thing. So I’d really encourage you to check those out. They’re available for free on the Apple App Store and then also on the Google Play Store. And once you download the app, Can I Eat This? will work completely offline. So if you’re in another country and you don’t have Wi-Fi or data, you can still use it. TravWell, once you build a trip, it will work offline. So tried to make those convenient for travelers who might not always be connected. Then we do have a couple of outreach campaigns that are going on right now I wanted to let you know about. The first one is called Viajo Sin Zika and it’s a Spanish and English language campaign that’s focusing on Zika prevention among Latinos who are traveling to Latin America and the Caribbean. It’s mostly a digital company that’s disseminated through media and social media, some advertisements, and through partners. But you can check out our website to see some of those materials. And that we have another campaign coming out to launch this summer called Think Travel. That one is focused on clinicians. and we are trying to raise the awareness of the need to incorporate travel health into patient care. So that might be pre-travel or post-travel. So be on the lookout for that in the coming weeks. Then we have a number of ways that you can stay in touch with us. Travel health and travel medicine are always changing, and if you would like to keep up with notices about outbreaks, new travel notices, new products, or — that we have available, please sign up for our email distribution list. You can follow the link in the instructions I have on this slide. Or if you go to our website, there will be a popup on the homepage that will allow you to sign up for our newsletter. We also have CDC Info, which is a service that CDC provides for public inquiries. You can call the phone Monday through Friday or you can email in. People are available to answer questions in English and in Spanish. And any really complicated question will get passed on to us to answer. Or if it can be answered with our information that we have posted online and things like that, you’ll be given it on the phone. And then we have several social media channels in Traveler’s Health. On Facebook you can find us at CDC Traveler’s Health. We’re on Twitter @CDCTravel. And then Figure 1, which is a social media platform for clinicians, we’re CDCTravel. We’d love to have you follow us and interact there. You’re welcome to ask questions there if you would like. All right. That brings me to the end. And we would love to answer some questions.

>> Thank you both so much for that very informative presentation. We will now transition to our Q&A session. Just as a reminder, if you do have a question, please press the Q&A button on your screen and type your question there. Mabel, can you please read the first question?

>> Okay, thank you very much. We had a question from Steve, who’s asking, “How long does yellow fever vaccine last?”

>> Excuse me. I must remember to unmute. So people might remember that yellow fever vaccine used to be given every ten years. But a number of years ago it was established that yellow fever vaccine is effective for life. And so now we do not recommend in usual circumstances for people to get a booster dose. So one dose is sufficient for travelers.

>> Thank you. Another question is: Are there any update on yellow fever epidemic in Brazil, especially Rio de Janeiro and Sau Paulo? And then when do we expect things to return to normal without the need for the yellow fever vaccination?

>> So a couple of things. I have already mentioned already mentioned earlier in this presentation the areas of Brazil that we recommend yellow fever vaccine and the new areas where vaccine is now recommended. All of that information is on the Travelers’ Health website and on the Brazil destination page. So you can look at that. There’s an interactive map that you can use to look up your destinations. Yellow fever is endemic in Brazil. And so we would expect to see yellow fever activity to continue, but it is seasonal. And we — occasionally some years we get outbreaks that are a little bit worse than others. But we are entering now of — our summer, we’re entering the lower season. But that does not mean that there’s no risk for yellow fever vaccine. It’s just activity decreases a little bit during that period.

>> Thank you very much. So we have another question. Someone is asking, “What is the name of the medication for traveler’s diarrhea? Is it Cipro?”

>> Yeah. So as I mentioned, there are different types of — excuse me, I keep doing that. There are certain medications that are available to treat traveler’s diarrhea, and they might be provided to travelers to self-treat should they get a severe episode of traveler’s diarrhea. There are two different types of vaccine. The one mentioned here was ciprofloxacin, but also azithromycin could be given. And as I mentioned earlier, there are resistance issues. So providers should select carefully which is suitable for a given destination. Thank you.

>> Can someone — sorry, can a person have P. Falciparum Malaria without a significant fever among some of the presenting symptoms?

>> So one of the concerns about malaria is that is doesn’t always have very specific symptoms. It often can mimic other diseases or infections — even influenza, for example. And so sometimes people talk about the typical malaria symptoms, but providers and travelers should be aware that anytime they have fever while visiting an area where malaria is present or after returning from an area where malaria is present that they should seek medical attention. So the question was whether you could have malaria and not have severe symptoms? Yeah, your symptoms might be less severe. But if you do have a fever, please seek medical attention.

>> Okay. Do we have — people are complaining about storage of yellow fever vaccine, and that’s having to alter travel arrangements based on this; do you have any solutions for that or any suggestions on that?

>> So we would always recommend that if yellow fever vaccine is recommended for the destination, people should make sure they are vaccinated before travel. And because of the shortage and because of the fewer sites where yellow fever vaccine is available, there might be difficulty accessing yellow fever vaccine for the next year — six months to a year. And that might impact travel. I would advise travelers to start looking and planning to obtain yellow fever vaccine as soon as they have an indication that they might be traveling to a destination and make sure they allow enough time to find the vaccine and get vaccinated.

>> Thank you. And someone is asking about Zika and asking, “How long would a patient need to prevent Zika using condoms?”

>> So right now CDC’s recommendation is that if a woman has traveled, that they would use condoms for two months after the trip. If a man or a male/female couple has traveled together, then that’s six months. Some of those recommendations may be changing in the near future. So I would individuals that people, you know, keep up-to-date with that website for the latest recommendations.

>> Thank you. With malaria, the problem is many times information is country specific but not granular enough for small areas; is there a way to connect to local data, e.g. MOH?

>> Sorry, my unmute didn’t work. Our destination pages do indicate whether malaria is present in their country, whether it is present in the whole country, so it’s wholly endemic, or whether just certain areas need — there is risk for malaria. Our recommendations also include whether you need malaria prophylaxis or whether mosquito bite precautions will be specific. I would suggest that people — US travelers — use the information on our website to make decisions. There are information from other sources across of the Internet, including ministries of health in other countries. We cannot evaluate those individually. And so we do not recommend that people look at those sources. The one source that could be used to supplement CDC’s recommendations is WHO.

>> Thank you. We have one more question from Carl, and it says, “Is there an age limit for yellow fever vaccine at which it’s considered unsafe?”

>> Yeah. So there’s a contraindication to give yellow fever vaccine to a child under six months old. And then there’s an advisory to give it — a precaution to give it under nine months. So depending on the circumstances and the risk, a provider might decide to provide yellow fever vaccine to a child between six and nine months. But over nine months, children can receive vaccine.

>> We have a question, someone asking about measles. He says, “When you were describing about measles, it sounded like a six-month infants should have measles vaccine before traveling.”

>> That’s correct. So everyone should be up-to-date with their recommended schedule. And children have a recommended vaccine schedule, including measles. But anyone over the age of six months should have at least one dose of measles.

>> Someone is asking about the Ebola outbreak and the potential for passenger monitoring.

>> This is a very new situation, so people might have seen reports about an Ebola outbreak in DRC — the Democratic Republic of Congo. Ebola is endemic in that country, and we have seen a number of outbreaks over the last 30 years. And in most circumstances they are small and contained. CDC is monitoring the situation very closely. And response has included CDC personnel and WHO personnel to the area. The DRC is very experienced in handling these outbreaks. So in the meantime we are monitoring the situation. And as things change, we will change our recommendations and certainly change some of our actions.

>> Can I just add one thing to that, that we do recommend that anybody who’s traveling from DRC and especially in that area where the outbreak is occurring would monitor their health — their own health, self-monitor for 21 days and report any symptoms.

>> This is a good reminder that when physicians see travelers to ask about recent travel.

>> Okay. Will the TDAP be recommended over TD despite the ACIP recommendations for only one dose of TDAP?

>> I’m sorry, I can’t answer that information, that question off hand. I’d have to check on that.

>> Another question is on diarrhea, and they’re asking, “What are some of the microbes that cause travel diarrhea?”

>> So a lot of things can cause traveler’s diarrhea. Sometimes it might not be an infection, it might just be an exposure to unusual foods. But viruses can cause traveler’s diarrhea, bacteria can, and certain other organisms such as parasites might cause traveler’s diarrhea. About 80% of cases are caused by bacteria, though.

>> We have one more question, the final question. “Is the alternative yellow fever vaccine just as good as the primary one?”

>> Yes, it is an equivalent vaccine that is actually authorized by WHO. It is used — it’s been used for a long time in Europe. And it’s basically an equivalent vaccine to the vaccine that was previously available here in the US.

>> Thank you, everyone. We are at time right now. It is 2:00 o’clock. And so I’d just like to thank you all again for joining us today. If you do have additional questions — and I know we couldn’t get to a lot of them — please email them at That’s And then we will route them to the Travelers’ Health branch. As a reminder, today’s presentation has been recorded. And you can earn continuing education for your participation. Please follow the instructions that you received in your invitation for today. And the course access code is EPIC0522 with all letters capitalized. Thank you so much, and please have a wonderful day. Goodbye.

Page last reviewed: June 20, 2018