Name:
A 46-Year-Old Seeking Travel Advice
Description:
A 46-Year-Old Seeking Travel Advice
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Duration:
T00H05M49S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi. Welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener
CHARLIE: and we're coming to you from the Johns Hopkins School of Medicine. Welcome to Episode 26: A 46-Year-Old Seeking Travel Advice. The question reads, a 46-year-old man wishes to travel to Kenya for a two-week vacation. He is human immunodeficiency virus-positive and is taking antiretroviral therapy. His last CD4 count was 625/µl and his viral load was undetectable. His nadir CD4 count was 250µl.
CHARLIE: He has never had an acquired immunodeficiency syndrome, or an AIDS-defining illness. In addition to HIV, he has a history of hypertension and is known to have proteinuria due to HIV-associated nephropathy. Which of the following is your recommendation to this patient, regarding his travel plans? Option A reads, he should not receive the live measles vaccine prior to travel. Option B reads, he should receive the yellow fever vaccine prior to travel. Option C reads, he will be required to show proof of HIV testing upon entry into the country.
CHARLIE: Option D reads, his likelihood of a response to the influenza vaccine will be less than 50%. And Option E reads, with a CD4 count greater than 500/µl, he is at no greater risk during travel than persons without HIV. Okay, Cathy, this is a complicated question. Where do you want to start?
CATHY: So, in general, individuals with HIV are considered at higher risk of infectious complications when traveling abroad. However, individuals who have no symptoms and a CD4 count that's over 500, appear to be at no greater risk than individuals who don't have HIV infection. So, the best answer for this question is Option E. Thinking about some of the other choices, many countries do routinely deny entry for HIV-positive individuals if they're going to be staying for prolonged visits.
CATHY: And proof of HIV testing is required in some countries for stays really longer than three months. It should be noted that these restrictions don't appear to decrease the rates of transmission of HIV, however.
CHARLIE: So, I think it's important to say right away, that all patients who are thinking of traveling to overseas countries should at least check out www.state.gov to find out are there any restrictions on health requirements et cetera. That is one thing everybody should do. Now, this man's proposing a two-week holiday. Any thoughts about that?
CATHY: Generally, for short trips, US citizens aren't required to disclose anything about their health status. And like you mentioned, the consular offices or a state department website, should be consulted prior to travel to see if any special documentation is required.
CHARLIE: For patients with HIV infection, how do you factor in their CD4 count into your decision making?
CATHY: Well, for vaccination purposes, the response to immunization could be impaired if the CD4 count is less than 200. And even in some cases, this happens at higher counts. So, HIV-infected persons should be vaccinated as early as possible to ensure that you get an adequate immune response to vaccines. For patients who are starting antiretroviral therapy, at least three months must elapse before you have regeneration of the CD4 T cells, to a point where they can be considered fully functional.
CATHY: So, vaccination of these patients should be delayed until they've been on antiretroviral therapy for a few months.
CHARLIE: Okay, evidently, this patient was going to be traveling around flu season, how should we think about the flu shot, or flu vaccination specifically?
CATHY: Well, response varies based on the baseline immune function of the person. So, estimated rates of response to the flu vaccine are over 80% among persons with asymptomatic HIV infections and that's similar to the general public. Option D mentions a response rate less than 50% and that's seen among people who really have a diagnosis of AIDS. How much protection the flu shot provides varies based on the circulating strains of the flu, but it's helpful even in decreasing the severity of flu symptoms and in preventing complications.
CHARLIE: Right, and that's true about the general public, too.
CATHY: Yes, absolutely.
CHARLIE: All of what you were saying before, I assume, is about the flu shot, what about the nasal flu vaccine?
CATHY: Yeah, so the nasal flu vaccine is different. So, that nasal spray is a live attenuated vaccine and those are contraindicated for persons who have immune dysfunction. So, this includes people who have HIV, or are on immunocompromising drugs, but also populations like pregnant women.
CHARLIE: Measles vaccine is mentioned in the question. That's a live attenuated viruses. What are your thoughts on that?
CATHY: As I mentioned, generally live attenuated virus vaccines are not given to HIV-infected individuals. Measles is a special case though, because it can be lethal in HIV so this vaccine is actually recommended, unless the CD4 count is less than 200. Now, let's contrast that with the yellow fever vaccine, so that's another live virus vaccine, and that is not given to HIV-infected travelers. Now, it is a required vaccination in some countries but individuals who have a CD4 count less than 200, should probably be discouraged from traveling to countries with endemic yellow fever.
CHARLIE: Okay, so the teaching point here is that prior to travel, it's important to research the travel requirements for the specific country of travel, particularly for individuals with HIV, but in general, that's true for all of us. The recommendations and efficacy of specific vaccines may vary or do vary based on the CD4 count, and generally speaking, patients with HIV infections should not receive live virus vaccines.
CATHY: And to read more about this, you can look up Harrison's chapter on infectious disease, health recommendations for international travel, and other websites that are really good to look at are the CDC website and the state department website about recommendations for travel worldwide. ♪ (music) ♪