Good afternoon, everyone. I'd like to welcome you all to ACOM's webinar, a global travel for work in a changing climate, an update on a threat of unknown and emerging infectious diseases presented by Dr. Irene Eliaki. And I'd like to go over a few housekeeping tips before we get started. My name is Nikki Hoffman. I will be your ACOM staff liaison today. Before we get started there, I just want to let you all be aware that there are two features available to communicate with the panelists and other attendees. If you have any questions, you may post general messages in the chat feature. Messages can either be shared or entered with panelists or all participants. Use the drop down box to select who you want to share your message with. Go ahead and give it a try by introducing yourself to all the panelists and attendees or let us know where your role and where you're listening from today. If you have any questions, which I encourage you to submit throughout today's presentation, we'll be taking questions at the end. But questions, on the other hand, should be submitted via the Q&A box. Panelists will be monitoring this box, so be sure to post all your questions there and not in the chat box. If you're not familiar with ACOM, welcome. We are a membership organization that promotes the health and safety of workers, workplaces, and environments through education, research, development, and public policy in advancing the field of occupational health. Before we get started, just a reminder that we are recording today's session and that recording will be available on ACOM's Online Learning Center and then within this next week or so. Now I would like to welcome Dr. Russell Tons, who will be our moderator for today and who will be introducing today's speaker. Welcome, Dr. Tons. Hey, now, thanks, Amelia and Nikki. So, hey, guys. Greetings to all from the greater Boston-Cambridge area here. It's my absolute pleasure to introduce one of my colleagues, Dr. Irene Iliaki, superstar who received her medical degree from CRETE, her home country in Greece, or MPH from the TH Harvard School of Public Health, Internal Med Residency and Fellowship at Boston Medical Center, Boston University. She's an instructor here at the Harvard Medical School with a specialized certificate in travel medicine and also holds an appointment in the Cambridge area in the Biosafety Committee. She is a board-certified infectious disease physician, also, you know, serves as our occupational health specialist here at Cambridge Health Alliance in Cambridge, Massachusetts, and manages quite a wide range of inpatient, outpatient-setting infectious disease, post-exposure, immigration TB, does a lot of international consults. Today, she's going to hit her specialty here with us in terms of travel medicine. So, Dr. Iliaki, the stage is yours. Perfect. Thank you very much for the invitation. It's a privilege and everything I teach today is because I learned not only from my teachers but my colleagues here in occupational health and in the infectious diseases department. So global travel for work in a changing climate. This will be an update on the threat of old and emerging infectious diseases. The objectives for today after participating in these sessions, attendees should be able to assess infectious diseases risk of travelers for work in a systematic way, summarize current infection diseases trend of known and emerging pathogens propelled by climate change and select appropriate established travel related vaccines and boosters and to prepare for upcoming vaccine development. And the outline for today, I'll start with the case presentation. I'll go ahead with a systematic review of risk. I'll discuss the link between climate change and infections. We'll discuss select vector-borne infections, food and water infections, infections through contact airborne, latest literature on returned travelers, a summary table and the case follow-up. So a 65-year-old male presents to our travel clinic prior to a documentary film trip. This is going to take place in Manaus in Brazil for 28 days during the month of May. And he will be in remote locations primarily filming. And these are pictures that he provided for us of the location. He has depression, hyperlipidemia, hypertension and asthma. He is on vanilla vaccines, Invastatin, Amlodipine, Fluticasone, Propionate and Salmeterol. He is allergic to shellfish, no history of travel-related illnesses. And his exam in our clinic is normal. He's providing us with a list of vaccines, as you can see. And as usual, you know, we go on the CDC website, which is offered for free, the yellow, 2024 yellow book at the CDC. And there you get what I call like a vaccine salad in terms of multitude of vaccines to assess for and medications. There are no, there's no easy way to get to what he's already had all those vaccines, what needs boosters and more details in the assessment. And so we will gradually get introduced how to approach this subject systematically so we don't get overwhelmed when we're faced with this vaccine precaution salad when we use our online modalities to advise our travelers. I want to point out for this group that global travel increases yearly. In 2024, global scheduled passenger volume is projected to reach just below 5 billion as we're ending 2024, a continuous increase. And of those, about 15% is felt to be for work. So 750 million travelers for work. This could be your colleagues, your clients. There's lots more occupations than what is mentioned in this slide. But just to point out a few, obviously, our military personnel, humanitarian aid workers, medical missions, journalists that go internationally, photographers, videographers, tour guides, cruise ship staff, merchant mariners and seafarers, commercial pilot and crew, archaeologists, field researchers, diplomats, and executives in international companies and consultants. I'm often asked, are business travelers very different from other travelers for work? And my answer is, based on data, they're as likely as other travelers to develop some travel-related illnesses. And only 45% of travelers, the business executive type, got pre-travel advice. So another target group to address. So a very large number of employed persons travel for work and are in need of pre-travel consultation. And when we do that, we go over items on the host, especially if they're immunocompromised, their medications, allergies. Are they pregnant, breastfeeding, or planning to become pregnant in the next three months? That goes for women and for men who might want to use their sperm to impregnate. The trip details and, of course, a location. So I'll start with the first objective, which is how to look at risk in a systematic way. So I look at it in buckets. In buckets, four main buckets. The first and the biggest one is really vector-borne illnesses. And again, this is not a slide that includes everything. It's from the CDC. But an indication of the basic vector-borne illnesses. There's about 100 of them that have been found in humans. And this is just a small proportion. First and foremost, mosquitoes. There are three main types, Aedes, Anopheles, and Culex. As you can see on the right-hand side, diseases that are caused by Aedes mosquitoes include chikungunya, dengue, rift valley fever, yellow fever, Zika. These are all viral infections. Lymphatic filariasis, you'll see, is able to get transmitted by all the types of mosquitoes. The Anopheles mosquitoes also, as you know, carry malaria. Culex, which are abundant, they can carry Japanese encephalitis, lymphatic filariasis, West Nile fever. They can also carry Oropucha fever, as do the midges of Culicoides flies. The aquatic snails carry schistosomiasis, black flies, onchocerciasis, fleas, plague, and tangiasis, lice, typhus. Sunflies, leishmaniasis. Ticks, you're very familiar with Lyme disease and other Rickettsia here in the U.S., but there's also Crimean Congo hemorrhagic fever. There are other Rickettsial diseases like African tick bite fever, tick-borne encephalitis, tularemia. The triatom bugs carry Chagas disease or American trypanosomiasis, and then the tsetse flies that carry sleeping sickness or American or African trypanosomiasis. The other bucket is of food and waterborne. And hepatitis A, I think, is the hallmark here. And I have poliomyelitis here because I want people to remember that even though it's mainly person-to-person, it's fecal-oral. So, in my mind, it belongs in this category. And your traveler's diarrhea with the usual Z. coli, Shigella, Campylobacter, your typhoid fever or your non-typhoid salmonellas, your Vibrio cholera, Giardia. And remember recreational water exposure for which leptospirosis and schistosomiasis are big risks. You've also heard about Nigleria fowleri, Vibrio vulnificus, and cryptosporidiosis. Infections through contact is the third bucket I put things in. As you know, there might be more than one ways of transmission. So, I'm sticking to the basic or main ways of transmission here. So, contact, your rabies, herpes B can be found in non-human primates around the world. So, remember that as well. Tetanus, your hemorrhagic fevers, Marburg, Ebola, mpox, HIV, sexually transmitted infections, hepatitis B and C. And then you have the airborne, anything through the air. So, respiratory viral infections, the usual ones like flu, COVID-19, RSV, a lot of other respiratory viruses that are not listed here. Remember measles, varicella, they are airborne. And yes, you can also get varicella from touching the secretions or the content of vesicles and then mucous membranes. But main routes are airborne. Meningitis, pertussis, tuberculosis, hantavirus. So, these are the main four buckets that we think of. And at the end of the presentation, we will have a table where we're going to have categories of these infections with personal protective measures that we can advise, with vaccines we can recommend, and medications we can prescribe. So, that way, you, of course, always have to go to CDC or any other online module of your preference that's reliable to compile your final consultation. But at least you're going to have categories in your brain. I have another here, although not my expertise and the point of this talk. I want people to be aware, of course, of other important items. So, we discussed these basic four buckets. And now we're going to dive in and take into account climate change and infections. So, in the next part of the presentation, that will be the focus, as well as select infections that we're going to dive in. This is a climate map. So, as you might imagine, the areas on the blues in the middle of the planet are the ones that have the higher risk for all kinds of infections because they are in tropical areas. And then the location a little above, a little below, these are subtropical areas, also at risk. Annual precipitation matters, as you know, because of vectors that can multiply. And as the climate is warming, there are additional areas, like in Europe or North America, where we see mosquitoes, ticks, other vectors that previously were not able to survive, now surviving, lasting longer in the seasons. And the temperature is allowing them, making them more able to carry those viruses. There's a lot of literature in this topic. What you can see here in this screen, due to a number of drivers that drive the climate change, we see extreme weather. And this has downstream effects that are direct, but also indirect, causing human migration. We see a change in the animal and vector ecology that I just talked about. We talked about the rising temperature, and then the water quality, quantity, is changing with warming of the climate. Warming of the waters. This is just an estimate that about half of the infectious diseases are climate sensitive, and that they could be aggravated through climate change. And as always, the most vulnerable are affected. And you see this, you will see this with your travelers, and you're seeing it, and travelers for work, and also with local populations. So, before diving into specific illnesses that have been aggravated by climate change, I'll just take a moment to show you all the in terms of counseling for personal protective measures. This is something that we can't stress more. I tell my travelers that your bug spray, your permethrin-treated clothes, are your best friend for this trip. Don't forget them. Have them in your mind always. And I'll just, just to prep the scene, I'm going to ask you which four vaccines for vector-borne diseases are FDA approved for use in the U.S. for travelers, and which two vaccines of the list that I'll show you are licensed for use in areas of endemicity. This is the list I showed you before, so you can take a silent moment to go over the four vaccines for travelers that are already approved for vector-borne illnesses, two that are approved in endemic areas. So, here we are. So, there is an FDA approved vaccine for chikungunya, for yellow fever, for Japanese encephalitis, and tick-borne encephalitis. Malaria vaccines are approved for endemic areas. And dengue vaccines, there's already a couple not used in the U.S., and one that's going to be coming up. So, we're going to talk more about those. So, let's dive in now. We're going to start with chikungunya. It means that which bends up because of the posture of suffering patients, because chikungunya causes arthralgias, that is the major symptom, along with fevers and a rash. But fever, arthralgias, and rash is very common with chikungunya, with dengue, with Zika, with Arapuche, we're going to talk about it. But the hallmark for chikungunya is arthralgias. And 50% of affected patients have arthralgias about three months after infection, based on seven studies. So, a large proportion of patients states debilitated. There's also mortality associated in the older population. Is that as of 2024, there are about 480,000 cases of chikungunya virus disease and 190 deaths. Usually, the epidemics are explosive, they're rapid. And then they're followed by periods of lower incidence. So, it's important to catch it in an early stage. And what happens is, I'll show you the map where the current outbreaks. So, we talked about the vaccine briefly in the other slide. But I'll go over it in a bit more detail here. It was a pivotal study using a surrogate of protection as an immunogenicity endpoint. And it's a single shot live attenuated vaccine. There was a double blind multicenter randomized placebo controlled phase three trial. And it was found to be 98% seroprotective at one month and 96% at six months and safe, no evidence of alarm. So, in your travelers, it is recommended for persons who go to an area of an active outbreak. Of note, currently, the CDC has not recognized an active outbreak. The bar is high to characterize that. What the CDC, as you can see here on the screen, there is no dark blue area on the map. There's lighter blue areas, which characterize areas that have had chikungunya outbreaks in the last five years. And so, a chikungunya vaccine can be considered for travelers who go to areas that had outbreaks in the past five years, as long as they are more than 65 years old, particularly if they have underlying conditions, and they're going to stay more than two weeks. Like my traveler, he's 65, he's planning to stay for a month. Or persons that are staying for a cumulative period of more than six months. So you can always go to the CDC website and look at the map. We're going to go to yellow fever now. I think this is a topic that's close to a lot of you, so I'm not going to go into detail, but the slides will be available. It's worth noting that there was an increase in the cases in 2016, so I want to point out that when I visited Brazil, which was in about 2010, these areas here were areas where vaccination was not recommended. But starting in 2017, the mosquitoes that carry the disease spread to include major cities like Rio de Janeiro. I'm not going to go into detail here. Dengue. I think dengue gets the first prize. Unfortunate. It's an unfortunate first prize here, but this is where we've seen literally a complete explosion of the cases. You can see on the map here the case explosion, and this was just a few months ago. Just a couple days ago, the numbers were finalized for 2024, and we've reached 12.6 million cases in 2024, along with 7,700 deaths. This is more than a 200% increase. You can see the countries affected here, and you can see the global spread and even autochthonous cases in France, and that happens every year throughout other areas in the world that are not traditionally considered to have endemic dengue. I want to highlight here, and I want you to prepare your travelers. When you talk to them about protecting themselves from dengue, please mention that there will be a vaccine within a year, two years. It should be approved. I'm going to point your attention here in the middle of the slide. Very nicely studied, the Butantan dengue virus live attenuated tetravalent vaccine. It was found to be safe and effective for ages 2 to 59 for people with or without a history of dengue infection. So please keep an eye for that for travelers. Now, on the left-hand side, you will see there are two other vaccines, and one of them is already approved in the European Union and other countries, but the license application was withdrawn in the USA, so we're not going to see it here at least anytime soon, as far as I understand, and there is another vaccine that was available for US territories with dengue, but it will no longer be available as the production is stopping due to decreased demand. I'm going to go to malaria now. So we discussed chikungunya. We discussed the vaccine that was approved about a year ago and available, and to please screen and see if your patients qualify for that. We discussed dengue, and to prepare your travelers for what is coming, and now malaria, about 10,000 to 30,000 malaria cases in travelers worldwide, and you can see the distributions here, and again, just a couple days ago, we got the final numbers for 2023, and yes, it takes a year to finalize numbers for the year prior when it comes to malaria because it is complicated, and the number of cases has increased to 263 million in 2023, actually, from 50 in 2022. As you can see, it's a constant increase. The deaths have remained about stable, and as always, it's about 75% that affect kids. Those are the malaria deaths, kids under fives. There are vaccines for malaria now, a huge success, two of them, and not only the, you know, phase three studies that showed really good results, but we now have even results from pilot programs on the ground, and we do see that the vaccine effectiveness is about 75%, and there's already been a 13% decrease in pediatric mortality in the areas of the pilot program, so really promising. They're not for travelers right now. There is a lot of demand. They're prioritized for the countries that suffer, and travelers can use the other measures, the personal protective and medications at this point. I'm not going to go into malaria chemoprophylaxis because I think you're all very familiar with it, so let's go to Oropuce, our fourth infectious disease that we're going to spotlight in vector-borne illnesses, so Oropuce. It's a virus of the genus Orthobunia virus, and between January 1st and 25 November in 2024, there have been about 11,500 confirmed Oropuce cases, including two deaths, and they have been reported in the region of the Americas, so you can see the map. There are 94 cases reported in the US, and I believe all of them, if not the vast majority, are from Cuba right now, but there is a heightened concern because there is an area in Southeast Brazil, in Espirito Santo, where there is high, very high increase in cases right now, so I'm sure you hadn't heard about it until a few months ago. It was first described in Trinidad and Tobago and in the Amazon Basin in 1995. In 2023 is when we started seeing increase in cases. The symptoms, acute febrile illness, like we talked about, fevers, arthralgias, possibly rash, but also there is the potential for meningoencephalitis, an invasive neuroinvasion. 60% may have symptom recurrence. It's also, in terms of its transmission, we talked about the Culex mosquitoes. We talked about the midges, the tiny little forms that you see next to the bigger mosquito, and it was also found in semen, and there was also a case of vertical transmission, and as you very well know from Zika, it is feared that sexual transmission is possible and vertical transmission is also possible. So these are, so far, what we have talked about, the four items on the top, and now I'm going to go to quickly touch on food and water via contact and airborne before we go into some literature. Food and water and airborne infections. So hepatitis A, and on the left-hand side, I showed you those infections earlier, and in terms of preparing our travelers, you're all very familiar with avoiding tap water, not even for brushing the teeth, using bottled water, and how to safely consume cooked food, avoid anything that's raw, undercooked, vegetables, anything that cannot be peeled, and because these are not, these are layers of protection. We, of course, want to highlight vaccines, the typhoid vaccine. It's not perfect, 50 to 80% effective, but better than zero. Hepatitis A vaccine is excellent. Cholera is only for humanitarian missions and can be requested, and remember a polio booster. There are, since 2014, there are countries that have wild polio circulating and a lot of countries with vaccine-derived polio, so it's absolutely necessary to look into that for your traveler. You're familiar with medications for traveler diarrhea, leptospirosis assessment, and if there is risk, you could do weekly preventive measures with medication, and if there is risk for schistosomiasis, you can check serology is exposed upon return after two months. For infections through direct contact, we went through a list previously, and now we can talk about the available vaccines. So for rabies, there is, of course, vaccine for pre-travel, two doses for pre-travel purpose. I find that there's a big barrier because of the financial cost, and I try to put things on perspective and to show value for it as depending on the itinerary and the activities and as the risk increases. As you know, despite pre-travel vaccine upon return, sorry, if there is an exposure, then, again, the traveler needs to seek care at the site. Viral hemorrhagic fevers. You heard of the Marburg outbreak recently, and I have here the bar diagram that shows that likely we are on the clear, and I did have travelers visiting the area for purposes of work meetings. So during the epidemic, so I had to give advice about avoiding close contact with locals, avoiding contact with wild animals, and protection measures if in mass gatherings. Remember MPOCs. On the right-hand side on the bottom, I have the map where you can see there is a CLAID-1 epidemic, mainly in Central Africa, and in West Africa, there is still a CLAID-2 epidemic, which is what we see worldwide and is still evident, but specifically for Central Africa, CLAID-1 is very severe right now, and the MPOCs vaccine is available for high-risk travelers. So please assess risk factors. If there is risk for HIV, people can go on pre-exposure prophylaxis, and it's okay to discuss it with your clients. Sexually transmitted infections as well, we can have prophylaxis for that. Hepatitis B vaccine. Or go to infections through the air, and you're very familiar with your flu, COVID, RSV vaccines. Remember meningitis for areas that qualify, in the meningitis belt or for mass gatherings for religious reasons. Remember your Tdap. Not only protects from tetanus, but also pertussis. For tuberculosis, the biggest infectious disease killer in the world right now, we are talking about millions of cases, and for over a million deaths every year. So number one infectious disease killer. Travelers become at risk if they stay longer periods of times in areas. Anyone who stays over one month, it's recommended that they get pre-screening, tuberculosis infection test, post-screening test. If they test positive, we treat them. There is no vaccine for travelers, but it's been studied. There's actually a group at the BI. They do, and they are assessing the very well-known BCG vaccine for those who never have it and are traveling. Hantavirus, measles. Remember, measles right now is surging worldwide with 10 million infections in 2023 alone. So please double-check for proof of 2-MMR vaccines or perform serologies. So we discussed all the four buckets and what can be done to cancel with vaccines, with medications, and now what does the latest literature tell us about trends in returned sick travelers? So the most recent publication is from a wonderful group that I've learned a lot from and collaborated with in the past and was published in Lansant Regional Health in Europe, and they looked at travel infections presenting in Europe and 20-year analysis. So they looked at data from about 100,000 ill travelers that were evaluated in multiple areas in centers that belong to the GeoSentinel Center, where it's centers of excellence, to diagnose infections in travelers. So what they saw in five-year increments in the last 20 years is greater proportion of patients that were migrants or visiting friends and relatives. The business travel-associated illness has remained stable. Tourism-related illness has decreased. Falsiparum malaria was amongst the most frequently diagnosed illness with about 5,000 cases and the most frequent cause of death. Animal exposures requiring rabies post-exposure prophylaxis increased. The proportion of patients with seasonal influenza also increased, and there were 44 cases of viral hemorrhagic fevers, and the vast majority was within the past five years. Arboviral infection, which is another word for arthropod-borne or vector-borne, mosquito-borne, numbers increased significantly, as did the range of diseases, with dengue and chikungunya having increased the most. And one more word for business travelers. As we talked about earlier, I want to highlight, again, they have less risk perception, but the risk is there. And again, this is based on data. And back to the study that I mentioned earlier, the business travelers that were studied, 9% returned and was diagnosed with malaria, 8% with acute diarrhea, viral syndrome, or bacterial diarrhea. And only 45% of the travelers that returned ill had gotten the pre-travel advice, and of those who got the advice, 92% did not take the prophylaxis or took an incomplete course of prescribed medication. Hopefully, there were some vaccines, and hopefully, there were pointers as to what to look for upon return. So I think there's still value in that pre-travel advice, but it's a good reminder to know the population. So to summarize here, I wanted to look into boosters because I remember finding myself frustrated every time I got a traveler who's a seasoned traveler with a lot of traveler-related vaccines. Hello folks, it looks like the video just froze, so please stand by. I'm sorry, I think there was an internet issue. All good, all good. We'll get you back up and running. Perfect. So, almost done. So, I was talking about the yellow fever, so I'm not sure if you guys heard. I was just saying that... Do you mind re-sharing your screen? We lost your presentation. No problem. We're going to be on time despite this. Almost there. All right, looks like we're back up and running. Thank you for your time. Perfect. Okay, I'm not sure if you heard about yellow fever, but I'll just repeat that one dose is good for life with very, very few exceptions. Japanese encephalitis, two dose series, yes to a booster, one lifetime booster, and usually one year after primary series. For chikungunya, what's been studied is for one dose with no boosters, it is a virus and the vaccine is felt to give lifelong immunity. Typhoid injection, I'm sorry, typhoid injectable. The typhoid injectable is a single-shot vaccine and is good for every two years. The typhoid oral is every five years. And rabies, if someone is vaccinated after 2022 with two doses, then some people will need booster after three years. This protection of the two doses lasts nicely for three years, but after three years, you would either require a booster or check titers to see if they're more than 0.5, and then you don't need that booster to keep you for lifelong. Depending on higher risk, there might be other requirements, but for travelers, these, you know, the usual travelers, that should be adequate. For those vaccinated with three doses appropriately before 2022, there is no need for further boosters. And just to summarize in this slide here, I have included everything we basically talked about to make it easy for people to just kind of orient themselves. And I want to highlight that even though those routine vaccinations are up here, you'll see them in their respective categories as well because they're so important. Remember, road safety injuries are always the number one reason for morbidity and mortality. So, although I'm an infectious disease physician and my talk was focused on infections, I want to make sure you also address other aspects that you'll see on the right-hand side. And lastly, I want to talk about the traveler responsibility in a changing climate. And I want you guys to avoid spreading infection to the destination. So, there are either good examples of traveler spreading infection, and I'll point you to the cholera outbreak in Haiti, Zika in the Americas, and remember COVID-19 introduction in Boston. So, my advice is, if you're sick and you're traveling, cancel the trip. If you have to travel, please use mitigation measures, remain in your room if you're sick, intense hand washing, remain in your room if you're sick, intense hand washing, have a rash if you have one, avoid skin-to-skin contact, wear a mask, just things that make sense. The mosquitoes don't travel that far. People do. So, I think we addressed all the objectives here. And for the sake of time, I think we have a couple minutes so I can update you on the case. As I said, we are sticklers to MMR. He was not born before 1957, so we asked him to check serology, so he was immune to measles, mumps, rubella, and varicella. We canceled him on the chikungunya vaccine, and he decided to receive it, and he did really well with it. He would address RSV vaccine with his PCP. We had to restart his hepatitis B. He got another typhoid because it was more than two years since his last typhoid, and we prescribed hematovac and proguanil for malaria prophylaxis and azithromycin in case of traveler's diarrhea. And here is Dan, who's allowed me to share his picture during his trip. As you can see, he's wearing loose, light-colored clothes. He took off the hat for the picture. He promised me he was wearing it, and when he came back, he told us that he lost, actually, mid-travel. He's atovoc and proguanil, and we canceled him about malaria symptoms, which he did not develop any, luckily. So, all the other preventive measures that he did worked, and no post-travel illness was reported. So, that brings us to the take-home messages, which are that changing climate is more conducive to travel-related infections. We have to cancel and encourage personal protective measures. We need to address routine vaccines as if they're travel vaccines, highlighting MMR and polio, but also mpox, for example. Assess for chikungunya eligibility. Repair for the dengue vaccine and the other vector-borne vaccines that exist. Risk-based preventive and post-exposure medications, and always err on the side of cautions. Oftentimes, I print them up for a country, and half the country says there is malaria, and half says there isn't. But, if there's no serious differences in the landscape, I do err on the side of caution because of climate change, because mosquitoes like weather more than 60 Fahrenheit and more than 60 percent humidity. So, if these conditions exist, it's quite possible that malaria will be in an area near that line. And, review traveler responsibility. This is all I had, and thank you again. A special thanks to Dr. Varvarigu, who's my partner in crime here in the travel clinic, and again, all the staff here. Of course, our patients. I'm happy to take questions. Thank you so much for your presentation today. As a reminder to our attendees, as we give everybody a few minutes to submit their questions, please go ahead and type those questions in the Q&A box at the bottom of your screen so we can take a track of those. So, and then I'm going to talk, I believe we had had one question that was in the chat, Dr. Tons, if you wanna take that one from there, but please submit them through the Q&A. Sure, hey, Dr. Iliaki, looks like Dr. Guerrero was asking, do you administer all the vaccines at one time? Great question. Yeah, thank you for the question. It's a great question. What I tell my travelers is that when I take my kid to the pediatrician, they can get up to five or six vaccines, which is, I believe the maximum is six, if I'm not mistaken, but definitely five we can give at the same time. Yes, there will be sore arms, and the next day it's expected to feel fatigue, low grade temps. So I do advise persons to the next day to take it easy, hydrate well, take acetaminophen or ibuprofen. Hey, Dr. Iliaki, another question here. Duke Oral, looks like cholera vaccine for travelers, diarrhea, your opinion on that? Very good point, I'm asked frequently. So it is not recommended other than humanitarian relief aid, meaning even when I consult for travelers who travel for work and will be in a year in a hospital, part of a mission in a hospital, it's not even recommended for them. So it has to be relief aid workers. There is a reason for that, it's limited. So it's prioritized for areas that have cholera outbreaks. I didn't have time to go in depth about the increase in the cholera cases, but I mentioned briefly as the waters are warmed up and we have the extreme phenomena, obviously there's more cholera. And if you go on the CDC, you can see where you can request it. Like if you go CDC cholera request vaccine, there's an email and you can request it if you have persons who qualify for it. Great question, thanks Dr. Sacks. So Dr. Wilmoth has a question here about dengue vaccine and the researchers working with the virus, whether or not the vaccine will protect them, I presume for sort of that laboratory experience and the exposure risk. Great question, it's a fantastic question. So it depends where the laboratory workers are located. In the US right now, it is not indicated because it's not approved. So I had the exact same question like you in a setting. So I asked, I looked it up. So it depends on the location. If it is a location in the world where a dengue vaccine has been approved, sure, absolutely. Hey, another great question here from Dr. Harry Gee. It looks like a similar question I was going to ask as well. Why Zithro versus fluoroquinolone? Ah, I'm an infectious disease doctor. And by definition, I detest fluoroquinolones. They're very broad, they're wonderful. They're wonderful, but they're very broad and they have side effects. So they're very broad, they kill everything under the sun. They are our only weapon for oral treatment of pseudomonas. So I don't want to burn it easily. Side effects, neurotoxicity, tendons, QT prolongations. QT prolongations. And also there is abundant resistance of enterics to fluoroquinolones, abundant resistance. So multiple reasons why I strongly prefer azithromycin. No, thanks, Dr. Eliaki. So I think Dr. Yakes is asking a similar great question. I'll move to Dr. Bender here. It looks like which types of reported activities have prompted the recommendation for the tick-borne encephalitis vaccine for a traveler going to Europe is mentioned here. Yes, so another chapter, of course, and in my extra slides, I have a map. It depends on the location and I believe it also depends on the duration. I know military personnel has to get it if they're visiting these areas. And for persons, for example, who are gonna be in forested areas spending most of their times hiking in forested areas in these specific locations where the map indicates, the CDC map indicates. That's fantastic. I don't see any other open questions here. I do see Dr. Berry says hello from Robbins Air Force Base. So always a pleasure. I should thank the residents as well of our occupational program. And I shouldn't forget to thank Derek because he prompted me to do a similar presentation for the residents. So always learn a ton from our residents. Thank you guys. Thank you, Dr. Iliaki. That was an awesome presentation. I hope everyone had the same chance I do on a daily basis here working with Dr. Iliaki as an awesome expert in terms of this field and many fields. So she's a fantastic doctor, person, colleague. So thank you for that presentation, Dr. Iliaki. Thank you very much. Pleasure is mine. Yes, and on the behalf of ACOM, thank you so much for joining us today, Dr. Iliaki and Dr. Tons for moderating and to all of our attendees who took time out of their day to join us for this great presentation. As a reminder, you are able to claim your CME through ACOM's online learning center. You'll just need to log in using your ACOM username and password. And under my courses, you should be able to access this webinar and complete the evaluation, which is required in order to claim your CME. And then your CME will show up in your transcripts once you've completed that evaluation. If you have any questions, please reach out to educationinfo at acom.org. Thank you all again for attending. A recording of this presentation will be made available for purchase later this week. Take care and have a wonderful afternoon.

infectious diseases

climate change

vector-borne diseases

travel health

vaccinations

malaria prophylaxis

occupational health

antibiotic resistance

personal protective strategies