{"version":"1.0.0","segments":[{"startTime":0.211,"endTime":3.185,"body":"♪ (music) ♪"},{"startTime":3.185,"endTime":5.649,"body":"(Cathy) Hi. Welcome to \u003ci\u003eHarrison's Podclass\u003c/i\u003e"},{"startTime":5.649,"endTime":8.564,"body":"where we discuss important concepts"},{"startTime":5.649,"endTime":8.564,"body":"in internal medicine."},{"startTime":8.564,"endTime":10.822,"body":"- I'm Cathy Handy."},{"startTime":8.564,"endTime":10.822,"body":"- (Charlie) And I'm Charlie Wiener"},{"startTime":10.822,"endTime":13.909,"body":"and we're coming to you"},{"startTime":10.822,"endTime":13.909,"body":"from the Johns Hopkins School of Medicine."},{"speaker":"Welcome to Episode 26","startTime":15.751,"endTime":20.704,"body":"A 46-Year-Old Seeking Travel Advice."},{"speaker":"Welcome to Episode 26","startTime":20.704,"endTime":22.095,"body":"The question reads,"},{"speaker":"Welcome to Episode 26","startTime":22.095,"endTime":24.648,"body":"a 46-year-old man"},{"speaker":"Welcome to Episode 26","startTime":22.095,"endTime":24.648,"body":"wishes to travel to Kenya"},{"speaker":"Welcome to Episode 26","startTime":24.648,"endTime":26.246,"body":"for a two-week vacation."},{"speaker":"Welcome to Episode 26","startTime":26.246,"endTime":29.537,"body":"He is human"},{"speaker":"Welcome to Episode 26","startTime":26.246,"endTime":29.537,"body":"immunodeficiency virus-positive"},{"speaker":"Welcome to Episode 26","startTime":29.537,"endTime":32.196,"body":"and is taking antiretroviral therapy."},{"speaker":"Welcome to Episode 26","startTime":32.196,"endTime":35.738,"body":"His last CD4 count was 625/µl"},{"speaker":"Welcome to Episode 26","startTime":35.738,"endTime":37.965,"body":"and his viral load was undetectable."},{"speaker":"Welcome to Episode 26","startTime":37.965,"endTime":41.998,"body":"His nadir CD4 count"},{"speaker":"Welcome to Episode 26","startTime":37.965,"endTime":41.998,"body":"was 250µl."},{"speaker":"Welcome to Episode 26","startTime":41.998,"endTime":44.937,"body":"He has never had an acquired"},{"speaker":"Welcome to Episode 26","startTime":41.998,"endTime":44.937,"body":"immunodeficiency syndrome,"},{"speaker":"Welcome to Episode 26","startTime":44.937,"endTime":47.061,"body":"or an AIDS-defining illness."},{"speaker":"Welcome to Episode 26","startTime":47.061,"endTime":50.169,"body":"In addition to HIV,"},{"speaker":"Welcome to Episode 26","startTime":47.061,"endTime":50.169,"body":"he has a history of hypertension"},{"speaker":"Welcome to Episode 26","startTime":50.169,"endTime":54.198,"body":"and is known to have proteinuria"},{"speaker":"Welcome to Episode 26","startTime":50.169,"endTime":54.198,"body":"due to HIV-associated nephropathy."},{"speaker":"Welcome to Episode 26","startTime":54.198,"endTime":57.101,"body":"Which of the following"},{"speaker":"Welcome to Episode 26","startTime":54.198,"endTime":57.101,"body":"is your recommendation to this patient,"},{"speaker":"Welcome to Episode 26","startTime":57.101,"endTime":59.311,"body":"regarding his travel plans?"},{"speaker":"Welcome to Episode 26","startTime":59.311,"endTime":65.026,"body":"Option A reads, he should \u003ci\u003enot\u003c/i\u003e receive"},{"speaker":"Welcome to Episode 26","startTime":59.311,"endTime":65.026,"body":"the live measles vaccine prior to travel."},{"speaker":"Welcome to Episode 26","startTime":65.026,"endTime":70.312,"body":"Option B reads, he \u003ci\u003eshould\u003c/i\u003e receive"},{"speaker":"Welcome to Episode 26","startTime":65.026,"endTime":70.312,"body":"the yellow fever vaccine prior to travel."},{"speaker":"Welcome to Episode 26","startTime":70.312,"endTime":74.357,"body":"Option C reads, he will be required"},{"speaker":"Welcome to Episode 26","startTime":70.312,"endTime":74.357,"body":"to show proof of HIV testing"},{"speaker":"Welcome to Episode 26","startTime":74.357,"endTime":76.883,"body":"upon entry into the country."},{"speaker":"Welcome to Episode 26","startTime":76.883,"endTime":81.211,"body":"Option D reads, his likelihood"},{"speaker":"Welcome to Episode 26","startTime":76.883,"endTime":81.211,"body":"of a response to the influenza vaccine"},{"speaker":"Welcome to Episode 26","startTime":81.211,"endTime":83.134,"body":"will be less than 50%."},{"speaker":"Welcome to Episode 26","startTime":83.134,"endTime":88.095,"body":"And Option E reads, with a CD4 count"},{"speaker":"Welcome to Episode 26","startTime":83.134,"endTime":88.095,"body":"greater than 500/µl,"},{"speaker":"Welcome to Episode 26","startTime":88.095,"endTime":92.163,"body":"he is at no greater risk during travel"},{"speaker":"Welcome to Episode 26","startTime":88.095,"endTime":92.163,"body":"than persons without HIV."},{"speaker":"Welcome to Episode 26","startTime":92.163,"endTime":94.417,"body":"Okay, Cathy,"},{"speaker":"Welcome to Episode 26","startTime":92.163,"endTime":94.417,"body":"this is a complicated question."},{"speaker":"Welcome to Episode 26","startTime":94.417,"endTime":95.743,"body":"Where do you want to start?"},{"speaker":"Welcome to Episode 26","startTime":95.743,"endTime":98.433,"body":"(Cathy) So, in general,"},{"speaker":"Welcome to Episode 26","startTime":95.743,"endTime":98.433,"body":"individuals with HIV"},{"speaker":"Welcome to Episode 26","startTime":98.433,"endTime":101.339,"body":"are considered at higher risk"},{"speaker":"Welcome to Episode 26","startTime":98.433,"endTime":101.339,"body":"of infectious complications"},{"speaker":"Welcome to Episode 26","startTime":101.339,"endTime":102.836,"body":"when traveling abroad."},{"speaker":"Welcome to Episode 26","startTime":102.836,"endTime":107.856,"body":"However, individuals who have no symptoms"},{"speaker":"Welcome to Episode 26","startTime":102.836,"endTime":107.856,"body":"and a CD4 count that's over 500,"},{"speaker":"Welcome to Episode 26","startTime":107.856,"endTime":109.279,"body":"appear to be at no greater risk"},{"speaker":"Welcome to Episode 26","startTime":109.279,"endTime":111.896,"body":"than individuals"},{"speaker":"Welcome to Episode 26","startTime":109.279,"endTime":111.896,"body":"who don't have HIV infection."},{"speaker":"Welcome to Episode 26","startTime":111.896,"endTime":115.955,"body":"So, the best answer"},{"speaker":"Welcome to Episode 26","startTime":111.896,"endTime":115.955,"body":"for this question is Option E."},{"speaker":"Welcome to Episode 26","startTime":115.955,"endTime":117.733,"body":"Thinking about some of the other choices,"},{"speaker":"Welcome to Episode 26","startTime":117.733,"endTime":121.876,"body":"many countries do routinely deny entry"},{"speaker":"Welcome to Episode 26","startTime":117.733,"endTime":121.876,"body":"for HIV-positive individuals"},{"speaker":"Welcome to Episode 26","startTime":121.876,"endTime":125.158,"body":"if they're going to be staying"},{"speaker":"Welcome to Episode 26","startTime":121.876,"endTime":125.158,"body":"for prolonged visits."},{"speaker":"Welcome to Episode 26","startTime":125.158,"endTime":127.971,"body":"And proof of HIV testing"},{"speaker":"Welcome to Episode 26","startTime":125.158,"endTime":127.971,"body":"is required in some countries"},{"speaker":"Welcome to Episode 26","startTime":127.971,"endTime":130.378,"body":"for stays really longer than three months."},{"speaker":"Welcome to Episode 26","startTime":130.378,"endTime":132.267,"body":"It should be noted that these restrictions"},{"speaker":"Welcome to Episode 26","startTime":132.267,"endTime":135.538,"body":"don't appear to decrease"},{"speaker":"Welcome to Episode 26","startTime":132.267,"endTime":135.538,"body":"the rates of transmission of HIV, however."},{"speaker":"Welcome to Episode 26","startTime":135.538,"endTime":137.801,"body":"(Charlie) So, I think it's important"},{"speaker":"Welcome to Episode 26","startTime":135.538,"endTime":137.801,"body":"to say right away,"},{"speaker":"Welcome to Episode 26","startTime":137.801,"endTime":141.348,"body":"that all patients who are thinking"},{"speaker":"Welcome to Episode 26","startTime":137.801,"endTime":141.348,"body":"of traveling to overseas countries"},{"speaker":"Welcome to Episode 26","startTime":141.348,"endTime":147.316,"body":"should at least check out \u003ci\u003ewww.state.gov\u003c/i\u003e"},{"speaker":"Welcome to Episode 26","startTime":141.348,"endTime":147.316,"body":"to find out are there any restrictions"},{"speaker":"Welcome to Episode 26","startTime":147.316,"endTime":149.163,"body":"on health requirements et cetera."},{"speaker":"Welcome to Episode 26","startTime":149.163,"endTime":151.176,"body":"That is one thing"},{"speaker":"Welcome to Episode 26","startTime":149.163,"endTime":151.176,"body":"everybody should do."},{"speaker":"Welcome to Episode 26","startTime":151.176,"endTime":153.343,"body":"Now, this man's proposing"},{"speaker":"Welcome to Episode 26","startTime":151.176,"endTime":153.343,"body":"a two-week holiday."},{"speaker":"Welcome to Episode 26","startTime":153.343,"endTime":154.765,"body":"Any thoughts about that?"},{"speaker":"Welcome to Episode 26","startTime":154.765,"endTime":157.813,"body":"(Cathy) Generally, for short trips,"},{"speaker":"Welcome to Episode 26","startTime":154.765,"endTime":157.813,"body":"US citizens aren't required"},{"speaker":"Welcome to Episode 26","startTime":157.813,"endTime":160.127,"body":"to disclose anything"},{"speaker":"Welcome to Episode 26","startTime":157.813,"endTime":160.127,"body":"about their health status."},{"speaker":"Welcome to Episode 26","startTime":160.127,"endTime":162.048,"body":"And like you mentioned,"},{"speaker":"Welcome to Episode 26","startTime":160.127,"endTime":162.048,"body":"the consular offices"},{"speaker":"Welcome to Episode 26","startTime":162.048,"endTime":165.257,"body":"or a state department website,"},{"speaker":"Welcome to Episode 26","startTime":162.048,"endTime":165.257,"body":"should be consulted prior to travel"},{"speaker":"Welcome to Episode 26","startTime":165.257,"endTime":168.08,"body":"to see if any special documentation"},{"speaker":"Welcome to Episode 26","startTime":165.257,"endTime":168.08,"body":"is required."},{"speaker":"Welcome to Episode 26","startTime":168.08,"endTime":171.605,"body":"(Charlie) For patients with HIV infection,"},{"speaker":"Welcome to Episode 26","startTime":168.08,"endTime":171.605,"body":"how do you factor in their CD4 count"},{"speaker":"Welcome to Episode 26","startTime":171.605,"endTime":173.211,"body":"into your decision making?"},{"speaker":"Welcome to Episode 26","startTime":173.211,"endTime":174.832,"body":"(Cathy) Well, for vaccination purposes,"},{"speaker":"Welcome to Episode 26","startTime":174.832,"endTime":178.173,"body":"the response to immunization"},{"speaker":"Welcome to Episode 26","startTime":174.832,"endTime":178.173,"body":"could be impaired if the CD4 count"},{"speaker":"Welcome to Episode 26","startTime":178.173,"endTime":179.65,"body":"is less than 200."},{"speaker":"Welcome to Episode 26","startTime":179.65,"endTime":182.479,"body":"And even in some cases,"},{"speaker":"Welcome to Episode 26","startTime":179.65,"endTime":182.479,"body":"this happens at higher counts."},{"speaker":"Welcome to Episode 26","startTime":182.479,"endTime":185.037,"body":"So, HIV-infected persons"},{"speaker":"Welcome to Episode 26","startTime":182.479,"endTime":185.037,"body":"should be vaccinated"},{"speaker":"Welcome to Episode 26","startTime":185.037,"endTime":186.884,"body":"as early as possible"},{"speaker":"Welcome to Episode 26","startTime":185.037,"endTime":186.884,"body":"to ensure that you get"},{"speaker":"Welcome to Episode 26","startTime":186.884,"endTime":189.573,"body":"an adequate immune response to vaccines."},{"speaker":"Welcome to Episode 26","startTime":189.573,"endTime":192.22,"body":"For patients who are starting"},{"speaker":"Welcome to Episode 26","startTime":189.573,"endTime":192.22,"body":"antiretroviral therapy,"},{"speaker":"Welcome to Episode 26","startTime":192.22,"endTime":193.86,"body":"at least three months must elapse"},{"speaker":"Welcome to Episode 26","startTime":193.86,"endTime":196.651,"body":"before you have regeneration"},{"speaker":"Welcome to Episode 26","startTime":193.86,"endTime":196.651,"body":"of the CD4 T cells,"},{"speaker":"Welcome to Episode 26","startTime":196.651,"endTime":199.234,"body":"to a point where they can be considered"},{"speaker":"Welcome to Episode 26","startTime":196.651,"endTime":199.234,"body":"fully functional."},{"speaker":"Welcome to Episode 26","startTime":199.234,"endTime":201.334,"body":"So, vaccination of these patients"},{"speaker":"Welcome to Episode 26","startTime":199.234,"endTime":201.334,"body":"should be delayed"},{"speaker":"Welcome to Episode 26","startTime":201.334,"endTime":204.57,"body":"until they've been on"},{"speaker":"Welcome to Episode 26","startTime":201.334,"endTime":204.57,"body":"antiretroviral therapy for a few months."},{"speaker":"Welcome to Episode 26","startTime":204.57,"endTime":207.129,"body":"(Charlie) Okay, evidently,"},{"speaker":"Welcome to Episode 26","startTime":204.57,"endTime":207.129,"body":"this patient was going to be traveling"},{"speaker":"Welcome to Episode 26","startTime":207.129,"endTime":209.641,"body":"around flu season,"},{"speaker":"Welcome to Episode 26","startTime":207.129,"endTime":209.641,"body":"how should we think about the flu shot,"},{"speaker":"Welcome to Episode 26","startTime":209.641,"endTime":211.758,"body":"or flu vaccination specifically?"},{"speaker":"Welcome to Episode 26","startTime":211.758,"endTime":212.947,"body":"(Cathy) Well, response varies"},{"speaker":"Welcome to Episode 26","startTime":212.947,"endTime":215.427,"body":"based on the baseline"},{"speaker":"Welcome to Episode 26","startTime":212.947,"endTime":215.427,"body":"immune function of the person."},{"speaker":"Welcome to Episode 26","startTime":215.427,"endTime":219.382,"body":"So, estimated rates of response"},{"speaker":"Welcome to Episode 26","startTime":215.427,"endTime":219.382,"body":"to the flu vaccine are over 80%"},{"speaker":"Welcome to Episode 26","startTime":219.382,"endTime":221.862,"body":"among persons"},{"speaker":"Welcome to Episode 26","startTime":219.382,"endTime":221.862,"body":"with asymptomatic HIV infections"},{"speaker":"Welcome to Episode 26","startTime":221.862,"endTime":224.304,"body":"and that's similar to the general public."},{"speaker":"Welcome to Episode 26","startTime":224.304,"endTime":227.458,"body":"Option D mentions"},{"speaker":"Welcome to Episode 26","startTime":224.304,"endTime":227.458,"body":"a response rate less than 50%"},{"speaker":"Welcome to Episode 26","startTime":227.458,"endTime":231.604,"body":"and that's seen among people"},{"speaker":"Welcome to Episode 26","startTime":227.458,"endTime":231.604,"body":"who really have a diagnosis of AIDS."},{"speaker":"Welcome to Episode 26","startTime":231.604,"endTime":233.382,"body":"How much protection the flu shot provides"},{"speaker":"Welcome to Episode 26","startTime":233.382,"endTime":235.965,"body":"varies based on"},{"speaker":"Welcome to Episode 26","startTime":233.382,"endTime":235.965,"body":"the circulating strains of the flu,"},{"speaker":"Welcome to Episode 26","startTime":235.965,"endTime":239.95,"body":"but it's helpful even in decreasing"},{"speaker":"Welcome to Episode 26","startTime":235.965,"endTime":239.95,"body":"the severity of flu symptoms"},{"speaker":"Welcome to Episode 26","startTime":239.95,"endTime":241.683,"body":"and in preventing complications."},{"speaker":"Welcome to Episode 26","startTime":241.683,"endTime":244.217,"body":"(Charlie) Right, and that's true"},{"speaker":"Welcome to Episode 26","startTime":241.683,"endTime":244.217,"body":"about the general public, too."},{"speaker":"Welcome to Episode 26","startTime":244.217,"endTime":245.225,"body":"(Cathy) Yes, absolutely."},{"speaker":"Welcome to Episode 26","startTime":245.225,"endTime":248.767,"body":"(Charlie) All of what you were saying"},{"speaker":"Welcome to Episode 26","startTime":245.225,"endTime":248.767,"body":"before, I assume, is about the flu shot,"},{"speaker":"Welcome to Episode 26","startTime":248.769,"endTime":250.588,"body":"what about the nasal flu vaccine?"},{"speaker":"Welcome to Episode 26","startTime":250.588,"endTime":253.197,"body":"(Cathy) Yeah,"},{"speaker":"Welcome to Episode 26","startTime":250.588,"endTime":253.197,"body":"so the nasal flu vaccine is different."},{"speaker":"Welcome to Episode 26","startTime":253.197,"endTime":256.001,"body":"So, that nasal spray"},{"speaker":"Welcome to Episode 26","startTime":253.197,"endTime":256.001,"body":"is a live attenuated vaccine"},{"speaker":"Welcome to Episode 26","startTime":256.001,"endTime":259.197,"body":"and those are contraindicated"},{"speaker":"Welcome to Episode 26","startTime":256.001,"endTime":259.197,"body":"for persons who have immune dysfunction."},{"speaker":"Welcome to Episode 26","startTime":259.197,"endTime":263.486,"body":"So, this includes people who have HIV,"},{"speaker":"Welcome to Episode 26","startTime":259.197,"endTime":263.486,"body":"or are on immunocompromising drugs,"},{"speaker":"Welcome to Episode 26","startTime":263.486,"endTime":265.882,"body":"but also populations like pregnant women."},{"speaker":"Welcome to Episode 26","startTime":265.882,"endTime":268.252,"body":"(Charlie) Measles vaccine"},{"speaker":"Welcome to Episode 26","startTime":265.882,"endTime":268.252,"body":"is mentioned in the question."},{"speaker":"Welcome to Episode 26","startTime":268.252,"endTime":270.272,"body":"That's a live attenuated viruses."},{"speaker":"Welcome to Episode 26","startTime":270.272,"endTime":271.897,"body":"What are your thoughts on that?"},{"speaker":"Welcome to Episode 26","startTime":271.897,"endTime":275.403,"body":"(Cathy) As I mentioned,"},{"speaker":"Welcome to Episode 26","startTime":271.897,"endTime":275.403,"body":"generally live attenuated virus vaccines"},{"speaker":"Welcome to Episode 26","startTime":275.403,"endTime":278.124,"body":"are not given to HIV-infected individuals."},{"speaker":"Welcome to Episode 26","startTime":278.124,"endTime":281.391,"body":"Measles is a special case though,"},{"speaker":"Welcome to Episode 26","startTime":278.124,"endTime":281.391,"body":"because it can be lethal in HIV"},{"speaker":"Welcome to Episode 26","startTime":281.391,"endTime":283.536,"body":"so this vaccine is actually recommended,"},{"speaker":"Welcome to Episode 26","startTime":283.536,"endTime":286.371,"body":"unless the CD4 count is less than 200."},{"speaker":"Welcome to Episode 26","startTime":286.371,"endTime":288.918,"body":"Now, let's contrast that"},{"speaker":"Welcome to Episode 26","startTime":286.371,"endTime":288.918,"body":"with the yellow fever vaccine,"},{"speaker":"Welcome to Episode 26","startTime":288.918,"endTime":290.886,"body":"so that's another live virus vaccine,"},{"speaker":"Welcome to Episode 26","startTime":290.886,"endTime":293.716,"body":"and that is not given"},{"speaker":"Welcome to Episode 26","startTime":290.886,"endTime":293.716,"body":"to HIV-infected travelers."},{"speaker":"Welcome to Episode 26","startTime":293.716,"endTime":296.273,"body":"Now, it is a required vaccination"},{"speaker":"Welcome to Episode 26","startTime":293.716,"endTime":296.273,"body":"in some countries"},{"speaker":"Welcome to Episode 26","startTime":296.273,"endTime":299.203,"body":"but individuals who have"},{"speaker":"Welcome to Episode 26","startTime":296.273,"endTime":299.203,"body":"a CD4 count less than 200,"},{"speaker":"Welcome to Episode 26","startTime":299.203,"endTime":301.51,"body":"should probably be discouraged"},{"speaker":"Welcome to Episode 26","startTime":299.203,"endTime":301.51,"body":"from traveling to countries"},{"speaker":"Welcome to Episode 26","startTime":301.51,"endTime":303.264,"body":"with endemic yellow fever."},{"speaker":"Welcome to Episode 26","startTime":303.264,"endTime":306.645,"body":"(Charlie) Okay, so the teaching point here"},{"speaker":"Welcome to Episode 26","startTime":303.264,"endTime":306.645,"body":"is that prior to travel,"},{"speaker":"Welcome to Episode 26","startTime":306.645,"endTime":308.947,"body":"it's important to research"},{"speaker":"Welcome to Episode 26","startTime":306.645,"endTime":308.947,"body":"the travel requirements"},{"speaker":"Welcome to Episode 26","startTime":308.947,"endTime":310.72,"body":"for the specific country of travel,"},{"speaker":"Welcome to Episode 26","startTime":310.72,"endTime":312.632,"body":"particularly for individuals with HIV,"},{"speaker":"Welcome to Episode 26","startTime":312.632,"endTime":314.646,"body":"but in general, that's true for all of us."},{"speaker":"Welcome to Episode 26","startTime":314.646,"endTime":318.61,"body":"The recommendations and efficacy"},{"speaker":"Welcome to Episode 26","startTime":314.646,"endTime":318.61,"body":"of specific vaccines may vary"},{"speaker":"Welcome to Episode 26","startTime":318.61,"endTime":320.87,"body":"or \u003ci\u003edo\u003c/i\u003e vary based on the CD4 count,"},{"speaker":"Welcome to Episode 26","startTime":320.87,"endTime":323.96,"body":"and generally speaking,"},{"speaker":"Welcome to Episode 26","startTime":320.87,"endTime":323.96,"body":"patients with HIV infections"},{"speaker":"Welcome to Episode 26","startTime":323.96,"endTime":327.366,"body":"should not receive live virus vaccines."},{"speaker":"Welcome to Episode 26","startTime":327.366,"endTime":330.474,"body":"(Cathy) And to read more about this,"},{"speaker":"Welcome to Episode 26","startTime":327.366,"endTime":330.474,"body":"you can look up \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"Welcome to Episode 26","startTime":330.474,"endTime":331.922,"body":"on infectious disease,"},{"speaker":"Welcome to Episode 26","startTime":331.922,"endTime":334.098,"body":"health recommendations"},{"speaker":"Welcome to Episode 26","startTime":331.922,"endTime":334.098,"body":"for international travel,"},{"speaker":"Welcome to Episode 26","startTime":334.098,"endTime":336.303,"body":"and other websites"},{"speaker":"Welcome to Episode 26","startTime":334.098,"endTime":336.303,"body":"that are really good to look at"},{"speaker":"Welcome to Episode 26","startTime":336.303,"endTime":338.945,"body":"are the CDC website"},{"speaker":"Welcome to Episode 26","startTime":336.303,"endTime":338.945,"body":"and the state department website"},{"speaker":"Welcome to Episode 26","startTime":338.945,"endTime":341.276,"body":"about recommendations"},{"speaker":"Welcome to Episode 26","startTime":338.945,"endTime":341.276,"body":"for travel worldwide."},{"speaker":"Welcome to Episode 26","startTime":341.276,"endTime":344.275,"body":"♪ (music) ♪"}]}