BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE June 26, 2015

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BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE June 26, 2015 Belgian Scientific Study Group on Travel Medicine PART 1b malaria version 25/11/15 Pr. A. Van Gompel Dr. U Maniewski (ITG) Pr. F.

1 BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE June 26, 2015 Belgian Scientific Study Group on Travel Medicine PART 1b malaria version 25/11/15 Pr. A. Van Gompel Dr. U Maniewski (ITG) Pr. F. Jacobs (Hôp. Erasme, ULB) Pr. P. Lacor & Dr. L Seyler (UZ-Brussel) Dr. Ph. Leonard (CHU-ULg) Pr. W. Peetermans (U.Z. - K.U.Leuven) Pr. S. Callens(UZ.- U.Gent) Dr. S. Quoilin (iph.fgov.be) Dr. P. Soentjens (Belgian Defence) Pr. B. Vandercam (CHU. St. Luc, UCL) Pr. Y. Van Laethem & Dr. C Martin (CHU. St. Pierre, ULB)

2 2015 REPORT BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE June 26, 2015 PART 1b The consensus meeting was chaired by A. Van Gompel and Y, Van Laethem Secretary of the meeting was P Lacor A preliminary PowerPoint, prepared by A. Van Gompel, was presented The discussion and recommendations of the meeting are included in this finale presentation. The ESSENTIAL SLIDES (pdf-version) & the CONSENSUS BROCHURE (in Dutch and French) highlighting the proposals for changes will been sent to all participants. May be used for teaching. These documents will serve as a proposal for approval by the governmental Belgian Health Council section Vaccinations, on Responsable final redaction : A. Van Gompel

3 2015 PART 1 1.a - Vaccination for Yellow Fever 1.b - Malaria PART 2 2.A - Other vaccinations 2.B - TD, other infections,., 2.C - VARIA

5 Malaria

6 WHO Only a few chapters are updated 2014 & 2015 Only these chapters are updated They are freely downloadable

7 2015 Malaria The guidelines for malaria have not really changed in 2015

8 ABCDE of A: Awareness B: Bite prevention C: Chemoprophylaxis, if indicated. D: Diagnosis malariaprevention for travellers E: Environment: Avoid outdoor activities in environments that are mosquito breeding places, especially in late evenings and at night. 8

9 2011 = 12 = 13 zone 2011 = 2012 = 2013 A A C 2014 C

10 the Belgian guidelines are not changing yet 2014

11 2015 A/B or (very) low risk of P falciparum Mosquito bite prevention + think of malaria when T + /- chemoprophylaxis intermittent or SBET Alternatively, for travel to rural areas with low risk of malaria infection, mosquito bite prevention can be combined with stand-by emergency treatment (SBET). 11

12 WHO 2014 = 2015

14 2015 There is a need to be capable to give more nuanced malaria-prevention advice for many / most regions in Asia & Latin America:

15 Concept Low risk malaria areas (< 1 case/1000/year in local population) Low risk - Very low risk - Negligible low risk **************** 2- Many long-term travellers, not necessarily backpackers only, have no fixed itinerary, and often stay only briefly in higher risk areas

16 2013

17 Switzerland Germany Austria.SBET only since more than years 2014

18 In low risk malaria areas? 2015 Switzerland, Germany, Austria Mosquito bite prevention Belgium Mosquito bite prevention PLUS always In case of fever think malaria too AND always SBET = Standby emergency treatment Noodbehandeling Traitement d urgence PLUS always In case of fever think malaria too PLUS only in some cases SBET AND / OR only in some cases Intermittently chemoprofylaxis on demand??

19 On-demand malaria chemoprophylaxis based on regional risk? 2015 cfr on demand pacemaker, of on demand omeprazole, ventolin, etc better? intermittent risk based malaria chemoprofylaxe intermittent regional risk based malaria chemoprofylaxis on risk malaria chemoprophylaxis or? Standby malaria chemoprophylaxis SBCP (confusion with SBET?)

Voumard Switzerland When travelling to moderate- to low-risk malaria areas, 85% of interviewees chose not to take chemoprophylaxis as malaria prevention, although most (non-swiss) guidelines

20 Voumard Switzerland When travelling to moderate- to low-risk malaria areas, 85% of interviewees chose not to take chemoprophylaxis as malaria prevention, although most (non-swiss) guidelines recommend it. hence 15 % of interviewees chose to take chemoprophylaxis as malaria prevention, although Swiss guidelines do not recommend it... They had coherent reasons for their choice. New recommendations should include shared decision-making to take into account travellers preferences.

21 Switzerland Germany Austria.SBET only since more than years 2015

22 Let s take India

23 Lectures on Malaria India 2014 NECTM 5 Bergen Norway Malaria-risk for the local population in India is grossly underestimated by official WHO numbers However for most travelers the risk is very low to negligible Breakpoint = Areas of low transmission = where the reported malaria case incidence from all species was < 1 per 1000 (persons within the local population) per year we should adopt the malariaguidelines of the German speaking countries

24 Lectures on Malaria in India NECTM5 Bergen Norway 2014

25 Rigid USA position about e.g. Mumbai - India.but David Shlim is a wise American From: Travel Medicine Clinical Discussion List [mailto:travelmed@yorku.ca] On Behalf Of David Shlim Sent: woensdag 14 mei :17 Subject:.. about whether to recommend malaria prophylaxis for a visitor to Mumbai and Agra in October The discussion is illustrative of one of the key unresolved issues in travel medicine. Merely knowing the risk or the potential for risk is not enough. There is a threshold of risk for some diseases that remains subjective. Is the goal of malaria prophylaxis : to prevent any possible case of malaria (as has been the thrust of CDC advice), or is it to strike a balance of protection and likelihood when the risk is very low? When one takes into account the actual likelihood of malaria, then one has to confront the concept of threshold at what level of risk is it worthwhile to recommend prophylaxis. Is it a risk of 1/1000, 1/10,000, 1/100,000, or 1/1,000,000? 2014

26 Rigid USA position about e.g. Mumbai - India.but David Shlim is a wise American From: Travel Medicine Clinical Discussion List [mailto:travelmed@yorku.ca] On Behalf Of David Shlim Sent: woensdag 14 mei :17 Subject:.. about whether to recommend malaria prophylaxis for a visitor to Mumbai and Agra in October 2014 It would seem that the traveler should be a participant in making a decision about prophylaxis in circumstances that one could call minimal risk. The risk is not zero, but it is so low that some people will elect not to take prophylaxis (and some people will elect to take prophylaxis). In most of Africa, the risk of malaria is so significant that this type of discussion is not appropriate. However, in many parts of India, Central and South America, and SE Asia, it is appropriate. There may be no right answer in these situations. India is a complex risk situation, with the overall number of cases in returning travelers to US on the increase, mainly in the VFR population. However, it is difficult to find case reports of malaria that occurred in non-vfr travelers who only visited an urban area. Warmly, David David R Shlim MD President, ISTM Jackson Hole, Wyoming

27 2014

28 2014

29 2014

31 Belgium : 2015

32 Sri Lanka

WHO 2014 http://www.plosone.org/article/info%3adoi%2f10.1371%2fjournal.pone.

falciparum (12%) exists throughout the year, except in the districts of Colombo, Galle,

33 WHO WHO/ITH 2015 Malaria (2015): Limited malaria risk P. vivax (88%), P. falciparum (12%) exists throughout the year, except in the districts of Colombo, Galle, Gampaha, Kalutara, Matara and Nuwara Eliya. No locally acquired cases reported since October Recommended prevention in risk areas: A

34 .Viet Nam

35 Tropimed WHO 2014

So for many / most regions in Asia & Latin America : 25-11-2015 formerly not a NB anymore at the end of the handout-text, but a clear statement at the intro In most regions of Asia & Latin America

The malaria risk is mostly low to negligible, even for adventurous travellers and/or long term travelers, and depends on the visited region, the season, rural vs urban stay, but foremost on the

36 So for many / most regions in Asia & Latin America : formerly not a NB anymore at the end of the handout-text, but a clear statement at the intro In most regions of Asia & Latin America (see map of the German-speaking countries: the continuous intake of malaria tablets (chemoprophylaxis) can be dropped after a thorough evaluation of the risk. The malaria risk is mostly low to negligible, even for adventurous travellers and/or long term travelers, and depends on the visited region, the season, rural vs urban stay, but foremost on the quality of accommodation for the night, and on the availability of a good quality local health care providing reliable malaria diagnosis and appropriate treatment. It is imperative to always avoid mosquito bites between sunset and sunrise, by means of repellents and mosquito nets. Fever that appears during or after travel to a region with a low malaria risk may still be due to malaria. This diagnosis has to be ruled out, even if the absolute risk is very low. In case different regions are visited (with a generally low regional malaria-risk, but probably locally more elevated malaria risk) there are more options besides continuous malaria chemoprophylaxis an standby emergency malaria treatment (e.g. atovaquone/proguanil) can be carried in the travel kit with complete instructions on how and when to use. and/or a planning for temporary malaria chemoprophylaxis (atovaquone/proguanil) based on the regional malaria risk, when the malaria risk in the region visited is sufficiently high (information on

37 2015 Mefloquine precautions & legal obligations!!!

38 Medasso / ITG Gezondheidsadviezen voor reizigers Uitgave Medasso / IMT Conseils de santé pour voyageurs Edition

39 Roche - Lariam Obligatory patient alert card to share with the clients 2014

40 2014

41 2014

42 2015

43 2015

44 Travel medicine Seminar 19 /11/15 Travel medicine Seminar 20 years later MILITAIR HOSPITAAL as in Introduction Yellow Fever Immunization: where are we up to now? CHARLOTTE MARTIN The last-minute traveler: an update on accelerated vaccine schedules PATRICK SOENTJENS Epidemiologic flashes & edge cutting news / new vaccines STEVEN CALLENS Coffee break Travellers diarrhea LUCIE SEYLER Malaria: when prevention is not clear-cut ULA MANIEWSKI Traveller's Thrombosis PETER VERHAMME What did change (drastically) in the last 20 years in travel medicine? FONS & YVES Have a look at for the pdf s of the powerpoints of all the lectures since 2009

45 End Malaria 2013

BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE. June 20, 2014

BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE June 20, 2014 Belgian Scientific Study Group on Travel Medicine PART 1b malaria version 05/11/2014 Pr. A. Van Gompel (ITG) Pr. F. Jacobs (Hôp. Erasme, ULB)