Pre-travel basics and Malarial Prevention (ABC s)

Transcription

1 Pre-travel basics and Malarial Prevention (ABC s) A N J L I A C H A R Y A B S C. P H A R M, R P H C A N A D A F I O N A G E N A S I M N. R N, F F T M ( G L A S ) S C O T L A N D I S T M W O R K S H O P M A Y 2 5, p m 6 : 3 0 p m

2 Disclosures Anjli Acharya: I have no relationship with the event sponsors to declare. Fiona Genasi: I have no relationship with the event sponsors to declare I am employed by the NHS in Scotland who provide TRAVAX

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5 Qualified in 1984 from Caledonian University, Glasgow, Scotland Worked in general nursing before specialising in Infectious & Tropical Diseases In 1990, began working in Glasgow with Dr Eric Walker to establish TH services for travellers in UK Now a Nurse Consultant responsible for national TH programmes at Health Protection Scotland

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7 Receptionist Consultant Physician Cashier Clinic Sister Nurse in charge of vaccine stock Senior Registrar Nursing Staff 9th Asia Pacific Travel Health Conference 2-5 May 2012 Singapore

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9 Pharmacist in a clinic based multidisciplinary practice. Clinical specialty - 7 years Involved in both federal and provincial regulation of pharmacists and competencies in travel health. World traveler with kids!

10 About you? Where are you all from? Profession? What kind of setting are you working in? Level of experience? (audience participation here!!)

11 Today Interactive dialogue on our topics Risk assessment, vaccine classifications cases Malaria in common travel areas around the world. This is a core knowledge course (ABCs) Cases

12 What is the Risk? Of 100,000 travelers to a developing country for 1 month: 50,000 will develop some health problem 8,000 will see a physician 5,000 will be confined to bed 1,100 will be incapacitated in their work 300 will be admitted to hospital 50 will be air evacuated 1 will die Steffen R et al. J Infect Dis 1987; 156:84-91

13 We can reduce travel related risk Only 34% of all travelers seek pre-travel advice. 1:10 have an accident travelling 2:10 need to seek medical attention while travelling abroad. Family practitioners were the primary source of information for travellers and were more likely to prescribe an inappropriate chemoprophylactic regimen than were travel clinics or public health centres (76% v. 36%). CMAJ 1999;160:

14 When to Engage? 1. Patient has told you they are travelling or planning to travel 2. Patient fills an extended supply of medication 3. Patient fills a travel related prescription 4. Patient fills a travel related vaccination 5. Patient asks or approaches you in the OTC aisle 6. Patient fills a medication that can cause a photosensitivity reaction.

15 Travel Health The practice of travel health includes the individualized assessment and management of identified travel-related health risks using competent risk communication skills, understanding of the global epidemiology of diseases and conditions affecting international travellers, fundamentals of immunization and vaccinology, and basic pharmacology (including important drug-drug and drug-disease interactions). Travel health includes interventions such as individualized risk assessments, counseling and advice on the prevention and self-treatment of travel-related health issues (e.g., malaria, other vector-borne diseases, travellers' diarrhea, sexually transmitted infections, injuries, as well as information on high altitude illnesses and adaptation to other hostile environments). It aims to prepare travellers to ensure they remain healthy overseas and recognizes those with special needs, e.g. immune-compromised hosts, children, pregnant women, persons visiting friends and relatives (VFRs), workers and volunteers, and medical tourists. The practice of travel health includes the recognition and triage of common syndromes in returned travellers. PHAC 2012

16 Travel Risk Assessments Medical History Current and past illness, immunosuppression, pregnancy/lactation Medications (Rx/OTC) Allergies Vaccination History Travel Plans Itinerary Accommodations Style of Travel Activities

17 HOW versus WHERE WHERE? Where?

18 HOW versus WHERE

19 WHEN versus Where Kenya: dry/wet seasons

20 HOW & WHEN versus WHERE Full itinerary Dates, duration, stopovers Seasonal considerations Styles of travel Rural vs. urban Budget vs. luxury Accommodation Hotel vs. camping Activities Business vs. tourism Adventure, safari, climbing, trekking, diving, snorkeling Missionary/Humanitarian/NGO/Medical

21 Infectious & Non-Infectious Risk 1. Infectious Disease Prevention Vaccination Education on Infectious Disease Prevention Providing the tools for Self-assessment, Self-treatment, and Self-care 2. Environment Based Risk Prevention Motion sickness Pollution Injury and activities Altitude Natures Elements (sun, water, heat, cold) Political and Cultural Awareness

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24 Selecting patient advice leaflets on TRAVAX...

25 advice to your traveller rather than printing out.. Link to patient notes as a record of the consultation

26 Vaccinations in Travel Health Hepatitis A and B Typhoid Cholera/ETEC Yellow Fever Meningococcal Japanese encephalitis Varicella Pneumococcus Tetanus/Diphtheria Polio Measles, Mumps, Rubella Pertussis Tick borne encephalitis Rabies Influenza

27 Routine-Recommended-Required Routine: Provided as part of the public vaccination program in the country of origin Recommended: To reduce risk of infectious disease when in an area of risk Required: Mandatory vaccination required for the admission or movement between countries that have or risk of transmitting a disease

28 Routine-Recommended-Required Routine Recommended Required Measle, Mumps and Rubella Tetanus/diphtheria Polio Hepatitis B Pneumococcal Pertussis Hemophalus Influenza B Varicella Meningococcal (Quad) Gardasil *Routine in some countries Hepatitis A Influenza Japanese encephalitis* Tick borne encephalitis* Varicella/Shingles Meningococcal (Quad/B) Gardasil Polio Yellow Fever* Rabies Cholera/ETEC Yellow Fever Meningococcal (Quad) Influenza Polio

29 Case 1: Business Traveller Abdul is travelling to Saudi Arabia for oil and gas work. Primarily office based with periodic site visits. There for 3 months in Riyadh, may travel after. Healthy, no medication, first international position Date of birth 9/9/1987 (27) (Canadian- AB) What routine vaccinations should Abdul have? My questions: MMR x 2?, tdap/td booster?, hep B complete? Chicken pox immunity?

30 Case 1: Business Traveller What required vaccines? None What recommended vaccines? Hep A and Typhoid, polio?, meningitis? Influenza? Abdul indicates that he is planning to complete a Hajj Pilgrimage at the end of his trip. How does your recommendation change? How would you adjust your pre-travel advice?

31 Case 2: Last Minute Traveller Jim is an engineer fit and healthy regular traveller. His company wants him to fly out to China at the last minute. He leaves in 3 days time. He expects to be in China for at least 4 months. Jim does not like needles! What additional information are you interested in before you complete your risk assessment? What pre-travel Advice would you discuss with Jim?

32 Case 2: Last Minute Traveller You complete a risk assessment and determine: He requires 4 inactivated vaccines (boosters of HepB, HepA, Typhoid and JEV) What will you do? Jim received Green Cross JE vaccine 5 years ago (0,7,28) What are our options in 2015 for boosting this course?

33 Case 2: Last Minute Traveller It is 5 years since he last had these vaccines. At that time he had two doses of HepB (0, 1 month), one dose of HepA and Typhoid Will the boosters work? Should he re-start primary courses of some?

34 World Malaria ~2o0 million clinical cases occur each year worldwide ~ deaths annually, 90% are in children <5 years Every year up to 30,000 North American and European travellers contract malaria

35 WHO World Malaria Report published each year Find it on

36 Why is Malaria important in TM Serious, potentially life threatening Common worldwide Imported into Canada... (or wherever you may practice) Largely preventable

37 Epidemiology of Malaria Caused by an intracellular, protozoan parasite Transmitted by the bite of an Anopheles mosquito Five Species described: Plasmodium falciparum Plasmodium vivax Plasmodium ovale Plasmodium malariae - Plasmodium knowlesi

38 Principles of Malaria Advice Awareness of risk Bite avoidance Chemoprophylaxis - appropriate drugs taken correctly Diagnosis & treatment appropriate and prompt

39 Awareness of Risk What helps determines malaria risk? Incidence of malaria Type of malaria present Drug resistance or not

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41 Bite Avoidance

42 Chemoprophylaxis What is the ideal anti-malarial? One dose prevents malaria for entire trip Given out free with airline ticket Tastes like Swiss chocolate Only side effect - increases IQ Wisdom courtesy of Kevin Kain, Canada

43 Chemoprophylaxis Malarial Prophylaxis: Atovoquone/Proguanil (Malarone) Mefloquine (Larium) Doxycycline Chloroquine Proguanil* Primaquine*

44 Chiodini PL, Field VK, Hill DR, Whitty CJM, Lalloo DG. Guidelines for malaria prevention in travellers from the UK. London, Public Health England, July 2013

45 Diagnosis & Treatment Signs & Symptoms of Malaria Appearance of symptoms takes ~ 8-30 days Non-specific erythrocytic stage parasites fever/sweats/chills malaise myalgia headache diarrhoea cough

46 Diagnosis & Treatment FEVER with or without any other symptom Thick and thin blood films / rapid diagnostic tests Only considered negative after three negative tests (12 24 hour apart)

47 Malaria Case 1 Cruise Americas Mr and Mrs Scott (70yrs) & (67yrs) are going on a cruise: Embark Miami, Cuba (1 day), Aruba (1 day), Belem to Manaus (Brazil, 7 days), Miami. They leave in 4 weeks time. Cruising for 10 days and having day trip excursions. Mr Scott takes no medication, Mrs Scott takes ranitidine for indigestion. Otherwise well. What advice do you give them re: A, B, C, D?

48 A awareness of risk Miami nil Cuba nil Aruba - nil Belem low Manaus high Endemic P.falciparum Drug resistance present (Chloroquine and Mefloquine

49 Bite Avoidance

50 C = Compliance with chemoprophylaxis

51 Malaria Case 2 Cruise Americas What if, instead, Mr and Mrs Scott (70yrs) & (67yrs) decided to cruise: Embark Miami, Cuba (1 day), Bahamas (1 day) Dominican Republic (1 day) Aruba (1 day), Panama (1 day) Costa Rica (1 day) Miami. They leave in 4 weeks time. Cruising for 10 days total and having day trip excursions. What advice do you give them re: A, B, C, D?

52 Malaria Case 3 West Africa Julie (23yrs) has booked a last minute sun holiday to Gambia for 2 weeks, leaving in 8 days time. She is staying in a small, 3 star beach hotel. She comes to you for yellow fever vaccine. She is unaware of any malaria risk in Gambia. She is well, takes no medications has no allergies. What advice do you give her re: A, B, C, D?

53 High risk Endemic A awareness of risk P.falciparum Drug resistance present (Chloroquine)

54 Bite Avoidance

55 C = Compliance with chemoprophylaxis

56 Malaria Case 4 - Thailand, Cambodia & Vietnam Jackson (19 years), backpacking round Thailand, Cambodia and Vietnam. Open ticket for 6 months with no clear itinerary. Flying into Bangkok and wants to spend at least two months on the beaches and islands in the gulf of Thailand but after that just wants to explore cities and rural areas. On a tight budget. Leaving in 3 weeks time Fit and well

57 A awareness of risk High risk (but not everywhere) Endemic P.falciparum, P.vivax, P.knowlesi Multi-drug resistance present (Chloroquine, Mefloquine, Artesunate, Quinine)

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59 Bite Avoidance

60 C = Compliance with chemoprophylaxis

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62 Standards of Practice /publications ISTM Body of Knowledge

63 Questions? CANADIAN IMMUNIZATION GUIDELINES CDC - YELLOW BOOK home-2010.aspx CDC TRAVELERS HEALTH WEBSITE CATMAT INTERNATIONAL SOCIETY OF TRAVEL MEDICINE

64 Final case Brooke Family Ted (28yrs) and Helen (26 yrs) Brooke are going to work as missionaries in north eastern Kenya for 6 months. They leave in 3 weeks time Is a yellow fever vaccination certificate required for entry into Kenya? Would you recommend yellow fever vaccine for them? What are you going to tell them about the vaccine and its side effects? Ted has an egg allergy should he be vacccinated?

65 Final case Brooke Family Ted (28yrs) and Helen (26 yrs) Brooke are going to work as missionaries in north eastern Kenya for 6 months. They leave in 3 weeks time Would you give them rabies vaccine? Would you advise them to have the quadravalent meningococcal vaccine? Do they need a certificate showing proof of vaccination?

66 Final case Brooke Family Ted (28yrs) and Helen (26 yrs) Brooke are going to work as missionaries in north eastern Kenya for 6 months. They leave in 3 weeks time What other vaccines would you advise them to have? Specifically consider HepB, Typhoid, Cholera