Ready for a Trip Around the World: Travel Vaccines in the Community Pharmacy

Transcription

1 Ready for a Trip Around the World: Travel Vaccines in the Community Pharmacy

2 Presenters Megan N Dunlop, PharmD, CTTS PGY1 Community Pharmacy Resident Duquesne University and Mainline Pharmacy Brian J Sidone, PharmD, CTTS Director of Pharmacy Mainline Pharmacy, Residency Program Director

3 Disclosures No disclosures

4 Learning Objectives Review the travel vaccines available and their indications Practice identifying needed travel vaccines based on patient travel itineraries Discuss business opportunities in the community pharmacy surrounding travel vaccines

5 Part 1 Travel Vaccines and Malaria Prophylaxis

6 Travel Vaccines Hepatitis A Hepatitis B Yellow Fever Typhoid Japanese encephalitis Rabies Meningococcal Polio

7 Hepatitis A How is it spread? Contaminated food and water Commonly from improper hand hygiene Rarely from sexual contact What are the symptoms? Fever Fatigue Loss of appetite Nausea and vomiting Jaundice How to prevent? Safe food/ water practices Hand hygiene Vaccine CDC. Yellow Book. Hepatitis A.

8 Hepatitis A Vaccine Brand names: Havrix and Vaqta 1 ml (50 units) IM on day 1, and then a booster of 1 ml 6-18 months later Indicated for travelers to developing countries, especially rural areas GSK. Havrix. Google image.

9 Hepatitis B How is it spread? Blood and bodily fluids IV drug use What are the symptoms? Fever Fatigue Stomach Pain Dark Urine Joint Pain Jaundice How to prevent? Do not participate in high risk activities Use protection latex condoms Clean needles Vaccine CDC. Yellow Book. Hepatitis B.

10 Hepatitis B Vaccine Brand names: Engerix B, Recombivax For adults 20 years of age or older, 1 ml IM dose given at 0, 1 and 6 months For adults years old, 0.5 ml IM dose given at 0, 1 and 6 months Indicated for healthcare workers and those engaging in high risk activities traveling to endemic regions, especially Africa, Asia, South American and the Caribbean GSK. Engerix. Google Images.

11 Yellow Fever How is it spread? Virus spread through mosquito bites What are the symptoms? Symptoms take 3-6 days to present Fever, chills, muscle ache 15% go on to develop bleeding, shock, organ failure How to prevent? Avoid mosquito bites (DEET, long sleeve clothes, mosquito netting, avoid standing water) Vaccine CDC. Yellow Book. Yellow Fever.

12 Yellow Fever Vaccine Brand names: YF Vax, Stamaril 0.5 ml SQ dose once provides life long immunity (though some countries still require 10 year booster shots, this is not recommended by WHO) Only given at specified yellow fever vaccine clinics in the US in PA Yellow Fever Vaccine Stamps CDC. Yellow Book. Yellow Fever.

13 Typhoid How is it spread? Contaminated food and water In most non-developed countries (everywhere but US, Canada, Europe, Australia and Japan) What are the symptoms? Lasting high fevers Stomach pain Weakness Sometimes constipation and rash Rarely internal bleeding and death How to prevent? Safe food/ water practices Vaccine CDC. Yellow Book. Typhoid Fever.

14 Typhoid Vaccine Oral capsules Injection Contain 2-10 x 10^9 live Salmonella typhi bacteria 1 capsule by mouth 1 hour before a meal with cold or luke-warm liquid (not warmer than body temperature) on days 1, 3, 5 and 7 for a total of 4 oral doses Complete at least 1 week before travel Repeat in 5 years if continued exposure 0.5 ml IM at least 2 weeks before travel Repeat in 2 years if continued exposure Truhaven Health Analytics. Micromedex. Typhoid Fever Vaccine.

15 Japanese Encephalitis How is it spread? Virus through mosquito bites Higher risk in rural and agricultural areas Higher risk in tropical climates or summer months What are the symptoms? Take 5-15 days to present Fever, headache, vomiting, confusion, difficulty moving May progress to brain swelling, coma and death How to prevent? Avoid mosquito bites Vaccine CDC. Yellow Book. Japanese Encephalopathy.

16 Japanese Encephalitis Vaccine Brand Name: Ixiaro 0.5 ml IM for 2 doses, 28 days apart; complete series at least one week prior to travel Booster dose of 0.5 ml IM may be given if repeat exposure and more than one year since last JE vaccine Valneva. Ixiaro. Google Images.

17 Rabies How is it spread? Virus spread through saliva of infected animals What are the symptoms? Pain Delirium Fear Hallucinations Difficulty swallowing Excessive Salivation Aggression Coma Brain Death How to prevent? Avoid animals Vaccine Seek medical treatment immediately for animal bite CDC. Yellow Book. Rabies.

18 Rabies Vaccine Brand names: Imovax, Rabavert 1 ml IM given on days 0, 7 and 21 or 28 Post-exposure prophylaxis also available Booster shots based on titers Museums of Health Care. Imovax. Google Images.

19 Meningococcal How is it spread? Bacteria Neisseria meningitidis spread by close contact with infected individuals Though worldwide, most concerned about patients traveling to Meningitis Belt What are the symptoms? Fever Headache Stiff neck Fast breathing Diarrhea Purple rash Potentially Lethal How to prevent? Hand hygiene Avoid those infected Vaccine CDC. Yellow Book. Meningococcal Disease.

20 Meningococcal Disease Vaccine Brand name: Menveo Adults: 0.5 ml IM injection once, at least 7-10 days before departure Adults with a high-risk condition: 0.5 ml IM injection twice, two months apart Can revaccinate in 5 years for those who remain at risk for infection Required for Hajj Pemberton, B. The Sun. Going the Distance.

21 Polio How is it spread? Person to person contact Food or water contaminated with feces What are the symptoms? Usually, minor flu-like symptoms Rarely, progression to muscle function loss (usually in the legs) and loss of muscle function needed for breathing How to prevent? Safe food/ water practices Vaccine CDC. Yellow Book. Polio

22 Polio Vaccine Brand names: None, not patented In US, part of regular childhood vaccines For adults not vaccinated: 0.5 ml IM or SQ at 0, 1or 2 and 6-12 months If not enough time before exposure, at least 1 month between doses as many as you can fit in before departure Especially concerned about travel to and from Afghanistan, Nigeria and Pakistan Hail to Pitt! Salk Polio Vaccine Marker. Google Images.

23 Check In #1 Which two vaccines mentioned are required for entry into some countries? A) Yellow Fever and Typhoid B) Yellow Fever and Meningococcal C) Meningococcal and Polio D) Meningococcal and Typhoid

24 Malaria How is it spread? Protazoal infection spread through mosquitos What are the symptoms? Flu-like Anemia Jaundice In severe cases, seizures, kidney failure, respiratory distress, coma and death How to prevent? Mosquito Avoidance Chemoprophylaxis CDC Yellow Book Online. Chapter 3.

25 Malaria Map

26 Malaria Chemoprophylaxis Medication Frequency When to Start When to finish Mefloquine Weekly 1-2 weeks before departure 4 weeks after trip Doxycycline Daily 1-2 days before 4 weeks after trip Chloroquine Weekly 1-2 weeks before 4 weeks after Atovaquoneproguanil Daily 1-2 days before 1 week after CDC Yellow Book Online. Chapter 3

27 Malaria Chemoprophylaxis Medication Positives Negatives Mefloquine Can be used in pregnancy Cannot be used in areas with mefloquine resistance Do not use in patients with seizure, psych or cardiac conduction disorders Doxycycline Last minute travelers May prevent additional infections Usually least expensive Sun sensitivity Stomach upset Do not use in pregnancy Not for children <8 Chloroquine Can be used in pregnancy May exacerbate psoriasis Do not use in areas with chloroquine or mefloquine resistance Atovaquone-proguanil Last minute travelers Well tolerated Pediatric dosing available Do not use when pregnant or breastfeeding Do not use in kidney impairment CDC Yellow Book Online. Chapter 3

28 Check In #2 Which would be the best choice in malaria prophylaxis for a pregnant patient with bipolar disorder? A) Mefloquine B) Doxycycline C) Chloroquine D) Atovaquone-proguanil

29 Part 2 Travel Health Appointments

30 Reasons for Travel Business Adventure/ vacation Visiting family/ returning to home country Study abroad Religious Pilgrimage

31 Pre-travel Screening Ideally at least 4-6 weeks before travel Detailed health information Medical conditions Medications Vaccine history Detailed travel itinerary Where? How long? What will you be doing? What will you be eating? What is your purpose?

32 Meet Stephen Stephen is a 40 YO male bat photographer from Pittsburgh Stephen is traveling with a camera crew across many islands in Japan in August Stephen is an adventurous eater and likes to collect tattoos from every country he travels to Stephen takes sertraline 25 mg daily for depression and loratadine 10 mg daily for mild allergies Stephen got all childhood vaccines, a Tdap when he stepped on a nail last year, and a flu shot every November Can you help Stephen?

33 Meet Stephen

34 Meet Stephen

35 Meet Stephen

36 Meet Stephen

37 Meet Stephen

38 Can you help Stephen? What vaccines do you recommend? Hep A, Hep B, Rabies, Japanese Encephalopathy What other medications do you recommend? Does not need malaria chemoprophylaxis Not traveling to high altitudes May need anti-diarrheal medication Will need supply of his Rx and OTC med to last him through the trip What non-pharm patient counseling can you provide? Safe food/ water practices Hand hygiene Dangers of tattoos abroad Avoid bat bites Avoid mosquitos

39 Part 3 Case Practice

40 Practice Case 1 Megan 24 YO female pharmacy student traveling to Namibia for last APPE pharmacy rotation Plans to work in Windhoek Central Hospital in Windhoek, Namibia for three weeks, followed by a three day Safari in Erindi, Namibia and a three day visit to the coast in Swakopmund, Namibia Ask me questions! (5 minutes) Come up with a plan! (10 minutes)

41 Patient Case 1 Megan What vaccines do you recommend? What other medications do you recommend? What non-pharm patient counseling can you provide?

42 Practice Case 1 Thanks to your pharmacy skills, Megan is here today!

43 Practice Case 2 Brian Brian is a 30 YO male, traveling to Nicaragua for an epic vacation. The majority of his time will be spent in the San Juan region near the coast of Costa Rica, but he is also considering a weekend of hiking in Peurto Cabezas or a weekend trip to the capital city of Managua. Ask me questions! (5 minutes) Come up with a plan! (10 minutes)

44 Patient Case 2 Brian What vaccines do you recommend? What other medications do you recommend? What non-pharm patient counseling can you provide?

45 Practice Case 2 Thanks to your pharmacy skills, Brian is here today!

46 Part 4 Business Opportunities

47 Collaborative Practice Agreements Vaccines Malaria chemoprophylaxis Altitude sickness medications Traveler s diarrhea medications Charge for conducting screenings

48 Recommend products or make kits Bottled water/ water filters/ water purification tablets Common OTC medications like Tylenol or Benadryl that may be prescription in other countries Mosquito netting, permethrin-treated equipment, DEET and other bug spray Extra diabetes testing supplies What else can you think of?

49 Opportunities vs. Challenges Inventory Management Challenge: Expensive Vaccines, Package Size Issues (e.g. 10 dose MDV) Opportunity: Many competitors will/can not stock and/or special order Contracting and Billing Marketing Challenge: Many vaccines covered under Medical Benefit vs. Pharmacy Benefit Opportunity: Expanded billing opportunities and being uniquely positioned to provide services other competitors are not able to provide Challenge: To educate the patients and providers Opportunity: Potential for new patients/customers

50 Check In #3 Which of the following can be implemented as business opportunities in a community pharmacy? A) Travel Health Screenings B) Collaborative practice agreement to prescribe malaria chemoprophylaxis C) Making kits for patients based on their travel destination D) All of the above

51 Questions?

52 References 1. CDC. Traveler s Health. Hepatitis A Accessed December 21, Truhaven Health Analytics. Hepatits A Vaccination SYNC/48E650/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.IntermediateToDocumentLink? docid=1547&contentsetid=31&title=hepatitis+a+vaccine%2c+inactivated&servicestitle=hepatitis+a+vaccine%2c+inactivated#. Accessed December 21, GlaskoSmithKline. Havrix. QXFvNXhM:. Accessed December 21, CDC. Traveler s Health Accessed December 21, Truhaven Health Analytics. Hepatitis B Vaccine SYNC/056D28/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchT erm=hepatitis+b+vaccine+recombinant&fromintersaltbase=true&false=null&false=null&=null#. Accessed December 21, GlaskoSmithKline. Engerix B. Accessed December 21, CDC. Yellow Fever Booster Updates, Accessed December 21, CDC. Search for Yellow Fever Vaccine Clinics Accessed December 21, CDC. Typhoid Fever Accessed December 21, Truhaven Health Analytics. Typhoid Fever Vaccine SYNC/0AC03C/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.IntermediateToDocumentLink?docId=1329&contentSetId=31&title=TYPHOID+VACCINE&servicesTitle=TYPHOID+VACCINE#. Accessed December 21, Berna Biotech Ltc. Vivotif. Accessed December 21, 2017.

53 References 12. CDC. Japanese Encephalitis Accessed December 21, Valneva UK. Ixiaro BbMrppxUM:. Accessed December 21, Truhaven Health Analytics. Japanese Encephalitis Virus Vaccine, inactivated Absorbed. 2017http:// DSYNC/CBA0BE/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.GoToDashboard?docId= &contentSetId=100&title=Japanese+Encephalitis+Virus+Vaccine%2C+Inactivated+Adsorbed&servicesTitle=Japanese+Encephalitis+Virus+Vaccine%2C+Inactivated+Ads orbed&brandname=ixiaro#. Accessed December 21, CDC. Rabies Accessed December 21, Museums of Health Care. Imovax. Accessed December 21, Truhaven Health Analytics. Rabies Vaccine. NC/777EE3/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=r abies%20vaccine&usersearchterm=rabies%20vaccine&searchfilter=filternone&navitem=searchglobal#. Accessed December 21, CDC. Meningococcal Disease Accessed December 22, Truhaven Health Analytics. Meningococcal Oligosaccharide Vaccine, Diphtheria Conjugate NC/BF88AB/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm= Meningococcal+Oligosaccharide+Vaccine%2C+Diphtheria+Conjugate&fromInterSaltBase=true&false=null&false=null&=null#. Accessed December 22, Royal Embassy of Saudi Arabia. Visa Application Accessed December 22, Pemberton, B. The Sun. Going the Distance. September Accessed December 22, CDC. Polio Accessed December 22, Truhaven Health Analytics. Poliovirus vaccine NC/B86E23/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.IntermediateToDocumentLink?docId =2442&contentSetId=31&title=POLIOVIRUS+VACCINE&servicesTitle=POLIOVIRUS+VACCINE#. Accessed December 22, 2017.

54 References 24. The Salk Polio Vaccine Marker. Google Images. Accessed December 22, CDC. Yellow Book Online. Chapter 3: Infectious Diseases Related to Travel Accessed December 22, CDC. CDC Malaria Maps Accessed December 22, 2017.