Reaching VFR Travellers

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Stephanie Daniels
5 years ago
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1 Reaching VFR Travellers Pierre J. Plourde Medical Officer of Health Medical Director, Travel Health and Tropical Medicine Winnipeg Regional Health Authority

2 VFRs Visiting Friends and Relatives immigrants and their children going back to their homelands

3 Why we see so many VFR Travellers

5 Objectives First encounter with VFRs Health risks for VFRs Barriers to Pre-travel Health services for VFRs Some recommendations

6 Case Scenario 33-year-old computer programmer has just arrived in Canada 3 weeks ago, from India, with his family (spouse and three children) He tells you that other than some vague abdominal aches in his children, he and his wife are asymptomatic

7 Case Scenario How would you assess this family?

8 Stool Parasite Prevalence in Immigrants* Protozoa ( data): Giardiasis 5-30% Amebiasis 1-5% Helminths ( data): Trichuriasis 10-30% Hookworm 1-20% Ascariasis 5-10% Schistosomiasis 0-17% * Minnesota Department of Health

9 Strongyloides Prevalence in Immigrants* Varies by region (1989 data): South America 15-85% Southeast Asia 25-40% SubSaharan Africa 25-50% Central America 1-20% Eastern Europe 1-7% * Minnesota Department of Health

10 Immigration Medical Examination Medical history, physical and mental status examination Routine Lab Tests Urinalysis (>( 5 yrs) Chest X-ray X (>( 11 yrs) Syphilis blood test (>( 15 yrs) HIV blood test (>( 15 yrs, children - adoptees, blood products, or HIV positive mother)

11 What Screening Accomplishes Urinalysis does not rule out renal insufficiency CXR does not rule out latent tuberculosis Syphilis serology - consider BFP HIV serology not bad idea, but designed to exclude immigrants Screening currently ignores hepatitis B & C Results may be outdated (up to 12 months)

12 So Screen for: Complete blood count Nutritional deficiencies iron/folate/b12 deficiency anemia Eosinophilia worms s.a. schistosomiasis, strongyloidiasis, filariasis Stool O&P (not sensitive) Serologies (limited availability)

13 So Screen for: Hepatitis high prevalence of hepatitis B and C in developing world hepatitis B and C testing regardless of liver enzymes (public health intervention with HAV and HBV immunization)

Be on the Lookout for: Chronic cough (and fever/sweats) High risk (5-15%) of activation of latent (dormant) TB in first five yrs after immigration to Canada

14 Be on the Lookout for: Chronic cough (and fever/sweats) High risk (5-15%) of activation of latent (dormant) TB in first five yrs after immigration to Canada (>60% TB in Canada seen in foreign born ) CXR, sputum TB smear and culture Mantoux skin testing (TST) not diagnostically helpful; but is good screening tool for LTBI

15 Be on the Lookout for: Under-immunization Assume none given or completed Start routine immunization schedules for children and adults not immunized in early infancy (as per Canadian Immunization Guide) Diphtheria, tetanus, pertussis, measles, mumps, rubella, HBV, varicella, (Hib)

16 Case Scenario continued 43-year-old computer programmer originally from India comes to see you for fevers, headache and chills on January 12, after having spent the Christmas holiday with his family in the Punjab He tells you he has malaria He is toxic appearing on examination

17 Blood Smear

18 Case Scenario In reviewing his record you find he has presented 3 and 6 years ago with P. falciparum malaria What do you do with this patient? How can you use this teachable moment?

21 Why VFRs at Higher Risk? Travel last minute (sick relative, funeral, wedding) Travel despite pregnant, multiple medical problems Travel with small children Stay in family/rural settings Prolonged stays (>4 wks) Use local transportation or drive self

22 Why VFRs at Higher Risk? Behave as if at home, because they have gone home : Drink tap water Brush teeth with tap water Eat raw delicacies (ceviche, sushi, koi pla) Don t use insect precautions Don t take chemoprophylaxis

23 VFRs highest risk Canadian travellers! typhoid (70-80% of imported typhoid occurs in VFRs; esp India 47%, Pakistan 10%, Bangladesh 10%, Mexico 7%, Philippines 4%, Haiti 2%) malaria (40-70% malaria in VFRs; Pf mostly from Africa, also India) VFRs have 8X risk of malaria JAMA 2009;302:859-65, CID 2006;43:

24 VFRs US-born VFR children 5X more likely to have + TST UK VFRs <15 yo going to India 10X higher risk of HAV vs other tourists highest prevalence (7.4%) of HBV in Canadian immigrants (Africa, Asia) only 6% Canadian VFRs to India sought pre-travel health advice* *CMAJ 1999;160:

25 Barriers to Care Patient & Provider Barriers Education/awareness barriers: Lack of knowledge of services available Lack of pre-travel providers to recognize unique needs Insufficient knowledge and training of primary care providers Health belief barriers: Belief that previous immunity will be protective Use of non-traditional, inappropriate medications, or counterfeit medications

26 Counterfeit Drugs Counterfeit artesunate purchased in : Thailand 27% Lao PDR 54% Cambodia 23% Myanmar 21% Vietnam 92% Trop Med Int Health 2004;9:

27 Counterfeit Drugs Trop Med Int Health 2004;9:

28 Barriers to Care Structural and Systems Level Financial limitations (lack of insurance, limited income) Physical access, clinics located away from population, transportation issues Lack of previous healthcare (i.e. immunizations) or records of care Other: Concerns over legal status/distrust in the health system Low literacy

30 Decreasing Barriers to Care Education/awareness Community education/outreach ( word of mouth ) Local newspapers/periodicals, radio programs, postings Exploitation of internet Use of travel agents serving ethnic populations Engage community organizations

31 Decreasing Barriers to Care Education/awareness Primary care clinic Take travel medicine to at risk populations--not the other way around Train specific providers in pre-travel medicine All providers Take advantage of your cultural/language skills Reassurance that the provider/clinic has patients best interest in mind (i.e. legal status)

32 Decreasing Barriers to Care Structural changes: Language and cultural barriers Employ multilingual, bicultural staff Prescription & handouts in patient s language as well as English 6 handouts in 19 languages Insect avoidance and malaria chemoprophylaxis Travellers diarrhea Trauma avoidance and evacuation insurance Travel with children Immunizations Special issues with travel to the Hajj

34 Tailoring Pre-Travel Advice to VFRs Clinical Suggestions Start with asking what they know: What do you know about malaria? How do you plan to obtain potable water? How do you plan to get around? Are you concerned about the cost of today s visit (negotiate and prioritize)? What are your plans if you got sick or had an accident?

35 Tailoring Pre-Travel Advice to VFRs Clinical Suggestions Frequent hand washing (use of alcohol based hand sanitizers) Stress boiling (or bottled) water and avoiding high risk food items Use simple medication regimens (i.e. single dose standby therapy for severe TD) Sell difficult to obtain travel items at wholesale in the clinic (i.e. ITNs)

36 Tailoring Pre-Travel Advice to VFRs Clinical Suggestions Choose inexpensive medication when given an option Enquire about drug plans/coverage to help with drug and vaccine costs Access and use translated informational handouts ( Stress trauma avoidance (i.e. night-time driving, motorcycles, bicycles)

Reaching VFR Travellers Conclusions Travel medicine is in the infancy of learning to provide care to this high- risk population Simple things can

37 Reaching VFR Travellers Conclusions Travel medicine is in the infancy of learning to provide care to this high- risk population Simple things can be done by individual providers and clinics that will make a big difference Clinics need to share experiences of successes that can be replicated

Travel-Related Infections in Canadian Children

Travel-Related Infections in Canadian Children Maryanne Crockett MD MPH FRCPC FAAP DTM&H Depts. of Pediatrics & Child Health and Medical Microbiology University of Manitoba Objectives To discuss travel-related