Microbes at Our Doorstep: Emerging issues in infection control and travel-related infections Peel November 2, 2016
Learning Objectives At the end of this session, participants will be able to: 1. Identify common and serious infection prevention and control (IPAC) lapses that may be occurring in their office 2. Implement risk strategies to prevent and control infectious disease transmission to patients and staff 3. Identify key contacts and resources to support effective IPAC practices in the clinical office setting
Learning Objectives At the end of this session, participants will be able to (cont d): 4. Describe the common travel-related communicable diseases in Peel and potential barriers to seeking a pre-travel medical consultation 5. Implement strategies for counselling patients on prevention of travel-related communicable diseases
Agenda 6:30-7:00 Dr. Kate Bingham, Peel Emerging Issues in Travel-Related Infections in Peel 7:00-8:00 Dr. Maureen Cividino, Ontario (with Donna Moore) Emerging Issues in Infection Control in Clinical Office Settings 8:00-8:30 Q&A and evaluation
Housekeeping Peel staff and resources Your feedback Kahoot application Evaluation reminder Certificates for Mainpro+ credits
Travel-related infections in Peel: Enhancing our knowledge of the local context Kate Bingham, MSc CCFP(EM) FRCPC Associate Medical Officer of Health Peel
Presenter Disclosure Presenter: Dr. Kate Bingham Relationships with commercial interests: Not applicable
Disclosure of Commercial Support No commercial support
Mitigating Potential Bias Not applicable
Peel s population 1.4 million >50% born outside of Canada Nearly half in South, East, or Southeast Asia >20% East Indian
Rates of travel-related illness 2-4x provincial average (2011-2015) Age-Standardized Incidence Rate (Cases per 100,000) 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 Hepatitis A Malaria Paratyphoid Fever Peel Ontario Typhoid Fever
What s going on? Who is getting sick? Recent immigrants? Visitors to Canada? Returning travelers? Are travellers taking precautions to prevent illness? Immunization? Prophylaxis? Pre-travel advice? What are effective interventions to reduce travelrelated illness in Peel?
Enhanced Surveillance in Peel Initiated in 2012 for hepatitis A, malaria, typhoid, paratyphoid Additional questions during routine public health case management: Detailed destination information Pre-travel medical consultation Travel purpose, type of accommodation, duration Preventive measures (e.g., vaccination)
Most cases were travel-related Peel cases (2012-2015) Total cases Travel cases (%) Hepatitis A 72 56 (78%) Malaria 163 114 (70%) Paratyphoid fever 60 52 (87%) Typhoid fever 133 117 (88%) Non-Travel Cases: Recent immigrant 36 (40%) Visitor to Canada 16 (18%) Local transmission 21 (24%) Unknown 16 (18%)
Demographics varied by disease Hepatitis A Malaria Paratyphoid fever Typhoid fever Sex: Female Male 52% 48% 31% 69% 37% 63% 50% 50% Age (years): Median Range 18 2-74 43 <1-84 27 4-76 20 1-80
Almost 50% traveled to India Country of birth 1. India (38%) 2. Canada (27%) 3. Pakistan (8%) Travel country 1. India (48%) 2. Pakistan (18%) 3. Nigeria (9%)
Most of Peel s travel cases are VFRs 8% 3% Purpose of travel 4% VFR 85% Tourism
Visiting Friends and Relatives (VFR) Experience higher rates of travel-related infectious diseases: Travel to higher risk destinations Lack of awareness or underestimation of risk Lack of pre-travel health care encounter Longer trips (i.e., more exposure time)
Most stay with friends/family and stay for longer than 1 month Type of accommodation* Friends/relatives 89% Hotel/resort 13% Homestay 12% Apartment/condo 3% Hostel <1% Other 2% Duration of stay (days) Median Range Hepatitis A 49 5-380 Malaria 36 3-1110 Paratyphoid 33 10-185 fever Typhoid fever 38 7-343 *May have selected >1 option
Few cases had a pre-travel medical consultation Percent of Peel travel-related cases with pre-travel consultation
Limitations Unknown denominator for the number of travellers to other countries Unable to quantify risk of disease associated with travel to a particular destination Don t know about the people who have similar exposures but don t get sick
Rapid review of the evidence What are effective ways to encourage travellers to take preventive measures against travel-related diseases?
Rapid review of the evidence Use gain-framed messaging and target communication to specific audiences Multi-component interventions are effective, which may include: Communications Resources Environmental supports (e.g., prompts) https://www.peelregion.ca/health/library/pdf/travellers-preventive-measures.pdf
Understanding VFR travellers Research study to understand barriers and facilitators to pre-travel consultations in South Asian communities Peel, in partnership with the University of Toronto, Punjabi Community Health Services and India-Rainbow Community Services of Peel Focus group design
The Study: Focus Groups
Preliminary Results Travellers have other priorities when preparing for travel (visa, packing, gifts, booking flights) Potential barriers to seeking a pre-travel consult: cost, medication side effects, lack of awareness, perception of unavoidable risk, unable to get pretravel advice through family doctor Facilitators: travelling with children, prior illness, perceived susceptibility
Preliminary Results Several potential opportunities exist to increase uptake of pre-travel health advice Family physicians Travel agents Advocacy for provision of subsidies
Some other notable travel-related infections in Peel MEASLES! Sexually-transmitted infections Zika virus
Measles Average 1-2 cases/year in Peel All travel-related Often infants <1 year Often multiple visits to healthcare settings prior to diagnosis significant contact exposures Ask about travel at early well-baby visits and consider accelerated immunization schedule MMR can be given at 6 months! (2 additional doses still required after 1 year)
Sexually-transmitted infections 178 Peel cases in 2014 reported meeting their partner outside of Ontario: 1) Infectious syphilis 29% 2) HIV 20% 3) Gonorrhoea 9% 4) Chlamydia 5% Top three reported travel countries: 1) Jamaica; 2) USA; 3) Canada, outside of Ontario
Zika virus Transmission reported in nearly all of South and Central America, the Caribbean, and Miami, FL Primarily transmitted via bite from infected mosquito Sexual transmission can occur, even while asymptomatic Vertical transmission associated with microcephaly and other congenital malformations
Zika virus Guidance for specific risk groups Pregnant women Women of reproductive age Avoid unnecessary travel to affected areas If travel is absolutely necessary, counsel regarding strict mosquito bite protection and prevention of sexual transmission Wait at least 8 weeks after travel before trying to conceive Use most effective form of contraception that meets individual needs during this time Men Wait at least 6 months after travel before trying to conceive If partner is pregnant: Use condoms for vaginal, anal, and oral sex throughout pregnancy Consider using condoms with all sexual partners for 6 months after possible exposure
Zika virus Additional information and clinical guidance: CDC: http://www.cdc.gov/zika PHAC: http://www.healthycanadians.gc.ca/diseasesconditions-maladies-affections/disease-maladie/zikavirus/index-eng.php Current testing recommendations and information: Ontario Laboratory: http://www.publichealthontario.ca/en/servicesandto ols/laboratoryservices/pages/zika-virus.aspx
Key messages 1. Be opportunistic! Patients may not have an accurate perception of their risk Anticipate travel-related health risks in all patients Immunizations (routine and travel-related) Prophylaxis Food, vectors, water, risk behaviours 2. Consider accelerated immunization schedules for infants and young children at risk