Keeping Healthy On Holiday

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Keeping Healthy On Holiday

  1. 1. TB and Other Infections How can we assess risk and advise our Renal Patients?
  2. 2. Background <ul><li>The chronic kidney patient population as a whole are generally immunosuppressed. </li></ul><ul><li>Both humoral and cell mediated immunity has been shown to be defective </li></ul><ul><li>Immunosuppressive drugs and malnutrition increase this risk. </li></ul><ul><li>Different destinations and types of holiday accomodation alter risk. </li></ul>
  3. 3. This talk will cover…. <ul><li>TB awareness, risks and prevention </li></ul><ul><li>Travellers diarrhoea </li></ul><ul><li>Prophylaxis </li></ul><ul><li>General health advice for travellers </li></ul><ul><li>Sources of information for both staff and patients to use </li></ul>
  4. 4. This talk will not cover….. <ul><li>Malaria (covered elsewhere) </li></ul><ul><li>Viral infection (covered elsewhere) </li></ul><ul><li>Vaccines (covered elsewhere) </li></ul><ul><li>Weird and wonderful tropical diseases….. </li></ul><ul><li>How to persuade our patients to give us advance notice of their holidays! </li></ul>
  5. 5. Tuberculosis and Renal Patients <ul><li>TB is uncommon in the general UK population </li></ul><ul><li>Risk is increased with age, ethnicity, country of birth, malnutrition, diabetes and CKD </li></ul><ul><li>CKD has been estimated to increase TB risk by 6-50 times 1 </li></ul><ul><li>An Audit in Preston showed that 4 of 70 (5.71%) new starters to dialysis were diagnosed with TB over 5 years (population rate in North West = 0.009%) </li></ul><ul><li>Much of the TB seen in Renal patients represents the reactivation of latent TB rather than new infection. </li></ul>
  6. 6. TB and Travelling <ul><li>TB is relatively hard to catch under normal circumstances </li></ul><ul><li>TB is airborne and spread by droplets from smear positive patient who are coughing. </li></ul><ul><li>M Bovis can be transmitted via unpasteurised dairy products. </li></ul><ul><li>5-10% infected with TB bacilli become clinically infected in their lifetime </li></ul><ul><li>Clearly this figure is much higher in CKD pts. </li></ul>
  7. 7. Risk of TB with travel <ul><li>Holiday to Western Europe, USA, Australasia, Japan </li></ul><ul><li>Staying in hotel or apartments </li></ul><ul><li>Sticks to “tourist routes” </li></ul><ul><li>Shorter stay (1-2 weeks) </li></ul><ul><li>Travel to endemic area – Eastern Europe, Middle East, Most of Asia </li></ul><ul><li>Staying with family/ friends </li></ul><ul><li>Close contact with local populations </li></ul><ul><li>Longer stays (3+ weeks) </li></ul>LOWER RISK HIGHER RISK
  8. 8. What can we do to reduce risk? <ul><li>Cannot vaccinate ~ Live Vaccine </li></ul><ul><li>Prophylaxis not recommended </li></ul><ul><li>No extra advice to those going to developed countries as “tourist”. </li></ul><ul><li>Travellers to non-developed countries should avoid unpasteurised milk and cheese. ( M Bovis) </li></ul><ul><li>Important to consider TB as a diagnosis in returning traveller in the higher risk group. </li></ul><ul><li>Symptoms often vague and hard to elicit </li></ul><ul><li>May be extrapulmonary </li></ul><ul><li>Up to 30% have cutaneous anergy </li></ul><ul><li>Culture of mycobacterium is the Gold Standard </li></ul>
  9. 9. Treatment Issues <ul><li>Multiple resistance a major problem </li></ul><ul><li>Rates of up to 50% reported in some areas 2 </li></ul><ul><li>From a public health perspective, poorly supervised or incomplete treatment of TB is worse than no treatment at all. 3 </li></ul><ul><li>Cultures may be hard to get & empirical treatment may be started </li></ul><ul><li>Involve expert help if TB suspected!! </li></ul><ul><li>Ensure treatment supervision. </li></ul>
  10. 10. Travellers Diarrhoea <ul><li>Is a very common problem even in healthy individuals. </li></ul><ul><li>May affect up to 80% individuals in High Risk areas. </li></ul><ul><li>Usually follows ingestion of contaminated food, drink or drinking water </li></ul><ul><li>Contaminated recreational water is also a risk – rivers, streams, lakes, pools etc.. </li></ul><ul><li>Simple preventative steps should be taken </li></ul>
  11. 11. Prevention of diarrhoea <ul><li>avoid consumption of potentially contaminated food or drink; </li></ul><ul><li>avoid contact with potentially contaminated recreational waters; </li></ul><ul><li>know how to treat diarrhoea; </li></ul><ul><li>carry oral rehydration salts and water-disinfecting agents if appropriate </li></ul><ul><li>?prophylactic antibiotics </li></ul>
  12. 12. Specific Risks <ul><li>Hookworms - contaminated faeces </li></ul><ul><li>Tapeworms - undercooked beef/pork </li></ul><ul><li> - contact with infected dogs </li></ul><ul><li>Roundworms - soil contaminated food i.e. </li></ul><ul><li> - unwashed fruit and veg </li></ul><ul><li>- street vendors </li></ul><ul><li>Giardiasis - contaminated food, water, person-to person </li></ul><ul><li>Cryptosporidiosis - contaminated water, hard to eradicate and possibly resistant to chlorination </li></ul>
  13. 13. Management of Diarrhoea <ul><li>Patient specific advice </li></ul><ul><li>Oral rehydration salts: </li></ul><ul><li>5 sachets in 1l = Na + 60 mmol, K + 20 mmol </li></ul><ul><li>May need to stop some drugs </li></ul><ul><li>Anti-diarrhoeal agents </li></ul><ul><li>Seek medical help if: </li></ul><ul><li>~ lasts >24-48hrs </li></ul><ul><li>~ bloody stools </li></ul><ul><li>~ febrile </li></ul><ul><li>~ dizzy/collapsing </li></ul><ul><li>If medical help scarce may need a supply of antibiotics </li></ul><ul><li>Ciprofloxacin 250mg BD </li></ul>
  14. 14. General illness prevention <ul><li>Ensure enough medication, in both hand luggage and cases. </li></ul><ul><li>Ensure documentation of medications </li></ul><ul><li>Avoid dehydration </li></ul><ul><li>Avoid potentially contaminated food and water </li></ul><ul><li>Avoid insect bites </li></ul><ul><li>Avoid swimming in non-filtered or chlorinated water </li></ul><ul><li>Safe sun exposure – particularly if on immunosuppressive drugs. </li></ul><ul><li>Fluid intake (alcohol?) </li></ul>
  15. 15. Useful Resources <ul><li>www.who.int (world health organisation) </li></ul><ul><li>www.masta.org.uk </li></ul><ul><li>www.dh.gov.uk/PolicyAndGuidance </li></ul><ul><li>www.kidney.org.uk/holidays </li></ul><ul><li>www.hammersmithkpa.org.uk </li></ul><ul><li>www.globaldialysis.com </li></ul>
  16. 16. References <ul><li>1) Semin Dial, 16(1) Jan/Feb 2003; 38-44 </li></ul><ul><li>Tuberculosis & Chronic Renal Failure (rev) </li></ul><ul><li>Hussein M, Mooij Jm, Ronjonleh, H. </li></ul><ul><li>2) NEJM 1998:338, 1641-40 </li></ul><ul><li>Global Surveillance for Anti-Tuberculous Drug Resistance </li></ul><ul><li>Pablos- Mendez et al </li></ul><ul><li>3) www.who.int/mediacentre/factsheets </li></ul>

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