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Sunday, March 25 - Travel Health Update

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Travel Health Update
0006-0000-18-008-L06-P | .2 CEUs |
Mark P. Walberg, PharmD, PhD, CTH

Published in: Health & Medicine
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Sunday, March 25 - Travel Health Update

  1. 1. Travel Health Update Mark P. Walberg, Pharm.D., Ph.D., CTH Associate Professor of Pharmacy Practice Regional Coordinator, San Fernando Valley-Los Angeles Region University of the Pacific Thomas J. Long School of Pharmacy and Health Science
  2. 2. Course ID
  3. 3. Financial Disclosures • Mark P. Walberg, PharmD, PhD, CTH discloses the following relationships: • Previously employed Merck Vaccines • Currently employed by GlaxoSmithKline • This conflict has been resolved per ACPE best practices
  4. 4. Course Objectives • Describe the approved regulations for providing travel health services in California following the passage of SB493. • Identify reliable resources and references for travel health information. • Compare the efficacy and safety of medications used for malaria prophylaxis. • Choose an optimal malaria prophylaxis regimen based on patient- and destination-specific factors. • State recommendations for the prevention and treatment of travelers’ diarrhea, highlighting medication adverse events and antibiotic resistance. • Describe recent changes to CDC vaccine recommendations for travelers.
  5. 5. Outline • How to be compliant with training and regulations. • Where are the best sources for travel health information? • Which medications can be used for malaria prophylaxis? • What are options for purifying water and treating travelers’ diarrhea? • Who gets a shot in the arm today?
  6. 6. Travel Medicine Regulations (§1746.5)
  7. 7. American Pharmacists Association Certificate Training Programs • Pharmacy-Based Immunization Delivery • Pharmacy-Based Travel Health Services, APhA Advanced Competency Training • Immunization Certification is a prerequisite • Includes: • Introduction to offering travel health services • General preventative measures (e.g., food and water precautions) • Travel vaccines • Malaria prophylaxis Required Training Programs
  8. 8. Good Faith Evaluation
  9. 9. CDC online training and free continuing education • Includes programs on immunizations, travel vaccines, malaria, etc. • Many/most are accredited through ACPE • Completion of Yellow Fever Vaccine: Information for Health Care Professional Advising Travelers is required prior to applying to become a certified provider CDC Training/CE Program
  10. 10. Pretravel Case CF (28 yo female) and DF (32 yo male) are a couple who will be traveling to Brazil for several weeks for their honeymoon. They will be leaving in about a month and plan to start a family within a few months upon returning from this vacation. Their vacation will include a week in the Amazon. Neither is taking any medications, nor do they have any significant medical conditions. They would like to speak with you about their trip and also have some online resources to look at. A. What internet sites should you recommend? B. Do you have any specific travel recommendations for them?
  11. 11. Medical info and the internet…
  12. 12. Key References & Resources • Centers for Disease Control and Prevention (CDC; www.cdc.gov) • World Health Organization (WHO; www.who.int) • International Society of Travel Medicine (ISTM; www.istm.org) • Shoreland Travax (www.travax.com)
  13. 13. CDC Travel Health Resources • Centers for Disease Control and Prevention (CDC), www.cdc.gov • Publishes Health Information for International Travel, a.k.a. “The Yellow Book” • All content available online at no charge through CDC website • Regularly updated as information changes or becomes available • wwwnc.cdc.gov/travel/page/yellowbook-home-2018
  14. 14. Recommendations for Specific Destinations • http://wwwnc.cdc.gov/Travel • Can also go to www.cdc.gov and search for “travel health” • Select traveler destination under “For Clinicians” • Also check appropriate boxes below
  15. 15. Recommendations for Specific Destinations • Information includes: • Vaccines • Malaria prophylaxis • Non-preventable diseases (e.g., vectorborne diseases) • Patient counseling • Packing list • Travel health notices • Advice for returning travelers
  16. 16. World Health Organization (WHO) • World Health Organization (WHO), www.who.int • Publishes International Travel and Health, a.k.a. “The Green Book” • Portions available online for no cost (e.g., Malaria chapter) • Can download the entire book as an Adobe pdf file from http://www.who.int/ith/en/
  17. 17. World Health Organization (WHO) Information includes: • Vaccine information (international) • Yellow fever requirements • Malaria prophylaxis and treatment • Disease distribution maps
  18. 18. International Society of Travel Health International Society of Travel Medicine (ISTM) • Offers Certificate of Knowledge in Travel Health (CTH®) • Requires passing the CTH® examination offered at annual meetings • Exam is based on Body of Knowledge for the Practice of Travel Medicine • Requires a 10-year renewal process to maintain certification • Members get free CE programs and journal access, can list travel clinics in directory and have access to travel health listserve (this alone is worth the annual membership fee!)
  19. 19. Shoreland Travax • Travax offers travel health resources (subscription only) • Detailed destination reports • Build custom reports for each patient’s itinerary • Huge library of pertinent references • Regular emails of updates • Recent publications • New guidelines • Outbreak alerts and status updates • Cons: • $895 per year • Only one address/clinic can use it per subscription
  20. 20. Pretravel Case CF (28 yo female) and DF (32 yo male) are a couple who will be traveling to Brazil for several weeks for their honeymoon. They will be leaving in about a month and plan to start a family within a few months upon returning from this vacation. Their vacation will include a week in the Amazon. Neither is taking any medications, nor do they have any significant medical conditions. They would like to speak with you about their trip and also have some online resources to look at. A. What internet sites should you recommend? B. Do you have any specific travel recommendations for them?
  21. 21. Pretravel Case… continued… CF (28 yo female) and DF (32 yo male) are a couple who will be traveling to Brazil for several weeks for their honeymoon. They will be leaving in about a month. They will be postponing their plans to start a family within a few months upon returning from this vacation. Their vacation will include a week in the Amazon. They do not have any significant medical conditions and will be using condoms +/- oral contraceptives for CF during and after travel. What would you recommend regarding malaria prophylaxis?
  22. 22. Malaria in the East
  23. 23. Malaria in the West • Mosquitos clearly follow international borders • Activities and accommodations should be considered along with destination • If there is malaria, other mosquito-borne diseases are most likely present (99.9999%) • Cannot just give prophylaxis without bite precautions!
  24. 24. Prevention of Malaria • Highest number of cases in Sub-Saharan Africa (82%) followed by Asia (11%), the Caribbean and Americas (6%) and Oceania (1%) • Five species known to infect humans with Plasmodium falciparum being the most common and most severe • P. falciparum resistant to chloroquine except for island of Hispaniola (Dominican Republic & Haiti) and resistant to mefloquine in Southeast Asia (Myanmar, Cambodia, Laos, Malaysia, Thailand, Vietnam) • Prophylaxis only prevents clinical disease • Only way to prevent infection is to avoid mosquito bites!
  25. 25. Malaria Lifecycle • Upon injection from a mosquito bite, parasites quickly migrate to the liver • They remain dormant for 1 week to several months (species dependent) • Once they emerge from the liver they infect red blood cells and cause hemolysis (clinical disease) • Most antimalarials only affect the erythrocytic stage
  26. 26. Malaria Prophylaxis* Medication Atovaquone-Proguanil (AP) Doxycycline Mefloquine Dosing Frequency Daily Daily Weekly Dose 250 mg A / 100 mg P 100 mg 250 mg (salt) Administration With food or milk Avoid administering with dairy or cations With food and 8 oz of water Start Prior to Travel 1-2 days 1-2 days 2-3 weeks** Post Travel Duration 7 days 28 days 4 weeks Use in Pregnancy NO NO Yes (preferred) Contraindications CrCl < 30 ml/min < 8 years of age Psychiatric conditions, seizures, arrhythmias Resistance None known None known Southeast Asia
  27. 27. Switching prophylaxis • General rule is you can only switch from weekly to daily medications or between daily medications • Mefloquine to doxycycline or AP is ok • Cannot switch to mefloquine from doxycycline or AP • Acquiring a reliable supply of medication can be difficult when in country • Approximately 10% of medications in low-middle income countries are substandard or falsified • Antibiotics and antimalarials are the most common medication classes
  28. 28. Switching prophylaxis • Switching to doxycycline from either medication requires continuation for 4 weeks after return from an endemic area/country • Switching to AP from either medication depends on timing of switch: Timing of Switch Length of Prophylaxis > 3 weeks before departing endemic area/country AP daily while in endemic area and requires only 1 week of therapy following return < 3 weeks before departing endemic area/country AP daily while in endemic area and requires 4 weeks of therapy following return After departing endemic area/country Requires 4 weeks of total therapy after the date of return from endemic area/country
  29. 29. Relevance of Switching… Adverse Events Relative risk of mefloquine adverse events compared to other antimalarials; values are relative effect (95% CI) Adverse Event Compared to AP Compared to Doxycycline Discontinuation d/t AE 2.68 (1.53-5.31) 1.08 (0.41 to 2.87) Abnormal Dreams 2.04 (1.37 to 3.04) 10.49 (3.79 to 29.10) Insomnia 4.42 (2.56 to 7.64) 4.14 (1.19 to 14.44) Anxiety 6.12 (1.82 to 20.66) 18.04 (9.32 to 34.93) Depressed Mood 5.78 (1.71 to 19.61) 11.43 (5.21 to 25.07) Nausea 2.72 (1.52 to 4.86) 0.37 (0.30 to 0.45)
  30. 30. Malaria Reminders… • Malaria’s clinical presentation is almost identical to influenza • Malaria can occur weeks and sometimes months after returning from an endemic area • Make sure patients know to disclose recent travel to healthcare providers • Malaria is a MEDICAL EMERGENCY • Higher fatality rates and sequalae in children < 5 years and pregnant women • Prophylaxis is not 100% effective at preventing malaria • Must still seek out medical care if on prophylaxis. • If prophylaxis failed, cannot use same medication for treatment. • Even if patient has stand-by emergency treatment available, they must still seek out medical care.
  31. 31. Choice of Malaria Prophylaxis CF (28 yo female) and DF (32 yo male) are a couple who will be traveling to Brazil for several weeks for their honeymoon. They will be leaving in about a month. They will be postponing their plans to start a family within a few months upon returning from this vacation. Their vacation will include a week in the Amazon. They do not have any significant medical conditions and will be using condoms +/- oral contraceptives for CF during and after travel. What would you recommend regarding malaria prophylaxis? A. Atovaquone-Proguanil B. Doxycycline C. Mefloquine D. Any of the above E. No prophylaxis needed
  32. 32. Choice of Malaria Prophylaxis CF (28 yo female) and DF (32 yo male) are a couple who will be traveling to Brazil for several weeks for their honeymoon. They will be leaving in about a month. They will be postponing their plans to start a family within a few months upon returning from this vacation. Their vacation will include a week in the Amazon. They do not have any significant medical conditions and will be using condoms +/- oral contraceptives for CF during and after travel. They have decided to both use doxycycline for malaria prophylaxis. How should doxycycline be dosed for malaria prophylaxis and what is the total duration of therapy if they will be in an endemic area for 7 days?
  33. 33. Pretravel Case… continued… CF (28 yo female) and DF (32 yo male) are a couple who will be traveling to Brazil for several weeks for their honeymoon. They will be leaving in about a month. They will be postponing their plans to start a family within a few months upon returning from this vacation. Their vacation will include a week in the Amazon. They do not have any significant medical conditions and will be using condoms +/- oral contraceptives for CF during and after travel. They have decided to both use doxycycline for malaria prophylaxis starting 2 days prior to exposure, while in the Amazon for a week, and for four additional weeks after potential exposure. They heard from a friend who was in Brazil during the Olympics that “you have to be careful what you eat and drink” while in country. What advice can you offer them?
  34. 34. Food and Water Precautions • “Boil it, cook it, peel it, or forget it” sounds great • May not be practical and strict adherence doesn’t always prevent diarrheal illness • Bacteria cause up to 90% of infections • E. coli most common, but Campylobacter resistance is also a factor • Incubation of a few hours to a few days (similar to viruses) lasting 3-7 days • Giardia is most common protozoan • Incubation is typically weeks and can last months/years if untreated
  35. 35. Travelers’ Diarrhea (TD) Prophylaxis • Antibiotic prophylaxis is not recommended for most travelers • Increased resistance to fluoroquinolones • Increased chance of acquiring ESBL-producing bacteria or adverse events • Typically only for immunocompromised travelers or “critical” trips (e.g., Olympic athletes) • Despite recommendation against use, can be up to 90% effective • Bismuth subsalicylate (BSS) 2 oz or 2 tablets QID • Required dosing makes compliance unlikely (laughable?) • Adverse events may be subjectively worse than TD • Can be up to 50% effective
  36. 36. Definitions and Recommendations Severity Mild Moderate Severe Definition diarrhea that is tolerable, is not distressing, and does not interfere with planned activities diarrhea that is distressing or interferes with planned activities diarrhea that is incapacitating or completely prevents planned activities; all dysentery is considered severe Rehydration YES! YES!! YES!!! Antimotility Agents Loperamide or BSS Loperamide (alone or +/- antibiotic) Maybe Antibiotics NO Azithromycin, fluoroquinolone, or rifaximin Azithromycin; if nondysenteric can use fluoroquinolone or rifaximin
  37. 37. When Travelers’ Diarrhea Occurs… Drink before you drug! (so clean water is a must)
  38. 38. So how do we ensure clean water… Technique Virus Bacteria Protozoa Heat YES YES YES Filtration (pore size in microns) Typically NO (~0.01) YES (0.2-0.4) YES (1) Halogens YES YES Maybe Ultraviolet YES YES YES
  39. 39. Options/Techniques for Water Purification • Filtration • Basic filter pump • Lifestraw’s scalable filter systems • Ultraviolet (UV) purification • SteriPEN • Puralytics SolarBag • Chemical decontamination with halogens • Potable Aqua electrolytic water purifier • Iodine tablets
  40. 40. Filtration PROS • Simple • Quick • Many options • Can improve taste • Good combination if followed by chemical decontamination CONS • Heavier and bulkier than other options • No virus removal • Improper use can decrease effectiveness • Will eventually clog or require field repair • No prevention of recontamination
  41. 41. Lifestraw Filter Systems
  42. 42. Ultraviolet Light Purification Systems PROS • No taste alteration • Portable devices • Effective against all pathogens • Increased treatment does not increase side effects • UV pens are fast and simple CONS • MUST HAVE CLEAR WATER • No taste improvement • Relatively high cost • Requires power (unless solar) • Unknown if dose if sufficient • No prevention of recontamination • Solar requires time and weather-dependent
  43. 43. Puralytics SolarBag • Built in prefilter to remove large debris • 3L purified in 2-3 hours on “sunny day” • Increased to 4-6 hours if cloudy or water is “tea-colored” • Has test strips to verify decontamination • Can be reused “100’s of times” or 7 years from first use • Recommends using clear water • Turbid water not recommended • Claims to remove metals and contaminants
  44. 44. Chemical Decontamination – Halogens PROS • Probably least expensive option • Taste can improved with vitamin C • Flexible dosing for large or small volumes • Persists at active concentrations so prevents recontamination CONS • Taste/odor • Have to use correct dose and wait for appropriate contact time • Potential for adverse events if too much iodine ingested • Not effective against some protozoan cysts • Efficacy decreased with low temperature and water clarity
  45. 45. Chemical Decontamination – Chlorine • Potable Aqua® PURE™ Electrolytic Water Purifier • Requires brine solution (salt water) • Generates sodium hypochlorite solution • Scales from 1L to 20L • Power requirements • Rechargeable via USB or solar panel on back • Cons • Tastes like chlorinated water (so use vitamin C!)
  46. 46. Food and Water Precautions… CF (28 yo female) and DF (32 yo male) are a couple who will be traveling to Brazil for several weeks for their honeymoon. They will be leaving in about a month. They will be postponing their plans to start a family within a few months upon returning from this vacation. Their vacation will include a week in the Amazon. They do not have any significant medical conditions and will be using condoms +/- oral contraceptives for CF during and after travel. They have decided to both use doxycycline for malaria prophylaxis starting 2 days prior to exposure, while in the Amazon for a week, and for four additional weeks after potential exposure. They heard from a friend who was in Brazil during the Olympics that “you have to be careful what you eat and drink” while in country. What advice can you offer them? (Select all that apply.) A. Bismuth subsalicylate can be used for prevention and/or treatment of TD B. A single dose of azithromycin can be used for moderate TD C. UV purification is the most effective way to purify water D. A combination of filtration and either UV or halogenation is a reasonable option
  47. 47. Pretravel Case… continued… Our couple mentions that they have heard about a yellow fever outbreak in the news. Their friend who went to the Olympics also mentioned that there is dengue in Brazil… is there anything to prevent these diseases?
  48. 48. Travel Vaccine Update • Poliovirus • Global shift to inactivated vaccine • Change to bivalent oral vaccine • Yellow Fever • One dose, good for most • Dengue • Maybe not a worst-case scenario…
  49. 49. Changes for Polio • Worldwide shift to trivalent inactivated polio vaccine (IPV) from oral polio vaccine (OPV) • Travelers still recommended to receive one dose of IPV as an adult prior to travel to any country with polio in the last year based on: • Circulating wild poliovirus • Outbreaks of wild or vaccine-derived poliovirus • Environmental presence (e.g., sewage contamination) • May also need a subsequent dose if in endemic area for over 1 month
  50. 50. Poliovirus in the World
  51. 51. IPV versus OPV in 2015
  52. 52. IPV versus OPV in 2016
  53. 53. Poliovirus Type 2… only from OPV!
  54. 54. On the verge of another polio victory… • Switch from trivalent OPV (tOPV) to bivalent OPV (bOPV) used to suppress serotype 1 outbreaks • Serotype 2 has not been detected since 1999 and was declared eradicated in 2015 • If remove type 2 virus from OPV, no continued chance of vaccine-derived virus outbreaks • No serotype 3 detected since 2012… • The epidemiological silence of polio requires a long wait time before declaring it is eradicated (e.g., 15-16 years for serotype 2)
  55. 55. Poliovirus Type 3
  56. 56. Poliovirus Type 3
  57. 57. Yellow Fever Vaccine • As of July 11, 2016 a single dose of yellow fever vaccine is good for life • Exceptions to this rule include: • Women who receive the dose while pregnant • Individuals who undergo a stem cell transplant after the dose • Individuals with HIV who receive a dose (obviously not while symptomatic) • Booster doses may be considered for patients who had a previous dose > 10 years ago and will be in an endemic area for a prolonged time or going to an area with an active outbreak
  58. 58. Current Yellow Fever Outbreak: Brazil • Recall that YF can be transmitted in urban areas by Ae. Aegypti mosquitos • If there is YF, other mosquito- borne diseases are also likely • Dengue • Chikungunya (?) • Zika
  59. 59. Dengue Vaccine • Chimeric vaccine • Combination of yellow fever vaccine strain 17D and one of four different RNAs that encode for dengue surface proteins • Current dengue vaccine is tetravalent • Must have each type to confer immunity • Has not been tested in individuals from non- endemic countries
  60. 60. Dengue Vaccine Safety Issues • Multiple safety issues of theoretical concern • Live attenuated vaccines carry risks that inactivated vaccines do not • Observed higher rates of hospitalization and severe dengue in later years of clinical trials • Waning immunity? • Immune enhancement? • Chance occurrence?
  61. 61. Dengue Vaccine Safety Issues Only beneficial if previously infected with dengue virus
  62. 62. Pretravel Case… continued… Our couple mentions that they have heard about a yellow fever outbreak in the news. Their friend who went to the Olympics also mentioned that there is dengue in Brazil. Both completed their childhood vaccinations and received a dose of Tdap in the last 10 years. Which of the following vaccines would you recommend for these travelers? (Select all that apply.) A. IPV B. bOPV C. Yellow fever vaccine D. Dengue vaccine E. Typhoid vaccine (either one)
  63. 63. Remember… • You cannot prevent everything, but you can be as prepared as possible • In many cases there is no hard or fast “rule” or “correct answer” with travel health/medicine… clinical judgement is key • When in doubt, ask an expert… • The only adverse effect from over preparedness is financial and maybe a few extra things to pack
  64. 64. Questions? mwalberg@pacific.edu

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