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Patient Consult 101: Performing Patient Consult 101: Performing a Travel Health Risk Assessmenta Travel Health Risk Assessment
Manitioba 13th Annual Travel Health ConferenceApril 7, 2016
Anjli Acharya, Bsc. PharmCTH
DisclosureDisclosure
Anjli Acharya B. Sc. Pharm, RPh
• This presentation is funded by Manitoba Travel Health Network
• Travel health consultant at Bowmont Travel Clinic
• I have no conflict of interest to declare.
• Pharmacist in a clinic based multidisciplinary practice.
• Clinical specialty - 8 years
• Involved in both federal and provincial regulation of pharmacists and competencies in travel health.
World traveler with kids.
About you?About you?
GoalsGoals
1. Understand the scope of travel health practice.
2. Understand the components of an effective travel health assessment
3. Understand the importance of prioritizing risk and education.
4. Review resources available to support the delivery of quality care
Travel Health Travel Health –– A Study in Risk…A Study in Risk…
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Travel HealthTravel Health
The practice of travel health includes the individualized assessment and management of identified travel-related health risks using competent risk communication skills, understanding of the global epidemiology of diseases and conditions affecting international travellers, fundamentals of immunization and vaccinology, and basic pharmacology (including important drug-drug and drug-disease interactions). Travel health includes interventions such as individualized risk assessments, counseling and advice on the prevention and self-treatment of travel-related health issues (e.g., malaria, other vector-borne diseases, travellers' diarrhea, sexually transmitted infections, injuries, as well as information on high altitude illnesses and adaptation to other hostile environments). It aims to prepare travellers to ensure they remain healthy overseas and recognizes those with special needs, e.g. immune-compromised hosts, children, pregnant women, persons “visiting friends and relatives” (VFRs), workers and volunteers, and medical tourists. The practice of travel health includes the recognition and triage of common syndromes in returned travellers. – PHAC 2012
What is the Risk?What is the Risk?Of 100,000 travelers to a developing country for 1
month:● 50,000 will develop some health problem
● 8,000 will see a physician
● 5,000 will be confined to bed
● 1,100 will be incapacitated in
their work
● 300 will be admitted to hospital
● 50 will be air evacuated
● 1 will die
• Steffen R et al. J Infect Dis 1987; 156:84-91
• ~200 million clinical cases occur
each year worldwide
• ~584 000 deaths annually,
90% are in children <5 years
• Every year up to 30,000 North
American and European
travellers contract malaria
World Malaria RiskWorld Malaria Risk
www.who.int/malaria/publications/2015
A risk assessment is a systematic process of evaluating the potential risks that may be involved in a projected activity or undertaking.
Risk AssessmentRisk Assessment
Travel Risk AssessmentsTravel Risk Assessments
• Medical History – Current and past illness, immunosuppression,
pregnancy/lactation
• Medications (Rx/OTC)• Allergies• Vaccination History• Travel Plans – Itinerary– Accommodations– Style of Travel– Activities
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• Full itinerary– Dates, duration, stopovers– Seasonal considerations
• Styles of travel– Rural vs. urban– Budget vs. luxury
• Accommodation– Hotel vs. camping
• Activities– Business vs. tourism– Adventure, safari, climbing, trekking, diving, snorkeling– Missionary/Humanitarian/NGO/Medical
HOW versus WHEREHOW versus WHERE HOW versus WHEREHOW versus WHERE
HOW versus WHEREHOW versus WHERE WHEN versus WhereWHEN versus Where
Kenya:
dry/wet seasons
“Everyone travels differently for different reasons and with different risks.”
“To understand travel risk, you have to understand the nature of the traveller”
Compartmentalizing RiskCompartmentalizing Risk
1. Travel Risk Infectious disease versus environmental risk
2. Vaccines Risk● Live versus inactivated vaccines● Routine, recommended, required
3. Patient Risk● Medications, Medical conditions, pregnancy, lactation● Age● immunosuppression
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Travel RiskTravel Risk
1. Infectious Disease Prevention Vaccination Education on Infectious Disease Prevention Providing the tools for Self-assessment, Self-treatment,
and Self-care
2. Environment Based Risk Prevention● Motion sickness ● Pollution● Injury and activities● Altitude● Natures Elements (sun, water, heat, cold)● Political and Cultural Awareness
Major Topics for DiscussionMajor Topics for Discussion
Immunization
Malaria
Travellers Diarrhea
Respiratory Illness
Other vectorborneDisease
Altitude Illness
Environmental Hazards
Personal Safety
Sexual health and blood borne pathogens
Disease specific counseling
http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/the-pre-travel-consultation
CATMAT CATMAT –– Guidelines Guidelines
Sortable – Subject, Date or Title
http://www.phac-aspc.gc.ca/tmp-pmv/catmat-ccmtmv/index-eng.php/
CATMAT CATMAT –– Guidelines Guidelines • Travellers’ Diarrhea• Tubercolusis• Typhoid• Visiting Friends and Relatives• Yellow Fever• Malaria• Motion Sickness• Older Travellers• Pediatrics• Polio• Pregnancy• Japanese Encephalitis• Jet Lag• International Adoption
• Meningococcal Disease
• Rabies
• Risk of Injury
• Sexually Transmitted Infections
• Tick Borne Encephalitis
• Travel Medicine
• Arthropod Bites
• Cruise Ship Travel
• Dengue Fever
• Fever
• Hepatitis
• High Altitude Illness
• Immunocoprimised Traveller
http://www.phac-aspc.gc.ca/tmp-pmv/catmat-ccmtmv/index-eng.php/
CATMAT CATMAT –– Guidelines Guidelines
http://www.phac-aspc.gc.ca/tmp-pmv/catmat-ccmtmv/index-eng.php/
Manitoba Travel Health NetworkManitoba Travel Health Network
• Unique in Canada
• Supports MB travel health professionals
• Telephone information line
• Online travel health manual
• Manitoba Travel Health Conference
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Public Vaccine Public Vaccine Resource (CIG)Resource (CIG)
Canadian Immunization Guide
http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php
Public Vaccine Resource (NACI)Public Vaccine Resource (NACI)
National Advisory Committee on Immunization
• Guidelines – Canadian Immunization Guide
• NACI makes recommendations for the use of vaccines currently or newly approved for use in humans in Canada.
• Identification of high risk groups for vaccination.
• NACI guidelines versus Provincial Guidelineshttp://www.phac-aspc.gc.ca/naci-ccni/
Case Case -- Argentina Argentina
Patient Related Risk:
Review patient assessment sheets.
Verify medical conditions listed and medication and allergies.
Ask if he has brought any immunization records
• Jim: Healthy, NKA, HTN stable – Ramipril 10 mg daily• 66 years old (DOB 3/14/1950)• Jim mentions that he has injured his hand doing fence work “It
was a bad one but its ok.”• Has immunization records • Gets flu shot regularly, hepatitis A and B series done
How bad did you hurt your hand?Did you see a doctor? Did you get or need stitches? When was your last tetanus booster? Do you have a record of your last tetanus booster?
• Jim lives on a ranch• He admits the wound was borderline and he considered going in for stitches.• It is healing well.
Tetanus – dirty wound risk (td or tdap?)
Age - 66
NO – High risk medical or allergies
Vaccine Status:-Hep A and B complete-Flu completed yearly
Vaccines? Child hood?, MMR, PneumococcalTravel : Yellow fever, typhoid, rabies
Case Case -- Argentina Argentina
Travel Risk:Do you have planned or open itinerary?Where are you going? Hotels/camping?Patagonia? Climbing Trekking? Ranch? Wine tours? What is your plan?
• Travelling to BA , city tours nice hotel and then up toIguassu Falls (May 2016)
• 4 days at the Falls hiking and exploring. • Total travel days 14 days• May go on a wine tour – doesn’t like the ocean/ water • Prefers local food and is excited to try everything.
Case Case -- Argentina Argentina
CDC – YellowbookCATMAT – Malaria
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Tetanus – dirty wound risk
NO - High Risk MedicalNO - Malarial riskNO - Altitude riskNO - High-risk ruralNO - Ocean risk
Adventurous eater
Outdoor day trips and activities
Vector borne risk – YF, Dengue
Age - 66
Vaccines? Child hood?, MMR, PneumococcalTravel : Yellow fever, typhoid, rabies
Vaccine Status:-Hep A and B complete-Flu completed yearly
No - Chagas riskNo – LeishmaniasisLow - Schitso
CaseCase
Jim provided us with records for Flu and Jim provided us with records for Flu and hepatitis a and b.hepatitis a and b.
1. Routine vaccines: Td/Tdap, MMR, childhood,
flu and pneumococcal
2. Recommended: Typhoid, Hep A and B, Rabies
3. Required: Yellow fever
Case Case -- Argentina Argentina
Vaccine Risk:Did you have mumps or measles as a child?Have you had your pneumonia vaccine?Did you get the childhood vaccines available when you were young?
• Jim got all his vaccinations as a child• He used to volunteer at the hospital library so they gave
him a booster for mmr, doesn’t recall whooping cough• He remembers talking about pneumococcal with his GP
and received it last year at age 65
Manitoba Manitoba –– Eligibility CriteriaEligibility Criteria
http:// http://www.gov.mb.ca/health/publichealth/cdc/vaccineeligibility.html /
EASILY AND READILY
AVAILABLE ONLINE.
ManitobaManitoba ImmunizationImmunization ScheduleSchedule
http://www.gov.mb.ca/health/publichealth/cdc/div/schedules.html
ManitobaManitoba Health: Td or Tdap?Health: Td or Tdap?
Do you have a close family member expecting a new born? Have a new born, or are planning to start a family in the next few years?
http://www.gov.mb.ca/health/publichealth/cdc/div/schedules.html
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Tetanus – dirty wound risk/newborn - Tdap
NO - High Risk MedicalNO - Malarial riskNO - Altitude riskNO - High-risk ruralNO - Ocean risk
Adventurous eater
Outdoor day trips and activities
Vector borne risk – YF, Dengue
Age - 66
Travel : Yellow fever, typhoid, rabies
Vaccine Status:-Hep A and B complete-Flu completed yearly-MMR ok, Pneumo done
No - Chagas riskNo – LeishmaniasisLow - Schitso
Prioritizing RiskPrioritizing Risk
What do you believe is the highest priority risk?What do you believe is the highest priority risk?
1. Food and water – Travellers diarrhea
2. Insect borne risk – YF, chikungunya, dengue
3. Injury based risk – Trekking, hiking
4. Other
Prioritizing RiskPrioritizing Risk
How would you prioritize this patients risk?
Tetanus – dirty wound risk/newborn - Tdap
NO - High Risk MedicalNO - Malarial riskNO - Altitude riskNO - High-risk ruralNO - Ocean risk
Adventurous eater
Outdoor day trips and activities
Vector borne risk – YF, Dengue
Age - 66
Travel : Yellow fever, typhoid, rabies
Vaccine Status:-Hep A and B complete-Flu completed yearly-MMR ok, Pneumo done
No - Chagas riskNo – LeishmaniasisLow - Schitso
Case Case -- Argentina Argentina
Patient Risk– Jim is 66 years old– YF vaccine has increase YF-AND and YF-AVD
associated with age.• for those 60-69 years of age, the risk is estimated to be 1.0-
1.1 per 100,000; for those 70 years or older, the risk is estimated to be 2.3-3.2 per 100,000
– Increased risk of adverse reaction– Age is a precaution to vaccination.
Educate Jim on the risk, provide the injection
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/13vol39/acs-dcc-2/index-eng.php
Tetanus – dirty wound risk/newborn - Tdap
NO - High Risk MedicalNO - Malarial riskNO - Altitude riskNO - High-risk ruralNO - Ocean risk
Adventurous eater
Outdoor day trips and activities
Vector borne risk – YF, Dengue
Age - 66
Travel : Yellow fever, typhoid, rabies
Vaccine Status:-Hep A and B complete-Flu completed yearly-MMR ok, Pneumo done
No - Chagas riskNo – LeishmaniasisLow - Schitso
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Case Case –– Argentina Argentina
Education:
• Insect bite prevention – day and evening
• Food and water precaution
• Treatment of Travellers diarrhea
• Animal bite avoidance and education around rabies
• OTC products to travel with, first aid and then environmental and secondary risks.
Vaccines Recommended:
Tdap, YF, Typhoid, Rabies (cost/risk)
Travel Health Travel Health –– A Study in Risk…A Study in Risk…
QUESTIONS?QUESTIONS?
CANADIAN IMMUNIZATION GUIDELINESwww.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php
CDC - “YELLOW BOOK”http://wwwnc.cdc.gov/travel/content/yellowbook/
home-2010.aspx
CDC TRAVELERS’ HEALTH WEBSITEwww.cdc.gov/travel
WORLD HEALTH ORGANIZATION www.who.int/int
INTERNATIONAL SOCIETY OF TRAVEL MEDICINE
www.istm.org
Public Health Public Health Resources (Patient)Resources (Patient)Patient Resource:
Health – Healthy Living – Immunization & Vaccines
• Travel Vaccines
• Vaccines in pregnancy
• Vaccine preventable disease
• Vaccination in Adults
• Immunization registries, coverage, supply and schedules.
www.healthycanadians.gc.ca
Resources for Canadian PractitionersResources for Canadian Practitioners
• Canada Communicable Disease Report CCDR
• Conferences and Courses
• Reference texts/journals/webpages
• Online subscription services
• Outbreak reports and travel advisories
• Sources of malaria recommendations
• Travel medicine clinics in Canada and abroad
• Certification.
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/15vol41/dr-rm41-05/res-eng.php