BELGIANCONSENSUS MEETINGon TRAVEL MEDICINE

May 31, 2013

Belgian Scientific Study Group on Travel

Medicine

Pr. A. Van Gompel (ITG)Pr. F. Jacobs (Hôp. Erasme, ULB)

Pr. P. Lacor (UZ-Brussel) Dr. Ph. Leonard (CHU-ULg)

Pr. W. Peetermans (U.Z. - K.U.Leuven) Pr. S. Callens(UZ.- U.Gent) Dr. S.Quoilin (iph.fgov.be)

Dr.P. Soentjens (Belgian Defence)Pr. B. Vandercam (CHU. St. Luc, UCL)

Pr. Y. Van Laethem (CHU. St. Pierre, ULB)PART 1b Malaria version 23-08-2013

REPORTBELGIAN CONSENSUS MEETING on TRAVEL MEDICINE

May 31, 2013 – PART 1b

2013

• The consensus meeting was chaired by A. Van Gompel• Secretary of the meeting was Y, Van Laethem• A preliminary PowerPoint, prepared by A. Van Gompel,

was presented• The discussion and recommendations of the

meeting are included in this finale presentation.• The ESSENTIAL SLIDES (pdf-version) & the

CONSENSUS BROCHURE (in Dutch and French) highlighting the proposals for changes will been sent to all participants. May be used for teaching.

• These documents will serve as a proposal for approval by the governmental Belgian Health Council – section Vaccinations, on 10-10-2013

• Responsable final redaction : A. Van Gompel

PART 1• 1.a - Vaccination for Yellow Fever• 1.b - Malaria

PART 2• 2.A - Other vaccinations• 2.B - TD, other infections, …., • 2.C - VARIA

2013

Malaria

Malaria 1. The WHO guidelines for malaria have not changed in 2013 2. Malaria chemoprophylaxis & WHO maps of the low risk areas in Asia

and Latin America – see lecture F. Van Gompel ITM - 24th OCTOBER 2013 Joint Symposium SBIMC-BVIKM with the Scientific Study Group for Travel Medicine

3. RDTs for travelers ? Not yet !!1. CISTM 2013 lectures by E, Bottieau IMT / D'Acremont & Bertod2. PlosOne 2013 Malthe IMT. Self-Diagnosis of Malaria by Travelers

and Expatriates4. Lancet 2012 case report about fake artesunate5. CISTM 13 POSTER

One spray for all biting bugs? A literature review- of repellent efficacy

6. Varia– Generic Malarone in the UK & The Netherlands – not necessarily much cheaper ?

- patent will expire on short term ? – ,,,,,

2013

Malaria 1. The WHO guidelines for malaria have not changed in 2013

2013

A

C

C

zone

A

2011 = 2012 = 2013

2013

2012 = 2013

Malaria 2. Malaria chemoprophylaxis & WHO maps of the low risk areas in Asia

and Latin America –

see lecture F. Van Gompel ITM –

24th OCTOBER 2013

Joint Symposium

SBIMC-BVIKM with the Scientific Study Group for Travel Medicine

2013

2012

WHO maps 2011

“ in blue”

http://www.who.int/malaria/world_malaria_report_2011/97

89241564403_eng.pdf

2012

WHO 2012 maps 2011

2013

WHO maps 2012

“ in brown”

http://www.who.int/malaria/publications/world_malaria_report_2012/wmr2012_country_profiles.pdf

2013

WHO 2013 maps 2012

SOME EXAMPLES

(http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0043162) 

SRI LANKA

Areas shown in light pink are those at the lowest levels of risk, where annually averaged infection prevalence in 2-10 year olds (PfPR2-10) is likely to be lower than 5%.

Areas shown in red are those at intermediate risk, where PfPR2-10 is likely to be higher than 5% but less than 40%.

Areas shown in dark red are those at the highest levels of risk, where PfPR2-10 is likely to exceed 40%.

RWANDA

RWANDA

RWANDA

Malaria For many countries in Asia and South America the risk is highly variable depending on area, season and way of traveling. Strict anti-mosquito measures (plus an emergency self treatment in many cases) can be discussed with the individual traveler as a valid alternative.

2011

GREECE

Malaria: • Very limited malaria risk (P. vivax only)

may exist from May to October in villages of theEvrotas delta area in Lakonia district (an area of 20km2) in agricultural area with large migrant populations.

• There is no risk in tourist areas. • Recommended prevention in risk area: I

2012

2012

Travelers should monitor their health during travel and for up to one year after return from the Bahamas for any symptoms of malaria, which are flu‐like, such as fever and chills. If symptoms occur, the traveler should seek immediate medical care and inform their health‐care provider of their travel to an area currently experiencing a malaria outbreak.

2012

Malaria 3. RDTs for travelers ? Not yet !!

1. PlosOne 2013 Malthe IMT. Self-Diagnosis of Malaria by Travelers and Expatriates

2. CISTM 2013 lectures by E, Bottieau IMT3. CISTM 13 lecture by D'Acremont & Bertod

2013

doi:10.1371/journal.pone.0053102

BEST CHOISES ?

CarestartTM Malaria HRP2/Pldh (Pf/PAN) COMBO Single Test Access Bio, Inc., New Jersey

SD BIOLINE Malaria Ag P.f/Pan POCT SDFK63 Standard Diagnostics, Hagaldong,

What can be Done to Improve RDTs for Self-diagnosis?• First of all, an accurate performance needs to be assured.

Products like Labstix and OneStep performed insufficiently, they contained no CE mark but were actually delivered to users in theEuropean Union.

• Next, IFUs should give understandable information about the product performance, including the limitations for the diagnosis of the non-falciparum species.

• Furthermore, the IFU needs to become more user-friendly and the procedure and interpretation sections need to be completed at least with the topics mentioned in Table 4.

• Also for a traveler, multiple lancets, transfer devices and alcohol wipes are advised.

• A tag for temperature control (i.e. a small device or sticker that changes color when the maximal temperature has been exceeded) may be of additional value.

• Important, fulfillment of all these requirements does not preclude the need for training and counseling of the enduser of these tests.

• Although not presently studied, previous reports have demonstrated the needs for training and the benefits of a comprehensive training program.

• For expatriates and travelers performing RDTs abroad who ask for advice, we currently ask them to send a photograph of the RDT. Future technical developments, such as cell-phone based RDT readers should be assessed for applications.

1. Rapid Diagnostic tests for self-testing

• :• - for P. falciparum, some are good, others are not. We tested kits packed for

individual testing available in Belgium and recommend CarestartTM Malaria HRP2/ pLDH (Pf/PAN) COMBO Test (Access Bio Inc, New Jersey, USA) and SD BIOLINE Malaria Ag P.f/Pan POCT (SDFK63), Standard Diagnostics, Korea. TODA MALARIADIAG4+ (Toda PHARMA, Brussels, Belgium or Strasbourg, France) is also OK but we have less experience with this kit. Of note, SD BIOLINE is stable to 40°C, the others to 30°C.

• - None of these kits (in fact any kit) is reliable for diagnosis of P. ovale and P. malariae (false negatives)

• 2. Foresee: extra lancets andantiseptics• 3. Beware of:• - faint line intensities are also positive• - repeat test after 8h if negative and symptoms persist• 4. Test should be carried out by a healthy crew member (patients with fever are not

adequately performing the test). It is advisable to train one (or more) crew member(s). We can send our SOP if you want

• Let us know if you need further information • Kind regards Jan - Jan Jacobs <jjacobs@itg.be

Malaria 4. Lancet 2012 case report about fake artesunate

2013

Fake antimalarials 2013

Malaria 5. CISTM 13 POSTER One spray for all biting bugs? A literature review-

of repellent efficacy

2013

2010

2013 CISTM – 2013 – MAASTRICHT - Poster

2013

2013

• Our chart shows that the choice of repellents can be tailored, to some extent, according fo the profile of biting vectors at the travellers' destination.

• Aedes species are tolerant to many repellent products. According to our analysis, – DEET at concentration of 20% or more presented the best efficacy against

Aedes species, providing up to 10 hours protection, while – Picaridine and IR3535 showed inferior efficacy. – Citriodora repellency against this mosquito genus was lower compared to the

other products. – Also between subspecies a difference could be observed: Ae. aegJJpti proved

more difficult to repel than Ae. Albopictlls. .• Fewer studies have been conducted on mosquito species Anopheles and Culex.

– The repellency profile against Anopheles species was similar for the four principal repellents of interest, providing on average 4 to 10 hours of protection.

– Culex mosquitos are easier to repel and all four repellents provided good protection against this species.

• Few studies have been conducted on tick species Ixodes. According to our results – the longest protection against Ixodes scaplliaris wi!s provided by repellents

containing IR3535, while – DEET and commercial products containing Picaridine or PMD showed a better

response than IR3535 against Ixodes ricinlls.

Malaria 6. Varia

– Generic Malarone in the UK & The Netherlands – not necessarily much cheaper ? -patent will expire on short term ?

– ,,,,,

2013

End Malaria

2013