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Case Studies: The Pre-Travel Consultation
Elyse L. Tung, PharmD, BCACPClinical Pharmacist, Kelley-Ross Pharmacy
Clinical Assistant ProfessorUniversity of Washington School of Pharmacy
June 3, 2016 Northwest Pharmacy Convention
Cape of Good Hope, South Africa
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Disclosure:I have no actual or potential conflict of interest in relation to this
program/presentation within the past 12 months.
Rawai, Thailand
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Disclosure: I will not discuss off label use and/or investigational use in my presentation.
Mpumalanga, South Africa
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Objectives Pharmacist:
Devise a complete plan for immunizations in an international traveler. Justify the appropriate use of the yellow fever vaccine. Analyze patient characteristics to determine anti-malarial therapy of choice. Compare and contrast antibiotics for the treatment of traveler’s diarrhea.
Technician: Discuss the importance of pre-travel health planning for an international traveler Review the immunizations and medications that maybe prescribed for international
travel List circumstances when a yellow fever vaccine will be recommended, and side
effects from the vaccine List medications commonly used to treat traveler’s diarrhea
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Patient Cases• Adult Case
• Pediatric Case
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Learning Strategies: • Audience response with mQlicker: https://respond.cc• Enter session code: XXXX
• Group discussion and questions
Soweto, South Africa
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Resources
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Consultation Overview Patient interview
Review travel itinerary
Vaccinations - recommended versus required
Antimalarial recommendations
Antibiotics for traveler’s diarrhea
Miscellaneous - altitude sickness, jet lag, flight anxiety, anaphylaxis, road safety, travel/medical/evac insurance
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Immunizations Required by IHR
Meningitis
Yellow Fever
Polio
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Adult Traveler43 yo female (DOB 4/5/1971) visiting Quito and Tena, Ecuador on 4/02/2016 - 4/22/2016.
Activities: Field visits on foot into jungles and villages. Site visits include health care facilities to observe vaccination campaigns. Potential patient interaction, but no direct patient care. Tourist activities on Galapagos Islands for 3 days.
Lodging: westernized hotels with air-conditioning in Quito, local guest houses in rural areas
Food: hotels and restaurants, packaged foods
Not pregnant and no plans on becoming pregnant in the next 3 months.
PMH: none
Medications: Loestrin 24 Fe
NKDA, No known vaccine reaction
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Vaccine HistoryPer patient, received all childhood vaccine series, including the following:
Vaccine Dates of Administration
Hepatitis A 2/6/2006, 3/1/2007
Hepatitis B 1/14/1989, 2/10/1989, 1/3/1990
Typhoid 4/12/2011 – Typhim Vi
MMR Childhood series complete
Polio Childhood series complete
tetanus 03/11/2001 Td
influenza 10/31/2015
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CDC Recommendations for Brazil
Routine vaccines
Hep A
Hep B
Typhoid
Yellow Fever
Rabies
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Typhoid Fever Fecal-oral contamination with
Salmonella Typhi.
N/V/D and fever lasting months.
Two vaccines available: Oral live attenuated Ty21a (Vivotif
®) Injectable polysaccharide (Typhim
Vi ®)
Patient has no preference for pills or injection
Which vaccine would you recommend?
a. Vivotif
b. Typhim Vi
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Yellow Fever
Transmitted via mosquito bites in certain parts of Africa and South America.
Death in 20-50%, no treatment, only symptomatic support
Prevention: mosquito bite avoidance and vaccination
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YF-Vax® Live-attenuated viral vaccine.
Indications: ages >9 mn traveling/living in risk areas
Serious adverse events: YEL-AND (0.8:100,000) and YEL- AVD (0.4:100,000) Only vaccinate people 1) at risk of exposure or 2) who require proof
of vaccination to enter country
Follow country specific information
Life long immunity (updated July 2015)
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Yellow Fever Letter of Exemption
http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/yellow-fever
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Yellow fever vaccination for Ecuador
Required Recommended
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Should she get the yellow fever vaccine?
a. Yes
b. No
What if she had a layover in Peru?
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Rabies Transmitted through mammal bites.
Encephalitis, paralysis, and severe neurologic involvment. 100% fatal without post-eposure prophylaxis.
Parts of Africa, SE Asia, and the Indian subcontinent have the highest reported cases.
Children are higher risk d/t smaller stature, curiosity and attraction to animals.
Evaluate travel activities including access to healthcare.
Pre-exposure vaccination: Imovax® or RabAvert®: 3 doses on day 0, 7, 21 or 28.
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Rabies Recommendation for Ecuador
Would you vaccinate her for rabies?
a. Yes
b. No
What if she had a layover in Peru?
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Malaria Bite of an infected female Anopheles mosquito. Feeding
occurs dusk and dawn.
Flu like symptoms, seizures, cerebral malaria and death. Presents usually in 1 month, may lay dormant up to 1 year.
Prophylaxis is always preferred since treatment of malaria can still be fatal. Atovaquone-proguanil, chloroquine, hydroxychloroquine, doxycycline,
mefloquine, primaquine
Review country specific information
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Malaria Recommendation for Ecuador
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Malaria Recommendation for Ecuador
Which antimalarial would you recommend?
a. Atovoquone-proguanilb. Doxycyclinec. Mefloquined. chloroquine
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Other Mosquito Borne Illnesses
Chickanunga
Dengue
Zika
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Zika Virus 1:5 infections are symptomatic
Transmitted from mother to fetus
Causes microcephaly
Aedes aegypti mosquito
Sexually transmitted
US outbreaks this summer?
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Mosquito Avoidance Techniques
Provide education at each encounter
DEET 30% sprays versus lotions
Permethrin-treated clothes
Sleeping in AC
Bed nets treated with permethrin
Zimbabwe
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Recommended Items
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Traveler’s Diarrhea
Most common infection for travelers: 30-70%
Pathogens: ETEC in Africa and Latin America, FQ-resistant Campylobacter in SE Asia, Shigella, Salmonella
Steffen R, Tornieporth N, Costa Clemens SA, et al. Epidemiology of travelers' diarrhoea: details of a global survey. J Travel Med 2004;11(4):231- 238
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Prevention versus Treatment
Prevention:
Pepto-Bismol 60ml po qid
Rifamixin 200mg qday - bid
Cipro 500mg bid*
Treatment
Cipro 500mg bid x 1-3 days
Azithromycin 1000mg po x 1
Rifamixin 200mg tid x 3 days
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Traveler’s Diarrhea
Which antibiotic regimen would you recommend for her?a. Rifamixin 200mg qday for preventionb. Cipro 500mg bid for 1-3 daysc. Azithromycin 1000mg x 1 dosed. Rifamixin 200mg tid x 3 days for treatment
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Mpumalanga, South Africa
The Pediatric Traveler
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Pediatric Traveler7yo (DOB 10/27/2008) male (19.8kg) traveling with parents to India on 5/2/16-
7/28/16. Layovers in Dubai.
Activities: Visiting and staying with extended family in a town outside of Bihar. Will visit Agra and Delhi.
Lodging: Family home in India. Westernized hotels in Delhi.
Food: family cooked meals, hotels, restaurants
PMH: none
Medications: none
NKDA, No known vaccine reactions
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Vaccine HistoryWA State Immunization Information System (WAIIS)
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CDC Vaccine Recommendations for India
Routine vaccines
Hep A
Hep B
Japanese Encephalitis
Rabies
Typhoid
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Minimum Ages for Vaccinations
Yellow fever: 9 mn
Hep A: 1 yr
Typhoid Oral: 6 yrs Injectable: 2 years
Rabies: no minimum
Japanese encephalitis: 2mn
Meningitis: Conjugate: Menveo 2mn,
Menactra 9mn Polysaccharide: Menomune
2yr
Influenza: 6 mn
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Typhoid Vaccine in Pediatrics
Which typhoid vaccine would you recommend?a. Oral vaccine (Vivotif)b. Injectable vaccine (Typhim Vi)
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Japanese Encephalitis Transmitted through mosquito bites
Rare disease for US travelers: 1992-2011 only 7 cases
Most common in rural, agricultural areas of Asia, SE Asia, and the Indian subcontinent, residents or long term travelers, substantial time outdoors, no AC in lodging
Death in 20-30%, 50% of survivors have permanent neurological and cognitive sequelae.
Ixiaro ® vaccine: day 0 and day 28 2mn to 3yr: 0.25ml
> 3 yr: 0.5ml
Always evaluate travel activities, season, and destination.
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Japanese Encephalitis risk for IndiaWould you recommend the Japanese encephalitis vaccine?
a. Yesb. No
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Rabies Vaccine in Pediatrics
Smaller stature and curiosity increases risk of being bit
Often afraid to report exposure
Weight based dosing of rabies immune globulin (RIG) injection into all wounds. Small children often run out of drug before all wounds have been treated.
Human RIG is difficult to access in most countries
Rabies vaccine dose is the same for children
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Antimalarias in Pediatric Patients
• Use weight based dosing• Nothing comes in kid-friendly preparation unless compounded • Use any disguise or bribe: the sweeter, the richer, the better.
• Medication options• Atovaquone-proguanil: min. weight 5 kg, (11 lbs)• Chloroquine: safe in all ages, resistance areas• Mefloquine: safe in all ages• Doxycycline: minimum age 8 years
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Malaria in India
Which antimalarial would you recommend?a. atovaquone-progruanilb. Cloroquinec. Mefloquined. doxycycline
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Traveler’s Diarrhea in Pediatrics
Which antibiotic regimen would you recommend?a. Cipro 30mg/kg/d divided bid x 3db. Azithromycin 10mg/kg/d x 3dc. Rifamixin 100mg qid x 3 days
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Summary
Devised a complete plan for immunizations in three different types of travelers.
Justify the appropriate use of the yellow fever vaccine.
Analyze patient characteristics to determine anti-malarial therapy of choice.
Determined the best antibiotics of choice for the treatment of traveler’s diarrhea.
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Questions?
Phang Nga Bay, Thailand