4/28/2016 - Winnipeg Regional Health Authority · Political and Cultural Awareness Major Topics for Discussion ... YF, Dengue Age - 66 Vaccines? Child hood?, MMR, Pneumococcal ...

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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


CATMAT CATMAT –– Guidelines Guidelines


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


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.


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


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


Adventurous eater



Age - 66

Travel : Yellow fever, typhoid, rabies

Vaccine Status:-Hep A and B complete-Flu completed yearly-MMR ok, Pneumo done


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?



Adventurous eater



Age - 66





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



Adventurous eater



Age - 66




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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

4/28/2016 - Winnipeg Regional Health Authority · Political and Cultural Awareness Major Topics for Discussion ... YF, Dengue Age - 66 Vaccines? Child hood?, MMR, Pneumococcal ...

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