Download Patient Consult 101: Performing a Travel Health Risk Assessment

4/28/2016
Disclosure
Anjli Acharya B. Sc. Pharm, RPh
Patient Consult 101: Performing
a Travel Health Risk Assessment
Manitioba 13th Annual Travel Health Conference
April 7, 2016
Anjli Acharya, Bsc. Pharm
CTH
• 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.
• This presentation is funded by Manitoba
Travel Health Network
• Travel health consultant at Bowmont Travel
Clinic
• I have no conflict of interest to declare.
About you?
World traveler
with kids.
Goals
Travel Health – A Study in Risk…
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
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Travel 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?
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
•
World Malaria Risk
Steffen R et al. J Infect Dis 1987; 156:84-91
Risk Assessment
A risk assessment is a systematic process of
evaluating the potential risks that may be
involved in a projected activity or undertaking.
• ~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
www.who.int/malaria/publications/2015
Travel 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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HOW versus WHERE
HOW versus WHERE
• 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 WHERE
WHEN versus Where
Kenya:
dry/wet seasons
“Everyone travels differently for different
reasons and with different risks.”
Compartmentalizing Risk
1. Travel Risk
“To understand travel risk, you have to
understand the nature of the traveller”

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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Major Topics for Discussion
Travel Risk
1. Infectious Disease Prevention



 Immunization
 Malaria
 Travellers Diarrhea
 Respiratory Illness
 Other vectorborne
Disease
 Altitude Illness
 Environmental Hazards
 Personal Safety
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
 Sexual health and blood
borne pathogens
 Disease specific
counseling
http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/the-pre-travelconsultation
CATMAT – Guidelines
CATMAT – Guidelines
Sortable – Subject, Date or
Title
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•
•
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•
•
•
•
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•
•
•
•
http://www.phac-aspc.gc.ca/tmp-pmv/catmat-ccmtmv/index-eng.php/
CATMAT – 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
•
•
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•
•
•
•
•
•
•
•
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•
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/
Manitoba Travel Health Network
•
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•
Unique in Canada
Supports MB travel health professionals
Telephone information line
Online travel health manual
Manitoba Travel Health Conference
http://www.phac-aspc.gc.ca/tmp-pmv/catmat-ccmtmv/index-eng.php/
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Public Vaccine Resource (CIG)
Canadian Immunization Guide
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 Guidelines
http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php
http://www.phac-aspc.gc.ca/naci-ccni/
Case - Argentina
Patient Related Risk:
• Jim: Healthy,
NKA,
HTN stablesheets.
– Ramipril 10 mg daily
Review
patient
assessment
• 66 years old (DOB 3/14/1950)
Verify
medicalthat
conditions
listedhis
and
medication
• Jim mentions
he has injured
hand
doing fenceand
work “It
allergies.
was
a bad one but its ok.”
• Hasifimmunization
records
Ask
he has brought
any immunization records
• Gets flu shot regularly, hepatitis A and B series done
• How
Jim lives
a ranch
badondid
you hurt your hand?
• He admits the wound was borderline and he considered going in
Did you see a doctor? Did you get or need stitches?
for stitches.
When was your last tetanus booster?
• It is healing well.
Do you have a record of your last tetanus booster?
Case - Argentina
Age - 66
Tetanus – dirty wound risk (td or tdap?)
Vaccines? Child hood?, MMR, Pneumococcal
Travel : Yellow fever, typhoid, rabies
Vaccine Status:
-Hep A and B complete
-Flu completed yearly
NO – High risk
medical or allergies
Case - Argentina
Travel Risk:
•Do
Travelling
to BA
, city tours
nice hotel
and then up to
you have
planned
or open
itinerary?
Iguassuare
Falls
(May
2016)Hotels/camping?
Where
you
going?
• 4 days at the Falls hiking and exploring.
Patagonia? Climbing Trekking? Ranch? Wine
• Total travel days 14 days
is your
•tours?
May goWhat
on a wine
tourplan?
– doesn’t like the ocean/ water
• Prefers local food and is excited to try everything.
CDC – Yellowbook
CATMAT – Malaria
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Case
Outdoor day trips and activities
Age - 66
Vector borne risk – YF, Dengue
Adventurous eater
Jim provided us with records for Flu and
hepatitis a and b.
Tetanus – dirty wound risk
1. Routine vaccines: Td/Tdap, MMR, childhood,
Vaccines? Child hood?, MMR, Pneumococcal
Travel : Yellow fever, typhoid, rabies
flu and pneumococcal
2. Recommended: Typhoid, Hep A and B, Rabies
Vaccine Status:
-Hep A and B complete
-Flu completed yearly
No - Chagas risk
No – Leishmaniasis
Low - Schitso
NO - High Risk Medical
NO - Malarial risk
NO - Altitude risk
NO - High-risk rural
NO - Ocean risk
Case - Argentina
3. Required: Yellow fever
Manitoba – Eligibility Criteria
Vaccine Risk:
youallhave
mumps or as
measles
• Did
Jim got
his vaccinations
a child as a child?
you
your at
pneumonia
• Have
He used
tohad
volunteer
the hospitalvaccine?
library so they gave
him
booster
for mmr,
doesn’tvaccines
recall whooping
cough
Didayou
get the
childhood
available
• when
He remembers
talking
about pneumococcal with his GP
you were
young?
and received it last year at age 65
EASILY AND
READILY
AVAILABLE
ONLINE.
http:// http://www.gov.mb.ca/health/publichealth/cdc/vaccineeligibility.html /
Manitoba Immunization Schedule
Manitoba 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
http://www.gov.mb.ca/health/publichealth/cdc/div/schedules.html
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Prioritizing Risk
Outdoor day trips and activities
Age - 66
What do you believe is the highest priority risk?
Vector borne risk – YF, Dengue
Adventurous eater
Tetanus – dirty wound risk/newborn - Tdap
1. Food and water – Travellers diarrhea
2. Insect borne risk – YF, chikungunya, dengue
Travel : Yellow fever, typhoid, rabies
3. Injury based risk – Trekking, hiking
Vaccine Status:
-Hep A and B complete
-Flu completed yearly
-MMR ok, Pneumo done
No - Chagas risk
No – Leishmaniasis
Low - Schitso
NO - High Risk Medical
NO - Malarial risk
NO - Altitude risk
NO - High-risk rural
NO - Ocean risk
4. Other
Prioritizing Risk
How would you prioritize this patients risk?
Outdoor day trips and activities
Age - 66
Vector borne risk – YF, Dengue
Adventurous eater
Tetanus – dirty wound risk/newborn - Tdap
Travel : Yellow fever, typhoid, rabies
Vaccine Status:
-Hep A and B complete
-Flu completed yearly
-MMR ok, Pneumo done
No - Chagas risk
No – Leishmaniasis
Low - Schitso
NO - High Risk Medical
NO - Malarial risk
NO - Altitude risk
NO - High-risk rural
NO - Ocean risk
Case - Argentina
Outdoor day trips and activities
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 1.01.1 per 100,000; for those 70 years or older, the risk is
estimated to be 2.3-3.2 per 100,000
Age - 66
Vector borne risk – YF, Dengue
Adventurous eater
Tetanus – dirty wound risk/newborn - Tdap
Travel : Yellow fever, typhoid, rabies
– 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
Vaccine Status:
-Hep A and B complete
-Flu completed yearly
-MMR ok, Pneumo done
No - Chagas risk
No – Leishmaniasis
Low - Schitso
NO - High Risk Medical
NO - Malarial risk
NO - Altitude risk
NO - High-risk rural
NO - Ocean risk
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Case – Argentina
Travel Health – A Study in Risk…
Education:
•
•
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•
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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)
QUESTIONS?
Public Health Resources (Patient)
Patient Resource:
www.healthycanadians.gc.ca
CANADIAN IMMUNIZATION GUIDELINES
www.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 WEBSITE
www.cdc.gov/travel
WORLD HEALTH ORGANIZATION
www.who.int/int
INTERNATIONAL SOCIETY OF TRAVEL
MEDICINE
www.istm.org
Health – Healthy Living – Immunization & Vaccines
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Travel Vaccines
Vaccines in pregnancy
Vaccine preventable disease
Vaccination in Adults
Immunization registries, coverage, supply and
schedules.
Resources for Canadian Practitioners
• Canada Communicable Disease Report CCDR
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/15vol41/dr-rm41-05/res-eng.php
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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.
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