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5/28/2014 So You Wanna Be a Travel Health Pharmacist? Dr. Darin P. Cherniwchan BSc(Pharm) MD CM CCFP FCFP Certificate in Travel Health™ Clinical Instructor, Faculty of Medicine, University of British Columbia Medical Director, Fraser Valley Travel Clinic 1 “CATMAT firmly believes that travel medicine requires more than a ‘cookbook’ approach.” “Those who choose to enter this exciting field are cautioned to take the responsibility seriously. cautioned to take the responsibility seriously ” Dr. A.E. McCarthy Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 CATMAT = Committee to Advise on Tropical Medicine and Travel Objectives • Definition of Travel Medicine • Overview of Travel Health Services and When to Refer • Current Canadian Guidelines and Standards of Practice • Resources 1 5/28/2014 Presenter Disclosure • Relationships with Commercial Interests – Speaker Speaker’ss Bureau/Honoraria: Crucell, GSK, Bureau/Honoraria: Crucell, GSK, Johnson & Johnson, Merck, Pfizer, Novartis, Sanofi Pasteur – Clinical Instructor, Faculty of Medicine, University of British Columbia Presenter Disclosure • Dr. Cherniwchan has received an honorarium by the BC Pharmacy Association in exchange for providing this presentation • There are no conflicts of interest to declare. Travel Medicine Proverb 2 5/28/2014 Travel Medicine Proverb “Travel medicine is not Twinrix” You the Pharmacist • The most accessible healthcare professional – Frontline – No appointment; walk‐in • Uniquely positioned to: – Educate – Administer immunization A Good Health Care Professional • Knows what he/she knows AND knows what he/she doesn’t know • Your role is different now – Before: OTC’s, Compounding & Dispensing – Now: OTC’s, Compounding, Dispensing, Medication Review Services, Immunization – Your responsibilities are much greater 3 5/28/2014 Let me share with you briefly what ISTM would like you to know about travel health and I will inject caveats as they relate to the scope of pharmacy practice… ISTM = International Society of Travel Medicine 4 5/28/2014 Mortality in Travellers • For every 100 travel related deaths, how many are caused by infection? 5 5/28/2014 Role of Travel Health • Reduce Morbidity – Physical and Emotional Well‐being • Reduce Mortality – Pretty well everything else other than ID 6 5/28/2014 7 5/28/2014 8 5/28/2014 Hey Mom! I’ve just got my Certificate in Travel Health™! 9 5/28/2014 Certificate of Knowledge NOT Expertise The ISTM Certificate of Knowledge Program was created to: • Establish an international standard for travel medicine practitioners • Encourage individual and global professional development in the E i di id l d l b l f i ld l t i th area of travel medicine • Formally recognize individuals who pass the Certificate of Knowledge Examination • Serve the public by promoting quality travel medicine services • Demonstrate the global validity of epidemiological data and of preventive strategies http://www.istm.org/WebForms/Members/MemberResources/cert_travhlth/about.aspx#ireceived Canadian Travel Medicine Guidelines • Canada Communicable Disease Report – GUIDELINES FOR THE PRACTICE OF TRAVEL MEDICINE • CCDR Vol 25 (ACS‐6)1 December 1999 • CCDR Vol 25 (ACS‐8) December 2009 10 5/28/2014 Purpose of the Guidelines • “CATMAT presents these guidelines to serve as a stimulus for discussion and a blueprint for the practice of travel medicine.” Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Introduction • Increased need for travel medicine services • Travel medicine has become more complex – dynamic nature of changes in global health risks – increases in population mobility – various host factors Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Introduction • These complexities include: – malaria distribution and drug resistance – emergence and re emergence and re‐emergence emergence of TB of TB – travellers with co‐morbid health issues • DM, HIV, CA, CVD, Pulmonary • pregnancy • extremes of age – ever expanding vaccine portfolio Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 11 5/28/2014 Introduction • Several million Canadian travellers to tropical Several million Canadian travellers to tropical locales per year • <10% seek pre‐travel health advice Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Introduction • Multiple concerns and reports about ill‐equipped practitioners providing travel health advice and vaccine • Incorrect advice common • Severe consequences and death Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Introduction • CATMAT’s guidelines based on: – Qualifications, knowledge, skills and attributes of the travel medicine practitioner – Required facilities, equipment and resources required for the practice of travel medicine Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 12 5/28/2014 Definition of Travel Medicine • Travel medicine is the field of medicine concerned with the promotion of health and the prevention with the promotion of health and the prevention of disease or other adverse health outcomes in the international traveller • Travel Medicine Tropical Medicine Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Attributes and Qualifications of a Travel Medicine Practitioner • Physician‐based – Background in family practice, internal medicine, pediatrics, public health or infectious diseases – Utilize current travel medicine guidelines – Recognize urgent/non‐urgent post‐travel medical problems • Established mechanism of timely referral • RN collaboration Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Knowledge • Knowledge base is complex: – Geography – Global distribution, epidemiology, mode of transmission, prevention and, if appropriate, self‐treatment of travel‐associated infection pp p – Immunology – Indications, contraindications, pharmacology, drug interactions, and adverse events of available travel‐related drugs and vaccines – Prevention and management of non‐infectious risks – Have available appropriate TM info resources Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 13 5/28/2014 Skills • All pre‐travel consultations should include the following: – A basic health assessment – Evaluation of: • any underlying health problems Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Skills • Individual Risk Assessment – Itinerary – Location (Rural and/or Urban) – Style of Travel – Duration Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Skills • Individual Risk Assessment continued – Underlying health – Age – Current immunization status – Status of infectious disease risk and other health risks at destinations during proposed time of travel Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 14 5/28/2014 Skills • Risk Reduction Strategies – Vaccine – Travel behavior risk identification and modification – Intra‐travel treatment strategies Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Skills • Effectively communicate to facilitate the retention of and compliance of advice – Addressing cultural, language and educational barriers – Address any misconceptions – Use of tools to reinforce information provided (e.g. brochures, flyers) – Questions should be asked to verify understanding of advice provided Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Skills • All post‐travel consultations should be managed by a physician Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 15 5/28/2014 Practice Issues • Consultation – 30 minutes (up to 60 minutes for complex* cases) • *complexity of geographic exposures, risk behavior and inter‐current health issues Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Practice Issues • Clinic Facilities – Equipment • Vaccine refrigerator and freezer that meet standards of storage of immunization products (e.g. temperature monitor, alarm) • Telecom and internet access Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Practice Issues • Clinic Facilities cont’d – Supplies and disposables Supplies and disposables • Those required to provide vaccination, including appropriate disposal equipment • Resuscitation equipment and meds Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 16 5/28/2014 Practice Issues • Clinic Facilities cont’d – Documentation • Maintenance of patient medical record (medical standards) • Completion of traveller’s vaccination record Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Practice Issues • Clinic Facilities cont’d – Consent • Informed, voluntary consent for vaccination, testing and treatment Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Practice Issues • Clinic Facilities cont’d – Office facilities • Waiting room/reception area • Private clinic room – Exam treatment/bench – Suitable for teaching – Resources for lab testing (internal or external) Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 17 5/28/2014 Practice Issues • Office policies – Infection control practices for universal precautions and the disposal of sharps and other hazardous material – Proper handling, delivery and storage for vaccines and drugs – Immunizations administered as per current NACI guidelines Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Practice Issues • Office policies – Post‐immunization observation period – Client confidentiality Client confidentiality – Criteria for telephone advice – Management of emergencies and allergic reactions – Research Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Practice Issues • Products – Ready access to vaccines and biologics including the procedures for obtaining non‐licenced the procedures for obtaining non licenced vaccines – Written material (e.g. flyers, pamphlets) concerning preventive measures such as bed nets, insect repellants, water treatment (sale of products not required) Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 18 5/28/2014 Practice Issues • Products – Educational materials including information for travellers with special needs (e.g. pregnant or travellers with special needs (e.g. pregnant or diabetic travellers) – Information on resources for health‐care coverage for the traveller (e.g. IAMAT, travel health insurance, adequate repatriation insurance) Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Maintenance of Competence • To maintain clinical expertise, it would be optimal to carry out a minimum of 5‐10 travel medicine consultations per week • In order to be effective, the health‐care practitioner must be willing to keep up with new developments in the field and remain current with the most up‐to‐date travel medicine resource references Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Maintenance of Competence • CATMAT and NACI guidelines and updates • CDC (US) and WHO guidelines and updates • Canadian Immunization Guide Canadian Immunization Guide • Geographic reference • Public Health Publications (e.g. CCDR, MMWR) • Access to outbreak information and security alerts (e.g. PROMED, PHAC, DFAIT) Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 19 5/28/2014 Maintenance of Competence • Continuing education directly related to travel medicine is essential for all travel medicine health care practitioners – Regular attendance at related conferences and seminars (e.g. public health, immunization, travel medicine and infectious disease conferences) – Membership in at least one related organization • International Society of Travel Medicine (ISTM) • American Society of Tropical Medicine and Hygiene (ASTMH) • Canadian Public Health Association, or, • Canadian Infectious Diseases Society Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 Move Forward a Decade • “CATMAT updates its guidelines on the qualifications, knowledge, skills and attributes of a travel medicine practitioner, as well as the facilities, equipment and resources required for the practice of travel medicine.” Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 So here are the changes made So here are the changes made… 20 5/28/2014 Definition of Travel Medicine ”Travel medicine is the field of medicine concerned with the promotion of health in addition to the prevention of disease or other adverse health outcomes in the international traveller The practice of travel medicine is distinct from the practice of tropical medicine as it focuses on health promotion as a means to maintain the health and well being of it focuses on health promotion as a means to maintain the health and well‐being of travellers ; tropical medicine focuses on the diagnosis and treatment of illness associated with travel. For example, travel medicine may include advice on how to prevent malaria and other vector‐borne diseases, travellers' diarrhea, sexually transmitted diseases, injuries and accidents, as well as information on acclimatization and adaptation to hostile environments. ” Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 The Responsible Traveller The Responsible Traveller Complexities of Travel Medicine • Considerations added in 2009: – >10% world’s population crosses a border/yr – Prevention of environmental risks Prevention of environmental risks – Travel medicine is rapidly changing and increasingly complex • TB • Chronic disease, pregnant, age extremes Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 21 5/28/2014 Complexities of Travel Medicine • Malaria – Up to 50% Cdn cases not reported – 32% Rx compliant • Increasing drug resistance patterns • VFR’s (visiting friends and relatives) Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 DEFINITION OF VFR An immigrant, ethnically and racially distinct from the majority population of the country of residence (a higher‐income country), who returns to his or her home country (lower‐income country) to visit friends or relatives. http://wwwnc.cdc.gov/travel/yellowbook/2014 66 Included in the VFR category are family members, such as the spouse or children, who were born in the country of residence. e e bo t e cou t y o es de ce http://wwwnc.cdc.gov/travel/yellowbook/2014 67 22 5/28/2014 VFR’s • 1/3 of all Canadian travellers • Higher incidence of: – Traveller’s diarrhea – Malaria – Typhoid fever – TB – Hep A – STI’s VFRs Can Be Your Toughest Travel Patients • Lack of awareness of risk • ≤30% have a pre‐travel health care encounter • Financial barriers to pre‐travel health care • Clinics are not geographically convenient • Cultural and language barriers with health care providers • Lack of trust in the medical system • Last‐minute travel plans and longer trips • Travel to higher‐risk destinations, such as staying in homes and living the local lifestyle that often includes lack of food and water precautions and use of bed nets • Belief that they are immune (VFR health beliefs likely contribute to lower rates of vaccination against hepatitis A and typhoid and infrequent use of malaria chemoprophylaxis, compared with other international travelers.) http://wwwnc.cdc.gov/travel/yellowbook/2014 69 Who is accessing pre‐travel health services? • New section • 35‐68% now get travel clinic advice when travelling to higher risk destinations travelling to higher risk destinations – Increased perceived risk – Yet cost remains biggest barrier to care – VFR’s most under‐served Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 23 5/28/2014 Quality of pre‐travel health services • New Section • Travel health curriculum needs to be standardized Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 Recommendation for the Standards and Quality of Travel Medicine Advice in Canada • Since 1999, CATMAT has provided evidence based recommendations, and, where evidence is lacking, expert opinions are sought • 2002 ISTM Body of Knowledge • 2006 Infectious Disease Society of America – Evidence based guidelines for the practice of travel medicine Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 Preparing the Traveller • The “essence” of preparing the traveller: – Risk Assessment • Health of traveller • Health risk of travel (itinerary analysis) – Education about disease prevention and health maintenance – Vaccines ID’d to administer • Informed Consent – Post‐travel assessment and referral Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 24 5/28/2014 Attributes and qualifications of a travel medicine practitioner • Still does not include pharmacist • New emphasis: – 2002 ISTM Body of Knowledge – 2006 IDSA Evidence Based Guidelines – Credentialing Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 Travel Medicine Resources • Added to list: – CDC’s Yellow Book – IAMAT’s World Malaria Risk Chart – Control of Communicable Diseases Manual – Redbook – WHO IHR Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 Documentation • Added: – Vaccine record must include: • Trade name • Disease(s) against which it protects • Date given Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 25 5/28/2014 Documentation • Dose • Site • Route of Administration • Manufacturer • Lot Number • Name and Title of Vaccine Administrator – Reporting of adverse events to Health Canada Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 Maintenance of competence • Added: – Competence through training and experience with training the most important starting point with training the most important starting point – Canadian Malaria Network – WHO WER, outbreak reports Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 Certification • CTH™ – Proficiency and competency baseline – Not expertise status Not expertise status • Diploma in Tropical Medicine and Hygiene • Post‐graduate training in infectious disease • Certificate of Knowledge in Clinical Tropical Medicine and Traveller’s Health Canada Communicable Disease Report Vol. 35 (ACS-8) December 2009 26 5/28/2014 Kiss Principle • Know What You Know – OTC’s, The Enterics, Routine Immunization • Know When to Refer – Malaria – Yellow Fever – Travel more than three weeks – Immunocompromised travellers – High Altitude >2800m – Complex Traveller Health History – ANYTHING that makes you uncomfortable (heroes are not welcome) In Conclusion In Conclusion… “CATMAT firmly believes that travel medicine requires more than a ‘cookbook’ approach.” “Those who choose to enter this exciting field are cautioned to take the responsibility seriously. cautioned to take the responsibility seriously ” Dr. A.E. McCarthy Canada Communicable Disease Report Vol. 25 (ACS-6) 1 December 1999 CATMAT = Committee to Advise on Tropical Medicine and Travel 27 5/28/2014 Questions? Thank you! 5 2 28 The Responsible Traveler A Brief Guideline to the Health Issues and Cultural Codes of Traveling promoted by the International Society of Travel Medicine Whether traveling from state to state or across the ocean, cultural, hygienic, agricultural and ethical differences often pose challenges to travelers. Taking precautionary measures to avoid health problems such as gastrointestinal disorders, fevers or infections is important, but does not cover all the challenges presented on some excursions. Beyond health issues, it is important for travelers to also educate themselves on other crucial information about their destination to avoid any unintentional conflict or disrespect to their host country. Over the years, tourism has brought millions of much needed dollars to countries around the world. While contributing to these countries economic prosperity, tourists have, unfortunately, also shared diseases and infections, and have used – and abused – valuable resources, such as water and electricity. And, due to the emergence of resorts and timeshare condominiums, local residents often find that tourism has taken away much of the affordable land, the cost of housing often becoming out-of-reach for many residents. As a result, resentment toward tourists in some countries has grown, making it crucial for tourists to educate themselves about not only any medical and health concerns but also the cultures and the local lifestyles of their destinations before leaving on their trip. The International Society for Travel Medicine Council has created a guide for “The Responsible Traveler” to help ensure cross-cultural travel remains safe and beneficial to tourists as well as host countries. 1. Be an Informed Traveler Did you know that tipping is frowned upon in many societies? Or, that sitting with your legs crossed is considered rude in some countries? Or, that you should ask permission in some countries before you can take a photo? These little issues could turn into major problems all because a traveler was not well informed. The more a traveler knows about a host country the more fulfilling a trip can be. Travelers should utilize all the valuable resources now available, such as the Internet and a vast array of guidebooks, to educate themselves on the specifics about potential health risks, environmental and lifestyle differences, and the cultural and ethical codes of the host country. By educating ourselves and being respectful of a host country’s lifestyles and cultural codes, tourists can remain “good neighbors” and © International Society of Travel Medicine May 2003 www.ISTM.org keep traveling safe, fun and educational for the visitor as well as the visited. With most Western societies used to a rapid pace, some adjustment usually needs to be made to acclimate to the slower, more relaxed pace of another country. By realizing that you will need to exercise patience before you embark on your journey, it may eliminate much frustration during your trip. Be open-minded. Many aspects of life will differ when you leave home, this is one of the main reasons for travel – to learn and absorb the culture of other countries. 2. Know the Dos and Don’ts of a Country In many countries the dress code is much more conservative than in Western cultures. Some countries still frown upon women exposing their shoulders or baring their legs. Therefore, when visiting these countries travelers should be respectful of the culture and adhere to local dress codes. Public displays of affection often cause embarrassment for local residents in countries where there are such strict dress and honor codes. Likewise, visible anger is also perceived as offensive. Listen to the way the locals address each other, the senior residents and those with religious affiliations. By being respectful of those titles and mannerisms, often times, unintentional ill will can be avoided. Gestures can also be misinterpreted or carry a different meaning – for instance, in some countries, pointing your finger at an object or when asking directions is considered rude, it is best to make indications with a flat hand. Be aware of religious holidays and observances and be respectful of the customs that accompany those events. Don’t take souvenirs from a historical, cultural, natural or archaeological site. 3. Respect Your Host Country It has become quite popular to visit third-world and developing countries as romantic getaways or adventure trips. These countries present special challenges to travelers who need to be mindful of the health and medical hazards that accompany visiting a country with less advanced medical practices. The fact that you are able to visit exotic places means that you have the income to afford such luxury, which may not be the case with many of the residents of the countries that you visit. By understanding and being respectful of the socio-economic differences between countries, a traveler can not only enjoy his trip, but also enhance the economic situation for the host country. © International Society of Travel Medicine May 2003 www.ISTM.org Avoid obvious displays of wealth or handing out money, this may create an immediate barrier and build resentment between you and the locals. Bargain for food/products only if it is an acceptable custom, but do not be too aggressive, for many local people these sales are their livelihood. At all costs avoid exploitation of the residents of your host country – if a service is provided, make sure that person has been monetarily cared for either by the hotel, or through tipping. Many local tourism employees receive very low pay for long hours, so you want to be sure that you reciprocate when they provide assistance that helps make your vacation go smoothly. Sex travel and child prostitution are unacceptable practices and are risky for the traveler as well. Support local communities, hotels, restaurants and churches whenever possible. This not only helps the country economically, but it also allows the traveler to fully embrace the feel and culture of a country. Avoid the use of renewable resources – don’t insist on a daily bath if water is a scare commodity. Avoid pollution wherever possible, e.g. re-use towels and bed sheets to reduce use of laundry powder. 4. Stay Healthy While many travelers are concerned about the health hazards that will be posed to them, they may not realize that they also present health issues to the persons they are visiting, especially in developing countries. Like you would at home, be considerate in your behavior to safeguard your own and your hosts’ health. Sexually transmitted diseases are particularly linked to travel. Avoid unsafe sex to protect yourself and your partner. Flu epidemics in susceptible local populations have been linked to tourism (e.g. cruise ships). If you are traveling in a group or on a cruise, get vaccinated against the flu before you leave. A cold is a common problem among tourists. Sharing a cold is particularly easy when in crowded conditions such as a market or on a bus, therefore, try to avoid spreading your cold by washing your hands with soap and water and limiting personal contact with others. Diarrhea or gastrointestinal disorders are very common ailments among travelers. While only a minority of cases should cause concern, please be sure to bring anti-diarrhea medications and to retain the same high-level of hygiene that you would at home to avoid infections. Poor working conditions of tourism employees often have severe health implications, such as frost bite or decompression sickness in scuba guides. Stay aware of possible health problems with your assistants and help them get proper medical attention if necessary. © International Society of Travel Medicine May 2003 www.ISTM.org Don’t forget before leaving to consult a travel doctor for the necessary advice, vaccinations and prescription for malaria prevention. Remember you are visiting someone else’s home. The local people are the core of any destination, respect and be considerate of them so they can make your trip a pleasant, enjoyable experience. For more information to help be a responsible traveler, visit: www.tourismconvern.org.uk www.ippg.net www.ecpat.net www.icrtourism.org www.iipt.org If you need medical help while traveling you may be able to locate one of the ISTM Member Clinics by looking up the website www.ISTM.org. Prepared by the Destination Communities Support Interest Group of the International Society of Travel Medicine. For information purposes only. © International Society of Travel Medicine May 2003 www.ISTM.org
