Download BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE June 15

BELGIAN
CONSENSUS MEETING
on TRAVEL MEDICINE
June 15, 2007
Pr. A. Van Gompel (ITG),
Dr. R. Snacken (WIV- LP),
Pr. F. Jacobs (Hôp. Erasme, ULB),
Pr. W. Peetermans (U.Z. - K.U.Leuven),
Pr. Y. Van Laethem (CHU. St. Pierre, ULB),
Pr. B. Vandercam (CHU. St. Luc, UCL),
Pr. R. Peleman (UZ.- U.Gent)
Pr. P. Lacor (AZ-VUB),
Dr. Ph. Leonard (CHU-ULg),
Dr.P. Soentjens (Belgian Army)
final version – PART II malaria & varia 21/06/2007
Belgian
Scientific Study
Group on Travel
Medicine
2007
REPORT
BELGIAN CONSENSUS MEETING on TRAVEL MEDICINE
June 15, 2007 – final version – PART II
• The consensus meeting was chaired by A. Van Gompel
• Secretary of the meeting was W. Peetermans.
• The CONSENSUS HAND-OUT (in Dutch and French)
highlighting the proposals for changes was distributed as
a hard copy during the meeting & the final version will be
sent by email to all participants.
• A PowerPoint presentation was prepared by A. Van
Gompel
• The discussion and recommendations of the
meeting are included in this presentation. The pdfversion of the essential slides of the presentation will
been sent to all participants.
• This document served as a proposal for approval by the
governmental Belgian Health Council – section
Vaccinations, on June 21, 2007
• Responsable final redaction : A. Van Gompel
Malaria
•
•
•
2007
The malaria map 2007 by the ITG-ITM is identical to
the map 2006.
The malaria map in de CDC book 2008 shows risk
areas for resistance to mefloquine in South-east
Asia. CDC mentions figures of 50% or more
resistance, while a WHO map shows the areas with
a figure of > 10%.
CDC proposes not to use mefloquine in these areas.
1
Chemoprophylaxis Belgium
2
THAILAND
MEFLOQUINE
RESISTANCE
CDC 2004
CDC 2007-8
Î
Malaria
•
•
Î
2007
Travelers who are taking mefloquine (e.g. for
India) crossing the mefloquine resistance
area can remain on this prophylaxis. Standby
treatment with Malarone is then advised.
On the other hand German speaking
countries do not (or rareley) recommend drug
prophylaxis at all for these areas.
3
2005
(Adventurous) travelers in Asia – Latin America
In many areas in Asia and Latin America it may be possible for travelers
on adventure-type trips to drop their chemoprophylaxis after a detailed
discussion with a specialist doctor and careful evaluation of the malaria
risk in relation to the type of accommodation, and on condition that strict
anti-mosquito measures are taken from sunset to sunrise and that malaria
emergency treatment (Malarone®) and full instructions are on hand.
http://www.dtg.org/21.0.html
4
Malaria
•
•
2007
Prophylaxis with Nivaquine + Paludrine can start 1
day before entering malaria endemic area
(pharmacokinetically protective serum levels).
Some countries recommend to start Malarone in
the morning arriving in malaria area. This is,
however, no consensus yet.
Ochtend –aankomst ?
1 dag
5
Le matin de l’arrivée ?
1 jour
6
Malaria
2007
The maximum duration of drug prophylaxis differs
from country to country:
• Mefloquine: WHO and USA unlimited; UK 3
years.
• Malarone: USA no limits; UK 1 year.
• Doxycycline: WHO and USA 4 to 6 months;
UK 2 years.
Chloroquine : 300 mg base weekly long-term use
• WHO :
– “The risk of serious side-effects associated with
longterm prophylactic use of chloroquine and
proguanil is low,
– but retinal toxicity is of concern when a cumulative
dose of 100 g of chloroquine is reached.
– Anyone who has taken 300 mg of chloroquine
weekly for more than 5 years and requires further
prophylaxis should be screened twice-yearly for
early retinal changes.
– If daily doses of 100 mg chloroquine have been
taken, screening should start after 3 years
• UK :
Doxycycline : longterm use
• WHO : “Available data on longterm
chemo-prophylaxis with doxycycline (i.e.
more than 4–6 months) is limited but
reassuring”
• US :
• UK : 2 years
7
Mefloquine : longterm use
• WHO : “data indicate no increased risk of
serious side-effects with long-term use of
mefloquine if the drug is tolerated in the
short-term”
• US : no limit
• UK : 3 years
Atovaquone + Proguanil : long-term use
• WHO : “Atovaquone–proguanil is
registered in European countries with a
restriction on duration of use (varying
from 5 weeks to 3 months); in the USA
no such restrictions apply.”
• US : no limit
• UK : 1 year
• France : 3 months
8
• In North America, there is no stated limit on duration of
use of AP as a prophylactic agent, whereas in much of
Europe, AP is only approved for up to 4 weeks of travel.
• A randomized prophylaxis trial administered AP to
participants for up to 20 weeks,16 and two observational
prophylaxis studies have reported daily use of AP for
26–34 weeks (63,64) all with excellent tolerability.
• As single agents, atovaquone and proguanil have been
used with good tolerability for much longer periods of
time
• atovaquone has been used as prophylaxis against P.
jirovecki pneumonia 2-3 years.
9
•
•
Methods . We initiated a prospective observational study on ailments
reported by travelers using A/P on a long-term basis.
Ailments were recorded on a regular questionnaire. Travelers rated their
ailments as
– (1) mild, not interfering with their daily activities;
– (2) moderate, causing interference with daily activities; or
– (3) severe, resulting in a visit to a doctor or clinic.
•
Results .
–
–
–
–
169 used A/P for a total of 2.974 weeks.
153 (90.5%) traveled to malaria-endemic regions in Africa.
75 (44%) who used A/P for 1.140 weeks, reported no ailments.
94 (56%) who used A/P for 1.834 weeks reported a total of 363 ailments.
• Diarrhea was the most common ailment (13.5%; graded as mild in 7.2%, moderate in
4.7%, severe in 1.7%).
• Further complaints were headache (7.4%), malaise (6.1%), insomnia (5.2%), abdominal
pain (5.0%), nausea (5.0%), and oral ulcers (4.1%).
• Four (2.4%) subjects discontinued prophylaxis due to complaints.
• No patient was admitted.
• Five (3.0%) cases of self-reported malaria
•
Conclusions . In our observational study encompassing more than 57
person-years of follow-up, A/P was tolerated well when taken longer than
the current recommendation of 28 days of travel. Treatment-limiting
ailments resulting in discontinuation of chemoprophylaxis were observed in
4 of 169 (2.4%) participants, whereas none of them was admitted. There
were five (3.0%) cases of self-reported malaria. These observations
suggest that A/P is also a safe and effi cacious drug for the long-term
chemoprophylaxis of falciparum malaria.
Malaria : Lariam ®
•
2007
Mefloquine and pregnancy: there is no enhanced risk of
taking mefloquine during pregnancy. There remain some
doubts for the time immediately following conception.
Therefore the recommendation holds not to become pregnant
until 3 months after the last dose of mefloquine.
Mefloquine - bijsluiter
Zwangerschap en borstvoeding:
•
•
•
In een dosis van 5 tot 20 maal de therapeutische dosis bij de mens is
mefloquine teratogeen bij ratten en muizen en embryotoxisch bij konijnen; in
de klinische ervaring met Lariam werden evenwel geen teratogene of
embryotoxische effecten waargenomen.
Desondanks mag Lariam tijdens het eerste trimester enkel worden gebruikt
als het verwachte nuttig effect het potentiële risico voor de foetus
rechtvaardigt.
Vrouwen op vruchtbare leeftijd moeten de raad krijgen contraceptie toe te
passen tijdens een profylaxe van malaria met Lariam en dit tot 3 maanden
na de stopzetting van de profylaxe. Chemoprofylaxe van malaria met
Lariam is evenwel geen indicatie voor zwangerschapsonderbreking mocht
onverwacht toch een zwangerschap optreden.
Mefloquine wordt in de moedermelk uitgescheiden in kleine hoeveelheden,
waarvan de activiteit niet gekend is. Daarom wordt herhaald gebruik van
mefloquine niet aangeraden tijdens de borstvoeding.
10
Mefloquine - notice
Grossesse et Allaitement:
•
•
•
•
•
A la dose de 5 à 20 fois la dose thérapeutique chez l'homme, la méfloquine
est tératogène chez le rat et la souris et embryotoxique chez le lapin;
l'expérience clinique avec Lariam n'a cependant pas révélé d'effets
tératogènes ou embryotoxiques.
Néanmoins, Lariam ne devrait être utilisé pendant le premier trimestre que
si le bénéfice attendu justifie le risque potentiel pour le foetus.
Les femmes en âge de procréer seront avisées de pratiquer une
contraception lors d'une prophylaxie du paludisme par Lariam et ce, jusqu'à
3 mois après l'arrêt de la prophylaxie.
Cependant, dans le cas d'une grossesse imprévue, la chimioprophylaxie du
paludisme par Lariam n'est pas considérée comme une indication pour
interrompre la grossesse.
La méfloquine est excrétée dans le lait maternel en petites quantités dont
l'activité n'est pas connue. C'est pourquoi l'usage répété de méfloquine
n'est pas recommandé pendant l'allaitement.
2006
Medasso 2006-7
11
Malaria : Malarone ®
•
•
•
2007
Malarone is now allowed for children starting at 5 kg. The
dose is 5 mg/kg, which means ½ half pediatric tablet for 5 to
8 kg and ¾ of a pediatric tablet for 8 to 10 kg.
Cutaneous side effects of Malarone have been described
(rash with eosinophilia and systemic symptoms and 3 cases
of severe Stevens- Johnson syndrome).
Malarone and pregnancy: FDA has given Malarone category
C. The first observations indicate indeed that Malarone is
safe during pregnancy
Malarone induced DRESS syndrome (Drug eruption, eosinophilia and systemic symptoms
12
Use During Pregnancy.
•
•
Pregnancy category C§. An insufficient number of trials have been performed to clearly show
safety. One small randomized, open-label treatment trial did not show a difference in birth weight,
duration of gestation, congenital anomalies, or growth and developmental parameters at 1 year
between the atovaquone–proguanil arm and quinine arm. Atovaquone–proguanil is currently not
recommended for use during pregnancy.
§ FDA pregnancy category C: either studies in animals have revealed adverse effects on the fetus
and there are no controlled studies in women or studies in women and animals are not available.
Drugs should only be given if the potential benefit justifies the potential risk to the fetus.
Use During Breastfeeding.
•
Currently, AP is not recommended for women breastfeeding infants weighing < 5 kg.
Use in Children.
•
Treatment efficacy, safety, and pharmacokinetic data in children 5–11 kg have been extrapolated
to recommend prophylaxis doses in children 5–11 kg (off-label use).
13
Malaria : Malarone ®
•
2007
It has been confirmed that Malarone
treatment in mefloquine resistance areas
remains effective.
97.8% (95% ci 95.4 –100%)
responded to therapy
Malaria : Malarone ®
•
2007
When Malarone is started too late or has been
interrupted, there is loss of causal prophylaxis
and the Malarone prophylaxis must be
continued until 28 days after these events.
Malarone does not eradicate schizonts or
hypozoits.
14
Atovaquone + Proguanil
Causal prophylactic BUT very probably narrow window
– only in the first (few) day(s) of the liver-stage
schizont ???
It is unknown whether AP will function as a causal agent when
started after exposure to malaria; therefore, individuals who
switch from a blood schizonticide agent such as mefloquine
(MQ) or doxycycline to AP during exposure should take AP
for 4 weeks after the drug change but not beyond 4 weeks
after return
Malaria : Riamet ®
•
•
•
•
•
•
2007
Riamet (Lumefantrine + Artemeter) will soon become
available in Belgium.
24 tablets = 6x 4 tablets (0-8-24-36-48-60 hours)
It is recommended for uncomplicated Malaria.
The fever and parasite clearance is somewhat more
rapid than with other drugs.
It must be taken with food.
Price is 38 €.
Riamet® versus Malarone®
There is no comparative study regarding efficacy
of Riamet® versus Malarone® published in the
standard literature.
In several publications, the range of the measured
• mean fever clearance time
– for Malarone® is
– for Riamet® is
18.8 to 59h,
17.1 to 32h
• mean parasite clearance time
– for Malarone®
– for Riamet®
46.7 to 65h
29.7 to 49.9h
15
MALARONE PRIX BAS ???
<http://www.astrium.com/boutique/>
•
•
•
Nous avons mené une étude (juin 2007, close le 29.06) sur les prix
pratiqués pour la Malarone par 100 pharmacies parisiennes.
La moyenne est de 43 € (prix public conseillé : 34,95 €).
A ces cent officines, nous en avons ajouté huit signalées sur des forums de
discussion.
•
Compte tenu du risque vital lié à ce problème de coût, il nous paraît
indispensable de nous intéresser à la partie gauche de la courbe
gaussienne des prix.
•
Le prix le moins cher identifié dans cette étude est pratiqué par l'officine du
– 121, avenue de Saint-Ouen, 75017 : 29,00 €.
– 74 rue Monge, 75005 : 29,50 €.
– 30 rue Monge, 75005 : 29,90 €.
City-pharma, 26 rue du Four, 75006, bien connue pour casser les prix, n'est
pas ici la plus compétitive : 33,00 €.
•
Malaria
•
•
•
2007
There is a warning of QT prolongation which implies that very
often an ECG must be taken before treatment. This is
especially true when exposed to other drugs with QT
prolongation such as macrolides of fluoroquinolones.
In Switzerland Riamet is an alternative for Malarone as
standby treatment while The Netherlands are more restrictive
In the tropics this same combination is very widely used as
Co-artem ®.
N. White – Mansons Tropical Diseases 2003 p.1259 :
“Concerns about possible cardiotoxicity have been refuted by careful
studies. Lumefantrine is not cardiotoxic”
Riamet ®
16
Riamet ®
Auto-treatment d'urgence
Critères pour le choix d’un antipaludique à utiliser en auto-traitement d'urgence
dans les régions à souches de P. falciparum majoritairement sensibles à la méfloquine (posologie adulte)
Produit
Méfloquine
LARIAM®, MEPHAQUIN®
3, 2, 1 cp à 250 mg,
intervalles de 6 h
Atovaquone+proguanil
MALARONE®
4 cp/jour x 3 jours
Artéméther+luméfantrine
RIAMET®
2 x 4 cp/jour x 3 jours
Points positifs
Points négatifs
•Sécurité
•Grande expérience clinique
•Efficace contre toutes les espèces plasmodiales
•Utilisation large (enfants >5 kg, grossesse)
•Schéma thérapeutique court (18 h)
•Faible coût
•Neurotoxicité (1:216 Fälle)
•Résistance de P. falciparum (SE asiatique >50%)
•Interactions (par ex. anticoagulants, antidiabétiques)
•Efficacité >95% (P. falciparum, P. vivax)
•Bon profil d’effets secondaires
•Sécurité: substances isolées connues et éprouvées
•Efficace contre les souches multi-résistantes de P. falciparum
•Potentiel à développer rapidement des résistances
•Interactions avec paracétamol, métoclopramide
•Uniquement patients de >11 kg (poids corporel)
•Contre-indication: grossesse
•Effets secondaires gastro-intestinaux, céphalées
•Prise avec un repas
•Haut profil de sécurité
•Bon profil d’effets secondaires
•Efficacité rapide contre toutes les espèces plasmodiales
•Efficace contre les souches multi-résistantes de P. falciparum
•Délai de péremption court (<2 ans)
•Contre-indication: grossesse
•Prise avec un repas
Malaria : DEET-repellent
•
The UK recommendation allows the use of
DEET up to 50% in pregnant women and
children older than 2 months.
•
•
•
2007
DEET is considered effective
–
–
up to 12 hours for the 50% concentration
up to 6 hours for the 30% concentration
–
but only up to 3 hours for the 20% concentration
“There is no further increase in duration of
protection beyond a concentration of 50%”.
“Sweat-off time varies with activity. The interval
between applications depends on this as well
as the DEET formulation and concentration
used”
This has implications for the interval of the
applications.
17
www.hpa.org.uk/infections/topics_az/malaria/default.htm
Malaria : DEET-repellent
2007
Often it means 3 applications / 24 hours (allowed for the 30%
concentration):
–
–
–
morning dose (to avoid dengue),
late afternoon dose or early evening dose (to avoid dengue),
A dose for the late evening or night (to avoid malaria).
http://www.invs.sante.fr/beh/2007/31_32/beh_31_32_2007.pdf
18
Geographical issues
Epidemiological changes
New hot spots
Malaria : Caribbean region
•
•
•
2007
Some remarks concerning geography of
malaria endemic areas were given.
Recommendations concerning the Dominican
Republic are identical to previous year (low
risk, Nivaquine prophylaxis can be
recommended).
The risk areas in Jamaica Kingston are
limited to certain sites. The recommendations
are the same as for the risk areas in Dom.
Rep.
19
Dominican Republic
2006
ZONE A
Dominican Republic
Dominican Republic
Malaria in the Dominican Republic
Updated: January 29, 2007
PHAC has recently been notified of a third case of malaria in a Canadian traveller
returning from the Dominican Republic (Punta Cana). A single case has also
been reported in a US traveler.
PHAC reminds travellers that antimalarial medication and the use of personal
protective measures against mosquito bites are recommended for travel
travel to resort
areas within the province of La Altagracia as well as all rural areas of the
Dominican Republic.
20
Jamaica
Outbreak of malaria in Kingston, Jamaica
•Jamaica had been malaria free for the last 41 years.
•From Dec-January 2007 more than 200 cases in Kingston and 6 of the
cases in the adjacent parish of St. Catherine and a single case in the
parish of Clarendon.
•1 case in a US resident who traveled to Kingston in November 2006
•All confirmed infections have been caused by Plasmodium falciparum.
•Since December 4,
2006,
CDC
has recommended prophylactic
antimalarial medication with chloroquine for travelers who stay overnight in
Kingston, Jamaica, only. Travelers to other areas of the island do not need
to take an antimalarial drug. This recommendation is expected to be
temporary.
Jamaica
Jamaica
Kingston
• Dit is een tijdelijke aanbeveling
• Er is sinds eind 2006 beperkt malariarisico (P.
falciparum) in bepaalde wijken van Kingston.
• Extra aandacht voor de antimugmaatregelen
van valavond tot zonsopgang is hier
aangewezen.
• Personen die na zonsondergang toch vele uren
buiten zullen doorbrengen, kunnen overwegen
Nivaquine te nemen (zie nota 1).
• In geval van koorts bij terugkeer uit Jamaica
dient ook steeds van bij het begin aan malaria te
worden gedacht.
21
Jamaica
Kingston
• Recommandation temporaire à propos de la Jamaïque:
• Il existe depuis fin 2006 un risque limité de malaria (P.
falciparum) dans certains quartiers de la capitale
Kingston.
• Les mesures de protection supplémentaires contre les
piqûres de moustiques (de la tombée du soir jusqu'au
lever du soleil) restens essentielles dans la prévention
de la malaria.
• Les voyageurs qui, une fois le soir venu, passent une
grande partie de leur temps dehors, envisageront une
prophylaxie avec la Nivaquine (note 1).
• En cas d’accès de fièvre dans les premières semaines
qui suivent le retour, la possibilité de malaria doit être
considéré.
Malaria : India
•
•
2007
Goa in India is considered a risk area.
The UK guideline recommends Nivaquine +
Paludrine for the central part of India, while
WHO is moving towards a B/C transition
zone..
2006
BC
22
India: Goa
23
24
MALARIA - GOA
ProMED-mail post16 Jul 2007
•
The state's health ministry today [16 Jul 2007]
expressed worry over the rising cases of
falciparum malaria, with almost 788 cases
reported between January-June 2007, as
against last year's [2006] figure of 240 cases.
•
The Health minister Vishwajit Rane today said
that the existing machinery had been geared
up to combat the problem, with all energies
being diverted to target construction sites,
which, in his opinion, are the potential breeding
grounds for mosquitoes in the state.
•
"The construction sites not only include
commercial constructions but also house
constructions, particularly in Dona Paula and
Caranzalem,“ he said. Statistics furnished by
the health department today [16 Jul 2007]
indicate a high number of falciparum malaria
cases in Tiswadi (354 cases), followed by
Bardez with 342 cases.
•
Data show that nearly 2883 malaria cases
have been reported all over Goa during the
last 6 months, as against 1552 reported last
year [2006].
•
[ProMED 1st reported on malaria imported
from Goa to Europe on 1 Jan 2007, and the
increased number of imported cases since
November 2006 was summed up in
Eurosurveillance on 11 Jan 2007, also
published by ProMED.
India
Malaria in Goa (India)
TropNetEurop
European Network on Imported Infectious Disease
Surveillance
• No malaria cases in European travellers to Goa for the past 2 years.
years.
• Nov 0606-Jan 07= 8 cases: 2 in Germany, 4 in Denmark, and 2 in Sweden.
• 5 stayed in Goa for 22-3 weeks and had not visited other regions within
India.
• March 07= another case in a UK traveller on chloroquinechloroquine-proguanil
prophylaxis.
• Acquired in the area to the north of Panaji,
Panaji, the capital of Goa
• Has coincided with a period of intense rainfall (50% above average)
average) in the
Goan and Konokan region since October 2006. This may be the cause of
increased vector breeding and transmission during the current rainy
rainy
season.
India: Goa
TropNetEurop
European Network on Imported Infectious
Disease Surveillance
• Visitors may consider using WHO type IV prevention, which
is mosquito bite prevention plus chemoprophylaxis with
atovaquone/proguanil,
atovaquone/proguanil, doxycycline,
doxycycline, or mefloquine,
mefloquine,
• or they may consider travelling with emergency standby
treatment
http://www.eurosurveillance.org/ew/2007/070111.asp
25
India: Goa
•
•
Advice for travellers
Based on the additional cases of falciparum malaria reported from Goa, the
ACMP now advises that health professionals who are advising travellers:
– highlight the risk of malaria
– instruct on the use of mosquito bite avoidance measures
– consider recommending malaria prevention tablets for travellers visiting Goa
•
•
•
This advice for travellers to Goa to consider taking malaria prevention
tablets is a change to current ACMP guidelines for India [5] and remains in
effect until further notice. Continued review of this advice will be made
based on surveillance for malaria cases. Complete recommendations for
other areas of India should be consulted [5].
The recommended malaria prevention tablets for Goa are chloroquine plus
proguanil. Alternatives are mefloquine, atovaquone/proguanil (Malarone®)
or doxycycline.
Travellers should seek medical attention promptly if they become unwell
and inform their doctor that they have been in a malarious area. Healthcare
workers should consider malaria in every ill patient who has recently
returned from the tropics.
India
changes made in recommendations for travellers in some EU
member states
• DENMARK:
DENMARK: Dec 06, changed its malaria advice until further
notice, as a precautionary measure. The new
recommendation is WHO type IV chemoprophylaxis.
• SWEDEN:
SWEDEN: No changes in recommendations.
recommendations. But malaria
prophylaxis can be considered for travellers visiting Goa. The
drugs that might be used are AtovaquoneAtovaquone-Proguanil,
Proguanil,
Mefloquine or Doxycycline.
Doxycycline.
• GERMANY:
GERMANY: No changes in the recommendations have been
made
India
changes made in recommendations for travellers in some EU
member states
ENGLAND: The ACMP recommend malaria
chemoprophylaxis to those travellers who will
be visiting Goa, particularly areas north of
Panaji,
Panaji, and who will be remote from medical
care.
The recommended is chloroquinechloroquine-proguanil.
proguanil.
Alternatives are mefloquine,
mefloquine, atovaquoneatovaquoneproguanil,
proguanil, or doxycycline.
doxycycline.
26
India
changes made in recommendations for travellers in some EU
member states
SCOTLAND
http://www.searo.who.int/LinkFiles/Malaria_in_
the_SEAR_ind_ml_st04.pdf
2006
http://www.searo.who.int/LinkFiles/Malaria_in_
the_SEAR_MalEndemicity_india.pdf
2006
27
http://w3.whosea.org/malaria/slidepositivity.htm
Distribution of SlidePositivity Rate In India,1986-97
http://www.traveldoctor.info/trip/result.1.116.1.html
Varia
•
•
•
•
•
Dengue
Chikungunya
Avian flu
Rift Valley fever
TB
• DVT – WHO report
• melatonin
• Sun protection
28
Malaria : DEET-repellent
2007
Often it means 3 applications / 24 hours (allowed for the 30%
concentration):
–
–
–
morning dose (to avoid dengue),
late afternoon dose or early evening dose (to avoid dengue),
A dose for the late evening or night (to avoid malaria).
InVS France – juin 2007 :
entre 0-5 cas de Chik par semaine = Maurice, Mayotte, Réunion, Comores
http://exhibit.gideononline.com/Zika.JPG
29
Avian FLU
2007
http://gamapserver.who.int/mapLibrary/app/searchResults.aspx
Avian influenza A/H5N1 is currently not a very
contagious virus for humans, but there is a small and
real risk of infection for people who have close
contact with sick birds.
Rift Valley Fever
• No risk for the traveler or
expatriate
• promedmail.org
• CDC guidelines for
travelers
http://www.cdc.gov/ncido
d/dvrd/spb/mnpages/dis
pages/rvf.htm
30
8.8 Million Tb cases each year
1.6 Million deaths each year
450.000 MDR-TB each year
25 - 30.000 XDR-TB cases each year
To date, no case of active TB has been
identified as a result of exposure on a
commercial aircraft.
From 1992 to 1994, the US-CDC,
conducted 7 contact investigations,
In only 2 of the investigations was there
evidence to suggest transmission of M.
tuberculosis infection: no evidence of
TB disease has been reported among
those known to have been infected with
M. tuberculosis during air travel.
2006
No other instances of possible TB
transmission on aircraft have been
published since then.
The risk of infection with M. tuberculosis
during air travel is similar to that
associated with other activities in which
contact with potentially infectious
individuals may occur (e.g. train travel,
bus travel, any gathering in enclosed
spaces).
31
Informing those passengers seated in the same row as the index patient and
those seated in the two rows ahead and behind, as well as cabin crew members
working in the same cabin section, will therefore usually be sufficient.
June 2007
•
•
•
In a cohort of healthy individuals the absolute risk of VTE per more than
four-hour flight, was 1 in 6000.
The risk of VTE approximately doubles after a long–haul flight (>4 hours)
(and also with other forms of travel where travellers are exposed to
prolonged seated immobility).
The risk increases
– with the duration of the travel
– with multiple flights within a short period.
– in the presence of other known risk factors of VTE
•
•
•
•
•
obesity
extremes of height
use of oral contraceptives
presence of prothrombotic blood abnormalities
Based on these findings, there is a need for travellers to be given
appropriate information regarding the risks
Mélatonine dans le jet-lag
•
•
Il ressort d’un article de synthèse sur le jet-lag paru récemment dans le
Lancet [ 2007 ; 369 : 1117-29 ] qu’il n’existe pas encore de remède univoque
pour prévenir ou traiter le jet-lag.
Outre quelques mesures non médicamenteuses, certains recommandent la
mélatonine. En ce qui concerne la mélatonine dans le jet-lag, les données
restent contradictoires:
– une Revue Cochrane a apporté des preuves d’un effet favorable [voir Folia d’ avril
2004 ],
– contrairement à une méta-analyse récente [ Brit Med J 2006 ; 332 : 385-8 , avec
un éditorial 2006 ; 332 : 373-4 ].
•
Il existe en outre peu de données concernant l’innocuité de la mélatonine; il
est suggéré que la mélatonine contrecarre l’effet des anticoagulants oraux et
diminue le seuil convulsif.
•
Depuis 1997, la délivrance de médicaments à base de mélatonine était
interdite en Belgique.
Cette interdiction a été levée l’an dernier (Moniteur belge du 9 mai 2006).
Cela signifie que la mélatonine peut maintenant être délivrée: il n’existe
cependant pas de spécialité en Belgique (ni pour autant que l’on sache
ailleurs dans le monde), mais elle peut être prescrite en magistrale. La vente
de denrées alimentaires contenant de la mélatonine reste interdite.
•
http://www.bcfi.be/
32
Melatonine bij jet-lag
•
•
Uit een recent overzichtsartikel over jet-lag in de Lancet [2007 ; 369 : 1117-29]
blijkt nogmaals dat er geen eenduidige remedie is om jet-lag te voorkómen of
te behandelen.
Naast enkele niet-medicamenteuze maatregelen, raden sommigen melatonine
aan. In verband met melatonine bij jet-lag blijven tegenstrijdige resultaten
verschijnen:
– een Cochrane review vond evidentie van een gunstig effect [zie Folia april 2004 ],
– in tegenstelling tot een recente meta-analyse [ Brit Med J 2006 ; 332 : 385-8 , met
editoriaal 2006 ; 332 : 373-4 ].
•
Daarenboven is weinig bekend over het veiligheidsprofiel van melatonine; er
zijn suggesties dat melatonine het effect van orale anticoagulantia tegengaat,
en dat het de convulsiedrempel verlaagt.
•
Sinds 1997 bestond er in België een verbod om geneesmiddelen op basis van
melatonine af te leveren.
Vorig jaar werd dit verbod opgeheven (Belgisch Staatsblad van 9 mei 2006).
Dit betekent dat melatonine nu wel kan worden afgeleverd: het bestaat in
België echter niet als specialiteit (en voor zover we kunnen nagaan ook
nergens anders in de wereld), maar het kan magistraal worden
voorgeschreven. De verkoop van voedingsmiddelen die melatonine bevatten,
blijft verboden.
•
http://www.bcfi.be/
An efficient
sunscreen should
be at least an
SPF of 30 and be
reapplied as
recommended,
especially after
water exposure.
Kullavanijaya P, Lim
HW .
Photoprotection.
J Am Acad Dermatol
2005; 52 : 537 –
538.
33