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Travel Health for Primary Care Clinicians Tuesday 12th May 2015 1.30 pm – 4.30 pm Venue: Holiday inn Royal Victoria Sheffield, Victoria Station Road, Sheffield, S4 7YE Travel Health for Primary Care Clinicians 1.30 pm – 4.30 pm, Tuesday 12th May 2015 Ballroom, Holiday Inn Royal Victoria, Victoria Station Road, Sheffield, S4 7YE Agenda Time Agenda Lead Pre travel Risk Assessment Jacqui Clarke, Sister, Infectious Disease/Travel Clinic, Royal Hallamshire Hospital 2.30 pm Migrant health 3.00 pm The Roma Slovak community and Hepatitis B Marlene Scott, Nurse Practitioner, Clover Group Practice Ann Gregory, Practice Nurse, Page Hall Medical Centre 3.30 pm 3.45 pm 4.30 pm Refreshment break The Returning Traveller Close 1.00 pm 1.30 pm 1.40 pm Registration Welcome and introduction Dr Cariad Evans, Virology/ID registrar This event is kindly sponsored by the pharmaceutical companies Actavis and Napp who will be exhibiting a stand at this event. The above have had no involvement in the agenda or speaker selection. The financial support provided is used to help with the cost of the venue and refreshments. Pre Travel Risk Assessment HOLIDAY INN ROYAL VICTORIA SHEFFIELD MAY 12TH 2015 JACQUELINE CLARK Introduction Sister in Infectious Diseases and Travel Clinic, E floor of the RHH 2005-2007 completed the MSc in International and Travel Health at Sheffield Hallam Travel Clinic started in 2008 as a pilot for STH and university staff, students and partners Limited space, only run Wed afternoons & see approx. 24 pts (12 new, 12 FU) in a 4 hour period with 2 nurses 1 Dr 1 Basics How long do you have to do a travel clinic consultation? 10, 15, 20 minutes? In that time are you expected to administer vaccines also? RCN Guidelines recommend a minimum of 20 minutes for the consultation / risk assessment. Increasing this if complex travel plans, multiple travellers or complex medical history. What training have you had? RCN Guidelines recommend; Evidence of learning in the field… ‘minimum of 15 hours of relevant learning plus mentorship in clinical skills before undertaking a travel consultation alone.’ alongside yearly updates in immunisation practice and attendance at study days or conferences. Risk Assessment 1 Pre travel questionnaire Age, sex, destination, departure date & length of stay, medical history & medications, allergies, vaccine history, current health, planned activities and accommodation etc. Often find I get a lot of information from their non verbal behaviour as much as on the form, & can gauge my advice and depth of conversation based on this We use a variety of information sources mainly Travax, Nathnac and FCO I also recommend the patients look at ‘Fit for Travel’ and the FCO after the consultation 2 Risk assessment 2 Once you’ve got the patient in the room a lot of the risk assessment is about balancing their current knowledge and expectations against the recommended advice. VFR’s Frequent travellers Students (Electives) Gap Year travellers Older Travellers We have a clinic evaluation sheet which I work through with all patients At the end of the discussion I email leaflets from Travax to the pt to re-read later Scenario 1 Couple in their 30’s going on honeymoon to Kenya, 1 week on Safari in the Maasai Mara, 1 Week in a hotel in Mombassa. They inform you they would like to get pregnant whilst on honeymoon. Regular advice (water, food, sun, bite avoidance) & vaccines: Typhoid, DTP, Hep A, Consider Rabies, ? Low risk (Monkeys at Diani Beach) Malaria – need to understand risks of conceiving whilst on antimalarials (risk of the drugs vs risk of illness) also manage expectation 2 weeks is a tight timeframe for a honeymoon baby! Other risks, RTA, Water based activities, crime / terrorism 3 Scenario 2 19yr old male travelling with a few friends through South East Asia for 6-12 months depending on finances, they may work to make money. Tells you he is a well controlled diabetic. Regular advice and vaccines Rabies, JE - cost vs risk Malaria advice difficult, Jane Chiodini has developed an information leaflet which can be downloaded that encourages patients to research the available options on fit for travel then come to the session or a follow up vaccine session having made their own decision. Diabeties, transporting medication, maintain supply, what to do in an emergency, monitoring blood sugar, disposal of sharps, medical letters, adjusting dose across time zones, could his friends cope in an emergency? Other risks: sexual health, personal safety and travel insurance (small print) Scenario 3 Mr and Mrs Jones (65 and 59) are going on a cruise which includes time going through panama canal. Mr Jones has high blood pressure. They have a lot of questions about Yellow Fever but don’t seem concerned about any other risks. Regular travel advice, + Extra care re D+V, Discuss current health, extra medication etc awareness of ship Dr, Regular vaccine advice + Has Mr Jones had his Flu and pneumococcal vaccines? Discuss Yellow fever, not recommended for canal area only but where else are they travelling? Increase in risk of side effects due to age, (has he had it before?) however balance of risk. Malaria advise - Bite avoidance / antimalarials Dengue 4 Scenario 4 16 yr old girl travelling on a group trip to Tanzania to climb Mount Kilimanjaro for charity. Had a splenectomy 4 years ago. Has booked well in advance & has her itinerary and all paperwork to hand. Regular advise and vaccines Rabies, Yellow fever (is she travelling via Kenya? Which boarder crossing?) Reduced efficacy of vaccines due to splenectomy, does she take regular meds? Any other health issues? Risk of Altitude sickness, Killamanjaro known for rapid assents and climbing more than the recommended gain in altitude due lack of safe stopping places. Also group pressure to keep going ‘fight through it it’s for charity…’ Scenario (extra’s) Male couple travelling to Dubai, both HIV positive in good health, travelling for a business trip. Your receptionist gets a phone call from a local organisation wanting to send 15 people to Africa in 10 days, can you accommodate them all? medication travel restrictions, cultural difficulties, Group vs individual advice, Staffing, Is it feasible? Impact on other work, who pays? Reason for urgency, Older male / female frequently travels to Thailand / Gambia, to visit their girl/boyfriend, Consider if they are being exploited or exploiting, financial, sexual health 5 Resources Jane Chiodini’s website: http://www.janechiodini.co.uk/ Travax: http://www.travax.nhs.uk/ Nathnac: https://www.nathnac.org/ FCO: https://www.gov.uk/government/organisations/foreign-commonwealth-office Fit for Travel: http://www.fitfortravel.nhs.uk/home.aspx Yellow book (Health Information for Overseas Travel), Hard copy from NaTHNaC Green book: https://www.gov.uk/government/collections/immunisation-againstinfectious-disease-the-green-book#the-green-book Malaria Reference Laboratory: Malaria Prevention Guidelines: https://www.gov.uk/government/publications/malariaprevention-guidelines-for-travellers-from-the-uk RCN guidelines: http://www.rcn.org.uk/__data/assets/pdf_file/0006/78747/003146.pdf 6 Marlene Scott Specialist Nurse Practitioner Mulberry Practice Asylum seeker vs refugee All vulnerable migrants, including refugees and asylum seekers, have the right to be fully registered with a NHS general practice. People who are failed asylum seekers but are appealing the decision are entitled to full NHS treatment People who are finally failed (no leave to appeal) are entitled to full primary care services but are not eligible for secondary care service unless it is urgent or life threatening. Language Use of interpreters Not understanding NHS structure Cultural differences/ expectations 1 BP, height, weight, allergies Circumstances of migration Immunisation history Screening TB (Quantiferon blood test) HIV Hepatitis B and C Treponema Chlamydia (urine) Gonorrhoea (urine) Urine dipstick TB usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine. not everyone infected with TB bacteria becomes sick. 80% of people who contract the bacteria eliminate it. Of the 20% most will encapsulate the bacteria and prevent it multiplying (latent) Only a very small amount of people go on to active disease Overall, without treatment, about 5 to 10% of latent infected persons will develop active TB disease at some time in their lives. Latent TB •Has a normal chest x-ray and a negative sputum test •Has TB bacteria in his/her body that are alive, but inactive •Does not feel sick, no weight loss •Cannot spread TB bacteria to others At Mulberry practice we have fortnightly clinic run by an infectious disease consultant to see people with latent TB and treat if aged under 35years. 2 May have an abnormal chest x-ray, or positive sputum smear or culture Has active TB bacteria in his/her body Usually feels sick and may have symptoms such as coughing, fever, and weight loss May spread TB bacteria to others Needs treatment irrespective of age Not just for children! WHO website gives individual country details What we offer at first appointment DTP and MMR to over 25 years MMR and Men C age 10 years to 25 years MMR and HIB/Men C to under 10 years Schistosomiasis (bilharzia) ◦ Infection caused by parasite that lives in fresh water (haematobium, japonicum, mansoni) ◦ Symptoms can be acute or develop over months or years Cystitis Blood in urine (NVH) Abdominal pain/ cramps Haematemisis 3 Reason for migration will have significant impact on health seeking behaviour Social isolation Shared housing/risk of infections (TB, hepatitis) Expressing health concerns/symptoms, language barriers, cultural differences There are bees in my head My whole body is burning I am itching on the inside Many languages have no word for ‘cancer’ Mental illness may be taboo or even not recognised 4 /www.cdc.gov http://pathways.nice.org.uk/pathways/tuberc ulosis 5 The Roma Slovak Community and Hepatitis b Ann Gregory Practice Nurse Page Hall Medical Centre Where is Slovakia? 1 HISTORY • The Roma people left northern India about 1,500 years ago; those Roma now in Europe migrated through the Balkans about 900 years ago. • The Roma are the largest minority ethnic population in the European Union, making up to 2% of the 450 million inhabitants of the EU. • In 2004 Slovakia joined the EU and migration has been increasing since: Sheffield Council estimated in 2013 that there were at least 3000 Slovak-Roma residents. • Estimates are now significantly higher, and the public health teams are in the process of gathering data from practices to map the numbers in Sheffield. HEALTH AND THE ROMA SLOVAK COMMUNITY • Many Roma in Europe face prejudice, intolerance, discrimination and exclusion in their daily lives • Roma have a life expectancy 10 years lower than other European citizens • Roma child mortality rates are between 2 and 6 times higher than the general population of Europe • Fewer than half of Roma children complete primary school and a very low number attend secondary school • Employment rates are lower for Roma than the general population • Housing is often poor, with inadequate access to services (1) 2 Health Inequalities Years of discrimination and poor access to health services in their home country has become evident in the Roma communities in the North of Sheffield High rates of chronic disease, diabetes, CHD, smoking, obesity Teenage pregnancy/ large families/ vulnerable children Poor uptake and knowledge of screening/vaccination Contraception awareness Poor housing/overcrowding Mobile population Hepatitis B/ TB 3 What is Hepatitis B? • Hepatitis B is an acute viral infection of the liver. It is a blood borne virus • The risk of Hepatitis B is exacerbated by people living in deprived circumstances in overcrowded homes • Individuals can carry (and pass on) the infection throughout their lives, especially if they are children when they are infected • Around 20% of people with chronic hepatitis B will go on to develop cirrhosis, which can take 20 years to develop, and around 1 in 10 people with cirrhosis will develop liver cancer Prevalence of Hepatitis B in Slovakia (~1%) ECDC 2010 (2) 4 Hepatitis B in the UK Current estimates of the prevalence of hepatitis B in the UK would suggest the UK falls into the lowest category of prevalence for HBV, as determined by the World Health Organisation The prevalence rate is believed to be between 0.1% and 0.5% of the UK population(5) What we found at Page Hall Page Hall Medical Centre is an inner city practice that cares for more than 7,200 patients, 76% of whom are migrants As part of the routine health check offered at registration of new patients, Page Hall has offered routine screening for all blood borne viruses including hepatitis B for over 10 years Prevalence of hepatitis B in the Sheffield Roma Slovak population has been shown to be high, at around 9.4% compared to 0.3% for the general population The World Health Organisations advocates that vaccination strategies are cost effective even in low prevalence populations. The hepatitis B LES proposal is for a community with a high prevalence of hepatitis B 5 Burden of disease Based on the Page Hall data, it is estimated that around 240 people of the estimated 3,000 current Roma Slovak community in Sheffield could currently have chronic Hepatitis B infection Of these around 72 are likely to develop liver failure from which 18 will die within 5 years of diagnosis and between 12 and 24, hepatocellular carcinoma which has an extremely poor prognosis (average survival from diagnosis of 6 months) (6) Who is at risk for chronic disease? The likelihood that infection with the virus becomes chronic depends upon the age at which a person becomes infected. Children less than 6 years of age who become infected with the hepatitis B virus are the most likely to develop chronic infections 80–90% of infants infected during the first year of life develop chronic infections 30–50% of children infected before the age of 6 years develop chronic infections In adults:<5% of otherwise healthy persons who are infected as adults will develop chronic infection 20–30% of adults who are chronically infected will develop cirrhosis and/or liver cancer (WHO 2015) 6 Current schedule for vaccination in the UK for hepatitis B There is a vaccine thought to be 95% effective in preventing hepatitis B. Because of the relative rarity of hepatitis B in England, the vaccine is not given as part of the routine childhood vaccination schedule. NHS Choices Hepatitis B LES Started in April 2014 Screening all newly registered Roma Slovak patients for Hepatitis B, (approx. 1,200 per year) Catch-up programme to screen the patients previously registered (predicted to achieve about 10% take-up rate- approx. 300) Vaccinate patients with no immunity against Hepatitis B (screening and first vaccination will be given together where possible) Advice to patients testing positive for Hep B. (information from www.hitsheffield.org.uk is available in Slovak) Referral into secondary care for those diagnosed with chronic disease 7 8 References 1/ Improving the health of Roma communities in the Yorkshire and Humber Region a guide to good practice 2012 2/ Hepatitis B and C in the EU neighbourhood: prevalence, burden of disease and screening policy – September 2010 3/ Should Slovak-Roma patients be screened routinely for Hepatitis B in primary care? Ann Marie Gregory 1 Alicia Vedio 2 Benjamin Stone 2 Stephen Green 2 Christopher Bronsdon 1 1 Page Hall Medical Centre, Sheffield, UK 2 Sheffield Teaching Hospitals NHS Foundation Trust 4/ Hepatitis B and C: ways to promote and offer testing to people at increased risk of infection. NICE public health guidance 43. December 2012. 5/http://www.who.int/csr/disease/hepatitis/whocdscsrlyo20022/en/index4.html#world 6/Stuart, K E et al. Primary Hepatic Carcinoma, Medscape, May 2012 9 Hepatitis B screening and vaccination for Slovak Roma population in Sheffield. 1/Start standard schedule of hepatitis B vaccination if history of incomplete vaccination (DOH Green Book) and 2/ Screen for hepatitis B. Age < 16 Send blood sample as for >16 Child to attend Sheffield Children's Hospital. This would be age appropriate, suitability for venous access should be individually assessed by the clinician. Dry Blood Spot sampling is also an option.* Age >16 Contact patient and arrange appointment to inform of likely hepatitis B diagnosis. Send 1 clotted venous blood sample to Virology. Request ‘high risk baseline prevaccination screen’-this requests 1.Hepatitis B surface antigen (HBsAg) 2.Hepatits B surface antibody (HBsAb) Repeat bloods to confirm diagnosis add LFT and check for hepatitis A immunity. Refer patient to relevant adult/child Infectious Diseases Unit or Hepatology. Children < 16 years should be referred to Sheffield Childrens Hospital. Give lifestyle advice, including safe sex and alcohol recommendations. Yes Is the patient hepatitis B surface antigen positive ? Follow Interpretation of hepatitis B results pathway. If Immune inform patient and stop vaccination schedule. If non – immune continue vaccination schedule. Give hepatitis B information leaflet in English and Slovakian. Explain that all household contacts should be tested and vaccinated if not immune, they should attend their own GP for this. (See pathway for management of household contacts) Household contacts should receive the accelerated Hepatitis B schedule if non-immune. ** See additional notes for babies born to hep b su ag positive mothers A/G 11/13 Management of household contacts of a person diagnosed with active hepatitis B The person has been informed of the diagnosis, and consent obtained to contact trace household members is documented in the patients record. Start contact tracing Determining household contacts Aged 0 -12 months Give accelerated hepatitis B vaccine and test once completed Identify household contacts, arrange testing and /or vaccination as needed (1) Household contacts are defined as those who share a bedroom, kitchen, bathroom or sitting room with the index case. (2) Document in clinical record, read code Xa1pO hepatitis B contact. The nature of the contact can be added i.e. Index case is hepatitis B surface antigen positive. aged >1 year Commence accelerated hepatitis B vaccine, and arrange blood test at time or after the first dose of vaccine Virology request ‘high risk baseline pre vaccination screen’. (HBsAg +HBsAb) Manage results by following the hepatitis B screening and vaccination for Slovak Roma in Sheffield pathway. A/G 11/13 Interpretation of hepatitis B results Hepatitis B surface antigen positive * Hepatitis B surface antibody <10 Chronic Infection Refer patient to Infectious diseases unit or Hepatology. Test / vaccinate contacts Not immune Requires full course of vaccination with booster at 5 years Hepatitis B surface antigen negative Hepatitis B surface antibody <10 Hepatitis B surface antigen negative Hepatitis B surface antibody >10 Laboratory will automatically request HB core antibody Hepatitis B core antibody positive Hepatitis B core antibody negative Past Infection Previously vaccinated Inform patient of past history of infection, no other action needed. Hepatitis B surface antibody10-100 iu/ml Hepatitis B surface antibody >100 iu/ml Partial response to vaccination Boost Hepatitis B vaccine *Laboratory will automatically request HB core IgM: Full response to vaccination No action required. Single booster required 5 years after primary vaccination course. if positive = Acute infection Flag to GP – to assess need for referral. Telephone Public Health (notifiable infection). Test and vaccinate contacts. Ann Gregory/Alicia Vedio 11/13 References and notes. • • • 1/ Hepatitis B: the green book, chapter 18, Updated 19 April 2013. Public Health England. 2/ Hepatitis B and C - ways to promote and offer testing. Nice 12 December 2012. 3/ http://hitsheffield.org * Dry Blood Spot kits are available for local testing. ** Babies born to mothers of hepatitis B su ag positive patients are screened and vaccinated in accordance with DOH Green Book and local procedures. Thanks to Dr Alicia Vedio: Infectious Diseases, Royal Hallamshire Hospital Sheffield Dr Helena Ellam and Dr Raza: Virologists, Northern General Hospital Sheffield. Ann Gregory. Practice Nurse, Page Hall Medical Centre. [email protected] Slovak Roma community and Hepatitis B Useful links Translated information on hepatitis B, as well as videos to play to patients in different languages http://hitsheffield.org CCG Business case for the LES on hepatitis B http://www.sheffieldccg.nhs.uk/Downloads/CCG%20Board%20Papers/December%20Board%20Pap ers/PAPER%20F%20Hepatitis%20B%20business%20case.pdf The health needs of the Slovak Roma community in Sheffield. Gill G. Community Pract. 2009 Mar;82(3):34-7. Hepatitis B screening and vaccination of the Slovak Roma http://www.sheffieldccgportal.co.uk/pressv2/index.php/clinical-pathways/item/hepatitis-bscreening-and-vaccination-of-roma-slovak http://www.sheffieldccgportal.co.uk/pressv2/index.php/clinical-pathways/tag/Roma World Health Organisation hepatitis B http://www.who.int/mediacentre/factsheets/fs204/en Research from Page Hall Medical Centre https://www.researchgate.net/publication/258725677_Should_SlovakRoma_patients_be_screened_routinely_for_Hepatitis_B_in_primary_care_Report_of_unexpected high prevalence in a cohort in Sheffield https://www.researchgate.net/publication/263853028 Targeted testing in Primary Care demonstrates high prevalence of Hepatitis B infection within the Slovak-Roma population in Sheffield UK Journal of Viral Hepatitis Targeted testing in Primary Care demonstrates high prevalence of Hepatitis B infection within the Slovak-Roma population in Sheffield, UK Vol 21, Issue 10, start page 0 AID JVH12287 Ann Gregory Practice Nurse Page Hall Medical Centre 101 Owler lane Sheffield S4 8GB [email protected] Fever in the returning traveller The essentials Cariad Evans ST7 Infectious Diseases/Virology Objectives • To be able to take a travel and exposure history from a patient with fever returning from abroad • To know the main differential diagnoses • To know the minimum investigations required Objectives • In relation to malaria – to recognise that malaria is a medical emergency – to be aware of the complications of falciparum malaria and its management – to know the first-line treatment for both falciparum and non-falciparum malaria 1 Overview • • • • • Forty minutes Three clinical cases Interactive case based discussion Explanations as we go along Discussion Imported fevers • Growing problem • Can be a manifestation of minor selflimiting illness or can herald lifethreatening illness • Initial findings may not help distinguish between trivial and serious infections Three important questions... 1. What infections are possible given where the patient has lived or travelled, and when exposures may have occurred? 2. Which of these infections is more probable given clinical findings? 3. Which of these infections is treatable or transmissible or both? 2 ...and some common sense! • Common things are common! • Rule out life-threatening or highly transmissible infections first • Do not focus on unusual diagnoses alone • Many non-infectious diseases also cause fever – consider if initial investigations do not yield a diagnosis It’s all in the timing! • Exact dates of travel • Dates spent in specific geographical areas, including stop-overs • Dates of any specific exposure • Date of onset of symptoms • Allows calculation of incubation period Clinical Case One 3 GP consultation • 38 year old businessman • Nigerian origin, lived in UK for six years • Returned seven days ago from two week business trip to Lagos • Four day history of fever, night sweats • Vomiting, frequent loose watery stools • T39.8, BP 90/60, P120 SR, RR30, SaO2 93% on air, slightly jaundiced • Little else on examination Questions for discussion 1. Any other history you would like to know? 2. What are the differential diagnoses? 3. What initial investigations would you send? 4. Any empirical treatment? Specific history • • • • • • • • Malarial chemoprophylaxis Pre-travel vaccinations Accommodation? Urban or rural? Ingestion – food, water Infectious contacts? Companions? Animal exposure? Bites? Recreational activities? Sexual contacts? 4 Differential diagnoses • • • • • • • • Malaria Dengue fever Enteric fever Viral haemorrhagic fever (Ebola/Lassa) Acute viral hepatitis HIV seroconversion Respiratory tract infection Gastroenteritis Query VHF is on your list… • What do you first? • Where do you look for advice? • Who you gonna call? 5 Investigations: bare minimum! • FBC, U+Es, LFTs, (clotting), CRP • Thick and thin blood film (urgent) +/ICT (repeat daily if negative, x3 total) • (Blood cultures) • Urine dip +/- mc+s • Serum save for acute serology • Throat swabs • If diarrhoea: stools for mc+s & OCP What treatment do you give? 1. Oral quinine 600mg tds + doxycycline 200mg od for 7 days 2. IV quinine 20mg/kg loading dose, then 10mg/kg 8 hourly, by slow infusion 3. IV artesunate 4. IV artesunate + plasma exchange 5. Oral chloroquine 600mg, then 300mg for three days, followed by primaquine if no G6PD deficiency for 2 weeks 6 What treatment do you give? 1. Oral quinine 600mg tds + doxycycline 200mg od for 7 days 2. IV quinine 20mg/kg loading dose, then 10mg/kg 8 hourly, by slow infusion 3. IV artesunate 4. IV artesunate + plasma exchange 5. Oral chloroquine 600mg, then 300mg for three days, followed by primaquine if no G6PD deficiency for 2 weeks Malaria • Preventable, life-threatening disease • Approximately 90% will not develop symptoms until after they have returned home • Approximately 2000 cases annually in travellers returning to the UK from malaria-endemic countries • Deaths in the UK are on the increase 7 Four species of significance • Plasmodium falciparum (“malignant”) – responsible for the vast majority of malaria deaths – illness usually 7 to 40 days after inoculation of parasite • Non-falciparum malaria (“benign”) – Plasmodium vivax and Plasmodium ovale (dormant phase in liver – illness can occur months to years after inoculation) – Plasmodium malariae Complicated falciparum malaria • Impaired consciousness or seizures • Renal impairment (oliguria <0.4 ml/kg/h or creatinine > 265mmol/l) • Acidosis (pH < 7.3) • Hypoglycaemia (<2.2 mmol/l) • Pulmonary oedema or ARDS • Haemoglobin <8 g/dL • Spontaneous bleeding; DIC • Shock (BP < 90/60 mmHg) • Haemoglobinuria (without G6PD deficiency) • Parasite count > 2% Admit 8 Rx uncomplicated falciparum • Admit for at least 24 hours observation • Oral quinine 600mg tds for 7d • Simultaneous doxycycline* 200mg od for 7d • Alternatives to quinine: Malarone® or Riamet® *contraindicated in pregnancy, use clindamycin 450mg tds Treatment of benign malarias • Outpatient setting • Chloroquine 600mg po, then 300mg at 6, 24 and 48 hours • For P. vivax and P. ovale check G6PD level at outset – if ok then give primaquine* for 2 weeks • For all forms, always remind the patient to use prophylaxis next time (Travel Clinic) *contraindicated in pregnancy 9 Clinical Case Two Attended GP • 37 year old male • Normally fit and well • Returned from 2/52 trekking holiday near Thai-Cambodian border • Took mefloquine anti-malarial prophylaxis, slept under mosquito net • Travel vaccinations up to date prior to travel Referral from GP • • • • • • • • Returned three days ago 24 hour history of fever and chills Generalised muscle and joint pains Girlfriend noticed onset of red rash over trunk T38.8, P110, BP100/60, SaO2 96%, RR24 Cervical lymphadenopathy Mild photophobia Blanching macular rash over trunk 10 Questions for discussion 1. Any other history you would like to know? 2. What are the differential diagnoses? 3. What initial investigations would you send? Initial results • • • • • • • First malarial film and ICT negative Hb 12.0 Pts 110 WCC 3.0 Neut 2.6 Hct 0.45 Clotting normal CRP 43 ALT 56, other chemistry normal CXR – NAD ...What do you do next? 11 What do you do next? 1. Give IV ceftriaxone 2g od 2. Give oral ciprofloxacin 750mg bd 3. Give oral clarithromycin 500mg bd and send atypical respiratory screen 4. Give IV colloid and monitor fluid balance 5. Give regular paracetamol and ibuprofen What do you do next? 1. Give IV ceftriaxone od 2. Give oral ciprofloxacin 750mg 3. Give oral clarithromycin 500mg bd and send atypical respiratory screen 4. Give IV colloid and monitor fluid balance 5. Give regular paracetamol and ibuprofen Dengue • • • • Arbovirus Transmitted by Aedes mosquitoes 100 million cases worldwide per year Growing problem, particularly on the Indian sub-continent and SE Asia • Incubation 7 (up to 10) days • Usually asymptomatic or non-specific febrile illness 12 Dengue • Two main clinical syndromes: 1.Dengue Fever: – Fever – Arthralgia – Rash – Retro-orbital pain, photophobia – Lymphadenopathy 2.Dengue Haemorrhagic Fever: – Pts<100 +/- circulatory collapse • Supportive management only • Usually self-limiting 13 Clinical Case Three Febrile patient out of hours • 30 year old female • Returned from one month in Pakistan staying with relatives • Stayed in town near large city • Ate food prepared by relatives • No prophylaxis or vaccines • Fever started ten days after return to UK Blood cultures positive day 2 14 What is the best treatment? 1. 2. 3. 4. 5. IV ceftriaxone 2g od Oral ciprofloxacin 750mg bd Oral co-trimoxazole 960mg tds Oral azithromycin 1g od Oral chloramphenicol 500mg qds What is the best treatment? 1. 2. 3. 4. 5. IV ceftriaxone 2g od Oral ciprofloxacin 750mg bd Oral co-trimoxazole 960mg tds Oral azithromycin 1g od Oral chloramphenicol 500mg qds Admit Enteric fever • Typhoid, paratyphoid • Systemic, potentially fatal, febrile illness • Caused by Salmonella typhi and Salmonella paratyphi types A, B and C • Faeco-oral transmission, ingestion of contaminated food or water • Protection with typhoid vaccine (not against paratyphoid) 15 Clinical features • Incubation time: 1 to 3 weeks • Insidious onset of fever, myalgia, abdominal pain and severe headache. • Cough, constipation and deafness are common • Diarrhoea occurs in <40% • Relative bradycardia • Hepatosplenomegaly • (Rose spots) Natural history • Untreated, fever persists for several weeks • Mortality (untreated) = 20% • Deaths occur due to intestinal perforation or haemorrhage • Many complications: psychosis; hepatitis; cholecystitis; pneumonia; pericarditis; meningitis Management • Antibiotic therapy reduces the mortality to <1% • First line therapy IV ceftriaxone 2g od – particularly if patient has returned from Indian sub-continent – while waiting for sensitivities • If sensitive can switch to oral ciprofloxacin 500mg to 750mg bd • Treat for 10 to 14 days 16 In Summary.. Approximately 23.3% of ill returning travellers present with a fever Leder et al. Ann Intern Med 2013 Geosentinel surveillance of Returned Travellers 2007 ‐ 2011 Summary regions 17 Questions? References Reviews: Lalloo, D. et al. Journal of Infection 2007;54:111-121 Guidelines and epidemiology data: http://www.britishinfectionsociety.org http://www.hpa.org.uk http://www.who.org/int 18 South Yorkshire and Bassetlaw Screening and Immunisation Team Communications 13th April 2015 Please cascade to ALL relevant staff Seasonal Flu Update – for information: Flu activity remains stable compared to the previous week, however acute respiratory outbreaks continue to be reported - Seven in the past seven days: three in care homes, one in hospital, one in school and two in other settings. There were 23 new admissions to HDU/ITU with confirmed influenza. Seasonal Flu 2015/16 – Reminder Important for Information and Action: I know we are only just coming out of the 2014/15 flu vaccination season, but in order to improve uptake and therefore subsequent protection for those most susceptible to flu and its associated complications, it is important that we start planning as early as possible to enable to implement the changes necessary to achieve this. Please see the Flu Plan and Tripartite Letter (formally CMO letter) https://www.gov.uk/government/publications/flu-plan-2015-to-2016. Shingles – For Action Practices are reminded that the second year of the shingles programme runs until 31 August 2015, and they should not delay and should continue to actively offer Zostavax (shingles vaccine) to this years’ eligible cohorts (those who were aged 70, 78 and 79 years on 1 September 2014). Polio Update – Vaccination Advice Important Information The World Health Organization (WHO) originally issued a statement on 5 May 2014 declaring that the recent international spread of wild poliovirus was a Public Health Emergency of International Concern (PHEIC). Following a review of the situation and potential risks, the WHO (and PHE) have issued the following advice, as the UK has significant numbers of travellers to and from the affected countries who are affected by Polio. Risk Categories are as follows: 1. states currently exporting wild polio virus 2. states infected with wild polio virus but not currently exporting 3. states no longer infected by wild poliovirus, but which remain vulnerable to international spread All travellers: • should practise strict food, water and personal hygiene precautions. Polio is transmitted by the faecal-oral route (through close personal contact with an infected individual) • should have completed a primary vaccination course according to the UK 1 schedule (previous poliomyelitis does not confer immunity against another episode of poliomyelitis) • who have not completed a primary course of polio vaccine or have not had a polio vaccine booster in the last 10 years should receive a polio vaccine before travel 1. Category 1: Travellers to countries currently exporting wild poliovirus: Equatorial Guinea (until 4 April when it will move to risk category 2) and Pakistan: • Travellers to settings with extremely poor hygiene (e.g. refugee camps), or likely to be in close proximity with cases (e.g. healthcare workers), and/or visiting for 6 months or more, are advised to have a booster dose of poliocontaining vaccine if they had not received vaccination in the past 12 months*. • Travellers who intend to visit these countries for four weeks or more should be aware that proof of vaccination, given four weeks to 12 months before departure from the country, an International Certificate of Vaccination or Prophylaxis (ICVP), may be required on exit. Failure to produce this documentation may result in vaccination at the point of departure most likely with oral polio vaccine. • Immunosuppressed and their household contacts or pregnant individuals (in whom OPV is contraindicated) who plan to travel to these countries for one month or more are advised to receive inactivated polio vaccine (IPV) within 1 year before planned departure from these countries and to ensure this is recorded on an ICVP. • Further information relating to the advice and ICVP issues is available on the NaTHNaC website. 2. Category 2: Travellers to countries infected with wild polio virus but not currently exporting: Afghanistan, Cameroon, Iraq (until 19 May when it will move to risk category 3), Israel (until 28 April when it will move to risk category 3), Nigeria and Somalia: • Travellers to settings with extremely poor hygiene (e.g. refugee camps), or likely to be in close proximity with cases (e.g. healthcare workers), and/or visiting for six months or more, are advised to have a booster dose of poliocontaining vaccine if they had not received vaccination in the past 12 months*. • Travellers are encouraged to carry documentary evidence of their polio vaccination status (an International Certificate of Vaccination or Prophylaxis is NOT required by these countries). • Further information relating to this advice is available on the NaTHNaC website. 3. Category 3: Travellers to countries no longer infected by wild poliovirus, but which remain vulnerable to international spread: Ethiopia, Syrian Arab Republic. [Should there be no further detection of wild poliovirus in Israel by 8 April and in Iraq by 19 May, these countries will also meet the criteria for this risk category.]: These travellers should follow the usual advice for all travellers. *Although previous complete vaccination will give good personal protection against polio, there is evidence that immunity in the gut wanes over time following vaccination. This means the virus can be carried and excreted, thus posing a risk to public health, but little risk to the vaccine protected individual. An additional dose of polio vaccine will boost gut immunity and reduce the risk of international spread of the virus. Vaccine Supply/Deliveries – For Information Due to the May Bank Holiday, there will be no deliveries or order processing by Movianto UK on Monday 4th May and Monday 25th May 2015. Please see the table below for revised order and delivery dates. For customers with standard delivery dates of Monday, please be aware that; • • after the 27th of April, your next available delivery day will be the 11th May 2015 after the 18th of May, your next available delivery day will be the 1st June 2015 Practices are reminded that staff receiving vaccine deliveries should be appropriately trained in cold chain. We have had recent incidents whereby vaccine has had to be destroyed when the person receiving the delivery was not aware that the vaccines needed to go straight in to the fridge. Reminder: What to do if issues with vaccine storage/cold chain management are identified during a Care Quality Commission inspection Guidance on the above has been circulated previously, however it has come to our attention that during CQC visits, some practices may be being given inappropriate advice. PHE has put together a Q&A sheet, available via the link below, but in the immediate term you should: • Contact your local screening and immunisation team as soon as possible (see table below) • DO NOT dispose of any vaccines or storage equipment until a full risk assessment has been undertaken and advice sought from the manufacturers. • Label vaccines ‘do not use’ and quarantine the vaccine fridge. It is important that vaccines remain refrigerated between 2 and 8oC (or in their current storage conditions if these are not between 2 and 8⁰C), but are not used until a thorough risk assessment has been undertaken. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/36162 9/Vaccine_storage_management_Care_Quality_Commission_Inspection_a_CC_upd ate.pdf Additional Information: Following a recent cold chain incident one practice in Barnsley has developed a simple protocol to help to manage vaccine handling and storage. This has been adapted slightly and enclosed (with the practices permission) for use by other practices should you wish. cold chain protocol.doc Coordinator Contact Details Geographical Area Barnsley Bassetlaw Doncaster Rotherham Sheffield Name Tracey Turner Tracey Turner Bel O’Leary Bel O’Leary Rachel Staniforth Contact Number 0113 82 53475 0113 82 53475 0113 82 53354 0113 82 53354 0113 82 50826 Email: [email protected] – this email address is monitored continually and your query will be forwarded to the most appropriate person. Cold Chain/ Fridge Temperature Monitoring Standard Operating Procedure (Example) • • • • • • • • • Practice Nurses to take receipt of vaccines delivered to the practice and they are refrigerated immediate. The vaccines are stock rotated the same day. The nurses will make reference to the temperature monitoring sheets to identify when the fridge has been opened for this happen to enable stock rotation. Reading to be taken 3 times daily – Morning/Midday/Evening The monitoring of minimum, maximum and internal temperature is to be recorded on monitoring sheets. Folders to store monitoring sheets allocated to each fridge. The monitoring sheet enables the recording of the date, time, minimum, maximum, internal fridge temperature, name and signature of the user and a comment box so that the nurse can record any temperature variation, why this might have happened and actions taken. Vaccines to be stored in accordance with product license and national guidance protocols/Green Book i.e. between 2oC and 8oC, away from direct light and in their original packaging to maintain their effectiveness. After each reading the thermometer must be reset (following manufacturers instruction) so that new temperature can be recorded. If the readings fall outside of the recommended temperatures then this is to be reported immediately to either the Practice Manager or GP Partner. Contact the local Screening and Immunisation team as soon as possible for further guidance. Acknowledgement to Wombwell Medical Practice, Barnsley who developed the original protocol. Evaluation & Feedback Thank you for attending the Travel Health for Primary Care Clinicians event today. As ever, we would love to hear your feedback and ask that you take 5 minutes to complete the online questionnaire. Evaluation link: https://www.surveymonkey.com/r/Travel-Health-Evaluation-12May2015 We recently asked you to give us suggestions for topics and we had a great response, thank you. Your feedback has helped us develop the topics for these sessions and the first of which Travel Health today. We also had an overwhelming request for Wound Care which will be taking place in September; if you haven’t yet done so, don’t forget to book on. Two more sessions are planned for the 13th October and the 18th November; the sessions have yet to be decided but please pop these dates in your diary. For information about all of our training events please go to www.sheffieldccgportal.co.uk/pressv2/index.php/listevents which is updated regularly with the latest information. Your feedback is very important to us and has helped us shape these events to meet your needs. We will continue to make improvements and appreciate your help in making these a success. Thank you – The Events Team