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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