5/18/2016

1

The image part with relationship ID rId2 was not found in the file.The image part with relatio

Case Studies: The Pre-Travel Consultation

Elyse L. Tung, PharmD, BCACPClinical Pharmacist, Kelley-Ross Pharmacy

Clinical Assistant ProfessorUniversity of Washington School of Pharmacy

June 3, 2016 Northwest Pharmacy Convention

Cape of Good Hope, South Africa

The image part with relationship ID rId2 was not found in the file.The image part with

Disclosure:I have no actual or potential conflict of interest in relation to this

program/presentation within the past 12 months.

Rawai, Thailand

The image part with relationship ID rId2 was not found in the file.The image part with relati

Disclosure: I will not discuss off label use and/or investigational use in my presentation.

Mpumalanga, South Africa

5/18/2016

2

The image part with relationship ID rId2 was not found in the file.

Objectives Pharmacist:

Devise a complete plan for immunizations in an international traveler. Justify the appropriate use of the yellow fever vaccine. Analyze patient characteristics to determine anti-malarial therapy of choice. Compare and contrast antibiotics for the treatment of traveler’s diarrhea.

Technician: Discuss the importance of pre-travel health planning for an international traveler Review the immunizations and medications that maybe prescribed for international

travel List circumstances when a yellow fever vaccine will be recommended, and side

effects from the vaccine List medications commonly used to treat traveler’s diarrhea

The image part with relationship ID rId2 was not found in the file.

Patient Cases• Adult Case

• Pediatric Case

The image part with relationship ID rId2 was not found in the file.

The image part with relationship ID rId2 was not found in the file. The image part wi

Learning Strategies: • Audience response with mQlicker: https://respond.cc• Enter session code: XXXX

• Group discussion and questions

Soweto, South Africa

5/18/2016

3

The image part with relationship ID rId2 was not found in the file.

Resources

The image part with relationship ID rId2 was not found in the file.

Consultation Overview Patient interview

Review travel itinerary

Vaccinations - recommended versus required

Antimalarial recommendations

Antibiotics for traveler’s diarrhea

Miscellaneous - altitude sickness, jet lag, flight anxiety, anaphylaxis, road safety, travel/medical/evac insurance

The image part with relationship ID rId2 was not found in the file.

Immunizations Required by IHR

Meningitis

Yellow Fever

Polio

5/18/2016

4

The image part with relationship ID rId2 was not found in the file.

Adult Traveler43 yo female (DOB 4/5/1971) visiting Quito and Tena, Ecuador on 4/02/2016 - 4/22/2016.

Activities: Field visits on foot into jungles and villages. Site visits include health care facilities to observe vaccination campaigns. Potential patient interaction, but no direct patient care. Tourist activities on Galapagos Islands for 3 days.

Lodging: westernized hotels with air-conditioning in Quito, local guest houses in rural areas

Food: hotels and restaurants, packaged foods

Not pregnant and no plans on becoming pregnant in the next 3 months.

PMH: none

Medications: Loestrin 24 Fe

NKDA, No known vaccine reaction

The image part with relationship ID rId2 was not found in the file.

Vaccine HistoryPer patient, received all childhood vaccine series, including the following:

Vaccine Dates of Administration

Hepatitis A 2/6/2006, 3/1/2007

Hepatitis B 1/14/1989, 2/10/1989, 1/3/1990

Typhoid 4/12/2011 – Typhim Vi

MMR Childhood series complete

Polio Childhood series complete

tetanus 03/11/2001 Td

influenza 10/31/2015

The image part with relationship ID rId2 was not found in the file.

CDC Recommendations for Brazil

Routine vaccines

Hep A

Hep B

Typhoid

Yellow Fever

Rabies

5/18/2016

5

The image part with relationship ID rId2 was not found in the file.

Typhoid Fever Fecal-oral contamination with

Salmonella Typhi.

N/V/D and fever lasting months.

Two vaccines available: Oral live attenuated Ty21a (Vivotif

®) Injectable polysaccharide (Typhim

Vi ®)

Patient has no preference for pills or injection

Which vaccine would you recommend?

a. Vivotif

b. Typhim Vi

The image part with relationship ID rId2 was not found in the file.

Yellow Fever

Transmitted via mosquito bites in certain parts of Africa and South America.

Death in 20-50%, no treatment, only symptomatic support

Prevention: mosquito bite avoidance and vaccination

The image part with relationship ID rId2 was not found in the file.

YF-Vax® Live-attenuated viral vaccine.

Indications: ages >9 mn traveling/living in risk areas

Serious adverse events: YEL-AND (0.8:100,000) and YEL- AVD (0.4:100,000) Only vaccinate people 1) at risk of exposure or 2) who require proof

of vaccination to enter country

Follow country specific information

Life long immunity (updated July 2015)

5/18/2016

6

The image part with relationship ID rId2 was not found in the file.

Yellow Fever Letter of Exemption

http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/yellow-fever

The image part with relationship ID rId2 was not found in the file.

Yellow fever vaccination for Ecuador

Required Recommended

The image part with relationship ID rId2 was not found in the file.

Should she get the yellow fever vaccine?

a. Yes

b. No

What if she had a layover in Peru?

5/18/2016

7

The image part with relationship ID rId2 was not found in the file.

Rabies Transmitted through mammal bites.

Encephalitis, paralysis, and severe neurologic involvment. 100% fatal without post-eposure prophylaxis.

Parts of Africa, SE Asia, and the Indian subcontinent have the highest reported cases.

Children are higher risk d/t smaller stature, curiosity and attraction to animals.

Evaluate travel activities including access to healthcare.

Pre-exposure vaccination: Imovax® or RabAvert®: 3 doses on day 0, 7, 21 or 28.

The image part with relationship ID rId2 was not found in the file.

Rabies Recommendation for Ecuador

Would you vaccinate her for rabies?

a. Yes

b. No

What if she had a layover in Peru?

The image part with relationship ID rId2 was not found in the file.

Malaria Bite of an infected female Anopheles mosquito. Feeding

occurs dusk and dawn.

Flu like symptoms, seizures, cerebral malaria and death. Presents usually in 1 month, may lay dormant up to 1 year.

Prophylaxis is always preferred since treatment of malaria can still be fatal. Atovaquone-proguanil, chloroquine, hydroxychloroquine, doxycycline,

mefloquine, primaquine

Review country specific information

5/18/2016

8

The image part with relationship ID rId2 was not found in the file.

Malaria Recommendation for Ecuador

The image part with relationship ID rId2 was not found in the file.

Malaria Recommendation for Ecuador

Which antimalarial would you recommend?

a. Atovoquone-proguanilb. Doxycyclinec. Mefloquined. chloroquine

The image part with relationship ID rId2 was not found in the file.

Other Mosquito Borne Illnesses

Chickanunga

Dengue

Zika

5/18/2016

9

The image part with relationship ID rId2 was not found in the file.

Zika Virus 1:5 infections are symptomatic

Transmitted from mother to fetus

Causes microcephaly

Aedes aegypti mosquito

Sexually transmitted

US outbreaks this summer?

The image part with relationship ID rId2 was not found in the file.

Mosquito Avoidance Techniques

Provide education at each encounter

DEET 30% sprays versus lotions

Permethrin-treated clothes

Sleeping in AC

Bed nets treated with permethrin

Zimbabwe

The image part with relationship ID rId2 was not found in the file.

Recommended Items

5/18/2016

10

The image part with relationship ID rId2 was not found in the file.

Traveler’s Diarrhea

Most common infection for travelers: 30-70%

Pathogens: ETEC in Africa and Latin America, FQ-resistant Campylobacter in SE Asia, Shigella, Salmonella

Steffen R, Tornieporth N, Costa Clemens SA, et al. Epidemiology of travelers' diarrhoea: details of a global survey. J Travel Med 2004;11(4):231- 238

The image part with relationship ID rId2 was not found in the file.

Prevention versus Treatment

Prevention:

Pepto-Bismol 60ml po qid

Rifamixin 200mg qday - bid

Cipro 500mg bid*

Treatment

Cipro 500mg bid x 1-3 days

Azithromycin 1000mg po x 1

Rifamixin 200mg tid x 3 days

The image part with relationship ID rId2 was not found in the file.

Traveler’s Diarrhea

Which antibiotic regimen would you recommend for her?a. Rifamixin 200mg qday for preventionb. Cipro 500mg bid for 1-3 daysc. Azithromycin 1000mg x 1 dosed. Rifamixin 200mg tid x 3 days for treatment

5/18/2016

11

The image part with relationship ID rId2 was not found in the file.The image part with relatio

Mpumalanga, South Africa

The Pediatric Traveler

The image part with relationship ID rId2 was not found in the file.

Pediatric Traveler7yo (DOB 10/27/2008) male (19.8kg) traveling with parents to India on 5/2/16-

7/28/16. Layovers in Dubai.

Activities: Visiting and staying with extended family in a town outside of Bihar. Will visit Agra and Delhi.

Lodging: Family home in India. Westernized hotels in Delhi.

Food: family cooked meals, hotels, restaurants

PMH: none

Medications: none

NKDA, No known vaccine reactions

The image part with relationship ID rId2 was not found in the file.

Vaccine HistoryWA State Immunization Information System (WAIIS)

5/18/2016

12

The image part with relationship ID rId2 was not found in the file.

CDC Vaccine Recommendations for India

Routine vaccines

Hep A

Hep B

Japanese Encephalitis

Rabies

Typhoid

The image part with relationship ID rId2 was not found in the file.

Minimum Ages for Vaccinations

Yellow fever: 9 mn

Hep A: 1 yr

Typhoid Oral: 6 yrs Injectable: 2 years

Rabies: no minimum

Japanese encephalitis: 2mn

Meningitis: Conjugate: Menveo 2mn,

Menactra 9mn Polysaccharide: Menomune

2yr

Influenza: 6 mn

The image part with relationship ID rId2 was not found in the file.

Typhoid Vaccine in Pediatrics

Which typhoid vaccine would you recommend?a. Oral vaccine (Vivotif)b. Injectable vaccine (Typhim Vi)

5/18/2016

13

The image part with relationship ID rId2 was not found in the file.

Japanese Encephalitis Transmitted through mosquito bites

Rare disease for US travelers: 1992-2011 only 7 cases

Most common in rural, agricultural areas of Asia, SE Asia, and the Indian subcontinent, residents or long term travelers, substantial time outdoors, no AC in lodging

Death in 20-30%, 50% of survivors have permanent neurological and cognitive sequelae.

Ixiaro ® vaccine: day 0 and day 28 2mn to 3yr: 0.25ml

> 3 yr: 0.5ml

Always evaluate travel activities, season, and destination.

The image part with relationship ID rId2 was not found in the file.

Japanese Encephalitis risk for IndiaWould you recommend the Japanese encephalitis vaccine?

a. Yesb. No

The image part with relationship ID rId2 was not found in the file.

Rabies Vaccine in Pediatrics

Smaller stature and curiosity increases risk of being bit

Often afraid to report exposure

Weight based dosing of rabies immune globulin (RIG) injection into all wounds. Small children often run out of drug before all wounds have been treated.

Human RIG is difficult to access in most countries

Rabies vaccine dose is the same for children

5/18/2016

14

The image part with relationship ID rId2 was not found in the file.

Antimalarias in Pediatric Patients

• Use weight based dosing• Nothing comes in kid-friendly preparation unless compounded • Use any disguise or bribe: the sweeter, the richer, the better.

• Medication options• Atovaquone-proguanil: min. weight 5 kg, (11 lbs)• Chloroquine: safe in all ages, resistance areas• Mefloquine: safe in all ages• Doxycycline: minimum age 8 years

The image part with relationship ID rId2 was not found in the file.

Malaria in India

Which antimalarial would you recommend?a. atovaquone-progruanilb. Cloroquinec. Mefloquined. doxycycline

The image part with relationship ID rId2 was not found in the file.

Traveler’s Diarrhea in Pediatrics

Which antibiotic regimen would you recommend?a. Cipro 30mg/kg/d divided bid x 3db. Azithromycin 10mg/kg/d x 3dc. Rifamixin 100mg qid x 3 days

5/18/2016

15

The image part with relationship ID rId2 was not found in the file.

Summary

Devised a complete plan for immunizations in three different types of travelers.

Justify the appropriate use of the yellow fever vaccine.

Analyze patient characteristics to determine anti-malarial therapy of choice.

Determined the best antibiotics of choice for the treatment of traveler’s diarrhea.

The image part with relationship ID rId2 was not found in the file.The image part with relati

Questions?

Phang Nga Bay, Thailand