Post on 10-Mar-2018
January 20-22, 2012Des Moines Marrio , 700 Grand Avenue, Des Moines, IA
Session 3: Infec ous DiseaseC: Traveling the World:
Keeping Pa ents Safe and Healthy3:00pm - 4:00pm
ACPE UAN 107-000-12-021-L01-P 0.1 CEU/1.0 HrAc vity Type: Applica on-Based
Program Objec ves for Pharmacists: Upon comple on of this CPE ac vity par cipants should be able to:1. List the travel immuniza ons required or recommended by the CDC by specifi c region of travel2. Discuss recommenda ons and concerns associated with Hepa s A, Hepa s B and typhoid3. Discuss precau ons when dealing with an area of travel that has a malaria risk4. List risk versus benefi t of yellow fever5. Discuss the risk of vaccine overuse and what it means for popula on health
Speaker: Adam Jackson, PharmD, BCPS, received his Doctor of Pharmacy from the University of Florida College of Pharmacy in 1998. He then went on and completed his residency in Infec ous Diseases Pharmacy Prac ce at Bay Pines VA in St. Petersburg, Florida. Since 1999 he has served primarily as the Clinical Pharmacy Specialist in Infec ous Diseases for Kaiser Permanente Colorado. His roles have included serving the Infec ous Disease team in assessing HIV drug regimens, designing and implemen ng various an bio c use ini a ves, educa ng the region on appropriate an bio c and vaccine use and implemen ng new vaccines into the region as well. During his me at Kaiser Permanente he has also helped develop, analyze and implement various pharmacy benefi t and formulary policies as a Pharmacy Benefi ts Analyst. He served as the supervisor for the Clinical Pharmacy Interna onal Travel Clinic and con nues to be a clinical consultant to that group.
Speaker Disclosure: Adam Jackson does not report any actual or poten al confl icts of interest in rela on to this CPE ac vity. Off -label use of medica ons will not be discussed during this presenta on.
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Adam B. Jackson, PharmD, BCPS
Clinical Pharmacy Specialist in Infectious Diseases
Kaiser Permanente Colorado
Traveling the World: Keeping Patients Safe and Healthy
Faculty Disclosure Adam Jackson reports he has no actual or potential conflicts
of interest associated with this presentation.
Adam Jackson has indicated that off-label use of medication will be discussed during this presentation.
Learning Objectives Upon completion of this activity pharmacists (or pharmacy technicians)
will be able to:
Assess travel-related health risks.
Assess general types of itineraries for health risks.
Assemble general travel medicine recommendations.
Evaluate pharmacy roles in travel medicine.
Pre-Assessment Questions What questions would you ask, and what travel
recommendations would you consider, for the following itineraries?
55 year old male with CAD going to Puerto Vallarta a. adult imms / mode of travel
b. hepatitis A / duration of stay
c. diarrhea / adult imms
d. yellow fever / typhoid fever
Pre-Assessment Questions What questions would you ask, and what travel
recommendations would you consider, for the following itineraries?
45 year old male going to Europe a. zoster / locations
b. typhoid fever / hepatitis A
c. adult imms / locations
d. polio / hepatitis A
Pre-Assessment Questions What questions would you ask, and what travel
recommendations would you consider, for the following itineraries?
34 year old female going to “the Holy Land” a. where / adult imms
b. polio / malaria
c. hepatitis A / typhoid fever
d. yellow fever / typhoid fever
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Pre-Assessment Questions What questions would you ask, and what travel
recommendations would you consider, for the following itineraries?
38 year old nurse travelling to Mozambique a. purpose / “order up”
b. adult imms / malaria
c. polio / malaria
d. tetanus / varicella
Pharmacist’s Role Formulary
Storage
Administration
Dosing, scheduling
Patient and provider education
Documentation
Screening
Pre and postexposure prophylaxis
Resources CDC Yellow Book
CDC Pink Book
CDC MMWR
AHFS
Package insert
Pediatric Redbook
IAMAT
Travax (Shoreland)
Emerging Infectious Diseases
Clinical Infectious Diseases
Journal of Infectious Diseases
Thompson’s Travel and Routine Immunizations
Recommending Vaccines Age
Allergy status
Past vaccination history
Comorbidities
Disease risk factors
Past disease exposures
Recommending Travel Vaccines
Where exactly are you going?
What exactly will you be doing?
Exactly how long will you be staying?
What medications are you currently taking?
Categorization of Vaccines
Routine infant vaccines
pertussis, tetanus, Hib, hepatitis B, conj pneumococcal, rotavirus, poliovirus, MMR, varicella, hepatitis A, influenza
Routine adult vaccines
pneumococcal, influenza, tetanus-pertussis, hepatitis B, zoster
Routine adolescent vaccines
Tetanus / pertussis, conj meningococcal, HPV
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Categorization of Vaccines
Travel vaccines (commonly used) Tetanus / pertussis, hepatitis A, typhoid fever, polio
Travel vaccines (less commonly used) yellow fever, hepatitis B, meningococcal
Travel vaccines (rarely used) Japanese encephalitis, rabies
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Lowest Risk Destinations
Resorts in Mexico
Cruises
Europe
Japan
China tours
Australia
Japan
Israel
Russia
Kansas
Hepatitis A
Contaminated food and water
Children - asx; adults - sx;
no chronic state, rarely fulminant
Past HAV = lifelong immunity
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Hepatitis A
Childhood series
MSM
All but the lowest risk destinations
Typhoid Fever
Salmonella typhi – contaminated food / water
Travelers in areas of poor sanitary conditions
Risk increases w/ duration, rural, non-tourist
Typhoid Fever Central America
Costa Rica
Nicaragua
South America Brazil
Argentina
Venezuela
Peru
India
Africa Kenya
Tanzania
Mali
Southeast Asia Malaysia
Burma
Thailand
Typhoid Fever
Oral vaccine (Vivotif Berna) live vaccine – 70-80% effective 4 doses - 1 cap qod, 1 h before meals, w/ lukewarm - cool
water, refrigerate series should be completed 1 week prior to trip 5 year duration ADRs - GI separate series 24 h from abx do not give to immunocompromised or <6 yo
Typhoid Fever
Injectable vaccine (Typhim Vi) inactivated vaccine – 70-80% effective 1 dose dose should be given 2 weeks prior to trip 2 year duration ADRs - mild local sx, possible flu-like s/s only for use in pts >2 yo
Yellow Fever
Mosquito borne disease
200k cases globally annually
mortality rate - 60%
may be required for entry
only administered at licensed centers
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Yellow Fever
Live vaccine - >90% effective
Travelers to equatorial S. America, Africa
1 dose
10 year duration
Yellow Fever
South America Brazil
Argentina
Venezuela
Peru
Africa Kenya
Tanzania
Mali
Yellow Fever
Warnings NEVER give to pts < 6mo - encephalitis Risk of encephalitis increases at < 9mo anaphylaxis to eggs immunocompromised
Concerns in elderly, especially if first time
ADRs - mild local “bee sting”
Meningococcal
Conjugate vaccine preferred FDA indication 9 mo - 55 years of age
Targeted populations: adolescents 11-18 years old travelers to “meningitis belt” of Africa often recommended for the Hajj pilgrimage asplenic patients
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Meningitis Belt Mali
Nigeria
Ethiopia
Cote d’Ivoire
Rabies
Neurologic disease - animal bites
any animal bite in developing nation
avoid close contact with animals
Targeted population: probable exposure to animals working w/ animals, spelunkers, caves, bats prolonged travel in risk area
Rabies Central America
Costa Rica
Nicaragua
South America Brazil
Argentina
Venezuela
Peru
India
Africa Kenya
Tanzania
Mali
Southeast Asia Malaysia
Burma
Thailand
Japanese Encephalitis
Leading cause of encephalitis in Asia
20-30% die
30-50% neurologic complications
transmitted through mosquitoes
overall risk is very low (1/mill, 1/20k/wk)
rice paddies, marshes, pig farming
Japanese Encephalitis
Targeted population intensive short term exposure, moderate long term exposure
(Asia, Indian subcontinent)
Two vaccines JE-VC > 17 years; 2-dose series JE-MB 1 – 16 years; 3-dose series, widely unavailable
Traveler’s Diarrhea
Prevention is the best medicine peel it, boil it, cook it or forget it meats are OK if cooked thoroughly breads are OK if baked thoroughly
Proph abx should not be used routinely
Bismuth sub-salicylate (BSS)
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Traveler’s Diarrhea Supportive treatment
rehydration
loperamide
Antibiotic treatment Fluoroquinolones
Azithromycin
Rifaximin
Metronidazole
Nitazoxanide
SMX/TMP no longer
Malaria
#1 parasitic disease worldwide
Mosquito borne parasitic disease
Severity of disease depends on species Plasmodium falciparum
P. vivax
P. malariae
P. ovale
Malaria
Risk increases with: rural travel nighttime travel lower altitudes
Prevention is vital DEET spray Permethrin 0.5% on clothes, nets, walls Tight closing doors, central AC bed nets sprayed w/ permethrin
Malaria
Chemoprophylaxis does pt need medication? what is drug resistance in the area? areas of Central and South America areas of Middle East most of Africa all of India areas of SE Asia
Malaria Central America
Nicaragua
Honduras
South America Brazil
Venezuela
Peru
India
Africa Kenya
Tanzania
Mali
Southeast Asia Malaysia
Burma
Thailand
Malaria
Chloroquine used only in C. America due to resistance 500 mg po qweek starting 1 week before trip stop 4 weeks after leaving area GI ADRs possible, CNS, cardiac unlikely
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Malaria
Mefloquine: used in areas of chloroquine resistance 250 mg po qweek starting 2 weeks before trip stop 4 weeks after leaving area CNS rxns - HA, insomnia, vivid dreams rarely seizures, psychosis possible cardiac effects - cardiac rhythm drugs
Malaria
Doxycycline: borders Thailand, Cambodia, Myanmar/ Burma 100 mg po qd starting 1 day before trip stop 4 weeks after leaving area ADRs - vaginal yeast infxns, GI do not use in children < 8 yo, pregnancy
Malaria
Atovaquone / Proguanil (Malarone) active against mefloquine resistance well tolerated more expensive for most trips no more effective than other agents once daily, 1 day prior through 7 days after
Miscellaneous Travel Concerns
Motion sickness dimenhydrinate, meclizine, promethazine Transderm-Scop patches
Altitude sickness keep hydrated gradual ascent acetazolamide dexamethasone
Special Populations
Pregnant women inactivated vaccines are generally safe avoid live vaccines (YF, MMR, varicella, OPV) mefloquine concerns no evidence with atovaquone / proguanil
Immunocompromised assess level of immune deficiency TNF-inhibitors usually contraindicated Steroids dependent on dose, duration, route avoid live vaccines if possible
Special Populations
Health care workers Hep B, varicella, MMR, influenza
Older adults pneumococcal, influenza, tetanus
Adults w/ chronic illnesses pneumococcal, influenza
Travelers use as opportunity to bring pts up to date
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Scavenger Hunt
KF is 35 yo w/ RA.
10/10/11 refill of methotrexate
Traveling to Thailand on business in one week
Staying for two weeks
States “in good health”
Haven’t seen rheumatologist in 10 months
Kaiser Permanente Colorado (KPCO)
Service membership population of 532,087
21 outpatient clinics
Integrated care
Patients access vast majority of care at KP
Electronic medical record
History of KPCO CPITC
MD consults or referrals outside of KPCO
Recommendations not consistent
Founded in 1992
One pharmacist a few hours a week
Telephone service
1994 two full-time pharmacists
KPCO CPITC Today
Three part-time (0.8 FTE) pharmacists
Centralized telephone-based service
Supported by float pharmacists PRN
Supported by pharmacy technicians
Serves KPCO and KP Ohio
Overview of the Service
Provide comprehensive, consistent and cost-effective travel medicine adviceGather trip informationVerify current medications and allergiesAssess drug interactions / contraindicationsDiscuss vaccines and medicationsReview insect, and food / water precautionsCounsel on estimated costs
Technician Process
Intake w/ questionnaireDeparture date Length of tripCountry/countries Purpose of tripCallback phone number
Book telephone appointments Same day appointmentRegular appointment 20 minute vs. 40 minute
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Pharmacist Process
18 consults per day / providerConsultationDocumentation/orderingRoute to ID MD for approvalRoute to clinic for nurse visit appointmentMail or email follow up information
Pharmacist Roles
Healthcare provider questions
Follow-up patient calls and emails
Travel alerts/new information
Keep documents up to date
Clinic Set Up
Documentation
Electronic medical Record Pre-built progress notesOrdering template Standardized letter
Clinic Set Up
Resources
ShorelandTravax
Centers for Disease Control and Prevention (www.cdc.gov)
World Health Organization (www.who.int)
Outcome Measures
Reported weekly
Number of consults per day per provider
Supply/demand
Access Metrics Same day appointments BacklogNo Shows
Scheduled vs. Non-Scheduled Consults
Reduce number of patient call-backs
Prioritizes work during busier months
Improved member preparedness
Improved member service
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Post-Assessment Case 1Questions 1-2 A.F. is a 12-year-old female who is traveling to Tanzania. She
is traveling with her family on a church mission that leaves in April and will stay there for 6 weeks. A.F. and her family will be living in local villages. Her past medical history is significant for bipolar disorder. A.F. received all of her childhood vaccines. At this time A.F. has not had a routine adolescent visit with her primary care physician and has not received any of her routine adolescent vaccinations.
Post Assessment Question #1 Which one of the following is the best medication for A.F. to
receive to help prevent malaria?
a. mefloquine
b. atovaquone / proguanil
c. chloroquine
d. tetracycline
Post Assessment Question #2 Which one of the following is the most important additional
step for A.F. to take to avoid malaria?
a. Use DEET
b. Drink bottled water
c. Put permethrin netting around bed
d. Stay in urban hotels
Post-Assessment Case 2Questions 3-4
J.F. is a 68-year-old male who is taking a cruise in three weeks, on January 7, to the Caribbean. His past medical history is significant for coronary artery disease with an acute myocardial infarction (AMI) 4 years ago. He currently takes simvastatin, lisinopril, and atenolol.
Post Assessment Question #3 Which one of the following is J.F.’s greatest health risk while
on his Caribbean cruise?
a. Coronary artery disease
b. Cholera
c. Typhoid fever
d. Hepatitis A
Post Assessment Question #4 J.F.’s physician asks you what vaccines J.F. should receive.
Which one of the following is the best response to J.F.’s physician?
a. Hepatitis A / Typhoid Fever
b. Influenza / Pneumococcal
c. Tetanus / Influenza
d. Hepatitis A / Pneumococcal
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Post Assessment Question #5 Which one of the following trips would place a patient at
highest risk for Yellow fever?
a. 4 week trip to Mali
b. 10 day trip to Costa Rica
c. 2 week trip to Vietnam
d. 2 week trip to Egypt
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2012 Educational Expo Traveling the World: Keeping Patients Safe and Healthy Adam Jackson, PharmD, BCPS
Post‐Assessment Questions
For questions 1 – 2, please refer to the following case: A.F. is a 12‐year‐old female who is traveling to Tanzania. She is traveling with her family on a church mission that leaves in April and will stay there for 6 weeks. A.F. and her family will be living in local villages. Her past medical history is significant for bipolar disorder. A.F. received all of her childhood vaccines. At this time A.F. has not had a routine adolescent visit with her primary care physician and has not received any of her routine adolescent vaccinations. 1. Which one of the following is the best medication for A.F. to receive to help prevent malaria?
A. mefloquine B. atovaquone / proguanil C. chloroquine D. tetracycline
2. Which one of the following is the most important additional step for A.F. to take to avoid malaria?
A. Use DEET B. Drink bottled water C. Put permethrin netting around bed D. Stay in urban hotels
For questions 3 – 4, please refer to the following case: J.F. is a 68‐year‐old male who is taking a cruise in three weeks, on January 7, to the Caribbean. His past medical history is significant for coronary artery disease with an acute myocardial infarction (AMI) 4 years ago. He currently takes simvastatin, lisinopril, and atenolol. 3. Which one of the following is J.F.’s greatest health risk while on his Caribbean cruise?
A. Coronary artery disease B. Cholera C. Typhoid fever D. Hepatitis A
4. J.F.’s physician asks you what vaccines J.F. should receive. Which one of the following is the best response to J.F.’s physician?
A. Hepatitis A / Typhoid Fever B. Influenza / Pneumococcal C. Tetanus / Influenza D. Hepatitis A / Pneumococcal
5. Which one of the following trips would place a patient at highest risk for Yellow fever?
A. 4 week trip to Mali B. 10 day trip to Costa Rica C. 2 week trip to Vietnam D. 2 week trip to Egypt
Infectious Disease: Traveling the World: Keeping Patients Safe and Healthy
“Healthy” Business Traveler
KF is a 35-year-old with rheumatoid arthritis who presents to the pharmacy on October 10 for a refill of her methotrexate. While she is paying for her prescription she states that she is excited because she leaves in only one week for a trip to Thailand. You ask her what sort of medical preparations she has taken for her trip and she states none because she’s only staying there for two weeks on business and she’ll be staying in hotels the whole time. You express some concern over this but she states that she is in great health, the methotrexate keeps her arthritis symptoms well under control. She feels so good in fact that she has not seen her rheumatologist in about 10 months.
What went wrong? (Assessment)
Patient problems:
System problems:
Intervention: (Plan)