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)