1. health and fitness
2. disease

January 20-22, 2012
Des Moines Marrio , 700 Grand Avenue, Des Moines, IA
Session 3: Infec ous Disease
C: Traveling the World:
Keeping Pa ents Safe and Healthy
3:00pm - 4:00pm
ACPE UAN 107-000-12-021-L01-P
Ac vity Type: Applica on-Based
0.1 CEU/1.0 Hr
Program Objec ves for Pharmacists: Upon compleƟon of this CPE acƟvity parƟcipants should be able to:
1. List the travel immuniza ons required or recommended by the CDC by specific region of travel
2. Discuss recommenda ons and concerns associated with Hepa s A, Hepa s B and typhoid
3. Discuss precau ons when dealing with an area of travel that has a malaria risk
4. List risk versus benefit of yellow fever
5. 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 benefit
and formulary policies as a Pharmacy Benefits 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 conflicts of interest in rela on to this
CPE ac vity. Off-label use of medica ons will not be discussed during this presenta on.
1/10/2012
Faculty Disclosure
Traveling the World:
Keeping Patients Safe and Healthy
Adam B. Jackson, PharmD, BCPS
Clinical Pharmacy Specialist in Infectious Diseases
Kaiser Permanente Colorado
 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
Pre-Assessment Questions
 Upon completion of this activity pharmacists (or pharmacy technicians)
 What questions would you ask, and what travel
will be able to:
recommendations would you consider, for the following
itineraries?
 Assess travel-related health risks.
 55 year old male with CAD going to Puerto Vallarta
 Assess general types of itineraries for health risks.
 Assemble general travel medicine recommendations.
 a.
adult imms / mode of travel
 b.
hepatitis A / duration of stay
diarrhea / adult imms
yellow fever / typhoid fever
 c.
 d.
 Evaluate pharmacy roles in travel medicine.
Pre-Assessment Questions
Pre-Assessment Questions
 What questions would you ask, and what travel
 What questions would you ask, and what travel
recommendations would you consider, for the following
itineraries?
recommendations would you consider, for the following
itineraries?
 45 year old male going to Europe
 34 year old female going to “the Holy Land”
 a.
zoster / locations
 a.
where / adult imms
 b.
typhoid fever / hepatitis A
adult imms / locations
polio / hepatitis A
 b.
polio / malaria
hepatitis A / typhoid fever
yellow fever / typhoid fever
 c.
 d.
 c.
 d.
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Pre-Assessment Questions
Pharmacist’s Role
 What questions would you ask, and what travel
 Formulary
recommendations would you consider, for the following
itineraries?
 38 year old nurse travelling to Mozambique
 a.
purpose / “order up”
 b.
adult imms / malaria
polio / malaria
tetanus / varicella
 c.
 d.
 Storage
 Administration
 Dosing, scheduling
 Patient and provider education
 Documentation
 Screening
 Pre and postexposure prophylaxis
Resources
Recommending Vaccines
 CDC Yellow Book
 Emerging Infectious Diseases
 Age
 CDC Pink Book
 Clinical Infectious Diseases
 CDC MMWR
 Journal of Infectious Diseases
 Allergy status
 AHFS
 Thompson’s Travel and Routine
 Package insert
Immunizations
 Pediatric Redbook
 IAMAT
 Past vaccination history
 Comorbidities
 Disease risk factors
 Past disease exposures
 Travax (Shoreland)
Recommending Travel Vaccines
 Where exactly are you going?
 What exactly will you be doing?
Categorization of Vaccines
 Routine infant vaccines
 pertussis, tetanus, Hib, hepatitis B, conj pneumococcal, rotavirus, poliovirus,
MMR, varicella, hepatitis A, influenza
 Routine adult vaccines
 Exactly how long will you be staying?
 What medications are you currently taking?
 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
Hepatitis A
 Contaminated food and water
 Resorts in Mexico
 Australia
 Cruises
 Japan
 Europe
 Israel
 Japan
 Russia
 China tours
 Kansas
 Children - asx; adults - sx;
 no chronic state, rarely fulminant
 Past HAV = lifelong immunity
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Hepatitis A
Typhoid Fever
 Childhood series
 Salmonella typhi – contaminated food / water
 MSM
 Travelers in areas of poor sanitary conditions
 All but the lowest risk destinations
 Risk increases w/ duration, rural, non-tourist
Typhoid Fever
Typhoid Fever
 Central America
 Africa
 Costa Rica
 Kenya
 Nicaragua
 Tanzania
 South America
 Brazil
 Mali
 Southeast Asia
 Argentina
 Malaysia
 Venezuela
 Burma
 Peru
 Thailand
 India
 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
Yellow Fever
 Injectable vaccine (Typhim Vi)
 inactivated vaccine – 70-80% effective
 Mosquito borne disease
 1 dose
 200k cases globally annually
 dose should be given 2 weeks prior to trip
 mortality rate - 60%
 2 year duration
 ADRs - mild local sx, possible flu-like s/s
 only for use in pts >2 yo
 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
Yellow Fever
 South America
 Africa
 Brazil
 Kenya
 Argentina
 Tanzania
 Venezuela
 Mali
 Peru
 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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Rabies
Meningitis Belt
 Mali
 Neurologic disease - animal bites
 Nigeria
 any animal bite in developing nation
 Ethiopia
 avoid close contact with animals
 Cote d’Ivoire
 Targeted population:
 probable exposure to animals
 working w/ animals, spelunkers, caves, bats
 prolonged travel in risk area
Japanese Encephalitis
Rabies
 Central America
 Africa
 Costa Rica
 Kenya
 Nicaragua
 Tanzania
 Mali
 South America
 Brazil
 Southeast Asia
 Argentina
 Malaysia
 Venezuela
 Burma
 Peru
 Thailand
 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
 India
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
Malaria
 Antibiotic treatment
 rehydration
 Fluoroquinolones
 loperamide
 Azithromycin
 #1 parasitic disease worldwide
 Rifaximin
 Mosquito borne parasitic disease
 Metronidazole
 Severity of disease depends on species
 Nitazoxanide
 SMX/TMP no longer
 Plasmodium falciparum
 P. vivax
 P. malariae
 P. ovale
Malaria
Malaria
 Risk increases with:
 Chemoprophylaxis
 rural travel
 does pt need medication?
 nighttime travel
 what is drug resistance in the area?
 lower altitudes
 areas of Central and South America
 Prevention is vital
 areas of Middle East
 DEET spray
 Permethrin 0.5% on clothes, nets, walls
 Tight closing doors, central AC
 all of India
 areas of SE Asia
 bed nets sprayed w/ permethrin
Malaria
Malaria
 Central America
 most of Africa
 Africa
 Chloroquine
 Nicaragua
 Kenya
 Honduras
 Tanzania
 used only in C. America due to resistance
 Mali
 500 mg po qweek starting 1 week before trip
 South America
 Brazil
 Southeast Asia
 Venezuela
 Malaysia
 Peru
 Burma
 India
 stop 4 weeks after leaving area
 GI ADRs possible, CNS, cardiac unlikely
 Thailand
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Malaria
 Mefloquine:
Malaria
 Doxycycline:
 used in areas of chloroquine resistance
 borders Thailand, Cambodia, Myanmar/ Burma
 250 mg po qweek starting 2 weeks before trip
 100 mg po qd starting 1 day before trip
 stop 4 weeks after leaving area
 stop 4 weeks after leaving area
 CNS rxns - HA, insomnia, vivid dreams
 ADRs - vaginal yeast infxns, GI
 rarely seizures, psychosis
 do not use in children < 8 yo, pregnancy
 possible cardiac effects - cardiac rhythm drugs
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
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
 avoid live vaccines if possible
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1/10/2012
Scavenger Hunt
 KF is 35 yo w/ RA.
 10/10/11 refill of methotrexate
Kaiser Permanente Colorado
(KPCO)
 Traveling to Thailand on business in one week
 Service membership population of 532,087
 Staying for two weeks
 21 outpatient clinics
 States “in good health”
 Integrated care
 Haven’t seen rheumatologist in 10 months
 Patients access vast majority of care at KP
 Electronic medical record
History of KPCO CPITC
KPCO CPITC Today
 MD consults or referrals outside of KPCO
 Three part-time (0.8 FTE) pharmacists
 Recommendations not consistent
 Centralized telephone-based service
 Founded in 1992
 Supported by float pharmacists PRN
 One pharmacist a few hours a week
 Supported by pharmacy technicians
 Telephone service
 Serves KPCO and KP Ohio
 1994 two full-time pharmacists
Overview of the Service
 Provide comprehensive, consistent and cost-effective
travel medicine advice
 Gather trip information
 Verify current medications and allergies
 Assess drug interactions / contraindications
 Discuss vaccines and medications
 Review insect, and food / water precautions
 Counsel on estimated costs
Technician Process
 Intake w/ questionnaire
 Departure date
 Length of trip
 Country/countries
 Purpose of trip
 Callback phone number
 Book telephone appointments
 Same day appointment
 Regular appointment
 20 minute vs. 40 minute
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Pharmacist Process
Pharmacist Roles
 18 consults per day / provider
 Healthcare provider questions
 Consultation
 Follow-up patient calls and emails
 Documentation/ordering
 Travel alerts/new information
 Route to ID MD for approval
 Keep documents up to date
 Route to clinic for nurse visit appointment
 Mail or email follow up information
Clinic Set Up
 Documentation
 Electronic medical Record
Clinic Set Up
 Resources
 ShorelandTravax
 Pre-built progress notes
 Ordering template
 Standardized letter
 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
 Backlog
Scheduled vs. Non-Scheduled
Consults
 Reduce number of patient call-backs
 Prioritizes work during busier months
 Improved member preparedness
 No Shows
 Improved member service
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Post-Assessment Case 1
Questions 1-2
Post Assessment Question #1
 A.F. is a 12-year-old female who is traveling to Tanzania. She
 Which one of the following is the best medication for A.F. to
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 #2
receive to help prevent malaria?
 a.
 b.
 c.
 d.
mefloquine
atovaquone / proguanil
chloroquine
tetracycline
Post-Assessment Case 2
Questions 3-4
 Which one of the following is the most important additional
step for A.F. to take to avoid malaria?
 a.
 b.
 c.
 d.
Use DEET
Drink bottled water
Put permethrin netting around bed
Stay in urban hotels
 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
Post Assessment Question #4
 Which one of the following is J.F.’s greatest health risk while
 J.F.’s physician asks you what vaccines J.F. should receive.
on his Caribbean cruise?
 a.
 b.
 c.
 d.
Coronary artery disease
Cholera
Typhoid fever
Hepatitis A
Which one of the following is the best response to J.F.’s
physician?
 a.
 b.
 c.
 d.
Hepatitis A / Typhoid Fever
Influenza / Pneumococcal
Tetanus / Influenza
Hepatitis A / Pneumococcal
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Post Assessment Question #5
Continuing Pharmacy Education
 Which one of the following trips would place a patient at
 Go to www.GoToCEI.org click on My Portfolio
highest risk for Yellow fever?
 Scroll down to Take Exam – Enter Access Code: (case
sensitive)
 a.
 b.
 c.
 d.
4 week trip to Mali
10 day trip to Costa Rica
2 week trip to Vietnam
2 week trip to Egypt
Pharmacists - _________
Technicians - __________
13
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)