Don’t let the travel bugs get you

This meeting is sponsored by GSK

Dr Jenny Visser

Senior Lecturer in Travel Medicine

University of Otago School of Medicine

Wellington

Chaired by Dr Bryn Thompson

General Practitioner, Crawford Medical Centre, Auckland

To understand the:

The importance of travel medicine

The steps that form the foundations for an effective pre-travel consultation

Common travel health topics, including:

Vaccine-preventable diseases

Malaria prevention

Objectives for today’s meeting

Resource to support your pre-travel

consultations

Pre-travel consultation checklist

Written by Jenny Visser & provided in your

delegate folders from GSK

Email checklist@holidayhealthnz.co.nz

for an electronic version if you want

to print additional copies

Request from GSK – “help us improve our meetings”

Evaluation form is also in your delegate folders

Please complete and leave on your chair at the

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5

Hint: listen very carefully to Jenny’s presentation....

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TRAVEL MEDICINE

GP CME CONFERENCE ROTORUA

2014

Dr

DR JENNY VISSER

GSK BREAKFAST SYMPOSIA

Don't let the travel

bug get you”

Disclaimer

The speaker received funding from GlaxoSmithKline (GSK)

to prepare and present this symposia. She has no other

commercial interests to disclose.

Outline

Overview of Travel

Medicine

Key Resources

The Pre-Travel

Consultation

Information gathering

Travel Health Topics

Vaccine preventable diseases

Malaria

Q&As

Why Travel Medicine? Because

People travel

Destinations often

tropical

developing countries

Travellers get sick

Modern travel is usually rapid

the chance for acclimatisation

is limited

We can offer some protection

from travel related risks

It’s fun!

How many NZers travel/year?

Total NZ Residents short-term departures*

2013: 2.20 million

2012: 2.17 million

2011: 2.09 million

2010: 2.03 million

2009: 1.92 million

2000: 1.28 million

*Ministry of Transport. See http://www.transport.govt.nz/ourwork/tmif/transport-volume/tv011/

See: http://www.transport.govt.nz/assets/TI-Images/TV011-series1-image1.PNG

NZ Resident short-term departures: Top 10

“main” destination 2013/%*

#1 Australia (46.0%)

#2 USA (6.5%)

#3 Fiji (5.2%)

#4 UK (4.4%)

#5 China (3.3%)

#6 Cook Islands (3.3%)

#7 Samoa (2.0%)

#8 Thailand (1.9%)

#9 India (1.9%)

#10 Indonesia (1.1%)

* Statistics New Zealand. See http://www.stats.govt.nz/browse_for_stats/industry_sectors/imports_and_exports/global-nz-dec-13.aspx

Travellers get sick*

Between 20-70% of

international travellers

suffer some illness

About 5% need to seek

medical care

About 1% hospitalised

*Steffen R, Amitirigala I, Mutsch

M. Health Risks Among Travelers

— Need for Regular Updates.

Journal of Travel Medicine.

2008;15(3):145-6.

Travel Medicine: Assessing Risk

Hazard+Exposure+Susceptibility

Individualised Risk Assessment

Risk Management/Health Promotion

Outline

Overview of Travel

Medicine

Key Resources

The Pre-Travel

Consultation

Information gathering

Travel Health Topics

Vaccine preventable diseases

Malaria

Q&As

Travel Medicine resources Travel medicine

practitioners

Electronic: World Health Organization Centre for Disease Control and

Prevention (USA) Fit for Travel UpTo Date BPAC NZ Holidayhealth.co.nz NZ Ministry Foreign Affairs

Publications

Travel Medicine Research Reviews

MIMS Travel Medicine Guide

World Health Organization Travel Health Homepage http://www.who.int/topics/travel/en/

International Travel & Health http://www.who.int/ith/en/

Country list http://www.who.int/ith/ITH_country_list.pdf?ua=1

“Annex 1” http://www.who.int/ith/ITH_Annex_I.pdf?ua=1

Disease Topics http://www.who.int/topics/en/

WHO: International travel and health

and Country List

Centre for Disease Control and

Prevention

Travel Health Homepage

http://wwwnc.cdc.gov/travel/

CDC Health Information for International Travel “Yellow Book”http://wwwnc.cdc.gov/travel/page/yellowboo

k-home-2014

Destinationshttp://wwwnc.cdc.gov/travel/destinations/list

/?s_cid=cdc_homepage_topmenu_003

Areas with malaria: Present in the

following districts: Central and

North West (including Chobe National

Park). None in the cities of

Francistown and Gaborone.

Estimated relative risk of malaria

for

US travelers:Very low.

Drug resistance4: Chloroquine.

Malaria species: P. falciparum 90%,

P. vivax 5%, P. ovale 5%.

Recommended chemoprophylaxis:

Atovaquone-proguanil, doxycycline,

or mefloquine.

CDC Yellow Book Chapter 3: Travel Vaccines and Malaria Information by Country: See

http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-

related-to-travel/travel-vaccines-and-malaria-information-by-country/botswana#seldyfm533

UK Resources

“Fit for Travel”

http://www.fitfortravel.scot.nhs.uk/

The National Travel Health and Network

Centre

http://www.nathnac.org/

“Fit for Travel: See http://www.fitfortravel.nhs.uk/home.aspx

UpToDate

UpToDate general information and patient

education

http://www.uptodate.com/contents/tra

vel-

advice?source=search_result&search=trav

el&selectedTitle=1~150

BPAC NZ

Providing Medical Advice to Travellers

http://www.bpac.org.nz/BPJ/2011/dec

ember/travellers.aspx

Holidayhealth.co.nz

http://www.holidayhealth.co.nz/

Research Reviews

http://www.researchreview.co.nz/nz/Clin

ical-Area/Internal-Medicine/Infectious-

Diseases/Travel-Medicine.aspx

MIMS Travel Medicine Guide

NZ Travel Advisories

NZ MFAT “Safe Travel”

https://www.safetravel.govt.nz/

Outline

Overview of Travel

Medicine

Key Resources

The Pre-Travel

Consultation

Information gathering

Travel Health Topics

Vaccine preventable diseases

Malaria

Q&As

The Pre-travel Consultation..setting the

scene

24 year old about to embark

on a 12 month backpacking

trip through Asia, Europe and

Africa.

What more do you need to

know?

What topics do you need to

cover in the pre-travel

consultation?

Pre-Travel Consultation: What information

do you need?

About them

Demographics Contact details

Travel experience Past Medical History

Past DVT/VTE Ongoing & specific medical

conditions Regular & intermittent medications Allergies (general and specific) Recent

illness/operations/hospitalisations/investigations

Women:Pregnancy(current or planned)/Contraception

Vaccination history

About the trip

When do they leave

Where? (Exact itinerary)

How long?

Type of trip? Guided Independent Business/Employment Holiday Volunteer

Mode of transport?

Type of accommodation?

Planned activities?

Any specific concerns?

Pre-Travel Consultation: Range of topics

to covered

Fitness to Fly Issues Vaccine preventable

diseases/vaccines Preventing food and water-

borne illnesses Travellers diarrhoea

Prevention of Vector-borne Diseases

Malaria

Dengue

Chikungunya

Zika Sexual & Reproductive Health

STIs

Other Infectious Diseases

Schistosomiasis Activity specific advice

Altitude/Trekking

Scuba diving Management of ongoing

medical conditions Psychological preparedness Safety & Security/Responsible

travel Medical Kit Post Travel visit

How are you going to fit this into your

busy practice?

Refer some/all

Yellow Fever Nearest approved vaccinator

Rabies/JE

Identify pre-travel consultations

Book dedicated consultation

30 minutes

Submit itinerary before

Multiple visits

Team approach

Inter-professional

Written material/online traveller resources

Use the pre-travel checklist

Develop resources eg pre-travel health questionnaire

Up skill

PG qualifications

ISTM Certificate of Knowledge

Outline

Overview of Travel

Medicine

Key Resources

The Pre-Travel

Consultation

Information gathering

Travel Health Topics

Vaccine preventable diseases

Malaria

Q&As

Vaccinations for Travel: The Three “Rs”

Routine

National vaccination schedule

Childhood

Adult boosters

Influenza

Required

Yellow Fever

Meningococcal

Polio

Recommended for travel

Routine: WHO Extended Programme

Immunisation* Diphtheria/Tetanus/Pertussis

Poliomyelitis

Measles/Mumps/Rubella

Varicella

Haemophilus influenzae type b

Pneumococcal disease

Hepatitis B

Human papillomavirus**

Rotavirus**

Influenza**

Tuberculosis (BCG)**

**may be targeted

THE PRE TRAVEL CONSULTATION IS AN OPPORTUNITY TO ENSURE THAT THE

TRAVELLER IS UP TO DATE FOR ALL ROUTINE VACCINATIONS

*http://www.who.int/ith/ITH_chapter_6.pdf?ua=1

The pre-travel consultation and Routine

vaccines

“The pre travel consultation is

an opportunity to ensure that

the traveller is up to date for

all routine vaccinations” .

Update these especially if:

Any doubt regarding status

Single adult booster good for

life

Polio

Recent outbreaks/resurgence

Pertussis

Measles/Mumps

Measles in travellers: 2013/2014 Many countries reporting

importation of measles including Including New Zealand (ex

Philippines and Vietnam) http://www.health.govt.nz/our-

work/diseases-and-conditions/2014-measles-outbreaks

Australia http://www.health.nsw.gov.au/infecti

ous/pages/measles.aspx

USA http://www.cdc.gov/measles/cases-

outbreaks.html

Europe

ttp://ecdc.europa.eu/en/publications/Publications/measles-rubella-monitoring-february-2014.pdf

If any doubt:

Give MMR pre-travel

Catch-up vaccines; Are FREE for all NZ

resident adults and children*

Children

Up to 18th birthday

Includes

Tdap

Hepatitis B

*See:

http://www.immune.org.nz/ne

ws/extension-catch-eligibility

Adults (18yrs +)

NZ Resident or Refugee

Eligible for

3 Td

3 IPV

2 MMR (DOB > 1/1/1969)

3 HPV (females 18-20 yrs)

All funded vaccines but

cannot claim vaccine

administration charge

NZ Immunisation Schedule: July 1st

2014 changes *

New Vaccines listed: Rotavirus (for all eligible

patients) Varicella (for patients at high

risk from infection) Hepatitis A (for eligible

patients) Higher strength hepatitis B

for the vaccination of dialysis patients and patients who have had a liver or kidney transplant

Monovalent conjugated meningococcal C.

Other changes: Gardasil funded up to 18 years Pneumococcal: 13 valent

Prevenar® replaces 10 valentSynflorix®

Revaccination of children post immunosuppression funded

Meningococcal: Menactra® (conjugate) replaces Menomune®(polysaccharide)

See: * http://www.pharmac.health.nz/news/notification-2013-12-17-national-immunisation-schedule-changes/

As Travel Medicine practitioners we

need to be familiar with

NZ National Immunisation

Schedule

Overseas schedules

Europe: http://vaccine-

schedule.ecdc.europa.eu/Pages/S

cheduler.aspx

USA:

http://www.cdc.gov/vaccines/sc

hedules/easy-to-read/child.html

Criteria for funded vaccines

for at risk populations

Pre/Post Splenectomy &

functional asplenia

Hib

Pnuemococcal

Meningococcal

IMAC/MOH

recommendations for use of

non-funded vaccines

2013 Vaccination “Research

Review”

Travel Vaccines -Recommended

Hepatitis A

Typhoid fever

Cholera

Japanese encephalitis

Meningococcal disease

Rabies

Tick-borne encephalitis

Yellow fever (personal

protection)

Travel Vaccines -Required

International Health Regulations 2005

Yellow fever (public health)

Meningcoccal disease

Saudi Arabia to attend Haj

Polio

Saudi Arabia to attend Haj

May 2014: All residents/long term travellers leaving Cameroon, Pakistan & Syria

Temporary Polio Requirements (effective as of 5th May 2014 and will be reviewed in 3m)*

Exporting Countries

“Cameroon

Pakistan

Syria

Recommendations: Countries which are currently

exporting wild poliovirus should ensure that all residents and long-term visitors (of over 4 weeks) receive a dose of oral polio vaccine (OPV) or inactivated poliovirus vaccine (IPV) between 4 weeks and 12 months before international travel; and should ensure that such travellers are provided with proof of vaccination” (ie on International Certificate of Vaccination or Prophylaxis)

Other Polio Affected Countries “Afghanistan

Equatorial Guinea

Ethiopia

Iraq

Israel

Nigeria

Somalia

Recommendations:

Other polio-affected countries are encouraged to vaccinate residents and long-term visitors before international travel”.

*http://www.polioeradication.org/Infectedcountries/PolioEmergency.aspx#sthash.lCe6RgnG.dpuf

Rationalising Travel Vaccines

STEP 1: What vaccine preventable diseases are a hazard, what is exposure & susceptibility?

STEP 2: Risk Assessment: Which ones are a high enough risk to justify vaccination?

STEP 3: Negotiate with the traveller

STEP 4: Which vaccines and when?

Helpful Hint: Split into those

Highly recommended

Recommended

Are they planning other travel in the future?

Some are both Routine and

Recommended for Travel

Tetanus/Diptheria/Pertussis

Polio

Influenza

Hepatitis B

The Pre-Travel Consultation and Vaccines:

Quick and Easy approach….

Always Routine

Required Nearly always*

Tetanus, Diphtheria & Pertussis

Hepatitis A

Influenza Often*

Typhoid

Hepatitis B Sometimes*

Yellow fever

Meningitis

Rabies

Cholera

Japanese encephalitis

Pneumococcal

(* Assuming travel to developing country)

Best value for money?

What is the most commonly caught vaccine preventable disease of International Travellers?

Influenza*

*Steffen R. Influenza in Travelers: Epidemiology, Risk, Prevention, and Control Issues. Curr Inf Dis Rep. 2010;12(3):181-5.

Common pre-travel “vaccine errors”

Ordering serology eg pre-MMR and hepatitis B

Poor advice regarding rabies

Revaccinating hepatitis B

Giving a single Twinrix® pre-travel

Ideal traveller for Twinrix®

Older

Time for full series Licensed for rapid schedule

(Day 0, 7, 21 and 12 months)*

*http://www.medsafe.govt.nz/profs/datasheet/t/Twinrixinj.pdf

Prescribe, Schedule & Administer

Administration of Vaccines

The maximum number of vaccines that can be given at one visit is:

One

Two

Four

Six

No limit

Administration of Vaccines

The maximum number of injections that can be given into one

muscle is:

One

Two

Four

No limit

Live vaccines

General administration

principles?

Either on same day or 4

weeks apart

MMR & Hepatitis B in 2014

Hepatitis B Covered?

Age up to 26yr Yes: 3 x Hep B vaccinations, so immune

Age 26 – 30 Probably: Pre-school catch-up programme

Age 31 – 40 Possibly: School based catch up programme extended in 1990

Age 40+ No: unlikely vaccinated

MMR

Age up to 25yr Yes: 2 x MMR

Age 25 - 36 No: 1 x MMR only

Age 36 - 45 No: 1 x monovalent measles only

Age 45+ Yes: Natural immunity from childhood disease

Vaccination Scenario 50-year old Dan going on a high end 3-week African adventure

Starting with 2 days in Stellenbosch, Capetown, before flying to

Skeleton Coast (Namibia) & visiting Etosha

Overlanding to Chobe & the Okovango Delta in Botswana

Crossing into Zambia, staying in Livingstone and seeing Victoria

Falls

Flying to Zanzibar via Dar Es Salaam for 4 days on the beach

Return flight: Zanzibar, Jo-Burg, Perth, NZ

He leaves in I month

Vaccines for Dan?

Routine:

Did he get his childhood vaccines? MMR

ADT at 45 years

Influenza

Has he had chicken-pox/Varicella (the disease)?

Required:

Yellow Fever Risk of exposure very low

But having been in Zambia and Tanzania ,South Africa can demand proof of vaccination

Recommended:

AdTap (if > 10years)

Influenza

Hepatitis A

Discuss

Rabies

Typhoid

Hepatitis B

ETEC (Dukoral®)

Polio

Meningococcal

WHO: Yellow Fever Vaccination

Recommendations

See: http://gamapserver.who.int/mapLibrary/Files/Maps/ITH_YF_vaccination_africa.png?ua=1

Vaccines for Dan?

He agrees to:

AdTap

Influenza

Hepatitis A

Hepatitis B

Rabies

Yellow fever

Vaccines for Dan?

Which vaccines? AdTap

Boostrix®/Adacel®

Influenza Fluarix® /Influvac®/Fluvax®

Hepatitis A Havrix®/Vaqta®/Avaxim®

Twinrix®

Hepatitis B Engerix®/HBVax®

Twinrix®

Rabies Verorab®

Yellow Fever Stamaril®

And if had opted for Typhoid:

Typherix® /TyphimVi®

Hepatyrix® /Vivaxim®

Vaccine Schedule: Name/Dose/Route: one

example

Vaccine Visit one - Day 0 Visit two – Day 7 Visit three – Day21

Boostrix®

0.5ml IM

*

Twinrix®1.0ml IM

* * *

Stamaril® 0.5ml SC *

Fluarix® 0.5ml IM *

Verorab® 0.5ml IM * * *

* 4th Twinrix® due 12 months

Vaccination…….

There is no magic list

Many vaccine preventable diseases and few absolute guidelines

Need to make a careful risk assessment and advise which vaccinations would be beneficial for each specific traveller

Need to strike the right balance. Just because there is a vaccine does not mean every traveller should get it.

Travel vaccines are NOT cheap, the cost to the traveller (or employer/aid agency) rapidly adds up

Outline

Overview of Travel

Medicine

Key Resources

The Pre-Travel

Consultation

Information gathering

Travel Health Topics

Vaccine preventable diseases

Malaria

Q&As

Malaria in Travellers

Annually approximately 25-30 million international

travellers from non endemic areas travel to endemic areas*

Internationally an estimated 30 000 cases of travel-associated

malaria occur**

Evidence that incidence is reducing in returning travellers,

but proportion of falciparum malaria increasing***

*Loutan, L. (2003) Malaria: still a risk to travellers. Int J Antimicrob Agents 21, 158-63

** Kain, K., & Keystone, J. (1998) Malaria in travellers: epidemiology, disease and prevention. Inf Dis

Clin N Am 12, 267-84

*** Schlagenhauf P, Hommel M. (2011) Travellers' malaria-'one shoe does not fit all'. Malaria J.

10(1):129

Malaria notifications New Zealand

NZ Imported Malaria: 13 years data* 666 cases

80% (533) non-military: 20% (133) military

In non-military

Average 41 cases/year

Acquired in PNG (24.4%)

India (18.6%)

Solomon Islands (8.8%)

Indonesia (6.1%)

Vanuatu (5.9%)

Uganda (2.9%)

Thailand (2.7%)

Tanzania (2.7%)

Malawi (2.7%)

*Lau et al. VBZ Dis. 2014;14(2):134-40.

Lau et al. VBZ Dis.

2014;14(2):134-40.P. vivax: 72.7%

P. falciparum: 27.2%

Imported malaria Auckland 2008-

2009*

34 cases in 32 individuals

24 male & 8 female

Mean age 21 (6m-75 yrs)

Background

11/32 NZ residents

21/32 new arrivals

11 refugees

10 migrants

*Camburn et al. NZMJ

2012;125(1365):1-6.

Of 11/32 NZ residents

8/11 VFRs

3/11 missionaries

6 falciparum malaria

4 vivax malaria

1 both

“Malaria in Akld is seen

in new arrivals and VFR

travellers, not in

tourist travellers”

Lau et al. VBZ Dis.

2014;14(2):134-40.

Risk of Malaria Incidence of malaria in travellers without chemoprophylaxis

(per month)*

PNG >3%

Solomon Islands >3%

West Africa 2.4%

East Africa 1.2%

India 0.35%

South-east Asia 0.1%

South America 0.05%

*Loutan L. Malaria: still a threat to travellers. International Journal of Antimicrobial Agents. 2003;21(2):158-63.

PREVENTING MALARIA in Travellers

A Awareness-know the risk

B Bites by mosquitoes-prevent

C Compliance with Chemoprophylaxis

D Diagnose malaria swiftly and treat

appropriately

Malaria Chemoprophylaxis Malaria chemoprophylactics

currently available in New Zealand

Chloroquine

Mefloquine

Doxycycline*

Malarone

Primaquine**

* Not licensed as an antimalarial in NZ

Unlicensed medication. Available only under Section 29 of Medicines Act.

Malaria transmission and drug sensitivity across the world.

Lalloo D G , Hill D R BMJ 2008;336:1362-1366

©2008 by British Medical Journal Publishing Group

Anti-malarial Regimens* All Regions (no mefloquine

resistance) Mefloquine Doxycycline Atovaquone plus Proguanil

(Malarone®)

Regions with chloroquine sensitivity Chloroquine

Mefloquine resistant areas Doxycycline Malarone

* WHO: http://www.who.int/ith/ITH_country_list.pdf?ua=1

MALARIA LIFECYCLE

Chloroquine resistant malaria World wide all P falciparum

malaria is chloroquine resistant*

In areas of chloroquine resistance (but no mefloquine resistance) use*:

Mefloquine or Doxycycline or Malarone®

* WHO: http://www.who.int/ith/ITH_country_list.pdf?ua=1

This order implies nohierarchy of choice.

Which is chosen will depend on pre-existing conditions

concomitant medications

personal preference

what the traveller can afford.

Chloroquine In New Zealand currently

only available as Hydroxychloroquine

(Historically and overseas chloroquine sulphate/phosphate)

Dose: 400mg (310mg base) once weekly commenced 2 weeks prior to entering malarial area, weekly while there and weekly for 8 weeks after*

* http://www.medsafe.govt.nz/profs/datasheet/p/Plaqueniltab.pdf

Only indicated in areas where no chloroquine resistance recorded* BUT

Only in areas with P vivax alone

Few destinations, parts of Central America

Few travellers go to these areas

In chloroquine sensitive P vivax regions, can use doxycycline, mefloquine or Malarone®

Hydroxychloroquine costs about the same as mefloquine

RARELY used

** WHO: http://www.who.int/ith/ITH_country_list.pdf?ua=1

Mefloquine Lariam® in New Zealand

Various generics available overseas

DOSE*: one tablet (250mg) once weekly commencing 2-4 weeks prior to entering malarial zone, once weekly while there and once weekly for 4 weeks after

Rapid loading dose is licensed (but use with caution) one tablet daily for 3 days and

weekly there-after

* http://www.medsafe.govt.nz/profs/datasheet/l/lariamtab.pdf

Adverse events Neuropsychiatric (NP)

Prevalence highly variable depending on study population and definitions

One review.* Disabling NP AEs reported in 0.008-0.1% of users

Recent “Blackbox” warning in USA**

Carefully select who you prescribe it to

* Toovey S. Mefloquine neurotoxicity: A literature review. Trav Med Inf Dis. 2009;7(1):2-6.

** http://www.fda.gov/drugs/drugsafety/ucm362227.htm

Doxycycline Widely used as malaria

chemoprophylaxis

Not licensed as such in NZ, but widely prescribed

DOSE: 100mg once daily commencing 2 days prior to entering malarial zone, daily while there and daily for 4 weeks after*

* WHO: http://www.who.int/ith/ITH_country_list.pdf?ua=1

Adverse events*

oesophagitis, oesophageal perforation, indigestion/dyspepsia

sun sensitivity/rash

Candidiasis

* http://www.medsafe.govt.nz/profs/datasheet/d/Doxinetab.pdfand http://www.medsafe.govt.nz/profs/datasheet/d/Doxytab.pdf

Malarone® Combination tablet of

Atovaquone 250mg and Proguanil 100mg

Dose: One tablet once daily commencing one day before entering malarial area, daily while there and daily for 7 days after leaving*

* http://www.medsafe.govt.nz/profs/datasheet/m/Malaronetab.pdf

Adverse events

Low discontinuation rates**

Commonest adverse events nausea and headache*

** Høgh B et al. Atovaquone-proguanil versus chloroquine-proguanil for malaria prophylaxis in non-immune travellers: a randomised, double-blind study. Lancet. 2000;356(9245):1888-94.

Primaquine

Not licensed in NZ Section 29

Used for eradication therapy (of the hypnozoite) in known vivax malaria or in those at increased risk of vivax malaria *

Must check for G6PD deficiency

A handful of small but well conducted studies show it is also an effective chemoprophylactic agent and it is worth considering for those where all else contraindicated **, ***

* http://www.who.int/ith/ITH_chapter_7.pdf?ua=1

** Fernando D et al. Primaquine in vivax malaria: an update and review on management issues. Malaria Journal. 2011;10(1):351

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

To prescribe or Not? Hospitalisation rate for adverse

events due to chloroquine or mefloquine has been measured as 1 per 10 000 users*

The incidence of malaria in travellers to many destinations (egmuch of Asia and the Americas) is less than the risk of adverse events due to chemoprophylaxis

Therefore, prescribing must be tailored taking into account: destination, season, type of travel, length of travel and personality

*Steffen R et al.(1993). Mefloquine compared with other chemoprophylactic regimens in tourists visiting East Africa.

Lancet, 341, 1299-1303

Medication Advantages Disadvantages

Mefloquine (Lariam®) Weekly dosing

Long half life

Good data for long term use

“No” accumulative adverse events

Pregnancy?: NZ Medsafe Category

B3 and advises against use in first

trimester

Safe in children ( ≥5kg)

Real and perceived adverse events

Excess neuropsychiatric side

effects

“Mid range” price

“Black Box” warning USA FDA

and European Drug safety

authorities considering the same

Doxycycline Cheap

Widely prescribed

Daily dosing

Generally well tolerated (but risk

of gastrointestinal side effects)

Compliance with 4 weeks post

travel dosing

Can’t use in children < 11yrs

(?8yrs) and pregnant women

(except maybe 1st trimester)

Atovaquone/Proguanil

(Malarone®)

Short course/easy compliance

Long half life

Well tolerated

Safe in children (≥11kg)

Cost

Limited data on use in pregnancy

Outline

Overview of Travel

Medicine

Key Resources

The Pre-Travel

Consultation

Information gathering

Travel Health Topics

Vaccine preventable diseases

Malaria

Q&As

Want to learn more?

Postgraduate qualifications in Travel

Medicine University of Otago,

Wellington.

See

http://www.otago.ac.nz/wellington

primarycare.distance@otago.ac.nz

jenny.visser@otago.ac.nz

Join NZ Society of Travel Medicine

www.nztravelmedicine.co.nz

Conference August 30th/31st Rotorua

Questions?

15/06/2014

95

Reminder — evaluation forms please & remember to pass your quiz

entry to GSK as you leave the room