Tuesday, June 2, 2015

Sun, Sand, Sea along with Hepatitis A and B? A Brief Overview of Travel Medicine

So far I have written two blogs, both outlining my personal experience at mdBriefCase. This blog is a little different. I thought it would be nice to review an rxBriefCase program, and present highlights from a pharmacy student's perspective. By no means is this blog intended to be a comprehensive report on travel medicine; it’s simply just a bird’s eye view of the topic (no pun intended). 

After searching through the program directory, I decided to explore Stay Safe, Play Safe: Topics in Travel Medicine.

Why? Well, for a couple of reasons.

Firstly, I have the travel bug. So at a personal level, this topic seemed relevant and interesting. My most memorable travel destination thus far would have to be the beautiful island of Tenerife. Check it out

Secondly, as a future pharmacist, I believe it is very important to have knowledge in the area of travel medicine. As one of the most accessible health care professionals, pharmacists are likely the first to receive questions from patients related to their travel health. As pharmacists, it is even more important to know where to find travel health information. Not only is this body of knowledge quite cumbersome, travel advisory warnings are dynamic over time. 

Overview of Travel Health

In 2012, Canadians made about 1.6 million overnight trips to Mexico, over 1 million trips to Cuba and over 900,000 trips to the Dominican Republic 1. However, only 4% of those Canadians conducted online research for travel advisory warnings 2. Compare that to the 35% who researched things to do while at their destination 2. Shocking!

Travelers are often quick to assume that there is little to no risk of infectious disease associated with travel to popular vacation destinations. However it is important to remember that in addition to turtles, dolphins and birds of paradise…bacteria, viruses and parasites are all the more present.

Pre-Travel Health Assessment

I’m pretty confident in stating that all pharmacy students love mnemonics! Personally, I find them useful as mini mental check-lists, guiding me through patient interactions.

A pre-travel health assessment contains three parts…so commit these to memory and you will ACE every patient encounter! 

  1. Assessment of the traveler’s risk: through collection of detailed information related to the traveler’s health status AND the travel itinerary
  2. Communication of this risk to the traveler
  3. Execution of a travel plan: including information on ways to reduce risk, as well as manage undesirable outcomes should they occur
The Centers for Disease Control and Prevention has excellent summary tables which can help guide your pre-travel health risk assessment.

Recommended Vaccines
Vaccines can be divided into three categories. Remember them as the 3 R’s
  1. Routine:  recommended for all Canadians irrespective of travel, according to provincially authorized schedules
  2. Recommended: specifically recommended based on the particular travel destination, the details of the travel itinerary and the traveler’s health status
  3. Required: the traveler must have these vaccines in order to be granted entry into the visiting country
As mentioned, recommended vaccines are advised to travelers in part, based on the particular travel location. For example, you wouldn't recommend a patient receive a typhoid vaccine if the destination they are travelling to is not endemic to typhoid fever. 

Two excellent sources of information outlining country specific travel advisories are:
  1. The World Health Organization International Travel and Health Interactive Map
  2. The Government of Canada's travel section outlining Country Travel Advice and Advisories
TIP: Conducting a pre-travel health assessment provides a window of opportunity to help identify patients whose routine vaccinations are not up-to-date. Capitalize on this time to provide information on routine vaccination schedules, which can be found on the Public Health Agency of Canada's website. There are also great apps (i.e. Immunize Canada) which are available to help your patients keep track of their immunization record...much more convenient than little pocket cards which frequently get misplaced.

Hepatitis A and Hepatitis B

Hepatitis A and B are considered travel concerns in many popular tourist destinations, yet they are often overlooked as such by travelers. Therefore, I have decided to provide some information on ways to decrease the risk of contracting this virus during travel. 

Hepatitis A 3

One of the ways in which Hepatitis A can be transmitted is through intake of food or water which has been contaminated with the virus. Some food and water precautionary tips include:
  • Encourage:
    • eating freshly cooked food that is served hot
    • drinking water from sealed water bottles or drinking carbonated water
  • Avoid:
    • eating from buffets (especially outdoors, where food is exposed to milder temperatures for an extended period of time)
    • eating foods washed with non-portable water (i.e. unpeeled raw fruits and vegetables)
    • consuming raw or under-cooked meat and/or seafood
    • drinking non-portable water (i.e. water that is not in a sealed bottle) 

Vaccination becomes paramount in order to prevent Hepatitis A. There are three monovalent vaccines available in Canada; the Canadian Immunization Guide provides dosages and schedules.

Hepatitis B 3

Hepatitis B is transmitted through direct or indirect contact with infected blood or body fluids. To reduce the risk of Hepatitis B, it is very important to avoid partaking in risky behaviours such as:
  • unprotected sexual contact
  • sharing of needles and/or equipment
  • cosmetic procedures using improperly sterilized tools (i.e. tattooing, piercing, manicuring)
Similar to Hepatitis A, vaccination becomes paramount in order to prevent contraction. There are two monovalent vaccines available in Canada; the Canadian Immunization Guide provides dosages and schedules.

Don't Forget About Mosquitoes

We know too well the struggle of enjoying a peaceful evening outside, while trying to swat away mosquitoes. However, in addition to being annoying, they can also carry serious health risks.

Chikung-whata? Chikungunya!

The Chikungunya virus is carried by very aggressive daytime biting mosquitoes (Aedes mosquito) and symptoms such as fever and polyarthritis typically appear within 3 to 7 days after the bite 3.The virus was first identified in Tanzania in the early 1950s 4. It can now be identified in nearly 40 countries, which means that even travelers to the Caribbean, Central or South America, Mexico and the United States, should be educated on mosquito avoidance tips 4,5

Did you know? The recent outbreak of 2013 caused more than 1,600 travelers to return to the United States with chikungunya fever 5

Mosquito Avoidance Tips 3

Physical Barriers
  • If your working or accommodations are outdoors, protect your area with screen and/or net coverings on all doors and windows
  • If your working or accommodations are indoors, keep the room cool with air conditioning, as mosquitoes do not prefer cooler temperatures
  • If you will be outdoors after dusk, wear light coloured clothing (i.e. white or beige), as mosquitoes are more attracted to bright colours
Chemical Barriers
  • Use mosquito repellents (i.e. DEET 30%)

TIP: If your patient is applying both sunscreen and mosquito repellent on their skin, encourage them to apply the sunscreen first, wait 15 minutes, then apply the mosquito repellent. This allows for maximum sun protection and minimum mosquito repellent absorption.

One Final Word...Vaccine Hesitancy

The topic of vaccination always receives a lot of media attention. Many individuals receive unsubstantiated claims which have been disseminated by social media. It is our task, as health care professionals, to dispel these false reports while continuing to show empathy in responding to patient concerns. The Canadian Immunization Guide provides great tips on Principles of Effective Communication

1.     Statistics Canada. Travel by Canadians to foreign countries, top 15 countries visited (2012). Available at:http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/arts37a-eng.htm. Accessed June 1, 2015.
2.     EKOS Research Associated Inc. Survey of Travellers on Key Issues Relating to Travel Health. (2008). Accessed June 1, 2015. http://www.ekospolitics.com/articles/0688.pdf
3.     Centres for Disease Control. CDC Health Information for International Travel 2014. The Yellow Book. Available at http://wwwnc.cdc.gov/travel/page/yellowbook-home-2014. Accessed June 1, 2015.
4.     World Health Organization. Chikungunya. Available at http://www.who.int/denguecontrol/arbo-viral/other_arboviral_chikungunya/en/. Accessed June 1, 2015.
5.     Centres for Disease Control. CDC Newsroom: Chikungunya Outbreak Progresses in Caribbean, Central and South America. Available at http://www.cdc.gov/media/releases/2014/p1106-chikungunya-outbreak.html. Accessed June 1, 2015