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Student Electives 2008. Dr Alisdair MacConnachie Consultant in Infectious Diseases Brownlee Centre. Plan. Bite avoidance Malaria Dengue fever HIV and use of PEP Water exposure and Bilharzia Rabies risk and vaccination. Bite Avoidance. Aedes. Anopheline. Physical Avoidance. Indoors

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Student Electives 2008

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Student electives 2008

Student Electives 2008

Dr Alisdair MacConnachie

Consultant in Infectious Diseases

Brownlee Centre


Student electives 2008

Plan

  • Bite avoidance

  • Malaria

  • Dengue fever

  • HIV and use of PEP

  • Water exposure and Bilharzia

  • Rabies risk and vaccination


Bite avoidance

Bite Avoidance

Aedes

Anopheline


Physical avoidance

Physical Avoidance

  • Indoors

    • AC; screens

  • Impregnated netting

    • Permethrin

    • “tucked in”

    • “mosquito free”

  • Clothing

    • Cover up (arms, legs, ankles, feet)

    • Spray/soak clothing


  • Repellant

    Repellant


    Student electives 2008

    DEET

    -

    -

    30% re apply every 3-4 Hrs

    -


    Malaria

    Malaria

    • 27-48% hospitalised returning travellers1

    • Most common cause fever in travellers from sub saharan Africa

    • 10% Geosentinal no report of fever

      • GI

      • Respiratory

      • Headaches

  • Diagnosis initially missed up to 59% cases2

    • Rx 7.6 days after admission

    • Doherty et al QJM 1995;88:277-81, O’Brien et al CID 2001;33:603-9, Antimori et al J Trav Med 2004;11:135-42

    • Kain et al CID 1998;27:142-9


    Student electives 2008

    INCUBATION

    P.falciparum 7-14 dy

    P.vivax 12-17dy

    P.ovale 15-18dy

    P.malaria 18-40dy (>1yr)

    DIAGNOSIS

    Antigen testing

    Blood films (thick & thin)

    PCR


    Malaria1

    Malaria

    • Clinical Features

      • Fever, malaise, headache, myalgia, diarrhoea etc…………..

      • Anaemia

      • Jaundice

      • Renal impairment

  • Severe malaria

    • Parasitaemia >2%

    • Cerebral malaria

    • Severe anaemia

    • Renal failure

    • Shock

    • DIC

    • Acidosis

    • Pulmonary oedema

  • Treatment

    • Quinine + Doxycicline

    • Malarone

    • Artemesinins


  • Chemoprophylaxis

    Chemoprophylaxis

    • Must be used in conjunction with PPM

    • Suppress/prevent symptoms caused by blood stages

      • Continued post travel

  • Choices

    • Mefloquine

    • Doxycicline

    • Malarone (atovaquone/progaunil)


  • Mefloquine larium

    Mefloquine (Larium)

    • 250mg once weekly

      • With food

      • Same time & day

  • Start 1 week prior, throughout risk & 4 weeks after

    • 3 weekly doses prior for toxicity

  • Contraindications

    • Severe liver disease; epilepsy; psychiatric illness

  • Side effects

    • Nausea etc

    • Psychiatric illness (sleep disturbance to psychosis)


  • Doxycicline

    Doxycicline

    • 100mg daily

      • With food

  • Start 2-3 days prior, throughout risk & 4 weeks after

  • Contraindications

    • Pregnancy; children; porphyria

    • Drug interactions (OCP)

  • Side effects

    • Nausea etc

    • Photosensitivity


  • Malarone

    Malarone

    • 1 tablet daily

      • With food

  • Start 1-2 days prior, throughout risk & 1 week after

  • Contraindications

    • Drug interactions; pregnancy

  • Side effects

    • Nausea etc

    • Cost!


  • Standby therapy

    Standby Therapy

    • Allows prompt treatment

      • Remote from medical care

  • NOT substitute for medical attention

  • Regimes

    • Malarone 4 tabs daily for 3 days

    • Quinine/doxycicline

    • Riamet

  • Interactions & SEs

    • Medical evaluation


  • Dengue fever

    Dengue fever

    • 100 million cases/yr

    • Day biting

    • Incubation 5-14 days


    Clinical features

    Clinical Features

    • “Breakbone Fever”

      • Headache

      • Fever

      • Retro-orbital pain

      • Arthralgia/myalgia

      • Rash

      • Cough

      • Sore throat

      • Nausea

      • Diarrhoea

  • Laboratory

    • Leucopenia

    • Thrombocytopenia

    • Transaminitis


  • Dengue haemorrhagic fever

    Dengue Haemorrhagic Fever

    • <1% infections

    • Definition

      • ↑vascular permeability

      • Thrombocytopenia

      • Fever

      • Bleeding

  • Less likely in travellers


  • Hiv pep

    HIV PEP


    Adults and children estimated to be living with hiv 2005

    Adults and children estimated to be living with HIV – 2005

    Eastern Europe & Central Asia

    1.5 million

    [1.0 – 2.3 million]

    Western &

    Central Europe

    720 000

    [550 000 – 950 000]

    North America

    1.3 million

    [770 000 – 2.1 million]

    East Asia

    680 000

    [420 000 – 1.1 million]

    North Africa & Middle East

    440 000

    [250 000 – 720 000]

    Caribbean

    330 000

    [240 000 – 420 000]

    South & South-East Asia

    7.6 million

    [5.1 – 11.7 million]

    Latin America

    1.6 million

    [1.2 – 2.4 million]

    Sub-Saharan Africa

    24.5 million

    [21.6 – 27.4 million]

    Oceania

    78 000

    [48 000 – 170 000]

    Total: 38.6 (33.4–46.0) million


    Routes of transmission

    Routes of transmission

    • Sharing injecting equipment

    • Unprotected penetrative sexual contact

    • Oral sex

    • Mother to baby

    • Blood products

    • Needle stick injury


    Hiv is not passed on through social contact

    HIV is not passed on through social contact

    Such as :

    • Hugging

    • Kissing

    • Shaking hands

    • Sharing cups or cutlery

    • Sitting on the same toilet seat


    What are the risks

    What Are The Risks?

    • Malawi seroprevalence1 in 12

    • Needlestick1 in 300

    • Receptive vaginal intercourse1 in 500

    • Insertive vaginal intercourse1 in 1000

    • Receptive anal intercourse1 in 33

    • Insertive anal intercourse1 in 1667


    Post exposure prophylaxis

    Post Exposure Prophylaxis

    • First Aid

      • Encourage bleeding

      • Wash with soap & water

      • Wash mucosal surfaces

  • Antiretroviral PEP

    • Reduced risk by up to 100 fold

    • Most effective within 1 hour


  • Post exposure prophylaxis1

    Post Exposure Prophylaxis

    • Combivir 1 tab b.d

      • AZT & Lamivudine (3TC)

      • Headache, nausea

      • Anaemia

  • Kaletra 2 tab b.d

    • Lopinovir/ritonavir

    • Nausea, diarrhoea

    • Drug interactions +++

  • Continued for 28 days (testing at 3 months)


  • Hiv risk

    HIV Risk

    • Know your risks

    • Do not put yourself at unnecessary risk

    • Prompt first aid and PEP

    • Get home


    Student electives 2008

    Schistosomiasis (Bilharzia)


    Schistosomiasis bilharzia

    Schistosomiasis (Bilharzia)

    • Helminth: Trematode (flatworm)

    • 3 major species:

      • S. haematobium

      • S. mansoni

      • S. japonicum


    Schistosomiasis

    Schistosomiasis

    • Second most prevalent tropical disease after malaria.

    • 500-600 million people worldwide at risk

    • 200 million infected worldwide: 120 million symptomatic and 20 million have severe disease

    • 80% of those infected are in sub-Saharan-Africa: annual mortality in sub-Saharan Africa is estimated to exceed 150,000 (WHO)


    Schistosomiasis exposure risk

    Schistosomiasis Exposure Risk

    Freshwater (saltwater is safe)

    • Swimming

    • Paddling

    • Splashing

    • Washing

    • Showers

    • Drinking


    Infection

    Infection

    • Infection is usually asymptomatic, especially in residents of endemic areas

    • Symptomatic infection:

      - “Swimmers itch” soon after infection

      - Katayama fever at least 6 weeks after infection - immunological reaction to soluble egg antigen, as the worms begin to lay eggs.


    Student electives 2008

    S. mansoni

    S. haematobium

    S. japonicum


    Bladder and ureter calcification

    Bladder and Ureter Calcification


    Schistosomiasis risk reduction

    SchistosomiasisRisk Reduction

    Avoid water contact

    No evidence for efficacy of:

    • Brisk towelling after water contact

    • DEET before water contact

    • Waterproof sun cream

      …but it might be worth a try!


    Schistosomiasis diagnosis

    SchistosomiasisDiagnosis

    At least 8 weeks after last exposure

    • Katayama fever (3%)

      Asymptomatic screening:

    • Serology

    • Stools x 3

    • Urine – 24 hour collection


    Schistosomiasis treatment

    SchistosomiasisTreatment

    • Praziquantel 40mg/kg on one day

    • Side effects very rarely reported

    • 80% effective (reduction in egg counts, endemic areas)

    • Serology remains positive


    Student electives 2008

    Rabies


    Rabies risk

    Rabies Risk

    Infected saliva –warm blooded animal

    • Bite

    • Lick

    • Scratch


    Rabies prevention

    Rabies Prevention

    • Avoid contact

    • Pre-exposure vaccination: 0, 7, 21 or 28 days


    Rabies wound management

    RabiesWound Management

    • Wash by flushing under running tap for 10 minutes then wash with soap or water

    • Do not scrub, rub or squeeze

    • Apply disinfectant: 40-70% alcohol, tincture or aqueous povidine iodine, cetrimide

    • Do not suture, if possible


    Rabies post exposure prophylaxis

    RabiesPost Exposure Prophylaxis

    Following pre-exposure vaccinations:

    • 2 doses of rabies vaccine on days 0 and 3

      No pre-exposure vaccination:

    • HRIG (human rabies immunoglobulin) 20iu/kg

      plus

    • 5 doses vaccine on days 0, 3, 7, 14, 28


    Rabies why have pre travel vaccination

    Rabies - Why have pre-travel vaccination?

    • Less likely to die of rabies

    • Less stressful

    • HRIG world shortage

    • Fewer post exposure vaccinations


    Student electives 2008

    “Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts.  Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one's lifetime.” 

    Mark Twain


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