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Student Electives 2008

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Anopheline. Physical Avoidance. Indoors. AC; screens. Impregnated netting. Permethrin 'tucked in' ... Most common cause fever in travellers from sub saharan ... – PowerPoint PPT presentation

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Title: Student Electives 2008


1
Student Electives 2008
  • Dr Alisdair MacConnachie
  • Consultant in Infectious Diseases
  • Brownlee Centre

2
Plan
  • Bite avoidance
  • Malaria
  • Dengue fever
  • HIV and use of PEP
  • Water exposure and Bilharzia
  • Rabies risk and vaccination

3
Bite Avoidance
Aedes
Anopheline
4
Physical Avoidance
  • Indoors
  • AC screens
  • Impregnated netting
  • Permethrin
  • tucked in
  • mosquito free
  • Clothing
  • Cover up (arms, legs, ankles, feet)
  • Spray/soak clothing

5
Repellant
6
DEET
-
-
30 re apply every 3-4 Hrs
-
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9
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
  1. Doherty et al QJM 199588277-81, OBrien et al
    CID 200133603-9, Antimori et al J Trav Med
    200411135-42
  2. Kain et al CID 199827142-9

10
INCUBATION P.falciparum 7-14 dy P.vivax
12-17dy P.ovale 15-18dy P.malaria 18-40dy (gt1yr)
DIAGNOSIS Antigen testing Blood films (thick
thin) PCR
11
Malaria
  • Clinical Features
  • Fever, malaise, headache, myalgia, diarrhoea
    etc..
  • Anaemia
  • Jaundice
  • Renal impairment
  • Severe malaria
  • Parasitaemia gt2
  • Cerebral malaria
  • Severe anaemia
  • Renal failure
  • Shock
  • DIC
  • Acidosis
  • Pulmonary oedema
  • Treatment
  • Quinine Doxycicline
  • Malarone

12
Chemoprophylaxis
  • Must be used in conjunction with PPM
  • Suppress/prevent symptoms caused by blood stages
  • Continued post travel
  • Choices
  • Mefloquine
  • Doxycicline
  • Malarone (atovaquone/progaunil)

13
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)

14
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

15
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!

16
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

17
Dengue fever
  • 100 million cases/yr
  • Day biting
  • Incubation 5-14 days

18
Clinical Features
  • Breakbone Fever
  • Headache
  • Fever
  • Retro-orbital pain
  • Arthralgia/myalgia
  • Rash
  • Cough
  • Sore throat
  • Nausea
  • Diarrhoea
  • Laboratory
  • Leucopenia
  • Thrombocytopenia
  • Transaminitis

19
Dengue Haemorrhagic Fever
  • lt1 infections
  • Definition
  • ?vascular permeability
  • Thrombocytopenia
  • Fever
  • Bleeding
  • Less likely in travellers

20
HIV PEP
21
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 (33.446.0) million
22
Routes of transmission
  • Sharing injecting equipment
  • Unprotected penetrative sexual contact
  • Oral sex
  • Mother to baby
  • Blood products
  • Needle stick injury

23
HIV is not passed on through social contact
  • Such as
  • Hugging
  • Kissing
  • Shaking hands
  • Sharing cups or cutlery
  • Sitting on the same toilet seat

24
What Are The Risks?
  • Malawi seroprevalence 1 in 12
  • Needlestick 1 in 300
  • Receptive vaginal intercourse 1 in 500
  • Insertive vaginal intercourse 1 in 1000
  • Receptive anal intercourse 1 in 33
  • Insertive anal intercourse 1 in 1667

25
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

26
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)

27
HIV Risk
  • Know your risks
  • Do not put yourself at unnecessary risk
  • Prompt first aid and PEP
  • Get home

28
Schistosomiasis (Bilharzia)
29
Schistosomiasis (Bilharzia)
  • Helminth Trematode (flatworm)
  • 3 major species
  • S. haematobium
  • S. mansoni
  • S. japonicum

30
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)

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33
Schistosomiasis Exposure Risk
  • Freshwater (saltwater is safe)
  • Swimming
  • Paddling
  • Splashing
  • Washing
  • Showers
  • Drinking

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35
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.

36
S. mansoni
S. haematobium
S. japonicum
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39
Bladder and Ureter Calcification
40
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!

41
SchistosomiasisDiagnosis
  • At least 8 weeks after last exposure
  • Katayama fever (3)
  • Asymptomatic screening
  • Serology
  • Stools x 3
  • Urine 24 hour collection

42
SchistosomiasisTreatment
  • Praziquantel 40mg/kg on one day
  • Side effects very rarely reported
  • 80 effective (reduction in egg counts, endemic
    areas)
  • Serology remains positive

43
Rabies
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48
Rabies Risk
  • Infected saliva warm blooded animal
  • Bite
  • Lick
  • Scratch

49
Rabies Prevention
  • Avoid contact
  • Pre-exposure vaccination 0, 7, 21 or 28 days

50
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

51
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

52
Rabies - Why have pre-travel vaccination?
  • Less likely to die of rabies
  • Less stressful
  • HRIG world shortage
  • Fewer post exposure vaccinations

53
  • 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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