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Student Electives 2008

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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  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 -

  7. 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

  8. 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

  9. 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

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

  11. 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)

  12. 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

  13. 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!

  14. 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

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

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

  17. Dengue Haemorrhagic Fever • <1% infections • Definition • ↑vascular permeability • Thrombocytopenia • Fever • Bleeding • Less likely in travellers

  18. HIV PEP

  19. 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

  20. Routes of transmission • Sharing injecting equipment • Unprotected penetrative sexual contact • Oral sex • Mother to baby • Blood products • Needle stick injury

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

  22. 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

  23. 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

  24. 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)

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

  26. Schistosomiasis (Bilharzia)

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

  28. 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)

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

  30. 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.

  31. S. mansoni S. haematobium S. japonicum

  32. Bladder and Ureter Calcification

  33. 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!

  34. SchistosomiasisDiagnosis At least 8 weeks after last exposure • Katayama fever (3%) Asymptomatic screening: • Serology • Stools x 3 • Urine – 24 hour collection

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

  36. Rabies

  37. Rabies Risk Infected saliva –warm blooded animal • Bite • Lick • Scratch

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

  39. 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

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