Malaria, Zika und Co. auf Reise Wissenswertes für Schwangere und

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1 Malaria, Zika und Co. auf Reise Wissenswertes für Schwangere und

2 Prof. Dr. Patricia Schlagenhauf, PhD University of Zürich Centre for Travel Medicine, Biostatistics, Epidemiology and Prevention Institute Declara(ons Member of the GeoSen(nel Leadership Team Editor-in-Chief, Travel Medicine and Infec/ous Disease Consultant on an(-malarials to Pharma and Ministries Page 2

3 Mückenübertragbare Infektionen THE BIG FOUR Mücke Therapie Dengue Aedes* Mückenschutz Paracetamol Hydrierung, BeFruhe 5-8 Tage Chikungunya Aedes* Mückenschütz Paracetamol Hydrierung, BeFruhe 2-8 Tage (1-12) Zika Aedes* Mückenschütz Paracetamol Hydrierung, BeFruhe 3-14 Tage Malaria Anopheles Mückenschütz Chemoprophylaxe Verschiedene Malariameds 7 Tage bis Monaten * tagesaktiv Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Seite 3

4 Circa 500 million travellers travel per year to areas with mosquito-borne illness! Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Seite 4

5 Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Seite 5

6 Dengue Global Risk Map Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Seite 6

7 Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Page 7

8 ZIKA GLOBAL DISTRIBUTION February 2017 (ECDC) Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Seite 8

9 Rodriquez Morales A, et al Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Page 9

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11 Zika Cases imported by travellers n=93 4 Cases of pregnancy- Zika infected foetus (2)

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13 WHICH REPELLENT IS BEST? DEET (N,N-diethyl-3-methylbenzamide) at concentra(ons of!20% shows the highest efficacy and longest protec(on period (up to 10 hours) against Aedes species Increasing the concentra(on is not recommended, repellents are water soluble A. aegyp/ is harder to repel than A. albopictus Day(me use sunsreen first Page 13

14 DEET Repellents! - are considered safe in pregnancy! - risk of accumulation in the fetus is low! The mosquito net John Singer Sargent (1912)! 14

15 Insek(zide Abtötende Wirks(ffe die auf Kleider und Mückennetze aufgebracht oder in Räumen verwendet werden Sprays enthalten meist Pyrethroide (BioKill, MückoRex, NOBITE Kleidung, Trix Räucherspiralen (English:coils)- Pyrethrum Insek(zidverdampfer die an der Steckdose verdampfenden WirkstoffpläFchen setzen Pyrethroide frei Considered safe for use in pregnancy

16 WHO recommends that men and women returning from ZIKA areas should Prac(ce safe sex for 6 months regardless of whether or not they have symptoms

17 Sexual transmission of Zika virus Current guidelines for testing of returning travellers for ZIKV infection -> Swiss TPH WHO recommends that men and women returning from ZIKA areas should Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Practice safe sex for 6 months regardless of whether or not they have symptoms Page 17

18 ZIKV in breast milk? All children were being breasled while their mothers presented with a rash and Zika infec(on. In all cases, breast milk tested posi@ve by RT-PCR and subsequently inoculated on Vero cells in order to detect replica(ve ZIKV. Where serum and breast milk samples were collected no more than one day apart, ZIKV RNA load in breast milk samples was much higher than in sera Infec@ve viral par@cles with substan@al viral loads were reported from New Caledonia University of Zurich, NECTM 6, Patricia Schlagenhauf Consequences? Page 18

19 Anopheles Mosquito borne infections and prevention 2017, University of Zurich, New Zealand_Pre Patricia history Schlagenhauf to future, Patricia Schlagenhauf Seite 19 Seite 19

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21 Changes of global malaria incidence, (WMR/WHO 2014) MOSQUITO NETS WORK! Malaria mortality: 25% Global reduction 33% reduction in WHO Africa Region over the last 10 years: > 1 Million lives saved

22 The Lancet Infectious Diseases, January 2015! 32,000 ill returned travellers evaluated! Time frame 5 years! Possible to iden(fy risk groups and risk des(na(ons Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Page 22

23 THINK MALARIA first if a traveller returns with fever... Male:female Travel reason B:I:M/V:T:VFR Exposure region SSA:SEA:SCA:SA:EU:NA Malaria Acute unspecified diarrhoea Viral syndrome (no rash) Chronic diarrhoea, unknown cause Acute bacterial diarrhoea, unknown cause Dengue fever Giardiasis Insect bites Skin and soft tissue infections Campylobacter infection Active tuberculosis Schistosomiasis Chronic hepatitis Post-infectious irritable bowel syndrome Influenza and influenza-like illness Gastroenteritis Cutaneous larva migrans, hookworm Upper respiratory tract infection Rabies post-exposure prophylaxis Febrile illness, unknown cause (duration <3 weeks) 68:32 44:56 54:46 41:59 47:53 51:49 47:53 38:62 60:40 52:48 58:42 60:40 60:40 36:64 51:49 46:54 47:53 47:53 51:49 60:40 12:6:9:14:52 14:0:9:68:7 16:1:7:61:15 11:1:12:67:6 14:0:15:60:10 10:0:5:71:11 11:3:17:62:5 10:0:6:77:6 10:2:8:65:12 11:0:6:75:6 2:75:0:3:17 9:18:33:21:16 1:84:1:3:10 10:0:43:40:2 14:1:4:65:12 9:2:11:62:16 5:1:5:83:4 11:1:16:55:15 5:0:3:76:13 12:3:12:50:18 86:1:5:5:0:1 28:16:19:6:3:9 33:18:10:4:3:2 18:13:19:8:3:9 32:12:15:4:6:10 0:43:14:12:1:0 23:6:43:6:2:6 25:22:10:11:8:3 25:25:12:7:5:4 15:23:25:3:13:5 36:7:21:4:11:5 74:2:1:2:0:10 44:10:10:5:15:5 28:10:15:7:2:10 25:11:7:5:14:2 25:14:17:5:11:8 17:41:4:18:1:1 26:17:13:5:6:3 9:37:9:9:8:14 39:12:8:6:2: Proportionate morbidity per 1000 ill patients Figure 2: Top diagnoses in all ill travellers presenting to EuroTravNet clinics (N=32 136) in Colours: red bars are febrile illness, purple bars are gastrointenstinal tract illness, light blue bars are dermatological illness, green bars are respiratory illness, and dark blue Mosquito borne infections and prevention 2017, Page 23 Patricia Schlagenhauf

24 Malaria cases in Switzerland (FOPH) Number of reported cases / 0-3 deaths per year 24

25 " Mehr als 630 Fälle, meistens Plasmodium falciparum " > 58% sind in W. Afrika mit Malaria infiziert " Risiko Gruppe 1 VFR Visi@ng Friends and Rela@ves " Weniger als 20% haben eine Malariaprophylaxe eingenommen " Mückenschutz UND Mefloquine Malariaprophylaxe sind empfohlen

26 Malaria: Ursache und Krankheit ÜBERTRÄGER: Anopheles-Mücke, sticht nur nachts ERREGER: ABLAUF: Plasmodien (Parasiten) # P. falciparum $ Malaria tropica, 1-2% Tod # P. vivax, P. malariae, P. ovale # P. knowlesi # Parasiten gelangen in Leber, dort Vermehrung # Innerhalb 6 Tage - meistens 4 Wochen: Parasiten von Leber in Blutbahn SYMPTOME: # Fieber, Kopf- und Gliederschmerzen, "Grippe", nach 24 h Koma, Nierenversagen etc. Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Seite 26

27 Information betreffend Malariaprävention NUR NEED TO KNOW % Epidemiologie wo Übertragungsrisiko? ev. Ausmass % Ae(ologie Übertragungsweg % Pathophysiologie Inkuba(onszeit 6 Tage Parasiten Leber $ Erythrocyten < 4 Wochen Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Seite 27

28 Which chemoprophylaxis in pregnancy? Priority Antimalarial" for chloroquine resistant Pf (CRPF)"! Mefloquine*! 250mg WEEKLY"! Atovaquone/proguanil*! 250mg/100mg daily"! Doxycycline*! 100mg daily"! Future?: Tafenoquine NON OPTION - Homeopathy Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Seite 28

29 CHECKLIST for PRESCRIBERS Germany

30 Summary pregnancy/an(malarials Atovaquone Proguanil Contraindicated new guidelines..? An(malarials for Prophylaxis** in Pregnancy Mefloquine Doxycycline Chloroquine Allowed 1*, 2, 3 trimester Contraindicated BUT... Allowed 1, 2, 3 trimester Primaquine Contraindicated * CDC. Canada **For multi-drug resistant Pf areas there is NO SAFE chemoprophylaxis for pregnant women Schlagenhauf 2017 Page 30

31 The model Claudia S, 39, pregnant with her third child will join her husband in Lagos where he has a 2-month contract. Should she defer the trip? Can she use a chemoprophylaxis? Can you advise her on the use of repellents and other personal protec@on measures in pregnancy? Vitamin B? Garlic? Is there an evidence base? Schlagenhauf 2017 Page 31

32 ANTI- MALARIA MEASURES IN PREGNANCY Experience Evidence grade Insec(cide treated nets Posi(ve. Results from RCTs, Cochrane report. 1 A Repellents Posi(ve 1 A Mefloquine prophylaxis Atovaquone/proguanil prophylaxis Doxycycline prophylaxis RCT : randomised controlled trial Posi(ve. 2 x RCT, Database analysis Expert opinion posi(ve No RCT. Expert opinion posi(ve No RCT. Expert opinion (Swedish) posi(ve for early pregnancy Schlagenhauf 2017 Page 32 1A 3 B 3 B

33 Chemoprophylaxis and Concep(on How long must one wait before becoming pregnant? Mefloquine 0*-3 Months Atovaquone/proguanil 2 Weeks Doxycycline 1 Week * US, Canada Schlagenhauf 2017 Page 33 33

34 Maxine M, 27, is breasleeding her daughter Nicole (5 kg) and must travel to Sudan. Can you advise her on the risk and preven(on of malaria for herself and her breasled infant? The other children will stay in Zürich with her husband Schlagenhauf

35 Maxime s village is approx 100 km south of Khartoum. Plasmodium falciparum > 95%. Chloroquine resistance reported. Schlagenhauf/Funk, PDQ Travellers Malaria 2003 Schlagenhauf

36 Lacta(on - Breasleeding There is insufficient antimalaria drug in " breast milk to protect the infant. " Breastfed babies require their own chemoprophylaxis! Schlagenhauf 2017 Page 36

37 Breastfeeding - Lactation Mefloquine Is excreted in breast milk.compatible with lactation (CDC, WHO) Doxycycline Excreted in milk. Allowed by CDC, AAP, contraindicated by WHO Atovaquone/ proguanil Excreted in milk - Allowed for breastfed infants >5kg (CDC) Fouquet J., Virgin and Child, 1481! Schlagenhauf 2017 Page 37

38 % Ein effek(ver Mückenschutz ist die beste vorbeugende Massnahme für alle Mückenübertragbare Krankheiten % MückenschützmiFel (Repellent) für die Haut -> DEET % Insek(zide auf Kleider sprayen, Netze in Malariagebiete % Besondere Richtlinien für Schwangere die in Zika Gebiete reisen und safe sex % DENV, CHIKV, ZIKA : Paracetamol bei Schmerzen % Malaria hochrisiko Gebiete : Prophylaxe : Mefloquine Unerwünschten ArzneimiFelwirkungen, KI % Fieber nach Rückkehr? Immer an Malaria denken! Vielen Dank Mosquito borne infections and prevention 2017, Patricia Schlagenhauf Page 38