An effective travel medicine consult considers the individual patient in the context of their personal risk factors and itinerary, says Associate Professor Bernie Hudson, Director of Microbiology and Infectious Diseases at Sydney’s Royal North Shore Hospital.
He warns that it’s not quite business as usual in terms of travel health and safety. “Civil disruptions, strife, and economic effects have been significant,” he says. “There is a strong likelihood that infrastructure for disease control in many countries has been impacted by COVID and other things.”
This impacts patterns of disease risk, as well as access to healthcare services, and Hudson recommends we forget what we thought we knew about what diseases are a risk. “Even a destination where you’ve been before, and you think you know everything about the country, think again,” he says.
Malaria chemoprophylaxis is a particular issue. Malaria cases decreased during COVID lockdowns, but are on the rise again and there have been shifts in the geographical risk. “If you were only taking anti-mosquito measures [pre-COVID], think again,” he warns.
Tafenoquine is a newer option in malaria chemoprophylaxis that has been on the Australian market since 2019.
“The advantage with tafenoquine is that after taking the loading doses, you only have to take it weekly,” Associate Professor Hudson says. “It’s also effective against all stages of the parasite including in the liver.”
It offers causal prophylaxis similar to atovaquone/proguanil, and is not much more expensive. It does require a G6PD assay prior to prescription.
“Prescribing for men is pretty straightforward,” Hudson says, with a normal qualitative or quantitative test meaning it is safe to prescribe. “For women, it’s a little bit problematic due to polymorphisms,” but quantitative testing still provides adequate guidance.
Tafenoquine is not recommended for pregnant patients due to lack of data. “But there are not many options for women who are pregnant, and they are better off avoiding travel to areas where they could be at risk of malaria,” Associate Professor Hudson says.
Associate Professor Hudson says there is increasing evidence that atovaquone/proguanil is still effective even if the full post-exposure dosage regimen is not followed, however it is still best to recommend the full seven days.
Atovaquone/proguanil as treatment remains an option for people entering malaria-prone areas for short periods only who prefer not to use a full course of prophylaxis. Four tablets a day for three days may be taken at the first sign of potential malaria symptoms.
Associate Professor Hudson recognises it can be tricky to provide confident individualised advice to some travel patients, especially for complicated itineraries or when patients aren’t entirely sure where they are going. He says that recommendations for what prophylaxis or vaccines are needed is a based on local data, but this may not always be accurate. “The collection of data in many countries is insufficient to say this is evidence-based,” he says, noting that this also means advice may change.
He recommends GPs have access to some sort of validated advice that is as up to date as possible. This is sometimes in-built in practice software, but there are also fee-for-report services like Travel Health Advisor, of which he is the Director. The service allows the patient and their GP to receive a personalised advice plan from a specialist such as him.
Associate Professor Bernie Hudson will be giving a Travel Medicine Update at Healthed’s next webcast. Register here to attend.
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