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1 Disclosure Generic drug names are identified in this presentation. Their corresponding Brand name is also identified. This was done to enhance recognition.

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Presentation on theme: "1 Disclosure Generic drug names are identified in this presentation. Their corresponding Brand name is also identified. This was done to enhance recognition."— Presentation transcript:

1 1 Disclosure Generic drug names are identified in this presentation. Their corresponding Brand name is also identified. This was done to enhance recognition of vaccine information and appeal to a non-pharmacist audience I have NO actual or potential conflict of interest in relation to this educational activity or presentation

2 22 Developing a Preventive Health Care Plan for a College-Aged Student: A Pharmacist’s Perspective. Grace Earl, PharmD, BCPS University of the Sciences in Philadelphia Philadelphia College of Pharmacy g.earl@usp.edu June 3, 2010

3 3 Description Clinical health initiatives of the Healthy Campus 2010 campaign address the need for primary prevention in a college-age population. The goal of the presentation is to develop an age-based plan for preventive care screenings and drug therapy interventions. Points on immunization practices will be emphasized such as understanding the indications, benefits and risks of vaccines that impact young men and women’s health. Barriers may include lack of adequate insurance coverage.

4 4 Outline Observations on College Health Serious Infectious Illnesses: Targets for Vaccination Human Papilloma Virus Vaccine for Women & Men Age-based Preventive Care Plan

5 5 http://www.cdc.gov/Features/CollegeHealth/

6 6 http://www.smith.edu/health/quiz.html

7 7 http://olin.msu.edu/survivalquiz.phpOlin Health Center

8 8 College Health Quiz Websites Center for Disease Control & Prevention College Health and Safety Issues Quick Quiz http://www.cdc.gov/Features/CollegeHealth/ Smith College, Northampton, MA http://www.smith.edu/health/quiz.html Michigan State University http://olin.msu.edu/survivalquiz.php

9 9 Pair and Share Questions Refer to your handout for a series of pair and share questions Consult with a partner and discuss your answers

10 10 Observations on College Health

11 11 College Student Health Quiz 1 What condition can run in families, usually starts between the ages of 15 and 30, and is experienced by about 20 million people in the United States? From Center for Disease Control & Prevention College Health and Safety Issues Quick Quiz http://www.cdc.gov/Features/CollegeHealth/

12 12 College Student Health Quiz 2 True or false: Sexually active adolescents and young adults are at lower risk for getting sexually transmitted diseases. http://www.cdc.gov/Features/CollegeHealth/

13 13 College Student Quiz 3 Which group of females is most likely to exhibit disturbances in behaviors such as anorexia, bulimia, or preoccupation with dieting, those that are….. underweight, normal weight, or overweight? Cohort from Eastern North Carolina University Sira N, Pawlak R. Nutr Res Pract 2010; 4(1):36-42

14 14 College Student Quiz 4 College students who are knowledgeable about the dietary nutrition guidelines are more likely to make healthy food choices when eating at the dining hall. Kolodinsky J, et al. J Am Diet Assoc. 2007 Aug;107(8):1409-13.

15 15 College Student Quiz 5 Which counter-marketing approach was more persuasive in changing college students inclination toward quitting smoking ….. Ads describing health consequences Ads showing tobacco industry manipulation Ads demonstrating social norms Murphy-Hoeffer R, et al. Am J Health Behav 2008;32(6):725-34

16 16 College Student Quiz 6 Which group had the greatest influence on encouraging college age students to receive the influenza vaccination? Media Nurses Parents Physicians Student health center Merrill RM, et al. Med Sci Monit 2010 Feb;16(2):PH29-34.

17 17 Take Home Message….

18 18 We need to remember… Young people do not recognize their risks Healthy appearing students may not have healthy behaviors Knowledge does not equal correct choices Linking an unhealthy behavior with a negative health consequence was shown to be effective in changing attitudes Health professionals can influence student choices

19 19 Learning Objectives Serious infectious illnesses - seasonal influenza and H1N1 flu - meningitis - tetanus, diphtheria, pertussis - chicken pox Human papilloma virus vaccine - cervical cancer risk factors and causes - cervical cancer presentation and outcomes - indications and dosing of human papilloma virus vaccine - potential adverse reactions Age-based preventive care plan - general health (vision, dental) - blood pressure screening - bone health (calcium and vitamin D) - mental health screening (alcohol; depression; smoking)

20 20

21 21 What Vaccines Do You Need? From CDC Vaccines & Immunizations Tailors for Gender: male/female I could become pregnant? I am pregnant now Do you live in a dormitory? Assesses Hepatitis A & B risk: sexual contact & street drug use Age 11-18 years or first year college student living in dormitory (meningitis) Have you been vaccinated against chicken pox? http://www2.cdc.gov/nip/adultImmSched/

22 22 Blood disorder ▫Anemia ▫Leukemia ▫Sickle cell anemia Cancer or cancer treatments Weakened immune system (HIV/AIDS) Diabetes Heart or lung disease Liver or kidney disease Factors Impeding Vaccination Do you have any of these diseases or medical conditions? http://www2.cdc.gov/nip/adultImmSched/

23 23

24 24 Seasonal Influenza & H1N1 flu Emerging epidemiology Seasonal vaccine will include H1N1 for 2010-11 Prevention with oseltamavir (Tamiflu®) and zanamivir (Relenza®)

25 25 Cases

26 26 Hospitalizations

27 27 Deaths

28 28 Flu Season 2010-2011 The H1N1 virus will be included in the seasonal influenza vaccine Announced Feb 22, 2010 http://www.flu.gov/news/blogs/blog20100222.html

29 29 FAQs: Why do I get the flu when I get the shot? 2 week lag time to achieve complete immune protection Those with weak immune system may not be mount a full immune response Circulating viruses do not match the vaccine virus types Change in circulating viruses during season http://www2c.cdc.gov/podcasts/player.asp?f=11042

30 30 Influenza resources http://www.flu.gov/http://www.flu.gov/http://www.flu.gov/ http://www.cdc.gov/flu/weekly/http://www.cdc.gov/flu/weekly/http://www.cdc.gov/flu/weekly/ Podcasts at CDC http://www2c.cdc.gov/podcasts/browse.asp\http://www2c.cdc.gov/podcasts/browse.asp\http://www2c.cdc.gov/podcasts/browse.asp\

31 31 Meningitis Signs and Symptoms Sudden onset of fever, headache, and stiff neck Photophobia (sensitivity to light) Confusion Nausea Vomiting http://www.cdc.gov/meningitis/about/symptoms.html http://www.nlm.nih.gov/medlineplus/ency/imagepages/2938.htm

32 32 Meningitis Complications Can be rapidly fatal Cranial nerve palsy Cerebral edema Mental retardation Deafness http://www.who.int/mediacentre/factsheets/fs141/en/

33 33 Meningitis Prevention Menactra – intramuscular injection ▫Quadrivalent conjugate, Ages 2 to 55 years Menveo – intramuscular injection (NEW) ▫Ages 11 to 55 years ▫Quadrivalent oligosaccharide conjugate Menomune – subcutaneous injection ▫Ages 2 and older ▫Quadrivalent polysaccharide vaccine ▫A, C, W-135 and Y

34 34 Meningitis Candidates Pre-teens & college freshman Institutionalized – colleges Individuals with sickle cell anemia or splenectomy Travelers Military recruits Hajj Sub-Saharan Africa (June to December)

35 35 Meningitis Exposure Treat close contacts with antibiotic prophylaxis Rifampin Ciprofloxacin (quinolone) Ofloxacin (quinolone) Azithromycin (macrolide)

36 36 Whooping Cough http://www.topnews.in/health/files/Whooping-Cough.jpg

37 37 Tetanus, Diphtheria, Pertussis Tetanus: Lockjaw Diptheria: mucous coating in back of throat Pertussis: Whooping Cough Link – the sounds of whooping coughLink – the sounds of whooping cough http://www.soundsofpertussis.com/mediaplayer.html

38 38 Pertussis Outbreaks National Notifiable Diseases Surveillance System Endemic – occurs every 3-5 years Last outbreak in 2005 with 25,616 reported cases including children and adults Vaccinate infants at 2, 4, & 6 months Fourth vaccine at 15-18 months Fifth vaccine when they enter school 4-6 years

39 39 Tdap vs. Td vaccines Td: tetanus & diptheria Tdap: tetanus, diptheria & acellular pertussis Td: given every 10 years, or after a cut or injury to protect against tetanus Tdap: licensed in 2005 Adults 19 to 65: substitute Tdap for the next booster dose Indicated for 1 lifetime dose to prevent pertussis

40 40 Chicken Pox Varicella Zoster Virus (VZV) Complications: Cerebellar ataxia, encephalitis, pneumonia due to secondary bacterial infection Maternal Transmission During 1 st and early 2 nd trimester Fetal death or skin scarring, eye abnormalities, limb hypoplasia Congenital Varicella Syndrome (CNS damage) http://www.nlm.nih.gov/medlineplus/images/chickenpox.jpg

41 41 Chicken Pox Risk groups Immunocompromised individuals Taking steroids or immunosuppressants Infants, children, adolescents Chronic diseases Pregnant women

42 42 Chicken Pox Contagious Period 1-2 days before rash appears up to crusting of lesions Return to school when vesicles have crusted At risk individuals ▫Antiviral drug ▫Oral acyclovir 80 mg/kg in 4 divided doses ▫Treat for 5 days http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1301.jpg

43 43 Chicken Pox Catch up vaccination ▫Anyone who has not had chicken pox > 12 months of age ▫No evidence of immunity ▫Varivax® ▫Live attenuated vaccine

44 44 Chicken Pox Evidence of immunity- required for entry to college Documentation of age-appropriate vaccinations Laboratory testing Birth in United States before 1980 (unless you are in at at risk group) Verification by a health care professional that individual had diagnosis of chicken pox or shingles

45 45 German Measles http://www.nlm.nih.gov/medlineplus/ency/imagepages/2943.htm

46 46 Measles, Mumps, Rubella Measles (Rubeola): fever, cough, runny nose, conjunctivitis Mumps: cough, sneezing, swollen salivary glands, fever Rubella (German Measles): maculopapular rash, onset of rash is 2 weeks after exposure ▫Maternal exposure: Congenital Rubella syndrome

47 47 Rubella No longer endemic 15 cases reported per year At risk ▫Individuals born outside the United States ▫Individuals from areas with low vaccine usage ▫Post pubertal men and women such as military recruits, college age students ▫Health care professionals

48 48 Measles, Mumps, Rubella Require on entry to college Proof of 2 vaccinations Titers demonstrating immunity Proof of physician diagnosed illness http://www.cdc.gov/vaccines/vpd-vac/combo-vaccines/mmr/faqs-nipinfo-mmr.htm

49 49 Vaccine Cases 4 scenarios

50 50 Vaccine Mini-case #1 A student enrolled in a health care professional program will be starting a rotation at a hospital. They send in evidence from their physician that they had chicken pox as a child. The practice site refuses this form of documentation and requires either titers or vaccination as proof. Why?

51 51 Vaccine Mini-case #2 A student is injured in a community service project. While involving with planting new trees, they cut their hand. Which vaccine should be administered?

52 52 Vaccine Mini-Case #3 During an H1N1 mass vaccination program, one of the students returns 20 minutes after administration of the vaccine with hives. What action do you take?

53 53 Vaccine Adverse Event Reporting VAERS 1-800-822-7967 http://vaers.hhs.gov

54 54 Vaccine Mini-Case #4 A young person has Rheumatoid Arthritis and hates “shots.” She asks if she can receive the seasonal influenza live attenuated vaccine that is administered intranasally. What advice can you offer?

55 55 Immunosuppressant Drugs Use in Asthma Inflammatory bowel disease Rheumatoid athritis Allergic Reactions Nephrotic Syndrome Oral Steroids Prednisone (Deltasone®) Methylprednisone (Medrol Dosepak®) Use in Rheumatoid Arthritis Inflammatory Bowel Disease Tumor Necrosis Factor (TNF) inhibitors Adalimumab - Humira® Certolizumab – Cimzia® Etanercept – Enbrel® Golimumab – Simponi® Infliximabe - Remicade®

56 56 Immunosuppressants for Rheumatoid Arthritis Azathioprine Mercaptopurine Methotrexate Cyclosporine - Neoral ® Natalizumab -Tysabri ® ▫A monoclonal antibody that attacks a molecular on leukocytes

57 57 Learning Objectives Serious infectious illnesses - seasonal influenza and H1N1 flu - meningitis - tetanus, diphtheria, pertussis - chicken pox Human papilloma virus vaccine - cervical cancer risk factors and causes - cervical cancer presentation and outcomes - indications and dosing of human papilloma virus vaccine - potential adverse reactions Age-based preventive care plan - general health (vision, dental) - blood pressure screening - bone health (calcium and vitamin D) - mental health screening (alcohol; depression; smoking)

58 58 Human Papilloma Virus Most common sexually transmitted infection Most often it is asymptomatic Transmitted by vaginal, anal, oral, and genital- to-genital contact 50% of men & women acquire HPV 70% of cervical cancers caused by HPV types 16 and 18 HPV can also affect the mouth and throat

59 59 Prevalence of HPV Infection 2003-4 http://www.cdc.gov/mmwr/preview /mmwrhtml/mm5633a5.htm

60 60 Human Papilloma Virus Vaccine Human Papilloma Virus Quadrivalent Vaccine, Recombinant Types 6, 11, 16 and 18 Gardasil® Human Papilloma Virus Bivalent Vaccine, Recombinant Types 16 and 18 (Cerevix®) http://origin.cdc.gov/std/hpv/st dfact-hpv-vaccine-hcp.htm

61 61 Human Papilloma Virus Vaccine Indications in females Quadrivalent HPV vaccine Females ages 11 and 12 years (or ages 13 to 26 years if missed at younger age) Bivalent HPV vaccine Females ages 10 through 25 years Provisional recommendation in males Prevent genital warts Boys and young men ages 9 to 26 years

62 62 HPV and Cervical Cancer Prevention HPV vaccine Pap test annually ▫Begins 3 years after sexual intercourse (but no later than age 21 years) ▫Conventional Pap test yearly, or ▫Liquid Pap test every 2 years

63 63 Human Papilloma Virus Vaccine 25% experience injection site reaction Syncope Majority self-limiting (fever) Serious ▫Guillain-Barre ▫Blood clots (risk factor: oral contraceptives) Other issues Insurance coverage gaps

64 64 HPV Mini-cases 4 mini-cases http://www.cdc.gov/std/hpv/common-questions.htm

65 65 HPV – Mini-case #1 A 21 year-old female has received 3 doses of the quadrivalent HPV vaccine. Does this change your preventive care strategy on cervical cancer screening?

66 66 HPV- Mini-case #2 A 28 year-old sexually active female student asks if she should get the HPV vaccine. What advice can you offer?

67 67 HPV – Mini-case #3 You are asked to participate in a college health fair. How do you prepare to answer this question: What is the best method for preventing transmission of HPV infection?

68 68 HPV – Mini-case #4 The administrative director and pharmacist are discussing the pharmacy formulary for vaccines. What factors would be considered when evaluating the HPV-quadrivalent and HPV- bivalent vaccine?

69 69 HPV – Mini-case #4 HPV - Quadrivalent HPV- Bivalent Hypersensitivity cautions YeastLatex Coverage4 viral types2 viral types Approval by age11-26 years10-25 years Use in boys and young men YesNo

70 70 Learning Objectives Serious infectious illnesses - seasonal influenza and H1N1 flu - meningitis - tetanus, diphtheria, pertussis - chicken pox Human papilloma virus vaccine - cervical cancer risk factors and causes - cervical cancer presentation and outcomes - indications and dosing of human papilloma virus vaccine - potential adverse reactions Age-based preventive care plan - general health (vision, dental) - blood pressure screening - bone health (calcium and vitamin D) - mental health screening (alcohol; depression; smoking)

71 71 Illness-Wellness Continuum John W. Travis, MD http://www.thewellspring.com/template_images/Illness- WellnessContinuumW.jpg

72 72 Vision The American Optometric Association Ages 18-64 years; every 2 years ≥ 65 years: annually Drug-induced causes of vision changes: digoxin for heart failure: halos around object or discoloration (red, yellow, green, blue, changes) Hearing American Speech- Language-Hearing Association Ages 18-49 years: every 10 years ≥50 years: every 3 years Drug-induced: diuretics, amino glycoside antibiotics, high dose aspirin causes tinnitus. General Health

73 73 Hypertension http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/18166.jpg http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/18166.jpg Accessed 2009 Sept 9

74 74 Percent of Total Deaths A Total CVD B Cancer C Accidents D Chronic Lower Respiratory Diseases E Diabetes Mellitus F Alzheimer’s Disease CVD and other major causes of death for white males and females (United States: 2005). Source: NCHS. www.americanheart.org

75 75 Percentage of Total Deaths by Age group (US 2006) Percent (%) 15-19 yrs 20-24 yrs A AccidentsD Cancer B AssaultE Cardiovascular disease C Suicide F Cerebrovascular http://www.cdc.gov/ nchs/data/nvsr/nvsr5 8/nvsr58_14.pdf

76 76 Blood pressure JNC 7 Screening every 2 years with BP < 120/80 mm Hg Screening every year with SBP of 120-139 mm Hg or DBP of 80- 90 mm Hg. Onset: starting at age 18 years - all adults Screening JNC 7: The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

77 77 DEXA scan National Osteoporosis Foundation All men age 70 and over & all women age 65 and older Those with risk factors: cigarette smoking, excessive alcohol use, diet low in calcium, use of certain medication such as steroids, broken bone Bone health Screening: dual energy x-ray absorptiometry (DEXA) scan http://www.womenshealth.gov/minority/africanamerican/images/woman.jpghttp://www.womenshealth.gov/minority/africanamerican/images/woman.jpg Accessed 2009 Sept 10

78 78 Bone health: Nutritional Supplements National Osteoporosis Foundation 2008 Calcium: 1000 mg age 21-50 yrs: 1200 mg age > 50 yrs Calcium sources: milk, yogurt, cheese, fortified juices, soybean, tofu, baked beans, broccoli, salmon Daily vitamins D 2 or D 3. 400-800 IU age 21-50 yrs 800-1000 IU age > 50 yrs Vitamin D sources: fortified milk, egg yolks, saltwater fish, liver www.nof.org

79 79 www.nof.org

80 80 Mental Health: Depression Screening: Recommended that screening for all adults >18 years of age is effective. Screening Tools: Beck Depression Inventory, Zung Self- Assessment Depression Scale. General Health Questionnaire. Sample questions: Over the past 2 weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things? Recommendation by: United States Preventive Services Task Force http://www.ahrq.gov/clinic/uspstf/uspsaddepr.htm

81 81 Drugs causing Depression Substance abuse: ▫Alcohol, Cocaine, Amphetamines Inflammatory conditions: corticosteroids Oral contraceptives Drugs for migraines: Barbituates - Fioricet® Persistent Nausea – metoclopramide -Reglan® For cancers (HIV Kaposi’s Sarcoma, Solid tumors and leukemia): interferon – Roferon A ® and Intron A ® Merck Manuel of Diagnosis and Therapy, 18 th edition, 2006, on Stat!Ref

82 82 Smoking cessation: 5 A ’ s Ask about tobacco use: Identify & document tobacco use status at every visit Advise to quit: In a clear, strong, & personalized manner, urge every smoker to quit. Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time? Assist in quit attempt: for the patient willing to make a quit attempt, offer medication & provide or refer for counseling or additional treatment Arrange follow up: for the patient willing to make a quit attempt, arrange for follow up contacts, beginning within the first week after the quit date. www.rxforchange.ucsf.edu/ http://www.ahrq.gov/clinic/uspstf/uspstbac2.htm#summary

83 83 Cost Analysis DrugCost perCost per year Varenicline Chantix ® $445.50 – 12 weeks1 continuing & 1 starting pack $148.50 ea Bupropion SR 150 mg – generic 2 tabs daily $296.00 – 12 weeks Transdermal Nicotine Patch Nicoderm CQ ® $161.97 – 6 weeks Cigarettes (1 pack/day) $588.00$2555.00 www.drugstore.comwww.drugstore.com Accessed: 2010 May 25

84 84 Nicotine Replacement Products PharmacotherapyDoseAdministration Nicotine transdermal patch (Nicoderm CQ, Nicotrol) 7, 14, 21 mg/24h or 5, 10, 15 mg/16h OTC Highest dose daily for 6 wk, then taper Nicotine gum (Nicorette) 2, 4 mg OTC One piece every 1-2 hr for 6 wk, then taper Nicotine lozenges (Commit) 2, 4 mg OTC Nicotine inhaler (Nicotrol) 2 mg per cartridge Rx 6 to 16 cartridges inhaled daily for 6 -12 wk, then taper Nicotine nasal spray (Nicotrol NS) 0.5 mg per spray Rx1-2 sprays in each nostril every hour for 8 wk, then taper

85 85 Alcohol Screening CAGE: Screening Tools for Alcohol Abuse Have you ever felt the need to:Cut down on drinking? Have you ever felt:Annoyed by criticism of you drinking? Have you ever felt:Guilty about your drinking? Have you ever taken a morning:Eye opener? Two answers of “yes” are considered to be a positive prevention. In: Current Medical Diagnosis and Treatment. 48th ed. New York: Lange. Available in: Stat!Ref. http://pubs.niaaa.nih.gov/publications/arh28-2/94-104.htm

86 86 Preventive Care Plan Jacy is 22 year-old female and is returning to college for the Fall semester. She is concerned about all of the media reports on the influenza epidemic. She is working as a pharmacy technician. She met with her family doctor, dentist, and gynecologist for check-ups this year. She does not have any chronic medical problems. Develop a Preventive Intervention Plan for Jacy.

87 87 Mini-case #1: Jacy Primary Prevention: Weight yearly Vision every 2 years Hearing every 10 years Calcium 1000 mg po daily Vitamin D 400-800 IU daily If not sexually active: Pap test at age 21 y HPV vaccine up to age 26 years if not sexually active BP every 2 years Seasonal influenza vaccine for Fall 2010 (includes H1N1) Screen for smoking at every visit Screen for alcohol in primary care (pregnant, prior history of alcohol misuse)

88 88 Thanks to: Trent Towne, PharmD, Assistant Professor, Dept of Pharmacy Practice & Administration, Philadelphia College of Pharmacy Bonnie Packer, RN, Nurse Manager, Student Health Services, University of the Sciences in Philadelphia Paul Furtaw, PsyD, Director of Student Health and Counseling, University of the Sciences in Philadelphia

89 89 http://www.dogtipper.com/tip/2009/05/preventing-meter-reader- bites.htmlhttp://www.dogtipper.com/tip/2009/05/preventing-meter-reader- bites.html Accessed 2010 May 13 National Dog Bite Prevention Day


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