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A news article published in the last couple of weeks has provided a reminder that we aren’t immune from many of the diseases that are prevalent in other regions of the world, even developed ones; not when we are such avid travellers. (In February this year, over 830,000 Australian residents took short term holidays overseas1.)

The report2 referred to a hepatitis E infection that a young boy contracted back in 2014 during a liver transplant. Testing showed that the hepatitis E virus (HEV) was passed on to the boy through blood that was transfused during the surgery – the first time this has occurred in Australia. The Red Cross routinely screens donated blood for a number of diseases (HIV; hepatitis B & C; human T-cell lymphotropic virus I and II; and syphilis3), but not HEV. It turns out that the blood was donated by a man who had become infected in southern France – by eating pork. For most people visiting France, the risk of contracting an infection from the food would be furthest from their minds (more likely a ‘crise de foie’, or liver crisis, which in most other languages would translate as ‘overindulging’)!

A 2011 study by Mansuy et al4 found that a staggering 52.5 percent of voluntary blood donors in the Midi-Pyrénées (south-western France) showed a long term response to HEV infection (elevated IgG levels). They concluded that the consumption of wild boar and deer (common sources of infection), often raw or undercooked, together with the leakage of pig manure used to fertilise crops into rivers and canals, had created a hyperendemic incidence in the region. Figatellu, a sausage prepared from raw pig liver is a common delicacy in this part of France. (By comparison, testing of Australian blood supplies found HEV infection in 1:14,799 samples2)

The disease

According to the World Health Organization, 44,000 people lost their lives due to complications of hepatitis E infection in 2015 and there were 20 million cases globally5. Like the hepatitis A virus, HEV is transmitted through the faecal-oral route, meaning by consuming contaminated food or water (more often through water). Infection may go undetected, with minimal symptoms – this is more likely to occur in young children. But of those that are apparent, signs and symptoms can include jaundice, loss of appetite, a tender liver, abdominal pain and tenderness, nausea, vomiting, fatigue and fever, which can last for up to 2 weeks. In most people, hepatitis E disappears without treatment and with no long-term effects. However, people with weakened immune systems, such as those with leukaemia and post-organ transplant patients, may develop a chronic form of the disease which can quickly lead to cirrhosis and permanent liver damage6.

One group is far more susceptible to severe illness and death from Hep E than any other – pregnant women. The E strain is fatal for between 15-30% of mothers-to-be in their third trimester. Tragically, even if the mother survives, it’s common for the foetus to die.
It’s not known why pregnant women are at higher risk of severe outcomes.
The high mortality rate is not seen in the other hepatitis viruses and at least one study7 has suggested that a fall in the number of protective T-cells that occurs during pregnancy may play a role, along with hormonal changes and other factors.

Vaccines

While there are highly effective vaccines for hepatitis A and hepatitis B, no vaccine is currently available for hepatitis E in Australia, although one was approved for use in China in 20118. The boy who received the HEV infected blood was treated with antiviral medications which removed all traces of the virus.

Our advice for all travellers, but particularly pregnant women:
– Don’t drink untreated water. If sealed, reputable bottled water isn’t available, treating tap water by boiling or chlorinating will kill both hepatitis A & E viruses.
– Choose safe food and beverages options. (While Hep E is usually transmitted in via drinking water, food-borne transmission may occur from raw shellfish, and uncooked or undercooked meat - in particular pork - from infected animals.)
– Observe strict personal hygiene. Hand washing after using the toilet and before eating.

Call us to make an appointment for a one-stop pre-travel medical consultation with a team of medical professionals experienced in travel medicine at your nearest clinic. We provide advice, vaccines and medications for your particular itinerary, dependent on the season of travel, length of stay and type of activities undertaken. Travelvax Australia’s free travel health advisory service can be reached on 1300 360 164.

1. http://www.abs.gov.au/ausstats/abs@.nsf/mf/3401.0
2. http://www.smh.com.au/national/health/hepatitis-e-boy-6-first-to-be-infected-after-receiving-australian-blood-donation-20170414-gvl4sn.html
3. http://mytransfusion.com.au/about-blood/ensuring-blood-safety
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3311200/
5. http://apps.who.int/iris/bitstream/10665/255016/1/9789241565455-eng.pdf?ua=1
6. https://www.ncbi.nlm.nih.gov/pubmed/24396139
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575020/#!po=62.9032
8. https://www.hepmag.com/article/hev-vaccine-china-26972-69711881

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Routine vaccinations are the ones that you have during childhood – like tetanus, diphtheria, polio, measles, mumps, rubella (MMR) & meningococcal disease; but also when you’re an adult, as needed for job applications (e.g. hepatitis B), when pregnant/planning parenthood (e.g. whooping cough, influenza & MMR), following an injury (tetanus) or on reaching mature age (e.g. influenza, pneumococcus & shingles).

Right on cue, just when we were considering posting an article on routine vaccinations for travellers, news on several outbreaks at home and overseas have cropped up to prove our important point! This is significant, because a recent study by Robert Menzies et al (2017)  has found that there are around 4.1 million under-vaccinated Australians each year, the majority of those are adults. According to co-author Prof Raina McIntyre: “Adults contribute substantially to ongoing epidemics of vaccine-preventable diseases. Most cases of whooping cough, for example, occur in adults. About half of all cases of measles that occur in Australia are in those aged 19 years or over”. 

Over the past few weeks, our local press has reported on measles infections brought back to Australia following trips to Bali (measles is no longer endemic here). They include cases in Victoria, Western Australia, NSW, QLD  and the Northern Territory. Also this year, other countries where Australians became infected with measles were MalaysiaThailand and India.
Measles is a highly infectious disease, so there is a very high risk of a single case spreading the disease to unvaccinated others either during the return journey home or once home.

And even among developed countries, the burden is not ours alone. The European Centre for Disease Control issued an update for March 19-25, 2017, in which it was noted that: ‘In the EU/EEA Member States, measles cases have been reported in Austria, Belgium, Bulgaria, Denmark, France, Germany, Hungary, Italy, Spain and Sweden as well as in Romania where 3,799 cases have been reported as of 17 March 2017. Outside of the EU, outbreaks have been detected in Australia, Canada, Democratic Republic of Congo, Guinea, Mali, Republic of South Sudan, Syria and South Africa.  Of course measles is just one of the so-called childhood (infectious) diseases.

Some other routine vaccines

Tetanus is present world-wide, but thankfully infections are rare in Australia. In 2016, there were only 7 cases here (4 of those in adults aged over 40). Often the reason that middle-aged or elderly contract and fall seriously ill from tetanus is the waning immunity from vaccines they had too long ago. If you are travelling, tetanus boosters are usually given every 10 years but may be recommended after 5 if, due to planned activities (such as with hiking, bike riding or mountain climbing), there is a risk of injury causing a soil-contaminated, tetanus-prone wound. Just last month a 7 year- old girl in Lismore, NSW, contracted tetanus after her parents declined tetanus booster vaccinations as part of treatment for her tetanus-prone wound. 

Diphtheria, as with tetanus, no longer causes the countless cases and deaths in Australia that it did prior to the introduction of the vaccine in the early 20th century. Last year we recorded 8 cases – all in adults over 20 years of age – and across the globe there were over 4,500 cases in 2015. The diphtheria antigen is included in the tetanus booster.

Mumps, or epidemic parotitis, continues to cause outbreaks in both developed and developing countries. In the last few years it has been young adults, even up to their 30s, who are more likely to become infected: in 2016, Australia recorded 523 mumps infections in people aged between 10 and 34 years. The national total for the year was 804 cases, with over half of those from Western Australia. North America has seen a surge in cases over the past few months. Two doses of the measles-mumps-rubella (MMR) vaccine are given at least 4 weeks apart.

Chickenpox (or varicella) vaccine is one of the routine immunisations now given to infants, with a catch-up program for younger teenagers. Varicella infection causes brain inflammation in one on 100,000 cases and is particularly serious in pregnancy due to the high risk of congenital malformations in the baby. Having the vaccine is also significant as someone who has had a prior infection with chickenpox can suffer from shingles at a later time - the virus can lie dormant for a period of time and then reactivate. Chickenpox occurs in both developed and developing countries. Last year (2016) there were almost 2,500 cases in Australia – 23 percent of those in adults over 20 years of age. 

Influenza is included in the ‘routine’ category as the vaccine is updated each year to cover what are expected to be the dominant circulating flu strains. When it comes to travel, influenza is the most common vaccine-related infection and the peak season covers the globe at all times of the year: Southern Hemisphere winter, Northern Hemisphere winter and year-round in the tropics. In Australia, flu-related illnesses kill over 3,000 people each year and many more end up in hospital. Government funded vaccines are available at the start of each flu season for at-risk groups, such as people aged 65 years and over, Aboriginal and Torres Strait people aged six months to less than five years and those aged 15 years and over, pregnant women and anyone over 6 months of age with medical conditions such as severe asthma, lung or heart disease, low immunity or diabetes that can lead to complications from influenza. 

Communicable diseases can strike and then spread quickly at home and abroad; their appearances rarely make it onto our nightly news and so aren’t usually common knowledge. In many developing countries, and even developed countries, where Australians love to holiday, vaccination coverage for these common childhood diseases is much lower than ours, leaving a larger pool of people who can infect others. So for the 4 million+ Australian adults who are known to be under-vaccinated (& under-prepared) for the medical problems that can attack them here, overseas travel has the potential to offer many more risks.

 

Vitoria, Espírito Santo: © Filipe Frazao | Dreamstime.com

 

There will still be many, many people who are content to miss the pizzazz of the Carnival in Rio and take in all that Brazil has to offer once the parades are over. Whether it’s the city sights and beaches of Rio, a cruise down the Amazon, wildlife tour of the Pantanal or taking in the magnificent Iguaçu Falls at the triple border of Argentina, Brazil and Paraguay, there’s plenty to enjoy!

At this time, there’s an extra consideration to make sure your trip goes according to plan and it’s very much about protecting your health: An expanding outbreak of yellow fever (YF) is taking place in several Brazilian states. It started back in December in the state of Minas Gerais, and has now spread to Espírito Santo, Bahia, Rio Grande do Norte, São Paulo, Tocantins and Goiás. Yellow fever vaccination has long been indicated for travel to government prescribed ‘Areas with Vaccination Recommendation–ACRV  but with this outbreak, the list of towns and districts has been extended to cover even more municipalities – including the entire state of Espírito Santo  - where the protective vaccine is advised for anyone over 9 months of age* who is not already vaccinated.

We dealt with yellow fever infection, the vaccine (which is given at licensed clinics such as Travelvax in Australia) and International Health Regulations in our article posted on Nov 28th last year, Yellow fever vaccination certificate changes, but we think in this instance it’s worthwhile giving some background on yellow fever in Brazil: The yellow fever virus maintains its presence in the country through infections transmitted by mosquitoes between certain species of monkeys that live in the forests. When humans who are unimmunised (and not actively preventing insect bites) venture into these areas, they are bitten by infected mosquitoes - this is the sylvatic cycle of yellow fever infection. Once the infected humans return to a town, an urban cycle continues the spread as urban-dwelling Aedes aegypti mosquitoes transmit the virus between non-immune people.

Yellow fever is endemic in the Amazon region, but periodic outbreaks occur outside this area when unvaccinated people are exposed to the virus, such as during the 2008-9 epidemics which hit the southern states of Rio Grande do Sul and São Paulo. Many of those infections occurred in parts of the country where vaccination was not recommended at that time and so the ACRV guidelines were revised to include expanded new regions.

Evolution of geographic risk classification for yellow fever vaccination recommendations in Brazil, 2001–2010ˣ . 

On a national level, the response to the current outbreak  has entailed nearly 15 million YF vaccine doses being sent to the states of Minas Gerais, Espírito Santo, São Paulo, Bahia and Rio de Janeiro. The strategy is to ensure the population living in affected areas is immunised, as well as increasing disease surveillance and controlling the virus’s mosquito vectors. (As the outbreak is not contained as yet, we advise anyone heading to Brazil to speak to their yellow fever licensed doctor for the most up-to-date information.)

The World Health Organization has this advice for travellers who will be visiting YF risk areas in Brazil: “vaccination against yellow fever at least 10 days prior to the travel; observation of measures to avoid mosquito bites, awareness of symptoms and signs of yellow fever, promotion of health care seeking behaviour while travelling and upon return from an area at risk for yellow fever transmission, especially to a country where the competent vector for yellow fever transmission is present.” 

Planning a trip to Brazil? Call Travelvax Australia’s free travel health advisory service on 1300 360 164 for advice on recommended and required vaccinations. You can also make an appointment for a pre-travel medical consultation with a team of medical professionals experienced in travel medicine.

* Each traveller’s suitability for yellow fever vaccination is determined during a pre-travel medical consultation with a YF licensed doctor- there are some contraindications and precautions to vaccination. Additionally, itineraries that include YF endemic regions must be checked for all destination countries’ vaccination requirements for arriving travellers. Other recommended vaccines and preventive measures regarding the itinerary can also be discussed, including crucial insect bite avoidance measures.
ˣ Romano APM, Costa ZGA, Ramos DG, Andrade MA, Jayme VdS, et al. (2014) Yellow Fever Outbreaks in Unvaccinated Populations, Brazil, 2008–2009. PLOS Neglected Tropical Diseases 8(3): e2740. doi:10.1371/journal.pntd.0002740 http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002740

Don Daeng & Mekong River

High on the list of up-and-coming tourist destinations for Australian travellers is the Lao People's Democratic Republic, or Laos. Now, it’s the varied and spectacular landscape and historic architecture that draw the tourists - the region is very popular with Europeans who tend to visit during their peak summer months. But not that long ago, Vang Vieng in the country’s north was popular with backpackers in search of a party. The picturesque town became (in)famous for the tragic deaths of young men and women who had taken to ‘zip-lining’ and ‘tubing’ down the Nam Song river while extremely inebriated. 

Laos is land-locked, sandwiched between Myanmar to the west, Thailand to the south-west, Cambodia to the south, China to the north and Vietnam to the west. Over two-thirds of the terrain is mountainous, crossed by the mighty Mekong River which produces spectacular waterfalls and rapids, especially during the May to October tropical monsoon season (annual rainfall ranges from 1,360mm in Luang Prabang to 3,700mm in the Bolaven Plateau). The chief arable regions, with rice as the main crop, are in the south-central plains of Savannakhét and Champasak provinces. Adjacent to the Cambodian border is Si Phan Don, an archipelago of 4,000 islands that sits in a 10km-wide stretch of the Mekong River – 3 of the islands are popular with tourists: Don Khet, Don Khon and Don Khong.

In an early kingdom established in what is now the province of Champasak, a temple complex was constructed which formed part of the ancient Khmer cultural landscape. This is Wat Phu and, like the structures near Siem Reap in Cambodia, it is made of sandstone that has been ornately carved to honour the deities and the rulers of the time. Both Hinduism and Buddhism have been followed at different times over the centuries. Now, around half of the Laotian population are Theravada Buddhists and the overwhelming majority of the remainder adhere to various Lao folk religions.

You can still find influences from the time when Laos formed part of the French Colonial Empire from the late 1800s until it gained self-rule in 1953. Baguettes and French restaurants are common in the capital Vientiane, but it’s the famous Laotian cuisine that is a big drawcard, featuring such delicacies as Khao Niaw (sticky rice), Sai Oua (Lao sausage) and Larb.

General health concerns are similar to those in other developing countries in the region.

Vaccinations for Laos

There are no REQUIRED (mandatory) vaccinations: Yellow fever is NOT a requirement, unless you arrive from an endemic country of Africa or South America.  
Updating your childhood vaccinations is considered ROUTINE before any overseas trip. Check with your GP and, if necessary update measles-mumps-rubella (MMR) , diphtheria-tetanus-pertussis, chickenpox, and polio. Also ensure you are protected against seasonal influenza, the most common vaccine-preventable illness among international travellers.
Heading the list of RECOMMENDED vaccinations is Hepatitis A, considered a moderate risk for all travellers, regardless of the length of stay or type of accommodation. Hepatitis B is especially relevant for young singles, frequent flyers, and those heading ‘off the beaten track’ where medical facilities are scant. There’s a moderate risk of typhoid in Laos and vaccination is recommended for even short stays, especially if planning to visit towns or villages. Cholera is not generally a risk in Laos. (Read about Rabies and Japanese encephalitis below).

Malaria and mozzies

Laos’ annual malaria data for 2014 showed that there had been 38,131 cases with 28 deaths. The capital Vientiane is the only area considered to be malaria-free and the mosquito-borne disease remains a SIGNIFICANT RISK in other areas of the country. America’s CDC ranks the overall malaria risk as ‘very low’ for travellers but warns that 65% of cases are the potentially fatal P. falciparum strain. (Adding a more dangerous dimension to the malaria risk is the multi-drug resistance that is now widespread along parts of the north-east and south-east borders.) 
Malaria medication: For Australians, the most commonly prescribed and effective anti-malaria chemoprophylaxis (started before potential exposure to prevent malaria and continued during your stay in the malarial area and for a period of time after leaving it) includes Doxycycline or Malarone. Ask your doctor which of these is most appropriate for you.
Whether or not you take medication to prevent malaria or treat it is a decision you should make after discussing your travel itinerary with a doctor, ideally one experienced in travel medicine. Your doctor will determine whether taking prevention medication or carrying a drug to treat malaria at the first sign of infection would be best for you, based on your itinerary, length of stay, and level of exposure.
Other reasons to pack repellent
Dengue fever infection is even more common than malaria in Laos, while its ‘cousins’, chikungunya and the Zika virus can occur there, too. All are spread by two species of day-time feeding mosquitoes, Aedes aegypti and Aedes albopictus. Unlike the mainly rural-dwelling mosquitoes that spread malaria, the Aedes mozzies are equally at home in the biggest cities or the smallest villages – anywhere, in fact, people live.
Two other mosquito-borne diseases that are present but much less common among travellers are lymphatic filariasis, a parasitic disease caused by thread-like worms, and Japanese encephalitis (JE). JE is thought to occur countrywide in Laos, with most human cases reported from June to September. However, JE is rare among travellers and vaccination is usually reserved for those spending an extended period in rural farming areas, those living in endemic areas, or those staying in locations where outbreaks are occurring.
BYO repellent and bed net
Effective insect repellents can be hard to obtain in Laos, so bring enough from home to last the duration of your stay. Some guesthouses and hotels don’t have mosquito nets either so, once again, if you plan to stay in budget accommodation, pack your own permethrin-impregnated net.
Beware other ‘bities’, too
Mozzie bites aren’t the only ones to be wary of. The rabies risk in Laos is rated ‘high’ although, as with Japanese encephalitis, vaccination is usually recommended for long-stay expats or those travelling in rural areas, especially if on bicycle tours, camping, or hiking etc. However we advise that you discuss rabies vaccination with your doctor, as at-risk bites are also reported in the first couple of weeks of travel.
Be prepared for traveller’s diarrhoea
The risk of traveller’s diarrhoea (TD) in Laos is rated ‘moderate’, which makes it important to follow the rules of personal hygiene – especially regular hand washing – and selecting the safer food and beverage options. TD often clears up without specific treatment, but it’s wise to keep oral rehydration fluids on hand to replace lost fluids and electrolytes. Travellers who pass three or more loose bowel motions in an eight-hour period accompanied by other symptoms of dysentery like fever, nausea, vomiting, abdominal cramps and blood in stools should consider taking a course of antibiotics. Ask about the appropriate medication and dosages during your pre-travel medical consultation. If diarrhoea persists despite therapy, see a doctor – the cause may be a parasitic infection. Learn more about traveller’s diarrhoea and how to avoid it

WHAT TO PACK

Insect repellent – Apply repellent containing an active ingredient, such as DEET (30-50% formulations for adults, or up to 30% for young children aged from 6 months), Picaridin, or oil of lemon eucalyptus when outdoors. Read more on avoiding biting insects
A treated bed net – Permethrin is an insecticide that is safe for humans, but kills insects that come into contact with material treated with it. You can buy a net that’s already treated or make up the solution and treat your net, clothing, hats etc.  
Sunscreen – To ward off the tropical sun’s UV rays, take a 50+ sunscreen and apply it to all exposed skin as directed when outdoors.
First-aid kit – In case of an accident, it’s reassuring to know you have a travel first-aid kit containing syringes, needles, sutures etc. that local medical personnel can use, along with basic first-aid items you might need from day to day. The standard of medical facilities in Laos is extremely limited, particularly outside Vientiane (Australia’s embassy has a medical clinic for nationals). Travellers are advised to avoid surgical procedures, (including dental work) due to the danger of hepatitis, HIV/AIDS and other infections from unsterile dental and medical instruments.
Finally, read more on the importance of comprehensive travel insurance, areas to avoid, and local conditions on Smartraveller, the Australian Department of Foreign Affairs’ website for Australian travellers. Warnings are in place for travellers to Xaisomboun province due to attacks in recent years and the department also advises against travelling by road between Vang Vieng and Luang Prabang, and from Kasi to Phou Khoun and Muang Nan.
Australia’s embassy in Laos is located at KM4, Thadeua Road, Watnak Village, Sissatanek District, Vientiane. Telephone: +856-353800 Facsimile: +856 – 353801 E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it. Website: laos.embassy.gov.au
(In a consular emergency if you are unable to contact the Embassy you can contact the 24-hour Consular Emergency Centre on +61 2 6261 3305 or 1300 555 135 within Australia or +61 421 269 080 for SMS.)
For more expert, no-obligation advice on staying healthy on your next overseas trip, or to book your pre-travel medical consultation at a Travelvax Australia clinic, please call 1300 360 164 (toll-free for landlines).

 

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Australia has seen an increasing number of dengue notifications in recent years – the more-than-2,000 confirmed cases reported last year were the highest in 20 years. Of the 2129 notifications, around 1 in 4 were in adults aged between 25 and 34 years. So we are asking - Are Australian travellers putting themselves at risk because of the Aussie ‘you’ll be right, mate’ mind-set, or is it due to the YOLO (you only live once) attitudes of younger travellers? Or could it be a lack of awareness which is fuelling this increase in infection rates?

In a survey carried out on over 1,000 Australian travellers by the pharmaceutical company Sanofi, 40% of them admitted to a YOLO attitude when travelling. The survey also exposed a lack of homework before eating food from street vendors and security lapses through falling asleep outdoors. What’s more, over 40 % of travellers said they did get sick, 50% didn’t have the recommended vaccinations and more than 60% didn’t consult their GP or a travel medicine specialist clinic prior to travel!

But back to dengue fever…

Dr Cameron Webb, University of Sydney-based medical entomologist and clinical lecturer, said recently that ‘dengue fever cases were increasing globally and travellers are bringing the disease back to Australia’ as a result. Unfortunately, many popular holiday destinations are also prone to outbreaks of dengue. The opportunities to be infected are most certainly there: In June last year, there were 824,300 short-term resident departures from Australia and many of the top 10 tourist destinations (Indonesia, Thailand, Singapore, Fiji and India) are dengue endemic countries. Western Australia was in number one spot across the country last year with 533 dengue notifications - maybe that’s because cheap air fares to (dengue-affected) Bali make it a popular travel destination.

Dengue, like other mosquito-borne diseases caused by Zika and chikungunya viruses, is transmitted by Aedes aegypti and Aedes albopictus mosquitoes. The mosquito vectors are both aggressive day-time feeders that breed and bite in urban locations and prefer cool, shaded places. They are found in areas close to people, their favourite source of the blood meal the females need to lay eggs. 

While only about 25% of people infected with dengue viruses actually get symptoms, those that do fall ill can experience fever, headache, pain behind the eyes, rash, and severe aching of muscles, joints, and bones (and this is the reason why dengue also has another more evocative name, ‘breakbone fever’).

Dengue isn’t just a problem for travellers, it’s one of the most significant mosquito-borne viral diseases globally with a worldwide public health burden estimated at around 50 to 390 million infections, including dengue fever and the potentially fatal dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). The mounting disease presence across the globe is believed to be due to climate change, the expansion of dengue vectors to new geographic regions, increasing human movement across borders, global trade and urban migration.

Our advice to avoid dengue?

Before you ask, there isn’t a dengue vaccine ... or at least not yet for tourists. A vaccine has been developed and is currently registered in 11 countries – but they are all countries with a significant dengue burden, and this is where the vaccine will be most useful. It is expected to reduce the levels of severe dengue illness and the resulting hospitalisations through its actions in the 9 to 45 years age group. 

For many travellers staying at major resorts, there will be mosquito control programs in place that substantially reduce the risks of dengue. Perhaps this is why fewer older Australian travellers are returning infected with dengue. However, even if staying in a resort with minimal risk, be aware that day trips to local villages or towns may bring with them a risk of exposure to mosquitoes, so take steps to avoid these bites.

Minimise mosquito bites and you reduce the risk of infection

Dr Webb says Australian travellers can reduce their risk of being bitten by following these measures:
– The mosquitoes that spread dengue viruses bite during the day. This means travellers must be actively avoiding mosquito bites during the day, not just in the afternoon and evening. Wearing loose, long-sleeved shirts and long pants outdoors together with topical insect repellents will provide the best protection.
–The most effective insect repellents are those containing DEET, Picaridin or extract of lemon eucalyptus oil. It is always best to take insect repellent with you from Australia as it may be difficult to find suitable formulations at your holiday destination. See here for the range of repellents that Travelvax stocks. 
– Where possible, ensure where you’re staying is air conditioned and has screened windows and doors.
– Get rid of any standing water around your accommodation, including pot plant bases and other containers that collect water.
– If you are using sunscreen, apply it first BEFORE your insect repellent.
– If you’re likely to be consistently exposed to insect bites, soak your clothing and bed net (if your room is not screened) with permethrin. This contact insecticide repels mosquitoes and other insects, and also kills them when they come in contact with the treated material. (Permethrin shouldn’t be applied directly to your skin.) Read more about permethrin and how to protect yourself against insect bites
– Mosquito coils and “plug-in” devices can also assist in reducing mosquito bites around your accommodation
The fewer times you get bitten, the lower the risk of infection. Don’t get bitten and there’s absolutely no chance at all.
No excuse for the lack of awareness now.

Did you know you can get no-obligation, country-specific advice on insect-borne diseases and other potential health risks of your next overseas destination by calling Travelvax Australia’s travel health advisory service on 1300 360 164 (free to landlines)?

 

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You may have seen mention in the media of the introduction of separate meningococcal vaccination programs in South Australia  and Western Australia  – they’re being implemented in response to a number of outbreaks of meningococcal disease in those states. The South Australian Health Department, together with the University of Adelaide and vaccine manufacturer GSK, have announced that they are offering the meningococcal B vaccine to 60,000 adolescents in grades 10, 11 or 12 from 2017. Testing has proved the B strain to be responsible for 19 of the 24 meningococcal meningitis cases this year in SA. While WA is providing a one-off administration of the vaccine that protects against the W strain in a program directed at children and young adults (aged four years and under and 15 – 19 years of age) living in Kalgoorlie, Boulder, Coolgardie and Kambalda - 5 cases caused by the W strain have occurred in Kalgoorlie in the past 2 months.

What do we know about this life-threatening illness?

Neisseria meningitidis (a meningococcus), is a leading cause of bacterial meningitis, producing sepsis (blood poisoning), pneumonia and other localised infections3. We know it causes death in around 1 in 20 of individuals infected1,2 in high-income countries, and several times higher in developing countries. Further, approximately half of all survivors have neurological complications, including hearing, visual or cognitive impairment1, loss of fine motor skills, seizures, hydrocephalus and limb amputations due to tissue cell death3.

There are 13 serogroups of Neisseria meningitidis but most human disease is caused by only 5 of them - A, B, C, W & Y4. Meningococcal bacteria can live harmlessly in our throat and nose; around 10% of people will be colonised by these bacteria at any one time without ever becoming ill – they are ‘healthy carriers’. It isn’t completely understood why in some people these common bacterial colonisers are able to evade the body’s natural defences and cross the blood-brain barrier to cause meningitis1. There are, however, several risk factors which increase susceptibility, including: specific age groups, medical conditions causing lowered immune defences and genetic factors1. When it comes to someone transmitting the bacteria to another person, this is more likely to occur in smokers (higher incidence of being a carrier), in those people with close contact (i.e. with saliva, such as during coughing, kissing or sharing eating utensils) or living in the same household. You can’t catch the bacteria through casual contact or, unlike measles, from merely being in the same room as someone with the infection1.

Australia and Meningococcal Meningitis

From the 1950s, serotypes B & C were responsible for most disease recorded in Australia, but, with the introduction of the C strain vaccine into the National Immunisation Program in 2003, the incidence of meningococcal infections due to this serotype dropped from 3.5 cases per 100,000 in 2001 to 1.1 per 100,000 in 2011. Subsequently the majority of IMD cases in Australia have been due to the B strain5.

Statistics available for 2016 show that Victoria has had 57 meningococcal meningitis cases this year to date - up from 50 cases in 2015 and 26 cases in 2014. In New South Wales there have been 63 cases so far in this year, with 43 in 2015 and 35 in 2014 (of which 39 cases were not strains B or C). In WA numbers have been static from 2014 to 2015 with 17 cases annually and usually only 1 to 2 W strain cases, but there have been 20 cases this year with the W strain accounting for 12.

In Australia, the disease has a peak incidence during the cooler months of winter and early spring, but smaller outbreaks also occur at other times. Age groups with the highest incidence of disease are under 4 years and again, to a lesser extent, between 15 and 24 years of age5.

Number of invasive meningococcal disease cases reported to the National Notifiable Diseases Surveillance System compared with laboratory confirmed data from the Australian Meningococcal Surveillance Programme, Australia, 1991 to 20145.



Global incidence

It is estimated that there are approximately 1.2 million cases of invasive meningococcal disease (IMD) causing approximately 135,000 deaths across the globe each year. The world-wide burden of IMD varies by region: countries are grouped into ‘high, moderate and low-incidence’ and Africa falls into the first category by virtue of the frequent epidemics that occur in 25 countries of sub-Saharan Africa - the so-called ‘meningitis belt’. These epidemics strike during the dry season (Dec-June)6, alternating with an endemic incidence during the rainy season (June-Oct)7.

Distribution of common and predominant meningococcal serogroups by region. Predominant strains are highlighted in bold text3

  Population Health Metrics 2013, 11:17 

Available vaccines

Vaccines used to protect against meningococcal meningitis disease in Australia come in 2 forms – one cannot be used under 2 years of age, is shorter-acting and will not eliminate the bacteria from the individual’s respiratory tract (polysaccharide vaccine), whereas the other covers a wider range of ages, has a longer duration and reduces nasopharyngeal carriage of the bacterium (conjugate vaccine).

The Australian National Immunisation Program provides one dose of serogroup C vaccine (in combination with Haemophilus influenzae type b (Hib)) to infants at the age of 12 months8. Another, a meningococcal B vaccine, is available on the private market so is without government subsidy at this time.

So the 4 formulations of meningococcal vaccines currently available for use in Australia8:

  • Meningococcal C conjugate vaccines, also in combination with Hib
  • Recombinant multicomponent meningococcal B vaccines
  • Meningococcal A, C, W135 and Y conjugate vaccines
  • Meningococcal A, C, W135 and Y polysaccharide vaccines

Travel and meningococcal meningitis

Specific itineraries that are more likely to warrant the recommendation of the meningococcal vaccine are:
- Travel to the meningitis belt in sub-Saharan Africa
- Annual Hajj pilgrimage and Umrah (the ACWY vaccine is a requirement for entry into Saudi Arabia)
- Travel to a region with a current outbreak of IMD
- Young people travelling in groups or living in dormitories i.e. at college
- Extensive close contact with the local community in regions of high IMD incidence
- Some medical conditions, including functional or anatomical asplenia, HIV infection and haematopoietic stem cell transplant.

As always, the final decision on what is best for any traveller will be decided during a pre-travel consultation with a medical practitioner.

For more information please call Travelvax’s travel health advice line on 1300 360 164.

 

1. Adriani, K.S, Brouwer, M.C., & van de Beck, D. (2015) Risk factors for community-acquired bacterial meningitis in adults. The Netherlands Journal of Medicine (73:2) p.53 – 60. Accessed 20.12.16 Available at: http://www.njmonline.nl/getpdf.php?t=i&id=180#page=6
2. Van de Beek, D., Brouwer, M.C., Thwaites, G.E. & Tunkel, A.R. (2012) Bacterial meningitis 2 – Advances in treatment of bacterial meningitis. Accessed 20.12.16 Available at: http://www.researchgate.net/profile/Matthijs_Brouwer/publication/233393830_Advances_in_treatment_of_bacterial_meningitis/links/0fcfd51406cbf566f6000000.pdf
3. Jafri, R.Z, Messonnier, N.E., Tevi-Benissan, C., Durrheim, D., & Eskola, J. et al. (2013) Global epidemiology of invasive meningococcal disease. Population Health Metrics (11:17) Accessed 20.12.16 http://www.pophealthmetrics.com/content/pdf/1478-7954-11-17.pdf
4. Halperin, S.A, Bettinger, J.A, Greenwood, B., Harrision, L.H., & Jels, J. et al (2012) The changing and dynamic epidemiology of meningococcal disease. Vaccine (30S) p.B26-B36. Accessed 20.12.16 Available at: http://www.researchgate.net/publication/51897100_The_changing_and_dynamic_epidemiology_of_meningococcal_disease
5. National Centre for Immunisation Research and Surveillance Meningococcal Disease Factsheet July 2015. Accessed 20/12/16 Available from: http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf
6. Department of health Meningococcal (2014) Australian Meningococcal Surveillance Programme annual report (40: 2). Communicable Disease Information. Accessed 20.12.16 Available from: http://www.health.gov.au/internet/main/publishing.nsf/content/cda-cdi4002f.htm
7. Koutangani, T., Mainasara, H.B., Mueller, J.E (2015) Incidence, Carriage and Case-Carrier Ratios for Meningococcal Meningitis in the African Meningitis Belt: A systematic review and meta-analysis. PLOS One (6) Accessed 20.12.16 Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0116725
8. Australian Government Department of Health and Ageing. Australian Immunisation Handbook, 10th edition, 2013. Canberra: DoHA; 2013. Meningococcal meningitis. Available at: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home~handbook10part4~handbook10-4-10
9. US CDC Health Information for International Travel 2016 (Chapter 3. Infectious diseases related to travel – Meningococcal Meningitis) Accessed 20.12.16 Available from: https://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/meningococcal-disease