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Bacteria developing resistance to antibiotics is hardly news, but when it’s a common sexually transmitted infection (STI) like gonorrhoea and the level of resistance means that some cases have been impossible to treat using available antibiotics, that’s alarming!

Earlier this month a World Health Organization news release confirmed that some wealthy countries with good disease reporting systems are seeing gonorrhoea cases that don’t respond to any known antibiotics. And there are very real fears that the global situation is much worse when you consider the under-reporting that takes place in less developed countries due to the lack of proper diagnostic techniques1

Gonorrhoea - what we know

It is caused by a bacterium from the genus Neisseria - N. gonorrhoeae, or gonococcus (plural gonococci). Another pathogenic, or disease-causing, bacterium from the same genus is N. meningitidis (meningococcus), the cause of meningococcal meningitis. One major difference between the two species of bacteria is that meningococcal bacteria can be found as part of the normal flora in the throats of 10-20% of the population, whereas the gonococcus is only acquired through sexual activity (all types including oral) or by a baby during a vaginal birth2.

• Each year there are approximately 78 million new gonorrhoea infections1.
• After chlamydia, it’s the 2nd most common STI.
• It’s a very old disease indeed, first noted in the 2nd century by the Greek physician Galen3.
• Syphilis and gonorrhea were thought to be one and the same disease until the 15th century.
• A German doctor, Albert Neisser first identified and then named the gonococcus in 18794.
• AKA the clap - one explanation for this slang term is that it’s derived from the French name for brothels – les clapiers.
• A single contact with gonococci can produce infection in 60-90% of women & 20-50% of men5.
• The incubation period ranges from 1 to 14 days, but can be longer in men6.
• Males are more likely to experience symptoms, but asymptomatic infections can occur.
• Up to 50% of women with uncomplicated disease have no symptoms.
• Symptoms in men include a yellowish, purulent discharge from the urethra and painful, burning urination.
• Symptoms in women can appear as a vaginal discharge, lower abdo pain or painful urination.
• Women suffer more complications (pelvic inflammatory disease, ectopic pregnancy & infertility)2.
• Complications suffered by men can include inflammation of the prostate or testes and urethral strictures and fistula formation.
• Infection can be localised to the urethra, cervix, rectum, eye & throat (most [90%] throat infections are asymptomatic)3.
• If the infection spreads to other parts of the body, it can cause dermatitis-arthritis syndrome, septic arthritis, endocarditis and meningitis
• Previous infection doesn’t provide immunity, so it ‘can be re-acquired with no apparent reduction in severity or duration of disease.’7
• And lastly, gonorrhoea infection (or any STI in fact) can increase the risk of HIV transmission8.

Remedy worse than the disease?

Treatment over the years has involved dried Indonesian pepper fruit and sap from a South American tree; later it entailed the use of injected or fumigated mercury compounds and diversionary activities such as bowls & archery as alternatives to ‘moral carelessness'9.

In the 1920s and 30s, the discovery of the anti-bacterials, penicillin and sulphur compounds, meant that, finally, effective treatments were available to cure the age-old scourge, but even as early as 1946 resistant strains of the gonococcus were identified10.

Fast-forward to 2009 and the first sign of the extent of the unfolding super-bug gonococcus crisis occurred in Japan when a prostitute who tested positive to the bacteria failed to respond to the last-line antibiotic treatment, a cephalosporin, injectable ceftriaxone3.

Three new treatment drugs are in development1, but progress towards an effective vaccine has been slow. Some good news arrived earlier this month when NZ researchers released their findings on the lower rates of gonorrhoea among people who had received a vaccine against a particular strain of meningococcus compared to the general community11, suggesting some cross-protection. More study is needed however, but with a high degree of genetic match between the 2 species of Neisseria bacteria, there is some optimism.

So… it’s about prevention

The WHO set up the Gonococcal Antimicrobial Surveillance Programme (GASP), a network of surveillance laboratories to monitor disease resistance and collate data, but it is also promoting education on safer sexual practices, including correct condom use. As noted in the July 7 news release: ‘Today, lack of public awareness, lack of training of health workers, and stigma around sexually transmitted infections remain barriers to greater and more effective use of these interventions.’1

The message

If it’s not on, it’s not on: A catchy phrase and good advice, but if you believe it’s just for the young, think again…

With today’s seniors more fit and socially active than in the past, it’s hardly unusual that sex would continue to play an important part in many of their lives. (Add to that the availability of erectile dysfunction drugs, online dating sites and no fear of pregnancy!)

Rates of STIs in the over-50s have risen over the past few years in the UK and the USA so it would follow that it’s happening here too. In 2016, we recorded 23,888 gonococcal infections countrywide and nearly 1,700 of those were in the 50+ years age group (& 13 in the over 80s)12. Bear in mind too that seniors are less likely to be undergoing regular STI testing so it’s possible there could be even more.

And our advice

  • Before you travel, pack condoms. Remember that those sold overseas may not be of reliable quality - check the expiry date and make sure the pack carries a recognised quality assurance mark.
  • Always use a condom with any new sexual partner.
  • They are for single use only – discard after use.
  • Use condoms correctly
  • Water-based lubricants can be used with all types of condoms, oil-based only with those made of polyurethane.
  • Store condoms away from heat or cold and sharp objects.
  • If prevention is forgotten or fails, do not ignore tell-tale symptoms. Seek medical advice and have the appropriate tests and treatment.

 

1. http://www.who.int/mediacentre/news/releases/2017/Antibiotic-resistant-gonorrhoea/en/
2. http://textbookofbacteriology.net/neisseria.html
3. http://www.newyorker.com/magazine/2012/10/01/sex-and-the-superbug
4. http://www.antimicrobe.org/h04c.files/history/Neisser.pdf
5. http://emedicine.medscape.com/article/333612-overview#a6
6. http://dvkeywords.blogspot.com.au/2010/10/gonorrhoea_26.html
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812424/
8. https://www.cdc.gov/std/hiv/stdfact-std-hiv.htm
9. http://www.evolve360.co.uk/data/10/docs/10/10plumb.pdf
10. http://www.antimicrobe.org/h04c.files/history/Gonorrhea.asp
11. https://www.theguardian.com/science/2017/jul/10/meningitis-vaccine-may-also-cut-risk-of-untreatable-gonorrhoea-study-says
12. http://www9.health.gov.au/cda/source/rpt_5.cfm

A Victorian man in his 60s who’d holidayed in Phuket, Thailand in early May died this week from Japanese encephalitis (JE) in a Melbourne hospital.

The traveller was on a 13-day trip to Thailand and stayed at a local resort. On day 8 of his trip, he suddenly became lethargic, however continued his travels to Bangkok 2 days later. While in Bangkok he remained lethargic, slept for several hours each day, had a poor appetite and was sweaty. He flew back to Victoria on Day 13 of his trip and presented to a local hospital a day later suffering from confusion. The following day, due to his deteriorating mental state and lethargy, he was placed on a ventilator and transferred to the Royal Melbourne Hospital. The diagnosis of JE occurred on day 22 of his illness after blood tests confirmed the presence of the virus - details of the traveller’s itinerary indicated that he hadn’t visited rural areas, however multiple mosquito bites were noticed. (This information is reported in Promed, on behalf of the Victorian Institute of Infectious Disease Service, the Royal Melbourne Hospital and the University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Victoria, Australia.)

On the face of it, the man in his 60s wasn’t at a great risk of contracting this viral disease. He had a typical short stay: just over a week at a resort in Phuket and then a return trip via Bangkok to Victoria. We’re told he didn’t spend any time in rice-growing areas, where most JE outbreaks occur. (Wading birds in rice fields and pigs serve as reservoirs, or ‘amplifying hosts’, in the virus’ transmission cycle. Mosquitoes transfer it between the two animal species before passing it on to humans who are termed ‘dead-end hosts’ because we are unlikely to have enough virus in the blood that a mosquito could ingest and then transmit to others.) 

JE cases are very rare

Promed has previously reported on a case of JE originating from Thailand and, while it is an unusual occurrence in short-term travellers to Thailand, the disease actually is endemic there. This recent case is now the second recorded in Victoria, after another man was hospitalised in February 2015 following a stay in Canggu on the Indonesian island of Bali. It appears the Melbourne man did not seek any pre-travel health advice prior to travelling to Phuket.

The US Centers for Disease Control and Prevention (CDC) reports that for most travellers to Asia, the risk of JE is extremely low, with ‘the overall incidence of JE among people from non-endemic countries travelling to Asia estimated to be <1 case per 1 million travellers; however the degree of risk is based on the destination, length of stay, season of travel and activities.

Only 79 cases of JE among travellers or expatriates from non-endemic countries were reported to the CDC from 1973 through to 2015 – 10 of those were recorded after a vaccine became available in the United States in 1993. In Australia, since 2001 there have been 10 reported cases of JE – most of them in Cape York Peninsula and the Torres Strait Islands.

Rare, but potentially severe outcome

The Japanese encephalitis virus is an arbovirus and is closely related to other mosquito-borne viruses such as West Nile, St Louis encephalitis, yellow fever and dengue fever.
Most cases occur among local people living in rice-producing areas of China, the Indian subcontinent, and Southeast Asia. More recently JE has become established in Papua New Guinea and the Torres Strait Islands, with the occasional case in Northern Australia.
Most JE infections are mild: usually a slight fever and a headache. But, for around 1-in-100 victims, the infection is severe and statistics show that 20-30% of these patients will die while 30% - 50% will be left with a severe neurological disability.
Because so few returned travellers show signs of illness – unlike the unfortunate Victorian gentleman – the incidence of JE is almost certainly under-reported here and elsewhere around the world.

Those at higher risk of JE

Inevitably, cases like the Victorian one fuel the vaccination question: should short term travellers to Asian holiday resorts such as Phuket and Bali be vaccinated?
The fringes of holiday resort areas and major towns and cities in Asia often do have rice paddy fields and pigs (such as Canggu and Seminyak in Bali) – so, we shouldn’t be surprised that the JE virus is present in mosquitoes in these areas. All travellers to Asia (and other tropical regions) must be fully aware of the need to take appropriate measures to avoid mosquito bites.
Typically, the vaccine is recommended for backpackers passing through regional areas for more than a month, for rural-based aid workers, and expats living or working in an endemic region for extended periods, particularly during or just after the wet season.
The Australian Immunisation Handbook recommends that doctors consider advising vaccination for travellers in the following situations:

  • JE vaccination is recommended for travellers spending 1 month or more in endemic areas in Asia and Papua New Guinea during the JE virus transmission season, including persons who will be based in urban areas but are likely to visit endemic rural or agricultural areas.
  • The Handbook further advises that “it is important to note that, as JE has occurred in travellers after shorter periods of travel, JE vaccination should be considered for shorter-term travellers, particularly if the travel is during the wet season, or anticipated to be repeated, and/or there is considerable outdoor activity, and/or staying in accommodation without air conditioning, screens or bed nets”. Risk is negligible for short stay business travellers to urban areas.

The imperative of insect bite avoidance

So, should Australians planning to visit Thailand or anywhere else in Asia where Japanese encephalitis occurs be concerned? The answer is yes and no.
No, because for a traveller on a typical short holiday in Asia, the risk of getting JE is clearly so low that vaccination is very rarely recommended.

Yes, because the Victorian case demonstrates that no-one travelling to a tropical Asian destination – even well-travelled ones like Phuket - can afford to be blasé about avoiding mosquito bites. Not anywhere. Not any time.

And the repellent won’t just prevent JE: Dengue, Zika and chikungunya are a significantly higher risk for travellers in many tropical and sub-tropical destinations because they’re spread by the urban-breeding, daytime-feeding Aedes species.

Adopt some or all of these bite avoidance measures:

- Apply an insect repellent containing an effective ingredient such as DEET (30-50% formulations for adults, or 10-20% formulations for young children and infants as young as 2 months of age), Picaridin or preparations containing extract of lemon eucalyptus oil, as necessary when outdoors.

- Wear long, loose-fitting, light-coloured clothing after dark, particularly around dusk and dawn when JE (Culex) mozzies are most active. Treating your clothing with the contact insecticide permethrin creates a deadly barrier to mozzies and other bugs that can bite through light material.

- Sleep under a treated bed net, especially if you are staying in a tent or in budget accommodation without screened doors and windows, or air-conditioning. You can buy a treated net or purchase a DIY kit and use it to treat a net and clothing to give yourself a strong barrier against biting insects.

Pre-travel vaccinations

While the focus is still on a risk assessment and the full range of bite protection measures, the length of the trip is no longer the main consideration for vaccination. Increasingly, it is being discussed in terms of a long-term ‘investment’ in healthy travel, particularly for the more adventurous who regularly head off the beaten track in Asia, as well as those who expect to continue travelling there regularly for leisure or work and want the extra protection (and peace of mind) immunisation offers.

There are two very effective vaccines against Japanese encephalitis for those at sufficiently high risk to warrant that level of protection, or who are unsure of their itinerary and wish to be proactive. One of these vaccines (Imojev) affords protection for at least 5 years. Unfortunately these vaccines are more expensive than your typical travel vaccines so discuss the need for this and other vaccinations for your trip with an experienced travel medicine practitioner.

If this sounds like you, discuss the merits of vaccination with your travel doctor at least 6 weeks before departure.

Heading to Asia? Learn more about the risks of Japanese encephalitis and the potential travel health issues for your trip by calling the Travelvax Australia travel health advisory service on 1300 360 164 for the latest country-specific information.

If you have a dog at home you’ll know full well that Buddy or Bella must be wormed regularly - for their sake as well as your own, so you don’t become infected too.

What you may not know is that there are parasitic infestations that can be contracted by humans through the food we eat when the source, like raw or undercooked meats, is contaminated1. Also, three of the more well-known ones are transmitted through raw, undercooked or pickled seafood, and tourists who are travelling on standard itineraries, taking in cities and large towns in developing countries are potentially at risk. On rare occasions these infections occur in developed nations too.

If you’re a fan of sushi, sashimi, ceviche, gravlax or marinated anchovies, this could be of interest to you …

Anisakiasis
In one high risk country, Japan, authorities have issued a health notice2 in response to a recent rise in the number of human cases of marine roundworm infections caused by the larvae of the Anisakis nematode (worm). Anisakiasis, as the infection is known, is most commonly contracted when people eat contaminated raw seafood (fish, eels, octopus and squid) in sushi and sashimi, but it can also be a risk if the dish you are scoffing contains infected fish that is cured with salt or vinegar (pickled or smoked herring). (The recommendation is for restaurants serving raw seafood to freeze it for an extended period of time before serving to ensure any larvae have been killed.)

Other countries with high rates of consumption of raw, smoked or cured seafood also have a higher incidence of infections and these include the Netherlands, Scandinavia, Spain and the west coast of South America3.

The life cycle of Anisakis worms starts as eggs released into the ocean by infected marine mammals. The eggs develop into larvae, which then become part of the food chain: eaten by crustaceans which are then eaten by fish or octopus which are then eaten by humans. A person consuming the larvae-containing raw seafood may or may not notice an unusual, tingling sensation - the worm passing through their mouth - and it can then be removed or coughed/vomited out. If the worm is swallowed, it can move to the stomach or intestines and become embedded, shielded from gastric acid by a protective coating. Ultimately the larva will die, but before that occurs, it can cause inflammation, peritonitis or obstruction.

The US Centers for Disease Control & Prevention (CDC) webpage on Anisakiasis4 lists the signs and symptoms of infection as: ‘abdominal pain, nausea, vomiting, abdominal distention, diarrhoea, blood and mucus in stool, and mild fever. Allergic reactions with rash and itching, and infrequently, anaphylaxis, can also occur.’

The very good news is that Anisakis infection can be treated by using an anthelmintic medication, or the worm can be removed by endoscope. If it has become embedded or moved outside the intestines, surgery may be required.

The other two more common helminth infections that are transmitted through eating raw or undercooked seafood, Clonorchiasis and Diphyllobothriasis, have similar life cycles to the Anisakis nematode with the exception that humans and terrestrial mammals are the infective hosts.

Diphyllobothriasis
The fish or broad tapeworm that causes diphyllobothriasis is much more widespread, being found in Europe, North America, and Asia, as well as Chile and Uruguay in South America. Furthermore, exportation of fish from endemic countries can lead to human cases in non-endemic regions. Just over 10 years ago, and after extensive testing, a few cases were diagnosed in sushi-eaters in Brazil5. Brazil doesn’t have the climate to support fish farming and tracing of the product showed it was sourced from freshwater lakes in southern Chile.

As with aniskaniasis, the larvae are consumed when contained within the raw seafood, but Diphyllobothrium larvae move to the small intestine of the host and attach to the lining. There they mature into adult tapeworms - the largest tapeworm to affect humans – and grow up to 10 metres in length. They are also prolific egg producers – up to 1 million per day, per worm. Less than one-quarter of infected people will experience symptoms: abdominal pain or discomfort and diarrhoea are common, pernicious anaemia from Vitamin B12 malabsorption, inflammation of the gall bladder and intestinal obstruction are also possible outcomes. Treatment of uncomplicated diphyllobothriasis also involves administration of anthelmintic medication.

Clonorchiasis
In the endemic countries of Korea, China, Taiwan, and Vietnam, Chinese or Oriental liver fluke (Clonorchis sinensis) infection or clonorchiasis is also known to occur through eating salted, pickled, or smoked freshwater fish containing the immature parasitic flatworm or metacercariae. The larvae mature inside the human small intestine after ingestion and move to the bile ducts to mature, producing acute phase symptoms of abdominal pain, nausea and diarrhoea. Long-term infections can lead to inflammation of the gall bladder, gall stones, pancreatitis, and cancer of the bile ducts. As with Anisakiasis, treatment is through anthelmintic medication or surgery.

While these infections are rare, they are noteworthy reasons behind the travel medicine mantra on food selection – ‘Peel it, boil it, cook it, or forget it!

1. https://www.cdc.gov/parasites/food.html
2. http://outbreaknewstoday.com/japan-sushi-rise-anisakis-90077/
3. https://web.stanford.edu/group/parasites/ParaSites2010/Lucia_Constantine/parasiteproject/Anisakiasis.htm
4. https://www.cdc.gov/parasites/anisakiasis/
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2725803/

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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