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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.

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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

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).