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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.

 

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While Laura Hawkins' story is a stark reminder of how a holiday can go horribly wrong - being bitten by a monkey in Bali and needing a rabies vaccination course - one of our concerns is that this will highlight just one aspect of a risk and not give the whole story. Advice based on personal experiences can be valuable and will usually ensure the essence of the message is carried, but it is rarely complete or comprehensive. 

To use the same rabies illustration: Yes, travellers must be aware of wild and domesticated animals in rabies-endemic countries and yes, comprehensive travel insurance is vital as instances like this show, when returning home ASAP was the best option. But, we as travel health advisors know, this is just one snippet of vital information that travellers need to know before heading overseas.

Measures required to prevent rabies infection would include avoiding contact with animals and seeking prompt, appropriate medical treatment if exposed to a rabid (or potentially rabid) animal, but travel health professionals would also stress that a bite is not the only way that rabies is transmitted. If an animal licks its claws and then scratches you that is an at-risk exposure; if an animal’s saliva or infected tissue comes into contact with open cuts or mucous membranes such as the mouth or eyes, that’s an at-risk exposure.

There is a wealth of other important information on the prevention of rabies, as highlighted in one of our articles on rabies earlier this year: Monkey See, Monkey Bite, Urgent Flight.

If all the right steps are taken, rabies infection (a virtually 100% fatal illness once symptoms have appeared) can be averted. And this is why all measures should be discussed and understood during a pre-travel health consultation.

Now for the other health concerns on a trip to Bali …

No mandatory vaccinations, only those to protect your health

For some time the focus has largely been on the risk of acquiring Zika virus infection - previously considered innocuous; the mosquito-borne virus is now known to pose a serious risk to pregnant female travellers. Yet there are other similarly transmitted disease hazards which travellers may be exposed to - dengue fever and chikungunya are commonly encountered mosquito-borne viral diseases in Bali. In other parts of Indonesia malaria is still a risk for travellers but not in Bali.  

For any Aussie traveller visiting Bali, taking steps to avoid insect bites must become second nature. These include: 
– Applying 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, IR3535, or preparations containing extract of lemon eucalyptus oil when mosquitoes are about – especially at dawn and dusk when they are most active.
– Wearing long, loose-fitting, light-coloured clothing at peak feeding times.
– Sleeping under a treated bed net if staying in a tent or in budget accommodation without screened doors and windows, or air-conditioning. A permethrin treated net or DIY kit can be purchased to treat both the net and clothing. Used in conjunction with a personal insect repellent, permethrin is a safe contact insecticide which creates an additional barrier that repels and ultimately kills biting bugs that land on bed nets or clothes.
Reducing the number of times you are bitten reduces the chances of an insect-borne illness bringing your trip of a lifetime to an abrupt end. 

Other recommendations

Hepatitis A – strongly recommended for travel to Bali and Indonesia in general (and other developing regions of the world). 
Hepatitis B – consider vaccination, particularly if the stay is for more than a month or for frequent overseas travel. As Hep B is a blood- and body fluid-transmitted infection, those undertaking adventurous activities, body piercing, tattooing, or at risk of sexually transmitted infections should be vaccinated. 
Typhoid – recommended, particularly for ‘adventurous eaters’, especially if likely to head of the ‘beaten track’ or remain for an extended stay. 
And…
Boosters for MMR (measles/mumps/rubella), dTpa (diphtheria/tetanus/whooping cough), chickenpox as needed, as well as pneumococcus if advised.   
Influenza – is the most common vaccine preventable illness in travellers and vaccination should be sought at least 2 weeks prior to departure. 
More…
Traveller’s diarrhoea: Up to 60% of all leisure and business travellers are laid low by travellers’ diarrhoea (TD) – this means at least a day or more of inconvenience and discomfort. We recommend hand washing or using alcohol based hand gels before handling food, carrying treatment medication, plus sachets of rehydration solution – just in case – and avoid the obvious traps: ice made with tap water, undercooked or raw foods, salads washed in tap water, unpeeled fruits, and protein foods kept at room temperature. Read more about avoiding and treating TD. 

Planning a trip to Bali? 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.

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You have only to read through our weekly travel health alerts to appreciate that travel medicine is an ever-changing field and, while new vaccines, preventive medications and treatments are not developed every day, new diseases emerge, and previously common ones re-emerge, on a regular basis.

Regulations surrounding health requirements for travellers arriving in any country are largely set by that country but, in this age of mass rapid transport, all nations have an interest in stopping or limiting the spread of infectious disease threats. For that purpose the International Health Regulations (IHR)1, which were established (and are regularly monitored) by the Member states of the World Health Organisation (WHO) at the World Health Assembly meetings, aim ‘to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide2.’ The IHR are updated when new information is received as in the case of disease outbreaks or changes in vaccine recommendations. Yellow fever3 is currently the only disease under the IHR ‘for which proof of vaccination may be required for travellers as a condition of entry to a State Party’.

In an Amendment to International Health Regulations (2005), Annex 7 (yellow fever)4, the duration of protection offered to people with normally functioning immune systems from the yellow fever vaccine has been extended to the life of the person vaccinated. This follows a recommendation made by the WHO’s Strategic Advisory Group of Experts on Immunisation (SAGE) back in 2013 ‘that a single dose of vaccination is sufficient to confer life-long immunity against yellow fever disease5’. (If the yellow fever vaccine cannot be administered due to medical contraindications, a waiver letter can be provided by a licensed medical practitioner. Travellers should check with the embassies or consulates of all countries on a planned itinerary to ensure this document will be accepted at border controls.)

The Australian government’s implementation of the Annex 7 amendments took effect on June 16th, 2016 and advice provided on the Department of Health website was updated to, ‘From 16 June 2016, international yellow fever vaccination certificates presented at Australia’s border will be accepted even if the vaccination was given more than ten years ago6.’

The thing is, all situations are not necessarily clear-cut … While a traveller may not need the yellow fever vaccination to enter a country (sometimes even when the disease is present there), proof of vaccination may be required for the next destination on their itinerary, or the one after. We have to consider the timing of the itinerary as well as the areas and countries visited.

And now to a matter that needs to be discussed when planning travel that includes yellow fever risk regions: A recent article on arrivals into Tanzania published in the Journal of Travel Medicine confirms information we have from some of our clinics. Immigration authorities in some countries will randomly request to check yellow fever vaccination documents (even from travellers who have not arrived from a yellow fever-affected area or only transited one briefly - <12 hours). In the case of arrival from a yellow fever risk area, if a valid certificate or waiver letter cannot be produced, an on-the-spot fine may be issued or the vaccine is administered there and then, otherwise entry is prohibited. The journal article also details how the departure point, arrival port and mode of transport into a country sometimes determined whether vaccination certificate checks were more likely to be carried out.

Further, while Australian authorities will accept yellow fever vaccination certificates issued over 10 years previously, that is not necessarily the case in all countries; the onus is on each traveller to check that their certificate or waiver letter will be accepted by border officials on arrival. In one instance that we have been made aware of, travellers planning a trip to Ghana had to return to a clinic in Adelaide to be revaccinated against yellow fever despite having a valid vaccination certificate as far as Australian laws are concerned i.e. issued more than 10 years ago but current under our new regulations. The travellers were advised by the Ghanaian authorities that if they did not have a new, current vaccination certificate they would be vaccinated at the airport on arrival and would not be allowed to leave their accommodation for 7 days.

Yellow Fever

The disease:
Yellow fever is a viral haemorrhagic infection that is reported in tropical areas of Africa and Central/South America. Transmission occurs in jungle (sylvan) areas where mosquitoes transmit the disease from monkey hosts to other primates or humans AND in urban areas where the Aedes mosquito spreads the infection among the human population.

Risk to travellers:
Yellow fever occurs only rarely in travellers (because the vast majority travelling to yellow fever risk areas have been vaccinated), however it does present a risk, particularly if the conditions are right: season, duration of travel to endemic area and sub-optimal insect bite avoidance measures. If travelling to a country where yellow fever is present, travellers should take precautions against insect bites and discuss the appropriateness of yellow fever vaccination at a yellow fever accredited medical centre.

Signs and Symptoms:
The incubation period of yellow fever ranges from three to six days and leads to the acute phase characterised by fever, muscle pains, headache, shivers, nausea and vomiting. Treatment is symptomatic. Most infected individuals will improve, but around 15 percent will experience a temporary remission (saddle-back fever) then deteriorate, passing into the toxic phase of the illness. Jaundice and bleeding complications such as vomiting blood, bleeding gums and blood-stained urine lead to shock and multiple organ failure. Death rates in this phase range from 20 to 50 percent and mostly occur 7–10 days after onset.

Prevention:
Live attenuated viral vaccine (Stamaril)
Standard schedule
• Single dose protects for life (an International Certificate of Vaccination or Prophylaxis is required to confirm vaccination – this becomes valid 10 days after vaccine administration).
• Suitable for ages 9 months and over.
Discuss yellow fever vaccine administration contraindications and precautions with your yellow fever licenced prescribing practitioner.
Contact Travelvax Australia’s travel health advisory service (1300 360 164) for country-specific information and advice, including possible immunisations, for your next overseas travel. You can also make an appointment to have your vaccinations completed in a consultation with a team of medical professionals experienced in travel medicine.

1. http://www.who.int/topics/international_health_regulations/en/
2. http://apps.who.int/iris/bitstream/10665/246107/1/9789241580496-eng.pdf?ua=1
3. http://www.travelvax.com.au/resource_files/Yellow-fever-updated-June2016-1-.pdf
4. http://www.who.int/ith/annex7-ihr.pdf
5. http://www.who.int/mediacentre/news/releases/2013/yellow_fever_20130517/en/
6. http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlth-strateg-communic-factsheets-yellow.htm

Shingles rash
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As part of a pre-travel health consultation, we look at routine vaccinations and ensure each traveller is current with the recommended vaccines for their age group.

From this month, another vaccine has been added to the range used to protect the 70+ age group – Zostavax. This vaccine, which offers protection against Herpes zoster virus (cause of the painful condition shingles), is offered to those eligible residents aged 70 years. A 5-year catch up for the 71-79 year age group will be in place until October 2021. Your doctor will determine each person's suitability for vaccination - immunocompromise, acute illness, allergy and recent shingles infection are some of the conditions that need to be considered.

Read more about the Herpes zoster virus and how after primary infection with chickenpox (varicella) the latent virus can reactivate in later life to cause shingles. 

As the Immunise Australia website so succinctly puts it: ‘Vaccinations don’t stop at childhood.’ Read more

The announcement of successful human trials of a vaccine against the Chikungunya virus is good news for travellers and those who live with the risk of the mosquito-borne virus across the tropical world.

Conducted by the US’ National Institute of Allergy and Infectious Diseases (NIAID), the Chikungunya vaccine trials involved 25 volunteers aged 18 to 50, who received three doses of varying strengths over 5 months.
Most had neutralising antibodies in their blood after the first dose and all 25 had them after the second dose. Antibodies were still present after 6 months, while after 11 months antibody levels were similar to those in people who had recovered after natural Chikungunya infection, suggesting that the vaccine could provide long-term protection.
Key trial results reported by the research team included:
- The vaccine generated antibodies against multiple Chikungunya genotypes, suggesting it will be effective against all strains of the virus. (In contrast, the most advanced dengue vaccine due to be released next year appears to offer only incomplete and variable protection across the 4 dengue virus serotypes.)
- It will be relatively economical to make in large quantities.
- The same technique could be used to produce vaccines against a range of encephalitis-causing viruses related to Chikungunya.

Read more ...

By Dr Jennifer Sisson*

Do you have a fear of needles? You’re not alone.
A Canadian study found 24% of adults and 63% children surveyed disliked having medical injections due to their fear of needles.
So, it’s hardly surprising that most people find the prospect of getting several vaccinations for an overseas trip daunting – even when they are recommended or actually required for entry or to return home.
But, there is good news for aichmophobics (people who fear sharp objects): A new generation of needle-free vaccines is in the wings.

Read more ...