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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

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

 

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

 

© Ezumeimages | Dreamstime.com

 

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

What do we know about this life-threatening illness?

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

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

Australia and Meningococcal Meningitis

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

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

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

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



Global incidence

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

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

  Population Health Metrics 2013, 11:17 

Available vaccines

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

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

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

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

Travel and meningococcal meningitis

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

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

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

 

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

 

Wounded dog in Durbar Square, Kathmandu, Nepal

September 28th is World Rabies Day and we thought it worthwhile to acknowledge the event with some reminders on how to manage a potential rabies exposure – what to do in the way of first aid and what medical treatment should involve – as a well as sharing a link to a recent article in the guardian online.

The story we wanted to share was written by a young woman who survived rabies infection – an extremely rare occurrence unfortunately. The young woman’s name is Jeanna Giese and the piece: Experience: I was bitten by a rabid bat
I had become the first known person ever to survive rabies without a vaccination, and the treatment became known as the Milwaukee protocol. 

It is important, however, to point out that the Milwaukee Protocol has been attempted many times since it was published, with little or no success. It is thought that Jeanna’s case was caused by a less virulent strain of bat rabies virus that allowed her immune system to mount a vigorous, early immune response. There have been similar other rare cases of survivors, with or without treatment, usually infected with bat variant rabies virus.

Things to know about rabies

Rabies is present in almost every country on earth, but most human cases occur in South Asia – particularly India. While dogs are responsible for most of the estimated 55,000 deaths each year, virtually any mammal can carry the virus, typically passing it on by biting another animal – or a person.
When you’re overseas, patting, feeding or even approaching animals – domestic or wild, healthy, sick or injured – is problematic: The virus is always fatal once its symptoms manifest themselves so you can’t ignore a potential exposure.
You know all this, right? Well, here are a few things you might not know about rabies…
You don‘t have to be bitten to get infected – Though rare, transmission can occur through infected saliva contacting the mucous membranes of your nose or eyes, or via a lick on a scratch or other break in the skin.
Infection isn’t immediate – After multiplying in the wound, the virus inevitably reaches nerve tissue. It then travels via the nervous system to the brain, where it continues to multiply with progressively more gruesome and painful clinical symptoms. If rabies post-exposure prophylaxis (PEP) is administered before the virus enters the nervous system, death can be prevented.
Animals may not appear rabid – The Hollywood image of a dog foaming at the mouth is a far less common sign of rabies than sudden, unexplained paralysis or a change in behaviour. A friendly cat may suddenly be very aggressive, while a normally playful puppy becomes shy and withdrawn. Not eating, eating strange (non-food) objects, pawing the mouth, appearing to choke, difficulty swallowing, chewing the bite wound, seizures, hypersensitivity to touch or sound are among the other sign an animal is infected.
Rabies incubation periods can vary – It usually takes 3-8 weeks for the rabies virus to incubate, but human cases have ranged from just days to years. That’s why it is important to receive post-exposure prophylaxis (PEP) as soon as possible and start within 48 hours. If medical care was not sought at the time of the bite it is still possible to get PEP well after the potential exposure, because if the incubation period is at the protracted end, the PEP may still be effective. 

Rabies is 100% preventable

While it’s 100% deadly, rabies is also 100% preventable. But, a series of steps needs to be taken in the right order to prevent infection.
1 – The wound needs to be cleansed thoroughly with lots of soap and water.
2 – If available, alcohol or iodine (such as betadine) should be applied. The wound should be covered with gauze to prevent infection (but not bound), or left uncovered.
3 – It is critical to seek expert medical attention as soon as possible. (Don’t wait for confirmation that the animal was infected. That could take days – even weeks.) It’s important to find a medical facility experienced in rabies treatment that stocks (or can obtain quickly) both Human Rabies Immune Globulin (HRIG) and the first dose of rabies cell culture vaccine. Injected at the site of the wound, HRIG contains rabies antibodies that immediately inactivate and control the rabies virus until the vaccine begins to work.
4 - Have a tetanus booster, if one is required.
5 - Observe the wound for redness and discharge. Bacterial infection may occur after animal bites and antibiotics may be required.

Vaccination provides lifelong protection

Discuss pre-travel rabies vaccination with your travel doctor or GP if you are:
– Travelling to a rabies-endemic country, irrespective of length of stay. Children in particular are at greater risk.
– Planning to live and work overseas in a rabies-endemic country.
– Wanting the protection that immunisation offers.
The course of rabies vaccine is relatively expensive. On the plus side, no booster is required unless you will be at risk of regular exposure through your occupation, or if indeed you have an exposure.
The advantages of pre-exposure vaccination are:
- If bitten or potentially exposed to the virus you will need only 2 injections over 3 days, not the 4-5 over 14-28 days required if you haven’t been vaccinated.
- The HRIG is not necessary, greatly simplifying treatment after a potential exposure. (HRIG is notoriously difficult to obtain overseas and always very expensive when you can.)
For regular travellers, rabies vaccination is a life-long investment in peace-of-mind travel.