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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

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.

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In tropical regions, chickenpox (or varicella) is a disease affecting older children or adults that’s more likely to strike during the ‘tourist’ season when it’s dry and the temperatures are cooler. For temperate climates, which most Australians live in, spikes of infection occur mostly in winter or spring1.

Proof indeed!
Before the chickenpox (varicella) vaccine was introduced into our national immunisation program in 2005 (a single dose was given to children under 14 years of age), each year over 200,000 cases of chickenpox were reported and around 1,500 of those needed hospitalisation. Even worse, an average of 7 deaths annually resulted2. Now, some 11 years later, that annual number of cases is now around 2,4003, and the greatest benefit has been seen in children aged 1-4 years and indigenous Australians4.

The USA added the vaccine to its routine vaccination program in 1996 in response to an estimated 4 million chickenpox cases each year, including 11,000 to 13,500 hospitalisations and 100 to 150 chickenpox-related deaths. The result was an astounding 85% reduction in the incidence of chickenpox. However because of continued outbreaks in schools and high rates of ‘breakthrough’ infections among immunised children3, a second dose was included in the routine childhood immunisation schedule in 2006. The National Notifiable Diseases Surveillance System has since documented an overall 97% reduction in the incidence of chickenpox since the varicella vaccination program was implemented5.

What do we do next?
Leading Australian immunisation resources, the Australian Technical Advisory Group on Immunisation (ATAGI) and the National Health and Medical Research Council (NHMRC), through the Australian Immunisation Handbook, have recommended a second vaccine dose as it provides protection similar to that of natural infection, adds to herd immunity and minimises the chance of breakthrough infection in children under 14 years of age, but acknowledge that the lack of funding means that it must be paid for by parents and carers privately.

The disease
Varicella-Zoster Virus (VZV), better known as chickenpox, is one of eight herpes viruses that can cause infection in humans and it’s highly contagious - up to 90% of household contacts will develop the disease. The virus is transmitted via the upper respiratory tract by aerosol spread of infected respiratory secretions or contact with the vesicular fluid from those infected. There is a 10 to 21 day incubation period and infected individuals are contagious from 2 days before the onset of the typical vesicular rash until all the rash vesicles are crusted. Typically the illness commences with a prodromal phase with symptoms such as fever, malaise. 1-2 days later the typical itchy, blister-like rash begins to appear. Initially the blisters (vesicles) affect the trunk and face and then spread to the rest of the body. Each vesicle has a red base which develops into a pustule that eventually forms a crust. New vesicles continue to appear for 3 to 7 days, with an average of 300 lesions (but can number from 10 up to 1,500).

Some 5% of children exposed actually get subclinical infections with subsequent immunity without knowing that they had contracted the infection.

Serious complications of acute varicella infection are rare, occurring in approximately 1% of cases. These may present as secondary bacterial infections of the skin lesions, pneumonia, encephalitis and hepatitis. Infection is usually more severe in adolescents and adults2. Following infection, antibodies are produced which will keep the virus at bay; however as we age, we become more susceptible and the virus can emerge and cause the painful herpes zoster infection, also known as shingles.

Vaccines: What we have and who do we give it to?
In Australia there are 2 vaccines containing live, attenuated varicella zoster virus, plus 2 others used only in children that are in combination with measles, mumps and rubella.
While not publicly funded, varicella vaccination is also recommended for non-immune adults at high risk of developing the disease: healthcare professionals, child-care workers, non-immune women prior to falling pregnant and parents. Also, household contacts with no immunity should be vaccinated to prevent the virus’ spread to immunosuppressed individuals. The vaccine schedule for the 14 years and older age group is 2 doses administered at least 4 weeks apart. An important note is that varicella-containing vaccines are contraindicated for pregnant women and pregnancy should be avoided for at least 28 days after vaccination.

If you’re travelling overseas
The risk of chickenpox is as high in developed countries as in developing ones. Very few countries include the vaccine in their routine childhood schedules - Canada, Costa Rica, Germany, Greece, Korea, Latvia, Luxembourg, Qatar, Saudi Arabia, UAE, Uruguay, USA and some parts of Spain & Italy1 - but coverage is increasing. Non-immune adults and children should consider vaccination, especially if planning longer stays or extensive travel.

1. http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/varicella-chickenpox
2. http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/varicella-fact-sheet.pdf
3. http://www9.health.gov.au/cda/source/rpt_3.cfm
4. http://www.who.int/bulletin/volumes/92/8/13-132142.pdf?ua=1%20A
5. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm

 Talk to anyone born prior to the 1960s and they will tell you about how polio used to be a terrifying reality. Hundreds of thousands of children across the globe were left paralysed in its wake and confronting images of wards full of iron lung machines circulated. With the introduction of the Salk vaccine in the mid-1950s, polio outbreaks became less frequent – the last epidemic to hit Australia was in the early 1960s. By 1966, the oral Sabin vaccine came into use and this was replaced with a more effective inactivated vaccine in 2005.  

About polio

Polio is a potentially serious viral illness spread through contact with infected faeces or saliva. It is made up of 3 types of wild polio virus WPV 1, 2 & 3 – all of which can cause disease. Polio has a variable incubation period of 3-21 days. Infected individuals are most infectious from 10 days before to 10 days after the onset of symptoms. In 90% of cases, polio infection passes without symptoms but, if they are present, they include headache, fever, vomiting, tiredness, neck and back stiffness, limb pain with or without paralysis. Severe paralytic polio occurs as a complication of WPV in 1 in 200 cases. It affects the spinal cord in 79% of cases, which leads to acute flaccid paralysis (AFP) affecting the limbs (mainly the legs and is asymmetrical). Paralytic polio can lead to death in 2 - 5% of children and 15 – 30% of adults. There is no cure and treatment is supportive; immunisation is the only way to prevent infection.

The largely asymptomatic nature of polio is a major hurdle in the eradication efforts as authorities try to identify cases in often remote regions of the world.

 

Figure from Global Polio eradication initiative 2011 report  http://www.polioeradication.org/Portals/0/Document/Data&Monitoring/IMB_Reports/IMB_Report_April2011.pdf

 Eradication efforts

In 1988, the World Health Assembly (WHA) resolved to target polio with a view to achieving eradication by the year 2000 and formally founded the Global Polio Eradication Initiative (GPEI). At the time the GPEI was established, more than 1000 children a day worldwide were diagnosed with polio. Since then, in excess of 2.5 billion children have been immunised against polio and there has been some success in eradicating certain strains of WPV: the last case of WPV type 2 was reported in 1999 and the last WPV type 3 in 2012.

By 2006 the number of WPV cases had reduced by more than 99% and only four countries showed no interruption in WPV transmission, namely Afghanistan, India, Nigeria and Pakistan. India was removed from the list of endemic countries in March 2014 and in October 2015 Nigeria was also taken off the list.

In 2016 year-to-date, there have been 22 cases of polio reported across the globe compared to 350, 000 in 1988 and until last week (11th of August) the only 2 countries reporting wild polio were in fact Afghanistan and Pakistan. But in a major setback to the global eradication campaign, Nigeria has notified the WHO that after more than 2 years without wild polio 2 children have been diagnosed with paralytic polio in the northern state of Borno.

Polio Global Eradication Initiative – Data and monitoring http://www.polioeradication.org/Dataandmonitoring/Poliothisweek/Poliocasesworldwide.aspx

It was in 2012 that the World Health Organisation (WHO) instigated the Polio Eradication and Endgame Strategic Plan 2013 -2018 which outlined an all-inclusive strategy addressing how to deliver a polio-free world by 2018.

Successes

The Regional Commission for the Certification of Polio Eradication declared the WHO’s 11 country South-East Asia Region free of circulating wild poliovirus in March 2014 when India’s polio status changed. The region was the 4th of the 6 WHO regions to be certified as having interrupted all indigenous WPV circulation (the Americas in 1994, the Western Pacific in 2000 & the European Region in 2002).

Current situation

While the eradication programme has had successes, many factors stand in the way of reaching the eradication goal:

- The growing conflict and insecurity in the Horn of Africa and Middle East has played a major role in precipitating outbreaks in this area
- Increased instability in Pakistan, allowing continued transmission
- Disruption to immunisation activities in these areas has led to low population immunity and ongoing insecurity hampers the efforts to respond to outbreak reports
- Rapid detection of cases can be hindered in some areas by suboptimal surveillance
- Supplementary immunisation activities have had insufficient impact on stopping transmission in Pakistan and Afghanistan – this is mainly due to poor planning which results in the same groups of children missing vaccine doses.

Recommendations for travellers

In May 2014, the WHO declared the international spread of wild poliovirus from endemic areas into polio-free areas a ‘public health emergency of international concern’ and instituted some temporary recommendations: currently these only apply to Afghanistan & Pakistan and require that residents are to be vaccinated against polio and supplied with an International Certificate of Vaccination or Prophylaxis.

According to the US Centers for Disease Control and Prevention (CDC): Long-term travelers (staying >4 weeks) to the polio-infected countries may be required to show proof of polio vaccination when departing the polio-infected country. To meet these WHO requirements, long-term travelers should receive polio vaccine between 4 weeks and 12 months before the date of departure from the polio-infected country.

Australian children receive a primary course of polio vaccinations as part of the National Immunisation Program. For those adults who have completed a primary course and will be travelling to countries where wild poliovirus transmission still occurs, a single booster dose is recommended. However travel requirements do occasionally change in response to outbreaks, so up to date advice should be sought from your travel health provider or through the Australian Government Department of Health website.

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Both food poisoning and stomach flu can give rise to nausea, vomiting, cramps and diarrhoea - but the two conditions are in fact of different aetiology. Consuming food that has been contaminated with viruses, bacteria or parasites at some point during production causes food poisoning, whereas stomach flu is a viral infection of the digestive system. Stomach flu is most commonly brought on by norovirus or rotavirus, and is different from the conventional flu, which attacks the respiratory system. Both food poisoning and stomach flu cause a condition known as gastroenteritis –inflammation of the gut, which may involve the stomach, the small and/or large intestine.

According to the World Health Organization (WHO) report on the estimates of the global burden of foodborne diseases in 2010, there were approximately 600 million foodborne illnesses causing 420,000 deaths. 

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