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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).

 

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Australia has seen an increasing number of dengue notifications in recent years – the more-than-2,000 confirmed cases reported last year were the highest in 20 years. Of the 2129 notifications, around 1 in 4 were in adults aged between 25 and 34 years. So we are asking - Are Australian travellers putting themselves at risk because of the Aussie ‘you’ll be right, mate’ mind-set, or is it due to the YOLO (you only live once) attitudes of younger travellers? Or could it be a lack of awareness which is fuelling this increase in infection rates?

In a survey carried out on over 1,000 Australian travellers by the pharmaceutical company Sanofi, 40% of them admitted to a YOLO attitude when travelling. The survey also exposed a lack of homework before eating food from street vendors and security lapses through falling asleep outdoors. What’s more, over 40 % of travellers said they did get sick, 50% didn’t have the recommended vaccinations and more than 60% didn’t consult their GP or a travel medicine specialist clinic prior to travel!

But back to dengue fever…

Dr Cameron Webb, University of Sydney-based medical entomologist and clinical lecturer, said recently that ‘dengue fever cases were increasing globally and travellers are bringing the disease back to Australia’ as a result. Unfortunately, many popular holiday destinations are also prone to outbreaks of dengue. The opportunities to be infected are most certainly there: In June last year, there were 824,300 short-term resident departures from Australia and many of the top 10 tourist destinations (Indonesia, Thailand, Singapore, Fiji and India) are dengue endemic countries. Western Australia was in number one spot across the country last year with 533 dengue notifications - maybe that’s because cheap air fares to (dengue-affected) Bali make it a popular travel destination.

Dengue, like other mosquito-borne diseases caused by Zika and chikungunya viruses, is transmitted by Aedes aegypti and Aedes albopictus mosquitoes. The mosquito vectors are both aggressive day-time feeders that breed and bite in urban locations and prefer cool, shaded places. They are found in areas close to people, their favourite source of the blood meal the females need to lay eggs. 

While only about 25% of people infected with dengue viruses actually get symptoms, those that do fall ill can experience fever, headache, pain behind the eyes, rash, and severe aching of muscles, joints, and bones (and this is the reason why dengue also has another more evocative name, ‘breakbone fever’).

Dengue isn’t just a problem for travellers, it’s one of the most significant mosquito-borne viral diseases globally with a worldwide public health burden estimated at around 50 to 390 million infections, including dengue fever and the potentially fatal dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). The mounting disease presence across the globe is believed to be due to climate change, the expansion of dengue vectors to new geographic regions, increasing human movement across borders, global trade and urban migration.

Our advice to avoid dengue?

Before you ask, there isn’t a dengue vaccine ... or at least not yet for tourists. A vaccine has been developed and is currently registered in 11 countries – but they are all countries with a significant dengue burden, and this is where the vaccine will be most useful. It is expected to reduce the levels of severe dengue illness and the resulting hospitalisations through its actions in the 9 to 45 years age group. 

For many travellers staying at major resorts, there will be mosquito control programs in place that substantially reduce the risks of dengue. Perhaps this is why fewer older Australian travellers are returning infected with dengue. However, even if staying in a resort with minimal risk, be aware that day trips to local villages or towns may bring with them a risk of exposure to mosquitoes, so take steps to avoid these bites.

Minimise mosquito bites and you reduce the risk of infection

Dr Webb says Australian travellers can reduce their risk of being bitten by following these measures:
– The mosquitoes that spread dengue viruses bite during the day. This means travellers must be actively avoiding mosquito bites during the day, not just in the afternoon and evening. Wearing loose, long-sleeved shirts and long pants outdoors together with topical insect repellents will provide the best protection.
–The most effective insect repellents are those containing DEET, Picaridin or extract of lemon eucalyptus oil. It is always best to take insect repellent with you from Australia as it may be difficult to find suitable formulations at your holiday destination. See here for the range of repellents that Travelvax stocks. 
– Where possible, ensure where you’re staying is air conditioned and has screened windows and doors.
– Get rid of any standing water around your accommodation, including pot plant bases and other containers that collect water.
– If you are using sunscreen, apply it first BEFORE your insect repellent.
– If you’re likely to be consistently exposed to insect bites, soak your clothing and bed net (if your room is not screened) with permethrin. This contact insecticide repels mosquitoes and other insects, and also kills them when they come in contact with the treated material. (Permethrin shouldn’t be applied directly to your skin.) Read more about permethrin and how to protect yourself against insect bites
– Mosquito coils and “plug-in” devices can also assist in reducing mosquito bites around your accommodation
The fewer times you get bitten, the lower the risk of infection. Don’t get bitten and there’s absolutely no chance at all.
No excuse for the lack of awareness now.

Did you know you can get no-obligation, country-specific advice on insect-borne diseases and other potential health risks of your next overseas destination by calling Travelvax Australia’s travel health advisory service on 1300 360 164 (free to landlines)?

 

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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

 

 

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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