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It’s not long now to the 2018 World Cup in Russia starting on June 14 and if you’ve booked your tickets to see the Socceroos in action (or you’re about to) NOW is the time to think about getting the recommended vaccinations and advice. Most vaccines can be given at one time but a few may need to be spaced out over a month, so make an appointment for your pre-travel medical very soon.

The ten Russian cities that are hosting matches cover some 3,000kms from east to west, and nearly 2,400kms north to south: Moscow, St Petersburg, Kazan, Sochi, Rostov-on-Don, Saransk, Samara, Volgograd, Nizhny Novgorod, Kaliningrad and Ekaterinburg – the Socceroos' first 3 matches are in Kazan, Samara and Sochi.

Nearly 5 million fans have put their names in the first draw for tickets, just over half of them from Russia. Among the international fans, going by the top 10 countries for ticket requests, you can expect to see plenty of people from Germany, Argentina, Mexico, Brazil, Poland, Spain, Peru, Colombia, USA and the Netherlands1.

Crowd control

When travelling to sporting, cultural or political events or religious festivals, anywhere there are large gatherings of people from all over the world you should be aware that they carry their own set of health risks. The World Health Organization2 (WHO) has been active in supporting host cities and countries in their preparations for these packed events, including the Olympic Games in London and Sochi, UEFA championships and even the Eurovision Song Contest!

With respect to the potential for health consequences, the WHO explains that mass gathering events ‘can be settings for disease outbreaks and other health problems … All this can stress the public health system and resources of host countries and the countries where the visitors return to’.

In the planning stages, assistance is rendered to host countries by the WHO in areas such as:

- ‘travel medicine: procedures to provide updated health advice and vaccination guidance for visitors on vaccinations, food and water safety, and other information, including emergency contact numbers; and

- promotion of healthy behaviours: activities before and during mass gatherings to encourage, for example, increased physical activity, observing local laws and customs, avoiding aggressive and inappropriate behaviour, cessation of tobacco use, avoidance of excess alcohol and using safe sex practices2.’

Vaccinations for Russia

First, here’s an overview of the vaccinations we would typically discuss for leisure travel to Russia, which fall under 2 headings.
ROUTINE vaccinations such as measles-mumps-rubella (MMR), diphtheria, pertussis, tetanus, chickenpox, meningococcal disease, and seasonal influenza should be up to date for every overseas trip. (Outbreaks of measles have been common in developed and developing countries recently, while flu is the number one vaccine-preventable risk for overseas travellers. Both are a concern when lots of people come together from all points of the globe!)

RECOMMENDED vaccinations for Russia would include hepatitis A, which can be given on its own or in combination with hepatitis B. Hotel workers in Moscow have been required to get hepatitis A vaccinations in preparation for the arrival of the Cup players and fans - their vaccination checks also include diphtheria, tetanus, hepatitis B, measles and rubella3. Unlike Hep A, which is spread by eating or drinking contaminated food or water, Hep B is passed from person to person through the transfer of infected blood or bodily fluids. Vaccination is usually suggested for young singles, travellers on longer stays, those heading ‘off the beaten track’, or those who plan to travel regularly in the future (regardless of age). Typhoid fever, a bacterial disease spread through contaminated food or water, is present in Russia. The disease is usually not considered a significant risk for people on short visits staying in quality accommodation, but vaccination may be suggested if you’ll be staying on to see more of Russia after the Cup or you plan to visit other countries in the region. (Rabies is also present in Russia, but vaccination is more likely to be recommended for longer stays, especially in rural areas.4)

Traveller’s diarrhoea rates are considered moderate by international standards so following safe food and water guidelines is recommended. (A locally produced vaccine is available for the prevention of dysentery outbreaks caused by Shigella sonnei bacteria in the Russian population, but it would not be used for international Cup fans5.) Food and water precautions would also be advisable in the prevention of parasitic intestinal infections such as has occurred from time to time in Russia among people who have consumed undercooked pork or meat from other animals (bear, badger, walrus)6. Check with your travel health practitioner if a diarrhoea treatment kit would be useful for your trip – they’ll advise you on the medications you’d need.

In a tick…

Repellent, long sleeves, long trousers and some enclosed footwear are important items to pack if you plan to hit the rural or forested areas of the country - this is to avoid tick bites. The Ixodes species of tick is the vector of the viral illness, tick-borne encephalitis (TBE). This infection, which strikes the central nervous system of humans, is endemic in many European countries and causes anywhere from 5,000 to 13,000 cases each year. Russia reports more cases than any other6. (A word of warning: you can also contract TBE from consuming unpasteurised dairy products.)

The risk of tick bites occurs below 750 metres in altitude generally, but the range is increasing upwards, and the warmer months of April through to November are peak TBE transmission months – more so in the summer when ticks are most active.

A TBE vaccine is available through the Special Access Scheme, however it is generally used for travellers who will have extensive outdoor activities (camping, berry picking, hiking) in affected areas. Ask your medical practitioner for more information.

If you don’t plan on heading out of the cities and you don’t consume unpasteurised dairy products, your risk of TBE is very low indeed; however if you needed more reasons to avoid tick bites, they are also responsible for a number of other infections in Russia – Crimean Congo haemorrhagic fever, tularemia and Lyme disease8.

Guard your personal safety, too

A major sporting event held in a large stadium with often volatile fans has the potential for emotional and physical stress, as well as aggression. So it’s important to pay attention to your own security, drink plenty of water to prevent dehydration, avoid no-go areas, and don’t drink alcohol to excess.

When it comes to STIs, play defensively and BYO (condoms).

All of this is good advice for sports fans – even more critical when you’re more than 14,500kms from home.
And, our final two pre-game tips: Don’t forget travel health insurance and register your travel with Smartraveller!

For more information, call our phone information service on 1300 360 164 Monday to Friday 9am to 6pm AEDT.

1. http://www.fifa.com/worldcup/news/y=2018/m=1/news=2018-fifa-world-cuptm-tickets-impressive-figures-mark-the-closing-of-t-2927411.html

2. http://www.euro.who.int/en/health-topics/emergencies/disaster-preparedness-and-response/activities/health-planning-for-large-public-events

3. https://en.riavrn.ru/news/v-voronezhe-obsluzhivayushchiy-personal-chm-2018-privyut-ot-gepatita-a-i-dizenterii-zonne/

4. https://wwwnc.cdc.gov/travel/destinations/clinician/none/russia

5. http://iliveok.com/health/inoculation-dysentery-sonne_112492i15828.html

6. https://www.ncbi.nlm.nih.gov/pubmed/16081220

7. https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/tickborne-encephalitis

8. https://www.medscape.com/viewarticle/717730_10

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BAT: Noun /bæt/ Order Chiroptera: the second biggest order within the animal division (class) of Mammalia with over 1,300 species; found in most places except for the two Poles and a few Pacific islands. The largest, the tropical fruit bat, has a wingspan of over 1.5 metres, the bumblebee bat of Thailand and Myanmar is the smallest weighing in at just 2 grams1.

They are, without doubt, fascinating creatures that have across the centuries been associated with evil spirits, darkness and ghosts in some cultures, but in others such as China, they’re considered a symbol for long life and happiness2. These days they are more likely linked to video games or super heroes!

ABL – ‘our rabies’

Many of us are familiar with the sight of colonies of flying foxes taking to the skies in the early evening and passing again to return to their roosting places hours later – they are part of our landscape. But it’s the closeness of our urban areas to their habitation and feeding grounds that has led to warnings of the dangers of being bitten or scratched by bats because of the risk of Australian Bat Lyssavirus (ABL) infection3. (In fact, the risk of ABL transmission is quite low – <1 percent of bats are infected4.)

Since  ABL was first identified back in 1996, initial testing identified only a few of our fruit bat species and one that is insectivorous as being able to transmit the viral infection. Now however the consensus seems to be that any of our bat species has the potential to be a host of the rabies virus – fruit bats and insect-eating varieties5.

ABL is closely related to the rabies virus we recognise in terrestrial mammals, most commonly dogs. Rabies virus and ABL are both Lyssaviruses.

On the qui vive

And these warnings do not apply to Australia alone: Before you even think about handling or approaching a bat you should know that the standing advice from the US Centers for Disease Control and Prevention is: ‘Bat bites anywhere in the world are a cause of concern and an indication to consider (rabies) prophylaxis.’ 6 (Of note, bat bites have been the cause of most recent human rabies cases in the USA.7)

While dogs are responsible for most rabies infections in humans across the world, mammals as a whole are capable of transmitting the virus. This occurs through bites mostly, but in rare cases it can also happen if the animal licks its claws and then scratches you, or if its saliva comes into direct contact with your eyes, mouth, nose or an open wound. And so it is with bats.

Infection isn’t immediate.

Tragically, three Australians have lost their lives to ABL – of the 2 with known exposure to bats, one had onset of symptoms after a few weeks, the other after more than 2 years5.

The length of the incubation period is determined by the amount of virus (contained in the saliva) inoculated into the wound, its proximity to the brain i.e. head & neck, and the number of nerve cells in the area. 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 pre-exposure vaccines have been administered (3 doses over 3-4 weeks), 2 more doses of vaccine are needed as well as the appropriate first aid (see below). In those cases where there has been no pre-exposure vaccines, first aid and then post-exposure prophylaxis (PEP) must be administered before the virus enters the nervous system, so that death can be prevented.

Rabies and ABL are 100% preventable

While it’s virtually 100% deadly, rabies is 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, gently but thoroughly, with lots of soap and water.
2 – If available, alcohol or iodine 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 doses of rabies cell culture vaccine. Injected at the site of the wound, HRIG contains rabies antibodies that immediately inactivate the rabies virus until the vaccine begins to work. The rabies vaccine is equally effective against ABL and terrestrial rabies and is highly immunogenic. So a correctly and timely administered course of post-exposure prophylaxis should prevent rabies 100% of the time.
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.

After exposure

When it comes to following up on any potentially rabid exposure, do it promptly; however the rule is ‘better late than never”.

Bats have by varying degrees been associated with other infections (i.e. histoplasmosis, leptospirosis, salmonellosis, Nipah & Ebola virus and SARS)6 and in some regions their habitats have been damaged or destroyed by the local population out of fear8. But bats play a vital role in our ecosystem and are an important gauge of its health - they pollinate, disperse seeds and control pests9 so they should be valued and admired – from a distance.

1. https://www.livescience.com/28272-bats.html
2. http://www.britishmuseum.org/pdf/Chinese_symbols_1109.pdf
3. http://www.abc.net.au/news/2017-11-06/nsw-bats-infected-with-rabies-like-virus-lyssavirus/9122874
4. https://theconversation.com/why-we-shouldnt-be-so-quick-to-demonise-bats-87693
5. http://conditions.health.qld.gov.au/HealthCondition/condition/14/217/10/Australian-Bat-Lyssavirus
6. https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/rabies
7. http://www.who.int/mediacentre/factsheets/fs099/en/
8. http://www.batcon.org/resources/media-education/bats-magazine/bat_article/57
9. https://www.nature.com/articles/s41559-017-0071

There’s a lot of appeal in the street markets that you come across in some developing countries – where else would you find hugely discounted products with high end brand names? And of course there is no pretence that they are the real deal - what does it matter if those items fall to pieces or stop working in a few months? The trouble is that it’s not just merchandise that’s counterfeited, it is life-saving medicines too. While most of us find it hard to believe that some person or persons would wish to make money from this miserable trade, according to the World Health Organization (WHO) it has been going on for centuries and, thanks to globalisation and the online marketplace, it’s booming.

What are we referring to?

The definition of the bogus medications has recently been expanded and it now covers those which are: substandard/ spurious/ falsely-labelled/ falsified/ counterfeit medical products (or SSFFC). The WHO places them into 3 classifications:

· ‘Substandard medical products: Also called “out of specification”, these are authorized medical products that fail to meet either their quality standards or their specifications, or both.

· Unregistered/unlicensed medical products: Medical products that have not undergone evaluation and/or approval by the national or regional regulatory authority for the market in which they are marketed/distributed or used, subject to permitted conditions under national or regional regulation and legislation.

· Falsified medical products: Medical products that deliberately/fraudulently misrepresent their identity, composition or source.’ http://www.who.int/medicines/regulation/ssffc/definitions/en/

WHO’s keeping tabs on them

The Global Surveillance and Monitoring System for substandard and falsified medical products (GSMS) was established by the WHO four years ago, providing a central agency for the receipt and compilation of information on new and previously identified suspect products – an ‘international data exchange’. In the past this has enabled countries to cross-reference the details, and even the images, of dangerous medications which had caused harm in one country and confiscate them before more damage could be done in their own population. Another function of the GSMS is to broadcast alerts when they are notified of deficient or false products.

The Executive Summary of the GSMS report released last month stresses that the SSFFC products that they are aware of are only the tip of a very large iceberg: 1,500 cases since 2013 and ‘some cases involve millions of doses of medicines, others a single dose’. What’s more, according to the report, they cover ‘everything from cancer medicines to contraception, from antibiotics to vaccines. They are not confined to high-value medicines or well-known brand names; antimalarials and antibiotics are the two most frequently reported medicines in the database.’

What that means…

At the very least, taking a counterfeit medication will mean that you have wasted time and money.

But the consequences can be so much worse as pointed out in a WHO factsheet:

· It could result in a worsening or prolonging of the condition which caused you to take the medication.

· It can lead to drug resistance – a disaster is already unfolding as we run out of effective antibiotics and malaria treatments.

· The ingredients of the drug/ medication could be toxic and cause you harm or even be fatal.

Of course you don’t even need your passport to access some overseas medications – they can often be purchased online. In this instance we found some useful advice from the Therapeutic Goods Administration if you are considering sourcing your medications this way. But when it comes to buying medications when you are travelling overseas, Smartraveller advises: 'If you need to purchase medication at your destination, be careful not to buy imitation or counterfeit medications and prescription drugs, and always check the strength of a medication with a doctor. Be aware that packaging and labelling may be similar to those available in Australia, but the strength and active ingredients can vary from country to country.'

So, if you can, it would be so much safer and more predictable to take what you need with you (with a doctor's letter certifying the medications are prescribed for the traveller's use), or in the case of vaccines, have them here in Australia before departure through clinics such as Travelvax.

Also, be aware that some countries have limits on the importation of some types and amounts of medications. Check with the embassies or consulates here in Australia well in advance of leaving.

More information on taking PBS medications overseas can be found through the Department of Health or by calling the PBS information line on 1800 020 613. And if you would like to know more about travelling with medication, click on this link to the Travelvax website, try the Department of Human Services website or call the Overseas Drug Diversion information line on 1800 500 147.

 

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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

A Victorian man in his 60s who’d holidayed in Phuket, Thailand in early May died this week from Japanese encephalitis (JE) in a Melbourne hospital.

The traveller was on a 13-day trip to Thailand and stayed at a local resort. On day 8 of his trip, he suddenly became lethargic, however continued his travels to Bangkok 2 days later. While in Bangkok he remained lethargic, slept for several hours each day, had a poor appetite and was sweaty. He flew back to Victoria on Day 13 of his trip and presented to a local hospital a day later suffering from confusion. The following day, due to his deteriorating mental state and lethargy, he was placed on a ventilator and transferred to the Royal Melbourne Hospital. The diagnosis of JE occurred on day 22 of his illness after blood tests confirmed the presence of the virus - details of the traveller’s itinerary indicated that he hadn’t visited rural areas, however multiple mosquito bites were noticed. (This information is reported in Promed, on behalf of the Victorian Institute of Infectious Disease Service, the Royal Melbourne Hospital and the University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Victoria, Australia.)

On the face of it, the man in his 60s wasn’t at a great risk of contracting this viral disease. He had a typical short stay: just over a week at a resort in Phuket and then a return trip via Bangkok to Victoria. We’re told he didn’t spend any time in rice-growing areas, where most JE outbreaks occur. (Wading birds in rice fields and pigs serve as reservoirs, or ‘amplifying hosts’, in the virus’ transmission cycle. Mosquitoes transfer it between the two animal species before passing it on to humans who are termed ‘dead-end hosts’ because we are unlikely to have enough virus in the blood that a mosquito could ingest and then transmit to others.) 

JE cases are very rare

Promed has previously reported on a case of JE originating from Thailand and, while it is an unusual occurrence in short-term travellers to Thailand, the disease actually is endemic there. This recent case is now the second recorded in Victoria, after another man was hospitalised in February 2015 following a stay in Canggu on the Indonesian island of Bali. It appears the Melbourne man did not seek any pre-travel health advice prior to travelling to Phuket.

The US Centers for Disease Control and Prevention (CDC) reports that for most travellers to Asia, the risk of JE is extremely low, with ‘the overall incidence of JE among people from non-endemic countries travelling to Asia estimated to be <1 case per 1 million travellers; however the degree of risk is based on the destination, length of stay, season of travel and activities.

Only 79 cases of JE among travellers or expatriates from non-endemic countries were reported to the CDC from 1973 through to 2015 – 10 of those were recorded after a vaccine became available in the United States in 1993. In Australia, since 2001 there have been 10 reported cases of JE – most of them in Cape York Peninsula and the Torres Strait Islands.

Rare, but potentially severe outcome

The Japanese encephalitis virus is an arbovirus and is closely related to other mosquito-borne viruses such as West Nile, St Louis encephalitis, yellow fever and dengue fever.
Most cases occur among local people living in rice-producing areas of China, the Indian subcontinent, and Southeast Asia. More recently JE has become established in Papua New Guinea and the Torres Strait Islands, with the occasional case in Northern Australia.
Most JE infections are mild: usually a slight fever and a headache. But, for around 1-in-100 victims, the infection is severe and statistics show that 20-30% of these patients will die while 30% - 50% will be left with a severe neurological disability.
Because so few returned travellers show signs of illness – unlike the unfortunate Victorian gentleman – the incidence of JE is almost certainly under-reported here and elsewhere around the world.

Those at higher risk of JE

Inevitably, cases like the Victorian one fuel the vaccination question: should short term travellers to Asian holiday resorts such as Phuket and Bali be vaccinated?
The fringes of holiday resort areas and major towns and cities in Asia often do have rice paddy fields and pigs (such as Canggu and Seminyak in Bali) – so, we shouldn’t be surprised that the JE virus is present in mosquitoes in these areas. All travellers to Asia (and other tropical regions) must be fully aware of the need to take appropriate measures to avoid mosquito bites.
Typically, the vaccine is recommended for backpackers passing through regional areas for more than a month, for rural-based aid workers, and expats living or working in an endemic region for extended periods, particularly during or just after the wet season.
The Australian Immunisation Handbook recommends that doctors consider advising vaccination for travellers in the following situations:

  • JE vaccination is recommended for travellers spending 1 month or more in endemic areas in Asia and Papua New Guinea during the JE virus transmission season, including persons who will be based in urban areas but are likely to visit endemic rural or agricultural areas.
  • The Handbook further advises that “it is important to note that, as JE has occurred in travellers after shorter periods of travel, JE vaccination should be considered for shorter-term travellers, particularly if the travel is during the wet season, or anticipated to be repeated, and/or there is considerable outdoor activity, and/or staying in accommodation without air conditioning, screens or bed nets”. Risk is negligible for short stay business travellers to urban areas.

The imperative of insect bite avoidance

So, should Australians planning to visit Thailand or anywhere else in Asia where Japanese encephalitis occurs be concerned? The answer is yes and no.
No, because for a traveller on a typical short holiday in Asia, the risk of getting JE is clearly so low that vaccination is very rarely recommended.

Yes, because the Victorian case demonstrates that no-one travelling to a tropical Asian destination – even well-travelled ones like Phuket - can afford to be blasé about avoiding mosquito bites. Not anywhere. Not any time.

And the repellent won’t just prevent JE: Dengue, Zika and chikungunya are a significantly higher risk for travellers in many tropical and sub-tropical destinations because they’re spread by the urban-breeding, daytime-feeding Aedes species.

Adopt some or all of these bite avoidance measures:

- Apply an insect repellent containing an effective ingredient such as DEET (30-50% formulations for adults, or 10-20% formulations for young children and infants as young as 2 months of age), Picaridin or preparations containing extract of lemon eucalyptus oil, as necessary when outdoors.

- Wear long, loose-fitting, light-coloured clothing after dark, particularly around dusk and dawn when JE (Culex) mozzies are most active. Treating your clothing with the contact insecticide permethrin creates a deadly barrier to mozzies and other bugs that can bite through light material.

- Sleep under a treated bed net, especially if you are staying in a tent or in budget accommodation without screened doors and windows, or air-conditioning. You can buy a treated net or purchase a DIY kit and use it to treat a net and clothing to give yourself a strong barrier against biting insects.

Pre-travel vaccinations

While the focus is still on a risk assessment and the full range of bite protection measures, the length of the trip is no longer the main consideration for vaccination. Increasingly, it is being discussed in terms of a long-term ‘investment’ in healthy travel, particularly for the more adventurous who regularly head off the beaten track in Asia, as well as those who expect to continue travelling there regularly for leisure or work and want the extra protection (and peace of mind) immunisation offers.

There are two very effective vaccines against Japanese encephalitis for those at sufficiently high risk to warrant that level of protection, or who are unsure of their itinerary and wish to be proactive. One of these vaccines (Imojev) affords protection for at least 5 years. Unfortunately these vaccines are more expensive than your typical travel vaccines so discuss the need for this and other vaccinations for your trip with an experienced travel medicine practitioner.

If this sounds like you, discuss the merits of vaccination with your travel doctor at least 6 weeks before departure.

Heading to Asia? Learn more about the risks of Japanese encephalitis and the potential travel health issues for your trip by calling the Travelvax Australia travel health advisory service on 1300 360 164 for the latest country-specific information.

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/