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By Dr Eddy Bajrovic, Medical Director of Travelvax

A colleague told me how she had managed to get typhoid fever while working at a holiday resort in Mexico back in the early 1980s. One meal taken in the nearby town proved to be her undoing. But after two week’s rest, a simple course of oral antibiotics and countless banana sandwiches (the only thing she could stomach and hasn’t been able to eat since), she recovered. Fast-forward thirty-five years and treating typhoid fever has become much more problematic after new, resistant strains of the bacterium appeared and then started to spread.

Infection that is exclusively ours

Only humans can contract typhoid fever. Caused by a bacterium, Salmonella enterica serovar typhi (S. typhi), it is one of the enteric fevers – there are three others caused paratyphoid bacteria (S Parayphi serotypes A, B and C). Typhoid is a severe systemic infection that can produce symptoms such as abdominal pain, rash, headache, malaise, coated tongue, as well as sustained fever and either diarrhoea or constipation. Without treatment, between 12 and 30 percent of people infected with typhoid will die from complications such as intestinal perforation or haemorrhage1.

In most cases typhoid is passed on to someone when an infected human, who can feel sick or have no symptoms whatsoever (asymptomatic), contaminates food or water for consumption by others with faecal matter2. Between two and five percent of people convalescing from typhoid infection will become carriers, appearing well but able to transmit the infection to others, as was the case with the famous figure Typhoid Mary3.

Typhoid fever is more common, either endemic or in producing epidemics, in developing countries with poor infrastructure, so regions of Asia and Sub-Saharan Africa in particular are significantly affected. As laboratory testing can be sub-standard or even non-existent in some areas, the number of cases worldwide is probably an underestimate of the true burden of disease. The Coalition against Typhoid uses various sources and calculations in putting the number of infections between ‘12 to 21 million cases and 128,000 to 223,000 deaths per year’4.

Worrying times

It was in 1990 when typhoid bacteria resistant to three commonly used antibiotics were first observed in India and nearby countries; one of the main reasons for their emergence is said to be from people self-treating with antibiotics. By 1996, when another antibiotic was added to the list of treatment failures, the spread of multi-drug resistance (MDR) and reduced sensitivity escalated, eventually being felt as far afield as the UK, Thailand, Mexico and Peru5.

One step further

One of the resistant strains that was discovered in the 1990s, known as H58, has adapted and spread faster, evolving into an extensively drug-resistant (XDR) form by 2016, when it was first identified in Pakistan. With the inclusion of a small piece of DNA, a plasmid, that is found in bacteria and in nature and can replicate independently, the H58 strain could reproduce quickly. As explained by the Coalition against Typhoid, ‘This is a troubling development because previous reports of XDR typhoid have been sporadic and isolated, while this particular strain has already caused a large-scale outbreak and is spreading within and outside Pakistan. It has already been carried as far as the United Kingdom: our colleagues at Public Health England detected this strain in a patient who had recently returned from Pakistan’6.

During an interview with a local news source, a senior doctor in the field of pathology and microbiology in Islamabad said there had already been 2,000 cases of XDR typhoid this year in Pakistan and without new treatments ‘it could turn the clock 70 years back when surviving the disease was more a matter of luck than treatment’.

Current advice

Just a few weeks ago, the US Centers for Disease Control and Prevention (CDC) issued a travel advisory for Pakistan recommending that ‘Travelers to South Asia, including Pakistan, should take precautions to protect themselves from typhoid fever, including getting a typhoid fever vaccination’ and ‘…should also take extra care to follow safe food and water guidelines’.

Vaccines

From a pre-travel health point of view, vaccination against typhoid is recommended for travel to endemic regions, particularly to areas outside the usual tourist routes and for extended stays. Targeting particular groups of travellers is also important: children, the elderly, pregnant women, people visiting friends and relatives, and those with medical conditions that can increase the risk of infection (reduced stomach acidity or intestinal pathology relating to inflammatory bowel disease, surgery or cancer)7.

Two different types of vaccines used to prevent typhoid are available in Australia8: one, a live vaccine which is not suitable for all travellers, the other, an injectable form. Both are repeated after three years if there is to be continuing risk i.e. more travel to typhoid endemic or epidemic regions.

We would also encourage travellers to observe good personal hygiene and the careful selection of food and beverages. Drink only safe bottled or filtered water and avoid raw (undercooked) shellfish, salads, cold meats and ice in drinks.

In closing, we must add that, unlike hepatitis A infection, having contracted typhoid fever once does not protect you from another bout at a later date, so vaccination and following safe food and water guidelines remain your best methods of protection.

Before you travel, call Travelvax Australia’s telephone advisory service on 1300 360 164 (toll-free from landlines) for country-specific advice and information. You can also make an appointment at your nearest Travelvax clinic to obtain vaccinations, medication to prevent or treat illness, and accessories for your journey.

  1. https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/typhoid-paratyphoid-fever
  2. http://www.who.int/mediacentre/factsheets/typhoid/en/
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959940/
  4. http://www.coalitionagainsttyphoid.org/policy-advocacy-to-take-on-typhoid/how-to-talk-about-typhoid/
  5. https://onlinelibrary.wiley.com/doi/full/10.1002/nmi2.46
  6. http://www.coalitionagainsttyphoid.org/sequencing-a-superbug-how-typhoid-became-extensively-drug-resistant/
  7. http://www.antimicrobe.org/b106.asp
  8. http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home~handbook10part4~handbook10-4-21#4.21.4

 

Tick image: ©Henrikhl Dreamstime.com

By Dr Jennifer Sisson

The lush European countryside in summer is renowned for emerald green meadows and the sound of cowbells, but there are many visitors, including Australian tourists, who are oblivious to a tiny, but potentially dangerous, insect that may be lurking in the grass – ticks, and they are capable of transmitting a number of diseases.
This year, popular tourist destinations such as Switzerland and Germany have already experienced a rise in the rates of infections transmitted by ticks, particularly tick-borne encephalitis (or TBE). Switzerland has recorded some 150 TBE cases since the beginning of 2018, while in Germany, when compared to last year, TBE case numbers have also increased and they correlate with the high tick activity observed by researchers in the country’s south (a hot spot for tick activity). More and more travellers from non-infected countries are visiting at-risk areas and undertaking adventurous and off-the-beaten track travel, so there is a very real need for travellers to be aware and prepared for this rare, but high consequence, disease.

About TBE

Tick-borne encephalitis is caused by a virus that is transmitted to humans by the bite of infected ticks (Ixodes persulcatus and Ixodes ricinus species) or as a result of consuming contaminated unpasteurised milk products. There are three related sub-types: European, Siberian and Far-Eastern and they are all caused by a flavivirus, a genus of viruses that includes dengue fever, Zika virus, yellow fever and Japanese encephalitis, all of which are transmitted to humans and animals by insects such as mosquitoes and ticks. The virus acts by attacking the human central nervous system and it’s the most common tick-borne infection in Europe and Asia, affecting at least 27 European countries and several Asian nations. Within the risk areas there’s considerable variation in both the prevalence of the virus in the tick species, and in the pervasiveness of infected ticks.

Symptoms of TBEV infection

The incubation period of tick-borne encephalitis virus (TBEV) infection ranges from two to 28 days, with an average of seven to 14 days; however if the virus is ingested, that drops to around 3 to 4 days. As with other illnesses caused by a flavivirus, only a small number of infections actually lead to symptomatic disease – around three-quarters of TBE infections produce no symptoms. For those that do, there is often a two-part progress: a non-specific illness with fever, muscle aches and headache, followed by the most recognised clinical manifestation, neurological disease such as meningitis, encephalitis and encephalomyelitis.
The severity of the disease depends on the virus sub-type: the Far-eastern sub-type generally follows a one-stage illness with death rates of up to 35 percent, while the European and Siberian sub-types tend to produce a less severe illness, with fatality rates of 0.5–2 and 1-3 percent respectively. However, also associated with the European sub-type is the incidence of age-related complications: adults aged over 40 are more likely to develop severe disease and if they are over 60 years of age, the incidence of death or lasting effects increases again.

Risk of TBE infection in travellers

Just how many travel-associated TBE cases there have been is unknown, and the reporting of infections in tourists is likely to be underestimated, particularly as the illness’ average incubation period is two weeks, meaning clinical symptoms are likely to occur when travellers return home.
The risk of contracting a TBE infection depends on the season of travel (ticks are active during the warmer months of April to November) and the amount of unprotected outdoor exposure (activities planned in forested areas where ticks may live, usually with grass, bushes and shrubbery and up to 1,500 metres in altitude). The activities that constitute the highest risk for travellers are camping, hiking, biking, mushroom- and berry-picking, mountaineering, horse riding (a popular past-time for tourists in Mongolia) and playing golf. The first imported case of TBE in Australia, as reported in a study by Chaudhuri et al (2013), concerned a traveller returning from Russia and it highlighted the difficulty in making a definitive diagnosis because of its rarity and the unavailability of laboratory testing.

Prevention of TBE

Bite avoidance measures
The advice is to avoid tick-infested areas and protect yourself against tick bites by dressing appropriately (long sleeves and long trousers tucked into socks) and use an effective insect repellent. Repellents containing DEET, Citriodiol or picaridin can be applied directly on exposed skin, while clothing and camping gear can be impregnated with a contact insecticide such as permethrin. Following outdoor activities, clothes, hair and skin should be routinely examined for ticks and if found, they should be removed promptly. Additionally, consumption of unpasteurised milk products should be avoided.

Vaccination
Besides preventing tick bites, immunisation is the best way to protect against TBE. In Australia, a vaccine (Ticovac) is available through the Therapeutic Goods Administration’s Special Access Scheme but we advise you to contact your travel health practitioner well in advance of travel as more than one dose is needed to offer protection.

References:

1. Bogovic, P. & Strle, F. (2015) Tick-borne encephalitis: A review of epidemiology, clinical characteristics and management
2. Haditsch, M. & Kunze, U. (2013) Tick-borne encephalitis: a disease neglected by travel medicine. Travel Medicine and Infectious Disease (11) 295 -300.
3. Heinz, F.X, Stiasny, K., Holzmann, H., Gric-Vitek, M., Kriz, B., Essl, A. & Kundi, M. (2013) Vaccination and tick-borne encephalitis, Central Europe.
4. US Centers for Disease Control and Prevention (CDC) Travelers Health – Chapter 3. Infectious Diseases related to Travel (Tick-borne encephalitis).
5. Rendi-Wagner, P. (2004) Risk and Prevention of Tick-borne Encephalitis in Travellers.
6. Chaudhuri A., & Růžek D. (2013) First documented case of imported tick-borne encephalitis in Australia.
7. The European Centre for Disease Control, Factsheet about tick-borne encephalitis (TBE) https://ecdc.europa.eu/en/tick-borne-encephalitis/facts/factsheet
8. The Australian Immunisation Handbook 10th edition 3.2 Vaccination for international travel

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Right now it’s the rainy season in many regions of Asia popular for travellers, such as India, Thailand, Vietnam, Cambodia and Laos.You may not want to hear this if you’re heading over there for a holiday soon but … when the rainfall increases, so do the activities of biting mosquitoes.

Disease vector

Mozzies. They’re not just pesky insects; they cause diseases that sicken or kill millions of people worldwide each year. We know that it’s the female mosquito that bites us, requiring a blood meal to incubate her eggs. And of the species that prefer meals from vertebrates (including humans), some bite at night (dusk to dawn) while others feed during the day (dawn till dusk).

The insects are drawn to us by the carbon dioxide we exhale and our body heat, but how they decide which individual to zoom in on is dependent on the preference of the particular mosquito species. It can be genetics, a colour tone (dark), or an odour, for instance, from beer drinkers, lactic acid found in sweat, pregnant women, some skin bacteria or feet that are ‘on the nose’. Interestingly, one study found that Anopheles (malaria-transmitting) mosquitoes were more likely to be drawn towards humans who had malaria. This would of course enhance the risk of onward transmission of the malaria parasite to the next person the mosquito feeds from.

If you’re travelling to Asia at this time of year it’s wise to get the right advice by speaking to a travel health practitioner. That way you can learn about any potential risks for your itinerary, in particular mosquito-borne infections which are likely to be more prevalent due to the ideal breeding conditions presented by the rainfall. The doctor will take you through the best ways to prevent infection, which includes when the disease vectors (mozzies) are active: malaria- and Japanese encephalitis virus-transmitting mosquitoes fall into the night-time biting category, while those that transmit dengue fever, chikungunya and Zika virus are more active in daylight or if the area is brightly lit.

 Home-grown infections

They’re not very common fortunately, but we do hear tales of dengue fever or malaria infections in Australian travellers returning home. (So far this year over 350 people have contracted dengue and 147 malaria.) Of course mosquito-borne illnesses can also be caught here without leaving the country. Last year was a particularly bad one for Ross River virus infections, with nearly 7,000 casesover 5,000 of those from Qld, Victoria and NSW. We also have Barmah Forest virus, Murray Valley encephalitis and Kunjin virus, among others. The chain of infection is mostly between animal or bird reservoirs and mosquitoes but if they’re unlucky, and unprotected by clothing and repellents, humans can become sick when bitten by an infected mosquito.

Keep your guard up and avoid bites

It takes just one bite from an infected mosquito for you to get sick. And, it’s especially easy to let your guard down when you’re on holidays.
Until effective vaccines are available, we have to rely on 
avoiding mozzie bites by:
- Using an
effective insect repellent containing DEET, Picaridin, or Citriodiol (PMD).
- Getting rid of water-holding containers around your accommodation where mozzies can breed, and
- Either going inside around dawn and dusk or changing into long sleeves, long pants, and shoes and socks (the clothing can be treated with a contact insecticide,
permethrin).
- Sleeping under a
permethrin-treated bed net if your room is not screened or air-conditioned. 

Don’t become another travel statistic.
Before you fly, call Travelvax Australia’s travel health advisory service on 1300 360 164 (toll-free from landlines) to learn more about the mosquito-borne diseases at your destination. You can also arrange a consultation to get recommended vaccinations and personalised illness prevention advice from medical professionals with an interest in travel medicine.

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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

© Beth Baisch | Dreamstime.com

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.