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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
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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

 

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Bacteria developing resistance to antibiotics is hardly news, but when it’s a common sexually transmitted infection (STI) like gonorrhoea and the level of resistance means that some cases have been impossible to treat using available antibiotics, that’s alarming!

Earlier this month a World Health Organization news release confirmed that some wealthy countries with good disease reporting systems are seeing gonorrhoea cases that don’t respond to any known antibiotics. And there are very real fears that the global situation is much worse when you consider the under-reporting that takes place in less developed countries due to the lack of proper diagnostic techniques1

Gonorrhoea - what we know

It is caused by a bacterium from the genus Neisseria - N. gonorrhoeae, or gonococcus (plural gonococci). Another pathogenic, or disease-causing, bacterium from the same genus is N. meningitidis (meningococcus), the cause of meningococcal meningitis. One major difference between the two species of bacteria is that meningococcal bacteria can be found as part of the normal flora in the throats of 10-20% of the population, whereas the gonococcus is only acquired through sexual activity (all types including oral) or by a baby during a vaginal birth2.

• Each year there are approximately 78 million new gonorrhoea infections1.
• After chlamydia, it’s the 2nd most common STI.
• It’s a very old disease indeed, first noted in the 2nd century by the Greek physician Galen3.
• Syphilis and gonorrhea were thought to be one and the same disease until the 15th century.
• A German doctor, Albert Neisser first identified and then named the gonococcus in 18794.
• AKA the clap - one explanation for this slang term is that it’s derived from the French name for brothels – les clapiers.
• A single contact with gonococci can produce infection in 60-90% of women & 20-50% of men5.
• The incubation period ranges from 1 to 14 days, but can be longer in men6.
• Males are more likely to experience symptoms, but asymptomatic infections can occur.
• Up to 50% of women with uncomplicated disease have no symptoms.
• Symptoms in men include a yellowish, purulent discharge from the urethra and painful, burning urination.
• Symptoms in women can appear as a vaginal discharge, lower abdo pain or painful urination.
• Women suffer more complications (pelvic inflammatory disease, ectopic pregnancy & infertility)2.
• Complications suffered by men can include inflammation of the prostate or testes and urethral strictures and fistula formation.
• Infection can be localised to the urethra, cervix, rectum, eye & throat (most [90%] throat infections are asymptomatic)3.
• If the infection spreads to other parts of the body, it can cause dermatitis-arthritis syndrome, septic arthritis, endocarditis and meningitis
• Previous infection doesn’t provide immunity, so it ‘can be re-acquired with no apparent reduction in severity or duration of disease.’7
• And lastly, gonorrhoea infection (or any STI in fact) can increase the risk of HIV transmission8.

Remedy worse than the disease?

Treatment over the years has involved dried Indonesian pepper fruit and sap from a South American tree; later it entailed the use of injected or fumigated mercury compounds and diversionary activities such as bowls & archery as alternatives to ‘moral carelessness'9.

In the 1920s and 30s, the discovery of the anti-bacterials, penicillin and sulphur compounds, meant that, finally, effective treatments were available to cure the age-old scourge, but even as early as 1946 resistant strains of the gonococcus were identified10.

Fast-forward to 2009 and the first sign of the extent of the unfolding super-bug gonococcus crisis occurred in Japan when a prostitute who tested positive to the bacteria failed to respond to the last-line antibiotic treatment, a cephalosporin, injectable ceftriaxone3.

Three new treatment drugs are in development1, but progress towards an effective vaccine has been slow. Some good news arrived earlier this month when NZ researchers released their findings on the lower rates of gonorrhoea among people who had received a vaccine against a particular strain of meningococcus compared to the general community11, suggesting some cross-protection. More study is needed however, but with a high degree of genetic match between the 2 species of Neisseria bacteria, there is some optimism.

So… it’s about prevention

The WHO set up the Gonococcal Antimicrobial Surveillance Programme (GASP), a network of surveillance laboratories to monitor disease resistance and collate data, but it is also promoting education on safer sexual practices, including correct condom use. As noted in the July 7 news release: ‘Today, lack of public awareness, lack of training of health workers, and stigma around sexually transmitted infections remain barriers to greater and more effective use of these interventions.’1

The message

If it’s not on, it’s not on: A catchy phrase and good advice, but if you believe it’s just for the young, think again…

With today’s seniors more fit and socially active than in the past, it’s hardly unusual that sex would continue to play an important part in many of their lives. (Add to that the availability of erectile dysfunction drugs, online dating sites and no fear of pregnancy!)

Rates of STIs in the over-50s have risen over the past few years in the UK and the USA so it would follow that it’s happening here too. In 2016, we recorded 23,888 gonococcal infections countrywide and nearly 1,700 of those were in the 50+ years age group (& 13 in the over 80s)12. Bear in mind too that seniors are less likely to be undergoing regular STI testing so it’s possible there could be even more.

And our advice

  • Before you travel, pack condoms. Remember that those sold overseas may not be of reliable quality - check the expiry date and make sure the pack carries a recognised quality assurance mark.
  • Always use a condom with any new sexual partner.
  • They are for single use only – discard after use.
  • Use condoms correctly
  • Water-based lubricants can be used with all types of condoms, oil-based only with those made of polyurethane.
  • Store condoms away from heat or cold and sharp objects.
  • If prevention is forgotten or fails, do not ignore tell-tale symptoms. Seek medical advice and have the appropriate tests and treatment.

 

1. http://www.who.int/mediacentre/news/releases/2017/Antibiotic-resistant-gonorrhoea/en/
2. http://textbookofbacteriology.net/neisseria.html
3. http://www.newyorker.com/magazine/2012/10/01/sex-and-the-superbug
4. http://www.antimicrobe.org/h04c.files/history/Neisser.pdf
5. http://emedicine.medscape.com/article/333612-overview#a6
6. http://dvkeywords.blogspot.com.au/2010/10/gonorrhoea_26.html
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812424/
8. https://www.cdc.gov/std/hiv/stdfact-std-hiv.htm
9. http://www.evolve360.co.uk/data/10/docs/10/10plumb.pdf
10. http://www.antimicrobe.org/h04c.files/history/Gonorrhea.asp
11. https://www.theguardian.com/science/2017/jul/10/meningitis-vaccine-may-also-cut-risk-of-untreatable-gonorrhoea-study-says
12. http://www9.health.gov.au/cda/source/rpt_5.cfm

If you have a dog at home you’ll know full well that Buddy or Bella must be wormed regularly - for their sake as well as your own, so you don’t become infected too.

What you may not know is that there are parasitic infestations that can be contracted by humans through the food we eat when the source, like raw or undercooked meats, is contaminated1. Also, three of the more well-known ones are transmitted through raw, undercooked or pickled seafood, and tourists who are travelling on standard itineraries, taking in cities and large towns in developing countries are potentially at risk. On rare occasions these infections occur in developed nations too.

If you’re a fan of sushi, sashimi, ceviche, gravlax or marinated anchovies, this could be of interest to you …

Anisakiasis
In one high risk country, Japan, authorities have issued a health notice2 in response to a recent rise in the number of human cases of marine roundworm infections caused by the larvae of the Anisakis nematode (worm). Anisakiasis, as the infection is known, is most commonly contracted when people eat contaminated raw seafood (fish, eels, octopus and squid) in sushi and sashimi, but it can also be a risk if the dish you are scoffing contains infected fish that is cured with salt or vinegar (pickled or smoked herring). (The recommendation is for restaurants serving raw seafood to freeze it for an extended period of time before serving to ensure any larvae have been killed.)

Other countries with high rates of consumption of raw, smoked or cured seafood also have a higher incidence of infections and these include the Netherlands, Scandinavia, Spain and the west coast of South America3.

The life cycle of Anisakis worms starts as eggs released into the ocean by infected marine mammals. The eggs develop into larvae, which then become part of the food chain: eaten by crustaceans which are then eaten by fish or octopus which are then eaten by humans. A person consuming the larvae-containing raw seafood may or may not notice an unusual, tingling sensation - the worm passing through their mouth - and it can then be removed or coughed/vomited out. If the worm is swallowed, it can move to the stomach or intestines and become embedded, shielded from gastric acid by a protective coating. Ultimately the larva will die, but before that occurs, it can cause inflammation, peritonitis or obstruction.

The US Centers for Disease Control & Prevention (CDC) webpage on Anisakiasis4 lists the signs and symptoms of infection as: ‘abdominal pain, nausea, vomiting, abdominal distention, diarrhoea, blood and mucus in stool, and mild fever. Allergic reactions with rash and itching, and infrequently, anaphylaxis, can also occur.’

The very good news is that Anisakis infection can be treated by using an anthelmintic medication, or the worm can be removed by endoscope. If it has become embedded or moved outside the intestines, surgery may be required.

The other two more common helminth infections that are transmitted through eating raw or undercooked seafood, Clonorchiasis and Diphyllobothriasis, have similar life cycles to the Anisakis nematode with the exception that humans and terrestrial mammals are the infective hosts.

Diphyllobothriasis
The fish or broad tapeworm that causes diphyllobothriasis is much more widespread, being found in Europe, North America, and Asia, as well as Chile and Uruguay in South America. Furthermore, exportation of fish from endemic countries can lead to human cases in non-endemic regions. Just over 10 years ago, and after extensive testing, a few cases were diagnosed in sushi-eaters in Brazil5. Brazil doesn’t have the climate to support fish farming and tracing of the product showed it was sourced from freshwater lakes in southern Chile.

As with aniskaniasis, the larvae are consumed when contained within the raw seafood, but Diphyllobothrium larvae move to the small intestine of the host and attach to the lining. There they mature into adult tapeworms - the largest tapeworm to affect humans – and grow up to 10 metres in length. They are also prolific egg producers – up to 1 million per day, per worm. Less than one-quarter of infected people will experience symptoms: abdominal pain or discomfort and diarrhoea are common, pernicious anaemia from Vitamin B12 malabsorption, inflammation of the gall bladder and intestinal obstruction are also possible outcomes. Treatment of uncomplicated diphyllobothriasis also involves administration of anthelmintic medication.

Clonorchiasis
In the endemic countries of Korea, China, Taiwan, and Vietnam, Chinese or Oriental liver fluke (Clonorchis sinensis) infection or clonorchiasis is also known to occur through eating salted, pickled, or smoked freshwater fish containing the immature parasitic flatworm or metacercariae. The larvae mature inside the human small intestine after ingestion and move to the bile ducts to mature, producing acute phase symptoms of abdominal pain, nausea and diarrhoea. Long-term infections can lead to inflammation of the gall bladder, gall stones, pancreatitis, and cancer of the bile ducts. As with Anisakiasis, treatment is through anthelmintic medication or surgery.

While these infections are rare, they are noteworthy reasons behind the travel medicine mantra on food selection – ‘Peel it, boil it, cook it, or forget it!

1. https://www.cdc.gov/parasites/food.html
2. http://outbreaknewstoday.com/japan-sushi-rise-anisakis-90077/
3. https://web.stanford.edu/group/parasites/ParaSites2010/Lucia_Constantine/parasiteproject/Anisakiasis.htm
4. https://www.cdc.gov/parasites/anisakiasis/
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2725803/

© Daniel Kaesler | Dreamstime.com

A news article published in the last couple of weeks has provided a reminder that we aren’t immune from many of the diseases that are prevalent in other regions of the world, even developed ones; not when we are such avid travellers. (In February this year, over 830,000 Australian residents took short term holidays overseas1.)

The report2 referred to a hepatitis E infection that a young boy contracted back in 2014 during a liver transplant. Testing showed that the hepatitis E virus (HEV) was passed on to the boy through blood that was transfused during the surgery – the first time this has occurred in Australia. The Red Cross routinely screens donated blood for a number of diseases (HIV; hepatitis B & C; human T-cell lymphotropic virus I and II; and syphilis3), but not HEV. It turns out that the blood was donated by a man who had become infected in southern France – by eating pork. For most people visiting France, the risk of contracting an infection from the food would be furthest from their minds (more likely a ‘crise de foie’, or liver crisis, which in most other languages would translate as ‘overindulging’)!

A 2011 study by Mansuy et al4 found that a staggering 52.5 percent of voluntary blood donors in the Midi-Pyrénées (south-western France) showed a long term response to HEV infection (elevated IgG levels). They concluded that the consumption of wild boar and deer (common sources of infection), often raw or undercooked, together with the leakage of pig manure used to fertilise crops into rivers and canals, had created a hyperendemic incidence in the region. Figatellu, a sausage prepared from raw pig liver is a common delicacy in this part of France. (By comparison, testing of Australian blood supplies found HEV infection in 1:14,799 samples2)

The disease

According to the World Health Organization, 44,000 people lost their lives due to complications of hepatitis E infection in 2015 and there were 20 million cases globally5. Like the hepatitis A virus, HEV is transmitted through the faecal-oral route, meaning by consuming contaminated food or water (more often through water). Infection may go undetected, with minimal symptoms – this is more likely to occur in young children. But of those that are apparent, signs and symptoms can include jaundice, loss of appetite, a tender liver, abdominal pain and tenderness, nausea, vomiting, fatigue and fever, which can last for up to 2 weeks. In most people, hepatitis E disappears without treatment and with no long-term effects. However, people with weakened immune systems, such as those with leukaemia and post-organ transplant patients, may develop a chronic form of the disease which can quickly lead to cirrhosis and permanent liver damage6.

One group is far more susceptible to severe illness and death from Hep E than any other – pregnant women. The E strain is fatal for between 15-30% of mothers-to-be in their third trimester. Tragically, even if the mother survives, it’s common for the foetus to die.
It’s not known why pregnant women are at higher risk of severe outcomes.
The high mortality rate is not seen in the other hepatitis viruses and at least one study7 has suggested that a fall in the number of protective T-cells that occurs during pregnancy may play a role, along with hormonal changes and other factors.

Vaccines

While there are highly effective vaccines for hepatitis A and hepatitis B, no vaccine is currently available for hepatitis E in Australia, although one was approved for use in China in 20118. The boy who received the HEV infected blood was treated with antiviral medications which removed all traces of the virus.

Our advice for all travellers, but particularly pregnant women:
– Don’t drink untreated water. If sealed, reputable bottled water isn’t available, treating tap water by boiling or chlorinating will kill both hepatitis A & E viruses.
– Choose safe food and beverages options. (While Hep E is usually transmitted in via drinking water, food-borne transmission may occur from raw shellfish, and uncooked or undercooked meat - in particular pork - from infected animals.)
– Observe strict personal hygiene. Hand washing after using the toilet and before eating.

Call us to make an appointment for a one-stop pre-travel medical consultation with a team of medical professionals experienced in travel medicine at your nearest clinic. We provide advice, vaccines and medications for your particular itinerary, dependent on the season of travel, length of stay and type of activities undertaken. Travelvax Australia’s free travel health advisory service can be reached on 1300 360 164.

1. http://www.abs.gov.au/ausstats/abs@.nsf/mf/3401.0
2. http://www.smh.com.au/national/health/hepatitis-e-boy-6-first-to-be-infected-after-receiving-australian-blood-donation-20170414-gvl4sn.html
3. http://mytransfusion.com.au/about-blood/ensuring-blood-safety
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3311200/
5. http://apps.who.int/iris/bitstream/10665/255016/1/9789241565455-eng.pdf?ua=1
6. https://www.ncbi.nlm.nih.gov/pubmed/24396139
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2575020/#!po=62.9032
8. https://www.hepmag.com/article/hev-vaccine-china-26972-69711881

 

Vitoria, Espírito Santo: © Filipe Frazao | Dreamstime.com

 

There will still be many, many people who are content to miss the pizzazz of the Carnival in Rio and take in all that Brazil has to offer once the parades are over. Whether it’s the city sights and beaches of Rio, a cruise down the Amazon, wildlife tour of the Pantanal or taking in the magnificent Iguaçu Falls at the triple border of Argentina, Brazil and Paraguay, there’s plenty to enjoy!

At this time, there’s an extra consideration to make sure your trip goes according to plan and it’s very much about protecting your health: An expanding outbreak of yellow fever (YF) is taking place in several Brazilian states. It started back in December in the state of Minas Gerais, and has now spread to Espírito Santo, Bahia, Rio Grande do Norte, São Paulo, Tocantins and Goiás. Yellow fever vaccination has long been indicated for travel to government prescribed ‘Areas with Vaccination Recommendation–ACRV  but with this outbreak, the list of towns and districts has been extended to cover even more municipalities – including the entire state of Espírito Santo  - where the protective vaccine is advised for anyone over 9 months of age* who is not already vaccinated.

We dealt with yellow fever infection, the vaccine (which is given at licensed clinics such as Travelvax in Australia) and International Health Regulations in our article posted on Nov 28th last year, Yellow fever vaccination certificate changes, but we think in this instance it’s worthwhile giving some background on yellow fever in Brazil: The yellow fever virus maintains its presence in the country through infections transmitted by mosquitoes between certain species of monkeys that live in the forests. When humans who are unimmunised (and not actively preventing insect bites) venture into these areas, they are bitten by infected mosquitoes - this is the sylvatic cycle of yellow fever infection. Once the infected humans return to a town, an urban cycle continues the spread as urban-dwelling Aedes aegypti mosquitoes transmit the virus between non-immune people.

Yellow fever is endemic in the Amazon region, but periodic outbreaks occur outside this area when unvaccinated people are exposed to the virus, such as during the 2008-9 epidemics which hit the southern states of Rio Grande do Sul and São Paulo. Many of those infections occurred in parts of the country where vaccination was not recommended at that time and so the ACRV guidelines were revised to include expanded new regions.

Evolution of geographic risk classification for yellow fever vaccination recommendations in Brazil, 2001–2010ˣ . 

On a national level, the response to the current outbreak  has entailed nearly 15 million YF vaccine doses being sent to the states of Minas Gerais, Espírito Santo, São Paulo, Bahia and Rio de Janeiro. The strategy is to ensure the population living in affected areas is immunised, as well as increasing disease surveillance and controlling the virus’s mosquito vectors. (As the outbreak is not contained as yet, we advise anyone heading to Brazil to speak to their yellow fever licensed doctor for the most up-to-date information.)

The World Health Organization has this advice for travellers who will be visiting YF risk areas in Brazil: “vaccination against yellow fever at least 10 days prior to the travel; observation of measures to avoid mosquito bites, awareness of symptoms and signs of yellow fever, promotion of health care seeking behaviour while travelling and upon return from an area at risk for yellow fever transmission, especially to a country where the competent vector for yellow fever transmission is present.” 

Planning a trip to Brazil? Call Travelvax Australia’s free travel health advisory service on 1300 360 164 for advice on recommended and required vaccinations. You can also make an appointment for a pre-travel medical consultation with a team of medical professionals experienced in travel medicine.

* Each traveller’s suitability for yellow fever vaccination is determined during a pre-travel medical consultation with a YF licensed doctor- there are some contraindications and precautions to vaccination. Additionally, itineraries that include YF endemic regions must be checked for all destination countries’ vaccination requirements for arriving travellers. Other recommended vaccines and preventive measures regarding the itinerary can also be discussed, including crucial insect bite avoidance measures.
ˣ Romano APM, Costa ZGA, Ramos DG, Andrade MA, Jayme VdS, et al. (2014) Yellow Fever Outbreaks in Unvaccinated Populations, Brazil, 2008–2009. PLOS Neglected Tropical Diseases 8(3): e2740. doi:10.1371/journal.pntd.0002740 http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0002740