SASTM NEWS. THE PRESIDENT S Travel Log. The South African Society of Travel Medicine. Guiding the Profession, Protecting the Public.

Transcription

1 SASTM NEWS The South African Society of Travel Medicine Guiding the Profession, Protecting the Public February 2015 FOR YOUR DIARY 2015 TRAVEL MEDICINE COURSE May CONTACT SASTM Ph: Fx: Illegal bushmeat: A global threat THE PRESIDENT S Travel Log The current Ebola epidemic in West Africa has been a startling re-awakening of the potential of zoonotic disease transmission. Eidolon helvum, the straw-coloured bat, has been associated with the spread of the viral haemorrhagic disease. About of these flying mammals are sold annually in Ghana as bush meat, with the radius of the area of consumption being about 400km. Previous epidemics of Ebola rapidly fizzled out or were quickly contained, but the current one which started in December 2013 is only now in January 2015 showing signs of abating. It is worthwhile to consider other current events which may impact the spread of other zoonotic diseases. Bats, monkeys and other mammals are often considered exotic delicacies by the locals in areas such as West Africa as well as in the Far East. The taste for such meat has to be put into the global context of migrating populations still having desires and longings for traditions, customs and dishes of their native villages. It is widely considered that 75% of emerging diseases are zoonotic, and the ease of procuring illegally obtained and transported meat is a growing worldwide phenomenon. After all, where there is a demand for a product, whether it be illicit drugs or exotic animal products, a supplier will somehow want to profit by sourcing it by hook or crook. Ease of transportation in a rapidly shrinking global village once again highlights the potential spread of zoonotic diseases. POSTAL ADDRESS PO Box 8216 Greenstone 1616 PHYSICAL ADDRESS 27 Linksfield Road Block 2A Dunvegan, Edenvale 1609 South Africa Registered as a Nonprofit Organisation NPO This newsletter has been made possible through an educational grant provided by HHL Technology In the Cross River State of Nigeria, 8 people succumbed to rabies after being bitten by dogs during a 2013 outbreak. Dog meat is part of the customary diet in some parts of southeast Nigeria neighbouring the Cross River State. Out of a sample of 100 healthy asymptomatic dogs that were tested for rabies, 5% tested positive in both their saliva and brain samples. Butchers who slaughtered the animals used their bare hands and were potentially exposed to this fatal disease. There is of course the potential for the transfer of the virus if salivary fluids or nervous tissues of the infected dogs get into contact with breaks in the skin of consumers before the meat is cooked. Though there has not been any documented case as yet, it is not beyond the realm of possibility that such products could be part of the 273 tons of meat that is smuggled into Paris annually via Charles de Gaulle Airport. A significant percentage comes from West Africa.

2 PAGE 2 February 2015 THE PRESIDENT S Travel Log Continued Ebola importation and spread in an unsuspecting population in such a manner has also been widely speculated about in the lay press. It is estimated that 7500 tons of bush meat enters the UK annually. A BBC investigation in London s Ridley Street found widespread and easy availability of bushmeat. Bushmeat is like drugs; you can get it everywhere if you know the right people, but you won't see it openly on sale. It s word of mouth and under-the-counter deals, one dealer said. In the famous Bronx area of New York, home to large numbers of immigrants from West Africa, there have been numerous reports of easily available illegally imported bushmeat. Cooking would destroy most pathogens but most of the meat is simply processed to prevent it from rotting. A study conducted in 2012 at John F. Kennedy airport revealed that airport officials confiscated bushmeat which included specimens of baboon, chimpanzee, mangabey, guenon, green monkey and cane rat meat. Of course the meat did not arrive alone; it carried with it many unseen microorganisms. Smoked bushmeat may appear safe, but the flesh inside is still blood-filled. This is the ideal transport medium for organisms and Simian foamy virus and herpes viruses showed up in the samples of confiscated bushmeat. The investigators didn't find Ebola, but they tested only a few samples as the research was done before the current Ebola outbreak. Bushmeat from all parts of the world is found in large markets such as China where different types of wildlife get stored on top of each other in warehouses. Bushmeat containing pathogens that would normally never be in close contact would either be in the same environment or would have different potential hosts in close proximity. The Severe Acute Respiratory Syndrome (SARS) epidemic of is thought to have originated in a live animal market in China. The SARS virus resides in bats, and as humans don t consume bats in China, the virus would most likely not have spread. However the bats were kept in cages close to those housing civets, which are eaten by humans. Somehow the virus moved from bats to civets to humans acquiring mutations along the way. The end result was an epidemic that infected more than humans in 37 countries before it was contained. Many countries are shoring up their entry points to prevent the spread of this potential global threat. More studies are needed to fully evaluate all factors involved.

3 PAGE 3 February 2015 EDUCATING & Training Prevention of malaria: it is not just chemoprophylaxis Lee Baker Although South Africa has made significant progress in reducing malaria cases since the more than reported cases in 2000, and is endeavouring to eliminate malaria by 2018, there has been an increase in cases over the past two years, both locally and imported. This article will focus on prevention of malaria with an emphasis on personal protection measures to prevent mosquito bites. Fortunately not all mosquitoes transmit malaria, so it is important to determine the risk in the area. Generally, anopheles mosquitoes favour a warm moist environment, with the risk of malaria being greatest in areas below metres above sea level. The female anopheles mosquito feeds (and therefore bites) between dusk and dawn, so the most important time to take precautions is at night. Clothing Long sleeved shirts, long pants, socks and shoes, will minimise exposed areas of skin. The clothes can be impregnated with an insecticide, permethrin, which will repel mosquitoes. Clothing and other items should be treated hours before being used, to allow them to dry. The repellency effect will remain after a number of washes, but to ensure long-term efficacy, follow product instructions. Vital Protection * and Tabard Fabric Guard are available in South Africa. Permethrin should NOT be applied directly to skin, but only to clothing and bednets etc. Bednets Bednets, especially those that have been impregnated with a pyrethroid such as permethrin, are very effective in protecting a person while sleeping. The bednet should not have and holes and should tuck in under the mattress. Long lasting insecticide impregnated mosquito nets are now available and they remain effective for up to three years. These are essential in high risk areas where accommodation is not adequately screened or air-conditioned. Room protection Air conditioners reduce the likelihood of mosquito bite by reducing the night time temperature in the room. Ceiling fans are also effective as they reduce the ability of the mosquito to land on the skin. Doors and windows of bedrooms should be screened with fine mesh netting. To kill any mosquitoes that could have entered the room during the day, a knockdown spray should be used before dusk. Vapour mats and mosquito coils are also effective, but a new one should be used each night. Repellents Published data indicate that repellent efficacy and duration of protection vary considerably among products and among mosquito species. Ambient temperature, level of activity, amount of perspiration, exposure to water, and other factors, affect the efficacy and duration of protection of the repellents. In general, higher concentrations of active ingredient provide longer duration of protection, regardless of the active ingredient. Diethyl-m-toluamide (DEET) - based insect repellents are recommended by the authorities and are considered to be the gold standard. Other repellents that are also recommended but are not as effective as DEET include picaridin, IR3535 and PMD (oil of lemon eucalyptus). Pure oil of lemon eucalyptus (an essential oil) is not recommended. Of these, only DEET-containing products are available in South Africa. A number of studies have shown that there is a low risk of adverse effects when DEET is applied according to product directions. DEET has been used for more than 40 years by millions of people worldwide and although there have been a few sporadic reports of systemic reactions such as behavioural changes, seizures, confusion, irritability and insomnia, most of these reports were cases resulting from accidental swallowing or spraying into the eyes. Complaints of transient skin or eye irritation have also been reported. DEET may cause damage when applied to some synthetic fibres and plastics, thus its use is not recommended for treatment of clothes and camping gear.

4 PAGE 4 February 2015 EDUCATING & Training Continued Studies suggest that concentrations of DEET above approximately 50% do not offer a marked increase in protection time against mosquitoes. Concentrations of 20-50% are recommended for adults and children over the age of two months, including pregnant women. Table 1: Approximate protection times of some insect repellents for personal use Active ingredient Approximate protection time Citronella 30 minutes 2 hours DEET 5% 2 hours DEET 10% 3 hours DEET 15% 5 hours DEET 30% 6 hours Icaridine (picaridin) 19.2% 1 hour (against Anopheles mosquitoes) Up to 5 hours (for other mosquito species) IR3535 (EBAAP) Long acting formulation 7-10 hours PMD (Lemon eucalyptus extract) 30% 4 hours PMD (Lemon eucalyptus extract) 50% 6 hours DEET- containing products available in South Africa Tabard Stick: 350mg DEET in 1g (35%) Lotion: 195mg DEET in 1mL (19.5%) Aerosol: 150mg DEET in 500mg (15%) Peaceful Sleep Stick: 350mg DEET in 1 g (35%) Cream: 250mg DEET in 1g (25%) Aerosol: 150mg DEET in 1g (15%) Mylol Aerosol: 73.53mg DEET in 1 ml (7.353%) Precautions when using insect repellents Apply repellent sparingly to exposed skin or clothing. Do not apply repellents under clothing. Repeat applications at intervals according to the duration of action of the particular repellent. Re-apply more frequently after bathing, showering, sweating, etc. Avoid contact with the eyes and mucous membranes, and do not apply directly to the face spray on hands first and then apply to face. Do not inhale or ingest. Wash hands after application. Avoid applying high concentrations of the products to the skin, particularly in children. Avoid applying repellents to the hands of young children, as these are likely to have contact with the eyes and mouth. Avoid using plant extracts if prone to allergy. People with sensitive skin should avoid lotions and gels. These often contain alcohol. Do not use on broken skin. If a suspected reaction to insect-repellent occurs, wash treated skin and seek immediate medical help. STOP using DEET and obtain immediate medical advice if a change in behaviour is noticed. Read the entire repellent label before use and use only as directed. Note that DEET can opacify spectacles, binoculars and other plastics. Keep repellents out of the reach of children. If a sunscreen is used at the same time, the DEET containing repellent should be applied after the sunscreen, as DEET reduces the efficacy of the sunscreen.

5 PAGE 5 February 2015 EDUCATING & Training Continued What not to use! There is no scientific evidence to show that any of the following options are effective for the prevention of malaria: Herbal and homeopathic remedies Electronic buzzers these are completely ineffective and companies selling them have been prosecuted in the United Kingdom Vitamin B1 and B12 (including savoury yeast extract products such as Marmite Garlic Tea tree oil. Oil of citronella- based products are not recommended and have been withdrawn in Europe. Avoiding mosquito bites should be the mainstay of malaria prevention, and in some instances, chemoprophylaxis in addition may be required. When this is the case, the Guidelines for the Prevention of Malaria in South Africa 2009 should be followed. One of the three recommended regimes should be used: Mefloquine (weekly). Start at least one week before entering a malaria area, take weekly while there and for FOUR weeks after leaving the malaria area, OR Doxycycline (daily). Start one day before entering a malaria area, take daily while there and for FOUR weeks after leaving the malaria area, OR Atovaquone-proguanil (daily). Start one to two days before entering malaria area, take daily while there and for SEVEN days after leaving the area. Malaria is a life-threatening disease that poses a major health risk for residents and travellers to malaria areas. Appropriate advice, the use of drugs when appropriate and, most importantly, measures to prevent mosquito bites can prevent persons from contracting the disease. Avoiding mosquito bites is at least as important as using chemoprophylactic medicines. Measures that reduce contact with mosquitoes have the advantage that they are less toxic than chemoprophylactic drugs and that their effectiveness does not depend on the drug sensitivity of the parasite. Goodyer LI, Croft AM, et al. Expert review of the evidence base for arthropod bite avoidance. Journal of travel medicine 2010;17(3): Department: Health. Guidelines for the prevention of malaria in South Africa CDC Health Information for International Travel accessed 16/01/2015 Chiodini PL, Field VK, Whitty CJM, Lalloo DG, Guidelines for malaria prevention in travellers from the UK 2014 London. Public Health England July *Vital Protection can be purchased from the SASTM Shop

6 PAGE 6 February 2015 SUPPORTING & Informing SASTM 2015 TRAVEL MEDICINE JOURNAL CLUBS SASTM will roll out the Travel Medicine Journal Clubs, which will be held in the various regions on a quarterly basis. The pilot Journal Club will be held in Durban, 18 March TRAVEL MEDICINE UPDATE A Travel Medicine Update will be held in Durban, Cape Town and Midrand during the course of the year. More information will follow. FIDSSA CONGRESS: NOVEMBER 2015 This will be held at the Champagne Sports Resort from 5 8 November. SASTM will again have a travel medicine track. This Congress provides the opportunity of networking with other colleagues in the infectious disease disciplines. SELF AUDIT ASSESSMENT TOOL Thank you very much for the interest shown in the Assessment tool for Travel clinics. The majority of you have expressed a preference for the self-assessment tool, and in keeping with our endeavours to meet your (the members) needs, we will now adapt the tool so that it can be used for self- assessment. Once this has been completed, we will notify you. BEYOND CHILDHOOD VACCINATION: UPDATE An electronic update of certain chapters of this publication is planned. The electronic version will only be available for those who have already purchased a copy, so if you do not have one, order it now. SASTM SHOP Visit the SASTM Shop as Vital Protection has been added to the items that can be purchased at a special rate to SASTM members. Like our Facebook page: Follow us on Twitter:

7