Vaccine-Preventable Diseases for Travellers to Oceania- Part 1

Transcription

1 Vaccine-Preventable Diseases for Travellers to Oceania- Part 1 Pre-travel essentials International Congress for Tropical Medicine and Malaria 2016 DrPH, FRGS, FRNZCGP, FFTM RCPS (Glas), DipTravMed Professor, James Cook University, Qld, Australia Medical Director WORLDWISE Travellers Health Centres, Auckland, NZ WORLDWISE OnLINE (worldwise.co.nz) Travel Health Information for Professionals THIS PRESENTATION Overviews common vaccine preventable diseases (VPD) in Oceania, that the travel-health professional (THP) needs to be informed on and to advise the traveller upon Reinforces common principles in disease and dis-ease prevention Why do Travellers go there? Tourism Business traveller Eco-traveller, honeymooners Backpackers, hostellers, students Environment American Samoa, Cook Islands Business New Caledonia Television and film locations Survivor Remote adventure Pitcairn Humanitarian resolve Solomon Situation Religious intentions... throughout the region Mining nickel in Noumea, PNG Water-world-sports Palau, Fiji Retirement Norfolk Islands 1

2 What is Special about Oceania there? Special Features: Isolation Emphasis on rest and relaxation Focus on self, and self-indulgence Scuba, fishing, surfing, sailing Yachting through the islands Smiling and friendly populations Speak English! Variety of alcohol-based cocktails WHO and What are the TRAVELLERS to Oceania Tourists, including Family Rest and Recreation Business traveller Eco-traveller Backpackers, hostellers, students Corporate travellers Sports groups Military forces Refugees and migrants Expedition and scientific groups Humanitarian and NGOs Aviation and aeromedicine groups Aeromedical evacuation The 20 minute Travellers Health Consultation 6 Practical PUNCH-POINTS! 1. Scan the traveller for their information What/How EXACTLY is the trip to be! 2. Perform a risk analysis of their intended journey What is intended on the trip 3. Safety and Security How will the traveller take care 4. Determine arthropod borne illness Malaria and ARBOVIRAL 5. Assess immunisation history Past and proposed 6. Specialised travel health technique Refer, refer, referrrrrr! 2

3 International Tourist Arrivals - WTO International tourist arrivals 1.1 billion in 2015 Can travel globally anywhere in < 24/24 International travel affected by weakening economies of major tourism markets impact of globalterror EMERGING DISEASES Ebola in Africa MERS: Corona-like virus. Saudi Arabia 2012 ZIKA and YELLOW FEVER Natural disasters: Tsunami, Floods, Earthquakes Societal disasters refugee boats Currently travel to non-threatening regions in the world is on the increase: Africa: Namibia, Botswana, Zambia, Zimbabwe India, Vietnam, Cambodia, Laos, Thailand Sth America: Peru, Bolivia, Ecuador, Brazil Pacific Samoa, Cook Islands Pre-Travel Traveller s Scan Itinerary to determine health risks Country of birth (esp. for VFR) Country raised in Considers relative risks of diseases Protects ag. community diseases Considers disease and dis-ease of itinerary Who is going on the trip? Are there any particular health issues to be addressed?? Children,? Pregnancy,? Seniors,? Immunocomp Tools of the THP: 1. Past Medical History 2. Vaccination History PH personal vaccines [? Region dependent] Disease patterns and paediatric vaccine Coverage of country to be visited PRACTICAL PUNCHPOINTS Must focus on important travel-related information Reviews past history of all immunisations 70% of 70 yr olds NOT protect. ag TETANUS Resp infections common? Flu vaccine! Any medical conditions requiring prophpneumococcus Arrange routine non-travel series / boosters Infectious diseases account for up to 40-70% of travel advice Need to focus on the individual and their trip Most medical issues are as per home country e.g. CHD, Resp, CVS 3

4 Travel Risk Analysis Itinerary to determine health risks Detailed itinerary of overseas trip Season of intended travel Air-travel direction Places and duration of travel Types of accommodation /eating facilities Rural or urban Climate, temperature, altitude of the trip Tools for the Travel Health Professional: Personal Experience of MO References: WHO, CDC, Worldwise NZ ATLAS For the Traveller in Vaccine Consultation They want to be told that they are safe from diseases They want to be told they don t need vaccinations They want to be told that they don t need to take malarial medicines If they do need any of the above then they want them only if they have to (What does this mean!! Probably only if the Doc/Nurse REALLY Insists!) Of those who visit a travel health professional (anecdotally Worldwise) 60% travellers will have what is advised 20% have what they have to have 20% have what they think they have to have There are those who are arrogant about their travel these are the people that one prays will get sick and call you to apologise! There are those who have to travel for they will learn There are those who should not travel for they will not learn a thing! Pacific Surveillance Network 4

5 Assess Immunisation Decision on Travellers Vaccinations to Oceania The Catholic Nine shots for travel to Oceanic countries (Measles, Mumps, Rubella) (Tetanus/Diphtheria/Pertussis) Influenza Hepatitis A Hepatitis B Typhoid Pneumococcus Cholera / Travellers Diarrhoea (Polio) MEASLES MUMPS RUBELLA MEASLES In 2013, measles deaths globally 400 deaths every day or 16 deaths / hour Measles vaccination gave 75% drop in measles deaths between worldwide In 2013, about 84% of the world's children received one dose of measles vaccine by their first birthday Measles infects 90% of those who are not immune MUMPS The risk of exposure to mumps among travellers can be high in most countries of the world, especially for travellers who are older than 12 months and who do not have evidence of mumps immunity Approximately 300,000 global cases per year mainly China RUBELLA Rubella = contagious, generally mild viral infection that occurs most often in children & young adults Rubella infection in pregnant women may cause fetal death or congenital defects known as congenital rubella syndrome Worldwide, an estimated babies are born with CRS every year. PRACTICALLY IN Australia 2 vaccinations for longevity Born between late 1960s to mid-1980s (especially the birth cohort) need boosting Tetanus/Diphtheria/Pertussis RESPIRATRORY TRACT BACTERIAL TRANSMISSION Incubation: 7-10 (-21) It is a major cause of illness worldwide and with severe complications and death occurring most commonly in infants under six months of age Worldwide it is estimated that there are actually 16 million pertussis cases every year, including approximately 195,000 childhood deaths Pertussis is a public health issue in Australasia Vaccination is advised for travellers Adolescent and Adult Formulation (Tdap) Less D than Childhood DTaP Boostrix and Adacel World Health Organization. Immunization, Vaccines and Biologicals. Pertussis. 5

6 Influenza Most frequent vaccine-preventable infection with potential morbidity in travellers Transmission of influenza during transportation reported in airplanes and cruise ships Cruise ships, shared itineraries, hotels and buses used by different tour groups probably facilitate influenza transmission and the spread of other viruses, as does the fact that passengers are usually from different countries and both hemispheres On cruise ships, passengers are often elderly and have additional risk factors for the respiratory complications of influenza that can lead to potential morbidity HEPATITIS A ORAL-FAECALVIRAL INFECTION Incubation: days Incidence: approx 1: million cases reported globally each year - true incidence is 3-10 times higher ENDEMIC REGIONS: Africa, India, Asia Australia and New Zealand: low incid. SALADS, WATER/ICE, SEAFOOD Disease not serious in children ages < 12 years, but they may excrete virus for up to 6/12 Virus can survive for at least a week in ambient conditions and in water for as long as 10 months Those fully vaccinated (with both doses of vaccine) against hepatitis A DON T need boosting (NB Serology after one dose NOT confirmatory) Duration of action years! Shaw MTM. Common Vaccine-Preventable Travel-Related Diseases. In: The Practical Compendium of Immunisations for International Travel. Shaw MTM, Wong C (eds). Adis, Auckland ISBN: (Print) (Online) PRACTICAL PUNCHPOINTS HEP A Give guidance on food and water ingestion Cook it, Peel it, Boil it or Avoid it Hepatitis A vaccine Havrix Hepatyrix Avaxim Vivaxim Immunisation is advised for Oceanic travellers Hep A vaccines have an excellent safety profile, are effective, and immunity develops quickly 6

7 HEPATITIS B BODILY FLUIDS VIRAL INFECTION Incubation: days Incidence: approx 0.2 (Africa) 0.6:1000 (Asia) Est 240 million with chr. HBV infection Publ. reports of travellers acq. HBV rare Risk for travellers without high-risk exposures is low. Est 25% travellers to endemic countries at high risk Growing health tourism brings special HBV risk ENDEMIC REGIONS: Oceania and Western Pacific, SE Asia 100 x more contagious than HIV Viable outside human for 1/12 Virus survives for 1 + wk (ambient conditions), water (10 mths) Shaw MTM. Common Vaccine-Preventable Travel-Related Diseases. In: The Practical Compendium of Immunisations for International Travel. Shaw MTM, Wong C (eds). Adis, Auckland ISBN: (Print) (Online) PRACTICAL PUNCHPOINTS HEP B Hepatitis B (and C and D) usually results from contact with infected body fluids: * sexual contact * contaminated blood (transfusions) or blood products, * invasive medical procedures (e.g dental work, injections, cosmetic procedures) using contaminated equipment * tattoos - * body piercings * acupuncture or * activities that result in abrasions or broken skin Immunisation is advised for global travellers The vaccine - excellent safety profile, is effective, immunity develops quickly Offer to travellers going remotely in Oceania Twinrix gives incr rates of seroprotection ag Hep B cf monovalent vax in 40s TYPHOID / PARATYPHOID ORAL- FAECAL BACTERIAL TRANSMISSION Incubation: 3-60 days Incidence: 22 mill cases / yr 200,000 deaths 7 mill from Asia, 4 mill from Africa, 0.5 mill Sth Am ENDEMIC REGIONS: Africa, Asia, Latin America, Oceania Oceania is a region of medium incidence /100,000 cases/year Incidence in Travellers: General Travellers incid 3-30/100,000 approx 1 in 3,000 Especially note: Samoa, Fiji, Tonga Red High risk: >100/100,000/yr Australia now sees typhoid cases Brown each year Mod risk: /100,000/yr double the number of Grey less than Low a decade risk: <10/100,000/yr ago New Zealand cases per year Shaw MTM. Common Vaccine-Preventable Travel-Related Diseases. In: The Practical Compendium of Immunisations for International Travel. Shaw MTM, Wong C (eds). Adis, Auckland ISBN: (Print) (Online) Aust Federal Depart. of Health's national notifiable diseases 7

8 TYPHOID / PARATYPHOID One of the primary cause of febrile illness in the returning traveller Enteric fever is classically caused by: Salmonella enterica (serovar) typhi (typhoid); but similar syndrome caused by: Salmonella enterica (serovar) paratyphi A / B (paratyphoid) Typhoid tends to be associated with factors within a household: recent case in the house, no soap for hand-washing, sharing of food from the same plate, no toilet in the house Whereas Paratyphoid was associated with sources outside the household: such as food from street vendors flooding PRACTICAL PUNCHPOINTS TYPHOID Travellers are ordinarily at low risk of contracting typhoid fever Best predictor of typhoid risk in travellers is destination of travel with the greatest risk for travellers being those going to Samoa, Tonga, Fiji Travellers are advised to ensure: Food is prepared hot Water is bottled or purified with Ice and tap water are to be avoided Wash raw vegetables No raw seafood No swimming/harvesting of seafood in lagoons Devel handwashing routines Immunisation is recommended for travellers to at-risk countries the Pacific Nations of Samoa a, Tonga and Fiji as well as for Africa, Asia and Sth America PRACTICAL PUNCHPOINTS TYPHOID ALERT DRUG-RESISTANT TYPHOID: TIME TO RETHINK VACCINATION Drug-resistant strain of typhoid bacterial disease is responsible for a previously undetected epidemic, which has spread from eastern and southern Africa into Southeast and Western Asia to Fiji in the Pacific Typhoid s H58 lineage, which is resistant to multiple drugs, has replaced antibiotic-sensitive isolates in many regions of the world PRACTICALLY: 1. multiple antibiotic-resistant typhoid is here to stay. 2. travellers visiting developing countries for shorter stays ARE ADVISED TO BE vaccinated Typherix GSK Typhim Vi Sanofi Vivotif - Seqirus Abstract: Media release: 8

9 CHOLERA ORAL- FAECAL BACTERIAL TRANSMISSION produces a toxin similar to ETEC Toxins reflect major effects of both diseases Incubation: 1-5 days Incidence: 3 to 5 million annually (120,000 deaths) Risk to travellers 0.2 cases per 100,000 ENDEMIC REGIONS: Africa, Asia, Indian Sub-Continent, Papua New Guinea 75-90% of people infected with V. cholerae asympt. but bacteria present in faeces 7 14 days after infection and shed back into environment, thus infecting others Among symptomatic 80% have mild / moderate symptoms, 20% develop acute watery diarrhoea/dehydration Shaw MTM. Common Vaccine-Preventable Travel-Related Diseases. In: The Practical Compendium of Immunisations for International Travel. Shaw MTM, Wong C (eds). Adis, Auckland ISBN: (Print) (Online) Aust Federal Depart. of Health's national notifiable diseases PRACTICAL PUNCHPOINTS CHOLERA Risk of traveller getting CHOLERA is very low; approximately 1/50, ,000 Cholera = disease of mass migratory populations (refugees) or where the sanitary infrastructure has broken down rather than one affecting the casual traveller The VACCINE NOT routinely recommended unless outbreak or risk of disease Immunisation is recommended in Oceania only in limited circumstances and generally can be considered for: Relief and disaster workers Those travelling to remote areas or where there is limited access to medical care Those working in areas of cholera endemicity or epidemicity Those with gastrointestinalor suppressed immune medical problems, inflammatory bowel disease, irritable bowel syndrome, malabsorption Military personnel Travellers Diarrhoea - Immunisation 40-60% RISK IN DEVEL. COUNTRIES esp: Mexico, Peru, India, Egypt Travellers diarrhoea affects 40+% Oral-faecal transmission 50% TD rainy season c.f. 4% = dry 80% resolves within 2 days Defining Travellers Diarrhoea: this tends to have subjective comp. includes 3 loose stools with 8 hours OR 4 within 24 hours ROLE OF THE DOC/ NURSE: In the provision of preventative advice: we need to teach i) when to treat ii) what to self treat with iii) when to seek advice PLUS 1 of: nausea, vomiting, Faecal Urgency abd. cramps, fever 9

10 Travellers Diarrhoea - Immunisation Dukoral Vaccine NOT routinely recommended for travellers to low risk regions (e.g. Bali or Phuket for 2/52 travel, in estab. tourism surroundings) Dukoral Oral not indicated for TD in Australia ETEC : % protection for 3/12 (Incidence of ETEC: 10% approx) Generalisation: up to 10% -57% of those going to high risk destinations may get some significant protection against ETEC The Vaccine is over prescribed for TD Snap Therapy 6 Top Tips! 1. Alimentary Hygiene DOES work but is not reality too impractical for most travellers! 2. WHO recommend: 1 teasp salt+8 teasp sugar in 1 L potable H20 Food should be started as soon as the patient can eat 3. ORS OK because electrolytes/ sterility of mixtures, HOWEVER ORS had no influence on symptoms, thus soups, juices etc 4. Wait til get ongoing diarrhoeal symptoms b4 Rx 5. With TD parameters being met Loperamide + antibiotic combo. = illness few hrs 6. IMMUNISATION ag. ETEC good for 3 months - 60% effective It is the job of a Travel Health Professional to guide the knowledge that contributes to the good judgement acquired by our travellers for their health whilst travelling THANK YOU 10