Travelling safe: a travel medicine update

 

VICKY SHEPPEARD:

So moving on, the next routine vaccines we are going to talk about are diphtheria, tetanus and polio. Obviously we normally think of them as a set but each of them are important in their own way for travel. Now we don’t see a lot of clinical diphtheria in Australia but there was a fatality in 2011 in a young Queensland woman who was in a family of vaccine refusers. She didn’t travel herself but her boyfriend had travelled to New Guinea, brought the bug back and then she acquired it and died. That’s a rare instance but we are seeing increasing introductions of toxogenic diphtheria in wounds acquired in the Pacific islands. So it’s very fortunate that those travellers are fully vaccinated and that their contacts back here in Australia are fully vaccinated but while ever there is diphtheria in the world and so it’s clearly in the Pacific islands and there have been outbreaks in Russia and the Caribbean. It’s really important that out travellers are protected having received at least three lifetime doses against it.

I guess Tim similarly with tetanus, which is the next slide that we are going to go to.

TIM SENIOR:

That’s right.

VICKY SHEPPEARD:

Again, this is, I think people are pretty aware that it’s very important that everyone is adequately protected against tetanus before they travel and we certainly recommend a booster dose if more than 10 years since their primary course of tetanus or their last dose of tetanus.

TIM SENIOR:

And so I think the next slide is about the particular vaccines we’re using and the recommendations for diphtheria, tetanus and polio.

VICKY SHEPPEARD:

Yeah, so just summarising that, so I’ve, we’ll talk about polio later when we’re talking about required vaccines because at the moment it is subject to international health regulations but, so make sure children are up to date and adults 19 to 64 who are travelling and haven’t had a booster should have a single dose of DTPA. If it’s more than 10 years since their last booster and the travel is with a high tetanus risk, either DT or DTPA and then people who are travelling to polio risk areas should have DTPA with IPV in it and at the moment that’s required in Pakistan and Afghanistan but there’s other, in that broader part, central Africa and those affected parts of the Middle East it’s also recommended to have that polio booster.

NICK ZWAR:

It’s probably worth noting there’s quite a number of parts of the world where polio is no longer present. Obviously in Australia we haven’t had a cases of polio locally since the 1960s or so but there was that case imported in the late 80s or was it more recently than that from a student who was going back to Pakistan to work? The Americas are also declared polio-free so there are some parts of the world for which you don’t need to have a polio booster.

VICKY SHEPPEARD:

Yeah, and I think we’ve got a map a bit later on that looks at polio, where polio’s circulating.

TIM SENIOR:

And so the recommendations on the vaccine?

VICKY SHEPPEARD:

Yes, and this next slide is just giving a couple of suggested courses and it’s

partly depending on what vaccines are available. So you can give Adacel-IPV or Boostrix IPV followed by two doses of DT with IPOL or, you know, depending on your patient’s circumstances and the availability of vaccines it’s perfectly acceptable to give three doses of the Boostrix Adacel IPV combination with a minimum interval of four weeks. So this is for people who, and you know, you might find it more often in people who are not born in Australia, they’ve got no idea if they’ve received these vaccines as children, and if you’re unable to determine that then it’s quite safe to give them this course.

NICK ZWAR:

Yeah, sometimes people can remember being given the oral polio vaccine but of course we don’t use that in Australia anymore, but I remember looking after some refugee patients from Rwanda some years ago and that’s one thing they could recall was in the refugee camp being given their DOX and that seemed reasonably reliable but as Vicky’s saying often people cannot remember whether they had a primary course particularly if they’ve come to Australia as a refugee or some, you know, disruption to their lives and have left, you know, in a hurry.

TIM SENIOR:

And we’ve also got a few questions come through about the shortage in supply of vaccine DTPA and DTPAIPV, any comments on that?

VICKY SHEPPEARD:

Yes, well we certainly acknowledge there is a lack of both DTPA and to a lesser extent DTPAIPV in the private market and that’s been a problem for several months now. The two manufacturers tell us they’ll have a steady supply in in the next few months but in general the DTPAIPV has been in better supply than the straight Boostrix or Adacel.

TIM SENIOR:

Lovely. Thank you very much.

VICKY SHEPPEARD:

You’re welcome.

TIM SENIOR:

I think the next vaccine is hepatitis B from the routine.

NICK ZWAR:

Yeah. So hepatitis B is clearly an important disease and, you know, as you know, we vaccinate all our children in Australia against hepatitis B. Some travellers are at particular risk and they include they travellers who are doing those sorts of activities that are on the slide. You know, intravenous drug users, new sexual partners, tattooing, body piercing, which some people do. Make sure, of course, children have received their three valid doses as part of just checking on the routine immunisations and, you know, do consider for previously unvaccinated adults. There’s still a reasonably big cohort of Australians who didn’t get the hep B vaccine either in childhood or as part of the adolescent programme who could be at risk and we do, and as the next slide will show we live in a part of the world where prevalence of chronic hepatitis B is very low in Australia but many of the surrounding areas where people travel to or go to visit friends and relatives for holiday for VFR travel are high prevalence countries for hep B carriage. So, you know, I think it is an important one to think about for the situation of travellers.

VICKY SHEPPEARD:

So that’s our routine vaccines and so we’ll just shift right into that category of required vaccines. So polio is in there at the moment because in 2014

the World Health Organisation declared the international spread of wild polio a public health emergency of international concern and that means it is subject to international health regulations. Initially that was a fairly broad number of countries that were caught up in the International Health Regulations Declaration but earlier this year it has now been restricted back to Afghanistan and Pakistan as the only two countries having ongoing endemic transmission of polio. So for the traveller to those countries, if they’re spending more than four weeks in Afghanistan or Pakistan they’re actually required to show proof of polio vaccine prior to leaving that country. So your patient, if they’re planning travel to that part of the world, they should’ve received the polio booster between four weeks and 12 months before they’re planning to leave that country. So that might just take a little bit of coordination between you and your patient depending on how long they’re going to be away to make sure that they can receive that polio dose but, as Nick said, you know, other countries there are still occasional polio cases detected. So if your patient is going to be doing travelling to parts of the world where there is polio and they’re going to be in, you know, rarely this is going to be in the cities, if they’re going to rural areas that’s the areas where you need to be thinking about polio booster as well.

NICK ZWAR:

I think previous there was some activity along, in Syria but fortunately I think that’s come under control and along the border with Israel as well as transmission into the Horn of Africa but that seems to have fortunately kind of been dealt with.

VICKY SHEPPEARD:

Yeah and also intermittent outbreaks along the Burma/Chinese border for example. So, you know, it’s really where there are displaced people and displaced health systems where that really basic polio programme has not been able to be maintained.

So the next slide was just describing polio. I’m sure you’re all familiar with that but, you know, other important things to remind your patients are that, you know, how polio is spread. So faecal/oral route, and so they can reduce their risk by hand washing and making sure any food or water they consume is appropriately boiled or cooked and as we’ve already said, a single booster for adult travellers to endemic areas and a 10 yearly booster for those at ongoing risk.

NICK ZWAR:

Okay, we’re going to move on now to talk about required vaccines, where was the next ‘R’. Remember we had routine, required and recommended. There aren’t many required vaccines under International Health Regulations. Yellow fever is the major one. Just a little bit of information there to remind you about yellow fever, it’s transmitted by daytime biting mosquitoes particularly aedes, very topical with Zika at the moment, which we’ll come to later and, you know, our human habitation, human activity tends to encourage the breeding sites for those mosquitoes and under International Health Regulations the vaccine can be required for certain destinations in South America and Sub-Saharan Africa. It’s a single dose of live attenuated vaccine. So it’s important to remember it’s a live vaccine so as Vicky said earlier, if you’re giving a live vaccine it has to be on the same day or separated by four weeks. So it’s something to think about if you’re not a yellow fever provider that your patient needs to have yellow fever, think about what other vaccines you might need to give or let the yellow fever vaccination centre give other live vaccines when they do the yellow fever as it can sometimes cause some problems. So accredited providers, the New South Wales accredited providers across the State and the information of where they are is available from your public health unit for the contact details. There have been concerns about the adverse reactions. It’s contraindicated obviously if there’s previous anaphylaxis to the vaccine or any of its components, under nine months of age because there’s a greater incidence of neurological adverse reactions but probably the most important is if your patient is immunodeficient or has a thymus disorder, maybe they’ve had a thymic tumour or a thymectomy or even myasthenia gravis as well, then they may be at higher risk of viserotropic adverse reactions, which can be quite severe and can be fatal and there’s a whole discussion about older people are also at greater risk of these viserotropic adverse reactions and so people over 60 and particularly over 65 who are having the vaccine for the first time it can be a balance between the safety of giving the vaccine or not giving the vaccine and so that is something that the yellow fever vaccination centre will have to weigh up. It is possible to write a waive. If your patient has a medication contraindication you could write waive letter and that patient could take that with them to their country of destination. One thing that’s changed with yellow fever or in the process of changing is a group of experts called the Strategic Advisory Group of Experts, the SAGE group. Wouldn’t you like to be part of that group, it sounds so important? Reviewed yellow fever vaccination recommendations on behalf of the World Health Organisation and said that they think a single lifetime dose is sufficient and you don’t need to boost after 10 years. That change to the International Health Regulations is coming into force in June this year, so it’s very topical but actually it might take some countries a bit longer to actually individually roll it out. So that will be an issue of some uncertainty is whether your patient, if it’s more than 10 years since a dose, you know, in this interim period at least whether they might be safer to have a second dose if it is not clear whether that’s been implemented in the country they’re going to. That’s going to be tricky I think for people to establish Vicky. I wonder what your thoughts are on that.

VICKY SHEPPEARD:

I think people could contact, you know, it now seems a pity to have this, you know, there are risks associated with this vaccine as well as inconvenience and expense so, you know, we’d really prefer people not to have a second dose at this stage. So I think if you do have a patient in that situation they could enquire of their country of destination. Certainly it won’t be any problem coming back into Australia but that’s true that, you know, depending on where they’re going that country may not have switched over yet.

NICK ZWAR:

Yeah. Okay.

TIM SENIOR:

And there’s another question on the yellow fever vaccine. Just what needs to be included in the waive letter if someone does have a medical contraindication, and presumably that’s just setting out the contraindication they have and your name perhaps, registration number and qualifications.

NICK ZWAR:

Yeah, there’s information about this in the Australian Immunisation Handbook so that’s a good place to refer but exactly as you say Tim, you should have, it should be on your practice letterhead, it should have the date, it should have the reason for the medical waive and obviously your signature and yeah, and that should be sufficient. The patient might be wise to take a copy of that or photograph it on their phone so if they lose the letter they’ve still got some record.

TIM SENIOR:

Lovely.

NICK ZWAR:

This just shows the areas of the world where yellow fever is endemic according the UN Centres for Disease Control. I always find these maps interesting because sometimes the mosquitoes seem to know to turn around when they reach borders and I think they’re very well educated mosquitoes to know that, but clearly …

TIM SENIOR:

They don’t have passports.

NICK ZWAR:

Yeah, they haven’t got a passport. They don’t have a yellow fever vaccination certificate clearly but they are somewhat sort of schematic. They’re an idea and they do depend on the quality of the reporting of that country, which is not always, you know, depending on the country’s infrastructure, may be an issue but, you know, anyway it’s kept up to date in the MMWR and, you know, you can look up that to see what the most recent countries are.

VICKY SHEPPEARD:

Well there’s a very active outbreak in Angola at the moment and the Democratic Republic of Congo have just announced that the outbreak has spread there as well. So they’re particularly high risk areas at the moment.

NICK ZWAR:

Now clearly an issue would be the upcoming Olympics with people travelling more broadly in Brazil. The main area of risk in Brazil is Amazonia kind of around, you know, people will go on river cruises on the Amazon from Manaus, that kind of area, may be something people are thinking of doing as part of their trip to Rio.

VICKY SHEPPEARD:

I would.

NICK ZWAR:

Vicky’s, I think she’s going to do one. So it is important to kind of think about that. There have been, some years ago there were some US tourists in that part of the world and got yellow fever and I think one or two died. So it does happen occasionally.

TIM SENIOR:

Okay, shall we move on to the next required vaccine in particular circumstances?

NICK ZWAR:

Yeah, so that is really for people attending the Haj pilgrimage in Saudi Arabia, the Muslim pilgrimage, which is a big event, like two and a half million people each year go to Mecca, Medina and they do need to get a Haj visa, they need to have evidence of being vaccinated again meningococcal disease and the quadrivalent is the one that needs to happen because it used to be that it was just a bivalent vaccine but then there was an outbreak of a W135 sero group and so then the Saudi authorities moved to the quadrivalent and, of course, there are other parts of the world where there’s risk particularly Sub-Saharan Africa that belt across Africa where there are outbreaks, particularly in the winter months of meningococcal A disease in particular. That’s lessening and there’s been a vaccination programme I understand happening in that part of the world but there are fairly large outbreaks still on a reasonably regular basis. I would encourage people, if they can afford it, to have the conjugate vaccines and you can see some names of brands there. The reason for that is that it probably produces longer lasting immunity than the polysaccharide vaccines and there is some evidence that perhaps they are less likely to have nasopharyngeal carriage than if you had a polysaccharide. There are instances in that outbreak that happened at the Haj one year pilgrims going back to their countries of origin in the US and England and other parts of the world and they weren’t sick but their contacts got ill because they were carrying the meningococcal in the nasopharynx, so may be less likely to happen with the polysaccharides.

 

VICKY SHEPPEARD:

Alright, well now we’re moving on to the group that is recommended. So not necessarily routine, not required, but ones to consider for each of your patients. So top of my list here is flu because that’s by far one of the commonest vaccines preventable diseases that’s acquired with travel and you just need to think about the mixing that occurs with travel, the enormous airports, people, airplanes, cruises, it’s a perfect opportunity to catch flu. So particularly if your patients are travelling in either hemisphere during that hemisphere’s winter, strongly recommend thinking about the flu vaccine. And I’ve just included a slide here that shows, we’ve shown it in past webinars, so it’s flu A and flu B since 2011 notified cases in New South Wales and the red line is flu A and the blue line is flu B. What I just wanted to focus on at the moment if, of course, there’s the big peaks each winter particularly influenza A and last year of influenza B but it’s this what we call interseasonal flu, so we’re getting peaks January, February, March and we can particularly see that in 2014, 2015 and again this year in 2016. So this is flu brought back from the northern hemisphere by travellers and predominantly flu A and this year it’s pretty much all been H1N1, which as we’ll see in the next slide if one of the predominant strains that has been circulating in the northern hemisphere during their winter. So it’s, I guess to me it’s pretty straightforward, your know, that our people, Australian people travel to Europe during their winter, to North America and come back here and bring the predominant strains that are circulating. So that’s, as you know, highly preventable and usually by using the current flu vaccine that you have that will be fairly well matched in most circumstances with what’s happening in the northern hemisphere if that’s where their travel is.

TIM SENIOR:

Thank you. So these are the flu vaccines?

VICKY SHEPPEARD:

Yeah, and Tim we did go through this in the last webinar but just here as a reminder. The quadrivalent vaccines that are available this year are covering, well matched to the strains that are circulating, particularly H1N1, which has been the predominant northern hemisphere strain and is predominant so far in New South Wales, plus the two ‘B’ strains that are circulating. Now, of course, there’s a little more for those patients of yours who aren’t covered by the National Immunisation Programme, the quadrivalent is a little more expensive but, you know, I think you can tell them that it would give them a bit better protection against a wider range of flu strains.

NICK ZWAR:

Okay. I think we’re going to move on now to some of the recommended vaccines and we’ll start off with hep A and I’ll be fairly brief because I think probably hep A is fairly well known. You know, we think about this for lots of our travellers who are going to parts of the world where sanitation is, you know, can be a problem and faecal/oral disease is more common. A single dose will provide protection for about a year but I really encourage patients to have that second dose six months to 12 months later typically to give long-term protection but you don’t need to restart if your patient comes to see you three or four years after their first dose, just finish the course. It’s not necessary to restart and if they need hep B cover as well, there is the option of the combination Twinrix vaccine. If they’re already immune to hepatitis B then obviously we’ve got other options.

I think we should just keep moving to typhoid. It was already mentioned earlier that we do have some importation of typhoid into Australia every year and, you know, it’s often from places where Australians commonly go such as Bali but in fact, you know, the Indian subcontinent particularly specific areas of risk, think about it in young adults particularly visiting friends and relatives. It’s not the most effective vaccine. It’s not like hepatitis B or hepatitis A vaccines, which give very high rates of protection, it’s around you can see the 50-80% effective, whether it’s the oral one or whether it’s the parenteral one. We don’t have a vaccine for paratyphoid. Just looking at the vaccine options on the next slide, as I said there’s a parenteral option, which is probably simpler probably in some ways. You don’t have to worry about all the issues of a live vaccine, which is the oral one and more rapid protection, you can use it in kids, it’s not contraindicated in pregnancy and it’s not a live vaccine so there’s no issue with immunocompromised patients. Some people though really don’t like needles so the live one is an option. It’s important to keep the capsules in the fridge, complete the three dose regimen and there are issues with anything that might be active against salmonella typhi like an antibiotic or some antimalarials. You need to make sure people have completed the course before they start on that and you wouldn’t want to give this to people who are immunocompromised, as I said, and probably not in pregnancy either and either about after three years you would consider a booster dose if people were at ongoing risk.

Moving on to cholera, not one that we need to think about very often. It’s really for people who are going, you know, maybe aid workers, people who might be veterinary workers, people going to, you know, really working in humanitarian situations, people going on really sort of off the beaten track, you know. You know, those people that used to do the whole top to toe of Africa on the back of a truck-type trip, you know, but they don’t happen as much as they used to. Also perhaps people with achlorhydria and people with complicated diabetes because of course if they got unwell and dehydrated that would be quite problematic, and inflammatory bowel disease. So it is a selected group of patients that we would recommend cholera vaccine, certainly not everyone.

The next slide I think shows just the cholera vaccine we have available, which is an oral inactivated vaccine and you can see there are different dosage regimens whether you’re aged over six or under six and you do want to have this interval between cholera and oral typhoid vaccines and it doesn’t give a long duration of protection so that’s an issue. I know someone’s going to ask where reasonably about the cross protection against enterotoxic E.coli and yes there is some because it happens that the enterotoxic E.coli toxin is just similar in its shape, molecular shape to the cholera beta subunit. So, yes there is a little bit of crossover protection for travellers diarrhoea caused by enterotoxic E.coli. That’s probably the main thing to say about the cholera vaccine I think.

TIM SENIOR:

And next up in the recommended vaccines is rabies.

VICKY SHEPPEARD:

Yes. So, this is something to consider and again it’s very particular patients that you might want to consider this for and it’s really those who are going to have extended stays or be in quite rural areas where they’re going to have trouble getting post-exposure prophylaxis if they do get a rabies prone bite. So we see people that have come back and had rabies prone bites and most commonly that’s monkeys in Thailand or Bali or street dogs. Bali and India I would say are the most common places where we get bites from street dogs. So if your patient is in that category where they’re going to be for a long period in that kind of setting or have trouble accessing medical care. So I know when my son kind of backpacked through South America I made sure that he had pre-exposure prophylaxis because, you know, how was he going to negotiate getting appropriate treatment in a hurry. So the pre-exposure course is three doses of vaccine. It’s a first dose then another dose seven days later and the third dose somewhere between 21 to 28 days later. It is an expensive vaccine and I know that some people do consider the intradermal course and that’s certainly available in some travel medicine practices. So it’s cheaper because only a tenth of the dose is required, so 10 patients can receive vaccine from the same vial but as is warned in the handbook, if your patients are having an intradermal course it’s important that they have time to have their serology checked two to three weeks after finishing the course so you can make sure that they have sero-converted.

NICK ZWAR:

I’ll just mention Vicky that I think sometimes if people are planning to go travelling, you know, recurrently over their lifetime, you’re seeing a younger person going off to Asia for the first time or South America you can sort of say to them I think very justifiably, look this is an investment for your whole travelling lifetime to do the pre-exposure because it makes the post-exposure just so much more simple and, you know, major lack of supply of human rabies immunoglobulin around the world that makes it really quite difficult to get the best quality post-exposure prophylaxis.

VICKY SHEPPEARD:

Yes and not even offered in many countries.

NICK ZWAR:

Yes.

VICKY SHEPPEARD:

So the next slide is a map of where rabies is high risk. So obviously the red countries are acknowledged as high risk countries right through Asia, Africa, must of South America and Central America and a medium risk in the balance of South America and the Middle East and into parts of Europe. Australia, as is North America, is yellow there, low risk and our risk is only from bats at the moment and New Zealand is one of the very few places where there’s no risk. Also the Pacific islands don’t have any risk of rabies.

The next slide is just an example of some of our experience in New South Wales with post-exposure prophylaxis. So you can see there the graph shows how many people have been referred to us each year. So in 2015 about 500 people were referred to public health units in New South Wales for post-exposure prophylaxis and about 300 of those were from bites or scratches obtained overseas. So mainly South East Asia, mainly Bali followed by Thailand, those are the places of highest risk. I think there are some things we can do first off, which is the next slide is to prevent these bites in the first place. So by giving some of this sensible pre-travel advice to your patients of not feeding monkeys for example in Thailand and Bali, we could actually reduce the number of people put at risk. The other thing you can do is to forewarn your patients with what to do if they do get a bite or a scratch from a rabid dog or a monkey and the wound care is very important, so washing with copious soap and water, applying an antiseptic like Povidone and then seeking medical attention because irrespective of whether they’ve had pre-exposure prophylaxis some post-exposure vaccine is necessary and if they’ve had no pre-exposure prophylaxis then it’s good for them to search out some immunoglobulin as well as vaccine as soon as possible. So the next couple of slides I don’t think we need to dwell on. This is what we do with rabies immunoglobulin if we do get high risk bites referred to us. So it’s a matter of a weight-based dosage and infiltration as much as possible into the wound and we can do it up to seven days after vaccination commenced and that’s not uncommon actually that travellers will get the vaccine in Thailand and Bali and return here and it’s still within the seven days. So we do provide the immunoglobulin in that circumstance to optimise the preventive treatment. And then the final slide on rabies vaccination is about the vaccine itself. So we have two vaccines usually available in Australia. They both can be used for pre or post-exposure prophylaxis but if a patient incurs a bite or a scratch that’s rabies prone then we supply the vaccine for free and then the dose is a ml, it’s intramuscular into the deltoid and so if they’ve not been previously vaccinated it’s a four dose course now at zero, three, seven and 14 days but if they’ve had a previous vaccine they only need to have two doses at zero and three days. So that’s about it for rabies.

NICK ZWAR:

Okay. We’ll move on to another recommended one occasionally and that’s Japanese encephalitis. It’s another mosquito-borne infection and we really think about it for people travelling to rural parts of Asia, particularly during the wetter times of the year or if there’s a lot of kind of outdoor exposure, people who are going into rural areas where there are rice paddies, pigs because the transmission is between water birds and pigs and humans can just be unfortunate enough to get in the way. Also travellers who are spending more than a year even in some cities in Asia except Singapore, you would think about JE as well. In fact most JE cases in the local populations are asymptomatic but if you are unfortunate enough to get the symptomatic Japanese encephalitis it is really quite a severe disease. It can be fatal in about 20-30% of people who get infected. In terms of the vaccines, we’ve got two options, Jespect and Imojev. Jespect is an inactivated vaccine. It has a two dose regimen. It’s not the only vaccine currently available in Australia, that’s obviously wrong because we’ve got Imojev as well, which is a live attenuated vaccine and you can see that Jespect is not licensed for paediatrics but Imojev is but, of course, Imojev is a live vaccine so there’s all the issues of live vaccines to think about there. You need a while before the traveller leaves for the two dose regimen, so that can be an issue because it’s days zero and 28 and even with Imojev it probably takes about two weeks to get sero-protective antibodies after vaccination.

 

VICKY SHEPPEARD:

Look I’ll just quickly speak about TB. The BCG vaccine is recommended but only for children under five years of age who are going to be spending three or more months in an endemic country. This is only accessible through chest clinics in New South Wales but there is currently an international shortage so there’s quite limited availability in both Australia and overseas so we are using a different product at the moment, a Polish produced product and we’re looking at importing one from India so that there could well be difficulties accessing BCG vaccine at the moment but chest clinics can give advice to families if they’re not able to access the vaccine before they travel, and of course, this is another live vaccine so particularly in this age group it’s important to kind of line that up with their MMR or MMRV before they travel if they haven’t had those vaccines.

NICK ZWAR:

And you certainly don’t want to give BCG to someone who is immunocompromised.

VICKY SHEPPEARD:

No.

NICK ZWAR

Just a little bit about the older or chronically ill traveller. As we said earlier, quite a lot of older people with chronic illnesses are travelling so think about, you know, trying to make sure they’re protected against things like influenza, that they’re up to date with pneumococcal, the Zoster vaccine, hepatitis B also as they may not be immune and the others will depend on risk assessment. As we’ve mentioned that yellow fever vaccine there is that higher risk of adverse events in older people.

Moving on to just a list of travelling vaccines in children and this is just recommended lower age limit, it’s just a sort of aide-memoire slide in terms of the various age at which you can start giving those vaccines. With the yellow fever you might notice that the immunisation handbook says nine months, the product information says six months and in Australia we prefer to use the nine months as the starting age for that one.

VICKY SHEPPEARD:

Yeah, and if I could just point out the MMR, it’s unfortunate the number of children that we do see coming back from the subcontinent at just about 12 months of age with measles. So if they are travelling before their first birthday it’s perfectly acceptable to give that vaccine as early as nine months to provide that added protection when they’re in a high risk travel setting.

NICK ZWAR:

Mmm, that’s an important point. Yeah, and just keeping going …

TIM SENIOR:

Just to clarify while we’re on the children’s slide, we did have a couple of people asking earlier about typhoid vaccine in children under two and just commenting that that’s outside the license and just clarifying that and I think that’s what it said on that slide.

VICKY SHEPPEARD:

Yeah.

NICK ZWAR:

Yeah, it’s not known that it’s harmful or dangerous but there isn’t the safety data. So that’s always an issue with off label use.

TIM SENIOR:

Thank you.

NICK ZWAR:

Just keeping going here, you can see for Japanese encephalitis there’s slightly different dosage for younger kids with Jespect and you can see the lower limits for meningococcal, for the conjugate vaccines that we talked about earlier.

VICKY SHEPPEARD:

So Tim I just wanted to give in this context of travel, it’s not about vaccination but just an update about Zika virus because it’s still very important that we’re all familiar with the current situation. So it’s a flavivirus, it’s very similar to Dengue and it’s mainly transmitted by aedes agypti, which is the yellow fever mosquito but we believe that aedes albopictus is also a competent vector and as we learn more about it we’re finding that sexual transmission is possible and mother to child transmission is possible but mosquito-borne remains the predominant means of transmission. Now, just in the past couple of weeks the World Health Organisation has confirmed the association with severe congenital neuropathic effects in infants born to women who have had Zika virus infection during pregnancy and there’s also an emerging association with Guillain-Barre and other neurological syndromes in adults and they remain under investigation about the strength of that association. So the presentation of Zika virus, its onset is three to 12 days after a bite and symptoms last from four to seven days. It’s emerging that rash is probably the commonest presenting symptom or sign, fever also common but not as common as rash, headache, retro-orbital pain, nonpurulent conjuctivitis, myalgia can be quite marked but important for the epidemiology to note that about 80% of infections are asymptomatic.

The next slide is the most recent map of countries with active transmission. So we’re looking at most of Central America, the Caribbean and a fair chunk of South America but we’ve also got active transmission reported in New Guinea and other Pacific islands. In counselling your patients about pre-travel advice about Zika, I’d really encourage you to check the latest information and the Commonwealth is keeping that updated on their website because it is such a dynamic outbreak and affected countries can be changing within days or weeks. We have good testing for Zika virus in New South Wales and encourage you to talk with your local pathology provider or ID specialist about the right test for your patients according to, you know, the time since symptoms and travel and so forth. You know, we usually in the acute phase are needing to exclude other infections such as Dengue and malaria and depending on the time since symptoms we have a PCR available or we may need to use serology to confirm infection and this is all done at ICPMR at Westmead. Really importantly is this travel advice and I can’t say it enough times, pregnant women should defer unnecessary travel to regions with active transmission and then all travellers to affected areas should take very stringent precautions to avoid mosquito bites. So the basics are there, daily application of repellent with effective chemicals whether that’s DEET or picaridin and it’s important for your patients to know these are day-biting mosquitoes so they need to put this on every morning. Try to make sure they book accommodation that has fly screening and if they’re in really high risk situations such as, you know, camping and so forth, getting their clothing treated with insecticide. So we’ve got all that information summarised on a fact sheet that you can access and give to your patients and then for people who return. So for women who have travelled to areas with active Zika virus and they are pregnant, there’s very specific advice issued for them and that’s detailed on the Commonwealth website but basically they do need assessment to see if they have been infected with Zika either clinical or subclinical infection and again I encourage you to visit the website because this information and guidance will be amended as information emerges about the best management for women.

Then for men who have travelled to areas with active Zika virus infection, we’re recommending that if their partner is pregnant, whether or not they’ve had symptoms, they should abstain from sex or use condoms for the remainder of the pregnancy and then men who had had confirmed Zika virus infection, they should abstain from sex or use condoms for three months and this is to prevent sexual transmission.

NICK ZWAR:

Okay. There’s a range of resources available to kind of help and for decision support in travel medicine there’s a list here, you know, the WHO site and the CDC site probably being the best known but these are really useful websites and can help you very much in providing good quality advice to your patients so I certainly encourage you to have those, you know, on your browser so you can click on them easily and, you know, it can be very useful to go through some of that information with our patient as part of the consultation and maybe print out some of the materials for them to take home and do some reading afterwards. So we won’t go through them but they’re there and I certainly hope you’ll use those.

TIM SENIOR:

Excellent. Thank you very much. I would just like to reassure people that that list of websites you will be sent the PowerPoint afterwards and so you’ll have access to all of those websites and you can click through to them and I think that’s going to be crucial. The other information on the slides will also be available to you and so I note some of the questions that have come through will be answered in the slides. Other questions, I’m just aware it’s ten to nine now and so we did have quite a few questions come through and we shall store those and endeavour to get back to you with answers on those because we haven’t got time to go through them in sufficient detail tonight. I would like to thank Nick and Vicky for going through such a comprehensive set of useful information over the last hour and to Penny for doing all the behind the scenes that makes it float so easily, so thank you to all of you for doing that. Thank you to everyone for being online and for paying attention and asking excellent questions. As I say, we’ll get through to those and a reminder that 14 September there’s another vaccination update this time on shingles vaccination and so contact the New South Wales Faculty to register for that online as well. Thank you very much indeed. Any final comments from Penny or from Nick or Vicky.

PENNY:

No thank you. Thank you very much for another fantastic webinar and thanks to Vicky and to Nick as well. Good night.

TIM SENIOR:

Thank you very much. Have a good night everyone.