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.