Archive for the ‘Clinic Stories’ Category

To take or not to take. That is the question.

Dr Catherine Meehan

McLeod St Medical  Cairns

 

To Be or Not to Be

 

Travel vaccinations and malaria prophylaxis.

 

To take or not to take. That is the question.

 

When travelling to high-risk countries, the answer to this question is a lot easier. You weigh up the pros and cons and usually, the pros win. You can be visiting a remote PNG village or trekking in the bush somewhere. You know there will be mosquitos and so most will be prepared. You may be eating local food in the villages or street stalls. The risk of contamination or infection is present.

 

When travelling on a boat, the answer is not so easy. You are often at sea away from the shore, in airconditioned comfort. Visits to the shore are usually short and during the day, avoiding dawn and dusk high-risk times. The food you eat is prepared on board. The water you drink is usually desalinated water made on the vessel and is safe to drink.

 

Recently, while travelling on a liveaboard dive boat, in PNG, I questioned the guests and the non-indigenous crew about their feelings on malaria prophylaxis and vaccinations. The guests were from Australia, USA and UK, and the crew were from Australia and Europe.

 

I asked the following questions:

 

-what made you come to PNG?

-who did you book your trip with?

-what travel health advice where you given prior to your trip and from what source?

-what was the advice regarding vaccinations and malaria prophylaxis?

-what vaccinations and malaria prophylaxis did you have, or did you decline?

-what other health issues were you aware of such as travellers’ diarrhoea, dengue etc?

-do you consider a liveaboard stay to be less risky than a land stay?

 

The non-indigenous crew had not had vaccinations, nor were they taking malaria prophylaxis They considered malaria to be endemic in the area, and they would treat any symptoms accordingly.

 

All passengers on this diving trip had, on my advice, been provided with comprehensive written health information about PNG from CDC (Centers for Disease Control and Prevention) and a visit to a doctor with experience in travel medicine was advised.

 

Of the 3 divers from USA, the two men had all the information but decided not to go ahead with anything.

 

The other diver from USA, a female who is a nurse, did seek medical advice at health department of a county hospital and was given Hepatitis A vaccination, but not offered typhoid vaccination. She was taking Doxycycline for malaria prophylaxis but discontinued due to side effects.

 

The two divers from the UK were both fully vaccinated and taking malaria prophylaxis.

 

All but one of the Australians were fully vaccinated and taking malaria prophylaxis

 

All the divers felt that the risk on a vessel was less than for a shore stay. However, our dive boat was moored on a jetty for 3 of the nights we were on board and we had 3 visits to shore, and ate at the nearby resort, so we did have dawn and dusk exposure.

 

Another type of boat travel is on a cruise boat, and I was recently privileged to be able to go on a small (100 passenger) expedition cruise to Papua New Guinea, Indonesian Spice Islands and Raja Ampat (West Papua).

 

I was unable to interview passengers, but in casual conversation was able to ask what people were doing to prevent malaria, or if they had vaccinations.

 

From these casual discussions, I would say that about half of the passengers were taking malaria prophylaxis and had had travel vaccinations.

 

All of them considered that the risk on a vessel was less than on land, and on the back deck of the vessel was insect repellent, and everyone was encouraged to apply this prior to leaving the vessel and also to wear suitable clothing, offering cover from the sun and mosquitos.

 

I must admit, that during most of the shore excursions, which were mainly coastal with a coastal breeze, I did not see many mosquitos. It may have been the herd effect of so many passengers covered in Deet, that may have kept the mosquitoes at bay.

 

Although the airconditioned vessel was free from mosquitos and the evening events on the vessel were away from the shore, we did have a wonderful sunset event with champagne and local snacks at a fort on Banda Island. And a visit to a swampy area in West Papua to see how Sago was harvested, and we all went to the mangrove restoration area and planted a mangrove plant.

 

No-one that I am aware of on the cruise developed malaria. However, there were some cases of travellers’ diarrhoea, and I myself was unfortunate enough to pick up some intestinal parasites during my cruising.

 

So, it comes back to the eternal question, of what to do, and although the risks for acquiring a tropical illness during ocean travel may be less than land travel, the risks still exist.

 

Every ocean traveller should research the itinerary and the events in their package, to see what their exposure risk may be.

 

It is also recommended that they seek expert travel health advice from a doctor with experience in travel medicine at least a month prior to travel.

 

That will make the question of “to take or not to take” a lot easier to answer.

 

Locals checking out the visitors: Kimbe Bay, West New Britain, PNG

Sammy planting a mangrove branch, assisting the locals with their mangrove regeneration program: Kofiau, Raja Ampat, West Papua

Our floating home

An offering of local delicacies made from Sago flour and palm sugar: Kampung Deer, Kofiau, Raja Ampat, West Papua

A local pet, the Cuscus. The cuscus is a large marsupial native to the Northern forest of Australia and the large, tropical island of Papua New Guinea. The cuscus is a subspecies of possum with the cuscus being the largest of the world’s possum species.

Checking out the Sago Plantation and being photographed by the local villages: Rumah Olat, Sawai, Moluccas, Spice Islands, Indonesia

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Going Home To Visit Grandma

Dr Chris Davenport , TMA Boronia

 

It’s Monday morning, another busy day in General Practice filled with the usual interesting patients – for blood pressure reviews, medication repeats, women’s health discussions and children with the latest coughs and colds.

7-year-old Alice has come with her mother for a review of her eczema. It’s the school holidays and I ask what the holidays will hold for her.

“We are going on a holiday to see my Grandma,” she replies, “ She lives in Vietnam, where Mum and Dad came from and we are taking our new baby to see her”

They are leaving in a few days, travelling to stay with their grandparents and catch up with the extended family. The children had been born in Australia and this was to be their first trip “back home”. They were up to date with the Australian childhood vaccinations but no thought had been given to obtaining travel advice or vaccinations.  “As they were just going home.”

This is a common scenario, where families return to their country of origin to visit friends and relatives without seeking travel advice.  Or some families present asking for vaccines for the children while assuming that they (the adults) will be OK. They feel they know the risks, grew up in that environment, feel comfortable and assume all will be well.

However, Immigrants and their children who return to their country of origin to visit friends and relatives (VFR) are at increased risk of acquiring infectious diseases compared with other travellers.  (Heywood, et al., 2016)Several studies have shown that of all Australians returning from overseas with an infectious illness 65% are from the VFR group, whereas the VFR group only makes up 23% of Australians travelling.

VFR travellers are a large and important group as one-quarter of Australia’s population were born overseas and do travel “home” to visit family.

Their risk is higher due to several reasons.

They have a lower perception of risk as they are familiar with the destination. There is a perception of protection from prior immunity developed in childhood – an immunity that may have waned since leaving their home country.  Their children have not been exposed to the diseases and infections common in their parents’ place of origin. They are more likely to travel to resource-poor settings and have a longer duration of travel than those travelling for tourism or business. VFR travellers are more likely to have closer contact with the local population e.g. while catching up or living with extended family, close contact with large groups, the children playing and in close contact with family members. They are more likely to consume local water and less likely to be concerned with Malaria prevention. As a group, they are less likely to be vaccinated prior to travel compared with holiday traveller for the reasons mentioned above.

It is important to discuss travel and prevention of infectious disease when opportunities like this present themselves, and important too, to discuss with the adults that they may also be at risk.

 

Mekong Delta

 

 

Bibliography

Heywood, A. E., Zwar, N., Forssman, B. L., Seale, H., Stephens, N., Musto, J., . . . MacIntyre, C. (2016). The contribution of travellers visiting friends and relatives to notified infectious diseases in Australia: state-based enhanced surveillance. Epidemiology and Infection, 144(16), 3554-3563. Retrieved 1 30, 2020, from https://ncbi.nlm.nih.gov/pmc/articles/pmc5111124

 

 

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Scuba Diving for the first time in my late 40s – from a desert chick from the Centre of Australia.

here

Dr Deb Mitchell   TMA member in Alice Springs

I am wearing close to 40kg of extra weight with all the gear for my first dive (needless to say I am not keen to reveal my baseline weight but let’s just say it’s a lot!!) and as a group we are walking from the car park at Alma Bay on Magnetic Island off the coast of Townsville, wearing full-length wetsuits, and I pretend not to notice the stares of strangers. I am excited, yet nervous as all hell, hot with the sun baking on the wetsuit material, and can feel my face getting redder, as I try not to huff and puff like a steam train. I am slightly reassured as my younger colleagues complain about how heavy the tank and weight belts are.

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Uganda – volunteer in health clinic

Kate McGowan RN

TravelBugs Adelaide

It’s a week into my four week Uganda trip and I find myself in a not-unfamiliar environment. It feels like I’ve been here before: Poverty and lack of resources in the tropics tends to send cities into a familiar decline.  It’s warm, humid and hazy, the air is heavy with wood smoke, diesel and leaded petrol fumes from the old cars that inhabit the roads.

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Solomon Islands – Student Medical Placement

Dr Jo Grey

TMA Brisbane

Earlier this year, I accepted an invitation to spend two weeks on Guadalcanal Island, part of the Solomon Islands group supervising medical students from Bond University on an elective placement.  The students were seeking a doctor to accompany them who would be happy to work alongside and supervise them in a tropical, low-resource environment. I happily accepted, having worked and travelled previously in other Pacific nations, but never visited the Solomon Islands – what a great opportunity!  What a challenge!
The placement was a student initiative, organised by Bushfire, the Bond University Rural Health Club.  This year is only the second year that this student-run initiative has taken place, following on from the successful inaugural trip in 2018.

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Staying safe during an Ebola mission

Dr Saschveen Singh, Capstone Health, Wembley

Ebola Staff health: not your average travel medicine story.

Since the West African outbreak made international headlines in 2015-2017, Ebola has been shrouded in myth. Many had forgotten its existence.

But the recent major outbreak in the Democratic Republic of Congo (DRC) has put the disease centre-stage again.

When I was placed at an Ebola treatment centre with Médecins Sans Frontières (MSF, Doctors without Borders) my friends and family first asked me why on earth I wanted to go there; and, second, what I would do to stay safe.

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Altitude Illness in the Andes  

Dr Jason Rajakulendran, TMA Sandringham.

A recent holiday to the Andean mountains of Ecuador & Peru highlighted to me the importance of careful preparation for any time spent at altitude. The Andes as the world’s second highest mountain range, allow relatively easy flight access to stunning high-altitude regions and active pursuits. As I climbed above 5000m on the glacial volcano of Cotopaxi, I started feeling the dramatic effects of altitude illness despite some efforts to acclimatise. Fortunately, I was able to recover quickly and enjoy the remainder of the holiday. Please read on for advice on how to help prevent and manage altitude illness when travelling to high places.

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Antarctica: Icebergs and secret weapon

Dr Cormac Carey,
Medical Director, Toowoomba.

After sampling the wonderful delights of Buenos Aires we flew South to Ushuaia, the southernmost city in the world. Here, we boarded our expedition vessel RCGS ( Royal Canadian Geographical Society) Resolute, our home for the next nine nights on a calm Friday afternoon.
The weather certainly allayed the potential for the dreaded sea sickness.  Having been previously severely affected on several fishing trips,
I had researched all possible preventive options and was armed with an arsenal.

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Medical illnesses can present serious challenges overseas

by Dr Daniel Priest and Dr Donald Leitch – Shoal Bay, NSW

Have you seen random articles on Facebook etc explaining the things that annoy flight attendants? There is quite a list: clipping your toenails … who does that on a plane?? Going barefoot… that’s smelly bad behaviour. Clicking fingers for attention, requesting a temperature change, not bringing a pen (to fill in the customs forms on international flights) to name just a few.

When you travel, especially overseas, there is so much medical advice we can give. Travel doctors are passionate about giving good, relevant, up to date advice in a comprehensive way… not just a few shots and something for malaria. It is such a privilege to be of assistance to help you have a safe and pleasant trip… but we want to do it well… and that takes time and attention.

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 An African Safari

Potential travellers are now thinking about the Australian winter in 2019 and many are thinking of safaris in Africa. Common destinations include Kruger National park in South Africa, and other fabulous destinations in Botswana, Zambia, & Kenya. They will have a wonderful time, but all should consult their Travel Medicine professional before travelling, ideally at least 6 weeks in advance.

Make sure your tetanus vaccine is up to date.

 

Topics currently in the news include:
Rabies:
According to South Africa’s National Institute for Communicable Diseases, 14 confirmed, dog-related, human rabies cases (a significant increase over average incidence) have been reported since January 2018 in Eastern Cape and KwaZulu-Natal provinces. These cases are linked to an ongoing outbreak of dog rabies in the 2 provinces. Travelers should seek medical care if bitten, scratched, or licked by a dog, another terrestrial mammal, or bat.

Monkeys in Botswana

Rabies is most commonly from a dog bite.
And the BBC recently reported that a Briton has died after contracting rabies while on holiday in Morocco, health officials have said.
The World Health Organization advises that the disease occurs in more than 150 countries and causes tens of thousands of deaths every year, mainly in Asia and Africa. It says in up to 99% of cases, domestic dogs are responsible for the transmission of the virus to humans.
The UK government says north African countries such as Morocco, Algeria, and Tunisia are among 139 nations where there is a high risk of Rabies.
Rabies is a viral infection that affects the brain and central nervous system. It is passed-on through bites and scratches from an infected animal.
§ Initial symptoms can include anxiety, headaches and fever
§ As the disease progresses, there may be hallucinations and respiratory failure
§ Spasms of the muscles used for swallowing make it difficult for the patient to drink
§ The incubation period between being infected and showing symptoms is between three and 12 weeks
§  If you are bitten, scratched or licked by an animal you must wash the wound or site of exposure with plenty of soap and water and seek medical advice without delay
§ Once symptoms have developed, rabies is almost always fatal
§ Before symptoms develop, rabies can be treated with a course of vaccine – this is “extremely effective” when given promptly after a bite – along with rabies immunoglobulin if required
§ Every year, more than 15m people worldwide receive a post-bite vaccination and this is estimated to prevent hundreds of thousands of deaths
§ But effective treatment for rabies is not readily available to those in need
§ Pre-exposure immunisation is recommended for people in certain high-risk occupations and for travellers to rabies-affected, remote areas

Road trauma is the commonest cause of death in travellers. Don’t do anything you wouldn’t do at home. Motorcyclists should wear protective clothing and helmets

 

Also remember to practice safe sex to and discuss emergency anti-HIV medications.

Madagascar: Measles
According to WHO’s regional office, more than 860 confirmed cases of measles (a significant increase over average incidence) have been reported in October / November 2018.
All individuals ≥ 12 months of age born in 1957 or later (1970 or later in Canada and the U.K.; 1966 or later in Australia) without history of disease or of 2 countable doses of live vaccine at any time during their lives should complete a lifetime total of 2 doses of MMR vaccine (spaced by at least 28 days). All infants aged 6-11 months should receive 1 extra dose of MMR vaccine.

Keep your typhoid vaccine up to date, generally every 2 years

This fellow kills more people in Africa than any other animal

Democratic Republic of the Congo: Ebola Virus Disease Uncontrolled
According to WHO and international health authorities, more than 32 cases of Ebola virus disease (EVD; caused by EBOV-Zaire strain) per week are occurring, mainly in the North Kivu Province health zones of Beni, Butembo, and Katwa, as well as in the newly affected health zones of Kyondo and Mutwanga along the Ugandan border. The initial cases in Kyondo and Mutwanga health zones were known contacts of cases in Butembo and Beni, respectively. Case numbers have significantly increased in the past month due to civil unrest and community distrust of the response campaign and are likely to be underestimated due to the deteriorating response infrastructure, especially in Beni. Approximately 344 cases of EVD (including 306 laboratory-confirmed and 38 probable cases and 211 deaths) have been reported since mid-July 2018
No cases have been reported in neighbouring countries to date. Countries at risk of spread are Angola, Burundi, Central African Republic, Republic of the Congo, Rwanda, South Sudan, Tanzania, Uganda, and Zambia;
There is no vaccine yet widely available, and travellers should reconsider their need to visit such places.

Take a well-stocked medical kit with you as you can’t  obtain one at the airport.

All travellers should consult their Travel Medicine professional before travelling, ideally at least 6 weeks in advance.

 

Enjoy your travels

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