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Travel health
Unit 524 January–February 2016
Acronyms 3
More Australians than ever before are now travelling to other countries, Sonny Lau (Case 4) CTH, MBBS, MPH&TM, FRCP(Edin), FFTM,
with rates increasing 2.5 times between 2000 and 2013 to more RCPS (Glasg), was born in Hong Kong and is a medical graduate
than 7.63 million visits.1 General practitioners (GPs) are best placed of the University of Melbourne. After his internship in 1984 in
to provide expert advice to travellers on risks associated with specific Melbourne, he worked in Hong Kong where he received his basic
destinations. In particular, travellers need to be aware of infectious physician training. He then gained training in infectious diseases at
diseases that may be acquired when visiting other countries; GPs can the Fairfield Infectious Diseases Hospital in Melbourne in 1992. He
provide information about how to best avoid or minimise contact with has worked specifically in the travel medicine field since 1993, at
sources of infection, as well as provide appropriate vaccinations. the Travel Doctor – TMVC. Dr Lau has been the Medical Director of
Schistosomiasis is an infectious disease that affects an estimated the Melbourne Clinic since 1995. He is a member of the examination
240 million people globally, with more than 700 million living in an committee of the International Society of Travel Medicine since August
endemic area.2 In a systematic review on the sexual behaviours 2005. His special interest is tropical diseases in returned travellers.
associated with international travel, about 50% of travellers who Cora Mayer (Case 3) MBBS (Hons), DRANZCOG, FRACGP, MPH&TM,
engaged in new sexual relationships inconsistently used condoms. FACTM is a GP in Melbourne whose special interests include travel
The review also found that the risk of developing a sexually and tropical medicines. Dr Mayer has worked in rural and remote
transmissible infection while travelling increased threefold.3 Influenza health, and in Aboriginal and Torres Strait Islander health, and has
causes an estimated 3500 deaths, 18,000 hospitalisations and more completed postgraduate studies in public health, tropical medicine
than 300,000 GP consultations each year in Australia.4 Japanese and travel medicine. She has contributed to the Australian Family
encephalitis is a mosquito-borne viral disease that is most prevalent Physician in this area and is a Fellow of the Australian College of
in many parts of Asia and most cases in Australia are from returning Tropical Medicine. She recently volunteered at Bairo Pite clinic in Dili.
travellers.5 In 2011–12, there were more than 350 notifications Nick Medland (Case 5) MBBS, BA (Hons), FAChSM, is a sexual
of overseas-acquired malaria in Australia, mainly from travellers health physician at Melbourne Sexual Health Centre and Royal
returning from the Asia-Pacific region, Africa and the Middle East.6 Melbourne Hospital. He has previously worked as the clinical director
This edition of check considers the management and treatment of of the Victorian AIDS Council Gay Men's Health Centre Clinic in
travel health that may present in general practice. Melbourne, as the deputy director of the Harvard Medical School HIV
AIDS Initiative in Vietnam, director of HIV AIDS Care and Treatment
LEARNING OUTCOMES Programs at United States Centres for Disease Control and Prevention
in Vietnam and assistant director for clinical research at the HIV
At the end of this activity, participants will be able to:
Netherlands Australia Thailand Research Collaboration in Bangkok.
• describe the assessment of a returned traveller presenting with fever He is completing a PhD in clinical HIV research in early uptake of
• discuss the diagnosis of schistosomiasis antiretroviral therapy.
• outline protective and preventive measures against Japanese Jennifer Sisson (Case 4) MBBS, FRACGP, MPH & TM, FACTM,
encephalitis FFTM (ACTM), is Medical Director of Travel Doctor TMVC Perth and
• summarise the recommendations for investigating and treating GP educator through the RACGP. Dr Sisson is co-author of 'The
influenza effectiveness of intradermal pre-exposure rabies vaccination in an
Australian travel medicine clinic', published in the Journal of Travel
• list current options for malaria chemoprophylaxis
Medicine, and presented on ‘Specific Travel Vaccinations’ at the
• review the management of sexually transmissible infections in APICTM conference in Melbourne in 2008. She regularly presents to
returned travellers. GPs, practice nurses, and school and adventure travel groups in the
area of travel medicine. Dr Sisson was chair of the Australian Faculty
AUTHORS of Travel Medicine between 2010 and 2014.
Trish Batchelor (Case 1) MBBS, FRACGP, MPH, DipCH, is a GP, Dean Zinghini (Case 2) MBBS, is an intern at Royal Prince Alfred
Travel Medicine Specialist and Occupational Physician trainee. Dr Hospital and a conjoint associate lecturer at the University of Western
Batchelor has worked at the CIWEC Clinic in Nepal, with International Sydney. He has experience in education on the management of
SOS in Vietnam, was previously Medical Director at the Travel Doctor, influenza in the primary care setting and a strong interest in infectious
and lectures in travel and tropical medicine on the Postgraduate diseases in general practice.
Diploma in Travel Medicine at the University of Otago.
Penny Burns (Case 2) BMed, MPHTM, is a Senior Lecturer in the PEER REVIEWERS
Department of General Practice at Western Sydney University. She Tony Gherardin FRACGP, FACTM, MPH, CTH, is the Senior Medical
has a range of experience working in primary care in tropical regions Adviser for the Department of Foreign Affairs and Trade, and has lived
including Far North Queensland, Papua New Guinea and Columbia. and worked in various overseas settings for several years. His main
Dr Burns is a member of the Specialist Influenza Group, chaired the interests are in travel and tropical medicine.
development of the RACGP’s Pandemic flu kit in 2014 and represents
Nicholas Zwar MBBS, MPH, PhD, FRACGP, is Professor of General
the RACGP on the national GP Round Table. She is involved in
Practice in the School of Public Health and Community Medicine at
research on disasters, including pandemics.
2
check Travel health CASE 1
REFERENCES
1. Austrade. Australians travelling overseas. Canberra: Austrade, 2015.
Available at www.tra.gov.au/statistics/australians-travelling-overseas.html
[Accessed 12 November 2015].
2. World Health Organization. Schistosomiasis: A major public health
problem. Geneva: WHO, 2015. Available at www.who.int/schistosomiasis/
en [Accessed 12 November 2015].
3. Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and
sexually transmitted infections: Systematic review and meta-analysis.
International Journal of Infectious Disease 2010;14(10):e842–51.
4. Newall A, Scuffham PA, Hodgkinson B. Economic report into the cost
of influenza to the Australian health system. Melbourne, Vic: Influenza
Specialist Group, 2007.
5. Federal Department of Health. National Notifiable Diseases Surveillance
System – Number of notifications of Japanese encephalitis virus infection,
Australia. Canberra: DoH, 2015. Available at www9.health.gov.au/cda/
source/rpt_3.cfm [Accessed 4 December 2015].
6. Knope KE, Doggett SL, Kurucz N, et al. Arboviral diseases and malaria in
Australia, 2011–12: Annual report of the National Arbovirus and Malaria
Advisory Committee. Commun Dis Intell 2014;38(2):E123–43.
ACRONYMS
ASPREN A ustralian Sentinel Practices HBV hepatitis B virus MMR mumps, measles and rubella
Research Network HIV human immunodeficiency virus NAAT nucleic acid amplification test
BCG Bacillus Calmette-Guérin IAMAT International Association for NAI neuraminidase inhibitor
CDC Centers for Disease Control Medical Assistance NICE National Institute for Health
and Prevention to Travellers Care and Excellence
CRP C-reactive protein ISTM International Society for Travel PHU Public Health Units
dTPa diphtheria, tetanus and pertussis Medicine RADT rapid antigen detection test
ELISA enzyme-linked JE Japanese encephalitis RNA ribonucleic acid
immunosorbent assay LFT liver function test STI sexually transmissible infection
FBE full blood evaluation MDR multidrug-resistant TB tuberculosis
GP general practitioner MERS Middle East respiratory WHO World Health Organization
syndrome
3
CASE 1 check Travel health
QUESTION 1
What further information should you obtain from Jane? What physical
examination would you perform?
FURTHER INFORMATION
Jane’s malaria smears are negative, her blood tests are normal
(apart from a very mild eosinophilia), urinalysis is normal and her
chest X-ray is also reported as normal.
FURTHER INFORMATION
QUESTION 3
Jane tells you that she returned to Australia three weeks ago
after a four-week trip to Kenya, Uganda and Madagascar. She What is your working diagnosis?
spent 10 days in Uganda, which included a trek in the Ruwenzori
mountains, then three days relaxing on the coast of Kenya in
Mombasa, before a two-week ‘eco tourism’ project in Madagascar.
Jane travelled with four friends, one of whom developed a fever
and itchy rash yesterday. Her friend’s general practitioner (GP)
had suggested she was having an allergic reaction, perhaps to the
doxycycline she was still taking for malaria prophylaxis.
Jane was vaccinated against yellow fever, hepatitis A and
typhoid prior to her trip. She had previously completed hepatitis B
vaccination, mumps, measles and rubella (MMR) and diphtheria,
tetanus and pertussis (dTPa) vaccinations as part of her
occupational requirement. She had discussed rabies vaccine
with the clinic but decided against it, and had proven immunity
to varicella. She had taken atovaquone/proguanil for malaria
prophylaxis, as directed, and had experienced no side effects.
She recalled many insect bites, had one casual sexual encounter
in Uganda with a British traveller (but had used a condom),
experienced no animal bites, and drank no raw dairy products.
About one week after arriving in Madagascar, she visited the Lily
Waterfall and had a very quick swim, only for about five minutes.
4
check Travel health CASE 1
QUESTION 4 QUESTION 7
What are the common signs and symptoms of acute schistosomiasis? Should Jane’s travelling companions be tested?
How is it diagnosed?
QUESTION 8
QUESTION 5
What advice should travellers who are going to schistosomiasis-
How common is acute schistosomiasis? Where is it found and how is endemic areas be given before travel?
it treated?
QUESTION 6
What follow-up should Jane be advised to undertake?
5
CASE 1 check Travel health
• chest X-ray
CASE 1 ANSWERS • urinalysis
• liver function tests (LFTs)
• serum to hold.
ANSWER 1
The usual history taking would apply as for any standard consultation. ANSWER 3
It would be easy to dismiss this presentation as just another respiratory The incubation period, clinical symptoms and signs, and mild
tract infection. However, it is important to ask any febrile patient the eosinophilia, combined with Jane's freshwater exposure at
simple question, ‘Have you travelled anywhere in the past 12 months?’. the Lily Waterfalls in Madagascar point to a diagnosis of acute
A positive answer should prompt further enquiry into the exact schistosomiasis, also known as Katayama fever.4,5
itinerary, travel dates in each destination, date of return to Australia,
specific exposures, pre-travel vaccinations and, if appropriate, whether ANSWER 4
antimalarial medication was prescribed and taken as directed. Specific The diagnosis of acute schistosomiasis remains a challenge.
exposure enquiries should include sexual contacts, the use of personal The clinical stages of schistosomiasis reflect the life cycle of the
protective measures against insects, insect bites noted, exposure to parasite (Figure 1).6
fresh water, animal bites, contact with farm animals, and consumption
of other potentially contaminated foods and fluids (eg raw foods). It can Some individuals, 5–100% in various studies, develop a diffuse
also be helpful to enquire if any of Jane’s fellow travellers had been pruritic maculopapular rash within 24 hours of exposure to
sick either on the trip or after returning to Australia.1 fresh water. This reflects a reaction to the transcutaneous
penetration of the cercariae7 and usually only lasts from minutes to
Physical examination should ensure standard vital signs are recorded,
hours. A history of such a reaction should be sought.
followed by a particular focus on the chest, abdomen and skin.
The next stage of the lifecycle is the tissue migration and
maturation of the schistosomules. Acute schistosomiasis is
ANSWER 2
thought to reflect a hypersensitivity reaction to the schistosomules,
It is important to consider all diseases that you would consider in a non- and symptoms typically occur two to six weeks after exposure
traveller. A proportion of febrile illness post-travel is caused by non- (range one to 12 weeks). The most common symptoms are fever,
travel-related infections such as pneumonia or urinary tract infection. abdominal pain, cough, headache, myalgia and an urticarial rash.
Given Jane’s sexual encounter and abdominal pain, pregnancy should Symptoms may vary with the species (Table 1).
be excluded, as should sexually transmissible infections (STIs).
Although Jane took her antimalarial medication as directed, it remains Table 1. Common symptoms of acute
important to exclude malaria in any febrile traveller who has returned schistosomiasis7,13
from a malaria endemic area within the previous 12 months – Signs and S. mansoni, % S. haematobium, % S. mekongi, %
Plasmodium falciparum is the priority diagnosis.1 Note, the Northern symptoms (n = 95) (n = 34) (n = 7)
Territory guidelines recommend testing travellers who have returned
from endemic malaria regions in the past two years.2 Fever 54–100 93–94 86
The list of differential diagnoses is long; however, the initial focus Abdominal 33–93 0 42
should be on identifying any diseases that are rapidly progressive, pain
treatable or transmissible including:3 Dry cough 17–91 44–86 71
• malaria
Headache 33–87 31–93 86
• typhoid
• leptospirosis Diarrhoea 25–81 14 28
• acute human immunodeficiency virus (HIV) Myalgias 50–74 14–69 28
• hepatitis E Neck pain 64 71 No comment
• amoebic liver abscess
Urticaria 8–17 13–57 71
• East African trypanosomiasis
• acute schistosomiasis. The symptoms of acute schistosomiasis typically last from days to
The incubation period of longer than three weeks makes dengue fever, weeks, whereas the cough, in particular, can linger for up to six
chikungunya and rickettsial spotted fevers unlikely.3 weeks. There is no specific diagnostic test available at this stage.
Initial investigations should include: Eosinophilia is often, but not universally, present8 and, furthermore,
is often delayed by up to three weeks from the onset of symptoms.7
• malaria smear and rapid test x 3 at 12- to 24-hour intervals Ova production does not occur until the end of the maturation
• full blood evaluation (FBE) phase, so there is a delay of at least 30–50 days between exposure
• blood cultures and egg production. Thus, a search for ova in the stool or urine at
this stage is usually fruitless. Similarly, seroconversion is unlikely to
6
check Travel health CASE 1
Reproduced with permission from Gray DJ, Ross AG, Li YS, McManus DP. Diagnosis and management of schistosomiasis. BMJ 2011;342:d2651. Available at www.bmj.com/
content/342/bmj.d2651 [Accessed 21 October 2015].
7
CASE 1 check Travel health
occur less than six weeks after exposure. The mean interval from the patients – the diagnoses retained after the first consultation
the onset of symptoms to seroconversion is 26 days.7 included viral infection (19%), invasive gastroenteritis (12%),
Therefore, diagnosis is based on the exclusion of other infections pneumonia (6%) and typhoid (6%). Rather alarmingly, only 6%
and a thorough exposure history. entertained the diagnosis of malaria.14
Acute schistosomiasis usually resolves spontaneously, but there The current edition of Therapeutic Guidelines – Antibiotics does not
have been case reports of serious acute complications, including make specific comment on acute schistosomiasis.
myocarditis, pericarditis and neurological complications secondary It is important not to treat acute schistosomiasis with praziquantel,
to eosinophilia-induced cerebral vasculitis.7,9,10 as this is likely to cause a worsening of symptoms, which may even
become life threatening.9,10 Corticosteroids may be indicated in
ANSWER 5 severe cases,6 and such cases should be managed by an infectious
Acute schistosomiasis is increasingly being recognised in travellers diseases physician.
returning from endemic countries and can occur with all species. In Chronic schistosomiasis remains a major public health issue in tropical
one study of 1800 febrile Belgian travellers, acute schistosomiasis countries. Transmission occurs in 78 countries and over 230 million
was the third most common cause of fever in travellers from Africa, people are estimated to be chronically infected.11 There are six species
after malaria and rickettsial infections.12 of schistosomiasis; the majority of cases are caused by Schistosoma
haematobium, S. mansoni and S. japonicum (Figure 2).
The vast majority of cases are found in travellers exposed in
Africa, but in the Asian regions, cases have been reported from
travellers to Laos, where S. mekongi is prevalent. Traditionally, only ANSWER 6
southern Laos was considered an area of risk, yet one study found Periodic serological testing should be undertaken. It may take three
a small number of travellers with acute schistosomiasis whose only to six months after exposure for serology to become positive.15
freshwater exposure was in northern Laos.13 Serology does not allow for speciation, so it is worth collecting stool
Awareness of acute schistosomiasis in the general practice setting and urine samples to search for ova. Urine collected in the middle
has been shown to be low.14 A recent report of a cluster of 36 of the day is more likely to identify ova, but the yield is generally
French patients exposed at the Lily Waterfalls in Madagascar poor; one Australian study of 28 travellers identified eggs in only
found that 78% ultimately had positive serology. Of these, 7.8% of those diagnosed via positive serology.16
82% had symptoms compatible with acute schistosomiasis and Praziquantel is an effective treatment against the adult worm17,18
70% of these travellers had seen their GP while sick. Acute and must be prescribed only after sufficient time has passed to
schistosomiasis was not considered as a diagnosis in any of ensure the parasite is now mature. Three months post-exposure is
Reproduced with permission from Gray DJ, Ross AG, Li YS, McManus DP. Diagnosis and management of schistosomiasis. BMJ 2011;342:d2651. Available at www.bmj.com/
content/342/bmj.d2651 and adapted from Gryseels B, Polman K, Clerinx J, Kestens L. Human schistosomiasis. Lancet 2006;368:1106–18.
8
check Travel health CASE 1
9
CASE 2 check Travel health
QUESTION 2
CASE 2
What is the most likely diagnosis?
AMY PRESENTS WITH A DRY COUGH
It is January and Amy, aged 22 years, calls your
practice requesting an appointment. She takes the
last free appointment and comes in to see you. She
says she is staying with one of your regular patients,
a mother with two children, aged 3 and 6, who is
pregnant with her third child. She complains that for the
past three days, she has had ‘a horrible dry cough’, has
been ‘feeling hot and tired’, and ‘just feels sore all over’.
QUESTION 1
How would you manage this consultation? What features of the
history are you most interested in?
FURTHER INFORMATION
Amy tells you that while she visited her grandmother at the local
nursing home, the television news was reporting about Middle
East respiratory syndrome (MERS). Amy is worried that she
might have MERS.
QUESTION 3
Where would you look for information and support in management if
you suspected MERS in the differential?
FURTHER INFORMATION
Amy is a healthy, active university student. She describes an
abrupt onset of symptoms one day after arriving home from a
recent overseas trip. She spent most of her time staying with
friends in Tokyo, Japan who were also coughing and unwell. Amy
also spent several days in Saudi Arabia visiting temples at the
beginning of the trip five weeks ago. She is otherwise well and
has no personal or family history of asthma or other respiratory
conditions. She is a nonsmoker. She tells you that she has not had
any vaccinations since she left high school.
On examination, Amy has a temperature of 38.5°C and looks
flushed. She has a respiratory rate of 25 breaths/min with
no respiratory distress. Her respiratory and cardiovascular
examinations are unremarkable.
10
check Travel health CASE 2
QUESTION 4
Would you consider doing any investigations? What is your rationale
CASE 2 ANSWERS
for this choice? Would you consider giving Amy any medication?
ANSWER 1
Transmission of infection
As Amy has presented with symptoms of a communicable disease, it is
important to consider the risk of transmission both within your practice and
with outside contacts. It would be reasonable to consider implementing
transmission-based procedures (ie droplet and contact precautions).1–3
This could include offering the patient a surgical mask to wear when not in
isolation, and practising hand hygiene and cough etiquette.
The use of signage in practices informs patients presenting with flu-
like symptoms to immediately tell staff on arrival, to don a surgical
mask (Grade C evidence), and perform hand hygiene (Grade B
evidence) with use of alcohol-based hand rubs that contain 60–80%
v/v ethanol or equivalent (Grade B evidence) or, if visibly dirty, using
soap and water (Grade B evidence).1–4
QUESTION 5
History and examination
What is the risk for the pregnant mother if she acquires Amy’s A full history is important in attaining a likely diagnosis. The
illness? What is the benefit of vaccination for the mother? onset, duration and severity of symptoms, as well as associated
symptoms, will be important in guiding clinical management. Ask
about associated symptoms including cough, dyspnoea, sore throat,
myalgia, headaches and diarrhoea.5
Details of recent travel and vaccination status are vital in formulating
a diagnosis of communicable disease. A history of contact with
unwell individuals and a knowledge of the epidemiology of disease
prevalence in the countries visited will help to rule out conditions such
as malaria, and rule in others such as influenza. Websites such as
CDC Travel have updated information available.6
A history of contact with animals (eg poultry or bats during travel in
Asia) is useful in reference to possible contact with the H5N1 avian
influenza or rabies.7
FURTHER INFORMATION
Exploring the patient’s comorbidities, including chronic conditions
Amy reminds you that she visited her elderly grandmother at the such as cardiovascular, respiratory, obesity, smoking, and pregnancy
local nursing home while she was unwell. Her grandmother’s status, will assist in understanding the patient’s risk of developing
medical history includes hypertension, hyperlipidaemia and a past serious illness.8
history of acute myocardial infarction one year ago.
Identification of any potential contact at high risk of complications from
an infectious disease is useful for early detection and treatment of others.
QUESTION 6 Amy has had contact with a pregnant woman and her two children.
11
CASE 2 check Travel health
In particular, influenza is associated with travel to the Northern Local Public Health Units (PHU) are available for consultation and
Hemisphere during the period of December through February. advice in such situations, and should be alerted immediately to any
Travellers to tropical regions are at risk of influenza all year round.12 potential threat. Infectious disease consultants at the local hospital are
Amy was in Japan in January, the peak influenza season in the also a source of information and advice. Notification of such diseases
Northern Hemisphere. Amy also had other significant risk factors for to the local PHU is required under the Public Health Act 2010; MERS
influenza, including a trip duration of >30 days and ‘the reason for and influenza are currently notifiable diseases. Information and forms
travel’ being to visit friends and relatives. The latter alone increases are available on state health websites. If you did suspect MERS as per
the risk of acquiring influenza six-fold.11 the guidelines, you would isolate the patient in a single room using
This knowledge allows targeting of higher risk individuals for pre- standard and transmission-based precautions,1 and immediately call
travel influenza vaccination, which should be given two weeks prior the local PHU. Current advice is that you should not collect specimens
to travel to allow for the development of immunity.5 There is currently for testing.15 Laboratory-confirmed influenza should be notified in
no evidence available to support re-vaccination before overseas travel writing within five days of diagnosis.3
in those who have already been vaccinated during the preceding A returned traveller with a fever is a potential carrier of a new
influenza season, so re-vaccination is not recommended.12 infectious disease across international borders. GPs involved with
There are different vaccines available for northern and southern the Australian Sentinel Practices Research Network (ASPREN; www.
hemispheres. These are only available in the relevant hemispheres.12 aspren.com.au/index.html) are swabbing 25% of patients presenting
The vaccines differ as the influenza viruses that become the with fever, cough and fatigue as part of frontline surveillance, but all
predominant seasonal ‘flu’ vary over time and geographical regions. The GPs are a crucial part of the frontline surveillance. Early identification
influenza vaccines are revised after each season at the recommendation by GPs can assist in preventing the spread of the disease.
of WHO, which advises on the strains predicted to be circulating in the
upcoming season in the particular geographical region. Currently, these ANSWER 4
vaccines contain three or four strains. Sometimes, the genetic code in a Influenza can be difficult to distinguish from respiratory illnesses
flu strain can drift, or mutate, within the six-month flu season to reduce caused by other pathogens on the basis of signs and symptoms
the effectiveness of the vaccine. This occurred in the previous winter alone. Diagnosis is usually made clinically on the basis of symptoms
(2014–15) in the Northern Hemisphere, and the effectiveness of the with consideration of the epidemiological context – for example, in
vaccine was shown to be around 23%.32 a clinical illness consistent with uncomplicated influenza in an area
There is no pathognomonic symptom of influenza, so diagnosis based where influenza virus is prevalent.5,8,13
on symptoms and signs alone is limited and must be assisted by There are many other organisms that can cause similar influenza-
epidemiological data to support the clinical suspicion: in this case, the like illness, including respiratory syncytial virus, parainfluenza virus,
annual peak influenza season in Japan. adenovirus, rhinovirus and coronavirus; all are common causes of
Several studies have shown that during influenza season, cough and lower and upper respiratory tract infections.5,10
fever >38°C have a positive predictive value of 79–86.8%, and a In cases where a definite diagnosis would support clinical decision
sensitivity of 77–85% with the inclusion of myalgias.5 making and help define treatment choices, diagnostic testing such as
Influenza viruses are single-stranded ribonucleic acid (RNA) nasopharyngeal swabs should be considered5 – for example, if:17
orthomyxoviruses classified as A, B or C subtypes. The A and B • the condition was severe
subtypes can cause significant disease in humans. The incubation
• the results would change management
period is usually two to three days but can last up to one week. After
an incubation period of one to three days, influenza often manifests • there is a high risk of complications in the patient or contacts
as a sudden onset of systemic symptoms such as malaise, lethargy, • the epidemiological data did not support the diagnosis
headache, myalgia and anorexia, with fever particularly prominent. • it was an institutional setting.
Sore throat, cough, nasal discharge and sneezing can also be
In this situation, as there are four contacts at high risk of
present. Fevers and myalgias can last three to five days, and the
complications (your regular patient and her two children, and Amy’s
cough may persist for longer than two weeks.8,10,13,14
grandmother), performing a nasopharyngeal viral swab for culture
could be indicated. Nasopharyngeal specimens usually have higher
ANSWER 3 yield than nasal or throat swab specimens.18 Although viral culture
Amy was not in Saudi Arabia within the last 14 days, so her case will provide the most accurate method of diagnosis, a result is often
does not fit the current case definition for MERS.15 She therefore does available only in two to 10 days (see 'Resources for Doctors' for a
not fit the epidemiological criteria, and so is unlikely to have MERS guide on the collection of nasopharyngeal specimens.)5,12,13 Note that
(the recent MERS guidelines are available at www.health.gov.au/ laboratory-confirmed influenza is notifiable in Australia.
internet/main/publishing.nsf/Content/5691BD39B3859DBCCA257BF0 The neuraminidase inhibitors (NAIs) currently available in Australia,
001A8E27/$File/MERS-CoV-Information-GPs-2015-09-14.pdf).15 oseltamivir (Tamiflu) and zanamivir (Relenza), are active against
Guidelines for general practitioners (GPs) on emerging infectious diseases influenza A and B viruses.12 These antivirals work by preventing the
including case definitions, investigations, treatment and management release of the virus from infected cells to reduce spread. If the NAIs
are available on the relevant state/territory and Commonwealth health are taken within 48 hours of onset of symptoms, they have been
websites.15 These guidelines are regularly updated. shown to limit the duration of illness by one to three days, as well as
12
check Travel health CASE 2
decrease the severity of illness with a reduction in complications such evidence from Omer et al showed that confirmed influenza in pregnancy
as pneumonia, otitis media, hospitalisation mortality, antibiotic use nearly doubled the risk of fetal death.26
and disease progression.15,19 Vaccination with inactivated influenza vaccine is safe for pregnant
NAIs are well tolerated and severe events are rare. Oseltamivir can women at any stage of the pregnancy or while breastfeeding,8,27,28
cause nausea and vomiting in the first two days, so should be taken and reduces the risk of contracting influenza by about 70%.22 It is
with food. There have been reports of wheezing or shortness of breath also the most effective way to protect young babies during the first six
after zanamivir, so it should be avoided in those with chronic lung months.8,19,29 All influenza vaccines currently available in Australia are
disorders such as asthma or chronic obstructive pulmonary disease.19 inactivated viruses containing three or four strains of virus.8
Administration of antiviral therapy is usually reserved for high-risk Children are more likely to present with symptoms of vomiting and
patients and is based on clinical judgement that takes into consideration diarrhoea than adults. They have higher rates of influenza than adults
the patient’s age and comorbidities, the disease severity, the likelihood and may shed the virus for longer, making them a major source of
of influenza, and time since onset of symptoms.19 transmission. Although it varies with the particular strain of influenza,
Current recommendations suggest antiviral medication should be children under two years of age are more likely to be hospitalised due
considered for patients within 48 hours of onset of influenza-like to influenza complications. The hospitalisation rate is similar to that
illness and with likely exposure and at high risk of complications from of the elderly, but with a much lower mortality rate. Children under
influenza. Those at high risk include:19–22 six months tend to develop severe disease.12 As mentioned above,
maternal vaccination is the most effective protection for this group.
• >65 years of age
As the children Amy was in contact with are older than two years
• pregnant20
of age, they are not in the higher risk group. Vaccination would not
• have chronic illnesses including cardiac, respiratory, neurological, protect the children from the recent exposure.
endocrine (diabetes), renal and immunological conditions
The current childhood vaccination schedule does not include routine
• have significant obesity (BMI >30 kg/m2) influenza vaccination for children, except for those older than six
• younger than 10 years old and are receiving long-term aspirin months, who are at high risk of influenza complications due to
therapy medical conditions, or Aboriginal and Torres Strait Islander peoples.
• Aboriginal and Torres Strait Islander peoples aged >15 years old Note that the influenza vaccination and age eligibility may vary from
• residents of nursing homes and other chronic care facilities year to year as the influenza strain and the vaccines change.8
• individuals who are experiencing homelessness
ANSWER 6
• children younger than five years of age, especially younger than
two years. Amy’s grandmother’s age and her chronic condition increase her risk
of complications from influenza. She is at higher risk of serious lower
There has been ongoing international discussion on the use of NAIs.
respiratory tract infections such as bacterial pneumonia. Pneumococcal
A report recently released by the Academy of Sciences and Wellcome
and influenza vaccination status should be up to date.4,8
Trust reviewing the use of antivirals in influenza concluded that there
is no evidence for the routine use of NAIs in patients with seasonal Her institutional setting increases the need for early accurate
influenza who are not severely ill, unless the seasonal influenza is diagnosis and management, along with transmission-based infection
particularly virulent or prevalent.16 It suggests there is evidence to control to manage any risk of communicable disease, such as
support the use of NAIs in the treatment of hospitalised patients, influenza, early.5,14,20,30
including women who are pregnant. The review notes a need for Worsening of underlying chronic diseases and precipitation of
more evidence on some of the other high-risk groups and children.16 cardiovascular events are potential complications of influenza.
There are no indications to treat Amy with NAIs. She has presented MacIntyre et al have recently reported a significant reduction in
outside the 48-hour window, is not severely unwell, was in an area cardiovascular death in patients vaccinated for influenza; influenza
of high influenza prevalence and is at low risk for complications. vaccination reduced the risk of acute myocardial infarction by 45% in
Amy should be advised to isolate herself from anyone at high risk of those with a prior history.31 Although influenza does not predict the
complications from influenza. Most adults who are ill with influenza occurrence of an acute myocardial infarction, having the influenza
are infectious from the day before symptom onset to approximately vaccination was significantly protective against acute myocardial
five to seven days after symptom onset. Ninety-five percent of virus infection, yet is still underused.31
transmission occurs within three days of illness onset.12
RESOURCES FOR DOCTORS
ANSWER 5 • Australian Immunisation Guidelines, www.immunise.health.gov.au/internet/
immunise/publishing.nsf/Content/Handbook10-home
Amy’s pregnant contact is at increased risk of both catching influenza
• Department of Health – Health professionals site for up-to-date information
from Amy due to the suppression of the immune system during
on current diseases of concern that may arrive in Australia, www.health.
pregnancy, and of complications if she does. Pregnant women have a gov.au/internet/main/publishing.nsf/Content/For+Health+Professionals-1
five-fold increased risk of hospitalisation for H1N1 influenza.8 Influenza
• The Royal Australian College of General Practitioners – Managing
infection increases the risk of stillbirth, premature birth and poor fetal pandemic influenza in general practice, www.racgp.org.au/your-practice/
growth,23 with protection provided by the flu vaccination.24–26 Recent business/tools/disaster/pandemics
13
CASE 2 check Travel health
14
check Travel health CASE 3
QUESTION 3
CASE 3 What other preventive measures would you advise? What are the
other two main mosquito-borne infections to prevent?
ELIZABETH VOLUNTEERS TO TRAVEL TO
EAST TIMOR
Elizabeth, 52 years of age, is a general practitioner
from Melbourne who is planning to travel to Timor-
Leste (East Timor) to volunteer for one to two weeks
in a medical clinic in the capital, Dili. She intends to
travel there annually after this trip to volunteer for
one to three weeks at a time. On her first trip, she
will spend most of her time in Dili, but intends to visit
some rural areas and work during the day with a
mobile clinic, then stay in Dili at night. During future
trips, she is likely to spend more time in rural areas,
staying in simple accommodation. Elizabeth is up to
date with her hepatitis A and B vaccines.
FURTHER INFORMATION
Elizabeth asks about a recent case of Japanese encephalitis (JE)
acquired in Bali.
QUESTION 1
Which travel vaccines would you recommend for Elizabeth? QUESTION 4
Is Elizabeth at risk of acquiring JE? Would you advise Elizabeth to
vaccinate against JE?
QUESTION 2
Would you recommend malaria prophylaxis? If so, which medication(s) FURTHER INFORMATION
would you recommend? Elizabeth is leaving in two weeks and decides to be vaccinated
against JE. She requests information about the vaccine(s) and timing
of booster doses. She also asks about another doctor travelling with
her, who has previously been vaccinated with JE-Vax.
15
CASE 3 check Travel health
QUESTION 5
Which vaccine do you recommend for Elizabeth? What general advice
CASE 3 ANSWERS
can you give regarding JE vaccine boosters for her colleague?
ANSWER 1
Elizabeth should be up to date with routine vaccinations, including
measles, mumps and rubella (MMR); diphtheria, tetanus and pertussis
(dTpa); varicella; polio and the annual influenza vaccine. She should also
have a typhoid vaccine1 and consider vaccination for JE and rabies.2
The incidence of tuberculosis (TB) in East Timor is >100 cases per
100,000 population, the highest risk category.3,4 However, the proportion
of multidrug-resistant (MDR) TB is thought to be low,5 with only three
laboratory-confirmed cases of MDR TB reported in 2014.6 TB infection
control measures should be instituted at the clinic. Bacillus Calmette-
Guérin (BCG) vaccine is not indicated unless the risk of exposure to
multidrug-resistant TB is high,1,3,4,7 but tuberculin skin testing or
quantiferon testing could be considered before and after travel.3,5
ANSWER 3
It is important to give advice on avoidance of mosquito bites by covering
up with clothing such as long sleeves and trousers, especially after
sunset (but also during the day, to prevent dengue fever); regularly
applying DEET-containing insect repellents on exposed skin; and
using insecticide-impregnated mosquito nets when necessary. Spray
thin clothing with insect repellent or pre-impregnate with permethrin,
and spray insecticide in the room or use pyrethroid mosquito coils. If
travelling to high-risk malarious areas that are remote from medical
facilities, carrying emergency malaria standby treatment may be
considered,1 especially for trips that are three weeks or longer.9
The other two main mosquito-borne infections to prevent are dengue
fever, which is associated with urban areas and daytime mosquitoes,9–11
and JE. Chikungunya has also been reported in Timor.12
ANSWER 4
JE is the leading cause of viral encephalitis in Asia and occurs in
almost all Asian countries.13 It is a zoonosis that is transmitted
16
check Travel health CASE 3
in an enzootic cycle between Culex mosquitoes and amplifying countrywide endemic areas.17 Transmission season has been reported
vertebrate hosts, mainly pigs and wading birds. Infection and to occur during the rice-growing seasons from September to December
illness in humans are incidental and there is no person-to-person and February to May,14 although the CDC reports a lack of data
transmission.1,14 Culex mosquitoes feed outdoors between dusk and regarding seasonal transmission.1 The risk is high on the Maliana Plain
dawn, and breed in flooded rice paddies and marshy environments.15 and data suggest that 65% of Dili’s population tested were seropositive
Approximately one in 250–1000 infections in susceptible humans for JE by enzyme-linked immunosorbent assay (ELISA).14
hosts is symptomatic,14,15 but in non-indigenous individuals, including The estimated overall incidence of JE among travellers from non-
travellers, this figure may be up to one in 25.7 endemic countries to Asia is less than one per one million travellers.
JE occurs in rural areas, city peripheries and urban areas of most This risk increases with risk factors and prolonged stays. Risk
Asian countries, including East Timor (Figure 1), Papua New Guinea factors for JE infection include exposure to mosquitoes between
and in the outer Torres Strait Islands of Australia (including three dusk and dawn in rural areas (more likely in longer term visitors who
cases on Badu Island, two of which were fatal). Nine cases of JE have spend time outdoors, including aid workers, students, missionaries,
been notified in Australia since 2001.15 Most recently, a traveller, researchers, cyclists or hikers and expatriates).1,15
45 years of age, developed symptoms of encephalitis four days after Other specific risk factors include age >50 years, JE infection
returning from Indonesia, the first JE infection notified in Victoria.16 in childhood, dual neurological infections (eg with mumps or
Transmission can occur in a seasonal or year-round pattern.1,14 neurocysticercosis), compromised blood–brain barrier (cochlear
Information regarding the risk of JE by country, with geographical and implants, shunts etc), pregnancy (miscarriage in first or second
seasonal information, can be found on the Centers for Disease Control trimester), genetic susceptibility, and those with chronic conditions
and Prevention (CDC) website (see 'Resources for doctors'). such as solid organ transplantation, cardiovascular disease, diabetes
In Timor-Leste, sporadic cases of JE are reported and the disease is mellitus and renal disease.1,15
presumed to be endemic countrywide. The World Health Organization There is no specific antiviral treatment for patients with JE, and
(WHO) considers Timor-Leste to be an area of high incidence with management is supportive.18
Reproduced with permission from Centers for Disease Control and Prevention. Geographic distribution of Japanese encephalitis virus. Atlanta, SA: CDC,2015. Available at www.cdc.gov/
japaneseencephalitis/maps [Accessed 15 December 2015].
17
CASE 3 check Travel health
18
check Travel health CASE 3
Elizabeth’s previously vaccinated colleague could consider having a 3. Neilson A, Mayer C. Tuberculosis – Prevention in travellers. Aust Fam
single dose of Imojev, but would also gain two years of protection Physician 2010;39(10):743–50.
from a single JEspect booster dose. 4. Shoreland Travax. Medical summary – BCG vaccine. Milwaukee, WI:
Shoreland Travax, 2015. Available at www.travax.com/scripts/MedLibrary
[Accessed 12 October 2015].
ANSWER 6
5. Centers for Disease Control and Prevention. Travelers’ health: 2016 Yellow
Data for the co-administration of Imojev with other vaccines, other Book. Atlanta, GA: CDC, 2015. Chapter 3, Tuberculosis. Available at wwwnc.
than yellow fever vaccine and MMR vaccine – which can be given cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/
at the same time, using separate syringes and injection sites, or tuberculosis [Accessed 14 December 2015].
otherwise at least four weeks apart7 – are not available. 6. World Health Organization. Tuberculosis profile Timor-Leste. Geneva: WHO,
2015. www.who.int/countries/tls/en [Accessed 12 December 2015].
JEspect can be given at the same time as hepatitis A vaccine,
quadrivalent meningococcal conjugate vaccine, and rabies vaccine. 7. National Health and Medical Research Council. The Australian immunisation
handbook. 10th edn. Canberra: NHMRC, 2015.
Co-administration with other vaccines (including yellow fever vaccine)
has not been studied. 8. The Travel Doctor. Travel health fact sheet East Timor. Sydney: The Travel
Doctor, 2015. Available at www.traveldoctor.com.au/files/editor_upload/
If other vaccines need to be given at the same time as either JE File/fact-sheets/9115%20TD%20Health%20Fact%20Sheet%20East%20
vaccine, injections should be given in separate limbs.7 Timor_print.pdf [Accessed 14 October 2015].
For practical reasons, Elizabeth should receive all recommended 9. Shoreland Travax. Provider summary Timor-Leste, 2015. Milwaukee, WI:
vaccines during her visit, in separate limbs as advised. Shoreland Travax, 2015. Available at www.travax.com/scripts/destina/
ShowSummary.aspx?countryID=200&type=PS [Accessed 12 October
Recommendations regarding the newer JE vaccines will be updated 2015].
when suitable evidence becomes available.
10. Department of Health. Increasing notifications of dengue in Australia related
to overseas travel, 1991 to 2012. Canberra: DoH, 2013. www.health.gov.au/
RESOURCES FOR PATIENTS internet/main/publishing.nsf/content/cdi3701f [Accessed 14 October 2015].
• International Society of Travel Medicine, www.istm.org 11. Department of Health [NT]. Dengue fever. Darwin: DoH, 2014. Available at
• Fit for Travel, UK, www.fitfortravel.nhs.uk http://health.nt.gov.au/library/scripts/objectifyMedia.aspx?file=pdf/45/15.
pdf&siteID=1&str_title=Dengue%20Fever.pdf [Accessed 14 October 2015].
• Travax, www.travax.nhs/uk
12. Centers for Disease Control and Prevention. Chikungunya virus. Geographic
• IAMAT, www.iamat.org Distribution – Countries and territories where chikungunya cases have been
• Australian Government Smart Traveller, www.smartraveller.gov.au reported (as of October 20, 2015). Atlanta, GA: CDC, 2015. Available at
www.cdc.gov/chikungunya/geo/index.html [Accessed 15 December 2015].
RESOURCES FOR DOCTORS 13. World Health Organization. International travel and health. Geneva: WHO,
2014. Available at www.who.int/ith/ITH_chapter_6.pdf?ua=1 [Accessed
• International Society for Infectious Diseases program for monitoring emerging
29 October 2015].
diseases (ProMed), www.promedmail.org
14. Yung A, Leder K, Torresi J, et al. Manual of travel medicine. 3rd edn.
• World Health Organization, www.who.int/ith/updates/en and www.who.int/
Melbourne: IP Communications, 2011.
topics/en
15. Mayer C, Neilson A. Japanese encephalitis – Prevention in travellers. Aust
• Centers for Disease Control and Prevention, wwwnc.cdc.gov/travel (with links
Fam Physician 2010;39(6):389–94.
to outbreak news and Yellow Book)
16. Smith, B. Melbourne man contracts rare and potentially fatal Japanese
• Japanese encephalitis distribution map, www.cdc.gov/japaneseencephalitis/maps
encephalitis virus in Bali. The Age. 10 February 2015. Available at www.
• Risk for Japanese encephalitis by country, wwwnc.cdc.gov/travel/ theage.com.au/victoria/melbourne-man-contracts-rare-and-potentially-fatal-
yellowbook/2016/infectious-diseases-related-to-travel/japanese-encephalitis japanese-encephalitis-virus-in-bali-20150210-13amk7.html [Accessed
• Australian Immunisation Handbook, www.immunise.health.gov.au/internet/ 14 October 2015].
immunise/publishing.nsf/Content/Handbook10-home~handbook10part4~ha 17. Campbell G, Hills S, Fischer M, et al. Estimated global incidence of Japanese
ndbook10-4-8 encephalitis. Bulletin of the World Health Organization 2011;89:766–74E.
• Batchelor P, Petersen K. Japanese encephalitis: A review of clinical guidelines Available at www.who.int/bulletin/volumes/89/10/10-085233.pdf [Accessed
and vaccine availability in Asia. Tropical Diseases, Travel Medicine and 29 October 2015].
Vaccines 2015 1:11. Available at http://tdtmvjournal.biomedcentral.com/ 18. World Health Organization. Fact sheet no 386 – Japanese encephalitis.
articles/10.1186/s40794-015-0013-6 [Accessed 11 December 2015]. Geneva: WHO, 2014. Available at www.who.int/mediacentre/factsheets/
fs386/en [Accessed 29 October 2015].
REFERENCES 19. Sanofi Pasteur. Australian product information JE-CV. Imojev. Australian PI,
1. Centers for Disease Control and Prevention. Travelers’ health: 2016 Yellow v 3.2. Available at http://products.sanofi.com.au/vaccines/IMOJEV_AUS_CMI.
Book. In: CDC Health Information for International Travel. Centers for Disease pdf [Accessed 29 October 2015].
Control and Prevention. Atlanta, GA: CDC, 2015. Available at wwwnc.cdc. 20. Shoreland Travax. Medical summary – Japanese encephalitis. Milwaukee,
gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/japanese- MI: Shoreland Travax, 2015. Available at www.travax.com/scripts/MedLibrary
encephalitis [Accessed 2 September 2015]. [Accessed 12 October 2015].
2. Centers for Disease Control and Prevention. Health information for 21. Batchelor P, Petersen K. Japanese encephalitis: A review of clinical
travelers to Timor-Leste (East Timor). Atlanta, GA: CDC, 2015. Available guidelines and vaccine availability in Asia. Tropical Diseases, Travel Medicine
at wwwnc.cdc.gov/travel/destinations/traveler/none/east-timor [Accessed and Vaccines 2015 1:11. Available at http://tdtmvjournal.biomedcentral.com/
11 December 2015]. articles/10.1186/s40794-015-0013-6 [Accessed 11 December 2015].
19
CASE 4 check Travel health
QUESTION 1
CASE 4
What are the current guidelines for malaria chemoprophylaxis? What
medications would you recommend?
GERALD TRAVELS TO MOZAMBIQUE
Gerald, aged 54 years, is going to spend six months
in Nacala in northern coastal Mozambique, working
for a mining company there. There is a high risk
for malaria throughout Mozambique.1–5 Gerald
presented for a pre-travel medical consultation and
you strongly advised him to take appropriate malarial
chemoprophylaxis. Gerald declined, stating that ‘I have
worked in these sorts of areas before and no one else
took malaria tablets. I might get malaria anyway, and
the tablets only mask the symptoms and they have
lots of side effects. Besides, the locals get malaria
most of the time and they are fine.’
FURTHER INFORMATION
Gerald became unwell on site in Mozambique. Figure 2
Mozambique is outlined in red in the upper panel.
describes the evolution of his illness. It was unknown if he had
Day 1 Day 6
20
check Travel health CASE 4
QUESTION 3
What were some pitfalls in Gerald’s medical management while he CASE 4 ANSWERS
was overseas?
ANSWER 1
Current guidelines for malaria chemoprophylaxis can be found on
the Centers for Disease Control and Prevention (CDC),3 World Health
Organization international travel and health4 and UK Travel Health Pro
websites.5 Other useful references in the Australian context are the
Manual of travel medicine6 and Therapeutic Guidelines.7
There are many factors that need to be taken into consideration
when considering which malaria chemoprophylaxis to use. The
above references discuss this well, particularly the Manual of travel
medicine.6 In this case, we are considering chemoprophylaxis for a
fly-in, fly-out worker, who has special considerations, many of which
will be covered as we progress through this case.
QUESTION 4 Doxycycline is generally the most cost-effective choice for malaria
chemoprophylaxis. Atovaquone+proguanil (Malarone) is far more
If Gerald had been well while overseas but developed a fever and expensive, but it is equally effective and has a favourable side-effect
flu-like symptoms after returning to Australia, how would you manage profile. Travellers can stop taking atovaquone+proguanil seven days
his condition? Describe your differential diagnosis, history and after leaving a malaria-risk area.6,7 For doxycycline, treatment should
examination, and symptoms you would be looking for? continue for four weeks after leaving the area.6,7 Therefore, if there
is no cost constraint, for fly-in, fly-out workers on a four-weeks-on,
four-weeks-off roster, for example, atovaquone+proguanil is preferred
to doxycycline. This means they are off their malaria medication for
some time between rotations, which would not be the case with
doxycycline.
Mefloquine is a further option for this area. According to the
Therapeutic Guidelines, it should be started two to three weeks
before the patient leaves so the patient can transition to an
alternative chemoprophylaxis prior to travel if there are any
concerning side effects. However, in the author’s experience it
should be started two to three weeks before the first deployment;
during subsequent visits, mefloquine can be taken weekly one to
21
CASE 4 check Travel health
two weeks before leaving, while at risk and four weeks after leaving who present with fever. In Africa, unlike Australia, malaria is not
the area.6 If a worker were on a four-week-on, four-week-off roster, generally thought of as a life-threatening disease. Many patients
as with doxycycline there would not be a break in medication are treated as outpatients, often with undesirable outcomes. Severe
between rotations. This medication has been associated with malaria normally develops three to seven days after the onset of
serious neuropsychiatric side effects, the incidence of which is symptoms. The most common severe complications in travellers
1/10,000.6 Milder neuropsychiatric effects, such as mood changes, are cerebral malaria, acute renal failure and respiratory failure.13
nightmares and depression can occur in about 5–10%.6 They If a person such as Gerald contracts falciparum malaria, without
can also be an issue in those involved in tasks requiring delicate having taken malaria chemoprophylaxis, his medical condition often
coordination and spatial discrimination.6 This combination of deteriorates significantly, and he may die within a few days14 if
possible adverse events has made this medication less popular with definitive treatment is not given as soon as possible in the illness
many employers. process. In Gerald’s case, he did not present for medical treatment
until day 6. Although he was commenced on treatment, he may
ANSWER 2 not have taken the medication, or if he did take it, it is likely that
he brought it up when he vomited. In a US study, mortality from
You could explain and emphasise the following points:
P. falciparum is related to poor adherence to chemoprophylaxis,
• Malaria can be fatal, particularly in individuals infected with the but a large number (66%) were due to medical errors such as
more severe type of malaria (Plasmodium falciparum), especially failure to prescribe correct chemoprophylaxis, failure to diagnose
when not taking appropriate anti-malarial medication or when patients correctly at presentation and failure to initiate treatment
there are delays in receiving proper treatment. promptly at diagnosis.13 Any fever in a patient presenting unwell
• The primary purpose of malarial chemoprophylaxis is to minimise from a malarious area should be treated as malaria until proven
the risk of dying from malaria when travelling to or residing in otherwise. Warning signs for severe malaria include confusion,
high-risk malaria areas. unconsciousness, respiratory distress, renal failure and acidosis.13
• Although there is the risk of adverse reactions to anti-malarial In a country such as Australia, all cases of falciparum malaria
medication, this is usually low with the medications currently should be referred to an infectious disease physician for hospital
used. On weighing up the pros and cons, taking appropriate anti- admission.
malarial medication is much preferred to contracting malaria (in
high-risk malaria areas). ANSWER 4
• Taking anti-malarial medication may make the diagnosis of If a returned traveller presents with a fever, up to at least one
malaria more difficult, which could delay the correct diagnosis year after visiting a malaria-risk area, regardless of whether
and management.8 However, in regions with poor health chemoprophylaxis was taken, malaria must always be considered as
infrastructure and deficient access to high-quality medical a differential diagnosis.10–12
facilities, the main role of anti-malarial medication is to enhance
Malaria is the most common specific diagnosis in Australian and
survival.
multinational travellers with febrile illnesses acquired overseas.15,16
• Malaria mortality mainly occurs in childhood. After surviving Malaria is also the most common potentially life-threatening
malaria a few times, usually in childhood, with continuous travel-related infection.6 Given his substantial risk of falciparum
exposure to malaria, residents of areas where malaria is malaria if Gerald had returned to Australia and presented to a
prevalent often develop partial immunity to malaria (semi- general practice with a fever, it would be best to refer him for
immune).9 They may tolerate a low-parasite load without assessment by an infectious diseases unit as soon as possible. A
becoming sick with malaria. Nevertheless, even local residents person with falciparum malaria should always be admitted to an
may die from malaria following their first infection. When the experienced infectious diseases or tropical diseases unit for further
immune system is not being subjected to repeated infections of management.
malaria, the partial immunity diminishes. Once the individual has
been away from a malarious area for an extended period of time, Other diagnoses, in decreasing order of frequency, are:15,16
they would be considered to have lost this partial immunity. • respiratory illnesses
In addition to recommending anti-malarial medication, you should • gastrointestinal illness
also advise Gerald to take protective measures against insect bites • idiopathic
(eg use of insect repellents and protective clothing).10–12 If he
• dengue fever
develops a fever, he should seek expert medical advice as soon as
possible. • chikungunya
• enteric fever
ANSWER 3 • rickettsial infection.
Healthcare workers in malaria-endemic regions, more so than in A thorough history should be taken, including Gerald’s medical and
non malaria–endemic countries, often do not consider malaria travel history, and physical examination of all systems should be
as the most important differential diagnosis in managing patients performed. The important clinical features to look for are:
22
check Travel health CASE 4
Confirm fever
Reproduced with permission from the Medical Journal of Australia from Looke DFM, Robson JMB. Infections in the returned traveller. Med J Aust 2002;177:212–19.
23 23
CASE 4 check Travel health
ANSWER 5 5. Public Health England. Guidelines for malaria prevention for travellers
from the UK 2015. London: Public Health England, 2015. Available at
Initial investigations should include:17,18 www.gov.uk/government/publications/malaria-prevention-guidelines-for-
• full blood examination (FBE) travellers-from-the-uk [Accessed 13 December 2015].
• kidney and liver function tests, C-reactive protein (CRP) 6. Yung A, Leder K, Torresi J, et al. Manual of travel medicine. 3rd edn.
Melbourne: IP Communications, 2011.
• blood cultures
7. Antibiotic Guidelines Expert Group. Malaria. Chemoprophylaxis. In: eTG
• thick and thin blood smears for malaria (repeated examination Complete [Internet]. Melbourne: Therapeutic Guidelines, 2014. Available
may be required) at www.tg.org.au [Accessed 1 December 2015].
–– As a rule, pathology service providers in Australia routinely do 8. Warrell DA, Hemingway J, Marsh K, et al. Malaria. In: Warrell D, Cox TM,
rapid antigen detection testing (RADT) when thick and thin films Firth J, editors. Oxford Textbook of Medicine, 5th ed. Oxford: Oxford
are requested. They can also be used in areas where malaria University Press, 2010.
diagnosis on slides is difficult or unavailable. Currently, there 9. Centers for Disease Control and Prevention. Malaria. Atlanta, GA: CDC,
are issues with these test kits being widely used in the field, 2015. Available at www.cdc.gov/malaria/about/biology/human_factors.
html [Accessed 13 December 2015].
namely accuracy, cost and adverse field conditions.19 Training
10. Batchelor T, Gheradin T. Prevention of malaria in travellers. Aust Fam
can increase accuracy.20
Physician 2007;36(5):316–20.
• Dengue and Chikungunya serology 11. Queensland Health. Malaria. Brisbane: Queensland Health, 2015.
• rickettsial serology Available at www.health.qld.gov.au/cdcg/index/malaria.asp [Accessed
22 November 2015].
• stool examination if indicated (including multiplex PCR test)
12. Department of Health [NT]. Guidelines for malaria. Darwin: DoH, 2012.
• chest X-ray Available at http://health.nt.gov.au/library/scripts/objectifyMedia.
• urine microscopy and culture. aspx?file=pdf/10/94.pdf&siteID=1&str_title=Malaria.pdf [Accessed 22
November 2015].
Refer to Figure 3 for the general plan of management for a returned
13. Swhwartz E. Malaria in travelers. In: Schwartz E, editor. Tropical diseases
traveller with fever.
in travelers. Chichester, West Sussex: Wiley-Blackwell, 2009.
14. Griffith KS, Lewis LS, Mali S, et al. Treatment of malaria in the United
RESOURCES FOR DOCTORS States: A systematic review. JAMA 2007;297(20):2264–77.
• fitfortravel by Health Protection Scotland – a division of NHS National 15. O’Brien D, Leder K , Matchet E, et al. Illness in returned travellers and
Services Scotland, travel health information for people travelling abroad immigrants: The 6-year experience of 2 Australian infectious diseases
from the UK, www.fitfortravel.nhs.uk units. J Travel Med 2006;13(3):145–52.
• Centers for Disease Control and Prevention, Travelers’ health, www.nc.cdc. 16. Wilson ME, Weld LH, Boggild A, et al. Fever in returned travelers:
gov/travel Results from the GeoSentinel Surveillance Network. Clin Infec Dis
• Centers for Disease Control and Prevention, CDC health information for 2007;44(12):1560–68.
international travel 2016, wwwnc.cdc.gov/travel/page/yellowbook-home 17. Gheradin T, Sisson J. Assessing fever in the returned traveller. Aust
• World Health Organization. International travel and health: Situation as in Prescr 2012;35:10–14.
2015, www.who.int/ith/en 18. Locke D, Robson J. Infections in the returned traveller. Med J Aust
• TravelHealthPro, National Travel Health Network and Centre (NaTHNaC), 2002;177(4):212–19.
http://travelhealthpro.org.uk 19. Centers for Disease Control and Prevention. Malaria. Atlanta, GA: CDC,
• International Association for Medical Assistance to Travellers, a division of 2015. Available at www.cdc.gov/malaria/diagnosis_treatment/diagnosis.
the Foundation for the Support of International Medical Training (FSIMT), html [Accessed 13 Dec 2015].
www.iamat.org 20. Trachsler M, Schlagenhauf P, Steffan R. Trop Med Int Health
• Yung A, Leder K, Torresi J, et al. Manual of travel medicine, 3rd ed. 1999:4(6):442–47.
Melbourne: IP Communications, 2011.
REFERENCES
1. Google. Google maps. Santa Clara, Ca: Google, 2015. Available at www.
google.com.au/maps [Accessed 11 October 2015].
2. Health Protection Scotland. Fitfortravel. Glasgow: Health Protection
Scotland, 2015. Available at www.fitfortravel.nhs.uk/destinations/africa/
mozambique/mozambique-malaria-map.aspx [Accessed 13 December
2015].
3. Centers for Disease Control and Prevention. Malaria information and
prophylaxis, by country. Atlanta, GA: CDC, 2015. Available at www.cdc.gov/
malaria/travelers/country_table/a.html [Accessed 13 December 2015].
4. World Health Organization. International travel and health: Situation as in
2015. Geneva: WHO, 2015. Available at www.who.int/ith/en [Accessed
13 December 2015].
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check Travel health CASE 5
QUESTION 2
CASE 5
What STIs might Jeff be at risk of? How do you guide his
investigation?
JEFF IS TIRED AND ANXIOUS
Jeff is a company director, 39 years of age, who
returned from a business trip to Vietnam yesterday.
He is generally well, but has been feeling tired and
anxious since his return. Jeff admits that he spent
the last night of his visit with a woman he had
met at a nightclub at his hotel. He used a condom.
Jeff wants to be tested for sexually transmissible
infections (STIs) and wonders if he should take some
antibiotics in case he has acquired an infection.
QUESTION 1
What information do you need from Jeff at this point in the consultation?
FURTHER INFORMATION
You give Jeff a dose of hepatitis B vaccination and order
blood for HIV serology, hepatitis B core and surface antibody,
syphilis serology, and a first-pass urine collection for Neisseria
gonorrhoeae and Chlamydia trachomatis nucleic acid
amplification test (NAAT). You advise him to avoid sex until
further advice.
Jeff returns two days later complaining of a urethral discharge.
He is upset that he was not given antibiotics at his initial
presentation. On examination, you note a profuse creamy
discharge.
QUESTION 3
What is the most likely cause of Jeff’s symptoms? How would you
FURTHER INFORMATION manage this change in the presentation?
Jeff tells you that his local business associates had invited him
to dinner at a restaurant, then to a club at his hotel to celebrate
the successful conclusion of their business deal. They seemed
keen for him to enjoy himself as much as possible. Later in the
evening, he was introduced to one of several young women who
had joined them. He had consumed a considerable amount of
alcohol, but agrees that even at the time, he recognised that she
was probably some sort of sex worker. Back in his hotel room,
they had vaginal intercourse using condoms, but only after she
performed oral sex on him, and he on her. This sexual encounter
occurred approximately 36 hours before your consultation with
him. Jeff has no symptoms, in particular, no discharge or dysuria.
He is married and has three children. His wife has had a tubal
ligation. They have not had any sexual contact since his return. He
cannot recall his vaccination history. He is not taking any medication
and, in particular, was not taking any antibiotic prophylaxis.
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CASE 5 check Travel health
QUESTION 4
CASE 5 ANSWERS
What explanation can you give Jeff for withholding antibiotics at the
initial presentation?
ANSWER 1
You should ask Jeff for further details about the sexual exposure and its
context. For example, it is relevant to know the nationality of the woman
he had met and whether she was, or could have been, a sex worker. For
the sexual contact that occurred in the hotel room, in addition to knowing
that a condom was used, it is relevant whether any oral, vaginal, penile
(or anal) sexual contact occurred while the condom was not being used.
You should also ask Jeff about his hepatitis B immunisation status
and if he is taking any medication. If an individual presents with any
sort of human blood or body fluid contact in South-East Asia or a
country where hepatitis B is endemic, it is important to verify and
record the history of hepatitis B vaccination.
ANSWER 2
Sexual risk taking is common in travellers, and STIs are a common
FURTHER INFORMATION travel presentation.1 Providing sexual entertainment for business
partners is not uncommon in many parts of the world, and Jeff’s
Jeff’s symptoms resolve quickly. The NAAT testing on his
sexual partner for that night may well have been a commercial
initial presentation indicates that N. gonorrhoeae was detected
sex worker. The epidemiology of STIs is highly demographically
and C. trachomatis was not detected. The culture isolated
and geographically specific, as are recommendations about their
N. gonorrhoeae, which was susceptible to ceftriaxone. The
treatment. However, assessment of an asymptomatic individual with
blood tests indicated that Jeff had received hepatitis B
a sexual exposure in Europe, the Americas and Eastern Asia can
vaccination previously, which was confirmed by vaccination
be conducted without specialist consultation, as the most common
records from his previous general practitioner (GP). HIV and
conditions occurring will overlap with the Australian epidemiology.
syphilis serology were negative.
Many sexual health centres in capital cities in Australia operate a
telephone specialist consultation service for GPs and would be able to
QUESTION 5 provide a list of conditions to test for.
The consistent and correct use of condoms during vaginal or anal sex
What follow-up is required? is effective as a barrier in the prevention of human immunodeficiency
virus (HIV) infection and Jeff is not at risk.2 However, you could
include HIV testing (at baseline and at six to 12 weeks) in this
situation for the purposes of allaying the patient’s anxieties.
Approximately 15% of the adult population in Vietnam carries the
hepatitis B virus (HBV), a much more transmissible infection than HIV.
Post-exposure vaccination reduces infection (ideally within 24 hours
but acceptably within 14 days,3 and Jeff should be vaccinated while
you establish his vaccination status. Hepatitis B surface antibody titre
is often used to screen for prior vaccination in individuals who might
in the future be exposed to HBV. However, vaccination records are
even more useful as some patients lose measurable levels of surface
antibody without losing the protective effect, which is considered
to be cellular. Delaying the dose while waiting for evidence of prior
vaccination might delay eventual vaccination and reduce its efficacy.
On the other hand, vaccinating an already vaccinated individual,
which occurs quite commonly, is quite harmless.
Oral sex without condoms does not represent a risk of HIV, but does
have the potential to transmit other STIs.2,4 In particular, gonorrhoea
is commonly transmitted by oral sex in men who have sex with men
in Australia.5
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check Travel health CASE 5
ANSWER 3 You could also contact the general practice information line at your
Gonorrhoea, chlamydia, syphilis, hepatitis B and HIV infection are local sexual health centre for further information about sexually
more prevalent in sex workers in Vietnam than Australia, where transmissible infections.
they are uncommon.6 In Jeff’s case, gonorrhoea is the most likely
presentation, on clinical and epidemiological grounds, as it is the only ANSWER 4
cause of urethral discharge commonly transmitted through oral sex. You should explain to Jeff that ‘blind’ treatment at the initial
It is also common for patients with gonorrhea to present with quite presentation may not have prevented the infection that he has now
noticeable symptoms within two to three days of exposure. developed. Furthermore, such treatment would have significantly
NAAT is the most commonly used (and reliable) screening test. complicated and obscured effective diagnosis and treatment at this
However, it is insufficient in a patient with symptomatic disease, stage.
particularly if the infection is acquired outside Australia. It is important Emergence of N. gonorrhoeae antibiotic resistance is a major
to also collect a specimen for culture and antibiotic sensitivity testing. public health surveillance concern in Australia. Thanks to the
The type of testing is important in this case, as is the withholding of quality of these data, we can be confident that the recommended
antibiotics (see Answer 4). treatment for locally acquired gonorrhea will cover known or likely
NAAT can use a first-void urine specimen in the case of urethral strains of the bacteria. However, less information is available from
infection, and a throat swab, ensuring that the swab comes into South-East Asian countries where, in the past, drug-resistant
contact with the posterior pharynx. The materials for these tests are strains have been first to emerge.8
commonly provided to general practices by the pathology provider as Prophylactic or presumptive treatment relies on a good knowledge
they are used for a range of purposes. of the antibiotic sensitivities in commonly isolated bacterial strains.
First-void urine samples avoid the need for intimate examination and When it fails, it actively selects for the resistant organism, which
uncomfortable testing procedures in well, asymptomatic patients the index patient, in this case Jeff, might continue to transmit in
presenting for screening. Testing recommendations for screening an the mistaken belief that he is cured. Precisely this mechanism
asymptomatic individual who may have been exposed to infection, is likely to be an important step in the initial movement of drug-
and possible sites of specimen collection, are summarised below: resistant gonorrhoea into Australia.9 Concern is rising about
• pharyngeal swab the possibility of ceftriaxone-resistant gonorrhoea becoming
established in Australia, which has the potential for very serious
• high vaginal or cervical swab or first void urine
public health consequences. So, in an asymptomatic patient, we
• urethral swab or first void urine would only recommend prophylactic treatment in a known exposure
• swab of anorectal canal. in the setting of well-documented epidemiology. For a symptomatic
• all swabs using the laboratory preferred swab type. patient, specimens for culture must be taken before treatment
is delivered so that the results are collated in surveillance and it
Symptomatic patients need to be examined, and the specimens (other
can be confirmed that the individual has received the appropriate
than urine) taken by the clinician. Patients are often uncertain how
treatment.
best to describe genital symptoms and additional clinical signs are
commonly present. The advent of NAAT has certainly simplified the diagnosis of
bacterial STIs in men. However, only culture will give information
For laboratory culture, the specimen must contain live bacteria and
about antibiotic sensitivity for N. gonorrhoeae, which varies
it must be transported to the laboratory in a manner that preserves
significantly worldwide.8 In particular, there are no oral antibiotics
it. Neisseria gonorrhoeae has fastidious growth requirements, and
available in Australia that reliably treat the commonly found
the commonly used in-clinic culture swabs may not be adequate.
strains of N. gonorrhoeae. More seriously, ceftriaxone-resistant
Laboratories will provide, if asked, a swab tube transport medium
N. gonorrhoeae strains are being reported10 and their prevalence
specifically designed to keep organisms viable. Locally acquired
in countries without reliable public health monitoring of gonorrhoea
symptomatic gonorrhoea urethritis is rising fairly steadily in much of
drug susceptibility, such as Vietnam, is unknown.9 A negative
Australia, and it is always advisable to take a specimen for culture
gonorrhoea NAAT result effectively excludes the possibility of
before delivering treatment.
infection, but only a culture will confirm that the treatment given is
Gonoccocal infection is treated with a single dose of 500 mg effective.
ceftriaxone diluted in 2 ml of 1% lignocaine and a single oral dose
of 1000 mg (2 x 500 mg tablets) of azithromycin.7 A symptomatic
ANSWER 5
patient should be offered this treatment immediately, but only after
appropriate samples have been taken. The patient should be advised The minimum time between exposure and testing for
to avoid all sexual contact until the diagnosis, the appropriateness N. gonorrhoeae or C. trachomatis on NAAT has not been
of the original treatment and, if necessary, proof of cure, have been established, although it is characteristically very short. It would be
confirmed. The patient should be requested to return after one week entirely plausible for a positive test to precede the development
to discuss the results, the success of treatment, and when it is safe of symptoms. Jeff should have a repeat gonorrhoea NAAT test at
to recommence sexual activity. least four weeks after he received treatment.
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CASE 5 check Travel health
CONCLUSION
Jeff decides that he would prefer not to discuss this STI with his
wife, nor is he prepared to expose her to the low risk of HIV or
syphilis exposure that he might have encountered. He decides to use
condoms or avoid sex until follow-up serology indicates that he is
uninfected.
REFERENCES
1. Matteelli A, Schlagenhauf P, Carvalho AC, et al. Travel-associated
sexually transmitted infections: An observational cross-sectional
study of the GeoSentinel surveillance database. Lancet Infect Dis
2013;13(3):205–13.
2. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV
transmission. Cochrane Database Syst Rev 2002(1):CD003255.
3. Australian Technical Advisory Group on Immunisation. The Australian
immunisation handbook. 10th edn. Canberra: Federal Department of
Health, 2015.
4. Ballini A, Cantore S, Fatone L, et al. Transmission of nonviral sexually
transmitted infections and oral sex. J Sex Med 2012;9(2):372–84.
5. Nash JL, Hocking JS, Read TR, et al. Contribution of sexual practices
(other than anal sex) to bacterial sexually transmitted infection
transmission in men who have sex with men: A cross-sectional analysis
using electronic health records. Sex Transm Infect 2014;90(1):55–57.
6. Tang H, Hocking JS, Fehler G, Williams H, Chen MY, Fairley CK. The
prevalence of sexually transmissible infections among female sex workers
from countries with low and high prevalences in Melbourne. Sexual Health
2013;10(2):142–45.
7. Groups AE. Therapeutic Guidelines: Antibiotic, Version 15. Melbourne:
Therapeutic Guidelines, 2014.
8. Workowski KA, Berman SM, Douglas JM Jr. Emerging antimicrobial
resistance in Neisseria gonorrhoeae: Urgent need to strengthen
prevention strategies. Ann Intern Med 2008;148(8):606–13.
9. Barbee LA. Preparing for an era of untreatable gonorrhea. Curr Opin
Infect Dis 2014;27(3):282–87.
10. Unemo M. Current and future antimicrobial treatment of gonorrhoea –
The rapidly evolving Neisseria gonorrhoeae continues to challenge. BMC
Infect Dis 2015;15:364.
11. Chen M. Australasian contact tracing manual. 4th edn. Melbourne:
Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine,
2010.
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check Travel health MULTIPLE CHOICE QUESTIONS
MULTIPLE CHOICE QUESTIONS
QUESTION 1
FURTHER INFORMATION
The current recommendation for malaria chemoprophylaxis is:
Lucas decides to have the Imojev vaccine, as well as hepatitis A,
A. doxycycline 100 mg, starting one day before and continuing for rabies, typhoid and cholera vaccines. He is up to date with
seven days after leaving a malarious area vaccinations for measles, mumps and rubella (MMR); diphtheria,
B. atovaquone+proguanil (Malarone) 250+100 mg tablets, starting tetanus and pertussis (dTpa); tuberculosis; and polio. He also had
one to two days before and continuing for seven days after leaving the seasonal influenza vaccine through work. He takes malaria
a malarious area chemoprophlaxis as directed.
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MULTIPLE CHOICE QUESTIONS check Travel health
MULTIPLE CHOICE QUESTIONS
QUESTION 9
QUESTION 5
Which of the following would be the best reason for considering
What should you do next? investigations for influenza?
A. Ask Jonas to provide a first-void urine sample to do a nucleic acid A. Lucas’s occupation
amplification test (NAAT) for gonorrhoea.
B. Exclusion of other infections, such as malaria
B. Take pharyngeal, urethral and anorectal swabs for NAAT.
C. The timing of symptom onset
C. Collect specimens for culture and antibiotic sensitivity before
D. Lucas’s anxiety about taking additional time off work
prescribing antibiotics.
D. Prescribe a single dose of 500 mg ceftriaxone immediately.
QUESTION 10
According to current recommendations, treatment of influenza with
QUESTION 6
antiviral medication should be considered within:
How would you manage Jonas’s infection?
A. 48 hours of onset of influenza-like illness in a patient aged
A. Treat the infection with 500 mg ceftriaxone or 1000 mg of 60 years
azithromycin.
B. 72 hours of onset of influenza-like illness in a patient known to
B. Ask Jonas to see you one week after treatment to assess have been exposed to influenza
symptom resolution.
C. 48 hours of onset of influenza-like illness in a patient aged
C. Advise Jonas to see you only if his symptoms persist. 70 years known to have been exposed to influenza
D. Repeat the NAAT one week after treatment. D. 72 hours of onset of influenza-like illness in a patient aged
70 years known to have been exposed to influenza.
FURTHER INFORMATION
Lucas went back to work the day after returning from his trip.
Two days later, he presents complaining of fatigue, headache and
muscle aches. He has a cough and on examination, you find that
his temperature is 38.5°C. He is concerned about taking more time
off work.
QUESTION 7
Which of the following statements is true?
A. A diagnosis of dengue fever is possible as the incubation period is
three to 10 days.
B. A diagnosis of malaria can be excluded as Lucas had taken
malaria chemoprophylaxis.
C. A diagnosis of acute schistosomiasis can be excluded as
symptoms occur within two weeks of exposure to the parasite.
D. A diagnosis of influenza is unlikely, as Lucas had been vaccinated
prior to travel.
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Independent learning program for GPs