World TB Day - 24th March 2011

Today is World Tuberculosis (TB) Day. World TB Day commemorates the day when in 1882 when Dr Robert Koch announced he had discovered the cause of tuberculosis. The goal of the Stop TB Campaign is to inspire innovation in TB research and care in the fight for TB elimination worldwide.
TB can affect any part of the body but the most common type is pulmonary TB. Pulmonary TB infection is  spread through inhalation of droplets from an infected person. These are passed on through coughing and you usually have to have prolonged contact with an infected person to contract TB yourself. Tuberculosis is responsible for nearly two million deaths each year, mainly in  Africa, South and South East Asia. The majority of cases occur in Bangladesh, India, Indonesia, Myanmar and Thailand.(1) Those infected with HIV are more at risk of death as TB can enhance progression of HIV and visa versa.

Do I need a TB Vaccine for travel to infected areas?

This is a question we get asked often in travel clinic. The UK introduced  a BCG vaccination programme in 1953 to inoculate children of school leaving age. The programme has undergone several changes since then and in the UK routine vaccination against TB is now not offered to school leavers. Studies have shown that the vaccine  is less effective in preventing respiratory disease, which is the more common form in adults and so guidance has changed accordingly. The Department of Health Guidance now recommends only the following people should be vaccinated:

• all infants (aged 0 to 12 months) living in areas of the UK where the annual incidence of TB is 40/100,000 or greater*
• all infants (aged 0 to 12 months) with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater
• previously unvaccinated children aged one to five years with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. These children should be identified at suitable opportunities, and can normally be vaccinated without tuberculin testing
• previously unvaccinated, tuberculin-negative children aged from six to under 16 years of age with a parent or grandparent who was born in a country where the annual incidence of TB is 40/100,000 or greater. These children should be identified at suitable opportunities, tuberculin tested and vaccinated if negative (see section on tuberculin testing prior to BCG vaccination)
• previously unvaccinated tuberculin-negative individuals under 16 years of age who are contacts of cases of respiratory TB (following recommended contact management advice – see National Institute for Health and Clinical Excellence (NICE), 2006)
• previously unvaccinated, tuberculin-negative individuals under 16 years of age who were born in or who have lived for a prolonged period (at least three months) in a country with an annual TB incidence of 40/100,000 or greater.
BCG is not usually recommended for people aged over 16 years, unless the risk of exposure is great (e.g. healthcare or laboratory workers at occupational risk). If you think you may need a BCG vaccination discuss it with your doctor or nurse. References 1. Nathnac http://www.nathnac.org/pro/factsheets/TB.htm

Call for boys to be vaccinated against Human Papilloma Virus (HPV)

There has been a lot in the media this week suggesting that boys should now be vaccinated against the human papilloma virus (HPV) after a study found that 50% of boys are infected with the virus. The study was carried out by researchers in Florida and the results published in the medical journal, The Lancet.
HPV causes 99% of all cervical cancers. Cervical cancer is cancer of the cervix (the entrance to the womb) and the HPV vaccine has been shown to prevent pre- cancerous legions caused by HPV types 16 and 18. The UK currently has a vaccination programme for girls age 12 - 18 years, but boys are not included in the current campaign. This new study has raised the debate on whether it is cost effective for the NHS to include boys in the National Vaccination programme.
A few weeks ago there was a very interesting documentary on the BBC presented by actress Jaime Winstone. The programme highlighted the increase in throat cancers caused by infection with HPV through oral sex.Again the HPV vaccine was discussed and Professor Stanley on the programme suggested the vaccine should be available to both men and women. However, David Salisbury, Director of Immunisation, said the government had no current plans to extend the scheme.
In our clinic we have recently seen an increase in the numbers of enquiries about the HPV vaccine from both men and women aged over 18 years who are not included in the NHS vaccination programme. Sussex Travel Clinic offers the Gardasil vaccine. Gardasil is the only cervical cancer vaccine that helps protect against 4 types of papillomavirus: 2 types cause 70% or cervical cancer cases, and 2 more types that cause 90% of genital warts cases. The vaccine is given on day 0, 1-2 months later and a booster dose at 6 months.
Gardasil is licensed for use in women up to the age of 45 and for use in boys age 9 - 15 years.

Rabies Death Toll Continues to Rise in Bali

Travellers visiting Bali, Indonesia should consider getting a course of Rabies vaccinations. Since 2008 there has been an on going rabies epidemic on the island and more recent reports suggest it is now present in the surrounding islands of Nusa Penida, which include the islands of Nusa gede, Nusa Cenningan and Nusa Lembongan. These islands were considered rabies free until the recent deaths of 2 residents.
Reports from the International Society for Infectious Diseases ( ISID)  suggest that the death toll from the outbreak of rabies in Bali is continuing to rise, despite mass immunisation of  dogs on the island, with at least 5 people known to have died in 2011. This takes the official death toll from rabies to 119 since the outbreak began in 2008.The Indonesian Authorities now confirm there are no longer any areas that are free from the disease.
Rabies is nearly always fatal and is spread through the bite, scratch or lick to an open wound from an infected animal.
Unvaccinated travellers need to have immediate treatment with rabies immunoglobulin which is currently unavailable on the island. Having a course of pre exposure rabies vaccines eliminates the need for rabies immunoglobulin.

Advice to travellers

• Avoid contact with animals on the island.
• Consider having a pre exposure course of rabies vaccine before your trip. This is given on day 0, 7 and 21 or 28. Discuss this with your doctor or nurse at least 6 weeks before your planned journey.
• Certain activities such as cycling put you at higher risk.
• If you do get bitten seek immediate medical attention, even if you have had pre exposure rabies vaccination.
• Check your insurance covers you for medical evacuation in the event you do get bitten and need to fly home for treatment.

Do I need a Cholera Vaccination?

Cholera is spread through drinking contaminated water . It can also be caught through eating contaminated shellfish or food. Cholera is present in many countries in Africa, India, South East Asia and some countries in South America and the Caribbean. Click here to see a map of countries reporting Cholera  in 2009.

Am I at risk?

Cholera in travellers is rare and vaccination is not normally required. However, if you are working in slum regions or refugee camps in countries with cholera outbreaks your doctor or nurse may recommend you have the cholera vaccine before your trip. Having access to clean drinking water and avoiding contaminated food is essential to avoid getting infected with cholera.

Cholera Vaccination

The Cholera vaccine is given orally and two doses are required. You need a second dose 1-6 weeks after the first dose has been administered. You should not eat or drink for 1 hour before or 1 hour after having the vaccination. The vaccine is suitable for adults and children aged 2 years and over. A booster is required every 2 years if you are at continued risk of exposure to cholera.
Side effects: most people tolerate the vaccine very well, common side effects reported are headaches and stomach upsets.

Tips for avoiding contaminated food and water

• Ensure you only drink clean water. Boiled water or bottled water is fine but check the seals to ensure it has not been filled with tap water.
• Clean your teeth with bottled or boiled water.
• Canned drinks and hot drinks are usually ok to drink.
• Avoid ice in your drinks.
• Consider using a sterilising agent such as chlorine if you are unsure if the water is safe or not.
• Eat only well cooked fresh food.
• Avoid left over or reheated foods
• Avoid salads that may have been washed in contaminated water.
• Never drink unpasteurised milk
• Avoid ice cream, if made from unpasteurised milk.
• Wash your hands regularly or use an alcohol hand gel.

The Importance of Travel Insurance- Are you covered?

So you've booked your holiday but have you purchase an insurance policy? Many people travel abroad uninsured and find that when things go wrong it can be very costly, running into thousands if you need to be repatriated to the UK.

Following the recent political unrest in Tunisia and Egypt it is vital all travellers check what their insurance policy actually covers them for. The FCO says that 60% of travel policies now cover terrorism, but most will not cover you for political unrest.

 European Health Insurance Cards (EHIC)

A recent report in the Journal of BTHA[i] states that holidaymakers in Europe could have their insurance claims rejected if they do not have a valid EHIC card. These cards allow you to access state-provided healthcare in all of the European Economic Area (EEA) countries and Switzerland at a reduced cost or sometimes free of charge. It should not be used as a substitute for private travel insurance as it does not cover things like mountain rescue or repatriation to the UK. You can apply online and the card last up to 5 years. If you are due to travel to Europe soon apply or check yours is in date today. Children need their own card.

What happens when things go wrong?

holidaytravelwatch.net shows many examples of what can happen when things go wrong. The one that drew my attention was the importance of having travel vaccinations. A couple had to cancel their holiday to Egypt as they had been told by their travel agent that inoculations were not required for travel to Egypt. Whilst there is no entry requirement for vaccinations to Egypt, vaccinations are recommended for your own protection. This couple had to cancel their holiday as their insurance would not cover them as they had not had their vaccinations. Speak to your doctor, nurse or travel clinic for advice when travelling.

What to look for when taking out insurance?

·         Shop around for travel insurance, the cheapest policy may not be the best – always check what is excluded.
·         Check your policy covers you for sports such as skiing, white water rafting or water skiing for example.
·         Check the cancellations section carefully – what are you covered for?
·         Always tell your insurance company about pre- existing medical conditions. If you fail to reveal a medical condition it may invalidate your insurance.

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[i]  Journal of the BTHA, Volume XVI, 2011

Register with the LOCATE service from the FCO

With the recent demonstrations in Egypt and Tunisia many are traveller's will feel apprehensive if travelling to areas with political unrest. The Foreign and Common Office (FCO) offer a great service called LOCATE .We recommend this service in our travel clinic.

It is very easy to register online and once registered the FCO have your details so that if a major catastrophe occurs, such as a terrorist attack or a tsunami they have an instant record of your details enabling them to contact you to make sure you’re OK and provide advice. It also means if family and friends need to get in touch with you they can help them to find you.

You only need to register once and you can update your travel details at any time. Whilst we mainly recommend this to our backpacking travellers the FCO is happy for you to register for short trips. Given the recent unrest we would recommend that all travellers to these regions register now.

 

Useful tips

 

•  Ensure you have adequate travel insurance and make sure your policy does not exclude terrorism
•  Check the FCO website for updates before you travel to ensure it is safe to go to your destination
•  Check your passport is in date and ensure you have any visa’s you may require for entry
•  Make copies of your passport and any other important documents
•  Ensure you have had all your travel vaccinations and have any necessary malaria tablets

  

 

 

Have you travelled to Egypt or Tunisia recently? Share your stories with us.

Should I have a rabies vaccination?

Rabies is spread through bites or licks on broken skin from an infected animal. It is estimated that there are between 50000 and 60000 deaths from rabies worldwide each year. Over half these deaths occur in South East Asia. Rabies is present in over 150 countries worldwide, most other cases occur in Africa and Latin America.  According to the World Health Organisation (WHO) it is estimated 10 million people worldwide receive post-exposure treatments each year after being bitten by a suspected rabid animal. Over 99% of rabies deaths in humans are from dog bites. Rabies is nearly always fatal.

Since 2001 there have been 4 deaths in UK travellers. These cases were acquired in Nigeria, the Philippines, Goa and South Africa. 3 cases were dog bites and none of the cases were known to have received pre or post exposure vaccination.

Advice for traveller’s

·         If you are travelling to a high risk area for 1 month or more or will be more than 24 hours from treatment or are unsure about the availability and quality of rabies vaccine and rabies immune globulin (RIG) you should consider a course of pre exposure rabies vaccine.

·         Certain activities such as cycling and running increase your risk of being bitten. Working with animals aboard carries a high risk.

·         You should see you doctor or nurse at least 6 weeks before travel to start the course. Rabies vaccine is administered on days 0, 7 and 21 or 28. If you do not have time to complete the course before travel it is still worth considering starting the course as it will prime your immune system.

·         Post exposure vaccination and treatment should be administered as soon as possible, even if you have received pre exposure vaccine. In many counties availability of rabies immunoglobulin are in short supply and therefore a pre exposure course is recommended.

·         Pre exposure vaccine does not mean you do not need treatment if bitten. If bitten wash the wound with cold running water for 5 minutes, apply iodine or alcohol to the wound , get to hospital as soon as possible and carry your vaccination card if possible.

·         Ensure you have medical insurance in place.