Travel Medicine Alliance eUpdate - health news & information for international travellers

July 2009

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In this issue:

Swine Flu Update

Many countries around the world have had confirmed cases of H1N1 flu and a world wide pandemic alert is in effect. A pandemic is defined as an epidemic of an infectious disease spread through human populations across a large region.

H1N1 virus is unique because it is a combination of genes from pigs (swine), birds, and human flu. People who become infected with H1N1 flu usually display symptoms such as fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Some people have also reported diarrhoea and vomiting.

The CDC (Center for Disease Control and Prevention) recommends that travellers at high risk of complications from flu should discuss their travel plans with their doctor prior to departure. Travellers considered at high risk include children <5 years old, adults >65 years old, pregnant women, and those with chronic medical conditions or immunosupression (weakened immune system). For further information on this and other related topics of H1N1 flu see www.cdc.gov and www.who.int.

Top 10 Swine Flu Tips

1. WASH YOUR HANDS / CARRY HAND SANITISER. Wash hands after using public amenities, after the toilet and especially before touching your face or eating. The influenza virus can survive 2 days on surfaces. A common way to catch the flu is by touching something that has been coughed or sneezed upon by an infected person. For example, someone who used the shopping trolley before you may have had the flu.

2. CARRY TISSUES. Have tissues with you at all times. Cough or sneeze into tissues or hankies. If you get caught without them, cough into your elbow. Tissues are easy because they can be used once and thrown straight into the bin. Hankies are okay but after one use must be washed in hot water.

3. COVER YOUR COUGH. If you are in public, and you are coughing you should wear a mask. This will stop the disease spreading Masks are not very helpful at preventing influenza. Using a mask incorrectly may increase the risk of a well person catching the disease, rather than reduce it.

4. PHONE YOUR DOCTOR IF YOU GET SICK. if you have sudden onset of a fever of over 38 degrees C, with cough, tiredness and lack of appetite then phone your doctor. If you have difficulty breathing as well, phone your doctor urgently, or go to the nearest casualty department. It is not possible to test everyone for swine flu at the present time as the labs are overwhelmed. Do not arrive at your doctors without calling first.

5. OBSERVE QUARANTINE RULES; STAY HOME IF YOU ARE SICK. Keep children home if they are sick. Quarantine means staying home from work or school, avoiding public transport, the shops, the movies, the EKKA, meeting friends at their house etc etc. This quarantine should last for 7 days if you have swine flu symptoms, and have not taken medication. For persons who have taken Tamiflu and are now without a fever, the recommended quarantine is for 3 days (6 doses of Tamiflu).

6. GO HOME IMMEDIATELY IF YOU BECOME SICK. The virus can spread even before you get symptoms but it spreads much more once you start coughing the virus into the environment. Quarantine yourself somewhere while you wait for transport. Surfaces you have coughed on should be cleaned.

AVOID CROWDS if you have medical problems. Persons with medical problems should not expose themselves to crowds e.g. go to the exhibition (EKKA) as the virus will be spreading there and you are more likely to get severe disease if you get swine flu (or other flu). ONLY USE ANTIVIRAL DRUGS IF PRESCRIBED BY YOUR DOCTOR. Beware of internet purchases of anti-virals, it is easy to receive fake drugs, risk your health and waste your money. HAVE THE REGULAR INFLUENZA VACCINE – it won't stop swine flu, but will stop you looking like you have swine flu. EAT AS MUCH PORK AS YOU LIKE!  You cannot catch swine flu from properly cooked pork. The human swine flu virus is not circulating in pigs. ...prepared by Dr Deb Mills, Travel Medical Alliance, Brisbane, Queensland Diarrhoea, vomiting, headaches, muscle fatigue, unco-ordination ... Would any of us make it to the top of Kilimanjaro? Kilimanjaro is the largest free-standing mountain in the world. There are many routes, but all of them have beautiful walks across savannahs, equatorial rainforest, moorland, alpine desert, and finally glacial plateau. My wife and I set off in a party of 9 climbers and 45 (!) support staff to conquer one of the great non-technical walks of the world, as we wanted to see Kilimanjaro before the glaciers possibly melt and disappear. Whether it is due to climate change, or whether it is just nature's normal variability in events, the glaciers at the top of Kilimanjaro are melting and shrinking, and it is postulated that they may disappear altogether sometime in the next 20 to 50 years. Kilimanjaro is the largest free-standing mountain in the world Mount Kilimanjaro's Uhuru Peak at 5,895 meters is the highest peak in Africa. Fabled stories of a snow covered mountain near the equator in Africa were scoffed at by Westerners, as the idea seemed ludicrous and illogical at the time. In 1848, the German missionary Johannes Rebman was the first Westerner to document the existence of Mount Kilimanjaro. His findings were submitted to the Royal Geographical Society, but his description of a snowcapped mountain in equatorial Africa was still doubted. More Europeans over the next 40 years were able to see Kilimanjaro first hand, and many attempts were made to climb it, with defeats due to the ice and altitude. Finally in 1889, Dr. Hans Meyer and his large party of advisors and porters, on his 3rd attempt, managed to reach the summit successfully. The intrepid Meyer took almost 6 weeks to reach the summit, much longer than the average week it takes current walkers. 9 climbers and 45 (!) support staff Every year, about 20 000 people from all over the world attempt to summit Kilimanjaro. Estimates of success rates range between 40-60%. Many climbers have to turn back before reaching the top because of altitude sickness. Worse than this, up to 10 climbers die on Kilimanjaro each year, together with an unknown number of local porters - figures for these are guessed at between 10-20. There are difficulties in arranging evacuation should any mishaps occur, as helicopter or other vehicular access is impossible on parts of the trails, and then medical care is many hours away. But yes, with the right preparation anyone with reasonable health and fitness can reach the roof of Africa, and be exhilarated by a stunning sunrise with magnificent vistas. Walking on the 'snow' roof of Africa What tips can I share with you if you are considering climbing Kili? There are many routes up the mountain, and success is more likely if plenty of time is taken to wander up the trails. Acclimatisation takes place slowly, and if people rush up, the reduced amount of oxygen reaching their brain and their lungs leads to severe repercussions. Try to choose the longest trip you can afford. Guides and permits are required to ascend Kilimanjaro. The well trained guides that came with us set such an extremely slow pace right from the beginning that we thought we would take an eternity to get anywhere, but the benefits of this were that our party had a 100% success rate summitting Kilimanjaro, whereas the trekkers in other groups around us who were skylarking and throwing frisbees succumbed to altitude sickness and had summit rates of 15-40%. Pole Pole (slowly slowly) is the catch cry of the guides on the mountain trails. Ignore them at your own peril. Keeping well hydrated helps in the acclimatisation process. Our walking company had employed amongst the cooks and guides and tent porters and luggage porters, several men whose job was purely to lug water from the few flowing streams to the campsite so everyone could drink at least 4 litres a day. Another saviour is to have some diamox (acetazolamide) to hand. This medication can prevent or treat altitude sickness symptoms, with minor inconvenient side effects such as having to urinate more (not fun if in subzero temperatures in the middle of the night), and tingling in the peripheries (less fun than it sounds!). The staff at your friendly travel clinic will be able to inform you on when and how to use this appropriately. And for those who feel too unwell, coming down the mountain is essential. Choice between pride and being a sad statistic? That should be a much easier decision than it is for some. As you can see from the pictures, we had magnificent scenery as we climbed up and down Kilimanjaro, and had a great sense of achievement at being able to summit. Having great guides, walking slowly, keeping hydrated, having medication available, all were keys to our success, and yours too, should you choose to see the snows of Kilimanjaro before they disappear. Park rules   Dr Stan and friends at the peak ...prepared by Dr Stan Khoo, Travel Medical Perth, WA Disease focus - Ciguatera Fish Poisoning What is Ciguatera? Ciguatera is a toxin produced by marine microalgae in the tropics, particularly in the Pacific Islands, Caribbean, and Indian Ocean Islands. Tropical marine fish can accumulate this toxin through their diet by eating algae or smaller fish. As big fish eat smaller fish, this toxin moves up the food chain, and can reach toxic levels in large fish. What are the symptoms? When humans eat contaminated fish, they can develop a condition called ciguatera fish poisoning. The symptoms may include nausea, vomiting, tummy pain, diarrhoea, muscle cramps, and tingling around the mouth and in the fingers and toes. Some people also develop abnormal temperature sensation, where hot things feel cold, and cold things feel hot. These symptoms can start within 10 minutes of eating toxic fish, but sometimes take up to 24 hours. They usually last for a few days, but can occasionally persist for weeks or months.

How is it diagnosed?

Diagnosis is usually made based on the history of eating fish in ciguatera risk areas, and on the above symptoms. If portions of the fish are available, they can be tested for ciguatera toxin. In places where this condition does not occur, doctors may not be familiar with it, and the diagnosis is often missed. If you think you might have ciguatera fish poisoning, you should tell your doctor that you have eaten tropical fish in a risk area.

How is it treated?

There is no specific treatment for ciguatera fish poisoning, but your doctor can help you manage symptoms such as nausea and vomiting. The majority of people recover spontaneously after a few days, and it is unusual to have any long-term problems.

How can I avoid getting it?

You can't tell whether fish is toxic by looking at it or tasting it. Ciguatoxin is very heat-stable, so cooking WILL NOT make the toxic fish safe to eat. The risk of a fish being toxic depends on where it is caught rather than on its species, and local fisherman may be also able to tell you which areas to avoid or which species of fish to not eat. If in doubt, it is best to avoid large reef fish such as barracuda and grouper - they are more likely to be toxic because they can accumulate toxins by eating lots of smaller fish.

... prepared by Dr Colleen Lau, Travel Medicine Alliance, Perth, WA

Outbreak Information and News

DENGUE FEVER

Many countries around the world that are experiencing outbreaks of dengue fever. The geographical spread of this disease includes northern Australia (Queensland), northern Argentina, south and south eastern Brazil, and the entire Singapore, Malaysia, Taiwan, Thailand, Vietnam, Indonesia, Honduras, Costa Rica, Philippines, Pakistan, India, Sri Lanka, Bangladesh, Mexico, Suriname, Dominican Republic, Puerto Rico, Jamaica, Bolivia, Brazil, Guyana, Venezuela, Barbados, Trinidad and Samoa.

Dengue fever is a virus that is transmitted to humans via mosquito bites. These mosquitoes prefer to live in urban areas, and are daytime biters. The signs and symptoms of dengue fever include a sudden onset of severe headache, muscle and joint pains (severe pain that gives it the nickname of break-bone fever), fever, and rash.

MEASLES CASES

There have been reported cases of measles in New Zealand, specifically in Christchurch on the South Island. Before travelling to this area, you should be vaccinated against measles if you are not immune.

Measles is a highly contagious viral illness that is spread through respiratory droplets of an infected person i.e. breathing, coughing and sneezing. Contact by a non-immune person with someone infectious leads to a 90% probability of contracting the illness. The incubation period for measles is approximately 14 days (range 9-19 days) after contact with an infected person.

Characteristics of measles are a runny nose, conjunctivitis (red and sore eyes), fever and a raised and angry looking rash all over the body.

Complications associated with measles include pneumonia, encephalitis (brain inflammation) and possible miscarriage or premature labour in pregnant women.

Immunisation with MMR vaccine is readily available in Australia, relatively inexpensive, and offers long-term immunity against measles, mumps and rubella. 

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