17th Travelling Well now available

Dr Deb At Vic Falls Zimbabwe

The next edition of Travelling Well is now available -

Edition 17.

This is the 9th cover and includes a photo at Victoria Falls – from the Zimbabwe side  - given the recent publicity about yellow fever Not being required by the South Africans if travellers visit the Zimbabwe side of the falls, this seemed particularly fitting.

There are now 170,000 copies in print

The first question everyone asks is ..Aside from a new cover,  whats new inside?

A …It is a minor update and much will look the same to the frequent user of this book, however as usual, details have been added in response to feedback from travellers.

There is now information about the newest app, Vaccine Record for Travellers.

Changes summary

Page / Detail

13	mention of the address to find International Society of Travel Medicine  travel clinics
17	duration Table; delete Gamma Globulin duration / add menveo & menactra 5 years
18	add genital warts and anal cancers to gardasil/ HPV vaccine benefits
19	add menveo / menactra to types of meningitis vaccines
28	suggestion to persist for a few days if minor side effects from malarone
32	add oragel to the kit contents list
45	mention rivaroxaban for dvt prevention
75	altitude;  delete theophylline, add dexamethazone to prevention as per recent consensus
82	minor change to culture shock/ disaster planning
84	mention International Association of Medical Assistance to Travellers as another way to find doctors overseas
93	add information on chikungunya disease
94	add ciguatera and scombroid (fish)  poisoning to food poisoning section
104	expand Azithromycin dosage chart for children and mention of nitazoxanide tablet used overseas for giardia
120	reword rabies to cover scratches on broken skin, add story of patient getting abused for asking about WHO schedule, mention day 28 post exp not always given
126	add treatment for persons who experience a foreign body in the ear
127	add orajel to treatment of gum pain and mouth ulcers
130	information in the treatment of altitude sickness now includes information on how to use and interpret readings from a pulse oximeter
138	Information on on emergency contraception has been condenses to make way for information in emergency section on needlestick injury
143	kids diamox dose has been added to the drug reference table as per recent consensus
154	dengue map  has been removed as was old (2005) – replace with  info in text form
all	minor typographical errors fixed, adjustment to index

Working with Polio Eradication

 

 

 

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Many travellers who have visited our clinics will have received polio vaccination. One of our patients has kindly written this piece for our newsletter. Jenny Horton is an Australian Rotarian who has volunteered with the program for over 10 years in Ethiopia, Botswana, Nigeria, Pakistan and now India. Jenny writes … It is great to see the situation now, where truly eradication is in sight. Serving the program has taken me to all levels of the program, from remote areas to advocacy visits at national level, from working in a rubbish dump to ensure all children living there are vaccinated to inaugurations at the Chief Ministers home. It has been a privilege to serve humanity in this way, to know the work done by so many is actually making an impact in the world. Over 5 million disabilities have been prevented in children. Health infrastructure is being developed that is already serving for elimination of other diseases (eg measles). For most people in western countries under 50 years of age, polio is not a familiar disease, but in developing countries until recently, persons disabled by polio were very visible. In 1978 an Australian accountant was President of Rotary International, and made initial enquiries about what Rotary could do to make an impact on the world. In this way, Sir Clem Renouf of Nambour started the ball rolling on what is now the largest public health initiative ever undertaken. Rotary International has partnered with WHO, UNICEF and US Centers for Disease Control and Prevention (CDC) and many others working in all corners of the world towards the eradication of Polio. Campaigns are managed by the government with support from the polio partners. In India for example; in one national polio campaign over 172 million children were vaccinated with 2,400,000 volunteers door knocking every house to ensure all children were reached with the Oral Polio Vaccine. Polio vaccination in the rubbish dump! In 1988, at the start, there were 350,000 polio cases per year in 125 countries. In 2009 there were 1604 cases globally in only 4 endemic countries. Great progress is being made towards the eradication of the second disease in the world. Rotary Australia continues to fundraise for this program. Bill Gates donated $355M to Rotary for polio eradication stating that rotary had to raise $200M. Currently there is a campaign underway to raise those funds so the program can continue. No child deserves to live with a disability that is preventable, and thanks to an Australian Rotarian, and many others, at least one more disease is on the way to eradication. More info on Rotary’s polio eradication work here.

Hookworms may help patients with coeliac disease

Hookworms may provide a key to treating coeliac disease, according to research undertaken in Australia

Persons with Coeliac disease cannot tolerate the wheat protein, gluten, in their diet. This is a challenge as they cannot eat regular bread, pasta, and even some medications. The study found that infection with a common species of hookworm (necator americanus, NA), was safely and successfully tolerated without any sustained ill effect by participants with histologically confirmed coeliac disease.

Ten participants received infective NA larvae into their skin and 10 received placebo, after which they were given a gluten challenge.

The larvae travel through the skin into the gut. After the gluten being administered, there was a significant deterioration in symptoms scores and overall well-being in the PLACEBO  group, and the Marsh scores deteriorated in 90% of the placebo group (p<0.05) but not in the  hookworm infected group.

Lead author Dr James Davison said  he believed the process of having the worms burrow through the skin began a complex immunomodulatory response. He added that none of the patients involved in the study seemed to mind being infected with hookworm. When it came to the end of the trial and we offered them drugs to kill the hookworm, they didn’t want to take them. More research will be undertaken on this intriguing finding.

Diabetes and insulin pumps during flight

Patients with type 1 diabetes should ensure that their seatbacks are upright, their seatbelts fastened and their insulin pumps disconnected before takeoff, researchers say.

They should also ensure their pump contains only 1.5mL of insulin before flying, remove any air bubbles before reconnecting the pump at cruising altitude, and disconnect again during emergencies.

The advice comes from an Australian study showing that drops in atmospheric pressure can lead pumps to dispense excess insulin – up to 0.6% of the chamber’s contents.

The effect is caused by the formation of new air bubbles in the pump chamber, which displace insulin from the cartridge. Existing bubbles in the insulin can also expand in size by as much as 36%, researchers wrote this week in Diabetes Care (online).

They warned the effect could lead to hypoglycaemia, and made the following recommendations for prospective flyers:

1) Insulin pump cartridges should contain only 1.5mL of insulin when flying.

2) Disconnect the pump before takeoff.

3) At cruising altitude, take the cartridge out of the pump and remove any air bubbles before reconnecting.

4) After the aeroplane lands, disconnect the pump, “prime the line” with two units, then reconnect the pump.

5) Disconnect the insulin pump during in-flight emergencies involving cabin decompression.

The researchers, led by Dr Bruce King of the University of Newcastle, NSW, studied 10 insulin pumps during a commercial Boeing 767-338 flight. They also studied the pumps in a hypobaric chamber mimicking the drop in cabin pressure when flying.

Diabetes Care 2011; online

more info 

Please vote online to help a school in Nepal

Dear Readers, could you spare a minute to vote online to help one of my patients win a $5000 grant to build classrooms in a remote Nepalese village school ( I am also one of the directors of the Overseas Aid fund for the Nepal Australia Friendship Association so can vouch for the organisation NAFA)

Sunsuper will give a charity $5000 for the most votes! We’re not asking for your money, just your vote.

It only took me about 3 mins but I had to check my junk mail for the confirming vote.

Voting is quick and easy so please click on this link http://sunsuperdreams.com.au/dreams/user/kylie-gilbert and follow the instructions to lodge your vote.

Voting starts on 1st July and finishes on 31st July. Thanks for any help you can give to spread the word.

More info below from Kylie Gilbert

Supporter of NAFA and Nepal
www.nafa.org.au
www.aHANDforNEPAL.blogspot.com

VOTE for TWO CLASSROOMS in a POOR Rural Area of NEPAL

Please give just a few minutes of your time and vote to help make “the dream come true” for a school in a poor rural area of Nepal.

“Help Build Two Classrooms in Rural Nepal”

My dream is to help make the dream for the 23 teachers and 500 students of Shree Mahakali School, in a poor rural area of Nepal, come true! – to build two new classrooms and provide a learning environment for Grade 9 students.

Shree Mahakali School operates with many challenges; it receives very little Government funding and the students who attend are from very poor farming families. The school currently only has facilities to Grade 8; so a $5,000 grant will not only provide two Grade 9 classrooms, which will allow the children to have continuity in their most important schooling years, but will also save the students walking time to another school further away. Majority of these students now walk over 2 hours a day to attend Shree Mahakali School; but they do it happily and willingly in every season as they love learning.

The teachers of this school are very passionate and they have a vision; to create a model school by providing quality education and support to their students (eventually up to Grade 10, the last and most important year for students before College), training for teachers, and new technology for children living in this poor rural area who would normally not have access to education. The school is very forward thinking in that they have an ECO club, scouts group, library, small computer room and nursery. The teachers are dedicated and work hard to bring these poor rural students up to the same standard as city students, who have many more opportunities.

I truly admire these teachers as I know how difficult it is for Nepalese children to receive an education. My dream is to help support these teachers in their vision to give these children a quality education, and as a result, a brighter future!

The $5,000 grant would be donated to the Nepal Australia Friendship Association (Qld) Inc (NAFA). It would be spent on materials and skilled labour to build the two classrooms while the community would donate the many hours of unskilled labour. NAFA (21 years strong), a very dedicated group of people, tirelessly raises funds to assist remote communites in Nepal in the areas of health, education and water infrastructure. NAFA members visited Shree Mahakali school early in 2011 and would return later in this year to monitor the building of the two classrooms.

Thanks everyone for your continued support … it is always very much appreciated by NAFA and myself.

Kind regards,

Kylie Gilbert
Supporter of NAFA and Nepal
www.nafa.org.au
www.aHANDforNEPAL.blogspot.com

An 11 year old girl has died in the USA from Japanese Encephalitis (JE) after travelling to the Philippines for 3 weeks.

On July 18, 2010, a previously healthy little girl aged 11 years was hospitalized in Nevada, USA  after 2 days of fever, headache, nausea, vomiting, and neck pain. During 21st June  to 12th July, she had visited the Philippines with four relatives and had received numerous mosquito bites.   (JE is contracted from a mosquito bite) Two of the girl’s relatives were born in the Philippines; the patient and her parents (who did not accompany her on the trip) were born in the United States.

The girl had no history of JE vaccination and neither she nor her travel companions sought pretravel health advice.  She spent most of her time in Metro Manila, staying with relatives in a screened house in a compound in urban Quezon City. They took day trips on four occasions to coastal and rural destinations within a few hours’ drive of Manila. They also took a 2-night trip to a resort on an island where they slept in air-conditioned, screened accommodations. While at the resort, they walked on the beach one evening.

On admission to hospital, she had fever 39.4°C.    Healing insect bites were noted on examination. She was alert and able to walk  until the evening of July 19, but she deteriorated over the next two days and tragically died. She had only been sick for 5 days.  JE is caused by a virus and there is no specific treatment for the disease. Many survivors are left with brain damage.

This tragic case highlights the seriousness of Japanese Encephalitis and the importance of proper pre travel advice and vaccination.

More info on this story

JE vaccine is only available for children in Australia as part of a clinical trial. More info on the trial

QLD Health expands Free Whooping cough program

We have just been advised by QLD Health that they have expanded the free whooping cough (pertussis)  vaccination program to include all adults in the household of a baby under 6 months of age. This is great news for the newborns of QLD.

Babies cannot be vaccinated against pertussis until age 2 months. Babies who get whooping cough cannot cough. Babies have episodes where they stop breathing and can die. The only way to protect these newborns is to vaccinate those persons around the baby; eg parents, grandparents etc. Children up to age 20 are protected via the routine childhood immunisation program, and parents and grandparents are already entitled to free vaccination.

Now all the household members can be vaccinated free so the baby can be ‘cocooned’ to help prevent the baby’s caregivers inadvertently bringing pertussus into the household.

Studies have shown most babies with pertussis catch it from their parents or household members. One study in 2006-2008 in the Netherlands, found that 14% of those who gave pertussis to a baby had no symptoms, so it is not good enough just to keep sick persons away from newborn babies.

The Whooping cough vaccine is not available as a separate vaccine, it is included with tetanus and diphtheria vaccines. The vaccine costs about $50 if it is not on the free program.

Extra benefit of Cervical Cancer vaccination

Rates of Genital warts have dropped in both young women and and heterosexual men following widespread vaccination of girls and women aged 12-26 years with the Cervical Cancer vaccine.  Since 2007 the Gardasil vaccine against Human papilloma virus has been provided free to young women in this country.

About 80% of eligible adolescent girls have received one dose, and about 70% have received all three doses.

Sexual health centres have been monitoring the rate of newly diagnosed genital warts, and found that the rate remained steady from 2004 to 2006, but declined by about one third from 2007 to 2009.  The rates of other diseases, eg Herpes did not change More info This provides extra evidence to support the case for vaccination of boys and  finishing the courses for the girls.

Dangers of staying home at ones desk

I would guess most of my readers love to travel. Now we have a medical excuse? Recently someone sent me this blog post outlining  the dangers of sitting at ones desk all day!

Melatonin?

I have recently been asked about Melatonin for jetlag

A product circadan = 2 mg slow release melatonin was approved last year in australia by The Therapeutic Goods Administration (TGA)  for use in persons over 55 years of age

http://www.medicalobserver.com.au/news/tga-approves-melatonin-for-adult-insomnia

However the cochraine review

http://www2.cochrane.org/reviews/en/ab001520.html

…did not encourage the use of 2mg slow release melatonin as per extract below

Eight of the ten trials found that melatonin, taken close to the target bedtime at the destination (10pm to midnight), decreased jet-lag from flights crossing five or more time zones. Daily doses of melatonin between 0.5 and 5mg are similarly effective, except that people fall asleep faster and sleep better after 5mg than 0.5mg. Doses above 5mg appear to be no more effective. The relative ineffectiveness of 2mg slow-release melatonin suggests that a short-lived higher peak concentration of melatonin works better. The estimated number needed to treat (NNT) is 2, based on the only two trials that gave the necessary data. The benefit is likely to be greater the more time zones are crossed, and less for westward flights.

So the melatonin available on a general script in Australia  is not the one to recommended.

(Incidentally, your local compounding pharmacy will make 5mg melatonin non – slow-release  tablets from a script that is for 5mg Melatonin)

Personally I always carry melatonin and especially use it for the first few nights when travelling to the USA / Canada.  In the USA you can buy melatonin 5 mg without a script from local pharmacies.