Medical Advisory Services For Travellers Abroad
PO Box 905 Balgowlah NSW 2093
T: +61 2 9948 8278
F: +61 2 9948 4268
Trip departs from and returns to Australia
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Note: The information in this document is provided as a general guide. We advise it be used together with a doctor's advice.
Standard Vaccinations: Travellers should be up to date with all standard vaccines recommended by their National Immunisation Program.
Yellow Fever does NOT occur in this country
This country also requires a Yellow Fever Vaccination Certificate for travellers who have transited through the airport of a country with risk of yellow fever transmission, within the previous 6 days (see health brief and itinerary to determine if yellow fever occurs in countries that will be visited in the 6 days prior to entering this country). If there is any contra-indication to vaccination, a Yellow Fever Vaccination Exemption Certificate should be provided
Overseas travel provides an opportunity for all travellers to review their current immunisation status. All travellers are advised to be up to date with their regular immunisations as per their National Immunisation Program Schedule e.g. travellers should be 'in date' for the tetanus, diphtheria, polio, pertussis, measles/mumps and rubella (MMR). All travellers should carry an International Certificate of Vaccination or Prophylaxis in which their immunisations are recorded.
Influenza is a common infection in travellers. All travellers should be vaccinated against influenza prior to travelling overseas, provided there are no contraindications.
Notes on other travel health risks (eg Altitude Sickness, dengue, chikungunya and others) appear in the Health News by Destination section. Additional information on many of these health risks, as well as vaccine preventable illnesses, special aspects of malaria, cruise ship travel, children, pregnancy and travellers with specific medical conditions can be found in the MASTA Fact Sheets section on the website. Subscribers can print out these free Fact Sheets for their travellers as appropriate.
There is a risk of Hepatitis A on your journey - Vaccination is Recommended
Hepatitis A is a virus infection of the liver. It is acquired by consuming contaminated food and water. In adults, up to 2% of cases are fatal, but higher rates (eg 4%) may be seen. Cases either recover spontaneously or die.
Vaccination: Hepatitis A vaccines are safe and highly effective at preventing infection.
There is a risk of Hepatitis B on your journey - Vaccination is Recommended
Hepatitis B is a virus infection of the liver. It is spread by sexual contact, contaminated blood & body secretions. Contaminated needles, syringes and any instrument that breaks the skin or contacts mucosal surfaces can also spread the virus. It can lead to liver damage, cirrhosis, liver cancer, liver failure & death. About 5% of adults remain carriers after acute hepatitis B and can infect other people, including from mother to baby.
Vaccination: Hepatitis B vaccine is very effective protection against infection. The vaccine is usually given as a 3 dose course over 6 months, but accelerated regimes can be used if time is short.
There is a risk of Typhoid on your journey - Vaccination is Recommended
Typhoid is caused by bacteria (Salmonella typhi) which is contracted by ingesting food or water contaminated by the typhoid bacteria. The bacteria enter the blood stream from the gut. Illness usually causes fever, lethargy and change in bowel habit. Typhoid can be fatal. Prevention is by food and water precautions, and vaccination.
Vaccination: There are 3 moderately effective vaccines: one oral (Vivotif Oral); and two (Typherix and Typhim Vi) as injections. A combined hepatitis A and typhoid vaccine (Vivaxim) is also available and is useful for groups at risk of contracting both infections. Protection is thought to last up to 3 years with all available typhoid vaccines.
The requirements for these immunisations may depend on your activities, lifestyle and length of stay. We advise you to discuss these with your travel health advisor.
There is a risk of Japanese Encephalitis on your journey - Vaccination should be Considered (see below for guidance)
Japanese Encephalitis (JE) is a virus infection of the brain that causes a severe flu-like illness with prominent headache, neck stiffness, confusion and coma. Death rates may be up to 30% or higher and long-term brain damage is common in persons who survive. There is no cure. Cases either recover spontaneously, die or develop permanent brain damage. It occurs mostly in rural areas of many parts of South East Asia, China, Korea, Northern India and Nepal and some parts Papua New Guinea. It is spread mostly in rural areas where conditions favour breeding of the mosquito that carries the virus. They are most likely to bite from late afternoon to early evening. Use an effective insect repellent. Effective repellents include products that contain adequate amounts of deet, picaridin or extract of lemon eucalyptus (for more information, go to www.mosiguard.com.au).
Guidelines for Vaccination: Although seasons are not entirely predictable risk is greatest during the months stated below. JE vaccination is generally only given if staying in rural areas in endemic areas for more than 2 weeks during the season. For trips of < 2 weeks duration in rural areas, antimosquito measures are usually only required. For trips of 2-4 weeks in rural areas, many authorities still do not recommend JE vaccination, preferring to recommend it only for persons travelling in rural areas during the season for 4 weeks or more. Expatriates staying in endemic areas with regular rural exposure are recommended to have the JE vaccination. The previously available JE vaccine (JE-Vax) is no longer readily available. A new JE vaccine (JESPECT) became in 2009. It is licensed for use in persons aged over 18 years. The shortest immunisation protocol for JESPECT vaccine is 2 doses 28 days apart. It is preferred that the last dose be completed at least 7 days before exposure in order to allow adequate immunity to JE to develop. The JESPECT vaccine is also marketed in many countries under a different name (IXIARO). In December 2012, the first single dose vaccine for JE (IMOJEV) became available in Australia. IMOJEV is a live attenuated vaccine. It is licensed for use in persons aged 12 months and older. By 14 days after vaccination with IMOJEV, over 90% of adults have developed protective antibodies and over 84% still have protective antibodies at 5 years. By 28 days after vaccination with IMOJEV, over 95% of children had developed protective antibodies. Therefore, ideally, children should be vaccinated with IMOJEV at least 28 days before exposure and adults at least 14 days before exposure. For children, data has not been previously available for JESPECT. New studies however show it to be immunogenic and safe for use in children aged 2 months to 18 years of age. Therefore, while currently the lower age limit for the JESPECT vaccine is 18 years of age, it is likely that dosage recommendations will be available in 2013 for children aged over 2 months of age. For the moment, however, until the JESPECT approved prescribing information is formally changed to cover paediatric use, for persons aged between 12 months and 18 years for whom JE vaccination is indicated, IMOJEV is preferred. Recommendations on booster requirement and timing of boosters for JESPECT and IMOJEV have not been determined as yet.
There is a risk of Rabies on your journey - Vaccination should be Considered (see below for guidance)
Rabies is a virus infection of the nervous system. Symptoms are muscular paralysis and spasm with bizarre behaviour leading to delirium and convulsions and death. Infection is usually contracted from the saliva of an infected or rabid animal (any mammal). Most human cases are acquired from a dog or cat bite but just a lick on an open cut, sore, or even the eyes or mouth may be enough. Once symptoms develop, death is inevitable in all cases. There is no cure.
Prevention: Prevention is extremely important. Immediately after the bite,lick or exposure treat the wound or exposed part of the body with soap (or detergent) and water to thoroughly clean the wound then flush with water all exposed areas. Then seek immediate medical care to ensure all appropriate measures have been taken to prevent rabies.
Vaccination: Current rabies vaccines available in Australia and New Zealand are safe and very effective. The vaccine can be given either before travel (pre-exposure prophylaxis) or after exposure (post-exposure prophylaxis). Pre-exposure prophylaxis is often advised for persons going to remote areas of rabies countries, especially if risk of rabies is high or if travelling in rural areas for longer than 1 month. Rabies has occurred in travellers in shorter trips and in urban locations. Cyclists, Children and Health and Humanitarian Aid Workers are often at increased risk. Never accept a “she’ll be right” or “it won’t happen to me” approach after potential rabies exposures, even from medical personnel. Expert medical advice on rabies management is essential. All travellers should be aware of the risk and consider pre-exposure prophylaxis in discussion with their doctor.
There is a risk of Cholera on your journey - Vaccination should be Considered (see below for guidance)
Cholera is a bacterial infection of the gut that causes painless but profuse watery diarrhoea which rapidly leads to dehydration. Vomiting may also occur. If diarrhoea is profuse death can occur within a day. The cholera bacteria are usually spread by water or food contaminated with infected faeces.
Guidelines for Vaccination: Cholera is not very common at all in travellers. For most travellers safe food and water precautions alone usually are enough to prevent cholera. The following persons are at higher risk of cholera and should consider cholera vaccination more strongly - health care and aid workers who are likely to have close contact with the local population, persons travelling or working in rural areas of a country especially when a cholera outbreak is occurring and/or who may be in a remote location away from reliable medical care.
Philippines (Highest Risk)
Malaria risk exists throughout the year in rural areas below 600m, except in the provinces of: Aklan, Albay, Benguet, Bilaran, Bohol, Camiguin, Capiz, Catanduanes, Cavite, Cebu, Guimaras, Iloilo, Leyte (Northern & Southern), Marinduque, Masbate, Samar (Eastern, Northern & Western), , Seequijor, Surigao del Norte and Metropolitan Manila. No risk is considered to exist in urban areas. If these malaria free areas are to be visited only, and no others, even in transit, then antimalarial tablets are not required, but antimosquito measures are still advisable. If you are in any doubt or your plans may change, we advise you take them. P.knowlesi ("monkey malaria") cases have been reported from Palawan Province. Prevention measures are the same as for P.falciparum quoted below.
|Legend: Dark Green denotes High Risk Area, Light Green denotes Low Risk Area|
Malaria risk is high for both Benign Malaria (mostly P.vivax) & Malignant Malaria (P.falciparum) & Malignant Malaria (P.falciparum) is Resistant to Chloroquine, Proguanil & sometimes other drugs.
Antimosquito measures plus Preventive Medication (chemoprophylaxis) as follows:
Choose either Doxycycline (daily) or Malarone (daily) or Mefloquine (weekly).
Which medication suits you best depends on side effects, cost, convenience & length of stay. You should discuss the best choice for you with your travel health advisor.
ADULT DOSE SCHEDULES
Doxycycline ONE (100mg) tablet DAILY - Take with food. Start 2 Days before departure & Continue Tablets for 28 Days after leaving the Malaria area
Malarone ONE tablet DAILY - Take with food. Start 2 Days before departure & Continue Tablets for 7 Days after leaving the Malaria area
Mefloquine (Lariam) ONE (250mg) tablet WEEKLY. Start 2 Weeks before departure & Continue Tablets for 4 Weeks after leaving the Malaria area
There are few alternatives to the above medications. Seek specialist advice if alternatives are required.
CHILDREN, PREGNANT & BREAST-FEEDING MOTHERS
Malaria prevention and anti-malarial medications should be discussed with a knowledgeable medical practitioner.
If none of the above medications is suitable for you, you should discuss with your doctor whether it is safe for you to travel to the malaria areas in this country. No preventive measures are guaranteed to be 100% effective in preventing malaria. Therefore, any fever occurring within the first 3 months (even up to 12 months) of having been exposed to malaria should be evaluated for malaria. See below ("Malaria Symptoms and Treatment").
Use an insect repellent that works e.g. products that contain DEET, Picaridin or Extract of Lemon Eucalyptus (Mosiguard). Don't use products whose claims can't be supported. MASTA recommends Mosiguard. Extensive testing by world leaders in insect repellent research proves Mosiguard to be powerful, effective and safe for all the family (aged 12 months or over). Mosiguard provides effective protection for at least 6 hours, but 10 hours or more under field condition - easily superior to all other natural repellents & equivalent to, or better than, all synthetic repellents. Mosiguard is DEET-free, so it won’t dissolve or damage your sunglasses, expensive synthetic garments like swimwear, sportswear, fishing gear or your golf club grip! For more information, go to www.mosiguard.com.au
Dress appropriately especially in between dusk and dawn (long sleeved shirts/tops, long trousers etc to minimise bare skin exposed to mosquitoes)
Air conditioned accommodation provides very good protection against mosquitoes. If air conditioning is not available, we advise you sleep under a mosquito net impregnated with insecticide (permethrin). A knock-down spray (fly spray) at night to kill any mosquitoes in your room may also be advisable. Plug-in vapourisers containing permethrin and related compounds are very effective provided there is 24 hour power supply. "Buzzers", "Zappers", Thiamine (vitamin B1) do not protect against mosquito bites.
The most important symptom to remember is a raised temperature of 38oC or higher starting at least one week after first potential exposure to malaria (the minimum incubation period). Other symptoms are very variable and cannot be relied on. If you do develop a fever a week or more after exposure to malaria, you must seek medical attention as soon as possible. If you cannot get to medical attention within 24 hours and/or your condition is deteriorating, you should consider emergency self-treatment. Riamet (artemether/lumefantrine) is suitable to use as an emergency treatment, but you should still see a doctor as soon as possible. Dose (adults): 4 tablets as an initial dose followed by five further doses of four tablets taken at 8, 24, 36, 48 and 60 hours thereafter. Alternative emergency treatment is Malarone (atovaquone/proguanil) taken as 4 tablets once daily for 3 days. Note that previously reports came from border areas of Cambodia, Myanmar and Thailand as well as from East Africa of P.falciparum resistant to mefloquine but, in recent years, resistance to artesunate, lumefantrine and piperaquine also seem to be emerging in those locations. This problem may become more widespread with time, even though measures are being taken to reduce spread of these multi-resistant P.falciparum strains to other countries and regions. Travellers should bear this in mind as treatment failures may become more frequent with any of the recommended standby treatment drugs.
Cholera outbreaks occur in the Philippines. In 2010, outbreaks were reported from Caloocan City and Zamboanga City. Cholera is transmitted by contaminated food and water. Outbreaks tend to occur in areas with poor sanitation. An oral cholera vaccine is available for those at particular risk.
Outbreaks of dengue fever, transmitted by mosquitoes, are reported annually. This unpleasant viral disease causes fever, rash and joint pains. Rarely, it can be fatal. There is no specific cure. Treatment is given to relieve symptoms. In dengue especially one should avoid the use of aspirin and other anti-inflammatory medications as they may aggravate bleeding tendencies caused by the disease. Use paracetamol instead. Dengue is transmitted by daytime biting mosquitoes so travellers should take steps to avoid mosquito bites. See MASTA Fact Sheets. The Health Department reported well over 100,000 cases of dengue fever throughout the country in 2010, more than double the number in 2009. Large outbreaks have been reported in Calabarazon, National Capital including Metro Manila, and Western Visayas.
Measles outbreaks occur in Philippines with an ongoing outbreak since early start of 2010, with many cases in Bicol, Calabarazon, Central Luzon, National Capital Region, and recently in 2011 in Davao del Norte & Davao Oriental. Canadian authorities have reported cases in travellers returning from the Philippines in January 2011. Travellers should know their measles immune-status. Unless there is a history of confirmed measles in the past, or of having had two measles vaccinations, measles vaccination is recommended for all travellers, providing there are no contra-indications to having the vaccine. Around 300 people die from rabies each year in the Philippines. Consider having pre-exposure rabies vaccines especially you are staying for a long time or travelling away from reliable medical facilities. All travellers should know what steps to take if bitten.
A recent outbreak of schistosomiasis in a Leyte town (Palo) is a reminder that schistosomiasis is still endemic in parts of Philippines. Palo is about 12 kilometres from Tacloban (capital). Risk may have been increased by recent floods. Wading or swimming in fresh water should be avoided, especially in floodwaters. See the MASTA Schistosomiasis Fact Sheet for more information. Outbreaks of typhoid fever occur in Philippines. In December 2010, over 500 cases were reported in an outbreak in Cebu (Alegria and Malabuyoc towns). In February 2011, an outbreak has been reported in Northern Samar (especially Gamay town). This bacterial infection transmitted predominantly through contaminated food and water can be a serious illness, but modern vaccines offer up to 80% protection.
Illness related to fish consumption is regularly reported in the Philippines. In June 2010, over 20 persons were hospitalised in Illoilo with ciguatera. This is an illness caused by ingestion of reef fish that have cigua toxin in their body. Many types of large reef fish are implicated wth the aforementioned outbreak being after ingestion of "maya-maya". The toxin is not killed by cooking so that care with selection of fish is advised as the main preventive measure. Travellers are also advised to avoid eating raw or undercooked fresh water fish. A number of people were found to have heterophyiasis on Mindanao island during 2006. This parasite usually only affects the intestine but occasionally worm eggs can travel to and cause damage to other organs such as the heart. The Department of Health regularly reports outbreaks of leptospirosis especially after flooding. In late 2010, Luzon and Metro Manilla reported outbreaks. Leptospirosis can be contracted when water infected with the urine of rats and other animals, comes in to contact with broken skin or mucous membranes. Swimming, rafting and caving are recognised as risk factors.
An outbreak of anthrax related to eating meat from a dead carabao was reported in Cagayan in early 2010 with over 400 cases and at least two deaths. According to reports, 30% of drug stores visited by drug enforcement officers carry and sell counterfeit drugs. Travellers should be extra careful when buying medicines, always attend a recognised clinic. Take sufficient supplies of medicines with you if possible. Medical facilities vary in standard across the Philippines. Although sufficient in major cities, medical care is limited in more remote areas. Ensure you have adequate medical insurance to cover the costs of emergency evacuation.
WHO (World Health Organisation) classifies this country as a high incidence country (HIC) for tuberculosis (TB) with over 100 new cases per year per 100,000 of population. Prevention of TB in travellers is discussed further in the MASTA Fact Sheets "Tuberculosis in Travellers" and "Travelling with Children Aged less than 10 years" which are available to subscribers in the Fact Sheet Section of the website www.masta.edu.au.
• First aid kit containing antiseptic, bandages, plasters, scissors, thermometer, tweezers
• Consider taking a sterile medical equipment kit (needles, sutures, syringes for emergency treatment of injuries in countries where sterile needles & syringes may not be available so there could be a risk of HIV, Hepatitis B or C)
• Consider taking an emergency dental kit for temporary treatment of dislodged fillings and crowns
• Carry a note that states your blood group & consider joining the Blood Care Foundation in case emergency safe blood transfusion could be required
• Repellent that works against biting insects
• Mosquito net impregnated with permethrin
• Plug in insecticide vaporiser and pads
• Knockdown insect spray (fly spray)
• Water purification tablets or an Iodine resin water purifier
• Sun block
• “After Sun” skin care products
• Condoms if appropriate
• Travel sickness medication as required
• Antimalarial drugs for malaria prevention if recommended
• Loperamide and oral rehydration preparations for Travellers’ Diarrhoea
• Malaria treatment medication (Malarone or Riamet) for emergency (standby) treatment of malaria for travellers who may be unable to access to reliable medical attention
• Antifungal treatments for women taking doxycycline for malaria prevention
• Antibiotics may be appropriate for treatment of diarrhea, skin and chest infections (this should be discussed with your doctor)
• If you are on any regular medication, it is a good idea to take a bit more than is required for the trip duration in case of loss or damage. Keep some in your hand luggage and some in your check-in luggage. Carry a letter from your regular doctor listing your regular medications (both the trade and generic names) and the dosages you take
• Documentation that lists any allergies which you have ever had and any medications which you cannot take
• Copy of your travel insurance policy with emergency contact numbers
Travellers' Diarrhoea Note
"Travellers' Diarrhoea" (TD) is a term often applied to any type of diarrhoea in travellers, irrespective of cause. Classically TD is an illness with non-bloody diarrhoea, without fever, that starts within 1 or 2 weeks of arrival in a developing country and lasts for 3-5 days. TD can vary from just a few extra, loose bowel movements per day to an illness with profuse bloody diarrhoea and fever (dysentery). Dysentery occurs in up to 10% of persons. Of those affected, it is estimated that 30% will be confined to bed, and 40% will have to curtail their activities. In warm climates dehydration can be severe, even fatal, particularly in children.
The microbes that cause TD are usually spread by contaminated water or food. TD is seen in visitors to virtually any country with only Australia, New Zealand, northern Europe, Canada and the U.S.A. being regarded as low risk destinations.
Treatment of TD is with fluid replacement with oral or intravenous fluids in severe cases. Antibiotics can also be given but fluid replacement is most important. Sachets of ORS (oral rehydration solution) are preferred for fluid replacement and should be carried when travelling overseas.
Prevention of TD is by practising simple food and water precautions. An easily remembered aphorism is “boil it, cook it, peel it, or forget it”.
Under some circumstances antibiotics may be advised for certain travellers to prevent TD. This should only be done after seeking medical advice. This is less commonly advised now because of the prevalence of antibiotic resistant bacteria that cause travellers’ diarrhea. Other preventive measures are also available and include the oral cholera vaccine, Dukoral, some probiotics and Travelan. Protection provided by each does vary so you should discuss these options with your doctor.
Every effort has been made to ensure the accuracy of the information supplied herein, but MASTA makes no warranty, express or implied, as to the accuracy, completeness or usefulness of the information and all liability is excluded save in respect of personal injury or death caused by the negligence of MASTA. Copyright Newmasta Pty Ltd 2012.