Medical Advisory Services For Travellers Abroad
PO Box 905 Balgowlah NSW 2093
www.masta.edu.au

E: masta@masta.edu.au
T: +61 2 9948 8278
F: +61 2 9948 4268

Traveller Details

Itinerary Details
Generated on: March 8, 2013, 8:57 am
Number of Days: 92
This report is valid only for the period of travel
Name of Traveller(s)
Christopher Gain

Destination Details

Trip departs from and returns to Australia

Country Arrival (dd/mm/yyyy) Departure (dd/mm/yyyy) Accommodation
Philippines 01/05/2013 31/07/2013 RURAL

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 Travel Information

Specific Country Information:

Other Vaccine Preventable Diseases

Recommended immunisations for your journey

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.

Hepatitis A

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.

Hepatitis B

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.

Typhoid Fever

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.

Immunisations to be considered for your journey

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.

Japanese Encephalitis

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.

Local notes for:
  • Philippines: Japanese encephalitis outbreaks occur throughout the year.
    Note that this information is for guidance only as seasons for outbreaks are not fully predictable.

Rabies

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.

Cholera

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.

Malaria

There may be a risk of malaria on your trip.
Malaria, a serious disease than can be fatal, is caused by a parasite (Plasmodium species) of red blood cells transmitted by mosquitoes. Not all mosquitoes transmit malaria. The species that transmits malaria is the anopheline mosquito. It usually prefers to bite between dusk and dawn. Whilst feeding it injects saliva containing the parasites which then travel to the liver and develop over the next 8-21 days (incubation period) before appearing in the blood stream. Therefore, minimum period between mosquito bite and  first symptom is 7 or 8 days.  There are two main forms of malaria:
1. Malignant malaria (due to P.falciparum) is fatal if untreated. A similarly serious form of malaria may also be caused in humans by P.knowlesi ("Monkey Malaria").
2. Benign malaria (due to P.vivax, P.ovale or P.malariae) is rarely life threatening but relapses may occur over several years (up to 10 years after last exposure to malaria)

This section of your health brief describes the geographical risk areas for malaria (in dark green ) in the countries to be visited and the relevant preventive measures. If antimalarial drugs are recommended in your Health Brief, they should provide protection for all malaria risk areas visited on your journey.
Note: Malaria maps are for guidance only. Malaria borders can change. If there is any doubt, we advise that you take the antimalarial drugs. Dark green shaded areas indicate that antimalarial drugs may be advised. Check geographical data in the text description of malaria risk that accompanies the map.
Choose one of the recommended antimalarial drugs and its schedule listed below. Generally, we do not advise changing antimalarials while you are travelling, unless you suffer significant side effects, or develop malaria. In either case, decision on an alternative should be made in consultation with a knowledgeable medical practitioner.
Risk Areas Description
Map of Philippines. 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

Recommended anti-malarial drugs

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.

PREVENTION
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
OR
Malarone ONE tablet DAILY - Take with food. Start 2 Days before departure & Continue Tablets for 7 Days after leaving the Malaria area
OR
Mefloquine (Lariam) ONE (250mg) tablet WEEKLY. Start 2 Weeks before departure & Continue Tablets for 4 Weeks after leaving the Malaria area

ALTERNATIVES
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.

WARNING

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").

Avoiding Mosquito Bites

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.

Malaria Symptoms and Treatment

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.

Health News by Destination

Security Advice

Important Items You May Need To Take With You

Emergency
• 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

Bites
• Repellent that works against biting insects
• Mosquito net impregnated with permethrin
• Plug in insecticide vaporiser and pads
• Knockdown insect spray (fly spray)

Safe Water
• Water purification tablets or an Iodine resin water purifier

Sun Protection
• Sun block
• “After Sun” skin care products

Sex
• Condoms if appropriate

Medication
• Painkillers
• 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

Travel Insurance
• 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.

Disclaimer

Disclaimer
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.