Health Advice for Members of Australian Medical Assistance Teams Going to the Asia-Pacific Area
This document provides health advice about personal health protection to persons planning to travel to disaster-affected areas in the Asia-Pacific area as a member of an Australian government health team.
This disclaimer should be read in conjunction with all publications produced by CDNA.
DRAFT 14 February 2007
The purpose of this document is to provide information about personal health protection to people who are planning to travel to disaster-affected areas in the Asia-Pacific area as a member of an Australian government health team. The information is a guide only and you should seek medical advice specific to your situation. The team leader will normally ensure that the equipment and preventive measures you require are provided for you, however it is important to check that this is the case.
BEFORE YOU DEPART
- Consult an experienced travel medicine doctor as early as possible about immunisations, malaria preventive therapy and other travel health advice.
- Consult a doctor (even if you are one) if you have a pre-existing medical condition, such as diabetes or epilepsy, for advice on whether you should join a relief team.
- Pregnant women are advised not to participate in medical assistance teams in the Asia-Pacific area as many of the recommended immunisations and all the effective malaria preventive therapies are contra-indicated in pregnancy.
- If you have not done so recently, have a dental check up before leaving. You may not be able to locate a dentist should you suffer an acute dental condition while deployed.
- Have a baseline Mantoux test. This will assist in diagnosis if you develop symptoms of TB after you return home and also allows preventive treatment if you become infected but not diseased during deployment (ie. Mantoux converts to positive on testing 2 months after return).
- Start taking your malaria preventive therapy as directed (see malaria prevention and treatment).
What to take
- A passport (and re-entry visa if applicable) is essential (even if you have been told it is not).
- A vaccination card listing the immunisations you have received.
- Local or US currency.
- Supply of any regular prescription medications to last the length of time you expect to be away.
- Spare prescription glasses or other prostheses.
- Personal travel medical kit containing medications to help manage diarrhoea (e.g., oral re-hydration tablets or powder, anti-diarrhoeal medication (e.g., loperamide), antibiotics in case of severe diarrhoea); anti-nausea medication; antiseptic solution (e.g., povidine-iodine/Betadine) and dressings for bites and minor wounds; pain reliever (e.g., paracetamol) and cold/sinus medication (paracetamol + pseudoephedrine). Kits can be purchased from some travel medical centres, or maybe provided for the team.
- Insect repellent (containing DEET or picaridin); sunglasses; sunscreen (SPF 30+); wide-brimmed hat.
- Toilet paper; condoms; women need to take supplies of tampons etc.
Check that your sponsoring agent will provide/have available
- Maps of the area.
- Information about the local area including a phrase book.
- Bed nets (see below – mosquito avoidance measures).
- A medical kit for the team which includes items routinely contained in a doctor’s emergency medical bag plus the following: antimicrobials (e.g., oral azithromycin, ciprofloxacin, cephalexin, tinidazole, sofradex); rabies post-exposure prophylaxis; HIV post-exposure prophylaxis (and a protocol for its use); malaria rapid detection kits; antimalarial treatment (e.g., artemether-lumefantrine or quinine); dressings and povidine-iodine.
- Access to a facility for intravenous antibiotics and treatment for malaria if needed.
ImmunisationsPrior to travel to affected regions, 4 to 6 weeks is ideally required for a complete course of immunisations to be given. However, some vaccine schedules can be accelerated. It is important to take into account any previous vaccines you have received and whether you have immunity from previous infection. The following vaccines are grouped into two categories.
Immunisations recommended for all relief workersHepatitis A: This is a common food- and water-borne pathogen. Hepatitis A vaccine given 2 weeks prior to departure will provide adequate protection and is available in 3 formulations: alone, in combination with hepatitis B vaccine, or in combination with typhoid vaccine. Hepatitis A vaccine can also be given in a rapid schedule (see below – hepatitis B). A second dose of hepatitis A vaccine is required 6 months after the first dose.
Hepatitis B: Hepatitis B infection is very common in the Asia-Pacific area and vaccination against hepatitis B is essential for health-care staff. All health care workers should know their immune status to hepatitis B. If you have not been vaccinated, you should receive 3 accelerated doses of vaccine prior to travel, and a fourth dose 12 months after the first dose, as below. This schedule is for either the hepatitis B vaccine (Engerix–B 10ug) or hepatitis B/hepatitis A combination vaccine.*
|Hepatitis B||H-B-Vax II or Engerix–B 10ug||0, 7, 21 days||12 mths|
|Hepatitis B/Hepatitis A combination||Twinrix (720/20)||0, 7, 21 days||12 mths|
Note: Engerix–B can also be given using a 0, 1, 2, and 12 month schedule.
Influenza: Influenza immunisation is recommended to protect yourself and the population you will be working with.
Measles: You will need measles-mumps-rubella (MMR) vaccine if you are not immune to measles. It is particularly important in this setting because of the increased likelihood of measles outbreaks. MMR is not required if you have documented evidence that you have either received two doses of a measles vaccine more than one month apart, or have antibody to measles. Just a belief that you have had measles infection or vaccination (without evidence) is not enough to assume immunity.
Polio: Polio still occurs in India and has reemerged in Indonesia and some other parts of the world. Polio vaccine is recommended unless you have received a dose within the last 10 years.
Tetanus/Diphtheria/Pertussis: Tetanus is not uncommon in the Asia-Pacific area following disasters. You need a booster dose unless you have received one within the last 5 years. Boostrix® (adolescent/adult diphtheria-tetanus-acellular pertussis vaccine, dTpa) is recommended as you will gain protection against whooping cough (pertussis), as well as tetanus and diphtheria. Alternatively adult diphtheria-tetanus vaccine (known as ADT or dT) can be given.
Typhoid vaccine is recommended as a single dose intramuscular (IM) injection or as a combination typhoid/hepatitis A IM vaccine. Typhoid vaccines only provide up to 77% protection against typhoid fever, so precautions for the prevention of gastrointestinal disease should be followed. Persons previously immunised should be re-immunised after 3 years.
Varicella vaccine is recommended for non-immune workers (those with no definite history of chickenpox or negative serology). 2 doses of varicella vaccine, 1 to 2 months apart are required.
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Immunisations recommended in some circumstancesCholera: There is a risk of cholera in developing countries from contaminated water or food. Precautions for the prevention of gastrointestinal disease should be followed, as not all cholera strains are preventable by the available vaccine. The only cholera vaccine available in Australia is Dukoral® (Aventis Pasteur). Immunisation is recommended for anyone working in a refugee camp, and for other relief workers if a confirmed outbreak of cholera has been reported.* 2 doses should be given orally at least 1 week apart (but not more than 6 weeks apart).
Japanese encephalitis (JE): Japanese encephalitis is endemic in Southeast Asia. The level of risk depends on the mosquito population, season, location and duration of stay. The use of mosquito avoidance measures is essential at all times. Vaccination is recommended and 3 doses of injectable vaccine over 4 weeks (days 0, 7, 28) are required. However, an accelerated schedule of 2 doses (days 0, 7) provides protection in up to 80% of people.* There is a risk of severe allergic reaction to the vaccine for up to 10 days following each dose, so you should remain within ready access to medical care for 10 days following the vaccine being given. Persons previously immunised should have a booster after 3 years.
Meningococcal disease: Immunisation against meningococcal disease is only required in the event of an outbreak. A single dose of meningococcal polysaccharide vaccine (Mencevax or Menomune) provides protection against 4 strains of meningococcal bacteria (A, C, W135 and Y) for about 3 years.
Rabies: Rabies is endemic in many parts of the world, so it is essential to avoid animal contact that could lead to scratches or bites. Adequate protection against rabies requires 3 immunisations over 28 days with a schedule of day 0, 7 and 28. Preexposure immunisation is recommended for those who will be spending prolonged periods (i.e., more than one month) in rural parts of rabies-affectedareas. If a potential exposure to rabies occurs (such as a bite or scratch from an animal from an endemic area) it is essential to seek urgent medical care. Left untreated, rabies is almost always fatal. Affected wounds must be immediately washed as described below (wound and skin infections). Post-exposure rabies prophylaxis for anyone who is not fully immunised consists of human rabies immune globulin (HRIG) and 5 doses of rabies vaccine. Those who have completed pre-exposure immunisation require 2 further doses of rabies vaccine in the event of an exposure.
Yellow fever immunisation is only recommended if travelling to affected areas in East Africa. There is no yellow fever in Asia or the Pacific. However, some countries, such as Indonesia, require documentation of yellow fever immunisation if you have travelled from a yellow fever endemic area. (For more information see: http://whqlibdoc.who.int/publications/2007/9789241580397_11_eng.pdf
* the advice provided here differs from the Australian Immunisation Handbook for some vaccines because of the unusual circumstances in which these vaccines are being used.
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PRECAUTIONS WHILE YOU ARE DEPLOYED
- Illness and injury are real possibilities when you are working overseas. If you develop any symptoms, seek medical advice immediately. This includes psychological support and counselling if necessary.
- Wear loose cotton clothing for comfort in tropical climates. Remember that conservative dress sense is the social norm in most countries in Asia and that women should cover their shoulders. Wear covered shoes and long trousers at all times when outdoors, not just when working - this will help protect you from snake bites and some soil-borne infections.
- The most common serious problem is motor vehicle trauma. Do not drink and drive. Wear your seat belt, follow the local customs and laws, avoid using bicycles and motor bikes (wear a helmet if you must use them), and don’t board overcrowded vehicles.
- In some areas there may be fallen electricity lines, or land mines in areas of conflict. Take care when moving around the countryside and follow instructions from local police or military officers.
Mosquito avoidance measures
- Malaria, dengue fever and Japanese encephalitis are significant mosquito-borne diseases that you might be exposed to.
- Wear light coloured, long sleeved shirts, long trousers and socks.
- Use personal repellent containing high levels of DEET (e.g., Rid®, Tropical strength Aerogard®, Bushman’s®) or picaridin (Autan Repel®). Lotions and gels last longer than sprays. Repellents should be re-applied at least every 4 hours, depending on amount of sweating.
- Sleep under a mosquito bed net, preferably one that has been treated with permethrin insecticide. Make sure that the mesh size is small enough to prevent the entry of mosquitoes.
- Avoid going out at dusk/dawn if possible but also remember that many species of mosquitoes may feed during the day, as well as at night.
Malaria prevention and treatment
- Malaria preventive therapy is required for many countries on the Asia-Pacific area. Following a disaster, malaria may become resurgent in some areas where it has not recently been a problem.
- There is no drug regimen that provides complete protection against malaria and there is a chance that you could still contract malaria despite taking the preventive therapy. Seek urgent medical attention if you experience symptoms of malaria including fever, chills, sweating, headache, muscle aches, cough, vomiting and diarrhea
Recommended malaria preventive therapy
- Doxycycline is preferred as it can also prevent other infections. Take 100mg orally every day, starting 2 days before entering and continuing until 4 weeks after leaving a malarious area. Doxycycline can cause oesophagitis (or ‘heart burn’ - best avoided by taking the drug with plenty of fluid and remaining upright for at least 1 hour afterwards), photosensitivity (avoid by using sunscreen and hat), and vaginal thrush (take standby topical antifungal with you, e.g., clotrimazole cream/pessary).
- An alternative drug is atovaquone+proguanil (Malarone™) 250/100 mg; take 1 tablet daily orally with food starting 1-2 days before entering and continuing until 7 days after leaving a malarious area. This is more expensive. It may cause nausea or diarrhoea in some people.
Gastrointestinal diseasesWater: Functioning municipal water supplies may have been disrupted by a disaster. Unless you are certain the water supply is safe, boil water for consumption and tooth-brushing, bringing it to a rolling boil. Alternatively, use water purification tablets (e.g., iodine or chlorine tablets) and use as per the instructions on pack.
Food: Care should be taken with the source of food - hot food should be truly hot, fruit should be peeled yourself, cold food truly cold (and best avoided). Non-perishable food items are likely to be safest. Ideally stick to the food supplied by the team.
Handwashing, preferably with soap, after using the toilet, other potential contamination, and before preparing and eating food, is an important preventive measure.
Management of diarrhoea: Diarrhoea is common. Minimise dehydration by taking an oral rehydration solution (e.g., Gastrolyte® tablets/sachets in water). If no fever or bloody stools, use loperamide (as per instructions on the pack). For moderate to severe diarrhoea, also take azithromycin 1 g (as a single dose) or norfloxacin 800 mg (as single dose). In addition, seek medical advice if you have fever, chills, bloody diarrhoea or severe diarrhoea lasting more than 24 hours.
Wound and skin infections
- Wound infections resistant to a wide range of antimicrobials have been reported following disaster.
- To help avoid these infections it is important to clean any wounds, cuts or animal bites immediately and thoroughly. Wash with clean water and soap until the wound and surrounding area is visibly clean, ensuring that all dirt is removed. Then clean with a disinfectant, which should remain in contact with the damaged area for 90 seconds, apply povidine-iodine, keep the area dry and covered and seek medical attention as soon as possible.
- Check your tetanus vaccination status: if you have a tetanus prone wound, and have had fewer than 3 doses of vaccine or more than 5 years has passed since your last dose you may need a booster vaccine and tetanus immune globulin.
Heat related illness
- Drink plenty of water and monitor your hydration (e.g., amount and colour of your urine). Include salty food in your diet (ration packs normally provide this). Rest out of the sun and get plenty of sleep.
- Take care with blood contact - hepatitis B virus is common and hepatitis C and HIV also occur.
- If you are involved in an incident where you are at risk of being infected with a blood-borne virus (e.g., needlestick injury), immediately consult an infectious diseases physician (if available) or doctor nominated by your sponsoring organisation for review of the necessity / provision of post-exposure prophylaxis.
- Take care with sexual contacts and always practice safe sex (take condoms).
- Rabies is endemic in the region. Do not touch any animals (wild or pets). Rabies-infected animals may exhibit unusually friendly behaviour, not just aggression.
- Animal bites: clean the wound immediately (see above) and seek urgent medical attention. You will need to receive post-exposure prophylaxis (if you have been immunised you still need to receive a shorter course of post-exposure prophylaxis - see immunisation section). Left untreated, rabies is almost always fatal.
- There are many venomous snakes in the region and displaced snakes are likely to be a problem following flooding. Leave them alone.
- Treatment: immediate immobilisation is the best first aid. Immobilisation without pressure bandaging is recommended for snake bites in Asia unless you definitely know whether the snake is one with neurotoxic venom. After transport to a health facility for assessment, the management and use of antivenom will depend on local protocols and antivenom availability for snakes from that region.
- If you become unwell after you return home, it is very important to see a doctor and to tell them that you have been working in a disaster area.
- Please read the information sheet "Health Advice for Australian Medical Assistance Teams Returning from the Asia-Pacific Area".
- Australian Government Department of Health and Ageing: http://www.health.gov.au/
- The Australian Immunisation Handboook. 9th Edition, 2008. NHMRC. http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home
- US Centers for Disease Control and Prevention (CDC): http://www.cdc.gov/
- World Health Organization: http://www.who.int/en/
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Communicable Disease Network Australia – Liability DisclaimerThis document provides health advice about personal health protection to persons planning to travel to disaster-affected areas in the Asia-Pacific area as a member of an Australian government health team.
This health advice captures the knowledge of experienced professionals, build on past research efforts, and provide advice on best practice based upon the best available evidence at the time of completion.
This health advice is necessarily general and readers should not rely solely on the information contained within this advice. The information contained within this advice is not intended to be a substitute for advice from other relevant sources including, but not limited to, the advice from a health professional. This health advice is intended for information purposes only.
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