Independent learning program for GPs

Unit 524 JanuaryFebruary 2016

Travel health

www.racgp.org.au/check

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Independent learning program for GPs

Independent learning program for GPs

Travel health
Unit 524 JanuaryFebruary 2016

About this activity

Acronyms 3
Case 1 Jane has a fever

Case 2 Amy presents with a dry cough

10

Case 3 Elizabeth volunteers to travel to East Timor

15

Case 4 Gerald travels to Mozambique

20

Case 5 Jeff is tired and anxious

25

Multiple choice questions

29

The five domains of general practice

Communication skills and the patientdoctor relationship
Applied professional knowledge and skills
P
 opulation health and the context of general practice
Professional and ethical role
Organisational and legal dimensions

ABOUT THIS ACTIVITY

check Travel health

ABOUT THIS ACTIVITY

More Australians than ever before are now travelling to other countries,
with rates increasing 2.5 times between 2000 and 2013 to more
than 7.63 million visits.1 General practitioners (GPs) are best placed
to provide expert advice to travellers on risks associated with specific
destinations. In particular, travellers need to be aware of infectious
diseases that may be acquired when visiting other countries; GPs can
provide information about how to best avoid or minimise contact with
sources of infection, as well as provide appropriate vaccinations.
Schistosomiasis is an infectious disease that affects an estimated
240 million people globally, with more than 700 million living in an
endemic area.2 In a systematic review on the sexual behaviours
associated with international travel, about 50% of travellers who
engaged in new sexual relationships inconsistently used condoms.
The review also found that the risk of developing a sexually
transmissible infection while travelling increased threefold.3 Influenza
causes an estimated 3500 deaths, 18,000 hospitalisations and more
than 300,000 GP consultations each year in Australia.4 Japanese
encephalitis is a mosquito-borne viral disease that is most prevalent
in many parts of Asia and most cases in Australia are from returning
travellers.5 In 201112, there were more than 350 notifications
of overseas-acquired malaria in Australia, mainly from travellers
returning from the Asia-Pacific region, Africa and the Middle East.6
This edition of check considers the management and treatment of
travel health that may present in general practice.
LEARNING OUTCOMES
At the end of this activity, participants will be able to:
describe the assessment of a returned traveller presenting with fever
discuss the diagnosis of schistosomiasis
outline protective and preventive measures against Japanese
encephalitis
summarise the recommendations for investigating and treating
influenza
list current options for malaria chemoprophylaxis
review the management of sexually transmissible infections in
returned travellers.
AUTHORS

Sonny Lau (Case 4) CTH, MBBS, MPH&TM, FRCP(Edin), FFTM,

RCPS (Glasg), was born in Hong Kong and is a medical graduate
of the University of Melbourne. After his internship in 1984 in
Melbourne, he worked in Hong Kong where he received his basic
physician training. He then gained training in infectious diseases at
the Fairfield Infectious Diseases Hospital in Melbourne in 1992. He
has worked specifically in the travel medicine field since 1993, at
the Travel Doctor TMVC. Dr Lau has been the Medical Director of
the Melbourne Clinic since 1995. He is a member of the examination
committee of the International Society of Travel Medicine since August
2005. His special interest is tropical diseases in returned travellers.
Cora Mayer (Case 3) MBBS (Hons), DRANZCOG, FRACGP, MPH&TM,
FACTM is a GP in Melbourne whose special interests include travel
and tropical medicines. Dr Mayer has worked in rural and remote
health, and in Aboriginal and Torres Strait Islander health, and has
completed postgraduate studies in public health, tropical medicine
and travel medicine. She has contributed to the Australian Family
Physician in this area and is a Fellow of the Australian College of
Tropical Medicine. She recently volunteered at Bairo Pite clinic in Dili.
Nick Medland (Case 5) MBBS, BA (Hons), FAChSM, is a sexual
health physician at Melbourne Sexual Health Centre and Royal
Melbourne Hospital. He has previously worked as the clinical director
of the Victorian AIDS Council Gay Men's Health Centre Clinic in
Melbourne, as the deputy director of the Harvard Medical School HIV
AIDS Initiative in Vietnam, director of HIV AIDS Care and Treatment
Programs at United States Centres for Disease Control and Prevention
in Vietnam and assistant director for clinical research at the HIV
Netherlands Australia Thailand Research Collaboration in Bangkok.
He is completing a PhD in clinical HIV research in early uptake of
antiretroviral therapy.
Jennifer Sisson (Case 4) MBBS, FRACGP, MPH & TM, FACTM,
FFTM (ACTM), is Medical Director of Travel Doctor TMVC Perth and
GP educator through the RACGP. Dr Sisson is co-author of 'The
effectiveness of intradermal pre-exposure rabies vaccination in an
Australian travel medicine clinic', published in the Journal of Travel
Medicine, and presented on Specific Travel Vaccinations at the
APICTM conference in Melbourne in 2008. She regularly presents to
GPs, practice nurses, and school and adventure travel groups in the
area of travel medicine. Dr Sisson was chair of the Australian Faculty
of Travel Medicine between 2010 and 2014.

Trish Batchelor (Case 1) MBBS, FRACGP, MPH, DipCH, is a GP,

Travel Medicine Specialist and Occupational Physician trainee. Dr
Batchelor has worked at the CIWEC Clinic in Nepal, with International
SOS in Vietnam, was previously Medical Director at the Travel Doctor,
and lectures in travel and tropical medicine on the Postgraduate
Diploma in Travel Medicine at the University of Otago.

Dean Zinghini (Case 2) MBBS, is an intern at Royal Prince Alfred

Hospital and a conjoint associate lecturer at the University of Western
Sydney. He has experience in education on the management of
influenza in the primary care setting and a strong interest in infectious
diseases in general practice.

Penny Burns (Case 2) BMed, MPHTM, is a Senior Lecturer in the

Department of General Practice at Western Sydney University. She
has a range of experience working in primary care in tropical regions
including Far North Queensland, Papua New Guinea and Columbia.
Dr Burns is a member of the Specialist Influenza Group, chaired the
development of the RACGPs Pandemic flu kit in 2014 and represents
the RACGP on the national GP Round Table. She is involved in
research on disasters, including pandemics.

PEER REVIEWERS

Tony Gherardin FRACGP, FACTM, MPH, CTH, is the Senior Medical

Adviser for the Department of Foreign Affairs and Trade, and has lived
and worked in various overseas settings for several years. His main
interests are in travel and tropical medicine.
Nicholas Zwar MBBS, MPH, PhD, FRACGP, is Professor of General
Practice in the School of Public Health and Community Medicine at

CASE 1

check Travel health

UNSW Australia. Professor Zwar has a long-term clinical, teaching

and research interest in travel medicine. He is a member of the
International Society for Travel Medicine (ISTM) and holder of the
ISTM Certificate in Travel Health. Professor Zwar is the RACGP
representative on the Australian Travel Health Advisory Group, a
joint medical and travel industry group promoting healthy travel. He
is a member of the editorial board of the journal Travel Medicine
and Infectious Disease. Professor Zwar has published research on
hepatitis A and hepatitis B risk and vaccination of Australian travellers,
and is currently one of the lead investigators on an Australian
Research Councilfunded grant examining the risks and behaviours of
travellers visiting friends and relatives. Professor Zwar has written a
regular column on travel medicine for Australian Doctor for more than
17 years.
REFERENCES
1. Austrade. Australians travelling overseas. Canberra: Austrade, 2015.
Available at www.tra.gov.au/statistics/australians-travelling-overseas.html
[Accessed 12 November 2015].
2. World Health Organization. Schistosomiasis: A major public health
problem. Geneva: WHO, 2015. Available at www.who.int/schistosomiasis/
en [Accessed 12 November 2015].
3. Vivancos R, Abubakar I, Hunter PR. Foreign travel, casual sex, and
sexually transmitted infections: Systematic review and meta-analysis.
International Journal of Infectious Disease 2010;14(10):e84251.
4. Newall A, Scuffham PA, Hodgkinson B. Economic report into the cost
of influenza to the Australian health system. Melbourne, Vic: Influenza
Specialist Group, 2007.
5. Federal Department of Health. National Notifiable Diseases Surveillance
System Number of notifications of Japanese encephalitis virus infection,
Australia. Canberra: DoH, 2015. Available at www9.health.gov.au/cda/
source/rpt_3.cfm [Accessed 4 December 2015].
6. Knope KE, Doggett SL, Kurucz N, et al. Arboviral diseases and malaria in
Australia, 201112: Annual report of the National Arbovirus and Malaria
Advisory Committee. Commun Dis Intell 2014;38(2):E12343.

ACRONYMS
ASPREN A ustralian Sentinel Practices
Research Network
BCG
Bacillus Calmette-Gurin
CDC
Centers for Disease Control
and Prevention
CRP
C-reactive protein
dTPa
diphtheria, tetanus and pertussis
ELISA enzyme-linked
immunosorbent assay
FBE
full blood evaluation
GP
general practitioner

HBV
HIV
IAMAT
ISTM
JE
LFT
MDR
MERS

hepatitis B virus
human immunodeficiency virus
International Association for
Medical Assistance
to Travellers
International Society for Travel
Medicine
Japanese encephalitis
liver function test
multidrug-resistant
Middle East respiratory
syndrome

MMR
NAAT
NAI
NICE
PHU
RADT
RNA
STI
TB
WHO

mumps, measles and rubella

nucleic acid amplification test
neuraminidase inhibitor
National Institute for Health
Care and Excellence
Public Health Units
rapid antigen detection test
ribonucleic acid
sexually transmissible infection
tuberculosis
World Health Organization

CASE 1

CASE 1
JANE HAS A FEVER
Jane, 29 years of age, is a registered nurse who
presents to you with a two-day history of fever, dry
cough and abdominal pain. She has no significant past
medical history and her only regular medication is the
oral contraceptive pill. She has no known allergies.

check Travel health

On examination, Janes temperature is 38.5C, heart rate is 92

beats per minute and blood pressure is 125/80 mmHg. She looks
only mildly unwell. She has no rash or lymphadenopathy. Her
chest examination reveals bilateral wheeze. Her abdomen is soft
and she has some mild peri-umbilical tenderness.
QUESTION 2
What are your differential diagnoses? What tests would you order?

QUESTION 1
What further information should you obtain from Jane? What physical
examination would you perform?

FURTHER INFORMATION
Janes malaria smears are negative, her blood tests are normal
(apart from a very mild eosinophilia), urinalysis is normal and her
chest X-ray is also reported as normal.
FURTHER INFORMATION
Jane tells you that she returned to Australia three weeks ago
after a four-week trip to Kenya, Uganda and Madagascar. She
spent 10 days in Uganda, which included a trek in the Ruwenzori
mountains, then three days relaxing on the coast of Kenya in
Mombasa, before a two-week eco tourism project in Madagascar.
Jane travelled with four friends, one of whom developed a fever
and itchy rash yesterday. Her friends general practitioner (GP)
had suggested she was having an allergic reaction, perhaps to the
doxycycline she was still taking for malaria prophylaxis.
Jane was vaccinated against yellow fever, hepatitis A and
typhoid prior to her trip. She had previously completed hepatitis B
vaccination, mumps, measles and rubella (MMR) and diphtheria,
tetanus and pertussis (dTPa) vaccinations as part of her
occupational requirement. She had discussed rabies vaccine
with the clinic but decided against it, and had proven immunity
to varicella. She had taken atovaquone/proguanil for malaria
prophylaxis, as directed, and had experienced no side effects.
She recalled many insect bites, had one casual sexual encounter
in Uganda with a British traveller (but had used a condom),
experienced no animal bites, and drank no raw dairy products.
About one week after arriving in Madagascar, she visited the Lily
Waterfall and had a very quick swim, only for about five minutes.

QUESTION 3
What is your working diagnosis?

CASE 1

check Travel health

QUESTION 4

QUESTION 7

What are the common signs and symptoms of acute schistosomiasis?

How is it diagnosed?

Should Janes travelling companions be tested?

QUESTION 8
QUESTION 5
How common is acute schistosomiasis? Where is it found and how is
it treated?

What advice should travellers who are going to schistosomiasisendemic areas be given before travel?

QUESTION 6
What follow-up should Jane be advised to undertake?

CASE 1

CASE 1 ANSWERS

check Travel health

chest X-ray
urinalysis
liver function tests (LFTs)
serum to hold.

ANSWER 1
The usual history taking would apply as for any standard consultation.
It would be easy to dismiss this presentation as just another respiratory
tract infection. However, it is important to ask any febrile patient the
simple question, Have you travelled anywhere in the past 12 months?.
A positive answer should prompt further enquiry into the exact
itinerary, travel dates in each destination, date of return to Australia,
specific exposures, pre-travel vaccinations and, if appropriate, whether
antimalarial medication was prescribed and taken as directed. Specific
exposure enquiries should include sexual contacts, the use of personal
protective measures against insects, insect bites noted, exposure to
fresh water, animal bites, contact with farm animals, and consumption
of other potentially contaminated foods and fluids (eg raw foods). It can
also be helpful to enquire if any of Janes fellow travellers had been
sick either on the trip or after returning to Australia.1
Physical examination should ensure standard vital signs are recorded,
followed by a particular focus on the chest, abdomen and skin.
ANSWER 2
It is important to consider all diseases that you would consider in a nontraveller. A proportion of febrile illness post-travel is caused by nontravel-related infections such as pneumonia or urinary tract infection.
Given Janes sexual encounter and abdominal pain, pregnancy should
be excluded, as should sexually transmissible infections (STIs).
Although Jane took her antimalarial medication as directed, it remains
important to exclude malaria in any febrile traveller who has returned
from a malaria endemic area within the previous 12 months
Plasmodium falciparum is the priority diagnosis.1 Note, the Northern
Territory guidelines recommend testing travellers who have returned
from endemic malaria regions in the past two years.2
The list of differential diagnoses is long; however, the initial focus
should be on identifying any diseases that are rapidly progressive,
treatable or transmissible including:3
malaria
typhoid
leptospirosis
acute human immunodeficiency virus (HIV)
hepatitis E
amoebic liver abscess
East African trypanosomiasis
acute schistosomiasis.
The incubation period of longer than three weeks makes dengue fever,
chikungunya and rickettsial spotted fevers unlikely.3
Initial investigations should include:
malaria smear and rapid test x 3 at 12- to 24-hour intervals
full blood evaluation (FBE)
blood cultures

ANSWER 3
The incubation period, clinical symptoms and signs, and mild
eosinophilia, combined with Jane's freshwater exposure at
the Lily Waterfalls in Madagascar point to a diagnosis of acute
schistosomiasis, also known as Katayama fever.4,5
ANSWER 4
The diagnosis of acute schistosomiasis remains a challenge.
The clinical stages of schistosomiasis reflect the life cycle of the
parasite (Figure 1).6
Some individuals, 5100% in various studies, develop a diffuse
pruritic maculopapular rash within 24 hours of exposure to
freshwater. This reflects a reaction to the transcutaneous
penetration of the cercariae7 and usually only lasts from minutes to
hours. A history of such a reaction should be sought.
The next stage of the lifecycle is the tissue migration and
maturation of the schistosomules. Acute schistosomiasis is
thought to reflect a hypersensitivity reaction to the schistosomules,
and symptoms typically occur two to six weeks after exposure
(range one to 12 weeks). The most common symptoms are fever,
abdominal pain, cough, headache, myalgia and an urticarial rash.
Symptoms may vary with the species (Table 1).

Table 1. Common symptoms of acute

schistosomiasis7,13
Signs and
symptoms

S. mansoni, % S. haematobium, % S. mekongi, %

(n = 95)
(n = 34)
(n = 7)

Fever

54100

9394

86

Abdominal
pain

3393

42

Dry cough

1791

4486

71

Headache

3387

3193

86

Diarrhoea

2581

14

28

Myalgias

5074

1469

28

Neck pain

64

71

No comment

817

1357

71

Urticaria

The symptoms of acute schistosomiasis typically last from days to

weeks, whereas the cough, in particular, can linger for up to six
weeks. There is no specific diagnostic test available at this stage.
Eosinophilia is often, but not universally, present8 and, furthermore,
is often delayed by up to three weeks from the onset of symptoms.7
Ova production does not occur until the end of the maturation
phase, so there is a delay of at least 3050 days between exposure
and egg production. Thus, a search for ova in the stool or urine at
this stage is usually fruitless. Similarly, seroconversion is unlikely to

check Travel health

CASE 1

Figure 1. Schistosome lifecycle

Reproduced with permission from Gray DJ, Ross AG, Li YS, McManus DP. Diagnosis and management of schistosomiasis. BMJ 2011;342:d2651. Available at www.bmj.com/
content/342/bmj.d2651 [Accessed 21 October 2015].

CASE 1

occur less than six weeks after exposure. The mean interval from
the onset of symptoms to seroconversion is 26 days.7
Therefore, diagnosis is based on the exclusion of other infections
and a thorough exposure history.
Acute schistosomiasis usually resolves spontaneously, but there
have been case reports of serious acute complications, including
myocarditis, pericarditis and neurological complications secondary
to eosinophilia-induced cerebral vasculitis.7,9,10
ANSWER 5
Acute schistosomiasis is increasingly being recognised in travellers
returning from endemic countries and can occur with all species. In
one study of 1800 febrile Belgian travellers, acute schistosomiasis
was the third most common cause of fever in travellers from Africa,
after malaria and rickettsial infections.12
The vast majority of cases are found in travellers exposed in
Africa, but in the Asian regions, cases have been reported from
travellers to Laos, where S. mekongi is prevalent. Traditionally, only
southern Laos was considered an area of risk, yet one study found
a small number of travellers with acute schistosomiasis whose only
freshwater exposure was in northern Laos.13
Awareness of acute schistosomiasis in the general practice setting
has been shown to be low.14 A recent report of a cluster of 36
French patients exposed at the Lily Waterfalls in Madagascar
found that 78% ultimately had positive serology. Of these,
82% had symptoms compatible with acute schistosomiasis and
70% of these travellers had seen their GP while sick. Acute
schistosomiasis was not considered as a diagnosis in any of

check Travel health

the patients the diagnoses retained after the first consultation

included viral infection (19%), invasive gastroenteritis (12%),
pneumonia (6%) and typhoid (6%). Rather alarmingly, only 6%
entertained the diagnosis of malaria.14
The current edition of Therapeutic Guidelines Antibiotics does not
make specific comment on acute schistosomiasis.
It is important not to treat acute schistosomiasis with praziquantel,
as this is likely to cause a worsening of symptoms, which may even
become life threatening.9,10 Corticosteroids may be indicated in
severe cases,6 and such cases should be managed by an infectious
diseases physician.
Chronic schistosomiasis remains a major public health issue in tropical
countries. Transmission occurs in 78 countries and over 230 million
people are estimated to be chronically infected.11 There are six species
of schistosomiasis; the majority of cases are caused by Schistosoma
haematobium, S. mansoni and S. japonicum (Figure 2).
ANSWER 6
Periodic serological testing should be undertaken. It may take three
to six months after exposure for serology to become positive.15
Serology does not allow for speciation, so it is worth collecting stool
and urine samples to search for ova. Urine collected in the middle
of the day is more likely to identify ova, but the yield is generally
poor; one Australian study of 28 travellers identified eggs in only
7.8% of those diagnosed via positive serology.16
Praziquantel is an effective treatment against the adult worm17,18
and must be prescribed only after sufficient time has passed to
ensure the parasite is now mature. Three months post-exposure is

Figure 2. Global distribution of schistosomiasis

Reproduced with permission from Gray DJ, Ross AG, Li YS, McManus DP. Diagnosis and management of schistosomiasis. BMJ 2011;342:d2651. Available at www.bmj.com/
content/342/bmj.d2651 and adapted from Gryseels B, Polman K, Clerinx J, Kestens L. Human schistosomiasis. Lancet 2006;368:110618.

CASE 1

check Travel health

recommended, and the Therapeutic Guidelines recommend a dose

of 40 mg/kg divided into two doses of 20 mg, given four hours
apart for S. mansoni and S. haematobium, and 60 mg/kg in three
divided doses for S. mekongi and S. japonicum.19
Serology tends to remain positive for long periods; only 45% of
travellers have a four-fold decrease in serology after 12 months and
64% at 24 months post-treatment.16 Thus, it is not recommended
to repeat serology as a proof of cure.16 One Danish study found a
20% treatment failure rate with single-day praziquantel treatment
on the basis of viable ova identified in tissue samples.20 The authors
recommended consideration of a repeat dose of praziquantel after
one to three months in all travellers; however, this is not reflected
in current Australian guidelines. Yong and colleagues suggest
repeat treatment should instead be confined to those with ongoing
symptoms, ongoing eosinophilia or parasite identification.16
ANSWER 7
All travellers to endemic areas who have had even a one-minute
exposure to fresh water should be tested with serology three months
post travel. Many cases of schistosomiasis in travellers will be
asymptomatic, but there have been numerous case reports of late
complications including infertility.21
ANSWER 8
Travellers should be aware of the possibility of schistosomiasis
transmission with exposures even as short as one minute.21 They
should be aware of the potentially serious complications of acute
schistosomiasis, including myocarditis, pericarditis and neurological
manifestations including seizures, motor paralysis and ataxia.7
Furthermore, travellers should be advised that it is common practice
for locals to tell them that a body of water is safe when this is
not the case. Travellers are often advised by locals to take a dose
of praziquantel immediately after swimming this is not only
ineffective but has been shown to delay the detection of eggs by up
to 11 months, and should thus be avoided.15 Unfortunately, warning
people about schistosomiasis appears to be ineffective. In the group
of French travellers previously described, about half reported that
they were aware of the risk, yet 80% still swam in the waterfall.14
Thus, travellers should be informed of the importance of attending
follow-up three months post-travel for serological testing, even if
they are asymptomatic.
RESOURCES FOR PATIENTS
CDC Frequently asked questions schistosomiasis, www.cdc.gov/parasites/
schistosomiasis/gen_info/faqs.html
IAMAT Be aware of schistosomiasis fact sheet, www.iamat.org/assets/files/
Be Aware of Schistosomiasis_2015.pdf

RESOURCES FOR DOCTORS

CDC schistosomiasis fact sheet, www.cdc.gov/parasites/schistosomiasis
International Association for Medical Assistance to Travellers (IAMAT)
schistosomiasis distribution, www.iamat.org/assets/files/World%20
Schistosomiasis%20Risk%20Chart_2015.pdf

REFERENCES
1. Gheradin T, Sisson J. Assessing fever in the returned traveller. Aust Prescr
2012;35:1014. Available at www.australianprescriber.com/magazine/35/1/
article/1248.pdf [Accessed 21 October 2015].
2. Centre for Disease Control, Darwin and Infectious Diseases Unit, Royal
Darwin Hospital. Guidelines for malaria 2012. Darwin: Northern Territory
Department of Health, 2012.
3. Centers for Disease Control and Prevention. CDC Health information for
international travel 2016. Atlanta, GA: Oxford University Press, 2015.
Available at wwwnc.cdc.gov/travel/yellowbook/2016/post-travel-evaluation/
fever-in-returned-travelers [Accessed December 5 2015].
4. World Health Organization. Schistosomiasis. Geneva: WHO, 2015. Available
at www.who.int/mediacentre/factsheets/fs115/en [Accessed 21 October
2015].
5. Centers for Disease Control and Prevention. Infectious diseases related to
travel: Scistosomiasis. Atlanta, GA: CDC, 2014. Available at wwwnc.cdc.gov/
travel/yellowbook/2016/infectious-diseases-related-to-travel/schistosomiasis
[Accessed 21 October 2015].
6. Gray DJ, Ross AG, Li YS, McManus DP. Diagnosis and management of
schistosomiasis. BMJ 2011;342.
7. Jaurguiberry S, Paris L, Caumes E. Acute schistosomiasis, a diagnostic and
therapeutic challenge. Clinical Microbiology and Infection 2010;16(3):22531.
8. Meltzer E, Artom G, Marva E, Assous MV, Rahav G, Schwartzt E.
Schistosomiasis among travelers: New aspects of an old disease. Emerg
Infect Dis 2006;12(11):1696700.
9. Jaureguiberry S, Ansart S, Perez L, Danis M, Bricaire F, Caumes E. Acute
neuroschistosomiasis: Two cases associated with cerebral vasculitis. Am J
Trop Med Hyg 2007;76(5):96466.
10. Epelboin L, Jaurguiberry S, Estve JB, et al. Myocarditis during acute
schistosomiasis in two travelers. Am J Trop Med Hyg 2010;82(3):36567.
11. Colley DG, Bustinduy AL, Secor WE, King CH. Human schistosomiasis.
Lancet 2014;383(9936):225364.
12. Bottieau E, Clerinx J, Schrooten W, et al. Etiology and outcome of fever after
a stay in the tropics. Arch Intern Med 2006;166(15):164248.
13. Leshem E, Meltzer E, Marva E, Schwartz E. Travel-related schistosomiasis
acquired in Laos. Emerg Infect Dis 2009;15(11):1823.
14. Rochat L, Bizzini A, Senn N, Bochud PY, Genton B, de Vallire S. Acute
schistosomiasis: A risk underestimated by travelers and a diagnosis
frequently missed by general practitioners A cluster analysis of
42travelers. J Travel Med 2015;22(3):16873.
15. Grandiere-Perez L, Ansart S, Paris L, et al. Efficacy of praziquantel
during the incubation and invasive phase of schistosoma haematobium
schistosomiasis in 18 travelers. Am J Trop Med Hyg 2006;74(5):81418.
16. Yong MK, Beckett CL, Leder K, Biggs BA, Torresi J, OBrien DP. Longterm
followup of schistosomiasis serology posttreatment in Australian travelers
and immigrants. J Travel Med 2010;17(2):8993.
17. Corachan M. Schistosomiasis and international travel. Clin Infect
Dis 2002;35(4):44650. Available at http://cid.oxfordjournals.org/
content/35/4/446.long#ref-15 [Accessed 21 October 2015].
18. Centers for Disease Control and Prevention. Parasites: Scistosomiasis.
Resources for health professionals. Atlanta, GA: CDC, 2012. Available at
www.cdc.gov/parasites/schistosomiasis/health_professionals [Accessed 21
October 2015].
19. Therapeutic Guidelines. Antibiotics: Miscellaneous infections:
Schistosomiasis. In: eTG complete [Internet] Melbourne: Therapeutics
Guidelines, 2015.
20. Helleberg M, Thybo S. High rate of failure in treatment of imported
schistosomiasis. J Travel Med 2010;17(2):9499.
21. Bailey SL, Price J, Llewelyn M. Fluke infertility: The late cost of a quick
swim. J Travel Med 2011;18(1):6162.

CASE 2

CASE 2

check Travel health

QUESTION 2
What is the most likely diagnosis?

AMY PRESENTS WITH A DRY COUGH

It is January and Amy, aged 22 years, calls your
practice requesting an appointment. She takes the
last free appointment and comes in to see you. She
says she is staying with one of your regular patients,
a mother with two children, aged 3 and 6, who is
pregnant with her third child. She complains that for the
past three days, she has had a horrible dry cough, has
been feeling hot and tired, and just feels sore all over.

QUESTION 1
How would you manage this consultation? What features of the
history are you most interested in?

FURTHER INFORMATION
Amy tells you that while she visited her grandmother at the local
nursing home, the television news was reporting about Middle
East respiratory syndrome (MERS). Amy is worried that she
might have MERS.
QUESTION 3
Where would you look for information and support in management if
you suspected MERS in the differential?

FURTHER INFORMATION
Amy is a healthy, active university student. She describes an
abrupt onset of symptoms one day after arriving home from a
recent overseas trip. She spent most of her time staying with
friends in Tokyo, Japan who were also coughing and unwell. Amy
also spent several days in Saudi Arabia visiting temples at the
beginning of the trip five weeks ago. She is otherwise well and
has no personal or family history of asthma or other respiratory
conditions. She is a nonsmoker. She tells you that she has not had
any vaccinations since she left high school.
On examination, Amy has a temperature of 38.5C and looks
flushed. She has a respiratory rate of 25 breaths/min with
no respiratory distress. Her respiratory and cardiovascular
examinations are unremarkable.

10

CASE 2

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QUESTION 4
Would you consider doing any investigations? What is your rationale
for this choice? Would you consider giving Amy any medication?

CASE 2 ANSWERS
ANSWER 1
Transmission of infection
As Amy has presented with symptoms of a communicable disease, it is
important to consider the risk of transmission both within your practice and
with outside contacts. It would be reasonable to consider implementing
transmission-based procedures (ie droplet and contact precautions).13
This could include offering the patient a surgical mask to wear when not in
isolation, and practising hand hygiene and cough etiquette.

QUESTION 5
What is the risk for the pregnant mother if she acquires Amys
illness? What is the benefit of vaccination for the mother?

The use of signage in practices informs patients presenting with flulike symptoms to immediately tell staff on arrival, to don a surgical
mask (Grade C evidence), and perform hand hygiene (Grade B
evidence) with use of alcohol-based hand rubs that contain 6080%
v/v ethanol or equivalent (Grade B evidence) or, if visibly dirty, using
soap and water (Grade B evidence).14
History and examination
A full history is important in attaining a likely diagnosis. The
onset, duration and severity of symptoms, as well as associated
symptoms, will be important in guiding clinical management. Ask
about associated symptoms including cough, dyspnoea, sore throat,
myalgia, headaches and diarrhoea.5
Details of recent travel and vaccination status are vital in formulating
a diagnosis of communicable disease. A history of contact with
unwell individuals and a knowledge of the epidemiology of disease
prevalence in the countries visited will help to rule out conditions such
as malaria, and rule in others such as influenza. Websites such as
CDC Travel have updated information available.6

FURTHER INFORMATION
Amy reminds you that she visited her elderly grandmother at the
local nursing home while she was unwell. Her grandmothers
medical history includes hypertension, hyperlipidaemia and a past
history of acute myocardial infarction one year ago.

A history of contact with animals (eg poultry or bats during travel in

Asia) is useful in reference to possible contact with the H5N1 avian
influenza or rabies.7
Exploring the patients comorbidities, including chronic conditions
such as cardiovascular, respiratory, obesity, smoking, and pregnancy
status, will assist in understanding the patients risk of developing
serious illness.8

QUESTION 6

Identification of any potential contact at high risk of complications from

an infectious disease is useful for early detection and treatment of others.
Amy has had contact with a pregnant woman and her two children.

What places Amys grandmother at higher risk? What is the benefit of

vaccination for those in this risk group?

ANSWER 2
Considering that Amy was predominantly in Japan, potential risks
include hepatitis A and B, Japanese encephalitis (JE), rabies, tickborne encephalitis, H5N1 avian influenza and current seasonal
influenza. Most of these can be excluded by her presenting symptoms
and the fact she spent her time in the city. For example, she is not at
high risk for JE as she was not in rural areas or in the peak season.6,9
The most likely diagnosis is seasonal influenza.
Influenza is the most common vaccine-preventable health risk
for travellers.8 Hundreds of millions of people travel annually and
1550% experience health problems. Respiratory tract infections,
including pharyngitis, influenza and pneumonia, are the second most
common cause of illness in travellers, and of fever.10,11

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In particular, influenza is associated with travel to the Northern

Hemisphere during the period of December through February.
Travellers to tropical regions are at risk of influenza all year round.12
Amy was in Japan in January, the peak influenza season in the
Northern Hemisphere. Amy also had other significant risk factors for
influenza, including a trip duration of >30 days and the reason for
travel being to visit friends and relatives. The latter alone increases
the risk of acquiring influenza six-fold.11
This knowledge allows targeting of higher risk individuals for pretravel influenza vaccination, which should be given two weeks prior
to travel to allow for the development of immunity.5 There is currently
no evidence available to support re-vaccination before overseas travel
in those who have already been vaccinated during the preceding
influenza season, so re-vaccination is not recommended.12
There are different vaccines available for northern and southern
hemispheres. These are only available in the relevant hemispheres.12
The vaccines differ as the influenza viruses that become the
predominant seasonal flu vary over time and geographical regions. The
influenza vaccines are revised after each season at the recommendation
of WHO, which advises on the strains predicted to be circulating in the
upcoming season in the particular geographical region. Currently, these
vaccines contain three or four strains. Sometimes, the genetic code in a
flu strain can drift, or mutate, within the six-month flu season to reduce
the effectiveness of the vaccine. This occurred in the previous winter
(201415) in the Northern Hemisphere, and the effectiveness of the
vaccine was shown to be around 23%.32
There is no pathognomonic symptom of influenza, so diagnosis based
on symptoms and signs alone is limited and must be assisted by
epidemiological data to support the clinical suspicion: in this case, the
annual peak influenza season in Japan.
Several studies have shown that during influenza season, cough and
fever >38C have a positive predictive value of 7986.8%, and a
sensitivity of 7785% with the inclusion of myalgias.5
Influenza viruses are single-stranded ribonucleic acid (RNA)
orthomyxoviruses classified as A, B or C subtypes. The A and B
subtypes can cause significant disease in humans. The incubation
period is usually two to three days but can last up to one week. After
an incubation period of one to three days, influenza often manifests
as a sudden onset of systemic symptoms such as malaise, lethargy,
headache, myalgia and anorexia, with fever particularly prominent.
Sore throat, cough, nasal discharge and sneezing can also be
present. Fevers and myalgias can last three to five days, and the
cough may persist for longer than two weeks.8,10,13,14
ANSWER 3
Amy was not in Saudi Arabia within the last 14 days, so her case
does not fit the current case definition for MERS.15 She therefore does
not fit the epidemiological criteria, and so is unlikely to have MERS
(the recent MERS guidelines are available at www.health.gov.au/
internet/main/publishing.nsf/Content/5691BD39B3859DBCCA257BF0
001A8E27/$File/MERS-CoV-Information-GPs-2015-09-14.pdf).15
Guidelines for general practitioners (GPs) on emerging infectious diseases
including case definitions, investigations, treatment and management
are available on the relevant state/territory and Commonwealth health
websites.15 These guidelines are regularly updated.

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Local Public Health Units (PHU) are available for consultation and
advice in such situations, and should be alerted immediately to any
potential threat. Infectious disease consultants at the local hospital are
also a source of information and advice. Notification of such diseases
to the local PHU is required under the Public Health Act 2010; MERS
and influenza are currently notifiable diseases. Information and forms
are available on state health websites. If you did suspect MERS as per
the guidelines, you would isolate the patient in a single room using
standard and transmission-based precautions,1 and immediately call
the local PHU. Current advice is that you should not collect specimens
for testing.15 Laboratory-confirmed influenza should be notified in
writing within five days of diagnosis.3
A returned traveller with a fever is a potential carrier of a new
infectious disease across international borders. GPs involved with
the Australian Sentinel Practices Research Network (ASPREN; www.
aspren.com.au/index.html) are swabbing 25% of patients presenting
with fever, cough and fatigue as part of frontline surveillance, but all
GPs are a crucial part of the frontline surveillance. Early identification
by GPs can assist in preventing the spread of the disease.
ANSWER 4
Influenza can be difficult to distinguish from respiratory illnesses
caused by other pathogens on the basis of signs and symptoms
alone. Diagnosis is usually made clinically on the basis of symptoms
with consideration of the epidemiological context for example, in
a clinical illness consistent with uncomplicated influenza in an area
where influenza virus is prevalent.5,8,13
There are many other organisms that can cause similar influenzalike illness, including respiratory syncytial virus, parainfluenza virus,
adenovirus, rhinovirus and coronavirus; all are common causes of
lower and upper respiratory tract infections.5,10
In cases where a definite diagnosis would support clinical decision
making and help define treatment choices, diagnostic testing such as
nasopharyngeal swabs should be considered5 for example, if:17
the condition was severe
the results would change management
there is a high risk of complications in the patient or contacts
the epidemiological data did not support the diagnosis
it was an institutional setting.
In this situation, as there are four contacts at high risk of
complications (your regular patient and her two children, and Amys
grandmother), performing a nasopharyngeal viral swab for culture
could be indicated. Nasopharyngeal specimens usually have higher
yield than nasal or throat swab specimens.18 Although viral culture
will provide the most accurate method of diagnosis, a result is often
available only in two to 10 days (see 'Resources for Doctors' for a
guide on the collection of nasopharyngeal specimens.)5,12,13 Note that
laboratory-confirmed influenza is notifiable in Australia.
The neuraminidase inhibitors (NAIs) currently available in Australia,
oseltamivir (Tamiflu) and zanamivir (Relenza), are active against
influenza A and B viruses.12 These antivirals work by preventing the
release of the virus from infected cells to reduce spread. If the NAIs
are taken within 48 hours of onset of symptoms, they have been
shown to limit the duration of illness by one to three days, as well as

CASE 2

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decrease the severity of illness with a reduction in complications such

as pneumonia, otitis media, hospitalisation mortality, antibiotic use
and disease progression.15,19
NAIs are well tolerated and severe events are rare. Oseltamivir can
cause nausea and vomiting in the first two days, so should be taken
with food. There have been reports of wheezing or shortness of breath
after zanamivir, so it should be avoided in those with chronic lung
disorders such as asthma or chronic obstructive pulmonary disease.19
Administration of antiviral therapy is usually reserved for high-risk
patients and is based on clinical judgement that takes into consideration
the patients age and comorbidities, the disease severity, the likelihood
of influenza, and time since onset of symptoms.19
Current recommendations suggest antiviral medication should be
considered for patients within 48 hours of onset of influenza-like
illness and with likely exposure and at high risk of complications from
influenza. Those at high risk include:1922
>65 years of age
pregnant20
have chronic illnesses including cardiac, respiratory, neurological,
endocrine (diabetes), renal and immunological conditions
have significant obesity (BMI >30 kg/m2)
younger than 10 years old and are receiving long-term aspirin
therapy
Aboriginal and Torres Strait Islander peoples aged >15 years old
residents of nursing homes and other chronic care facilities
individuals who are experiencing homelessness
children younger than five years of age, especially younger than
two years.
There has been ongoing international discussion on the use of NAIs.
A report recently released by the Academy of Sciences and Wellcome
Trust reviewing the use of antivirals in influenza concluded that there
is no evidence for the routine use of NAIs in patients with seasonal
influenza who are not severely ill, unless the seasonal influenza is
particularly virulent or prevalent.16 It suggests there is evidence to
support the use of NAIs in the treatment of hospitalised patients,
including women who are pregnant. The review notes a need for
more evidence on some of the other high-risk groups and children.16
There are no indications to treat Amy with NAIs. She has presented
outside the 48-hour window, is not severely unwell, was in an area
of high influenza prevalence and is at low risk for complications.
Amy should be advised to isolate herself from anyone at high risk of
complications from influenza. Most adults who are ill with influenza
are infectious from the day before symptom onset to approximately
five to seven days after symptom onset. Ninety-five percent of virus
transmission occurs within threedays of illness onset.12

evidence from Omer et al showed that confirmed influenza in pregnancy

nearly doubled the risk of fetal death.26
Vaccination with inactivated influenza vaccine is safe for pregnant
women at any stage of the pregnancy or while breastfeeding,8,27,28
and reduces the risk of contracting influenza by about 70%.22 It is
also the most effective way to protect young babies during the first six
months.8,19,29 All influenza vaccines currently available in Australia are
inactivated viruses containing three or four strains of virus.8
Children are more likely to present with symptoms of vomiting and
diarrhoea than adults. They have higher rates of influenza than adults
and may shed the virus for longer, making them a major source of
transmission. Although it varies with the particular strain of influenza,
children under two years of age are more likely to be hospitalised due
to influenza complications. The hospitalisation rate is similar to that
of the elderly, but with a much lower mortality rate. Children under
six months tend to develop severe disease.12 As mentioned above,
maternal vaccination is the most effective protection for this group.
As the children Amy was in contact with are older than two years
of age, they are not in the higher risk group. Vaccination would not
protect the children from the recent exposure.
The current childhood vaccination schedule does not include routine
influenza vaccination for children, except for those older than six
months, who are at high risk of influenza complications due to
medical conditions, or Aboriginal and Torres Strait Islander peoples.
Note that the influenza vaccination and age eligibility may vary from
year to year as the influenza strain and the vaccines change.8
ANSWER 6
Amys grandmothers age and her chronic condition increase her risk
of complications from influenza. She is at higher risk of serious lower
respiratory tract infections such as bacterial pneumonia. Pneumococcal
and influenza vaccination status should be up to date.4,8
Her institutional setting increases the need for early accurate
diagnosis and management, along with transmission-based infection
control to manage any risk of communicable disease, such as
influenza, early.5,14,20,30
Worsening of underlying chronic diseases and precipitation of
cardiovascular events are potential complications of influenza.
MacIntyre et al have recently reported a significant reduction in
cardiovascular death in patients vaccinated for influenza; influenza
vaccination reduced the risk of acute myocardial infarction by 45% in
those with a prior history.31 Although influenza does not predict the
occurrence of an acute myocardial infarction, having the influenza
vaccination was significantly protective against acute myocardial
infection, yet is still underused.31
RESOURCES FOR DOCTORS

ANSWER 5
Amys pregnant contact is at increased risk of both catching influenza
from Amy due to the suppression of the immune system during
pregnancy, and of complications if she does. Pregnant women have a
five-fold increased risk of hospitalisation for H1N1 influenza.8 Influenza
infection increases the risk of stillbirth, premature birth and poor fetal
growth,23 with protection provided by the flu vaccination.2426 Recent

Australian Immunisation Guidelines, www.immunise.health.gov.au/internet/

immunise/publishing.nsf/Content/Handbook10-home
Department of Health Health professionals site for up-to-date information
on current diseases of concern that may arrive in Australia, www.health.
gov.au/internet/main/publishing.nsf/Content/For+Health+Professionals-1
The Royal Australian College of General Practitioners Managing
pandemic influenza in general practice, www.racgp.org.au/your-practice/
business/tools/disaster/pandemics

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CASE 2

Influenza Specialist Group Guidelines for GPs, www.isg.org.au

FluNet World Health Organization (WHO) Influenza Laboratory Surveillance
Information, www.who.int/influenza/gisrs_laboratory/flunet/charts/en
National Institute for Health Care and Excellence (NICE) guidelines, www.
nice.org.uk/guidance
Centers for Disease Control and Prevention (CDC) Travelers health,
wwwnc.cdc.gov/travel

check Travel health

internet/main/publishing.nsf/Content/5691BD39B3859DBCCA257BF000
1A8E27/$File/MERS-CoV-Information-GPs-2015-09-14.pdf [Accessed 2
October 2015].
16. Academy of Medical Sciences and Wellcome Trust. Use of neuraminidase
inhibitors in influenza. London: Wellcome Trust, 2015. Available at: www.
acmedsci.ac.uk/more/news/prepare-to-conduct-pandemic-flu-trials-inhospitals-now [Accessed 9 October 2015].

REFERENCES

17. DynaMed Plus. Recommendations influenza in adults. Ipswich, MA: EBSCO

Information Services, 2015. Available at http://web.a.ebscohost.com/
dynamed/detail?vid=3&sid=8f56e1cf-9ee1-4092-bdee-3ceaa25531b0%4
0sessionmgr4003&hid=4206&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3
BlPXNpdGU%3d#AN=435301&db=dme [Accessed 1 October 2015].

1. National Health and Medical Research Council. Australian guidelines for the
prevention and control of infection in healthcare. Canberra: NHMRC, 2010.
Available at: www.nhmrc.gov.au/_files_nhmrc/publications/attachments/
cd33_complete.pdf [Accessed 20 September 2015].

18. Center for Disease Control and Prevention. Rapid diagnostic testing for
influenza: Information for health care professionals. Atlanta, GA: CDC,
2015. Available at www.cdc.gov/flu/professionals/diagnosis/rapidclin.
htm#table2 [Accessed 29 October 2015]

2. The Royal Australian College of General Practitioners. Infection prevention

and control standards: For general practices and other office-based and
community-based practices 5th edn. East Melbourne, Vic: RACGP, 2014.
Available at www.racgp.org.au/your-practice/standards/infectioncontrol
[Accessed 6 October 2015].

19. Influenza Specialist Group. Antiviral treatments for influenza: A guide for
general practitioners. Melbourne: Influenza Specialist Group, 2014.

CDC specimen collection posters, www.cdc.gov/flu/pdf/freeresources/

healthcare/flu-specimen-collection-poster.pdf

3. Communicable Disease Network Australia. Influenza infection: National

guidelines for public health units. Canberra: Department of Health, 2011.
Available at: www.health.gov.au/internet/main/publishing.nsf/Content/cdnasong-influenza.htm [Accessed 3 October 2015].
4. The Royal Australian College of General Practitioners. Managing pandemic
influenza in general practice. East Melbourne, Vic: RACGP, 2014. Available at
www.racgp.org.au/your-practice/business/tools/disaster/pandemics [Accessed
22 September 2015].
5. Montalto N. An office-based approach to influenza: Clinical diagnosis and
laboratory testing. Am Fam Physician 2003;67(1):11118 Available at www.
aafp.org/afp/2003/0101/p111.pdf [Accessed 22 September 2015].
6. Centers for Disease Control and Prevention. Travellers health. Atlanta, GA:
CDC, 2015. Available at wwwnc.cdc.gov/travel [Accessed 6 December 2015].
7. Centers for Disease Control and Prevention. Yellow book travelers health
Chapter 3: Infectious diseases related to travel. Avian bird flu. Atlanta,
GA: CDC, 2013. Available at wwwnc.cdc.gov/travel/diseases/avian-bird-flu
[Accessed 2 October 2015].
8. Department of Health. The Australian immunisation handbook 10th edition.
Canberra, ACT: DoH, 2014.
9. Centers for Disease Control and Prevention. Japanese encephalitis. Atlanta,
GA: CDC, 2015. Available at www.cdc.gov/japaneseencephalitis/qa/index.html
[Accessed 27 October 2015].
10. Radojicic C. Influenza infection. London: BMJ Best Practice, 2015. Available
at http://bestpractice.bmj.com/best-practice/monograph/6/highlights.html
[Accessed 27 Sept 2015].
11. Leder K, Sundararajan V, Weld L, Pandey P, Brown G, Torresi J. Respiratory
tract infections in travelers: A review of the geosentinel surveillance network.
Clinical Infectious Diseases 2003;36(4):399406.
12. Epperson S, Bresee J. Yellow book travelers health Chapter 3: Infectious
diseases related to travel: Influenza. Atlanta, GA: CDC, 2015. Available at
wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/
influenza [Accessed 6 December 2015].
13. Center for Disease Control and Prevention. Influenza signs and symptoms
and the role of laboratory diagnostics. Atlanta, GA: CDC, 2015. Available at
www.cdc.gov/flu/professionals/diagnosis/labrolesprocedures.htm [Accessed
2October 2015].
14. Influenza Specialist Group. Treatment of influenza in interpandemic periods.
Melbourne: Influenza Specialist Group, 2006.
15. Department of Health. Information for GPs on Middle Eastern respiratory
syndrome (MERS). Canberra: DoH, 2015. Available at www.health.gov.au/

14

20. Cheng A, Dwyer D, Kotsimbos A, et al. 2009 Summary of the Australasian

Society for Infectious Diseases and the Thoracic Society of Australia and
New Zealand Guidelines: Treatment and prevention of H1N1 influenza 09
(human swine flu) with antiviral agents. Med J Aust 2009;191(3):14245.
21. National Institute for Health and Clinical Excellence. Amatadine, oseltamivir
and zanamivir for the treatment of influenza. NICE technology appraisal
guidance 168. London: NICE, 2009. Available at www.nice.org.uk/
guidance/ta168 [Accessed 2 October 2015].
22. Center for Disease Control and Prevention. 2015 Seasonal influenza health
professionals antiviral drugs influenza antiviral medications: Summary
for clinicians. Atlanta, GA: CDC, 2015. Available at www.cdc.gov/flu/
professionals/antivirals/summary-clinicians.htm [Accessed 4 October 2015].
23. Influenza Specialist Group. Influenza and pregnancy: A guide for doctors
and midwives. Melbourne: Influenza Specialist Group, 2006. Available at
www.isg.org.au/assets/assets/Pregnancy-7.pdf [Accessed 28 September
2015].
24. Kallen B, Olausson PO. Vaccination against H1N1 influenza with Pandemrix
during pregnancy and delivery outcome: A Swedish register study. BJOG
2012;119(13):158390.
25. Haberg, S et al. Risk of fetal death after pandemic influenza virus infection
or vaccination. N Engl J Med 2013;368:33340.
26. Omer S, Goodman D, Steinhoff M, et al. Maternal influenza immunization
and reduced likelihood of prematurity and small for gestational age births:
A retrospective cohort study. PLoS Med 2011;8(5):e1000441.
27. Osterholm MT, Kelley NS, Sommer A, Belongia EA. Efficacy and
effectiveness of influenza vaccines: A systematic review and meta-analysis.
Lancet Infect Dis 2012;12(1):3644.
28. Tamma PD, Ault KA, del Rio C, et al. Safety of influenza vaccination during
pregnancy. Am J Obstet Gynecol 2009;201(6):54752.
29. Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal influenza
immunization in mothers and infants. N Engl J Med 2008;359(15):155564.
30. Stuart R, Cheng A, Marshall C, Ferguson J. ASID (HICSIG) position
statement: Infection control guidelines for patients with influenza-like
illnesses, including pandemic (H1N1) influenza 2009, in Australian health
care facilities. Med J Aust 2009:191(8):45458. Available at www.asid.net.
au/documents/item/147 [Accessed 28 September 2015].
31. Macintyre C, Heywood A, Kovoor P, et al. Ischaemic heart disease,
influenza and influenza vaccination: A prospective case control study. Heart.
2013;99(24):184348.
32. Flannery B, CLippard J, Zimmerman RK, et al. Early estimates of seasonal
influenza vaccine effectiveness, United States, January 2015. Atlanta, GA:
Centers for Disease Control and Prevention, 2015.

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QUESTION 3

CASE 3
ELIZABETH VOLUNTEERS TO TRAVEL TO
EAST TIMOR
Elizabeth, 52 years of age, is a general practitioner
from Melbourne who is planning to travel to TimorLeste (East Timor) to volunteer for one to two weeks
in a medical clinic in the capital, Dili. She intends to
travel there annually after this trip to volunteer for
one to three weeks at a time. On her first trip, she
will spend most of her time in Dili, but intends to visit
some rural areas and work during the day with a
mobile clinic, then stay in Dili at night. During future
trips, she is likely to spend more time in rural areas,
staying in simple accommodation. Elizabeth is up to
date with her hepatitis A and B vaccines.

What other preventive measures would you advise? What are the
other two main mosquito-borne infections to prevent?

FURTHER INFORMATION
Elizabeth asks about a recent case of Japanese encephalitis (JE)
acquired in Bali.

QUESTION 1
Which travel vaccines would you recommend for Elizabeth?

QUESTION 4
Is Elizabeth at risk of acquiring JE? Would you advise Elizabeth to
vaccinate against JE?

QUESTION 2
Would you recommend malaria prophylaxis? If so, which medication(s)
would you recommend?

FURTHER INFORMATION
Elizabeth is leaving in two weeks and decides to be vaccinated
against JE. She requests information about the vaccine(s) and timing
of booster doses. She also asks about another doctor travelling with
her, who has previously been vaccinated with JE-Vax.

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CASE 3

QUESTION 5
Which vaccine do you recommend for Elizabeth? What general advice
can you give regarding JE vaccine boosters for her colleague?

check Travel health

CASE 3 ANSWERS

ANSWER 1
Elizabeth should be up to date with routine vaccinations, including
measles, mumps and rubella (MMR); diphtheria, tetanus and pertussis
(dTpa); varicella; polio and the annual influenza vaccine. She should also
have a typhoid vaccine1 and consider vaccination for JE and rabies.2
The incidence of tuberculosis (TB) in East Timor is >100 cases per
100,000 population, the highest risk category.3,4 However, the proportion
of multidrug-resistant (MDR) TB is thought to be low,5 with only three
laboratory-confirmed cases of MDR TB reported in 2014.6 TB infection
control measures should be instituted at the clinic. Bacillus CalmetteGurin (BCG) vaccine is not indicated unless the risk of exposure to
multidrug-resistant TB is high,1,3,4,7 but tuberculin skin testing or
quantiferon testing could be considered before and after travel.3,5
FURTHER INFORMATION

ANSWER 2

Elizabeth is up to date for the MMR and influenza vaccines, and

has natural varicella immunity. She will defer her rabies vaccine
due to the lack of time. She decides to have the Imojev vaccine,
but needs to have a typhoid vaccine and a tetanus, diphtheria,
pertussis and polio vaccine on the same day.

The risk of exposure to malaria is high in rural areas of East Timor.

The advice regarding malaria risk in Dili varies from low8 to very
high,9 and is probably variable and seasonal. Although her trip is
short, Elizabeth should be advised to take malaria prophylaxis.9 Local
information can be helpful in this setting.

QUESTION 6
What do you advise?

Malaria in East Timor is chloroquine-resistant. Of the malaria species,

50% are Plasmodium falciparum, nearly 50% are P. vivax, and <1%
are P. ovale or P. malariae.1
The recommended antimalarial medications are either:
doxycycline 100 mg once daily, starting one day before entering
and continuing for four weeks after leaving the malarial area
atovaquone 250 mg/proguanil 100 mg tablets (malarone), starting
one to two days before and continuing for seven days after leaving
the malarial area.
ANSWER 3
It is important to give advice on avoidance of mosquito bites by covering
up with clothing such as long sleeves and trousers, especially after
sunset (but also during the day, to prevent dengue fever); regularly
applying DEET-containing insect repellents on exposed skin; and
using insecticide-impregnated mosquito nets when necessary. Spray
thin clothing with insect repellent or pre-impregnate with permethrin,
and spray insecticide in the room or use pyrethroid mosquito coils. If
travelling to high-risk malarious areas that are remote from medical
facilities, carrying emergency malaria standby treatment may be
considered,1 especially for trips that are three weeks or longer.9
The other two main mosquito-borne infections to prevent are dengue
fever, which is associated with urban areas and daytime mosquitoes,911
and JE. Chikungunya has also been reported in Timor.12
ANSWER 4
JE is the leading cause of viral encephalitis in Asia and occurs in
almost all Asian countries.13 It is a zoonosis that is transmitted

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in an enzootic cycle between Culex mosquitoes and amplifying

vertebrate hosts, mainly pigs and wading birds. Infection and
illness in humans are incidental and there is no person-to-person
transmission.1,14 Culex mosquitoes feed outdoors between dusk and
dawn, and breed in flooded rice paddies and marshy environments.15
Approximately one in 2501000 infections in susceptible humans
hosts is symptomatic,14,15 but in non-indigenous individuals, including
travellers, this figure may be up to one in 25.7
JE occurs in rural areas, city peripheries and urban areas of most
Asian countries, including East Timor (Figure 1), Papua New Guinea
and in the outer Torres Strait Islands of Australia (including three
cases on Badu Island, two of which were fatal). Nine cases of JE have
been notified in Australia since 2001.15 Most recently, a traveller,
45 years of age, developed symptoms of encephalitis four days after
returning from Indonesia, the first JE infection notified in Victoria.16
Transmission can occur in a seasonal or year-round pattern.1,14
Information regarding the risk of JE by country, with geographical and
seasonal information, can be found on the Centers for Disease Control
and Prevention (CDC) website (see 'Resources for doctors').
In Timor-Leste, sporadic cases of JE are reported and the disease is
presumed to be endemic countrywide. The World Health Organization
(WHO) considers Timor-Leste to be an area of high incidence with

countrywide endemic areas.17 Transmission season has been reported

to occur during the rice-growing seasons from September to December
and February to May,14 although the CDC reports a lack of data
regarding seasonal transmission.1 The risk is high on the Maliana Plain
and data suggest that 65% of Dilis population tested were seropositive
for JE by enzyme-linked immunosorbent assay (ELISA).14
The estimated overall incidence of JE among travellers from nonendemic countries to Asia is less than one per one million travellers.
This risk increases with risk factors and prolonged stays. Risk
factors for JE infection include exposure to mosquitoes between
dusk and dawn in rural areas (more likely in longer term visitors who
spend time outdoors, including aid workers, students, missionaries,
researchers, cyclists or hikers and expatriates).1,15
Other specific risk factors include age >50 years, JE infection
in childhood, dual neurological infections (eg with mumps or
neurocysticercosis), compromised bloodbrain barrier (cochlear
implants, shunts etc), pregnancy (miscarriage in first or second
trimester), genetic susceptibility, and those with chronic conditions
such as solid organ transplantation, cardiovascular disease, diabetes
mellitus and renal disease.1,15
There is no specific antiviral treatment for patients with JE, and
management is supportive.18

Figure 1. Geographic distribution of Japanese encephalitis virus

Reproduced with permission from Centers for Disease Control and Prevention. Geographic distribution of Japanese encephalitis virus. Atlanta, SA: CDC,2015. Available at www.cdc.gov/
japaneseencephalitis/maps [Accessed 15 December 2015].

17

CASE 3

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Vaccination advice
Although Elizabeths current trip will be short and the risk of JE
exposure is low, she will be spending the nights in an urban area (and
Culex mosquitoes are active from dusk until dawn), she plans to travel
to East Timor annually (with repeated risk of exposure) and plans
to visit rural areas overnight in the future. Although JE vaccination
remains optional for this trip, it will be useful for future travel and
should be considered (Table 1). Elizabeth has also expressed concern
about her risk of exposure given the recent case notified in Victoria.

Table 1. Vaccine recommendations for JE vaccination1,3,14

Current NHMRC recommendations for JE vaccination, and individuals
in whom to consider vaccination because of increased risk
Current NHMRC vaccine
recommendations

Consider vaccination in these

groups

Travellers spending 1 month or more

in rural/endemic areas of Asia or
Papua New Guinea, especially during
transmission season, including those
based in urban areas but are likely to
visit rural areas; and/or considerable
outdoor activity, and/or staying in
suboptimal accommodation, even in
shorter-term travellers; or <1 month
in areas of epidemic transmission

Repeat travellers who are at

risk of cumulative duration of
exposure

All other travellers spending 1

year or more in Asia, including
urban areas (except Singapore,
where cases have been reported
but routine vaccination is not
recommended). Up-to-date
information on country-specific
JE risk can be found at wwwnc.
cdc.gov/travel/yellowbook/2016/
infectious-diseases-related-to-travel/
japanese-encephalitis#3880

have greater outdoor exposure

Residents of the outer Torres Strait

Islands

are on anti-TNF therapy

Non-residents who will be working in

the outer Torres Strait islands for 30
days or more during the wet season
(December to May). The risk is
greatest from February to March
All those who wish to minimise risk /
request vaccination if fully informed
of risks and benefits

Any individual with prolonged

duration of stay, regardless of
itinerary
Any traveller to rural areas
Travellers visiting regions at risk
of JE transmission who:
are aged >50
are aged <10 (greater risk of
mosquito bites)
have chronic conditions such
as hypertensions, diabetes
mellitus, chronic renal disease
have had solid organ
transplant, cochlear implant or
ventriculoperitoneal shunts
are known to have genetic
predisposition to JE (eg
CCR5delta32 homozygosity)
are pregnant (risk of
miscarriage in first and
second trimester)

ANSWER 5
Vaccine options in Australia include inactivated Japanese encephalitis
vaccine (JEspect), and monovalent live, attenuated vaccine (Imojev).
These are safer than the inactivated mouse brain-derived JE vaccine,
JE-Vax, which is no longer manufactured,7 and carried a risk of
neurological and delayed hypersensitivity reactions.14,15 Both vaccines
were registered on the basis of an immunological correlate of
immunity, a neutralising antibody titre of 1:10.7 Other vaccines are
available and in use overseas.13

18

Imojev is a single-dose, Vero cellderived, live attenuated,

monovalent, recombinant viral vaccine. A booster is not necessarily
required in adults, but may be considered after five years.7,14,19
In children vaccinated at 1224 months of age with a single dose of
Imojev, protective antibody levels were demonstrated in 75% at three
years.7 There are no immunogenicity data for children aged eight to
17 years, so immunity is assumed on the basis of the available data in
other age groups. A booster dose is recommended in children over nine
months of age to <18 years, one to two years after the primary dose.
Imojev is not suitable for children under nine months of age. It is also
contraindicated in pregnancy and breastfeeding, and in individuals who
are immunocompromised due to disease or medical treatment.8,14
Imojev has been shown to provide excellent protection if used as
a booster vaccine in children two to five years of age, who were
previously vaccinated with a mouse brainderived vaccine.7
JEspect is a Vero cellderived, inactivated vaccine based on an
attenuated strain of the JE virus. Two doses are given 28 days apart.
Data suggest that an accelerated course given on days one and seven
provides a non-inferior immune response, but there are no clear
recommendations regarding this in the Australian guidelines, and the
length of protection is not known.7 A booster dose is recommended
one to two years after the primary course in adults,1,7,14,20 but no
firm recommendations have been given as yet for booster dosing in
children. In adults, data indicate seroprotection for 10 years or longer
after the first booster.20
JEspect is registered for use in those 18 years or older, but can be
given to babies between two and nine months of age, as well as to
older infants and children where an alternative is not available or if
it is contraindicated. Infants and children under three years of age
receive a half dose (0.25 ml) per dose. Pregnant women at risk of JE
should be offered JEspect, as no adverse pregnancy outcomes have
been attributed to JE vaccination, although there is a theoretical risk.
Data regarding lactation and JE vaccine are lacking, but the vaccine
should be offered if there is increased risk of acquiring JE.7
Data suggest that a single dose of JEspect can provide protective
antibody levels for up to two years in adults previously vaccinated with
a completed course of mouse brainderived vaccine.7,20
Both Imojev and JEspect are generally well tolerated and lack the
serious adverse events associated with JE-Vax. Local reactions
and minor systemic reactions (headache, myalgia) are common to
very common after vaccination. JE vaccines are contraindicated in
individuals who have had anaphylaxis following a previous dose of any
JE vaccine or any vaccine component.7
Given that Elizabeth is leaving in two weeks, the single-dose Imojev
vaccine is the best option. If Elizabeth had contraindications to a
live vaccine, a rapid course of JEspect on days one and seven could
be considered, although no clear recommendations can be given.
Alternatively, she could have her first JEspect dose now, travel this
time with only partial protection, and have her second dose after
this years trip on day 28 in preparation for future travel. Depending
on the itinerary, it may be possible to complete a course of JEspect
in Dili, where its availability was confirmed as of May 2015.21
Imojev is also preferable to JEspect because it will also provide
longer lasting protection, without the need for a booster over the
next five years.

check Travel health

Elizabeths previously vaccinated colleague could consider having a

single dose of Imojev, but would also gain two years of protection
from a single JEspect booster dose.
ANSWER 6
Data for the co-administration of Imojev with other vaccines, other
than yellow fever vaccine and MMR vaccine which can be given
at the same time, using separate syringes and injection sites, or
otherwise at least four weeks apart7 are not available.
JEspect can be given at the same time as hepatitis A vaccine,
quadrivalent meningococcal conjugate vaccine, and rabies vaccine.
Co-administration with other vaccines (including yellow fever vaccine)
has not been studied.
If other vaccines need to be given at the same time as either JE
vaccine, injections should be given in separate limbs.7
For practical reasons, Elizabeth should receive all recommended
vaccines during her visit, in separate limbs as advised.
Recommendations regarding the newer JE vaccines will be updated
when suitable evidence becomes available.
RESOURCES FOR PATIENTS
International Society of Travel Medicine, www.istm.org
Fit for Travel, UK, www.fitfortravel.nhs.uk
Travax, www.travax.nhs/uk
IAMAT, www.iamat.org
Australian Government Smart Traveller, www.smartraveller.gov.au

RESOURCES FOR DOCTORS

International Society for Infectious Diseases program for monitoring emerging
diseases (ProMed), www.promedmail.org
World Health Organization, www.who.int/ith/updates/en and www.who.int/
topics/en
Centers for Disease Control and Prevention, wwwnc.cdc.gov/travel (with links
to outbreak news and Yellow Book)
Japanese encephalitis distribution map, www.cdc.gov/japaneseencephalitis/maps
Risk for Japanese encephalitis by country, wwwnc.cdc.gov/travel/
yellowbook/2016/infectious-diseases-related-to-travel/japanese-encephalitis
Australian Immunisation Handbook, www.immunise.health.gov.au/internet/
immunise/publishing.nsf/Content/Handbook10-home~handbook10part4~ha
ndbook10-4-8
Batchelor P, Petersen K. Japanese encephalitis: A review of clinical guidelines
and vaccine availability in Asia. Tropical Diseases, Travel Medicine and
Vaccines 2015 1:11. Available at http://tdtmvjournal.biomedcentral.com/
articles/10.1186/s40794-015-0013-6 [Accessed 11 December 2015].

REFERENCES
1. Centers for Disease Control and Prevention. Travelers health: 2016 Yellow
Book. In: CDC Health Information for International Travel. Centers for Disease
Control and Prevention. Atlanta, GA: CDC, 2015. Available at wwwnc.cdc.
gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/japaneseencephalitis [Accessed 2 September 2015].
2. Centers for Disease Control and Prevention. Health information for
travelers to Timor-Leste (East Timor). Atlanta, GA: CDC, 2015. Available
at wwwnc.cdc.gov/travel/destinations/traveler/none/east-timor [Accessed
11December 2015].

CASE 3

3. Neilson A, Mayer C. Tuberculosis Prevention in travellers. Aust Fam

Physician 2010;39(10):74350.
4. Shoreland Travax. Medical summary BCG vaccine. Milwaukee, WI:
Shoreland Travax, 2015. Available at www.travax.com/scripts/MedLibrary
[Accessed 12 October 2015].
5. Centers for Disease Control and Prevention. Travelers health: 2016 Yellow
Book. Atlanta, GA: CDC, 2015. Chapter 3, Tuberculosis. Available at wwwnc.
cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/
tuberculosis [Accessed 14 December 2015].
6. World Health Organization. Tuberculosis profile Timor-Leste. Geneva: WHO,
2015. www.who.int/countries/tls/en [Accessed 12 December 2015].
7. National Health and Medical Research Council. The Australian immunisation
handbook. 10th edn. Canberra: NHMRC, 2015.
8. The Travel Doctor. Travel health fact sheet East Timor. Sydney: The Travel
Doctor, 2015. Available at www.traveldoctor.com.au/files/editor_upload/
File/fact-sheets/9115%20TD%20Health%20Fact%20Sheet%20East%20
Timor_print.pdf [Accessed 14 October 2015].
9. Shoreland Travax. Provider summary Timor-Leste, 2015. Milwaukee, WI:
Shoreland Travax, 2015. Available at www.travax.com/scripts/destina/
ShowSummary.aspx?countryID=200&type=PS [Accessed 12 October
2015].
10. Department of Health. Increasing notifications of dengue in Australia related
to overseas travel, 1991 to 2012. Canberra: DoH, 2013. www.health.gov.au/
internet/main/publishing.nsf/content/cdi3701f [Accessed 14 October 2015].
11. Department of Health [NT]. Dengue fever. Darwin: DoH, 2014. Available at
http://health.nt.gov.au/library/scripts/objectifyMedia.aspx?file=pdf/45/15.
pdf&siteID=1&str_title=Dengue%20Fever.pdf [Accessed 14 October 2015].
12. Centers for Disease Control and Prevention. Chikungunya virus. Geographic
Distribution Countries and territories where chikungunya cases have been
reported (as of October 20, 2015). Atlanta, GA: CDC, 2015. Available at
www.cdc.gov/chikungunya/geo/index.html [Accessed 15 December 2015].
13. World Health Organization. International travel and health. Geneva: WHO,
2014. Available at www.who.int/ith/ITH_chapter_6.pdf?ua=1 [Accessed
29October 2015].
14. Yung A, Leder K, Torresi J, et al. Manual of travel medicine. 3rd edn.
Melbourne: IP Communications, 2011.
15. Mayer C, Neilson A. Japanese encephalitis Prevention in travellers. Aust
Fam Physician 2010;39(6):38994.
16. Smith, B. Melbourne man contracts rare and potentially fatal Japanese
encephalitis virus in Bali. The Age. 10 February 2015. Available at www.
theage.com.au/victoria/melbourne-man-contracts-rare-and-potentially-fataljapanese-encephalitis-virus-in-bali-20150210-13amk7.html [Accessed
14October 2015].
17. Campbell G, Hills S, Fischer M, et al. Estimated global incidence of Japanese
encephalitis. Bulletin of the World Health Organization 2011;89:76674E.
Available at www.who.int/bulletin/volumes/89/10/10-085233.pdf [Accessed
29 October 2015].
18. World Health Organization. Fact sheet no 386 Japanese encephalitis.
Geneva: WHO, 2014. Available at www.who.int/mediacentre/factsheets/
fs386/en [Accessed 29 October 2015].
19. Sanofi Pasteur. Australian product information JE-CV. Imojev. Australian PI,
v 3.2. Available at http://products.sanofi.com.au/vaccines/IMOJEV_AUS_CMI.
pdf [Accessed 29 October 2015].
20. Shoreland Travax. Medical summary Japanese encephalitis. Milwaukee,
MI: Shoreland Travax, 2015. Available at www.travax.com/scripts/MedLibrary
[Accessed 12 October 2015].
21. Batchelor P, Petersen K. Japanese encephalitis: A review of clinical
guidelines and vaccine availability in Asia. Tropical Diseases, Travel Medicine
and Vaccines 2015 1:11. Available at http://tdtmvjournal.biomedcentral.com/
articles/10.1186/s40794-015-0013-6 [Accessed 11 December 2015].

19

CASE 4

check Travel health

QUESTION 1

CASE 4

What are the current guidelines for malaria chemoprophylaxis? What

medications would you recommend?

GERALD TRAVELS TO MOZAMBIQUE

Gerald, aged 54 years, is going to spend six months
in Nacala in northern coastal Mozambique, working
for a mining company there. There is a high risk
for malaria throughout Mozambique.15 Gerald
presented for a pre-travel medical consultation and
you strongly advised him to take appropriate malarial
chemoprophylaxis. Gerald declined, stating that I have
worked in these sorts of areas before and no one else
took malaria tablets. I might get malaria anyway, and
the tablets only mask the symptoms and they have
lots of side effects. Besides, the locals get malaria
most of the time and they are fine.

QUESTION 2

Figure 1. Mozambique map1

How would you manage Geralds situation? What information can you
provide to Gerald to give a balanced opinion on malaria prophylaxis in
this situation?

FURTHER INFORMATION
Gerald became unwell on site in Mozambique. Figure 2
describes the evolution of his illness. It was unknown if he had

Mozambique is outlined in red in the upper panel.

Figure 2. Evolution of illness

Friday 9 May
2015 Flu-like
illness; flies back
to Johannesburg

20

Day 1

Saturday 10 May
2015 Gets a flu
injection from
pharmacist

Monday 12 May
2015 Back on
site

Thursday 15 May
2015 diagnosis:
malaria on site

Day 6

Informed
insurance
and medevac
arranged

CASE 4

check Travel health

a pre-deployment travel or medical assessment, if he had any

underlying medical conditions, or if he had taken any malaria
chemoprophylaxis.

QUESTION 5
What investigations would you order initially?

He attended the onsite medical clinic in the mine site in Nacala.

The medical practitioner correctly diagnosed malaria and
commenced Gerald on a standby treatment course of artemether
+ lumefantrine. Gerald returned to his residence, but a few hours
later was found unconscious on the floor in his room, with vomitus
around his body. It was decided that he should be transferred to
South Africa for further medical treatment as soon as possible.
By the time the medevac company was contacted, one week after
onset of illness, Gerald was comatose with malaria, pneumonia,
renal failure and liver complications. The medical team from the
air ambulance resuscitated him for seven hours to stabilise his
medical conditions for the flight to South Africa.
QUESTION 3
What were some pitfalls in Geralds medical management while he
was overseas?

CASE 4 ANSWERS

ANSWER 1
Current guidelines for malaria chemoprophylaxis can be found on
the Centers for Disease Control and Prevention (CDC),3 World Health
Organization international travel and health4 and UK Travel Health Pro
websites.5 Other useful references in the Australian context are the
Manual of travel medicine6 and Therapeutic Guidelines.7
There are many factors that need to be taken into consideration
when considering which malaria chemoprophylaxis to use. The
above references discuss this well, particularly the Manual of travel
medicine.6 In this case, we are considering chemoprophylaxis for a
fly-in, fly-out worker, who has special considerations, many of which
will be covered as we progress through this case.
QUESTION 4
If Gerald had been well while overseas but developed a fever and
flu-like symptoms after returning to Australia, how would you manage
his condition? Describe your differential diagnosis, history and
examination, and symptoms you would be looking for?

Doxycycline is generally the most cost-effective choice for malaria

chemoprophylaxis. Atovaquone+proguanil (Malarone) is far more
expensive, but it is equally effective and has a favourable side-effect
profile. Travellers can stop taking atovaquone+proguanil seven days
after leaving a malaria-risk area.6,7 For doxycycline, treatment should
continue for four weeks after leaving the area.6,7 Therefore, if there
is no cost constraint, for fly-in, fly-out workers on a four-weeks-on,
four-weeks-off roster, for example, atovaquone+proguanil is preferred
to doxycycline. This means they are off their malaria medication for
some time between rotations, which would not be the case with
doxycycline.
Mefloquine is a further option for this area. According to the
Therapeutic Guidelines, it should be started two to three weeks
before the patient leaves so the patient can transition to an
alternative chemoprophylaxis prior to travel if there are any
concerning side effects. However, in the authors experience it
should be started two to three weeks before the first deployment;
during subsequent visits, mefloquine can be taken weekly one to

21

CASE 4

two weeks before leaving, while at risk and four weeks after leaving
the area.6 If a worker were on a four-week-on, four-week-off roster,
as with doxycycline there would not be a break in medication
between rotations. This medication has been associated with
serious neuropsychiatric side effects, the incidence of which is
1/10,000.6 Milder neuropsychiatric effects, such as mood changes,
nightmares and depression can occur in about 510%.6 They
can also be an issue in those involved in tasks requiring delicate
coordination and spatial discrimination.6 This combination of
possible adverse events has made this medication less popular with
many employers.
ANSWER 2
You could explain and emphasise the following points:
Malaria can be fatal, particularly in individuals infected with the
more severe type of malaria (Plasmodium falciparum), especially
when not taking appropriate anti-malarial medication or when
there are delays in receiving proper treatment.
The primary purpose of malarial chemoprophylaxis is to minimise
the risk of dying from malaria when travelling to or residing in
high-risk malaria areas.
Although there is the risk of adverse reactions to anti-malarial
medication, this is usually low with the medications currently
used. On weighing up the pros and cons, taking appropriate antimalarial medication is much preferred to contracting malaria (in
high-risk malaria areas).
Taking anti-malarial medication may make the diagnosis of
malaria more difficult, which could delay the correct diagnosis
and management.8 However, in regions with poor health
infrastructure and deficient access to high-quality medical
facilities, the main role of anti-malarial medication is to enhance
survival.
Malaria mortality mainly occurs in childhood. After surviving
malaria a few times, usually in childhood, with continuous
exposure to malaria, residents of areas where malaria is
prevalent often develop partial immunity to malaria (semiimmune).9 They may tolerate a low-parasite load without
becoming sick with malaria. Nevertheless, even local residents
may die from malaria following their first infection. When the
immune system is not being subjected to repeated infections of
malaria, the partial immunity diminishes. Once the individual has
been away from a malarious area for an extended period of time,
they would be considered to have lost this partial immunity.
In addition to recommending anti-malarial medication, you should
also advise Gerald to take protective measures against insect bites
(eg use of insect repellents and protective clothing).1012 If he
develops a fever, he should seek expert medical advice as soon as
possible.

check Travel health

who present with fever. In Africa, unlike Australia, malaria is not

generally thought of as a life-threatening disease. Many patients
are treated as outpatients, often with undesirable outcomes. Severe
malaria normally develops three to seven days after the onset of
symptoms. The most common severe complications in travellers
are cerebral malaria, acute renal failure and respiratory failure.13
If a person such as Gerald contracts falciparum malaria, without
having taken malaria chemoprophylaxis, his medical condition often
deteriorates significantly, and he may die within a few days14 if
definitive treatment is not given as soon as possible in the illness
process. In Geralds case, he did not present for medical treatment
until day 6. Although he was commenced on treatment, he may
not have taken the medication, or if he did take it, it is likely that
he brought it up when he vomited. In a US study, mortality from
P. falciparum is related to poor adherence to chemoprophylaxis,
but a large number (66%) were due to medical errors such as
failure to prescribe correct chemoprophylaxis, failure to diagnose
patients correctly at presentation and failure to initiate treatment
promptly at diagnosis.13 Any fever in a patient presenting unwell
from a malarious area should be treated as malaria until proven
otherwise. Warning signs for severe malaria include confusion,
unconsciousness, respiratory distress, renal failure and acidosis.13
In a country such as Australia, all cases of falciparum malaria
should be referred to an infectious disease physician for hospital
admission.
ANSWER 4
If a returned traveller presents with a fever, up to at least one
year after visiting a malaria-risk area, regardless of whether
chemoprophylaxis was taken, malaria must always be considered as
a differential diagnosis.1012
Malaria is the most common specific diagnosis in Australian and
multinational travellers with febrile illnesses acquired overseas.15,16
Malaria is also the most common potentially life-threatening
travel-related infection.6 Given his substantial risk of falciparum
malaria if Gerald had returned to Australia and presented to a
general practice with a fever, it would be best to refer him for
assessment by an infectious diseases unit as soon as possible. A
person with falciparum malaria should always be admitted to an
experienced infectious diseases or tropical diseases unit for further
management.
Other diagnoses, in decreasing order of frequency, are:15,16
respiratory illnesses
gastrointestinal illness
idiopathic
dengue fever
chikungunya
enteric fever

ANSWER 3

rickettsial infection.

Healthcare workers in malaria-endemic regions, more so than in

non malariaendemic countries, often do not consider malaria
as the most important differential diagnosis in managing patients

A thorough history should be taken, including Geralds medical and

travel history, and physical examination of all systems should be
performed. The important clinical features to look for are:

22

CASE 4

check Travel health

lymphadenopathy

neck stiffness

hepatomegaly

photophobia

splenomegaly

conjunctivitis

jaundice

neurological signs

anaemia

evidence of bleeding.

wheeze

Routine urinalysis should be performed. Repeated physical

examinations are often required to monitor the evolution of
symptoms and signs, and response to therapy.17,18

rash or skin lesions

muscle or joint involvement

Figure 3. Evaluation and initial management of fever in a returned traveller12

Suspected febrile illness in a returned traveller
Confirm fever
Severe sepsis
(confusion, collapse,
cyanosis, tachypnoea,
hypotension, neck
stiffness, peritonism
or digital gangrene)
Resuscitation if
shocked, blood
cultures, malaria
films, penicillin
or ceftriaxone (if
meningococcal
disease likely)

No features of severe sepsis

History: travel and fever onset (compare with typical incubation periods)
Pattern of fever: occasionally helpful (eg second-daily paroxysm in vivax malaria)
Focal features: Neck stiffness, cellulitis, abdominal tenderness, pulmonary consolidation
Investigations: full blood count, liver function tests, blood cultures (two), chest X-ray, urine microscopy and
culture, baseline serologucal tests, specific investigations for focal disease
Malaria possible

Thick and thin

malaria films (if
initially negative,
repeat 3 times)
Plasmodium vivax,
ovale or malariae
Plasmodium falciparum

Rash

Consider dengue or
rickettsial disease
Serological disease
Consider empirical
doxycycline for
rickettsia

Respiratory symptoms
Return within
3 days from
country with
acute influenza

Pulmonary
consolidation
Consider influenza
Rapid antigen or PCR test

Fever >7 days, malaria ruled out

Consider enteric fever
Blood, stool and
urine cultures
Consider empirical
quinolone or
third-generation
cephalosporin

Consider unusual causes of

pneumonia (eg Legionnaires
disease, melioidosis)
If severe, give empirical
treatment, including macrolide
or quinolone

Urgent hospital transfer

Jaundice

Consider
Acute hepatitis
(eg A, B, C, E,
Epstein-Barr
virus, dengue,
Q fever):
serological tests
Acute cholangitis
(stones, liver
fluke): blood
cultures,
ultrasound and
stool examination
Liver abscess
(amoebic,
pyogenic):
blood cultures,
serological tests

PCR, polymerase chain reaction

*Evaluation should also include the differential diagnoses that would be considered in a non-traveller with fever
Travel to high-risk area, rural or prolonged travel, non-compliance with prophlaxis
Reproduced with permission from the Medical Journal of Australia from Looke DFM, Robson JMB. Infections in the returned traveller. Med J Aust 2002;177:21219.

23

23

CASE 4

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ANSWER 5
Initial investigations should

include:17,18

full blood examination (FBE)

kidney and liver function tests, C-reactive protein (CRP)
blood cultures
thick and thin blood smears for malaria (repeated examination
may be required)
As a rule, pathology service providers in Australia routinely do
rapid antigen detection testing (RADT) when thick and thin films
are requested. They can also be used in areas where malaria
diagnosis on slides is difficult or unavailable. Currently, there
are issues with these test kits being widely used in the field,
namely accuracy, cost and adverse field conditions.19 Training
can increase accuracy.20
Dengue and Chikungunya serology
rickettsial serology
stool examination if indicated (including multiplex PCR test)
chest X-ray
urine microscopy and culture.
Refer to Figure 3 for the general plan of management for a returned
traveller with fever.

5. Public Health England. Guidelines for malaria prevention for travellers

from the UK 2015. London: Public Health England, 2015. Available at
www.gov.uk/government/publications/malaria-prevention-guidelines-fortravellers-from-the-uk [Accessed 13 December 2015].
6. Yung A, Leder K, Torresi J, et al. Manual of travel medicine. 3rd edn.
Melbourne: IP Communications, 2011.
7. Antibiotic Guidelines Expert Group. Malaria. Chemoprophylaxis. In: eTG
Complete [Internet]. Melbourne: Therapeutic Guidelines, 2014. Available
at www.tg.org.au [Accessed 1 December 2015].
8. Warrell DA, Hemingway J, Marsh K, et al. Malaria. In: Warrell D, Cox TM,
Firth J, editors. Oxford Textbook of Medicine, 5th ed. Oxford: Oxford
University Press, 2010.
9. Centers for Disease Control and Prevention. Malaria. Atlanta, GA: CDC,
2015. Available at www.cdc.gov/malaria/about/biology/human_factors.
html [Accessed 13 December 2015].
10. Batchelor T, Gheradin T. Prevention of malaria in travellers. Aust Fam
Physician 2007;36(5):31620.
11. Queensland Health. Malaria. Brisbane: Queensland Health, 2015.
Available at www.health.qld.gov.au/cdcg/index/malaria.asp [Accessed
22November 2015].
12. Department of Health [NT]. Guidelines for malaria. Darwin: DoH, 2012.
Available at http://health.nt.gov.au/library/scripts/objectifyMedia.
aspx?file=pdf/10/94.pdf&siteID=1&str_title=Malaria.pdf [Accessed 22
November 2015].
13. Swhwartz E. Malaria in travelers. In: Schwartz E, editor. Tropical diseases
in travelers. Chichester, West Sussex: Wiley-Blackwell, 2009.

RESOURCES FOR DOCTORS

14. Griffith KS, Lewis LS, Mali S, et al. Treatment of malaria in the United
States:A systematic review. JAMA 2007;297(20):226477.

fitfortravel by Health Protection Scotland a division of NHS National

Services Scotland, travel health information for people travelling abroad
from the UK, www.fitfortravel.nhs.uk

15. OBrien D, Leder K , Matchet E, et al. Illness in returned travellers and

immigrants: The 6-year experience of 2 Australian infectious diseases
units. J Travel Med 2006;13(3):14552.

Centers for Disease Control and Prevention, Travelers health, www.nc.cdc.

gov/travel

16. Wilson ME, Weld LH, Boggild A, et al. Fever in returned travelers:
Results from the GeoSentinel Surveillance Network. Clin Infec Dis
2007;44(12):156068.

Centers for Disease Control and Prevention, CDC health information for
international travel 2016, wwwnc.cdc.gov/travel/page/yellowbook-home
World Health Organization. International travel and health: Situation as in
2015, www.who.int/ith/en
TravelHealthPro, National Travel Health Network and Centre (NaTHNaC),
http://travelhealthpro.org.uk
International Association for Medical Assistance to Travellers, a division of
the Foundation for the Support of International Medical Training (FSIMT),
www.iamat.org
Yung A, Leder K, Torresi J, et al. Manual of travel medicine, 3rd ed.
Melbourne: IP Communications, 2011.

REFERENCES
1. Google. Google maps. Santa Clara, Ca: Google, 2015. Available at www.
google.com.au/maps [Accessed 11 October 2015].
2. Health Protection Scotland. Fitfortravel. Glasgow: Health Protection
Scotland, 2015. Available at www.fitfortravel.nhs.uk/destinations/africa/
mozambique/mozambique-malaria-map.aspx [Accessed 13 December
2015].
3. Centers for Disease Control and Prevention. Malaria information and
prophylaxis, by country. Atlanta, GA: CDC, 2015. Available at www.cdc.gov/
malaria/travelers/country_table/a.html [Accessed 13 December 2015].
4. World Health Organization. International travel and health: Situation as in
2015. Geneva: WHO, 2015. Available at www.who.int/ith/en [Accessed
13 December 2015].

24

17. Gheradin T, Sisson J. Assessing fever in the returned traveller. Aust

Prescr 2012;35:1014.
18. Locke D, Robson J. Infections in the returned traveller. Med J Aust
2002;177(4):21219.
19. Centers for Disease Control and Prevention. Malaria. Atlanta, GA: CDC,
2015. Available at www.cdc.gov/malaria/diagnosis_treatment/diagnosis.
html [Accessed 13 Dec 2015].
20. Trachsler M, Schlagenhauf P, Steffan R. Trop Med Int Health
1999:4(6):44247.

CASE 5

check Travel health

CASE 5
JEFF IS TIRED AND ANXIOUS

QUESTION 2
What STIs might Jeff be at risk of? How do you guide his
investigation?

Jeff is a company director, 39 years of age, who

returned from a business trip to Vietnam yesterday.
He is generally well, but has been feeling tired and
anxious since his return. Jeff admits that he spent
the last night of his visit with a woman he had
met at a nightclub at his hotel. He used a condom.
Jeff wants to be tested for sexually transmissible
infections (STIs) and wonders if he should take some
antibiotics in case he has acquired an infection.

QUESTION 1
What information do you need from Jeff at this point in the consultation?
FURTHER INFORMATION
You give Jeff a dose of hepatitis B vaccination and order
blood for HIV serology, hepatitis B core and surface antibody,
syphilis serology, and a first-pass urine collection for Neisseria
gonorrhoeae and Chlamydia trachomatis nucleic acid
amplification test (NAAT). You advise him to avoid sex until
further advice.
Jeff returns two days later complaining of a urethral discharge.
He is upset that he was not given antibiotics at his initial
presentation. On examination, you note a profuse creamy
discharge.
QUESTION 3
FURTHER INFORMATION

What is the most likely cause of Jeffs symptoms? How would you
manage this change in the presentation?

Jeff tells you that his local business associates had invited him
to dinner at a restaurant, then to a club at his hotel to celebrate
the successful conclusion of their business deal. They seemed
keen for him to enjoy himself as much as possible. Later in the
evening, he was introduced to one of several young women who
had joined them. He had consumed a considerable amount of
alcohol, but agrees that even at the time, he recognised that she
was probably some sort of sex worker. Back in his hotel room,
they had vaginal intercourse using condoms, but only after she
performed oral sex on him, and he on her. This sexual encounter
occurred approximately 36 hours before your consultation with
him. Jeff has no symptoms, in particular, no discharge or dysuria.
He is married and has three children. His wife has had a tubal
ligation. They have not had any sexual contact since his return. He
cannot recall his vaccination history. He is not taking any medication
and, in particular, was not taking any antibiotic prophylaxis.

25

CASE 5

QUESTION 4
What explanation can you give Jeff for withholding antibiotics at the
initial presentation?

check Travel health

CASE 5 ANSWERS

ANSWER 1
You should ask Jeff for further details about the sexual exposure and its
context. For example, it is relevant to know the nationality of the woman
he had met and whether she was, or could have been, a sex worker. For
the sexual contact that occurred in the hotel room, in addition to knowing
that a condom was used, it is relevant whether any oral, vaginal, penile
(or anal) sexual contact occurred while the condom was not being used.
You should also ask Jeff about his hepatitis B immunisation status
and if he is taking any medication. If an individual presents with any
sort of human blood or body fluid contact in South-East Asia or a
country where hepatitis B is endemic, it is important to verify and
record the history of hepatitis B vaccination.
ANSWER 2
FURTHER INFORMATION
Jeffs symptoms resolve quickly. The NAAT testing on his
initial presentation indicates that N. gonorrhoeae was detected
and C. trachomatis was not detected. The culture isolated
N.gonorrhoeae, which was susceptible to ceftriaxone. The
blood tests indicated that Jeff had received hepatitis B
vaccination previously, which was confirmed by vaccination
records from his previous general practitioner (GP). HIV and
syphilis serology were negative.
QUESTION 5
What follow-up is required?

Sexual risk taking is common in travellers, and STIs are a common

travel presentation.1 Providing sexual entertainment for business
partners is not uncommon in many parts of the world, and Jeffs
sexual partner for that night may well have been a commercial
sex worker. The epidemiology of STIs is highly demographically
and geographically specific, as are recommendations about their
treatment. However, assessment of an asymptomatic individual with
a sexual exposure in Europe, the Americas and Eastern Asia can
be conducted without specialist consultation, as the most common
conditions occurring will overlap with the Australian epidemiology.
Many sexual health centres in capital cities in Australia operate a
telephone specialist consultation service for GPs and would be able to
provide a list of conditions to test for.
The consistent and correct use of condoms during vaginal or anal sex
is effective as a barrier in the prevention of human immunodeficiency
virus (HIV) infection and Jeff is not at risk.2 However, you could
include HIV testing (at baseline and at six to 12 weeks) in this
situation for the purposes of allaying the patients anxieties.
Approximately 15% of the adult population in Vietnam carries the
hepatitis B virus (HBV), a much more transmissible infection than HIV.
Post-exposure vaccination reduces infection (ideally within 24 hours
but acceptably within 14 days,3 and Jeff should be vaccinated while
you establish his vaccination status. Hepatitis B surface antibody titre
is often used to screen for prior vaccination in individuals who might
in the future be exposed to HBV. However, vaccination records are
even more useful as some patients lose measurable levels of surface
antibody without losing the protective effect, which is considered
to be cellular. Delaying the dose while waiting for evidence of prior
vaccination might delay eventual vaccination and reduce its efficacy.
On the other hand, vaccinating an already vaccinated individual,
which occurs quite commonly, is quite harmless.
Oral sex without condoms does not represent a risk of HIV, but does
have the potential to transmit other STIs.2,4 In particular, gonorrhoea
is commonly transmitted by oral sex in men who have sex with men
in Australia.5

26

CASE 5

check Travel health

ANSWER 3
Gonorrhoea, chlamydia, syphilis, hepatitis B and HIV infection are
more prevalent in sex workers in Vietnam than Australia, where
they are uncommon.6 In Jeffs case, gonorrhoea is the most likely
presentation, on clinical and epidemiological grounds, as it is the only
cause of urethral discharge commonly transmitted through oral sex.
It is also common for patients with gonorrhea to present with quite
noticeable symptoms within two to three days of exposure.
NAAT is the most commonly used (and reliable) screening test.
However, it is insufficient in a patient with symptomatic disease,
particularly if the infection is acquired outside Australia. It is important
to also collect a specimen for culture and antibiotic sensitivity testing.
The type of testing is important in this case, as is the withholding of
antibiotics (see Answer 4).
NAAT can use a first-void urine specimen in the case of urethral
infection, and a throat swab, ensuring that the swab comes into
contact with the posterior pharynx. The materials for these tests are
commonly provided to general practices by the pathology provider as
they are used for a range of purposes.
First-void urine samples avoid the need for intimate examination and
uncomfortable testing procedures in well, asymptomatic patients
presenting for screening. Testing recommendations for screening an
asymptomatic individual who may have been exposed to infection,
and possible sites of specimen collection, are summarised below:
pharyngeal swab
high vaginal or cervical swab or first void urine
urethral swab or first void urine
swab of anorectal canal.
all swabs using the laboratory preferred swab type.
Symptomatic patients need to be examined, and the specimens (other
than urine) taken by the clinician. Patients are often uncertain how
best to describe genital symptoms and additional clinical signs are
commonly present.
For laboratory culture, the specimen must contain live bacteria and
it must be transported to the laboratory in a manner that preserves
it. Neisseria gonorrhoeae has fastidious growth requirements, and
the commonly used in-clinic culture swabs may not be adequate.
Laboratories will provide, if asked, a swab tube transport medium
specifically designed to keep organisms viable. Locally acquired
symptomatic gonorrhoea urethritis is rising fairly steadily in much of
Australia, and it is always advisable to take a specimen for culture
before delivering treatment.
Gonoccocal infection is treated with a single dose of 500 mg
ceftriaxone diluted in 2 ml of 1% lignocaine and a single oral dose
of 1000 mg (2 x 500 mg tablets) of azithromycin.7 A symptomatic
patient should be offered this treatment immediately, but only after
appropriate samples have been taken. The patient should be advised
to avoid all sexual contact until the diagnosis, the appropriateness
of the original treatment and, if necessary, proof of cure, have been
confirmed. The patient should be requested to return after one week
to discuss the results, the success of treatment, and when it is safe
to recommence sexual activity.

You could also contact the general practice information line at your
local sexual health centre for further information about sexually
transmissible infections.
ANSWER 4
You should explain to Jeff that blind treatment at the initial
presentation may not have prevented the infection that he has now
developed. Furthermore, such treatment would have significantly
complicated and obscured effective diagnosis and treatment at this
stage.
Emergence of N. gonorrhoeae antibiotic resistance is a major
public health surveillance concern in Australia. Thanks to the
quality of these data, we can be confident that the recommended
treatment for locally acquired gonorrhea will cover known or likely
strains of the bacteria. However, less information is available from
South-East Asian countries where, in the past, drug-resistant
strains have been first to emerge.8
Prophylactic or presumptive treatment relies on a good knowledge
of the antibiotic sensitivities in commonly isolated bacterial strains.
When it fails, it actively selects for the resistant organism, which
the index patient, in this case Jeff, might continue to transmit in
the mistaken belief that he is cured. Precisely this mechanism
is likely to be an important step in the initial movement of drugresistant gonorrhoea into Australia.9 Concern is rising about
the possibility of ceftriaxone-resistant gonorrhoea becoming
established in Australia, which has the potential for very serious
public health consequences. So, in an asymptomatic patient, we
would only recommend prophylactic treatment in a known exposure
in the setting of well-documented epidemiology. For a symptomatic
patient, specimens for culture must be taken before treatment
is delivered so that the results are collated in surveillance and it
can be confirmed that the individual has received the appropriate
treatment.
The advent of NAAT has certainly simplified the diagnosis of
bacterial STIs in men. However, only culture will give information
about antibiotic sensitivity for N. gonorrhoeae, which varies
significantly worldwide.8 In particular, there are no oral antibiotics
available in Australia that reliably treat the commonly found
strains of N. gonorrhoeae. More seriously, ceftriaxone-resistant
N.gonorrhoeae strains are being reported10 and their prevalence
in countries without reliable public health monitoring of gonorrhoea
drug susceptibility, such as Vietnam, is unknown.9 A negative
gonorrhoea NAAT result effectively excludes the possibility of
infection, but only a culture will confirm that the treatment given is
effective.
ANSWER 5
The minimum time between exposure and testing for
N.gonorrhoeae or C. trachomatis on NAAT has not been
established, although it is characteristically very short. It would be
entirely plausible for a positive test to precede the development
of symptoms. Jeff should have a repeat gonorrhoea NAAT test at
least four weeks after he received treatment.

27

CASE 5

Gonorrhoea is a notifiable disease and it is a common practice for

laboratories to send general practitioners a notification form with
the microbiology result. The usual practice is to contact sexual
partners to suggest that they receive testing and treatment. Tracing
the Vietnamese sex worker in this case is unlikely to be successful.
Jeff has had no sexual partners since the exposure and no further
contact tracing is required.11
CONCLUSION
Jeff decides that he would prefer not to discuss this STI with his
wife, nor is he prepared to expose her to the low risk of HIV or
syphilis exposure that he might have encountered. He decides to use
condoms or avoid sex until follow-up serology indicates that he is
uninfected.
RESOURCES FOR DOCTORS
State capital sexual health centres operate an information line to provide
telephone advice to GPs.

REFERENCES
1. Matteelli A, Schlagenhauf P, Carvalho AC, et al. Travel-associated
sexually transmitted infections: An observational cross-sectional
study of the GeoSentinel surveillance database. Lancet Infect Dis
2013;13(3):20513.
2. Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV
transmission. Cochrane Database Syst Rev 2002(1):CD003255.
3. Australian Technical Advisory Group on Immunisation. The Australian
immunisation handbook. 10th edn. Canberra: Federal Department of
Health, 2015.
4. Ballini A, Cantore S, Fatone L, et al. Transmission of nonviral sexually
transmitted infections and oral sex. J Sex Med 2012;9(2):37284.
5. Nash JL, Hocking JS, Read TR, et al. Contribution of sexual practices
(other than anal sex) to bacterial sexually transmitted infection
transmission in men who have sex with men: A cross-sectional analysis
using electronic health records. Sex Transm Infect 2014;90(1):5557.
6. Tang H, Hocking JS, Fehler G, Williams H, Chen MY, Fairley CK. The
prevalence of sexually transmissible infections among female sex workers
from countries with low and high prevalences in Melbourne. Sexual Health
2013;10(2):14245.
7. Groups AE. Therapeutic Guidelines: Antibiotic, Version 15. Melbourne:
Therapeutic Guidelines, 2014.
8. Workowski KA, Berman SM, Douglas JM Jr. Emerging antimicrobial
resistance in Neisseria gonorrhoeae: Urgent need to strengthen
prevention strategies. Ann Intern Med 2008;148(8):60613.
9. Barbee LA. Preparing for an era of untreatable gonorrhea. Curr Opin
Infect Dis 2014;27(3):28287.
10. Unemo M. Current and future antimicrobial treatment of gonorrhoea
The rapidly evolving Neisseria gonorrhoeae continues to challenge. BMC
Infect Dis 2015;15:364.
11. Chen M. Australasian contact tracing manual. 4th edn. Melbourne:
Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine,
2010.

28

check Travel health

MULTIPLE CHOICE QUESTIONS

check Travel health

MULTIPLE CHOICE QUESTIONS

ACTIVITY ID: 38733

TRAVEL HEALTH
This unit of check is approved for 6 Category 2 points
in the RACGP QI&CPD program. The expected time to
complete this activity is 3 hours and consists of:
reading and completing the questions for each
case study
you can do this on hard copy or by logging on to
the gplearning website, http://gplearning.racgp.
org.au
answering the following multiple choice questions
(MCQs) by logging on to the gplearning website,
http://gplearning.racgp.org.au
you must score 80% before you can mark the
activity as Complete
completing the online evaluation form.
You can only qualify for QI&CPD points by completing
the MCQs online; we cannot process hard copy answers.
If you have any technical issues accessing this
activity online, please contact the gplearning
helpdesk on 1800 284 789.
If you are not an RACGP member and would like
to access the check program, please contact the
gplearning helpdesk on 1800 284 789 to purchase
access to the program.

C. atovaquone+proguanil (Malarone) 250+100 mg tablets, starting

one to two days before and continuing for four weeks after leaving
a malarious area
D. mefloquine 100 mg, starting one to two days before and
continuing for seven days after leaving a malarious area.
QUESTION 2
What advice should you give Lucas regarding schistosomiasis?
A. Schistosomiasis transmission requires exposure to fresh water for
at least five minutes.
B. In the event of exposure, a dose of praziquantel should be taken
immediately to prevent infection.
C. Acute schistosomiasis usually resolves spontaneously and
serological testing at 12 months after exposure is recommended
as a proof of cure.
D. Serological testing is recommended at three months post-travel
even if asymptomatic.
QUESTION 3
Which of the following poses the greatest risk for Lucas of contracting
JE?
A. Lucass age
B. Cycling in Bangkok in the morning and early afternoon
C. Spending time outdoors at night in Chiang Mai
D. Not being exposed to JE in the past
FURTHER INFORMATION

CASE LUCAS AND JONAS

Lucas, 28 years of age, comes to see you for travel advice. Lucas is
a nurse at an aged care facility and has taken leave for an overseas
trip during the summer with his twin brother Jonas. First they will go
to South Africa for a one-week cross-country cycling tour and then
travel up the eastern coast of Africa as far as Egypt over the next
three weeks. From there they will fly to Crete, where they will stay for
two days, then to Turkey for five days, trekking in Nepal for five days,
then to Chiang Mai, Thailand, for three days and back to Australia via
Bangkok where they will spend two nights. During the consultation
you discuss measures for preventing malaria, schistosomiasis,
Japanese encephalitis (JE) and other infectious diseases of relevance
to the areas that Lucas and Jonas will be visiting.
QUESTION 1
The current recommendation for malaria chemoprophylaxis is:
A. doxycycline 100 mg, starting one day before and continuing for
seven days after leaving a malarious area
B. atovaquone+proguanil (Malarone) 250+100 mg tablets, starting
one to two days before and continuing for seven days after leaving
a malarious area

Jonas is an aid worker and travels regularly to Asia for work.

He has previously had a vaccination for JE and advised Lucas
to enquire about having this vaccine along with his other travel
vaccines. They are leaving in three weeks.

QUESTION 4
What factors should you consider when advising Lucas about JE
vaccines?
A. Lucas does not need to be vaccinated against JE as he will be in
an endemic area for a brief period of time.
B. Jespect cannot be given at the same time as hepatitis A and
rabies vaccines.
C. Imojev can be administered in the same syringe as other vaccines.
D. Lucas would only need a single dose of Imojev.
FURTHER INFORMATION
Lucas decides to have the Imojev vaccine, as well as hepatitisA,
rabies, typhoid and cholera vaccines. He is up to date with
vaccinations for measles, mumps and rubella (MMR); diphtheria,
tetanus and pertussis (dTpa); tuberculosis; and polio. He also had
the seasonal influenza vaccine through work. He takes malaria
chemoprophlaxis as directed.

29

MULTIPLE CHOICE QUESTIONS

check Travel health

MULTIPLE CHOICE QUESTIONS

FURTHER INFORMATION

QUESTION 8

Two days after returning from their trip, Lucass brother Jonas
comes to see you because he is worried that he may have
contracted a sexually transmissible infection (STI). On the last night
of their trip, Jonas had unprotected sex with a woman he met in
a bar in Bangkok. He noticed a urethral discharge last night. After
taking a more thorough history and examining Jonas you suspect
that he has gonorrhoea.

A diagnosis of acute schistosomiasis is based on:

QUESTION 5

A. the presence of parasitic ova in the stool or urine within 20 days

of suspected exposure.
B. positive serological tests within 30 days of suspected exposure.
C. the presence of eosinophilia.
D. exclusion of other infections and a thorough exposure history.
QUESTION 9

What should you do next?

Which of the following would be the best reason for considering

investigations for influenza?

A. Ask Jonas to provide a first-void urine sample to do a nucleic acid

amplification test (NAAT) for gonorrhoea.

A. Lucass occupation

B. Take pharyngeal, urethral and anorectal swabs for NAAT.

C. Collect specimens for culture and antibiotic sensitivity before
prescribing antibiotics.
D. Prescribe a single dose of 500 mg ceftriaxone immediately.
QUESTION 6
How would you manage Jonass infection?
A. Treat the infection with 500 mg ceftriaxone or 1000 mg of
azithromycin.
B. Ask Jonas to see you one week after treatment to assess
symptom resolution.
C. Advise Jonas to see you only if his symptoms persist.
D. Repeat the NAAT one week after treatment.
FURTHER INFORMATION
Lucas went back to work the day after returning from his trip.
Two days later, he presents complaining of fatigue, headache and
muscle aches. He has a cough and on examination, you find that
his temperature is 38.5C. He is concerned about taking more time
off work.

QUESTION 7
Which of the following statements is true?
A. A diagnosis of dengue fever is possible as the incubation period is
three to 10 days.
B. A diagnosis of malaria can be excluded as Lucas had taken
malaria chemoprophylaxis.
C. A diagnosis of acute schistosomiasis can be excluded as
symptoms occur within two weeks of exposure to the parasite.
D. A diagnosis of influenza is unlikely, as Lucas had been vaccinated
prior to travel.

30

B. Exclusion of other infections, such as malaria

C. The timing of symptom onset
D. Lucass anxiety about taking additional time off work
QUESTION 10
According to current recommendations, treatment of influenza with
antiviral medication should be considered within:
A. 48 hours of onset of influenza-like illness in a patient aged
60years
B. 72 hours of onset of influenza-like illness in a patient known to
have been exposed to influenza
C. 48 hours of onset of influenza-like illness in a patient aged
70years known to have been exposed to influenza
D. 72 hours of onset of influenza-like illness in a patient aged
70years known to have been exposed to influenza.

Independent learning program for GPs

Independent learning program for GPs