Destination Workshop: ���Pacific Island Nations

Prof. Nick Zwar University of New South Wales, Sydney, New South Wales, Australia

Prof. Peter A. Leggat James Cook University, Townsville, Queensland, Australia

Dr Colleen Lau Travel Medicine Alliance Clinics & University of Queensland, Australia

THE UNIVERSITY OF NEW SOUTH WALES

Workshop Objectives

•  Review common itineraries and places often visited in the region

•  Identify key issues to address in preparing people for travel for the various countries in Pacific Islands

•  Review common health concerns related to travel in the region including marine hazards

THE UNIVERSITY OF NEW SOUTH WALES

Pacific Island Groups

Tropical cyclones

Reasons for travel

•  Tourism –  Water activities such

as diving, snorkeling, kayaking and sailing

–  Land activities such as hiking, cultural and ecotourism

–  Cultural and eco-tourism

Reasons for travel •  Visiting family and friends

(VFR) •  Church groups, missionaries •  Work

–  Mining in PNG and New Caledonia

–  volunteers, humanitarian, aid workers, NGOs

–  Health workers –  Scientists, researchers –  Military and police e.g.

Solomon Islands

Reasons for travel

•  Romance – honeymoon destination #1 Bora Bora, #2 Maui, # 7 Fiji

•  http://www.honeymoonguide.com.au/top-10-honeymoon-destinations.html

•  Retirement e.g. Norfolk Island and Cook Islands

•  Television and film production e.g. “Survivor” in Fiji

Infectious diseases risks in Pacific Islands

Dr Colleen Lau Travel Medicine Alliance Clinics & University of Queensland, Australia

THE UNIVERSITY OF NEW SOUTH WALES

Malaria

Vanuatu is southeastern

limit of malaria in

Pacific

No malaria in: Fiji Samoa Tonga French Polynesia Cook Islands Micronesia

Dengue

•  Risk throughout Pacific region •  Outbreaks since 1970s, some affected up to 20% of pop •  Increasing incidence •  All 4 serotypes circulating •  Increased risk of DHF and DSS in VFRs

Emerging Arboviruses in the Pacific

Cao-Lormeau V et al. The Lancet 2014 384, 1571-1572DOI: (10.1016/S0140-6736(14)61977-2)

Emerging Arboviruses in the Pacific

Zika Virus

Zika Virus

Japanese Encephalitis

§  Papua New Guinea § Cases reported from Western Province §  Serological evidence of disease from Gulf and

Southern Highland Provinces § Case reported near Port Moresby in 2004 §  Vaccination recommended if > 4 weeks in

endemic areas or during outbreaks

Leptospirosis

§  Often misdiagnosed as dengue §  Common cause of acute febrile illness in tropics 1

§  Cambodia 2007 – 14% of fevers, more common than dengue, malaria, flu, or typhoid

§  Thai-Myanmar border 2002 – 17% of fevers, 2nd after malaria §  Delhi 2004 – 17% of fevers, 27% of acute jaundice, 17% of

acute renal failure §  High incidence in Pacific 2

§  Western Pacific median 66.4/100,000/year (non-outbreak) §  World 5.1, Africa 95.5, Americas 12.5, SE Asia 4.8, Europe 0.5

1.  Lau et al. Leptospirosis – An Emerging Disease in Travellers. Trav Med & Inf Dis 2011. 2.  WHO. http://whqlibdoc.who.int/publications/2011/9789241501521_eng.pdf

Leptospirosis – Incidence

Place Incidence (per 100,000 / year)

New Caledonia 2009 >150

Seychelles 101 Vanuatu 40 Thailand 40

New Caledonia 30 India 11

Sri Lanka 11 French Polynesia 11

Cambodia 8 Hawaii 3.3

New Zealand 2.8 Queensland 2.1

Australia 0.5 Temperate regions 0.1 to 1

Pacific Islands in blue Many high risk places are tropical islands

Lau et al. Leptospirosis – An Emerging Disease in travellers. Trav Med & Inf Dis 2011.

Leptospirosis

§  Australia: §  35% from recreation or travel, 19% acquired overseas

§  Hawaii: §  0% in 1970s to 50% in 1990s from recreation

§  California: 85% from recreation §  UK: >50% from travel §  Israel: 42% from travel

Lau et al. Leptospirosis – An Emerging Disease in TravellersTMID 2011. Katz et al. Leptospirosis in Hawaii. AJTMH 2002. Meites et al. Re-emerging leptospirosis, California. EID 2004.. Kariv et al. The changing epidemiology of leptospirosis in Israel EID 2001.

Food and Water Borne Diseases

§  Travellers’ diarrhoea §  Hepatitis A §  Typhoid §  Cholera

§  Outbreaks often related to cyclones, flooding and other natural disasters

Hepatitis B

Howell et al. An overview of hepatitis B prevalence, prevention, and management in the Pacific Islands and Territories. J of Gastroenterology and Hepatology 2014.

HIV

§  PNG has the highest prevalence in Oceania

§  ~32,000 people living with HIV in PNG in 2013

www.unaids.org. www.indexmundi.com

Marine environment & hazards: ���

Prof. Peter A. Leggat, AM MD, PhD, DrPH, FAFPHM, FFPH RCP(UK), FPHAA, FACTM, FFTM FFEWM ACTM,

FFTM RCPSG, FACAsM, FACRRM, FRGS, Hon FACTM, Hon FFPM RCP(UK) ISTM-CTH

Dean, College of Public Health, Medical & Veterinary Sciences James Cook University, Townsville, Queensland, Australia

Overview

•  Non-infectious mortality and morbidity of travelers

•  Location •  Potential marine hazards

URL. http://www.atlasobscura.com/articles/atlas-obscura-s-guide-to-islands-you-never-want-to-visit (accessed 14 May 2015)

Quarter of deaths of travelers

Transport 58%

Drowning 22%

Other 20%

Accidents….

Ref. Leggat PA, Wilks J. Overseas visitor deaths in Australia 2001-2003. J Travel Med 2009;16:243-7.

Transport - Air travel

•  Papua New Guinea 20th September 2014

•  Three people, including the Australian pilot and first officer, have been killed in a plane crash near Port Moresby

The plane that crashed near Port Moresby is believed to be a Twin Otter

Surfing and Scuba Diving

•  Surfing and Scuba diving in 156 M square km of Ocean off 30,000 islands –  American Samoa, Australia, Cook Islands, Coral Sea

Islands, Easter Island, Fiji, French Polynesia (Tahiti), Galapagos Islands, Guam, Hawaiian Islands, Hawaii (Big Island), Kauai, Lanai, Maui, Molokai, and Oahu, Hong Kong, Japan, The Marshall Islands, Micronesia (Carolines Islands), New Caledonia, New Zealand, Niue Island, Norfolk Islands, Palau Islands, Paracel Islands, Philippine Islands, Pitcairn Islands, Samoa, Soloman Islands, Spratly Islands, Taiwan, Tokelau, Tonga, Tuvalu, Vanuatu, and Wallis and Futuna Islands.

Pacific Island Surf Trip Vacation Destinations. URL. http://www.surftrip.com/destinations/islands/pacific/south_pacific.html accessed 19 May 2015

Quarter of deaths of travelers

Transport 58%

Drowning 22%

Other 20%

Accidents….

Ref. Leggat PA, Wilks J. Overseas visitor deaths in Australia 2001-2003. J Travel Med 2009;16:243-7.

Findings of coronial inquests

•  Remind travelers to heed the signs –  “Static signage and general safety information

brochures will only be effective if they are drawn to the attention of visitors, ideally before, or at least on arrival, at the particular destination” (p 52)*.

•  Ensure that an appropriate assessment of medical fitness of divers is conducted before diving.**

*Wilks J. Int Travel Law J. 2006; 13(1): 42-52; **Wilks J. JTM 2000; 7: 283-289

Things that sting you…

•  Jellyfish – Box jellyfish

•  Blue bottles •  Stingrays •  Stonefish •  Cone Shells •  Sea snakes

Box Jellyfish

•  Indo-Pacific region north of Australia.

•  Box Jellyfish tend to dwell near the surface and in open waters; mostly November-April.

•  Only a third (34%) of international travellers were aware of box jellyfish.

•  Irukandji jellyfish are tiny. Ref. Leggat P et al. Health advice obtained by tourists travelling to Magnetic Island: a risk area for “Irukandji’ jellyfish in North Queensland, Australia. Travel Med Inf Dis 2005;3:27-31.

•  Visual evidence of jellyfish-tentacles adherent to skin

•  Skin markings – inconspicuous to blistering and darkening of skin (scars)

•  Pain •  Symptoms of severe stings

– Difficulty/cessation of breathing – Cardiac arrest – Severe pain – Restlessness and irrational behaviour

Presentation

Ref: ARC Guidelines 8.9.6 Envenomation-Jellyfish Stings (2007)

Prevention

•  Awareness •  Swim in stinger net

enclosures/between the flags

•  Language appropriate information

•  Stinger suits •  First aid knowledge

Blue bottles (“Portuguese Man-of-War”)

•  Venemous tentacles are on average 10 meters (30 feet).

•  Sting is excruciatingly painful, but rarely deadly; however can ruin a day at the beach.

Things that can eat (and bite) you…

•  Crocodiles •  Sharks •  Snakes •  Spiders

Crocodiles in Oceania

•  On average, about one person per year is killed by a crocodile in Australia; little information available on the rest of Oceania

•  Further information: Marine Education Society of Australasia http://www.mesa.edu.au/friends/croc_kit/features/infosheet02.asp

1580-2014 Map of World's Confirmed Unprovoked Shark Attacks (N=2,777)

Australian Geographic. URL. https://www.flmnh.ufl.edu/fish/sharks/statistics/GAttack/World.htm (accessed 13 May 2015)

Potentially dangerous sharks

Shark Species Risk White Shark Carcharodon carcharias Responsible for most cool

water attacks, particularly on divers

Bull Shark Carcharhinus leucas Omnivorous, aggressive, opportunistic feeder

Tiger Shark Galeocerdo cuvier Omnivorous, aggressive, opportunistic feeder

Oceanic Whitetip Shark Carcharhinus ongimanus Not normally found near land - probably responsible for most open-ocean attacks, particularly after air or shipping disasters

Source: CSIRO, Australia

Cruise Passengers (2012)

The Global Cruise Port System. URL. http://people.hofstra.edu/geotrans/eng/ch7en/appl7en/global_cruise_port_system.html (accessed 13 May 2015)

Further Reading: •  Fenner PJ. Dangers in the ocean: the

traveler and marine envenomation. I. jellyfish. J Travel Med 1998;5:135-41.

•  Steffen R, DuPont H, Wilder-Smith A. Animal bites and stings. In. Manual of Travel Medicine and Health. Hamilton: Decker, 2007: 457-65.

Case 1. Brad and Angie

Brad is 32. Angie is 29. Both are in good health. They are getting married in a week’s time, and leaving the next day for a scuba diving trip to Vanuatu for ten days. They learned to scuba dive two years ago on a trip to the Caribbean. They are planning to stay on Hideaway Island, near Port Vila and do some dives in Mele Bay but may also go to Espiritu Santo. They were advised that they might need travel vaccinations and Angie wants to talk about how to skip a period using her oral contraceptive pill…

THE UNIVERSITY OF NEW SOUTH WALES

Pre-travel advice

•  Food and water •  Insect borne disease •  Vaccinations •  Diving •  Women’s health

Malaria in Vanuatu

•  CDC consider all of the islands to be areas of risk for malaria while

•  Other authorities consider that the northern islands including Espiritu Santo to be the highest risk area.

•  Most common form is plasmodium falciparum (60%) followed by plasmodium vivax (35-40%).

•  There have been reports of malaria in and around the capital Port Vila and the nearby resort islands.

Case 2. Andrew the Geologist §  28 single male, geologist. Two year mining

contract in PNG. §  What more information do you need

§ Regarding him? § Regarding his travel?

§  What areas of advice would you like to cover?

Case 2. Andrew the Geologist §  Pre-Travel Advice:

§  Insect borne diseases § Malaria

§ Anti-malarials, emergency self treatment, rapid diagnostic tests

§  Japanese encephalitis § Dengue and other arboviruses

§  Food & water borne §  HIV & STIs §  Vaccinations

§ Which ones? §  Altitude §  Medical Kit

§  Post-travel screening

Case 3. Tile the International Student

•  22 yo woman, visiting friends and relatives in Samoa for 2 months

•  Staying with cousins in village •  What more do you need to know

–  About her? –  About the trip?

Case 3. Tile the International Student

Pre-travel advice: §  Insect borne diseases

§  Dengue, DHF & DSS §  Other arboviruses

§  Food & water §  Travellers’ diarrhoea §  Hepatitis A & Typhoid

§  Leptospirosis §  Vaccinations

§  Which ones? §  Medical kit