the university of destination workshop: pacific island nations
TRANSCRIPT
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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
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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
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Pacific Island Groups
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Tropical cyclones
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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
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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
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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
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Infectious diseases risks in Pacific Islands
Dr Colleen Lau Travel Medicine Alliance Clinics & University of Queensland, Australia
THE UNIVERSITY OF NEW SOUTH WALES
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Malaria
Vanuatu is southeastern
limit of malaria in
Pacific
No malaria in: Fiji Samoa Tonga French Polynesia Cook Islands Micronesia
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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
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Emerging Arboviruses in the Pacific
Cao-Lormeau V et al. The Lancet 2014 384, 1571-1572DOI: (10.1016/S0140-6736(14)61977-2)
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Emerging Arboviruses in the Pacific
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Zika Virus
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Zika Virus
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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
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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
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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.
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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.
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Food and Water Borne Diseases
§ Travellers’ diarrhoea § Hepatitis A § Typhoid § Cholera
§ Outbreaks often related to cyclones, flooding and other natural disasters
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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.
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HIV
§ PNG has the highest prevalence in Oceania
§ ~32,000 people living with HIV in PNG in 2013
www.unaids.org. www.indexmundi.com
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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
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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)
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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.
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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
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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
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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.
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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
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Things that sting you…
• Jellyfish – Box jellyfish
• Blue bottles • Stingrays • Stonefish • Cone Shells • Sea snakes
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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.
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• 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)
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Prevention
• Awareness • Swim in stinger net
enclosures/between the flags
• Language appropriate information
• Stinger suits • First aid knowledge
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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.
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Things that can eat (and bite) you…
• Crocodiles • Sharks • Snakes • Spiders
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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
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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)
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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
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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)
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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.
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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
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Pre-travel advice
• Food and water • Insect borne disease • Vaccinations • Diving • Women’s health
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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.
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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?
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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
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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?
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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