PH advice vol14 iss1 web.fh9

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					ISSN 1177-9934 (Print)     ISSN 1177-9942 (Online)
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                                                                                           Sea Bather’s Eruption

                                                                                           Disease surveillance
                                                                                           summaries


 Public Health Quarterly Report                                    April 2009                                  Vol. 14, Issue 1

                 Preventing rabies in travelling New Zealanders
                                                                                                        Dr Brigid O’Brien (Medical Officer)
In December 2008 ARPHS was notified of a human rabies                  intend undertaking hiking or cycling activities while travelling
outbreak in Bali, a popular destination for holidaying New             intend undertaking activities that involve contact with wild
Zealanders which had previously been considered rabies                 or domestic animals
free. ARPHS has also had calls from GPs requesting advice
                                                                       intend to travel to areas where post exposure prophylaxis
on what to do for patients who have been bitten by animals
                                                                       may not be readily available (especially rabies
whilst overseas. Although New Zealand is rabies free, New
                                                                       immunoglobulin, of which there is a worldwide shortage)
Zealanders are increasingly travelling to regions where rabies
is endemic. GPs therefore need to be aware of the risk posed         Pre exposure prophylaxis consists of a series of 3 vaccinations
by rabies to travellers and how to advise correctly on               with modern cell culture vaccines (e.g. Verorab or Merieux,
preventative measures.                                               both of which are used in New Zealand) given over 3-4
                                                                     weeks (at day 0, 7 and 21 or 28). Those who are pre
Epidemiology and clinical features of rabies:                        vaccinated will still need 2 booster vaccinations in the event
Rabies is an acute viral encephalo-myelitis with a case fatality     of an exposure, at day 0 and day 3, but do not require rabies
rate of virtually 100%.                                              immunoglobulin (RIG), which is a major advantage given its
Rabies is endemic in more than 100 countries and is found            scarcity in developing countries.
on all continents except Antarctica.
                                                                     Post exposure prophylaxis (PEP):
See http://wwwn.cdc.gov/travel/yellowBookCh4-Rabies.aspx             This is indicated for risky exposure to any mammal in a
for a list of rabies free countries 2005 and                         rabies endemic region unless the mammal is known to be
http://www.who.int/rabies/rabies_maps/en/index.html                  rabies immune. It is highly effective if given correctly. PEP
for maps of rabies endemic regions.)                                 consists of RIG and/or vaccination with modern cell culture
                                                                     vaccines. Patients presenting in New Zealand following an
At least 60,000 people die annually worldwide from rabies            exposure should be referred urgently to a specialist travel
with 90% of these deaths occurring in Asia and the Indian            medicine clinic, or an infectious diseases hospital specialist
Subcontinent. It is transmitted by contact with infected             for PEP. The type and schedule of PEP varies depending
mammalian saliva, typically via a dog bite, less commonly            on whether the patient has had complete pre exposure
a scratch, or lick on broken skin and rarely via mucous              prophylaxis or not. In all instances the wound should not be
membrane exposure. It has a variable and long incubation             sutured.
period, usually 2-8 weeks, but sometimes years. Clinical             Additionally, GPs should ensure tetanus vaccination is up to
features include sensory changes at the exposure site followed       date and that appropriate antibiotic cover for bacterial infection
by CNS excitation, aerophobia, hydrophobia, delirium, seizures       has been given.
and coma. Unfortunately once clinical features have developed        1. Incomplete, incorrect or no pre exposure vaccination
death is virtually inevitable despite treatment (there have          given:
only been 6 recorded survivals). Thus management of this             a) RIG:
disease must be targeted at prevention. Prevention can be
divided into pre exposure prophylaxis and post exposure                 RIG is indicated for all mucous membrane or transdermal
prophylaxis and behavioural education.                                  exposures
                                                                        For maximum efficacy RIG should be given within 48
Pre exposure prophylaxis (PrEP):                                        hours of exposure
Consider referring patients intending travel to rabies-endemic
                                                                        However because of the long incubation period of rabies
areas to a travel medicine specialist for assessment and
advice regarding need for rabies vaccination. Greater                   RIG can still be given effectively at any point after exposure
consideration for specialist assessment should be given to              (even months or years later), provided it is administered
travellers who:                                                         within 7 days of commencing post exposure vaccination
                                                                        as detailed below (after this point the RIG impairs the
   intend staying for a long period in areas with rabies                immune response to the vaccine)
   intend travelling in remote or rural areas                           In New Zealand RIG is supplied by the blood bank at no
   will be travelling with children                                     charge to New Zealand residents
b) Post exposure vaccine:                                          the traveller to have comprehensive travel insurance to cover
   This is given in conjunction with RIG if a mucous membrane      the costs of such treatment (immunoglobulin is typically over
   or transdermal exposure has occurred, or without RIG if         NZ$1000) and possible flights to regions where there is RIG,
   the exposure was less severe such as a superficial scratch      should it be otherwise unavailable.
   without bleeding or a lick on broken skin
   It consists of a 5 dose course of modern cell culture           Rabies exposures in New Zealanders:
   vaccines, given at day 0, 3, 7, 14 and 28, with an additional   A recently published study of travellers exposed to rabies
   90 day booster suggested by some authorities                    (usually from dogs, bats, cats and monkeys) whilst overseas
   This course should be commenced as soon as possible,            who presented to travel medicine clinics in Auckland and
                                                                   Hamilton on return revealed that 75% of them had received
   but like RIG it is never too late after an exposure to start
                                                                   inadequate rabies post exposure prophylaxis whilst abroad,
   it, because of the long incubation period and fatal nature
                                                                   thus placing them at risk of potentially contracting rabies in
   of rabies
                                                                   the future. 90% of these travellers had not received rabies
2. Complete and correct pre exposure vaccination                   vaccinations prior to travel. The main reasons for in-adequate
previously given:                                                  PEP cited included lack of availability of RIG and modern
                                                                   vaccines abroad and lack of traveller knowledge about rabies.
  No RIG is necessary (a key reason for considering pre            Although there have been no reported rabies cases in NZ
  exposure vaccination in travellers, given its shortage in        travellers there have been several rabies deaths in English
  many rabies endemic regions)                                     and Japanese travellers in recent years. It is prudent that
  Post exposure vaccination is given with a 2 dose course          primary care doctors are knowledge-able about rabies, educate
  of modern cell vaccines, on day 0 and 3                          their travell-ing patients and refer when appro-priate to avoid
                                                                   preventable rabies deaths.
  This should be commenced as soon as practical, but again,
  it is never considered too late after an exposure to
  start it                                                           Key points:
Behavioural education:                                                 Rabies is a fatal, but preventable, encephalomyelitis
Behavioural education involves advising travellers of the risk         NZ travellers to endemic regions are at risk
of rabies, to avoid contact with mammals in endemic areas              GPs should advise intending and returning travellers
and if exposed, to perform appropriate first aid measures              of the risk
and seek immediate medical attention for PEP. First aid                GPs should refer for pre exposure and post exposure
measures include immediately washing the wound vigorously              prophylaxis where indicated and consult a travel
with water and soap (for 15 minutes) and then applying                 medicine specialist if unsure
ethanol (70%) or povidone-iodine if available.
The traveller who is exposed whilst abroad must be advised         References:
                                                                   Centers for Disease Control and Prevention 2009. Travellers Health – Yellow Book [accessed 23 January 2009]. Available
to request modern cell culture vaccines, not those derived         from: http://wwwn.cdc.gov/travel/yellowBookCh4-Rabies.aspx
                                                                   Gautret P et al 2008. Rabies postexposure prophylaxis in returned injured travelers from France, Australia, and New
from nerve tissue which are more reactogenic and less              Zealand: a retrospective study. Journal of Travel Medicine 15 (1): 25–30.

effective, and to seek immunoglobulin when indicated. If           Shaw M, O’Brien B, Leggat P 2009. Rabies postexposure management of travellers presenting to travel health clinics
                                                                   in Auckland and Hamilton. Journal of Travel Medicine 16 (1): 13-17.
vaccine/RIG are unavailable they may need to urgently fly          World Health Organization 2008. International Travel and Health [accessed 23 January 2009]. Available from:
                                                                   http://www.who.int/entity/ith/chapter%206.pdf
to a main centre to obtain them. It is also prudent to advise      E-mail brigido@adhb.govt.nz if you would like a copy of the referenced papers.




                                          Sea Bather’s Eruption
                                                                                                        Dr Brad Novak (Public Health Medicine Specialist)
                                                                                                        Dr Simon Baker (Medical Officer of Health)

What is it and what can you do about it?                           How does it occur?
Auckland Regional Public Health Service (ARPHS) released           Warm weather and onshore winds bring the tiny
a media statement in February 2008 discussing recent cases         hydromedusae organisms into the shoreline. Microscopic
of rash after swimming at several Auckland beaches                 and largely transparent, they become trapped underneath
(Takapuna, St Helier’s and Kohimarama). Overall at least 26        bathing suits or in peoples’ hair. Generally, as the swimmer
cases were reported, but it is highly likely that many more        gets out of the sea, water drains from their bathing suit and
went unidentified from these and other east coast beaches.         traps the organisms between the fabric and their skin, causing
The investigation of these cases found that “microscopic           their stinging cells to release toxin into the person’s skin.
jellyfish may be causing the rash often blamed on sea lice”.       Factors that worsen the rash include: wearing bathing suits
This finding has highlighted the little known disease of “Sea      for prolonged periods after swimming; mechanical stimulation
Bather’s Eruption”.                                                (rubbing with a towel); and osmotic changes that occur with
                                                                   evaporation or rinsing off with freshwater. Thorough laundering
What is Sea Bather’s Eruption?                                     is needed to remove the organisms before the bathing suit
Sea Bather's Eruption is an itchy rash, which tends to affect      is worn again.
the bathing suit-covered areas of the skin, rather than exposed
areas, after swimming in the sea. The rash is most pronounced      What are the health risks to humans from Sea
in areas where a person’s bathing suit clings to the skin,         Bather’s Eruption?
such as the buttocks and side of the torso. The rash results       Generally, those people affected have an itchy red rash in
from an allergic reaction to the toxin injected by the stinging    the bathing suit-covered areas. The rash can vary from being
cells in hydromedusae (the larval forms of certain jellyfishes     mild (slight discomfort) to being very severe (painful with
and sea anemones), which tends to come on after the person         systemic effects), and can last for longer than 2 weeks.
has left the water. Children are most affected possibly due        Calamine lotion, antihistamines and mild steroid creams may
to their softer skin. Those prone to allergies are also more       be helpful. Some children can become systemically unwell
likely to be affected and to experience symptoms of greater        with headaches, nausea and lethargy for several days,
severity.                                                          requiring treatment with oral steroids.
How do we know it isn’t just sea lice?                              After swimming, remove your togs as soon as possible
Sea lice generally bite people on uncovered parts of their          and thenshower without your togs on - rinsing the area
bodies. Their bites tend to resemble sand-fly bites. In contrast,   that was covered by your togs well. If there is a saltwater
Sea Bather’s Eruption occurs mainly under bathing suits,            shower, it is best to use that. If not, a freshwater shower
may appear urticarial, or may comprise of hundreds to               is better than nothing, but can cause the organism to sting,
thousands of little red dots (that can join together making         especially if togs are still worn
confluent red patches). It is also more likely to come on over      Don’t put togs back on till laundered properly, as the
time after the person gets out of the water.                        jellyfish can still sting even after they are dead
                                                                    If you develop a rash, have a shower, and get into cool
What can be done to prevent Sea Bather’s Eruption?                  clothing. Calamine lotion may help
ARPHS recommends:                                                   If the rash persists, visit your local pharmacy - antihistamine
  The only certain way to prevent being stung during at risk        tablets and mild steroid creams like hydrocortisone can
  times (generally the warmer months) is to avoid swimming          be helpful
  at affected beaches or to swim in a freshwater swimming           If problems are severe or persist or worsen, see a doctor
  pool instead
  Do not wear clothes that cover large areas of the body             Questions and Answers are available on ARPHS’ website
  into the water (but still stay sun smart)                          at www.arphs.govt.nz/Media Releases/JellyfishQA.pdf




              Commentary on Disease Surveillance Summaries
             For the six months from July to December 2008, notifications of dengue fever (40 cases), lead
             absorption (130 cases) and VTEC/STEC infection (17 cases) were all significantly increased compared
             to the same period in 2007.
             While there have been increases in the notifications of hepatitis A (16 cases, an approx. 100%
             increase), legionellosis (16 cases, an approx. 60% increase), meningococcal meningitis (19 cases,
             an approx. 25%increase) and pertussis (23 cases, an approx. 28% increase) these do not reach
             statistical significance. Tuberculosis and salmonellosis notification rates are essentially stable.
             The approximately 130% increase in dengue fever notifications (all overseas acquired) reflect
             ongoing outbreaks in various Pacific Island states (Fiji, Samoa and Tonga) and the travel/holiday
             patterns of New Zealand citizens, especially those of Pacific Island ethnicity.
             The very large (almost 1100%) increase in lead absorption notifications is due to a combination
             of enhanced routine occupational screening, direct laboratory notification and a reduction in the non-
             occupational blood level needed to trigger a notification.
             VTEC/STEC (Verotoxin producing E.coli/shigatoxin producing E.coli) notifications show a 240%
             increase over the same period in 2007. This increase appears to be part of a nationwide trend, the
             cause of which is unclear.
                             Disease Surveillance
           Selected Auckland disease notifications for 1 July 2008 to
            31December 2008 compared to the same period in 2007

  Campylobacteriosis▼
     Cryptosporidiosis*
        Dengue Fever*                                                                                  129%
       Gastroenteritis▼
            Hepatitis A
     Lead absorption▼                                                                                  1082%
          Legionellosis
Meningococcal Disease
             Pertussis
         Salmonellosis
  Tuberculosis disease
 VTEC/STEC infection*                                                                                  240%
                            -100                -50                 0                   50                 100
                                            % change in number of 2007 cases

                      Note: * denotes p<0.05          ** denotes p<0.01      ▼ denotes p<0.001




                          Selected Auckland notifications July 2008 to
                               December 2008 by Health District
                                      Central   North West     South    All Auckland
Disease                             cases rate* cases rate* cases rate* cases rate*
 Campylobacteriosis                  382     174.4     513     197.0      391     165.2      1286      179.6
 Cryptosporidiosis                    10        4.6       8       3.1      10        4.2       28        3.9
 Dengue fever                         10        4.6      11       4.2      19        8.0       40        5.6
 Gastroenteritis                                                                              775      108.2
 Giardiasis                          134       61.2      89     34.2       92       38.9      315       44.0
 Hepatitis A                           5        2.3       5       1.9        6       2.5       16        2.2
 Hepatitis B                           5        2.3       3       1.2        1       0.4        9        1.3
 Hepatitis C                           1        0.5               0.0        2       0.8        3        0.4
 Invasive pneumococcal disease        14        6.4      13       5.0      22        9.3       49        6.8
 Lead absorption                      72       32.9      39     15.0       19        8.0      130       18.2
 Legionellosis                         4        1.8       5       1.9        7       3.0       16        2.2
 Listeriosis                           3        1.4       2       0.8        5       2.1       10        1.4
 Malaria                               4        1.8       2       0.8        6       2.5       12        1.7
 Meningococcal disease                 5        2.3       3       1.2      11        4.6       19        2.7
 Mumps                                 4        1.8       2       0.8        4       1.7       10        1.4
 Paratyphoid fever                     2        0.9       2       0.8        3       1.3        7        1.0
 Pertussis                             2        0.9       9       3.5      12        5.1       23        3.2
 Rheumatic fever - initial attack      9        4.1      11       4.2      13        5.5       33        4.6
 Salmonellosis                        45       20.5      47     18.0       39       16.5      131       18.3
 Shigellosis                          10        4.6       9       3.5        7       3.0       26        3.6
 Tuberculosis                         22       10.0      18       6.9      34       14.4       74       10.3
 Typhoid fever                         4        1.8       1       0.4        9       3.8       14        2.0
 VTEC/STEC infection                  11        5.0       3       1.2        3       1.3       17        2.4
 Yersiniosis                          29       13.2      21       8.1      14        5.9       64        8.9

               Note: Annualised crude rate per 100,000 population calculated from estimated resident
                    population at mid-year 2008.




                                                          Public Health                      phone (09) 623 4600

				
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