Travel Medicine Consultation

Travel Medicine Consult

Destination: Vietnam (Hanoi, Ha Long Bay, Ho Chi Minh City) and Cambodia (Siem Reap, Phnom Penh)

Duration: 3 weeks

Departure: 15/11/2023

Plans During Trip

• 66yo male presenting for pre-travel medical consultation prior to a 3-week leisure and sightseeing holiday to Vietnam and Cambodia. Staying in 4-star hotels, taking guided day tours to rural temples and markets, and a 2-night cruise in Ha Long Bay.

Summary of Recommendations

• Vaccinations advised: Influenza (Quad), Typhoid (Typhim Vi), Hepatitis A (Avaxim), Rabies pre-exposure prophylaxis (Verorab).
• Non-vaccination advice: Strict food and water hygiene, mosquito bite avoidance (30% DEET, permethrin-treated clothing), malaria chemoprophylaxis for rural Cambodia, Gastrokit for self-treatment of traveller's diarrhoea, and animal bite avoidance.

Comprehensive Travel Consult Notes

Past Medical History

• Essential hypertension (well-controlled on perindopril 5 mg PO OD)
• Mild GORD

Past Vaccination History

• Childhood schedule complete.
• ADT booster: 12/05/2018.
• COVID-19 (Comirnaty): Primary course 2021, last booster 14/03/2023.
• Nil history of adverse reactions or anaphylaxis to previous vaccinations.

Risk Assessments

COVID and Influenza

• Advised that transit hubs and crowded tourist sites carry moderate-to-high risk for respiratory viruses.
• Eligible for a 2023 COVID-19 booster (> 6 months since last dose).
• Patient declined the COVID-19 booster today, preferring to wait until closer to next winter.
• Discussed year-round transmission of influenza in tropical Southeast Asia and recommended annual vaccination prior to travel.
• Patient is eligible and clinically suitable for the funded NIP influenza vaccine (> 65 years old).
• Patient accepted the influenza vaccination recommendation.

Hepatitis A

• High risk of Hepatitis A transmission across both Vietnam and Cambodia via contaminated food and water.
• Advised food/water precautions and active immunisation; noted patient has no prior history of Hep A immunity.
• Hepatitis A vaccination (Avaxim 160 U/0.5 mL IM) was advised and accepted for this trip.

Typhoid Fever

• Moderate-to-high risk of enteric fever in Southeast Asia, particularly when eating at local markets.
• Discussed safe food practices and efficacy of the polysaccharide vaccine (~70% protection).
• Typhoid Fever vaccination (Typhim Vi 25 mcg/0.5 mL IM) was advised and accepted for this trip.

Gastroenteritis

• High risk of bacterial, viral, and protozoal traveller's diarrhoea in both destinations.
• Advised "boil it, cook it, peel it, or forget it" rule, frequent hand hygiene with alcohol gel, and oral rehydration therapy as mainstay of management.
• Advised strictly avoiding tap water, ice made from tap water, raw salads, and unpasteurised dairy; stick to sealed bottled water (check seal integrity) even for brushing teeth.
• Patient agreed to take a "Gastrokit" with them (prescribed azithromycin 500 mg PO OD for 3 days for severe/dysenteric diarrhoea, loperamide 2 mg PO PRN, and oral rehydration salts).

Dengue Fever and Other Mosquito Borne Illnesses

• Dengue fever, Zika virus, and Chikungunya are endemic in urban and rural areas of Vietnam and Cambodia.
• Advised rigorous daytime and dusk/dawn mosquito bite avoidance: use topical repellent containing 30% DEET or 20% picaridin, wear loose long-sleeved clothing, and utilise air-conditioned or screened accommodation.

Malaria

• Low/negligible risk in Hanoi, Ho Chi Minh City, and Phnom Penh; low-to-moderate risk in rural Cambodia around Siem Reap outer temples.
• Discussed mosquito avoidance at night and risk vs benefit of chemoprophylaxis for the Cambodian leg of the itinerary.
• Malaria chemoprophylaxis was advised for the Cambodia portion of this trip.
• Prescribed atovaquone/proguanil (Malarone®) 250 mg/100 mg: 12 tablets supplied. Instructed to take 1 tablet PO OD with food/milky drink starting 1 day prior to entering Cambodia, daily while there, and for 7 days after leaving the risk area.

Japanese Encephalitis

• Endemic in rural agricultural areas (particularly near pig farming and rice paddies) in Vietnam and Cambodia.
• Discussed disease severity vs low overall risk for short-term urban/standard tourist itineraries; advised strict evening mosquito precautions.
• Japanese Encephalitis vaccination was considered unnecessary for this trip given short duration and lack of prolonged rural/outdoor night-time exposure.

Rabies

• Discussed high endemicity of rabies in dogs, bats, and monkeys (e.g., at Angkor Wat) and poor availability of Rabies Immunoglobulin (RIG) locally.
• Pre-exposure rabies vaccination was advised for this trip.
• Patient declined rabies vaccination despite the doctor's recommendation due to cost and time constraints prior to departure.
• Advised strict avoidance of all animals. In the event of any bite, scratch, or lick to broken skin: immediately flush wound with soap and running water for 15 minutes, apply povidone-iodine, and seek urgent medical attention for post-exposure prophylaxis (will require RIG and full vaccine course; may need medical evacuation to Bangkok).

Yellow Fever

• Nil risk of Yellow Fever transmission in Vietnam or Cambodia; no country entry requirements as patient is travelling directly from Australia.
• Discussed that vaccine is only required if arriving from a YF-endemic zone.
• Yellow Fever vaccination was considered unnecessary for this trip.
• Explained that Yellow Fever Vaccine (Stamaril) is a live attenuated vaccine; patient documented as having no immune-compromising conditions or contraindications to live vaccines.
• Patient is 66 years old; discussed increased age-related risks of YEL-AND and YEL-AVD in patients over 65. Agreed vaccine is not clinically indicated; Yellow Fever Waiver Certificate was not required or provided.

MPox

• Low risk of Mpox for general tourists in Southeast Asia unless engaging in high-risk close/sexual contact networks.
• Advised avoidance of close skin-to-skin contact with individuals showing rash or lesions.
• Mpox vaccination was considered unnecessary for this trip.

Tick Borne Encephalitis

• Discussed tick-borne encephalitis: nil risk in Southeast Asia (endemic to parts of Europe and Northern Asia). Explained standard schedule is 3 doses of FSME-IMMUN if ever travelling to endemic forests in Europe; not recommended for this itinerary.

Administration

• Vaccinations administered today: Avaxim 0.5 mL IM (left deltoid), Typhim Vi 0.5 mL IM (right deltoid), and FluQuadri 0.5 mL IM (right deltoid, 2.5 cm apart). Administered by RN Sarah Jenkins. Patient was observed in the waiting room for 15 minutes afterward with nil acute adverse reaction.

Costs

• Discussed out-of-pocket costs prior to administration: Level C travel consultation fee ($115.00 with Medicare rebate $80.10), Avaxim ($75.00), Typhim Vi ($65.00), Influenza vaccine ($0.00 - NIP funded). Total out-of-pocket vaccine cost $140.00 accepted by patient.