Could A Malaria Vaccine Be On The Way?

malaria
USAID and the President’s Malaria Initiative support the distribution and use of bednets to protect against malaria. Bednets are important for children and pregnant women who are most vulnerable to the disease. Photo: Alison Bird/USAID

The UK drug company GlaxoSmithKline is applying for regulatory approval of the world’s first malaria vaccine, the BBC reports.

The move comes after tests that the company said were promising. For the past several years, GlaxoSmithKline has conducted tests of its vaccine on almost 15,500 children in seven African countries. The company reports that 18 months after vaccination, there was a 27 percent reduction in malaria cases in infants aged 6-12 weeks and a 46 percent reduction in children aged 5-17 months.

Now it’s applying to the European Medicines Agency to start marketing the vaccine. GlaxoSmithKline’s research was supported by the Bill and Melinda Gates Foundation and the company says it will make the vaccine affordable for poorer nations.Ninety percent of the world’s malaria cases are in the poorer regions of sub-Saharan Africa where the vaccine was tested. Globally, malaria kills 800,000 people a year. It’s also a major hazard for adventure travelers. While antimalarial pills are generally effective, they can have serious side effects. A vaccination would go a long way to easing the burden on people who choose to visit the tropics.

Approval for the vaccine could come in 2014. Unfortunately, the percentages the company is quoting do not indicate that it will be as effective as many of the vaccines we are used to. Other measures are still needed like the education of the public of the dangers of standing water and the need to use mosquito netting. More innovative methods for fighting the disease like infecting them with bacteria are also being studied.

Hopefully GlaxoSmithKline’s vaccine will be just the first generation of a series of improving vaccines that will one day relieve the world of a dangerous disease.

Rabies Pre-Exposure Vaccine: Will Not Getting One Come Back To Bite You In The Butt?

dogRecently, a well-traveled friend of mine, whom I’ll call Jules, went to Belize on vacation. While on an idyllic, live-aboard sailing trip, Jules, her husband, and mother decided to explore some cays by sea kayak. What happened next is one of my worst developing nation nightmares.

While poking around what appeared to be an abandoned cay (this is why poking sans guide isn’t recommended, but few true travelers can resist), two semi-feral dogs “jumped out from beneath an overturned rowboat, barking ferociously.” Jules explains, “They were tied up, and we immediately headed back to our kayaks, when we saw a man. He told us the cay was ‘privado (private),’ and I started apologizing in Spanish as we pointed at our kayaks and picked up our pace. The next thing I knew, one of the dogs was let loose, and barreling after us. I started to run, and it bit the back of my right calf.”

The dog released her leg after Jules’ husband waved his arms at it while yelling, “NO, NO, NO, NO!” Then it re-launched itself at her, so she employed the same tactic, and eventually they made their way to their boats and escaped.

As if this story isn’t harrowing enough, the really terrifying part is that they were 10 miles out to sea and had four days left aboard ship. Fortunately, Jules’ mom is a medical professional. Immediately following the attack, she soaked her leg in sea water to flush the wound, then her mom accessed their first-aid kit and cleaned it with hydrogen peroxide, and applied antibiotic ointment. For the remainder of the trip, her mother repeated this procedure, changing the bandages up to three times a day.

dog biteI asked Jules why she didn’t insist upon returning to land immediately and seeking medical treatment.

“That’s an emotionally hard question to answer,” she explained. “The dogs weren’t foaming at the mouth, they didn’t look rabid, but rather in aggressive/protective mode. My mother was on the boat with us and she nursed my wound and kept checking my vital signs for any dangerous symptoms. Luckily, nothing bad came of it. There were no clinics in Placenia where we were, so I made the decision to go to the hospital as soon as I returned home six days later.”

There, she was advised to get rabies shots, which had to be administered through the ER (general practitioners apparently won’t provide them). Jules said the series of four treatments – eight shots the first visit, and one per follow-up – was awful. “I got one in each shoulder, one in each upper thigh, one in my butt, and three directly into the wound. The serum they inject feels thick and made my blood feel sluggish. I couldn’t think clearly and needed to nap every day.” She also wasn’t up-to-date on her tetanus, so that was the first shot she received.

Since Jules is one of the most energetic people I know, the shots really affected her ability to work, and she had to take a number of sick days on top of her two weeks vacation. That, of course, is the least concern in this scenario, and I asked my infectious disease doctor, John Szumowski, a fellow at the University of Washington, what the best course of action would be in such a situation.

“Once a person has symptoms of rabies, there’s little that can be done,” he says. “Only a handful of persons have survived even with intensive care. But the rabies pre-exposure prophylaxis vaccine series is felt to be very effective if administered to a person who doesn’t have symptoms.”

I’ve been telling myself for years that I should get rabies prophylaxis (a series of three recommended vaccinations) because I’m in what’s considered a high-risk group when I travel. I have a lot of exposure to animals, and I spend extended periods in rural areas where a delay in medical evaluation is likely. Thus, it’s a safe generalization to say that most adventure travelers would do well to get the series, even if they’re not animal lovers (for the record, despite my crazy dog/cat lady tendencies, I usually give creatures in developing nations a wide berth for this reason). I know I’m going to do it before my next big trip.

Getting the series, says Dr. Szumowski, “Also allows for a simpler course of post-exposure prophylaxis following a bite: fewer vaccinations and immunoglobin (which may not be readily available or of good quality internationally) isn’t needed. The pre-exposure series is available in travel clinics, but can be easily given in a primary care setting, too. Clinics may not have it immediately available, so calling the office ahead of time is a good idea.”
dog
Dr. Szumowski is quick to point out that getting the pre-exposure series does NOT mean medical evaluation should be skipped after an animal bite. Aside from rabies, bites can transmit other, primarily bacterial, infections. “Thorough cleansing of the bite site is an important step, regardless of vaccination status,” he adds. “Animal bites, even those that took place some time in the past, should be discussed with your medical provider because the incubation period for rabies can be up to years afterward.”

Need more compelling reasons for why adventure travelers should get pre-exposure shots? I’ve witnessed a puppy play-biting (drawing blood) a fellow traveler while we were visiting a Myanmar refugee camp in Thailand. I’ve seen a late-stage rabid dog staggering down the main street of a small village in Ecuador. I’ve been chased down an alleyway by a pack of mangy Vietnamese dogs, and had to scale a fence to escape. Gadling contributor Kyle Ellison has been chased by a dog while going for a run in a developing nation. I’ve been attacked and bitten two separate times by seemingly friendly cats here in the States, and still had to go to the ER, while animal control was required to quarantine and test the animals.

Rabies definitely isn’t limited to developing nations, nor is it restricted to dogs and cats. You should never get to close to wildlife, wherever you may be, for any number of safety reasons. But animals like raccoons, opossums, and bats are also frequent carriers of this deadly disease domestically.

For more information on rabies and other infectious diseases related to travel, the CDC’s Yellow Book is an excellent resource. And don’t let fear of rabies make you paranoid about indulging your fondness for animals when you travel.

Says Jules, “I’m an animal lover, and even after this horribly scary incident, I’ll continue to look for the wagging tails of approaching dogs. This was a minor blip on our trip, and will in no way stop me from continuing to see the world. It’s a part of traveling that makes us stop and re-evaluate taking precautions. We’re very protected in the U.S., and take that for granted. We need to respect the places that we visit and be our own advocates to protect ourselves and fellow travelers. From now on, I’ll also always consider travel insurance when visiting developing nations.”

[Photo credits: German shepherd, Flickr user State Farm; dog bite, Jules; dog, Laurel Miller]

Top five immunizations for adventure travelers

immunizationsSpending a lot of money to get poked with a needle may not be at the top of your pre-trip to-do list, but it should be. While some countries require proof of certain immunizations before they theoretically permit entry (details later in this post), there are a couple of vaccinations all travelers should get, barring any prohibitive allergies.

Getting vaccinated greatly reduces or virtually eliminates the odds of contracting certain serious illnesses or travel-related diseases, and helps prevent the spread of contagions. This is especially critical in developing countries, where there is generally little in the way of preventative or active health care, and lack of sanitation provides a fertile breeding ground for disease. As is true at home, infants, children, the elderly, and immuno-compromised are at greatest risk.

I consulted with Dr. John Szumowski, Clinical Fellow of the University of Washington Medical Center’s Division of Allergy and Infectious Disease, for expert advice before compiling the following list. As he pointed out, it’s tricky to generalize which immunizations are most important, since it depends upon where you’re going, and what you’re doing there.

That said, all of the immunizations on this list are a good idea if you travel frequently to developing nations, even if it’s for business or budget travel. They are especially important to have if you eat street food or visit rural areas.

The top five, after the jump.

[Photo credit: Flickr user johnnyalive]immunizations1. Flu
With flu epidemics making annual headlines, there’s no reason not to get a flu shot. This is especially true if you fly frequently or use other forms of public transit. Think of an airplane as a flying petri dish; why risk ruining your trip, or exposing others if you’re coming down with something? If you have an underlying health condition such as asthma, diabetes, or other lung or heart disease, it’s of particular importance to get immunized.

2. Tetanus
I grew up on a ranch, so tetanus shots have always been a part of my life. Many people don’t think about getting a tetanus vaccine, however, and as Dr. Szumowski points out, “It’s under-appreciated, and worth getting prior to travel given challenges of obtaining adequate, timely wound care.” Beats lockjaw, any day.

3. Hepatitis A
“Hepatitis A is common and can occasionally be quite serious,” cautions Dr. Szumowski. “For anyone with underlying liver disease (e.g. chronic hepatitis B or C) this is an especially important vaccination.”

4. Polio
Polio hasn’t been fully eradicated in parts of the developing world, so an inactivated poliovirus booster is important when traveling to areas where it’s still a problem, such as Nigeria and India.
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5. Typhoid
This vaccine can be taken either orally or by injection. Be aware that you must avoid mefloquine (an anti-malarial) or antibiotics within 24 hours of the vaccine doses.

Additional vaccines
Depending upon your destination, you may also require, by law, a Yellow Fever (tropical South America and sub-Saharan Africa), or Japanese Encephalitis/JE vaccination (parts of Asia and the Western Pacific). Dr. Szumowski recommends JE vaccine if you’re traveling for an extended (over one month) period in rural areas of affected countries.

Rabies vaccine isn’t usually recommended, but if you travel extensively in developing nations or have/expect frequent contact with animals, it’s a good idea. I’ve had a couple of canine-related experiences that have sold me on the idea. Dr. Szumowski notes that “excellent wound care and post-bite medical evaluation are still needed,” even if you’ve had a rabies pre-exposure vaccination.

Tips
It’s critical to allow ample time before your trip to allow the protective effects of the vaccines to establish themselves. Go to the Centers for Disease Control and Prevention’s vaccinations page for more information on what’s required and epidemic updates, if applicable. Often, your GP, internist, or local drugstore can provide some of these vaccinations; others require a specialist. For locations of a travel medicine clinic near you, click here.

Carry your immunization card with you as proof of vaccination, and email yourself a scanned copy, as well. The same goes for copies of your medical insurance cards.

Practice good hygiene and get enough rest, inasmuch as possible, while traveling, to maintain a healthy immune system. Airborne and Emergen-C are great immunoboosters to carry with you.

Consider travel insurance if you’ll be in a remote or sketchy area, or engaging in high-risk outdoor pursuits.

[Photo credits: swine flu, Flickr user ALTO CONTRASTE Edgar AVG. (away); polio, Flickr user Cambodia Trust;

Lariam Dreams (which pills do you pop?)

If you’ve traveled to a tropical country, you’ve probably heard of Mefloquine. It is the most popular prophylactic against malaria, and is often sold under its trade name, Lariam. Lariam can have some serious side effects such as depression, anxiety, paranoia, nightmares and insomnia. You might say, “having nightmares is better than catching malaria and ending up in a hospital or worse.” I’m sure everyone would agree with that.

But when you wake up in a strange foreign land after a Lariam-induced nightmare…and you aren’t quite sure if you are really awake or if your waking state is just another extension of your dream, it can be pretty unnerving.

After such an experience, you might ask yourself if it is really necessary to ingest Mefloquine every time you enter a tropical region. I’ve known people who pop the little pills once a week when they are in Hong Kong or Singapore where the chance of catching malaria is akin to the chance that you will win the lottery. I guess some travelers choose to err on the side of caution when they enter any unfamiliar place.I haven’t even mentioned the host of shots and other pills that some guidebooks and doctors say you might want to consider. Typhoid is a big one. Cholera is another. Neither of these have vaccines that are 100% effective and they can bring about particularly nasty side effects. That doesn’t stop doctors from recommending them and people from getting the shots.

So what do you really need when you are traveling in a developing, tropical country? I guess it depends on how apprehensive you are. For me, Lariam and obscure vaccines are out unless I find that I am entering an area where a particular disease is truly a threat (see the WHO web site if you want to research a country you plan to visit). I also keep up to date on basic immunizations like tetanus and Hep B. And keep in mind, no matter how Lariam happy you get, there are diseases like SARS and H5N1 out there to remind us that health concerns are always going to be a scary part of traveling. And so I ask you, Gadling readers: what do you consider a necessary part of your travel-sized medicine cabinet?

Yellow Fever: Vaccine Deaths and Outbreaks in South America

Most travelers to Africa and South America have heard of Yellow Fever, even if only because there are countries within that have mandatory vaccinization requirements. People that live in these “Yellow Fever Zones” (an estimated 508 million in Africa alone) know this disease as a killer. This is also what is happening in Brazil.

ProMED mail, from the International Society of Infectious Disease, recently reported a third case and second fatality from YF since the new year. The latest case involved a 24-year-old man from the region of Goianesa. In 2008, there are 26 suspected cases, three confirmed, and 17 pending results of labwork. Six of the suspected cases have been excluded. Brazil also reported to the World Health Organization (WHO) that monkeys were dying of YF, in December 2007.

The Center for Disease Control (CDC) in Atlanta has also released an outbreak notice and stresses the importance of the vaccine for travelers heading to yellow fever areas.

Immunization is the traditional preventative measure against Yellow Fever, and the in Congonhas airport in Sao Paulo — a major travel hub for the region — 1000 people a day are receiving the free vaccine. Savvy travelers may have heard news of a few vaccine associated deaths recently, in Peru. The vaccines in question were manufactured in Brazil, by Bio-Manguinos. All deaths are still under investigation and believed to be associated with the same lot numbers. The vaccines used in North America are from a seperate manufacturer, Sanofi-pasteur. All vaccines from the batch in question, and several from related lots, have been removed.

The Yellow Fever vaccine is considered relatively safe and effective by the CDC. Administered as a single dose under the skin, the vaccine is a live virus. Contraindications to the vaccine are people who are pregnant, immunocompromised or less than 9 months old. Interestingly, the vaccine is grown in chicken eggs and is also to be avoided by those with egg allergies. WHO advises the vaccine be given routinely to children in endemic areas, around the age of 9 months to one year of age. For travelers who are not candidates for the vaccine, a waiver is possible.

Why do you need the vaccine? Besides the country requirements for entry, the disease can be fatal.

Here is some basic information on the disease:

Basics: An Arbovirus spread via arthropods (mosquitos) in the genus Flavivirus. Symptoms include fever, head and backaches, fatigue and nausea. May progress to hemorrhagic complications and/or liver failure. Jaundice is also common. This is a vaccine preventable disease and proof of vaccinization is often required at customs.

Location: Only in Africa and South America. No reported cases in Asia, although the required mosquito species is present to carry the disease.

Transmission/Incubation: Bites from infected Aedes species mosquitoes in cities or Haemagogus species in jungles. The main vector is Aedes Aegypti in urban areas and an incubation of 3-6 days.

Prevention: Vaccination lasts for 10 years and is a live virus. Contraindicated with egg allergy, immunocompromised, pregnancy or less that 9 months old individuals. Mosquito awareness/ bite prevention is the other key.

Diagnosis: Antibodies to YF through a blood draw.

Treatment: This is a vaccine preventable disease, treatment once infected is supportive.

Resources:

CDC Yellow Fever Page

WHO Yellow Fever Vaccine

Interactive Health Map of South America