Health Protection Services Colindale: Travel and Migrant Health Section
17 March 2011
Earthquake and tsunami in Japan
On 11 March 2011, an earthquake measuring 9.0 on the Richter scale occurred in the Pacific Ocean
east of the coastal city of Sendai on Japan's largest island Honshu. The earthquake triggered tsunami
waves that affected the north eastern coast of the island causing extensive structural damage; a
large number of people have died and thousands more are missing or displaced from their homes.
The tsunami has also caused explosions at two nuclear power plants causing concerns about
potential radiation leaks. A massive rescue operation is underway and the situation remains
dynamic. Updates will be posted on the International Event Response pages as more information
becomes available. Experts have already been deployed from the UK to assist with the rescue
operation and it is likely that relief organisations and journalists from the UK will also be travelling to
Japan in the coming days and weeks. For those intending to travel to Japan, the Foreign and
Commonwealth Office should be consulted for their up to date travel advice, with current health
advice available from the National Travel Health Network and Centre (NaTHNaC).
Information for health professionals advising returning travellers
Infections would not be expected to be the predominant health problem among the people
returning to the UK from Japan [http://www.who.int/hac/crises/jpn/en/index.html]. Japan is a
temperate country with a similar infectious disease profile to the UK, therefore any infectious
disease risks will be those usually associated with earthquakes and flooding [1]. In the first instance
health needs are likely to be physical and psychological resulting from the trauma, shock and loss
that individuals have experienced or witnessed. It is important to establish, however, whether any
presenting patient has stopped or travelled elsewhere en route back to the UK; if this is the case
then check the NaTHNaC website country information pages or the HPA Migrant Health country
pages for disease risks associated with that country.
Specific questions and answers for health professionals seeing travellers returning from
Japan
NaTHNaC has developed a series of algorithms for the assessment of both ill and well returning
travellers [2]; these include algorithms for assessing those with fever, diarrhoeal illness, and
respiratory illness and are appended to the end of this document.
Any infections diagnosed in travellers returning from Japan should be reported to the Travel and
Migrant Health Section at [email protected]
Q1. A traveller returned from Japan has presented with a fever or a flu-like illness without
localising signs. What conditions should be considered?
Malaria is not endemic in Japan, however, if the patient has stopped over or travelled elsewhere on
route home where malaria is present, then malaria should first be excluded. Infections such as
dengue, chikungunya and yellow fever do not occur in Japan.
Infections to consider include:
•
Viral hepatitis (A, B, C, E). Japan has an intermediate prevalence for hepatitis B (2-7%) and a
higher prevalence of hepatitis C than the UK and therefore may be a higher risk in healthcare
Health Protection Services Colindale: Travel and Migrant Health Section
•
•
•
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17 March 2011
workers or anyone exposed to blood products. Both hepatitis A and E may be a risk from
consuming contaminated food or water. See the hepatitis A, B, C, and E pages for more
information.
Leptospirosis is a risk in those who have been exposed to fresh or brackish water that has been
contaminated with animal urine. This is less of a problem in salt water but sewage and water
mains will have been damaged by the earthquake and tsunami leading to the potential for
exposure once the sea waters have receded. See the HPA Leptospirosis page for more
information.
HIV is low prevalence in Japan but can present as a non-specific febrile illness.
Japanese encephalitis (JE) is rare in Japan, and when it occurs it is seasonal between June and
September.
Influenza occurs in Japan but activity is currently low. With thousands of people staying in
shelters it is possible that overcrowded conditions could increase transmission of respiratory
infections. No cases of avian influenza (H5N1) have been reported in areas of Japan affected by
the tsunami.
See appendices at the end of this document for the NaTHNaC algorithms for assessing fever and
respiratory illness in ill returned travellers. [2]
Q2. A traveller returned from Japan has presented with an infected wound. What microbiological
investigations should be undertaken and what treatment considered?
‘Standard’ wound swabs should be collected and the travel history should be noted on the request
form. The most likely infections are staphylococcal and streptococcal and, if contaminated by dirty
water, ‘coliform’ organisms may also be present. Vibrio vulnificus is also a potential risk if open
wounds are exposed to contaminated salt or brackish water. All of these will be readily detected by
standard wound swab cultures. Antimicrobial treatment, if indicated, should be based on local
polices for the treatment of infected wounds.
Q3. A traveller returned from Japan has sustained an injury. What should be done about tetanus
protection?
The patient should be assessed in the same way as for anyone with a possible tetanus prone wound
(see Green Book chapter:
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasse
t/dh_103982.pdf). If the wound is assessed as being tetanus prone and is high risk or the patient is
not fully immunised, they may need tetanus immunoglobulin which is available from Bio Products
Laboratory (see tetanus page of Immunoglobulin handbook:
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947314087).
Q4. A traveller returned from Japan has been bitten by/exposed to the saliva of an animal, should
rabies post-exposure prophylaxis be considered?
Japan is rabies-free so if the bite took place in Japan then there is no need for post exposure
prophylaxis for rabies. However, other precautions associated with management of animal bites
should be considered such as tetanus [see Q3] and other bacterial infections [see Q2].
Q5. A traveller returned from Japan has presented with a gastrointestinal illness. What
microbiological investigations should be undertaken?
Health Protection Services Colindale: Travel and Migrant Health Section
17 March 2011
The most common gastrointestinal infections that occur in returning travellers are caused by
Salmonella spp (non typhoidal), Campylobacter spp, E. coli, Shigella spp, Cryptosporidium, Giardia,
Vibrio spp (non cholera) and enteric viruses. Cholera and enteric fever do not occur in Japan except
as importations in travellers returning to Japan. Shigella is also uncommon. Laboratory confirmation
of the majority of gastrointestinal infections, including parasites, can be obtained through
examination of stool specimens. If submitting specimens it is important to indicate travel history to
Japan. Virological examination can also be considered. Local laboratories should send cultures to the
Laboratory for Gastrointestinal Pathogens as appropriate for confirmation and typing, or where no
diagnosis has been made send samples for further testing.
See appendices at the end of this document for the NaTHNaC algorithm for assessing diarrhoeal
illness in ill returning travellers [2].
Q6. A traveller returned from Japan has been admitted to hospital unwell or injured. What
infection precautions should be taken?
Standard infection control procedures should apply for patients with wound infections or
gastrointestinal illnesses. At the moment, no special precautions are believed to be required with
patients who are injured or otherwise unwell who have no signs of infectious illness. However, these
patients should be monitored closely for the development of infection during their admission and if
infectious disease is suspected in any way, the clinical team should liaise promptly with their hospital
infection control team for advice on appropriate management. This advice will be updated as
necessary should information from affected areas warrant this.
There is a relatively high use of antibiotics in Japan and hospitals admitting patients who have
been previously hospitalised in Japan should be aware of the possibility of resistant organisms.
Q7. What infection precautions should be taken in the community for patients who are unwell or
injured having returned from Japan? (E.g. for airport staff, paramedics, ambulance crew, primary
care and community nurses)
•
•
Standard infection control procedures should apply for patients with wound infections or
gastrointestinal illnesses.
No special precautions are believed to be required at the moment with patients who are injured
or otherwise unwell who have no signs of infectious illness. This advice will be updated as
necessary should information from affected areas warrant this.
Q8. A body has been brought back from Japan. What special infection precautions should be
taken? Are there infectious risks to families in viewing a relative’s body?
Most of those who lost their lives in the tsunami will have been killed by trauma/drowning not
infection. Even where infection was present in life, infectious agents do not survive for very long
after death. This means that no special infection precautions need to be taken for dead bodies being
returned from Japan over and above normal practices, and at this time there are not believed to be
any infectious risks to families in viewing a relative’s body. This advice will be updated as necessary
should information from affected areas warrant this. Further information on the infection hazards of
human cadavers is available [3-5].
Health Protection Services Colindale: Travel and Migrant Health Section
17 March 2011
Q9. A traveller returned from Japan has presented with emotional difficulties. How should they be
advised/treated?
Experiencing, or providing relief in the aftermath of, a devastating event such as an earthquake or
tsunami will expose an individual to traumatic and stressful scenes and experiences. This is likely to
have implications for emotional and psychological wellbeing including, in some instances, the
development of post-traumatic stress disorder (PTSD). It is important to remember that the
potential for experiencing psychological and emotional reactions will remain during the weeks and
months after having returned home. Advise them to take sufficient time to rest and recuperate, eat
and drink. Also suggest that if possible, they try and spend a proportion of time carrying out nonstressful tasks and that it may help to talk about their experiences with colleagues, family and
friends. If they have any further concerns or their feelings are prolonged, they should seek medical
assistance. More information can be found in section 4.4 of the IASC guidelines [6]. For information
on recognition of PTSD and for management guidelines please see the NICE guidelines on post
traumatic stress disorder.
Q10. What risk is there to returning travellers from radiation?
Please see HPA response to explosions at the Japanese nuclear power plant
References
1. World Health Organization. Flooding and communicable diseases fact sheet. Available at:
http://www.who.int/hac/techguidance/ems/flood_cds/en/index.html
2. Field, Ford L, Hill DR, eds. Health Information for Overseas Travel. National Travel Health
Network and Centre, London, UK, 2010
3. Healing TD, Hoffman PN, Young SEJ. The infection hazard of human cadavers. CDR Review 5: 116, 1995. http://www.hpa.org.uk/cdr/archives/CDRreview/1995/cdrr0595.pdf
4. Pan American Health Organization. Management of Dead Bodies in Disaster Situations. 2004.
www.paho.org/English/dd/ped/ManejoCadaveres.htm
5. Morgan O. Infectious disease risks from dead bodies following natural disasters. Rev Panam
Salud Publica 2004; 15 (5): 307–12. http://publications.paho.org/english/dead_bodies.pdf
6. Inter-Agency Standing Committee (2007). IASC Guidelines on Mental Health and Psychosocial
Support in Emergency Settings. Section 4.4 - Prevent and manage problems in mental health
and psychosocial well-being among staff and volunteers (pp 87-92). Available at:
http://www.humanitarianinfo.org/iasc/downloaddoc.aspx?docID=4445&type=pdf
Appendices:
NaTHNaC algorithms for assessing fever, respiratory and diarrhoeal illness in ill returned travellers
[2].
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