As I write this, we are still firmly in the grips of the global COVID-19 pandemic, with over six million cases and 380,000 deaths reported worldwide. Whilst the epidemic curve is starting to slow down in Western Europe and the US, we are seeing an upwards trend in Eastern Europe, South America and Africa. Almost every aspect of our lives has changed rapidly over the last three months, however it is now clear that Australians have pulled together and done a fantastic job of bringing the pandemic under control and protecting those most vulnerable to severe disease, our health care workers and our health care system.
At DVA we have been very aware of the potential negative health impacts of social distancing and isolation on the mental health of veterans and their families.
It has been a very interesting time for the health profession with the introduction of telehealth almost overnight — a process that would have normally taken years. As a General Practitioner (GP), I have found this a useful tool for my regular patients who have needed to self-isolate or who are reluctant to come to the surgery in case they might be exposed to COVID-19. However, despite the introduction of telehealth, data has shown a significant decrease in consultations amongst veterans, across all medical and allied health professions. This worries me, and I urge everyone to continue their routine medical care in one way or another.
In late April more than 70,000 veterans identified as being more vulnerable to severe disease should they contract COVID-19 due to their age or pre-existing conditions, and their GPs received a letter from me through our Veterans’ MATES program. This letter shared three simple messages — the importance of continuing routine medical care, the availability of medication home delivery services and a reminder to get the flu vaccine this year. I hope that by the time you are reading this we have started returning to some degree of normality.
On another topic I received an interesting letter from a Vietnam veteran a couple of months ago. He was pleased to let me know that he had finally managed to cure himself of the parasite Strongyloides stercoralis, which he had contracted when serving in Vietnam. I understand that about 20 years ago DVA ran an education campaign on Strongyloides, however given how long ago that is I thought it could be useful to revisit the topic.
The disease caused by this parasite, known as Strongyloidiasis, has been described as ‘the most neglected of the neglected tropical diseases’, with up to 370 million people being infected worldwide. Strongyloides is a parasitic worm which is contracted through skin contact with infected soil. The parasite is found in tropical and subtropical regions of the world, including northern Australia. In fact, some remote Aboriginal and Torres Strait Islander communities have up to 60 per cent of their population infected. Vietnam veterans are a recognised risk group, with a study published in 2015 showing that from a group of 309 Vietnam veterans tested in South Australia, 11.6 per cent had a positive blood test result.
Strongyloides is an unusual parasite in several ways. One is that it has an ‘auto-infective’ cycle meaning that the parasite can self-reproduce and remain persistent in an infected person for many decades after they have left the area where infection occurred. Incredibly, just one remaining female parasite can result in continued infection.
A serious issue, and the main reason we are concerned about diagnosing the parasite, is that many people will have no symptoms at all, but can develop a severe, over-whelming and even fatal infection if their immune system is significantly compromised. Typically, this occurs as a result of medications like chemotherapy, prednisolone or other immunosuppressing drugs.
If people have symptoms they are varied and often intermittent, making diagnosis difficult. Some of these symptoms include intermittent diarrhoea, upper abdominal discomfort, and a characteristic rash called ‘larva currens’ (a type of rash that looks like linear hives) that comes and goes.
The good news is that these days Strongyloides is relatively simple to diagnose and treat. The best test is a blood test checking for antibodies, which has essentially replaced stool testing due to the high likelihood of a false negative result.
Treatment is with an anti-parasitic drug called Ivermectin, which is available on the Repatriation Pharmaceutical Benefits Scheme (RPBS). Current protocols recommend two doses given 1-2 weeks apart. The blood test should be repeated after 6-12 months, with repeat treatment if it remains positive. It is my practice to refer patients to an Infectious Disease Physician if the test remains positive after two cycles of treatment.
If you are a Vietnam veteran, or have served at any time in the tropics and were not tested after your deployment you may have been exposed (note testing is now routine in the Australian Defence Force post deployment to the tropics) and should discuss testing with your GP. As one recent medical article stated — ‘Strongyloides, if you don’t look, you won’t find’.
There is another happy ending to this story. I made contact with the veteran who wrote to me — and rather incredibly he had served with my father in Vietnam. I think that made both of our days! Until next time stay well.
Updated information on Strongyloides and veterans’ health is available.