Travel Immunizations: Support For This Program Is Made Possible by The AAFP Foundation Through A Grant From Pfizer Inc

Travel Immunizations
Support for this program is made possible by the AAFP Foundation through a grant from Pfizer Inc.
Developed for AFMRD by
Gail Colby, M.D. and Wendy Biggs, M.D.
Midland Family Medicine Residency
2010
Ehab Molokhia, MD and Gerald Liu, MD

University of South Alabama Family Medicine Residency
Updated 2012
Competencies
Medical knowledge
List the 2 vaccines that are required for travel
List the geographic areas at risk for
yellow fever
List 3 contraindications for yellow
fever vaccine
Recite the severe side effects of yellow
fever vaccination
Competencies
Medical knowledge
Define the Meningitis Belt
State the vaccine required for the annual
pilgrimage to Mecca (Hajj)
Describe how typhoid is acquired
Explain how rabies vaccination changes
the post-exposure treatment
Competencies
Patient care
Recognize returning travelers may have
acquired an illness on the trip
Assess immunization status of patients
who will travel
Competencies
Interpersonal communication
Advise patient to obtain necessary
immunizations before travel
Counsel patients on malaria risks and need
for prophylaxis
Systems-based practice
Access on-line travel health information
from Center for Disease Control and
Prevention (CDC)
In 2004: 763,000,000
crossed international
borders
Important
considerations
Prior immunizations
Health needs
Locations/Exposures
Haiti - Photo by Tim Elzinga, M.D.
Madrid and Paris Photos by Wendy Biggs, M.D.
Case
Mr. M, a 45-year-old Muslim man, visits
your office in September. He was born
in Dearborn, Michigan and attended
public school there. He is going on
pilgrimage to Mecca with his father in
November. He thinks he needs some
vaccines before he goes.
What vaccines does he need?
How Do You Know What
Vaccines are Needed for
Travel?
The CDCs Health Information for
Travelers
Published every 2 years
The yellow book
Can search online at
http://wwwnc.cdc.gov/travel/yellowbook/search.aspx
Required Recommended
Yellow Fever Polio
Meningococcal Tetanus/Diphtheria/Pertussis
Influenza
Measles
Hepatitis A/B
Typhoid
Rabies
Japanese Encephalitis
Tick-borne Encephalitis
Case
Does Mr. M need Yellow Fever
Vaccine?
Yellow Fever
Mosquito-borne hemorrhagic fever
~200,000 cases per year, 90% in Africa
Indigenous case fatality rates vary
20-60%
Rare fatalities in travelers since vaccine
introduction
Yellow Fever
3 stages
Infection (3-4 days)
Fever, malaise,
leukopenia
Remission (48 hours)
Abatement of symptoms
15% progress
Intoxication
Return of symptoms,
Organ dysfunction, hemorrhage
www.yellowfever.com.au/map2.gif
Yellow Fever
Disease Transmission
From primates or humans
Mosquito vector
Disease Prevention
Avoid mosquito bites
DEET
Clothing
Mosquito nets
Eliminate standing water
Vaccination
Photo from www.cdc.gov. Image in public domain. Photo by James Gathany.
Yellow Fever Vaccine
Live-attenuated vaccine
Developed in 1936
Seroconversion >95%
Single 0.5ml subcutaneously
Revaccination at 10-year intervals
required by World Health Organization
Protection from one vaccine, however,
may last 30 or more years
Contraindications
Age <9 months old*
* Can consider at 6-9 months old during outbreaks
Pregnant women*
* Yellow fever can cross placenta
Severe egg allergies

Severe immunocompromise
Immunomodulatory drugs
Yellow Fever Vaccine Side
Effects
Adverse Reactions (10-30%)
Local soreness
Mild fever
Headache
Myalgias
Rare Severe Reactions
Anaphylaxis
Risk 1/131,000
Yellow fever associated neurotropic disease
(YEL-AND)
Risk 1:150,000 - 200,000
Multiple neurologic conditions
Encephalitis (esp. infants <9 months), Guillian-Barre,
Bells Palsy
Onset 2-28 days after vaccination
Rarely fatal
Rare Severe Reactions
Yellow fever associated viscerotropic disease
(YEL-AVD)
Mimics severe yellow fever infection
Major organ system failure occurs
Hepatic, renal, circulatory failure
50% or greater fatality rate
Occurs 1-8 days (average 3 days) after initial
vaccination
Risk 1:200,000 - 300,000
Greater risk if over age 60
Certification of vaccination required
International Certificate of Vaccination or
Prophylaxis for Yellow Fever form (ICVP)
Must be signed by licensed physician or
designee
Waiver form for medical contraindication
to vaccine, such as pregnancy
Vaccine given at a certified center
Uniform Stamp
Issued by state health departments
Stamp needed to validate the International
Certificate of Vaccination or Prophylaxis
against Yellow Fever form (ICVP)
Location of vaccination centers
wwwnc.cdc.gov/travel/yellowfever.aspx
Yellow Fever Vaccination
Proof
Angola
Required for Entry
French Guiana
Benin Gabon
Bolivia (or signed affidavit at Ghana
point of entry) Liberia
Burkina Faso Mali
Burundi Niger
Cameroon Rwanda
So Tom and Prncipe
Central African Republic
Sierra Leone
Congo, Republic of the
Togo
Cte dIvoire Always check up to date list at
Democratic Republic of Congo www.cdc.gov/travel
Case (once again)
Mr. M, a 45-year-old Muslim man, visits
your office in September. He was born
in Dearborn, Michigan and attended
public school there. He is going on
pilgrimage to Mecca with his father in
November. He thinks he needs some
vaccines before he goes.
What vaccines does he need?
Case
Since he is not going to tropical Africa
or South America, he does NOT need
Yellow Fever Vaccine.
Does he need Meningococcal

Vaccine?
Meningococcal Disease
Neisseria Meningitidis
Gram negative diplococci
Youngest children = highest risk
0.5-10/100,000 in non-epidemic areas
Up to 1,000/100,000 in epidemic areas
Meningitis Belt
X
Sub-Saharan Africa
Greatest risk: dry
season (Dec. - June)
Risk of travelers
0.4/100,000
Hajj pilgrimage to
Saudia Arabia
associated with outbreaks http://wwwnc.cdc.gov/travel/images/380.ashx
1-14 days post-exposure
Presents as meningitis
in 50%
Sepsis in up to 20%
Less dramatic symptoms
in < 2 year olds
Treatment
During epidemics
Ceftriaxone
Chloramphenicol
Photo from www.cdc.gov. Image in public domain.
Vaccine required
to attend the Hajj
(annual pilgrimage
to Mecca)
If under age 15,
polio vaccination
needed also
http://news.bbc.co.uk/cbbcnews/hi/pictures/galleries/newsid_1832000/1832100.stmproof
Available vaccines
MCV4 (Menactra)
2-55 years old
Preferred in <11 year olds
MPVS4 (Menomune)
2 years and older
Use for >55 years old
MenACWY-CRM (Menveo)
11-55 years old
Licensed for use in 2010
Revaccination
If high-risk (epidemic area or travel)
If vaccine given at 2-6 years old
Repeat after 3 years, then every 5 years
If vaccine given >6 years old

Repeat every 5 years
Case
Since he is going on Hajj to Mecca,
Mr. M needs Meningococcal Vaccine.
He could receive any of the three
Meningococcal Vaccines available.
Menveo or Menactra are preferred
Conjugated vaccines
Give better immune response
Case
Does he need additional vaccines?
Possibly
How would you know?
1)Need to review Mr. Ms immunization status
2)Need to know recommended vaccines
Case
To attend public school, Mr. M had primary
series of immunizations recommended 40
years ago
Most likely diphtheria/tetanus/pertussis, polio,
measles, mumps, rubella (or had disease
documented)
His age implies varicella immunity (born prior
to 1966)
He cannot recall his last tetanus booster
Recommended Vaccines for
Travel
Tetanus/Diphtheria/ Typhoid
Pertussis Rabies
Influenza Japanese
Polio Encephalitis
Measles Tick-borne
Hepatitis A Encephalitis
Hepatitis B
Tetanus
Omnipresent in the environment worldwide
Agricultural areas exposure to animal
excrement
Approximately 290,000 people died from
tetanus in 2006
Most in Asia, Africa and South America
Vaccination provides 10 years of protection
Booster
>10 years since last dose or if wound occurs and vaccination
is greater than 5 years old
Polio
Fecal-oral or oral transmission
Global Polio Eradication Initiative (GPEI)
Goal to eradicate polio
Wild polio virus: India, Nigeria, Pakistan, Afghanistan
Most cases of polio from these countries
2 vaccines worldwide: IPV and OPV
Only IPV in U.S.
Still OPV in other parts of the world
Rare cases of vaccine associated paralytic poliomyelitis
Vaccine recommended if traveling to endemic area and
incomplete series
Measles
20,000,000 cases globally each year
Almost every country
Travel guidelines closely match general
immunization guidelines
Immunity for travel:
6-11 months old 1 dose required (does not count in U.S.)
>12 months old 2 doses required
Laboratory evidence of immunity
Born before 1957
Physician-diagnosed case of measles
Hepatitis A
Worldwide prevalence
Fecal/oral transmission
Associated poor hygiene
or sanitation
Symptoms include
Jaundice
Fatigue
Abdominal pain
Anorexia
Nausea
Hepatitis A
Adults often contract from asymptomatic
children
Incubation 28 days (range 15-50 days)
Viral shedding 2 weeks before to
1 week after symptoms
Usually self-limited disease
Hepatitis A Vaccine
Inactivated Hep A virus (Havrix or Vaqta)
Combined with Hepatitis B (Twinrix)
Travel vaccine indications
Anyone >1 year old traveling anywhere
outside of
U.S. and Canada
Western Europe
Scandinavia
Japan
Australia and New Zealand
Hepatitis A Vaccine
Dose at 0 and booster at 6-12 months (Havrix)
Dose at 0 and booster at 6-18 months (Vaqta )
If using Twinrix (combination Hep A and Hep B)
0, 1, 6 months
0, 7 days, 21-30 days and 12 months (4-dose
accelerated series)
Hepatitis A
For healthy patients <40 years old, one dose
before travel confers adequate protection
Consider immunoglobulin treatment for
patients
Leaving in less than two weeks
Older
Immunocompromised
Chronic medical conditions
Under 12 months of age
Hepatitis B
Transmitted by blood and body fluids
Travelers generally low risk except:
Injuries that occur while traveling
Sexual contact
Drug injection
Piercings or tattoos
Recommended for travel to
intermediate/high risk areas
Hepatitis B Vaccine
Indications
International travel to endemic areas
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/hepatitis-b.aspx
Hepatitis B Vaccine
(Engerix-B)
Ideally 6 months or greater
before travel
Doses at 0,1 and 6 months
If <6 months before travel, consider
accelerated vaccine series
0, 7, 21-28 days and a booster at
12 months
Twinrix
Inactivated Hepatitis A with
Recombinant Hepatitis B
Indicated for 18 years old and older
3-dose series
0, 1, 6 months
Better choice if both vaccines are indicated
Influenza
Risk depends on timing and destination
Tropics: year round risk
Temperate climates: risk generally April-September
Avian subtype risks
Visiting poultry farms
Visiting open markets where live poultry are present
Eating undercooked poultry products (eggs, meat, etc.)
Preventative measures include
Hygiene: washing hands
Annual vaccination
Typhoid Fever
Typhoid fever acute life-threatening illness
Caused by Salmonella typhi
Humans only source
Acquired through fecal contamination of food
and water
22,000,000 cases worldwide/year
200,000 deaths
Typhoid
Southeast Asia
6-30 times more
common
Highest risk of
drug resistance
Africa, Caribbean,
Central and South America
Length of stay = increased risk
http://www.marioncountyhealthdept.org/images/Map_Typhoid.gif
Typhoid
Incubation period: 6-30 days
Headache, malaise, fever up
to 104 degrees F
Increasing in severity
Low-grade septicemia
Rose spots on the chest in a
Rose spots on trunk patient with typhoid
Serious complications (2-3 weeks)
Hepatosplenomegaly
Intestinal hemorrhage/perforation
No definitive test
Clinical diagnosis
Typhoid
Treatment
Oral rehydration
Antibiotics
Ciprofloxacin if no resistance (7-10 days)
3rd generation cephalosporin (10-14 days)
Azithromycin
Steroids in severe cases
Typhoid
Prevention
Avoid contaminated
food and water
Hygiene
Local cuisine
Vaccine(s)
2 available
Typhoid Vaccines
Vivotif Typhim Vi
Oral, live-attenuated Capsular polysaccharide
Ages 6 and older (IM)
50-80% protection Ages 2 and older
4 pills one every 50-80% protection
other day
Single 0.5ml injection
Completed 1 week before
potential exposure 2 weeks before exposure
Revaccination every Booster every 2 years
5 years
Rabies
Found globally
Consider
vaccination
If potential exposure
to wild animals
(especially dogs)
Prolonged exposure
where endemic
http://www.who-rabies-bulletin.org/Travel/Images/Rabies_World_2005.JPG
Rabies Vaccine
Pre-exposure prophylaxis
Series of 3 at 0, 7 and 21-28 days
2 vaccines available in U.S.
Imovax
Rabavert
Outside U.S. many other vaccines
Expense limits use
Rabies Vaccine
Post-exposure
Rabies Immunoglobulin (RIG) plus
vaccine
RIG days 0, 4
Vaccine days 0, 3, 7,14
If had vaccine
No RIG needed
Vaccine days 0 and 3
Japanese Encephalitis Virus
(JEV)
Most common cause of encephalitis in
Southeast Asia
Carried by mosquitoes
Risk
Little risk in urban areas
Mostly rural areas
Not recommended for
short-term travel to urban area Geographic
distribution in
Southeast Asia.
Map from www.cdc.gov
Incubation 5-15 days
Most infections asymptomatic
<1% develop clinical disease
Headache, fever, vomiting, diarrhea
Most recover in 1 week
1:300 severe symptoms with 30% fatality
Mental status changes
Focal neurological deficits
Parkinsonian syndrome
Seizures (especially children)
2 vaccines in U.S. (Multiple vaccines available in
Southeast Asian countries)
Inactivated Vero cell culture (JE-VC)
For people over 17 years old
Duration of protection unknown
Need for boosters undetermined
Pregnancy Category B
Inactivated mouse brain cell culture (JE-MB)
Production stopped 2006
Stockpile only for children <17 years old
Booster 2 years after primary series if needed
Tick-borne Encephalitis
Endemic to Europe and Russia
Biphasic illness
Febrile illness that remits
Returns as neuro-invasive disease
Risk in unvaccinated 1/10,000 person-months
Only 5 known cases in US in last decade
No vaccines available in US, but are in
Canada and Europe
Image in public domain. Photo taken by James Gathany.
Case
Since he is going to Saudi
Arabia, what additional
vaccines does
Mr. M need?
Case
In addition to meningococcal vaccine,
Mr. M needs
Hepatitis A and B (Twinrix)
Tdap
Influenza
He does not need measles, typhoid,
rabies or encephalitis vaccines
Case
Case
Does Mr. M need anything
for malaria?
Malaria
350,000,000 - 500,000,000
cases/year
1,000,000 - 3,000,000
deaths/year X
Mostly sub-Saharan Africa
http://www.rollbackmalaria.org/wmr2005/maps/map3.gif
Malaria
~1500 imported cases to US/year
Probably under-reported
6 deaths/year
Risk assessment
Location, season, elevation, duration
Military
Travelers visiting friends or relatives
Pregnancy
Symptoms of Malaria
http://en.wikipedia.org/wiki/File:Symptoms_of_Malaria.png. Image is in the pubic domain.
Malaria
NO VACCINE
Have to treat with
chemoprophylaxis
Malaria
Prevention Chemoprophylaxis
Clothing Atovaquone/proguanil
Insect repellant (Malarone)
Mosquito netting Primaquine
Chloroquine
Mefloquine
Doxycycline
Netting image originally posted to Flickr by Tjeerd Wiersma at http://flickr.com/photos/76396789@N00/2808846. Permission to re-use when credit given.
Malaria
Multiple regimens, multiple meds
Start before, end after
Important to plan ahead with your doctor
or travel clinic
Recommendations at CDC yellowbook
http://wwwnc.cdc.gov/travel/yellowbook/2010/ch
apter-2/malaria.aspx
Pregnancy
Chloroquine/mefloquine only
Case
Mr. M does NOT need malaria
prophylaxis
Travelers Responsibilities
4-6 weeks before travel see provider
Get necessary immunizations
Check CDC for up to date
recommendations
(www.cdc.gov.travel)
Check travel notices for outbreak
information
(http://wwwnc.cdc.gov/travel/notices.aspx)
Travelers Responsibilities
Travel health kit
Prescription medications and over-the-counter
medications
Advice available at:
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-
2/travel-health-kits.aspx
Commercial pre-assembled health kits
American Red Cross: www.redcrossstore.org
Adventure Medical Kits: www.adventuremedicalkits.com
Chinook Medical Gear: www.chinookmed.com
Travel Medicine, Inc.: www.travmed.com
Wilderness Medicine Outfitters: www.wildernessmedicine.com
Physicians
Responsibilities
Know some basic travel medicine advice
Hepatitis A and B for trips to Mexico/Caribbean
Prevention techniques
Clean water
Mosquito prevention
How to access the CDC website for travel
advice (www.cdc.gov/travel)
International Society of Travel Medicine
(www.istm.org) for those more interested
Summary
Medical knowledge
Yellow fever and meningococcal vaccines are
required for travel into some countries
Yellow fever is endemic to Sub-Saharan Africa and
South America
Travelers to those regions should be re-vaccinated
every 10 years
Contraindications for routine yellow fever vaccines
are immunocompromised, egg anaphylaxis, age
<9 months old, pregnancy
Summary
Medical knowledge
Yellow fever vaccine rarely can produce
anaphylaxis, associated neurotropic
disease (YF-AND) or associated viscerotropic
disease (YF-AVD)
The Meningitis Belt is in Sub-Saharan Africa
Meningococcal vaccine is required for the
annual pilgrimage to Mecca (Hajj)
Summary
Medical Knowledge
Typhoid is acquired by fecal contamination
of food and water
For a rabies vaccinated person exposed to
rabies, rabies immune globulin (RIG) is not
needed, and only 2 further vaccines at
days 0 and 3
Summary
Patient care
Many febrile illnesses are endemic to
particular geographic regions. Travelers
returning from overseas may have acquired
malaria, yellow fever, Neisseria meningitis or
typhoid, Japanese or tick-borne encephalitis,
for example.
Adults may need boosters of immunizations
before travel, such as Tdap, or begin vaccine
series, such as Hepatitis A and B.
Summary
Interpersonal communication
Health care providers should advise patients
to visit their clinician or a travel clinic minimum
4 to 6 weeks before departure to obtain
necessary immunizations before travel
Since malaria is endemic in many areas of the
world, healthcare providers should counsel
patients on malaria risks and the need for
chemoprophylaxis
Summary
Systems-based practice
The Center for Disease Control and
Prevention websites
www.cdc.gov/travel provides information
for travelers
www.cdc.gov/vaccines provides for
information on immunizations

Travel Immunizations: Support For This Program Is Made Possible by The AAFP Foundation Through A Grant From Pfizer Inc

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Travel Immunizations: Support For This Program Is Made Possible by The AAFP Foundation Through A Grant From Pfizer Inc

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Travel Immunizations

Ehab Molokhia, MD and Gerald Liu, MD

Severe egg allergies

Does he need Meningococcal

If vaccine given >6 years old

Mostly sub-Saharan Africa

http://en.wikipedia.org/wiki/File:Symptoms_of_Malaria.png. Image is in the pubic domain.

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