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 byGail 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)


Travel Immunizations• In 2004: 763,000,000

crossed international

borders

• Important

considerations– Prior immunizations

– Health needs

– Locations/ExposuresHaiti - Photo by Tim Elzinga, M.D.

Madrid and Paris – Photos by Wendy Biggs, M.D.


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?

CaseCase


How Do You Know What Vaccines are Needed for Travel?• The CDC’s Health Information for

Travelers

– Published every 2 years

– The “yellow book”

– Can search online at http://wwwnc.cdc.gov/travel/yellowbook/search.aspx


Travel Immunizations• Required

– Yellow Fever

– Meningococcal

• Recommended– Polio– Tetanus/Diphtheria/Pertussis– Influenza – Measles– Hepatitis A/B– Typhoid– Rabies– Japanese Encephalitis– Tick-borne Encephalitis


Does Mr. M need Yellow Fever Vaccine?

Case


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


www.yellowfever.com.au/map2.gif

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

Yellow Feaver


Yellow Fever• Disease Transmission

– From primates or humans – Mosquito vector

• Disease Prevention– Avoid mosquito bites• DEET • Clothing• Mosquito nets• Eliminate standing water

– VaccinationPhoto 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


Yellow Fever Vaccine 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


Yellow Fever Vaccine 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, Bell’s Palsy

– Onset 2-28 days after vaccination– Rarely fatal


Yellow Fever Vaccine 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


Yellow Fever Vaccine• 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


Yellow Fever Vaccine• 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 Required for Entry• Angola • Benin • Bolivia (or signed affidavit at

point of entry) • Burkina Faso • Burundi • Cameroon • Central African Republic • Congo, Republic of the • Côte d’Ivoire • Democratic Republic of Congo

• French Guiana• Gabon• Ghana• Liberia• Mali• Niger• Rwanda• São Tomé and Príncipe • Sierra Leone • Togo• Always check up to date list at

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?

CaseCase


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


http://wwwnc.cdc.gov/travel/images/380.ashx

Meningococcal Disease• “Meningitis Belt”

– Sub-Saharan Africa

• Greatest risk: dry season (Dec. - June)

• Risk of travelers– 0.4/100,000

• Hajj pilgrimage to Saudia Arabia associated with outbreaks

X


Meningococcal Disease• 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.


Meningococcal Disease• 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


Meningococcal Disease• 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


Meningococcal Disease

• 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


• 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. M’s 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

CaseCase


Recommended Vaccines for Travel• Tetanus/Diphtheria/

Pertussis• Influenza• Polio• Measles• Hepatitis A• Hepatitis B

• Typhoid• Rabies• Japanese

Encephalitis• Tick-borne

Encephalitis


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

X

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 trunk

• Serious complications (2-3 weeks)– Hepatosplenomegaly– Intestinal hemorrhage/perforation

• No definitive test– Clinical diagnosis

Rose spots on the chest in a patient with typhoid



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®

– Oral, live-attenuated

– Ages 6 and older

– 50-80% protection

– 4 pills – one every other day

– Completed 1 week before potential exposure

– Revaccination every 5 years

• Typhim Vi®

– Capsular polysaccharide

(IM)

– Ages 2 and older

– 50-80% protection

– Single 0.5ml injection

– 2 weeks before exposure

– Booster every 2 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)

Geographic distribution in

Southeast Asia.Map from www.cdc.gov

• 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


Japanese Encephalitis• 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)


Japanese Encephalitis• 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 EuropeImage in public domain. Photo taken by James Gathany.


Since he is going to Saudi Arabia, what additional vaccines does Mr. M need?

CaseCase


• 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

CaseCase


Case

Does Mr. M need anything for malaria?

Case


Malaria• 350,000,000 - 500,000,000

cases/year• 1,000,000 - 3,000,000

deaths/year• Mostly sub-Saharan Africa

X

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


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

Symptoms of MalariaSymptoms of Malaria


Malaria

NO VACCINE

Have to treat with chemoprophylaxis


Malaria• Prevention

– Clothing– Insect repellant– Mosquito netting

• Chemoprophylaxis– Atovaquone/proguanil

(Malarone®)– 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/chapter-2/malaria.aspx

• Pregnancy– Chloroquine/mefloquine only


Mr. M does NOT need malaria prophylaxis

CaseCase


Traveler’s 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)


Traveler’s 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


Physician’s 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.

Documents

travel immunizations

necessary immunizations

case slide

yellow feaver slide

yellow fever list

travel counsel patients

need yellow fever vaccine

vaccine introduction