Travel vaccinations

Diptheria

Disease risk areas
Worldwide,although the disease has virtually been eliminated from the UK.

Transmission
By droplet infection and through contact with articles soiled by infected persons.

Recommendations for travellers
Travellers should have received the normal British Childhood Immunisation Schedule. Vaccination is especially advised for visits to endemic areas when mixing with the local population (e.g. health workers or teachers) and these groups should receive ten yearly boosters of the adult (low dose) vaccine.

VACCINATION
Type: An inactivated toxoid.
Route: i/m or deep s/c
Primary immunisation: 3 doses given at 4 weekly intervals
Boosters: 10 yearly for those at risk

Side effects
Swelling and redness at the injection site. Fever and headache can also occur. Anaphylaxis and neurological problems occur very rarely.

Contraindications
Any febrile illness or a severe reaction to a previous dose.

Notes
Children. Primary courses are started from 1 month of age in some countries where the risk is considered to be high.
Adults. Adults require a smaller dose of vaccine than children. Since there has been a shortage of adult, low dose, diphtheria vaccine for some time adults are advised to have a fraction of the childhood monovalent diphtheria vaccine This should be used for both primary courses and boosters.

Hepatitis A

High risk areas.
All countries outside Western Europe, Scandinavia, North America, Japan, New Zealand, Australia; particularly those with poor sanitation and public hygiene.

Transmission
Spread by faecal-oral route.

Recommendations for travellers
Active vaccination with 'non-live' inactivated vaccine, is used to give longterm protection against hepatitis A. Active vaccination can be used from one year of age. In children hepatitis A is usually mild but asymptomatic infected children can spread virus to others.

Normal pooled Immunoglobulin (passive vaccination) is an alternative when active vaccination is contraindicated or when insufficient time is available before departure (less than 2 weeks) for protection to have been achieved.

ACTIVE VACCINATION
Always confirm details with manufacturer's literature

ADULTS
Type: non-live (inactivated)
Age: For those over 16 years of age.
Primary course: 1 dose
Route: I/M (deltoid not gluteal region)
Protection achieved: after 2 weeks.
First booster: 6-12mths
Length of protection: At least 1 year after primary dose and 10 years after the first booster.
Delayed first boosters: The manufacturer's do not give clear advice on what to do if the patient fails to return within 6-12 months for their first booster. If delayed the first booster will give at least one year's protection, as does the primary dose. However it is suggested you restart the course if this first booster is delayed by more than 1 year.
Further boosters: 10 yearly.

CHILDREN
Type: non-live, inactivated
Age: For those 1yr to 15yrs of age.
Primary course: 1 dose
Site: Deltoid - not gluteal region.
Protection achieved: 2-4 weeks after vaccination.
First booster: After 6-12 months
Length of protection: At least 1 year after primary dose 10 years after booster.
Further boosters: 5-10 yearly.

Side effects: Usually mild and most commonly local redness and swelling. Less commonly fever, malaise, headache and nausea.

Contraindications: Hypersensitivity to components of the vaccine. Febrile infections. In common with other inactivated viral vaccines it is not advised in pregnancy and lactation unless risk is substantial.

SEROTESTING
Serology testing for immunity after vaccination. The usual IgG test used to confirm previous "naturally acquired" infection is not reliable in this context since it is not sufficiently sensitive. If in doubt it is more logical to give unnecessary extra doses rather than risk inadequate protection.

COMBINED HEPATITIS A AND B VACCINE
There is acombined hepatitis A and B vaccine, introduced in 1997, is used in adults and adolescents from 16yrs.
The junior versionis used from 1 yr to 15 yrs of age.
This vaccine is useful when protection against both infections is indicated.
Schedule for both vaccines
Primary course: 3 doses over 6 months (first interval is 1 month after first dose, second interval is 6 months after first dose).
The hepatitis A dose is less than in a 'monodose' and protection is not achieved until after the first 2 doses have been administered. Maximum protection against hepatitis B is not achieved until after all 3 doses have been administered.
Boosters: Unclear as yet but probably after 5 years for Hepatitis B and 10 years for Hepatitis A.

Hepatitis B

Disease risk areas
Present worldwide.

Carriage rates of HBsAg
LOW (less than 2%) in most European and North America countries (excluding Alaska and the far north of Canada)
MEDIUM (2& to 7%) in most of the Middle East, eastern Europe and Russia, the Indian subcontinent, south and central America (excluding Amazonia), north Africa, Alaska and northern Canada.
HIGH (greater than 7%)in most of Subsaharan Africa, Amazonian parts of South America and the Far East including China, Indonesia and many South Pacific islands.

Transmission
Spread is through sexual intercourse and from contaminated blood products. It is also spread through 'blood to blood' contacts such as through injuries in playgrounds; contaminated instruments during medical, dental, acupuncture and other body piercing procedures; sharing intra-venous needles; at birth from an infected mother to her infant.

Vaccination for travellers
This should be considered for the following groups of travellers going to medium and high risk areas.
Those staying for long periods (e.g. more than 3 months) and frequent travellers.
Those at occupational risk (e.g. health care workers).
Young children mixing with locals in poor hygienic conditions.
Those with pre-exiting medical conditions who may need medical attention or surgical proceedures (e.g. if preganant).
Those who may be at sexual risk or at risk of sharing percutaneous needles.
Military personnel.

ACTIVE VACCINATION
Always confirm details with manufacturer's literature

ENGERIX - Smith Kline Beecham
Type: Inactive, recombinant.
Primary course: 3 doses.
Route: I/M (not buttocks)
1st interval: 1 month
2nd interval: 5 months
Accelerated schedule: 3 doses at monthly intervals with booster 12 months later.

HB-VAX - Pasteur Merieux
Ages: over 15 years
Type: Inactive, recombinant.
Primary course: 3 doses.
Route: I/M (not buttocks)
1st interval: 1 month
2nd interval: 5 months
The accelerated schedule described above can also be used.

HB-VAX II PAEDIATRIC - Pasteur Merieux
Ages: Birth - 15 years)
Type: inactive
Primary course: 3
Route: IM (anterolateral aspect of thigh in neonates, infants and young children)
Schedule: 0, 1 and 6 months
The accelerated schedule described above can also be used.
Boosters for both adult and childrens vaccines: duration of immunity is not yet clear but it is thought boosters will not be needed more often than 5 yearly. If given for occupational reasons in Britain the booster interval is usually decided after antibody test.

Side effects: Occasionally soreness and redness at the injection site may appear.

Contraindications: Vaccination should be postponed in individuals suffering from a febrile illness.

HB-VAX II-40 (Pasteur Merieux).
This vaccine (introduced in October 1998) is specifically aimed at protecting pre-dialysis and dialysis patients. It contains recombinant Hepatitis B Vaccine 40mcgms/millilitre. It can be used for all ages.
Primary course: 3 doses
Intervals: 1 month between first and second doses, 5 months between second and third doses. The accelerated schedule described above can also be used.

HYPER-IMMUNOGLOBULIN
Occasionally it can be appropriate to use hyperimmune hepatitis B immunoglobulin for short-term protection of those at "high risk".
For example: for medical or nursing personnel going to work in highly endemic areas, when there is either not enough time to give a course of active vaccine or when they are "non- responders" to previous courses of vaccination.

COMBINED HEPATITIS A AND B VACCINE
There is acombined hepatitis A and B vaccine, introduced in 1997, is used in adults and adolescents from 16yrs.
The junior versionis used from 1 yr to 15 yrs of age.
This vaccine is useful when protection against both infections is indicated.
Schedule for both vaccines
Primary course: 3 doses over 6 months (first interval is 1 month after first dose, second interval is 6 months after first dose).
The hepatitis A dose is less than in a 'monodose' and protection is not achieved until after the first 2 doses have been administered. Maximum protection against hepatitis B is not achieved until after all 3 doses have been administered.
Boosters: Unclear as yet but probably after 5 years for Hepatitis B and 10 years for Hepatitis A.

Notes:
04/11/98
Hepatitis B immunisation and the lack of any proven link with de-myelinating disease.
The World Health Organisation has issued a statement (WER 1998,73,329) expressing concern that the French Ministry of Health has suspended immunisation of teenagers and that this decision could influence the success of the international campaign to include hepatitis B immunisation in national programmes. WHO states that 'none of the evidence gathered by WHO from numerous scientifically reliable sources supports the causal link between hepatitis B vaccine and de-myelinating disease.

Japanese B Encephalitis

Distribution
Outbreaks occur after the rainy season in China, Japan, Republic of Korea, Nepal, Northern parts of Burma, India, Thailand, Laos and Vietnam.
Sporadic cases in Malaysia, Indonesia, Singapore, Southern parts of Thailand, Sri Lanka, India and Philippines.

Transmission
Spread is via mosquito bites which shoud be minimised. Other animals such as pigs are involved as intermediate hosts.

Recommendations for travellers
Repeated visits to, or prolonged stays (e.g.: >1 month) in infected countries especially if staying in rural areas.
Short stays in rural parts of endemic countries can also pose a risk, particularly if it is impossible to maintain satisfactory precautions against mosquito bites. Outbreaks frequently follow the rainy season.
Vaccination is important for infants and children who may be more likely to get serious disease.

VACCINATION
Always confirm details with manufacturer's literature
Type: Inactivated (not live).
Primary course: 3 doses.
Boosters: 3 yearly.
Route: subcutaneous. Intervals: Days 0, 7 and 28.
Can be given from birth.
Two doses administered a week apart will confer immunity in 80% of vaccinees for up to 3 months. This less effective schedule should only be used when there is no time to give the full course. Where exposure continues the third dose should be given as soon as possible.
Side effects: These follow approximately 3:1000 doses usually during primary courses and often after 1-3 days. The most common side effect is an urticarial or erythematous rash which can be widespread.
Oral antihistamines and/or steriods may be required.
Arthralgia, myalgia and fever can also occur up to 3 weeks later.
Reactions are less likely with boosters.

Notes:
Information from the University of Queensland - There is now convincing evidence that there are reservoirs of Japanese B encephalitis virus throughout Indonesia, including Bali, and as far south as Papua New Guinea and the Torres Strait.
This does not mean however that every one going to these areas should be immunised.
Risk assessment includes duration of stay, mosquito avoidance etc. as described above.
05/05/94. WHO have released numbers of proven cases of Japanese encephalitis during the period 1986 - 1990.
There were substantial numbers of cases in India, China, Japan, Vietnam, Nepal, SriLanka, Taiwan, Malaysia and Philippines.

Polio

Disease Risk Areas
The disease is endemic in many Asian and African developing countries. In countries with an high immunisation coverage the disease occurs only rarely. The Americas (North, south, central and the Caribean Islands) and have been declared poliomyelitis free. Europe and the Asia-Pacific regions are not far behind.

Transmission
Spread is via contact with pharyngeal secretions or faeces of an infected person.

VACCINATION
Always confirm details with manufacturer's literature

Primary immunisation of children
Recommended for infants from 2 months of age.
Live oral polio vaccine(OPV) is normally used in Britain and given at the same time as Diphtheria, Tetanus and Pertussis. Primary immunisation can be given earlier, which is the policy in some countries where poliomyelitis is common.
Boosters for children
Given 5 years after the primary course and 10 years later (usually mid-teens).
In endemic areas the primary course may include extra doses (e.g. up to 5) because response may be poor in those with gut parasitic infections or in those who are malnourished. Boosters may be continued every 10 years through adult life.

Primary immunisation of adults
As for children.
Boosters for adults
Ten yearly boosters are advised for those travelling to endemic areas. Extra adult boosters are not normally given for life in Britain except for health care workers at possible occupational risk.

VACCINE

Side effects
Very rarely cases of vaccine-associated poliomyelitis have been reported in individuals previously unvaccinated (including, for example, unvaccinated household contacts).
The risk of developing paralytic polio after live vaccination is roughly 1:520,000 after the 1st and 1:12,300,000 after subsequent doses. The risk to contacts is probably similiar. It is important that close contacts should be immunised or receive a booster if required.

Contraindications
Acute febrile illness (OPV and IPV) Vomiting or diarrhoea (OPV)
Serious immunocompromise (OPV)

INACTIVATED POLIOMYELITIS VACCINE(IPV) is available for individuals for whom a live vaccine is contraindicated (e.g: in pregnancy and in the immunocompromised). In some countries, usually where the only cases of poliomyelitis normally occuring are vaccine associated, IPV is used for the normal national schedule.

HIV INFECTION - In children known to be infected with HIV, OPV may be given provided their household contacts are not immunocompromised. Otherwise IPV should be used.

PREGNANCY - Whilst no adverse effects on the foetus have been demonstrated by administering OPV, this should normally be avoided especially during the first 4 months of pregnancy. IPV can be used instead.

OPV AND OTHER LIVE VACCINES
OPV can be given within 24 hours of other live vaccines. If this is not possible, ideally, 3 weeks should be left before administering another live vaccine. This is because the second vaccine might not be fully effective if given sooner.

OPV AND IMMUNOGLOBULIN
OPV should also ideally be given 3 weeks before or 3 months after immunoglobulin. If this is not done the response to OPV may be reduced. This is probably less important for booster doses.

VACCINATION AFTER POLIOMYELITIS
A patient who has had poliomyelitis should not be considered to be immune to the disease. Immunisation should still be advised.

AVAILABILITY
Inactivated polio vaccine is available on a named patient basis from:- Community Pharmacists. It is distributed by FARILLON.

EXTRA NOTES
12/12/97 Polio eradication.
Following the certification, in 1994, of the region of the Americas as free of indigenous wild poliovirus, the Western Pacific Region (WPR) is likely to be the second WHO Region coming close to eliminating the last remaining chains of wild poliovirus transmission.
The quality of surveillance has improved in all endemic countries and is expected to soon reach the levels necessary for certification. (WER 1997/72/50)
02/08/96 Polio eradication.
In September 1994 The International Commission for the Certification of Poliomyelitis Eradication declared the Americas POLIO-FREE. Although significant progress has been made towards global eradication of wild polio virus, until that is achieved, the English speaking Caribbean and the remainder of the Region of the Americas will remain at risk of the importation of wild poliovirus. (WER No29 19/07/96). The following countries are now declared to be polio-free.
America (All North), Antigua, Argentina, Bahamas, Barbuda, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, French Guinea, Haiti, Honduras, Jamaica, Martinique, Mexico, Nicaragua, Panama, Paraguay, Peru, Puerto Rico, St.Kitt's and Nevis, St.Lucia, St.Vincent, Trinidad and Tobago, Uruguay, Venezuela, Virgin Isles.
Accordingly all countries above have had immunisation against Polio removed from the "booster" recommendation section.

Rabies

Disease Risk Areas
Occurs in all continents except Australasia. Some countries are thought to be normally "rabies-free".

Transmission
Via the bite of a rabid animal or through mucous membranes (less common).

PRE-EXPOSURE VACCINATION
This can be considered for:
(a) to those travelling to countries where rabies is present and who intend to have regular contact with animals (e.g. veterinarians or zoologists)
(b) to those travelling to countries where rabies is endemic and if who will be more than 24 hours away from a reliable source of post-exposure vaccine and (ideally) rabies specific immunoglobulin.

Although pre-exposure vaccination is likely to give excellent protection post-exposure boosters (usually 2 doses) should still be sought as soon as possible after an exposure to ensure maximum protection.

POST-EXPOSURE VACCINATION is also very effective if a reliable vaccine is commenced according to manufacturer's instructions within 24 hours.
Those not previously vaccinated (or up to date with boosters) should also ideally receive rabies hyperimmunoglobulin to give immediate passive protection.
Immunoglobulin is unlikely to be of benefit more than 7 days after exposure (W.H.O).

The immunoglobulin dose is calculated by patient's weight and administered half around the wound and half intramuscularly.

VACCINE
Human Diploid cell
Always confirm details with manufacturer's literature.
Type: Inactivated (not live)
Primary course: 3 doses
Route: subcutaneous (S/C) or intradermal (I/D) (see note below) Intervals: Days 0, 7 and either 21 or 28
Boosters: 2-3 yearly
Rabies vaccine can be given to infants at the same dosage as for adults.
Side effects: Local discomfort, malaise and occassional systemic reactions are occasionally reported.
Contraindications: Hypersensitivity to a preceding dose. Pre-exposure vaccine should only be given to pregnant women if they are at high risk.

Imovax Rabies Vero
Type: Inactivated (not live)
Primary Course: 2 doses
Route: by subcutaneous or intramuscular route
Interval: 1 month apart
Boosters: 1 year later
Side Effects: Local minor reactions like redness and slight induration of the injection site. Rare febrile illness.
Contra indications: In view of the gravity of the disease and the essential character of this treatment all contra indications are secondary in case of rabid contamination.

Note
The intradermal route for pre-exposure vaccination is not covered in Britain by the manufacturers licence but it is in USA. It has however been shown to be effective if performed correctly but when the intra-dermal route is used maximum protection may not be achieved until about 30 days after the end of the course (see 'Health Information for International Travel - published by CDC Atlanta. USA).
If the traveller will be taking chloroquine or mefloquine for malaria prophylaxis the I/D course of vaccine should ideally be completed before starting prophylaxis.
A rapid schedule using multiple intra-dermal (I/D) doses (e.g. 4 doses with a single dose into each limb) have been used effectively for rapid post-exposure immunisation (see 'Immunisation against Infectious Disease' - Green book - published by the UK Departments of Health) .
This is an unlicensed option for pre-exposure vaccination if there is insufficient time for a recommended course. The traveller must be told this method usually gives good but less certain protection and protection is not immediate.

Tetanus

Disease Risk Areas
Worldwide.

Transmission
Tetanus spores are present in soil from contamination with human, animal and bird faeces and enter the body through injuries.

Primary immunisation of children
Given in Britain as "triple vaccine" (DPT) from 2 months of age. Immunisation is started as early as 1 month in some countries. If the pertussis component is contraindicated adsorbed Diphtheria/Tetanus vaccine should be given.

Primary immunisation of adults
Absorbed tetanus vaccine given in 3 doses either at monthly intervals as for children, or the third dose can be delayed for up to 6 months.

Boosters
Should be given 5 years after a primary course and then after 10 years. For life in Britain these 5 doses are considered sufficient unless the unless the risk of contaminated injuries is considered to be likely.
If an injury occurs and a booster has not been received within 10 years, a booster should then be given, ideally with tetanus hyperimmune globulin.
Travellers may warrent additional 10 yearly boosters if they are going to countries where specific tetanus immunoglobulin will not be available and tetanus prone injuries are possible.

VACCINATION
Type: Inactivated
Primary vaccination: 3 doses(adsorbed)
Route: Deep S/C or I/M
Length of protection: 5-10 years
Boosters: 5 years after primary course and then after 10 years. (See above for recommendations regarding additional boosters.

Side effects
Local reactions may occur but systemic reactions are rare.

Contraindications
Acute febrile illness (except when the patient is being immunised following a tetanus prone wound). Severe reaction to a preceding dose.
Hypersensitivity is common if booster doses are given too frequently. Marked soreness and inflammation around a tetanus vaccination site usually equates to adequate immunity.

Typhoid

Disease Risk Areas
Worldwide, but predominantly in countries where water or food supplies are liable to faecal contamination, most especially in countries in Africa, the Far East and South America.

Transmission
Mainly by food and drink that has been contaminated with excreta of a human case or carrier.

Recommendations for travellers
Recommended for travellers to areas where food and water are likely to be contaminated. When the risk is small vaccination may be limited only to those unable to maintain their own hygieme precautions or staying for long periods.

VACCINATION
Always confirm details with manufacturer's literature

OPTION 1
TYPHERIX (SmithKline Beecham)
Type: polysaccaride
Primary course: 1 dose
Route: i/m
Boosters: 3 yearly
Side effects: Sometimes sore injection site, mild fever or headache.
Contraindications: Hypersensivity to a previous dose. Febrile illness. Caution in pregnancy and lactation (no data available).
Licenced for use from 2 years of age.

OPTION 2
TYPHIM VI (Pasteur Merieux)
Type: polysaccaride
Primary course: 1 dose
Route: s/c or i/m
Boosters: 3 yearly
Side effects: Sometimes sore injection site and mild fever
Contraindications: Hypersensitivty to a previous dose. Febrile illness. Caution in pregnancy and lactation (no data available).
Chidren under 18 months: The response to the vaccine may be suboptimal but good protection is usually achieved.

OPTION 3
VIVOTIF (Medeva Pharma - previously Evans Medical)
Type: Live attenuated
Primary course: 3 doses on days 1,3,5)
Route: oral
Boosters: 3 yearly (an annual booster is recommended for high risk travellers)
Side effects: rarely diarrhoea or vomiting, urticarial rash.
Contraindications: fever, pregnancy, immunocompromised, diarrhoea or vomiting, concurrent antimicrobial or malarial therapy. Not for use in children < 6yrs.
Notes: This is a live vaccine and the capsules must not be kept out of cool storage (1 to 5 degrees C) for more than 48 hours.
Its administration should be separated from live poliomyelitis vaccine by at least 12 hours.

Note: A previous typhoid illness does not confer reliable immunity and, when indicated, vaccine should still be used.

Tuberculosis

Disease Risk Areas
Worldwide. Areas of particular risk (e.g. with more than 25 cases per 100,000 of the population) include the whole of South America, Africa (Subsaharan and North West) and the tropical Asia-Pacific regions, including the Indian subcontinent and Indonesia.
(Ref.: Abstracts on Hygiene and Communicable Diseases 1995:70;177-179.)

Transmission
Most commonly spread though infected sputum, either from those with pneumonia or asymptomatic carriers. Can also be spread through infected unpasteurised milk.

VACCINATION
Recommendations for Britain
In Britain most Health Authorities recommend vaccination for teenagers at around 14 years of age if they are tuberculin skin test (PPD) negative.
Recommendations for travellers
It should be ensured that travellers going to countries where tuberculosis is common have been vaccinated, especially those mixing closely with the local population such as health care workers. It may be less important for the short-term package tourist mixing mostly with other expatriates and staying in good accommodation.
Vaccination is especially helpful in preventing meningitic and miliary forms of tuberculosis and it can be given from birth.

BCG VACCINE (Bacillus Calmette-Guerin)
Always confirm details with manufacturer's literature
Type: Live attenuated.
No of doses: 1
Route: Intradermal - traditionally given into area over left deltoid although occasionally it is given into the hip to avoid scarring in an more obvious site.
Protection: At least 10-15 years
Effective from: 6-8 weeks
A tuberculin skin test should normally be performed before vaccination except in neonates. However serious complications are unusual when vaccination is given to those who are PPD positive, although a marked PPD positive like response may develop shortly after vaccination.
Boosters: Studies in endemic areas have suggested that after a successful BCG vaccination (confirmed by a visible scar), no further protection is gained from additional doses of BCG even when PPD skin test has reverted to negative. Whether this applies equally to travellers going from low to highly endemic areas is however not completely clear.If booster doses are given to those going to be at high risk and who have been previously vaccinated it must be remembered that the PPD skin test may become negative due to immunocompromise (e.g. due to HIV infection or the administration of corticosteroids) when BCG can be dangerous.
Severe injection site reactions: Side effects and abscesses are usually caused by faulty injection technique (e.g. giving the vaccine sub-cutaneously rather than intra-dermally).
Disseminated infection can occur in those who are immunocompromised (e.g. those with HIV infection and AIDS).
Severe or persistent skin reactions can can be treated with isoniazid powder (ground up tablet) placed on the ulcer or if necessary by oral anti-tuberculous drug(s). This may prevent unnecessary scarring.
Keloid formation at the injection site is not uncommon but can usually be avoided by ensuring that the mid-upper arm or thigh is used.
Contraindications: immunosuppression. HIV positivity. Pregnancy (delay BCG unless at high risk). Positive tuberculin skin test. Pyrexia. Generalised skin rashes.

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