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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
Competencies
• Patient care
– Recognize returning travelers may have
acquired an illness on the trip
– Assess immunization status of patients
who will travel
Travel Immunizations
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
Travel Immunizations
• 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.
Travel Immunizations
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?
Travel Immunizations
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
Travel Immunizations
• Required
– Yellow Fever
– Meningococcal
• Recommended
–
–
–
–
–
–
–
–
–
Polio
Tetanus/Diphtheria/Pertussis
Influenza
Measles
Hepatitis A/B
Typhoid
Rabies
Japanese Encephalitis
Tick-borne Encephalitis
Travel Immunizations
Case
Does Mr. M need Yellow Fever Vaccine?
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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.
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
Yellow Fever Vaccine Side Effects
• Adverse Reactions (10-30%)
– Local soreness
– Mild fever
– Headache
– Myalgias
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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?
Travel Immunizations
Case
Since he is not going to tropical Africa
or South America, he does NOT need
Yellow Fever Vaccine.
Does he need Meningococcal Vaccine?
Travel Immunizations
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
Travel Immunizations
Meningococcal Disease
• “Meningitis Belt”
– Sub-Saharan Africa
X
• 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
Travel Immunizations
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.
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
Recommended Vaccines for Travel
• Tetanus/Diphtheria/
Pertussis
• Influenza
• Polio
• Measles
• Hepatitis A
• Hepatitis B
• Typhoid
• Rabies
• Japanese
Encephalitis
• Tick-borne
Encephalitis
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
Hepatitis A
• Worldwide prevalence
• Fecal/oral transmission
– Associated poor hygiene
or sanitation
• Symptoms include
–
–
–
–
–
Jaundice
Fatigue
Abdominal pain
Anorexia
Nausea
Photo from www.cdc.gov. Image in public domain.
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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)
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
Hepatitis B Vaccine Indications
• International travel to endemic areas
X
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/hepatitis-b.aspx
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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)
Rose spots on the chest in a
patient with typhoid
– Hepatosplenomegaly
– Intestinal hemorrhage/perforation
• No definitive test
– Clinical diagnosis
Photo from www.cdc.gov. Image in public domain.
Travel Immunizations
Typhoid
• Treatment
– Oral rehydration
– Antibiotics
• Ciprofloxacin if no resistance (7-10 days)
• 3rd generation cephalosporin (10-14 days)
• Azithromycin
– Steroids in severe cases
Travel Immunizations
Typhoid
• Prevention
– Avoid contaminated
food and water
– Hygiene
– Local cuisine
• Vaccine(s)
– 2 available
Photo from www.cdc.gov. Image in public domain.
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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)
Travel Immunizations
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
Travel Immunizations
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.
Travel Immunizations
Case
Since he is going to Saudi Arabia,
what additional vaccines does
Mr. M need?
Travel Immunizations
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
Travel Immunizations
Case
Case
Does Mr. M need anything
for malaria?
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
Symptoms of Malaria
http://en.wikipedia.org/wiki/File:Symptoms_of_Malaria.png. Image is in the pubic domain.
Travel Immunizations
Malaria
NO VACCINE
Have to treat with
chemoprophylaxis
Travel Immunizations
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.
Travel Immunizations
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
Travel Immunizations
Case
Mr. M does NOT need malaria
prophylaxis
Travel Immunizations
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)
Travel Immunizations
Traveler’s Responsibilities
• Travel health kit
– Prescription medications and over-the-counter
medications
– Advice available at:
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter2/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
Travel Immunizations
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
Travel Immunizations
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
Travel Immunizations
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)
Travel Immunizations
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
Travel Immunizations
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.
Travel Immunizations
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
Travel Immunizations
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