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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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Presentation on theme: "Travel Immunizations Support for this program is made possible by the AAFP Foundation through a grant from Pfizer Inc."— Presentation transcript:

1 Travel Immunizations Support for this program is made possible by the AAFP Foundation through a grant from Pfizer Inc.

2 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

3 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

4 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 4

5 Competencies Patient care
Recognize returning travelers may have acquired an illness on the trip Assess immunization status of patients who will travel

6 Competencies Interpersonal communication Systems-based practice
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)

7 Travel Immunizations In 2004: 763,000,000 crossed international borders Important considerations Prior immunizations Health needs Locations/Exposures Other important travel considerations; insects, food/water, pregnancy, diabetes, tuberculosis, uncontaminated water, schistosomiasis, altitude, diving, or wilderness Haiti - Photo by Tim Elzinga, M.D. Madrid and Paris – Photos by Wendy Biggs, M.D.

8 Case Case What vaccines does he need?
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?

9 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 The Center for Disease Control and Prevention (CDC) publishes every 2 years a reference on health risks for international travelers. Book can be purchased from Elsevier Publishing on-line at Or can be searched on-line at 9

10 Travel Immunizations Required Recommended Yellow Fever Meningococcal
Polio Tetanus/Diphtheria/Pertussis Influenza Measles Hepatitis A/B Typhoid Rabies Japanese Encephalitis Tick-borne Encephalitis Some countries require vaccines on entry. Yellow fever and meningococcal vaccine are the most commonly required. Many other vaccines are recommended based on the locale to which the person is traveling.

11 Case Does Mr. M need Yellow Fever Vaccine? 11

12 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 True number may be up to 250 times the number reported due to difficulties in record keeping in developing countries.

13 Yellow Feaver 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 For a 2 week stay: risk of illness/death for an unvaccinated traveler to an endemic area is: West Africa: 10/100, /100,000 South America: /100,000 Highest risk during rainy season

14 Yellow Fever Disease Transmission Disease Prevention
From primates or humans Mosquito vector Disease Prevention Avoid mosquito bites DEET Clothing Mosquito nets Eliminate standing water Vaccination DEET insecticide as a spray/lotion. Long-sleeve and long-legged clothing can impede mosquito bites. The clothing can also be treated with permethrin. Photo from Image in public domain. Photo by James Gathany.

15 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 Immunity from vaccination occurs within ~ 1 week ** Protection from vaccine can last for 30 – 35 years or more. WHO International Health Regulations, however, recommend revaccination at 10 year intervals (

16 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 *The age limit is changed during epidemic/yellow fever outbreak – then considered for infants 6 months and older. Pregnant women can be vaccinated, but yellow fever virus can cross the placenta. However, no known congenital anomalies have been associated with Yellow Fever vaccination,. Yellow fever vaccine should never be administered to an infant less than 6 months old. Breastfeeding – unknown. Yellow fever virus has not been detected in breast-milk, but one case of possible transmission from vaccinated mother to breastfed infant. The virus is grown in eggs, therefore, egg anaphylaxis is a contraindication. The vaccine is live-attenuated and contraindicated in severe immunocompromised patients such as HIV/AIDS with CD4 count <200, on chronic corticosteroids, thymectomy. 16

17 Yellow Fever Vaccine Side Effects
Adverse Reactions (10-30%) Local soreness Mild fever Headache Myalgias

18 Yellow Fever Vaccine Rare Severe Reactions
Anaphylaxis Risk 1/131,000 Yellow fever associated neurotropic disease (YEL-AND) Risk 1:150, ,000 Multiple neurologic conditions Encephalitis (esp. infants <9 months), Guillian-Barre, Bell’s Palsy Onset 2-28 days after vaccination Rarely fatal YEL-AND: “associated neurotropic disease” Risk is 1:150,000 – 200,000 doses. Onset is 3 – 28 days after vaccination, mostly in first time vaccinations. Multiple neurologic conditions reported. Most encephalitis in infants < 9 mos old (before recommendations about age limit). Also, Guillian-Barre, Bell’s palsy, bulbar palsy have been reported. Rarely fatal. 18

19 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 Greater risk if over age 60 YEL-AVD: “associated viscerotropic disease” – formerly called Major Organ System Failure. Half will die if acquired. At greater risk if over age 60 (60-69 – 1.5x risk of reaction, >70 – 3x risk of reaction). Mimics severe yellow fever with virus proliferation and causes multi-organ failure. Occurs in 1-8 days (average 3 days) after initial vaccination. 40 confirmed cases worldwide. 19

20 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 The ICVP must be signed by a licensed physician or by a health-care worker designated by the physician supervising the administration of the vaccine. 20

21 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 must be given at a certified center in possession of an official “Uniform Stamp,” which can be used to validate the ICVP. ICVP can be ordered at State health departments are responsible for designating non-federal yellow fever vaccination centers and issuing Uniform Stamps to physicians. Information about the location and hours of yellow fever vaccination centers may be obtained by visiting CDC’s Travelers’ Health website at wwwn.cdc.gov/travel/yellowfever.aspx 21

22 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 Countries are in South America and tropical Africa. Up to date recommendations are available on-line at 22

23 Case (once again) Case What vaccines does he need?
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?

24 Case Case Since he is not going to tropical Africa or South America, he does NOT need Yellow Fever Vaccine. Does he need Meningococcal Vaccine? 24

25 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 Epidemic areas shown next slide

26 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 Up to 2 million people may be in Mecca performing the Hajj pilgrimage, which occurs for 6 days in the last month of the Muslim calendar. Devout Muslims believe each person should perform the Hajj pilgrimage at least once in their lifetime if able-bodied and can afford to do so.

27 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 Symptoms of meningitis include headache, neck stiffness, vomiting, photophobia Sepsis – purpura fulminans, organ failure. Sepsis occurs rapidly, within the first 24 hours of illness Photo from Image in public domain.

28 Meningococcal Disease
Vaccine required to attend the Hajj (annual pilgrimage to Mecca) If under age 15, polio vaccination needed also Polio vaccination must also be shown for < 15 year olds

29 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 MCV4 - Quadrivalent meningococcal polysaccharide–protein conjugate vaccine (Menactra™) (0.5ml) MPVS4 - Quadrivalent meningococcal polysaccharide vaccine (Menomune®) (0.5ml) MenACWY-CRM – Quadrivalent meningococcal oligosaccharide diphtheria CRM197 Conjugate Vaccine (Menveo®) Antibodies present within 7-10 days For more information regarding meningococcal vaccines, see Pediatric Immunization module

30 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

31 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 31

32 Case Does he need additional vaccines? How would you know? Possibly
1)Need to review Mr. M’s immunization status 2)Need to know recommended vaccines Most adults do not know their immunization status or what vaccine series were completed as a child. Some state registries have started entering adult data. Immigrants to the US are required to have up to date immunizations to obtain citizenship.

33 Case 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 33

34 Recommended Vaccines for Travel
Tetanus/Diphtheria/ Pertussis Influenza Polio Measles Hepatitis A Hepatitis B Typhoid Rabies Japanese Encephalitis Tick-borne Encephalitis First column – vaccines that adults should have gotten as a child, but may need boosters. Influenza is recommended during flu season, which varies by geographic location. Children now get Hepatitis A and Hepatitis B vaccinations, but most adults did not. The second column are available, but less commonly given. Physicians should have a general knowledge of them. 34

35 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 35

36 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 Wild Polio virus has not been interrupted in 4 countries – India, Nigeria, Pakistan and Afganistan IPV – Inactivated polio virus in injectable vaccine OPV – oral polio virus. Not used in US due to rare cases of vaccine associated polio 36

37 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 37

38 Hepatitis A Worldwide prevalence Fecal/oral transmission
Associated poor hygiene or sanitation Symptoms include Jaundice Fatigue Abdominal pain Anorexia Nausea The viral disease Hepatitis A is manifested here as icterus, or jaundice of the conjunctivae and facial skin. The liver infection causes jaundice. Adults will have signs and symptoms more often than children. In children younger than 6 years of age, most (70%) infections are asymptomatic. In older children and adults, infection is usually symptomatic, with jaundice occurring in more than 70% of patients. Photo from Image in public domain.

39 Hepatitis A Adults often contract from asymptomatic children
Incubation 28 days (range days) Viral shedding 2 weeks before to 1 week after symptoms Usually self-limited disease The incubation period of hepatitis A is approximately 28 days (range 15–50 days). Clinical illness usually does not last longer than 2 months, although 10%–15% of persons have prolonged or relapsing signs and symptoms for up to 6 months. Most cases are self-limited, but HAV can cause fulminant hepatitis and death. It also has significant direct and indirect medical costs. HAV infection occasionally produces fulminant hepatitis A. In the pre-vaccine era, fulminant hepatitis A caused about 100 deaths per year in the United States. The case-fatality rate among persons of all ages with reported cases was approximately 0.3% but could be higher among older persons (approximately 2% among persons 40 years of age and older). Hospitalization rates for hepatitis A are 11%–22%. Adults who become ill lose an average of 27 work days per illness, and health departments incur the costs of post-exposure prophylaxis for an average of 11 contacts per case. Average direct and indirect costs of hepatitis A range from $1,817 to $2,459 per adult case and $433 to $1,492 per pediatric case. In 1989, the estimated annual U.S. total cost of hepatitis A was more than $200 million.

40 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 See Adult Immunizations for other indications.

41 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, days and 12 months (4-dose accelerated series)

42 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 The first dose of hepatitis A vaccine should be administered as soon as travel is considered. For healthy persons 40 years of age or younger, 1 dose of single antigen vaccine administered at any time before departure can provide adequate protection. Unvaccinated adults older than 40 years of age, immunocompromised persons, and persons with chronic liver disease planning to travel in 2 weeks or sooner should receive the first dose of vaccine and also can receive immune globulin (IG) at the same visit. Vaccine and IG should be administered with separate syringes at different anatomic sites. Travelers who choose not to receive vaccine should receive a single dose of IG (0.02 mL/kg), which provides protection against HAV infection for up to 3 months. Persons whose travel period is more than 2 months should be administered IG at 0.06 mL/kg. IG should be repeated in 5 months for prolonged travel. 42

43 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 Map of endemic areas next slide 43

44 Hepatitis B Vaccine Indications
International travel to endemic areas See Adult Immunization Module for other adult indications for Hepatitis B X is on Saudi Arabia. Mecca is in Saudi Arabia, where Mr. M is going. X

45 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, days and a booster at 12 months 45

46 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

47 Influenza Risk depends on timing and destination Avian subtype risks
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 47

48 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 Paratyphoid is a clinically similar febrile illness caused from Salmonella paratyphii A, B, or C. In the US 400 cases of typhoid and 150 cases of paratyphoid are reported annually in US. Most cases are in recent travelers.

49 Typhoid Southeast Asia Africa, Caribbean, Central and South America
6-30 times more common Highest risk of drug resistance Africa, Caribbean, Central and South America Length of stay = increased risk Typhoid is most common in Southeast Asia and has the highest drug resistance. A traveler can acquire typhoid in less than a week in endemic area.

50 Rose spots on the chest in a patient with 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 A transient macular rash of rose-colored spots frequently appears on trunk. Low-grade septicemia – blood culture is only positive in half of cases. GI bleeding secondary to ileocecal lymphatic hyperplasia of Peyer’s patches Also can have diarrhea, pneumonia, encephalitis, endocarditis and many other symptoms Photo from Image in public domain.

51 Typhoid Treatment Oral rehydration Antibiotics
Ciprofloxacin if no resistance (7-10 days) 3rd generation cephalosporin (10-14 days) Azithromycin Steroids in severe cases Fluoroquinolones are considered first-line treatment for adults. According to Cochrane review, studies are small and varied but fluoroquinolones appeared better than chlorampenicol (used overseas, not in US). Typhoid resistance to fluoroquinolones common in subcontinent India. ( Ceftriaxone (Rocephin®) can be used intramuscularly or intravenously. Older drugs may be used but have a high level of resistance (amoxicillin, trimethoprim/sulfamethoxazole, chloramphenicol) A Cochrane database review suggests azithromycin works well in areas with multi-drug resistance, such as in India ( Steroids may help in severe febrile cases, but evidence is based on studies with chloramphenicol (which is less used since the use of fluoroquinolones and azithromycin increased) (Hoffman SL; Punjabi NH; Kumala S, et al. Reduction of mortality in chloramphenicol-treated severe typhoid fever by high-dose dexamethasone. N Engl J Med 1984 Jan 12;310(2):82-8). Despite giving the “right” antibiotic, patients will remain febrile for 3 to 5 days. Patients may also feel worse after antibiotics started and the fever is diminishing.

52 Typhoid Prevention Vaccine(s) Avoid contaminated food and water
Hygiene Local cuisine Vaccine(s) 2 available Travelers should be cautioned about eating fruits and vegetables (washed in local water), and should drink bottled water. Photo from Image in public domain.

53 Typhoid Vaccines Typhim Vi® Vivotif® Capsular polysaccharide (IM)
Ages 2 and older 50-80% protection Single 0.5ml injection 2 weeks before exposure Booster every 2 years 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 Vivotif® NO protection against S. Paratyphi Not 100% protection Needs to be refrigerated Cannot give if on antibiotics within 72 hours Contraindicated in pregnancy, immunodeficiencies Should not be given to children under 6 years Typhim Vi® Also in combination with Hep A Only contraindication – history of serious adverse reactions Safe in immunodeficiency states **adverse effects rare… HA, fever, local reaction** Should not be given to children less than 2 years Interesting point… CFTR (cystic fibrosis) mutation causes protection… like sickle cell protective against malaria

54 Rabies Found globally Consider vaccination
If potential exposure to wild animals (especially dogs) Prolonged exposure where endemic Rabies in dogs is still a major problem in Asia, Africa, Central and South America.

55 Rabies Vaccine Pre-exposure prophylaxis
Series of 3 at 0, 7 and days 2 vaccines available in U.S. Imovax® Rabavert® Outside U.S. many other vaccines Expense limits use Imovax® – human diploid cell vaccine Rabavert® – Purified chick embryo cell vaccine

56 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 Pregnancy not a contraindication, nor is immunosuppression for post-exposure prophylaxis against rabies. Rabies infection has mortality risk of 90-95%.

57 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

58 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) Most human infections with JEV are asymptomatic; <1% of people infected with JEV develop clinical disease. The incubation period 5–15 days. Illness usually begins with sudden onset of fever, headache, and vomiting. Mental status changes, focal neurologic deficits, generalized weakness, and movement disorders may develop over the next few days. Severe symptoms A parkinsonian syndrome resulting from extrapyramidal involvement is a very distinctive clinical presentation of JE. Acute flaccid paralysis, with clinical and pathological features similar to poliomyelitis, has also been associated with JEV infection. Seizures are very common, especially among children. 58

59 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 The vaccines available overseas have no randomized controlled trials. Cochrane Database analyzed available studies. The inactivated vaccine appeared to provide immunity for one year after a 2 dose series, but data limited. Booster Doses JE-VC The need for and timing of booster doses following a 2-dose primary series with JE-VC has not been determined, and further study is needed. The full duration of protection following primary vaccination with JE-VC is unknown. One immunogenicity study indicated that 95% (172/181) of subjects maintained protective neutralizing antibodies 6 months after receiving the first dose and 83% (151/181) still had protective antibodies 12 months after primary vaccination (164). However, a subsequent study determined that only 83% (96/116), 58% (67/116), and 48% (56/116) of subjects had protective antibodies at 6, 12, and 24 months after their first vaccination, respectively (165). JE-MB The full duration of protection following primary vaccination with JE-MB also is unknown. However, immunogenicity studies indicate that neutralizing antibodies likely persist for at least 2 years (175, ). A booster dose of 1.0 mL (0.5 mL for children aged <3 years) of JE-MB may be administered 2 years after the primary series when indicated for planned travel or possible laboratory exposure (see Recommendations for the Prevention of JE Among Travelers and Recommendations for the Use of JE Vaccines in Laboratory Workers. The duration of immunity after serial booster doses has not been well established. No data exist on the use of JE-VC as a booster dose after a primary series with JE-MB. Because of limited supply, remaining doses of JE-MB are being reserved for use in children aged years. If a booster dose of JE-MB is not available, adults aged ≥17 years who have received JE-MB previously and require further vaccination against JEV should receive a 2-dose primary series of JE-VC

60 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 30% of patients have the second neuro-invasive stage that appears as meningitis, encephalitis, or myelitis. Avoiding tick bites is recommended with trips to forested areas in Europe and Russia. Wearing long-sleeved and long-legged clothing, tucking pant legs into socks and using insecticide with DEET are recommendations. Image in public domain. Photo taken by James Gathany.

61 Case Case Since he is going to Saudi Arabia, what additional vaccines does Mr. M need? Slide to review question – answer next slide

62 Case 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 62

63 Case Case Does Mr. M need anything for malaria? 63

64 Malaria 350,000, ,000,000 cases/year 1,000, ,000,000 deaths/year Mostly sub-Saharan Africa X Malaria is very common and a significant cause of death, especially of children, in the areas indicated. X indicates Saudi Arabia

65 Malaria ~1500 imported cases to US/year 6 deaths/year Risk assessment
Probably under-reported 6 deaths/year Risk assessment Location, season, elevation, duration Military Travelers visiting friends or relatives Pregnancy People born in endemic areas who are going back to visit family have waning immunity to malaria. They also are less likely to receive prophylaxis. Pregnant women with malaria have an increased risk of spontaneous abortion and low-birth weight infants.

66 Symptoms of Malaria Symptoms of Malaria
Image is in the pubic domain.

67 Have to treat with chemoprophylaxis
Malaria NO VACCINE Have to treat with chemoprophylaxis 67

68 Malaria Prevention Chemoprophylaxis Clothing Insect repellant
Mosquito netting Chemoprophylaxis Atovaquone/proguanil (Malarone®) Primaquine Chloroquine Mefloquine Doxycycline DEET 30-50% safe for over 2 months of age Important to plan ahead – many areas are chloroquine resistant Netting image originally posted to Flickr by Tjeerd Wiersma at Permission to re-use when credit given.

69 Malaria Multiple regimens, multiple meds
Start before, end after Important to plan ahead with your doctor or travel clinic Recommendations at CDC yellowbook Pregnancy Chloroquine/mefloquine only The chemoprophylaxis regimens depend on the geographic area visited. In general, the regimens start before leaving the country and continue upon return for a specified time. If pregnant woman traveling to chloroquine resistant area, still treat with chloroquine plus strict mosquito avoidance.

70 Case Case Mr. M does NOT need malaria prophylaxis 70

71 Traveler’s Responsibilities
4-6 weeks before travel see provider Get necessary immunizations Check CDC for up to date recommendations ( Check travel notices for outbreak information (

72 Traveler’s Responsibilities
Travel health kit Prescription medications and over-the-counter medications Advice available at: Commercial pre-assembled health kits American Red Cross: Adventure Medical Kits: Chinook Medical Gear: Travel Medicine, Inc.: Wilderness Medicine Outfitters: 72

73 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 ( International Society of Travel Medicine ( for those more interested The International Society of Travel Medicine (ISTM) provides educational resources, including the Journal of Travel Medicine, an active listserv, and a Certificate of Knowledge in Travel Health (CTH), awarded upon completion of an exam. The ISTM website at is continually updated.

74 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

75 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)

76 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

77 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. 77

78 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 78

79 Summary Systems-based practice
The Center for Disease Control and Prevention websites provides information for travelers provides for information on immunizations 79


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