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