Dr Nick Kimpton MBBS FRACGP CTH© MPHTM Bal larat Medical Cent re 10 Drummond St South Bal larat 3350 Ph 53331 253

TRAVEL IMMUNISATION UPDATE 2017

V 2.0

DTP MMR Polio Hep B HiB Influenza Pneumococcal Varicella Meningococcal C /ACWY HPV

ROUTINE VACCINATIONS [NOT SPECIFIC TO TRAVEL]

International Certificate of Vaccination or Prophylaxis [ICVP] currently only Yellow Fever but may be altered under International Health Regulations at any time

The Haj and Umra, currently for Australian citizens only Men ACWY is compulsory, influenza vaccine strongly recommended http://www.who.int/wer/2016/wer9126-27.pdf?ua=1&ua=1

Employment /schooling requirements Outside of these itineraries, immunisations, antimalarials

and other health precautions are the decision of the traveller with our input and guidance

The concept of the VFR as a high risk traveller [Visiting Friends and Relatives] Children, immunocompromised, pregnant women etc all have unique considerations

ITINERARIES WITH COMPULSORY/REQUIRED VACCINATIONS

Hepatitis A Typhoid Cholera Meningococcal ACWY Yellow Fever Japanese Encephalitis Rabies Tuberculosis Tick Borne Encephalitis

TRAVEL SPECIFIC RECOMMENDED VACCINES

The commonest vaccine preventable disease of travel Only Southern Hemisphere formulation currently available in

Australia Despite this year’s poor protection I would offer this for all

tropical travel and for appropriate seasonal risk in temperate zones

INFLUENZA

Frequently forgotten in the context of a travel consultation Approximately 260,000 cases [2014] and 146,000 deaths [2013]

worldwide One of the most infectious agents known to humans Complications 1/3 infections, Deaths 1/500 in Western population More than 50% of infections in Australians are contracted overseas

during travel Remember d.o.b. 1966 or later and especially 1978-82 Older than that 95% immune BUT 30-50 yo only 60-80% ie around 1/3

do not have protective levels of antibodies ? Immunisation does not induce as good a long term memory as

infection Look for evidence of 2 doses of vaccine or serology to be protected No evidence give 2 doses [ I would even discuss a booster dose around

50] Remember is a l ive vaccine so must give with other l ive vaccines or

separated by a minimum of 4 weeks

MEASLES

Ditto for measles but less lethal and less infectious Remember d.o.b. 1966 or later and especially 1978-82 Look for evidence of 2 doses of vaccine or serology to be

protected Recently an outbreak in Auckland NZ [mainly in Maori and

Pacific Islander communities] Mumps is a highly infectious disease. Parotitis is a painful and

common symptom. Orchitis, meningitis, and encephalitis are less common complications, but potentially serious. Recommendations for inclusion of a third dose of mumps vaccine in routine vaccination schedules are under consideration in several countries, including the U.S. Meanwhile, travel health advisors may wish to offer a third dose of mumps vaccine to young adult and adult travellers at specific high-risk of mumps as two-dose immunity clearly wanes.

MUMPS

Men C given routinely in Australia at 12 months, Men B now available and recommended for 1-5 yo and 15-19 yo

Men ACWY [conjugate] currently available free in Vic for 15-19yo Men A has been especially important in sub-Saharan Africa

[meningitis belt] but is waning with C and W becoming the predominant strains

MenB is uncommon in Africa but important for Europe, North America, Australia and New Zealand

Quadrivalent vaccines for travel to protect against ACWY strains Conjugate vaccines, newer longer lasting and prevent nasal

carriage [? boost after 5 years in adults if increased risk or immunosupressed ]

Polysaccharide vaccines cheaper , should no longer be available [only use if not anticipating further travel to risk area,booster appears less effective than initial dose]

MENINGOCOCCAL VACCINES

Men cACWY required within last 5 years for travellers to Haj and Umra

Consider for all people especially 15-25 yo who travel and live in close contact eg Residential colleges, youth hostels or doing military service

Consider for younger children especially VFRs or anyone who is immunocompromised

For travellers to regions in the meningitis belt depending on the time and duration of travel [there are biannual peaks of incidence that vary across the region] look at each country for specific recommendations

MENINGOCOCCAL VACCINATION FOR TRAVELLERS

Currently the only mandated vaccine needing an ICVP A flavivirus with a large wild animal [non human primates]

reservoir through tropical Central and South America, and sub-Saharan Africa endemic infection with intermittent epidemics

Causes intermittent epidemics when aedes mosquitoes in urban settings cause human to human transmission, but also occasional cases where people come into contact with infected mosquitoes in jungles and savannah

Highest risk at the end of the wet season July –October for Africa and January – May for South America

YELLOW FEVER

2017 epidemic of yellow fever in Brazil that has spread beyond the usual boundaries on the map above to reach the Atlantic coast and affect urban areas of Rio de Janeiro, Sao Paulo and Salvador and the surrounding states

Historically there have been outbreaks of Yellow Fever in the 17-19th century in Europe and North America following infected people moving into those countries and establishing local transmission

YELLOW FEVER

Currently people entering Australia require a valid ICVP for Yellow Fever if coming from a country listed as having endemic YF [ 47 in Africa and 13 in S America] within the last 6 days, in accordance with the International Health Regulations

YELLOW FEVER

From June 2016, international yellow fever vaccination certificates presented at Australia’s border will be accepted even if the vaccination was given more than ten years ago. Individuals who cannot provide a yellow fever vaccination certificate at the border will still be required to go through border control processes when entering Australia. As is current practice, entry to Australia will not be refused on the basis of non-compliance with yellow fever monitoring and control requirements. http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-communic-factsheets-yellow.htm

YELLOW FEVER

A live attenuated vaccine that provides lifelong protection beginning 10 days after vaccination

Exclude from vaccination Severe allergy to egg protein Immune compromise [steroids and other immune

suppressants eg methotrexate,many monoclonal antibodies, HIV with CD4 counts below certain levels

Previous thymus surgery or radiation Pregnant women [unless risk of disease outweighs

risks to patient and fetus] Children < 9 months of age [consider for 6-9 months

old if risk of disease outweighs risks to patient of vaccine]

YELLOW FEVER VACCINATION

Certificates issued from June 2016 should read valid for the l ife of the person vaccinated

A letter of exemption can by provided by a YF approved medical practitioner where risks of vaccination are too great

Sometimes this is easy , often a more complex decision and requires consideration of risks to the traveller and the community of importation of YF and the risks of doing harm through vaccination

I will normally do an exemption letter specific to a particular time and itinerary to prevent its ongoing or indefinite use if the exemption is not for an absolute contraindication

YELLOW FEVER VACCINATION

Another mosquito borne flavivirus closely related to Murray Valley Encephalitis, the commonest cause of encephalitis in SE Asia

Carried by migratory water birds eg herons and egrets Commonest where there is flood irrigation and pig farming [

humans and most other domestic animals are dead end hosts]

Absolute risk per traveller is very low [ 1/250,000-1,000,000 per 2 week trip ?]

Risk increased by duration of travel, time in rural locations and season

Worldwide estimated to be 68,000 cases/yr and 13-21,000 deaths mostly in children, with epidemics occurring every 2-15 years

JAPANESE ENCEPHALITIS [LOW RISK HIGH IMPACT]

Risk of significant il lness estimated at only 1/250 infections [vast majority are asymptomatic or non specific viral i l lness]

But with severe disease 1/3 die , 1/3 have permanent neurologic sequelae

2001-2014 9 cases in Australians , all acquired overseas. But a death in a 60 yo Australian who spent 10 days North of Phuket in June 2017

In subtropical regions monsoonal il lness, in tropical regions all year round

Because of vaccination local infection rates in humans do not reflect risk to travellers

JAPANESE ENCEPHALITIS

Two vaccines available in Aus Imojev, l ive chimeric vaccine of JE spliced into YF single dose,

boost after 1-2 years if given between 9 mo and 18yrs, no booster needed for adults

Jespect [Ixiaro], inactivated JE virus 2 doses 4 weeks apart no booster needed if given 9 mo to 18yrs but boost after 1-2 yrs in adults

JE VACCINATION

No bites , no malaria, Dengue, Zika ,Chikungunyah, JE etc. Nets/ AC/ Screened rooms Repellent[DEET/Picardin] Cover up /Permethrin Insecticide /Knockdown/Coils

MOSQUITO BITE AVOIDANCE

Includes all the classic rabies strains and several others including Australian Bat Lyssavirus

Estimated to cause 80,000 deaths/year predominantly in Asia and Africa

Wound from terrestrial mammal, a bite a scratch or a lick on broken skin [or mucous membrane] Tell patients any animal with fur

All wounds regardless of vaccination status are managed the same initially ie wash vigorously and seek urgent medical attention

RABIES [LYSSAVIRUS]

Pre Exposure Prophylaxis [PreP] Post Exposure Prophylaxis [PEP] 2 Vaccines, Merieux Inactivated Rabies Vaccine [cell culture

derived] and Rabipur Inactivated Rabies Vaccine [ chick embryo derived] very similar but cant use Rabipur if egg protein allergy

Imogam Rabies Immunoglobulin [HRIG] human derived is the only Immunoglobulin used in Aus [many other countries especially in Asia use a horse derived immunoglobulin]

PreP is 3 doses IM on days 0,7, 21-28, for dog bite rabies in normal population considered to be l ifelong cover

PEP if previously vaccinated is 2 doses on days 0 and 3 PEP if not vaccinated is HRIG into the wound [calculated on body

weight] and 4 doses of vaccine days 0,3,7,14 but if immunocompromised add a fif th dose on day 28

RABIES

Awareness is at least as important as vaccination

The principle of PrEP is to create boostable immunity Tel l patients that any bite or scratch or a l ick on broken skin from a

furry animal is a r isk Do not give incomplete vaccine series as HRIG cannot be used if a

person has ever been vaccinated [ any dose more than 7 days previously] and it is not protective

Travel cl inics can of fer ID rabies vaccination [of f label]as i t is less expensive . I t is not recommended by the Australian Immunisation Guidelines [requires significant experience to administer] but is widely used in Australian Travel Cl inics and overseas

I f you see returned travellers who have had a potential rabies exposure either untreated [at any t ime in the past] or who have star ted PEP overseas contact the health dept to get access to HRIG and fur ther doses of vaccine[or immediately refer to a cl inic that is experienced in handling rabies PEP]

RABIES, SOME PRINCIPLES

In Victoria if you are contacted by someone after a potential rabies exposure you need to know;

Animal contact date and bite site/type of contact Commencement date of vaccination and regime given Patient’s weight Any immunocompromise in the bitten person Then ring the health dept

RABIES PEP

Good Reference Sites WHO http://www.who.int/immunization/en/ The Australian Immunisation Handbook

http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home

CDC http://www.cdc.gov/ Smartraveller [Aus Govt]

http://smartraveller.gov.au/Pages/default.aspx

QUESTIONS ?

HEPATITIS A

What a great vaccine! Single dose of age appropriate vaccine good for 1-3 years 2 doses 6 or more months apart for lifelong cover Can be given from 1 year of age Serology if unsure of vaccination history, adult with history of

hepatitis, immigrant, or over 65 and may have had wild disease

Worthwhile for anyone travelling outside of low risk Developed Countries

No contraindication to administering with any other vaccines Available in combination with typhoid and Hepatitis B

TYPHOID

Injectable Polysaccharide vaccine for 2yo and above, contraindications only allergy to vaccine or components

Oral live attenuated [days 1,3,5 ] for 6yo and above, precautions, must swallow whole and cannot be given with antibiotics, separate by at least 8 hours from cholera vaccine

Both provide 3 years of protection then revaccinate if ongoing risk [ 4 dose oral is good for 5 years], may get some partial protection against paratyphoid from oral vaccine too

Important disease in Indian subcontinent but anywhere outside of first world countries

CHOLERA

Oral ki l led vaccine of 4 of the 01 strains and recombinant B subunit Children 2-6yo, 3 doses 1-6 weeks apart , over 6yo 2 doses 1-6 weeks

apart Contraindications only al lergy to vaccine or components Not advised for pregnant or breastfeeding Don’t give during acute GI i l lness or within 8 hours of oral typhoid Good shor t term ef ficacy but rapidly wanes [no protection against

0139] Probable cross protection against ETEC [enterotoxigenic e col i] for 3

months giving approximately a 10% reduction in bacterial gastroenterit is, although there is significant dispute regarding this

Main indication is high r isk high exposure eg aid workers in refugee or disaster rel ief

Consider for ETEC cross protection if person is at much greater r isk of gastroenterit is or serious outcomes

Booster doses i f ongoing exposure at 6 months for 2-6yo and 1-2 years for over 6yo. I f outside of these periods a new primary course is advised

TUBERCULOSIS

Vaccination is BCG, increasingly hard to access in Aus Widely used throughout the developing world Tb testing is often required for health workers and travellers

to some destinations eg Nursing and Medical students in Aus prior to placement, Physiotherapists going to work in UK, many exchange students

Testing either with mantoux test or quantiferon gold test BCG available through some travel clinics , RCH and Monash

in Melbourne Consider especially for young children with prolonged [3

months] exposure eg VFRs to high risk countries and consider cumulative risk eg 4 weeks every year, not just a single journey. Ideally give 3 months pre travel

The concept of the microbiome, 100 trillion bacteria in the gut [ 10 times the number of human cells in the body] At least 500-1000 distinct species in a

mutualistic relationship with the human host We don’t tolerate them, we depend on them !

TRAVELLERS DIARRHOEA

Mild [tolerable not too interfering with activity] Moderate [distressing and preventing some

activity] Severe [incapacitating and includes all

dysentery]

TRAVELLERS DIARRHOEA CLASSIFICATION

Don't jump straight to antibiotics for all cases Mild cases should be managed expectantly with Oral Rehydration

Salts and possibly antidiarrhoeal medication Moderate cases depends on situation, eg other medical i l lness,

isolation and itinerary Travel to some destinations is associated with a heightened risk

of acquiring multi drug resistant bacteria and altering your microbiome [15-30%]

Antibiotic use doubles that risk [ up to 80%] For South and SE Asia consider azithromycin as the standby

antibiotic for severe bacterial gastro, bring from Australia [ up to 80% of medication in some destinations is counterfeit]

BUT Use of antibiotics may not prevent the development of Post Infectious Irritable Bowel Syndrome and may increase the risk in some circumstances

TRAVELLERS DIARRHOEA TREATMENT

Persistent and ongoing infection Unmasking previously undiagnosed GI disease eg

coeliac disease Post infectious sequelae of the enteric infection Around 10 % of people with travellers diarrhoea

develop a persistent illness

PERSISTENT DIARRHOEA POST TRAVEL