Travel and Travel and International International

VaccinesVaccinesMichael Martin, MDMichael Martin, MD

Inova Fairfax HospitalInova Fairfax Hospital

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The Pre-Travel The Pre-Travel ConsultationConsultation

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Data Risk Assessment

Advice to reduce exposure to health risks

Immunization

Chemoprophylaxis

Advice for Self Treatment

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The Pre-Travel ConsultationThe Pre-Travel Consultation-Risk Assessment--Risk Assessment-

ItineraryItinerary Reason for travelReason for travel Duration, style and season of travelDuration, style and season of travel Medical historyMedical history Immunization historyImmunization history AllergiesAllergies Special health needsSpecial health needs

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Risk ManagementRisk Management

Must be individualized by:Must be individualized by: Specific ItinerarySpecific Itinerary Class of TravelClass of Travel Acceptable risk to patientAcceptable risk to patient Outcome of disease if acquiredOutcome of disease if acquired Ability of patient to payAbility of patient to pay

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Travel ImmunizationTravel Immunization

Update of routine vaccinationUpdate of routine vaccination Required vaccinesRequired vaccines

International Health RegulationsInternational Health Regulations Medically recommendedMedically recommended

According to riskAccording to risk Patient tolerance of riskPatient tolerance of risk Risk may be behavior relatedRisk may be behavior related

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Routine ImmunizationsRoutine Immunizations Tetanus/diphtheria/pertussisTetanus/diphtheria/pertussis

5 year tetanus booster in select cases (not 5 year tetanus booster in select cases (not available in location where traveling)available in location where traveling)

MeaslesMeasles 2 lifetime doses if born after 19562 lifetime doses if born after 1956

PolioPolio 1 adult dose for endemic countries1 adult dose for endemic countries

PneumococcalPneumococcal VaricellaVaricella

Consider for long-stay travelersConsider for long-stay travelers

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““Any traveler who wants to reduce the risk for Any traveler who wants to reduce the risk for influenza infection should consider influenza influenza infection should consider influenza vaccination, preferably at least 2 weeks before vaccination, preferably at least 2 weeks before departure. In particular, person at high risk for departure. In particular, person at high risk for complications of influenza who were not complications of influenza who were not vaccinated with influenza vaccine before travel if vaccinated with influenza vaccine before travel if they plan to they plan to Travel to the tropics,Travel to the tropics, Travel with organized tourist groups at any time of year,Travel with organized tourist groups at any time of year, Travel to the Southern Hemisphere during April-Travel to the Southern Hemisphere during April-

September.”September.”

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HIGH RISK COUNTRIES: Pakistan, India, Afghanistan, Nigeria

(based on 2008 data)

DISTRIBUTION OF POLIO

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Medically Recommended Medically Recommended ImmunizationsImmunizations

Hepatitis AHepatitis A TyphoidTyphoid Hepatitis BHepatitis B MeningococcalMeningococcal RabiesRabies Japanese EncephalitisJapanese Encephalitis

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Distribution of Hepatitis Distribution of Hepatitis AA

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Hepatitis A VaccineHepatitis A Vaccine

Killed virus, 2 brands equivalentKilled virus, 2 brands equivalent Almost 100% protection 1 month after Almost 100% protection 1 month after

11stst dose dose 90-95% after 2 weeks90-95% after 2 weeks

Use of Ig for imminent departures Use of Ig for imminent departures (<2 weeks) in compromised hosts ( or (<2 weeks) in compromised hosts ( or over 40 yo)over 40 yo)

Booster: 6-18 months; long term Booster: 6-18 months; long term protectionprotection

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QuestionQuestion

When examining the vaccine records of a When examining the vaccine records of a 3 year old child you are seeing in 3 year old child you are seeing in continuity clinic, you notice that at the continuity clinic, you notice that at the age of one, she had hepatitis A age of one, she had hepatitis A administered, but no booster was given. administered, but no booster was given. What do you do?What do you do?

A.A. Forget the whole thing, immunizations Forget the whole thing, immunizations drive you crazydrive you crazy

B.B. Restart the series now (meaning give an Restart the series now (meaning give an additional 2 doses)additional 2 doses)

C.C. Do not restart, give the booster dose onlyDo not restart, give the booster dose only

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Answer: C, Give the Answer: C, Give the BoosterBooster

In the case of interrupted series, do In the case of interrupted series, do not restart the vaccination!not restart the vaccination!

Late boosters: effective even at 5 Late boosters: effective even at 5 years of ageyears of age

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Distribution of Hepatitis Distribution of Hepatitis BB

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Hepatitis B VaccineHepatitis B Vaccine

Risk: highly behavior drivenRisk: highly behavior driven All stays in any highly endemic countryAll stays in any highly endemic country Short stays in low endemic country if Short stays in low endemic country if

sexually active, needle exposure sexually active, needle exposure (dental, tattooing, body piercing, (dental, tattooing, body piercing, acupuncture), adventure travelacupuncture), adventure travel

Licensed regimens:Licensed regimens: 0, 1, 6 months or 0,1,2,12 months0, 1, 6 months or 0,1,2,12 months Brands interchangeableBrands interchangeable

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Quick Review of Quick Review of Hepatitis BHepatitis B

Approximately one third of infected Approximately one third of infected persons do not have a readily persons do not have a readily identifiable risk factoridentifiable risk factor

Person-to-person spread of HBV can Person-to-person spread of HBV can occur in settings involving occur in settings involving interpersonal contact over extended interpersonal contact over extended periods, such as when a chronically periods, such as when a chronically infected person resides in a infected person resides in a householdhousehold

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QuestionQuestion

At room temperature, how long At room temperature, how long can the Hepatitis B virus survive?can the Hepatitis B virus survive?

A.A. 1 week1 week

B.B. 2 weeks2 weeks

C.C. 2 months2 months

D.D. 6 months6 months

E.E. To infinity and beyond!To infinity and beyond!

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Answer: D, 6 months Answer: D, 6 months

Hepatitis B virus can survive when Hepatitis B virus can survive when stored for 15 years at -20°C, for 24 stored for 15 years at -20°C, for 24 months at -80°C, for 6 months at months at -80°C, for 6 months at room temperatures, and for 7 days room temperatures, and for 7 days at 44°C at 44°C

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Distribution of TyphoidDistribution of Typhoid

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TyphoidTyphoid

VaccineVaccine Live oral and killed injectable Live oral and killed injectable

polysaccharidepolysaccharide 70% efficacy (both vaccines)70% efficacy (both vaccines) Duration of protection 2-7 yearsDuration of protection 2-7 years

Vi-polysaccharide single doseVi-polysaccharide single dose Well tolerated; 2 year protectionWell tolerated; 2 year protection Vi=virulence antigen which is the Vi=virulence antigen which is the

capsular polysaccharide isolated from capsular polysaccharide isolated from specimens in blood culturespecimens in blood culture

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Typhoid Vaccine (oral)Typhoid Vaccine (oral)

Live attenuated Ty21a enteric coatedLive attenuated Ty21a enteric coated No field efficacy trials in non-endemicsNo field efficacy trials in non-endemics Efficacy at least 70%Efficacy at least 70% 4x1 capsule at 2 day intervals4x1 capsule at 2 day intervals Multiple difficulties:Multiple difficulties:

Refrigeration, antibiotics, lost capsulesRefrigeration, antibiotics, lost capsules Boosters – totally unclearBoosters – totally unclear

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Required VaccinesRequired Vaccines

Yellow FeverYellow Fever Live virus administered at licensed Live virus administered at licensed

centerscenters May be required if arriving from infected May be required if arriving from infected

areasareas MeningococcalMeningococcal

CholeraCholera No longer used!No longer used!

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Distribution of Yellow Distribution of Yellow FeverFever

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Yellow FeverYellow Fever

Live attentuated 17D virusLive attentuated 17D virus Egg eaters can have vaccine!!!Egg eaters can have vaccine!!!

WHO licensed centersWHO licensed centers Must be given > 10 days before entryMust be given > 10 days before entry Primary: single dosePrimary: single dose

Booster – every 10 yearsBooster – every 10 years Required if arriving from Required if arriving from

transmission risk areastransmission risk areas

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Yellow what?Yellow what? Arboviruses (arthropod-borne viruses) are spread by Arboviruses (arthropod-borne viruses) are spread by

mosquitoes, ticks, or sandflies and produce 4 mosquitoes, ticks, or sandflies and produce 4 principal clinical syndromes: principal clinical syndromes:

(1)(1) central nervous system (CNS) infection (including central nervous system (CNS) infection (including encephalitis, aseptic meningitis, or myelitis)encephalitis, aseptic meningitis, or myelitis)

(2)(2) an undifferentiated febrile illness, often with rashan undifferentiated febrile illness, often with rash(3)(3) acute polyarthropathyacute polyarthropathy(4)(4) acute hemorrhagic fever, usually accompanied by acute hemorrhagic fever, usually accompanied by

hepatitis.hepatitis.

Infection with some arboviruses produces congenital malformations Infection with some arboviruses produces congenital malformations and spontaneous abortion or, in the prenatal period, congenital and spontaneous abortion or, in the prenatal period, congenital perinatal illnessperinatal illness

-Western and Eastern Equine Encephalitis, St Louis Encephalitis, Powassan, California -Western and Eastern Equine Encephalitis, St Louis Encephalitis, Powassan, California Encephalitis (primarily La Crosse virus), Colorado Tick Fever, Dengue, Japanese Encephalitis (primarily La Crosse virus), Colorado Tick Fever, Dengue, Japanese Encephalitis, Venezuelan Equine Encephalitis, Yellow Fever, and West Nile EncephalitisEncephalitis, Venezuelan Equine Encephalitis, Yellow Fever, and West Nile Encephalitis

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Balancing RisksBalancing Risks Yellow fever has a 50% fatality rate!Yellow fever has a 50% fatality rate!

Africa 1:250 in epidemic areas, 1:4000 endemic areaAfrica 1:250 in epidemic areas, 1:4000 endemic area South America: 1:20,000South America: 1:20,000

Vaccine adverse effects:Vaccine adverse effects: 18 vaccine related deaths and 37 severe cases of 18 vaccine related deaths and 37 severe cases of

neurotropic or viscerotropic disease 1996-2005neurotropic or viscerotropic disease 1996-2005 Disturbing but rare events:Disturbing but rare events:

Used since 1937, 50 million doses given in year 2000Used since 1937, 50 million doses given in year 2000 Risk estimates: anaphylaxis 1 in 250,000, neurotropic Risk estimates: anaphylaxis 1 in 250,000, neurotropic

disease 1 in 8 million; viscerotropic disease 1 in disease 1 in 8 million; viscerotropic disease 1 in 400,000 based on US data (1:30,000 for age >65 400,000 based on US data (1:30,000 for age >65 years old)years old)

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Incidence of Meningococcal Incidence of Meningococcal DiseaseDisease

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Meningococcal Disease by Meningococcal Disease by SerogroupSerogroup

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Meningococcal VaccineMeningococcal Vaccine A,C,Y, W135 polysaccharide (MPSV4 A,C,Y, W135 polysaccharide (MPSV4

Menomune)Menomune) Primary – single dosePrimary – single dose Booster: 3-5 years, less for children under 4Booster: 3-5 years, less for children under 4

A,C,Y,W135 conjugate (MCV4; Menactra)A,C,Y,W135 conjugate (MCV4; Menactra) All adolescents from age 11 – routineAll adolescents from age 11 – routine FDA approved for 2-55 years oldFDA approved for 2-55 years old Booster not known, at least 10 yearsBooster not known, at least 10 years Preparation of choice – Guillain-barre dataPreparation of choice – Guillain-barre data

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Suggested IndicationsSuggested Indications Little data in travelers; known low riskLittle data in travelers; known low risk Tavelers anywhere within the classical African Tavelers anywhere within the classical African

meningitis belt during the dry season (Dec-June)meningitis belt during the dry season (Dec-June) Individuals anticipating close contact with local Individuals anticipating close contact with local

populations and traveling to certain epidemic populations and traveling to certain epidemic prone African countries south of the meningitis prone African countries south of the meningitis beltbelt

Health care workers traveling to any of the Health care workers traveling to any of the above countriesabove countries

Traveling to any area experiencing a current Traveling to any area experiencing a current epidemicepidemic

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Japanese B EncephalitisJapanese B Encephalitis Mouse-brain killed virus vaccineMouse-brain killed virus vaccine Primary – days 0,7,30 or 0,7,14Primary – days 0,7,30 or 0,7,14 Full protection 1 month laterFull protection 1 month later Boosters: 3 years but not clearBoosters: 3 years but not clear Side effects: delayed urticariaSide effects: delayed urticaria In season; long stay in rural farming In season; long stay in rural farming

areas, travel to epidemic area or hot areas, travel to epidemic area or hot spots, adventure travelspots, adventure travel

Risk is low to travelers, but liability is Risk is low to travelers, but liability is real real

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So you are thinking, “Yea, great Dr. So you are thinking, “Yea, great Dr. Martin, I will remember all of that 2 Martin, I will remember all of that 2 months from now when I see a months from now when I see a patient who is traveling…..”patient who is traveling…..”

DO NOT FRET…….DO NOT FRET……. HELP IS ON THE WAY

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