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Part II
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Travel vaccines- overview
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Vaccine administration issues
Not a Rote Selection of Vaccines
“…the choice of vaccines more often requires
thoughtful consideration based upon details of
the patient’s medical history, knowledge of
vaccine interactions with other vaccines and
medications, timing of departure, and nature of
travel with regard to vaccine-preventable
diseases and patient preferences.”
Barnett E, Chen R, and Rey M (2004) Vaccines for international travel. In
S Plotkin and W Orenstein (eds, Vaccines, 4th ed.
Travel Immunizations: 3R’s
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Routine:
 ACIP yrly updated schedules for children/adults
 disease risk in developing countries & outbreaks in
developed countries
 Adult vaccines include: flu, Td, pneumoccocal
 Need to clarify routine vaccinations of foreign-born
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Required / Regulated:
 International border crossings
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Recommended:
 Protect traveler’s health
 Depends on itinerary & trip activity-risk of infection
Travel Immunizations
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Routine: Td/ DTap, MMR, Polio, Pneumo,
Influenza, Varicella, (PPD)
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Required / Regulated: Yellow Fever
(Meningitis)
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Recommended: Hep A, Hep B, Typhoid fever,
Meningococcal Meningitis, Japanese
Encephalitis, Rabies, Twinrix
Some immunizations may fall into more than one category
Vaccines, schedules and availability differ worldwide
Focus for Student Travel
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Influenza
Polio
Yellow Fever
Hep A, Typhoid fever
Hep B
Rabies and Japanese Encephalitis
2001 Aventis Pasteur Inc.
Influenza
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Occurs worldwide; risk depends upon season
ACIP now advises infants, 50+ adults, chronic
illness, caregivers & anyone seeking protection
Documented airplane transmission
All travelers?
Year-round risk in tropics; for summer risk in
S. Hemisphere give travelers “northern dose”
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Components change yearly / June expiration
Inactivated injectable
Live Flumist / reformulation in pipeline
Shortages!
Polio Eradication/ Resurgence
Rotary International & WHO are working together to
eradicate polio from the planet
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Source: www.polioeradication.org
2002-2005:WPV imported
into 21 countries
Today: only Indian
subcontinent, Nigeria,
Somalia, Afghanistan
 risk for travelers: 20/1 mil
un-immunized pts
All eIPV schedule: VAPP
prevention
Vaccinate with eIPV for
single adult booster prn, if
primary series complete
Required:
Yellow Fever Vaccine
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Potential fatal viral illness: spread by Aedes
mosquitoes and named for characteristic
jaundice; no treatment (30% fatality rate)
Risk: “yellow fever belt” in tropical S A & subsahara Africa
Dramatic resurgence; CDC estimates U.S.
coverage only @ 10-20% necessary level
Live vaccine: required for entry as part of
international efforts to prevent spread of
disease, but not all affected countries require
Yellow Fever Belt
Source: CDC, Health Information for International Travel, 2005-2006
Yellow Fever Vaccine
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High levels of protection; > 95% seroconversion
Avoid if egg allergy, vaccine allergy, thymus disease
Don’t use during pregnancy; symptomatic HIV
Assess for actual YF risk factors
 Required for entry
 Recommended for travel to endemic area
Document:
 WHO International Certificate of Vaccination
 Give at least 10d before entry
 Protects 10y
 Given @ designated centers in US, Canada
 Give with other live vaccines or 28 days apart
YF SAE’s
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Two types of rare severe adverse events have been
described 2 to 28 days after vaccination:
 Viscerotropic: multi-organ damage, >60%
mortality
 Neurologic: encephalitis, GB, no deaths
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Cases have occurred with primary vaccination
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Risk is greater in travelers age 60 and older
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Thymus disorders and thymectomy are risk factors
Arguin et al. Eds. CDC (Yellow Book)
Health Information for International Travel. 2005-2006
Recommended Vaccines for Travel
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Single dose for protection for this trip
 Monovalent Hepatitis A
 Typhoid fever injectable
 Meningococcal meningitis: Menomune, Menactra
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Multiple dose series needed to protect
 Monovalent Hepatitis B
 Twinrix A+B
 Oral typhoid ty21a
 Rabies
 Japanese Encephalitis
Hepatitis A
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Hepatitis A: most common hepatitis with
incidence as high as 30 cases/10,000 travelers /m
Many countries endemic ;food & water hazard
Outbreaks from contaminated shellfish, food
handlers, person-to-person
Consider pre-vaccination serology: foreign born
in endemic region, history of jaundice
2 inactivated monovalent vaccines:
interchangeable, well-tolerated; 2 dose series
Twinrix (A+ B) for > 18 yo
Typhoid Fever
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Life-threatening bacterial illness with
high fever, loss of appetite, GI c/o, h/a,
rose-colored spots
Usually no diarrhea, often
constipation
Diagnosed by blood and stool cultures
for S. typhi
Growing antibiotic resistance
Risk depends upon destination,
accommodations, food & water
precautions
Typhoid Fever in Returning Travelers
A review of 1027 travel cases reported to the
CDC between 1994-1999
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Source: 76% of cases from 6 countries
India 30%
Mexico 12%
Pakistan 13%
Haiti 5%
Bangladesh 8%
Philippines 8%
Reason for travel: 80% cases in VFR’s
Trip Duration: 5% < 1wk
37% < 4 wks
16% < 2 wks
60% < 6 wks
Steinberg et al. CID 2004: 39 (15 July):186-91
Typhoid Fever Vaccine Choices
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Vaccinate: VFR and Indian subcontinent
“Adventurous eating habits”
Two vaccines offer ~ 60-70% protection
Duration: oral= 5yrs, inj= 2-3yrs
Typhim Vi-1 inj, Ty21A- 4 tabs po qod
Avoid oral with antibiotics, malaria meds,
pregnancy, acute GI upset, time constraint
No protection against paratyphoid disease
Meningitis Belt
Source: CDC (Yellow book) Health Information for International Travel. 2005-6
Meningococcal Meningitis
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N. meningitis bacterial infection- respiratory spread
Often epidemic;  risk w / local contact, crowds
Sub-Sahara dry season: Dec-June (“The Belt”) also
Burundi, Kenya, Tanzania, N. India, Nepal /check
outbreaks
Required for travel to the Hajj (Mecca)
2 vaccines against 4 serotypes:
 Conjugate-Menactra: 10 yrs, IM, booster?
 Polysacharide- Menomune: SQ, 3 yrs
Hepatitis B
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Blood & bodily fluid risk
Asia, Africa: many places
>8% endemic
U.S: < 2% endemic
Transmission during
travel:
 Unsafe sex
 Medical care-dirty
needles, blood
transfusions
 Unsafe dental care
 Acupuncture, shared
razors, tattoos, body
piercing
Hepatitis B
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Prevention: safer sex, no body piercing, injections,
tattoos, blood transfusions
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Series for: high risk occupations, exposures, behaviors;
stays > 6 mos; repeat travelers; potential for medical
/dental care abroad
All students travelers (per ACHA guidelines)
Energix, Recombivax, Twinrix (>18yrs):
0,1,6 mos; not buttocks; Energix: 0,1,2,12
Adults-3 doses, adolescents-2 doses / long-term?
Per AAP: 2 doses confer 75-80% protection
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Consider titer if lived in endemic area
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Rabies
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Life-threatening CNS viral infection
transmitted in saliva of rabid animals
 bites, esp face and hands
 scratches, licks to open wounds, mucosa
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50K deaths / yr; 10 mil PEP
Variable incubation: usual 30-60 days
2001 Aventis Pasteur Inc.
Rabies & Student Travelers
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Risk difficult to estimate- varies with activity
Consider all fur animals in CDC II, III countries at
risk: no direct contact
Teach avoidance & urgent post-bite care
Pre-vaccination does not prevent rabies / eliminate
need for post-bite care; does eliminate HRIG need
& shorten post-bite immunizations to 2 vs 5 doses
Student issues with inactivated vaccine: expensive,
3 doses x 1m, strict schedule: 0, 7, 21 or 28
Encourage travel medical evacuation insurance, if
no time or $ for rabies pre-vaccination
JE Geographic Distribution
www.cdc.gov/ncidod/dvbid/jencephalitis/index
Japanese Encephalitis
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Potentially fatal viral encephalitis: night-biting
Culex mosquito spread from infected pigs,
wading birds
Risk: rural Asia farms, rice fields; seasonal;
trip > 30 days in risk areas
Rare in travelers (CDC: 1/million; 1 case/yr)
JE-VAX: inactivated vaccine
 3 inj SQ 0, 7, 28d (or 0, 7, 14d)
 Avoid if history urticaria, wasp allergy
 Post-injection delayed AE risk x 10d;
(60/10,000 severe reactions - 88% w/in 3d)
Vaccines for Students:
Summary Points
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Up-date all routine, including Hep B, flu, TD
One dose Hep A before trip
Typhoid for at risk regions / behaviors
Meningitis for at risk regions during season
Polio booster for at risk adult students
Rabies if longer-stay, remote, no med evac insurance (has
time & $ for series)
JE for at risk region during season of transmission (consider
duration, region, season, behavior)
YF is required or at risk
Maximum protection for extended stay, health care setting /
local contact
Protect the VFR student
Vaccine Administration
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It is not enough to select travel vaccines
and develop a schedule
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You will need to comply with all
administration standards of care as listed
on the next slide
Administration: Critical Issues
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Protect the cold chain
Provide “informed decision-making”
Inquire re: contraindications & precautions
Give as many vaccines at one visit as tolerated
Preserve “minimum interval” between doses
Don’t repeat primary dose for delayed schedule
(except rabies: consult expert, if schedule gap)
Give VIS for each vaccine at each visit
Document according to NCVIA standards
Give student portable record
Resources for Vaccine Administration
There are an abundance of internet resources for
meeting administration standards of care. The
premiere resource is the Immunization Action
Coalition @ www.immunize.org. They offer:
 Screening questionnaires
 Standing orders
 Cold chain guidelines
 Vaccine Information Statements… and more
Other Administration Resources
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Advisory Committee on Immunization
Practices (ACIP): source for CDC official
statements on approved vaccines
@www.cdc.gov/nip/acip
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CDC National Immunization Program:
resource for VIS forms, other information on
vaccine administration
@www.cdc.gov/nip
Vaccine Administration Resources
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“Pink Book” Epidemiology of Vaccine-Preventable
Diseases: print syllabus for CDC web-course on
vaccines; excellent text for providers to better
understand how vaccines work
@www.cdc.gov/nip/publications/pink
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Routine and Travel Immunizations- yearly updated
paperback written by Richard Thompson, MD; very
useful tool for clinician to have at hand when talking to
patients about vaccine-decision-making
@www.shoreland.com
End of Part II
In the next set of slides, there is a review of
the non-vaccine preventable risks for
international student travel and
references for the entire slide set