IMMUNIZATION IN TRAVELERIMMUNIZATION IN TRAVELER

I K Agus Somia,

Division of Tropical and Infectious Diseases Department of Internal Medicine- Faculty of Medicine

Udayana University- Sanglah Hospital Denpasar BALI

Travel MedicineTravel Medicine• Travelers ?

– All people who make a travel• Travel medicine ?

– A new branch of med sciences which interdisciplinary directly study about the health to traveler, regionally and internationally, emphasized more on health promotion and disease prevention

Terms• Immunization:

– immunity by artificial means• Vaccination:

– immunity to a disease using a vaccine or special antigenic material to stimulate the formation of appropriate antibodies

• Vaccine – preparation of antigenic material – stimulates Ab production – confers active immunity vs. disease

Passive Immunization

• IgG - immediate protection - no memory

• Standard Igs (human, animals) Non-specific– Pooled plasma from donors– Igs vs. many common viruses

• Human hyperimmune serum (high titre) Specific– From donor c. high titre Abs to specific virus– Against specific (single) virus

Why need vaccination ?Why need vaccination ?• To avoid disease

– (communicable and noncommunicable)• Disease

– (vaccine preventable disease and nonpreventable disease)

• Aims to :– Prevent of getting infectious disease– Prevent of transmitting infectious disease at the country of

destination– Prevent of bringing an infectious agent into the country origin

When do travelers need When do travelers need immunization?(1)immunization?(1)• Asses history of basic medicine• Schedule of travel• Duration of travel• Occupation and possible risk of occupation on

health• Environmental health and possible contact• Epidemiology of infectious disease at the

country destination• Vaccine effectiveness

• Vaccination side effect• Schedule of immunization and available time

prior to travel• Asses malaria prophylactic needed• Drugs – vaccine interaction• Medical condition of the traveler• Pregnancy• Financial support

When do travelers need When do travelers need immunization?(2)immunization?(2)

Steffen R, Connor BA. J Travel Med 2005;12:26-35

Steffen R, Connor BA. J Travel Med 2005;12:26-35

Strategy vaccination choiceStrategy vaccination choice

Steffen R, Connor BA. J Travel Med 2005;12:26-35

Steffen R, Connor BA. J Travel Med 2005;12:26-35

Steffen R, Connor BA. J Travel Med 2005;12:26-35

Routine Vaccine-Preventable Routine Vaccine-Preventable DiseasesDiseases

• Diphtheria • Human Papillomavirus (HPV) • Influenza (Seasonal, Avian, and Pandemic) • Measles (Rubeola) • Mumps • Pertussis • Pneumococcal Disease (Streptococcus pneumoniae) • Poliomyelitis • Rubella • Tetanus • Varicella (Chickenpox)

Travel-Related Vaccine-Preventable Travel-Related Vaccine-Preventable DiseasesDiseases• Hepatitis A • Hepatitis B • Typhoid and Paratyphoid Fever • Yellow Fever   • Japanese Encephalitis (JE) • Meningococcal Disease • Rabies

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Hepatitis A Prevalence

• Endemic in most developing countries• Fecal-Oral Transmission• Incubation period 15-50 days• Most adults have not been vaccinated against it • 2 dose series; 0 & 6 months• Effective in as little as 2 weeks prior to travel, give even

if leaving in less than 2 weeks• 1 dose gives 95% protection, 2 doses= 99%• Consider Hep A Ig for those traveling in < 2 weeks

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Hepatitis A

-18% of cases in the US are related to travel

-Most are in travelers to Mexico, Central and South America

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Hepatitis A incidence

Combination Hepatitis A/B Vaccine Schedule

AGE GROUP (y) VOLUME NUMBER OF

DOSES SCHEDULE

≥18 (primary immunization schedule)

1.0 mL 3 0, 1, 6 months

≥18 (acccelerated schedule)

1.0 mL 40, 7, 21–30 days+ 12 months

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Hepatitis B Prevalence

• Blood & body fluid transmission, Shared Needles, Vertical Transmission

• Incubation Period 60-150 days• Not recommended for routine travel• Important for those in health care field or

those staying prolonged periods of time or those with high risk sexual behaviors

• Three dose series; 0, 1 & 6 months

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Hepatitis B

• Passed by airborne particles, intimate contact, or contact with nasal secretions

• Meningitis Belt in Africa (dry season highest risk Dec-Jun)

• Required for Hajj and Umrah pilgrims in Saudi Arabia

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases meningococcusmeningococcus

Common Vaccines for Travel:Meningococcus (Groups A, C, Y and W-135)

1) MPVS4/Menomune- • Approved 1981. Polysaccharide vaccine with expected

protection for three years. • Ages 2 and older. Currently only recommended >55yo

2) MCV4/Menactra- • Approved 2005. • Ages 9 months-55 yo • Newer conjugated vaccine with expected protection for

about 10 years3) MenACYW-CRM/Menveo-

• Approved 2010 • Ages 2-55

• Typhoid (Salmonella Typhi)

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases TyphoidTyphoid

• Fecal-Oral transmission• Case-fatality rates of 10% can be reduced

to less than 1% with appropriate antibiotic therapy

• Incubation period of 1-3 weeks• Good hand washing and food precautions

are helpful in prevention• Shed in feces for 6 weeks to 3 months

after infection

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases TyphoidTyphoid

• Travel to endemic area• Adventurous travelers• Traveling for > 3 weeks• Rural travel

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Typhoid vaccine indicationTyphoid vaccine indication

• Polysaccharide Vaccine/Typhim Vi– Expected 2 yrs of protection. To be given at

least 2 weeks prior to travel. Ages > 2.• Oral Live Vaccine/Vivotif

– Expected 5 yrs of protection. One refrigerated capsule QOD x 4 doses. Complete 1 wk prior to travel. Ages > 6.

– Don’t use in immunocompromised individuals– Avoid antibiotics during vaccine admin period

• Both Vaccines have 50-80% efficacy

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Typhoid: vaccinesTyphoid: vaccines

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Yellow feverYellow fever

• Incubation period usually appear 3–6 days • The first, or “acute”, phase: fever, muscle pain,

headache, shivers, loss of appetite, nausea and vomiting. After 3–4 days, most patients improve and symptoms disappear.

• However, in a few cases, the disease enters a “toxic” phase: fever reappears, jaundice and sometimes bleeding, with blood appearing in the vomit (the typical "vomito negro"). About 50% of patients who enter the toxic phase die within 10–14 days.

• There is no specific treatment for yellow fever. Vaccination is highly recommended as a preventive measure for travellers to, and people living in, endemic countries

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Yellow feverYellow fever

Flavivirus transmitted by Aedes aegypti mosquito (daytime biting mosquito)

• Vaccine (YF-Vax ) required for entry into countries where Yellow Fever is present, or if traveling through a country where transmission may be possible. 10 days prior to travel.

• Increased risk in W Africa at end of rainy season (July-October)

• Increased risk in S America in rainy season (Jan-May)• Must be > 9 mo old for administration• Protection is for 10 years• Must be an authorized site to be able to administer it

MMWR August 03, 2001 / 50(30);643-5MMWR August 03, 2001 / 50(30);643-5

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Yellow fever: common vaccineYellow fever: common vaccine

Common Vaccines for Travel:Yellow Fever: ACIP recommendation 12/09

ContraindicationsContraindications PrecautionsPrecautions

Allergy to vaccine componentsAllergy to vaccine components Age 6 to 8 monthsAge 6 to 8 months

Symptomatic HIV infection of CD4 Symptomatic HIV infection of CD4 cells < 15% total or <200/mm3cells < 15% total or <200/mm3 Age 60 and olderAge 60 and older

Thymus DisorderThymus Disorder Asymptomatic HIV infection and CD4 Asymptomatic HIV infection and CD4 cells 15 to 24% or 200-499/mm3cells 15 to 24% or 200-499/mm3

Primary ImmunodeficienciesPrimary Immunodeficiencies PregnancyPregnancy

Malignant NeoplasmsMalignant Neoplasms Breast feedingBreast feeding

TransplantationTransplantation

Immunosuppressive and Immunosuppressive and immunomodulatory therapiesimmunomodulatory therapies

http://www.cdc.gov/vaccines/recs/provisional/downloads/yf-vac-dec-2009-508.pdf Accessed 5/26/10

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Japanese EncephalitisJapanese Encephalitis

• Viral encephalitis is inflammation of the brain, caused by any one of a number of viruses.

• Arboviruses – viruses transmitted through insect bites – are among the most common causes of viral encephalitis, and include Japanese encephalitis and tick-borne encephalitis viruses

• Symptoms include high fever, headache, sensitivity to light, stiff neck and back, vomiting, confusion and, in severe cases, seizures, paralysis and coma. Infants and elderly people are particularly at risk of severe illness..

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Japanese EncephalitisJapanese Encephalitis

indication• short-term (<1 month) travelers to endemic areas during the

JEV transmission season if they plan to travel outside of an urban area and will have an increased risk for JEV exposure;

• travelers to an area with an ongoing JE outbreak• travelers to endemic areas who are uncertain of specific

destinations, activities, or duration of travel.

JE vaccine is not recommended for short-term travelers whose visit will be restricted to urban areas or times outside of a well-defined JEV transmission season.

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Japanese Encephalitis: vaccineJapanese Encephalitis: vaccine

• Vaccine– Approved 2009 – Monkey kidney-derived cell-culture inactivated– vaccine for those > 17yo. – 2 dose series days 0 and 28.

Japanese Encephalitis Vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP) MMWR March 12, 2010;59:RR-1.

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases Japanese Encephalitis: vaccineJapanese Encephalitis: vaccine

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases rabies: prevalencerabies: prevalence

• Pre-exposure prophylaxis is recommended for high risk travelers – Hikers/Backpackers– Cavers/Adventure Travelers– Non-travelers: Veterinarians, Animal control workers

and rabies researchers• Dose, schedule and route of vaccination:

– Three 1.0 ml– injections on days 0, 7, and 21 or 28– Intra muscular injection at M deltoideus

Travel-Related Vaccine-Preventable Diseases Travel-Related Vaccine-Preventable Diseases rabies: vaccinationrabies: vaccination

Recommended Adult Immunization Schedule Recommended Adult Immunization Schedule 2011 2011

All Persons At Risk CDC

19-26 27-49 50-59 60-64 ≥65

Td or TdapHPV

MMR

Varicella

Influenza

PPV23

Hep A

Hep B

Meningococcal

Zoster

1 dose Td booster every 10 yrs, IM

1 or 2 doses SC

2 dose (0,4-8 wks) SC

1 dose annually,IM

1 dose

1 dose,SC

1 dose ,SC

1-2 doses , IM/SC

2 doses (0,6-12 mos or 6-18 mos) , IM

3 doses (0,1-2, 4-6 mos), IM

1 or more doses,IM

3 doses female (0,2,6 mos),IM

Vaccine that might be indicated for adult 2011 (1)Indication Pregnancy Immunocompro

mizedHIV

<200 ≥ 200

Td or TdapHPV

MMR

Varicella

Influenza

PPV23

Hep A

Hep B

Meningococcal

Zoster

1 dose Td booster every 10 yrs,IM

contraindicated

1 dose annually,IM

Contraindicated

1 or 2 doses

2 doses (0,6-12 mos or 6-18 mos),IM

3 doses (0,1-2, 4-6 mos),IM

1 or more doses,IM

All Persons At Risk

3 doses for female through 26 yrs (0,2,6 mos), IM

contraindicated 2 doses

(0,4-8 wks)

1-2 doses ,IM/SC

CDC

Indication DM, Heart Ds, COPD, Chronic alkoholism

Asplenia

Td or TdapHPV

MMR

Varicella

Influenza

PPV23

Hep A

Hep B

Meningococcal

Zoster

1 dose Td booster every 10 yrs,IM

1 dose TIV annually,IM

1 or 2 doses,SC

2 doses (0,6-12 mos or 6-18 mos),IM

3 doses (0,1-2, 4-6 mos),IM

1 or more doses ,IM

All Persons At Risk

3 doses for female through 26 yrs (0,2,6 mos),IM

2 doses (0,4-8 wks) ,SC

1-2 doses,IM

1 dose ,SC

CDC

Vaccine that might be indicated for adult 2011 (2)

Indication CLD Kidney Failure, ESRD, HD

HCW

Td or TdapHPV

MMR

Varicella

Influenza

PPV23

Hep A

Hep B

Meningococcal

Zoster

1 dose Td booster every 10 yrs,IM

1 dose TIV annually,IM

1 or 2 doses,SC

2 doses (0,6-12 mos or 6-18 mos)

3 doses (0,1-2, 4-6 mos),IM

1 or more doses ,IM

All Persons At Risk

3 doses for female through 26 yrs (0,2,6 mos),IM

2 doses (0,4-8 wks),SC

1-2 doses,IM

1 dose ,SC

CDC

Vaccine that might be indicated for adult 2011 (3)

MalariaMalaria• Protozoan parasite transmitted by the Anopheles

mosquito– Bites from dusk to dawn

• 4 main species– P. falciparum and P. malariae– P. vivax and P. ovale (liver phase organisms)– Additional species P. knowlesi (simian

parasite) in SE Asia. Not known to have resistance

• Each year malaria causes 350–500 million infections worldwide and approximately 1 million deaths.

Malaria• Even within tropical and subtropical areas, transmission

will usually not occur:– In urban areas, except in Africa and India– At high altitudes (parasite is sensitive to cold) > 1500m– During cooler seasons in some areas – In deserts (excluding the oases) – In some islands in the Pacific Ocean, which have no local

Anopheles species capable of transmitting malaria – In some countries, where transmission has been interrupted

through successful eradication. • Generally, in warmer regions closer to the equator:

– Transmission will be more intense – Malaria is transmitted year-round – P. falciparum predominates.

• The highest transmission is found in Africa, south of the Sahara.

Malaria Distribution & Chloroquine Resistance

http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/malaria.aspx

Accessed June 21, 2010

Malaria prophylaxis • Dependent on resistance

– Chloroquine 500mg• Weekly; 4 weeks after return

– Mefloquine 250mg • Weekly*; 4 weeks after return

– Atovaquone/Proguanil (Malarone) • Daily; 1 week after return.

– Doxycycline 100mg • Daily; 4 weeks after return. Age > 7yo

* Start 2 weeks prior to travel

Insect PrecautionsInsect Precautions• restriction of outdoor activities between dusk

and dawn • screened-in accommodations • light-colored, long-sleeved shirts and pants • topical application of effective insect repellants

to skin and clothing (DEET 30-50%)• use of insecticide-impregnated (permethrin) bed

nets, tents, clothing, sleeping bags, etc. • mosquito-proofing of living quarters by spraying

insecticide and eliminating standing water • avoid perfumes

ReferencesReferences• www.travax.com• www.cdc.gov/travel• www.istm.org International Society of Travel

Medicine• www.astmh.org American Society of Tropical

Medicine and Hygiene• www.insuremytrip.com• https://travelregistration.state.gov