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Travel
Vaccine
Gary
Podolsky MD
Former
Chief Medical Officer Carnival Cruiselines
Expedition
Physician Tibet and Nepal
Emergency
Physician Grace Hospital
Dept
of National Defense
Skylark
Medical Clinic
Which
Travel Vaccines?
•
Vaccines remain the most cost effective way of dealing with many
infectious diseases.
•
Build on success of childhood vaccines and apply similar concept
to exotic diseases.
•
Vaccines are very safe.
(see
reference on safety at end)
Travel
Medicine
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Good medicine is good travel medicine.
•
Can use information, care studies evidence of other specialties
to build upon a rational approach to rational prevention and treatment
of adventures
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Build on traditional medicine with specialty knowledge
•
Not just infectious diseases
Useful
Resources
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American College of Sports Medicine ACSM
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American College of Emergency Medicine ACEP
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Wilderness Medical Society
•
WHO guidelines
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Centre of Disease Control CDC
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Divers Alert Network DAN
Other
Issues of General Health
Depending on the duration of your trip you
should review your health status with your physician.
•
Women should get a PAP test if they will be away for a long time
and enough contraceptives to last.
•
All medications should be in their original packaging and brought
in hand luggage.
•
Checked medications may become lost or frozen. Bring prescriptions
of your medication, and guess.
Childhood
Vaccines
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Tetanus -diphtheria
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Polio
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Measles Mumps Rubella
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Varicella (chickenpox)
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? New Pertussis to be included in future for boosting adults
Immunizations
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Patients should be up to date on all childhood immunizations.
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A tetanus booster should be given every ten years.
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Travel vaccines are elective depending on the destination, the time
of year and the local conditions of the location.
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Some countries insist on yellow fever, cholera and a letter stating
HIV status.
Tetanus
Diphtheria
TD
(child); Td (adult)
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Always together
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Tetanus caused by wound infection with Clostridium tetani -
worldwide
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American Trauma Life support course recommends every 10yrs
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Tetanus prone wounds need boosters when accident happens
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Must have primary series in childhood. If never vaccinated need
3 doses to catch up.
Diphtheria
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Severe life threatening disease
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Under control with vaccination
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Russia and Soviet nations stopped vaccinations as was no longer
thought to be necessary- severe rebound of disease
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Travelers should get Td every 10 yrs
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This is crucial if going to former USSR
Measles
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Now becoming rare.
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Report cases
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Targeted for world eradication 2007-2010?
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Must continue to vaccinate until cleared by WHO
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Ireland:
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False Medical paper blamed Measles.
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Vaccinations halted and increased deaths from Measles.
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High mortality if coexistent Vit A deficiency
Rubella
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Teratogenic infection for women
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Should be immune before becomes pregnant
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Important to confirm and document immunity prior to travel or pregnancy
Mumps
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Part of MMR
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Sometimes require to have documentation of vaccination as well for
Health Care workers and NGOs but generally considered by most to
be immune if born before 1957 although this is not always so.
Polio
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Polio once devastated world
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Now on roll back program
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'wild type' still present in Africa, India, and other foci.
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Vaccine derived polio in Dominican Republic
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Need to vaccinate travelers who could be exposed
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Important not to relax vaccination until cleared
Polio
Surveillance
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WHO does studies on flaccid paralysis cases in each county.
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Check stool for virus
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Polio only transmitted person to person so after new cases stop
occurring assumption that no circulating wild type
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But many people asymptomatic.
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Carrier state in immunosuppressed
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Need to maintain vaccination for a few years after last reported
case
Two
Polio vaccines- OPV (oral)
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no longer in North America
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Live vaccine
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Gives good gut immunity
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Occasionally reverts to wild type virus causing polio, in people
never vaccinated
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Do not give to immunosuppressed or pregnant
IPV
Vaccine
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Inactivated vaccine
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No risk of polio from vaccine
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Is often combined with other childhood vaccines or adult tetanus
( Td-polio)
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Note TDP refers to the childhood vaccine for tetanus-diphtheria-Pertussis
and not polio
Varicella
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Virus that causes chickenpox and shingles
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Infection causes systemic infection and most people know they have
had it.
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In Northern Temperate Climates most of population immune even if
never sick (sub clinical infection)
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Easy to confirm with blood test for antibody
Some
Individuals not Immune
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Some believe they were infected but are wrong
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People from Equatorial countries do not get near universal infection
with chickenpox and remain susceptible in adults
Susceptible
Children
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Children get fever, malaise rash and vesicular rash that fills with
pus, dries up and may lead to scars.
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Children rarely may get severe life threatening problems
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Flesh eating disease (Necrotizing fasciitis)
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Childhood stroke
Susceptible
Adults
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More Likely to get sick
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Chickenpox pneumonia
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Case report: Healthy young woman in Atlanta died of Chickenpox 1999
despite intensive care.
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Death such as this is extremely rare
Recommend
Vaccination: Varivax II
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All susceptible
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Children one dose
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Adults two dose
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Vaccination has been suggested to also alter the natural course
of herpes zoster (shingles)
Other
Vaccines Of Childhood
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Hib (H. Influenza B) Standard vaccination of childhood but adults
do not need.
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Bacille Camille Guilllame (BCG) Vaccine against Tuberculosis to
prevent miliary and meningitis in Children under 5. Not routinely
given in Manitoba.
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One death in previously unrecognized immunocompromised infant (disseminated
BCG)
Meningitis
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Not routinely recommended but sometimes when high risk
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Useful for institutionalized populations:
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Prisons
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Military recruits
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College dorms students and to lesser degree off campus college students
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?students in Manitoba
Two
Main Types of Vaccine
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Menume Polysaccharide against types A/C/Y/W. Gives immunity ~3-5
yrs
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Meningucate a conjucated vaccine that gives longer coverage against
A and C subtypes which are responsible for outbreaks in Canada
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No vaccine against type B- too closely resembles human glial cell
antigen.
Which
to use?
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Mengucate gives better protection against North American strains
and long acting. May be acceptable for travel to meningitis belt
of Africa if you know that outbreaks are confined to A or C serotypes
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Menume protects against 4 serotypes and more useful for international
travelers.
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Problem Menume not easily available. Must buy large 10 pack that
costs 80-90 $ per dose and must be used within 35 days. Financially
difficult to administer unless high volume patients
Travel
Vaccines
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Supplementary to regular vaccines of childhood
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Add to consultation based on informed consent:
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Risk to patient
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Practicality to patient
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Any adverse effects of vaccination including cost
Assess
Risks to Patient
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Food and water
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Insect borne disease
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Animal borne
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Person to person
Unfortunately
we have more diseases than vaccines and should not assume we are
completely protected for any of the above
Poor
Hygiene Diseases
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Hepatitis A, which is the most valuable vaccine to travelers.
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Typhoid
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And now Travelers diarrhea (Dukoral).
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Typhoid can be given orally or by injection.
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Hepatitis E in development as well as other travelers diarrhea vaccines
Insect
Borne
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Yellow fever
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Japanese Encephalitis
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and Lyme disease
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Tick Borne Encephalitis (available in Europe and by special order
in Canada)
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Dengue Fever, Malaria and West Nile Fever are in development
Person
to Person
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Influenza
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Pneumonia
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Pneumococcal,
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Meningiococcal Meningititis,
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Hepatitis B.
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Tuberculosis not a great vaccine
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Many are pending :Hepatitis C, HIV, Leprosy, Human Papilloma Virus
all experimental
Animal
to Person
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Plague and Anthrax little reason to vaccinate outside of Vetinarian
use
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Rabies.
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Bats
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Dogs
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Other wildlife majority are still dogs
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Neglected vaccine for travellers
Rabies
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If never vaccinated victim needs Rabies Immune globulin and 5 doses
of vaccine both of which may not be available in many countries
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If vaccinated and bitted STILL NEED TWO MORE BOOSTS OF VACCINE
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Rabies kills many
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If going away to remote area should consider
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COST $200 per dose.
Rabies
Vaccine Indicated
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Small Children
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More often bit by dogs
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Not always likely to report a bite to parent
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Even a lick by a stray dog is a plausible exposure
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People unable to access help abroad
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No access to good rabies vaccine
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No access to Rabies Immune globulin
Who
Gets what?
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Hepatitis A- Very Common
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Typhoid -less
*Both
are from food and water
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Hepatitis B
Only
if exposed for >3-6 months expatriates
Or
exposed to bodily fluids (sex, needles)
One
single dose of Twinrex does not protect against either A or B- Need
2 doses
Hepatitis
A
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Common in food and water of developing countries
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Risk is .3% per month traveling or higher
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Even safe eating habits may not protect
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Most important travel vaccine
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One dose lasts 12 months
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2 nd dose lasts at least 10-20 years
Typhoid
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1000 times less common than Hep A
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Worse in some countries
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2 vaccines:
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Ty21a (Berna)- live vaccine good for 5-7 yrs
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Typhim vi (Aventis), Or Typherix (Glaxo)- inactivated vaccine good
for 3 yrs
Cholera
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Risk low 2 in a million
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Not indicated except in extreme risk situations
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(Cipro may also protect against Cholera)
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New vaccine Dukoral (Aventis) protects against cholera and some
types of Travelers diarrhea.
Hepatitis
B
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Needed if exposure to blood or body fluid
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Many tourists have sex on trip with unknown
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Vaccine protects them from Hep B but still susceptible to HIV
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Two doses before trip with next booster in 6-12 months. One dose
is sub optimal but better than none
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Important-Some candidates do not respond to Hep B- Non responders.
We do not check travelers for titres like we do Health care personel
(CDC guidelines) Newer generations of Hep B vaccine will address
this
Twinrex
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Combo of hepatitis A and B antigen given in 3 doses at 0,28 days
and 6-12 months
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Identical effectiveness to other brands just convenience to patient
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Important to realize that one dose of Twinrex does not protect against
either A or B.
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Need second dose
Yellow
Fever Vaccine
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A live vaccine transmitted by daytime biting mosquitoes in parts
of Africa, and Central and South America
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Has caused a few deaths world wide very rare
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Is given at registered clinics only
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Never in young infants less than 4-9 months and with caution in
debilitated immune systems
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Never when CD4 <200
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Is required for entry to some countries
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May be recommended for travelers' protection
Japanese
Encephalitis Virus Vaccine
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Inactivated vaccine for daytime biting mosquitoes in Asia particularly
Micronesia
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Severe Mortality with infection
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Rarely Affects travelers
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Used for long stay travelers at exposed risk:
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Rice Paddies, Pig farms and during the rainy season
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Causes severe urticaria even over a week after vaccine
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Cost is 100$ per dose for 3 doses
Tick
Borne Encephalitis
EATING
SAFE
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The Peace Core originally came up with the slogan- "If you can't
boil it, cook it, broil it or peel it. Forget it!" This meant that
food should be scrutinized and carefully selected to avoid travelers
diarrhea.
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It was noticed that people who were careful and did not make any
dietary "mistakes" were also getting as sick as those who ate whatever
they wanted!
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It is believed that many fomites (inanimate objects) may carry bacteria
and viruses and also lead to travelers diarrhea.
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We stress that people wash their hands carefully before eating.
If clean water is unavailable, using a hand gel sanitizer such as
tea tree oil are effective.
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Taking antibiotics in advance to prevent diarrhea was once recommended
. But is now discouraged. The travel Medicine literature does recommend
taking a broad spectrum antibiotic such as Cipro to give to patients
to take on their trip.
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When a person does get sick they may take this antibiotic at the
beginning of their cramps and diarrhea. This will significantly
limit the dehydration and electrolyte loss.
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Taking Imodium with Cipro is more effective than Cirpo alone.
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Another strategy that does work is to take 2 tsp. (or tablets) four
times a day (commencing one day before and continuing up to 2 wks.)
significantly will reduce the incidence of diarrhea. Peptobismo
can stain the tongue and turn stool black. People with allergies
to ASA should avoid Peptobismo.
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If very sick try to continue to take fluids . We suggest seeing
a physician if diarrhea persists beyond 3 days.
Malaria
And Other Insect Borne Diseases
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We recommend checking with us on the distribution of:
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1.) Malaria
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2.) Dengue Fever
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3.) Yellow Fever
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4.) Japanese Encephalitis
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5.) Other obscure insects
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(leishmaniasis, schistosomiasis, sleeping sicknesses etc.)
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A simplified strategy against insects is effective against all.
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Some of these are preventable by vaccine or medications but many
aren't.
1.)
Application of DEET insect repellent of at least 20-30% on all exposed
skin surfaces. DEET is safe if used correctly. (for more information
www.deet.org )
2.)
Modification of behavior to avoid insects at their peak. (Malaria
mosquitoes bite at nigh/Yellow fever mosquitoes bite during the
day.)
3.)
Good clothing to discourage bites.
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We recommend permethrin spray (an insecticide that coats clothing,
that will bind to clothing and prevent insects from landing on you.)
Permethrin is safe for humans to use .
4.)
Mosquitoe netting coated with permethrin.
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Adequate netting prevents against malarious mosquitoes but sand
flies, which carry leishmaniasis, will slip between the holes in
the netting. Using permethrin-coated nets prevents even smaller
insects from biting people. Mosquito nets must be set up properly
and touching the ground to prevent crawling insects from biting.
Mosquito nets do nothing to prevent Dengue fever since that mosquito
bites during the daytime and using a net at night is irrelevant.
Tuberculosis
Screening
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Care Study
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Missionary giving to Solomon Islands. Was in Uganda for 2 years
over 3 years past
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+ Mantoux (30mm) ( Pre trip)
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Prompt recognition and referral
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Tb treatment continued in Solomon Islands
Tuberculosis
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Needs to be prevented because:
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Global Problem
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No good vaccine
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High prevalence
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Mantoux test has many problems even step if given in 2 steps
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Curable but still significant cause of mortality and death
Man
with leprosy outside Katmandu
Access
intentional risk like for any other traveler
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Resources for elderly
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Resources for women
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Resources for handicapped
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Needs of expedition (Military Model)
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First aid kits, # of people
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Assess the person not the trip
Goal:
Educate patients
Evaluate:
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Health baseline & exotic considerations
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Pre trip planning
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Ounce of prevention better than pound of cure
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Pound of prevention also better than an ounce of prevention
For
more information please check our website www.skylarkmedicalclinic.com
or the following excellent resources.
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www.cdc.com (center for disease
control)
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www.who.org (World Health Organization)
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www.voyage.gc.ca ( Canadian
Department of Foreign Affairs)
Medical
Help Abroad
There
are numerous ways to seek help abroad. Many guide books have the
best clinics listed. The Canadian embassy can suggest reliable clinics
(ask where the local expatriates go for help) available at www.voyage.gc.ca
.
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Also you can go to the International Society of Travel Medicine
website www.istm.com , which
has a list of clinics worldwide
Returning
Travelers
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We encourage our clients to seek good help abroad (see above resources).
If they have a problem we will make it a priority to see them ASAP.
Fever in a returned traveler, may be malaria until proven otherwise
and is an urgency that needs to be assessed the same day.
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If we are unavailable, we refer our patients to either the Health
Sciences Center or the St. Boniface emergency departments.
Our
Mission Statement
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Our mission is to protect travelers from disease and injury before,
during, and after their trips.
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We use recent scientific evidence to educate our clients about risks
and also feel responsible to clarify or debunk harmful or unproven
practices that may harm our clients either physically or financially.
We give each client individual counseling but it is still ultimately
his or her choice to decide before receiving any immunization, medication
or treatment.
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Our traveler clients include Adventurers, Athletes, Businesspersons,
Explorers, Expeditions, Missionaries, Photographers, Reporters,
Students and Vacationers.
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Safe travel brings people entertainment, enterprise, education,
and enlightenment as knowledge is gained about different countries,
peoples, and our environment.
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Helping each individual leads to greater benefits as diseases will
be prevented and even eradicated worldwide. Safe travel leads to
cross fertilization of ideas, which will enrich our way of life.
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