Immunizations

Visits to Zone II and III regions merit the use of certain available immunizations. The only required immunizations for International Travel is yellow fever in certain countries and meningitis in Saudi Arabia for Haji or Umra pilgrims. While not required by any country, border officials in several African countries demand the traveler have cholera immunization (which is no longer available in the United States).

The US Available Travel Related Immunizations (adopted from IAMAT International Immunization Guidelines, 2006)

 

Hepatitis A (Infectious Hepatitis)

All travelers going anywhere but Northern Europe, Canada, United States, Australia, and New Zealand should obtain this vaccine.

Two vaccines are currently available in the United States: VAQTA by Merck & Company and Havrix by GalaxoSmithKline  Pharmaceuticals. The primary series for either must be completed 2 weeks prior to potential exposure. Neither is to be used in children less than 2 years of age. The adult dosing for both follows a similar schedule. One intramuscular injection of 1 ml of VAQTA 50 units or of 1 ml of Havrix 1440 EL.U. constitutes the basic immunization. VAQTA should be boosted in 6 months and Havrix in 6 to 12 months. For youngsters age 2 to 18 years the dose of Havrix is 720 El.U./0.5 mL followed by the same dose as a booster in 6 to 12 months. The VAQTA schedule for youngsters age 2 to 17 years is 25 U/0.5 mL, followed by the same dose as a booster in 6 to 19 months later. Re-immunization should be done in three-year intervals for adults and children using the above doses of the respective vaccines.

A single dose of pooled immune globulin (10% solution) provides immediate protection against hepatitis A, although both VAQTA or Havrix  form an adequate antibody response rapidly enough to protect the traveler from simultaneous accidental exposure to this infection.  The VAQTA or Havrix may be given simultaneously at a different site. Immune globulin must not be given at the same time as the Measles, Mumps, Rubella (MMR) vaccine. It must be given at least 14 days after MMR or 6 weeks to 3 months (preferably 6 months) before MMR.  There are no apparent problems in the administration of Yellow Fever vaccine with or near immune globulin administration.  Dosage depends upon body weight and length of time of required protection.  At maximal doses it still must be repeated every 6 months for continued protection, but if VAQTA or Havrix has been obtained, the 3 month dose as shown on the following table is sufficient. Side effects are minimal other than rather mild possible pain at the injection site. Immune globulin must be given in the gluteal muscle, while VAQTA and Havrix are given in the deltoid muscle.

Hepatitis B (Serum Hepatitis)

Recommended as part of a standard immunization program regardless of travel.

This disease is most commonly spread by hypodermic usage, sexual contact, and blood transfusions.  In travelers the majority of hepatits B is contracted through unexpected surgical and dental emergencies. It has a very high prevalence in many areas of the world.  Immunization is from a series of 1.0 ml IM injections of Hepatitis B Vaccine, called "Recombivax HB" by the manufacturer Merck & Company or Engerix-B by its manufacturer GalaxoSmithKline. Either vaccine is usually given on day 0, 1 month, and 6 months. Special preparations of these vaccines and alternate schedules are used for children of various ages and for persons at very high risk, such as dialysis patients.  Duration of protection and need for revaccination has not been defined.  A blood test to determine adequate antibody response can be performed.  If the antibody level falls below 10 SRUs, revaccination with 1.0 ml of vaccine should be considered.  The injection must be given in the deltoid muscle. Side effects include: pain, inflammation at injection site; fatigue/weakness and low-grade temp; nausea and diarrhea; sore throat and upper respiratory symptoms in 1% or slightly greater of recipients.

Twinrix® Combined hepatitis A and B is manufactured by GalaxoSmithKline. It contains the same antigenic components used in their HAVRIX (hepatitis A) and ENERGIX-B (hepatitis B). Indicated for the simultaneous immunization against hepatitis A and B for persons 18 years and older. The immunization schedule follows the hepatitis B scheme, namely 1 ml intramuscularly at 0-, 1-, and 6-months.

Influenza

Recommended for jet travelers during September through February, persons over the age of 65, and persons with chronic medical problems.

Vaccines are prepared that give 1 to 2 years of immunity for prevalent strains of influenza A or B.  New strains are constantly arising that require formulation of new vaccines to compensate for this "antigenic drift." Dosage is 0.5 ml IM in the deltoid muscle, given in the fall of the year.  This vaccine is not required for routine travel, but may be suggested for the traveler heading into an epidemic area. Being confined on airplanes for long flights places you at high risk as the air breathed by everyone on the plane is re-circulated. A booster of 0.5 ml must be given yearly. Fewer than 1/3 of recipients have local soreness around the injection for less than 2 days; fever, muscle ache, malaise can begin 6 - 12 hours after injection and last 1 or 2 days; persons with very severe egg allergy have increased risk of allergic reaction.

Japanese Encephalitis

To be given travelers exposed for greater than 3 weeks to rice farming or pig raising areas of Southeast Asia, Philippines, south-eastern Russian Federation, the Indian subcontinent, islands in the Torres straight off the Australian mainland and China or Korea during warm months.

Immunization requires 3 doses to be given at weekly intervals, with a booster dose at 12 to 18 months and at 4-year intervals thereafter, if risk continues. This vaccine is now available in the U.S. Reactions are infrequent in children, but occur in 0.6% of adult Western recipients. There have been no reports of demyelinating disease or encephalitis from the vaccine. Fever and local reactions develop in fewer than 10% of recipients.  Pregnant women and persons with malignant diseases or other current illness should not take this vaccine.

Measles, Mumps, Rubella

Recommended as part of a standard immunization program regardless of travel.

One 0.5 ml dose given subcutaneously provides initial immunity.  The MMR vaccine provides adequate protection against all three viral diseases, but each vaccine is available separately.  May not be given if allergic to eggs or neomycin without special desensitization.  This vaccine must be given at least 14 days prior to or 6 weeks to 3 months after immune serum globulin. All persons born after 1956 should receive a booster of  measles containing vaccine to be considered immune. Side effects for these vaccines are as follows. Measles: low grade fever (99º to 102º F, 37º to 39º C) may occur 5-12 days after injection, rarely a generalized rash develops; fever higher than 103º F (39.4º C) occurs less than 15% of the time. Allergy to chicken eggs and neomycin may cause an allergic reaction. Mumps: Burning and stinging of short duration at injection site; occasional mild fever; fever above 103º F is uncommon; allergic reactions at the injection site are extremely rare; swelling of the parotid salivary gland—low incidence; testicle inflammation is very rare; seizures, deafness, and encephalitis are very rare. Allergy to chicken eggs or feathers or to neomycin may cause an allergic reaction. Any active infection is reason to delay receiving this vaccine.  Also any blood disorders, immune deficiency or use of corticosteroid is a contra-indication for vaccination. Rubella: Occasional moderate fever (101-102º F) less commonly high fever (over 103º F) burning at injection site; reactions are usually mild and transient, but include fever, rash, sore throat, nausea, vomiting, joint ache. Avoid giving during pregnancy, to persons with blood disorders, or to those receiving corticosteroid. Allergy to neomycin may cause an allergic reaction. Avoid giving if active illness is present.

Meningococcal Meningitis

Recommended for travelers to sub-Saharan Africa during the months of December to June. This vaccine is required for entry into Saudi Arabia during the period of the haji. This vaccine should be considered for persons providing health care to refugee populations in Africa. Universal immunization with the new Menactra® vaccine will reduce carrier states.

This vaccine need be used only under special circumstances (military personnel in the U.S. and persons traveling to areas of the world where meningococcal infection is epidemic).  The A/C/Y/W135 vaccine by Squibb-Connaught is given 0.5 ml subcutaneously.  Duration of protection is unknown, but appears to be at least 3 years in those over 4 years of age. A booster shot of 0.5 ml should be given every 3 to 5 years based on new or continued exposure risk. There might be local redness at the injection site for 1-2 days.  Reactions are uncommon and usually mild. This vaccine does not provide protection against the B serogroup of N. meningitidis which accounted for 28% of the U.S. (between 1994 and 1997) and some of the foreign outbreaks.

Menactra (Meningococcal Group A,C,Y, and W-135 Polysaccharide Diphtheria Toxoid Conjugate Vaccine by Sanofi (Pasteur) Aventis is approved in the US for persons 11 to 55 years of age. The vaccine is given as a 0.5 ml dose injected intramuscularly. Adverse reactions are mild and consist mainly of pain, redness, and induration at the injection site, headache, fatigue and malaise.

Pneumonia

Recommended for persons 50 years of age and over and those with high risk such as exposure to large numbers of people and those with chronic lungs problems and debilitating conditions.

The vaccine against streptococcal (formerly called pneumococcal) pneumonia is given with one 0.5 ml IM injection in the deltoid muscle probably. This vaccine should be boosted every 5 years. Local inflammation and pain at the injection site is relatively common, especially with the booster shot.

Poliomyelitis

A booster of inactivated polio vaccine is recommended for all persons born after 1956 traveling to Africa.

Inactive polio vaccine (IPV) is the vaccine of choice for all infants, children, and adolescents (up to their 18th birthday).  The primary series is 3 doses, with dose 2 given at least 6 weeks after 1 and dose 3 given 8 - 12 months after dose 2.  A supplemental dose is given to children at age 4 to 6 years. Anyone having a partial series may continue with the next dose(s), regardless of how long before the last dose was given. Un-immunized adults should be given the four full dose series of   inactivated polio vaccine (IPV)(3 doses given at 1 to 2 month intervals, followed by a 4th dose 6 to 12 months after the 3rd dose), if time allows, or a minimum of 2 doses of IPV given a month apart. No vaccine associated disease has been reported with the injectable vaccine, although there is a slight chance of allergy in people sensitive to cow serum, neomycin, and streptomycin.

Rabies

Recommended if traveling in remote areas of Iraq, Iran, central Africa and many parts of Asia and South America.

A pre-exposure regimen of rabies vaccine is appropriate for persons routinely exposed to potential rabid animals - including skunks, fox, raccoon and bats.  It does not eliminate the need for additional therapy after rabies exposure, but simplifies post-exposure therapy by eliminating the requirement for rabies immune globulin (RIG) and by decreasing the number of doses of vaccine required.  Prevention with human diploid cell vaccine (HDCV) is 3 doses given 1.0 ml IM in the deltoid muscle on days 0, 7, and 21 or 28.  A new dosage of 0.1 ml intradermally given on the same dosage schedule also seems effective for prophylaxis. Caution should be taken to avoid taking chloroquine for malaria prophylaxis while receiving rabies immunization as it has been shown to reduce the antibody response.

Post-exposure immunization for those previously immunized is 2 doses (1 ml each) on days 0 and 3, with no RIG.  If no prior immunization, give RIG 20 IU/kg (injecting as much as possible into and around the bite site and and any additional IM at a site distant from the HDCV injection site) and 5 doses (1 ml each) of HDCV on days 0, 3, 7, 14, and 28.  These injections must be given in the deltoid muscle as 2 incidents of failure of post-exposure immunization with RIG and HDCV have occurred when these injections were given in the gluteal muscle.

To determine if a booster is needed, obtain antibody testing every two years. There is a very low incidence of side effect with the new diploid cell vaccine; some local irritation possible and occasional muscle ache and headache.  In persons receiving a booster shot up to 6% may have hives, lymph node enlargement, and fever.

Tetanus - Diphtheria

Recommended as part of a standard immunization program regardless of travel.

All persons should have a tetanus booster every 10 years; 5 years for puncture wounds, bites, and other contaminated wounds.  This vaccine is so effective, that a booster sooner than every 10 years is probably not required. Dosage is 0.5 ml of dT vaccine given IM.  A different vaccine is prepared for use in children.  Infants receive a special diphtheria-tetanus-pertussis vaccine that is also a different formulation than that used in children.  Family physicians, pediatricians, and travel medicine clinics generally have all three vaccines in stock at all times. Both adult and children's vaccine should be given with diphtheria toxoid in combination. Infants should follow the routine pediatric immunization schedule with tetanus-diphtheria-pertussis-Hib combination vaccine. A local reaction at injection site is possible; fever may occur; severe allergic reactions are rare.

Typhoid

Recommended for travelers outside of the United States, northern Europe, Australia and New Zealand.

A new high potency oral vaccine became available in 1990 which provides at least 80% effective protection and which has considerably less side effects than the USP vaccine.  Immunization is with one capsule of the live attenuated Ty21a  vaccine (Vivotif Berna made by the Swiss Serum and Vaccine Institute), taken every other day for four doses (day 0, 2, 4, 6).  Booster requirements for the oral vaccine has not been determined but efficacy has been shown to persist at least 5 years. Therefore, an adequate booster will be achieved by repeating the 4 capsule every other day regime every five years.

A new injectable vaccine produced by Pasteur Mérieux Sérums & Vaccins and distributed in the U.S. by Connaught is the Typhim Vi polysaccharide vaccine. Studies show a four-fold increase in antibody protection in 88 to 96% of recipients. Efficacy studies have demonstrated protection rates from disease during exposure of 55%. Immunization dosage is a single .5 mL injection given IM. A booster is recommended using a single .5 mL injection every 2 years.

Yellow Fever

Immunization is required for travel to many countries in South America, Africa and Asia. 

The immunization consists of one 0.5 ml injection, which confers immunity for 10 years. It is available only at designated Yellow Fever Vaccination Centers (check your County or State Board of Health for the nearest facility). The booster dose is the same amount every 10 years. Approximately 5 to 10% of recipients have headache, lethargy, muscle ache and fever that occurs 5-10 days after vaccination. This immunization must be recorded on an International Certificate of Immunization and will not be considered valid for 10 days from the time of injection.