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1 Challenges and Controversies in Vaccination TRAVEL VACCINES Resat Ozaras, MD, Professor, Istanbul University Cerrahpasa Medical School Infectious Dis. Dept.

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4 Risk of exposure The severity of the disease if acquired The risk of the immunization itself

5 Vaccines to Consider for All Destinations Hepatitis A Hepatitis B Tetanus Typhoid Influenza Varicella

6 Mandell s, 7 th Ed.

7 Vaccines for Selected Destinations Mandell s, 7 th Ed.

8 Vaccines for Selected Destinations Yellow fever Meningococcus Rabies Japanese encephalitis (Vero cell) Polio Cholera Tick-borne encephalitis

9 Yellow Fever It falls under the International Health Regulations that may necessitate vaccination purely for regulatory reasons. All healthy adult travelers to areas with a risk of yellow fever transmission should be vaccinated. A country Only a portion of a country. Rare but serious vaccine-associated adverse side effects Persons who are not at any risk of exposure should not be vaccinated. Urban YF in South America: rare Vaccinate persons who will travel anywhere close to regions with risk of transmission.

10 Mandell s, 7 th Ed.

11 A number of African countries (Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Congo, Côte d Ivoire, Democratic Republic of Congo, Gabon, Ghana, Liberia, Mali, Niger, Rwanda, São Tomé, Sierra Leone, Togo) and one in South America (French Guiana) require proof of YF vaccination from all arriving travelers. Other countries, within the risk zone may require an official vaccination certificate for individuals arriving directly from or via (may include a brief transit stop) a country in the YF endemic zone to prevent entry of viremic travelers.

12 Officially valid for 10 years, The true duration of immunity from YF vaccination is probably much longer and may exceed 30 years.

13 Yellow Fever Vaccine Live attenuated virus Single dose Sc Further boster: 10 yr

14 Meningococcus For travelers to Africa s sub- Saharan meningitis belt during the dry season from December through June, especially if prolonged contact with the local population is likely. Out-of-season epidemics have recently occurred in Ethiopia, Somalia, and Tanzania, Possible changes in epidemiologic trends perhaps due to climate changes. Muslims undertaking Hajj and Umrah pilgrimages in Saudi Arabia A higher risk of meningococcal disease, Proof of vaccination with quadrivalent vaccine within the past 3 years is required for visas.

15 Mandell s, 7 th Ed.

16 Meningococcus Vaccine Quadrivalent conjugated polysaccharide (A, C, Y, W135) Single dose IM Further boster: >10 yr

17 Rabies A pre-exposure series for long-stay travel to endemic areas of Latin America, Asia, or Africa, The rabies threat is constant Access to postexposure rabies immune globulin and vaccine is limited. The highest risk Indian subcontinent, Thailand, Vietnam, and most sub- Saharan African countries.

18 Rabies For short-term travel, risk groups: adventure travelers, bikers, hikers, cave explorers, or travelers who travel for short but frequent trips and plan to go running outdoors Regardless of vaccination status, travelers should be instructed to cleanse well with soapy water any bite or animal scratch immediately to seek postexposure treatment for rabies

19 CDC

20 Rabies Inactivated cell culture viral 0, 7, days IM Further boosters: None routinely but two doses after each exposure

21 Japanese Encephalitis Endemic in rural areas of Southeast Asia, Indian subcontinent. Sporadic cases with sequelae continue to occur in travelers. In temperate regions, transmission : April to November. In tropical or subtropical regions of Oceania and Southeast Asia, transmission may occur year round.

22 Japanese Encephalitis Vaccination is recommended for long-stay travel to an endemic rural area; expatriation to anywhere in an endemic country; short-term travel to endemic rural areas with extensive unprotected outdoor exposure, such as with adventure travel; or short-term travel in the face of a current local epidemic. A new, inactivated vero cell JE vaccine with a safety profile replaced the older more toxic mouse brain JE vaccine in 2009

23 Mandell s, 7 th Ed.

24 Japanese encephalitis (Vero cell) Inactivated viral 0, 28 days IM Further boosters:?

25 Polio Because of eradication efforts, poliomyelitis remains in only a few countries, complete control remains elusive Adults traveling to countries that are currently polio endemic and who have previously completed a primary vaccine series Should receive a single dose of inactivated polio vaccine as a booster if the last dose or booster dose was administered >10 years previously.

26 Polio Oral polio is no longer produced in USA Inactivated viral Single dose if adequate childhood series SC, IM Further booster is not needed

27 Mandell s, 7 th Ed.

28 Cholera Cholera vaccination is no longer required by any country, and the risk to typical travelers is insignificant. Medical and aid workers staying for short periods in disaster areas or refugee camps may consider The parenteral inactivated vaccine is no longer available in US and has been officially disowned by WHO A highly effective oral killed whole cell B subunit vaccine is available. This vaccine also has about 50% efficacy against ETEC and a 7-23% efficacy against all traveler s diarrhea (TD)

29 Mandell s, 7 th Ed.

30 Cholera Killed bacteria + recombinant B toxin subunit licensed in some countries for traveler s diarrhea due to ETEC 0, 1 week Oral Further boosters: 2 yr for cholera; 3 mo for ETEC

31 Tick-borne Encephalitis Tick-borne encephalitis (TBE) is an emerging, important, and serious flavivirus central nervous system infection in endemic areas. Distribution is highly focal in a range that extends in a swath from Germany through Scandinavia and the Baltic to Siberia and Vladivostok in the east. Risk to travelers is low BUT extensive outdoor activities in forested regions in endemic areas.

32 Tick-borne Encephalitis Immunization against TBE is recommended for adventure travel, extensive outdoor exposure, or camping in the forests of the endemic countries between April and October. Tick precautions are also recommended. The vaccine is available in most endemic countries and by special release in Canada and UK

33 cdc.gov tbefacts.com

34 Tick-borne Encephalitis Not available in United States Available in endemic areas and in Canada and UK by special release. Inactivated viral 0, 1-3 mo, 9-12 mo IM Further booster: 3 years

35 Notes All currently indicated immunizations can and should be given at the same time and in any combination. If two live viral antigens are not administered on the same day, they must be spaced by a month. Live oral vaccines (typhoid, polio) can be administered at any interval with respect to any live virus vaccine. Minimum intervals between vaccine doses must be respected, although 4 or fewer days before the next interval are acceptable.

36 Interrupted series (except oral typhoid and rabies) need not be restarted but can be resumed beginning with the dose that is overdue. Anaphylactic egg allergy precludes administration of YF, influenza, and MMR vaccines. No current vaccine contains penicillin.

37 Baseline purified protein derivative (PPD) skin tests, often done in the pretravel setting, can be given on the day that live viral vaccines are administered or else must be done more than 4 weeks later. Antibacterial drugs should not be given within 24 hours of a dose of live oral typhoid or oral cholera vaccine. Concomitant mefloquine may interfere with oral typhoid vaccine.

38 Conclusion Apart from routine vaccination, travel to some countries may require others Consider the risk of exposure, the severity of the disease if acquired and the risk of the immunization itself See the references for every destination CDC WHO

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