Medical Travel Advice

Vaccinations

Vaccines administered to people traveling abroad are generally safe. Reactions consisting of pain, redness, and swelling at the site of the injection are not uncommon and resolve in 48 hours or less. Some people may experience low-grade fevers, headache, and malaise after certain vaccines. Permanent consequences are rare. If more severe reactions are experienced, however, patients should seek urgent medical care. Acetaminophen or aspirin is usually sufficient for relief. Specific contraindications are noted with the vaccine, but any hypersensitive reaction to previous vaccine doses, allergy to vaccine components, or severe acute illness are always reasons not to give vaccines.

Contraindications to immunizations during pregnancy may be relative to the risk. Contraindications during breastfeeding are related to the contraindications for giving the vaccine to children. Patients who are immunocompromised generally should not receive live agent vaccines. Recent blood transfusion may be a temporary contraindication to certain vaccines. No vaccine is 100% effective so all other preventive measures discussed above should be used at all times. Patients need to plan to receive vaccinations well before they travel -- 1-2 months is often needed -- so that all regimens can be completed before leaving home and prior to exposure. A card listing all vaccines administered should be issued upon completion.

Vaccine     Dose and Contraindications

• Cholera     No longer available in the United States. Diarrhea precautions should be followed.
• Hepatitis A     Inactivated vaccine, 2 doses given intramuscularly (IM), 6-18 months apart. If time is insufficient, 1 dose is often enough to provide 6 months' protection. If vaccination is refused or contraindicated, a single dose of immune globulin (0.02 mL/kg) provides up to 3 months of protection. Contraindications include pregnancy and less than 1 year of age.
• Hepatitis B     Three doses given IM at 0, 1, and 6 months. Many people develop some protection after the first dose should the entire series not be finished before travel. The combined hepatitis A/hepatitis B vaccine (Twinrix®) is available for those travelers needing protection against both diseases. Three doses are given at 0, 1, and 6 months. The first 2 doses are necessary prior to travel. Contraindications include allergy to baker's yeast.
• Influenza     One dose yearly. Contraindications include egg allergy.
• Japanese encephalitis virus (JEV)     Two inactivated JEV vaccines are available, and either is to be used only for patients at high risk for exposure. This is a mosquito-borne disease, and the preventive measures for avoiding mosquito bites are sufficient for most travelers. JE-Vax®, for patients 2-17 years of age is given as 3 doses at 0, 7, and 30 days and should be completed at least 10 days before exposure. Contraindicated in anyone who is highly allergic to more than 1 or 2 substances.
• Ixiaro® (available since 2009) is for use in persons older than 17 years of age. It is given as a 2-dose series at 0 and 28 days, and the series should be completed 7 days before exposure. If the traveler who received Ixiaro remains at risk after 1 year, a booster should be given. No data are available on pregnancy risk for either vaccine.
• Measles (usually available as combined measles, mumps, and rubella or MMR vaccine)     Live virus vaccine given as 1 dose IM to anyone born after 1957 (no matter where they are traveling) who received only 1 dose previously. Consider administration for anyone born before 1957 who is not immune and who will be at a very high risk for exposure. Vaccine side effects for this age group have not been well studied. Contraindications include altered immune system and anaphylactic response to eggs or neomycin.
• Meningococcus     Two vaccines are available, both of which give protection against types A, C, Y, and W135 of Neisseria meningitides. Both are given as a single dose IM with a booster in 3-5 years (check requirements of Saudi Arabia for people traveling to Hajj). The vaccine is particularly recommended for patients who have functional or anatomic asplenia and terminal complement deficiency. The MPSV4 (meningococcal polysaccharide vaccine) is a polysaccharide vaccine for pregnant patients and those over 55 years of age. The MCV4 (meningococcal vaccine) is a conjugate vaccine for patients less than 55 years of age. Contraindications include a history of Guillain-Barré syndrome.
• Pneumococcus     PPSV23 (23-valent pneumococcal polysaccharide vaccine) is a polysaccharide vaccine containing the 23 most common types of Streptococcus pneumoniae. It is given as a single IM dose. A second dose of PPSV23 may be recommended for those with heart, lung, or liver disease, sickle cell anemia, diabetes, cochlear implant, or who are not immunocompetent, because they are at particular risk for complications from pneumococcal illness.
• Poliomyelitis     Inactivated and live polio vaccines are available. The inactivated form is used in the United States. For primary vaccination, the schedule for the inactivated vaccine is 3 doses, -2 months apart with a booster at -12 months and then 4-6 years later. For adults previously vaccinated with either oral or inactivated polio vaccine, a booster is recommended when traveling to high-risk areas.
• Tetanus-diphtheria-pertussis     Available as DTaP (diphtheria, tetanus, and pertussis) for children under 7 years of age, Tdap (tetanus, diphtheria, and pertussis) for those 7-65 years of age and not pregnant. DT (diphtheria and tetanus) for children under 7 years of age and Td (tetanus and diphtheria) for those over 7 years of age is available for those in whom pertussis vaccine is contraindicated. Initial series is 3 doses at 2-month intervals and a booster 12 months later for children up to 7 years of age, and 2 doses in a 2-month interval plus booster 12 months later for those over 7 years of age. All are administered IM. Boosters should be given every 10 years thereafter for all ages. Td is not contraindicated for use during pregnancy. Tdap should be considered for all adults, including pregnant women who are at high risk for exposure to pertussis or if Td is not available.
• Typhoid     Two vaccines are available, neither of which has been extensively studied for efficacy in travelers. It should be considered for patients traveling to highly endemic areas or who are living with a chronic typhoid carrier. Typhim Vi®, a capsular polysaccharide vaccine, appears to be the most protective. It is given as a single parenteral dose followed by boosters every 2 years if needed. Vivotif Berna® (Ty21a) is a live bacteria vaccine given orally as 1 capsule every other day for 4 doses with boosters every 5 years. It is taken 30 minutes before eating and must be refrigerated. It is contraindicated in patients who are on antibiotics, lactose intolerant, less than 6 years of age, pregnant, breastfeeding, or who are immunocompromised. Ty21a should not be used if traveler is taking antibiotics, including malaria prophylaxis.
• Yellow fever     A live virus vaccine that must be administered at an official center and patients must obtain an international certificate of the vaccination or prophylaxis with the official stamp. Most travelers can avoid yellow fever by observing mosquito precautions, but international health regulations, which respect country needs to avoid importation of the virus and control outbreaks, are different from CDC and ACIP recommendations for use. It is given as a single subcutaneous dose at least 10 days before entry into the area where it is required. Boosters are given every 10 years. Rate of serious complications is higher in persons who are over 60 years of age given a first dose ever of vaccine. Contraindicated in infants less than 9 months of age, breastfeeding women, patients with thymus disorders including absence, and all other immunocompromised states. Your state health department can provide a list of approved yellow fever vaccination sites and an application to become a site if you wish to administer the vaccine in your practice.