Travel Health 2 Flashcards
Vaccines
► Typhoid
► Yellow Fever
► Japanese Encephalitis
► Rabies
► Meningococcal
► Polio
Typhoid Fever
Bacterial infection spread by contaminated food and water,
fecal-oral
► Symptoms - fever, rash, stomach pain
► Treatable with antibiotics
► Highest risk in south Asia - Afghanistan, Bangladesh, Bhutan,
India, Maldives, Nepal, Pakistan, Sri Lanka
► Risk in Africa, other parts of Asia, Latin America
Typhoid Fever Vaccine
Two different options
► Oral
► Injectable
Injectable Typhoid Fever Vaccine
► Inactivated vaccine
► IM as a single dose
► About 14 days for protection which lasts for 2-3 years
► For 2 years and older
Oral Typhoid Fever Vaccine
► Live vaccine
► PO - dosing schedule Day 1, 3, 5, 7
► About 7 days after last dose for protection which lasts
for 5-7 years
► For 5 years and older
Typhoid Fever Vaccine
Factors to consider when recommending oral vs
injectable
► Live vaccine okay for patient?
► Age of patient?
► Pre-existing GI conditions?
► Likelihood of following oral dosing schedule?
► Plans for future travel?
► Convenience
► Cost is the same
Yellow Fever
► Viral infection spread by mosquito
► Symptoms - fever, pain, jaundice -
can lead to organ failure
► Symptomatic and supportive
treatment - can be fatal
► Highest risk in sub Saharan Africa and
South America
► Not present in Asia (yet
Yellow Fever Vaccine
Factors to consider with Yellow Fever vaccine
► Live vaccine
► SC as a single dose
► About 10 days for protection which lasts for more than 10
years (protection last for more than 10 years. At 1 point in time we were saying, You need a booster every 10 years. Now we’re really not seeing that anymore. We’re we’re kind of presuming that you’ve got immunity for life)
► For 9 months and older
► Increased risk of adverse events for those 60 years and older
► Legally required for entry into some
countries
► Is the vaccine required to enter the country?
► Is the vaccine required to prevent the patient from getting
yellow fever?
► These factors may not always match
Japanese Encephalitis
► Viral infection spread by mosquitoes
► 99% asymptomatic
► 1% symptomatic - encephalitis
► ⅓ recover
► ⅓ long term CNS sequelae
► ⅓ die
► Supportive treatment
► Risk throughout Asia, can be seasonal in more
temperate areas
► Primarily in rural/agricultural areas
► Risk to travellers is typically low but NOT ZERO
Japanese Encephalitis Vaccine
factors to consider
► Inactive vaccine
► IM - Day 0 and Day 7-28
► Protection for 1-2 years - if get booster at 12-24
months protection extends to at least 10 years
► For 2 months and older
► Is travel mostly urban or rural/agricultural?
► Length of trip?
► Future travel
► Risk tolerance
► Price
Rabies
► Viral infection spread through the saliva of an infected
mammal
► If infected and post-exposure prophylaxis not given,
99.99% fatal and is a terrible way to die
► Prompt post-exposure prophylaxis will prevent
development of illness (and death)
► Risk throughout the world - monkeys, bats, dogs, any
mamma
Rabies Vaccine
Factors to consider with
Rabies vaccine
► Inactive vaccine
► IM - Day 0, 7 and 21-28
► WHO approved alternative schedules are off-label in
Canada
► Duration of protection determined by titres
Factors to consider with
Rabies vaccine
► Activities on trip - related to
animals?
► Spending a lot of time in caves?
► Remote travel - access to
medical care and post-exposure
prophylaxis
► Future travel
► Risk tolerance
► Price
the duration of protection is determined by titers. So we typically will tell people that they need to get their levels checked. as opposed to saying automatically, giving them a booster at a a period of time.
Meningococcal
Meningitis
► Viral infection spread
through coughing, sneezing
► Endemic but low risk in
Canada
► “Meningitis Belt” in Africa is a
high risk travel area,
particularly in dry season,
when outbreaks can occur
► Significant risk of fatality or
long term sequelae
Meningococcal Vaccine (ACWY)\
Factors to consider with
Meningococcal vaccine
► Inactive vaccine
► Protects against 4 serotypes
► IM as a single dose
► Protection lasts 3-5 years
► Quadrivalent ACWY vaccine given as part of Grade 9
vaccines in Alberta provincial program
► Locations visited within Africa
► Time of year
► Vaccine required for
pilgrimage travel to Mecca,
Saudi Arabia
Polio
► Viral infection spread via fecal-oral route
► Almost eradicated but still endemic in a couple of
countries (Afghanistan and Pakistan)
► Some cases of vaccine derived polio from areas
where oral live vaccine still used
Polio Vaccine
Factors to consider with Polio vaccine
Polio Vaccine
► Inactive vaccine
► Given as part of childhood vaccines in Alberta
vaccine program
► Adults can receive a booster as a single SC
dose
► Oral live polio vaccine not available in
Canada
Factors to consider with Polio vaccine
► Pakistan or Afghanistan?
► Some countries have required polio
vaccination within 12 months of travel
Malaria
► A mosquito-borne disease caused by a parasite.
► Symptoms can include fever, chills, and flu-like illness.
► Treatments available
► Without prompt treatment, death can occur,
particularly in children
Antimalarials available in Canada
How do you determine which one to pick?
- Chloroquine
- Mefloquine
- Doxycycline
- Atovaquone/Proguanil (Malarone™
► Medical history, current medical conditions and
medications
► Resistance
► Tolerability and risk of adverse events
► Dosing (daily or weekly) and how long does it need to
be continued after leaving risk area
► Cost
Antimalarial Choices
* Review medical history and current medications. Are
there any contraindications or drug interactions or
allergy concerns?
* Patient involvement: If products have similar efficacy
and risks associated are mostly equal, the patient
should be involved in decision
Chloroquine
benefits advantages
Benefits
* Weekly dosing
* Inexpensive
Disadvantages
* Resistance in most of world except Central America and
Caribbean
* Have to take at least 2 weeks prior and 4 weeks after leaving risk
area
* Tablets not commercially available in Canada at present
Mefloquine
Benefits
* Weekly dosing
* Inexpensive
Disadvantages
* Adverse events including psychological side effects
* Have to take at least 2 weeks prior and 4 weeks after leaving risk
area
Doxycycline
Benefits
* Inexpensive
Disadvantages
* Daily dosing
* Side effects including GI irritation, increased sun sensitivity, vaginal
yeast infections
* Have to take 28 days after leaving area
Atovaquone/Proguanil
Benefits
* Mostly well tolerated – possible GI upset
* Need to take only 7 days after leaving risk area
Disadvantages
* Daily dosing
* Cost - expensive
CASE #1
A 25 year old male and 22 year old female have
booked a last minute trip to Vietnam
► Scheduled to leave in 15 days
► Duration of trip is 24 days
► Itinerary includes Hanoi, Ha Long Bay, Ho Chi Minh
City and area, Da Nang and Hue (typical tourist
locations)
► Mode of travel within country is airplane (Ho Chi
Minh City to Hanoi), then on a bus tour down the
coast
► Neither patient has had any travel vaccinations
► Both born in Alberta and received all public health
vaccines scheduled when they were a child.
► Patients come to appointment and say they think
they need Twinrix™, typhoid vaccine and antimalaria pills
Is TWINRIX™ the most appropriate vaccine
for these two patients?
► Patients are 25 and 22 years old (born in
1998 and 2001)
HEP RECOMMENDATIONS
Hepatitis A
Vietnam: recommended for all travellers
Hepatitis B
* Vietnam: Recommended for
* prolonged stays
* frequent short stays
* adventure travelers
* possibility of acupuncture, dental work, or tattooing
* all health care workers
* the possibility of a new sexual partner during the stay
* injection drug users
* travelers with high potential to seek medical care in local facilities
* Consider for short stays in travelers desiring maximum pre-travel preparation.
Hepatitis vaccine plan for both
patients
Hepatitis A: Neither have never received any travel vaccinations
therefore no previous doses
Recommendation: Vaccinate for Hepatitis A
Hepatitis B: Both received through childhood public vaccination
program in Grade 5. Immunity should still be active
Recommendation: Do not vaccinate for Hepatitis B
Plan: Vaccinate with Hepatitis A vaccine (single entity)
* 2 doses: 0 and minimum 180 days apart
* 1 dose will provide protection for entire duration of trip
Follow Up: Provide second dose of Hepatitis A vaccine in 180+ days
Dont need twinrix, already got their hep B
We just need to give them hepatitis a 2 doses.
1 now and one 6 months later, f/u after trip
Hepatitis BCASE #1
A 25 year old male and 22 year old female have
booked a last minute trip to Vietnam
► Scheduled to leave in 15 days
► Duration of trip is 24 days
► Itinerary includes Hanoi, Ha Long Bay, Ho Chi Minh
City and area, Da Nang and Hue (typical tourist
locations)
► Mode of travel within country is airplane (Ho Chi
Minh City to Hanoi), then on a bus tour down the
coast
► Neither patient has had any travel vaccinations
► Both born in Alberta and received all public health
vaccines scheduled when they were a child.
► Patients come to appointment and say they think
they need Twinrix™, typhoid vaccine and antimalaria pills
Is TWINRIX™ the most appropriate vaccine
for these two patients?
► Patients are 25 and 22 years old (born in
1998 and 2001)
TYPHOID, MALARIA RECOMMENDATIONS
Typhoid vaccine
Vietnam: Recommended for all travellers
Vaccine plan: Oral or injectable?
for these patients right now, I would probably be more inclined to want to recommend oral just because of the fact that they’re young, They’re healthy. They don’t have gut issues. They don’t have any contr indications for live vaccines.
They’re probably more likely to travel more in the future. But that being said, if they wanted the make it quick and easy, and do just do the injectable
Either reasonable
Antimalarial medications needed?
Vietnam: Malaria is present in some locations
Note: Patients are staying in 2 or 3 star hotels
with air conditioning
Antimalarial Medications
Based on destinations on itinerary, accommodations, and activities,
antimalarial medications are unlikely to be needed since they are not
going to high risk areas.
Use of insect repellant would be recommended for protection against
malaria, dengue, and other mosquito related illnesses.
More likely to get dengue than malaria on this trip
Dengue fever
- Virus transmitted by Aedes mosquito – same as Zika and Chikungunya
- Daytime biting mosquito that does well in urban environments
- 50 million cases a year in over 100 countries – anywhere tropical
*Even some cases in Hawaii a few years ago - Symptoms: fever, headache, myalgia, retro-orbital pain, myalgia, rash and pain -
“breakbone fever” - lasts about a week - Severe dengue with hemorrhagic fever – rarely but life threatening
- Treatment is symptomatic and supportive
- 4 serotypes - subsequent infections are worse
- Preventative measures: bite protection: clothing, bug sprays
- Vaccines – coming soon
Dengue fever vaccines
None approved in Canada as of March 2023
1) Dengvaxia™ has been available for several years in some countries - not useful for
travellers
➢ dosing schedule
➢ effectiveness based on previous dengue infection
➢ some limited benefit for those living in endemic areas
2) Qdenga™ was approved in EU in late 2022, currently being reviewed in USA, no
application in Canada yet - may be useful for travellers
➢ live vaccine
➢ dosing schedule 0 and 3 months – data shows effectiveness after second dose
* Other candidates in the pipeline
