Travel Health 2

Question 1

Vaccines

Answer 1

► Typhoid
► Yellow Fever
► Japanese Encephalitis
► Rabies
► Meningococcal
► Polio

Question 2

Typhoid Fever

Answer 2

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

Question 3

Typhoid Fever Vaccine

Answer 3

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

Question 4

Typhoid Fever Vaccine
Factors to consider when recommending oral vs
injectable

Answer 4

► 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

Question 5

Yellow Fever

Answer 5

► 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

Question 6

Yellow Fever Vaccine

Factors to consider with Yellow Fever vaccine

Answer 6

► 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

Question 7

Japanese Encephalitis

Answer 7

► 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

Question 8

Japanese Encephalitis Vaccine

factors to consider

Answer 8

► 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

Question 9

Rabies

Answer 9

► 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

Question 10

Rabies Vaccine

Factors to consider with
Rabies vaccine

Answer 10

► 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.

Question 11

Meningococcal
Meningitis

Answer 11

► 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

Question 12

Meningococcal Vaccine (ACWY)\

Factors to consider with
Meningococcal vaccine

Answer 12

► 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

Question 13

Polio

Answer 13

► 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

Question 14

Polio Vaccine

Factors to consider with Polio vaccine

Answer 14

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

Question 15

Malaria

Answer 15

► 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

Question 16

Antimalarials available in Canada

How do you determine which one to pick?

Answer 16

• 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

Question 17

Chloroquine

benefits advantages

Answer 17

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

Question 18

Mefloquine

Answer 18

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

Question 19

Doxycycline

Answer 19

Benefits
* Inexpensive
Disadvantages
* Daily dosing
* Side effects including GI irritation, increased sun sensitivity, vaginal
yeast infections
* Have to take 28 days after leaving area

Question 20

Atovaquone/Proguanil

Answer 20

Benefits
* Mostly well tolerated – possible GI upset
* Need to take only 7 days after leaving risk area
Disadvantages
* Daily dosing
* Cost - expensive

Question 21

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

Answer 21

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

Question 22

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

Answer 22

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

Question 23

Dengue fever

Answer 23

• 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

Question 24

Dengue fever vaccines

Answer 24

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

Question 25

Any other vaccines?

Answer 25

Rabies
Vietnam: Significant risk from dogs exist throughout the country, also risk from bats
Our patients
* Are not going to be caring for or working with animals
* Are not spending a lot of time in caves
* Will be within 24 hours of access to rabies vaccine and immunoglobulin
Balance risk vs cost
Frequent travellers can consider vaccination will be relevant for future trips as well

Japanese Encephalitis
Vietnam
* Risk is present primarily in rural agricultural areas
* Based on patients’ itinerary: relatively low risk
* High cost for vaccine can be a factor
* Use an insect repellant
Risk is low but not zero
* Edmonton resident died from Japanese Encephalitis infection in 2016
* Patient needs to understand risk

Travellers Diarrhea
* Education re: food and water precautions
* Recommend prescribing antibiotics for self treatment
* Azithromycin 500mg daily x 3 days
* Ciprofloxacin resistance in SE Asia
* Dukoral™?
* OTC: Imodium, Pepto-Bismol

Question 26

CASE #2
A 20 year old nursing student is going to do medical aid work in
Mozambique in the summer for 3 months.
ITINERARY:
* Calgary to London,UK (switch planes)
* London,UK to Nairobi, Kenya (switch planes)
* Nairobi, Kenya to Johannesburg, South Africa
* Johannesburg, South Africa to Maputo, Mozambique
**Student saved $400 on airfare by stopping in Nairobi.
Patient concerned she may be required to have a yellow fever
vaccination to enter South Africa.

YELLOW FEVER RECOMMENDATIONS

Answer 26

Yellow Fever Risk by Country
* Canada
None
* United Kingdom
None and not leaving airport
* Kenya
Yes but not leaving airport
* South Africa
None and not leaving airport
* Mozambique
None

Is Yellow Fever Vaccine Needed?
* Risk of contracting yellow fever is negligible
* Will not leave the airport buildings in Kenya which
is the only yellow fever risk country

Is Yellow Fever Vaccine Required?
Yes – Yellow Fever vaccine is required
Both South Africa and Mozambique require proof of
yellow fever vaccination if transiting through a country
with risk of yellow fever transmission (Kenya).
If traveler skipped the Kenya stop and flown directly from
Europe to South Africa, yellow fever vaccination would
not be required for entry.

Question 27

Antimalarials for Mozambique
Entire country is high risk and antimalarials
are strongly recommended

Answer 27

Is Chloroquine an option?
No – drug resistance

Mefloquine, Doxycycline
and Atovaquone/Proguanil
All efficacious if taken as directed
No resistance in Africa

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
► For this case:
► Atovaquone/Proguanil is clinician’s preference but cost is often a
factor. If cost is not an issue, this is first choice.
► Doxycycline would be second choice. Patients need to
decide if cost savings outweigh possible side effects.

Question 28

Other travel health concerns
for case 2

Answer 28

► Altitude sickness
► Scuba diving
► Motion sickness
► Jet lag
Important to get the full picture of what the
patient will be doing to inform clinician
about making best risk evaluation

Question 29

Post Travel Management

Answer 29

► Most post-travel health issues may fall outside pharmacist
scope of practice
► Need to know when and where to refer - ideally a tropical
medicine clinic
► Educate patients that any fever in a returning traveller
should be evaluated immediately
► If you’ve been to a malaria country and you have
developed a fever, should be treated like you have malaria
until proven otherwise