Hepatitis A

WHO map (new window)

Hepatitis A is world-wide in distribution and is especially prevalent in the developing countries of Africa and Asia. The infection is spread by contaminated food, water and shellfish, from dishes and cutlery and person to person. There is no carrier state of hepatitis A. Hepatitis A can often be prevented by ensuring safe food and water, by passive immunization with Immune globulin and with Hepatitis A vaccine. Immune globulin is now seldom given to travellers Hepatitis A vaccine is given instead. The vaccine is given in 2 doses, one prior to travel, the second in 6-12 months (cost $60 per dose). Protection lasts at least a year after the 1st. dose and after the 2nd. dose for life. Side effects from this vaccine are usually mild (mainly being a sore arm). The older single strength vaccine was given in 3 doses. (cost $40 per dose) Persons who were born and raised in areas with high risk of hepatitis A returning to visit are likely immune and therefore at low risk. Children can catch hepatitis A but usually have mild symptoms and then are immune for the rest of their lives. They can transmit the disease to others after they return if their symptoms are mild. Children’s dose of the vaccine is $30.

(from the Australian immunization guide)

The inactivated hepatitis A vaccines induce HAV antibodies (anti-HAV) at titres many-fold greater than that provided by the recommended dose of normal human immunoglobulin. Although the vaccines are highly immunogenic (see below), the titres are usually below the detection limits of the routinely available commercial tests for anti-HAV.1 Therefore, serological testing to assess immunity after vaccination against hepatitis A is neither necessary nor appropriate. Likewise, it is also inappropriate to undertake testing if an individual cannot recall if he/she has been vaccinated against hepatitis A in the past; if no vaccination records are available, vaccination should be advised.

Hepatitis A vaccines are highly immunogenic in both children and adults, with virtually universal seroconversion 4 weeks after vaccination.1 Two randomised clinical trials conducted in the early 1990s showed that the vaccines have a very high protective efficacy, approaching 100%

Hepatitis B

Hepatitis B is a worldwide disease with carrier rates from .1% to 15% in various populations. The transmission of hepatitis B can be by inoculation with a contaminated needle, blood transfusion, sexual contact, intimate physical contact of any type and indirect routes such as shared razors. Vaccination is recommended for at risk persons 3 months of age and older. The risk depends on destination and on occupation. Health care workers should be immunized if they are likely to come in contact with blood. Missionaries, diplomats and military personnel traveling in North Africa, Sub Sahara Africa and South East Asia should be immunized if they plan to reside for more than 6 months in areas with high levels of endemic hep B and who will have close contact with the local population. Immunization of adults consists of 3 or 4 injections given intramuscularly on day 0, at 1 month and 6 months (or 0, 1, 2 and 12 months or 0, 7-10 days, 21 days and 1 year). The vaccine costs $30 per dose. At the present time booster doses are thought to be unnecessary even when antibody titres are undetectable

Hepatits A & B

For adults  who need both Hepatitis A and Hepatitis B protection, a new combined Hep.A and Hep.B vaccine is now available. The primary course of vaccination consists of three (3) doses, costing $60 each, it should be administered at 0, 1 month and 6 months. Children's vaccine is given at the same time interval and costs $30 per dose. Two adult twinrix 6 months or more apart can be given to children 15 months to 15 years instead of 3 childrens doses

Japanese Encephalitis vaccine

This is a mosquito borne viral encephalitis which may occur in epidemics in late summer and autumn in the temperate areas of Bangladesh, Burma, Kampuchea, China, India, Japan, Korea, Laos, Nepal, Thailand and eastern areas of the USSR. In endemic areas (tropical areas of Philippines, Singapore, Sri Lanka, Taiwan, Malaysia, Indonesia, southern India and southern Thailand) where there is no seasonal pattern, the risk is lower but occasional outbreaks occur.
The mosquitoes are present in greatest numbers from June through September and feed outdoors beginning at dusk and during evening hours. Thus, general protection measures used against malaria  are also important in avoiding J.E.

The vaccine is recommended for persons planning longterm residence in countries experiencing epidemic Japanese Encephalitis, especially when travel is in rural areas (particularly rice culture and pig farming) and during the months of risk. Short term travelers (less than 1 month) especially those to urban centres are at low or negligible risk. The new vaccine has less side effects and is given in 2 doses one month apart

CATMAT recommendations ---  Health Canada Information

 

Meningococcal vaccine

CDC info and MAP  meningitis belt

This vaccine is of benefit to travelers to countries recognized as having an epidemic of meningococcal meningitis. There is an area of sub-Saharan Africa which has a high risk of meningococcal disease known as the meningitis belt including Chad, Ethiopia, Sudan, Niger, Nigeria, Ghana, Togo, and Upper Volta. Consideration should be given to vaccinating those going to live or work in these areas for more than 3-4 weeks. Only mild local reactions occur. It is effective for 5 years.

Vaccine is also given in Canada to students and recommended for those in University residences

 

CATMAT recommendations

Mumps Measles Rubella

In developing countries measles causes significant mortality. Most persons born before 1957 are likely to have been infected naturally and can be considered immune. It is advisable that travelers be immune to measles. In Canada measles vaccine is administered as Mumps Measles Rubella (MMR) to children at 12 months of age. Children 6-12 months old may be immunized with measles vaccine if they will be in contact with young children in the country being visited. Children vaccinated before 12 months of age should be revaccinated at about 15 months of age. Rubella vaccination should be given to all women of child bearing age who are not immune and Mumps vaccination is recommended for adults with no history of mumps or prior immunization. The vaccines are available individually ( hard to find) but the MMR combination is frequently used. These are live vaccines and should not be used in pregnancy or in persons who are immune suppressed.

Pre-exposure Rabies

Rabies is a viral disease which is worldwide. Only those who are likely to come in intimate contact with wildlife (veterinarians, wildlife conservation personnel, biologists etc.) are at high risk and should be immunized. It is administered in three intramuscular doses on day 0, 7, and 21 or 28. The cost of one dose is about $125.00. An alternative dosage is .1cc. intradermal. If a previously immunized person is exposed to rabies, two post exposure doses should be given, one immediately and one three days later.

CATMAT recommendations

CIWEC Clinic  Risk of Rabies in Nepal 

CIWEC homepage

Tetanus Diphtheria Polio

In Ontario the vaccines for tetanus, diphtheria and polio are now being used for primary immunization. Travelers to both high and low risk areas should have these immunizations up to date. Tetanus should be updated every 10 years. It is advisable to give a booster if it is over 5 years and it is unsafe (because of the risk of aids or Hepatitis B or C from reused needles) to get a booster (if injured) in the country visited. Polio vaccine and diphtheria toxoid are effective for ten years.
Children's primary series of vaccines also include pertussis (whooping cough)  there is a new tetanus diphtheria vaccine for adults which includes an adult booster of pertussis (ADACEL) This vaccine is not yet covered by provincial health plans, cost- $40.

Tuberculosis

Medical personnel, missionaries, teachers and some children staying in endemic areas for prolonged periods of time in particular are at risk. A traveler at high risk should have a TB skin test done prior to departure (if they have not been previously immunized with a vaccine occasionally used called BCG). When this is negative the traveler should be advised to have a repeat tuberculin test every 1-2 years. If the skin test turns positive treatment may be considered depending on age and circumstances. BCG is not indicated if periodic skin testing is practical.

CATMAT -TUBERCULOSIS SCREENING AND THE INTERNATIONAL TRAVELLER

Typhoid

Typhoid occurrences are worldwide and unique to man. There are no known animal carriers of typhoid. It is especially prevalent in  south east and south Asia,  Typhoid vaccine is recommended when the traveler is exposed to unsafe food or water supply (the high risk traveler). Typhoid immunization provides protection against moderate amounts of ingested bacteria. There are now 2 new typhoid vaccines. A live oral vaccine, Vivotif, (a series of 4 capsules taken over a week or 3 doses of a liquid over 5 days) which cannot be taken with antibiotics, should be taken on an empty stomach and must be kept refrigerated (cost ~$30). A new injectable vaccine, Typhim Vi, which is given in a single dose and is good for 3 years. (cost ~$30). It has very few side effects and if necessary can be given as young as 2 years of age. The injectable vaccine is effective more quickly than the oral  
http://publications.gc.ca/collections/collection_2014/aspc-phac/HP40-98-2014-eng.pdf

CATMAT suggests that typhoid vaccine (Ty21a or Vi polysaccharide vaccine) be used  for Canadian travellers visiting South Asia*;

CATMAT suggests that typhoid vaccine (Ty21a or Vi polysaccharide vaccine) not (usually) be used for Canadian travellers visiting destinations other than the

South Asia;

•The decision of whether or not to use typhoid vaccination for destinations other than South Asia might be influenced by: other factors associated with risk of travel associated typhoid such as pediatric travel, visiting friends and relatives, longer duration of travel, the presence of achlorhydria or use of acid suppression therapy; and/or patient preferences.

* South Asia is defined as per the World Bank classification and includes Afghanistan, Pakistan, India, Nepal, Bangladesh, Maldives, Sri Lanka, Bhutan. Among these countries, the large majority (≥90%) of cases of typhoid among travellers were reported from India, Pakistan and Bangladesh (1;2).

Tick Borne Encephalitis (TBE)

A vaccine is manufactured in Austria and should be considered for long-term travellers to rural areas of parts of Europe, but the time factor would preclude its use for short-term tourists (who are at lower risk). The recommended regime is 3 doses of vaccine, the second dose usually being given 1 - 3 months after the first (but this can be shortened to 2 weeks) and the third after 9 - 12 months. This vaccine was available in Canada but the manufacturer has stopped distributing it. 

 

Lyme disease

This vaccine is unavailable from the manufacturer at the present time. 

Chickenpox (Varicella)

Chickenpox is a highly contagious disease.  In the United States   about 4 million people are infected each year, most  are children 5 to 9 years of age.

Chickenpox is  generally a mild disease in healthy children, but it can lead to serious complications such as bacterial infections and pneumonia. In the United States there are about 100 deaths and 10,000 people hospitalized. Chickenpox vaccine (Varivax) is recommended by the American Academy of Pediatrics and the Advisory Committee on Immunization Practices to the Centers for Disease Control and Prevention for universal use in early childhood and for immunization in susceptible older children and adolescents. Canadian recommendations are not yet published.  A single 0.5 mL injection of   Varivax is recommended for children age 12 months to 12 years; two 0.5 mL injections four to eight weeks apart are recommended for adolescents and adults