Diseases Subject to International Health Regulations

Yellow Fever

Yellow Fever inoculation is required for all travellers in transit or going to the yellow fever endemic zones of Africa and Central and South America. There are NO yellow fever endemic areas in Asia and travellers to these areas do not require yellow fever unless they go through Africa and South America. Yellow Fever vaccine must be administered by a WHO approved vaccination centre. Yellow fever vaccine is a live vaccine grown in eggs. It should not be given to those with cancer or to those with impaired immunity. It should not be given during pregnancy unless the risk of yellow fever is very high. It should be avoided in patients with a known allergy to eggs. Intradermal skin testing can be done to determine sensitivity in these cases. The vaccine is given to those over 6 to 9 months of age.

A single dose vaccinates the person for 10 years starting 10 days after administration. Travellers with contraindications to use or infants under 6 months of age will be given a certificate of exemption. Side effects include (2-5%)mild headache, muscle aches, & low-grade fever 5-10 days after the shot. Less than 0.2% curtail regular activities. Immediate hypersensitivity reactions (rash, hives, &/or asthma) are uncommon (1/130,000-250,000) and occur primarily in people with a history of egg or other allergies. Caution should used in people >65 y/o as older patients may be at higher risk of systemic adverse reactions.

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Meningococcal vaccine

This vaccine is of benefit to travellers to countries recognized as having an epidemic of meningococcal meningitis. Sub-Saharan Africa has a high risk of meningococcal disease otherwise known as the "meningitis belt". This includes Chad, Ethiopia, Sudan, Niger, Nigeria, Ghana, Togo, and Burkina Faso. Consideration should be given to vaccinating those going to live or work in these areas for more than 3-4 weeks. Only mild reactions occur, mainly injection site pain/redness(40%) and transient fever(6%). Severe reactions are rare (1 in a million). It is effective for 5-10 years. This vaccine is required for religious pilgrimages to Mecca in Saudi Arabia..

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The International Health Regulations abolished the requirement of a vaccination certificate in June 1973. No country should require a certificate from travellers arriving from Canada. The only persons at risk are aid workers servicing very spartan conditions. This was one of the vaccines commonly demanded by corrupt border guards in developing countries in order to extract a bribe. There is an oral cholera vaccine called Dukoral, which is now used for preventing moderate to severe Traveller's diarrhea.

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Recommended Vaccines

Tetanus Diphtheria Polio Pertussis

In Ontario, the adsorbed vaccines for tetanus, diphtheria, and polio are now being used for primary immunization. All travellers should have these immunizations up to date. Tetanus should be updated every 10 years. It is advisable to give a booster at 5 years if travelling to a very underdeveloped country. Diphtheria toxoid is effective for ten years. Polio has almost been eliminated throughout the world but a booster as an adult should suffice if travelling to a polio-infected country. Pertussis (whooping cough) has made a comeback in Canada and it is recommended that one should receive an adult dose. Adverse reactions are usually limited to localized pain, redness, and swelling. Fever is infrequently reported. Systemic reactions are rare. Often times if there is any doubt about the length of time since the last booster, we will insist on updating this vaccine.

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Mumps Measles Rubella

In developing countries, measles causes significant mortality. Most persons born before 1970 are likely immune. It is advisable that travellers be vaccinated for measles. In Canada, measles vaccine is administered as Mumps, Measles, and Rubella (MMR) to children after 12 months of age with a booster at 4-6 years of age. Children 6-12 months old may be immunized with MMR if they will be in contact with other young children in developing countries. Children vaccinated before 12 months of age should be revaccinated at 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. Note that both Measles and Mumps have made a recent comeback in Canada.

The individual vaccinations are not readily available so the MMR combination is used. These are live vaccines and should NOT be used in pregnancy or persons who are immune-suppressed. Most frequent adverse reactions are malaise, fever, and rash lasting up to 3 days (starting 7-12 days after the shot). One in 3000 children with fever may have febrile convulsions.

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Hepatitis A

Hepatitis A is the most common vaccine-preventable illness that travellers should be protected against. It is worldwide in distribution. The infection is spread by close contact with infected individuals or contact with contaminated food and water. Prevention by ensuring clean food and water are your best defense but an effective and well-tolerated vaccine exists. Two doses six months apart should provide at least 10 years of protection but is probably valid for life. Protection may last 2-5 years after the initial dose alone. Side effects are infrequent and usually very mild (sore injection site). Persons who were born and raised in areas with high risk of hepatitis A are likely immune.

Children in developing countries usually have mild symptoms and may be unaware that they are immune. Any history of jaundice as a youth is most likely hepatitis A infection. Infection confers lifelong immunity. We can verify immunity with a simple blood test. Immune globulin (passive immunization)is still used in developing countries to counter hepatitis A and is fraught with a high risk of contamination (including HIV). This is probably the single most important vaccine for travellers as it can occur at any level of travel (backpackers to luxury resorts/business travel). World Health Organization makes a rare blanket recommendation that "all non-immune travellers (should receive this vaccine) when travelling to countries or areas at risk" (i.e. developing countries).

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Typhoid is a febrile illness caused by the bacteria Salmonella typhi. It is transmitted by 'unclean' food and water. Distribution is worldwide with particular prevalence in Africa and Asia especially the Indian subcontinent. Those at particular risk are backpackers, rural travellers, 'adventurous eaters' (markets, street vendors, and home/local restaurants), and 'VFRs' ("visiting friends and relatives"). Persons with reduced gastric acid should also be wary of typhoid, e.g. "heartburn" patients on treatment. Typhoid vaccines confer between 50-80% immunity. They will only protect against a moderate amount of ingested bacteria. There are 2 types of typhoid vaccines.

A live oral vaccine, Vivotif, is a series of 4 capsules taken over one week, which should not be taken with antibiotics or antimalarials. They must be ingested on an empty stomach and be refrigerated. Adverse effects include diarrhea (5%), vomitting (2%), and low grade fever (2%). An injectable vaccine (Typhim Vi; Typherix) can be given as a single dose. Side effects are mild: injection site reaction (4%) and fever (1%)..

Vivotif confers protection for 5 years and the injectable forms (Typhim Vi, Typherix) last 2 years..

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There is a combination vaccine Vivaxim that combines Hepatitis A with Typhoid - a convenient vaccine for higher risk adventurous travellers.

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Traveller's Diarrhea

Infectious diarrhea is the most common ailment that will affect the traveller (up to 60% with at least 20% confined to bed for a day). Attention to "safe food and water precautions" will minimize the chance of traveller's diarrhea. Despite best medical advice, the average tourist will forget/neglect the food/water precautions within 2 days of their holiday and put themselves at risk! There is a cholera vaccine Dukoral which covers Enterotoxic E. coli (ETEC), a major pathogen for moderate to severe traveller's diarrhea. For example, in Mexico, ETEC accounts for 29-72% of all bacterial diarrhea. This vaccine is a series of 2 doses taken a week apart starting at least 2 weeks before departure. This confers protection against ETEC for 3 months and cholera for 2 years. A single booster dose within 5 years of the original 2 dose series will give 3 more months of protection against ETEC. Side effects are rare (nausea, abdominal pain, diarrhea) and severe reactions (headache, dizziness, shortness of breath) occur <1/100,000..

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Hepatitis B

Hepatitis B is a world wide disease with carrier rates from 0.1 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, and indirect routes such as shared razors. Vaccination is recommended for all at-risk persons at any age. The risk depends on destination and occupation. Health care workers should be immunized if they are likely to come in contact with blood. Missionaries, diplomats and military personnel travelling in North Africa, Sub-Saharan Africa and South East Asia should be immunized if they plan to reside more than 6 months in areas with high levels of endemic hepatitis B and who will have close contact with the local population. Ontario's immunization program provides 2 'adult' doses to school age kids in grade 7.

Most adults over the age of 29 will not have received the hepatitis B vaccine but may be at significant risk of exposure to the virus depending on their habits/practices and extent of travel. The sentiment of this office is that ALL Ontario residents should be immunized for hepatitis B especially those travelling internationally.

Keep in mind that motor vehicle accidents and high risk activities are some of the major reasons that would force a traveller to seek medical attention and to cut short their trip. More importantly, many clinics/hospitals in developing countries do not routinely screen their blood and may use unsterilized needles, a significant health threat. Immunization involves a series of three shots at 0, 1, and 6 months. Two accelerated series are available for travellers rushed for time (0, 7 day, 21 day & 12 months OR 0, 1, 2, & 12 months). The shots are extremely well tolerated and adverse effects are rare..

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For those travellers who desire both hepatitis A and B coverage, Twinrix provides the ideal vaccine. Dosing schedule is similar to 2 of the options for hepatitis B (0, 1, 6 months and 0, 7 days, 21 days & 1 year). The 3 dose schedule basically saves you half the cost of hepatitis B compared to having to do both hepatitis A and B separately. There is another dosing option for children aged 1-15 years with 2 "adult" doses given 6-12 months apart. There are no significant side effects..

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Pre-exposure Rabies

Rabies is a worldwide concern. Keep in mind that there are no reliable data on the number of cases in developing countries. Further complicating matters is the fact that few countries have adequate public health care systems to isolate and test suspected animals. Only those who are likely to come in contact with wildlife (veterinarians, expatriate children) are at high risk and should be immunized. Those at moderate risk are adventurous travellers that are "off the beaten path", far from adequate medical care. Another complicating factor is the fact that many poor countries do not stock the Rabies Immunoglobin (immediate passive immunity to block the rabies virus from spreading) and even the regular rabies vaccine may be hard to locate..

It is administered in 3 intramuscular doses on days 0, 7, & 21-28. If a previously immunized person is exposed to rabies, two post-exposure doses are required, one immediately and one in 3 days..

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Medical personnel, missionaries, teachers, and some children staying in endemic areas for prolonged periods of time should consider a 'TB skin test'. A traveller at high risk should have a TB skin test done prior to departure (caution should be exercised if previously immunized with the BCG vaccine). Assuming this test is negative, the traveller should be advised to repeat the Mantoux test within 2 months of returning from their trip. If the skin test turns positive, treatment will be considered depending on age and circumstance..

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Japanese Encephalitis (JE)

This is a mosquito-borne encephalitis resulting in fever, chills, nausea, vomiting, and neurological symptoms. The disease is usually asymptomatic, but when overt encephalitis occurs, JE is fatal up to 30% of cases. JE occurs in epidemics in late summer and autumn in the temperate areas of Pakistan, India, Nepal, Bhutan, Bangladesh, Myanmar, China, Laos, Cambodia, Thailand, Korea, Japan, and Eastern Russia. 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 during the rainy season. The mosquitoes are present in greatest numbers from June to October and feed from dusk to dawn. The same general protection measures used against malaria are also important in avoiding JE.

The vaccine is recommended for persons planning longterm residence in countries experiencing epidemic JE, especially when travel is in rural areas (particularly rice culture and pig farming) and during the months of risk. Shortterm travellers (<1 month) especially those staying in urban areas are at negligible risk. The one exception would be one staying for several weeks in rural settings (near rice fields). This vaccine frequently causes injection site reactions (20%). Systemic side effects are generally mild, principally headaches and muscle aches. Severe allergic reactions occur at a rate of 1/10,000 doses. The vaccine is given as a series of 2 shots at 0 and 28 days. A booster can be given every 1-2 years..

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Prepared by: John O. Lee MD, CCFP, FCFP, Certificate in Travel Health, Ottawa West Travel Medicine Clinic