Uncertainty and anticipation are the joys of travel. Once you have decided to go away, whether it is for a week or for two years, the fun begins! You will have many things on your mind. One of them should be your health. Some of the questions you should be asking yourself include:
Do I need any inoculations or "shots" before I go?
Where can I get them?
How soon should I begin?
Will I be travelling in malaria areas, and should I be asking antimalarial medications?
What other medications should I be taking along?
What other medical supplies will I need?
Am I healthy enough to travel? Would it be the best to see my doctor before I go?
Does the fact that I’m climbing Mt. Kilimanjaro or Rwenzori three weeks after my heart attack make a difference?
I may be pregnant. Is that ok?
Is there anything else over there that I don't know about?
Is there anything else over there that I don't know, about but should?
What do I do and who do I see if I become sick while am away?
Can anyone figure out what is the matter with me when I get home?
Others less medically oriented questions might be:
What's the weather like over there? (depends)
Do they have E-mail in Africa? (yes)
Is there a Starbucks in Uganda? (doubt it)
Can I catch The Simpsons every Sunday? (hopefully)
On which side of the road do they drive over there? (you'd better find out)
Now that you have finally finished asking all of these questions, you should probably arrange to see your doctor. If they are not able to provide with all of the accurate, up-to-date advice you need, then you should probably head off to see someone at a travel clinic.
Most travel medicine professionals have good understanding of geography, tropical medicine and travel – related illness .They should have the vaccines already stored in their fridge, and lots of interesting written information to give you. look for masks, paintings and other artifacts around their office in the hope that they not only know about your destination, but that they have been there as well!
Based upon your destination and other risk factors, the doctor or nurse should be able to plan with you the course of pre-travel inoculation and malaria prophylaxis if necessary. But it is about much more than just needless and pills. You should also learn how your own personal behavior can greatly lessen the probability of most infections and other catastrophes. As well, you should also find out how to deal with certain medical problems should they arise. I hope the following will provide you with much of the information you will need to know. So on your mark, get set …get ready!
Travel is fatal to prejudice, bigotry, and narrow-mildness
While it is certainly not the only topic of concern to traveler the issue of pre-travel inoculation, or "what shots do I need", certainly creates the most anxiety and confusion in the minds of travelers and medical personnel alike. some people believe that with a few needles, they are immune to everything to which they might be exposed. Not true! In fact, infectious diseases account for only a small proportion of the mortality in travelers. Having said that, immunization is an extremely effective means of preventing certain infections to which the travelers might be exposed.
We have a lot of vaccines, and there are a lot of countries, but not every one visiting every country needs every vaccine.how do we decide? well, practicing travel medicine is abit like being assurance agent. We do our best to assess the risks to which the traveler will be exposed, and will try to recommend the most appropriate forms of protection, whether it be needles, pills, condoms, or common sense. To do so requires knowledge of geography, tropical and many other fields of medicine, epidemiology and human behavior. It also requires knowledge of each individual traveler.
The most important principle we go by, is: “immunize according to risk…not just the country visited. In assessing these risks, the following are considered:
Each individual traveler will also help decide which vaccines to receive. Some people are petrified of needles and will choose to forego them. Often, when multiple dose of a vaccine are required (e.g hepatitis B, rabbies) there is not enough time to receive a full course of vaccination. Travelers who grew up in less developed countries may have pre-existing immunity to certain infections such as, such as Hepatitis A or B. Some parents will choose to worry only about their travel. And finally, the vaccines are not inexpensive, and this may play a role in choosing what to receive. It is up to medical professional to advise the patient to decide which vaccines to receive. To make things abit more confusing, .....not every travel medicine professional will make the same recommendations for the same traveler
To make things a little less confusing, we decide the shots available into those that are:
The routine vaccinations include:
Tetnus-Diphtheria-polio-while these infections have largely been eradicated in most industrialised countries, they occur in the tropics and some European countries. Polio has now been eradicated from the western hemisphere, and hopefully will soon disappear from the face of the earth. Many adults, however, no longer have adequate immunity against these infections. Its possible they they stopped getting regular boosters while still in high school
Boosters against tetanus and Diphtheria should be given every 10 years whether travelling or not. for 10 years.
Measles – This viral infection is still quite prevalent in lesser –developed countries. The vaccine is recommended for those born between 1970-1980, who have not already received a second dose of the vaccine. Children are immunized at the age of one, and again at five a years of age.
The required vaccines are:
Yellow fever-yellow fever is a viral infection that occurs in both tropical Africa and south America. It is transmitted by the culex mosquito. It's main effects are on the liver, and the mortality rate from this infection may be as high as 30%.
Yellow fever vaccine is a requirement for entry to several countries in Africa. And not just Afriac but also south America, and elsewhere, when one has recently traveled to another country which has yellow fever, which lies in the traditional endemic zones for yellow fever. For example, there is no yellow fever in Thailand, but if one were traveling from Nigeria or Brazil (which have yellow fever) to Thailand, but it would be required. In addition it is a good idea to be vaccinated if one is entering rural areas in the traditional endemic areas.
The vaccine, which is given as a single dose, is virtually 100% effective after 10 days, and provides protection for 10 years. It is a live vaccine and therefore is recommended for pregnant women, anyone who is immunosuppressed, or those with an egg allergy. However in some of these situations, one must weigh the risks] against the benefits. It can be given to children as young as 6 months of age if they are at significant risk. The side effects usually mild, and may not appear until 5 to 10 years after vaccination
Yellow fever vaccine is only administered at centers that are specially designated as yellow fever clinics. You should receive an international certificate of vaccination documenting your shot, and this may have to be presented when crossing international borders.
Contrary to some popular belief, no invocation are required to get back into any "western" countries.
The recommended vaccines are:
Typhoid fever - This is a serious bacterial infection that is transmitted via contaminated food and water. It can affect the blood stream, the lungs, intestines and brain. There are two vaccines available to help lessen the risk of typhoid fever. However, they are less than 70% effective. Therefore the most important measure is to take care of your food and water.
Typhim Vi is an injectable vaccine, which after one dose provides up to 70% protection for about 3years .the side effects are usually minor, and include some soreness at injection site. The vaccine is safe in pregnancy, and can be administered down to the age of 2.
Vivotif is an oral vaccine, which provides protection for up to 5 years. It consists of 3 to 4 capsules or packets of powder (the formulation keeps changing) which must be taken on alternate days. It may cause un upset stomach. Being a “live” vaccine, it should not be given to pregnant women or anyone who is immune suppressed. Due to dosing schedule and the need to keep capsules refrigerated, the compliance with this vaccine is often less than perfect.
Hepatitis A - Hepatitis A is a viral infection of the liver, transmitted through infected food and water, or from person to person. A few weeks after becoming infected, one may become ill with fever, nausea, weakness and fatigue. This is followed by jaundice (a yellowing of the skin and eyes). There is no specific treatment of hepatitis A. Thankfully, it usually is a self-limited least a month. The disease is usually quite mild, or undetectable in small children, but more serious in the elderly, with a mortality rate approaching 3%.
Doctors used to administer immune serum globulin, in the butt to prevent hepatitis. This has now been replaced by three excellent vaccines. Havrix, Vaqta and Avaxim all provide almost 100% protection against this virus. The three vaccines are quite comparable, consisting of an initial dose, ideally at least two weeks before departure (though even at last minute shot is worthwhile), followed by booster from 6 to 12 months later. If you happen to wait longer for your booster, don’t worry. It is still ok. The initial dose provides protection for at least a year and a booster for at least 10 years. Side effects are minimal. They are also interchangeable, so if your dose was with one, it can be boosted with one of the others if necessary. It is considered safe in pregnancy..
Many doctors do not immunize small children (less than 5 years of age) because the disease is so mild at this age. There is the risk, however, that such a child may return home infected, though not sick and pass the infection on to other non immune children or adults. It is worth while checking the immune status of those who were born in endemic countries, as they will often been exposed as children and will have immunity, and thus, not require the vaccine.
Cholera – Cholera is a bacterial infection of the intestine which causes severe watery diarrhea, and sometimes results into death. It is passed through infected water and food. Outbreak of cholera continue to occur in more than 60 countries worldwide. This infection is exceedingly rare in travelers (less than 1 in 50000), particularly in those who stay on the beaten path and even use a small bit of common sense with their choice of water.
A new, oral vaccine is now available against cholera, Mutacol Berna. It is superior to the old injectable vaccine which probably provided less than 50% protection. There are also very few side effects. It is a single dose, which has to be mixed with water. It's a live vaccine, and should not be used in pregnancy or those are immunosuppressed. It is also recommended under the age of 2. It provides up to 80% protection for at least 6 months.
While this vaccine is a good one, it is probably rarely indicated in travelers. Perhaps a health worker going to work in refugee camp where cholera has broken out, or someone returning to their village back home where there may be access to clean water should have the vaccine. Most travelers do have access to clean food and water and should be instructed on ways to minimize their risk, namely “Boil it, bottle, peel it, cook it…or forget it!
This vaccine is currently required for pilgrams travelling to Mecca for the Hajj.
As well, Zanzibar (off the coast of Tanzania) and Madagascar also require proof of inoculation. Many travel advisors will instead finish the patient with a certificate of exemption.
Meningitis – Meningococcal disease is caused by bacterium, which is transmitted from person to person via close contact .it may involve the blood (meningococcal )or the brain and spinal cord (meningitis ).the symptoms may include fever ,headache and a stiff neck. While it often begins like a mild illness, it may quickly progress to shock or coma it is usually accompanied by a petechial (small bruises) rash.
Meningococcal vaccine is recommended for travelers who are off to the areas where meningococcal diseases is prevalent, where there have been significant outbreaks in the recent past. This applies particularly to longer term travelers who will have close contact with the local population. The meningitis belt in Africa stretches from Gambia in the west to Ethiopia in the east. Outbreaks are common in the dry winter month between December and may. As well, because there have been large outbreaks in the past, vaccination is requirement for religious pilgrims entering Saudi Arabia.
The vaccine consists of one dose, and the side effects are minimal. It provides protection for between 3-5 years though this is less in children vaccinated under the age of 4.
Hepatitis B – This is a viral infection of the river, which is transmitted through the blood, blood products and unprotected sex. It differs from hepatitis A in its mode of transmission, but more importantly, in its ability to cause more severe acute, or chronic liver disease. While most of those who are infected recover and developed immunity, about 5% go on to become carriers of the virus. This carrier state may lead to conditions such as chronic hepatitis, cirrhosis or cancer of the liver.
In North America, less than 3% of the general population are carriers of hepatitis B virus. This figure may be high as 15% in other parts of the world, particularly Africa and Asia. Therefore the traveler to these destinations is at higher risk. It is not unreasonable to consider this vaccine for all travelers, as one never knows when an accident or illness will necessitate less than sterile medical treatment. In particular, it is strongly recommended for longer term travelers (more than 6 month) to the areas of the world with a high prevalence of hepatitis B in the local population (the figure of 6 month is arbitrary, and it would be un reasonable to offer it to shorter term travelers or anyone who will be at higher risk based upon occupational exposure or other dangerous behaviors e.g. health care workers, those who plan to engage in unsafe sex.
Two very safe and effective vaccines are available – Engerix B and Recombivax. The full schedule consists of 3 doses, traditionally given at 0-1-6 month. Accelerated, but effective, regimes for those lacking sufficient time are 0-1-2 month 0-7-21 days or 0-14-28 days. With these latter schedules, a further booster dose is suggested after one year. The full course of hepatitis B vaccination provides lifetime protection.
For many, it will be convenient, and little less expensive, to receive a combined hepatitis A and B vaccine, called twinrix. This vaccine is usually given at 0-1-6months,but may also be accelerated when necessary as above .
Rabies – Rabies is a viral infection of the central nervous system, which when contracted by humans is felt to be 100% fatal in the absence of property pre-or post exposure vaccination. It is transmitted by the bite, scratch or rarely a lick from infected animals, most commonly dogs. Cats, bats and monkeys may also be infectious. In many countries of the world, stray dogs, many of whom may have rabies, are a tremendous problem. Not all dogs behave like old yeller (If you remember the Disney movie from the 1950s). Rather, they may be docile and some pathetic looking …just the kind of animal you would love to pet! Don’t!
Pre-exposure vaccination, which consists of three injections (days 0 -7 -21 or 28), is only recommended for those at highest risk. This may include those with occupational exposure (veterinarians, spelunkers), or others who by nature of location and duration of their travels might be exposed. Children, who are reputed not to have the same common sense like adults, may be at greater risk. Pre-exposure vaccination does not preclude the need for further injections after a potentially rabid bite .rabies vaccine is quite expensive ($250-$300 Cdn or US. for 3 doses), and this certainly puts a limit of the number of people who receive it. By the way a spelunker is someone frequenting bat caves.
If such a bite occurs it is imperative that the wound is thoroughly cleansed with soap and water. If one has received pre- exposure vaccination, then there is still a need for 2 further injections (on days 0 and three)
Of vaccine after exposure for a person who has not previously been vaccinated, it is necessary to receive HRIG (Human Rabies Immune Globulin) as quickly as possible. This provides some immediate protection. As well, immunization with the rabies vaccine on days 0, 3, 7, 14 and 28 should be started.
Safe, effective rabies vaccines are not always available in some countries and when they are they may be exorbitantly expensive. Remember, if you are bitten, wash the wound thoroughly and seek good medical care as quick as possible. If effective vaccines are not available, you should travel to somewhere where they are where they are.
Tick-borne Encephalitis - This viral infection of the brain is found in rural areas of both eastern and western Europe .as the name implies, it is transmitted via ticks, which like to jump off the plants and bushes onto unsuspecting and un covered hikers. Ticks do their feedings from spring through fall, so only those who travel into rural areas during this period are at risk.
The vaccine (FSME IMMUNE) consists of two doses, given 1-3 months apart. Booster doses should be administered at about 12 months and then every three years if there is recurrent exposure. Personal measures such as wearing short pants and socks, using insect repellents, and inspecting ones skin at the end of the day for embedded ticks should be encouraged.
Influenza – The flue as it is better known, is a particular risk to the elderly (over 65) and to those which chronic underlying medical problems. These include respiratory conditions such as asthma and emphysema, heart disease immunodeficiency, diabetes and cancer. The flue season in the southern hemisphere occurs during our summer, as opposed other seasons elsewhere, which occurs between December and March. The vaccine would be recommended for those at higher risk as well as anyone wishing to reduce his or her risk of becoming ill with the flue.
Pneumococcal pneumonia – like influenza, this common respiratory infection is particularly lethal in the elderly, and those with underlying medical problems. All people at higher risk should receive this vaccine.
Tuberculosis - TB is a bacterial infection which primarily affects the lungs, though it may affect other organs such as the kidney, the bowel and the lymph, modes. Unfortunately, it is on the increase throughout the world, as are drugs resistant strains of the bacteria. Many people, especially in less developed countries, have been exposed to TB in the past, and have developed some immunity to the infection. However this so- called immunity may break down, sometimes because of other medications or medical problems, and the infection may reactivate.
Travelers going off to highly endemic areas for longer periods of time, and who will have lots of exposure to the local population. Long term volunteers and missionaries fit this description.
There is a fair bit of controversy regarding immunization to prevent TB. Most of the world outside of North America routinely administers BCG to children at birth. This is supposed to prevent TB, in fact, from the studies that have that have been done against certain forms of TB, and certain geographic areas the North American approach is to do “two-step” TB skin (Monteux test) prior to travel. This test is usually normal or negative, unless there has been past exposure to tuberculosis or vaccination with BCG. Being negative, the usual plan is to repeat the test few months after return. In this way we detect those who have “converted” from negative to positive. It is this group who is at higher risk of developing active TB, and hence would be offered some form of medication, usually isoniazid (INH), as chemoprophylaxis for six months.
Considering the spread of multi-drug resistant TB and difficulty in doing yearly skin tests, it might be worthwhile to at least discuss the pros and cons of BCG with high risk travelers, particularly young children.
What are the side effects?
“We have nothing to fear but fear itself” (Franklin Delano Roosevelt, 1944), could have been said about all of the needles. For the most part, the side effects and mild, consisting of localized soreness and tenderness at the site of injection within the first 48 hours. Allergic reactions tend to be quite rare, but they can occur, so it is the reason that you will be asked to remain in the office for at least 15minutes after your injection.
What is not so rare is vasovagal syncope, or a simple “fainting spell”, the combination of anticipation and a bit of pain is sometimes enough to provoke this reaction. If you are prone to such spells (if the sight of blood, upsetting news or standing in line at the bank in an overcoat for 30 minutes makes you feel weak and dizzy),let the doctor or nurse know in advance. They will have you lie down, so that a little more blood remains in your head where it belongs!
It is safe and necessary because of time constraints to administer several vaccines at the same time. In situation, you may be sore in a few places at the same time, but the vaccines will still be effective.
There is no shortage of people out there extorting the dangers of vaccination .if you choose to believe them. I suggest you do so at your own risk.
The simple answer is “well in advance”. There was a time when travelers received there series of vaccines over several visits. Perhaps one of the reasons for this was that the vaccines tended to be quite reactogenic, that is, they hurt! Generally, this is no longer the case, and as mentioned, several vaccines may be administered at the same time, but at different sites.
Having said that, remember that several of the infections against which are vaccinated, such as hepatitis B, Japanese encephalitis and rabies, require a series of shots. There are accelerated schedules in some cases as described, but if your living the next day, none of the schedules is that fast. Certain vaccines, such as havrix and engerix may go un refrigerated for up to two weeks, so a booster dose can be carried with you to your destination. Sometimes travelers have started a series of shots, but have not completed the whole series e.g. hepatitis B vaccine at other times, they fail to come back at the recommended time for a booster e.g. at 1 year for hepatitis A vaccine I think it was in the movie meatballs, where they chanted, “it just doesn’t matter!” By that, I mean that a booster dose can be given any time without the necessity of having to begin the original series all over again.
As well, there is a lag time of several days to two weeks until you will have developed adequate protective anti bodies to the diseases. And finally, in the case of yellow fever vaccine, it is not considered valid for 10 days, and hence you might not be granted admission to some countries, and if you are, it will probably cost you some hard earned us dollars
So that is the scoop of vaccines! They really don’t hurt as much as you think, so make sure that you get the ones you need.