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Vaccination in Travelling

Iris Rengganis

Divisi Alergi Imunologi Klinik

Departemen Ilmu Penyakit Dalam

FKUI/RSCM

Name : Dr. dr. Iris Rengganis, SpPD, K-AI, FINASIM DOB : Jakarta, 29 June 1958 Education : - Dokter Umum/S1 : FKUI 1983 - Dokter Spesialis Penyakit Dalam/S2 : FKUI 1994 - Konsultan Alergi-Imunologi/Sp2 : FKUI 2000 - Doktoral/S3 : IPB 2009 Working Experiences : - Puskesmas Kelurahan Cikoko, Jakarta Selatan, 1984-1988 - RS Haji Jakarta, Pondok Gede, Jakarta Timur, 1995-1997 - FKUI/RSCM, 1998-now Organization : - IDI (Ikatan Dokter Indonesia) - PAPDI (Persatuan Dokter Spesialis Penyakit Dalam Indonesia) - PERALMUNI (Perhimpunan Alergi Imunologi Indonesia) - DAI (Dewan Asma Indonesia)

Curriculum Vitae

Why Vaccinate Travellers?

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International

Travel Air travel and other public transportation modes

facilitate rapid spread of infectious diseases1

Frequent travelers contributed to the international spread of infections1

In 2005, 11.5 million passengers traveled on cruise ships worldwide1

Mortality and morbidity increased in travelers compared to those who stayed home2

Health problems in travelers are frequent2

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1.Marti, et.al. Exp Rev Vaccines 2008; 7 (5) :679-687 2.Steffen, et.al. Int J Antimicrob Agents 2003;21:89-95

Why Vaccinate Travellers? Hepatitis A – 1.4 million new cases/year

Hepatitis B – over 1 million deaths/year

Typhoid – 16 million new cases/year

The risk of infection increases with duration of travel and low levels of hygiene (e.g. unlikely to monitor food preparation in cafes, restaurants, etc)

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10x higher?1-3

1.WHO. Hepatitis A vaccines. Wkly Epidemiol Rec 2000; 75: 38–44.

2.WHO. Typhoid vaccines. Wkly Epidemiol Rec 2000; 75: 257–64.

3.Jong EC. Risks of hepatitis A and B in the travelling public. J Travel Med 2001; 8 Suppl 1: S3–8.

4.World Tourism Organisation. Facts and figures. August 2001. Available from: http://www.world-tourism.org [Accessed 1 September 2003]

5.Löscher T, Keystone JS, Steffen R. Vaccination of travellers against hepatitis A and B. J Travel Med 1999; 6: 107–14

Incidence of Vaccine-preventable

Diseases Among Travellers

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HAV HBV Rabies? Typhoid fever Polio

Incid

en

ce

(m

orb

idit

y p

er

10

0,0

00

tra

ve

lle

rs)

Cholera

Hikers Hotel- tourist

Hotel- tourist

(Animal bites in expat)

India, N/W

Africa & Peru

Other places

2000

300 80-240 200

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3 2

0.3

Steffen et al. J Med Virol 1994; 44: 460–2.

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Priority of Recommended Vaccinations

Infection Incidence Impact Total Vaccination

Hepatitis A +++ ++ +++++ Logical

priorities –

do not

primarily

immunise

against

infection on

bottom of

this list

Hepatitis B ++ +++ +++++

Rabies ++ ++ ++++

Yellow fever + +++ ++++

Influenza +++ + ++++

Typhoid fever ++ + +++

Measles ++ + +++

Diphtheria (+) ++ ++(+)

Tetanus (+) ++ ++(+)

Meningococcal disease (+) ++ ++(+)

Japanese encephalitis (+) ++ ++(+)

Poliomyelitis (+) ++ ++(+)

Cholera + + ++

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Rate per 100,000: +++ = >100; ++ = 1–99; + = 0.1–0.9; (+) = <0.1

Impact: +++ = high case fatality rate or serious sequelae;

++ = >5% case fatality rate or incapacitation >4 weeks;

+ = low case fatality rate, brief incapacitation

Steffen et al. Int J Antimicrob Agents 2003; 21: 175–80.

Infections Often Acquired by

Travellers in South East of Asia

Food/water-borne infections

◦ Mostly enteric pathogens such as enterotoxigenic E.coli, Salmonella, Campylobacter, Shigella & Giardia species.

◦ Others include HAV, typhoid and amoebiasis

Respiratory infections

◦ Vaccine-preventable infections include influenza, pertussis, diphtheria, measles, and invasive meningococcal disease.

◦ Tuberculosis is often acquired by expatriates living in high-risk areas for long periods

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Geographic Distribution of Potential Health Hazards to Travelers – Asia. Traveler’s Health - Yellow Book, 2008.

Available at: http://wwwn.cdc.gov/travel/yellowBookCh3-Asia.aspx [accessed on 15 January 2009]

Infections Often Acquired by

Travellers in South East of Asia

Vector-borne infections

◦ Mosquito-borne: malaria, dengue, Japanese

encephalitis.

Bloodborne infections

◦ Transmitted by blood transfusion, contaminated

needles, sexual activity or other body fluid

contact

◦ Include HBV, HCV and HIV

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Geographic Distribution of Potential Health Hazards to Travelers – Asia. Traveler’s Health - Yellow Book, 2008. Available at:

http://wwwn.cdc.gov/travel/yellowBookCh3-Asia.aspx [accessed on 15 January 2009]

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Vaccination For Travellers1,2

Advised before travel to the Asia-Pacific Hepatitis A

Typhoid Fever

Influenza

Rabies

Tuberculosis

Typhoid fever

Cholera

Japanese encephalitis

10 1. Introduction – General Recommendations on Vaccination and Prophylaxis. Traveler’s Health – Yellow Book

2008. 2. Health advice for international travel. Harrison’s Principles of Internal Medicine, 17th Ed, 2008.

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Vaccine Preventable

Disease

CDC divides vaccines for travel into

three categories: routine,

recommended, and required.

While your doctor will tell you which

ones you should have, it's best to be

aware of them ahead of time.

Are you aware of which

types of vaccinations you

or those traveling with

you may need?

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Routine Vaccination

Be sure that you and your family are up to date on your routine

vaccinations. These vaccines are necessary for protection from

diseases that are still common in many parts of the world even though

they rarely occur in some country. If you are not sure which

vaccinations are routine, look at the schedules.

Recommended Adult Immunization Schedule

Recommended Children Immunization Schedule

International Certificate of Vaccination

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Hepatitis A

Hepatitis B

Typhoid Fever Seasonal Influenza

Meningococcal

Yellow fever

Pneumococcal

Vaccine Preventable Disease

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Hepatitis A

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Hepatitis A: Facts

Spread via faecal–oral route1

Morbidity and mortality increase with age2

Most frequent vaccine-preventable disease in travellers3

No identified risk factors in 50% of cases1

1 WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7

2. CDC, Hepatitis surveillance report 61, 2006

3. Steffen, et al. Int J Antimicrob Agents 2003; 21: 175–80

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Geographical Distribution of

Hepatitis A, 2005

MMWR Recomm & Rep 1999 Vol. 48 NO, RR-12

Anti-hepatitis A

virus prevalence

High

Intermediate

Low

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Hepatitis A Risk Groups

Travellers

Chronic liver disease patients

Those at occupational riskthose at

occupational risk such as food handlers,

medical personnel in hospitals, people

working with non-human primates and

daycare centre employees.

WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7

Hepatitis B

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Hepatitis B surface

antigen (HBsAg)

prevalence

High

Intermediate

Low

Geographical Distribution of

Hepatitis B

Mast, et al. MMWR Recomm Rep 2006; 55 (RR16): 1–25

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Transmission Routes for HBV

Highly infectious blood-borne virus

Individuals often unknowingly put themselves

at risk of infection

Exposure to hepatitis B is associated with:

◦ healthcare treatment

◦ sexual activity

◦ non-sterile needles/equipment

◦ wound site where skin is punctured, tattoos

◦ sporting activities (go-karting, skiing)

WHO. Hepatitis B factsheet, 2000

Thypoid Fever

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Why Vaccinate Against Typhoid?

Endemic in the developing world, 16 million new cases of typhoid

and 600,000 deaths per year1

Prevents severe clinical symptoms and development of carriers

(2-5% risk)2

WHO recommends vaccination for travellers to high endemic

areas (despite lower risk but high case fatality than hepatitis A)1,3

Recommended for travellers to countries (e.g. Asia, Latin America,

Africa) with prolonged exposure to potentially contaminated food

& water4

1. Steffen R. Vaccine 1993;11:518-20

2. WHO. Typhoid fever factsheet, 1997 http://www.who.int/vaccine_research/diseases/diarrhoeal/en/index7.html

3. WHO. Typhoid vaccines. Wkly Epidemiol Rec 2000;75:257-64

4. Typhoid immunization. Recommendations of ACIP. MMWR 1994;43:1-7

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Transmission Routes for Typhoid

Via faecal–oral route thru contaminated water

and food (including ice cubes, shellfish, vegetables

eaten raw, milk and milk products)

http://www.who.int/vaccine_research/diseases/diarrhoeal/en/index7.html

(last accessed 15 January 2009)

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Prevention of Typhoid Fever

Preventing contamination of food

and water extremely important

(e.g. hand-washing, etc.)

Vaccination:

Vi capsular polysaccharide vaccine (ViCPS) given IM injection or oral, live attenuated vaccine (Ty21a)

International Travel with Infants and young Children. Vaccine Recommendations

for Infants and Young Children.Traveler’s Health. Yellow Book, 2008. Available

at: http://wwwn.cdc.gov/travel/yellowBookCh8-VacRecInfantsChidren.aspx

(last accessed 15 January 2009)

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Recommendations: Typhoid

Primary vaccination (single dose) against typhoid fever provides protection for up to 3 years

WHO and ACIP recommend revaccination every

3 years for continued protection

WHO. Wkly Epidemiol Rec 2000; 75: 257–64. ACIP. MMWR Recomm Rep 1990; 39: 1–5.

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Influenza

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Seasonal Influenza

Affects 5-15% of the world’s population annually

Second most frequent vaccine-preventable infection in travelers

Contributes to approximately 250,000 to 500,000 deaths annually

Guidelines on influenza vaccination for international travel are scarce

Marti, et.al. Expert Rev Vaccines 2008; 7(5): 679-687

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Seasonal Influenza

Easily transmissible (via respiratory droplets or fomites)

Increased risk at:

- air travel

- sea travel

- mass gatherings (e.g. Hajj pilgrimage, Olympic

games, etc.)

Marti, et.al. Expert Rev Vaccines 2008; 7(5): 679-687

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Recommendation for

Influenza Vaccine

High risk group :

◦ Elderly 65 years and above

◦ Chronic heart, lung, renal diseases

◦ Diabetics

◦ Healthcare workers

◦ Travelers to high risk area

When do you need to vaccinate every 6 months:

◦ If the new vaccine shows >one different strain

◦ If traveling to high risk areas

CDC. Pink Book. 10th ed, 2008

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For hajj pilgrimage: The Department of Health in Saudi Arabia1 and

Indonesia recommend that All receive influenza

vaccination prior to Hajj pilgrimage

Especially for high-risk pilgrims

Elderly >60 years old

Patients of chronic diseases (heart disease, kidney

disease, liver disease, DM etc)

Influenza Vaccination for Hajj

Pilgrimage

WHO. Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj).

Weekly Epidemiol Rec. 2006; 81(44): 417–24

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Year 2000 Hajj Outbreak

of Meningococcal Meningitis with W-1351,2

Worldwide hundreds of cases in Hajj returnees and close contacts1,2

Change in recommendation

from bivalent to quadrivalent vaccine in 2001

Visa requirement in 20022

Case fatality rate among travellers slightly exceeds 20%3

1. Taha, et.al. The Lancet 2000;356:2159

2. Balkhy. Int J Antimicr Agents 2003;21:193-199

3. Steffen,et.al. Int J Antimicr Agents 2003;21:175-180

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Meningococcal Vaccine

Recommended for those travelling to the ‘meningitis belt’ of Sub-

Saharan Africa (Senegal to Ethiopia)

those travelling to epidemics areas (Middle East)

Saudi Arabian Ministry of Health requires that all pilgrims attending the annual Hajj show

evidence of vaccination with tetravalent meningococcal

vaccine

CDC, Pink Book, 10th ed. 2008

Conclusions

Travellers often unknowingly put themselves at risk from many infections. Safe and effective vaccines against certain diseases are available. Monovalent and combined vaccines with flexible vaccination schedules ensure all travellers are accommodated (including last-minute travelers).

Prioritisation is important; vaccination is essential!

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Thank You