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Travel immunizations

American Family Physician, July 1, 2004 by Vincent Lo Re, III, Stephen J. Gluckman

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Primary vaccination with oral Ty21a consists of one enteric-coated capsule taken on alternate days for four doses. (30) Vaccine-elicited immunity occurs 14 days after receipt of the last vaccine dose, with an overall efficacy of approximately 50 to 80 percent. (30) [Evidence level A, RCT] A booster dose, consisting of the entire four-capsule regimen, is recommended every five years for those at continued risk. (30) The most common adverse effect reported is mild gastrointestinal upset. The vaccine is contraindicated in pregnant women, children under the age of six years, and immunocompromised patients. Care must be taken if this vaccine is given in association with antibiotics because they may kill the live-attenuated organisms.

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Primary vaccination with Typhim VI in patients two years or older consists of a single 0.5-mL dose given intramuscularly. Protective immunity is elicited 14 days after vaccine receipt. (30) The efficacy of this vaccine has been reported to be 50 to 80 percent. (8,30) [Evidence level A, RCT] A booster dose given every two years is recommended for continued exposure. No data have been reported regarding its use in pregnant women or immunocompromised patients, although it theoretically is a safer alternative in these groups.

MENINGOCOCCAL

Meningococcal vaccine (Menomune) is recommended for travelers to sub-Saharan Africa, where epidemics of serogroups A or C meningococcal disease occur frequently from December through June in the "meningitis belt" from Senegal to Ethiopia (31) (Figure 4). The vaccine is required for pilgrims to Saudi Arabia during the Hajj and at other religious holidays. (8)

The vaccine is effective only against sero-groups A, C, Y, and W-135.25,31 Primary immunization in patients two years and older consists of a single 0.5-mL dose given by subcutaneous injection, and this dose confers immunity for at least three years. (31) Protective levels of antibody are achieved in seven to 10 days. (8) Vaccination is not contra-indicated in pregnancy. (31) Revaccination may be considered within three to five years for continued exposure. (31)

RABIES

Canine rabies remains endemic in the Indian subcontinent, China, southeast Asia, the Philippines, parts of Indonesia, Latin America, Africa, and countries of the former Soviet Union. (1,2,32) Postexposure prophylaxis, although effective, may not be readily available. (33) Preexposure rabies vaccination should be considered for travelers who plan a prolonged stay (more than 30 days) in an endemic region, who travel in remote areas, work near animals, engage in activities that could attract animals (e.g., hiking, cycling), or for persons who cannot report an expo-sure if bitten (e.g., young children).

In the United States, intramuscular formulations of the purified chick embryo cell vaccine (RabAvert) and human diploid cell vaccine (Imovax) are available. Preexposure rabies immunization consists of three 1.0-mL doses of one of the rabies vaccine formulations given on days zero, seven, and 21 or 28.34 After a high-risk bite, travelers who received preexposure vaccination still require local wound care and two additional rabies vaccine doses (on the day of the bite and on day 3), but administration of rabies immune globulin is not necessary. (33)

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Travel immunizations

American Family Physician, July 1, 2004 by Vincent Lo Re, III, Stephen J. Gluckman

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