Travel vaccinations

Identify patient and type of holiday

Identify patient and ascertain where they are going to and for how long and the type of accommodation that they will be staying in.

Back packers or people staying abroad for more than 3 weeks may be at greater risk of Rabies.
Those travelling inland in countries such as Thailand, may be at risk from Japanese Encephalitis (particularly in pig farming areas).
Those walking and camping in the Black Forest in Europe, could be at risk from Tick-borne Encephalitis.
Meningitis C is required for visitors to the sub-Saharan Belt.
Malaria prophylaxis is required for many parts of the world.
If a traveller is staying in a risk area for a longer period or for work, then Hepatitis B, TB and Diphtheria need to be considered, however safe sex needs to be discussed when considering Hepatitis B as there is no vaccine for Aids!

Allergies, immuno-compromised, pregnancy or intention of pregnancy, age and wellness.

Does the patient have any known allergies, is immuno-compromised (Patients who are HIV positive are at greater risk from infections and therefore require immunisations, however consult 'Green Book' as some vaccines are contra-indicated e.g. Yellow Fever.)
The anti-malarial Mefloquine is contra-indicated in pregnancy and the patient should not try to get pregnant for 3 months after taking this drug.

Destination requirements, plan regime.

Ascertain from up-to-date immunisation schedule what immunisations are required for destination and stop-overs, and what they have had previously. If in doubt, consult the Green Book.
All destinations require that Tetanus and Polio is up to date.
Countries outside of Europe, USA and Australia usually require at least Hepatitis A and often include Typhoid.
LIVE VACCINES (Polio and Yellow Fever), must be given either together or three weeks apart. Note - Yellow Fever certificate must be dated from at least 10 days prior to destination date (charge £20).

Order of Immunisations

Usually give Yellow fever and Polio first (or 3 weeks apart). Remainder 2 weeks later (if attenuated) or 3 weeks (if live). However, if time is limited, all vaccinations can be given together, but in differing sites. Note - Hepatitis vaccines need to be given in deltoid muscle.
If 3 or fewer vaccines required (plus polio drops), then normally these are given at one visit (Unless Junior Hepatitis A needs to be ordered for <16) Order non-stock vaccines for next visit (patient to collect from Chemist) - Junior Havrix, Rabies, Meningitis A+C, Japanese and Tick-Borne Encephalitis.
Discuss anti-malarials (patient buys Chloroquine and Proquanil from Chemist, private prescription for Mefloquine).
Diphtheria and TB is endemic in former USSR - Low Dose Diphtheria and Tetanus mixed and Low Dose Diphtheria on its own, are available from vaccine suppliers. Note - DO NOT USE BABY STRENGTH DIPHTHERIA ON ADULTS.

Vaccines

Consult green book.
Discuss possible side-effects.
Tetanus and Polio
Primary course and 2 boosters are considered to confer life time immunity. However, practice policy is to boost every 10 years. First injection claim A; All others claim B.
Typhoid
Primary injection (claim A), Boosters at 3 years (claim B). Mixed vaccine of Hep A and Typhoid available (Heptyrix claim B x 1) - need booster of Hep A only.
Hepatitis A
Primary (claim B), Booster 6 - 12 months (No further claims can be made). Deltoid. Lasts 10 years. Aged 15 or less - Junior Havrix (order)
Hepatitis B
Given Day 0, one month, 6 months. (?sero-converted blood test at 9+months). Order Engerix B x 3 vials, no claim. Lasts 3-5 years. Deltoid.
Yellow Fever
Charge £20 and fill in certificate (must be given 10 days prior to destination date). Live vaccine - must be given on same day as other live vaccines (Polio etc) or 3 weeks apart. Lasts 10 years.
Rabies
Pre-exposure regime ( if bitten or scratched, will need further vaccinations). Give on days 0, 7 and 28. (Booster every 2-3 years) (order vaccine and no claim allowable).
Meningitis C
Single dose Mengivac A+C, (order from Chemist, no claim allowable). 3-5 years.
Tick-borne Encephalitis (2 x 0.5ml vials) and Japanese Encephalitis (3x 1ml vials)
Order from chemist - no claim allowable. Give Tick-Borne 0 and 4-12 weeks (booster at 9 months gives 3 yrs protection.) Japanese 0, 7 - 14, and 28 days ( full immunity one month afterwards).
Cholera Vaccine
Not given and no longer available.

Malaria prophylaxis

Consult malaria information resource, as recommendations change as resistance to drugs change.
Children must be weighed to calculate dose.
Give advice on precautions, avoidance of mosquito bites, nets, repellents and to consult a doctor if unwell.
Incubation period for Malaria can be many months.
Natives of country lose natural immunity after being absent for a year.
Chloroquine and/or proguanil should be started a week before travel and continued for 4 weeks after return. Mefloquine (contra-indicated if history of depression, pregnancy or intent to get pregnant <3 months).
Side effects have led to recommendation to commence prophylaxis 2-3 weeks prior to departure so that patient has time to change tablets.

Suggested schedule of vaccines

This is only a suggested guideline, as many patients have been previously immunised for some of the required vaccines. If time is short then a faster immunisation programme will need to be used or even all immunisations given at one visit. If a complete course cannot be given, then the patient must be informed that they may at best have only partial immunity.

Low risk countries requiring only Tetanus, Polio, Hep A and Typhoid (consider Heptyrix if both Typhoid and Hepatitis A due)	Give all vaccines required at one visit (Hep A in deltoid).
High risk countries requiring as above, and Yellow Fever	Give Yellow Fever and polio. Three weeks later give Hep A, Typhoid and Tetanus. (Malaria advice). If time limited or not all injections due, give in one visit.
High Risk Countries requiring meningitis cover	Give Yellow Fever, polio and Heptyrix (Hep A and Typhoid). Order Meningitis vaccine. 2-3 weeks give Tetanus and Meningitis

Full Regime outline

Hepatitis B should be commenced 6 months prior to departure (Hepatitis B immunoglobulin available for non-immunised who have been exposed to possible risk).

Day One	3 weeks	4 weeks	7 weeks
Yellow Fever Polio Booster Hepatitis A Typhoid (Tetanus Booster)	Tetanus Booster Meningitis A+C 1st Rabies 1st Jap Enceph. 1st Tick-borne E	2nd Rabies 2nd Jap. Enceph. 2nd Tick-borne E	3rd Rabies 3rd Jap Enceph.

Gap between day one and 3 weeks can be closed if time is short.
Note Yellow Fever must be given at least 10 days prior to departure, with correctly completed certificate.
Live vaccines to be given together or 3 weeks apart. (e.g. polio and Yellow Fever).

Advice

General advice should also be given on hygiene as many infections are through the faecal/oral route.
Drink bottled/sterilised water and avoid ice cubes in drinks.
Food should be freshly prepared and hot, avoid uncooked vegetables, salads and street vendors.
Eat fruits that can be peeled.
Sun - slip, slap slop. Slip on a tee shirt, slap on a hat and slop on some high factor sun screen. (Repeat sun screen after swimming).
Sex - safe sex, use condoms. Danger of Hepatitis and HIV.
Safety - think, it is tempting to do daft things when on holiday, diving into shallow water, unaware of dangerous local condition and don't touch animals. The British are unused to living in areas endemic to Rabies.
Insurance cover.
Take passport and yellow fever certificate!

Anaphylaxis

Resuscitation

Vaccine Storage and Use

Care must be taken to store all vaccines under the conditions recommended in the manufacturer's leaflet. Refrigerated storage is usually necessary; many vaccines need to be stored at 2 - 8 degree C and not allowed to freeze.
Opened multidose vials which have not been fully used should be discarded within one hour (live vaccines, excepting polio) or within 3 hours if vaccine contains preservative or polio drops. Particular attention should be paid to instructions on the use of diluents and ampoules should always be adequately shaken. If in any doubt, the Green Book must be consulted.

Contraindications

Most vaccines have some contra-indication to their use, and in general vaccination should be postponed if the subject is suffering from an acute illness. Minor infections without fever or systemic upset are not contra-indications.
Hypersensitivity to some antibiotics, eggs or previous anaphylaxis to vaccine may be a contraindication.
Live vaccines should be avoided in pregnant women and people with impaired immune responsiveness (disease, malignancy, radiotherapy, chemotherapy or high dose steroids/immunosuppressive drugs).

Prescriptions

Prescriptions for all vaccines used and held in stock by WCS need to be make out and given to Sheila (except polio, and Yellow Fever).
Non-stock items
- Send prescription to chemist
- Patient to pick the items up, keep in a fridge and then bring to the surgery.