Travel Health MIDTERM
Antimicrobial therapy is not a contraindication to vaccination, with 3 exceptions: (3/3) Live flu (nasal) vaccine?
Antiviral agents active against influenza virus (such as zanamivir and oseltamivir) may interfere with the response to live attenuated influenza vaccine (Nasal). • Ensure patients are not taking the above medications prior to administering live attenuated vaccines
Adverse effects from booster vaccinations?
Approximately 6% of people receiving booster vaccinations with HDCV may experience an immune complex-like reaction characterized by urticaria, pruritus, and malaise. The likelihood of these reactions may be less with PCEC.
When do infants receive a booster?
At 18 months of age, after completing a primary series.
If you get a fractional dose(due to shortages) it is protective for what?
At least 1 year
What route is the BCG vaccine administered? *THIS ONE STANDS OUT/DIFFERENT COMPARED TO OTHERS*
BCG vaccine is administered as a single intradermal dose.
Is BCG used for routine use in Canada?
BCG vaccine is not recommended for routine use in any Canadian population • Can be considered in exceptional circumstances
BCG vaccine is for what diease?
Bacille Calmette-Guérin (BCG) is a vaccine for tuberculosis (TB) disease.
What is the efficacy of the BCG vaccine?
Bacille Calmette-Guérin (BCG) vaccine efficacyis estimated to be about 51% in preventing any TB disease and up to 78% in protecting newborns from miliary (disseminated) or meningeal TB.
Encephalitis, Tick-borne: Indications for vaccination.
Because the routine primary vaccination series requires ≥6 months for completion, most travellers to TBE-endemic areas will find avoiding tick bites to be more practical than vaccination. • Travellers anticipating high-risk exposures, such as working or camping in forested areas or farmland, adventure travel, or living in TBE-endemic countries for an extended period of time, may wish to be vaccinated in Canada or Europe.
What if these people get their thymus removed?
Because there is no evidence of immune dysfunction or increased risk of yellow fever vaccine-associated serious adverse events in people who have undergone surgical removal of their thymus, these people can be given yellow fever vaccine if recommended or required.
Which antibiotics(drug class) have no drug interactions?
Floroquinolones no significant drug interactions. Macrolide antibiotics may have significant drug interactions (more with Clarithromycin than Azithromycin)
Doses of AB for TD
Flouroquinolones: Single dose or 1 day therapy effective* • Ciprofloxacin 500mg - 1 tab bid x 1-3 days • Azithromycin 500mg per day for 3 days effective* • Azithromycin 1000 mg - as a single dose (may divide to bid due to tolerability)
Medium risk: EF >40%,
Fly after 10 days
Hep A is what type of disease?
Food & Water born
The dosing for JE vaccine in children and adults vary, what is this difference? *KNOW THIS*
For children aged 2 months through 2 years, each dose is 0.25 mL (half of the adult dose) For adults and children aged ≥3 years, each dose is 0.5 mL.
MEDICATIONS FOR CHILDREN to treat motion sickness?
For children aged 2-12 years, the following can be given 1 hr before travel and q6h during trip: • dimenhydrinate (Gravol), 1-1.5 mg/kg per dose • diphenhydramine (Benadryl), 0.5-1 mg/kg per dose up to 25 mg Antihistamines are not approved for use in children and parents should always consult pharmacist/doctor for dosage information and before using antihistamines on children as over sedation can be life threatening.
What vaccines should last minute travellers get? If someone presents to pharmacy less than 21 days before travel, should they get the combo HA/HB vaccine?
For travellers presenting less than 21 days before departure, monovalent HA and HB vaccines should be administered separately, with the completion of both vaccine series after travel.
Which other meds can be used for altitude sickness?
Gingko biloba: shown to reduce AMS in adults in some trials, but it was not effective in others, probably due to variation in ingredients. Dosage: 100-120 mg po twice a day • Ibuprofen: was recently found to help prevent AMS, although it was not as effective as acetazolamide. Dosage: 600 mg po every 8 hours
Vaccine Interchangeability: Is it possible with HA vaccine?
Given their similar immunogenicity, a series that has been started with one brand of hepatitis A monovalent vaccine may be completed with the other brand of monovalent vaccine.
Multicomponent meningococcal vaccine (4CMenB)
Bexsero® Trumenba
Malaria Transmission Areas
Bolivia, Botswana, Brazil, Columbia, Ecuador, Namibia, Paraguay, Peru, South Africa)
tdap: Which vaccine is approved for 65 years old +?
Boostrix is also approved for adults 65 y/o and older
Severe Immune Compromise due to Symptomatic HIV/AIDS : cell count is less than what?
CD4 cell counts <200/mm3
MMR vaccine (who qualifies?)
Children 12 mths Adults Anyone born in 1970 or later who has not been immunized or does not have immunity to measles, mumps and rubella should get 2 doses of the MMR vaccin
What if a someone has had chickebox or shingles before at 1 year of age of older? Should they get the vaccine and if so which one?
Children and adults who have had chickenpox or shingles disease at 1 year of age or older do not need the chickenpox vaccine and these children should get the MMR vaccine at 4 years of age (Not MMRV). ****
Men-C vaccine (who qualifies?)
Children at 2 months, & 12 months of age Adults: The Men-C vaccine is provided free to people born before 2002 who are 24 years of age and under and did not receive a dose of the vaccine on or after their 10th birthday.
How many doses of the rotavirus is needed?
Children should get 2 or 3 doses, at least 4 weeks apart. Vaccination usually starts at around 6 to 14 weeks, with another dose at around 4 months and 6 months of age (if needed).
Chicken Pox vs MMRV vs MMR vaccine (which dose for which population?)
Children who have had chickenpox or shingles disease, confirmed by a lab test, at 1 year of age or older do not need the chickenpox vaccine, and should get the MMR vaccine at 4 years of age. The chickenpox vaccine is offered to students in grade 6 who did not receive 2 doses when they were younger. It is not necessary for those who had chickenpox or shingles disease, confirmed by a lab test, at 1 year of age or older to get the vaccine. Adults: Anyone born in 1970 or later who has not been immunized or does not have immunity to measles, mumps and rubella should get 2 doses of the MMR vaccine.
How effective is the Hib vaccine?
Clinical efficacy of Hib vaccination has been estimated at 95% to 100%. A significant component of protection of children arises because of herd immunity which relies upon good vaccination coverage.
Is ondanseteron effective more motion sickness?
Clinical trials have NOT SHOWN that ondansetron, a drug commonly used as an antiemetic in cancer patients, is effective in the prevention of nausea associated with motion sickness.
Encephalitis, Japanese : Indications for use
Clinicians must weigh the overall low risk of travel-associated JE, the high rate of death and disability when JE occurs, the low probability of serious adverse events after immunization, and the cost of the vaccine. It is expensive and can cost between 400-500$ • Evaluation of a traveler's risk should take into account the planned itinerary, including travel location, duration, activities, and seasonal patterns of disease in the areas to be visited
Side effects of acetazolamide
Common side effects: increased urination and paresthesias of the fingers and toes.
What route is the given given?
Conjugated pneumococcal vaccine should be administered intramuscularly (IM) Pneu-P-23 vaccine may be given either IM or subcutaneously (SC)
Polysacchride Vaccine (PPSV23): general info
Contains polysaccharide antigens • Stimulates B Cells to produce antibodies • T-cell independent immune response • Covers more serotypes • Not effective at preventing CAP that is not in the blood • Limited Herd Effect • Hyporesponsiveness on reimmunization
Conjugate Vaccine (PVC13): general info
Contains polysaccharide antigens covalently linked to a carrier protien • Stimulates T cells to help B cells produce antibodies and generate immune memory (IgG) • T-cell dependent immune response • Herd effect • Protects against fewer serotypes but effective against CAP and IPD (10% of CAP caused by PCV-13 serotypes) - Prevents the pathogens from entering the lungs, which prevents it from getting into the blood.
Trip Details - Itinerary
Countries and specific regions, including order of countries if >1 country • Rural or urban
Geography - EAST AFRICA
Countries: Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Réunion, Rwanda, Seychelles, Somalia, Somaliland, Tanzania, Uganda
MORE EFFECTIVE AT RAPIDY RELEIVING SYMPTOMS OF AMS than Acetazolamide: what is this drug?
DEXAMETHASONE
High risk: EF <40%,
Defer travel until condition stable
Detention is ?
Detention—holding in custody a traveler suspected of being infected with a communicable disease of concern, to allow further medical evaluation KEY WORD : SUSPECT
The most commonly reported health problems among child travellers are as follows:
Diarrheal illnesses • Dermatologic conditions, including animal and arthropod bites, cutaneous larva migrans, and sunburn • Systemic febrile illnesses, especially malaria • Respiratory disorders • Motor vehicle and water-related injuries are also major health problems for child travelers
Trip Details - Special Activities
Disaster relief • Medical care (providing or receiving) • High altitude or climbing • Diving • Cruise ship • Rafting • Cycling • Extreme sports
Medications used for infants and young children are the same as those recommended for adults, except under the following circumstances:
Doxycycline should not be given to children aged <8 years because (risk of teeth staining). • Atovaquone-proguanil not for children weighing <11 lb (<5 kg) because of lack of data on safety and efficacy. • Chloroquine, mefloquine, and atovaquone-proguanil have a bitter taste. - - - Role for compounding pharmacy
Cholera Vaccine: what is the brand name?
Dukoral - Oral Cholera Vaccine
Post-exposure prophylaxis should be offered to?
HA vaccine is effective as post-exposure prophylaxis to prevent infection in contacts and is recommended in preference to Ig for people aged 1-40 years of age. • One dose of HA vaccine should be given to susceptible contacts as soon as possible and preferably within 14 days of last exposure. However, HA vaccine should still be considered if more than 14 days have elapsed since last exposure, as there are no data on the outer limit of efficacy.
NACI statement on who should get the HA vaccine?
HA vaccine is recommended for pre-exposure immunization of persons 6 months of age and older at increased risk of infection
How effective is HB vaccine?
HB vaccine is 95% to 100% effective in preventing HB in people who receive a complete vaccine series.
Vivotif oral live vaccine: DOSES, AGE
Have to be more than 5 years old Total of 4 capsules need to be taken: one cap every 2nd day.
Treatment for TD?
First line antibiotics include: -fluoroquinolones -Ciprofloxacin -Levofloxacin
Adverse reactions of JE vaccine?
Headache, myalgia, fatigue, and an influenza like illness were each reported at a rate of >10%. In children, fever was the most commonly reported systemic reaction in studies.
Hepatitis B: indication
Hepatitis B vaccination should be administered to all unvaccinated people traveling to areas with intermediate to high prevalence of chronic hepatitis B (HBV surface antigen prevalence ≥2%). • Vaccination to prevent hepatitis B may be considered for all international travelers, regardless of destination, depending on the traveler's behavioral risk. Expatriates, missionaries, and long term development workers may be at increased risk for HBV infection in High Risk Countries
Who is the Hib vaccine recommended for?
Hib vaccine is recommended for individuals (5 years of age and older) with: congenital (primary) immunodeficiency; malignant hematologic disorders; HIV; anatomic or functional asplenia,including sickle cell disease; all transplant recipients; and cochlear implant recipients.
CONTRAINDICATIONSL: Haemophilus Influenzae type B
Hib vaccine should not be given to infants younger than 6 weeks of age
When is HiB not needed anymore?
Hib-containing vaccine is not needed in healthy children after 59 months of age (fifth birthday).
What route is HB vaccine given?
IM
What route is Polio vaccine given?
IM
What route is T/D vaccine given?
IM
What route is tDatp given?
IM
What do HCP need to fill out for travellers who need proof of YF vaccination?
INTERNATIONAL CERTIFICATE OF VACCINATION OR PROPHYLAXIS (ICVP)
When should the HB protection be started prior to travel?
Ideally, hepatitis B vaccination should begin ≥6 months before travel so the full vaccine series can be completed before departure.
Contraindications to MMR?
It is a LIVE VACCINE. Live vaccines are generally not recommended for people with congenital immunodeficiency states although some exceptions exist. • MMR and MMRV vaccines should generally not be given during pregnancy • MMR vaccine is contraindicated in individuals with active, untreated tuberculosis
What route is the MMR vaccine given?
It should be SC but it can also be given IM.
Is the JE vaccine recommended for short term travellers?
JE vaccine is not recommended for short-term travellers whose visits will be restricted to urban areas or times outside a well-defined JE virus transmission season. Long-term (>28day) travellers to endemic areas. • Short-term (<1 month) travellers to endemic areas during the JE virus transmission season, if they plan to travel outside an urban area and their activities will increase the risk of JE virus exposure.
What age group should NOT get the hepA vaccine?
Less than 12 months of age
Full dose is protective for?
Life
How effective is MMR vaccine?
One dose of MMR vaccine is about 93% effective at preventing measles if exposed to the virus and two doses are about 97% effective. • However, measles outbreaks have occurred in populations with high immunization coverage rates. Due to the high infectivity of measles (each case may infect 12 to 18 others) at least 95% of the population needs to be immunized to develop herd immunity.
What is an important counselling point about adverse events when it comes to yellow fever vaccine?
Reported events typically include low-grade fever, headache, and myalgias that begin within days after vaccination and last 5-10 days. This is longer than with other vaccines.
Travelling with oxygen: what must be done prior to travel?
Respiratory Conditions (Travelling with oxygen) - Arrangements for oxygen use must be made with the airline several days in advance of a flight.
Is revaccination for yellow fever recommend?
Revaccination IS NO LONGER required at 10- year intervals to comply with International Health Regulations (IHR) of the World Health Organization (WHO).
Who is the rotavirus vaccine not recommended for?
Rotavirus vaccine is not recommended for children older than 32 weeks. Window = Your child must get the first dose of rotavirus vaccine before 15 weeks of age, and the last by age 8 months
Hepatitis B vaccine: is it recommend for all children?
Routine HB immunization is recommended for all children.
Are boosters of HB needed?
Routine booster vaccinations in immunocompetent persons are not recommended since protection has been shown to last for at least 15 years (now at >20). • Studies of long term protective efficacy, however, will determine whether booster doses of vaccine are ever needed. • It is important to recognize that absence of detectable anti-HBs does not mean lack of protection, because immune memory persists.
When should MMR be given?
Routine childhood immunization: administer two doses of measles-containing vaccine (MMR or MMRV); the first dose at 12 to 15 months of age and the second dose at 18 months of age or any time thereafter, but should be given not later than around school entry. If the child has to leave the country it can be given as early as 6 months of age.
When is polio vaccine given?
Routine polio immunization of infants and children: administer DTaP-IPV-Hib vaccine at 2, 4, 6 and 12 to 23 months of age (generally given at 18 months of age).
Menomune (Sanofi Pasteur) Meningococcal polysaccharide vaccine (MPSV4) : what route is it?
S/C All the other ones are IM
What are the countries in South Asia?
South Asia is defined as per the World Bank classification and includes Afghanistan, Pakistan, India, Nepal, Bangladesh, Maldives, Sri Lanka, Bhutan.
Gastrointestinal Diseases • Absolute and Relative contraindications to airline travel
Surgery, including laparoscopic, within 10-14 days • Gastrointestinal bleed within 24 hours • Colonoscopy within 24 hours (recommended to wait 2 weeks) • Partial bowel obstruction • Liver failure (especially cirrhosis or heavy alcohol use)
AMS symptoms?
Symptoms are those of an alcohol hangover: headache (cardinal symptom), fatigue, loss of appetite, nausea, and occasionally vomiting.
TROPICAL SPRUE: what is it?
Syndrome of persistent TD associated with malabsorption, steatorrhea, and folate and vitamin B12 deficiency. Rare in short term travellers and occurring less commonly worldwide with cause still unknown
Potential adverse reactions from rotavirus vaccine? * A RISK THAT STANDS OUT, NOT SEEN WITH OTHER VACCINES
There is a small risk of intussusception from the rotavirus vaccination in the week after getting the first or second dose of the vaccine. Intussusception is a serious blockage of the intestine that must be treated in the hospital. It occurs in about 1 or 2 cases per 100,000 babies who get the vaccine. Just warn the patient that this might happen and to seek medical attention ASAP if this does happen.
Is there more adverse reactions when HA/HB is given together as one vaccine?
There is no increase in adverse events when HAHB vaccine is compared with HA vaccine given alone or concomitantly with HB vaccine at a different injection site. When adult dose HAHB vaccine is given to children in the two dose schedule, there is no increase in adverse events compared with those occurring after administration of the paediatric dose.
Tuberculin testing can be done when?
Tuberculin testing, can be done either on the day* that live- virus vaccines are administered or 4-6 weeks later.
Pre-travel flying advice for pregnant travellers
Ultrasound to establish a reliable due date and to confirm normal pregnancy • Travel Rarely Contraindicated in Normal Pregnancy • Gestational Age (Highest risk in 1st and 3rd TM) • High Risk Conditions • Up to Date on Routine Immunizations
MELATONIN RX FOR JET LAG
Use of the nutritional supplement melatonin is controversial for preventing jet lag • Some clinicians advocate the use of 0.5-5.0 mg of melatonin during the first few days of travel, and data suggest its efficacy.
What is the advantage of MMRV vaccine vs only the varicella product on its own + MMR?
Using the MMRV vaccine does result in one fewer injection • However, when used as a first dose at ages 12-23 months, studies have shown at this age, MMRV vaccine is associated with higher risks of fever within the 42 days after vaccination (with highest risk during the 5-12 days after vaccination) and febrile seizures during the 5-12 days after vaccination when compared with administration of first dose MMR and varicella vaccines at the same visit. • The available data do not suggest that children aged 4-6 years who receive MMRV vaccine have an increased risk for febrile seizures after vaccination compared with same-age children who receive MMR and varicella vaccines at the same visit
What is 80x more likely to spread into the blood stream in people with compromised immune systems especially those with chronic liver disease?
V. vulnificus is 80 times more likely to spread into the bloodstream in people with compromised immune systems, especially those with chronic liver disease. When this happens, severe symptoms including blistering skin lesions, septic shock, and sometimes this can lead to death
Travellers with the following conditions should be advised to consult a physician familiar with high-altitude medical issues before undertaking high-altitude travel:
heart failure • myocardial ischemia (angina) • sickle cell disease • any form of pulmonary insufficiency Diabetes
Live attenuated vaccines and the following medications interact:
immunomodulators, calcineurin inhibitors, cytotoxic agents, antimetabolites, and high-dose steroids
Youth and Pediatric dosing schedule of Hepatitis A and B When do children Get HepB?
in grade 6
Youth and Pediatric dosing schedule of Hepatitis A and B When do children Get HepA?
indigenous children only At 6 months & 18 mths
Post-exposure prophylaxis should be offered to:
infants born to HB-infected mothers - persons potentially exposed to blood or bodily fluids containing HB virus - household and sexual contacts of an acute HB case or chronic carrier
At this time, top priorities for most destinations would include vaccines against?
influenza, measles, and hepatitis A and B.
Repellents with DEET should not be used on infants aged ?
less than 2 months
Household contacts of severely immunocompromised patients may be given live-virus vaccines such as yellow fever, MMR, or varicella/zoster vaccines but should not be given the ?
live attenuated influenza vaccine
OTHER MEDICATIONS USED for motion sickness?
scopolamine (hyoscine, oral and transdermal) • antidopaminergic drugs (such as prochlorperazine) • Metoclopramide • Sympathomimetics • Benzodiazepines.
Know the difference between bacterial,viral & protozal symptoms,etc
slide 9/56 in powerpoint (could not copy/paste)
Polysacchride Vaccine (PPSV23): why is there not an as big of an immune reponse compared to the PCV13?
T-cell independent immune response
When should the series be completed? What if a patient asks you, "does it matter that I dont get my 2nd dose?"
The 2-dose series should be completed ≥1 week before travel. • Seroconversion of 29.7% 10 days after the first vaccination, and 97.3% once week after the second vaccination
Gardasil (who qualifies?)
The HPV vaccine is provided free to girls and boys in grade 6 as a series of 2 doses given 6 months apart.
Geography -WEST AFRICA - what countries ?
The West Africa UN subregion includes the following countries: Benin, Burkina Faso, Cape Verde, Côte D'Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Saint Helena, Senegal, Sierra Leone, Togo .
When is the certificate valid from? How long does it last?
The certificate is valid starting 10 days after the date of vaccination and expires 3 -5 years (depending on product) from the start date of validity.
When is the certificate for polio vaccine valid? *DIFFERENT THAN WITH MENC*
The certificate is valid starting on the date of vaccination and expires 12 months (one year) from the start date of validity. The date format is day, month, year, with the month printed for both start and end date.
Safety of HepA vaccine in pregnancy?
The safety of hepatitis A vaccine for pregnant women has not been determined. However, because hepatitis A vaccine is produced from inactivated HAV, the theoretical risk to either the pregnant woman or the developing fetus is thought to be low.
Pregnancy precautions with yellow fever vaccine?
The safety of yellow fever vaccination during pregnancy has not been studied in a large prospective trial. • If travel is unavoidable and the vaccination risks are felt to outweigh the risks of YFV exposure, pregnant women should be excused from immunization and issued a medical waiver to fulfill health regulations. • Pregnant women who must travel to areas where YFV exposure is likely should be vaccinated. • Wait 4 weeks after receiving the yellow fever vaccine before conceiving
What if someone has serious cuts or deep wounds?
The vaccine may also be given to people with serious cuts or deep wounds whose last tetanus vaccine was given 5 or more years ago.
Which form is used for the Men ACWY proof of vaccination?
The yellow fever yellow sheet is used but instead you write MEN ACWY under what vaccine was given. Can write on the same form if Traveler previously had yellow fever.
Dosing Schedule: HEP B
There are many different HB-containing vaccine schedules and dosages. • For monovalent HB vaccine, the preferred schedule is months 0, 1 and 6. The date of the first dose for infants is at birth, which is considered as month 0. • With few exceptions, persons with indications for both hepatitis A (HA) and HB vaccine should be immunized with combined HAHB vaccine.
AVAXIM® (schedule and age)
0, 6-36 months Ages: 12 years and older
ViVAXIM®
0, booster dose of HA vaccine at month 6-36 or HA-Typh-I vaccine at month 36 AGE: 16 years and older
VAQTA®
0,6 Age: 18+
HAVRIX® 720 Junior
0,6-12 Age: 1-18 years old
HB : when should the 2nd dose be given?
1 month of more after the 1st dose
Examples of higher-risk activities or itineraries include
1) spending substantial time outdoors in rural or agricultural areas, especially during the evening or night; • 2) participating in extensive outdoor activities (such as camping, hiking, trekking, biking, fishing, hunting, or farming); and • 3) staying in accommodations without air conditioning, screens, or bed nets.
What are the 3 exposure risk groups or immunization gaps?
1. Absence of 2 documented Doses in Childhood - Don't Have Records? 2. Only One dose in Childhood (Born Before 1996) - B.C. children born in or after 1996 routinely get two doses of the measles, mumps and rubella (MMR) vaccine, one dose when they turn a year old and another before they start kindergarten. 3. International Travel - The BC Outbreak started
RISK FACTORS for motion sickness
1. Age—children aged 2-12 years are especially susceptible, but infants and toddlers are generally immune. 2. Sex—women are more likely to have motion sickness, especially when pregnant, menstruating, or on hormones. 3.Migraines—people who get migraine headaches are more prone to motion sickness, especially during a migraine. 4.Medication—some prescriptions can worsen the nausea of motion sickness.
What are the live vaccines?
1. BCG 2. Influenza (live) 3. MMR 4. Typhoid (Ty21a) 5. Varicella (adults) 6. yellow fever 7. zoster
What are the inactivated vaccines?
1. Hib 2. HEPA 3. HEPB 4. Influenza (inactivated) 5. JE 6. Menigocogocal conjugate 7. PCV13 followed by 23 8. Polio 9. Rabies 10. Td or Tdap 11.Thyoid (VI)
What are the combo vaccine products for Hib?
1. Infranrix-IPV/Hib 2. Infranrix hexa 3. Pediacel
Contraindications (2) to MMRV vaccine?
1. It is recommended to avoid the use of salicylates (e.g., acetylsalicylic acid [ASA]) for 6 weeks after immunization with MMRV vaccine because of an association between wild-type varicella, salicylate therapy and Reye's syndrome. 2. Systemic antiviral therapy (such as acyclovir, valacyclovir, famciclovir) should be avoided in the peri-immunization period. People taking long-term antiviral therapy should discontinue these drugs, if possible, from at least 24 hours before administration of MMRV vaccine and should not restart antiviral therapy until 14 days after.
Which routine vaccine is live?
1. MMR
***Monovalent conjugate meningococcal vaccines (Men-C-C)
1. Meningitec® 2. Menjugate® 3.NeisVac-C®
Vaccines: which are usually REQUIRED for travellers?
1. Meningococcal 2. Yellow Fever Required - Only 2 vaccines are categorically required for some travellers: meningococcal vaccine for pilgrims traveling to Mecca during the Hajj and yellow fever vaccine for travellers to certain countries in Africa and South America.
Pneumococcal Vaccines Licensed for Adults in Canada
1. Pneumococcal Polysaccharide vaccine (PPSV23) 2. Pneumococcal Conjugate Vaccine (PCV) - PCV13 (Prevnar 13)
The steps to using vivaxim is specific. What are the steps?
1. Remove the tip-cap (A). • 2. Attach needle and needle shield (B) to the syringe. • 3. Screw the plunger rod (C) into the plunger stopper (stopper 2). • 4. Shake the syringe; then mix the vaccine components by slowly pushing the plunger, keeping the needle upwards. The vaccine in the lower chamber moves into the upper chamber by means of the by- pass channel. • 5. Shake vigorously until a homogeneous cloudy, whitish suspension is achieved. • 6. Holding the needle shield at the tip, remove by pulling upwards without twisting.
Altitude Sickness consists of 3 syndromes:
1.Acute Mountain Sickness (AMS) 2.High altitude cerebral edema (HACE) 3.High altitude pulmonary edema (HAPE)
Objectives of Pre-Travel Consultation
1.Assess: the traveler's trip plans and determine potential health hazards 2.Provide: immunizations for vaccine-preventable diseases and medications for prophylaxis, self-treatment, or both; 3.Educate: the traveler to manage his or her health during the trip through counseling and prevention messages.
Quadrivalent conjugate meningococcal vaccines (Men-C-ACYW)
1.Menactra® 2.MenveoTM 3. Nimenrix®
When do infants get a booster of Dtap-IPV-HIB?
18 months of age - after completing a primary series of 3 doses
What route is HA vaccine given?
2 doses IM (intramuscular)
12 year JE protection plan
2 doses in the primary series (2nd dose at least 1 week before departure) • Booster in 2 years • No need for any additional doses for 10 years (with data ongoing)
What is the "window" for when hib should be given?
2 months to 59 months (5 years old) Over 5 : vaccinate only if he patient has "special conditions"
Long-Term Complications of TD include what conditions?
2%-10% of patients experience persistent diarrhea (defined at 2 weeks or longer) Post-Infectious Irritable Bowel Syndrome (PI-IBS) - 5-10% of TD cases Reactive arthritis (RA) Guillian-Barre syndrome (GBS)
Time to flying after an MI (based on Ejection fraction and age)
those at very low risk—within 3 days after event • medium risk—within 10 days • high risk or awaiting further intervention or treatment—defer air travel until disease is stable
Countries in South East Asia
• Vietnam • Cambodia • Laos • Thailand • Burma • Indonesia • Philippines • Singapore • Malaysia
Travel following ACS : Low risk: age <65, first event, successful reperfusion, EF >45%, no complications, no planned investigations or interventions
can fly after 3 days
What does Dukoral protect agaisnt?
causes the body to produce antibodies against Vibrio cholerae bacteria serogroup 01 and the toxin these bacteria produce, which causes the symptoms of cholera. Prevent travellers' diarrhea caused by enterotoxigenic E. coli (ETEC) and cholera in adults and children 2 years of age and older.
Asplenic patients - routine vaccines, Hib vaccine dosing, pneumococcal vaccine dosing for asplenic patients
recommend immunization against 1. meningococcal, 2. pneumococcal, and 3. Haemophilus influenzae disease in these patients, regardless of travel plans.
AMS TREATMENT:
250 mg po twice a day • Pediatrics: 2.5 mg/kg po every 12 h
Optimal timing of TDAP administration in pregnant patients
27-36 weeks gestation
When is the ideal time during pregnancy for a woman to receive the dtap vaccine?
27-36 weeks gestation
Antimicrobial therapy is not a contraindication to vaccination, with 3 exceptions: (2/3) Zostavax?
Antiviral agents active against herpesviruses (such as valcyclovir) may interfere with the response to varicella-containing vaccines • For example antiviral agents within 48 hours of administering the Zostavax vaccine is a contraindication
Isolation is?
Isolation—separating and restricting the movement of an ill person who has a communicable disease of concern from those who are healthy, to minimize disease spread by preventing further transmission. KEY WORD : WHO HAS
Definition of mortality
A measure of the number of deaths in a given population "How many people have died from the disease" SMALLEST #
Most commercial airlines allow pregnant travellers to fly until ?
Most commercial airlines allow pregnant travellers to fly until 36 weeks' gestation.
The 6 major meningococcal serogroups associated with disease are
A, B, C, W, X, and Y.
Most common form of altitude illness.
AMS
Dose of dex for PREVENTION
AMS & HACE PREVENTION: • 2 mg po every 6 h or 4 mg every 12 h • Pediatrics: should not be used for prophylaxis
Dose of dex for TREATEMENT
AMS: 4 mg every 6 h • HACE: 8 mg once, then 4 mg every 6h • Pediatrics: 0.15 mg/kg/dose every 6 h up to 4 mg
Treatment for motion sickness?
ANTIHISTAMINES • Most frequently used and widely available medications for motion sickness
Which vaccines are contraindication in severely immunucompromised travellers?
ANY LIVE VACCINE
Pulmonary contraindications to air travel
Absolute and Relative contraindications to airline travel • Severe, labile asthma • Recent hospitalization for acute respiratory illness • Bullous lung disease • Active lower respiratory infection • Pneumothorax within 2-3 weeks • Pleural effusion within 14 days • High supplemental oxygen requirements at baseline • Major chest surgery within 10-14 days
What is the product that contains only Hip?
Act-HIB®
Definition of prevalence
Actual number of cases alive, with the disease either during a period of time or at a particular date in time • How many people have the disease at a given period of time • Chronic infectious diseases
Who is a booster of polio recommended for?
Adults previously immunized with polio vaccine: for those at increased risk of exposure to polio (e.g., those travelling to, or planning to work in areas that have wild polio or vaccine-derived polio outbreaks), a single lifetime booster dose of IPV-containing vaccine is recommended.
Adult dosing polio?
Adults previously unimmunized with polio vaccine • 3 doses: 2 doses of IPV administered at an interval of 4-8 weeks; a third dose should be administered 6- 12 months after the second.
Who should get the Hep A vaccine?
Advise people traveling outside Canada and the United States to consider hepatitis A vaccination regardless of their destination
Temporary polio vaccine recommendations affect the following countries:
Afghanistan, Nigeria, and Pakistan.
Where is Yellow Fever vaccination recommendated?
Africa South America
Map of Yellow Fever (areas with this)
Africa & South America
Precaution in what population for yellow fever vaccine?
Age 6-8 months (BBB is unformed yet) Two cases of Yellow fever vaccine-associated neurologic disease (YEL-AND). YEL-AND have been reported among infants aged 6-8 months,by 9 months of age, risk for YEL-AND is believed to be substantially lower • Age ≥60 years • Asymptomatic HIV infection and CD4 T-lymphocytes 200-499/mm3 • Pregnancy • Breastfeeding
Children less than how many months should NOT get the yellow fever vaccine?
Age <6 months • Yellow fever vaccine is contraindicated for infants aged <6 months. This contraindication was instituted in the late 1960s in response to a high rate of YEL-AND documented in vaccinated young infants (50-400 per 100,000). • The mechanism of increased neurovirulence in infants is unknown but may be due to the immaturity of the blood-brain barrier, higher or more prolonged viremia, or immune system immaturity.
The pneumococcal conjugate vaccine, PCV13 or Prevnar 13®, is currently recommended for?
All children younger than 5 years old • All adults 65 years or older • People 6 through 64 years old with certain medical conditions. • Conjugate is more immunogenic in children then the polysaccharide !
All polio vaccination administration should be documented on a?
All polio vaccination administration should be documented on an International Certificate of Vaccination or Prophylaxis (ICVP).
Contraindications to the yellow fever vaccine?
Allergy to vaccine component • Age <6 months • Symptomatic HIV infection or CD4 T-lymphocytes <200/mm3 • Thymus disorder associated with abnormal immune-cell function • Primary immunodeficiencies • Malignant neoplasms • Transplantation • Immunosuppressive and immunomodulatory therapies Allergy to vaccine component • Yellow fever vaccine is contraindicated for people with a history of acute hypersensitivity reaction to a previous dose of the vaccine, as well as those who have a history of an allergic reaction to any of the vaccine components, including eggs, egg products, chicken proteins, or gelatin. • The stopper used in vials of vaccine also contains dry natural latex rubber, which may cause an allergic reaction.
Distribution of Dengue
Americas and Caribbean, Africa and Middle East, Asia and Oceania)
Who qualifies for publically funded influenza vaccine in BC?
Annual influenza immunization is provided free to people at high risk of serious illness from influenza. It is also free for people who are able to spread influenza to those at high risk of serious illness.High Risk Program: British Columbia provides many vaccines free of charge to some people. For example, those with chronic illness or weakened immune systems may receive free vaccinations
Antimicrobial therapy is not a contraindication to vaccination, with 3 exceptions: (1/3) Oral thyphoid ?
Antibacterial agents may interfere with the response to oral typhoid vaccine • Do not administer oral typhoid vaccine to those taking antibiotics - wait at least 72 hours after the antibiotic course is completed
Sequence of vaccines?
Previously received PPSV23? YES - Less than 1 year ago vs More than 1 year ago? • Less than 1 year - Wait 1 year since PPSV23 - Givve PCV13 • More than 1 year - Give PCV13 Previously received PPSV23? • NO - Give PCV13 , then after a minimum of 8 weeks give PPSV23
Rabies • Risk Category = INFREQUENT (more than general population)
Primary course; no serologic testing or booster vaccination
Rabies • Risk Category = FREQUENT
Primary course; serologic testing every 2 years; booster vaccination if antibody titer is below acceptable level
Rabies: Risk is CONTINUOUS: how do you go about?
Primary course; serologic testing every 6 months; booster vaccination if antibody titer is below acceptable level
What is dose of IM vaccine?
Primary vaccination with ViCPS consists of one 0.5-mL (25-mg) dose administered intramuscularly.
Measles/Mumps/Rubella/Varicella : product name
Prioritx-tetra
VARIABLES AFFECTING JET LAG
Increased age may contribute to longer recovery period • intensity and duration of jet lag are related to the number of time zones crossed • Direction of travel • Ability to sleep while travelling • availability and intensity of local circadian time cues at the destination • Individual differences in phase tolerance
Trip Details - Travel Style
Independent travel or package tour • Propensity for "adventurous" eating • Traveler risk tolerance • General hygiene standards at destination • Modes of transportation • Accommodations (such as tourist or luxury hotel, guest house, hostel or budget hotel, dormitory, local home or host family, or tent)
Pneumococcal booster doses
Individuals who have previously received Pneu-P-23 vaccine and who require re-immunization following immunization with Pneu-C-13 vaccine, should receive Pneu-P-23 no sooner than 8 weeks after Pneu-C-13 vaccine and no sooner than 5 years after the initial dose of Pneu-P-23. • Remember - If conjugate is first - 8 weeks between conjugate and polysaccharide • Remember at least 5 years between polysaccharide doses • 2 doses of Polysaccharride between ages 19-65 y/o * if at high risk • 1 dose of polysaccharide for those over 65
Who is at highest risk of T/D/P?
Infants
Polio vaccine indication?
Infants and children should be vaccinated against polio as part of a routine immunization series • Polio vaccination is recommended for all travellers to countries with WPV circulation. • Countries are considered to have WPV circulation if they have evidence during the previous 12 months of ongoing endemic circulation, a polio outbreak, or environmental evidence (through sewage sampling) of WPV circulation.
Who is BCG vaccine indicated for?
Infants in high risk communities • Persons at high risk of repeated exposure • Long-term travellers to high prevalence countries • Infants born to mothers with infectious TB disease.
Gastrointestinal Diseases • Immunization Considerations
Influenza • Pneumococcal • Hepatitis A • Hepatitis B
Pulmonary Diseases • Immunization Considerations
Influenza • Pneumococcal • Hepatitis B
Renal failure and chronic renal insufficiency • Immunization Considerations
Influenza • Pneumococcal • Hepatitis B
Diabetic travellers, recommended vaccine immunizations
Influenza • Pneumococcal • Hepatitis B • A decreased response to hepatitis B vaccine has been observed in patients with diabetes
Which vaccines from special populations table are recommended for all special populations?
Influenza vaccine and TDAP recommended across the board
HAPE: Symptoms?
Initial symptoms are increased breathlessness with exertion • Eventually increased breathlessness at rest, associated with weakness and cough.
Does the BCG vaccine cause a scar after administration?
Intradermal administration of BCG vaccine usually results in the development of erythema and either a papule or ulceration (in about 50%), followed by a scar at the immunization site.
What route is the tick-borne vaccine given?
Intramuscular Injection
What are the routine vaccines?
1.Tetanus/Diphtheria 2.Tetanus/Diptheria/Pertussis 3.Haemophilus Influenzae type B 4.Measles/Mumps/Rubella 5. Varicella 6. Rotavirus 7.Pneumococcal 8.HPV - will be discussed in the HPV disease lecture 9. Influenza - Discussed in the influenza disease lecture
Definition of morbidity
Is a measure of sickness. Incidence or prevalence of a medical condition "How many people have the disease" LARGEST #
Dosage acetazolamide AMS & HACE PREVENTION:
125 mg po twice a day • 250 mg po twice a day if >100 kg. • Pediatrics: 2.5 mg/kg po every 12 h * FOR PREVENTION THE DOSE IS 125 MG WHILE FOR TREATEMENT IT IS DIFFERENT
Administering Menactra, PCV13, & PPSV23 - how to space?
13 needs to be given before 23. Wait 4 weeks before giving 23. If 23 was given for whatever reason before 13, then you need to wait 1 YEAR before giving 13. -Give Menactra MenACWY-D 4 weeks after PCV13*** -Give PPSV23 8 weeks after PCV13 -Give PCV13 1 year after PPV23
AVAXIM® Pediatric
0 6-12 months Age: 1-15 years old
TWINRIX® Junior
0, 1, 6 AGE: 1 to 18 years
TWINRIX®
0, 1, 6 or 0, day 7, day 21, month 12 AGE: 19 years and older
DURATION?
"beginning the day before ascent and continuing the first 2 days at altitude, or longer if ascent continues"
What is the rapid schedule for JE vaccine?
**Rapid Schedule - 2 doses at 0, 7 days
A physical examination or temperature measurement is not necessary to vaccinate a person who appears to be in good health. • Simply do the following in your clinic;
- Asking if a person is ill -postponing a vaccination for someone with even mild acute illness - Include the above in your pre-vaccination questionnaires
Elements of risk assessment in pre-travel consultation?
- Past medical history - Special Conditions - Immunization History -Prior travel experience
What is NOT a contraindication to air travel?
- Renal Failure - DM -Autoimmune diseases -Allergic Reactions
Which Rx can cause motion sickness?
- antibiotics - antiparasitics - estrogens - CVD - NSAIDS - antidepressants - asthma rx - bisphosphonates *LIST IS LONG
The PCV13 vaccine is provided free to:
- children 5 to 18 years of age with no spleen, or a spleen that is not working properly; and -adults and children 5 years of age and older with HIV infection or who have had a stem cell transplant.
CVD : immunization considerations?
- influenza - pneumococcal - Hep B
What are 2 continents that require vaccination for yellow fever?
-Africa -South America
Pneumovax® is a 23-valent pneumococcal polysaccharide vaccine (PPSV23) that is currently recommended for use in?
-All adults 65 years or older -People who are 2 years or older and at high risk for pneumococcal disease (e.g., those with sickle cell disease, HIV infection, or other immunocompromising conditions). -Given to people 2 years of age or older who have certain medical conditions • Publically funded for people at high risk
Travel Vaccines: Which ones are they?
-Bacille Calmette-Guerin -Encephalitis, Japanese - Encephalitis, Tick-borne - Rabies -Yellow Fever -Hepatitis A - Hepatitis B - Hepatitis A+B combined - Meningococcal - Cholera - Polio -Typhoid
Contraindications to Tetans/Diptheria vaccine
-Had a tetanus shot in the last 5 years; -Child less than 7 years of age.
Major topics of discussion in a pretravel consultation
-Immunizations • Malaria chemoprophylaxis • Travelers' diarrhea • Respiratory illnesses • Other vectorborne diseases • Altitude illness • Other environmental hazards • Personal safety • Sexual health and bloodborne pathogens • Disease-specific counseling
HAVRIX® 1440
0, 6-12 Age : 19+
Dosing HB vaccine?
3 does 0, 1, 6 months
Haemophilus Influenzae type B: when is it given?
3 doses at 2,4,6 months of age
What is considered "long term" for travel?
6 Months or more
Altitude Sickness - what is the cut off elevation for considering prophylaxis?
9000 ft
Efficacy of JE vaccine?
96% of adults and 100% of children aged 2 months through 17 years developed protective neutralizing antibodies after receiving a primary immunization series • There have been Zero (0) Cases of JE in vaccinated travelers • Dramatic decline in local populations that implemented the vaccine in childhood immunization programs
Predialysis patients - recommended immunizations, Hepatitis B brand and scheduling
A blunted response to hepatitis B vaccine has been reported in patients with chronic renal disease • Vaccination early in the course of renal disease produces higher seroconversion rates than vaccination after dialysis has been initiated. • Higher-dose hepatitis B vaccine preparations are used to promote optimal immunization of people undergoing hemodialysis
Deep/Dirty wound and tetanus shot?
A booster dose of the vaccine is recommended every 10 years. If you have a serious cut or wound and are at high risk for a tetanus infection it may be recommended that you get the vaccine.
What are the typhoid vaccine choices?
Either and IM inactivated vaccine or a live ORAL vaccine.
For Dialysis Patients
Engerix B 40 mcg (2.0 mL) - 0,1,2,6 months • 4-8 injections*
Tetanus/Diptheria : when should people get a booster?
Every 10 years
When do you have to be reimmunized with IM vaccine?
Every 3 years
When do you have to be reimmunized with the oral vaccine?
Every 7 years.
How is it treated?
Treatment: Tetracycline 250mg qid daily and folate 5mg for at least 6 weeks, consider IM vitamin B12
******Adult Pre-trip Polio Vaccination strategies
If >8 weeks is available before protection is needed, 3 doses of IPV should be administered ≥4 weeks apart. • If <8 weeks but >4 weeks is available before protection is needed, 2 doses of IPV should be administered ≥4 weeks apart. • If <4 weeks is available before protection is needed, a single dose of IPV is recommended. • If <3 doses are administered, the remaining IPV doses to complete a 3-dose series should be administered when feasible, at the intervals recommended above, if the person remains at increased risk for poliovirus exposure.
How effective is HepA-IG?
If given within 2 weeks of exposure to the virus, immunoglobulin (IG) is more than 85% effective in preventing hepatitis A virus (HAV) infection.
Measles/Mumps/Rubella: what age group is it recommended for?
Immunization of children and adolescents who missed measles immunization on the routine schedule. Measles-containing vaccine is recommended for susceptible adults born in 1970 or later. Adults born before 1970 can be presumed to have acquired natural immunity to measles; however, non-immune health care workers, travellers and military personnel should receive MMR vaccine, regardless of year of birth.
Contraindications to BCG vaccine?
Immunocompromised persons and pregnant women should not receive BCG vaccine, because it is a live vaccine.
Can you get only a measles vaccine in Canada?
In Canada, measles vaccine is only available in combination with mumps and rubella vaccine (MMR) or mumps, rubella and varicella vaccine (MMRV). In many countries outside of Canada measles vaccine alone is given.
HACE symptoms?
In addition to AMS symptoms, lethargy becomes profound, with drowsiness, confusion, and ataxia on tandem gait test.
What about in countries where FQ are resistance to AB?
In areas where microbial resistance to fluoroquinalones is present such as Thailand, Azithromycin is alternative.
Is the BCG vaccine the best approach for travellers?
In general travellers do not need BCG vaccine. TB screening and chemoprophylaxis as indicated is the preferred approach to TB control in travellers.
Is the protection from the tdap vaccine long?
In general, TDaP vaccination is effective for up to 8 or 9 out of 10 children who receive it, but protection fades over time. About 7 out of 10 children are fully protected 5 years after getting their last dose of TDaP
Drug interactions with Oral Typhoid
In people concurrently receiving antimicrobial agents (including antimalarial chemoprophylaxis), viral vaccines. • The growth of the live Ty21a strain is inhibited in vitro by various antibacterial agents, and vaccination with Ty21a should be delayed for >72 hours after the administration of any antibacterial agent. • Available data do not suggest that simultaneous administration of oral polio or yellow fever vaccine decreases the immunogenicity of Ty21a. If typhoid vaccination is warranted, it should not be delayed because of administration of viral vaccines. • Simultaneous administration of Ty21a and immune globulin does not appear to pose a problem.
Definition of incidence
Incidence is the rate of new (or newly diagnosed) cases of the disease • "How many new cases of the disease in a given period of time" - usually reported within a timeframe • Acute Infectious Diseases Example of this is COVID 19
Elements of risk assessment (essential information)- trip details?
Trip Details Timing Reason Style Special Activities
Contraindications to typhoid vaccine? oral or im which one is preferred and when?
Live attenuated Ty21a vaccine should not be given to immunocompromised travelers, including those infected with HIV. The intramuscular vaccine presents a theoretically safer alternative for immunocompromised travelers.
Spacing of live vaccines?
Live-virus vaccines administered on the same day or if on different days; should be given > 28 days apart (>30 days for yellow fever vaccine).
adjusting insulin (which type to adjust and when is it necessary to adjust it?)
Long Acting insulin is adjusted due to travel through time zones. • Premeal coverage using short-acting insulin would remain the same or be increased especially if they will be eating more than their usual amount, or if there are more meals than usual. basal - long does need to be adjusted meal time bolus - does need to be changed based on the different food intake. Don't adjust your watch! - Less than 5 time zones , and trips less than 3 days - continue Basal Insulin at usual times • For insulin pumps - continue normal routine, and adjust time setting on pump once the destination is reached. Let blood glucose levels run slightly higher on the first day - --- avoid hypoglycemia. • The timing of oral medications for diabetes is not as big of an issue
Adverse reactions are more common with what vaccine?
Low-grade fevers and local reactions, such as injection site pain, arm swelling, and pain that limits movement of the injected arm, are side effects seen after both conjugate and polysaccharide meningococcal vaccines but occur more commonly after conjugate vaccine.
Quadrivalent polysaccharide meningococcal vaccine (Men-P-ACYW-135)
MENOMUNE® A/C/Y/W-135
which vaccine is recommended for HIV patients if their CD4 counts are higher than 200?
MMR Vaccine for HIV patients with CD4 counts ≥200/mm3 for ≥6 months if they have no evidence of measles immunity
Trip Details - Timing
Trip duration • Season of travel • Time to departure
Spacing of antibody containing blood products and live vaccines such as MMR and varicella?
MMR and varicella vaccines either should be administered >2 weeks before receipt of a blood product or should be delayed 3- 11 months after receipt of the blood product, depending on the vaccine. • If the interval is <14days, the vaccine should be readministered. • IG preparations interact minimally with other inactivated vaccines. Can give simultaneously, but vaccines should be administered at different sites from the IG
Measles/Mumps/Rubella/Varicella: timing of adminsitration?
MMRV vaccine may be given to children from 1 through 12 years of age to protect them from these four diseases. • Two doses of MMRV vaccine are recommended: • The first dose at 12 through 15 months of age (Primary Schedule administers these separately) • The second dose at 4 through 6 years of age • These are recommended ages. But children can get the second dose up through 12 years as long as it is at least 3 months after the first dose. Routine Program in BC - The chickenpox vaccine is provided free as a series of 2 doses. • The first dose of vaccine is given at 12 months of age and the second starting at 4 years of age before a child enters kindergarten. • The second dose is given as a combination vaccine (MMRV) that also provides protection against measles, mumps and rubella. • In grade 6, the chickenpox vaccine is offered to students who did not receive 2 doses when they were younger. • People 13 years of age and over who have never received the vaccine also need 2 doses (of Varicella Vaccine only).
Typhoid majority of cases are in what par of the world?
Majority of cases in South Asia
What can be more severe in pregnant women?
Malaria can be much more severe in pregnant women Mefloquine or Chloroquine drug of choice • Doxycycline contraindicated • Malarone (atovaquone-proganuil) not recommended (no safety data)
Pregnancy
May be prudent to recommend that pregnant women do not stay at sleeping altitudes higher than 12,000 ft (3,658 m), if possible.
What if there is a contraindication to vaccination?
Medical Waivers (Exemptions) • Certificate of Medical Contraindication to Vaccination
How effective is the HA vaccine?
More than 95% of vaccinated people develop levels of anti-HAV that correlate with protection 1 month after the first dose. • For children and adults who complete the primary series, booster doses of vaccine are not recommended.
If someone receives only a fractional dose, should the HCP fill out a ICVP card?
NO, International Certificate of Vaccination or Prophylaxis (ICVP) card should not be filled out for a fractional dose. Patient should be provided a Certificate of Medical Contraindication to Vaccination provided by the Public Health Agency of Canada, indicating fractional dose was given due to severe shortage
Cane the person drink or eat before/after taking the vaccine?
No eating or drinking 1 hour before or after the vaccine
Rabies • Risk Category = RARE (general population)
No preexposure immunization necessary
Should pregnant people get the JE vaccine?
No studies of Ixiaro in pregnant women have been conducted. Therefore, administration of Ixiaro to pregnant women usually should be deferred. However, pregnant women who must travel to an area where risk for JE virus infection is high should be vaccinated when the theoretical risk of immunization is outweighed by the risk of infection.
Conjugate Vaccine (PVC13) - is it funded?
No, even though it is better compared to 23.
Can you get a pertussis vaccine on its own?
No, only comes in the combo with Tetanus/Diptheria
Because yellow fever is a live vaccine, should it be given to people who have immunodeficiencies?
No. Immunodeficiencies (other than thymus disorder or HIV infection) • Yellow fever vaccine is contraindicated for people with primary immunodeficiencies, malignant neoplasms, or transplantation. • If someone with an immunodeficiency cannot avoid travel to a yellow fever-endemic area, a medical waiver should be provided, and counseling on protective measures against mosquito bites should be emphasized.
What is risk for diabetics and going at high altitudes?
Not all glucose meters read accurately at high altitudes.Diabetic ketoacidosis may be triggered by altitude illness and may be more difficult to treat in those on acetazolamide.
Which vaccine is indicated for patients 65 +?
Note that Menomune (MPSV4) only vaccine indicated for patients over 65
Asplenic patients: pneumococcal vaccine dosing for asplenic patients
Over the age of 19, who have not received PCV13 or PPSV23..... • PCV13 vaccine is recommended for asplenic patients and should be followed by PPSV23 8 weeks and 5 years later.
Post-Exposure Prophylaxis • Scenario 2 - In Travellers Who Did Not Receive Preexposure Vaccination
PEP for a previously unvaccinated patient consists of injections of RIG (20 IU/kg) and a series of 4 injections of rabies vaccine over 14 days or 5 doses over a 1-month period in immunosuppressed patients
Post-Exposure Prophylaxis • Scenario 1: In Travellers Who Received Preexposure Vaccination
PEP for someone previously immunized consists of 2 doses of modern cell culture vaccine given on days 0 and 3 after the exposure. • The booster doses do not have to be the same brand as the one in the original preexposure immunization series. After wound cleansing, as much of the dose-appropriate volume of RIG (as is anatomically feasible should be injected at the wound site, striving to put the RIG in the areas where the animal's teeth have wounded the tissue. • If the wound is small and on a distal extremity such as a finger or toe, the health care provider will have to use judgment as to how much to inject at the wound to avoid local tissue compression and complications. • Any remaining dose should be administered intramuscularly. If the wounds are extensive, the dose-appropriate volume of RIG must not be exceeded. If the volume is inadequate to inject all the wounds, the RIG may be dilutedwith normal saline so that some can be injected in each of the wounds. This is a particular issue in children, whose body weight may be small in relation to the size and number of wounds.
Which medications can cause "severe immunocompromise"?
People taking any of the following categories of medications are considered severely immunocompromised: 1. High-dose corticosteroids— >2 mg/kg of body weight or ≥20 mg per day of prednisone or equivalent in people who weigh >10 kg, for ≥2 weeks, • Wait ≥1 month after discontinuation of high-dose systemic corticosteroid therapy before administering a live-virus vaccine. 2. Alkylating agents (such as cyclophos-phamide). 3. Antimetabolites (such as azathioprine, 6-mercaptopurine). 4.Transplant-related immunosuppressive drugs (such as cyclosporine, tacrolimus, sirolimus, azathioprine, and mycophenolate mofetil). 5. Cancer chemotherapeutic agents, excluding tamoxifen but including low-dose methotrexate weekly* regimens, are classified as severely immunosuppressive. 6. Tumor necrosis factor (TNF) blockers such as etanercept, adalimumab, certolizumabpegol, golimumab, and infliximab 7. Of all biological agents - "monoclonal antibodies" ie rituximab or alemtuzumab, are significantly immunosuppressive
Hepatitis A Immunoglobulin - Indications
People who need protection against HAV infection, but are allergic to the vaccine. • People who need protection against HAV but can't get the vaccine because of a weakened immune system. • Children younger than age 1 (or 6 months) who need to be protected against HAV infection.
Scopolamine Patch : how to use it?
Placed on the skin behind your ear - Patch should be applied at least 4 hours before its effects will be needed. - Each patch is good for 3 days.
Travellers at Risk of HB?
Poor infection control during medical or dental procedures • Receipt of blood products • Injection drug use • Tattooing or acupuncture.... "SPA's" • Unprotected sex
What route is the rabies vaccine given?
Preexposure vaccination consists of a series of 3 intramuscular injections in the deltoid with human diploid cell rabies vaccine (HDCV) or purified chick embryo cell (PCEC) vaccine.
What happens if someone does get exposed to rabies, even though they were vaccinated before the exposure?
Preexposure vaccination does not eliminate the need for additional medical attention after a rabies exposure, but it simplifies PEP (Post-Exposure Prophylaxis) .
The rabies vaccine being inactivated, is it a contraindication in pregnancy?
Pregnancy is not a contraindication to PEP. In infants and children, the dose of HDCV or PCEC for preexposure or PEP is the same as that recommended for adults.
Self treatable conditions (definition)
Prescribing certain medications in advance can empower the traveler to self-diagnose and treat common health problems. • Treatment strategies are providing a simple disease or condition definition, providing a treatment, and educating the traveler about the expected outcome of treatment. The patient cant treat themselves with medications they bring with them on their trip without having to go see a HCP. So that the patient can avoid going to the hospital abroad.
Pneumococcal Vaccine
Protects against "Invasive Pnuemococcal Disease" - caused by the infectious agent Streptococcus pneumoniae
Is the tdap vaccine free in BC?
Provided free as part childhood routine immunizations... But outside NOT of that..... • A booster dose of the Tdap vaccine is recommended for adults who were immunized in childhood but is not provided for free in B.C. During an outbreak of pertussis, the Tdap vaccine may be provided for free to women who are 26 or more weeks pregnant to protect them and their newborns.
Quarantine is?
Quarantine—separating and restricting the movement of people who are well but may have been exposed to a communicable disease, to monitor their health and prevent possible transmission to others, until it is determined that they are not infected.
When is RIG contraindicated to given given?
RIG is difficult to access in many countries. If modern cell culture vaccine is available but access to RIG is delayed, the vaccine series should be started as soon as possible, and RIG may be added to the regimen up to and including day 7. • After day 7, RIG is contraindicated because it may compromise the patient's adaptive immunity to the vaccination series. If you dont have access to RIG, then you can still give the vaccine because it is better than nothing, body will make antibodies to vaccines quickly.
• For Predialysis and Dialysis Patients
Recombivax 40 mcg (1.0 mL) - 0,1,6 months • 3 injections
Asplenic patients - Hib vaccine dosing
Recommend supplemental doses for splenectomized patients with incomplete Hib vaccination histories. • Children 5 years of age and older or adults with asplenia : administer a single dose of Hib vaccine, even if previously vaccinated when younger, with at least one year from a previous dose.
HACE
Severe progression of AMS and is rare • Most often associated with HAPE. • In addition to AMS symptoms, lethargy becomes profound, with drowsiness, confusion, and ataxia on tandem gait test. • A person with HACE requires immediate descent • Death from HACE can ensue within 24 hours of developing ataxia, if the person fails to descend.
YellowFever vaccine is administered via what route?
Single injection of reconstituted vaccine should be administered subcutaneously.
When are adverse reactions common with the MMR vaccine?
Six to 23 days after MMR immunization, approximately 5% of immunized children experience malaise and fever (with or without rash) lasting up to 3 days. However, reactions are less frequent after the second dose of vaccine and tend to occur only in those not protected by the first dose.
Hepatitis A Immunoglobulin
The hepatitis A IG is given by injection into a muscle (intramuscular injection). • Immunoglobulin (IG) contains antibodies that destroy the hepatitis A virus (HAV), preventing infection.
Acclimatization
The human body can adjust to hypoxia via the process of acclimatization with time. Acclimatizing for a few days at 8,000-9,000 ft before proceeding to a higher altitude is ideal. Acclimatization prevents altitude illness, improves sleep, and increases comfort and well-being Ascend gradually, if possible. Avoid going directly from low altitude to more than 9,000 ft (2,750 m) sleeping altitude in 1 day. Once above 9,000 ft (2,750 m), move sleeping altitude no higher than 1,600 ft (500 m) per day, and plan an extra day for acclimatization every 3,300 ft (1,000 m). Consider using acetazolamide (carbonic anhydrase inhibitor) to speed acclimatization, if abrupt ascent is unavoidable. Avoid alcohol for the first 48 hours. Participate in only mild exercise for the first 48 hours. Having a high-altitude exposure at more than 9,000 ft (2,750 m) for 2 nights or more, within 30 days before the trip, is useful.
What is the minimal interval between doses of MMR?
The minimum interval between doses of MMR vaccine is 4 weeks. Non-immune travellers, health care workers and military personnel born before 1970: administer two doses of MMR vaccine at least 4 weeks apart.
The polio vaccine must be received between ?
The polio vaccine must be received between 4 weeks and 12 months before the date of departure from the "polio-affected country."
How is the JE vaccine doses and what route is it given?
The primary immunization schedule for Ixiaro is 2 doses administered intramuscularly on days 0 and 28.
Administering Vivaxim
The purified Vi polysaccharide typhoid vaccine is contained in the chamber of the syringe closest to the syringe tip and the inactivated hepatitis A vaccine in the chamber closest to the plunger. • The two vaccine components should only be mixed immediately before injection. The final volume to be injected is 1 mL.
Timing between doses or MMRV?
The recommended interval between 2 doses of MMRV vaccine is at least 3 months; a minimum interval of 6 weeks between doses may be used if rapid, complete protection is required.
Rotavirus vaccine:what age is it given?
The rotavirus vaccine is part of the immunization schedule for infants and children in BC at 2 and 4 months.
How effective is the rotavirus vaccine?
The rotavirus vaccine protects about 98% of children from getting severe diarrhea caused by rotavirus. About 74% of children who get the vaccine do not get rotavirus diarrhea at all
DTap-HB-IPV-HiB is given when to infants?
This vaccine is given as a series of 3 doses to infants at 2, 4 and 6 months of age.
Breastfeeding and yellow fever?
Three YEL-AND cases have been reported in exclusively breastfed infants whose mothers were vaccinated with yellow fever vaccine. All 3 infants were diagnosed with encephalitis and aged <1 month at the time of exposure. • Until more information is available, yellow fever vaccine should be avoided in breastfeeding women. • However, when travel of nursing mothers to a yellow fever- endemic area cannot be avoided or postponed, these women should be vaccinated.
How many does or Dukoral and when?
To prevent cholera: Adults and children over 6 years of age should receive 2 doses of the vaccine at least 1 week apart and no more than 6 weeks apart. • The second dose should be given at least 1 week before departure. Protection lasts for 2 years. • A single booster dose can be given if the last dose was given between 2 years and 5 years earlier.
Trip Details - Reason
Tourism • Business • Visiting friends and relatives • Volunteer, missionary, or aid work • Research or education • Adventure • Pilgrimage • Adoption • Seeking health care(medical tourism)
Examples of a self-treatable condition?
Travelers' diarrhea • Altitude illness • Jet lag • Motion sickness • Respiratory infections • Skin conditions • Urinary tract infections • Vaginal yeast infections: • Malaria self-treatment
How many doses are needed before travel for rabies protection?
Travellers should receive all 3 preexposure immunizations before travel. If 3 doses of rabies vaccine cannot be completed before travel, the traveler should not start the series, as few data exist to guide PEP after a partial immunization series. "ALL OR NONE PHENOMEONA"
What does it mean to be at increased risk for HA?
Travellers to HA-endemic countries. • Canadian-born children of new Canadians returning to their country of origin to visit friends and relatives, may be at increased risk. • Individuals living in communities at risk of HA outbreaks or in which HA is endemic
Travelers' diarrhea is?
Travellers' diarrhea" is the sudden onset of abnormally loose, frequent stools. • The treatment is ciprofloxacin 500 mg, every 12 hours, for 3 days (6 doses). • The traveler should feel better within 6-24 hours. • If symptoms persist for 24-36 hours despite self- treatment, it may be necessary to seek medical attention.
Typhoid and Paratyphoid Fever ****Individual-specific risk factors****
Travelling children • Travellers visiting friends and relatives • Longer duration of travel • Functional or anatomic asplenia • Achlorhydria • Use of acid suppression therapy • Personal preference.
Tetanus/Diptheria/Pertussis is given to?
Vaccine is given to all students in grade 9. This is a booster dose for children immunized against these diseases at a younger age. • Children who received a booster dose of Tdap vaccine on or after their 10th birthday do not need a dose in grade 9. • The Tdap vaccine can also be given to children 7 years of age and older who have not been fully immunized, and to adults or immigrants who have not been immunized or whose immunization history is unknown.
"Consider" which vaccines for HIV Patients with CD4 counts ≥200/mm3?
Varicella and Zoster
Leading cause of death in children who travel is ?
Vehicle-related injuries are the leading cause of death in children who travel.
Potential Adverse Reactions IM vaccine?
ViCPS vaccine is most often associated with eadache (16%-20%) and injection-site reactions (7%).
Vivaxim - what does it contain?
ViVAXIM® (combined purified Vi polysaccharide typhoid and inactivated hepatitis A vaccine for injection), Sanofi Pasteur SA (manufacturer), sanofi pasteur Ltd. (distributor) (HA-Typh-I)
Which part of the world is high risk for HEP B?
West Africa
Jetlag: RISK FOR TRAVELLERS, is the risk bigger from west-east or east-west?
When travelling to the east coast the risk is greater.
Additional doses of yellow fever vaccine are recommended for certain travellers:
Women who were pregnant (regardless of trimester) when they received their initial dose of yellow fever vaccine should receive 1 additional dose of yellow fever vaccine before their next travel that puts them at risk for yellow fever virus infection [Category A]; Persons who received a hematopoietic stem cell transplant after receiving a dose of yellow fever vaccine and who are sufficiently immunocompetent to be safely vaccinated should be revaccinated before their next travel that puts them at risk for yellow fever virus infection [Category A]; Persons who were infected with human immunodeficiency virus when they received their last dose of yellow fever vaccine should receive a dose every 10 years if they continue to be at risk for yellow fever virus infection [Category A]. A booster dose may be given to travellers who received their last dose of yellow fever vaccine at least 10 years previously and who will be in a higher- risk setting based on season, location, activities, and duration of their travel [Category B]. This would include travellers who plan to spend a prolonged period in endemic areas or those traveling to highly endemic areas such as rural West Africa during peak transmission season or an area with an ongoing outbreak. Laboratory workers who routinely handle wild-type yellow fever virus should have yellow fever virus- specific neutralizing antibody titers measured at least every 10 years to determine if they should receive additional doses of the vaccine. For laboratory workers who are unable to have neutralizing antibody titers measured, yellow fever vaccine should be given every 10 years as long as they remain at risk [Category A].
Is yellow fever a live vaccine?
YES
Yellow fever vaccine is contraindicated for people with a what disorder?
Yellow fever vaccine is contraindicated for people with a thymus disorder that is associated with abnormal immune cell function, such as thymoma or myasthenia gravis. • If travel to a yellow fever-endemic area cannot be avoided in a person with such a thymus disorder, a medical waiver should be provided and counseling on protective measures against mosquito bites should be emphasized.
Yellow fever vaccine is contraindicated for people with with CD4 T- lymphocyte values less than what?
Yellow fever vaccine is contraindicated for people with with CD4 T- lymphocyte values <200. • This recommendation is based on a theoretical increased risk of encephalitis in this population • If travel to a yellow fever-endemic area cannot be avoided by a person with severe immune suppression based on CD4 counts (<200/mm3 a medical waiver should be provided, and counseling on protective measures against mosquito bites should be emphasized.
Yellow Fever vaccine recommendations?
Yellow fever vaccine is recommended for people aged ≥9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa. In addition, some countries require proof of yellow fever vaccination for entry.
Severe adverse reactions from yellow fever vaccine, when is the typical onset?
Yellow fever vaccine-associated neurologic disease (YEL-AND) The onset of illness for documented cases is 3-28 days after vaccination, and almost all cases were in first-time vaccine recipients. YEL-AND is rarely fatal. The incidence of YEL-AND in the United States is 0.8 per 100,000 doses administered.
Immunocompromised travellers should NOT receive the?
YellowFever vaccine, as there is increased risk of serious AE's (ie yellow fever vaccine-associated visoerotropic disease) • Travelers with severe immune compromise should be advised to avoid travel to destinations that present a true risk for yellow fever (YF). • Informed of the risk of YF • Carefully instructed in methods to avoid mosquito bites, • Provide a vaccination medical waiver • Option of deportation is preferable to receipt of YF vaccine at the destination
Varicella Vaccine: can you get this on its own?
Yes
Should travellers be up to date with routine vaccines prior to their trip?
Yes, Routine - travellers should be up-to-date with routine vaccines before international travel, regardless of destination. The benefits of vaccine administration extend beyond the travel period, and in many cases lifelong immunity is achieved. Routine vaccines are generally associated with lower costs
***The accelerated vaccination schedule calls for vaccine doses administered at what? Engerix- B (brand name)
at days 0, 7, and 21-30; a booster should be administered at 12 months to promote long-term immunity
HIV patients CD4 count - what should the count be?
at least 500
For all Travellers: Important non-drug measures?
avoid animal bites and seek care for such bites should they occur, • use insect precautions • observe food and water precautions at all times. • All travellers should practice but more critical for travellers who elect not to receive recommended vaccinations for any reason. Following safety (especially road traffic safety) and security guidelines • Observing sun protection • Following safe sexual practices
Typhim Vi (IM vaccine) : DOSES, AGE
one o.5 mL dose. Have to be more than 2 years old
It is not usually necessary to restart the series or add doses of any vaccine because of an extended interval between doses, the only exception to this rule is?
oral typhoid vaccine in some circumstances. • Some experts recommend repeating the series of oral typhoid vaccine if the 4-dose series is extended to more than 3 weeks
