IMMUNIZATIONS

IMMUNIZATIONS

Because the spectrum of infectious diseases changes with time and location, travelers to or between foreign countries should be aware of the necessity for immunizations. The Centers for Disease Control and Prevention (CDC) has a comprehensive traveler’s health website at wwwn.cdc.gov/travel/default.aspx.

A detailed, updated list of required immunizations by country can be obtained in the publication Health Information for International Travel (CDC), also known as the “Yellow Book.” The CDC Internet site, with links to the online copy of the Yellow Book and instructions for ordering a hard copy, is wwwn.cdc.gov/travel/contentYellowBook.aspx.

Vaccinations may be given under the supervision of any licensed physician. All travelers should carry a completed International Certificate of Vaccination with proper signature and validation for all vaccinations administered. Yellow fever and cholera vaccinations must be officially recorded and stamped. Failure to secure validation at an authorized city, county, or state health department renders the certificate invalid, and may force you to be revaccinated or quarantined.

It is extremely important to plan immunizations as far in advance of an expedition as possible, since some vaccines interact in ways that diminish effectiveness. For instance, yellow fever and cholera vaccines need to be given either on the same day or at least 3 weeks apart.

TETANUS

Everyone should be properly immunized against tetanus, which is caused by the bacterium Clostridium tetani. In the United States, diphtheria-tetanus-pertussis (DTAP) vaccine is given as an intramuscular injection at ages 2, 4, 6, and 8 months, followed by a booster at age 4 to 6 years, usually before entry into school. These shots provide immunity from tetanus, as well as from diphtheria and pertussis (whooping cough), for about 10 years. The first booster shot is usually given at age 11 or 12 years in the form of Tdap vaccine. Thereafter, Td (tetanus and diphtheria) vaccine is recommended at 10-year intervals. However, given a resurgence of whooping cough seen in adults, the recommendation may change to continue immunizing against pertussis with the Tdap vaccine in perpetuity. Following immunization against tetanus, immunity in any individual is unknown, and can be determined by measuring antibodies in blood. This is particularly important in elders, in whom the immune response to vaccination may be suppressed by a general lower level of the immune system associated with age.

Here are the vaccines that are licensed as of this writing for different age-groups:

1. Tdap (tetanus, diphtheria, pertussis): Adacel (Sanofi Pasteur) ages 11 to 64 years; Boostrix (GlaxoSmithKline) ages 10 to 18 years

2. DTaP (diphtheria, tetanus, pertussis): Daptacel (Sanofi Pasteur) ages 6 weeks to 7 years; Tripedia (Sanofi Pasteur) ages 6 weeks to 7 years; Infanrix (GlaxoSmithKline) ages 6 weeks to 7 years; Pediarix (GlaxoSmithKline) ages 6 weeks to 7 years

3. Td (tetanus, diphtheria): Td (Sanofi Pasteur) ages 7 years and older

One obvious question is, “Which vaccine should be used for children between ages 7 years and 10 years?” It is probably best to use the DTaP vaccine for this age-group, even though no vaccine is licensed for this age-group, and either Tdap or DTaP would likely induce the proper immunities.

The current practice is to take a booster shot (Td) if one sustains a “dirty” wound, deep puncture, serious burn, significant crush injury, or similar injury and has not had a tetanus shot in the preceding 5 years. If a wound is believed to be at particularly high risk for infection with C. tetani (e.g., if it is a very deep puncture or contaminated by soil or animal feces), it may also be recommended to have an injection of tetanus immune globulin, as well as a tetanus booster immunization. Whether or not to administer tetanus immune globulin is generally a judgment call by the treating health care professional. The immune globulin contains actual antibodies against the bacteria, so that the recipient carries protective antibodies against the bacteria until his or her body has a chance to manufacture its own antibodies in response to the Td booster shot.

Any traveler who will be away from medical care for more than 48 hours should have adequate tetanus immunization. The recommendations are as follows:

1. A person previously immunized should receive a booster dose of tetanus toxoid if his last dose was not administered within the past 10 years. A dose of Tdap vaccine (tetanus, diphtheria, and pertussis) may be administered if pertussis is a concern. Diphtheria immunization is usually boosted simultaneously. If there is a good chance that the traveler will suffer an injury during the trip, he should take a booster if the last dose was not administered within the past 5 years.

2. Nonimmunized individuals should become immunized with a series of three injections (this requires 3 to 6 months).

Low-risk (for tetanus infection) wounds are those that are recent (less than 6 hours old), simple (linear), superficial (less than ½ in, or 1.3 cm, deep), cut with a sharp edge (knife or glass), without signs of infection, and free of contamination with dirt, soil, or body secretions. High-risk wounds are those that are old (greater than 6 hours), crushed or gouged, deep (greater than ½ in deep), burns, frostbite, with signs of infection, and contaminated. If someone suffers a wound, here are standard recommendations:

Victim	Low-Risk Wound (not heavily contaminated)	Contaminated Wound (tetanus-prone)
Never Immunized	Tetanus toxoid Tetanus immune globulin	Tetanus toxoid Tetanus immune globulin
Immunized
Last booster within 5 yr	No shot	No shot
Last booster within 10 yr	No shot	Tetanus toxoid Tetanus immune globulin
Last booster over 10 yr	Tetanus toxoid	Tetanus toxoid Tetanus immune globulin

POLIOVIRUS; DIPHTHERIA; PERTUSSIS (WHOOPING COUGH); MEASLES, MUMPS, RUBELLA (GERMAN MEASLES); CHICKENPOX; HAEMOPHILUS B; ROTAVIRUS

Immunization against poliomyelitis, diphtheria, pertussis, measles, mumps, and rubella should be obtained before travel. These are routinely administered during childhood in the United States. Because of the incidence of these infectious diseases in developing countries, such immunizations are mandatory before travel. Immunizations against Haemophilus type b (which causes middle ear infections and meningitis) and the virus that causes chickenpox are available, and should be considered under recommendation from your physician. Measles vaccine should be given to any person born after 1956 who has not received a prior booster dose. Mumps (a viral infection) is making a comeback in the United States and other countries because of failure to vaccinate. It is not a trivial disease, particularly in adults, and is highly communicable. In children, mumps typically causes fever, headache, muscle aching, fatigue, loss of appetite, and swelling of salivary glands, in particular the parotid glands, which are located in the cheeks directly in front of the ears. In adults, complications of mumps may include inflammation of brain, meningitis, swollen and painful inflamed testicles, ovarian or breast inflammation, miscarriage, and deafness.

Polio is still present in developing nations (e.g., sub-Saharan Africa, India, Nepal, Indonesia, Pakistan). Unimmunized adults (age greater than 18 years) should receive a series of three injections of the inactivated (virus) Salk vaccine, not the oral (Sabin) vaccine, which is recommended for children. Those under 18 who have never been immunized should receive three doses of oral polio vaccine 1 month apart. People who travel to high-risk areas (e.g., outside the Western Hemisphere) who were immunized as children should receive one booster dose of oral polio vaccine or an injection of e-IPV polio vaccine.

Two adolescent/adult formulations of pertussis vaccine are combined with diphtheria and tetanus toxoids (Tdap): Boostrix (approved for ages 10 to 18 years) and Adacel (approved for ages 11 to 64 years). One of these should be given instead of standard tetanus-diptheria vaccine if pertussis is a concern.

RotaTeq is an oral vaccine given in a three-dose series recommended for infants to prevent the gastrointestinal illness caused by rotavirus. Rotarix is given in two doses. It is advised that children who have had an episode of intussusception not receive these vaccines.

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Tags: Medicine for the Outdoors The Essential Guide to Emergency Medicine

Aug 11, 2016 | Posted by admin in EMERGENCY MEDICINE | Comments Off

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