Vaccination in Travelling - jadeiisic2013 · 4/17/2013 2 International Travel Air travel and other...
Transcript of Vaccination in Travelling - jadeiisic2013 · 4/17/2013 2 International Travel Air travel and other...
4/17/2013
1
Vaccination in Travelling
Iris Rengganis
Divisi Alergi Imunologi Klinik
Departemen Ilmu Penyakit Dalam
FKUI/RSCM
Name : Dr. dr. Iris Rengganis, SpPD, K-AI, FINASIM DOB : Jakarta, 29 June 1958 Education : - Dokter Umum/S1 : FKUI 1983 - Dokter Spesialis Penyakit Dalam/S2 : FKUI 1994 - Konsultan Alergi-Imunologi/Sp2 : FKUI 2000 - Doktoral/S3 : IPB 2009 Working Experiences : - Puskesmas Kelurahan Cikoko, Jakarta Selatan, 1984-1988 - RS Haji Jakarta, Pondok Gede, Jakarta Timur, 1995-1997 - FKUI/RSCM, 1998-now Organization : - IDI (Ikatan Dokter Indonesia) - PAPDI (Persatuan Dokter Spesialis Penyakit Dalam Indonesia) - PERALMUNI (Perhimpunan Alergi Imunologi Indonesia) - DAI (Dewan Asma Indonesia)
Curriculum Vitae
Why Vaccinate Travellers?
3
4/17/2013
2
International
Travel Air travel and other public transportation modes
facilitate rapid spread of infectious diseases1
Frequent travelers contributed to the international spread of infections1
In 2005, 11.5 million passengers traveled on cruise ships worldwide1
Mortality and morbidity increased in travelers compared to those who stayed home2
Health problems in travelers are frequent2
4
1.Marti, et.al. Exp Rev Vaccines 2008; 7 (5) :679-687 2.Steffen, et.al. Int J Antimicrob Agents 2003;21:89-95
Why Vaccinate Travellers? Hepatitis A – 1.4 million new cases/year
Hepatitis B – over 1 million deaths/year
Typhoid – 16 million new cases/year
The risk of infection increases with duration of travel and low levels of hygiene (e.g. unlikely to monitor food preparation in cafes, restaurants, etc)
5
10x higher?1-3
1.WHO. Hepatitis A vaccines. Wkly Epidemiol Rec 2000; 75: 38–44.
2.WHO. Typhoid vaccines. Wkly Epidemiol Rec 2000; 75: 257–64.
3.Jong EC. Risks of hepatitis A and B in the travelling public. J Travel Med 2001; 8 Suppl 1: S3–8.
4.World Tourism Organisation. Facts and figures. August 2001. Available from: http://www.world-tourism.org [Accessed 1 September 2003]
5.Löscher T, Keystone JS, Steffen R. Vaccination of travellers against hepatitis A and B. J Travel Med 1999; 6: 107–14
Incidence of Vaccine-preventable
Diseases Among Travellers
6
HAV HBV Rabies? Typhoid fever Polio
Incid
en
ce
(m
orb
idit
y p
er
10
0,0
00
tra
ve
lle
rs)
Cholera
Hikers Hotel- tourist
Hotel- tourist
(Animal bites in expat)
India, N/W
Africa & Peru
Other places
2000
300 80-240 200
30
3 2
0.3
Steffen et al. J Med Virol 1994; 44: 460–2.
4/17/2013
3
Priority of Recommended Vaccinations
Infection Incidence Impact Total Vaccination
Hepatitis A +++ ++ +++++ Logical
priorities –
do not
primarily
immunise
against
infection on
bottom of
this list
Hepatitis B ++ +++ +++++
Rabies ++ ++ ++++
Yellow fever + +++ ++++
Influenza +++ + ++++
Typhoid fever ++ + +++
Measles ++ + +++
Diphtheria (+) ++ ++(+)
Tetanus (+) ++ ++(+)
Meningococcal disease (+) ++ ++(+)
Japanese encephalitis (+) ++ ++(+)
Poliomyelitis (+) ++ ++(+)
Cholera + + ++
7
Rate per 100,000: +++ = >100; ++ = 1–99; + = 0.1–0.9; (+) = <0.1
Impact: +++ = high case fatality rate or serious sequelae;
++ = >5% case fatality rate or incapacitation >4 weeks;
+ = low case fatality rate, brief incapacitation
Steffen et al. Int J Antimicrob Agents 2003; 21: 175–80.
Infections Often Acquired by
Travellers in South East of Asia
Food/water-borne infections
◦ Mostly enteric pathogens such as enterotoxigenic E.coli, Salmonella, Campylobacter, Shigella & Giardia species.
◦ Others include HAV, typhoid and amoebiasis
Respiratory infections
◦ Vaccine-preventable infections include influenza, pertussis, diphtheria, measles, and invasive meningococcal disease.
◦ Tuberculosis is often acquired by expatriates living in high-risk areas for long periods
8
Geographic Distribution of Potential Health Hazards to Travelers – Asia. Traveler’s Health - Yellow Book, 2008.
Available at: http://wwwn.cdc.gov/travel/yellowBookCh3-Asia.aspx [accessed on 15 January 2009]
Infections Often Acquired by
Travellers in South East of Asia
Vector-borne infections
◦ Mosquito-borne: malaria, dengue, Japanese
encephalitis.
Bloodborne infections
◦ Transmitted by blood transfusion, contaminated
needles, sexual activity or other body fluid
contact
◦ Include HBV, HCV and HIV
9
Geographic Distribution of Potential Health Hazards to Travelers – Asia. Traveler’s Health - Yellow Book, 2008. Available at:
http://wwwn.cdc.gov/travel/yellowBookCh3-Asia.aspx [accessed on 15 January 2009]
4/17/2013
4
Vaccination For Travellers1,2
Advised before travel to the Asia-Pacific Hepatitis A
Typhoid Fever
Influenza
Rabies
Tuberculosis
Typhoid fever
Cholera
Japanese encephalitis
10 1. Introduction – General Recommendations on Vaccination and Prophylaxis. Traveler’s Health – Yellow Book
2008. 2. Health advice for international travel. Harrison’s Principles of Internal Medicine, 17th Ed, 2008.
11
Vaccine Preventable
Disease
CDC divides vaccines for travel into
three categories: routine,
recommended, and required.
While your doctor will tell you which
ones you should have, it's best to be
aware of them ahead of time.
Are you aware of which
types of vaccinations you
or those traveling with
you may need?
4/17/2013
5
Routine Vaccination
Be sure that you and your family are up to date on your routine
vaccinations. These vaccines are necessary for protection from
diseases that are still common in many parts of the world even though
they rarely occur in some country. If you are not sure which
vaccinations are routine, look at the schedules.
Recommended Adult Immunization Schedule
Recommended Children Immunization Schedule
International Certificate of Vaccination
15
Hepatitis A
Hepatitis B
Typhoid Fever Seasonal Influenza
Meningococcal
Yellow fever
Pneumococcal
Vaccine Preventable Disease
4/17/2013
6
Hepatitis A
17
Hepatitis A: Facts
Spread via faecal–oral route1
Morbidity and mortality increase with age2
Most frequent vaccine-preventable disease in travellers3
No identified risk factors in 50% of cases1
1 WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7
2. CDC, Hepatitis surveillance report 61, 2006
3. Steffen, et al. Int J Antimicrob Agents 2003; 21: 175–80
18
Geographical Distribution of
Hepatitis A, 2005
MMWR Recomm & Rep 1999 Vol. 48 NO, RR-12
Anti-hepatitis A
virus prevalence
High
Intermediate
Low
4/17/2013
7
19
Hepatitis A Risk Groups
Travellers
Chronic liver disease patients
Those at occupational riskthose at
occupational risk such as food handlers,
medical personnel in hospitals, people
working with non-human primates and
daycare centre employees.
WHO, Hepatitis A, WHO/CDS/CSR/EDC/2000.7
Hepatitis B
21
Hepatitis B surface
antigen (HBsAg)
prevalence
High
Intermediate
Low
Geographical Distribution of
Hepatitis B
Mast, et al. MMWR Recomm Rep 2006; 55 (RR16): 1–25
4/17/2013
8
22
Transmission Routes for HBV
Highly infectious blood-borne virus
Individuals often unknowingly put themselves
at risk of infection
Exposure to hepatitis B is associated with:
◦ healthcare treatment
◦ sexual activity
◦ non-sterile needles/equipment
◦ wound site where skin is punctured, tattoos
◦ sporting activities (go-karting, skiing)
WHO. Hepatitis B factsheet, 2000
Thypoid Fever
24
Why Vaccinate Against Typhoid?
Endemic in the developing world, 16 million new cases of typhoid
and 600,000 deaths per year1
Prevents severe clinical symptoms and development of carriers
(2-5% risk)2
WHO recommends vaccination for travellers to high endemic
areas (despite lower risk but high case fatality than hepatitis A)1,3
Recommended for travellers to countries (e.g. Asia, Latin America,
Africa) with prolonged exposure to potentially contaminated food
& water4
1. Steffen R. Vaccine 1993;11:518-20
2. WHO. Typhoid fever factsheet, 1997 http://www.who.int/vaccine_research/diseases/diarrhoeal/en/index7.html
3. WHO. Typhoid vaccines. Wkly Epidemiol Rec 2000;75:257-64
4. Typhoid immunization. Recommendations of ACIP. MMWR 1994;43:1-7
4/17/2013
9
25
Transmission Routes for Typhoid
Via faecal–oral route thru contaminated water
and food (including ice cubes, shellfish, vegetables
eaten raw, milk and milk products)
http://www.who.int/vaccine_research/diseases/diarrhoeal/en/index7.html
(last accessed 15 January 2009)
26
Prevention of Typhoid Fever
Preventing contamination of food
and water extremely important
(e.g. hand-washing, etc.)
Vaccination:
Vi capsular polysaccharide vaccine (ViCPS) given IM injection or oral, live attenuated vaccine (Ty21a)
International Travel with Infants and young Children. Vaccine Recommendations
for Infants and Young Children.Traveler’s Health. Yellow Book, 2008. Available
at: http://wwwn.cdc.gov/travel/yellowBookCh8-VacRecInfantsChidren.aspx
(last accessed 15 January 2009)
27
Recommendations: Typhoid
Primary vaccination (single dose) against typhoid fever provides protection for up to 3 years
WHO and ACIP recommend revaccination every
3 years for continued protection
WHO. Wkly Epidemiol Rec 2000; 75: 257–64. ACIP. MMWR Recomm Rep 1990; 39: 1–5.
4/17/2013
10
Influenza
29
Seasonal Influenza
Affects 5-15% of the world’s population annually
Second most frequent vaccine-preventable infection in travelers
Contributes to approximately 250,000 to 500,000 deaths annually
Guidelines on influenza vaccination for international travel are scarce
Marti, et.al. Expert Rev Vaccines 2008; 7(5): 679-687
30
Seasonal Influenza
Easily transmissible (via respiratory droplets or fomites)
Increased risk at:
- air travel
- sea travel
- mass gatherings (e.g. Hajj pilgrimage, Olympic
games, etc.)
Marti, et.al. Expert Rev Vaccines 2008; 7(5): 679-687
4/17/2013
11
31
Recommendation for
Influenza Vaccine
High risk group :
◦ Elderly 65 years and above
◦ Chronic heart, lung, renal diseases
◦ Diabetics
◦ Healthcare workers
◦ Travelers to high risk area
When do you need to vaccinate every 6 months:
◦ If the new vaccine shows >one different strain
◦ If traveling to high risk areas
CDC. Pink Book. 10th ed, 2008
32
For hajj pilgrimage: The Department of Health in Saudi Arabia1 and
Indonesia recommend that All receive influenza
vaccination prior to Hajj pilgrimage
Especially for high-risk pilgrims
Elderly >60 years old
Patients of chronic diseases (heart disease, kidney
disease, liver disease, DM etc)
Influenza Vaccination for Hajj
Pilgrimage
WHO. Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj).
Weekly Epidemiol Rec. 2006; 81(44): 417–24
33
Year 2000 Hajj Outbreak
of Meningococcal Meningitis with W-1351,2
Worldwide hundreds of cases in Hajj returnees and close contacts1,2
Change in recommendation
from bivalent to quadrivalent vaccine in 2001
Visa requirement in 20022
Case fatality rate among travellers slightly exceeds 20%3
1. Taha, et.al. The Lancet 2000;356:2159
2. Balkhy. Int J Antimicr Agents 2003;21:193-199
3. Steffen,et.al. Int J Antimicr Agents 2003;21:175-180
4/17/2013
12
34
Meningococcal Vaccine
Recommended for those travelling to the ‘meningitis belt’ of Sub-
Saharan Africa (Senegal to Ethiopia)
those travelling to epidemics areas (Middle East)
Saudi Arabian Ministry of Health requires that all pilgrims attending the annual Hajj show
evidence of vaccination with tetravalent meningococcal
vaccine
CDC, Pink Book, 10th ed. 2008
Conclusions
Travellers often unknowingly put themselves at risk from many infections. Safe and effective vaccines against certain diseases are available. Monovalent and combined vaccines with flexible vaccination schedules ensure all travellers are accommodated (including last-minute travelers).
Prioritisation is important; vaccination is essential!
36
4/17/2013
13
Thank You