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Immunization information

Immunization Considerations and Recommendations
for Overseas Mission Service
Updated March 20, 2006

By Roger W. Boe, MD
Medical Consultant, HCV

GENERAL CONSIDERATIONS

1. One of the first questions often asked by prospective missionaries is "What shots do I need?" Requirements vary according to the country or countries visited, the length of stay, and the local risk of exposure.

2. The temptation to shorten an immunization schedule or skip it altogether should be balanced by a sober analysis of the risks involved in contracting a serious or even fatal disease.

3. Completing an immunization schedule requires some forethought and planning

4. Personal physicians or embassies are often unaware of vaccine recommendations or risks. It is best to contact an authoritative source such as the Center for Disease Control, (CDC), or State Health Department if you have questions. The CDC website, cdc.gov/travel/index, lists country specific risks and vaccine recommendations.

5. Immunosuppressed patients and pregnant women need to avoid live vaccines, including yellow fever, oral typhoid, oral polio, and measles (MMR). There are no restrictions for women who are breastfeeding.

6. Those with severe allergy to eggs need to know that influenza and yellow fever vaccines are egg derived. Desensitization is possible.

SPECIFIC VACCINE RECOMMENDATIONS

1. Cholera
a. Very low risk with normal precautions.
b. Injectable vaccine is 50% effective, poorly tolerated and is no longer recommended by CDC and WHO.
c. A new oral vaccine is much more effective, but is not currently licensed in the US

2. Diphtheria
a. Some exposure risk in developing countries (a member of a recent UMVIM team contracted a fatal case of diphtheria)
b. Part of routine childhood immunization
c. Booster, Diphtheria/Tetanus, (Adult DT) recommended every 10 years, or may be combined with acellular pertussis vaccine (Tdap).

3. Hepatitis A
a. The most frequent vaccine preventable disease
b. Highly recommended for all travelers to developing countries.
c. Inactivated virus, 2 doses
d. 95% protection with 1st dose
e. 2 doses give long term immunity
f. Immunoglobulin provides immediate short-term protection for 3 months. May be used for children too young to receive vaccine (<2yrs).

4. Hepatitis B
a. Major risk for those who are exposed to blood or body fluids.
b. Inactivated vaccine, 3 doses at 0, 1, 6 months
c. Protection essential for long term missionaries and health workers

5. Japanese Encephalitis
a. Endemic in parts of Asia
b. High Mortality, no effective treatment
c. Vaccine indicated for prolonged stay, rural settings, high risk areas.

7. Meningococcus.
a. Cause of epidemic contagious meningitis
b. Endemic in many developing countries
c. Vaccine recommended for current outbreaks in area of service
d. Should be considered by visitors to the Sub-Saharan meningitis belt (see CDC recommendations)

8. Pertussis
a. A major cause of death among children in developing countries
b. Significant risk of exposure, particularly in orphanages, health facilities.
c. Recent waning of adult protection in developed nations (That's us)
d. Consider adult booster with acellular pertussis vaccine if working in a high exposure setting
e. May be combined with diphtheria and tetanus as Tdap, (ADACEL or BOOSTRIX.)

9. Polio
a. Disease has been eliminated from the Western Hemisphere
b. Single adult booster indicated for travelers to Africa & Asia.
c. Need not be repeated for subsequent trips.

10. Rabies
a. Endemic in most countries
b. Vaccine is not always available locally
c. Vaccine should be considered if there is a high animal exposure, rural setting.

11. Tetanus
a. Single adult booster given every 10 yrs
b. Usually given as Diphtheria/Tetanus, (DT) or Tdap. (See diphtheria and Pertussis above)

12. Typhoid
a. Vaccine indicated for most settings in the 2/3 world
b. Oral vaccine is more effective than killed, requires 4 doses given every other day.
d. Difficult to administer to small children
e. Mefloquine, (Lariam), given at the same time will inactivate the vaccine

13. Tuberculosis
a. The most common serious chronic illness in developing countries
b. A routine Mantoux test is recommended before traveling, and repeated on return.
c. BCG vaccination is not recommended.

14. Yellow Fever
a. Rare but potentially fatal viral illness
b. Immunization required for entry into many countries in South America, Rural Panama and Sub Saharan Africa. (See CDC in-country recommendations and discussion of yellow fever)
c. Single injection confers lasting immunity
d. Booster required every 10 years

RECOMMENDED IMMUNIZATIONS, ROUTINE

VACCINE

SCHEDULE

Diphtheria/Tetanus (DT)

Every 10 years

Pertussis

As DPT in infancy. Single booster with Adult DT, (Tdap)

Polio

Single Booster, OPV

Hepatitis B

3 doses, 6mos, 5mos, 1 month before travel

MMR

1 mo before travel if non immune


RECOMMENDED IMMUNIZATIONS FOR TRAVEL TO COUNTRIES WHERE EXPOSURE RISK IS INCREASED OR DISEASE IS ENDEMIC

VACCINE

SCHEDULE

Hepatitis A

2 wks before travel, booster@6-18mo

Typhoid, oral

1 capsule every other dayX4 doses

Typhoid, polysaccharide

1 dose IM, repeat q. 2yrs

Meningococcal polyvalent

SQ single dose

Yellow Fever

SQ single dose, booster q 10 yrs

Rabies, (Imovax)

ID 3 doses @ 0, 7, 21-28 days

Rabies vaccine can be given post exposure. Use with rabies immunoglobulin

Japanese Encephalitis

IM 3 doses@ 0, 7, 14-30days


NOTE: For details about doses and schedules, refer to the CDC website,
www.CDC.gov/travel, under the country or region that you will be visiting.


REFERENCES

Ryan, ET, Kain, K. Health Advice and Immunizations for Travelers; NEJM 342:23, June8, 2000.

Steele, Russell; Management of Missionaries and Their Families: Infect Med 16(10) 653, 1999

Rosenbach, K, et al. Do You Really Want to Travel. 38th Annual Meeting, Infectious Diseases Society of America.(posted 20 January 2004)

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