Immunisation: Long-stay and remote travel vaccinations

Dr Mike Townend advises on jabs for long trips or remote destinations.

Yellow fever is transmitted by daytime biting mosquitoes (Photo: SPL)
Yellow fever is transmitted by daytime biting mosquitoes (Photo: SPL)

Long-stay travellers or those going to remote destinations face greater risk than short-stay tourists and should be advised accordingly.

Hepatitis B

Long-stay travellers are more likely to be exposed to the risk of blood-borne infection due to trauma or unsafe medical procedures. Hepatitis B is also recommended for travel to remote areas.

The vaccines available are:

  • H-B-Vax II and H-B-Vax II Paediatric (Sanofi Pasteur MSD)
  • Engerix B and Engerix B Paediatric (GlaxoSmithKline)
  • Fendrix (GlaxoSmithKline)

Possible adverse effects include mild local reaction, pyrexia, malaise, headache, nausea, arthralgia and rash; neurological reactions are rare.

For adults, the dose of H-B-Vax II and Engerix is 1mL IM; for children, 0.5mL IM.

The standard schedule consists of doses at zero, one and six months. A booster dose should be given after five years. An accelerated schedule (zero, seven and 21 days) may be used if time before departure does not allow for the standard schedule. This should be boosted after one year.

Fendrix is suitable for patients aged over 15 years, at a dosage of 20 microgram at zero, one, two and six months.

Rabies

Rabies vaccination is recommended for those working, or likely to come into close contact, with animals, or travellers to remote areas where post-exposure immunoglobulin is unlikely to be available.

The vaccines available are:

  • Rabies Vaccine BP (Sanofi Pasteur MSD)
  • Rabipur (Novartis Vaccines)

Possible adverse effects include redness, swelling and pain at the injection site, pyrexia, myalgia, headache and urticaria. Anaphylaxis or neurological complications are rare.

The standard schedule is 1mL IM at zero, seven and 28 days (from 21 days if time before travel is short), but an unlicensed schedule of 0.1mL intradermally at the same intervals is sometimes used. A booster dose is needed after two to three years (two to five years for Rabipur).

An unlicensed emergency schedule, using four intradermal doses of 0.1mL, one dose in each limb, is sometimes used for travellers leaving at short notice, but needs boosting after one year.

Intradermal vaccination should not be used if the patient is taking chloroquine or mefloquine for malaria prophylaxis.

Rabies immunity needs to be boosted at three to five years, or for those at continuous risk, such as veterinarians, if rabies antibody levels in the blood fall below 0.5 units/mL on six-monthly testing.

Yellow fever

Confined to tropical regions of South America and Africa, yellow fever is predominantly a jungle infection, but has been reported in some urban areas. It is one of the haemorrhagic fevers and has a high mortality. Transmission of infection is by bites from daytime biting mosquitoes.

Protection is required for those travelling to rainforest areas, but there is no risk of infection in high-altitude or desert areas, or most urban areas.

Stamaril (Sanofi Pasteur MSD) is a live vaccine, available only to approved yellow fever vaccination centres. A dose of 0.5mL is given subcutaneously and a booster dose is needed after 10 years for international certification purposes, although protection almost certainly lasts much longer.

Possible adverse effects include redness, swelling and pain at the injection site, pyrexia, myalgia and headache. Older patients who have not previously received the vaccine may be at risk of severe viscerotropic reactions.

There is an increased risk of meningoencephalitis from the vaccine in infants and vaccination is not usually advised under the age of nine months.

Live vaccines are not usually advised in pregnancy or in immunosuppressed patients, unless there is a very high risk of yellow fever and travel cannot be avoided.

A certificate of vaccination is required by some countries where the disease is not endemic, but where the insect vector is present, but only if the traveller arrives directly from an infected area.

Japanese B encephalitis

Japanese B encephalitis is confined to south and south-east Asia. For travellers spending more than one month in the wet season in rural areas, protection is advisable.

Ixiaro (Novartis Vaccines) is an inactivated vaccine. The dosage for adults and children over the age of three years is 0.5mL subcutaneously on days zero and 28, and 0.25mL at the same interval for children aged two months to three years. A booster is needed after one to two years.

Possible adverse effects include redness, swelling and pain at the injection site, pyrexia, myalgia, headache, nausea and vomiting, and less frequently, migraine, vertigo, dyspnoea, palpitation, tachycardia, thrombocytopenia and neuritis.

Tick-borne encephalitis

Tick-borne encephalitis is present in eastern Europe and some parts of Scandinavia and the former Soviet Union. It is transmitted by tick bites in forested areas.

TicoVac (MASTA) is an inactivated vaccine. The dosage for patients aged over 16 years is 0.5mL IM. The standard schedule is zero, one to three and five to 12 months, but the second dose may be given after 14 days if rapid protection is needed.

A booster dose is needed after three years, then every three to five years if the patient is still at risk.

Possible adverse effects include redness, swelling and pain at the injection site, pyrexia, myalgia, arthralgia, headache and less frequently, neurological complications.

  • Dr Townend is chairman and honorary fellow, British Global and Travel Health Association

Resources

  • Public Health England. Immunisation against Infectious Disease (The Green Book).
  • Zuckerman JN, Jong EC (eds). Travelers' Vaccines (second edition). Shelton CT, People's Medical Publishing House, 2010

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