Immunizations

• Tetanus diphtheria: the vaccine or boosters should be given to those not fully vaccinated or not vaccinated for the past five years (fully vaccinated is defined as three doses of a tetanus toxoid-containing vaccine with the last dose within five years).

• Hepatitis A: this should be given even if travel is imminent.

• Hepatitis B: the recommendation is for the three-dose series (months 0, 1 and 6), but it may be given in an accelerated schedule at days 0, 7 and 14.

• Influenza: this can be given if the vaccine is locally available using the inactivated formulation for injection; the alternative is the live virus vaccine that can be used for most healthy persons age 5-49 years who are not pregnant and not working directly with populations affected by tsunami. This decision may be largely based on the probability of influenza in the affected area (www.cdc.gov/nip/publications/acip-wist.htm).

• Typhoid: the injectable vaccine is given as a single dose, but protection does not begin for two weeks.

• Polio: a booster should be provided if there has been none since childhood.

• Measles: immunity is assumed if there is physician-diagnosed laboratory evidence of measles immunity, or proof of receipt of two doses of live measles vaccine after one year or birth before 1957. MMR vaccine may be given if there is concern about susceptibility, and this is one of the more important components of pre-travel immunizations.

• Rabies: this is a recognized risk, although rare. The problem is that preexposure immunization requires at least three weeks and incomplete pre-exposure provides minimal value. In the event of potential exposure, the traveler should receive post-exposure prophylaxis with Rabies Immune Globulin (RIG), plus five doses of vaccine. If this is not available on site, the exposed person should return to home or to the major city where it is available.

• Japanese encephalitis this was a major concern in the 2004 tsunami due to risk in all affected countries. Full vaccination requires 2-4 weeks, but an abbreviated schedule is two doses separated by seven days; this results in seroconversion in 80 percent. One potential concern is that reactions to the vaccine can occur in some at up to one week after vaccination; these include generalized pruritis, angioedema, or even anaphylaxis. If travel is planned later than two weeks, this vaccine should be given (www.cdc.gov/travel/dis-eases/jenceph.htm). For those who need to travel earlier, the traveler should be given advice about prevention of mosquito bites using insect repellent, and should sleep in insecticide-treated bed nets treated with permethrin (www. cdc.gov/travel/bugs.htm).

• Cholera: this vaccine is recommended if there is cholera in the area, but availability is a potential problem.

• Yellow fever there is no yellow fever risk in Asia, but this vaccine should be considered for those who travel to natural disasters in East Africa.

• Malaria prophlaxiS: recommendations are variable depending on the country, but risk may be enhanced by migration, breakdown in mosquito control, and flooding. Specific recommendations vary by country (www.cdc.gov/travel/ malariadrugs.htm). This site also provides a valuable list of side effects. The preferred agents are atovaquone/proguanil (A/P, malarone), doxycycline, or mefloquine (lariam and generic). Doxycycline is often considered preferred because of the protection afforded against other common infectious diseases, and its established merit for preventing malaria. The traveler should be warned that unexplained fever that occurs within a year of returning should prompt consideration of malaria. There is also a recommendation for empiric treatment of malaria for patients in areas of risk who have compatible clinical conditions. The recommendations for presumptive self-treatment are available at www.cdc.gov/travel/diseases/malaria. Another resource is the CDC malaria hotline on 770-488-7788 and, for emergency consultation after hours, 770488-7100, with the request to speak to the CDC malaria branch clinician.

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