Vaccines

Routine vaccination
Diphtheria
Hepatitis B
Haemophilus influenzae type b
Human papillomavirus
Seasonal influenza and Influenza A (H1N1)
Measles
Mumps
ertussis
!ubella
neumo"o""al disease
oliomyelitis (olio)
!otavirus
#uber"ulosis (#B)
#etanus
$ari"ella
Selective use for travellers
%holera
Hepatitis A
&apanese en"ephalitis
Menin'o"o""al disease
!abies
#i"()borne en"ephalitis
#yphoid fever
*ello+ fever
Required vaccination
*ello+ fever (see %ountry list)
Menin'o"o""al disease and polio (re,uired by Saudi Arabia for pil'rims- updates are available on
+++.+ho.int/+er
Cholera
Vaccine
A va""ine "onsistin' of (illed +hole)"ell $. "holerae 01 in "ombination +ith a re"ombinant B)
subunit of "holera to1in (2%/rBS) has been mar(eted sin"e the early 1334s. #his (illed va""ine is
+ell tolerated and "onfers hi'h)level (567348) prote"tion for 9 months after the se"ond
immunization in all va""inees a'ed more than : years. #he level of prote"tion is still about 648- ;
years after immunization in va""inees +ho +ere a'ed over 6 years at the time of va""ination. rimary
immunization "onsists of t+o oral doses <71= days apart for adults and "hildren a'ed 9 years and
over. >or "hildren a'ed :76 years- three doses are re"ommended. Inta(e of food and drin(s should be
avoided 1 hour before and after va""ination. If the se"ond dose is delayed for more than 9 +ee(s-
va""ination should be restarted. >ollo+in' primary immunization- prote"tion a'ainst "holera may be
e1pe"ted after about 1 +ee(. Booster doses are re"ommended after : years for adults and "hildren
a'ed 9 years and over- and every 9 months for "hildren a'ed :76 years. #he va""ine is not li"ensed
for individuals under : years of a'e.
In studies of travellers to "ountries or areas reportin' "holera outbrea(s- 2%/rBS +as also found to
indu"e appro1imately 648 short)term prote"tion a'ainst diarrhoea "aused by enteroto1i'eni"
?s"heri"hia "oli (?#?%).
#+o "losely related bivalent oral "holera va""ines are available in India and $iet Nam. #hese (illed
+hole)"ell va""ines are based on $. "holerae sero'roups 01 and 01;3 and do not "ontain the to1in B)
subunit@ they are reported to be safe and effi"a"ious- providin' 9979<8 prote"tion for at least t+o
years a'ainst "lini"ally si'nifi"ant "holera in "ountries or areas reportin' outbrea(s. #he Indian
va""ine is intended for both the national and the international mar(et.
Type of vaccine:
a) Ailled oral 01 +hole)"ell +ith B)subunit
b) Ailled oral 01 and 01;3
Number of doses:
a) #+o doses (minimum 1 +ee( and ma1imum 9 +ee(s apart). #hree doses for "hildren a'ed :76
years (minimum 1 +ee( and ma1imum 9 +ee(s apart).
b) #+o doses 1= days apart for individuals a'ed B1 year. 0ne booster dose is re"ommended after :
years.
Contraindications: Hypersensitivity to previous dose
Adverse reactions: Mild 'astrointestinal disturban"es reported
Before departure: : +ee(s
Consider for: #ravellers at hi'h ris( (e.'. emer'en"y or relief +or(ers)
Special precautions: None
Hepatitis A
Vaccine
Hepatitis A va""ination should be "onsidered for individuals a'ed B1 year +ho are travellin' to
"ountries or areas +ith moderate to hi'h ris( of infe"tion. #hose at hi'h ris( of a",uirin' the disease
should be stron'ly en"oura'ed to be va""inated re'ardless of +here they travel.
#+o types of HA$ va""ines are "urrently available internationallyC
1) >ormaldehyde)ina"tivated hepatitis A virus va""ines. Ina"tivated HA$ va""ines are used in most
"ountries. Monovalent ina"tivated HA$ va""ines are available in paediatri" dose (4.6 ml) for "hildren
a'ed D1 year to 16 years- and in adult dose (1 ml).
:) Eive attenuated va""ines (based on H: and EA)1 HA$ strains). #hese va""ines are manufa"tured
and used mainly in %hina and sporadi"ally in the private se"tor in India.
Ina"tivated hepatitis A va""ines are safe and hi'hly effe"tive. #+o doses are ne"essary to promote
lon')term prote"tion. !esults from mathemati"al models indi"ate that- after "ompletion of the
primary t+o)dose series- anti)HA$ antibodies may persist for :6 years or more. Serolo'i"al testin' to
assess antibody levels after va""ination is not indi"ated. #he %hinese live attenuated hepatitis A
va""ines have been sho+n to be safe and hi'hly prote"tive (368) a'ainst "lini"al infe"tion for at least
; years.
A "ombination hepatitis A/typhoid ($i %S ) va""ine- administered as a sin'le dose- "onfers hi'h
levels of prote"tion a'ainst both these +aterborne diseases.
A "ombination va""ine that provides prote"tion a'ainst both hepatitis A and hepatitis B should be
"onsidered for travellers +ho may be e1posed to both or'anisms (see under Hepatitis B va""ines).
eople born and raised in developin' "ountries- and those born before 13=6 in industrialized
"ountries- have usually been HA$)infe"ted in "hildhood and are li(ely to be immune. >or su"h
individuals- it may be "ost)effe"tive to test for antibodies to hepatitis A virus (anti)HA$) so that
unne"essary va""ination "an be avoided.
Type of vaccine: Ina"tivated or live- both 'iven i.m.
Number of doses: Ina"tivated va""ineC t+o@ live va""ineC one
Schedule: Ina"tivated va""ineC t+o doses- the se"ond dose normally 9 months after the first. If
needed- this interval may be e1tended to 157;9 months).
Eive va""ineC one dose. Minimum a'e for HA$ va""ination is 1 year.
Boosters: May not be ne"essary
Contraindications: Hypersensitivity to previous dose
Adverse reactions: Ina"tivated va""ineC mild lo"al rea"tion of short duration- mild systemi" rea"tion.
Eive va""ineC fe+ reported
Before departure: Ina"tivated and live va""inesC prote"tion is a"hieved :7= +ee(s after first dose.
Fiven the lon' in"ubation period of hepatitis A (avera'e :7= +ee(s)- the va""ine "an be administered
up to the day of departure and still prote"t travellers.
Recommended for: All non)immune travellers to "ountries or areas at ris(
Special precautions: None
apanese encephalitis
Vaccine
#he ina"tivated mouse)brain)derived (IMB) va""ine is no+ "ommonly repla"ed by "ell)"ulture)based
va""ines. #he live attenuated SA 1=)1=): va""ine is +idely used in %hina and in an in"reasin'
number of "ountries +ithin the Asian re'ion- in"ludin' India- the !epubli" of Aorea- Sri Ean(a- and
#hailand.
A $ero "ell)derived- ina"tivated &? va""ine +as approved in :443 in North Ameri"a- Australia and
various ?uropean "ountries. #he va""ine is based on the attenuated SA 1=)1=): &? viral strain-
ina"tivated and alum)adGuvanted. #he primary t+o doses are administered = +ee(s apart. A booster
dose is re"ommended 17: years after the primary immunization. #his va""ine has been 'iven
"on"omitantly +ith hepatitis A va""ine +ithout si'nifi"ant interferen"e +ith safety and
immuno'eni"ity. Data on "on"omitant administration +ith other va""ines fre,uently used in travellers
are "urrently unavailable. #he va""ine is li"ensed for use in individuals 1< years of a'e and older in
the Hnited States- and 15 years and above in other "ountries. ost)mar(etin' safety studies are under
+ay.
Another $ero "ell)derived ina"tivated &? va""ine +as li"ensed by the &apanese authorities in >ebruary
:443 and a similar va""ine +as li"ensed in :411. #hese t+o va""ines use the same strain of &? virus
(BeiGin')1) as the mouse)brain)derived va""ine. %lini"al trials have sho+n that the va""ines are safe
and immuno'eni"- +ith sero"onversion rates e1"eedin' 368. #heses va""ines are "urrently not
available outside &apan.
In addition- a ne+ live attenuated- &?7yello+ fever "himeri" va""ine has re"ently been li"ensed in
Australia and #hailand - and +ill be "ommer"ialized from :41:. #his va""ine re,uires a sin'le dose
for primary immunization@ the possible need for booster doses remains to be determined.
Precautions and contraindications
A hypersensitivity rea"tion to a previous dose is a "ontraindi"ation. #he live attenuated va""ine
should be avoided in pre'nan"y unless the li(ely ris( favours its administration. !are- but serious-
neurolo'i"al adverse events attributed to IMB va""ine have been reported from "ountries or areas at
ris( as +ell as from non)ris( "ountries or areas. Aller'i" rea"tions to "omponents of the va""ine o""ur
o""asionally. As su"h rea"tions may o""ur up to : +ee(s after administration- it is advisable to ensure
that the "omplete "ourse of va""ine is administered +ell in advan"e of departure.
Type of vaccine:
1) Eive attenuated va""ine (SA 1=)1=): strain)
:) Ina"tivated- $ero "ell)derived- alum)adGuvanted va""ine (SA 1=)1=): strain)
;) Ina"tivated $ero "ell)derived based va""ines (BeiGin')1 strain)
Schedule:
1) In %hina- the first dose of the live attenuated va""ine is 'iven sub"utaneously at a'e 5 months-
follo+ed by a booster dose at : years of a'e. In some areas- an additional booster is offered at 97<
years of a'e. rote"tion for several years may be a"hieved also +ith a sin'le dose of this va""ine.
:) rimary immunization of the ina"tivated- alum)adGuvanted va""ine "onsists of t+o intramus"ular
doses- = +ee(s apart
;) #he ina"tivated (BeGGin')1)) va""inesC three doses at days 4- < and :5- or t+o doses 'iven
preferably = +ee(s apart (4.:6 ml for "hildren I; years- 4.6 ml for all other a'es).
BoosterC #he duration of immunity is not +ell established for the above va""ines. >or 1) the live
attenuated va""ine- a booster dose is re"ommended in some "ountries. >or :) the &apanese va""ines- a
booster is re"ommended after year 1- and thereafter every ; years. >or ;) the ina"tivated- alum)
adGuvanted va""ine- one booster is re"ommended 1:71= months after "ompletion of the primary
immunization@ the possible need for further boosters to be determined.
Contraindications: >or all &? va""inesC hypersensitivity to a previous dose of va""ine. >or live &?
va""ineC pre'nan"y and immunosuppression.
Adverse reactions: 0""asional mild lo"al or systemi" rea"tions
Before departure: #he immunization series should be "ompleted at least 1 +ee( before potential
e1posure to &?$.
Special precautions: 2ith the ina"tivated- alum)adGuvanted- $ero "ell)derived SA1=)1=): va""ine-
safety and effe"tiveness have not been established in pre'nant +omen- in nursin' mothers- or in
"hildren and adoles"ents (youn'er than 1< years of a'e).
!enin"ococcal disease
Vaccine
olysa""haride and "onGu'ated menin'o"o""al va""ines
Internationally mar(eted menin'o"o""al polysa""haride va""ines are bivalent (A and %)- trivalent (A-
% and 2)1;6) or tetravalent (A- %- * and 2)1;6). #he va""ines are purified- heat)stable- lyophilized
"apsular polysa""harides from menin'o"o""i of the respe"tive sero'roups.
Both 'roup A and 'roup % va""ines have do"umented short)term effi"a"y levels of 5671448 in older
"hildren and adults. Ho+ever- 'roup % va""ines do not prevent disease in "hildren under : years of
a'e- and the effi"a"y of 'roup A va""ine in "hildren under 1 year of a'e is un"lear. Froup * and 2)
1;6 polysa""harides have been sho+n to be immuno'eni" only in "hildren over : years of a'e.
A prote"tive antibody response o""urs +ithin 14 days of va""ination. In s"hool"hildren and adults-
the bivalent and tetravalent polysa""haride va""ines appear to provide prote"tion for at least ; years-
but in "hildren under = years the levels of spe"ifi" antibodies de"line rapidly after :7; years.
#he "urrently available bivalent and tetravalent menin'o"o""al va""ines are re"ommended for
immunization of spe"ifi" ris( 'roups as +ell as for lar'e)s"ale immunization- as appropriate- for the
"ontrol of menin'o"o""al outbrea(s "aused by va""ine)preventable sero'roups (A and %- or A- %- *-
2)1;6 respe"tively). #ravellers +ho have a""ess to the tetravalent polysa""haride va""ine (A- %- *-
2)1;6) should opt for this rather than the bivalent va""ine be"ause of the additional prote"tion
a'ainst 'roups * and 2)1;6.
#hese va""ines do not provide any prote"tion a'ainst other sero'roups su"h as 'roup B and 'roup J
menin'o"o""i- +hi"h are important "auses of menin'o"o""al disease in some "ountries.
Precautions and contraindications polysaccharide vaccine
#he internationally available polysa""haride va""ines are safe- and si'nifi"ant systemi" rea"tions
have been e1tremely rare. #he most "ommon adverse rea"tions are erythema and sli'ht pain at the
site of inGe"tion for 17: days. >ever e1"eedin' ;5.6 K% o""urs in up to :8 of va""inees. No
si'nifi"ant "han'e in safety or rea"to'eni"ity has been observed +hen the different 'roup)spe"ifi"
polysa""harides are "ombined into bivalent or tetravalent menin'o"o""al va""ines.
Type of vaccine:
1) urified ba"terial "apsular polysa""haride menin'o"o""al va""ine (bivalent- trivalent or
tetravalent)
:) %onGu'ate va""ines a'ainst A- %- *- and 21;6
;) %onGu'ate MenA va""ine
Number of doses: 0ne
#uration of protection: >or 1 and :C ;76 years or more@ for ;C not (no+n
Contraindications: Serious adverse rea"tion to previous dose
Adverse reactions: 0""asional mild lo"al rea"tions@ rarely- fever
Before departure: : +ee(s
Consider for: 1 and :C all travellers to "ountries in the sub)Saharan menin'itis belt and to areas +ith
"urrent epidemi"s@ HaGG and Hmrah pil'rims (re,uired)@ ;C a "heaper alterative to 1 and : for
travellers to hi'hly endemi" Afri"an "ountries
Special precautions: %hildren under : years of a'e are not prote"ted by the va""ine
Conjugate meningococcal vaccines
A #)"ell)dependent immune response is a"hieved throu'h "onGu'ation of the polysa""haride to a
protein "arrier. %onGu'ate va""ines are therefore asso"iated +ith an in"reased immuno'eni"ity amon'
infants and prolon'ed duration of prote"tion.
Monovalent sero'roup % "onGu'ate va""ines +ere first li"ensed for use in 1333 and are no+
in"orporated in national va""ination pro'rammes in an in"reasin' number of "ountries. In "ontrast to
'roup % polysa""haride va""ines- the 'roup % "onGu'ate va""ine eli"its ade,uate antibody responses
and immunolo'i"al memory even in infants +ho are va""inated at :- ; and = months of a'e. %ross)
prote"tion does not o""ur and travellers already immunized +ith "onGu'ate va""ine a'ainst sero'roup
% are not prote"ted a'ainst other sero'roups.
In :414- a "onGu'ated sero'roup A menin'o"o""al va""ine desi'ned parti"ularly for use in the Afri"an
Lmenin'itis beltMre"eived re'ulatory approval in India and in a fe+ Afri"an "ountries. #his va""ine-
+hi"h is li"ensed for sin'le)dose immunization of individuals 17:3 years of a'e- has proved to be
safe and hi'hly immuno'eni". #he "onGu'ate MenA va""ine has been used in lar'e va""ine
"ampai'ns in Bur(ina >aso- Mali and Ni'er and is bein' pro'ressively introdu"ed in "ountries of the
Afri"an menin'itis belt.
#+o tetravalent "onGu'ate va""ines a'ainst sero'roups A- %- * and 2)1;6 have been li"ensed in
North Ameri"a and are 'radually be"omin' available in several other "ountries. In the Hnited States
and %anada these va""ines are li"ensed for individuals :766 years of a'e. A t+o)dose series of one of
these va""ines is li"ensed also for "hildren a'ed 37:; months. #hese va""ines are e1pe"ted to indu"e
prote"tion of similar effi"a"y to- but of lon'er duration than- that indu"ed by the polysa""haride
tetravalent menin'o"o""al va""ine.
Rabies
Vaccine
$a""ination a'ainst rabies is used in t+o distin"t situationsC
to protect those who are at risk of exposure to rabies, i.e. pre-exposure
vaccination;
to prevent the development of clinical rabies after exposure has occurred, usually
following the bite of an animal suspected of having rabies, i.e. postexposure
prophylaxis.
#he va""ines used for pre)e1posure and post)e1posure va""ination are the same- but the
immunization s"hedule differs. !abies immuno'lobulin is used only for post)e1posure prophyla1is.
Modern va""ines of "ell)"ulture or embryonated)e'' ori'in are safer and more effe"tive than the older
va""ines- +hi"h +ere produ"ed in brain tissue. #hese modern rabies va""ines are no+ available in
maGor urban "entres of most "ountries of the developin' +orld. !abies immuno'lobulin- on the other
hand- is in short supply +orld+ide and may not be available- even in maGor urban "entres- in many
do' rabiesinfe"ted "ountries.
Pre-exposure vaccination
re)e1posure va""ination should be offered to people at hi'h ris( of e1posure to rabies- su"h as
laboratory staff +or(in' +ith rabies virus- veterinarians- animal handlers and +ildlife offi"ers- and
other individuals livin' in or travellin' to "ountries or areas at ris(. #ravellers +ith e1tensive outdoor
e1posure in rural areas 7 su"h as mi'ht o""ur +hile runnin'- bi"y"lin'- hi(in'- "ampin'-
ba"(pa"(in'- et". 7 may be at ris(- even if the duration of travel is short. re)e1posure va""ination is
advisable for "hildren livin' in or visitin' "ountries or areas at ris(- +here they provide an easy tar'et
for rabid animals. re)e1posure va""ination is also re"ommended for individuals travellin' to isolated
areas or to areas +here immediate a""ess to appropriate medi"al "are is limited or to "ountries or
areas +here modern rabies va""ines are in short supply and lo"ally available rabies va""ines mi'ht be
unsafe and/or ineffe"tive.
re)e1posure rabies va""ination "onsists of three full intramus"ular doses of "ell)"ulture) or
embryonated)e'')based va""ine 'iven on days 4- < and :1 or :5 (a fe+ daysN variation in the timin'
is not important). >or adults- the va""ine should al+ays be administered in the deltoid area of the arm@
for youn' "hildren (under 1 years of a'e)- the anterolateral area of the thi'h is re"ommended. !abies
va""ine should never be administered in the 'luteal areaC administration in this manner +ill result in
lo+er neutralizin' antibody titres.
#o redu"e the "ost of "ell)derived va""ines for pre)e1posure rabies va""ination- intradermal
va""ination in 4.1)ml volumes on days 4- < and either :1 or :5 may be "onsidered. #his method of
administration is an a""eptable alternative to the standard intramus"ular administration- but it is
te"hni"ally more demandin' and re,uires appropriate staff trainin' and ,ualified medi"al supervision.
%on"urrent use of "hloro,uine "an redu"e the antibody response to intradermal appli"ation of "ell)
"ulture rabies va""ines. eople +ho are "urrently re"eivin' malaria prophyla1is or +ho are unable to
"omplete the entire three)dose pre)e1posure series before startin' malarial prophyla1is should
therefore re"eive pre)e1posure va""ination by the intramus"ular route.
eriodi" booster inGe"tions are therefore not re"ommended for 'eneral travellers. Ho+ever- in the
event of e1posure throu'h the bite or s"rat"h of an animal (no+n or suspe"ted to be rabid- individuals
+ho have previously re"eived a "omplete series of pre) or post)e1posure rabies va""ine (+ith "ell)
"ulture or embryonated)e'' va""ine) should re"eive t+o booster doses of va""ine. Ideally- the first
dose should be administered on the day of e1posure and the se"ond ; days later. #his should be
"ombined +ith thorou'h +ound treatment (see Lost)e1posure prophyla1isM- belo+). !abies
immuno'lobulin is not re,uired for previously va""inated patients.
Precautions and contraindications
Modern rabies va""ines are +ell tolerated. #he fre,uen"y of minor adverse rea"tions (lo"al pain-
erythema- s+ellin' and pruritus) varies +idely from one report to another. 0""asional systemi"
rea"tions (malaise- 'eneralized a"hes and heada"hes) have been noted after both intramus"ular and
intradermal inGe"tions.
Type of vaccine: Modern "ell)"ulture or embryonated)e'' va""ine
Number of doses: #hree- one on ea"h of days 4- < and :1 or :5- 'iven i.m. (1 or 4.6 ml/dose
dependin' on the va""ine) or i.d. (4.1 ml/ ino"ulation site)
a
Booster: Not routinely needed for 'eneral travellers
b
Adverse reactions: Minor lo"al or systemi" rea"tions
Before departure: re)e1posure prophyla1is for those plannin' a visit to a "ountry or area at ris(-
espe"ially if the area to be visited is far from maGor urban "entres and appropriate "are- in"ludin' the
availability of post)e1posure rabies prophyla1is- "annot be assured.
a
>or information on +hi"h va""ines are re"ommended for intradermal use- seeC
httpC//+++.+ho.int/rabies/human/poste1p/en/inde1.html.
b
In the event of e1posure throu'h the bite or s"rat"h of an animal (no+n or suspe"ted to be rabid-
individuals +ho have previously re"eived a "omplete series of pre)e1posure or post)e1posure "ell)
"ulture or embryonated)e'' rabies va""ine should re"eive t+o booster doses of va""ine- the first dose
ideally on the day of e1posure and the se"ond ; days later. !abies immuno'lobulin should not be
administered.
Post-exposure prophylaxis
In "ountries or areas at ris( of rabies- the "ir"umstan"es of an animal bite or other "onta"t +ith an
animal suspe"ted to be rabid may re,uire poste1posure prophyla1is. In su"h situations- medi"al
advi"e should be obtained immediately.
Stri"t adheren"e to the 2H0)re"ommended 'uidelines for optimal post)e1posure rabies prophyla1is
virtually 'uarantees prote"tion from the disease. #he administration of va""ine- and immuno'lobulin
if re,uired- must be "ondu"ted by- or under the dire"t supervision of- a physi"ian. ost)e1posure
prophyla1is depends on the type of "onta"t +ith the "onfirmed or suspe"t rabid animal- as follo+sC
a
?1posure to rodents- rabbits and hares seldom- if ever- re,uires spe"ifi" anti)rabies post)e1posure
prophyla1is.
b
If an apparently healthy do' or "at in or from a lo+)ris( "ountry or area is pla"ed under observation-
the situation may +arrant delayin' initiation of treatment.
"
#his observation period applies only to do's and "ats. ?1"ept in the "ase of threatened or
endan'ered spe"ies- other domesti" and +ild animals suspe"ted to be rabid should be humanely (illed
and their tissues e1amined for the presen"e of rabies anti'en usin' appropriate laboratory te"hni,ues.
d
ost)e1posure prophyla1is should be "onsidered for individuals +ho have been in "lose "onta"t +ith
bats- parti"ularly follo+in' bites or s"rat"hes or e1posure to mu"ous membranes.
1. Wound treatment
#horou'h +ashin' of the +ound +ith soap/deter'ent and +ater- follo+ed by the appli"ation of
ethanol or an a,ueous solution of iodine or povidone.
2. Passive immunization
Human rabies immuno'lobulin (H!IF) or e,uine rabies immuno'lobulin (?!IF) or >(abN): produ"ts
for "ate'ory III e1posures as +ell as some "ate'ory II e1posures (see table- above). assive
immunization should be administered Gust before or shortly after administration of the first dose of
va""ine 'iven in the post)e1posure prophyla1is re'imen. If it is not immediately available- passive
immunization "an be administered up until the seventh day after initiation of the primary series of
post)e1posure prophyla1is (+ith "ell)"ulture or embryonated)e'' rabies va""ine).
Dosa'e and administrationC #he dose for H!IF is :4 IH/(' body +ei'ht and for ?!IF and >(abN):
produ"ts =4 IH/(' body +ei'ht. #he full dose of rabies immuno'lobulin- or as mu"h as is
anatomi"ally feasible- should be administered into and around the +ound site. Any remainder should
be inGe"ted i.m. at a site distant from the site of a"tive va""ine administration. Multiple needle
inGe"tions into the +ound should be avoided. If the "orre"t dose of rabies immuno'lobulin is too
small to infiltrate all +ounds- as mi'ht be true of a severely bitten individual- it "an be diluted in
physiolo'i"al buffered saline to ensure 'reater +ound "overa'e.
3. Active immunization
%ell)"ulture) or embryonated)e'')based rabies va""ines should al+ays be used for post)e1posure
prophyla1is. #hey "an be administered either i.m. or i.d.
Intramus"ular re'imensC Both a five)dose and a four)dose i.m. re'imen are re"ommended for post)
e1posure va""ination@ the five)dose (L?ssenM) re'imen is the more "ommonly usedC
The fve-dose regimen is administered on days 0, , !, "# and $% into the deltoid
muscle.
The four-dose regimen is administered as two doses on day 0 &one dose in the
right and one in the left deltoid', and then one dose on each of days ! and $" into
the deltoid muscle.
An alternative post)e1posure re'imen for healthy- fully immuno"ompetent e1posed people +ho
re"eive +ound "are plus hi'h),uality rabies immuno'lobulin plus 2H0)pre,ualified rabies va""ines
"onsists of four doses administered i.m. on days 4- ;- < and 1=.
Intradermal re'imensC Intradermal administration of "ell)"ulture) and embryonated) e'')based rabies
va""ines has been su""essfully used in many developin' "ountries that "annot afford the five) or four)
dose i.m. s"hedules.
The two-site i.d. method( one i.d. in)ection at two sites on days 0, , ! and $%.
>or use +ithC 4.1 ml for purified $ero "ell rabies va""ine@ 4.1 ml for purified "hi"( embryo rabies
va""ine.
Tic$%borne &ncephalitis
Vaccine
#he va""ine should be offered only to at)ris( travellers.
Western European vaccines:
#+o va""ines are available in +estern ?urope- in adult and paediatri" formulations. Althou'h both are
based on the ?uropean subtype- immunity is indu"ed a'ainst all subtypes of the #B? virus. #hese
va""ines "ontain a suspension of purified #B? virus 'ro+n on "hi"( embryo "ells and ina"tivated
+ith formaldehyde. Both #B? va""ines provide safe and reliable prote"tion.. Eittle information is
available on the duration of prote"tion follo+in' "ompletion of the primary three)dose immunization.
0utside "ountries or areas at ris(- #B? va""ines may not be li"ensed and +ill have to be obtained by
spe"ial re,uest.
Adverse reactions
Althou'h adverse events are "ommonly reported +ith the +estern ?uropean va""ines- (transient
redness and pain at the site of inGe"tion in O=68 of "ases and fever B;5 P% in O6798)- none of these
events is serious or life)threatenin'.
Both !ussian va""ines have been reported to be moderately rea"to'eni" but +ithout indu"in' severe
adverse rea"tions. Ho+ever- some lots of the !ussian va""ine ?n"evir +ere re"ently +ithdra+n
be"ause of fre,uent hi'h fever and aller'i" rea"tions- parti"ularly in "hildren@ this va""ine is "urrently
not re"ommended for individuals a'ed ;71< years .
Type of vaccine: Ailled
Number of doses:
2estern ?uropean va""inesC primary series- three i.m. doses- administered at intervals of =71: +ee(s
bet+een the first and se"ond- and 371: months bet+een the se"ond and third doses.
!ussian va""inesC primary series- three doses administered at intervals of 17< months bet+een the
first and se"ond- and 1: months bet+een the se"ond and third doses.
Booster: In healthy individuals a'ed I64 years booster doses are "onventionally offered at intervals
of ;76 years if the ris( "ontinues- althou'h in some endemi" areas (S+itzerland) intervals of O14
years are no+ used. In individuals a'ed 64 years and above- booster intervals of ;76 years are
re"ommended until more definitive information be"omes available.
A""elerated s"hedules for travellersC dependin' on the "hoi"e of #B? va""ine- the manufa"turer
re"ommends either a rapid s"hedule based on immunization on day 4- day 1= and month 67<- or an
a""elerated s"hedule based on immunization on day 4- day < and day :1.
Russian vaccines: Booster doses are re"ommended every ; years for those at "ontinued ris( of
e1posure.
Contraindications: Hypersensitivity to the va""ine preservative thiomersal@ adverse rea"tion to
previous dose
Adverse reactions: Eo"al rea"tions o""asionally@ rarely fever
Before departure: Se"ond dose : +ee(s before departure
Recommended for: Hi'h)ris( individuals only
Special precautions: revent blood feedin' ti"(s from be"omin' atta"hed to the s(in throu'h use of
appropriate "lothin'@ remove ti"(s as soon as possible
Typhoid fever
Vaccine
*ral Ty$"a. The live, attenuated mutant strain of +almonella typhi Ty$"a,
supplied in enteric coated capsules, is given in three doses &four doses in ,orth
-merica ', $ days apart. .rotection is induced ! days after the fnal dose. -fter !
years, the average protective e/cacy was shown to be 0!1 in residents of
endemic countries, although the vaccine may be less e2ective in travellers from
non-endemic countries. - previously manufactured li3uid formulation is no longer
available.
4n)ectable 5i 6.+. The 5i capsular polysaccharide vaccine &5i 6.+' contains $7 8g
of polysaccharide per dose, and is given i.m. in a single dose. .rotection is
induced about ! days after the in)ection. 4n countries or areas at risk, the
protective e/cacy ".7 years after vaccination is about !$1 and about 701 after
years.
Both typhoid va""ines are safe and effe"tive.
A "ombined typhoid/hepatitis A va""ine is also available in some "ountries.
Precautions and contraindications
ro'uanil- meflo,uine and antibioti"s should be stopped from ; days before until ; days after the
administration of #y:1a.
No serious adverse effe"ts have been reported follo+in' administration of #y:1a or $i %S.
#hese va""ines are not re"ommended for use in infant immunization pro'rammes due to insuffi"ient
information on their effi"a"y in "hildren under : years of a'e.
Type of vaccine: 0ral #y:1a and inGe"table $i %S
Number of doses: #hree or four doses of live #y:1a- 'iven at :)day intervals as enteri" "oated
"apsules. 0ne dose of $i %S- 'iven i.m.
Booster: ?very :7; years for $i %S@ for #y:1a- see pa"(a'e insert.
a
Contraindications: #here are no "ontraindi"ations to the use of these va""ines other than previous
severe hypersensitivity rea"tions to va""ine "omponents.
Adverse reactions: None si'nifi"ant
Before departure: 1 +ee(
Recommended for: #yphoid fever va""ination may be offered to those travellin' to destinations
+here the ris( of typhoid fever is hi'h- espe"ially individuals stayin' in endemi" areas for D1 month
and/or in lo"ations +here antibioti" resistant strains of S. typhi are prevalent.
Special precautions: $i %S 7 not under : years of a'e@ avoid pro'uanil- meflo,uine and antibioti"s
+ith #y:1a
a
#he duration of prote"tion follo+in' #y:1a immunization is not +ell defined and may vary +ith
va""ine dose and possibly +ith subse,uent e1posures to Salmonella typhi (natural booster). In
Australia and ?urope- ; tablets are 'iven on days 1- ;- and 6@ this series is repeated every year for
individuals travellin' from non)endemi" to endemi" "ountries- and every ; years for individuals
livin' in "ountries or areas at ris(. In North Ameri"a- = tablets are 'iven on days 1- ;- 6- and < and
reva""ination is re"ommended only after < years (%anada) or 6 years (HSA) for all- re'ardless of
typhoid fever ris( in the "ountry or area of residen"e.
'ello( fever
Vaccine
#he 1<D va""ine- +hi"h is based on a live- attenuated viral strain- is the only "ommer"ially available
yello+ fever va""ine. It is 'iven as a sin'le sub"utaneous (or intramus"ular) inGe"tion. *ello+ fever
va""ine is hi'hly effe"tive (approa"hin' 1448). All individuals a'ed 3 months or older and livin' in
"ountries or areas at ris( should re"eive yello+ fever va""ine.
Precautions and contraindications
2ith the e1"eption of very rare "ases of va""ine)asso"iated neurotropi" and vis"erotropi" disease (see
belo+)- the 1<D va""ine is 'enerally "onsidered to be safe. Ho+ever- some va""ine re"ipients
develop mild systemi" rea"tions- in"ludin' myal'ia and heada"he. %ontraindi"ations in"lude true
aller'y to e'' protein- immunodefi"ien"y ("on'enital or a",uired) and symptomati" HI$ infe"tion
(%hapter 3). #here is a theoreti"al ris( of harm to the fetus if the va""ine is 'iven durin' pre'nan"y
and va""ination of nursin' mothers should be avoided be"ause of the ris( for the transmission of 1<D
virus to and en"ephalitis in the breast)fed infant.#hese ris(s must be +ei'hed a'ainst the ris( to the
mother of remainin' unva""inated and travellin' to an area +here e1posure to *>$ may o""ur. In
'eneral- unva""inated pre'nant or nursin' +omen should be advised not to travel to su"h areas.
Hypersensitivity rea"tions are rare- parti"ularly anaphyla"ti" rea"tions. Ho+ever- the va""ine is
produ"ed in embryonated "hi"(en e''s and is "ontraindi"ated in persons +ith a history of oral e''
intoleran"e or stron' aller'i" rea"tions to e'')based produ"ts.
?n"ephalitis has been reported as a rare event follo+in' va""ination- prin"ipally in infants under 9
months of a'e. As a result- the va""ine is "ontraindi"ated in infants under 9 months of a'e and is not
re"ommended for those a'ed 975 months- e1"ept durin' epidemi"s +hen the ris( of *>$
transmission may be very hi'h.
$a""ine)asso"iated vis"erotropi" disease is a re"ently des"ribed adverse event that on very rare
o""asions has o""urred after the first immunization +ith the yello+ fever 1<D va""ine. 0nset is
+ithin 14 days of va""ination and the patholo'i"al pro"ess is "hara"terized by severe multi)or'an
failure and an overall "ase7fatality rate in e1"ess of 948. Ano+n ris( fa"tors in"lude a history of
thymus disease (e.'. thymoma or thyme"tomy) and a'e B 94 years. In the Hnited Sates- the ris( for
people a'ed B <4 years of "ontra"tin' vis"erotropi" disease after re"eivin' va""ination a'ainst yello+
fever is estimated to be :.= "ases/144 444 va""ine doses.
In"reased in"iden"e of va""ine)asso"iated neurotropi" disease (e.'. menin'oen"ephalitis- a"ute
disseminated en"ephalomyelitis and Fuillain7BarrQ syndrome) has been reported in infants under 9
months of a'e and in va""ine re"ipients a'ed B94 years . #he reported rate of va""ine)asso"iated
neurotropi" disease in travellers from the Hnited States and ?urope ran'es bet+een 4.1; and 4.5 per
144 444 doses.
*ello+ fever va""ination is re,uired for travellers to "ertain "ountries and re"ommended for all
travellers to "ountries or areas +ith ris( of yello+ fever transmission (see %ountry list and Anne1 1).
#he ris( to unva""inated individuals +ho visit "ountries or areas +here there may be yello+ fever
transmission is often 'reater than the ris( of a va""ine)related adverse event. 2hile yello+ fever
va""ination should be en"oura'ed as a (ey prevention strate'y- it is important to s"reen travel
itineraries and "arefully evaluate the potential ris( of systemi" illness after yello+ fever va""ination.
Freat "are should be e1er"ised not to pres"ribe yello+ fever va""ination to individuals +ho are not at
ris( of e1posure to infe"tion- based on an a""urate assessment of the travel itinerary. Althou'h
va""ination is 'enerally not re"ommended for travellers 'oin' to areas +here the ris( of e1posure is
lo+- any ris( (e.'. as a result of prolon'ed travel or heavy e1posure to mos,uito bites) should be
+ei'hed a'ainst individual ris( fa"tors for va""ine)asso"iated adverse events (e.'. altered immune
status).
Type of vaccine: Eive- attenuated
Number of doses: 0ne dose of 4.6 ml
Booster: %urrently every 14 years (if re)"ertifi"ation is needed)
Contraindications: Infants a'ed less than 9 months@ history of aller'y to e'' or to any of the va""ine
"omponents- or hypersensitivity to a previous dose of the va""ine@ thymoma or history of
thyme"tomy- immunodefi"ien"y from medi"ation- disease or symptomati" HI$ infe"tion.
Adverse reactions: !arely- neurolo'i"al (en"ephalitis) or multi)or'an failure resemblin' +ild)type
yello+ fever
Before departure: International "ertifi"ate of va""ination be"omes valid 14 days after va""ination.
Recommended for: All travellers to "ountries and areas +ith ris( of yello+ fever transmission and
+hen re,uired by "ountries.
Special precautions: Not re"ommended for infants a'ed 9)5 months- e1"ept durin' epidemi"s +hen
the ris( of *> virus transmission may be very hi'h. #he ris(s and benefits of va""ination in this a'e
'roup should be "arefully "onsidered before va""ination. #he va""ine should be avoided durin'
pre'nan"y or breastfeedin'. Ho+ever- pre'nant or nursin' +omen may be va""inated durin'
epidemi"s or if travelin' to "ountry or area a ris( of transmission is unavoidable.
>or the international "ertifi"ate of va""ination- see %hapter 9 under L!e,uired va""inationsM.