Top Reasons to Follow the Recommended Vaccine Schedule

Every once in a while we see a child whose school nurse says the child’s vaccines didn’t count and need to be repeated. This can be due to many things, usually inappropriate timing of vaccines. Some electronic health records now have intelligent vaccine recommendation abilities. These smart vaccine logic systems are catching kids who had incorrect spacing before this technology. Staying on the routine vaccine schedule and keeping all records in one place can help avoid extra doses due to inappropriately spaced vaccines.

One thing to remember if your child needs extra doses: you don’t need to worry. They’re safe!

What’s in this post?

First you’ll need to understand about the different types of vaccines to know why they are scheduled like they are. Some are given in a series to boost the initial response, but others need to be repeated to cover those who weren’t protected with a first dose.

Then we’ll do a quick review of the risk of the diseases to remind us why we vaccinate in the first place.

Hopefully after learning some basics, you’ll see why the timing of vaccines is so important and why we should all follow the recommended vaccine schedule.

What’s not in this post?

If you want to know what to do if a recommended vaccine has been delayed, see What happens if a vaccine booster is delayed?

Dr. Vincent Iannelli has a list that includes some issues not discussed in this post, such as improper storage.

How vaccines work

Vaccines are made in different ways and the body responds to them in different ways.

Live attenuated vaccines

Live attenuated vaccines are made from weakened virus that teaches the body to recognize the real virus but doesn’t cause the symptoms of the virus in healthy people.

Those with weak immune systems should talk to their physician before receiving a live virus vaccine. The amount of immune compromise and specific vaccine must be taken into account on an individual basis.

It’s usually okay to be vaccinated with a live virus vaccine if you’ll be around an immunocompromised person, but again, let your physician know the risk of exposure.

Examples of live virus vaccine:
  • rotavirus
  • measles
  • mumps
  • rubella
  • varicella
  • nasal flu vaccine (NOT the injectable flu vaccine)

Many people respond sufficiently to the first dose of these, but repeat doses are given to help those who missed the response the first time.

The second dose doesn’t boost the first, but it gives a person a second chance at making immunity.

Spacing between doses:

Because of the way these vaccines work, they must follow special separation rules. More than one live virus vaccine can be given on the same day, but they cannot be given on separate days that are closer than 4 weeks apart.

If one live virus vaccine is given, you must wait a minimum of 28 days to give another. If they’re given too close together, the body doesn’t make immunity as well to the second one given. This second vaccine wouldn’t count.

As an example, if the FluMist (nasal flu vaccine) is given on January 1 and the Varicella vaccine is given January 15 of the same year, the Varicella vaccine will not count and must be repeated.

Live virus vaccines are the only vaccines that are subject to this 28 day rule. If another vaccine type is needed, it is okay to give in a shorter time frame.

For example, if a child has the MMR at his 4 year well visit, it is okay to do an injectable flu vaccine at a flu clinic later that same month. (Note: the nasal flu vaccine is a live virus vaccine, so it is NOT okay to give the FluMist within the month before or after the MMR.)

If there is less than 28 days between live virus vaccines, the one that was given second must be repeated.

I see this quite frequently in kids who move to the US from other countries. It seems quite common elsewhere for kids to get the varicella (chicken pox) vaccine about 2 weeks after the MMR. When this happens, another varicella vaccine is needed.

Live virus vaccines aren’t recommended under 1 year… usually

Many parents worry that we don’t give live virus vaccines to infants because they’re less safe, but that’s not why at all.

Maternal antibodies (fighter cells from mom that got into baby during pregnancy) can inhibit the body from being able to build its own antibodies well against a vaccine.

Maternal antibodies are good because as long as they’re in the baby’s body, they fight off germs and protect the infant! They tend to hang around for the first 6-12 months of life.

If a disease has a low incidence, it is acceptable to let the maternal antibodies do their job for the first year.

By the first birthday most maternal antibodies have left the infant, so a vaccine can be used to build the baby’s immunity.

International travel increases risks

If there is a high risk of exposure it is recommended to give the vaccine as early as 6 months in case the maternal antibodies are already too low for infant protection. Many parts of the world have high measles rates so fit into this recommendation.

If the antibody levels are still high, the vaccine won’t work, but the baby should still be protected against the disease from mom’s antibodies.

At some point the maternal antibodies go away, we just don’t know when exactly, so the baby who gets the MMR early needs another dose after his first birthday to be sure he’s making his own antibodies once mom’s go away. This dose after the birthday is the first that “counts” toward the two MMRs that are needed.

The next dose of MMR can be anytime at least 28 days after the first counted dose, but we traditionally give it between 4-6 years with the kindergarten shots.

Yes, I realize there are some measles outbreaks in the US, but the experts have not said to start giving that extra dose to babies who are staying here yet. If you’re worried, talk to your doctor.

Inactivated virus vaccines

Inactivated virus vaccines are made by killing the virus and using it to make the vaccine.

They aren’t as effective as live virus vaccines, so several doses are needed to build immunity to these.

Examples of inactivated virus vaccines:
  • inactivated polio vaccine
  • injectable flu vaccines
  • hepatitis A vaccine

Subunit, recombinant, polysaccharide, and conjugate vaccines

Subunit, recombinant, polysaccharide, and conjugate vaccines use specific pieces of a virus or bacteria to make a vaccine.

Because these vaccines use only specific antigens, they give a very strong immune response that’s specific to the infectious particle and side effects are less common.

This type of vaccine is safe for nearly everyone, including people with weak immune systems.

One limitation of these vaccines is that you may need booster shots to get ongoing protection against diseases.

Subunit, recombinant, polysaccharide, and conjugate vaccines include:
  • Hib (Haemophilus influenzae type b) – not related to influenza vaccine at all
  • Hepatitis B
  • HPV
  • whooping cough
  • pneumoccal disease
  • meningococcal disease

Toxoid vaccines

Toxoid vaccines prevent diseases caused by bacteria that produce toxins in the body.

The toxins are weakened into toxoids so they cannot cause illness and are used to make the vaccine.

When the immune system receives a vaccine containing a toxoid, it learns how to fight off the natural toxin.

Example of toxoid vaccine:
  • diphtheria and tetanus portions of the DTaP vaccine

Several shots are needed to build and continue immunity over time.

Passive immunization

Passive immunization is a bit different than any of the above.

Either catching a disease or getting any of the above vaccines stimulates your immune system to make memory cells to fight of that specific germ if it comes in contact with it.

Passive immunity results when a person is given someone else’s antibodies.

The protection offered by passive immunization is short-lived, usually lasting only a few weeks or months, but it helps protect right away.

Example of a passive vaccine:
  • Synagis (RSV) vaccine

Why are vaccines repeatedly given?

Vaccines interact with the T and B cells of our immune system to make memory cells.

If you want to learn more, see How Vaccines Work. It’s a really cool slide show from The College of Physicians of Philadelphia.

Some vaccines need several doses to help the body develop a strong immunity against the germs. Later boosters are required to maintain that level of protection.

Other vaccines require more than one dose to insure that most people develop the protection.

Age at time of vaccine matters

The CDC Immunization schedule allows for age ranges for many vaccines to be given. Many states allow a grace period around those ages, but not all do.

Some vaccines have been shown to work best at certain ages. Our vaccine schedule reflects the best ages to give vaccines so that they are safe and effective.

If a child receives a vaccine within the grace period of their current state, it might “count.” But if that child moves to another state, the vaccine might not count per the new state’s laws.

My office only gives the routine MMR, Varicella, and Hepatitis A vaccines on or after the first birthday to help prevent a child from moving to a location that does not have a grace period. This is despite the fact that Kansas does have a 4 day grace period.

We will give the MMR earlier under certain circumstances as discussed above, but it does not count toward the two needed after the 1st birthday.

Spacing matters

Many vaccines need to be separated by a minimum timeframe, often 4 weeks, but sometimes longer. The Hepatitis A vaccine has a minimum timeframe of 6 months between doses, for example.

If the vaccine doses are not separated by a minimum time, one or more will need to be repeated.

For spacing rules, see the CDC vaccine schedule at the bottom of this post. Click on “footnotes” to see the details for each vaccine.

Why not space them out further?

Many parents have come to believe the “too many too soon” theory. They believe this despite the overwhelming evidence that vaccines are safe and effective when given according to the CDC schedule.

The risks to waiting to give vaccines are many.

Increasing vaccine preventable disease rates

Young adults of today have grown up without seeing the suffering of vaccine preventable diseases. But we’re seeing an increase in these diseases where vaccine rates have fallen.

Infants who aren’t vaccinated are at risk of diseases that can lead to death. They are among the most vulnerable and need protection.

More trips = more exposure

Not only are underimmunized children more at risk for vaccine preventable diseases, but bringing them to a clinic more frequently to do one vaccine a time increases risk. Each time they visit the clinic, they’re exposed to all the common viruses. Why risk bringing them back again and again to get more exposures?

Giving the vaccines together has been shown to be safe and effective.

More visits = more stress

There are studies that show less overall stress to the body if vaccines are given together.

Studies have shown that the first injection causes a stress response measured by elevated heart rate, blood pressure, cortisol levels, and cry. Subsequent injections given at the same time do not increase as significantly the stress when compared to returning on different days to get further injections.

The immune system can handle it

Are you worried about “too many too soon” and that vaccines will overwhelm the immune system? Stop worrying. These fears are simply unfounded.

As Paul Offit summarized in Addressing Parents’ Concerns: Do Multiple Vaccines Overwhelm or Weaken the Infant’s Immune System?:

Current studies do not support the hypothesis that multiple vaccines overwhelm, weaken, or “use up” the immune system. On the contrary, young infants have an enormous capacity to respond to multiple vaccines, as well as to the many other challenges present in the environment. By providing protection against a number of bacterial and viral pathogens, vaccines prevent the “weakening” of the immune system and consequent secondary bacterial infections occasionally caused by natural infection.

Keep your child’s vaccine record handy

I see many kids who transfer to my office but I don’t have access to their vaccine records at the time of the visit. This makes it difficult to know which (if any) vaccines are needed.

Hopefully as we use Electronic Health Records with portals and vaccine registry databases more this will become a non-issue. At this time it’s still a problem.

This is one of the many reasons I prefer for all vaccines to be given at the same clinic. If you’re changing primary care providers, be sure records are transferred before your first visit.

Flu vaccines are especially troublesome.

Flu vaccines are commonly given in many locations: your primary care provider (PCP) office, a parent’s workplace, a local pharmacy, at a school flu vaccine drive. They need to be repeated yearly, so it’s easy to forget if each of your kids has had it this year.

It’s common for one parent to not know if their child got a flu vaccine already this season. That leads to a missed opportunity or vaccines given unnecessarily.

I have seen a few kids who couldn’t get their kindergarten vaccines at their well visit because they recently had a FluMist elsewhere. That requires another trip to the office for the family.

I have seen a few kids who did get the kindergarten vaccines inappropriately because the parent didn’t realize the other parent had taken them for a FluMist elsewhere. They needed to repeat the MMR and varicella vaccines, which didn’t make the kids happy!

FluMist is coming back to the US for the 2018-2019 flu vaccine season. It is not the preferred vaccine by many experts due to continued concerns about its effectiveness, but it will be preferred by many kids who hate needles. If your kids worry about shots, learn how to make them less painful.

Be sure to keep track if your kids get a FluMist – especially if they’re getting kindergarten vaccines around the same time!

Learn more about vaccine preventable diseases:

This comic book can teach kids and adults about viruses and how science works:

Dr. Paul Offit is one of the leading experts on vaccines. His many books can show how vaccines work and why they’re needed. He delves into the anti-vaccine movement in many of his books. He shows how delayed vaccine schedules are not effective or necessary in most of his books. I have many of these at my office available for patient families to check out. Just ask if you’re in my office. Otherwise, read about each on the links to see what best fits your needs.


Note: As an Amazon Affiliate Member, I will get a small percentage for the sale of the books if purchased from these links. This is at no additional cost to you.

Vaccine Resources for Kids and Teens is a great list of resources from the Children’s Hospital of Philadelphia.

15 Common Anti-Vaccine Arguments and Why They are a Load of Crap

How Math (and Vaccines) Keep You Safe From the Flu Simple (or not so simple) math shows how herd immunity works. Widespread vaccination can disrupt the exponential spread of disease and prevent epidemics.

Simulation of how herd immunity works. Is a free online simulation. Try it!

The CDC schedule:

 

 

Measles Outbreaks: What can you do to protect your family?

Any area can be affected by measles. My county is in the middle of an measles outbreak right now. This is despite relatively high MMR vaccine rates above 95% for at least 1 MMR by 3 years of age. There are a lot of questions about measles outbreaks, so I thought I’d tackle a few. Like most pediatricians, I’ve never seen measles and I hope to not miss it if I do. We all need to be aware of its symptoms so we can recognize it when we see it!

What is measles?

Measles is a viral illness that includes fever, cough, fatigue, red eyes, and a characteristic rash. The rash spreads from head to trunk to lower extremities.

Measles rash PHIL 4497 lores
Source: https://commons.wikimedia.org/wiki/File%3AMeasles_rash_PHIL_4497_lores.jpg

RougeoleDP
Source: https://commons.wikimedia.org/wiki/File%3ARougeoleDP.jpg
Measles is usually a mild or moderately severe illness. It can lead to pneumonia, encephalitis, and even death (risk of 2-3 per 1000).

One rare complication of measles infection that occurs many years after the illness appears to resolve is subacute sclerosing panencephalitis (SSPE). It is a fatal disease of the central nervous system that usually develops 7–10 years after infection.

 

 

 

Koplik spots, measles 6111 lores
Source: https://commons.wikimedia.org/wiki/File%3AKoplik_spots%2C_measles_6111_lores.jpg
Koplik spots are a specific rash seen in the inner cheek. Koplik spots are visible from 1 – 2 days before the measles rash and disappears to 1 – 2 days later. They look like white spots with a blue center on the bright red background of the cheek. They can easily be missed because they are not present for long, but if seen are classic for measles.

What is the timeline of symptoms after exposure?

Measles is highly infectious. It is primarily transmitted by large respiratory droplets in the air, so handwashing doesn’t help prevent exposure.

An area remains at risk for up to 2 hours after a person with measles was there. This is why it is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician. DO NOT go to a walk in clinic or your doctor’s office unannounced. You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

More than 90% of susceptible people develop measles when they’re exposed.

The average incubation period for measles is 11–12 days. It takes 7–21 days for the rash to show. It is due to this long time for the characteristic rash that susceptible people who were exposed are put in isolation for up to 21 days.

Most people are contagious from about 4 days before they show the rash until 4 days after the rash develops. If a person has measles and the rash resolves, they can leave isolation when cleared by their physician and/or the health department.

What is a measles outbreak?

Measles outbreaks are defined as 3 or more measles cases linked in time and space.

How do outbreaks start?

I know the big question on everyone’s mind during an outbreak is, “Where did it start?”

Often an unimmunized traveler brings the measles virus into the US. Countries in Europe, Africa, Asia, and the Pacific continue to have outbreaks. Travelers who visit those countries can return to the US and share the virus for a few days before symptoms are recognized. Anyone who was in the same area as an infected person for up to 2 hours after that person left the area could be exposed.

In case you’ve heard that vaccines can lead to outbreaks: that’s not the case. Measles shedding from the MMR does not cause disease.

What happens during an outbreak?

Measles Outbreaks: What can you do to protect your family?During an identified outbreak of any reportable infectious disease, the health department directs what to do. They attempt to identify and notify all people who are at risk.

Our current outbreak involves several infants from the same unnamed daycare in addition to people not associated with the daycare. I know many families are worried that their child was at that daycare. Families at that daycare will have been notified by the health department already. The health department will track all known contacts of those families.

Local health departments also will notify the public of known locations of potential contact with the virus. The above linked article lists the known locations that infected people visited during their contagious period.

Why are infants at risk?

Infants are at particular risk because they are not typically vaccinated against measles until 1 year of age.

When the virus is in a setting with infants, such as a daycare, it can easily spread.

Infants under 2 years of age who are infected also tend to have more complications from the disease than older children and adults. This is one of the biggest reasons to not wait until 2 years to start immunizations, as some anti-vaccine groups suggest.

If you think you were exposed to or have symptoms of measles

It is IMPERATIVE that you should not leave your house if you suspect you have measles until you have spoken with the health department or your physician.

DO NOT go to a walk in clinic or your doctor’s office unannounced.

You will need to make arrangements to meet someone outside and wear a mask into the building. You will be put in a special negative pressure room, which is not available in most clinics.

Do not go to the pharmacy to pick up medications. Don’t go to the grocery store for food.

Do not leave your home unless it is to a medical facility that knows you’re coming and is prepared.

(Yes, I know I repeated myself for much of this section, but it’s that important!)

The MMR vaccine can help stop the spread

The MMR vaccine is recommended routinely at 12-15 months and again at 4-6 years of age. Vaccines not only help the vaccinated, but provide herd immunity to those too young to be immunized and to those who are immunocompromised.

Please be sure your family is up to date on all their vaccines. All children over 1 year of age should have at least 1 MMR vaccine. All school aged children and adults should have 2 MMRs. By vaccinating your family, you not only protect them, but also those around you!

Why is a second dose given?

The second dose is used to provide immunity to the approximately 5% of people who did not develop immunity with the first dose. It is not a booster because it doesn’t boost the effect of the first dose.

The second MMR helps some people develop immunity if the first vaccine did not work effectively.

This second dose can be given as early as 28 days after the first.

Why don’t we start the vaccine series earlier?

Many parents worry that we don’t give live virus vaccines to infants because they’re less safe, but that’s not why at all.

Maternal antibodies (fighter cells from mom that got into baby during pregnancy) can inhibit the body from being able to build its own antibodies well against a vaccine.

Maternal antibodies are good because as long as they’re in the baby’s body, they fight off germs and protect the infant! They tend to hang around for the first 6-12 months of life.

If a disease has a low incidence, it is acceptable to let the maternal antibodies do their job for the first year.

By the first birthday most maternal antibodies have left the infant, so a vaccine can be used to build the baby’s immunity.

Sometimes we do vaccinate earlier

If there is a high risk of exposure it is recommended to give the vaccine as early as 6 months in case the maternal antibodies are already too low for infant protection.

Many parts of the world have high measles rates so fit into this recommendation. When infants between 6 and 12 months travel internationally, they should receive one dose of MMR vaccine prior to travel.

Sometimes during US outbreaks it is recommended to vaccinate infants 6-12 months. The local health department helps to determine which infants should be immunized in this situation.

If the maternal antibody levels are still high in the infant, the vaccine won’t work. In this situation the baby should still be protected against the disease from mom’s antibodies. That is why this early vaccine does not “count” toward the two needed after the first birthday.

At some point the maternal antibodies go away, we just don’t know when exactly, so the baby who gets the MMR early needs another dose after his first birthday to be sure he’s making his own antibodies once mom’s go away. This dose after the birthday is the first that “counts” toward the two MMRs that are needed.

The next dose of MMR can be anytime at least 28 days after the first counted dose, but we traditionally give it between 4-6 years with the kindergarten shots.

What if someone who hasn’t been vaccinated is exposed?

measles outbreaks, what can you do to protect your family
Source: http://www.immunize.org/photos/measles-photos.asp

The MMR vaccine may be effective if given within the first 3 days (72 hours) after exposure to measles. This is why the local health department is so aggressive in identifying cases during an outbreak.

Immune globulin (IGIM, a type of immunity that doesn’t require a person to make their own immunity) may be effective for as long as 6 days after exposure. IGIM should be given to all infants younger than 6-12 months who have been exposed to measles. The MMR vaccine can be given instead of IGIM to infants age 6 through 11 months, if it can be given within 72 hours of exposure.

Are boosters of the MMR needed?

are mmr boosters needed
From my practice Facebook page. Note: In this reply I was going off of my experience many years ago. At that time the advice was only 1 additional MMR, but my research for this blog shows otherwise!

Those of us who work in healthcare must have titers checked to verify immunity to many of the vaccine preventable diseases.

Healthcare workers come into contact with sick patients and patients with weak immune systems, so this is one way to help control disease spread.

From Immunize.org:
Adults with no evidence of immunity (defined as documented receipt of 1 dose [2 doses 4 weeks apart if high risk] of live measles virus-containing vaccine, laboratory evidence of immunity or laboratory confirmation of disease, or birth before 1957) should get 1 dose of MMR unless the adult is in a high-risk group. High-risk people need 2 doses and include healthcare personnel, international travelers, students at post-high school educational institutions, people exposed to measles in an outbreak setting, and those previously vaccinated with killed measles vaccine or with an unknown type of measles vaccine during 1963 through 1967.

Most people don’t know their immune status, and it’s not recommended at this time to check it for the general population.

During an outbreak exposed people might be asked to be tested to help identify risk factors and track disease patterns.

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Traveling Around the World

Spring Break is around the corner, which means many of my patients will be traveling to various areas of the world for vacation or mission trips. Many of these areas require vaccines prior to travel, so plan ahead and schedule a travel appointment with your doctor (if they do them) or at a travel clinic. Many insurance companies do not cover the cost of travel medicine visits, medications, or vaccines, but they are important and are a small cost in comparison to getting sick when on your trip.

Vaccinate when you can!

Immunization records will need to be reviewed, so if you are going to a travel clinic outside your medical home (doctor’s office) be sure to bring the records with you.

Vaccines work best when they are given in advance, so do not schedule the pre-travel visit the week you leave! Some vaccines that are recommended are easily available at your primary medical office but others are not commonly given so might require a trip to a local health department, large medical center, or travel clinic.

Check with your insurance company to see if the cost of the vaccine will be covered or not so you can include your cost in your travel budget if needed.

Watch the food and drinks

Many diseases are spread through eating and drinking contaminated foods. If in doubt: do not eat! Cooked foods are generally safer. Any fresh fruits or vegetables should be washed in clean water before eating. Be sure all dairy products are pasteurized. Avoid street vendors, undercooked foods (especially eggs, meats, and fish), salads and salsas made from fresh ingredients, unpeeled fruits, and wild game. Drink bottled water or water that has been boiled, filtered or treated in a way that is known to be reliable. Use the same water to brush teeth. Do not use ice unless you know it is from safe water because freezing does not kill the germs that cause illness.

As always, wash hands often, use sanitizer as needed when washing is not available, and avoid touching the “T” zone of your face (eyes, nose, and mouth). Do not share utensils or foods. Avoid people who are obviously ill.

Medicines for travelers Diarrhea

  • Many companies that schedule international travel recommend bringing antibiotics for prevention or treatment of diarrhea.
  • This is not recommended by many experts due to the rise of “superbugs” with the use of unnecessary antibiotics.
  • In general, the use of antibiotic prophylaxis is recommended only for high-risk travelers, and then only for short periods.
  • The average duration of illness when untreated will be 4 to 5 days, with the worst of the symptoms usually lasting less than a day.
  • Antibiotics might lead to yeast infections, allergic reactions, or even a chronic carrier state (colonization) or irritable bowel syndrome.
  • Antibiotics should be reserved for the treatment of more serious illnesses that include fever and significant associated symptoms such as severe abdominal pain, bloody stools, cramping, and vomiting.
  • Bismuth subsalicylate is available over the counter for adults and can reduce traveler’s diarrhea rates by approximately 65% if taken four times daily. Risks of bismuth products are that it can turn the tongue and stool black and they contain salicylate. Salicylate carries a theoretical risk of Reye syndrome in children, so should be avoided in children.
  • Probiotics and prebiotics have been shown to help prevent and treat diarrheal illnesses safely in most people with intact immune systems.

Mosquitos…

Many diseases are spread by mosquitos. Contact with mosquitoes can be reduced by using mosquito netting and screens (preferably insecticide-treated nets), using an effective insecticide spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body. Everyone at risk for mosquito bites should apply mosquito repellant. See below for prevention medication options.

Non-Infectious Risks

Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page.
  • Learn local laws prior to travelling.
  • Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.
  • Remind everyone to stay in groups and to not venture out alone.
  • Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.
  • Wear sunscreen! It doesn’t matter if you’re on the beach or on the slopes, you need to wear sunscreen every time you’re outside. Don’t ruin a vacation with a sunburn.
  • For more safety tips, see this helpful brochure.

Keep records

It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.

Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.

  • your name, address, and phone number
  • emergency contact name(s) and phone number(s)
  • immunization record
  • your doctor’s name, address, and office and emergency phone numbers
  • the name, address, and phone number of your health insurance carrier, including your policy number
  • a list of any known health problems or recent illnesses
  • a list of current medications and supplements you are taking and pharmacy name and phone number
  • a list of allergies to medications, food, insects, and animals
  • a prescription for glasses or contact lenses

Specific Diseases to Prevent

Risks of illness vary depending on where you will be travelling and what time of year it will be. I refer to the CDC’s travel pages and the Yellow Book for information on recommendations. Some of the most common issues to address are discussed below in alphabetical order.

Dengue Fever

Dengue is a mosquito-borne viral illness. It is seen in parts of the Caribbean, Central and South America, Western Pacific Islands, Australia, Southeast Asia, and Africa. There is no vaccine or specific treatment. Mosquito bite prevention measures are important.

Hepatitis

Infants should begin vaccinations against Hepatitis B starting at birth and against Hepatitis A starting at a year of age. Be sure these vaccines are up to date. Hepatitis A is spread through food and water, so be sure to follow the above precautions even if vaccinated.

Malaria

Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.

Prevention medications might be recommended, depending on when and where you will be travelling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication.

  • Atovaquone-proguanil should begin 1–2 days before travel, daily during travel, and 7 days after leaving the areas. Atovaquone-proguanil is well tolerated, and side effects are rare but include abdominal pain, nausea, vomiting, and headache. Atovaquone-proguanil is not recommended for prophylaxis in children weighing <5 kg (11 lb).
  • Mefloquine prophylaxis should begin at least 2 weeks before travel. It should be continued once a week, on the same day of the week, during travel and for 4 weeks upon return. Mefloquine has been associated with rare but serious adverse reactions (such as psychoses or seizures) at prophylactic doses but are more frequent with the higher doses used for treatment. It should be used with caution in people with psychiatric disturbances or a history of depression.
  • Primaquine should be taken 1–2 days before travel, daily during travel, and daily for 7 days after leaving the areas. The most common side effect is gastrointestinal upset if primaquine is taken on an empty stomach. This problem is minimized if primaquine is taken with food. In G6PD-deficient people, primaquine can cause hemolysis that can be fatal. Before primaquine is used, G6PD deficiency MUST be ruled out by laboratory testing.
  • Doxycycline prophylaxis should begin 1–2 days before travel to malarious areas. It should be continued once a day, at the same time each day, during travel in malarious areas and daily for 4 weeks after the traveler leaves such areas. Doxycycline can cause photosensitivity so sun protection is required.  It also is associated with an increased frequency of vaginal yeast infections. Gastrointestinal side effects (nausea or vomiting) may be minimized by taking the drug with a meal and it should be swallowed with a large amount of fluid and should not be taken before bed. Doxycycline is not used in children under 8 years. Vaccination with the oral typhoid vaccine should be delayed for 24 hours after taking a dose of doxycycline.
  • Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present. Prophylaxis should begin 1–2 weeks before travel to malarious areas. It should be continued by taking the drug once a week during travel and for 4 weeks after a traveler leaves these areas. Side effects include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and itching, but generally these effects do not require that the drug be discontinued.

Measles

We routinely give the first vaccine against measles (MMR or MMRV) at 12-15 months of age, but the MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks. Under 6 months of age, an infant is considered protected from his mother’s antibodies. These antibodies leave the baby between 6 and 12 months. The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday.

Any vaccine dose given before the first birthday does not count toward the two doses required after the first birthday, but might help protect against exposure if the immunity from the mother is waning. It is safe for a child to get extra doses of the vaccine if needed for travel between 6 and 12 months.

Meningitis

  • Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States. In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but can be given as young as 9 months of age. MenACWY-CRM is newly approved for children 2 months and older.
  • There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel.
  • Meningitis vaccines should be given at least 7-10 days prior to potential exposure.
  • Travellers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. The vaccine is available for children 9 months and older in my office and a newer vaccine is approved for 2 months and up. Boosters for people travelling to these areas are recommended every 5 years.

Tuberculosis

Tuberculosis (TB) occurs worldwide, but travelers who go to areas of sub-Saharan Africa, Asia, and parts of Central and South America are at greatest risk. Travelers should avoid exposure to TB in crowded and enclosed environments and avoid eating or drinking unpasteurized dairy products. The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States.

Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure.

It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body’s immune system is compromised, as with old age or another illness.

Appropriately treating the TB before it causes active disease is beneficial for the long term.

 

Typhoid

Typhoid fever is caused by a bacteria found in contaminated food and water. It is common in most parts of the world except in industrialized regions (United States, Canada, western Europe, Australia, and Japan) so travelers to the developing world should consider taking precautions. There are two vaccines to prevent typhoid.

  • Children over 2 years of age can be vaccinated with the injectable form. It must be given at least 2 weeks prior to travel and lasts 2 years.
  • The oral vaccine for children over 5 years and adults is given in 4 doses over a week’s time and should be completed at least a week prior to travel. The oral vaccine lasts 5 years.
  • Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.

Yellow Fever

Yellow fever is another mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.

Zika Virus

At this time it is advised that pregnant women and women who might become pregnant avoid areas in which the zika virus is found. For up to date travel advisories due to this virus, see the CDC’s Zika page.