Plan for Vacation – especially if you’re going outside the US

A little planning and preparation can help everyone in your group stay healthy while traveling. Some preventative treatments take up to 6 months to complete, so talk to your doctor early!

When families are able to travel, it can be a wonderful time of exploration and bonding. Don’t let illness get in the way. Many locations have diseases that you don’t typically see in your home town. Take a little bit of time to learn what you need to do to prepare for your vacation. Insurance doesn’t usually cover travel medicine, so be sure to consider these extra costs when planning a trip.

Keep track of everything

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 travel group. 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 copy 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

Prepare everyone for local specs

Learn what the local healthcare options are if someone in your travel group gets sick or injured. For several tips, see this travel information from the CDC.

Find out how you can use your phone overseas. Be sure to bring a charger that will work with local electrical outlets.

If you’re traveling with young children, plan ahead for where they’ll sleep. Infants will need a safe place of their own with a firm surface. Everyone will need time to adjust to new time zones.

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 traveling.

If you’re going to be somewhere above 8000 feet above sea level, prepare for the change in altitude with these tips.

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 sunscreen tips, see Sun and Water Safety.

For more safety tips, see this helpful brochure.

Prevent bug bites

When you travel be sure to protect against bug bites! #travel #prevention #vacation #questforhealthkc

Mosquitos, ticks and other bugs not only cause itchy rashes but they can carry diseases. Using insect repellant properly can help to prevent getting bit.

Use insect repellent with at least 20% DEET to protect against mosquito and tick bites. Follow package directions and reapply as directed. Do not use combination bug sprays with sunscreen. They should be applied separately.

Wear long sleeves and pants. Consider treating your clothes with permethrin and tucking your pants into your socks. Sleep in areas that are screened against bugs.

Vaccines

Extra vaccines may be needed when you travel, especially in infants who are too young to get a measles vaccine on our usual schedule and adults who have not gotten vaccines that are now on the regular schedule.

Before you travel you can look at destination-specific advice on the CDC’s Destination page.

MMR

The news routinely reports outbreaks of measles these days. Many of the US outbreaks are related to an unvaccinated person returning from abroad. The MMR protects against measles, mumps, and rubella.

While our standard vaccine schedule does not recommend the MMR until 12 months of age, the vaccine can be used in infants as young as 6 months. It is considered safe to use in infants, but we don’t know when their immunity from their mother goes down. If the maternal immunity is still active the vaccine won’t work. This immunity typically falls between 6 and 12 months. After 12 months the vaccine is more likely to be effective, so when the risk is lower, it is recommended to wait until that age for the vaccine.

Between 6 and 12 months of age the MMR is recommended for infants considered high risk for being exposed to measles. This is because if their immunity has fallen, we don’t want them to be unprotected. International travel is considered to be high risk. If your baby’s maternal immunity is still high, the vaccine won’t provide protection, but he or she is still protected until that maternal immunity falls.

Because we don’t trust that the vaccine is effective before a year of age, babies who get an early MMR will still need two after their first birthday.

Talk to your baby’s pediatrician about getting the MMR if your child is over 6 months of age. Ideally it will be given at least 2 weeks prior to travel to give the body time to develop immunity.

Hepatitis

Both hepatitis A and hepatitis B vaccines are now on the routine schedule for children in the US, but many adults did not get these vaccines as children. These vaccines are recommended for travel to many locations. Verify if your family has had both hepatitis A and hepatitis B vaccines before you travel.

It is recommended that infants start hepatitis B vaccines at birth. The series is completed at 6-9 months of age. There are catch up schedules for those who haven’t completed the series on time.

Children do not get the hepatitis A vaccine until 12 months of age. If they have not yet started the series and they are over a year, they can start at any time. The booster is given 6-12 months later.

It takes at least 6 months to complete each of these series, so plan early!

Typhoid

Typhoid is not a vaccine routinely given in the US but it is recommended for travel to many parts of the world. There are two main types of typhoid vaccine, injectable and oral.

Children 2 years and older can get an injectable typhoid vaccine, ideally at least 2 weeks prior to travel. It is only one dose and lasts 2 years.

The oral vaccine is only for people 5 years and older. It is given in 4 doses over a week’s time and should be completed at least a week prior to travel. It must be given on an empty stomach (1 hour before eating and 2 hours after eating). Antibiotic treatment can make this vaccine ineffective, so discuss any current medicine you are taking with your doctor. 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.

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 it can be given as young as 9 months of age. MenACWY-CRM is 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.

Travelers 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. Boosters for people traveling to these areas are recommended every 5 years.

Yellow Fever

Yellow fever is a 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.

Most physician offices do not offer this vaccine. A special license is required to be able to provide it. Check with your local health department or a travel clinic in your area. This vaccine should be given at least 10 days prior to travel.

Influenza

Remember that influenza hits various parts of the world at different times of the year. The southern hemisphere tends to finish their flu season just as ours is starting. Check to see when it’s flu season and vaccinate as needed.

Medications for your trip

Aside from bringing your routine prescription medications and over the counter medicines in their original prescription container, there are some medications that are recommended for traveling to various parts of the world.

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 traveling. 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. Review the area-specific travel recommendations with your doctor.

Anti-diarrhea medicines

I am commonly asked to prescribe antibiotics to prevent traveler’s diarrhea. This is discouraged due to growing bacterial resistance to antibiotics. It is best to prevent by avoiding local water, choosing foods wisely, using proper handwashing techniques, and considering bismuth subsalicylate or probiotic use.

Traveler’s diarrhea is often from bacteria, but it can also be from a viral source. Maintaining hydration with clean water with electrolytes is the most important treatment. Many cases of traveler’s diarrhea do not require antibiotics. See details of treatment recommendations in the Yellow Book.

After you return…

If you’ve been in an area of the world that has increased risk for tuberculosis (TB) or if you have suspected exposure to TB, testing for exposure is recommended.

Tuberculosis occurs worldwide, but travelers who go to most countries in Latin America, the Caribbean, Africa, Asia, Eastern Europe, and Russia are at greatest risk.

Travelers should avoid exposure to TB in crowded and enclosed environments. We should all 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.

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Alphabet Soup of Meningitis Vaccines: A, C, W, Y, B… What does it mean?

In my previous post I discussed the many different types of meningitis and most of the vaccines used to prevent them. Meningococcal meningitis deserves its own post because there are different strains of meningococcus and different vaccines to cover those strains. We’re familiar with the recommended vaccine schedule, but one type of meningitis vaccine falls into a lesser known category, so it’s very confusing. Here I’ll discuss the two main types of meningitis vaccines that protect against meningococcal meningitis as well as the recommendations for their use.

Meningococcal meningitis can refer to any meningitis caused by the type of bacteria called Neisseria meningitidis, but there are many different types of N. meningitidis. We have vaccines to protect against types A, C, W, Y, and B.

Who gets N. meningitis?

Infants, teens, and young adults are most likely to get meningococcal meningitis. You can see from the graph that infants have the highest risk, followed by the elderly, but there is a bump in the adolescent years. Among the adolescents, 16-23 years of age is the highest risk.

Meningococcal disease incidence by age.
Source: CDC

People at increased risk

Like most infectious diseases, risk increases if there are a lot of people living in close quarters. This is why college outbreaks occur, but even teens and young adults not in college are at a higher risk.

People who have weak immune systems or a damaged or missing spleen are at higher risk.

Sub-Saharan Africa is called the meningitis belt. People who live or visit there are at risk.

Living in or visiting areas of a current or recent outbreak of course elevates the risk.

Working in a lab that handles N. meningitidis bacteria is considered high risk.

Anyone at higher risk should talk to their doctor about when they are eligible for meningitis vaccines. These recommendations differ from the standard vaccine recommendations.

Rates of meningitis are falling

Rates of meningococcal disease have been falling in the US since the 1990s, mostly due to the routine use of meningococcal vaccines. Among 11 through 19 year olds, the rate of meningococcal disease caused by serogroups C, W and Y has decreased 80% since tweens and teens were first recommended to get a meningococcal conjugate vaccine.

Interestingly, serogroup B meningococcal disease has declined even though vaccines were not available to help protect against it until the end of 2014.

It is difficult to measure the impact of these vaccines because the overall incidence of the disease is so low. It takes large numbers of vaccines over time to measure effectiveness because the disease is so rare. It’s easier to notice change when something is frequent. The less common something is, the harder it is to follow trends and measure incidence.

Vaccines to prevent meningococcal meningitis

In the United States there are two types of meningococcal vaccines, quadrivalent and serogroup B.

Quadrivalent Conjugate Vaccines (MCV4)

Menactra and Menveo are different brands of meningococcal conjugate vaccine. These protect against serogroups A, C, W, and Y. Because there are four serogroups, it is called quadrivalent, shortened MCV4 – meningococcal conjugate vaccine 4.

Between 80-90% of tweens and teens vaccinated with Menactra show immune protection one month after completing the series. This protection drops to 70-90% of adults vaccinated with Menactra.

Between 70-90% of tweens, teens, and adults vaccinated with Menveo show immune protection 1 month after completing the series of vaccine.

The immunity from the MCV4 vaccines seems to fall after about 5 years.

Side effects from the vaccines are generally mild and self resolve within a few days. These side effects include redness and pain in the area of the injection as well as fever. More serious reactions, such as an allergic response, are possible but rare.

Any vaccine (or use of a needle for a blood draw) can lead to fainting in tweens and teens. It is recommended that they sit for 15 minutes after all vaccines and blood draws. This can help to prevent a head injury if they fall when they faint.

Routine recommendations

MCV4 is usually first given when kids are 11 to 12 years of age, followed by a booster at age 16 years.

The vaccine’s protection falls over time, so two doses are necessary. For most US children, getting the vaccine at 11 years protects through the early period of increased risk and the booster at 16 years covers the late teen and young adult years.

High risk groups

Children between 2 months and 10 years who are considered high risk based on the risk categories above should be vaccinated earlier.

Adults should get the MCV4 vaccine if they have the risk factors noted above.

Serogroup B Vaccines

Bexsero and Trumenba are meningococcal vaccines that protect against serogroup B. These vaccines are commonly called Meningitis B vaccines, or MenB. These vaccines are significantly different from one another, so if the series of vaccines is started, it needs to be completed with the same brand. They are not interchangeable, as are most vaccine brands. There is no preference of one brand over another.

Bexsero is a 2 dose series. Doses should be 1 month apart. Between 60-90% of people show immune response 1 month after completing the 2 dose series.

Trumenba is a 3 dose series. It should be given at 0, 1-2, and 6 months. If the 2nd dose is delayed beyond 6 months, only 2 doses are required. Eighty percent of people show a protective immune response one month after completing the series.

Side effects to MenB vaccines are generally mild. They include soreness, redness and swelling of the injection area, fatigue, headache, muscle or joint pains, fever, nausea, and diarrhea. If these symptoms occur, they generally self resolve within a week. More serious reactions, such as an allergic reaction, are possible but rare.

Again, it is recommended that tweens and teens sit for 15 minutes after all vaccines and blood draws due to the risk of fainting.

High risk people

MenB vaccines are recommended for people at high risk between 10 and 25 years of age.

Healthy, low risk people

The tricky part is that Men B vaccine is only given permissive use for most 16-23 year olds.

The CDC’s Advisory Committee on Immunization Practices (ACIP) makes recommendations for vaccine use based on all the data that is collected. Members of the Committee felt that the data available did not support the routine use of MenB vaccines, so it is not on the list of recommended vaccines.

What is permissive use?

Permissive use means it is approved for use, but it isn’t one of the standardly recommended vaccines.

This category is given because the vaccine is felt to be safe, but there is not sufficient evidence to recommend that it be given routinely.

Is it ever required for healthy people?

Some colleges require it. This is often due to a recent local outbreak so they are considered high risk.

Does insurance cover it if it’s not recommended?

Most often insurance does cover the MenB vaccine, but this is one of the concerns raised by the groups who argued that it should be routinely recommended. They argued that some insurance companies might not cover it if it is not recommended.

If you plan to get the vaccine, you should check with your insurance carrier to see if it is covered.

Why isn’t it recommended for everyone?

The meningitis A,C,W,Y vaccine is recommended for everyone at 11 and 16 years of age, so why isn’t the meningitis B vaccine recommended for all?

MenB vaccines protect against the majority of currently circulating strains of meningococcal B, but not all. The MenB vaccine also gives only a short duration of protection.

It is expensive to vaccinate, and since there is a relatively low incidence of meningitis B disease, it would take a lot of money to prevent a single case. While no price can be put on the value of human life, the overall risk remains low to individuals, even when they are not vaccinated. All of these factors led to the committee’s decision.

Dr. Vincent Iannelli discusses the risks and benefits in more detail at Understanding the Recommendations to Get a Men B Vaccine if you want more details.

Where can you get MenB if you choose to get it?

Physician offices, student health care centers, pharmacies, and county health departments might offer the MenB vaccine. Since it is not on the standard schedule, they might opt to not carry it. If you desire it, you should ask if it’s available.

My office offered the MenB vaccine last summer, but we did not have enough patients want it after discussing the current recommendations. Much of our stock went unused and had to be wasted.

We did not feel that we could push it strongly despite the fact that we were losing money on unused stock.

I know this might surprise some who believe that doctors are just pharmaceutical shills. (Shills is a term used to imply that doctors offer vaccines only to make money despite knowing about their dangers.)

My partners and I didn’t push this vaccine because we didn’t believe strongly in it. We bought it to be able to offer it to patients who desired it, but since we couldn’t honestly say we recommended getting it, we had few want it.

In the end we decided to not re-order it. We no longer offer MenB vaccine.

We strongly believe in giving the vaccines that are recommended. Recommended vaccines have been shown to not only be safe, but also effective in preventing disease. They can make a big impact on our health as individuals and as a community.

Final MenB Vaccine Thoughts

Unfortunately, the MenB vaccine has failed to show sufficient effectiveness to support the cost of vaccinating everyone.

Putting value on one person’s life is not possible, so if my patients want this vaccine, I suggest they go to the health department, a pharmacy, or student health on their college campus.

I do not think it is wrong to get the vaccine. I simply can’t say that everyone should get it.

Some students must get it due to their school’s requirement. If a school requires it, that should not be argued. The schools with MCV4 requirements often have had a recent outbreak and are considered high risk. In that case, protect yourself!