• Scenario: Cholera: covers advice for people travelling to areas endemic with cholera.
• Scenario: Hepatitis A: covers advice for people travelling to areas endemic with hepatitis A.
• Scenario: Hepatitis B: covers advice for people travelling to areas endemic with hepatitis B.
• Scenario: Japanese encephalitis: covers advice for people travelling to areas endemic with Japanese encephalitis.
• Scenario: Meningococcal meningitis: covers advice for people travelling to areas endemic with meningococcal group A strain, as well as Muslims undergoing the Hajj (annual pilgrimage to Mecca).
• Scenario: Poliomyelitis: covers advice for people who are not immunized against poliomyelitis and are travelling to endemic areas.
• Scenario: Rabies: covers advice for people whose travel puts them at risk of exposure to rabies.
• Scenario: Tetanus: covers advice for people travelling to areas with poor healthcare provision where post-exposure treatment might be unavailable or difficult to obtain.
• Scenario: Tick-borne encephalitis: covers advice for people travelling to areas endemic with tick-borne encephalitis.
• Scenario: Typhoid fever: covers advice for people travelling to areas endemic with typhoid fever.
• Scenario: Yellow fever: covers advice for people travelling to areas endemic with yellow fever (Africa and South America), and details of where to find yellow fever vaccination centres.
• Scenario: Vaccination at short notice: coves advice for people who require vaccinations and are travelling at short notice.

• Cholera is an acute diarrhoeal illness caused by an enterotoxin produced by Vibrio cholerae that have colonized the small bowel. It is a water-borne disease, being solely transmitted through contaminated water or food (especially shellfish).

• Consider vaccination against cholera for:
• Relief or disaster aid workers.
• People with remote itineraries in areas where cholera epidemics are occurring and there is limited access to medical care.
• For up to date, country by country, information see the 'Yellow Book', and NaTHNaC websites.

In depth

• Oral inactivated cholera vaccine (Dukoral^®) is the only licensed cholera vaccine available in the UK.

In depth

• Complete course at least one week prior to departure:
• Give adults and children over 6 years old two doses (up to 6 weeks apart).
• Give children aged 2–6 years old three doses (up to 6 weeks apart).
• Restart the course if more than 6 weeks have elapsed between doses.
• Booster doses:
• Give adults and children over 6 years old a booster dose 2 years after completing the primary course.
• Give children aged 2–6 years old a booster dose 6 months after completing the primary course.
• Repeat the primary course if more than 2 years have elapsed since the last vaccination.

In depth

• Mild gastrointestinal symptoms (abdominal pain, cramping, diarrhoea, nausea) are the most commonly reported. Serious adverse events are rare.

In depth

• Hepatitis A is an infection of the liver caused by hepatitis A virus. It is transmitted by the faecal–oral route through person-to-person contact and through contaminated food or drink.

• Anyone travelling to areas of moderate or high risk (Indian subcontinent, the Far East, and Eastern Europe) for prolonged periods, particularly if sanitation and food hygiene is likely to be poor.
• Individuals going to live in, or likely to be posted for long periods to, hepatitis A virus-endemic countries.

In depth

• There are several inactivated hepatitis A vaccines available: Avaxim^®, Epaxal^®, Havrix Monodose^®, Vaqta Paediatric^®, Twinrix^® (hepatitis A and B), and combined hepatitis A and typhoid (Hepatytix^®and ViATIM^®).

In depth

• Should be given at least 2 weeks before travelling, but can be given on the day of departure.

• If a combined hepatitis A and typhoid vaccine has been used to initiate immunization, give a dose of single hepatitis A vaccine 6–12 months later.
• A booster dose of the hepatitis A component is required 20 years after the second dose.
• A booster dose of the typhoid component will be required at 3 years.

In depth

• Mild, transient soreness, erythema, and induration at the injection site may occur. A small, painless nodule may form at the injection site; this usually disappears and is of no consequence.
• Fever, malaise, fatigue, headache, nausea, and loss of appetite are rare.

In depth

• Hepatitis B is an infection of the liver caused by the hepatitis B virus (HBV). Acute infection may occasionally lead to fulminant hepatic necrosis, which is often fatal.

• Travellers to areas of high or intermediate prevalence who place themselves at risk when abroad. Behaviours that place them at risk include unsafe sexual activity, injecting drug use, undertaking relief aid work, or participating in contact sports.
• Travellers who plan to remain in areas of high or intermediate prevalence for lengthy periods.
• Individuals who are travelling to visit friends or relatives with chronic hepatitis B infection.
• Families adopting children from countries with a high or intermediate prevalence of hepatitis B.
• People who may require medical care while travelling to areas of high- or moderate-endemicity.

In depth

• There are several inactivated hepatitis B vaccines available: Engerix B^®, Fendrix^®, HBvaxPRO^®, and Twinrix^® (combined hepatitis A and B).

In depth

In depth

In depth

• The most common adverse reactions are soreness and redness at the injection site. Serious adverse effects are very rare.

In depth

• Japanese encephalitis is caused by a flavivirus that is spread by the bite of infected mosquitoes. Illness ranges from asymptomatic infection to severe encephalitis with a high mortality rate and a high risk of permanent neurological sequelae.

• Japanese encephalitis vaccine may be recommended for:
• Travellers to south east Asia, Indian subcontinent, the Far East and tropical north east Australia (if staying for a month or longer in endemic areas during the transmission season, especially if travel will include rural areas).
• Travellers with shorter exposure periods if the risk is considered sufficient, such as those spending a short period of time in rice fields (where the mosquito vector breeds) or close to pig farming (a reservoir host for the virus).
• Country-specific recommendations and information on the global epidemiology of Japanese encephalitis can be found in the 'Yellow Book', Health information for overseas travel.

In depth

• There are two inactivated vaccines currently available for Japanese encephalitis:
• IXIARO^®
• Licensed in the UK for adults over 18 years of age.
• IXIARO^® is currently not recommended for use in young children, however it can be considered for off-label use in older teenagers.
• Black triangle: still under intensive post-marketing surveillance by the Medicines and Healthcare products Regulatory Agency (MHRA).
• Green Cross^®
• Unlicensed in the UK; only available on a named-patient basis.
• Recommended for children over of 1 year of age; not recommended for use in adults (licensed alternative available).
• JE-VAX^® is no longer available.

In depth

• Ideally, complete the vaccine schedule a month before travel (to allow immunity to develop).
• The Green Cross^® vaccine should be completed at least 10 days prior to departure (to allow for observation for delayed allergic reactions). People should be warned of the possibility of delayed anaphylactic reactions.
• This is not necessary for the IXIARO^® vaccine.
• Observe all recipients for 30 minutes (to check for urticaria, angio-oedema, and cardiovascular collapse). Full resuscitation facilities should be present.

In depth

• A rapid schedule of 3 doses of Green Cross^® vaccine, given on days 0, 7, and 14 can be used.
• Alternatively, a rapid schedule of 2 doses of Green Cross^® vaccine given one week apart can be used (but there is less immune response than if 3 doses of vaccine are given). Give a booster dose 3 months later.
• Complete the vaccine schedule at least 10 days prior to departure (to allow for observation for delayed allergic reactions), and ideally a month before travel (to allow immunity to develop).

In depth

• Tenderness, redness, and swelling have been reported in about 20% of vaccinated people. Fever, headache, malaise, chills, dizziness, nausea, vomiting, and abdominal pain have been reported in 10% of recipients.
• Local and mild systemic adverse effects occur in 10–20% of recipients.
• Serious systemic reactions (urticaria, angio-oedema, and cardiovascular collapse), occur in about 0.6% of vaccine recipients. Most occur within the first few minutes of vaccination, but may occur up to 2 weeks after vaccination with the Green Cross vaccine.

In depth

• Meningococcal disease is the result of systemic infection with Neisseria meningitidis. It is transmitted by droplet or by direct contact from carriers or individuals in the early stages of the disease. It has an incubation period of 2–7 days.
• There are 13 serotypes of Neisseria meningitidis of which groups B and C are the most common in the UK. In some areas of the world, the risk of acquiring meningococcal infection, particularly group A, is much higher than in the UK. The biggest risk is in the so-called meningitis belt from sub-Saharan West Africa to East Africa.
• Meningococcal disease most commonly presents as either meningitis or septicaemia, or a combination of both.

• The quadrivalent, inactivated, meningitis vaccine is recommended for travellers. A single dose provides cover against strains A, C, Y, and W135 of the disease. Two types are available:
• ACWY Vax^® (polysaccharide vaccine)
• Menveo^® (conjugate vaccine)
• Several other inactivated meningitis C vaccines are licensed for use in the UK.
• Meningitec^®
• Mengugate^®
• NeisVac-C^®
• Meningitis C with Haemophilus Influenza type B
• These vaccines are used as part of the routine childhood immunization programme. See the CKS topic on Immunizations - childhood for more information.
• Currently there is no vaccine available for meningitis B.

In depth

• Vaccination with meningitis ACWY^® is recommended prior to travel to areas with a high risk for Group A meningococcal meningitis for:
• People staying for extended time periods, such as 1 month or more.
• People engaging in high-risk holidays or work, such as backpacking or living in rural communities.
• People attending the Hajj (Mecca) and Umrah pilgrimages in Saudi Arabia (since there have been epidemics in recent years in these areas).
• People undertaking seasonal work in the Hajj area.
• Saudi Arabia requires proof of vaccination with ACWY Vax^® for visitors arriving for the Hajj and Umrah pilgrimages, or for seasonal working in the Hajj areas.
• Meningococcal C conjugate vaccine is part of the childhood immunization programme (see Immunizations - childhood for more information). This vaccine protects against group C disease only. Travellers should be immunised with the quadrivalent polysaccharide vaccine (ACWY^®), even if they have previously received the Meningococcal conjugate vaccine.

In depth

• For adults and children aged 1 year and older — vaccinate with quadrivalent meningococcal vaccine 2–3 weeks before travel.
• For children under 1 year of age — vaccinate with quadrivalent meningococcal vaccine 2 months before travel (two doses needed).
• Menveo^® (conjugate vaccine) is preferred to ACWY Vax^® (polysaccharide vaccine) for all age groups (off-label use in children under 11 years of age) because of better and longer lasting protection.
• Menveo^®
• Primary immunization:
• For adults and children aged 1 year and older, give a single dose of vaccine.
• For children under 1 year of age, give two doses of vaccine, one month apart.
• Booster doses:
• Children who received their primary immunization as infants should be given an additional dose of Menveo^® (with an interval of at least 12 months between completion of the primary course and the booster dose) if they remain at high risk.
• The need for booster doses in other age groups has yet to be determined, however it is likely to provide longer protection than ACWY Vax^®.
• ACWY Vax^®
• Primary immunization:
• For adults and children over 5 years old, give a single dose of vaccine.
• ACWY Vax^® is no longer recommended for children under the age of 5 years.
• Booster doses:
• For adults and children over 5 years old, give a booster dose every 5 years to those at continued risk.
• Children who were under 5 years when first vaccinated should be given a booster dose (preferably with Menveo^®) after 2–3 years if they remain at high risk.

In depth

• Menveo^®
• Commonly reported reactions include injection site reactions (such as pain, erythema, induration, pruritus), headache, nausea, rash, and malaise.
• ACWY Vax^®
• Generalized reactions to the quadrivalent vaccine are rare although pyrexia occurs more frequently in young children than in adults.
• Injection site reactions occur in approximately 10% of recipients and last for approximately 24–48 hours.
• Confirmed anaphylaxis after immunization is extremely rare, with anaphylactoid reactions reported for approximately 1 in every 500,000 doses.

In depth

• Poliomyelitis is an acute illness caused by invasion of the gastrointestinal tract by the polio virus. Transmission is via faeces and pharyngeal secretions.
• Most people (95%) who become infected with poliomyelitis are asymptomatic. However, a small number of infected people (< 1%) will go on to develop flaccid paralysis, affecting the legs or the facial nerves.

• Vaccination is indicated for people who are travelling to areas or countries where poliomyelitis is epidemic or endemic who:
• Have not been previously immunized.
• Have not been fully immunized according to the UK schedule.
• Received their last dose of polio vaccine 10 years (or longer) ago.

In depth

• There are two types of poliomyelitis vaccine available in the UK — inactivated and oral live (no longer recommended).
• The polio vaccine is normally given as part of a combined product:
• Infanrix-IPV-Hib^®, Pediacel^® (DTaP/IPV/Hib)
• Infanrix-IPV^® (DTaP/IPV or dTaP/IPV)
• Repevax^® (dTaP/IPV)
• Revaxis^® (Td/IPV)

In depth

• Children under 10 years who have not been vaccinated: vaccinate according to the childhood vaccination programme. See the CKS topic on Immunizations - childhood.
• For children over 10 years of age, and adults who have not been vaccinated, give:
• A primary course: three doses of vaccine (as Td/IPV) 1 month apart.
• Two booster doses: the first 5–10 years after the last dose of the primary course, and the second 10 years later.
• Give a booster dose to anyone who has been fully vaccinated (received five doses), has not received a booster dose in the last 10 years, and is travelling to polio-endemic regions.

In depth

• Pain, swelling, or redness at the injection site are common and may occur more frequently following subsequent doses. A small, painless nodule may form at the injection site; this usually disappears and is of no consequence.
• Confirmed anaphylaxis occurs extremely rarely.

In depth

• Rabies is an acute viral infection, caused by a rhabdovirus, that is nearly always fatal. Transmission is usually in saliva via the bite of an infected animal.

• The following travellers should be offered pre-exposure immunization:
• People living in, or travelling for more than 1 month to, rabies-enzootic areas (e.g. jungle habitat) where there is no access to reliable, prompt, safe medical care.
• People travelling for less than 1 month to enzootic areas but who may be exposed to rabies because of their activities, or those who would have limited access to post-exposure medical care.
• People who are working abroad with, or in close contact with, animals (e.g. veterinarians, zoologists).

In depth

• Refer immediately, for expert advice on risk assessment and management, anyone who has been exposed to rabies (even if the person has been fully immunized). This should be obtained from:
• Health Protection Agency Centre for Infection (020 8200 6868).
• Health Protection Scotland (0141 300 1100).
• Public Health Laboratory, Belfast City Hospital (028 9032 9241).
• Post-exposure vaccination (i.e. after a bite or scratch has occurred) depends on the immunization status of the person, the level of risk in the country, and the nature of the exposure.

In depth

• Two inactivated rabies vaccines are available in the United Kingdom: Rabies Vaccine BP and Rabipur^®.

In depth

• A primary course of immunization should be completed prior to departure.

In depth

• Local reactions may occur such as redness, swelling, or pain at the site of injection within 24–48 hours of administration. Systemic reactions are rare.

In depth

• Tetanus is an acute disease caused by the action of tetanus toxin, released following infection by the bacterium Clostridium tetani. Tetanus spores are present in soil or manure and may be introduced into the body through a puncture wound, burn or scratch.
• The symptoms of tetanus are characterized by generalized rigidity and spasms of skeletal muscles. The case fatality ratio ranges from 10 to 90%.

• All people should receive tetanus vaccine as part of the childhood vaccination programme.
• For travellers give a booster dose of tetanus/diphtheria/inactivated polio vaccine (Td/IPV), before departure, to:
• Anyone travelling to areas where medical attention may not be accessible and whose last dose of a tetanus-containing vaccine was more than 10 years previously even if the person has received five doses of vaccine previously (3 primary immunization doses and 2 booster doses).
• Anyone travelling to areas where medical attention may not be accessible and whose last dose of a tetanus-containing vaccine was more than 10 years previously and has received a tetanus primary immunization (3 doses) course but, none or one of the recommended booster doses.
• For travellers who have not received a tetanus primary immunization course (3 doses) it is usually worth giving the maximum number of doses of vaccines that the travel departure date allows and completing the course upon return.

In depth

• Tetanus vaccine is available as an inactivated vaccine and is only available as part of a combined product:
• Infanrix-IPV-Hib^®, Pediacel^® (DTaP/IPV/Hib)
• Infanrix-IPV^® (DTaP/IPV or dTaP/IPV)
• Repevax^® (dTaP/IPV)
• Revaxis^® (Td/IPV)

In depth

• Vaccinate all children under 10 years of age who have not been vaccinated according to the childhood vaccination programme (see the CKS topic on Immunizations - childhood).
• For children aged over 10 years and adults who have not been vaccinated give:
• A primary course: three doses of vaccine (as Td/IPV) 1 month apart.
• Two booster doses: the first 5–10 years after the last dose of the primary course, and the second 10 years later.
• Give a booster dose to anyone who has not received two booster doses at appropriate intervals.
• Give a booster dose to anyone who has been fully vaccinated, has not received a booster dose in the last 10 years, and is travelling to areas where medical attention may not be accessible.

In depth

• Pain, swelling, or redness at the injection site are common and may occur more frequently following subsequent doses. A small painless nodule may form at the injection site; this usually disappears and is of no consequence.
• Confirmed anaphylaxis is extremely rare.

In depth

• Tick-borne encephalitis is caused by a flavivirus and is usually spread by tick bites, although unpasteurized milk is also thought to be a source of the disease. There are three forms of the disease related to the virus subtypes, namely European, Far Eastern, and Siberian.

• Give tick-borne encephalitis vaccine to anyone who:
• Intends to live in tick-borne encephalitis-endemic areas.
• Is at occupational risk in endemic areas (e.g. farmers, forestry workers, soldiers).
• Intends to travel to rural endemic areas during late spring and summer (e.g. campers, hikers, Scout or Guide groups).

In depth

• One inactivated vaccine for tick-borne encephalitis is available in the UK: Ticovac^®.

In depth

• Maximum immunity is achieved 1 week after the second dose.

In depth

• Two doses can be given 2 weeks apart. Of those who receive this schedule 90% achieve immunity 2 weeks after the second dose.
• The third dose should be given 5 to 12 months after the second dose, either on return or, during travel if still overseas.

In depth

• Reported reactions to tick-borne encephalitis vaccine are rare. Local reactions such as swelling, pain and redness at the injection site may occur. Pyrexia, particularly after the first dose, can occur in children and adults, usually occurring within 12 hours of immunization and settling within 24–48 hours.

In depth

• Typhoid fever is a systemic infection caused by the Gram-negative bacillus Salmonella typhi spread primarily by the faecal–oral route.

• Give a typhoid vaccination to:
• Travellers to countries where typhoid is endemic (e.g. south Asia, parts of south east Asia, the Middle East, Central and South America, and Africa), especially if staying with or visiting the local population.
• Travellers to endemic areas with frequent and/or prolonged exposure to conditions where sanitation and food hygiene are likely to be poor.
• Laboratory personnel who may handle Salmonella typhi in the course of their work.
• Typhoid vaccine is not 100% effective. Advise the person to take all necessary precautions to avoid contact with or ingestion of potentially contaminated food or water.

In depth

• Two single component typhoid vaccines are available: Typherix^® and Typhim^®.
• Combined typhoid and hepatitis A vaccines are also available (Hepatyrix^® and ViATIM^®) which may be useful for people requiring simultaneous coverage against both illnesses.

In depth

• Maximum antibody response to the inactivated typhoid vaccine is achieved one month following vaccination and persists for about three years.

In depth

• Local reactions (pain, swelling, erythema, and induration at injection site) are the most commonly reported symptoms. Systemic reactions following the vaccine are infrequent. There have been rare reports of anaphylaxis.

In depth

• Yellow fever is caused by an acute flavivirus infection spread by the bite of infected mosquitoes. It ranges in severity from non-specific, self-limited symptoms of fever, malaise, photophobia and headache to an illness of sudden onset with fever, vomiting and prostration which may progress to jaundice and haemorrhage.

• The following groups should be immunized:
• Laboratory workers handling infected material.
• People aged 9 months or older who are travelling to countries that require an International Certificate of Vaccination or Prophylaxis (ICVP) for entry.
• People aged 9 months or older who are travelling to, or living in, infected areas or countries in the yellow fever endemic zone, even if these countries do not require evidence of immunization on entry.
• Infants aged 6–9 months should only be immunized if the risk of yellow fever during travel is unavoidable; expert opinion should be sought in these situations.
• Infants under the age of 5 months old should not be given a yellow fever vaccine.

In depth

• Proof of vaccination is required for all travellers coming from countries where yellow fever occurs, including transit through such countries.
• For a full list of countries that require a valid certificate see the WHO website, http://whqlibdoc.who.int (pdf).

In depth

• One (live) yellow fever vaccine is available in the UK.

In depth

• Immunization should be performed at least 10 days prior to travel at specialist centres. See www.nathnac.org for a full list of these centres.
• Give a booster dose after 10 years if there is a continued risk.
• A medical waiver letter can be issued if vaccination is contraindicated for medical reasons.

In depth

• Adverse reactions following yellow fever vaccine are typically mild and consist of headache, myalgia, low grade fever, and/or soreness at the injection site and will occur in 10–30% of recipients. Injection site reactions tend to occur from days 1–5 after immunization.
• Systemic adverse effects also occur early but may last up to 2 weeks.
• Rash, urticaria, bronchospasm, and anaphylaxis occur rarely (estimated to be 1 case per 130,000 doses of vaccine).
• Post-vaccine encephalitis may occur rarely in infants under 6 months old (0.5 to 4 cases per 1000 infants under 6 months old).

In depth

• The decision to vaccinate someone one who is travelling at short notice will depend upon an individual risk assessment:
• The risk of contracting a vaccine-preventable disease.
• The length of time before departure.
• Type of vaccine and schedules available.
• The length of the stay abroad.
• Full immunity may take up to 21 days to develop in some people. Travellers should be advised that if they do not leave enough time for travel vaccines to be given there may be an initial period for which they are not fully immunized. The decision to travel should be carefully considered after a risk assessment.
• If there is insufficient time to complete all the required vaccinations prior to departure seek specialist advise from the NaTHNaC advice line for health professionals:
• Telephone: 0845 602 6712
• Monday to Friday, 9 a.m. to 12 noon; 2 p.m. to 4.30 p.m.

• Hepatitis A, diphtheria, tetanus and poliomyelitis boosters may be given up to the day of departure.
• Hepatitis A primary doses may also be given up to the day of departure.
• Typhoid vaccine — full immunity can take up to 10 days to develop. If the person's trip is for an extended period, typhoid vaccine should be considered up to the day of departure. If the person's trip is to be short (e.g. 5 days) then it may not be worth vaccinating.
• Meningococcal vaccine — may be beneficial for some people given up to the day of departure depending on the area being visited (high-risk) and the length of stay planned:
• Full immunity can take 14–21 days to develop.
• Yellow fever vaccine
• If there is a risk of contracting yellow fever the vaccine may be given up to the day of departure. Full immunity develops 10 days after vaccine administration.
• For anyone who requires a valid yellow fever vaccination certificate at their destination, yellow fever vaccine should be given 10 days prior to travel. Travellers who will arrive in less than 10 days in a country for which yellow fever vaccine is mandatory should have the vaccine. However they should be advised that there is a possibility that they will be refused entry at their destination.

In depth

• Hepatitis B may be given as an accelerated course over 3 months or 3 weeks.
• Tick-borne encephalitis may be given as two doses 2 weeks apart.
• Ninety percent of those who receive this schedule achieve immunity 2 weeks after the second dose.
• The third dose should be given 5 to 12 months after the second dose, either on return or during travel if still overseas.
• Tetanus and poliomyelitis vaccines in previously unimmunized people:
• For people travelling at short notice it is usually worth giving the maximum number of doses of vaccines that the travel departure date allows and completing the course upon return.
• Japanese encephalitis may be given as two doses 1 week apart: this will induce antibodies in approximately 80% of recipients.
• The vaccine course should be completed 10 days prior to departure to allow for delayed allergic reactions.
• Seek specialist advise if someone requires a Japanese encephalitis vaccine and there is insufficient time to complete the course (< 10 days prior to departure).
• Rabies vaccine can be given as a course over 3 weeks. If vaccination is required at short notice seek specialist advice.

In depth