No 26a+b - 2015

Recommended vaccinations for foreign travel

As in previous years, Statens Serum Institut and a reference group appointed by the specialist societies have revised the country-specific recommendations for prevention of infectious diseases in connection with travels abroad:

Recommended vaccinations for foreign travel, EPI-NEWS 26b, 2015

Changes for malaria prophylaxis are described in EPI-NEWS 25/15. For the diseases that are preventable through vaccination, the following changes apply:

Yellow fever

In 2013, EPI-NEWS 26a+b/13, the WHO announced that a routine yellow fever booster every ten years is no longer recommended. Instead, a single vaccination should be considered to provide life-long protection. The WHO established a 3-year implementation period for this change, which is therefore expected to be in place in all countries as from June 2016.

A number of countries have already joined the WHO announcement, and now consider that a yellow fever vaccination provides life-long protection, but many countries have yet to approve the recommendation, and they insist on documentation that any yellow fever vaccination was given less than 10 years ago. Finally, a range of countries have not yet decided where they stand on this issue.

When travelling to countries that require yellow-fever vaccination, either before departure on direct travels or when entering the country via yellow fever-endemic areas, travellers may therefore still be asked to provide documentation that they received vaccination less than 10 years ago. A complete list of the countries that have such requirements in place is available here.

It is important to remember that transit stays in countries may trigger a vaccination requirement when continuing to another country, including to countries outside of the yellow fever transmission zone. The WHO recommends that transit stays lasting less than 12 hours in countries with a risk of yellow fever transmission should not trigger a vaccination requirement from the final destination. Still, many countries require travellers to have a valid yellow fever vaccination certificate, regardless of the duration of the transit period. The above-mentioned list also contains information on these conditions and specifies the age from which yellow fever vaccination is required. All of these conditions are subject to amendment at any time, and travellers should therefore always consult with the country's embassy/consulate before departing.

Japanese Encephalitis (JE)

The JE vaccine Ixiaro® is given as a 2-dose regimen on days 0 and 28. Booster vaccination is recommended after 12-24 months, and already after 12 months in cases of continuous risk, e.g. in persons living in endemic areas. Repeated booster vaccination was previously recommended after 4 years, EPI-NEWS 26a+b/13. Limited data now indicate that the duration of protection after the first booster may be at least 6 years. Until more studies confirm this finding, the reference group recommends, as a precautionary measure, that immunity be boosted 5 years after the initial booster dose.

Ixiaro® was also approved for an accelerated regime on Days 0 and 7 for persons aged 18-65 years. This recommendation is based on a randomised, observer-blinded phase-III study. A total of 217 persons aged 18-65 years were given Ixiaro® in conjunction with an inactivated rabies vaccine (Rabipur) on a rapid immunisation scheme on Days 0 and 7, and 56 test subjects received Ixiaro® only after the conventional immunisation scheme on Days 0 and 28. The share of test subjects who seroconverted 7 and 28 days after the last immunisation was the same for both vaccination schemes. Sero-conversion rates and antibody titres also remained relatively high until 12 months after the first immunisation under both vaccination schemes.

For both vaccination schemes, the primary immunisation shall have been concluded at least 1 week before potential exposure to Japanese encephalitis virus.

Use of the accelerated scheme is associated with uncertainty as to the duration of the protective period beyond 12 months. The reference group therefore recommends that the normal scheme is applied when possible and that the accelerated scheme is reserved for persons who will be initiating their travel less than 28 days after their first dose as the second dose should be given as late as possible after the first dose.

If the accelerated regimen is used, the first booster should always be given after 12 months.

Polio

The efforts made to eradicate polio are close to succeeding. To this date, 2015 has only seen the detection of wild polio virus cases in Pakistan (24) and Afghanistan (3). The most recent case of polio in Africa was recorded in Somalia in August 2014. In this critical phase, the WHO Emergency Committee decided at its latest meeting in the beginning of May 2015 to maintain the assessment that the risk of renewed international spreading of polio is a public health emergency of international concern (PHEIC). The extra requirements for polio vaccination when exiting some countries, EPI-NEWS 27a+b/14, remain in force until the next Emergency Committee meeting in 3 months because the current epidemiologic situation has given rise to the following classification of countries:

Presently, the following are classified as countries from which wild poliovirus is currently spreading: Afghanistan and Pakistan.

Travellers to these countries who will be staying for 4 weeks or more should receive (booster) vaccination before leaving Denmark if they received their previous polio vaccination more than 12 months ago, EPI-NEWS 27a+b/14.

Currently, the following countries are classified as areas from which wild polio virus have been detected (within the past 12 months), but from where the virus is currently not spreading: Cameroun, Nigeria and Somalia.

Travellers to these countries who will be staying for 4 weeks or more should also receive (booster) vaccination before leaving Denmark if they received their previous polio vaccination more than 12 months ago.

Presently, the following countries are classified as areas that are not infected with polio, but which are vulnerable to international spreading: Equatorial Guinea, Ethiopia, Iraq, Israel and Syria.

For travellers to these countries, there is no recommendation for (booster) vaccination, but travellers should have received full primary polio vaccination. (As Syria has introduced a specific requirement that all travellers who leave Syria shall receive polio vaccination, it is also recommended that all travellers for Syria receive (booster) vaccination before leaving Denmark).

Additionally, country-specific requirements for polio vaccination currently apply for travellers visiting the following countries:

(An updated list of polio-endemic areas and areas with polio outbreaks ("reinfected" areas) is available here)

Bahrain: Requirement for polio vaccine for travellers from polio-endemic areas.

Brunei: Requirement for polio vaccine for travellers from polio-endemic areas.

Egypt: Requirement for polio vaccination for travellers from Equatorial Guinea, Cameroun, Pakistan and Syria.

Iran: Requirement for polio vaccination for everyone below 15 years of age who arrives from polio-endemic or polio-reinfected countries.

Iraq: Requirement for oral polio vaccination for all travellers from polio-endemic areas and for all travellers from Iraq to polio-endemic areas.

Libya: Requirement for polio vaccination for travellers from Afghanistan and Pakistan a minimum of 4 weeks and no more than 12 months before entry.

The Maldives: Requirement for polio vaccination for travellers who arrive from countries from where spreading of polio occurs (currently Afghanistan and Pakistan) and from countries that are polio-endemic or currently affected by polio outbreaks.

Nepal: Requirement for polio vaccination (for all travellers).

Qatar: International vaccination certificate documenting polio vaccination for all travellers arriving from countries from where polio has spread (currently Afghanistan and Pakistan)

Saudi Arabia: Umrah and Hajj pilgrims: A general requirement for documentation of polio vaccination (OPV or IPV) a minimum of 4 weeks and no more than 12 months before entry from a polio-endemic area.

The Seychelles: Requirement for polio vaccination for travellers from countries with current polio outbreaks.

Sri Lanka: Requirement for polio vaccination for all travellers from polio-endemic or polio-infected (outbreaks) areas.

Syria: Requirement for polio vaccination for all travellers from Cameroun, Equatorial guinea, Pakistan and for all travellers who leave Syria.

Meningitis

Ethiopia: Has revoked the requirement for meningitidis vaccination of all travellers.

Libya: Requirement for vaccination against meningococcal meningitidis (no speciation of types, 4-valent vaccine is recommended).

Saudi Arabia: Umrah and Hajj pilgrims: Requirement for 4-valent meningococcal vaccine.

MMR

Paraguay: MMR vaccination no longer required.

Tick-borne encephalitis (TBE)

TBE virus is common in some parts of the Nordic Countries and in Central and East Europe. Please find a map showing the incidence at the sub-national level for the countries that make these data available, here

Germany has a national TBE incidence of < 0.5 per 100,000 inhabitants, but the risk is concentrated in South Germany where the primary TBE risk areas are: Baden-Württemberg, Bavaria, the southern part of Hessen and the south-eastern part of Thuringia. Local incidence is available here 

Vaccination may be considered in case of prolonged or repeated stays in TBE-endemic areas where the behaviour in question carries a high risk, e.g. forest work, or in cases in which the wood serves as the fixed location for play, sports (e.g. orienteering) or leisure activities.

Vaccination may also be considered in persons who are living permanently or have a fixed summer residence in TBE areas and who regularly leave the paths of woods and scrubland.

A total of three doses are given at a recommended interval of 1-3 months between the first and second dose. In cases where there is a need to achieve a rapid immune response, the second dose may be given 2 weeks after the first dose. The third dose is a booster, which should be given 5-12 months after the second vaccination.
(C.S. Larsen, Danish Society of Travel Medicine, S. Thybo, Danish Society for Infectious Disease, J. Kurtzhals, Danish Society for Clinical Microbiology, N.E. Møller, Danish College of General Practitioners, L.S. Vestergaard, Danish Society for Tropical Medicine and International Health, K. Gade, The Danish Paediatric Society, P. H. Andersen, A. H. Christiansen, Department of infectious Disease Epidemiology)

Summer holidays

Unless special circumstances arise, EPI-NEWS will not be published in Weeks 27-32. The editorial team wishes the readers of EPI-NEWS a pleasant summer.
(Department of Infectious Disease Epidemiology)

Link to previous issues of EPI-NEWS

24 June 2015