A Christmas holiday (and the vaccinations you'd need)
Our travel update this month takes a light-hearted look at the perils of last minute travellers – but still reminds us of the key issues and essential considerations
Janet and John and their twin sons Jack and Jacob decided last minute to book a two week Christmas break in a luxury hotel in Goa, determined to enjoy the sun and sand, away from the bustle of the UK, where the weather was cold and the daily news depressing! The 19 year-old twins have decided to start their gap year by staying on in India and backpacking around the country for 6 months as they’ve never travelled before. They attend my travel clinic and here is the advice I would give after a travel risk assessment!
What vaccines are needed?
It would be wise to check that all travellers are up to date for tetanus, hepatitis A and typhoid. The boys’ tetanus should be current as they have had a school booster but they would need hepatitis A and typhoid. The parents need a Revaxis update and a hepatitis A booster as they had a first dose 20 years ago. The Green Book says to give a first dose of hepatitis A then boost 6-12 months later, giving protection for 25 years from the booster dose – you don’t need to restart a course. Hepatitis A vaccine is 25 years old next year, so let’s hope one of my wishes on Santa’s list is granted and that the Green Book is updated so we know what to do in the future! Both injectable vaccines for typhoid (Typhim and Typherix) and the oral vaccine Vivotif are licensed for three years – one of these vaccines will be needed for all travellers.
Rabies is a high risk in India and advice needs to be given on management of a potential exposure. The parents say it’s too expensive to have the vaccine, but after I’ve impressed upon them the gravity of the risk, especially for the twins for their trip, they decide to pay for vaccine as their Christmas present!1 Hepatitis B would be a good idea especially for the boys. My local CCG tells us we can’t use Twinrix but I know this not to be the case if I decide it’s clinically indicated.2
However, I’m also challenged as we have no PGDs for any NHS travel vaccines so I’ll have to organise a PSD. Another wish to Santa is that this issue gets resolved next year, it would make my clinical care so much easier.3 If I don’t give hep B this way I have time to give them a monovalent vaccine on a 0, 7 and 21 day schedule (Engerix B) or start them on the revised schedule of 0, 1 and 2 months only.4 If they are only able to get two doses in they could look at the travel clinics abroad on www.istm.org for their third dose while away. Cholera might be a reasonable option for the twins too and now this is an NHS provision I can offer it to them. And lastly I’d discuss the risk of Japanese encephalitis especially if going to rural areas and tell them there is also a day 0 and 7 schedule for the 18-65 year old age group.
Time is running out – so I say I’ll certainly need to see the twins again for follow up vaccines and at that point I’ll discuss issues such as safety and security, sexual health advice, local laws and customs – for example drug usage in India carries a sentence from 6 months to 6 years and homosexual practice can carry a sentence of 14 years to life.5
I’ll also have to cover bite prevention because they probably won’t need malaria tablets but will need to be aware of risks and prompt diagnosis of mosquito-borne diseases, including dengue and chikungunya – and with the spread of Zika virus, that may be another threat in 2017. A DEET-containing product (up to 50%) could be a stocking present too!
Lastly I’ll impress upon them all to do some self-directed learning on health risks,6,7 and on a future occasion to plan well in advance and come and see me in good time – that’s if my NHS surgery is still standing!
RESOURCES
1. janechiodini.co.uk/news/help/rabies/
2. bma.org.uk/advice/employment/gp-practices/service-provision/hepatitis-b-immunisations
3. janechiodini.blogspot.co.uk/2016/09/prescribing-for-travel-vaccines.html
4. janechiodini.blogspot.co.uk/2016/07/heptitis-b.html
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