Travel and Vaccine

Posted by Dr. Tan Kok Kuan on Oct 18, 2010 in GP Services, Infectious Disease, Men's Health, Women's Health | 2 comments

Travel and Vaccination Clinic

Mandatory Vaccines

Your Travel Medical Kit

Adult Vaccine Schedules

Child’s Vaccine Schedules

Vaccinations for Children

National Childhood Immunisation Schedule (wef Jan 2008)

Find Out More About Yellow Fever

ANNEX 1
Countries1 with risk of yellow fever transmission2 and countries requiring yellow fever vaccination

ANNEX 2
International Health Regulations

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Travel and Vaccination Clinic

‘International travel can pose various risks to health, depending on the characteristics of both the traveller and the travel.’ WHO International travel and health report – 2008 Edition

Vaccination is a very safe and effective way of preventing certain infectious diseases.

Plan before you travel. Discuss your itinerary with our doctors and let us advice you on your vaccine requirements. See us at least 4 weeks before your travel date to allow sufficient time for optimal immunization schedules to be completed.

Mandatory Vaccines

Yellow Fever Vaccine

Mandatory for travelers going to or coming from certain countries in Sub-Saharan Africa and South America.

Yellow Fever Vaccination Certificate

Source: Singapore Immigration and Checkpoints Authority Website.

For entry into Singapore, a valid yellow fever vaccination certificate is required from travellers (over one year of age) who, within the preceding six days have been in or have passed through any country endemic for yellow fever.

The International Certificate of Vaccination for yellow fever is considered valid 10 days after vaccination. The certificate is for a period of 10 years.

Countries endemic for yellow fever are as follows:

Angola	Argentina	Benin
Bolivia	Brazil	Burkina Faso
Burundi	Cameroon	Central African Republic
Chad	Colombia	Congo
Cote d’lvoire	Democratic Republic of Congo	Ecuador
Equatorial Guinea	Ethiopia	French Guyana
Gabon	Gambia	Ghana
Guinea	Guinea-Bissau	Guyana
Kenya	Liberia	Mali
Mauritania	Niger	Nigeria
Panama	Paraguay	Peru
Rwanda	Senegal	Sierra Leone
Sudan	Suriname	Togo
Trinidad & Tobago	Uganda	Venezuela

Meningococcus Vaccine & Polio Vaccine

Mandatory for pilgrims to Saudi Arabia.

Your Travel Medical Kit

A medical kit is an absolute necessity for international travelers. The contents of the kit may vary depending on your specific needs, destination, quality of accommodation and assess to quality medical care.

Please remember that self-medication is not a substitute for proper medical care. Please seek medical attention as soon as possible especially if your symptoms do not improve.

These are some medicines that you might find useful to have in your travel medical kit. Recommended doses are for healthy adults. Please consult us for dosing in children, elderly and persons with chronic illnesses. Please do not take any drug that you have a known allergy to.

• For fever and pain.
• Take 2 tablets 4 times a day.
• Do not exceed 8 tablets a day.

• For gastritis.
• Take 2 tablets 4 times a day.
• Do not exceed 12 tablets a day.
• May cause constipation or diarrhea.

• For diarrhea.
• Take 1 tablet 3 times a day.

• For replacing essential salts and fluids in the event of severe vomiting or diarrhea.
• Dissolve 1 sachet in clean water and consume hourly.

• For blocked, stuffy or runny nose.
• Take 1 tablet every morning.

• For vomiting and motion sickness.
• Take 1 tablet 3 times a day.
• To prevent motion sickness, take 1 tablet at least 30 minutes before travel.

• This is a broad spectrum anti-biotic that is useful for traveler’s diarrhea, dysentery, cholera, urine tract infection and skin and soft tissue infections.
• Take 2 tablets 2 times a day for 5 days.
• Stop if you develop a rash.

• Take 1 tablet one day before departure.
• Take 1 tablet once every day while you are traveling.
• Take 1 tablet everyday for a week after you have returned.

• Attach the patch onto your skin or on clothes.
• Each patch lasts up to 12 hours.

• Apply to sun exposed areas concentrating on the face and neck.
• Avoid contact with eyes.
• Re-apply regularly especially if you are sweating profusely or are going swimming.

• Dissolve 1 sachet in clean water and consume 3 times a day.

• Wash wounds under clean running water.
• Apply Antiseptic Ointment and then cover with a clean gauze.
• Wrap the area with a clean bandage and tape the bandage securely.
• See a doctor as soon as possible.

Adult Vaccine Schedules

Please refer to the Child’s Vaccine schedule for ages below the age stated under each vaccine

Vaccine	Against	Sequence	Duration of Protection
Twinrix 16 years old and above	Hepatitis A+B	Rapid1st shot 2nd shot – day 7 3rd shot – day 21 4th shot- 1 yearStandard1st shot 2nd shot – month 1 3rd shot – month 6	10 years10 years
Engerix-B Adult 20 years old and above	Hepatitis B	Rapid1st shot 2nd shot – day 7 3rd shot – day 21 4th shot- 1 yearStandard1st shot 2nd shot – month 1 3rd shot – month 6	10 years10 years
Havrix Adult 19 years old and above	Hepatitis A	1st shot 2nd shot – month 6	10 years
Dukoral 7 years old and above	Cholera and E. Coli (Traveller’s Diarrhea)	1st drink 2nd drink – day 7	2 years
Typherix 2 years old and above	Salmonella (Typhoid Fever)	1 shot only	3 years
Fluarix 9 years old and above	Influenza	1 shot only	1 year
Boostrix 4 years old and above	Tetanus, Diphtheria and Pertussis	1 shot only	10 years
Mencevax 2 years old and above	Meningococcus NB. For travelers to Middle East or community living (eg dormitory)	1 shot only	10 years
Varilrix 13 years old and above	Varicella (Chickenpox)	1st shot 2nd shot – week 6	Life
Japanese Encephalitis 3 years old and above	Japanese Encephalitis NB. For travelers to rural/jungle Southeast Asia	1st shot 2nd shot – day 7 3rd shot – day 28	4 years
Stamaril 6 months old and above	Yellow Fever NB. For travelers to South America or Sub-Saharan Africa	1 shot only	10 years
Malarone 40 kg and above of body weight	Malaria	Pills to be taken everyday starting 1 day before entering and stopping 7 days after leaving the endemic area	As long as taking the pills
Cervarix	HPV Virus (Cervical Cancer)	1st shot 2nd shot – month 1 3rd shot – month 6	At least 5.5 years Need for booster is being studied

Child’s Vaccine Schedules

Please refer to the Adult’s Vaccine schedule for ages above the age stated under each vaccine

Vaccine	Against	Sequence	Duration of Protection
Twinrix 1 to 15 years old	Hepatitis A+B	1st shot 2nd shot – month 6	10 years
Engerix-B Ped 0 to 19 years old	Hepatitis B	1st shot 2nd shot – month 1 3rd shot – month 6	10 years
Havrix Junior 1 to 18 years old	Hepatitis A	1st shot 2nd shot – month 6	10 years
Dukoral 2 to 6 years old	Cholera and E. Coli (Traveller’s Diarrhea)	1st drink 2nd drink – day 7 3rd drink – day 14	2 years
Typherix 2 years old and above	Salmonella (Typhoid Fever)	1 shot only	3 years
Fluarix 6 months to 8 years old	Influenza	1st shot 2nd shot – week 4	1 year
Boostrix 4 years old and above	Tetanus, Diphtheria and Pertussis	1 shot only	10 years
Mencevax 2 years old and above	Meningococcus NB. For travelers to Middle East or community living (eg dormitory)	1 shot only	10 years
Varilrix 1 to 12 years old	Varicella (Chickenpox)	1 shot only	Life
Japanese Encephalitis (reduced dose) 0 to 3 years old	Japanese Encephalitis NB. For travelers to rural/jungle Southeast Asia	1st shot 2nd shot – day 7 3rd shot – day 28	4 years
Stamaril 6 months old and above	Yellow Fever NB. For travelers to South America or Sub-Saharan Africa	1 shot only	10 years
Malarone 11 to 20kg – ¼ pill 21 to 30kg – ½ pill 31 to 40 kg – ¾ pill	Malaria	Pills to be taken everyday starting 1 day before entering and stopping 7 days after leaving the endemic area	As long as taking the pills

Vaccinations for Children

Vaccinations serve to prevent illness and disease by stimulating the production of antibodies in us. This is especially useful for illnesses with no good cure, or for those which tend to spread very rapidly amongst our community.

Successful mass vaccination programmes can benefit even those in the community who fail to get vaccinated by reducing the incidence of the illness within the community.

In Singapore, measles and diphtheria vaccinations are required BY LAW. While the other vaccines on the National Immunization Programme ( NIP ) are not compulsory, parents and caretakers are strongly encouraged to adhere to the recommended vaccinations for your child’s own protection. Singapore’s National Childhood Immunization schedule can be found here.

While not officially incorporated into the NIP, we would like to encourage parents to consider providing the following vaccines for their children:

• Rotavirus vaccine ( oral ) at 2 months and 4 months of age.
• Seasonal Influenza every year from 6 months of age to 2 years of age.
• Chicken Pox ( Varicella ) vaccine, given after 12 months of age. To reduce the number of injections given to your child, this can be combined with the MMR vaccine at 13 months
• Human Papillomavirus ( HPV ) vaccine which reduces the risk of Cervical Cancer, for girls at 9 to 10 years of age.

Although mild coughs and colds should not stop you from bringing your child for scheduled vaccinations, do inform the clinic and the doctor if your child is feeling unwell.

In addition, please highlight to the doctor if your child has/had:

• Fever, with or without other symptoms
• Allergic reactions to any previous vaccines or medications, or egg allergy.
• A history of other medical problems, such as cancer, leukemia, SLE or uncontrolled epilepsy.
• Missed any previous doses of vaccines, which may require ‘catch-up’ vaccinations.

After the vaccinations, some of the common reactions include:

• Redness, soreness or induration ( hardening ) around the injection site
• Fever
• Irritability
• Mild rashes

If you child experiences these symptoms, using a topical cream to sooth the injection site or some Paracetemol syrup to control the fever may be useful. In very rare circumstances, if your child throws a fit ( seizure ) or becomes extremely lethargic or if  the fever does not settle within 1 to 2 days, please bring your child to the nearest clinic or hospital for review.

Some of the National Immunization schedules for other parts of the world can be found at:

• Australia: http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/nips2
• Japan: http://idsc.nih.go.jp/vaccine/dschedule/ImmEN-05rev.pdf
• UK: http://www.nhs.uk/Planners/vaccinations/Pages/Vaccinationchecklist.aspx
• USA: http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm

National Childhood Immunisation Schedule (wef Jan 2008)

Age	Standard Schedule	Common Schedule	Alternative Schedule
At Birth	BCG Hepatitis B	BCG Hepatitis B	BCG Hepatitis B
1 mth	Hepatitis B	Hepatitis B
2 mth			6 in 1 (DPT, HiB, Polio, HepB)
3 mth	DPT Polio	5 in 1 (DPT, HiB, Polio)
4 mth	DPT Polio	5 in 1 (DPT, HiB, Polio)	6 in 1 (DPT, HiB, Polio, HepB)
5 mth	DPT Polio	5 in 1 (DPT, HiB, Polio)
6 mth	Hepatitis B	Hepatitis B	6 in 1 (DPT, HiB, Polio, HepB)
1-2 yrs	MMR	15 mth – MMR	15 mth – MMR
18 mth	DPT Polio	5 in 1 DPT, HiB, Polio	5 in 1 DPT, HiB, Polio
6-7 yrs	MMR Polio	MMR Polio	MMR Polio
10-11 yrs	DT Polio	DT Polio	DT Polio

Optional Vaccines
1. Pneumococcus
2. Haemophilus Influenza
3. Rotavirus 4. Menigococcal
5. Varicella
6. Hepatitis A

NB
1. All above schedules are approved and accepted by the Ministry of Health (MOH).
2. Standard Schedule is the schedule as set out by MOH.
3. Common Schedule is the schedule that the majority of children are on.
4. Alternative Schedule is gaining popularity due to the fewer number of injections.

Find Out More About Yellow Fever

Yellow fever is a serious and frequently fatal viral disease transmitted by mosquitoes.

Vaccination against yellow fever is required from any person who is going to or coming from or has passed through any country which is wholly or partly endemic for yellow fever. (Please see below for the list of countries)

Yellow fever vaccination can only be given at designated Yellow Fever Vaccination Centers and travelers will be issued with a WHO International Certificate of Vaccination. Robertson Medical Practice is an approved Vaccination Center for Yellow Fever.

Certain people are not fit to receive the Yellow Fever Vaccine. These include pregnant mothers, children under 6 months of age, travelers who are allergic to egg and travelers with a compromised immune system. Such travelers need to obtain a medical waiver prior to travel.

Yellow fever vaccine generally has few side effects; fewer than 5% of vaccinees develop mild headache, muscle pain, or other minor symptoms 5 to 10 days after vaccination. A single dose confers immunity for 10 years.

ANNEX 1
Countries¹ with risk of yellow fever transmission² and countries requiring yellow fever vaccination

Country	Countries with risk of yellow fever transmission	Countries requiring yellow fever vaccination for travellers coming from countries with risk of yellow fever transmission	Countries requiring yellow fever vaccination for travellers from all countries
Afghanistan		Yes
Albania		Yes
Algeria		Yes
Angola	Yes		Yes
Anguilla		Yes
Antigua and Barbuda		Yes
Argentina	Yes
Australia		Yes
Bahamas		Yes
Bahrain		Yes
Bangladesh		Yes
Barbados		Yes
Belize		Yes
Benin	Yes		Yes
Bhutan		Yes
Bolivia	Yes	Yes
Botswana		Yes
Brazil	Yes	Yes
Brunei Darussalam		Yes
Burkina Faso	Yes		Yes
Burundi	Yes		Yes
Cambodia		Yes
Cameroon	Yes		Yes
Cape Verde		Yes
Central African
Republic	Yes		Yes
Chad	Yes	Yes
China		Yes
Christmas Island		Yes
Colombia	Yes
Congo	Yes		Yes
Congo, Democratic
Republic of	Yes		Yes
Costa Rica		Yes
Côte d’Ivoire	Yes		Yes
Djibouti		Yes
Dominica		Yes
Ecuador	Yes	Yes
Egypt		Yes
El Salvador		Yes
Equatorial Guinea	Yes	Yes
Eritrea		Yes
Ethiopia	Yes	Yes
Fiji		Yes
French Guyana	Yes		Yes
French Polynesia		Yes
Gabon	Yes		Yes
Gambia	Yes	Yes
Ghana	Yes		Yes
Grenada		Yes
Guadeloupe		Yes
Guatemala		Yes
Guinea	Yes	Yes
Guinea-Bissau	Yes	Yes
Guyana	Yes	Yes
Haiti		Yes
Honduras		Yes
India		Yes
Indonesia		Yes
Iran (Islamic Republic
of)		Yes
Iraq		Yes
Jamaica		Yes
Jordan		Yes
Kazakhstan		Yes
Kenya	Yes	Yes
Kiribati		Yes
Korea, Democratic
People’s Republic of		Yes
Lao People’s
Democratic Republic		Yes
Lebanon		Yes
Lesotho		Yes
Liberia	Yes		Yes
Libyan Arab
Jamahiriya		Yes
Madagascar		Yes
Malawi		Yes
Malaysia		Yes
Maldives		Yes
Mali	Yes		Yes
Malta		Yes
Mauritania	Yes	Yes
Mauritius		Yes
Montserrat		Yes
Mozambique		Yes
Myanmar		Yes
Namibia		Yes
Nauru		Yes
Nepal		Yes
Netherlands Antilles		Yes
New Caledonia		Yes
Nicaragua		Yes
Niger	Yes		Yes
Nigeria	Yes	Yes
Niue		Yes
Oman		Yes
Pakistan		Yes
Palau		Yes
Panama	Yes	Yes
Papua New Guinea		Yes
Paraguay	Yes	Yes
Peru	Yes
Philippines		Yes
Pitcairn Islands		Yes
Portugal		Yes
Reunion		Yes
Rwanda	Yes		Yes
Saint Helena		Yes
Saint Kitts and Nevis		Yes
Saint Lucia		Yes
Saint Vincent and
the Grenadines		Yes
Samoa		Yes
Sao Tome and
Principe	Yes		Yes
Saudi Arabia		Yes
Senegal	Yes	Yes
Seychelles		Yes
Sierra Leone	Yes		Yes
Singapore		Yes
Solomon Islands		Yes
Somalia	Yes	Yes
South Africa		Yes
Sri Lanka		Yes
Sudan	Yes	Yes
Suriname	Yes	Yes
Swaziland		Yes
Syrian Arab Republic		Yes
Thailand		Yes
Timor Leste		Yes
Togo	Yes		Yes
Tonga		Yes
Trinidad and Tobago	Yes	Yes
Tunisia		Yes
Uganda	Yes	Yes
United Republic
of Tanzania	Yes	Yes
Uruguay		Yes
Venezuela	Yes
Viet Nam		Yes
Yemen		Yes
Zimbabwe		Yes

¹ For the purpose of this publication, the term “country” covers countries, territories and areas.
² Risk of yellow fever transmission is defined as either yellow fever has been reported currently or in the past plus presence of vectors and animal reservoirs that create a potential risk of infection and transmission.
* Either yellow fever has been reported or disease previously reported plus the presence of vectors and animal reservoirs create a potential risk of infection and transmission.

ANNEX 2
International Health Regulations

The spread of infectious diseases from one part of the world to another is not a new phenomenon, but in recent decades a number of factors have underscored the fact that infectious disease events in one country may be of potential concern for the entire world. These factors include: increased population movements, whether through tourism or migration or as a result of disasters; growth in international trade in food; biological, social and environmental changes linked with urbanization; deforestation; alterations in climate; and changes in methods of food processing, distribution and consumer habits. Consequently, the need for international cooperation in order to safeguard global health has become increasingly important.

The International Health Regulations (IHR), adopted in 1969, amended in 1973 and 1981¹ and completely revised in 2005² provide the legal framework for such international cooperation. The stated purpose of the Regulations is to prevent, protect against, control, and provide public health responses to, the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.

Their main objectives are to ensure: (1) the appropriate application of routine, preventive measures (e.g. at ports and airports) and the use by all countries of internationally approved documents (e.g. vaccination certifi cates); (2) the notifi cation to WHO of all events that may constitute a public health emergency of international concern; and (3) the implementation of any temporary recommendations should the WHO Director-General have determined that such an emergency is occurring. In addition to its new notifi cation and reporting requirements, the IHR (2005) focus on the provision of support for affected states and the avoidance of stigma and unnecessary negative impact on international travel and trade.

¹ International Health Regulations (1969): third annotated edition. Geneva, World Health Organization, 1983.
² International Health Regulations (2005): http://www.who.int/ihr

The IHR (2005) entered into force on 15 June 2007. They take account of the present volume of international traffi c and trade and of current trends in the epidemiology of infectious diseases, as well as other emerging and re-emerging health risks.

The two specifi c applications of the IHR (2005) most likely to be encountered by travellers are the yellow fever vaccination requirements imposed by certain countries (see Chapter 6; country list) and the disinsection of aircraft to prevent importation of disease vectors (see Chapter 2).³

The vaccination requirements and the disinsection measures are intended to help prevent the international spread of diseases and, in the context of international travel, to do so with the minimum inconvenience to the traveller. This requires international collaboration in the detection and reduction or elimination of the sources of infection.

Ultimately, the risk of an infectious agent becoming established in a country is determined by the quality of the national epidemiological and public health capacities and, in particular, by day-to-day national health and disease surveillance activities and the ability to detect and implement prompt and effective control measures. The requirements for states to establish certain minimum capacities in this regard will, when implemented, provide increased security for visitors as well as for the resident population of the country.

³ Hardiman M., Wilder-Smith A. The revised international health regulations and their relevance to the travel medicine practitioner. Journal of Travel Medicine, 2007,
14(3):141—144.

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About Dr. Tan
Dr. Tan graduated from the National University of Singapore in 2001. His residency was in the two largest public hospitals in Singapore; Tan Tock Seng Hospital and Singapore General Hospital.

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