Saturday, November 5, 2011

9 Steps to Knowing the Required and Recommended Travel Immunizations and Pills

Another major item on our 6-month to-do list was figuring out the necessary travel immunizations.  6 months ahead seems like a long time, but with over 20 countries we plan on visiting, there are bound to be immunizations that are required, or at least highly recommended – some vaccination series requiring at least a 6-month head start such as the hepatitis series. 

If we were 20-something backpackers, would we even care about vaccines?  Maybe, maybe not.  We certainly wouldn’t be as cautious about the possibility of acquiring a number of deadly diseases abroad, had we been 20 years younger!  Alas, the wisdom (or paranoia) that comes with age.  One main reason for taking extra precautions is Akiko’s tendency to attract mosquitos no matter where in the world, and her tendency to have allergic reactions to their bites.  Many of these diseases abroad are carried by mosquitos.  If any of them could be prevented by a few shots or pills, it seems a worthwhile endeavor.   

There are a couple of vaccinations that are required for entry into certain countries or to obtain a visa.  However, most of the time, the choice to be vaccinated is ultimately up to you.  Our advice is to at least research what is recommended by the Centers for Disease Control and Prevention, and even make an appointment with a Travel Immunization specialist for a consultation so you can make an educated decision by weighing the pros and cons.  The major ‘con’ being cost, of course, and specifically for malaria – the side effects of some of the drugs. 

The following outlines the steps that we took to research the immunizations for our upcoming travel sabbatical. 

Step 1: Prepare a list of potential destinations

Step 2: Go to the Centers for Disease Control andPrevention (CDC) website and locate the Traveler’s Health section.   Under “Vaccinations”, the site offers a checklist of all of the things you need to consider.  There are 3 categories of vaccinations: Routine, Required, and Recommended.  Routine vaccinations include the regular childhood immunizations and such.  At this time, the CDC lists 2 required vaccinations.  Yellow fever if traveling to certain countries in sub-Saharan Africa and tropical South America.  The meningococcal vaccination is required by the government of Saudi Arabia for annual travel during the Hajj.  Without a certificate of vaccination, entry into the country will be difficult.  Per the CDC, Recommended vaccinations “help protect travelers from illnesses present in other parts of the world and to prevent the importation of infectious diseases across international borders.”  Recommendations and requirements are also listed by country under “Destination."

Step 3: Go to a Passport and Visa Services website such as and research immunization requirements for visas by destination.  This may be different than what the CDC states.  For example, Brazil is listed by the CDC as a country where yellow fever risk is present, but a vaccination is not required for entry.  However, if your nationality requires a visa to enter Brazil, you will need a yellow fever vaccination as a visa requirement. 

Step 4: Gather your immunization history, such as your childhood immunization records.  Questions that may be asked are: the last date of your tetanus shot, whether you received a Measles/Mumps/Rubella vaccination and booster, whether you’ve had chickenpox or not, etc.

Step 5: Schedule a consultation with a travel immunization clinic or specialist.  After doing our homework through the CDC website, we chose to schedule a consultation due to the sheer number of potential destinations and amount of overwhelming information.  We currently reside in Kansas City.  Thanks to the power of the internet, we were quickly directed to the Travel and Immunization Clinic in Overland Park.  Due to the complexity of our travel itinerary, our consultation ended up being approximately 1.5 to 2 hours and cost ~$150 for the both of us.  The consultation was very thorough and informative.  It gave us the necessary expert information and ability to ask questions, in order to help make educated choices.  The consultant also gave us prescriptions, should we choose to fill them.  We were also made aware of other travel conditions that could be easily treated or prevented, such as altitude sickness and traveler’s diarrhea.  We also discussed types of mosquito repellants!  Overall, it was a highly productive meeting to have a consultant break down 300 pages of travel documents into 90 minutes.

Step 6: Based on the CDC, Visa, and Travel Immunization Clinic information, make decisions on what immunizations and prescriptions you want or need.  This is the hard part.  Here is a general breakdown of what we are faced with:

ROUTINE: Both childhood and adult routine immunizations given at appropriate stages of life, including: influenza, pneumococcal, chickenpox (or varicella), polio, MMR, Td or Tdap (tetanus, diphtheria, pertussis), etc.
  • TETANUS, DIPHTHERIA, PERTUSSIS (Tdap):  Our consultant recommended we have the Tdap (with pertussis) instead of the former  tetanus and diphtheria vaccine without the pertussis or whooping cough.  The Tdap has been around since 2005.  If we have received a tetanus shot since 2005, chances are, it is the Tdap instead of Td.   

RECOMMENDED:  In general, the recommendations were given to us by region: South America, Eastern Europe, and Asia.  Fortunately, many of the vaccines overlapped between South America and Asia, so here, we will list the recommended prophylaxis by item and not by region.
  • HEPATITIS A and B SERIES: Recommended for all areas we are traveling to.   Hepatitis A: series of 2 vaccines, now and 6 months later.  Hepatitis B: series of 3 vaccines, now, 1-month, and 6-months later.   Akiko is in healthcare so these have been kept up-to-date as part of her job.  Mike needed the hepatitis A and B series.  The first dose for both is started 6-months prior to the last dose, so it was good timing that we looked into immunizations when we did, since our departure date is about 6 months away.  To prevent further delay, Mike went ahead and had the Immunization Clinic give the first doses of both A and B.  At the clinic, the cost for each shot was $70-85. 
  • TYPHOID:  Recommended for the South American and Morocco regions we are traveling to.  One dose given at least 2 weeks before travel, costing ~$75.
  • YELLOW FEVER (see “Required” section)
  •  RABIES: Only recommended if there is significant risk of being in direct contact with mammals that carry rabies.  The consultant stated that if we are bitten by an animal, we should seek medical attention within the day.
  •  MALARIA:  Unfortunately, a well-known downside to taking malaria prophylaxis is its potential for bad side effects.  20% to 25% of users report having: of vivid dreams, nightmares, insomnia, nausea, diarrhea, dizziness, changes in sensation, psychosis, confusion, or seizures, etc.  So, we really have to think about the pros and cons for taking anti-malarial pills.  Is it worth it?  When Mike was in Thailand previously, he recalls many travelers having full intention of taking their pills, but deciding against it, once they experienced the side effects.  For some, they were so bad that they’d ‘rather have malaria.’  That’s the legend of the anti-malarial pills. We were given 3 options for malaria prophylaxis.
    1. Doxycycline, an inexpensive antibiotic, can be taken 2 days before traveling to a malarious area and continued daily during the entire time in that area, and 4 weeks after leaving the area.  PRO: inexpensive, hardly any side effects except photosensitivity.  CON: daily dose, increase risk for vaginal yeast infections, negates effect of oral contraceptives.
    2. Malarone, a newer anti-malarial drug, is started 2 days before entering a malaria risk area, and continued daily during the stay, and for 7 days after leaving the area.  PRO: low occurrence of side effects, only taken for 7 days after leaving risk-area.  CON: more expensive ($8-10/dose) than doxycycline which can add up, still a daily dose.
    3.  Mefloquine is the one with all of the side effects listed above.  It is taken once weekly, 1-2 weeks prior to arriving in a malaria risk area, then continued weekly during the entire time in that area, and for 4 weeks after leaving the area.  PRO: weekly instead of daily.  Cost is reasonable.  CON: side effects.
    • Should we take malaria prophylaxis?  That is the question of the century!  I am freaked out about the potential side effects.  Our consultant offers to write a prescription for 3 weeks (3 doses) of mefloquine so her clients can do a test-run at home.  If the trial doesn’t cause side effects, it’s a good indication that they can take mefloquine without any problems.  If cost were not a major issue, the best option is probably the malarone.  Besides the cost and side effects, the other question is whether or not we even need to take malaria pills.  Looking at the malarial maps of South America and Asia, it only becomes important if we travel into the jungles.  Main cities and areas of high elevation are typically free of malaria.  It is recommended that adventure travelers with a flexible itinerary or travel plans longer than 1-month, take malaria prophylaxis.  Chances are, we will go ahead and do a 3-week trial run with the mefloquine.  If that does not agree with us, then option B is to go with the malarone.  We will let you know how our mefloquine trial goes!  Stay tuned!
  •  JAPANESE ENCEPHALITIS:   Recommended in Asia.  The mortality rate of those infected with Japanese encephalitis at 25% makes me want to get this vaccination.  It is a series of 2 shots, now and 28 days later.  The last dose needs to be given at least 1-week prior to departure.  The MAJOR con is its cost.  It is extremely expensive at $260/dose x 2 doses, so it costs ~$500 per person.
  • TRAVELER’S DIARRHEA:  Although we expect this to be a common place occurrence, some precautions should be taken to avoid this pesky problem.  To treat, Imodium and Pepto are always good standbys.   If the over-the-counters don’t do it, our consultant has written 2 prescriptions for antibiotics.  She expects these to work within 3 days.  If not, it’s probably something other than a bug causing traveler’s diarrhea and should be looked into further. 
    1. Cipro 500mg twice daily (except in Thailand, as strains are resistant to Cipro)
    2. Azithromycin 500 mg one day (for Thailand)
  • ALTITUDE SICKNESS:  We will be in some high altitude, especially in Ecuador and Peru. As a child, I remember getting so sick with altitude sickness in Colorado; I never want to experience that feeling again.  Our consultant wrote a prescription for acetazolamide to be taken twice a day, beginning 24 hours before ascent and for 2-3 days after arriving at high altitude.  It’s supposed to lessen the symptoms by increasing the breathing rate and helping with acclimatization.

REQUIRED: Official certification of Yellow Fever vaccination is required for entry into the South American countries we intend to visit, such as Ecuador and Uruguay.  In addition, if we decide to go to Brazil, a yellow fever vaccine will be required as both of our passports (U.S. and Japan) need a visa to enter Brazil.  As explained previously, part of the visa application requires proof of yellow fever vaccination.  A one-time vaccine is ~$115 and should be obtained at least 10 days prior to departure, and lasts 10 years.

Step 7: Research if medical insurance and prescription plans will cover part of the cost.  Depending on your existing health insurance and prescription plan, you may be able to get part of the cost covered.  Although our consultant didn’t think it was possible, it’s worth looking into.  For example, the cost of the antibiotics – if prescribed by an in-network (aka. Primary care physician) – may be covered.   The primary care physician may also be able to obtain some of the vaccinations and administer them for the cost of a co-pay.  If a plan is able to cover the cost of the Japanese encephalitis vaccine, that alone would be a huge cost savings.  The yellow fever immunization is limited to an approved vaccination clinic.  That information can be found on the CDC website.   These are areas we are continuing to research before we decide to spend a lot of money on immunizations!  Again, stay tuned and will report back on what we find out.

Step 8: Map out a schedule on when immunizations need to be completed.  This will also help spread out the cost of some of the immunizations.   After all is said and done, if insurance does not cover any of this, we should expect all the prophylaxis to cost upwards of $1,300 per person.  This includes the vaccines for typhoid, yellow fever, Japanese encephalitis series, hepatitis A and B series, malaria pills, and antibiotics.  Not to mention the office visit costs to get vaccinated.  So, depending on when vaccines are due and when the prescriptions can be filled, a pre-determined schedule where we do one vaccine each month, or fill one prescription each month, may help spread the cost.

Step 9: Finally, bite the bullet.  Just go get immunized and/or fill the prescriptions!