Pharmacists will soon be able to offer comprehensive travel consultations including prescribing travel-related vaccines. This session will serve as an introduction to the topic by taking you through the most common questions faced in community pharmacy.

1. POKING AROUND THE
WORLD OF IMMUNIZATIONS
CARMEN BELL, BSP | MEDSASK
PAS CONFERENCE
12 MAY 2018

2. DECLARATION OF CONFLICTS
• NONE

3. OBJECTIVES
Following this presentation the speaker hopes participants will be able to:
• understand general principles surrounding immunizations
• compare and contrast the different products available for the discussed vaccines
• identify reliable resources for travel recommendations and information

4. MEET THE KHANNAS
• Parmita
• Raj
• Aditi
• Gopesh

5. VACCINE RECOMMENDATIONS FOR
TRAVEL TO INDIA
• Routine
• Hepatitis A
• Hepatitis B
• Cholera
• Typhoid
• Japanese encephalitis
• Rabies
• Yellow fever

6. PARMITA, 44
MEDICAL CONDITIONS
• Crohn’s disease x 7 yrs
MEDICATIONS
• methotrexate 20 mg sc once weekly
• adalimumab 40 mg sc q14 days
IMMUNIZATION HISTORY
• routine childhood immunizations
• influenza Nov 3, 2017
• tetanus Jan 14, 2015
• pneumococcal Jan 14, 2015
PARMITA’S VACCINES:
Hep A, Hep B, Cholera/ETEC,
Typhoid

7. RAJ, 42
MEDICAL CONDITIONS
• none
MEDICATIONS
• none
IMMUNIZATION HISTORY
• routine childhood immunizations
• influenza Nov 3, 2017
• tetanus Jan 14 2015
• Twinrix doses: Jan 14, Jan 21 2015RAJ’S
VACCINES:
Hep A, Hep B,
Typhoid

8. ADITI, 13
MEDICAL CONDITIONS
• none
MEDICATIONS
• none
IMMUNIZATION HISTORY
• routine childhood immunizations to date
• influenza Nov 3, 2017
ADITI’S
VACCINES:
Hep A, Typhoid

9. GOPESH, 10
MEDICAL CONDITIONS
• asthma x 3 yrs
MEDICATIONS
• salbutamol MDI PRN
• Pulmicort Turbuhaler 100 mcg BID
IMMUNIZATION HISTORY
• routine childhood immunizations to date
• influenza Nov 3, 2017
GOPESH’S
VACCINES:
Hep A, Hep B, Typhoid

10. MEDICAL CONDITIONS AND TREATMENTS
ASSOCIATED WITH SEVERE IMMUNE
COMPROMISE
• MEDICATIONS
• HD corticosteroids
• alkylating agents (e.g. cyclophosphamide)
• antimetabolites (e.g. 6-MP, AZT, MTX)
• immunosuppression for transplants (e.g. calcineurin inhibitors, everolimus,
sirolimus, AZT, MMF)
• cancer chemotherapeutics
• TNF inhibitors (e.g. etanercept, adalimumab, certolizumab, golimumab,
infliximab)
https://wwwnc.cdc.gov/travel/yellowbook/2018/advising-travelers-with-specific-
needs/immunocompromised-travelers#4351

11. MEDICAL CONDITIONS WITHOUT
SIGNIFICANT IMMUNOLOGIC COMPROMISE
• Corticosteroids if:
• <20 mg PO OD or EOD prednisone or equivalent,
• LT, EOD with short-acting preps,
• physiologic doses,
• inhalers, topicals, IA, bursal, tendon,
• ≥ 1 month since on ≥ 20 mg pred or equiv x ≥ 2 weeks, or
• ≥ 2 weeks since been on ≥ 20 mg pred or equiv x < 2 weeks
https://wwwnc.cdc.gov/travel/yellowbook/2018/advising-travelers-with-specific-needs/immunocompromised-travelers#4351

12. IMMUNOSUPPRESSED TRAVELLERS
• INACTIVATED VACCINES
• can be safely given
• blunted response
• LIVE, ATTENUATED VACCINES
• AVOID

13. LIVE, ATTENUATED VACCINES
• herpes zoster (Zostavax)
• influenza (intranasal)
• MMR
• rotavirus
• typhoid (oral)
• varicella
• yellow fever

14. INACTIVATED VACCINES
• cholera & ETEC TD (Dukoral)
• diphtheria
• hepatitis (A, B, combined)
• herpes zoster (Shingrix)
• haemophilus influenza type B
• human papillomavirus
• influenza (IM)
• Japanese encephalitis
• meningococcal
• pertussis
• pneumococcal
• polio
• rabies
• tetanus
• typhoid (parenteral)

15. VACCINE RECOMMENDATIONS FOR
TRAVEL TO INDIA
• Routine
• Hepatitis A
• Hepatitis B
• Cholera
• Typhoid
• Japanese encephalitis
• Rabies
• Yellow fever

16. ROUTINE IMMUNIZATIONS IN ADULTS WHO
COMPLETED PRIMARY CHILDHOOD SERIES
https://www.ehealthsask.ca/services/manuals/Documents/sim-
chapter5.pdf

17. ROUTINE IMMUNIZATION SCHEDULE FOR
INFANTS, CHILDREN AND ADOLESCENTS
https://www.ehealthsask.ca/services/manuals/Documents/sim-
chapter5.pdf

18. VACCINE RECOMMENDATIONS FOR
TRAVEL TO INDIA
• Routine
• Hepatitis A
• Hepatitis B
• Cholera
• Typhoid
• Japanese encephalitis
• Rabies
• Yellow fever

19. HEPATITIS A / HEPATITIS B VACCINES
1st
Dose
2nd
Dose
3rd
Dose
4th
Dose
Standar
d
0 1 mo 6 mo
Rapid 0 7 days 21 days 12 mo
Labelled Twinrix Dose Schedules for Adults
1st Dose 2nd
Dose
3rd Dose
HAV 0 6-36*
mo
HBV 0 1 mo 6 mo
*Depending on product
Labelled Monovalent HAV and HBV Vaccine Schedules for
Adults

20. Hep A
Vaccine
Antigen per
Dose
Adul
t
Havrix 1440 1440 ELISA U
Twinrix 720 ELISA U
Avaxim 160 U
Vaqta 50 U
Ped
Havrix 720 720 ELISA U
Twinrix Jr 360 ELISA U
Avaxim Ped 80 U
Vaqta Ped 25 U
Hep B
Vaccine
HBsAg
per Dose
Adul
t
Engerix-B 20 mcg
Twinrix 20 mcg
Recombivax
HB
10 mcg
Ped
Engerix-B 10 mcg
Twinrix Jr 10 mcg
Recombivax
HB
5 mcg

21. HEPATITIS A / HEPATITIS B VACCINES
1st
Dose
2nd
Dose
3rd
Dose
4th
Dose
Standar
d
0 1 mo 6 mo
Rapid 0 7 days 21 days 12 mo
Labelled Twinrix Dose Schedules for Adults

22. HEPATITIS A / HEPATITIS B VACCINE
QUESTION
• Raj received 2 doses of Twinrix > 3 years ago. Do you restart
the series or start where left off?

23. GENERAL PRINCIPLE 1:
SERIES DELAY
In most cases, there is no
reason to restart a series if
there has been an extension
of recommended interval.

24. HEPATITIS A / HEPATITIS B VACCINES
1st
Dose
2nd
Dose
3rd
Dose
4th
Dose
Standar
d
0 1 mo 6 mo
Rapid 0 7 days 21 days 12 mo
Labelled Twinrix Dose Schedules for Adults

25. HEP A VACCINE SCHEDULE IN CHILDREN
Vaccine Antigen Schedule
Avaxim Pediatric 80 antigen units HA 0, 6-36
Havrix 720 Jr 720 ELISA units HA 0, 6-12
Vaqta Pediatric 25 units HA 0, 6-18

26. GENERAL PRINCIPLE 2:
INTERCHANGEABILITY
Ideally use same brand for all
doses of series; however, in
general if the original brand
cannot be used, another
brand can be substituted.

27. HEP A/ HEP B DOSING IN CHILDREN
Schedul
e
Age
(Year
s)
Vaccine (Dose HAV[U]/HBV
[mcg])
Schedule
(Months)
0 1 6 12
Standar
d
1-18 Twinrix Jr (360/10) x x x
Alterna
te
1-15 Twinrix (720/20) x x

28. NON-VACCINE PREVENTION
• Hepatitis A
• safe water and food precautions
• hygiene
• Hepatitis B
• avoid needles
• practice safe sex

29. VACCINE RECOMMENDATIONS FOR
TRAVEL TO INDIA
• Routine
• Hepatitis A
• Hepatitis B
• Cholera
• Typhoid
• Japanese encephalitis
• Rabies
• Yellow fever

30. CHOLERA / ETEC VACCINE
DUKORAL
• only product available for prevention of cholera
• also indicated for prevention of travellers’ diarrhea

31. Cholera Travellers’ Diarrhea
Pathogen Vibrio cholera O1
Enterotoxigenic E. coli
Enteroaggregative E.
coli
Campylobacter
Transmission
Ingestion of
contaminated food or
water
Ingestion of
contaminated food or
water
Risk of Infection
1 in 10 000 - 1 000
000
30-70% travellers
Symptoms
Watery, profuse
diarrhea. Many cases
are
asymptomatic/mild
Most mild: cramps,
diarrhea, abdominal
pain, vomiting
Sequelae
If severe (5-10%), can
lead to ARF,
Usually self-limited;
may develop
CHOLERA/ETEC VACCINE

32. TRAVELLERS’ DIARRHEA-
VACCINE PREVENTION
• Pooled results, protection against TD
• TD in placebo population: 37%
• TD in vaccinated population:35% [RR 0.94; 95% CI, 0.82-
1.09]

33. TRAVELLERS’ DIARRHEA- PREVENTION
• Dukoral not be routinely administered to Canadian travellers
as a means of preventing TD
• Benefits may outweigh risks in:
• brief illness cannot be tolerated
• ↑ susceptibility
• immunosuppressed due to hiv/other immunodeficiency states
• chronic illnesses ↑ risk serious consequences
- achlorhydria
- gastrectomy
- hx repeated severe
TD
- young children >
2yrs
e.g. CRF, CHF, IDDM,
IBD

34. NON-VACCINE PREVENTION
• Cholera/ETEC
• safe water and food precautions
• hygiene

35. DUKORAL DOSING - ADULTS
Indicatio
n
Primary Booster
Cholera 2 doses PO,
1-6 weeks
apart
1 dose PO, every 2 years
ETEC TD 1 dose PO, every 3 months

36. VACCINE RECOMMENDATIONS FOR
TRAVEL TO INDIA
• Routine
• Hepatitis A
• Hepatitis B
• Cholera
• Typhoid
• Japanese encephalitis
• Rabies
• Yellow fever

37. TYPHOID FEVER VACCINES
PRODUC
T
COMPOSITIO
N
ROA SCHEDULE ONSET RE-
IMMUNIZATION
INACTIVATED
Typhim
Vi
Typhoid IM 1 dose 14 days 3 years
Vivaxim
Typhoid +
HAV
IM 1 dose 14 days
3 years for
typhoid
LIVE, ATTENUATED
Vivotif Typhoid PO
Days 0, 2,
4, 6
7 days 7 years
X

38. NON-VACCINE PREVENTION
• Typhoid
• safe water and food precautions
• hygiene

39. TRAVELLERS’ DIARRHEA- PREVENTION
https://travel.gc.ca/travelling/health-safety/food-water

40. HEP A/HEP B VACCINES FOR THE KHANNAS
Family
Memb
er
Vaccine
Schedule
1st 2nd 3rd 4th
Parmit
a
Twinrix 0 7d 21d
12
mo
Raj Twinrix 0
5
mo
Aditi
Avaxim
Ped
0
6
mo
Gopes
h
Twinrix 0
6
mo

41. CHOLERA/ETEC VACCINE FOR PARMITA
DUKORAL
• 1ST dose now
• 2nd dose in 1 week

42. TYPHOID VACCINES FOR THE KHANNAS
Family
Membe
r
Vaccin
e
Schedule
1st 2nd 3rd 4th
Parmita
Typhim
Vi
0
Raj Vivotif 0 2d 4d 6d
Aditi Vivotif 0 2d 4d 6d
Gopesh Vivotif 0 2d 4d 6d

43. PARMITA’S SCHEDULE
Saturday May 12
• Twinrix, Typhim Vi, Dukoral
Saturday May 19
• Twinrix, Dukoral
Saturday Jun 2
• Twinrix
Sunday May 12, 2019
• Twinrix
RAJ’S SCHEDULE
Saturday May 12
• Twinrix, Vivotif
Monday May 14
• Vivotif
Wednesday May 16
• Vivotif
Friday May 18
• Vivotif
Friday Oct 12*
• Twinrix

44. GENERAL PRINCIPLE 3: TIMING
If two or more live parenteral
vaccines are required, they
need to be given on the same
day or ≥28 days apart.

45. ADITI’S SCHEDULE
Saturday May 12
• Avaxim Ped, Vivotif
Monday May 14
• Vivotif
Wednesday May 16
• Vivotif
Friday May 18
• Vivotif
Monday November 12*
• Avaxim Ped
GOPESH’S SCHEDULE
Saturday May 12
• Twinrix, Vivotif
Monday May 14
• Vivotif
Wednesday May 16
• Vivotif
Friday May 18
• Vivotif
Monday Nov 12*
• Twinrix

46. RESOURCES
Travel Medicine Recommendations and Information
• CDC Travellers’ Health
• https://wwwnc.cdc.gov/travel/destinations/list/
• IAMAT
• https://www.iamat.org/
• Gov of Canada (for the traveller)
• https://travel.gc.ca/
SK Immunization Schedules
• SK Immunization Manual (SIM)
• https://www.ehealthsask.ca/services/manuals/documents/sim-chapter5.pdf

47. RESOURCES
Vaccine Information
• Canadian Immunization Guidelines (CIG)
• https://www.canada.ca/en/public-health/services/canadian-immunization-
guide.html
• Center for Disease Control (CDC) Yellow Book
• https://wwwnc.cdc.gov/travel/yellowbook/2018/table-of-contents
• Committee to Advise on Tropical Medicine and Travel (CATMAT) TD Statement
• https://www.canada.ca/en/public-health/services/travel-health/about-
catmat/statement-travellers-diarrhea.html

48. HEPATITIS A VACCINE RECOMMENDATIONS
FOR INDIA
CDC
• RECOMMENDED FOR MOST TRAVELERS, INCLUDING THOSE WITH
"STANDARD" ITINERARIES AND ACCOMMODATIONS
IAMAT
• RECOMMENDED FOR ALL TRAVELLERS OVER 1 YEAR OF AGE

49. HEPATITIS B VACCINE RECOMMENDATIONS
FOR INDIA
CDC
• CONSIDER FOR MOST TRAVELERS; RECOMMENDED FOR THOSE WHO MIGHT BE
EXPOSED TO BLOOD OR OTHER BODY FLUIDS, HAVE SEXUAL CONTACT WITH THE
LOCAL POPULATION, OR BE EXPOSED THROUGH MEDICAL TREATMENT (E.G., FOR AN
ACCIDENT).
IAMAT
• IF YOU HAVE NOT BEEN VACCINATED, IT IS RECOMMENDED FOR TRAVELLERS ON
WORK ASSIGNMENTS IN THE HEALTHCARE FIELD SUCH AS PHYSICIANS, NURSES,
LABORATORY TECHNICIANS, DENTISTS, OR FOR THOSE WORKING IN CLOSE
CONTACT WITH THE LOCAL POPULATION SUCH AS TEACHERS, AID WORKERS, AND
MISSIONARIES.

50. CHOLERA VACCINE RECOMMENDATIONS FOR
INDIA
CDC
• ADULTS WHO ARE TRAVELING TO AREAS OF ACTIVE CHOLERA TRANSMISSION.
CHOLERA IS ASSUMED TO BE PRESENT IN INDIA. CHOLERA IS RARE IN TRAVELERS BUT
CAN BE SEVERE. CERTAIN FACTORS MAY INCREASE THE RISK OF GETTING CHOLERA
OR HAVING SEVERE DISEASE. AVOIDING UNSAFE FOOD AND WATER AND WASHING
YOUR HANDS CAN ALSO PREVENT CHOLERA.
IAMAT
• RECOMMENDED FOR LONG-TERM TRAVELLERS, HEALTHCARE AND HUMANITARIAN
WORKERS, AND IMMUNOSUPPRESSED TRAVELLERS GOING TO ENDEMIC AREAS, AS
WELL AS TRAVELLERS WITH REDUCED STOMACH ACID PRODUCTION.

51. TYPHOID FEVER VACCINE
RECOMMENDATIONS
FOR INDIA
CDC
• RECOMMENDED FOR MOST, ESPECIALLY IF STAYING WITH FRIENDS OR
RELATIVES, VISITING SMALLER CITIES, VILLAGES OR RURAL AREAS WHERE
EXPOSURE MIGHT OCCUR THROUGH FOOD OR WATER; OR PRONE TO
ADVENTUROUS EATING.
IAMAT
• ALL TRAVELLERS GOING TO ENDEMIC AREAS ARE AT RISK, ESPECIALLY LONG-
TERM TRAVELLERS, ADVENTURE TRAVELLERS, HUMANITARIAN WORKERS, AND
THOSE VISITING FRIENDS OR RELATIVES IN AREAS WITH POOR SANITATION.
NOTE THAT ORIGINAL INFECTION DOES NOT PROVIDE IMMUNITY TO
SUBSEQUENT INFECTIONS. (IAMAT)