Far-Off Adventures: Vaccinations And Overseas Travel

By Dr. Sherri Tenpenny DO
Issue 120, September/October 2003 http://www.mothering.com/articles/growing_child/vaccines/overseas.html

The time has finally arrived for the highly anticipated trip out of the country. The plans began long ago: airplane tickets, hotel reservations, rental car, sightseeing plans. The bags are being pulled from the attic to be packed, and the excitement mounts with each passing day. Everything is a go. But wait-what about vaccines? Is this one more preparation that needs to be added to the "To Do" list? Traveling out of the country can feel like a venture to another planet. Pictures of exotic destinations coupled with new, curious foods dance off the pages of the travel brochures. Anticipating the unexpected can be a challenge for even the most seasoned traveler. However, traveling with children adds an extra dimension to the anxiety-the thought of your child becoming ill in a foreign country is extremely frightening. Your doctor is recommending a variety of vaccines. Are they necessary? How do you evaluate the risks?

VACCINES IN THE US
Currently, eight different vaccines are recommended for children in the US: Hepatitis B, polio, diphtheria-tetanus-pertussis (DTaP), measles-mumps-rubella (MMR), chickenpox, HiB, Prevnar, and, most recently, an annual influenza vaccine. (HiB and Prevnar are given to prevent bacterial infections caused by H. influenza and Strep. pneumonia, respectively. Some of these vaccines are also recommended for international travel. But are the risks of getting these diseases any greater when traveling than they are at home? Let's take a closer look at the more worrisome infections that might be encountered while traveling abroad.

Hepatitis B is a viral infection that is spread through contact with blood. In the US, Hepatitis B is primarily found in adults, and is spread through intimate contact or through sharing needles used with illicit drugs. Hepatitis B is more common in the general population in East and Southeast Asia and in Sub-Saharan Africa. Even in these areas, the risk for contracting the infection is very low, but if you do, Hepatitis B can make you very ill. Still, the risk of long-term complications is much less than we are generally led to believe. More than 95 percent of those who contract Hepatitis B fully recover, and an infection will result in lifetime immunity for that person. Unless you plan to spend extended periods in close contact with infected persons, the risk of contracting Hepatitis B while traveling is nearly the same as in the US.

Polio, or poliomyelitis, is an infectious disease caused by a virus that attacks the nervous system. The disease is seen primarily in children under five years of age; the initial symptoms include fever, fatigue, headache, vomiting, stiffness in the neck, and pain in the limbs. Paralysis results in approximately 1 to 2 percent of children who contract the viral infection, though the vast majority recovers completely from this paralysis. A few, however, go on to have permanent, lifetime disability.

While polio was once common throughout the undeveloped world, today only seven countries continue to have polio-endemic rural areas: Afghanistan, Egypt, India, Niger, Nigeria, Pakistan, and Somalia. The disease is no longer a threat and will soon be completely eradicated. Although the Western Hemisphere was certified "polio-free" by the World Health Organization in 1994 and there have been no cases of wild polio in this region since 1991, the US vaccination schedule still includes four doses of the polio vaccine. 1 The reason given for this is that, until polio is eradicated entirely, the risk of reintroducing polio into this country is "only a plane ride away." However, an examination of the data reveals only six cases of imported polio documented between 1980 and 1998, the last in New York City in 1993.2 The risk for contracting polio is negligible, even at home.

Tetanus is an acute, spastic paralytic illness caused by a toxin released from the bacterium Clostridium tetani. The bacterium is found in soils and animal feces throughout the world.

There are several forms of tetanus: neonatal, cephalic, localized, and generalized. In infants, neonatal tetanus is the most common and most deadly. However, the vast majority of these cases occur following childbirth, as a result of using nonsterile equipment to cut the umbilical cord. Cephalic tetanus, the least common, causes muscle spasms in the face, leading to the classic case of "lockjaw." Localized tetanus is recurring muscle contraction near the original site of the infection; recovery can take many weeks.

Generalized tetanus, the most common, is the slowest to develop. The disease is characterized by a gradual increase in skeletal muscle rigidity and muscle spasm. Deep, dirty punctures are at greatest risk for developing the infection because the bacterium thrives only in areas that are deprived of oxygen.

The symptoms of any type of tetanus infection develop slowly. The incubation period-the time between when the injury occurred and the development of a full-blown infection-can range from five days to two months, but the initial symptoms most commonly begin to appear within 14 days. Early symptoms of infection include restlessness, headache, and localized itching or pain at the site of the injury. It is generally believed that tetanus is a highly fatal disease, but an examination of the data proves otherwise. In the most recent evaluation of tetanus data by the CDC, it was found that the death rate associated with tetanus was 11 percent, nowhere near the "nearly 100 percent fatal" so widely believed.3 It is also commonly accepted that a tetanus shot will prevent the onset of tetanus. Again, the data show that, even if a person has three or more tetanus shots, it is still possible to contract the disease.4 A recent issue of the British Medical Journal reported that tetanus can occur "despite adequate immunization and [adequate] levels of neutralizing antibodies."5

Frequent tetanus shots may give a false sense of security; the best way to protect from the disease is to thoroughly clean the wound with copious amounts of warm, soapy water, and to encourage the injury to bleed profusely. Prophylactic antibiotics, such as metronidazole and penicillin, are effective against the bacterium that releases tetanus toxin into the bloodstream. It might be a good idea to carry these with you in your travel kit if you are going to off-beat places. If you have access to medical care when traveling, a shot of tetanus immune globulin (TIG) can be given for severe injuries. Equivalent to a "dose of antibodies," TIG continues to circulate in the body for up to three weeks, and can effectively neutralize any toxin that might be released by the tetanus-causing bacterium.

WHAT ABOUT EXOTIC DISEASES?
When traveling overseas, it is possible to encounter some illnesses not generally seen in the US. The Centers for Disease Control lists the following infections as possible concerns for anyone traveling to any destination around the globe:6

Typhoid Fever, an acute, febrile illness caused by the bacterium Salmonella typhi, is characterized by fever, headache, and enlargement of the spleen. The greatest risk is for travelers to the Indian subcontinent and to developing countries in Asia, Africa, and Central and South America who will have prolonged exposure to potentially contaminated food and drink.

Yellow Fever is a mosquito-borne viral illness that can vary in severity from a flu-like syndrome to severe hepatitis and hemorrhagic fever. The disease occurs only in sub-Saharan Africa and rural, tropical South America.

Japanese Encephalitis, another mosquito-borne viral infection, is found throughout Asia, particularly in rural or agricultural areas of the temperate regions of China, Japan, Korea, and eastern Russia. The risk to short-term travelers and those who confine their travel to urban centers is very low.

Tick-borne Encephalitis, also known as spring-summer encephalitis, is a tick-borne viral infection that causes inflammation of the central nervous system. Although the disease is common throughout Europe, travelers are at low risk unless they visit forested areas and/or eat nonpasteurized dairy products.

Hepatitis A is a viral disease that has an onset of fever, malaise, nausea, and diarrhea, followed within a few days by jaundice. The disease ranges in clinical severity from no symptoms at all to a mild illness lasting one to two weeks. Although endemic throughout the world, Hepatitis A can be prevented by carefully following the hygiene and food recommendations listed in the sidebar "Minimizing Risks."

WHAT'S RECOMMENDED? WHAT'S REQUIRED?
Although the CDC recommends that all travelers obtain vaccines when traveling abroad, it is important to realize that, with one exception, no vaccine is required before you travel anywhere in the world: they are only "recommended." You will not be required to have a vaccination record to enter a country, nor will you be required to obtain vaccines to return home.

The sole exception is the Yellow Fever vaccine, which may be required if you travel to or from a South American or African country infected with Yellow Fever. The recommendations can vary from country to country; if such a destination is part of your travel plans, you should look up the Yellow Fever requirements for that specific country. The CDC's Comprehensive Yellow Fever Vaccination Requirements are available at www.cdc.gov/travel/yelfever.htm#yfcert.  

I have been a globe-trotter for most of my adult life. In the past 25 years, I have traveled to more than 40 countries. I have never been asked for a vaccine record, nor have I ever felt the need for any vaccines, even when traveling to remote, exotic destinations.

ARE THERE OTHER HEALTH RISKS TO CONSIDER?
Vaccines are available for all diseases mentioned above, should you choose to vaccinate. Infections that are a concern worldwide, and for which there are no vaccines, include malaria and Traveler's Diarrhea.

Malaria is a serious, sometimes fatal disease caused by a parasite that is injected into the body by an infected mosquito. The parasite grows in the liver, then infects circulating red blood cells. Symptoms of malaria include fever, shaking chills, headache, muscle aches, vomiting, diarrhea, and extreme fatigue. If untreated, death from malaria can occur due to dehydration and kidney failure.

For most people, the symptoms of malaria begin ten days to four weeks after they become infected, although the symptoms may not develop until as much as a year later. Anyone who begins to have recurring, shaking chills up to one year after returning home should seek professional medical care. Be sure to tell your healthcare provider that you have visited a malaria-risk area.

Prescription drugs for the prevention of malaria are sometimes recommended for those traveling to malaria-endemic countries. Some antimalarial drugs are more effective in some parts of the world than others, but all of them have side effects and potential complications. In addition, a medical condition may prevent your child from taking certain drugs.

An alternative to taking drugs is to use mosquito precautions (see sidebar). It is important to obtain a natural mosquito repellant, one that is free of DEET, the toxic additive found in most insect repellants. My favorite is Natural Mosquito Repellant, made by Royal Neem. It is free of chemicals and contains many natural ingredients: aloe vera; the oils of coconut, neem, lemongrass, citronella, cedarwood, and rhodiumwood; and extracts of myrrh, barberry, thyme, goldenseal, and chamomile. Further suggestions for additional natural insect repellents can be found at www.mercola.com.

If you contract malaria, a natural treatment is available that is perhaps even more effective than pharmaceuticals, and is certainly less toxic. During an archeological dig in the 1970s, instructions for treating malaria with an herb called wormwood, or artemisia, were found in a 2000-year-old Chinese tomb. Shortly thereafter, Western scientists isolated the herb's active component and called it "artemisinin." Studies in China and Vietnam have confirmed that artemisinin is a highly effective compound, with a close to 100 percent response rate in the treatment of malaria. Outside the US, artemisinin is the No. 1 natural herb used to treat malaria. The World Health Organization is investigating the use of this herb worldwide for malaria treatments. Because there can be a wide variation in quality, it is important that artemisinin be purchased from a reputable source, such as Allergy Research Group, www.allergyresearchgroup.com. It should be noted that this company only sells to licensed healthcare practitioners.

Traveler's Diarrhea This is, by far, the most common illness affecting those traveling outside the US. It is estimated that between 20 and 50 percent of travelers-nearly 10 million people each year-develop diarrhea. Although a variety of viral and parasitic pathogens can be the cause, by far the most common source of Traveler's Diarrhea is the bacteria E. coli.

Symptoms usually begin abruptly and increase over several days. The typical experience includes four or more watery bowel movements each day, associated with nausea, vomiting, abdominal cramping, fever, and malaise. Most cases are benign and resolve in one to two days without treatment. Although rarely life-threatening, Traveler's Diarrhea can bring a sudden halt to the fun and mystique of international travel.

The best way to avoid Traveler's Diarrhea is by strict adherence to food and water precautions (see sidebar, "Minimizing Risks"). In addition, studies have shown that taking two tablespoons of Pepto-Bismol four times a day (for adults) can decrease the incidence of Traveler's Diarrhea. The dosage for children nine to 12 is one tablespoon four times a day, children six to nine, two teaspoonfuls; three to six, one teaspoonful; under three, consult a physician before taking. (People allergic to aspirin, pregnant women, and those on the blood thinner Coumadin should not take Pepto-Bismol. Also, large doses of Pepto-Bismol can temporarily blacken the tongue and stool.)

The most important treatment for Traveler's Diarrhea is oral rehydration to replace lost fluids and electrolytes. Clear liquids are routinely recommended for adults, and, for children, electrolyte-based liquids such as Gatorade. On rare occasions, antibiotics may be required if the symptoms persist for more than a few days.

The Best Medicine
The best medicine for any type of infectious disease is always prevention. For most diseases around the world, common-sense precautions are the best way to stay healthy. Since for nearly every destination in the world vaccinations are only recommended, not required, a trip to your doctor for vaccines is one item you can cross off your pre-trip "To Do" list. Go and have fun!

MINIMIZING RISKS
1. Eat only cooked foods hot to the touch. Avoid eating food from street vendors.
2. Avoid eating raw fruits and vegetables unless you peel them yourself.
3. Drink only "safe" beverages: sealed bottled water, carbonated beverages, hot tea, coffee, beer, wine, and boiled water.
4. Don't drink beverages with ice.
5. Avoid eating raw or undercooked meat and seafood.
6. Avoid all tap water, and be careful of getting shower water in your mouth. When dining in restaurants, ask whether the salad greens have been washed in boiled or distilled or bottled water.
7. Avoid nonpasteurized milk and dairy products.

PROTECT YOURSELF FROM MOSQUITO BITES
o Pay special attention to mosquito protection between dusk and dawn.
o Wear long-sleeved shirts, long pants, and hats.
o Frequently apply natural insect repellant.

NOTES
1. CDC, "Certification of Poliomyelitis Eradication-The Americas," MMWR 43 (1994): 720-722
2. CDC, "Poliomyelitis Prevention in the United States Update," MMWR 49 (2000, RR05): 1-22
3. CDC, "Tetanus Surveillance," MMWR 47 (July 1998, 55-2): 13.
4. Ibid.
5. Letter to the Editor, British Medical Journal 320 (5 February 2000): 383.
6. CDC Travelers' Health, www.cdc.gov/travel/destinat.htm.

Sherri J. Tenpenny, DO, is board-certified in Emergency Medicine. She is CEO of OsteoMed II, located in Strongsville, Ohio, an Integrative Medicine clinic that treats ADD/ADHD, autism, and a wide variety of autoimmune disorders seen in children and adults. An advocate for healthcare choice, including the right to refuse vaccination, Dr. Tenpenny speaks nationally and internationally on the unspoken health risks of vaccines.