The final of our two-part special report on the major travel vaccines shows less protection than you’d think, says Lynne McTaggart
If the Department of Health had its way, anyone venturing outside the UK would turn into a human pincushion by the time he had all his requisite shots. The official line on travel vaccines boils down to ‘when in doubt, get the shot’, and each year there are ever more vaccines on offer to protect you from ever more exotic diseases, including emerging diseases like tick-borne encephalitis and Japanese encephalitis.
The problem with the ‘more is better’ mindset is that it ignores one simple fact: there is no such thing as a perfectly safe and effective vaccine. All vaccines carry risks, with some far more than others, and certain vaccines are more effective than others. Some will make you so ill they threaten to spoil your holiday. Many, if not most, are only necessary if you’re, say, a field worker heading off to the sub-Sahara during certain times of the year.
As we recommended in the first of these reports (see WDDTYJuly 2013), before you submit to a raft of jabs, the risks of which multiply with every injection, it’s important to ask the three essential questions first:
o How necessary is this vaccine?
o How effective is this vaccine?
o How safe is this vaccine?
In what follows, we’ve asked and answered these questions for you on vaccines for rabies, hepatitis B, Japanese encephalitis, tick-borne encephalitis and the various travel shots for meningitis. For information about hepatitis A, cholera, typhoid, yellow fever and malaria, see last month’s issue. In both issues we also offer (and answer) one final, essential question: what can I do instead?
Japanese Encephalitis
What’s it for?
Encephalitis (brain inflammation) with seizures or aseptic meningitis, caused by Flavivirus, often harboured by domestic pigs and wild herons, and transmitted by the bite of Culex tritaeniorhynchus and C. vishnui mosquitoes. Most prevalent in Southeast Asia and the Far East, and the leading cause of encephalitis in Asia, but mostly a disease of children in countries where flooding irrigation practised. Worldwide annual incidence is 35,000-50,000, of which 25 per cent of victims die and 40 per cent suffer permanent or long-term neurological or psychological problems.
What’s the vaccine?
Killed vaccine (trade names: Ixiaro, Intercell), taken in two doses 28 days apart. Licensed for those 17 and over in the US. US Food and Drug Administration (FDA) advises parents to have their children under 17 jabbed off-label or enrolled in an experiment, or to get hold of something manufactured overseas.
How necessary?
For the average tourist-not very. Risk for travellers remote (one case per million travellers per year); during 1973-2008, only 55 cases reported in people living in 17 countries without epidemics. More than 99 per cent of those bitten have no symptoms. Mostly recommended for at least month-long stays in endemic areas during the transmission season, for lab workers exposed to virus or for those planning to stray outside of urban areas during transmission seasons.1
How effective?
Good question. According to one Cochrane Collaboration review of eight trials, only one of the three vaccines currently used has been assessed for effectiveness in proper (scientific) trials. Effects appear to be short-lived, with the two-dose schedule only effective for a year.2 According to other studies, the vaccine doesn’t take in nearly one-fifth of recipients and coverage wanes after two years in just under half.3 Just before receiving a second dose 15 months after the primary jab, antibody levels can fall by almost a third.4
How safe?
Distinctly worrying. More than 10 per cent of recipients have headaches and muscle weakness. In four studies, nearly one in every 50 participants suffered serious adverse events after getting the jab, including multiple sclerosis and one death, and one in every 100 refused to carry on with the series. In another study, nearly 5 per cent had serious adverse effects, including dermatomyositis (skin and muscle inflammation), appendicitis, rectal haemorrhage, limb abscess (on the other, non-injected arm), chest pain, ovarian torsion (twisting of an ovary enough to block its arteries or veins) and other ovary problems, and three orthopaedic injuries.5
Contains protamine sulphate, known to cause hypersensitivity reactions in some.
What to do instead
Avoid travelling during the rainy season where the disease is endemic, and in summer and autumn in China, Japan, the Korean peninsula and eastern parts of the Russian Federation when risk is highest. Follow safe practices for avoiding mosquito bites (see WDDTY July 2013).
Rabies
What’s it for?
Protection against the disease; also, immunoglobulin offered to prevent clinical rabies in those bitten by a rabid animal.
What’s the vaccine?
Imovax, an egg-based killed vaccine, four doses injected intramuscularly or intradermally in the arm of adults and thigh of children under age 1 year. For those bitten by an infected animal: two doses plus human rabies immunoglobulin (HRIG) or equine rabies immunoglobulin (ERIG), if available, after exposure.
How necessary?
Minuscule risk for the average tourist. A GeoSentinel analysis of injuries related to animals among travellers found just 320 cases from 1998 to 2005, nearly half from bites received before the people set off on their travels.6 Highest incidences: Southeast Asia and the rest of Asia, then Australia/New Zealand, Africa, Latin America, North America and Europe, mostly from dogs, monkeys and cats. Risk greatest in those likely to come into contact with rabid wild or domesticated animals, and with limited access to appropriate medical care.
How effective?
Raised antibodies to rabies adequately in all but one of 38 travellers given the shot,7 but immunity drops off sharply. In one study, one-eighth of participants were considered ‘unprotected’ after two years; in another, immunity dropped to 34 per cent after five years.8 It also failed to protect one bitten tourist.9
How safe?
One-fifth of recipients suffer mild fever, headache, nausea, abdominal pain, muscle aches and dizziness during the first 24 hours, reports Imovax manufacturer Aventis Pasteur MSD in the UK (Sanofi Pasteur in the US). Occasionally, fever may be severe. Other adverse reactions are asthenia (abnormal weakness), pins and needles, joint ache, allergic skin reactions, serious anaphylactic reactions, and serum-sickness-like reactions causing fever, allergic skin wheals, joint and muscle pain, and swollen lymph nodes.
What to do instead
Avoid areas with a high incidence of rabid animals and never pet or go near stray dogs or cats. Try homeopathic rabies remedy. Thoroughly wash all bite wounds or scratches immediately and apply iodine or other topical virus-killing agents to the wound.
Meningitis
What’s it for?
Meningitis, or swelling of the membrane surrounding the brain and spinal cord,
caused by Neisseria meningitidis bacteria, caught after exposure to an infected person and transmitted via respiratory system. Most cases caused by groups A, B and C, less commonly by groups Y (emerging in the US), W135 (particularly in Saudi Arabia and West Africa) and X (Africa, Europe, US). Globally, half a million cases of meningitis every year, 7 per cent on average fatal. One-fifth of survivors sustain permanent nerve damage.
What’s the vaccine?
Four-in-one jabs are in fashion these days; Novartis’ Menveo, a newer killed conjugate version against bacterial groups A, C, Y and W135, given intramuscularly, considered slighter more effective than GlaxoSmithKline’s ACWY Vax. There are also individual vaccines for C, A and C, and A, C and W. No vaccines yet for meningitis B.
How necessary?
Certificate of vaccination against ACWY groups is requirement for entry if you’re heading off to Saudi Arabia for the Hajj and Umrah pilgrimages.
Otherwise, risk tiny unless you travel to high-risk areas; of 1,469 cases of meningococcal meningitis in the UK in 2010 reported by the Meningitis Foundation, all but 160 were cases of meningitis B, for which there is no vaccine.10 Most infections don’t cause clinical disease, says the WHO, as many of those infected are simply carriers of the bacteria. Susceptibility tends to decrease with age, but adolescents and young adults have increased risk.
How effective?
Short-term coverage. Department of Health now recommends that all children get Menveo, even though the drug’s datasheet (from Novartis) stipulates the vaccine should only be given to children 11 or over. According to the WHO, group A and C vaccine protection wanes quickly and fails up to 15 per cent of the time. Most of the four don’t work for children under age two.
Biggest headache: all vaccines don’t work against group B, the most common form of meningitis in the UK, and group X, a growing strain of meningitis in the US.
How safe?
Pretty scary. Novartis warns that some patients “may develop syncope, sometimes resulting in falling injury associated with seizure-like movements. Observation for 15 minutes after vaccination is recommended.” Another four-strain vaccine, this one a polysaccharide, showed “a potential” for increased risk of Guillain-Barr’e paralysis. The most common side-effects: headache (nearly a third); myalgia (nearly one in five); malaise (one in six); and nausea (one in 10). More serious side-effects: pneumonia; appendicitis; dehydration; joint pain; nausea; and vomiting. In one study, five recipients attempted suicide. Within 30 days, some recipients also developed Cushing’s syndrome (suggestive of adrenal exhaustion), viral hepatitis, pelvic inflammatory disease, seizures and suicidal depression.
Novartis has also received post-marketing reports of ear disorders, vertigo, eyelid problems, immune system disorders and cellulitis (serious skin infection) at the injection site. Also cases of falls and head injuries, impaired hearing, ear pain, vertigo, bone pain, balance disorders and loss of facial movements.
What to do instead?
Avoid endemic areas during seasons when incidence is high, including December-June in the ‘meningitis belt’ of sub-Saharan Africa. Forego Saudi Arabia during the pilgrimage.
Tick-Borne Encephalitis
What’s it for?
Nervous system disease caused by a virus of the Flaviviridae family and transmitted by bite of infected ticks from family Ixodidae (hard ticks) or occasionally by drinking unpasteurized milk. Infection starts with flu-like symptoms that may turn into potentially fatal encephalitis and meningitis. Severity of illness increases with patient’s age. Far-Eastern subtype considered more dangerous than European subtype.
What’s the vaccine?
Encepur (Novartis) and FSME-IMMUN (Baxter), both from killed viruses grown on chick embryo cells and inactivated by formaldehyde.
How necessary?
A growing problem in parts of Europe, Baltic States and Far East-currently about 10,000 cases a year worldwide-but chances of getting it still low, with just 10-30 per cent of infected people ever developing symptoms. Most cases seen between April and November; risk highest for hikers and campers in rural and forested areas.
How effective?
A review of 11 trials showed antibody rates of more than 87 per cent,16 but as the WHO admits, there’s “little information available on the duration of protection following completion of the primary three-dose immunization”. Effectiveness of the two vaccines equivalent, says the Public Health Agency of Canada. Boosters thought to be needed every three years.
How safe?
I’d take my chances with ticks. FSME-IMMUN: anaphylactic shock; joint and muscle pain; vertigo; and abdominal swelling. Can trigger herpes in previously exposed patients and precipitate autoimmune disorders (like multiple sclerosis), Guillain-Barr’e syndrome, spinal cord inflammation, sensory disturbances, neuralgia, optic neuritis, convulsions, encephalitis, facial palsy, paralysis, painful or abnormal sensations, reduced sense of touch or other sensation, pins and needles, rapid heartbeat, visual disorders, eye pain, ear disorders like tinnitus, gait disorders, connective tissue and bone disorders, aseptic meningitis and encephalitis.17 And the list goes on . . .
What to do instead
Avoid travel to endemic areas during March to November, when ticks are active. Wear long trousers and closed footwear when hiking or camping in countries or areas at risk; dark clothing attracts fewer ticks.18 If bitten, remove tick as soon as possible. Avoid biking, hiking or camping along the edge of forests, in parks or meadows, and where the countryside is moist and uncultivated with low brush and ground foliage. DEET and permethrin used together provide nearly 100 per cent protection.
Hepatitis B
What’s it for?
The more deadly form of hepatitis caused by a virus of the Hepadnaviridae family, spread through bodily fluids like blood.
What’s the vaccine?
GlaxoSmithKline’s Engerix B ‘recombinant’ version made from genetically engineered yeast and Merck’s Recombivax HB, also produced by yeast cells; both usually injected intramuscularly over three doses.
How necessary?
Although recommended for travellers where incidence is more than 2 per cent of the population, hep B is not a serious threat. Fewer than 50 cases contracted abroad every year in the UK. Only consider if planning to commingle your blood or other bodily fluids with someone likely to be infected or to receive acupuncture, cosmetic surgery or tattoos in endemic areas without adequate sterilization. One case of hep B per month in 2,000-10,000 short-term travellers and one case per 1,000 long-term travellers or expats per month.11
How effective?
Requires at least three doses for adequate coverage; boosters have a 13 per cent failure rate.12 Protection doesn’t last; although reported to last five years in adults and eight years in children, can decline just a few years after shots.13 Some 40 per cent of children vaccinated in infancy have no protective antibodies by age 10.14 Some evidence that women and younger people are more protected than older people and men.15 Combined hep A and B vaccine works less w
ell for hep B unless you have three doses.
How safe?
Russian roulette. Side-effects of GSK’s Engerix B: fever; joint and muscle pain; arthritis; headache; dizziness; fainting; nausea; vomiting; diarrhoea; abdominal pain; lymph gland swelling; abnormal liver function (confirmed by tests); and rashes. Rarely, severe skin disorders. Reports of pins and needles, paralysis, nervous system disorders like Guillain-Barr’e syndrome, optic neuritis (inflammation or damage to optic nerve) and multiple sclerosis.
What to do instead
Don’t have sex or share your blood with anyone who may be infected. Avoid tattoos, acupuncture or anything using needles that aren’t sterile and disposable
Areas of greatest risk
If you want to avoid the jabs, steer clear of these high-risk areas.
Hepatitis B
In developed areas such as the US, Western Europe and Australia, risk of infection is relatively low. Significantly greater risk of infection in developing countries like China and Southeast Asia, most of Africa, many Pacific islands, Haiti and the Dominican Republic, parts of the Middle East and in the Amazon Basin.
Japanese encephalitis
Mainly present in three areas: the Far East, the Indian subcontinent and Southeast Asia. Occasional outbreaks also reported in Guam and Saipan.
Rabies
Common in parts of Mexico, Colombia, Ecuador, El Salvador, Guatemala, India, Nepal, Peru, the Philippines, Sri Lanka, Thailand, Vietnam, Africa, Asia, and South and Central America.
Meningitis
Meningococcal meningitis is more prevalent in some areas of Africa and Asia.
Tick-borne encephalitis
Present in large parts of Central and Eastern Europe, particularly Austria, southern Germany and northern Switzerland, Baltic states (Estonia, Latvia, Lithuania), Czech Republic, Hungary, Poland and Siberia. In the Far East: northeast Russia, China and Japan.
Protect yourself naturally
Keep your family’s level of vitamins A, B and C high, which can protect against complications of a number of infectious diseases.1 Vitamin A is also reputed to offer protection against polio-type viruses.2 Take supplements of all three vitamins three months before you travel.
Suggested daily dosages: 5,000 IU vitamin A, one B complex 50, 1-3 g vitamin C.
Cut down on excessive consumption of sugar including refined carbohydrates and keep calcium consumption normal.
During the height of the polio epidemics, Dr Benjamin Sandler, a nutritional expert at the Oteen Veterans’ Administration
Hospital in North Carolina, demonstrated a relationship between polio and eating too much sugar and starch. He claimed that such foods leach calcium from the body, and calcium deficiency often precedes polio.
In 1949 when Dr Sandler had the media warn North Carolina residents to avoid ice cream and soda pop in the summer, they cut their consumption by 90 per cent-and polio decreased in the state by the same proportion.3
Don’t surrender your tonsils unnecessarily. Some researchers have hypothesized that the fashion for tonsillectomy in the middle of the last century contributed to the polio epidemics of the 1950s.4
References
1. N Engl J Med, 1990; 323: 160-4; Br Med J [Clin Res Ed], 1987; 294: 294-6
2. WDDTY, 1997; 7 [2]: 8
3. Medical Veritas, 2004; 1: 239-51
4. Am J Hyg, 1957; 66: 131-50
Homeopathic ‘vaccines’
A half century before the first isolation of the tubercle bacillus, tuberculosis vaccine nosodes (homeopathic dilutions of the bugs causing the illnesses in question, given orally) were commonly used as just-in-case measures against a wide variety of diseases. In 1974, more than 18,000 children were successfully protected against a meningitis epidemic with the nosode Menigococcinum 11C.1
Hepatitis
One Chelidonium Majus 30 taken eight days before departure; repeat the dose once every week of your stay.
Polio
One Lathyrus Sativus 30 taken seven days before departure.
Meningitis
If meningitis becomes epidemic while you’re away, take one Belladonna 30 weekly.
Rabies
One Lyssin 30C taken three times over 24 hours.
Japanese or tick-borne encephalitis
Nosodes of both available. Take at 30C potencies. Consult a homeopath for directions.
References
1. Eizayaga FX. Treatise on Homoeopathic Medicine. Buenos Aires: Ediciones Marcel, 1991
References
1. MMWR Recomm Rep, 2010; 59: 1-27
2. Cochrane Database Syst Rev, 2007; 3: CD004263
3. Vaccine, 2008; 26: 4382-6; Vaccine, 2010; 28: 5197-202
4. Vaccine, 2011; 29: 2607-12
5. http://www.bdipharma.com/Package%20Insert/Novartis/Ixiaro_pi_0212.pdf
6. Vaccine, 2007; 25: 2656-63
7. J Travel Med, 2006; 13: 329-33
8. Am J Med Sci, 1987; 293: 293-7; Clin Vaccine Immunol, 2011; 18: 1477-9
9. Clin Infect Dis, 2010; 50: 77-9
10. http://www.meningitis.org/facts
11. Vaccine, 1993; 11: 518-20
12. Postgrad Med J, 1987; 63 Suppl 2: 137-8; J Infect Dis, 2009; 200: 1390-6
13. BioDrugs, 1998; 10: 137-58
14. Hum Vaccin Immunother, 2013 Jun 20; 9; Epub ahead of print
15. Postgrad Med J, 1987; 63 Suppl 2: 125-8
16. Cochrane Database Syst Rev, 2009; 1: CD000977
17. http://www.baxter.ca/en/downloads/healthcare_professionals/products/FSME_IMMUN_PM_EN_2012Apr09.pdf
18. Scand J Infect Dis, 2005; 37: 361-4
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