Always check baseline immunity first. Pre-travel appointments are an opportunity to ensure all routine immunisations are up to date before adding travel-specific vaccines.
✓Routine Vaccines to Verify
- MMR (measles-mumps-rubella): 2 doses if born after 1970
- Tetanus/diphtheria/polio (Td/IPV): booster every 10 years; polio booster for travel to endemic areas
- Hepatitis B: check serology if high-risk travel (healthcare workers, risky activities)
- Influenza: annual for all travellers, especially those visiting southern hemisphere (different strain)
- Varicella: 2 doses if no prior history
- Pneumococcal: asplenic, elderly, immunocompromised travellers
▶International Certificate of Vaccination (ICVP)
Yellow Card / Carnet de Vaccination Internationale: Official WHO document (IHR 2005). Must be stamped by an authorised Yellow Fever Vaccination Centre. Some countries will deny entry without it.
- Valid from 10 days after primary yellow fever dose
- Now considered valid for lifetime (no expiry since 2016 revision)
- Keep original — photocopies not accepted
- GCC airports check yellow fever certificates from endemic country travellers
📋Hepatitis A
- Inactivated vaccine (e.g. Havrix, Avaxim, Vaqta)
- 2 doses: 0 and 6–12 months apart
- Single dose gives protection within 2 weeks, lasts ~1 year
- 2nd dose gives lifelong protection (~95% effective overall)
- Combined Hep A+B (Twinrix): 0, 1, 6 months; accelerated 0, 7, 21 days + 12 months
Indications: All travellers to developing countries. Food/water-borne transmission (faecal-oral). Particularly important for VFR travellers and those eating at local restaurants.
Safe in pregnancy
Safe in immunosuppression
Inactivated vaccine
📋Typhoid
| Type | Name | Route | Duration | Efficacy | Notes |
|---|
| Injectable polysaccharide | Typhim Vi / Typherix | IM | 3 years | 50–70% | Single dose; safe in immunosuppression |
| Oral live attenuated | Ty21a (Vivotif) | Oral | 5 years (3yr some guidelines) | 50–70% | 3–4 capsules on alt days; CONTRAINDICATED in immunosuppression; avoid with antibiotics/antimalarials |
Important: Neither vaccine is 100% effective. Food and water hygiene remains essential. "Boil it, cook it, peel it, or forget it."
⚠Yellow Fever Vaccine — Critical Details
- Live attenuated vaccine (17D strain)
- Single dose — lifelong protection (ICVP valid for life since 2016)
- Seroconversion ~99% after 1 dose
- Must be administered at authorised Yellow Fever Centre
- Required for entry to many sub-Saharan African and South American countries
CONTRAINDICATIONS:
- Immunosuppression (any cause)
- Age <6 months (absolute); <9 months (relative)
- Thymus disease/thymectomy
- Age >60 years with thymus disease (risk of viscerotropic disease)
- True egg allergy (vaccine grown in eggs)
- Pregnancy (relative — give if travel unavoidable)
YEL-AVD (Yellow Fever Vaccine-Associated Viscerotropic Disease): Rare but potentially fatal. Rate 0.4/100,000 doses overall; higher in elderly and those with thymus disease. Mimics wild-type yellow fever disease.
📋Meningococcal ACWY
- Conjugate vaccine (MenACWY): preferred; longer immunity than polysaccharide
- Polysaccharide (ACWY Vax): used for adults aged >55 where conjugate not available
- Single dose, booster every 3–5 years if ongoing risk
- Protects against serogroups A, C, W135, Y
Mandatory for Hajj: Saudi MOH requires MenACWY for all pilgrims. Pilgrims from meningitis belt (sub-Saharan Africa) additionally screened. Hajj-associated W135 outbreaks historically documented (2000–2001).
Meningitis Belt: Senegal to Ethiopia across sub-Saharan Africa — high endemicity for Men A. Seasonal peaks in dry season.
📋Rabies Pre-exposure Prophylaxis (PrEP)
- 3-dose schedule: Day 0, Day 7, Day 21–28
- Provides partial immunity — post-bite treatment still required
- However: eliminates need for rabies immunoglobulin (RIG) — critical where RIG unavailable
- Reduces post-bite vaccine doses from 5 to 2
Indications: Prolonged travel (>1 month) to endemic areas, particularly rural South/SE Asia and Africa. Travellers with risk activities (cycling, cave exploration, veterinary work). Children (high bite risk, lower wound severity awareness).
Post-bite ALWAYS seek care: Pre-exposure vaccination does not eliminate post-bite treatment need. Wound wash thoroughly with soap/water for 15 minutes.
📋Japanese Encephalitis
- Inactivated vaccine (IXIARO/Jespect): 2 doses, 28 days apart
- Indicated: rural travel to South/SE Asia during transmission season
- Risk: rice paddies, livestock farming areas, dusk/night exposure
- No specific treatment available — prevention essential
- Consider for travel >1 month in rural endemic areas, or any duration with high-risk activities
📋Other Travel Vaccines
- Cholera (Dukoral): Oral, 2 doses 1–6 weeks apart; also gives some protection against ETEC. Humanitarian workers, remote areas.
- Tick-borne Encephalitis: 3 doses; Central/Eastern Europe, Russia, forestry workers; no treatment available
- COVID-19: Follow current national and destination guidance; may be entry requirement
- Polio booster: Required for travellers to remaining endemic countries (Pakistan, Afghanistan)
Traveller's Diarrhoea: Most common travel-related illness. Defined as ≥3 loose/watery stools in 24 hours, or any loose stools with fever, blood, or mucus, occurring within 2 weeks of travel to a developing country.
▶Common Causative Organisms
| Organism | Type | Features | Treatment |
|---|
| ETEC (Enterotoxigenic E. coli) | Bacterial | Most common cause (30–40%); watery diarrhoea, cramps; self-limiting 3–5 days | ORS; ciprofloxacin if needed |
| Campylobacter | Bacterial | Undercooked poultry; bloody diarrhoea, fever; quinolone resistance in SE Asia | Azithromycin (SE Asia); ciprofloxacin elsewhere |
| Shigella | Bacterial | Dysentery (bloody diarrhoea, tenesmus); Shiga toxin species — avoid quinolones if Shiga-toxin producing | Azithromycin; ceftriaxone severe cases |
| Salmonella | Bacterial | Poultry, eggs, dairy; bacteraemia possible in immunosuppressed/asplenic | Usually self-limiting; antibiotics for severe/systemic |
| Giardia lamblia | Protozoan | Post-travel (onset weeks later); offensive floating stools, bloating, flatulence, no fever typically | Metronidazole 400mg TDS 5–7 days or tinidazole |
| Entamoeba histolytica | Protozoan | Amoebic dysentery; bloody diarrhoea; liver abscess complication | Metronidazole + diloxanide furoate (luminal agent) |
| Cryptosporidium | Protozoan | Waterborne; prolonged in immunosuppressed; no reliable treatment | Nitazoxanide; supportive |
| Norovirus | Viral | Cruise ships; vomiting + diarrhoea; highly contagious; 24–48h duration | Supportive only |
◆"Boil it, Cook it, Peel it, or Forget it"
Safe Food Principles
- Eat food that is thoroughly cooked and served piping hot
- Avoid salads, raw vegetables, cold buffets
- Peel all fruit yourself; avoid pre-cut fruit
- Avoid ice in drinks unless made from safe water
- Street food: only if freshly cooked in front of you at high temperature
- Dairy: pasteurised only; avoid raw milk/cheese in endemic areas
Water Purification Methods
- Boiling: Most reliable — 1 minute at sea level; 3 minutes at altitude (>2000m)
- Chlorine/Iodine tablets: Effective for bacteria/viruses; less effective for Cryptosporidium; iodine avoid in pregnancy/thyroid disease
- Filtration + UV (SteriPen): Removes protozoa and bacteria; UV kills viruses
- Bottled water: Check seal intact; avoid if bottle integrity uncertain
📋Standby Treatment
Oral Rehydration Salts (ORS): First-line for all cases. Prevents dehydration. WHO-ORS: 75mmol/L sodium, 75mmol/L glucose. If ORS unavailable: 1L water + 6 teaspoons sugar + 0.5 teaspoon salt.
- Ciprofloxacin 500mg BD × 3 days: Empirical treatment for moderate-severe watery TD. Start if: >3 loose stools/day interfering with travel or fever present (without blood)
- Azithromycin 500mg OD × 3 days (or 1g single dose): Preferred for SE Asia (quinolone-resistant Campylobacter prevalent). Also preferred in pregnancy and children.
- Loperamide: Reduces stool frequency; do NOT use if bloody diarrhoea or fever — masks severity, risk of toxic megacolon with invasive pathogens
Avoid ciprofloxacin if bloody/mucoid diarrhoea + suspected Shiga toxin-producing E. coli (STEC): Risk of haemolytic uraemic syndrome (HUS) if antibiotics promote toxin release.
⚠When to Seek Medical Care
- Bloody diarrhoea or mucus in stool (dysentery)
- Fever >38.5°C
- No improvement after 48 hours of self-treatment
- Signs of dehydration (sunken eyes, no urination >8h, rapid heart rate)
- Vomiting preventing oral rehydration
- Severe abdominal pain or rigidity
- Return to consciousness issues or confusion
▶Post-travel Diarrhoea (persisting >2 weeks)
- Giardia: Offensive floating stools, bloating, weight loss; stool microscopy x3; treat with metronidazole
- Amoebic dysentery: Bloody diarrhoea; liver abscess possible; treat metronidazole + diloxanide furoate (luminal agent to clear cysts)
- Post-infectious IBS: Exclude parasites; consider Rome criteria
- Tropical sprue: Rare; malabsorption; doxycycline treatment
▶Traveller's Diarrhoea Prophylaxis
Bismuth Subsalicylate (Pepto-Bismol): 2 tablets QID reduces incidence by ~60%. Mechanism: antimicrobial + antisecretory. Side effects: black stools/tongue (harmless), tinnitus at high doses. Avoid in aspirin allergy, children, pregnancy.
Not routinely recommended — behaviour modification preferred. Consider for: high-risk short trips where illness would be highly disruptive.
Antibiotic prophylaxis (rifaximin): Not routinely recommended due to resistance concerns. May be considered for very high-risk groups (immunosuppressed, inflammatory bowel disease, short critical trips). Rifaximin: non-absorbed antibiotic, ETEC-specific.
◆GCC as a Travel Medicine Demand Generator
- Large international workforce from malaria-endemic regions (South Asia, SE Asia, East Africa)
- GCC nationals increasingly travelling to high-risk destinations (adventure tourism, business, Hajj)
- UAE, Qatar, Bahrain, Kuwait host World Cup, Expo, and international events — influx of travellers
- Medical tourism incoming from lower-resource settings
- Port health nurses at Dubai, Abu Dhabi, Riyadh, Doha airports check ICV certificates
- DHA (Dubai Health Authority) and DOH (Department of Health Abu Dhabi) regulate travel medicine clinics
- SCFHS (Saudi Commission for Health Specialties) governs practice in Saudi Arabia
📈Hajj Health Coordination
Hajj is the world's largest annual mass gathering. Up to 2 million pilgrims from 180+ nations. Saudi MOH coordinates with WHO, and all GCC health authorities on vaccination requirements.
- Mandatory: Meningococcal ACWY conjugate vaccine (within 3–5 years)
- Mandatory (most years): Seasonal influenza
- Required from some countries: Polio vaccination certificate
- DHA/MOH issue Hajj health certificates for UAE residents
- Respiratory illness (MERS, influenza, COVID-19) major concern
- Heat stroke, stampede injuries, mass casualty preparedness
- Nurses involved in pre-Hajj clinics, airport screening, Hajj medical missions
Click an answer to reveal whether it is correct, then see the explanation.
1. A 32-year-old woman is travelling to rural India for 6 weeks and is 10 weeks pregnant. Which antimalarial prophylaxis is most appropriate if the destination has chloroquine-sensitive malaria?
- A. Doxycycline
- B. Chloroquine
- C. Atovaquone/proguanil
- D. Mefloquine
Chloroquine is the safest antimalarial in pregnancy and has the longest safety record. Doxycycline is contraindicated in pregnancy. Atovaquone/proguanil has limited safety data. Mefloquine is avoided in first trimester; may be considered in 2nd/3rd if benefits outweigh risks. The key here is chloroquine-sensitive area + pregnancy = chloroquine.
2. Which vaccine is MANDATORY for all pilgrims attending Hajj?
- A. Yellow fever
- B. Meningococcal ACWY
- C. Typhoid
- D. Hepatitis A
Meningococcal ACWY is mandatory for all Hajj pilgrims. This followed major outbreaks of N. meningitidis W135 associated with Hajj in 2000–2001. Influenza is also mandatory in most years. Yellow fever is required only for travellers coming from endemic countries.
3. A returning traveller from sub-Saharan Africa presents with fever 12 days after return. Blood film and malaria RDT are negative. What is the most appropriate next step?
- A. Discharge with antipyretics; malaria excluded
- B. Start empirical antimalarial treatment immediately
- C. Repeat blood films at 12–24 hour intervals (total of 3 sets)
- D. Test only for dengue and typhoid
A single negative blood film does NOT exclude malaria. Parasitaemia may be low or synchronised such that parasites are not detectable. Guidelines recommend 3 sets of thick and thin blood films at 12–24 hour intervals before malaria can be confidently excluded. The fever in this case is within the 3-month window and malaria must remain the diagnosis until proven otherwise.
4. Which Plasmodium species can cause relapsing malaria due to hypnozoites persisting in the liver?
- A. P. falciparum and P. malariae
- B. P. vivax and P. ovale
- C. P. falciparum only
- D. P. knowlesi and P. malariae
P. vivax and P. ovale form hypnozoites — dormant liver stages that can reactivate weeks to months (or even years) after the initial infection. Radical cure requires primaquine (or tafenoquine) in addition to blood-stage treatment. Primaquine must not be given without first checking G6PD status as it causes haemolytic anaemia in G6PD-deficient individuals.
5. A traveller to rural SE Asia is prescribed mefloquine prophylaxis. After the second weekly dose he reports vivid nightmares and anxiety. What is the correct management?
- A. Reassure; these are expected and will resolve
- B. Discontinue mefloquine and switch to an alternative prophylaxis
- C. Reduce the dose to half-weekly
- D. Add a benzodiazepine to manage the anxiety
Neuropsychiatric side effects of mefloquine (anxiety, nightmares, depression, psychosis, hallucinations) are a recognised class effect and require discontinuation. Importantly, mefloquine is started 3 weeks before travel precisely to identify neuropsychiatric intolerance before the traveller departs. Switch to atovaquone/proguanil or doxycycline depending on destination and contraindications.
6. Yellow fever vaccine is contraindicated in which of the following patients?
- A. A 25-year-old with well-controlled asthma
- B. A 30-year-old at 20 weeks gestation travelling to yellow fever endemic area
- C. A 45-year-old on high-dose methotrexate for rheumatoid arthritis
- D. A 70-year-old with no thymus disease travelling to endemic area
Yellow fever is a live attenuated vaccine, absolutely contraindicated in immunosuppression. Methotrexate (disease-modifying anti-rheumatic drug) causes immunosuppression, making live vaccines hazardous. Pregnancy is a relative contraindication — if travel is essential to endemic area, the risk-benefit discussion may favour vaccination. Asthma is not a contraindication. Age >60 with thymus disease is a specific risk factor, but 70-year-olds without thymus disease are not automatically excluded.
7. A traveller returns from Lake Malawi with a history of swimming in the lake. 6 weeks later they present with fever, urticaria, and marked eosinophilia. What is the most likely diagnosis?
- A. Dengue fever
- B. Malaria
- C. Katayama fever (acute schistosomiasis)
- D. Leptospirosis
Katayama fever is the acute hypersensitivity response to Schistosoma cercariae migration, occurring 4–8 weeks after freshwater exposure. Classic features: fever, urticaria, hepatosplenomegaly, and eosinophilia. Lake Malawi is highly endemic for S. mansoni. Dengue and malaria do not cause marked eosinophilia. Leptospirosis is possible but does not cause eosinophilia and the timeline is longer here.
8. Which antimalarial prophylaxis should be started 3 WEEKS before travel?
- A. Atovaquone/proguanil
- B. Doxycycline
- C. Mefloquine
- D. Chloroquine
Mefloquine requires a 3-week lead time before travel for two reasons: (1) it takes time to achieve steady-state blood levels, and (2) the early start allows detection of neuropsychiatric side effects while still in the home country, permitting a switch to an alternative before departure. Atovaquone/proguanil and doxycycline need only start 1–2 days before travel.
9. Which of the following best describes VFR travellers and their travel health risk?
- A. They are lowest risk because they have pre-existing immunity from childhood
- B. They are moderate risk but rarely contract malaria
- C. They are highest risk group for malaria and typhoid; immunity wanes after leaving endemic areas
- D. They require only hepatitis A vaccination as they are otherwise immune
VFR (Visiting Friends and Relatives) travellers are consistently identified as the highest-risk group in travel medicine. Key reasons: they believe (incorrectly) prior exposure confers ongoing immunity; they spend longer in rural/local accommodation; they eat home-cooked food without water precautions; they are less likely to seek pre-travel advice; and malaria/typhoid immunity wanes within months of leaving endemic areas. Nurses should proactively counsel this group.
10. A traveller returning from Southeast Asia has had watery diarrhoea for 4 days. Stool microscopy shows cysts with 4 nuclei on trichrome stain. What is the treatment?
- A. Ciprofloxacin 500mg BD for 5 days
- B. Azithromycin 500mg OD for 3 days
- C. Metronidazole 400mg TDS for 5–7 days
- D. Oral rehydration salts only
Cysts with 4 nuclei (quadrinucleate) on stool microscopy are characteristic of Giardia lamblia (Giardia intestinalis). Giardia causes post-travel diarrhoea with offensive floating stools, bloating, flatulence, and weight loss; fever is typically absent. Treatment is metronidazole 400mg TDS for 5–7 days, or tinidazole as a single 2g dose. Ciprofloxacin and azithromycin are used for bacterial TD.