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Find a Clinic

There are several places you can get vaccines and medicine before you travel.

Call your doctor or local health department to see if they can provide pre-travel advice, vaccines, and medicines.

List of health departments

If you want to see a travel medicine specialist, the International Society of Travel Medicine (ISTM) can help you find a clinic.

Directory of travel clinics

If you need yellow fever vaccine you must get vaccinated at an authorized yellow fever vaccine clinic. Many of these clinics also give other shots and medicines.

Yellow fever vaccine clinic search

Find where you can get a COVID-19 vaccine in your area.

Need to get tested? Find a COVID-19 testing clinic .

• Find out what vaccines you need for your destination
• Frequently Asked Questions
• Traveler Advice
• Clinician Tools and Resources

CDC provides these links as a convenience to international travelers. CDC does not endorse, recommend, or favor any clinics on these lists, nor does the appearance of a clinic on these lists imply a guarantee of service quality.

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• About the Handbook

Vaccination for international travellers

Ensure that travellers are up to date with routine vaccines. Also consider other vaccines based on travel itinerary, activities and risk of disease exposure.

Recently added

This page was added on  09 June 2018 .

Updates made

This page was updated on 23 October 2023 .  View history of updates

Millions of Australians travel overseas every year. More than half of these trips are to destinations other than New Zealand, North America and Europe. 1

This page helps with making decisions about travel vaccines. Also check the disease-specific chapters in this Handbook for details about specific vaccines.

See also Infographic. Vaccination for international travellers .

Health risks of overseas travel

Health risks associated with international travel include exposure to:

• infective agents
• altitude and temperature extremes
• other physical, psychological and environmental hazards
• poor-quality or limited access to clean water, shelter, hygiene and sanitation facilities, and health and medical care

The level of health risks depends on factors such as:

• the traveller’s underlying physical and mental health and physiological state
• the itinerary and activities undertaken
• the duration of exposure to various hazards during travel

Travellers at increased risk of serious travel-associated infections include:

• young children and infants
• pregnant women
• people with underlying medical conditions, especially immunocompromising conditions due to disease or medical treatment
• people spending extended periods in multiple regions with poor resources or in remote areas
• people participating in events where large numbers of people will gather, such as major sporting, cultural, social or religious events
• migrant families travelling back to their region of origin to visit friends and relatives

Those travelling to visit friends and relatives are more likely to: 2

• have closer contact with local populations
• stay in remote or rural areas
• consume higher-risk food and beverages

Those travelling to visit friends and relatives are less likely to: 2,3

• recognise the health risks associated with travelling
• seek pre-travel health advice
• obtain the recommended vaccines or prophylaxis

Common infections acquired by travellers

Exposure to infectious diseases is one of the many health hazards of international travel. Some of these diseases are vaccine preventable. Although some of these diseases are present in Australia, the risk of acquiring them overseas may be higher because of:

• higher disease incidence in other countries
• increased risk of exposure from participating in certain activities while travelling

Foodborne and waterborne infections

It is common for travellers to ingest contaminated food or beverages, resulting in an illness. 4-6  Practicing safe eating and drinking habits is essential to minimise the risk of contracting food and waterborne diseases while travelling. These include treating water or only drinking bottled water, avoiding undercooked meat, and avoiding raw fruit and vegetables (unless they can be peeled or washed in safe water prior to eating). Most infections are diarrhoeal diseases due to enteric pathogens, but some are due to extra-intestinal microorganisms, such as hepatitis A virus and Salmonella enterica serotype Typhi (causing typhoid).

Vaccines are available against hepatitis A, typhoid and cholera.

Vector-borne infections

Insect-borne — especially mosquito-borne — infections, such as malaria and dengue, are important causes of fever in Australian travellers returning from endemic areas, particularly Southeast Asia and Oceania. 4,6

A dengue vaccine (Dengvaxia) is available for the prevention of secondary dengue infections (not primary prevention of initial dengue infection ) in select individuals. See Clinical advice: ATAGI statement on use of Dengvaxia® for Australians .

Japanese encephalitis occurs throughout much of Asia and the Western Pacific region, including eastern Indonesia and Papua New Guinea. 7 Yellow fever occurs only in parts of Africa and South America, 8 and tick-borne encephalitis occurs in parts of Europe and Asia. 9

Vaccines are available against Japanese encephalitis , yellow fever and tick-borne encephalitis .

Some other vector-borne diseases and parasitic (including protozoal and helminthic) diseases are also important for international travellers. Some are preventable through appropriate barrier precautions and chemoprophylaxis (for example, malaria). 9

Aerosol-borne infections

Vaccine-preventable infections transmitted by aerosols and/or droplets include: 9

• influenza (the most common vaccine-preventable infection among travellers) 10
• meningococcal disease
• varicella (chickenpox)

The incidence of measles and mumps is higher in many overseas countries, including some developed countries, than in Australia.

Tuberculosis is a rare infection in travellers. 11 Expatriates who live in endemic areas for a long time are more likely to acquire tuberculosis than short-term visitors. 12

Vaccines are available against all of these diseases.

Bloodborne and sexually transmitted infections

Some Australian travellers may be at risk from bloodborne and sexually transmissible infections, such as chlamydia, gonorrhoea, hepatitis B, hepatitis C and HIV. In some areas, healthcare workers using non-sterile medical equipment or other poor infection control practices may transmit these viruses and other bloodborne agents.

Vaccines are available against hepatitis B.

Exotic infectious agents

Travellers may be exposed to a variety of other exotic infections, such as:

• rabies from bites or scratches from rabid dogs, bats and other mammals in many countries
• schistosomiasis from exposure to water infested with the parasites, especially in Africa
• leptospirosis through activities such as rafting or wading in contaminated streams

Of these diseases, vaccines are available only against rabies.

Recommending travel vaccines

Although recommending appropriate vaccines is important, it is not the only part of a pre-travel medical consultation. Travel vaccines — those relevant for travelling — include all relevant vaccines, not just the ones that prevent diseases that most commonly occur overseas.

Do not recommend a vaccine based only on the destination country, because there is no single ‘correct’ list of vaccines for travel to any particular country.

There are 3 categories of travel vaccines:

• routinely recommended vaccines (not specific to travelling overseas)
• selected vaccines based on travel itinerary, activities and likely risk of disease exposure
• vaccines required by the International Health Regulations 2005 (IHR) or for entry into specific countries

Questions for a pre-travel medical consultation

During a pre-travel medical consultation, ask questions about the traveller’s:

• personal information, including age and whether they are pregnant or planning pregnancy
• underlying medical conditions, particularly immunocompromising conditions, and current medicines
• vaccination history (including adverse events following immunisation) and allergy history
• purpose of travel and intended activities, especially those associated with various environmental risks and hazards
• plans for travel insurance

Also ask about their itinerary in detail, including:

• date of departure and time available for vaccinations
• specific localities and routes
• rural versus urban stay
• duration of stay
• likely access to health care and other services
• likelihood of changing the planned itinerary

This information helps to tailor recommendations about preventive vaccination or chemoprophylaxis for exposure risks during the proposed trip. It also allows the clinician to advise about other appropriate preventive health measures (for example, food and water precautions, avoiding bites from mosquitoes or other arthropods) and about managing possible health conditions during travel.

Organisational requirements for vaccination

Some overseas organisations, such as schools, colleges and universities, require evidence of vaccination or immunity against some vaccine-preventable diseases, such as measles and meningococcal disease. Consider these requirements when planning and scheduling vaccines before departure.

Routinely recommended vaccines (not specific to travelling overseas)

Vaccinate all prospective travellers according to the recommended vaccination schedule appropriate for their age, underlying health conditions, occupation and lifestyle. Vaccines might include, for example, pneumococcal polysaccharide vaccine for an older person, or hepatitis B vaccine for a first aid officer. 

Also ensure that all children are vaccinated according to the National Immunisation Program schedule. In exceptional circumstances, give the National Immunisation Program vaccines at the minimum age rather than the recommended age (see Table. Minimum acceptable age for the 1st dose of scheduled vaccines in infants in special circumstances ). Children vaccinated using the minimum age rather than the recommended age may need extra vaccine doses to ensure adequate protection. Observe the minimum interval requirements between doses (see Table. Minimum acceptable dose intervals for children <10 years of age ). The chances of being exposed to some diseases, such as measles and mumps, may be greater during overseas travel, even to other developed countries.

For some itineraries, it may be appropriate for the traveller to receive some booster doses earlier than the routine recommended time. An example may be diphtheria-tetanus booster.

Diphtheria, tetanus and pertussis

Vaccinate adult travellers against tetanus before departure, particularly if:

• their risk of sustaining a tetanus-prone wound is high
• there could be delays in accessing health services where they can receive tetanus toxoid boosters safely, if required

Offer dTpa vaccine during a pre-travel consultation if the traveller has never received a dose of dTpa . This provides protection against pertussis (see Pertussis ). 

For high-risk travel, consider giving a booster dose of either dTpa or dT vaccine if more than 5 years have passed (see Tetanus ).

Hepatitis B

Most Australian children born since 2000 have been vaccinated against hepatitis B under the National Immunisation Program or state and territory school-based vaccination programs.

Hepatitis B vaccine is recommended for long-term or frequent travellers to regions of intermediate or high endemicity of hepatitis B, including:

• Central and South America

This is because travellers may be exposed to hepatitis B virus through bloodborne routes (including during emergency medical or dental procedures) or sexual routes. According to 1 survey, about half of Australian travellers who spent at least 3 nights in Southeast or East Asia participated in at least 1 activity that had a risk of hepatitis B transmission. 13

See also Hepatitis B .

Influenza and pneumococcal disease

Older travellers and those with any relevant underlying medical or behavioural risk factors should receive pneumococcal vaccine. See Pneumococcal disease for more details.

Consider influenza vaccine for all travellers, especially if they are travelling to a region during its influenza season. Influenza vaccine is particularly relevant if:

• there is an influenza epidemic at the traveller’s destination
• the person is travelling in a large tourist group, especially one that includes older people
• the person is travelling on cruises, where people are relatively confined for days to weeks

See also Influenza. 

Measles, mumps and rubella

Inadequately vaccinated young adult travellers are responsible for most current measles outbreaks in Australia. This occurs when they acquire the infection overseas and bring it back to Australia. Some countries, regions or communities — including developed countries — have a higher incidence of measles and mumps than Australia. 9

Australians born during or since 1966 who have not received the recommended 2 doses of MMR (measles-mumps-rubella)–containing vaccines are recommended to receive MMR vaccine before travelling. This also applies to infants 6–12 months old travelling to areas with measles outbreaks or where measles is endemic . The exception is for pregnant women, because MMR is a live vaccine and is contraindicated in pregnancy. 

People born before 1966 do not need to receive measles-containing vaccine (unless serological evidence indicates that they are not immune). This is because circulating measles virus and disease were prevalent before 1966, so most people would have acquired immunity from natural infection .

However, confirmed cases of measles have occurred in people born before 1966. 14 If in doubt about a person’s immunity, it may be faster and easier to vaccinate the person than conduct serological testing . See Serological testing for immunity to measles . 

See also Measles . 

Unvaccinated travellers are recommended to receive varicella vaccine if they either:

• have not had clinical disease, or
• have an uncertain history of clinical disease and serology shows a lack of immunity 

The exception is for pregnant women, because varicella vaccine is a live vaccine and is contraindicated in pregnancy.

See also Varicella .

Meningococcal disease

Vaccination against meningococcal serogroups A, C, W-135, Y and B is recommended for certain age and population groups who are at increased risk of meningococcal disease.

In addition, MenACWY (quadrivalent meningococcal) vaccine is recommended for people who are:

• planning travel to, or living in, parts of the world where epidemics of serogroup A, C, W-135 or Y meningococcal disease occur, particularly the ‘meningitis belt’ of sub-Saharan Africa 15
• planning travel to mass gatherings, such as pilgrims travelling to the Hajj in Saudi Arabia

Seek up-to-date epidemiological information to determine whether a traveller needs meningococcal vaccination. See Accessing up-to-date travel information.

The Saudi Arabian authorities require that all pilgrims travelling to Mecca (for the Hajj or Umra) have evidence of recent vaccination with the quadrivalent meningococcal vaccine. 16  See Requirements for travellers to Mecca and Accessing up-to-date travel information .

See also Meningococcal disease .

Poliomyelitis

Ensure that all travellers are age-appropriately vaccinated against polio (see Poliomyelitis ).

If the person is travelling to a country where wild poliovirus is still circulating, they should receive inactivated poliovirus ( IPV ) vaccine if they have not completed a 3-dose primary course of any polio vaccine. Travellers who have completed the primary course should receive a single booster dose.

The World Health Organization (WHO) Global Polio Eradication Initiative website website has an up-to-date list of polio-affected countries.

Documented evidence of polio vaccination is not routinely required for travellers under the International Health Regulations. However, documented evidence of vaccination may be temporarily required according to WHO recommendations in response to new evidence of the spread of wild poliovirus (see Vaccines required by the International Health Regulations or for entry into specific countries and Documentation and certificates ).

International polio epidemiology and associated travel requirements can change. Check the Australian Government Department of Health website for current recommendations for Australian travellers .

Ensure that all travellers are age-appropriately vaccinated against COVID-19. Foreign governments may require evidence of COVID-19 vaccination before a traveller is allowed to enter. The Australian-issued International COVID-19 Vaccination Certificate is a secure way to prove COVID-19 vaccination history that has been developed to meet agreed international travel standards. Parents and carers of children <14 years of age, adolescents ≥14 years of age and adults can get a copy of their COVID-19 vaccination certificate at any time:

• using their Medicare online account through myGov
• through the Medicare Express Plus mobile app
• by calling 1800 653 809 (free call)

See also COVID-19 .

Vaccines based on travel itinerary, activities and likely risk of disease exposure

Use a risk assessment approach when recommending travel vaccines. Weigh the potential risks of disease exposure and protective benefits from vaccination against potential adverse effects, and the non-financial and financial costs of vaccination.

Prioritise vaccines for diseases that are:

• common and of significant impact, such as influenza and hepatitis A
• less common, but have severe potential adverse outcomes, such as Japanese encephalitis and rabies

Consider booster doses, where appropriate (see disease-specific chapters in this Handbook for recommendations). If the person is departing for travel soon, consider an accelerated schedule, if appropriate, such as for hepatitis B vaccine or the combination hepatitis A-hepatitis B vaccine (see Hepatitis A and Hepatitis B ). Although immunity may be established sooner with the accelerated schedule, people who receive an accelerated schedule need another dose about a year later to complete the course and ensure long-term protection.

Most travellers do not need cholera vaccine. 16,17  The risk of a traveller acquiring cholera is very low if they avoid contaminated food and water.

No country requires travellers to have certification of cholera vaccination. No country has official entry requirements for cholera vaccination

See also Cholera .

Hepatitis A

Hepatitis A vaccine is recommended for all travellers ≥1 year of age travelling to moderately or highly endemic countries (including all developing countries). The exceptions are people who have evidence of natural immunity after previous infection .

Normal human immunoglobulin is no longer used to protect travellers against hepatitis A.

See also Hepatitis A .

Japanese encephalitis

While now considered an emerging disease in Australia, Japanese Encephalitis is more likely in travellers to endemic regions overseas. 18 Japanese encephalitis ( JE ) vaccine is recommended for travellers spending a month or more in endemic areas in Asia, Papua New Guinea or the outer islands of Torres Strait during the JE virus transmission season.

Consider JE vaccination for shorter-term travellers, particularly if:

• travel is during the wet season 
• travel may be repeated
• the person will spend a lot of time outdoors 
• the person’s accommodation has no air-conditioning, screens or bed nets

Check a reputable source before travel for information about JE virus activity — for example, Health Information for International Travel (the ‘Yellow Book’) . 19

A traveller’s overall risk of acquiring JE in these JE - endemic countries is likely to be low (<1 case per 1 million travellers). Determine the specific risk according to the: 17

• season of travel
• regions visited 
• duration of travel
• extent of outdoor activity
• extent to which the person avoids mosquito bites 

See also Japanese encephalitis .

Before travel to rabies- endemic regions, advise people about:

• the risk of rabies infection
• avoiding close contact with wild, stray and domestic animals — especially dogs, cats, monkeys and bats 
• the importance of appropriate immediate wound care of all animal bites and scratches 

See also Rabies and other lyssaviruses, including Australian bat lyssavirus .

Recommendations for rabies vaccination as pre-exposure prophylaxis

When deciding whether to give a pre-travel prophylactic rabies vaccination, assess the:

• likelihood of exposure to potentially rabid animals
• access to appropriate health care and availability of post-exposure prophylaxis , including rabies immunoglobulin , should there be an at-risk exposure
• timeliness of access to health care after exposure

Use a lower threshold for recommending rabies pre-exposure prophylaxis for children travelling to endemic areas.

Benefits of vaccination as pre-exposure prophylaxis

Pre-travel rabies vaccination:

• ensures that the traveller has received a safe and efficacious vaccine
• simplifies the management of a subsequent exposure because the person will need fewer doses of vaccine
• means that rabies immunoglobulin — which is often extremely expensive, and difficult or even impossible to obtain in many developing countries — is not needed
• reduces the urgency of post-exposure prophylaxis

Tick-borne encephalitis

Tick-borne encephalitis (TBE) is caused by a tick-borne RNA flavivirus. The disease may involve the central nervous system. TBE is prevalent in parts of central and northern European temperate regions, and across northern Asia. Travellers are at risk when hiking or camping in forested areas in endemic regions during the summer months.

Safe and effective vaccines are available. Vaccination is recommended only for people with a high risk of exposure.

TBE vaccine is not registered in Australia, but a small stock of vaccine may be available for use under the Special Access Scheme .

Tuberculosis

Vaccination with BCG (bacille Calmette–Guérin) vaccine is generally recommended for tuberculin-negative children <5 years of age who will be staying in high-risk countries for an extended period (3 months or longer).

Vaccinating older children and adults appears to be less beneficial. However, consider vaccinating tuberculin-negative children aged ≥5 years but <16 years who may be living or travelling for long periods in high-risk countries.

A high-risk country is one that has a tuberculosis incidence of >40 per 100,000 population.

For travellers who need BCG vaccine, consider the following precautions when scheduling their vaccination visits:

• If possible, give BCG vaccine at least 3 months before the person will arrive in an endemic area.
• Give other live viral vaccines (for example, MMR , varicella, yellow fever) at the same time or with a minimum 4-week interval after BCG vaccination.
• A tuberculin skin test (TST; Mantoux), performed by trained and accredited healthcare practitioners, is recommended before receiving BCG vaccine for all individuals (except infants aged <6 months).
• People may suppress reactions to tuberculin for 4–6 weeks after viral infections or live viral vaccines, particularly measles infection and measles-containing vaccines.

State and territory tuberculosis services can provide tuberculin skin tests and BCG vaccine.

See also Tuberculosis .

Typhoid vaccine may be recommended for travellers ≥2 years of age travelling to endemic regions, including: 

• the Indian subcontinent
• most Southeast Asian countries 
• several South Pacific nations, including Papua New Guinea 

This advice is also relevant for those travelling to endemic regions to visit friends and relatives.

Inactivated parenteral and live oral typhoid vaccine formulations are available.

See also Typhoid fever .

Yellow fever

Yellow fever vaccine is recommended for all people ≥9 months of age travelling to, or living in, an area with a risk of yellow fever virus transmission. 20

To minimise the risk of introducing yellow fever, some countries require documented evidence of yellow fever vaccination for entry, in line with the International Health Regulations (see Vaccines required by the International Health Regulations or for entry into specific countries ).

When assessing the need for yellow fever vaccination, consider:

• the risk of the person being infected with yellow fever virus
• country entry requirements
• individual factors such as age, pregnancy and underlying medical conditions 

Vaccination is generally not recommended for travel to areas with a low probability of yellow fever virus exposure — that is: 

• where human yellow fever cases have never been reported 
• where evidence suggests only low levels of yellow fever virus transmission in the past 

However, consider vaccination for a small subset of travellers to lower-risk areas who are at increased risk of exposure to mosquitoes or who are unable to avoid mosquito bites. 20

People aged ≥60 years are at increased risk of severe adverse events after primary yellow fever vaccination. Weigh the adverse effects of vaccinating people in this age group against the potential for yellow fever virus exposure and, in turn, the benefits of vaccination. 17

See also Yellow fever .

Booster doses

Most people do not need a booster dose of yellow fever vaccine. A single dose induces protective antibody levels that last for many decades. However, certain people are recommended to receive a booster if their last dose was more than 10 years ago and they are at ongoing risk of yellow fever virus infection . See Yellow fever .

Vaccines required by the International Health Regulations or for entry into specific countries

Yellow fever requirements.

The International Health Regulations require yellow fever vaccination for travelling in certain circumstances. This is to:

• protect travellers who are likely to be exposed to yellow fever 
• stop importation of the virus into countries that have the relevant vectors (see Yellow fever ).

Some countries may require documented evidence of yellow fever vaccination as a condition of entry or exit (see Planning and documenting vaccines ). This includes countries that do not currently have yellow fever circulating.

Australia’s yellow fever travel requirements are detailed in the Australian Government Department of Health’s yellow fever fact sheet .

Contact the relevant embassies or consulates in Australia to confirm the entry requirements for yellow fever vaccination for the countries a traveller intends to enter or transit through. 

Requirements for travellers to Mecca

Each year, Saudi Arabia’s Ministry of Health publishes the requirements and recommendations for entry visas for travellers on pilgrimage to Mecca (Hajj and Umra). 16

For pilgrims travelling directly from Australia, only evidence of MenACWY vaccination is currently mandatory. However, check the current requirements when advising prospective Hajj and Umra pilgrims (see Meningococcal disease and Accessing up-to-date travel information ).

Temporary requirements

The International Health Regulations may temporarily introduce requirements for other vaccine-preventable diseases in response to changes in disease epidemiology that are of international health concern. An example is for polio vaccination.

Because country vaccination requirements are subject to change at any time, confirm all current vaccination requirements for the countries a traveller intends to enter or transit through before travel. See Poliomyelitis and Accessing up-to-date travel information .

Planning and documenting vaccines

Ideally, start vaccination courses early enough before departure to allow:

• monitoring of any possible adverse events 
• time for adequate immunity to develop

Requirements for multiple vaccines

A traveller may need multiple vaccines before they depart. Apply the standard recommendations and precautions when giving multiple vaccines (see Administration of vaccines ).

A traveller may need more than 1 clinic visit if they need multiple vaccines or doses (for example, rabies pre-exposure prophylaxis or hepatitis B vaccine). Pay special attention to scheduling of these visits, and consider:

• dose interval precautions (for example, for multiple live vaccines)
• requirements for pre-vaccination tests (for example, tuberculin skin test)
• potential interference by some antimalarials, if relevant (for example, rabies vaccine)

Documentation and certificates

It is important to document travel vaccines: 

• in the clinic’s record
• in the traveller’s record that they can carry with them 
• on the Australian Immunisation Register

The record should also include all the other routinely recommended vaccines that the traveller has ever received. 

For yellow fever vaccination, a traveller needs to have an International Certificate of Vaccination or Prophylaxis (ICVP), which only Yellow Fever Vaccination Centres can provide under the International Health Regulations (see Yellow fever ). 

Travellers may also need an ICVP for other vaccine-preventable diseases, such as polio, based on temporary recommendations.

See also Accessing up-to-date travel information .

Vaccinating travellers with special risk factors

See Vaccination for women who are planning pregnancy, pregnant or breastfeeding , Vaccination for people who are immunocompromised and the disease-specific chapters in this Handbook for recommendations for travellers who are pregnant or immunocompromised.

Accessing up-to-date travel information

International travellers’ health risks constantly change. Up-to-date information, and knowledge of the changing epidemiology and current outbreaks of infectious and emerging diseases are essential. Reliable online information sources include:

• World Health Organization (WHO) for disease outbreak news, and its Travel and health section for specific advice on travel and health, including travel vaccination recommendations
• Travelers’ health , United States Centers for Disease Control and Prevention (CDC)
• Travel health information , Australian Government Department of Health
• Smartraveller , the Australian Government’s travel advisory and consular information service, which provides up-to-date advice about health, safety and other risks of specific destinations for Australian travellers

The following resources have comprehensive technical advice on international travel and health, including vaccination:

• the latest edition of WHO’s International travel and health
• the CDC’s Health Information for International Travel (the ‘Yellow Book’)
• Australian Bureau of Statistics. 3401.0 – Overseas arrivals and departures, Australia, Mar 2018 (accessed May 2018). 
• Paudel P, Raina C, Zwar N, et al. Risk activities and pre-travel health seeking practices of notified cases of imported infectious diseases in Australia. Journal of Travel Medicine 2017;24(5):tax044.
• Heywood AE, Watkins RE, Iamsirithaworn S, Nilvarangkul K, MacIntyre CR. A cross-sectional study of pre-travel health-seeking practices among travelers departing Sydney and Bangkok airports. BMC Public Health 2012;12:321.
• Chen LH, Leder K, Barbre KA, et al. Business travel-associated illness: a GeoSentinel analysis. Journal of Travel Medicine 2018;25.
• Angelo KM, Kozarsky PE, Ryan ET, Chen LH, Sotir MJ. What proportion of international travellers acquire a travel-related illness? A review of the literature. Journal of Travel Medicine 2017;24.
• Freedman DO, Weld LH, Kozarsky PE, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. New England Journal of Medicine 2006;354:119-30.
• Halstead SB, Hills SL, Dubischar K. Japanese encephalitis vaccines. In: Plotkin SA, Orenstein WA, Offit PA, Edwards KM, eds. Plotkin's vaccines. 7th ed. Philadelphia, PA: Elsevier; 2018.
• Staples JE , Monath TP, Gershman MD, Barrett AD. Yellow fever vaccines. In: Plotkin SA, Orenstein WA, Offit PA, Edwards KM, eds. Plotkin's vaccines. 7th ed. Philadelphia, PA: Elsevier; 2018.
• World Health Organization (WHO). Chapter 6: Vaccine-preventable diseases and vaccines . In: International travel and health. Geneva: WHO; 2017. 
• Steffen R. Travel vaccine preventable diseases-updated logarithmic scale with monthly incidence rates. Journal of Travel Medicine 2018;25.
• Denholm JT, Thevarajan I. Tuberculosis and the traveller: evaluating and reducing risk through travel consultation. Journal of Travel Medicine 2016;23.
• Lachish T, Tenenboim S, Schwartz E. 35 - Humanitarian Aid Workers. In: Keystone JS, Kozarsky PE, Connor BA, et al., eds. Travel Medicine (Fourth Edition). London: Elsevier; 2019. (Accessed 6 July 2023). https://www.sciencedirect.com/science/article/pii/B9780323546966000355
• Leggat PA, Zwar NA, Hudson BJ. Hepatitis B risks and immunisation coverage amongst Australians travelling to Southeast Asia and East Asia. Travel Medicine and Infectious Disease 2009;7:344-9.
• Winkler NE, Dey A, Quinn HE, et al. Australian vaccine preventable disease epidemiological review series: measles, 2012-2019. Commun Dis Intell (2018) 2022;46.
• World Health Organization (WHO). Epidemic meningitis control in countries of the African meningitis belt, 2017. Weekly Epidemiological Record 2018;93:173-84.
• World Health Organization (WHO). International travel and health: health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj) . 2017 (accessed May 2018). 
• Freedman DO, Chen LH. Vaccines for International Travel. Mayo Clinic Proceedings 2019;94:2314-39.
• Furuya-Kanamori L, Gyawali N, Mills DJ, et al. The Emergence of Japanese Encephalitis in Australia and the Implications for a Vaccination Strategy. Trop Med Infect Dis 2022;7.
• Hills SL, Rabe IB, Fischer M. Infectious diseases related to travel: Japanese encephalitis . In: CDC yellow book 2018: health information for international travel. New York: Oxford University Press; 2017. 
• World Health Organization (WHO). International travel and health (accessed Apr 2018). 

Page history

Minor updates to clinical guidance around routinely recommended vaccines (not specific to travelling overseas), including the addition of advice regarding COVID-19.

Editorial update to reflect changes to pneumococcal vaccine recommendations for older adults and people with medical risk factors.

Guidance on vaccination of travellers against measles, mumps and rubella updated to reflect advice in the Measles chapter.

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The Department of Health and Aged Care acknowledges First Nations peoples as the Traditional Owners of Country throughout Australia, and their continuing connection to land, sea and community. We pay our respects to them and their cultures, and to all Elders both past and present.

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• v.152(4); Jul-Aug 2019

Travelers’ diarrhea: Clinical practice guidelines for pharmacists

Introduction.

Travelers’ diarrhea (TD) is the most common travel-related illness, affecting up to 70% of travelers to certain destinations. 1 Its etiology is predominantly bacterial, representing approximately 80% to 90% of illnesses, 1 including diarrheagenic Escherichia coli, Salmonella, Shigella and Campylobacter species, but it can also be caused by parasites, such as Giardia and Cryptosporidium , and viruses, such as norovirus. 1 , 2 Opportunity costs, changes to trip itineraries and seeking medical care abroad are just some of the consequences that can result from a bout of TD. Emerging data have affected the recommendations for the prevention and treatment of TD, resulting in the publication of a set of guidelines for the condition in a 2017 supplement to the Journal of Travel Medicine . 3 As highly accessible experts in pharmacotherapy, pharmacists are well positioned to address travel-related concerns, particularly regarding TD, at both the prescription counter and over-the-counter (OTC) aisle. Pharmacists can draw from the guidelines to ensure patients are counselled on safe and appropriate antibiotic therapy during international travel and can direct patients to important nonprescription products supported by the guidelines and provide advice on their safe and effective use. This article summarizes the key recommendations from the 2017 guidelines of interest to practising community pharmacists. Readers requiring additional information are encouraged to consult the full guideline publication. 3

Development of the guidelines

The International Society of Travel Medicine (ISTM) used a panel of experts with relevant experience in the disease’s management to formulate the Guidelines for the Prevention and Treatment of Travelers’ Diarrhea: A Graded Expert Panel Report. Despite ISTM not having a designated process and resources to develop clinical practice guidelines, the panel members attempted to follow the Institute of Medicine guideline standards and Grades of Recommendations, Assessment, Development and Evaluation (GRADE) framework. 3 Each recommendation in the guideline underwent the same procedures: “Recommendation formulation [with a threshold of 80% agreement among panel members], grading the quality of evidence in terms of the confidence in the estimates of the efficacy and harms of the intervention and grading the strength of the recommendation based on the balance of harms and benefits and knowledge of the values and preferences of the travelers.” 3 Prior to publication, the manuscript was peer-reviewed by experts in infectious diseases and travel medicine who were not involved in the development of the guidelines. Readers seeking additional details on guideline development are referred to the Journal of Travel Medicine . 3

TD definitions

TD has previously been classified quantitatively, based on the number of loose bowel movements experienced in a day (e.g., mild = 1-2 stools/24 hours, moderate = 3-5 stools/24 hours and severe = 6-9 stools/24 hours). 4 , 5 Classification is now qualitative, based on the functional impact TD has on the patient and his or her ability to participate in activities planned during travel ( Table 1 ).

Classifications of travelers’ diarrhea

Patients should be counselled on these definitions in order to properly recognize when to begin self-treatment and which treatments should be used (discussed below). It is important to emphasize the “functional impact” when educating, so that travelers can recognize the form of illness they are experiencing. For example, 1 episode with severe fever, cramping and bloody stools may be more impairing than 4 unformed stools without any other symptoms. Furthermore, as severe dysentery TD is typically accompanied by a fever, and traveling patients will likely not be carrying a thermometer, pharmacists should discuss its symptomatology so that patients can recognize this severe form of illness. Pharmacists should advise patients to seek medical assessment for TD lasting longer than 14 days, as persistent diarrhea may be associated with a higher frequency of certain bacteria, protozoal pathogens or other noninfectious conditions that may require targeted diagnosis and treatment.

TD prophylaxis

Antimicrobial resistance is a serious global health issue, necessitating the judicious use of antibiotics. For most travelers, antibiotics should not routinely be used for TD prophylaxis. However, antimicrobial prophylaxis can be considered for patients at a high risk for complications secondary to TD, such as those who have a clinically significant history of potential additional morbidity following an enteric infection (e.g., inflammatory bowel disease, reactive arthritis) or a chronic illness that predisposes them to TD (e.g., achlorhydria, gastrectomy) or its complications (e.g., immunocompromised, diabetes, renal dysfunction). 3 Other individuals who may be considered for TD prophylaxis include travelers who cannot afford to become sick with TD due to occupation or itinerary reasons (e.g., athlete in competition, musician, politician). 3 Because of the rapid efficacy of TD self-treatment and increasing rates of antimicrobial resistance, individual risk-benefit assessments and appropriate counselling must be performed before considering prophylaxis.

TD prophylaxis can be employed without antibiotics through the use of bismuth subsalicylate. Doses of 2.1 g/day or 4.2 g/day in 4 divided doses (with meals and bedtime) in either the liquid or tablet form have been studied and demonstrated a consistent protective effect against TD, upwards of 60%. 6 - 8 Despite robust evidence, its adverse effects, most commonly including black tongue and stools and least commonly being tinnitus, can be undesirable for traveling patients. 6 In addition, its contraindications in pediatric, pregnant, aspirin-allergic and aspirin-taking patients limit its use in the prevention of TD, and its frequent dosing may also affect adherence.

If antibiotic prophylaxis is warranted in a traveling patient, rifaximin is advised, 3 based on strong evidence of effectiveness, minimal antimicrobial resistance (excluding Campylobacter spp.) and favourable safety profile, as it is not systemically absorbed. Because of its resistance to Campylobacter spp., its effectiveness may not be as assured in South and Southeast Asia, where Campylobacter infection is more common. While 600 mg orally once daily is the standard prophylaxis dose for rifaximin, readers should be aware that it is currently available only in Canada as 550 mg tablets. The Committee to Advise on Tropical Medicine and Travel guidelines do not consider this difference in dose to be clinically significant 9 and therefore recommend that a regimen of 550 mg once daily can be used by Canadian travelers. The trials supporting rifaximin’s strong prophylactic protection against TD used a range of dosing regimens, from 200 mg to 1100 mg divided 1 to 3 times daily. 10 - 14 However, because of the risk of missing doses and the observed rebound infection following discontinuation of the drug, some clinicians advocate for a twice-daily regimen (200 mg or 550 mg) based on expert opinion. It should also be noted that effectiveness and safety have not been demonstrated beyond 2 weeks in multiple trials and thus may represent the best solution for short-term protection when needed. 15

Although they have long been prescribed for prophylaxis, fluoroquinolones are no longer recommended for prophylaxis of TD because of the emerging resistance of enteric pathogens. The use of fluoroquinolones exposes patients to potential harm to the peripheral and central nervous system, tendons, muscles and joints, as well as the possibility of Clostridium difficile –associated diarrhea. Therefore, based on its high-risk and low-benefit profile, the guidelines do not recommend the use of fluoroquinolones in TD prophylaxis. In addition, recommendations regarding azithromycin’s prophylactic use have not been determined in the 2017 guidelines. 3

Pharmacists are reminded to encourage patients to also practise food and water precautions to minimize their risk of exposure to TD-causing organisms. Frequent handwashing, especially prior to meals, with warm soap and water or the use of an alcohol-based hand sanitizer with ≥60% alcohol is recommended. 16 It is safest to eat food that is fully cooked and served hot, as raw or undercooked meals containing meat and fish are likely to be contaminated. 16 When selecting foods to eat abroad where hygiene and sanitation are inadequate or unknown, travelers should also be advised to avoid unpasteurized fruit juices, milks or cheeses, produce washed in local water sources and raw fruits that are unpeeled (e.g., strawberries), as opposed to fruits that are peeled by the traveler (e.g., bananas and mangoes). 16 Commercially bottled water with a preserved seal should be recommended for drinking, preparing food and beverages, making ice and brushing teeth. 16

Therapy for mild TD

Most cases of TD can be classified as mild: otherwise tolerable, nondistressing and does not interfere with planned activities. Because of increasing antimicrobial resistance and concerns regarding multidrug-resistant organisms, antibiotic conservation is advised. Therefore, antibiotic treatment is not recommended in patients with mild TD. Instead, supportive measures such as oral rehydration therapy and nonantibiotic, antimotility drugs such as loperamide can be used. Loperamide’s use in mild TD has been shown to decrease the duration of diarrhea and the frequency of passing unformed stools. 17 - 19 Although previously discouraged for TD treatment because of its antimotility effects and concerns about potential retention of pathogens in the gut, a number of observational studies support the safe and effective use of loperamide in the treatment of mild TD. 20 , 21

Loperamide and bismuth subsalicylate are the 2 OTC products with the most supportive evidence, with stronger evidence favoring loperamide over bismuth subsalicylate. 17 Other agents, such as activated charcoal or dimenhydrinate, are not recommended. Although loperamide is the recommended first-line agent, patients should be informed that if the diarrhea worsens or is accompanied by moderate-severe or invasive symptoms (1 or more of fever, moderate to severe abdominal pain or bloody diarrhea), then antibiotics should be used ( Table 2 ). To ensure ready access to antibiotic treatment if required while traveling, prescriptions should be dispensed to most travelers in advance of their departure. Filling medications at a Canadian pharmacy also prevents the exhaustion of the destination country’s medication supply and prevents the possible ingestion of international substandard or falsified medications. 22

Summary of treatment recommendations based on Canadian product availability

po, orally.

Therapy for moderate TD

TD can affect both a traveler’s well-being and finances, as illness may require the rebooking of flights, cancellation of major excursions and missing activities on the traveler’s itinerary. Patients with moderate illness may be treated with antibiotics, with or without adjunctive loperamide. Timely and effective self-treatment with antibiotics in moderate TD reduces the duration of illness to approximately 36 hours, with further reduction to less than 12 hours from combination therapy with loperamide. 9 , 23 - 25 Potential risks from antibiotic therapy, including the potential for acquisition of extended-spectrum beta-lactamase–producing Enterobacteriaceae (ESBL-PE) and C. difficile infection, must be weighed for each individual traveler against the benefits: (1) potentially favourable safety profiles from single-dose regimens and (2) theoretical mitigation of risk of developing long-term TD sequelae such as postinfectious irritable bowel syndrome. 20 , 26 - 30 However, more studies evaluating the nature and impact of these theoretical risks and benefits are needed.

Several class- and regimen-specific factors should be considered when choosing an antibiotic. Despite observational data of globally increasing resistance rates, 31 fluoroquinolones may still be used in the treatment of moderate TD. However, their use should be avoided in Southeast and South Asia, as widespread resistance, particularly against Campylobacter spp., has resulted in documented clinical failure. 32 These resistance rates and safety concerns regarding their potential for intestinal microbiota imbalance and musculoskeletal consequences have resulted in a nonunanimous recommendation by the guideline’s expert panel. Canadian readers should note that while ofloxacin is a fluoroquinolone listed for TD treatment in the guidelines, it is not currently marketed in an oral formulation in Canada. As an alternative to fluoroquinolones, azithromycin may also be considered for moderate TD, as studies indicate there is no significant difference in efficacy between azithromycin and fluoroquinolones. 9 However, it should be noted that as the TD classification changes from moderate to severe, the 2017 guidelines prefer azithromycin as the primary treatment option (discussed below). 3 Apart from concerns in Nepal, azithromycin has limited global resistance, and despite requiring increased concentrations to inhibit enterotoxigenic and enteroaggregative E. coli (ETEC and EAEC, respectively), this has not yet resulted in documented clinical failure. It also has a much more tolerable safety profile compared with fluoroquinolones, with the exception of nausea and vomiting, particularly when the single dose of 1000 mg is ingested. However, both azithromycin and fluoroquinolones potentially expose certain patients to the risk of QT prolongation and must be carefully considered for patients at risk of this, including those with a QTc interval >500 ms, advanced age, female sex and concomitant QTc-prolonging medications, such as some antidepressants and antipsychotics. 33

Finally, the guidelines also recommend rifaximin as another alternative for moderate TD. However, as the only rifaximin products currently licensed in Canada are 550 mg tablets, and the splitting of tablets is not recommended by the manufacturer, 34 product availability prevents Canadian patients from accessing the recommended treatment dose of 200 mg 3 times daily unless they purchase it abroad. As a poorly absorbed antibiotic, it has an excellent safety profile and limited global resistance rates; however, its use is cautioned for travel to regions with a high risk of invasive pathogens, such as Campylobacter, Shigella and Salmonella , because of its poor clinical success against these species. 35 , 36 A recent trial evaluating single high-dose rifaximin (1650 mg) in combination with loperamide was found to be comparable to single-dose levofloxacin (500 mg) and azithromycin (500 mg), with clinical cures of about 14 hours. 37

As mentioned previously, loperamide may be used either in combination therapy with antibiotics or as monotherapy for moderate TD. Its quick onset when used with antibiotics provides symptomatic relief in addition to curative treatment. Concerns about adverse effects, including disruption of the diversity of intestinal flora and ESBL-PE colonization, surrounding combination therapy remain unsubstantiated. Despite the apprehension of increasing a TD patient’s exposure to pathogens when motility is slowed, loperamide’s studied effectiveness has led to its safe recommendation as a solo therapy in nonsevere TD. 3 Other than constipation, which may occur from patients taking doses at too frequent intervals (patients should be advised that it has an onset of action of up to 1-2 hours), it is a well-tolerated agent. Combination therapy with loperamide has consistently demonstrated an advantage in time to clinical cure compared with antibiotics alone.

BOX 1 Key points regarding travelers’ diarrhea for pharmacists

The release of the 2017 guidelines for the prevention and treatment of travelers’ diarrhea has resulted in significant changes in the management of travelers’ diarrhea, many of which affect community pharmacy practice. The key points of interest to pharmacists are summarized here:

• •  Classification of TD
•  ○ TD severity should be based on a patient’s self-determination:
•   □  Mild : Tolerable, nondistressing and does not interfere with planned activities
•   □  Moderate : Distressing or interfering with planned activities
•   □  Severe : Incapacitating or completing stopping all planned activities, including dysentery and nondysentery presentations
•   □  Persistent : Diarrhea lasting ≥2 weeks
• •  TD prophylaxis
•  ○ Prophylaxis is not routinely used but can be considered for patients at high risk of health-related complications secondary to TD such as:
•   □ prior clinically significant history of potential additional morbidity following an enteric infection (e.g., inflammatory bowel disease, reactive arthritis) and
•   □ chronic illness that predisposes patient to TD (e.g., achlorhydria, gastrectomy) or its complications (e.g., immunocompromised, diabetes, renal dysfunction).
•  ○ Prophylaxis may be considered for travelers who cannot afford to become sick with TD because of their occupation or itinerary reasons (e.g., athlete in competition, musician, politician).
•   □ Bismuth subsalicylate may be considered for most travelers as prophylaxis.
•   □ If antibiotic prophylaxis is indicated, rifaximin is the recommended agent.
• •  Mild TD
•  ○ Patients can use loperamide for the treatment of mild TD to decrease the duration of diarrhea and frequency of passing unformed stool.
• •  Moderate TD
•  ○ Functional impairment and itinerary changes are the main factors to consider when using self-determining to use antibiotics for moderate TD.
•   □ Antibiotic treatment options available in Canada are azithromycin and fluoroquinolones (when traveling outside of Southeast Asia).
•   □ Because of emerging global resistance and efficacy, pharmacists may notice a shift in prescribing practices, in which azithromycin is used as the first-line treatment for both moderate and severe TD.
•  ○ Loperamide can be used either alone or as an adjunct to antibiotics.
• •  Severe TD
•  ○ Travelers should be educated on how to self-diagnose dysentery (presence of blood in the stool, possibly accompanied by fever and/or abdominal pain) to determine appropriate treatment measures.
•  ○ Antibiotics should be used for severe travelers’ diarrhea, both dysentery and nondysentery, with azithromycin being the antibiotic of choice.
•   □ Loperamide may also be used as an adjunct to azithromycin, in the absence of dysentery.

Therapy for severe TD

Severe TD includes both nondysenteric watery diarrhea affecting a traveler’s quality of life and dysentery. Both presentations are important to consider and discern as this guides the antibiotic management options. The main distinction between the 2 types of severe diarrhea is the presence of blood in the stool (possibly accompanied by fever and/or abdominal pain), as this depicts the hallmark clinical presentation of dysentery.

BOX 2 Resources for additional information regarding travelers’ diarrhea and other travel-related concerns

• • International Society of Travel Medicine ( www.istm.org/ )
•  ○ ISTM offers a Certificate in Travel Health (CTH) to health care practitioners who have developed competency in providing travel medicine services. Pharmacists interested in expanding their knowledge and providing more comprehensive travel medicine services are encouraged to write the CTH examination.
• • Committee to Advise on Tropical Medicine and Travel ( www.canada.ca/en/public-health/services/travel-health/about-catmat.html )
• • Centre for Disease Control and Prevention Health Information for International Travel, otherwise known as the CDC Yellow Book ( wwwnc.cdc.gov/travel/page/yellowbook-home )
• • Travel Health Pro ( travelhealthpro.org.uk/ )
• • American College of Gastroenterology (ACG) Clinical Guideline: Diagnosis, Treatment and Prevention of Acute Diarrheal Infections in Adults 4
•  ○ Readers should note that information presented in this guideline related to definitions of TD and management options based on the number of loose stools has been redefined in more recent guidelines; however, the document still provides valuable guidance on symptom management.
• • Pharmacy5in5 TD Infographic ( https://uwaterloo.ca/pharmacy/sites/ca.pharmacy/files/uploads/files/tdinfographic.pdf )
•  ○ Pharmacy5in5 is a free online learning platform designed by pharmacists for pharmacists and pharmacy technicians. Pharmacists interested in testing their TD knowledge are encouraged to complete the module on TD.

For both nondysenteric and dysenteric TD, azithromycin is the preferred agent because of its low global resistance against invasive pathogens and tolerable safety profile. 38 - 41 A single-dose antibiotic regimen can be tried initially and continued daily for up to 3 days if symptoms are not resolved within 24 hours. Therefore, pharmacists should ensure patients are provided sufficient antibiotics to allow for both a single dose and a complete 3-day regimen. Fluoroquinolones may be used to treat severe, nondysenteric TD, provided the traveler is not going to Southeast or South Asia (due to Campylobacter resistance) and a proper risk-benefit assessment has been completed regarding its safety profile. Rifaximin may also be used to treat severe, nondysenteric TD, provided the traveler is not going to a region that has a high risk of invasive pathogens, due to the drug’s lack of efficacy against them. However, as mentioned, this product is not available in a suitable strength in Canada and would need to be acquired by patients abroad, limiting its applicability to Canadian travelers. As with moderate diarrhea, combination therapy consisting of antibiotics with loperamide improves time to clinical cure compared with antibiotics alone. However, the combination should not be employed when dysentery is present.

Additional consensus statements of interest to pharmacists

Despite their appeal, prebiotics and probiotics are not currently recommended to prevent or treat TD. More research is needed to determine their use in TD, as questions remain regarding formulation, dosing, strain or combination for the right condition or individual, knowledge of the host microbiome and mechanisms of action. 3 In addition, there is an emerging concern involving the association between travel, the use of antibiotics in TD and the colonization of multidrug-resistant organisms. Carriage is mostly transient but can be persistent 1 year posttravel in approximately 10% of travelers and transmitted to household contacts. 3 Pharmacists should discuss with patients this multidimensional risk regarding travel, TD and the use of antibiotics abroad. Female patients presenting with a urinary tract infection with recent travel should have a urine culture to ensure appropriate antibiotic choice.

Changes to the definitions of illness severity to be largely based on its functional impact on patients (and treatment recommendations based on these symptoms) make it increasingly important for pharmacists to have shared decision-making discussions with patients, considering their individual risk of TD or its complications, their itinerary and goals of their travel and their ability to cope with symptoms abroad. As patients will often need to make symptom assessment and treatment decisions without pharmacist assistance abroad, these discussions at the time of dispensing are especially important to ensure optimal outcomes. ■

Key points for pharmacists related to the prevention and treatment of TD are summarized in Box 1 and the provided infographic, with additional resources that may be of interest provided in Box 2.

Author Contributions: H. Fernandes initiated the article and wrote and reviewed the final draft. S. Houle, A. Johal and M. Riddle wrote and reviewed the final draft.

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding: The authors received no financial support for the research, authorship and/or publication of this article.

Fellowship ceremony welcomes new GPs in Mackay region

The Royal Australian College of GPs (RACGP) is celebrating new fellows at a ceremony today in Mackay, marking their entry into the profession as GP specialists.

Fellowship of the RACGP (FRACGP) reflects a doctor’s qualification and expertise as a specialist GP, following around 11 years of education, training, rigorous assessment, and experience in primary care.

Mackay Mayor Greg Williamson, Executive Director of Queensland Office of Rural and Remote Health Elisha McGuinness, several senior members of the James Cook University general practice training team, and representatives from the from the North Queensland Primary Health Network attended the ceremony alongside RACGP leaders and new fellows’ friends and families.

Mackay GP and RACGP President Dr Nicole Higgins led the ceremony and welcomed the newly fellowed GPs and emphasised the importance of having a GP to manage and maintain a community’s health.

“The evidence shows that having a regular GP is better than any wonder drug,” she said.

“For our new fellows, this is the culmination of 11 years of study and experience, in medical school, in the hospital system and learning, studying, and working with patients in general practice. Earning your fellowship means you’re ready to help your patients tackle any problem, from a broken bone or a period of mental health challenges, to a long-term illness or a condition your GP will help to manage with a team of other specialists and health professionals.

“With today’s ceremony, 20 new specialist GPs join the profession, and I’m especially proud two of my registrars are among them.

“These new GPs are ready to support their communities to thrive, so it’s important our governments and regulators support them to succeed as well. GPs have a depth and breadth of scope that that varies depending on where they live and the needs of their community. We keep our patients healthy and out of hospital, so it’s important that our state and federal governments support our GPs with appropriate funding and support them to work efficiently by ensuring they spend their time delivering quality care, not wrestling with overregulation or arcane hospital processes.”

Four out of five rural GPs are RACGP members, and the RACGP is the only specialist medical college in Australia that offers its Queensland members the opportunity to attend a standalone fellowship ceremony in a regional location, rather than having to travel to Brisbane.

RACGP Queensland Chair Dr Cathryn Hester joined Dr Higgins in welcoming the new fellows.

“It’s truly fantastic and heartening to be able to welcome 20 new GPs who have trained across North Queensland,” she said.

“The award of Fellowship of the RACGP is an outstanding achievement in anyone’s terms – the result of years of constant effort, long hours of study, and many years of clinical practice and patient contact have allowed our new fellows to attain this great honour.

“The admission to the specialty of general practice is a highlight of any medical career and recognition from a GP’s peers and college of their excellence in general practice. It shows confidence these new GPs are ready to serve their communities in the broad discipline of general practice independently. Congratulations to our new GPs, and to the experienced GP supervisors whose mentorship and teaching prepared them to be her today.”

Also in attendance were RACGP Queensland Deputy Chair Dr Aileen Traves, RACGP Rural Council representative Dr Konrad Kangru, RACGP Queensland Censor Dr Nick Hummel, other members of the RACGP Queensland Faculty Council.

Journalists and media outlets seeking comment and information from the RACGP can contact John Ronan, Ally Francis and Stuart Winthrope via:

• 03 8699 0992
• [email protected]

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Travel and immunosuppressant medication

The use of potent immunosuppressant medications is becoming more common, particularly the use of biologicals for a range of conditions such as rheumatoid arthritis and inflammatory bowel disease.

This article focuses on the implications of immunosuppressant medications for travel, including pre-travel vaccinations, minimising risks during travel and travelling with medicines.

Pre-travel risk assessment is essential to prepare for safe travel. Live vaccines are contraindicated in people with significant immunosuppression because of the higher risk of adverse events and vaccine-associated disease. Inactivated vaccines can be used but may be less effective. Assessing the degree of immunocompromise in patients taking immunosuppressants includes considering both the medications and the underlying conditions. An individualised approach, often involving expert input, is needed to provide pre-travel health advice and immunisation. Planning ahead for travel is needed to minimise risks.

More than ever before, people who are immunocompromised are wanting to travel. In the USA, it is estimated that people who are immunocompromised comprise 1–2% of patients seen in travel clinics, 1 and this is likely to increase with widening indications for immunosuppressant medications. Immune suppression may be caused by a medical condition such as human immunodeficiency virus (HIV), by medication (eg steroids and biological agents) or by treatments (eg radiotherapy). There are multiple reasons for the increase in the number of people with immunosuppression who are travelling.These reasons include more older people and those with long-term conditions travelling, the advent of highly effective antiretroviral medications that have transformed HIV into a long-term condition, and the increasing use of tumour necrosis factor (TNF) and other biological agents for a range of diseases including inflammatory bowel disease, autoimmune inflammatory rheumatic diseases and skin conditions such as psoriasis.

This article focuses on the implications of immunosuppressant medications for travel and does not cover the effects of underlying diseases such as HIV, malignancies including leukaemia and lymphoma, aplastic anaemia, anatomical or functional asplenia, multiple sclerosis, graft versus host disease, renal disease and congenital immune deficiencies. It should be noted that such patients can be immunocompromised even when not receiving treatment, and caution and a collaborative approach involving other members of their treating team will be needed if travel is planned. Case-by-case advice from the oncology, rheumatology or immunology team may need to be sought.

Pre-travel health advice

All travellers would benefit from pre-travel health advice, but it is particularly necessary for those who are taking immunosuppressant medication. Ideally this group would seek advice at least six weeks before departure. A defining feature of travel medicine is risk assessment, which involves a thorough evaluation of the traveller’s health status and medical and vaccination history, destination-specific risks including the epidemiology of infectious diseases in the region of travel and itinerary-specific risks including the length of travel, type of accommodation, urban versus rural travel, modes of transport and higher-risk activities. 2,3 As well as advice about infectious diseases, including vaccine-preventable disease, travellers need advice on food and water hygiene, mosquito avoidance, avoidance of animal bites, safety and security and any destination-specific risks. Travellers who have significant medical conditions should carry a health summary, including a list of current medications and any allergies.

Live vaccines pose particular risks of adverse effects and vaccine-related disease in patients who are immunocompromised. Live vaccines include Bacillus Calmette–Guérin (BCG); live attenuated influenza vaccine; yellow fever vaccine; herpes zoster vaccine; varicella vaccine; measles, mumps and rubella vaccine; rotavirus vaccine; live attenuated Japanese encephalitis vaccine and oral typhoid vaccine. Oral polio vaccine is also a live attenuated vaccine but is no longer available in Australia. The vaccines most likely to lead to vaccine-related disease caused by unchecked infection (replication) by the live vaccine virus or bacteria are BCG and vaccines that contain measles, mumps, rubella or varicella-zoster virus. 4 Inactivated vaccines do not have an increased risk of adverse effects for people who are immunocompromised but may be less effective. 1,4

For people who are severely immunocompromised and planning travel to high-risk destinations, the advice sometimes needs to be not to travel or to significantly modify the itinerary. In the pre-travel consultation context, this issue most commonly arises when people plan to travel to areas of yellow fever risk. Yellow fever vaccine is contraindicated in people with significant immunosuppression as there is a higher risk of serious adverse effects including both viscerotropic and neurotropic reactions. 1 These severe adverse reactions can be fatal, as viscerotropic adverse effects can lead to multiple organ failure. If a patient who is immunocompromised decides to travel to a yellow fever risk area, then a yellow fever vaccination waiver letter can be provided, but the patient needs to be aware that they are at risk of severe disease and death if exposed when unvaccinated.

As the most common source of pre-travel medical advice, 5 the general practitioner (GP) will be the starting point for pre-travel health advice for most patients. The patient’s regular GP will also have knowledge of the underlying condition, comorbidities and vaccination history. However, advice varies depending on the underlying condition, immunosuppressant medication, travel risks and particular vaccines indicated. Given this complexity, a team approach is often needed involving the GP, the treating specialist or an immunologist and, depending on the GP’s degree of expertise, a specialised travel medicine clinic. It is important to adequately document the advice given.

Assessing effects of medication on immune status

The first step is to assess the reasons for and extent of the traveller’s immune compromise. One of the most commonly used groups of medications that can cause immune compromise are corticosteroids. The nature of the underlying condition needs to be considered, but according to the US Centers for Disease Control and Prevention (CDC), 1 people are generally not significantly immunocompromised if they are receiving:

• short- or long-term daily or alternating day doses of <20 mg prednisolone or equivalent
• inhaled or topical steroids
• steroid injections (eg intra-articular)
• physiological doses of maintenance steroids.

Patients are considered immunocompetent if more than one month has passed since the end of a course of high-dose steroid (>20 mg prednisolone for >2 weeks).

Particular care is needed when steroids are being taken with other medications that affect the immune system, and non-GP specialist advice will often be needed.

Some medications are highly likely to cause severe immunocompromise. According to both The Australian immunisation handbook 4 and the CDC, 1 people taking any of the following categories of medication are considered severely immunocompromised:

• High-dose corticosteroids, defined as ≥2 mg/kg per day (20 mg) of prednisone or equivalent in people who weigh >10 kg, when administered for ≥2 weeks. These patients should not receive a live vaccine for ≥1 month after discontinuation of high-dose systemic corticosteroids.
• Alkylating agents such as cyclophosphamide.
• Antimetabolites such as azathioprine, 6-mercaptopurine and methotrexate. However, at usual doses (methotrexate ≤0.4 mg/kg/week, azathioprine ≤3 mg/kg/day, or 6-mercaptopurine ≤1.5 mg/kg/day), it is generally considered safe to use either the live attenuated herpes zoster vaccine or the recently approved inactivated vaccine. According to The Australian immunisation handbook , 4 this includes people ≥50 years of age who are also taking low-dose corticosteroids (<20 mg per day of prednisone-equivalent dose).
• Transplant-related immunosuppressive medications including cyclosporine and tacrolimus.
• Cancer chemotherapeutic agents.
• Tumour necrosis factor blockers such as etanercept, adalimumab, certolizumab pegol, golimumab and infliximab.
• Other biological agents, particularly lymphocyte-depleting agents (thymoglobulin or alemtuzumab) and B cell–depleting agents (rituximab).

There are a number of older disease-modifying antirheumatic medications (sulfasalazine, hydroxychloroquine) that do not cause immune suppression at usual doses.

The Australian immunisation handbook recommendations for live vaccines and corticosteroids are presented in Table 1. The advice from the UK is somewhat different. 6 UK recommendations are that live vaccines are contraindicated in travellers for three months after the cessation of high-dose (2 mg/kg or ≥40 mg per day for ≥7 days, or 1 mg/kg/day for one month) oral or rectal corticosteroids for conditions other than adrenal insufficiency.  

Immunosuppressive medication and inactivated vaccines

Immunosuppressive medications can also have an effect on the immune response to inactivated vaccines. According to the CDC, 1 if doses of inactivated vaccines are given within two weeks before or while receiving medications causing severe immunocompromise, they should be regarded as ineffective and not counted towards a primary vaccination schedule. There are some exceptions; for example, a response to hepatitis A, influenza and pneumococcal vaccines is seen in patients taking TNF blockers.

There are considerations for specific vaccines, as shown in Table 2.

Immunosuppressant medication and other risks during travel

People who are immunosuppressed either because of medications or underlying disease, or a combination of both, are at higher risk of severe or chronic enteric infections. Great care with sanitation, particularly hand washing, and food and fluid choices is needed. Providing antibiotics for self-treatment of traveller’s diarrhoea should be considered, but there is a potential for medication interactions among patients already taking medications for chronic medical conditions. Malaria prevention advice and choice of prophylaxis are similar to other travellers, but immunosuppression may predispose the person to more severe malaria should they become infected. Sun protection is also important, as some medications induce photosensitivity, and immunosuppression predisposes the patient to skin cancer.

Planning for future immunosuppression

For people with long-term conditions such as inflammatory rheumatic conditions, it may be possible to plan ahead for future travel and administer vaccines before commencing medications that cause significant immunocompromise. The Australian immunisation handbook recommends people receive all indicated live vaccines at least one month before starting immunosuppressive therapy. 4 In the case of inactivated vaccines, these can be given up to two weeks before commencing immunosuppressive medication.

Vaccination after withdrawal of immunosuppressant medication

Adding another layer of complexity is the fact that the period of time after discontinuation of immunosuppressive medication before a live vaccine can be administered varies between vaccines. The waiting times for vaccine administration after corticosteroids for a range of ages and dosage regimens are shown in Table 1. The general recommendation from The Australian immunisation handbook 4 is that people with rheumatic disease treated with biological or targeted synthetic disease-modifying antirheumatic medications should not receive live vaccines until at least 12 months after therapy has ended. However, expert advice is often needed regarding the most appropriate interval for the person and their individual circumstances.

Practicalities of travelling while taking immunosuppressant medication

For people with chronic conditions, including those taking immunosuppressant medication, travel involves careful risk assessment and planning. Discussion and shared decision making with a GP and other health advisers will be needed. Travel health insurance, including medical evacuation insurance, is important but may be difficult to obtain as many policies have an exclusion for pre-existing conditions. Researching the health services available at the travel destination is part of the planning. Planning ahead is also important for travelling with medicines to ensure sufficient supplies and adequate documentation. 6 In general, the Pharmaceutical Benefits Scheme allows up to a six-month supply of subsidised medications to be taken overseas for personal use. Medicines should be transported in their original packaging whenever possible and stored in cabin baggage rather than checked baggage. However, if the medicine is delivered via injection, prior approval from the airline will be needed. In general, the only documentation required by the airline is a doctor’s letter. Refrigeration of medicines during flight is seldom necessary. Travellers should avoid purchasing medicines in low-income countries if possible, as substandard and counterfeit medicines are common. 7

Did you know you can now log your CPD with a click of a button?

• Kotton CN, Kroger AT, Freedman DO. Immunocompromised travellers. In: Brunette GW, Nemhauser JB. CDC yellow book 2020: Health information for international travel. New York: Oxford University Press, 2017. p. 395–409. Search PubMed
• Aw B, Boraston S, Botten D, et al. Travel medicine: What’s involved? When to refer? Can Fam Physician 2014;60(12):1091–103. Search PubMed
• Leder K, Steffen R, Cramer JP, Greenaway C. Risk assessment in travel medicine: How to obtain, interpret, and use risk data for informing pre-travel advice. J Travel Med 2015;22(1):13–20. doi: 10.1111/jtm.12170. Search PubMed
• Australian Technical Advisory Group on Immunisation (ATAGI). The Australian immunisation handbook. Canberra: Australian Government Department of Health, 2018. Search PubMed
• Zwar N, Streeton CL. Pretravel advice and hepatitis A immunization among Australian travelers. J Travel Med 2007;14(1):31–36. doi: 10.1111/j.1708-8305.2006.00088.x. Search PubMed
• Public Health England. Immunisation against infectious disease. London: Public Health England, 2017. Search PubMed
• Zwar N. Travelling with medicines in 2018. Aust Prescr 2018;41(4):102–04. doi: 10.18773/austprescr.2018.034. Search PubMed

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The R&K Guide To Moscow

The World Cup is upon us, but you could argue that it’s already a relic from another era, a time when Putin was looking for peaceable engagement with the West, before he annexed Crimea and unleashed his trolls on the world. But if ordinary Russians are supposed to play the part of pariah, they haven’t been told. It has been a long time since Moscow was this pleasant to visit. The city center is safe, sanitized, ready for your visit. Yes, the calm is a sign of an increasingly efficient autocracy. But we’ve known Moscow through many iterations, and for the casual visitor, this is one of the best yet. (Visit our St. Petersburg guide here.)

How To Do Moscow

Quick hits what to eat, quick hits what to drink, quick hits what to see, features from moscow, more city guides, r&k insider.

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