Immunization Recommended for Travelers
Name Dosage Booster Comment
Hepatitis A – brand names (Havrix, Avaxim) or Twinrix (combined A&B) 0 and 6-12 months (2 doses)

Twinrix- 0, 1 and 6 months

Not recommended. No need to check Hepatitis A antibodies. Rapid schedule available with Twinrix, 0,7 and 21-30 days with booster at 1 year
Hepatitis B – Engerix, Recombivax or

Twinrix (combined A&B)

0,1 and 6 months, rapid schedule – 0,7 and 21-30 days with booster at 1 year Not indicated routinely. If antibody levels are low in persons at high risk – 3 booster doses Antibody levels do not need to be checked routinely
HPV (human papilloma virus vaccine)

Gardasil 9

3 doses (0, 1-2 and 6-12 months) from 15- through 26 years No need for booster doses Only 2 doses (0, and 6-12 months) are required if started below 15 years of age
Influenza or the flu Single dose at the start of the flu season Every year Vaccine contains the H1N1 component
Japanese Encephalitis

Inactivated vero cell vaccine (JEEV) or

Live SA 14-14-2 strain

(CD.JEVAX)

2 doses 28 days apart for JEEV

 

Single dose of CDJEVAX

Booster within 2 years for JEEV

 

booster in 1 year for long term protection

JEEV is similar to Ixiaro that is available in most Western countries
Meningococcal Quadrivalent A,C,Y, W135 (Menactra) – not required for travel to  Nepal Single dose as adult

Can be given to children from age 9 months onwards

Required for the Hajj, needed for travel to meningitis belt of Africa, or college entry into the USA
Pneumonia vaccines (PCV -13) followed by PPSV -23 Start at 65 years of age routinely. Single dose of PCV -13 followed by PPSV 23, one year later. If PPSV-23 was received before, PCV 13  one year later Please read details on page 4 of handout for earlier use of vaccines
Polio vaccine Primary series as child Adult booster not required since Nepal is polio- free Should have booster dose if coming in from polio exporting country
Rabies vaccine 0, 7 and 21 or 28 days No need for booster doses as immune memory stays strong Recommended for all residents esp. children, optional for travelers
Tetanus diphtheria (Td)

Tdap (Adacel, Boostrix)

Single dose Tdap once, then Td every 10 years
Typhoid Vaccine (Typhim Vi) Single dose Every 2 years Strongly recommended
VZV or Varicella Zoster vaccine Single dose after age 60 years none Will bring on request, not stocked routinely

 

Introduction

Every decision to take a vaccine to prevent an illness is essentially a decision that the short term expense and slight discomfort (and slight risk) is worth the improved chance of avoiding an unpleasant or potentially fatal illness. The following recommendations are based on the advice of international agencies such as the World Health Organization and the Centers for Disease Control in the United States, coupled with our local experience. Vaccine recommendations occasionally vary from Europe to North America, usually in regard to the exact schedule of giving the vaccine. The results of vaccination can be the same with different schedules.
The protection that can be gained from vaccines is variable, so remember that even if you have taken a vaccine you might still get the disease, although you will have greatly reduced your chances of getting ill.

1. For the Prevention of Hepatitis A:
Hepatitis A is acquired through ingestion of contaminated food or water. The Hepatitis A vaccine is a highly effective and safe with long lasting protection. It is given as a series of 2 shots with adequate protection 2 weeks after the first shot. For Twinrix, the combined A and B vaccine given as a series of 3 shots, protection starts 2 weeks after the second dose. Nepali adults who used to be almost always immune to hepatitis A through clinical or silent infection in childhood may no longer be immune due to improved levels of personal hygiene and sanitation. It therefore makes sense to give this vaccine to Nepali adults who are not immune to hepatitis A. The vaccine offers protection even when given after exposure on account of the long incubation period of Hepatitis A.If you have had hepatitis A disease in the past, you will be immune for life and do not need the vaccine.

2. Prevention of Hepatitis B:
Hepatitis B Vaccine: This is a well established vaccine with high safety and efficacy. Hepatitis B is spread through direct contact with infected blood or through sexual contact. All adults and children are recommended to take this vaccine. Since there are no animal reservoirs of infection, an effort is being made to give hepatitis B vaccine to all humans, which would eventually eliminate the disease from the world. The regimen for hepatitis B vaccine is an initial injection followed by boosters at one month and six months. Rapid schedule is available for people with time constraints. Hepatitis B antibody levels do not need to be checked routinely for healthy adults. Health care workers, immuno-compromised persons can check levels 1- 2 months after the last dose of the hepatitis B vaccine. For persons with inadequate levels (<10 mIU/ml), further 3 doses of hepatitis B vaccine at 0, 1 and 6 months are currently recommended.

3. For the Prevention of Typhoid Fever:
Typhoid fever is a prolonged febrile illness caused by infection with Salmonella Typhi bacteria. An almost identical illness, called paratyphoid fever, is caused by Salmonella Paratyphi. The organisms are passed in human feces, and acquired by eating contaminated food or water. The disease can make you very ill and the bacteria have become drug resistant. There are currently two different typhoid vaccines on the market – an oral typhoid vaccine using live organisms, and a capsular polysaccharide injectable vaccine. At CIWEC Clinic, we stock the capsular polysaccharide typhoid vaccine (Typhim Vi) whichconsists of a highly purified coating of the Salmonella Typhi bacteria. Because the whole bacteria is not injected, side-effects are minimal. It consists of a single injection of the vaccine with protective efficacy around 55- 75%, with boosters required every two years. This does not offer any protection against paratyphoid fever.

4. For the Prevention of Meningococcal infections:
Meningococcal infection can cause meningitis, which is a severe bacterial infection of the lining of the brain or a severe blood stream infection called meningococcemia. Meningococcal vaccines are safe, and highly effective. We currently stock Menactra, the quadrivalent vaccine consisting of serotypes A, C, Y,W135. Protection from a single shot lasts 5 years as an adult. When given at age 11-12 years as recommended in the USA and UK, 2nd dose at age 16 years is required. Quadrivalent vaccine is required for the Hajj, and is needed for college entry into the USA and for travel to the meningitis belt of sub-Saharan Africa. There is currently no recommendation for this vaccine for travel to Nepal.

5. For the Prevention of Japanese Encephalitis (JE):
JE is caused by a virus carried by culex mosquitoes in rural areas of southern Nepal or the Terai and in Kathmandu. JE virus can cause a severe and often fatal infection of the brain. There has been a single case report of JE in a French traveler to Nepal in 2012. Persons visiting Nepal particularly in the post-monsoon months of late July through early October and all residents of the Kathmandu valley are recommended to receive immunization against JE. At CIWEC we stock the inactivated Vero cell vaccine JEEV and the live SA 14-14-2 strain of the vaccine. Supply of the live vaccine has been erratic at times since JEEV came into the market.

6. For the Prevention of Rabies Encephalitis:
Rabies virus is transmitted by the bite/scratch of infected animals or from saliva contact with mucous membranes. The disease is present throughout Nepal, India, and Tibet and dogs account for >96% of human cases. The rabies virus, once injected into a bite wound, travels slowly to the brain over a period of weeks to months, causing a fatal encephalitis. Because of the delay between the bite and clinical illness, rabies vaccine and immunoglobulin can be given after a bite to prevent illness. This post-exposure series offers essentially 100% protection but it does take a month to complete the five shots plus the initial injection of rabies immune globulin (human or equine). For this reason, long-term travelers or foreign and local residents often take a pre-exposure series, consisting of 3 shots on days 0, 7, and 28 days. These “pre-immunized” individuals require only two booster shots 3 days apart,if they are bitten by an animal. We highly recommend the pre-exposure series to everyone particularly children who may not report to their parents every contact with a stray animal or someone’s pet. World Health Organization (WHO) has recently stated that only 2 doses of vaccine on day 0 and 7 are required for pre-immunization but no long term data are available with this approach and most health authorities around the world are recommending the existing 3 dose series. There are currently no recommendations for booster doses of rabies vaccine in travelers because the immune memory stays strong and reacts appropriately when vaccine is given after exposure. In immune-compromised persons, both vaccine and immunoglobulin are required to be given, even if the person is pre-immunized.

7. For the Prevention of Tetanus:
Tetanus bacteria can infect small wounds and cause a fatal infection. The risk is the same throughout the world. Most people would have received tetanus vaccine as primary series in childhood mixed with other vaccines. Single dose of Tdap (mixed with diphtheria and pertussis) is recommended as an adult to boost pertussis immunity, followed by Td (mixed with diphtheria) every 10 years

8. For the Prevention of Polio:
Polio Vaccine: Several rounds of mass vaccinations of children under the age of 5 years against Polio have rendered Nepal polio-free since 2011. Almost all tourist and foreign residents have been vaccinated against this disease in childhood. Polio vaccine booster is not required for Nepal since Nepal ispolio-free. Booster is required if you are coming in from polio endemic countries like Pakistan and Afghanistan.
9. For the Prevention of Cholera:

Cholera Vaccine: The risk of cholera to the foreign traveler or resident in Nepal is close to zero as has been shown by diarrhea research that we do every 10 years or so. Cholera is mainly spread by heavily contaminated water, or by certain sea coast animals that concentrate the bacteria (such as oysters). If you are conscientious in not drinking untreated water (or milk, which might be contaminated with water), you will have almost no chance of getting cholera.For persons volunteering in remote earthquake affected areas where access to clean drinking water may not always be possible, cholera vaccination makes sense. We keep a small stock of the cholera vaccine Shanchol at CIWEC.

10. For the Prevention of the “flu”:

Influenza Vaccine: Influenza, or the flu is a viral illness that causes fever, muscle aches, cough, and misery for a number of days. The vaccine consists of killed particles of three different strains of influenza going around in the previous year, and can significantly cut your risk of getting sick with the flu. A single injection offers protection for about one year. There has been an outbreak of Influenza A of the H1N1 variety in Nepal and India in July and August 2017. CIWEC Clinic makes this vaccine available each year from when it is available – usually in September-October. We recommend the flu vaccine for all persons >6 months of age annually.

11. For the prevention of Pneumonia:

Pneumococcal conjugate vaccine or Prevnar- 13: Persons 65 years of age or older should receive one dose of PCV 13 followed by PPSV 23 (Pneumovax 23) one year later. If a prior dose of PPSV 23 has been received, PCV -13 should be given after one year. These vaccines should also be given to persons 19 through 64 years of age if they have no spleen, are immune-compromised, have CSF leak or cochlear implants. Single dose of PPSV-23 alone should be given after age 19 years in adults with chronic heart, lung or liver disease, diabetes, and smoking.

12. For the prevention of Herpes Zoster

Herpes Zoster vaccine: VZV (Varicella Zoster virus) causes chicken pox in childhood. The virus continues to reside in the nerve ganglion and reactivates much later in life as a painful condition called Herpes Zoster. An effective vaccine is now available that is recommended for persons >60 years of age to reduce the risk of Herpes Zoster and that of post herpetic neuralgia. Currently we do not have this vaccine in stock.

13. Human Papilloma Virus or HPV vaccine:

It is for the prevention of genital warts in men and women and cervical cancer in women. This vaccine is given as a series of 3 injections at 0, 1-2 and 6 months, from age 15 – 26 years, only 2 shots are required if given before 15 years of age e.g. at 11-12 years.