Previous changes

March 2025 — minor update. Engerix 20 and 10 updated with correct age ranges for each.

August 2023 — minor update. A minor typographical error has been corrected.

July 2023 — minor update. Added information regarding Avaxim Junior® and the appropriate dosing schedule for this immunization for the protection of children from hepatitis A. 

May 2021 — minor update. Recommendations that Revaxis and Avaxim should be used with caution in people with phenylketonuria have been added to this topic in line with the manufacturers' Summary of Product Characteristics. 

March 2021 — minor update. Adverse effects of meningococcal meningitis vaccination updated in line with revised manufacturer's SPC.

January to February 2021 — reviewed. A literature search was conducted in January 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

August 2020 — minor update. A typographical error has been corrected.

May 2019 — minor update. The MHRA have received 2 reports of fatal adverse reactions to the yellow fever vaccine (Stamaril). Due to an increased risk of life-threatening reactions, they advise that the vaccine must not be given to anyone with a medical history of thymus dysfunction or who is immunosuppressed. 

February 2018 — minor update. Product removed from topic as no longer available.

September 2017 — minor update. Information added to adverse effects of TicoVac as per updates to the manufacturers' summary of product characteristics. 

December 2016 — minor update. Information that the validity of the yellow fever vaccination certificate is now lifelong has been added to this topic WHO, 2016.

November 2016 — minor update. A typographical error has been corrected in Table 1, in the background information section of this topic.

August to October 2016 — reviewed. A literature search was conducted in August 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to clinical recommendations have been made.

February 2015 — two minor updates:

• Meningococcal meningitis vaccine ACWY Vax^® has been discontinued, Menveo^® is still available. Scenario updated to reflect the changes.
• Nimemrix^® is an additional available Meningococcal meningitis ACWY conjugate vaccine and has been added to the relevant scenario.

December 2014 — minor update to the table regarding countries where poliomyelitis is prevalent based on new World Health Organisation recommendations.

November 2014 — minor update to the text regarding co-administration of the yellow fever vaccine with the MMR vaccine.

September 2014 — minor update to the text for rabies vaccinations. People should be given post-exposure rabies vaccination and rabies immunoglobulin.

April 2014 — minor update. Minor update to the text for rabies vaccination. A booster dose can be considered at 10 years post-primary course for people who are infrequent travellers to high-risk areas.

January 2013 — minor update. Minor text changes to the Indications for Vaccine section of the Scenario Cholera have been made to reflect minor changes to Public Health England's Immunisation against infectious disease 'The Green Book' Chapter 14: Cholera.

December 2013 — minor update. Changes to the text in the Scenario: Japanese encephalitis and Prescribing Information sections have been made to reflect policy changes in Public Health England's Immunisation against infectious disease 'The Green Book'. Green Cross^® vaccine is not licensed or recommended for use in the UK as there is a licensed alternative Japanese encephalitis vaccine (IXIARO^®) available, and IXIARO^® vaccine is now licensed for use in infants from 2 months of age.

April 2013 — minor update. Advice from the Department of Health regarding the use of yellow fever vaccine in women who are breastfeeding has been added.

September 2012 — minor update. Advice from the National Travel Health Network and Centre (NaTHNaC) for pilgrims for the Hajj and Umrah season of 1433 (2012) has been added.

August 2012 — reviewed. A literature search was conducted in May 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made. Updates to the Department of Health publication Immunisation against infectious disease (the Green Book) and the National Travel Health Network and Centre (NaTHNaC) publications have been included.

June 2012 — minor update. Minor typographical error corrected.

April 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made

February 2011— minor update. Brand name of tick-borne encephalitis vaccine corrected to read TicoVac^®.

November 2010 — updated. Advice from the National Travel Health Network and Centre (NaTHNaC) for pilgrims for the Hajj and Umrah season of 1431 (2010) has been added. 

September 2010 — minor update. A new edition of Health information for overseas travel, the 'Yellow Book', has been published and has been included in this topic. 

August 2010 — minor update. Menveo^®, a new quadrivalent meningococcal conjugate vaccine, is now recommended in preference to ACWY Vax^® (polysaccharide vaccine) for all age groups requiring quadrivalent meningococcal vaccine.

June 2010 — minor typographical correction. 

April 2010 — minor update. Prescriptions amended to indicate which travel vaccinations are not available on the NHS. 

June 2009 — updated to include information on IXIARO^®, a Japanese encephalitis vaccine that has a UK product licence. 

December 2008 — minor update. Black triangle removed from cholera vaccine. 

March to July 2007— converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. This CKS topic has been developed following the publication of the 'Green Book' (Immunisation against infectious disease) by the Department of Health.

August 2008 — minor update to text regarding Revaxis^® and Repevax^®. 

June 2008 — minor update to information on Typhim Vi vaccine. This vaccine is now licensed from 2 years old (previously 18 months). 

March 2008 — minor update to the text to reflect changes in the yellow fever vaccination recommendations for people travelling to Argentina, Brazil, and Paraguay. From 15 December 2007, all yellow fever vaccinations should be documented in the International Certificate of Vaccination or Prophylaxis (ICVP). 

August 2007 — three minor updates to the text. The age for meningitis vaccine has been changed from three months to two months, minor change to text relating to typhoid, and update to the schedule information for hepatitis B vaccine for health care workers. Minor formatting changes made to the Clinical Summaries on Typhoid fever, Japanese encephalitis, and Vaccination at short notice. 

June 2004 — written. 

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 July 2025.

HTAs (Health Technology Assessments)

No new HTAs since 1 July 2025.

Economic appraisals

No new economic appraisals relevant to England since 1 July 2025.

Systematic reviews and meta-analyses

No new systematic reviews and meta-analyses since 1 July 2025.

Primary evidence

No new randomized controlled trials in the major journals since 1 July 2025.

New policies

No new policies since 1 July 2025.

New safety alerts

No new safety alerts since 1 July 2025.

Changes in product availability

No changes in product availability since 1 July 2025.

Hepatitis A

• Hepatitis A is an infection of the liver caused by the hepatitis A virus.
  • The incubation period is usually around 28–30 days but may occasionally be as short as 15 days or as long as 50 days.
  • It is transmitted by the faecal-oral route through person-to-person contact and contaminated food or drink. 
  • Food-borne outbreaks have been reported following ingestion of certain shellfish (bivalve molluscs, such as mussels, oysters, and clams, which feed by filtering large volumes of sewage-polluted waters), and contaminated fruit and salad vegetables.
  • The highest-risk areas for UK travellers are the Indian subcontinent, sub-Saharan and North Africa, parts of the Far East, Central and South America, and the Middle East, but the risk extends to Eastern Europe.
• The disease is generally mild, but severity tends to increase with age:
  • Asymptomatic disease is common in children.
  • Jaundice may occur in 70–80% of those infected as adults.
  • Fulminant hepatitis can occur but is uncommon.
  • The overall case-fatality ratio is low but is greater in older people and those with pre-existing liver disease.
  • There is no chronic carrier state, and chronic liver damage does not occur.
• Certain groups of people may be at higher risk of acquiring hepatitis A whilst travelling, including:
  • Frequent and/or long-stay travellers to areas where sanitation and food hygiene are poor.
  • Those with existing medical conditions, such as liver disease or haemophilia.
  • Men who have sex with men.
  • People who inject drugs.
  • Those who may be exposed to the virus through their work.
  • Those going to areas of hepatitis A outbreaks with limited access to safe water and medical care.
• For more detailed information on hepatitis A, see the CKS topic on Hepatitis A and the UK Health Security Agency and NaTHNaC websites.

[UKHSA, 2024b; NaTHNaC, 2025a]

Meningococcal disease

• Meningococcal disease is the result of systemic bacterial infection by Neisseria meningitidis.
  • Meningococci are divided into antigenically distinct groups. There are at least six disease-causing serogroups (A, B, C, W, X, and Y).
  • In the UK, approximately 10% of the general population carry the bacteria in the mucosa of the nose and throat asymptomatically. In infants and young children, the carriage rate is low.
  • Meningococcal bacteria are transmitted by droplet or by direct contact with respiratory secretions from carriers or individuals in the early stages of the disease. Transmission usually requires frequent or prolonged close contact. 
  • The disease has an incubation period of 2–7 days.
  • Invasive meningococcal disease most commonly presents as either meningitis or septicaemia, or a combination of both. 
    • Even with antibiotic treatment, the disease may progress to coma and death. 
  • In some areas of the world, the risk of acquiring meningococcal infection, particularly of developing group A disease, is much higher than in the UK. 
    • The highest risk is in the so-called meningitis belt from sub-Saharan West to East Africa (Senegal to Ethiopia). 
    • Large epidemics of both group A and group W135 meningococcal infection have occurred in association with Hajj pilgrimages to Saudi Arabia. The quadrivalent vaccine (protecting against the A, C, W, and Y serogroups) has been an entry requirement for all pilgrims to the Hajj and Umrah since 2002.
• For more detailed information on meningococcal disease, see the CKS topic on Meningitis - bacterial meningitis and meningococcal disease and the UK Health Security Agency and NaTHNaC websites.

[NaTHNaC, 2025b; UKHSA, 2025a]

Poliomyelitis

• Poliomyelitis (polio) is a potentially paralysing viral infection caused by one of three serotypes of polio virus (serotypes 1, 2, and 3).
  • The virus is transmitted through food and water contaminated with infected human faeces (faecal-oral route) or via pharyngeal secretions. 
  • Polio has an incubation period of about 3–21 days.
• Since the introduction of effective vaccines in the mid-1950s, polio has been eradicated from the developed world and is becoming less prevalent in the developing world.
  • Polio is currently endemic in Afghanistan and Pakistan, with occasional outbreaks elsewhere globally.
  • Polio is extremely rare among UK travellers, with the last recorded imported case being in 1993.
• Most people (95% or more) who become infected with poliomyelitis are asymptomatic. 
• Symptoms can range from a mild illness with fever (malaise, headache, limb pain, and gastrointestinal disturbances), to aseptic meningitis or paralysis. Although paralysis occurs in fewer than 1% of infections, it is frequently long-lasting and can be fatal when respiratory muscles are affected.
• For more detailed information on poliomyelitis, see the UK Health Security Agency and NaTHNaC websites.

[NaTHNaC, 2025c; UKHSA, 2025b]

Typhoid fever

• Typhoid fever is a systemic infection caused by the Gram-negative bacillus Salmonella typhi.
  • Clinical features range from mild diarrhoea, myalgia, and headache, to severe disseminated disease with multi-organ involvement in 10–15% of cases. 
  • Complications include intra-intestinal bleeding and perforation.
  • The case-fatality ratio is less than 1% with prompt antibiotic therapy but may be as high as 20% in untreated cases.
  • Children are at the highest risk of typhoid fever, with peak incidence occurring in individuals aged 5–15 years.
• Typhoid fever is spread primarily by the faecal-oral route (via contaminated food and water or directly from person to person) and is principally a disease associated with poor sanitation and low standards of personal and food hygiene.
  • The incubation period is usually 1–3 weeks.
  • Around 10% of people with the infection excrete the organism for up to 3 months after infection, and up to half of these may become long-term carriers (more than 1 year).
• The highest risk areas are South Asia and parts of South-East Asia; the risk in Central and South America and Africa is lower.
  • The estimated incidence of travel-related typhoid is approximately 0.3 cases per 1000 person months (pm) in South Asia, 0.01–0.02 per 1000 pm in North and sub-Saharan Africa, and 0.003 per 1000 pm in the Caribbean, Central America and the Eastern Mediterranean.
  • The majority of travel-related infections in the UK occur after visiting countries of the Indian subcontinent (Bangladesh, India, and Pakistan).
• Paratyphoid fever (caused by Salmonella paratyphi) is an illness that is clinically similar to, but usually less severe than, typhoid. Although there is no vaccine available to prevent paratyphoid infection, there is some evidence that some typhoid vaccines may provide cross-protection against the paratyphoid B serotype.
• The risks of contracting both typhoid and paratyphoid fever can be reduced by scrupulous personal, food, and water hygiene.
• For more detailed information on typhoid fever, see the UK Health Security Agency and NaTHNaC websites.

[UKHSA, 2020; Steffen, 2023; NaTHNaC, 2025d]

Tetanus

• Tetanus is an acute disease caused by the action of tetanus toxin, released following infection by the bacterium Clostridium tetani.
  • Tetanus spores are present in soil or manure throughout the world and may be introduced into the body through deep puncture wounds, wounds containing foreign bodies, bone fractures where the skin is broken, or burns.
  • The bacteria grow anaerobically at the site of the injury, and the disease has an incubation period of 4–21 days (most commonly about 10 days).
• The symptoms of tetanus are characterized by rigidity and spasms of skeletal muscles:
  • Muscle stiffness usually involves the jaw (lockjaw) and neck, and then becomes generalized.
  • Complications include respiratory failure, convulsions, bone fractures, and cardiac problems.
  • The case-fatality ratio ranges from 10–90%, and is highest in infants and the elderly.
  • With intensive medical support, death from tetanus occurs in 10–20% of cases. 
• For more detailed information on tetanus, see the UK Health Security Agency and NaTHNaC websites.

[NaTHNaC, 2025e; UKHSA, 2025c]

Yellow fever

• Yellow fever is caused by a flavivirus that is spread by the bite of infected mosquitoes.
  • The incubation period is usually 3–6 days but may be longer.
  • Yellow fever is found in sub-Saharan Africa, South America, eastern Panama in Central America, and Trinidad. There is no risk of transmission in the UK from imported cases since the mosquito vector does not occur in the UK.
• Symptoms of yellow fever range in severity from non-specific and self-limiting symptoms (fever, malaise, photophobia, and headache) to an illness of sudden onset with fever, photophobia, vomiting, and prostration that may progress to jaundice and haemorrhage.
  • There is no specific treatment once symptoms have started.
  • Approximately 15% of people with yellow fever develop moderate to severe illness.
  • In non-immune travellers and migrants, the case-fatality rate can exceed 50%. Death usually occurs 7–10 days after the onset of illness.
• The estimated incidence of yellow fever typically ranges from 0.5 cases per 1000 person months (pm) in South America to 1 per 1000 pm in West Africa in unvaccinated travellers, but has been estimated to be as high as 8 per 1000 pm during outbreak periods.
• The risk of contracting yellow fever can be reduced by employing mosquito bite-avoidance measures such as the use of insecticides.
• For more detailed information on yellow fever, see the UK Health Security Agency and NaTHNaC websites.

[Steffen, 2023; UKHSA, 2024a; NaTHNaC, 2025f]

Cholera

• Cholera is an acute illness caused by the bacterium Vibrio cholerae.
  • V. cholerae produces an enterotoxin that causes the secretion of fluid and electrolytes, leading to painless, watery diarrhoea, and occasional vomiting.
  • The incubation period of cholera is usually 2–5 days, but the disease may become symptomatic in only a few hours.
  • Most people infected with V. cholerae remain asymptomatic.
    • Symptoms occur in up to 25% of people, the majority of whom experience a mild or moderate illness, while 10–20% develop severe disease.
  • In severe disease, dehydration, metabolic acidosis, and circulatory collapse may follow rapidly.
    • Over 50% of the most severely affected people die within a few hours. However, prompt, effective treatment results in a mortality rate of less than 1%.
  • Cholera is contracted via ingestion of faecally-contaminated water or food (especially shellfish) and via person-to-person spread.
  • Cholera is endemic in areas with poor sanitation and hygiene. The burden of cholera is greatest in Africa and Southern Asia, with outbreaks also reported in the Indian subcontinent and South America. However, with adequate precautions (scrupulous personal, food, and water hygiene), the risk to the travellers is low.
• For more detailed information on cholera, see the UK Health Security Agency and NaTHNaC websites.

[UKHSA, 2024c; ECDC, 2025; NaTHNaC, 2025g]

Dengue

• Dengue is caused by the dengue virus, spread by the bite of infected Aedes mosquitoes.
  • Although 80% of cases are mild or asymptomatic, with improvement in symptoms and recovery occurring 3–4 days after onset, severe life-threatening disease occurs in approximately 5% of those infected.
  • It has an average incubation period of 4–7 days.
  • Common symptoms include sudden onset high fever (18–49%), headache and retro-ocular pain, myalgia, arthralgia, nausea/vomiting, and rash. Severe dengue develops as a consequence of increased vascular permeability, which leads to life-threatening hypovolaemic shock.
    • Severe illness is more common in children, adolescents, pregnant women, older adults, and those with comorbidities, including asthma, diabetes, obesity, hypertension, renal disease, bleeding disorders, and in people using anticoagulants. 
• Dengue is endemic in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, South-East Asia and the Western Pacific. Sporadic cases have been observed in some European countries (including Croatia, France, Italy, and Spain).
  • It is the leading vector-borne disease globally, with an estimated monthly incidence of 0.5–0.8% among non-immune exposed travellers.
• The risk of infection can be further minimized by employing mosquito bite-avoidance measures.
  • Dengue virus is predominantly spread by Aedes aegypti and Aedes albopictus mosquitoes, which are active during the day.
• For more detailed information on dengue, see the UK Health Security Agency and NaTHNaC websites.

[Steffen, 2023; UKHSA, 2024d; NaTHNaC, 2025h]

Hepatitis B

• Hepatitis B is an infection of the liver caused by the hepatitis B virus (HBV).
  • The virus is transmitted by exposure to infected blood or body fluids, through vaginal or anal intercourse, blood-to-blood contact (for example, sharing of needles and other equipment by injecting drug users: 'needlestick' injuries), perinatal transmission from mother to child, and bites from infected people (very rare).
  • The incubation period ranges from 40–160 days, with an average of 60–90 days.
  • The risk of hepatitis B for tourists is considered to be low, but can be increased by participation in certain activities. For more information, see the section on Hepatitis B - indications for vaccine.
• Many new infections with hepatitis B are subclinical or present as a flu-like illness.
• Symptoms occur in only about 10% of younger children and 30–50% of adults.
• Acute infection may occasionally lead to fulminant hepatic necrosis, which is often fatal.
• Infection can become chronic in a significant proportion of people. Chronic infection may lead to liver failure or liver cancer.
  • The prevalence of chronic hepatitis B infection varies worldwide.
    • In Sub-Saharan Africa, most of Asia, and the Western Pacific, more than 8% of people are chronically infected.
    • The Amazon, southern parts of Eastern and Central Europe, the Middle East, and the Indian sub-continent have a rate of chronic HBV infection of 2–8%.
    • In Australia, Northern and Western Europe, and North America, the prevalence of chronic hepatitis B viral infection is less than 2% of the general population.
• See the CKS topic on Hepatitis B and the UK Health Security Agency and NaTHNaC websites for more information.

[WHO, 2020; NaTHNaC, 2025i; UKHSA, 2025d]

Japanese encephalitis

• Japanese encephalitis (JE) is caused by a flavivirus that is spread by the bite of infected mosquitoes.
  • Illness ranges from asymptomatic infection (it is estimated that only about 1 in 250 infections become clinically apparent) to severe encephalitis with high mortality and a high rate of permanent neurological sequelae (such as paralysis, Parkinsonian-like movement disorders, recurrent seizures, or inability to speak) in 20–30% of survivors. Case fatality rates may be as high as 30%.
  • JE has an incubation time of 5–15 days.
  • It is endemic in most of Asia, except Japan, South Korea, Singapore, and Taiwan. Approximately 50% of all cases occur in China. It is particularly common in rural areas where pig farming and rice growing co-exist, and is associated with the rainy season in some countries.
• Reports in travellers are rare, and risk can be further minimized by employing mosquito bite-avoidance measures such as the use of insecticides.
  • The estimated incidence of travel-related JE is 0.1–0.4 cases per 100,000 person months.
• For more detailed information on JE, see the UK Health Security Agency and NaTHNaC websites.

[Steffen, 2023; UKHSA, 2024e; NaTHNaC, 2025j]

Rabies

• Rabies is an acute viral infection caused by a lyssavirus.
  • Transmission is generally via saliva from the bite or scratch of an infected animal (usually a dog).
  • The disease is preventable if the correct post-exposure prophylactic treatment is provided quickly.
  • The incubation period is generally 3–12 weeks but may range from 4 days to 19 years. In more than 93% of individuals, the onset is within 1 year of exposure.
  • Once symptoms are present, rabies is usually fatal, with death resulting from respiratory paralysis.
    • Early symptoms can include paraesthesiae around the wound site, fever, headache, and malaise. An infected person may present with hydrophobia, hallucinations, and maniacal behaviour, which progresses to paralysis and coma, or as an ascending flaccid paralysis with sensory disturbances.
• The rabies virus is endemic in most countries, and all continents of the world, except Antarctica, are affected. The principal carriers in Europe are thought to be foxes. In the United States, skunks, raccoons, and bats account for 95% of cases.
  • The estimated incidence of travel-related rabies is 4 cases per 1000 person months.
• For more detailed information on rabies, see the UK Health Security Agency and NaTHNaC websites.

[Steffen, 2023; UKHSA, 2023; NaTHNaC, 2025k]

Tick-borne encephalitis

• Tick-borne encephalitis is caused by a flavivirus from the same family as yellow fever and Japanese encephalitis.
  • It is usually spread by tick bites, although unpasteurized milk is also thought to be a source of the disease.
  • The incubation period is 2–28 days following exposure.
  • It occurs in Austria, Germany, Southern and Central Sweden, France (Alsace region), Switzerland, Norway, Denmark, Poland, Croatia, Albania, the Baltic states (Estonia, Latvia, and Lithuania), Czechia, Slovakia, Hungary, Russia (including Siberia), Ukraine, some other countries of the former Soviet Union, and Northern and Eastern regions of China. Since the 1930s, tick-borne encephalitis has been a major public health problem in central Russia.
  • The disease has never been endemic in the UK.
• There are three forms of the disease related to the virus subtypes, namely Western, Far Eastern, and Siberian.
  • The European form of the disease is biphasic, with an initial viraemic phase of fever and influenza-like symptoms, followed in some cases (after an afebrile period of 1–20 days) by central nervous system involvement. The case-fatality rate of the European form is 1%. Long-lasting or permanent neuropsychiatric sequelae occur in 10–20% of infected people.
  • The Far Eastern version is more gradual in onset and normally takes a more severe and longer course with a reported mortality of 5–20%.
• The estimated incidence of travel-related tick-borne encephalitis is 0.5–1.3 cases per 100,000 person months.
• For more detailed information, see the UK Health Security Agency and NaTHNaC websites.

[UKHSA, 2013a; Steffen, 2023; NaTHNaC, 2025l]

General overseas travel advice

Reassure the person that the overall risk of contracting infectious diseases from abroad is very low if precautions are taken.

• Routine vaccinations should be up to date, as many of these are required for overseas travel.
• Advise that the risk of contracting an infectious disease abroad depends upon:
  • The region visited — the risk may vary from country to country, and prevalence may vary within countries.
  • The length of stay — the longer the stay, the greater the risk of exposure.
  • The time of stay — some diseases are more prevalent at certain times of the year (e.g. the rainy season).
  • The type of holiday or work — in general, people are more at risk in rural areas than in urbanized or developed areas. Hence, backpacking may be more dangerous than a package holiday, and work in rural or wild areas is often particularly high-risk.
  • The age and health of the traveller — some people may be more susceptible to infections.
• Advise that the most common infectious diseases contracted abroad cannot effectively be prevented by vaccination.
  • Travellers' diarrhoea may occur in up to 50% of visitors abroad and can generally be prevented by avoiding contaminated food and drink. For more information, see the CKS topic on Diarrhoea - prevention and advice for travellers.
  • In addition to disease transmission, insect bites can lead to skin irritation or infection. Travellers should reduce their risk by using bite avoidance measures, including protective clothing, impregnated mosquito nets and insect repellents.
  • Malaria is one of the more common serious acute infectious diseases that is contracted abroad and can be prevented with appropriate chemoprophylaxis. See the CKS topic on Malaria prophylaxis for more information.
  • Zika virus is spread by day-biting mosquitos, is present in Africa, Asia, the Pacific Islands, Central and South America and the Caribbean, and can pose a risk to a developing baby if contracted during pregnancy. The risk of Zika virus can be reduced by using insect bite avoidance measures. For further information, see the TravelHealthPro website.
  • Sexually transmitted infections are commonly contracted abroad. Some areas, such as Thailand, sub-Saharan Africa, and the Indian subcontinent, are endemic with HIV.
  • Parasitic infestation (such as onchocerciasis, loiasis, schistosomiasis) may present long after the person has returned. Schistosomiasis may also present acutely a few weeks or months after exposure, but presentation can be delayed for much longer.
  • If not managed appropriately, animal bites can carry risks of rabies, tetanus or other bacterial infections. Travellers should be advised not to approach stray or wild animals, nor attract them by offering food or leaving litter, and to be aware of activities which may attract stray animals (such as running or cycling).
• Inform the person that health provision in developing countries may be inadequate or difficult to access. Travel insurance is essential.
• Assess and discuss other travel related health risks, considering the person's destination, their medical history, personal and lifestyle factors, and any specific activities planned whilst travelling.
  • Those taking medication should check if there are any restrictions on the medicines which can enter, or travel through, the countries on their itinerary. Medication should be carried in its original packaging with copies of prescriptions, and adequate supplies should be taken in case of unplanned extended stays or travel delays.
  • Travellers may benefit from taking a medical kit, tailored to their destination of travel, including basic supplies to manage pain (simple analgesics), wounds (antiseptics, gauze, dressings, plasters and tape), and gastroenteritis (anti-diarrhoeals and rehydration solutions). Other items may include sun screen, condoms and water disinfection equipment.
  • Those at risk of venous thromboembolism (VTE) undertaking a long journey may require low molecular weight heparin with or without compression stockings or flight socks. Advice should also be provided about reducing immobility during travel. For more information see the CKS topic on DVT prevention for travellers.
  • Advise that alcohol or drug use may increase the risk of accidents and injuries and can invalidate travel insurance claims. 

Information sources for overseas travel

• This CKS topic gives a summary of advice for the immunization of overseas travellers, but it is not intended to be comprehensive or exhaustive. In addition, although the guidance in this CKS topic is correct at the time of writing, the prevalence of infectious diseases abroad and guidelines for travel immunization can change quickly. If in any doubt, further advice should be obtained. Table 2 gives information on the main sources of up-to-date advice available in the UK.

Table 2. The main UK sources of information on the current recommendations for travel immunization.

Indications for vaccine

• Consider vaccination against cholera for:
  • Relief or disaster aid workers.
  • People with itineraries in areas where cholera epidemics are occurring and there is limited access to safe water and medical care.
  • Travellers to potential cholera risk areas.
• For up to date, country by country information see the NaTHNaC website.

Available vaccines and vaccination schedules

• In the UK, there are two cholera vaccines licensed for use in adults and children over 2 years of age:
  • Dukoral^® is an inactivated vaccine (killed, whole cell vaccine with a recombinant cholera toxin B subunit).
  • Vaxchora is a live vaccine (attenuated).
• Dukoral^® primary immunization:
  • Immunization should be completed at least 1 week prior to potential exposure to cholera.
  • Give adults and children over 6 years old two doses.
    • Give the second dose between 1 and 6 weeks after the first dose.
    • Restart the course if more than 6 weeks have elapsed between the first and second doses.
  • Give children aged 2–6 years three doses:
    • Give the second dose between 1 and 6 weeks after the first dose.
    • Give the third dose between 1 and 6 weeks after the second dose.
    • Restart the course if more than 6 weeks have elapsed between doses.
• Dukoral^® booster doses for continual protection:
  • Give adults and children over 6 years old a booster dose within 2 years after completing the primary course. If more than 2 years have elapsed since the last vaccination, the primary course should be repeated.
  • Give children aged 2–6 years a booster dose within 6 months after completing the primary course. If more than 6 months have elapsed since the last vaccination, the primary course should be repeated.
• Vaxchora^® primary immunization:
  • A single oral dose should be administered at least 10 days prior to potential exposure to cholera.
  • There are no recommendations available relating to the use of booster doses for continual protection with Vaxchora^®.
• Cholera vaccine is not recommended for children under 2 years of age as the protective efficacy in this age group has not been studied.

Contraindications to vaccine

• Do not give either cholera vaccine if the person has:
  • Had a confirmed anaphylactic reaction to a previous dose of oral cholera vaccine.
  • Had a confirmed anaphylactic reaction to any vaccine component.
• Do not give Vaxchora^® if the person:
  • Is immunosuppressed or has a congenital immune deficiency (Vaxchora^® is a live attenuated vaccine).
  • Has a rare hereditary galactose intolerance, congenital lactase deficiency, glucose-galactose malabsorption, fructose intolerance, or sucrose-isomaltose insufficiency (Vaxchora^® contains lactose and sucrose).
• Postpone immunization with any cholera vaccine if the person has:
  • A current severe febrile illness. Minor illnesses without fever or systemic upset are not valid reasons to postpone immunization.
  • Acute gastrointestinal illness.
• Postpone Vaxchora^® immunisation if the person has:
  • Received oral or parenteral antibiotics within 14 days prior to vaccination (immune response may be diminished). Oral or parenteral antibiotics should also be avoided for 10 days post-vaccination.
• Cholera vaccines may be considered for pregnant women if the risk of cholera is high. As there is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus, bacterial vaccines, or toxoids, Dukoral vaccine may be preferred over Vaxchora^® in pregnancy.

Adverse effects

• Dukoral^® vaccine:
  • Mild gastrointestinal symptoms (abdominal pain, cramping, diarrhoea, nausea) are the most commonly reported symptoms occurring at a frequency of 0.1–1%.
  • More serious adverse events (a flu-like syndrome, rash, arthralgia, and paraesthesia) are rare, occurring in fewer than 1 per 1000 doses distributed.
• Vaxchora^® vaccine:
  • Fatigue (30.2%), headache (28.3%), abdominal pain (18.4%), nausea/vomiting (17.9%), and decreased appetite (15.7%) are the most commonly reported adverse effects.
  • Uncommon effects include dizziness, rash, arthralgia and pyrexia, occurring at a frequency of 0.1–1%.

How to administer cholera vaccine

• Obtain and document verbal consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, they believe it, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
• Cholera vaccine is given orally. 
• Cholera vaccine can be given at the same time as injected vaccines.
  • The Vaxchora^® vaccine should be administered at least 10 days before starting antimalarial prophylaxis with chloroquine, as the immune response may be diminished when used concurrently.
• Record the date of administration, vaccine and product name, batch number, expiry date, and dose administered. 
• Observe the person after vaccination to detect immediate adverse reactions. 
  • Anaphylaxis is extremely rare, and usually becomes apparent within minutes. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Vaccination against hepatitis A is recommended for:
  • Anyone aged 1 year and over travelling to areas where hepatitis A vaccination is recommended (such as the Indian subcontinent), particularly for prolonged periods, and/or if sanitation and food hygiene are likely to be poor. For up-to-date information about the travel areas for which hepatitis A vaccination is recommended, please see the Country Information section of the TravelHealthPro website.
    • Hepatitis A vaccination is not recommended for children under the age of 1 year.
  • Individuals going to live in, or likely to be posted for long periods to, hepatitis A virus-endemic countries.
• If rapid protection against hepatitis A is required, for example, following exposure or during outbreaks, then a single dose of monovalent vaccine is generally preferred as this may provide protection more quickly than the two courses of combined vaccine.
• Give combined vaccines if:
  • Protection against both hepatitis A and hepatitis B infections is required, or
  • Protection against hepatitis A and typhoid fever is required (frequently endemic in the same areas).
• Immunization is not considered necessary for individuals travelling to or going to reside in Northern or Western Europe (including Spain, Portugal, and Italy), or North America, Australia, or New Zealand.
  • For up-to-date country-by-country advice, see the TravelHealthPro website.
  • Other specific indications for hepatitis A vaccination are described in the Department of Health publication Immunisation against infectious disease (The Green Book).

Available vaccines and vaccination schedules

• There are several monovalent hepatitis A vaccines licensed for use in the UK, all of which are inactivated and prepared from different strains of the hepatitis A virus. These are:
  • Avaxim^®.
  • Avaxim Junior^®.
  • Havrix Monodose^®.
  • Havrix Junior Monodose^®.
  • Vaqta^® Adult.
  • Vaqta^® Paediatric.
• The primary vaccination schedule for monovalent hepatitis A vaccines is a single dose, ideally given at least 2 weeks before travelling. However, it can also be given up to the day of departure. Protection from a single dose lasts for 1 year.
• Reinforcing doses can be given to people at continued risk. For details, please see Table 3.
• Combined hepatitis A and B (Ambirix^®, Twinrix Adult^®, Twinrix Paediatric^®) and hepatitis A and typhoid (Hepatyrix^®, ViATIM^®) vaccines are also available.

Table 3. Schedule for monovalent hepatitis A vaccination. For vaccination schedules for combined hepatitis A vaccines, please see the chapter on hepatitis A immunization in The Green Book.

• If the second dose has been missed there is no need to restart immunization. Give the second dose as soon as possible after the missed date.
• If a combined hepatitis A and typhoid vaccine has been used to start immunization, give a booster dose of single hepatitis A vaccine 6–12 months later.
• If a combined hepatitis A and B vaccine has been given in an accelerated schedule, a booster dose is required at 1 year.
  

   

Contraindications to vaccine

• Do not give hepatitis A vaccine if the person has:
  • Had a confirmed anaphylactic reaction to a previous dose of hepatitis A vaccine.
  • Had a confirmed anaphylactic reaction to any component of the hepatitis A vaccine.
• Postpone hepatitis A vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization.
• Hepatitis A vaccines may be given to pregnant women when clinically indicated. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus, bacterial vaccines, or toxoids.
• AVAXIM^® and Havrix^® (adult and paediatric) should be used with caution in people with phenylketonuria
  • AVAXIM^® (adult and paediatric) contains 10 micrograms phenylalanine per 0.5 ml dose, equivalent to 0.17 micrograms/kg for a 60 kg person.
  • Havrix^® Junior contains 83 micrograms of phenylalanine in each dose, and Havrix^® contains 166 micrograms of phenylalanine in each dose.

Adverse effects

• Adverse reactions to hepatitis A vaccines are usually mild and confined to the first few days after immunization.
  • The most common reactions are mild, transient soreness, erythema, and induration at the injection site.
  • A small, painless nodule may form at the injection site; this usually disappears and is of no consequence.
  • General symptoms such as fever, malaise, fatigue, headache, nausea, and loss of appetite are also reported less frequently.

How to administer hepatitis A vaccine

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Hepatitis A vaccine is usually given by intramuscular (IM) injection, into the upper arm in children over 1 year of age and adults. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
• Hepatitis A vaccine can be given at the same time as other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare, and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Hepatitis B vaccine is indicated for travellers to areas of high or intermediate prevalence who are at risk of contracting hepatitis B including: 
  • People participating in contact sports.
  • People undertaking relief aid work.
  • People who inject drugs.
  • People engaging in unsafe sexual activity. 
  • People who plan to remain in areas of high or intermediate prevalence for long periods.
  • People at risk of requiring medical or dental treatment in countries where unsafe therapeutic injections (i.e. the re-use of contaminated needles and syringes without sterilization) occur or where donated blood is not screened, including:
    • Children and others who may require medical care while travelling to visit friends or relatives in high- or moderate-endemicity countries.
    • People with chronic medical conditions who may require hospitalization while overseas.
    • Those travelling for medical care.
  • People who are adopting children from intermediate or high-risk countries.
  • People at occupational risk, including:
    • Healthcare workers.
    • Other emergency service workers who may come into contact with discarded needles.
    • Laboratory staff who may handle material containing the virus.
    • Staff of residential and other accommodation for those with learning disabilities.
    • Any occupation which involves routine use of needles to puncture or pierce the skin (such as morticians, embalmers and tattoo artists).
• For other specific indications for hepatitis B immunization, see The Green Book.

Available vaccines and vaccination schedule

• There are several monovalent hepatitis B vaccines licensed for use in the UK, all of which are inactivated. These are:
  • Engerix B^® 20 micrograms/1 mL (licensed for use from 16 years of age and above).
  • Engerix B^® 10 micrograms/1 mL (licensed for use from birth up to 15 years of age).
  • HBvaxPRO^® 10 micrograms (licensed for use from 16 years of age).
  • HBvaxPRO^® 5 micrograms (licensed for use from birth up to 15 years of age).
  • HBvaxPRO^® 40 micrograms (indicated for adult dialysis and predialysis patients).
  • Fendrix^® (indicated for people who have renal insufficiency, for use from 15 years of age).
• Combined hepatitis A and B vaccines are also available (Ambirix^®, Twinrix Adult^®, and Twinrix Paediatric^®).
• There are several vaccination schedules recommended for Hepatitis B.
  • Vaccination at 0, 1, and 2 months is used for most travellers.
  • In exceptional circumstances (for example, if the traveller is departing within 1 month), the initial doses can be given at 0, 7, and 21 days (licensed in adults aged 18 years and older, can be used off license in children aged 16–17 years).
  • A fourth dose administered 12 months after the first dose is required for ongoing protection.
• For more information, please see the chapter on Hepatitis B immunization in The Green Book.

Contraindications to vaccine

• Do not give hepatitis B vaccine if the person has:
  • Had a confirmed anaphylactic reaction to a previous dose of hepatitis B vaccine.
  • Had a confirmed anaphylactic reaction to any component of the hepatitis B vaccine.
• Postpone hepatitis B vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization.
• Hepatitis B vaccine should not be withheld from a pregnant woman if she is in a high-risk group. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus, bacterial vaccines, or toxoids.

Adverse effects

• Hepatitis B vaccine is generally well tolerated, and the most common adverse reactions are headache, fatigue, soreness and redness at the injection site.
  • Other common reactions include fever, rash, malaise, an influenza-like syndrome, diarrhoea, arthritis, arthralgia, myalgia, and abnormal liver function tests.
  • Serious suspected neurological reactions such as Guillain–Barré syndrome and other demyelinating disorders have been reported, although these have been very rare and a causal relationship with the hepatitis B vaccine has not been established.

How to administer the hepatitis B vaccine

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Hepatitis B vaccine is usually given by intramuscular (IM) injection, into the upper arm in children and adults, or the anterolateral thigh in infants under 1 year of age. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
• Hepatitis B vaccine can be given at the same time as other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare, and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Japanese encephalitis (JE) vaccination may be recommended for certain groups of people who are going to reside in an area where the disease is endemic or epidemic, such as:
  • Travellers to South-East Asia and the Far East staying for a month or longer in endemic areas during the transmission season, especially if travel will include rural areas.
  • Travellers with exposure periods of less than 1 month who will be spending time in rice fields (where the mosquito vector breeds) or close to pig farming (a reservoir host for the virus).
• JE vaccination may also be recommended for people with potential occupational exposure in a laboratory setting.
• Country-specific recommendations and information on the global epidemiology of JE can be found on the TravelHealthPro website.
• Note: Travellers to endemic regions are also advised to use standard precautions to prevent mosquito bites, as JE is transmitted to humans by Culex mosquitoes.

Available vaccines and vaccination schedules

• One inactivated Japanese encephalitis (JE) vaccine (IXIARO^®) is currently licensed in the UK for use in infants from 2 months of age, children, and adults.
  • There are two routine schedules for IXIARO^® vaccine depending on the age of the person (see Table 4).
  • Ideally, the vaccination schedule should be completed 1 week before travel to allow immunity to develop.
• Booster doses for continual protection:
  • For those at ongoing risk (such as laboratory staff or long-term travellers residing in JE endemic areas) and adults over 65 years of age, a booster dose should be given 12 months after primary immunisation.
  • For all other travellers, a booster dose should be given at 12–24 months following primary immunisation.
  • For adults 18–64 years of age, a second booster should be offered at 10 years to those who remain at risk.

Table 4. Recommended schedule for Japanese encephalitis IXIARO^® vaccine.

Contraindications to vaccine

• Japanese encephalitis (JE) vaccine should not be given to people who have had:
  • A confirmed anaphylactic reaction, or serious systemic reaction (e.g. generalized urticaria or angio-oedema) following a previous dose.
  • A confirmed anaphylactic reaction to any component of the vaccine.
• Postpone immunization with JE vaccine if the person has:
  • A current severe febrile illness. Minor illnesses without fever or systemic upset are not valid reasons to postpone immunization.
• Japanese encephalitis vaccine should be avoided in pregnancy where possible. However, healthcare professionals should help pregnant women to make an informed choice about the use of the vaccine by discussing with them the theoretical risks of vaccine exposure versus the potential risk of acquiring Japanese encephalitis. 
  • Miscarriage has been associated with JE acquired in the first two trimesters of pregnancy.
  • Healthcare professionals should help pregnant women make an informed choice about vaccination by discussing the theoretical risks of vaccine exposure versus the potential risk of acquiring JE.

Adverse effects

• The most common adverse reactions observed after administration of IXIARO^® are pain and tenderness at the injection site, headache, fatigue and myalgia.
  • These reactions are usually mild and typically occur and resolve within the first three days.
• Other reactions commonly reported are erythema, hardening, swelling, and itching at the injection site, influenza-like illness, pyrexia, and nausea.

How to administer the Japanese encephalitis vaccine

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no Contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Japanese encephalitis (JE) vaccine is usually given by intramuscular (IM) injection, into the upper arm in children and adults, or the anterolateral thigh in infants under 1 year of age. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
• JE vaccine can be given at the same time as other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare, and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Vaccination with a quadrivalent meningococcal vaccine that protects against the A, C, W, and Y capsular types is recommended for the following groups of people travelling to areas with a high risk of meningococcal meningitis (especially the sub-Saharan 'African Meningitis Belt'):
  • People staying for extended time periods, such as 1 month or more.
  • People visiting savannah regions between the months of December and June (the dry season) when rates of the disease are highest.
  • People engaging in activities, such as living or travelling 'rough' (including backpackers), or people living or working with local people, and/or in rural communities.
  • Healthcare workers.
  • People with asplenia or splenic dysfunction.
  • People with complement disorders (including those on complement inhibitor therapies such as eculizumab).
• Vaccination is also required for all people attending the Hajj (Mecca) and Umra pilgrimages in Saudi Arabia.
  • Proof of vaccination against the A, C, W, and Y capsular groups (covered in the quadrivalent vaccines) is now an entry requirement for pilgrims and seasonal workers travelling to Saudi Arabia.
• Outbreaks of meningococcal disease also occur periodically in other parts of the world. Healthcare providers should check the TravelHealthPro website for up-to-date information.
• Meningococcal C conjugate vaccine is routinely given as part of the childhood immunization programme (see Immunizations - childhood for more information). This vaccine protects against group C disease only. Travellers should be immunized with a quadrivalent vaccine, even if they have previously received the meningococcal C conjugate vaccine.

Available vaccines and vaccination schedules

• A quadrivalent, inactivated, meningitis vaccine is recommended for travellers. A single dose provides cover against strains A, C, Y, and W135 of the disease. Three types are available:
  • Menveo^® (conjugate vaccine) — use is off-label in children under 2 years of age. 
  • Nimenrix^® (conjugate vaccine) — use is off-label in children under 6 weeks of age.
  • MenQuadfi^® (conjugate vaccine) — use is off-label in children under 1 year of age.
• Menveo^®
  • Primary immunization:
    • For adults and children aged 1 year and older, give a single dose of vaccine.
    • For children under 1 year of age, give two doses of vaccine, 1 month apart (irrespective of MenC immunization history).
• Nimenrix^®
  • Primary immunization:
    • For adults and children aged 6 months and older, give a single dose of vaccine.
    • For children under 6 months of age, the manufacturer recommends giving two doses of vaccine 2 months apart. The UK Health Security Agency states that the two doses of vaccine can also be given 1 month apart.
• MenQuadfi^®
  • Primary immunization:
    • For adults and children aged 1 year and older, give a single dose of vaccine.
    • For children under 1 year of age, give two doses of vaccine, 1 month apart (irrespective of MenC immunization history).
• Booster doses for continual protection:
  • For travellers at continued risk, booster doses should be given every 5 years.

Contraindications to vaccine

• Do not give quadrivalent meningococcal vaccine if the person has:
  • Had a confirmed anaphylactic reaction to a previous dose of the vaccine.
  • Had a confirmed anaphylactic reaction to any component of the vaccine.
• Postpone quadrivalent meningococcal vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization.
• Meningococcal vaccines may be given to pregnant women when clinically indicated. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus, bacterial vaccines, or toxoids.

Adverse effects

• Menveo^®
  • Commonly reported reactions include injection site reactions (such as pain, erythema, induration, and pruritus), headache, nausea, rash, and malaise.
• Nimenrix^®
  • Commonly reported reactions include injection site reactions (such as pain, erythema, and swelling), headache, nausea, irritability, drowsiness, and loss of appetite.
  • Other adverse effects include lymphadenopathy (frequency unknown), febrile convulsion (rare) and urticaria (uncommon).
• MenQuadfi^®
  • Commonly reported reactions include injection site reactions (such as pain, erythema, and swelling), headache, myalgia, malaise and fever.

How to administer meningococcal vaccine

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Meningococcal vaccine is usually given by intramuscular (IM) injection, into the upper arm in children and adults, or the anterolateral thigh in infants under 1 year of age. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
• Meningococcal vaccine can be given at the same time as other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare, and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Vaccination is indicated for people who are travelling to areas or countries where poliomyelitis (polio) is epidemic or endemic if:
  • They have not been previously immunized,
  • They have not been fully immunized according to the UK schedule, or,
  • Their last dose of polio vaccine was 10 years ago, or more.
• Polio vaccination is part of the routine Childhood Immunization Programme in the UK. For more information, see the CKS topic on Immunizations - childhood.

Available vaccines and vaccination schedules

• Polio vaccine is only available as part of a combined product, with choice of vaccine being largely dependent on the person's age and prior vaccination history. The available products in the UK are:
  • Boostrix IPV^® (dTaP/IPV).
  • Infanrix Hexa^® (DTaP/IPV/Hib/HepB).
  • Infanrix IPV+Hib^® (DTaP/IPV/Hib).
  • Repevax^® (dTaP/IPV).
  • Revaxis^® (Td/IPV).
  • Vaxelis^® (DTaP/IPV/Hib/HepB).
• Ensure that ALL people are up to date with the recommended five-dose schedule for polio immunization, regardless of travel arrangements.
  • Anyone born before 1962 may not have received polio vaccination or may have received a low-potency vaccine.
• For children under 10 years of age who have not been vaccinated, vaccinate according to the Routine Childhood Immunization Programme. For more information, see the CKS topic on Immunizations - childhood.
• For children over 10 years of age and adults who have not been vaccinated, give:
  • A primary course of three doses of vaccine (as Td/IPV) 1 month apart
  • Two booster doses — the first at least 5 years after the last dose of the primary course, and the second 10 years after the first booster.
• For travellers to polio endemic or epidemic regions who have been vaccinated — give a booster dose if the person has not received one in the last 10 years.
  • This is particularly important for health workers in endemic regions.

Contraindications to vaccine

• Polio vaccines should not be given to people who have had:
  • A confirmed anaphylactic reaction, or serious systemic reaction following a previous dose.
  • A confirmed anaphylactic reaction to neomycin, streptomycin, or polymyxin B (which may be present in trace amounts).
• Postpone polio vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization.
• Children should continue immunization with polio-containing vaccines even with a history of fever (irrespective of severity), hypotonic–hyporesponsive episodes (HHE), persistent crying or screaming for more than 3 hours, or a severe local reaction (irrespective of extent) within 72 hours of a previous polio vaccination. 
• Polio-containing vaccines may be given to pregnant women when protection is required without delay. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus, bacterial vaccines, or toxoids.
• Revaxis® should be used with caution in people with phenylketonuria as it contains 10 micrograms of phenylalanine per 0.5 ml dose, equivalent to 0.17 micrograms/kg for a 60 kg person.

Adverse effects

• Pain, swelling, or redness at the injection site are common and may occur more frequently following subsequent doses. A small, painless nodule may form at the injection site; this usually disappears and is of no consequence.
• Rarely, fever, convulsions, high-pitched screaming, pallor, cyanosis, and limpness occur after vaccination with inactivated polio virus-containing vaccines.
• Confirmed anaphylaxis following vaccination occurs extremely rarely, occurring at less than 1 per million vaccine doses in the UK.

How to administer polio-containing vaccines

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Polio-containing vaccine is usually given by intramuscular (IM) injection, into the upper arm in children and adults, or the anterolateral thigh in infants under 1 year of age. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
• Polio-containing vaccine can be given at the same time as other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare, and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for pre-exposure immunization

• Travellers to rabies-enzootic areas should be offered pre-exposure immunization against rabies, especially if they are:
  • Staying for more than 1 month.
  • Unlikely to have access to reliable, prompt, safe medical care following a potential exposure.
  • Engaging in activities such as cycling or running, which can increase the risk of animal bites.
  • Working with or in close contact with animals (e.g. veterinarians, zoologists).
  • Healthcare workers in rabies enzootic areas who may have direct contact with rabies-infected patients.
• Other specific indications for rabies vaccination can be found in the Department of Health publication Immunisation against infectious disease 'The Green Book'.
• Note: People receiving the vaccine should be advised that if they are bitten or scratched by any animal abroad, they should immediately flush the wound under a running tap for several minutes, then thoroughly wash with soap/detergent and water to remove saliva, apply a disinfectant to the wound (70 percent alcohol or povidone-iodine), apply a simple loose dressing and seek immediate medical attention. If they do not seek immediate medical attention or are unable to access this while they are abroad, they should still seek it when they return to the UK, even if it is some time after the event.

Available vaccines and vaccination schedules

• The two rabies vaccines (both inactivated) currently available in the UK are:
  • Rabipur^®.
  • Verorab^®.
• Both vaccines are indicated for people of all ages.
• The primary schedule for rabies (pre-exposure) vaccination is three doses at days 0, 7, and 28, although the third dose can be given from day 21 if there is insufficient time before travel.
• An accelerated course may be given if there is insufficient time before travel to complete the 21–28 day course:
  
  • Rabipur^® — three doses on days 0, 3, and 7.
• A booster dose should be considered at 1-year post-primary course if travelling again to a high-risk area, and should be used in people still at risk who received an accelerated course.

Contraindications to vaccine

• Pre-exposure rabies vaccination should not be given to people who have had:
  • A confirmed anaphylactic reaction following a previous dose.
  • A confirmed anaphylactic reaction to any component of the vaccine.
    • The Rabipur^® vaccine contains residues of chicken proteins; consider an alternative vaccine for those with severe egg allergy.
• Postpone rabies vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization. 
• Rabies vaccine may be given to pregnant women when the risk of exposure to rabies is high, and rapid access to post-exposure prophylaxis would be limited. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus, bacterial vaccines, or toxoid.

Adverse effects

• Local reactions, such as itching, redness, swelling, or pain at the site of injection, may occur within 24–48 hours of administration.
• Systemic reactions such as headache, dizziness, fever, muscle aches, malaise, vomiting, and urticarial rashes are rare.
• Delayed hypersensitivity reactions have been reported from the USA. Reactions may become more severe with repeated doses.
• Extremely rarely, neurological conditions, such as Guillain–Barré syndrome, have been reported (a causal association with vaccination is not established).

How to administer rabies vaccine

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Rabies vaccine is usually given by intramuscular (IM) injection, into the upper arm in children and adults, or the anterolateral thigh in infants under 1 year of age. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. The vaccine must not be given by intravascular injection. 
• Rabies vaccine can be given at the same time as other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare, and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Tetanus can potentially be contracted worldwide.
• All people in the UK should receive a tetanus vaccine as part of the childhood vaccination programme. For more information, see the CKS topic on Immunizations - childhood.
• For travellers, give a booster dose of tetanus/diphtheria/inactivated polio vaccine (Td/IPV) before departure, to people travelling to areas where medical attention may not be accessible and whose last dose of a tetanus-containing vaccine was more than 10 years previously (regardless of whether the person has received a full five-dose course of vaccine).

Available vaccines and vaccination schedules

• Tetanus vaccine is available as an inactivated vaccine and is only available as a component of a combined product, with the choice of vaccine depending largely on the person's age and prior vaccination history. Available products are:
  • Adacel^® (TdaP).
  • Boostrix IPV^® (dTaP/IPV).
  • Infanrix Hexa^® (DTaP/IPV/Hib/HepB).
  • Infanrix IPV+Hib^® (DTaP/IPV/Hib).
  • Repevax^® (dTaP/IPV).
  • Revaxis^® (Td/IPV).
  • Vaxelis^® (DTaP/IPV/Hib/HepB).
• Check that ALL people are up to date with the recommended five-dose schedule for tetanus immunization, regardless of travel arrangements.
• For children under 10 years of age who have not been vaccinated, vaccinate according to the routine childhood immunization programme. For more information, see the CKS topic on Immunizations - childhood.
• For children over 10 years of age and adults who have not been vaccinated, give:
  • A primary course of three doses of vaccine (Td/IPV) 1 month apart.
  • Two booster doses — the first 5–10 years after the last dose of the primary course, and the second 10 years after the first booster.
• For travellers who have not received a primary tetanus immunization course (three doses), it is usually worth giving the maximum number of doses of vaccine that the travel departure date allows and completing the course upon return.
• Give a booster dose to anyone who has not received two booster doses at appropriate intervals.
• Give a booster dose to anyone who has been fully vaccinated (received five doses), has not received a booster dose in the last 10 years, and is travelling to areas where medical attention may not be accessible.

Contraindications to vaccine

• Tetanus vaccine should not be given to people who have had:
  • A confirmed anaphylactic reaction, or serious systemic reaction following a previous dose.
  • A confirmed anaphylactic reaction to neomycin, streptomycin, or polymyxin B (which may be present in trace amounts).
• Postpone tetanus vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization.
• Children should continue immunization with tetanus-containing vaccines even with a history of fever (irrespective of severity), hypotonic–hyporesponsive episodes (HHE), persistent crying or screaming for more than 3 hours, or a severe local reaction (irrespective of extent) within 72 hours of a previous tetanus vaccination. 
• Tetanus-containing vaccines may be given to pregnant women when protection is required without delay. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus, bacterial vaccines, or toxoids.
• Revaxis^® should be used with caution in people with phenylketonuria as it contains 10 micrograms of phenylalanine per 0.5 ml dose, equivalent to 0.17 micrograms/kg for a 60 kg person.

Adverse effects

• Pain, swelling, or redness at the injection site are common and may occur more frequently following subsequent doses. A small painless nodule may form at the injection site; this usually disappears and is of no consequence.
• Rarely, fever, convulsions, high-pitched screaming, pallor, cyanosis, and limpness occur after vaccination with tetanus-containing vaccines.
• Confirmed anaphylaxis following vaccination occurs extremely rarely, occurring at less than 1 per million vaccine doses in the UK.

How to administer tetanus-containing vaccines

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse responses have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Tetanus-containing vaccine is usually given by intramuscular (IM) injection, into the upper arm in children and adults, or the anterolateral thigh in infants under 1 year of age. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
• Tetanus-containing vaccine can be given at the same time as other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare, and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Tick-borne encephalitis vaccination is advised for people travelling to or going to reside in endemic areas. Vaccination is particularly important for people:
  • Travelling to warm, forested parts of endemic areas, particularly during the spring and summer.
  • Hiking, camping, hunting, or carrying out fieldwork in endemic forested areas.
  • Working in forestry, woodcutting, farming, or the military.
• Note: The person should be advised that they can further decrease their risk of contracting tick-borne encephalitis by covering arms, legs, and ankles when in high-risk areas, and using insect repellents on socks and outer clothes.
  • Any ticks attaching to the skin should be removed completely as soon as possible. Evidence suggests that the best method is slow, straight removal with tweezers.
  • Check clothes and whole body regularly for ticks. Although ticks can attach anywhere, common areas for ticks are armpits, back of knees, elbows, groin and hairline.
  • Tick-borne encephalitis can also be acquired by eating or drinking unpasteurised dairy products from infected animals. Consumption of raw dairy products should be avoided in endemic areas.

Available vaccines and vaccination schedules

• Ticovac^® (indicated for people from 16 years of age) and Ticovac Junior^® (lower dose indicated in children and young people aged 1–15 years) are the only available vaccines for tick-borne encephalitis in the UK.
• The primary course consists of three doses: the first on day 0, the second 1–3 months later, and the third 5–12 months after the second dose. However, for rapid short-term protection of children and adults, the second dose may be given 2 weeks after the first dose and offers at least 90% protection.
• Boosters are recommended every 3 years starting after an initial three-dose schedule if the person remains at risk. For people who remain at risk, a first booster dose should be given no more than 3 years after the third dose, with sequential booster doses given every 5 years.

Contraindications to vaccine

• Tick-borne encephalitis vaccine should not be given to people who have had:
  • A confirmed anaphylactic reaction following a previous dose.
  • A confirmed anaphylactic reaction to one of the vaccine components.
  • A confirmed anaphylactic reaction to egg ingestion.
• Postpone tick-borne encephalitis vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization.
• Tick-borne encephalitis vaccine may be given to pregnant women when protection is required without delay. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus, bacterial vaccines, or toxoids.

Adverse effects

• Reported reactions to tick-borne encephalitis vaccine are rare.
  • Local reactions such as swelling, pain, and redness at the injection site may occur.
  • Pyrexia, particularly after the first dose, can occur in children and adults, usually within 12 hours of immunization, settling within 24–48 hours.
  • Febrile convulsions have rarely occurred.
  • Generalised reactions such as fatigue, malaise, headache, muscle pain and nausea have also been reported, but are expected to be brief and mild.
  • Serious suspected neurological reactions such as Guillain–Barré syndrome and other demyelinating disorders have been reported, although these have been rare and a causal relationship with TicoVac^® has not been established.

How to administer tick-borne encephalitis vaccine

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Tick-borne encephalitis vaccine is usually given by intramuscular (IM) injection, into the upper arm in children over 1 year of age, and adults. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
• Tick-borne encephalitis vaccine can be given at the same time as other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare, and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Give a typhoid vaccination to travellers to countries where typhoid is endemic (for detailed information, see the NaTHNaC website), especially if they are:
  • Staying with or visiting the local population.
  • Likely to experience frequent and/or prolonged exposure to conditions where sanitation and food hygiene are poor.
• Note: the person should be advised that not all recipients of typhoid vaccines will be protected against typhoid fever, and the vaccine does not protect against paratyphoid infection. They should therefore take all necessary precautions to avoid contact with, or ingestion of, potentially contaminated food or water.

Available vaccines and vaccination schedules

• Two vaccines are available that offer protection against typhoid fever:
  • The inactive capsular polysaccharide typhoid vaccine (Typhim Vi^®) contains purified Vi capsular polysaccharide from Salmonella typhi organisms.
  • A live (oral) typhoid vaccine containing a live attenuated strain of S. typhi Ty21a in an enteric capsule (Vivotif^®) is also available.
    • Protection commences about 7–10 days after completion of a three-dose course of live oral typhoid vaccine.

Table 5. Schedule for typhoid vaccination.

Contraindications to vaccine

• Typhoid Vi vaccine should not be given to people who have had:
  • A confirmed anaphylactic reaction to a Vi-antigen-containing vaccine.
    • Severe reactions to a previous dose of non-Vi typhoid vaccine do not contraindicate the subsequent use of a Vi vaccine.
• Ty21a vaccine should not be given to those who:
  • Are immunosuppressed.
  • Have had a confirmed anaphylactic reaction to any component of the Ty21a vaccine or enteric-coated capsule, including gelatine.
• Postpone typhoid vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization.
• In the event of a gastrointestinal illness, vaccination with the Ty21a vaccine should be postponed until after recovery.
• Ty21a vaccine should not be commenced within 3 days of completing any antibacterial agents, and antibacterial therapy should not commence within 3 days after the last dose of vaccine.
• If malaria prophylaxis is required with Ty21a vaccine:
  • Atovaquone and proguanil can be given concurrently.
  • Doses of mefloquine should be separated by at least 12 hours.
  • Delay all other antimalarials for an interval of at least 3 days from the last dose of Ty21a.
• Typhoid vaccine may be given to pregnant women if the risk of typhoid is high. The inactivated Vi vaccine may be preferred in pregnancy. There is no evidence of risk from vaccinating pregnant women or those who are breastfeeding with inactivated virus, bacterial vaccines, or toxoids.

Adverse effects

• Vi vaccine:
  • Local reactions (pain, swelling, erythema, and induration at the injection site) are the most commonly reported symptoms following the Vi vaccine. These symptoms are usually mild and transient.
  • Systemic reactions following the vaccine are infrequent. Fever occurs in about 1% of vaccine recipients. Headache, nausea, diarrhoea, and abdominal pain have been reported but are uncommon.
  • There have been rare reports of anaphylaxis following administration of Vi vaccine.
• Ty21a vaccine:
  • The most commonly reported adverse events are gastrointestinal symptoms, fever, influenza-like symptoms, and headache.

How to administer typhoid vaccine

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty (if applicable). 
• Typhoid vaccine can be given by intramuscular (IM) injection or taken orally.
  • Injections should be given into the upper arm in children over 1 year of age and adults. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
  • Capsules should be taken about 1 hour before a meal with a cold or lukewarm drink (temperature not to exceed 37°C). The vaccine capsule should not be chewed and should be swallowed as soon as possible after being placed in the mouth.
• Typhoid vaccine can be given at the same time as other vaccines. If an additional injected vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Yellow fever vaccination is only available from a designated Yellow Fever Vaccination Centre:
  • For the location of vaccination centres, see the Yellow Fever Vaccination Programme section of the NaTHNaC website.
• Rare severe adverse events have been associated with yellow fever vaccination. It is therefore important to make a risk assessment prior to administering the vaccine, taking into account the person's age, travel destination, itinerary, season of travel, and planned activities. In general, the risk from yellow fever for travel to a yellow fever-endemic region outweighs the risks associated with the vaccine. 
• The following groups should be immunized:
  • People aged 9 months or older who are travelling to countries that require an International Certificate of Vaccination or Prophylaxis (ICVP) for entry. An ICVP is required for travellers coming from or transiting through countries where yellow fever occurs.
  • People aged 9 months or older who are travelling to, or will be living in, infected areas or countries in the yellow fever endemic zone, even if these countries do not require evidence of immunization on entry.
    • For up-to-date information on countries and areas affected by yellow fever, see the TravelHealthPro website.
• Infants aged 6–9 months should only be immunized if the risk is unavoidable; expert opinion should be sought in these situations. Infants below 6 months of age should not be vaccinated.
• People aged 60 years and older should only be immunized if there is a significant and unavoidable risk of acquiring yellow fever infection, such as travel to an area where there is a current or periodic risk of transmission. 
• Note: travellers to endemic regions are also advised to use standard precautions to prevent mosquito bites, as yellow fever is transmitted to humans by Aedes mosquitoes.

Available vaccines and vaccination schedules

• The yellow fever vaccine available in the UK (Stamaril^®) is a live attenuated preparation.
  • It is administered as a single dose and confers immunity in 95–100% of recipients.
  • Immunization should be performed at least 10 days prior to travel to an endemic area to allow protective immunity to develop and for an International Certificate of Vaccination (if required) to become valid.
    • Immunization should still be performed for last-minute travellers who should be counselled about the importance of insect bite precautions and the possible implications of an invalid ICVP.
  • For most people, a single dose of yellow fever vaccine appears to confer lifelong protective immunity. 
  • A booster dose after 10 years is recommended for people at persistent risk of contracting the disease who received their first yellow fever vaccination when aged less than 2 years old, during pregnancy, whilst infected with HIV or otherwise immunosuppressed, or before undergoing a bone marrow transplant. For further information, see The Green Book.
• Note: the international yellow fever vaccination certificate becomes valid 10 days after primary vaccination. It remains valid for the life of the traveller.

Contraindications to vaccine

• Yellow fever vaccine should not be given to:
  • Infants aged under 6 months.
  • People who have had a confirmed anaphylactic reaction to a previous dose of yellow fever vaccine.
  • People who have had a confirmed anaphylactic reaction to any of the components of the vaccine.
  • People who have had a confirmed anaphylactic reaction to egg or chicken proteins.
  • People with thymus disorders or thymectomy (for any reason).
  • People who are immunocompromised.
  • People aged 60 years or older who are travelling to areas where the yellow fever vaccine is generally not recommended by the World Health Organization (WHO). For information, see the country-by-country guide to disease prevalence on the National Travel Health Network and Centre (NaTHNaC) Travel Health Pro website.
  • People with a first-degree family history of yellow fever vaccine-associated viscerotropic disease (YEL-AVD) or yellow fever vaccine-associated neurological disease (YEL-AND) following vaccination that was not related to a known medical risk factor. 
    • Yellow fever vaccine-associated viscerotropic disease (YEL-AVD) is a very rare syndrome of fever and multi-organ failure.
    • Yellow fever vaccine-associated neurological disease (YEL-AND) is a very rare pattern of neurological adverse events.
    • For further information, see the section on Adverse effects.
• Yellow fever vaccine should not generally be given to pregnant women because of the theoretical risk of fetal infection from the live virus vaccine. Pregnant women should therefore be advised not to travel to a high-risk area. However, when travel is unavoidable, the risk from the disease and the theoretical risk from the vaccine should be assessed on an individual basis.
  • The WHO advise that in areas where yellow fever is endemic, or during outbreaks, the benefits of vaccination are likely to far outweigh the risks.
  • A patient information leaflet on the use of yellow fever vaccine in pregnancy is available from the UK Teratology Information Service at www.medicinesinpregnancy.org.
• If a yellow fever vaccine is required for a breastfeeding woman, seek specialist advice from the National Travel Health Network and Centre (NaTHNaC).
  • There is some evidence of transmission of the live vaccine virus through breast milk to infants under 2 months of age.
• Postpone yellow fever vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization.
• Anyone who cannot receive a yellow fever vaccine and who must travel should be informed of the risk of yellow fever and instructed on strict mosquito bite avoidance measures.
• Anyone who cannot receive a yellow fever vaccine and is travelling to a country where an International Certificate of Vaccination and Prophylaxis against yellow fever is required for entry, should request that a letter of exemption is issued by the Yellow Fever Vaccination Centre or by the practitioner treating the person. 

Adverse effects

• Adverse reactions following yellow fever vaccine are typically mild and consist of headache, myalgia, low-grade fever, and/or soreness at the injection site, and will occur in 10–30% of recipients.
  • Injection-site reactions tend to occur from days 1–5 after immunization.
• Systemic adverse effects also occur early but may last up to 2 weeks. Reactions are more likely in those with no prior immunity to yellow fever, and up to 1% of individuals may need to alter daily activities due to these effects.
• Rash, urticaria, bronchospasm, and anaphylaxis occur rarely (estimated to be 1.3 cases per 100,000 doses of vaccine).
• Post-vaccine encephalitis may occur rarely, particularly in infants (0.5–4 cases per 1000 infants under 6 months of age).
• Rarely, yellow fever vaccine-associated neurological disease (YEL-AND) may occur.
  • YEL-AND begins 2–56 days after vaccination with the onset of fever and headache that may progress to include one or more of: confusion, focal neurological deficits, coma, and Guillain–Barré syndrome. Most people recover completely. Almost all cases have occurred following primary vaccination (in people who have no underlying yellow fever immunity).
• Rarely, yellow fever vaccine-associated viscerotropic disease (YEL-AVD) may occur.
  • YEL-AVD begins 1–18 days after vaccination with the onset of fever, malaise, headache, and myalgias that progress to hepatitis, hypotension, and multi-organ failure; death has occurred in more than 60% of reported cases. All cases have occurred following primary vaccination (in people without underlying yellow fever immunity).
  • In the reports of viscerotropic disease, 17% have had a history of thymus disease with subsequent thymectomy. Thus, people with thymus disorders or those who have had a thymectomy should not receive yellow fever vaccine.
• The overall reporting rate in the US of neurological and viscerotropic adverse events following yellow fever vaccination is as follows:
  • Neurological events — 8 cases per million doses.
  • Viscerotropic events — 3 cases per million doses.
• For those who are aged 60 years or older, the risk of neurological and viscerotropic adverse events increases:
  • Neurological events — 22 cases per million doses.
  • Viscerotropic events — 12 cases per million doses.

How to administer yellow fever vaccine

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Yellow fever vaccine is usually given by intramuscular (IM) injection, into the upper arm in children and adults, or the anterolateral thigh in infants under 1 year of age. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
• Yellow fever vaccine can be given at the same time as most other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
  • However, yellow fever and measles, mumps, and rubella (MMR) vaccines should, where possible, be given at least 28 days apart.
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Indications for vaccine

• Dengue vaccination is advised for people travelling to or going to reside in endemic areas who have experienced dengue infection in the past.
  • Although severe dengue is rare in travellers, the risk for severe disease is increased among those with previous infections.
  • People who plan to spend long periods in endemic areas (such as expatriates or aid workers) are at increased risk.
  • Country-specific recommendations and information on the global epidemiology of dengue can be found on the TravelHealthPro website.
• Previous dengue infection may be suspected in people with past travel to an endemic country or region who report experiencing an acute illness consisting of fever (2–7 days duration), with at least 2 further symptoms:
  • Headache.
  • Retro-orbital pain.
  • Myalgia.
  • Arthralgia.
  • Rash.
  • Thrombocytopenia.
  • Leukopenia.
• Investigating previous dengue infection is recommended for:
  • Travellers who report a previous dengue infection but do not have laboratory evidence of infection (dengue polymerase chain reaction [PCR] or serology test results).
  • Travellers who do not report a previous infection but have previously lived in dengue endemic areas or who frequently travelled to dengue risk areas — testing is required to exclude past asymptomatic infection.
• Repeat serology testing is not required for those reporting infection with existing laboratory evidence, but careful interpretation of PCR or serology results is required.
• For both groups of people (those with new and historical serology evidence), dengue serology can be affected by other viruses and vaccinations, and so may not be definitive of past infection. Guidance is available from the UK Health Security Agency (see Table 1) to help with the interpretation of PCR and serology results.
• Note: The person should be advised that they can further decrease their risk of contracting dengue by practising bite avoidance measures, particularly around dawn and dusk, covering arms, legs, and ankles when in high-risk areas, and using insect repellents.

Available vaccines and vaccination schedules

• Qdenga^® (indicated for people from 4 years of age with a likely history of previous dengue infection) is the only licensed vaccine for dengue in the UK.
  • It is a tetravalent live attenuated vaccine.
• The primary course consists of two doses: the first on day 0, the second 3 months later.
  • Clinical trial data indicate that the Qdenga^® vaccine provides 86% protection against hospitalisation with dengue, and 65% efficacy against virologically confirmed dengue.
• The vaccine is not recommended for seronegative people.
• The need for a booster dose has not been established.

Contraindications to vaccine

• Dengue vaccine is contraindicated in:
  • Children under 4 years of age.
  • People who have had a confirmed anaphylactic reaction to a previous dose of dengue vaccine.
  • People who have had a confirmed anaphylactic reaction to any of the components of the vaccine.
  • People who are immunocompromised.
• Dengue vaccine should not generally be given to pregnant women because of the theoretical risk of fetal infection from the live virus vaccine. Pregnant women should therefore be advised not to travel to high-risk areas. However, when travel is unavoidable, the risk from the disease and the theoretical risk from the vaccine should be assessed on an individual basis.
• Dengue vaccine should not generally be given to breastfeeding women because of the theoretical risk of infection in the child due to the live virus vaccine. Breastfeeding women should therefore be advised not to travel to high-risk areas. However, when travel is unavoidable, the risk from the disease and the theoretical risk from the vaccine should be assessed on an individual basis.
• Postpone dengue vaccination if the person has a current severe febrile illness.
  • Minor illness without fever or systemic upset is not a valid reason to postpone immunization.
• Postpone dengue vaccination for a period of 1 year after a laboratory-confirmed dengue infection. 
  • Following dengue infection, there is a short-lived cross-protection against all dengue serotypes, which may impair the immune response to the vaccine. 
• Note: Anyone who cannot receive a dengue vaccine and who must travel should be informed of the risk of dengue and instructed on strict mosquito bite avoidance measures.

Adverse effects

• The most frequently reported adverse reactions were injection site pain and erythema, headache, myalgia, malaise, asthenia and fever.
  • These reactions were typically mild to moderate in severity, occurred within 2 days post-vaccination, had a short duration (1–3 days), and were less frequent with the second dose.
• Other common adverse reactions which have been reported include decreased appetite, irritability, somnolence, nasopharyngitis, pharyngotonsillitis and upper respiratory tract infection.

How to administer dengue vaccine

• Obtain and document consent at the time of vaccination for people aged over 16 years. For younger people, it is usual to get consent from a person with parental responsibility.
  • Adults over 18 years of age are presumed to be competent to consent to treatment provided they can comprehend and retain the information they are given, and they can consider the facts and make an informed decision.
  • Young people of 16 and 17 years of age are also presumed to be competent using the same criteria as older adults.
  • Younger people can also give consent if they fully understand what is involved, but ideally, a person with parental responsibility should also be involved.
• Ensure that: 
  • There are no contraindications to the vaccine.
  • The person, parent, or carer has been fully informed about the vaccine and the vaccination procedure.
  • Possible adverse reactions have been discussed, and the person, parent, or carer is aware of how to manage them. 
  • The vaccine is correct, has been stored appropriately, and has not expired. 
  • The vaccination site has been washed with soap and water if it is visibly dirty. 
• Dengue vaccine is usually given by intramuscular (IM) injection into the upper arm in the region of the deltoid in children and adults. However, if the person has a bleeding disorder, the vaccine should be given by deep subcutaneous (SC) injection to reduce the risk of bleeding. 
• Dengue vaccine can be given at the same time as most other vaccines. If an additional vaccine is required on the same day, use separate limbs if possible, or inject at sites at least 2.5 cm apart. 
• Record the date of administration, vaccine and product name, batch number, expiry date, dose administered, and site of administration for each vaccine. 
• Observe the person after vaccination to detect immediate adverse reactions. Ensure any bleeding has stopped and check for any symptoms of anaphylaxis before they leave.
  • Anaphylaxis is extremely rare and usually becomes apparent within minutes. By the time the site has been checked for bleeding and documentation has been completed, most reactions will have become apparent. For more information, see the CKS topic on Angio-oedema and anaphylaxis.
  • Record the details of any observed or reported adverse reactions. For more information, including details about how to report adverse reactions, see the CKS topic on Adverse drug reactions.

Vaccinations for Hajj and Umrah pilgrims

• All pilgrims should ensure that they are up-to-date with routine immunizations, including measles, mumps, and rubella (MMR) and polio. Travellers whose last dose of polio was more than 10 years ago should receive a booster, using the trivalent tetanus, diphtheria, and polio vaccine.
• All pilgrims should consider hepatitis B vaccination.
• The Ministry of Health of Saudi Arabia recommends that all pilgrims are vaccinated against seasonal influenza.
  • Those at particular risk of complications (such as those aged 65 years and older, pregnant women, or those with chest, heart, liver, or kidney conditions) are eligible for this vaccination on the NHS. See the CKS topic on Immunizations - seasonal influenza for further information.
  • For those travellers who do not fall into a risk category, seasonal influenza vaccination must be paid for. Vaccination can be carried out at some local GP surgery travel clinics, at some high street chemists, or at a private travel clinic.
• All pilgrims aged over 1 year are required to show proof of vaccination against meningococcal meningitis ACWY.
  • Vaccination is also a requirement for obtaining a visa.
  • The meningitis ACWY conjugate vaccine should have been received not more than 5 years, and not less than 10 days before arrival in Saudi Arabia, and should be recorded in a vaccination book showing the traveller's full name, or on an International Certificate of Vaccination or Prophylaxis (ICVP) booklet.
• COVID-19 vaccination is required for some travellers, including those aged over 65, pregnant women and people with chronic heart, respiratory, kidney or neurological disease, hereditary blood disorders, congenital or drug-induced immunodeficiency, or cancer.
  
  • The Ministry of Health of Saudi Arabia also recommends that all pilgrims be vaccinated against COVID-19.
• Proof of additional vaccinations may also be required for pilgrims travelling to Saudi Arabia via a country or area with risk for transmission of certain diseases, including:
  • Poliomyelitis — required for pilgrims travelling from a country reporting wild poliovirus, vaccine–derived poliovirus or Acute Flaccid Paralysis.
  • Yellow fever — required for pilgrims above nine months of age. The World Health Organization (WHO) provide a list of countries or areas where there is a risk of yellow fever transmission.
• Although not required, pilgrims should consider rabies vaccination.
• Further travel advice can be obtained from the National Travel Health Network and Centre (NaTHNac) leaflet Hajj and Umra.

Rapid vaccination courses and vaccination at short notice

• Consider rapid vaccination courses, and/or vaccination up to the day of departure for people without sufficient time before travel to allow standard vaccination schedules. Travellers should be advised that if they do not leave the recommended amount of time for travel vaccines to be given, there may be an initial period for which they are not fully protected. The decision to travel should be carefully considered after a risk assessment.
  • Hepatitis B vaccine may be given as an accelerated course over 3 weeks. For further information, see the section on Hepatitis B vaccination.
  • Tick-borne encephalitis vaccine may be given as two doses 2 weeks apart. For further information, see the section on Tick-borne encephalitis vaccination.
  • Japanese encephalitis vaccine may be given to people over the age of 2 months as two doses 7 days apart (instead of the usual 28 days). For further information, see the section on Japanese encephalitis vaccination.
  • Rabies vaccine can be given as an accelerated course over 1 week. For further information, see the section on Rabies vaccination.
  • Hepatitis A primary doses and hepatitis A, tetanus, and polio boosters can be given up to the day of departure.
    • Previously unimmunized people who require tetanus and polio vaccination should be given the maximum number of doses that the travel departure date allows, and the course should be completed upon return. For further information, see the sections on Hepatitis A vaccination, Tetanus vaccination, and Polio vaccination.
  • Typhoid vaccination can be considered up to the day of departure. Full immunity can take up to 1 month to develop, although a four-fold rise in antibody against Vi antigen has been detected 7 days following primary immunization with Vi vaccine. For further information, see the section on Typhoid vaccination.
  • Meningococcal vaccine may be beneficial for some people up to the day of departure, depending on whether the area being visited is considered high risk, and their length of stay. In a study cited by the manufacturer of Menveo^®, bactericidal antibodies were observed in at least 64% of people at 1-week post-vaccination. Vaccination must be given not less than 10 days before arrival in Saudi Arabia for entry to be granted. For further information, see the section on Meningococcal vaccination.
  • Yellow fever vaccine may be given up to the day of departure if there is a risk of contracting yellow fever. Full immunity develops 10 days after vaccine administration, and anyone receiving the vaccine at short notice should therefore be counselled about the importance of insect bite avoidance. People requiring a valid yellow fever vaccination certificate at their destination need to be vaccinated at least 10 days prior to travel. For further information, see the section on Yellow fever vaccination.
• If there is insufficient time to complete all the required vaccinations prior to departure, seek specialist advice from the NaTHNaC advice line for health professionals:
  • Telephone: 0845 602 6712, Monday to Friday, 13:00 to 15:00.