Mumps Vaccination for Outdoor Travelers

Mumps (a viral infection) is making a comeback in the U.S. and other countries because of failure to vaccinate. It is not a trivial disease, particularly in adults, and is highly communicable. In children, mumps typically causes fever, headache, muscle aching, fatigue, loss of appetite, and swelling of salivary glands, in particular the parotid glands, which are located in the cheeks directly in front of the ears. In all age groups, patients suffer from fever and inflamed salivary glands, which causes the "chipmunk" appearance, as if the person was a small animal storing nuts in his or her cheeks. In male adults, mumps can cause inflammation of the testicles (orchitis), which can become quite painful and debilitating. In other cases, mumps can cause deafness and inflammation of the brain and sensitive tissues around the brain. It can also cause ovarian or breast inflammation, miscarriage, and deafness. The severity of infection tends to increase with age.

In an article entitled "Recent Resurgence of Mumps in the United States" (New England Journal of Medicine 2008;358:1580-9), Gustavo H. Dayan, M.D. and his co-authors describe that the largest mumps outbreak in two decades in the U.S. occurred in the year 2006. This was in a population that received the proper immunization regimen of two doses of vaccine. Their conclusions were that it may be necessary to develop a more effective mumps vaccine or to make a change(s) in mumps vaccination policy (e.g., institution of a recommendation for a third dose of vaccine).

Why did the incidence of mumps increase? Some factors cited by the authors include declining immunity, high population density and contact rates among college students, the possibility that the vaccine did not provide sufficient immunity against certain ("wild") strains of the virus, and that perhaps the virus was transmitted by persons with very mild ("subclinical") disease or vaccine-modified disease.

What does this mean for the wilderness or foreign traveler? Outbreaks have certainly occurred in other countries, such as Canada. For now, it is just a reminder that all childhood immunizations should be brought up to date prior to travel, because exposure to mumps and other normally childhood diseases may periodically be higher in countries outside the U.S.

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

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Typhoid Fever Vaccine

Typhoid fever is caused by the bacteria Salmonella typhi, which are transmitted among humans through ingestion of contaminated food or water. Most cases are acquired abroad under conditions of poor hygiene.

After an incubation period of 10 to 14 days, victims suffer fever with or without diarrhea and abdominal pain. Most victims also complain of headache, fatigue, and loss of appetite. “Rose spots,” which are 2 to 4 mm red spots on the trunk that blanch (lose their color) when pressed, are seen in some cases. The liver may become inflamed.

Most cases resolve in 3 to 4 weeks. The seriously stricken individual may suffer a severely inflamed bowel, bleeding from the gastrointestinal tract, pneumonia, heart failure, severe fever, and death.

A physician who diagnoses typhoid fever will treat the victim with an intravenous antibiotic. The layperson can use trimethoprim-sulfamethoxazole; administer one double-strength tablet twice a day for 2 to 3 weeks. You can also use ampicillin 100 mg per kg (2.2 lb) of body weight in four divided doses for 2 to 3 weeks. It is important to keep the victim from becoming dehydrated.

Injectable and oral vaccines to prevent typhoid fever are available to people traveling to areas of high risk. Typhim Vi polysaccharide vaccine is available for immunization against typhoid fever caused by Salmonella typhi. Immunization is recommended only for travelers who visit regions (e.g., Nepal, South Africa, Indonesia) known to harbor the disease. A single intramuscular injection is required, followed by booster injection at 2-year intervals, depending on the local disease risk. An oral vaccine (Vivotif Typhoid Vaccine Live Oral Ty21a [Berna]) is given as one capsule every other day for four doses in people age 6 years or older. A booster series is necessary every 5 years. Side effects, which include fever, headache, and flu-like symptoms, are more commonly associated with the injections than with the oral capsules.

According to Berna Products, here are some recommendations on how to take typhoid vaccine capsules:

DO's:

1. DO complete taking the capsules at least one week before traveling.
2. DO take each capsule on an empty stomach (1 hour before eating or 2 hours after eating).
3. DO take each capsule with a full glass of cool or lukewarm water.
4. DO keep capsules in the refrigerator.

DON'T's:

1. DON'T take the vaccine if you are taking antibiotics (consult your doctor).
2. DON'T take the vaccine with alcohol (wait at least 2 hours before drinking alcohol).
3. DON'T open or chew the capsules.
4. DON'T forget to skip a day between capsules.
5. DON'T forget to take all 4 capsules.

The capsules are designed to stay intact and only dissolve then they reach the small intestine. The capsules should be taken at approximately the same time each day. If a person has had an adverse reaction to the oral typhoid vaccine or any other enteric coated capsule in the past, the oral vaccine should not be taken. If the person has a fever, continued vomiting, or diarrhea/stomach illness, the oral vaccine should not be taken.

It is very important to remember that this vaccine is not foolproof, so even if a person is vaccinated, he or she should avoid potentially contaminated food and water.

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Preview the textbook Wilderness Medicine

Preview the handbook Field Guide to Wilderness Medicine

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New Recommendations for Tetanus Prophylaxis in Wound Management

In medical parlance, “prophylaxis” refers to the process (usually by vaccination [immunization] or administration of a protective drug [such as is done to prevent an infection, such as malaria]) whereby an adverse medical condition, such as an infection or blood clot formation, is prevented. So,”tetanus prophylaxis” refers to the situation where a person is given an injection or series of injections to prevent infection with the bacterium Clostridium tetani, the causative agent of a tetanus infection. Because infection with tetanus can be very serious and even life-threatening, it is important for each of us to have active immunity.

The Immunization Branch or the State of California Department of Health Services recently released a new recommendation for tetanus prophylaxis in wound management. This was necessary because of the increasing prevalence of pertussis (“whooping cough”) in our communities, which necessitates that greater attention be paid to preventing this disease, which is caused by the bacterium Bordetella pertussis.

From this point forward, it is recommended that adolescents and adults who require tetanus toxoid vaccine for wound management should receive a single dose of Tdap (tetanus, reduced diphtheria, and acellular pertussis) vaccine instead of Td (tetanus, diptheria) vaccine.

Healthcare workers who have direct patient contact are also recommended by the Centers for Disease Control (CDC) to get a dose of Tdap vaccine to protect themselves, their families, and their patients.

Health care providers need to be aware of which vaccines are licensed for which age groups:

1. Tdap (tetanus, diphtheria, pertussis): ADACEL® (sanofi pasteur) ages 11-64 years; Boostrix® (GlaxoSmithKline) ages 10-18 years
2. DTaP (diphtheria, tetanus, pertussis): DAPTACEL® (sanofi pasteur) ages 6 weeks to 7 years; TRIPEDIA® (sanofi pasteur) ages 6 weeks to 7 years; Infanrix® (GlaxoSmithKline) ages 6 weeks to 7 years; Pediarix® (GlaxoSmithKline) ages 6 weeks to 7 years
3. Td (tetanus, diphtheria): Td (sanofi pasteur) ages 7 years and older

One obvious question is which vaccine should be used for children between the ages of 7 years and 10 years? It is probably best to use the DTaP vaccine for this age group, even though no vaccine is licensed for this age group, and either Tdap or DTaP would likely induce the proper immunities.

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