The German Thai Link Vaccination

A guide for expatriate parents resident in Thailand

Compiled by Dr. Olarn Seriniyom, Samitivej Hospital

INTRODUCTION

Increasingly, international travel exposes children to diseases for which vaccines are not available or not given in their own countries. Children of expatriate parents, whether they were born in Thailand or abroad, need to have vaccines which would normally be given in the country to which they will return, as well as those vaccines which will protect them during their stay in Thailand. Which particular vaccines they will need depend on how long they are likely to stay in Thailand. This leaflet aims to provide some guidance so that you, in conjunction with your doctor, may make an informed choice. The recommendations in this leaflet are partly based on the current expert advice as available to the Department of Health of the United Kingdom. In some circumstances they may differ from the opinions of other physicians, and there are a number of differences between these guidelines and the regime which applies to Thai children.

DIPHTHERIA, PERTUSSIS, TETANUS AND POLIO

The vaccines for these diseases are usually given together in the form of the Triple Vaccine (DPT) and oral polio drops. These are given almost everywhere in the world, although some of the diseases have become very rare in certain countries. Unless there is a special reason, every child should receive these vaccines. There is no difference between the DPT/polio vaccines given in Thailand and most other countries, but the timing may differ. For example, in the UK the first three doses are given at 2, 3, and 4 months of age, whereas in Thailand they are given at 2, 4, and 6 months. However, these differences in timing are of minor importance only The vaccines The DPT vaccine is given as an injection in the upper arm or thigh. The polio vaccine is given as three drops orally. If this is regurgitated (by spitting or vomiting) the dose needs to be repeated. Recommendation The primary course of these vaccines should be given at 2, 4, and 6 months of age. The first booster is given at 18 months. The second booster, from which the pertussis component may be omitted, is given between 4 and 5 years of age. A final booster dose of tetanus and polio only is given at 15 to 18 years of age. Side effects Swelling and redness at the injection site are moderately common. Malaise, transient fever and headache may also occur. Paracetamol can be given to reduce fever. Severe reactions are rare and your doctor should be consulted. Contra-indications. Your child should not be given the vaccine if he is acutely unwell or has a fever. However, minor illnesses such as a simple cold with no fever are not a reason to delay immunisation. A child with diarrhoea or vomiting should not receive oral polio vaccine. Consult your doctor if your child has a chronic illness.

MEASLES, MUMPS, AND RUBELLA

These diseases are rapidly becoming uncommon in countries where the vaccine has been used for some time. In most previously healthy children these diseases are often mild and self-limiting, however, occasional severe complications are seen and currently it is recommended that all children receive this vaccine. The MMR vaccine This is given as a single dose injection at 12 to 18 months of age. It is important that your child receive this vaccine even if he may have had measles, mumps or rubella infection previously. This will not cause a problem. The MMR can be given at the same time as the DPT/OPV. Recommendation All previously unimmunised children over 12 months of age should receive this vaccine. No boosters are required. Side effects Fever is moderately common six days to a week after vaccination and usually lasts no more that a day or two. A rash may also occur. Paracetamol is all that is required for the fever. Contra-indication Vaccination should be deferred for children with acute infection and fever. It should be avoided in children with genuine allergy to eggs, and not dislike or refusal to eat eggs.

TUBERCULOSIS: BCG IMMUNISATION

Although uncommon in the West, tuberculosis is found almost world-wide. It is still a major problem in Thailand and Asia generally. In western countries with large immigrant populations TB occurs sporadically. In the UK, BCG is given to all children over 10 years of age after a negative skin test. Entry in to universities and colleges often require testing for immunity to TB, and vaccination if not immune. In most parts of Asia as well as in certain British communities, BCG is given at birth. The BCG vaccine This is a live vaccine. The dose is very small but requires a specialised technique of injection and should only be given by an experienced practitioner. Recommendation All children born in Thailand should receive the BCG vaccine at birth. Other children should receive the BCG after a negative skin test if intending to stay in Asia for longer than two months. Side effects A reaction at the injection site is USUAL. Within two to six weeks a small lump develops which increases in size up to about 7mm. Occasionally a shallow ulcer up to 1cm. across develops. A dry dressing may be applied if there is any oozing from the ulcer. The dressing should not be air-tight as this delays healing. It is not essential to keep the site dry, but if it is oozing a watertight dressing may be applied to permit swimming. The reaction heals over a period of several weeks to a few months leaving a small scar. More severe reactions such as large ulcers, abscesses and large scar formations (keloids) are sometimes seen, usually as a result of incorrect or inappropriate injection. You should consult your doctor in such an event although the problem may be more troublesome than dangerous. Usually no treatment is required unless your child has an abnormal immune system.

HEPATITIS B

Hepatitis B is a disease of the liver which is mainly transmitted by contact with infected blood and contaminated sharp objects. It is occasionally transmitted by very close contact with an infected person. The disease can be fatal although it can also be mild. In the Far East hepatitis B is very common, although many infected people are carriers who exhibit no symptom. In common with most countries in the world, blood products used in hospitals in Thailand have been screened for hepatitis B and other diseases, and should be safe. Needles and other surgical instruments used in hospitals in Thailand are normally safe even though use of disposable sharps is not universal. There remains, however, a significant risk of infection for those intending to stay in Thailand for long periods, especially children. In Europe and North America, the hepatitis B vaccine is given only to those at special risk such as health workers. The hepatitis B vaccine The hepatitis B vaccine contains a part of the viral envelope. It is not a live vaccine. The primary course of injection consists of three doses given at 0, 1 and 6 months. In Thailand the first injection is commonly given to children at birth. Full protection may not be achieved until six months after the primary course. A small percentage of people vaccinated fails to develop immunity, which can be tested for if necessary. Recommendations For foreign children in Thailand, there is no clear guide line as to when it is essential to be vaccinated against hepatitis B. Commonly those born in Thailand and intending to stay for long periods are offered the vaccine. Older children coming from abroad probably should be vaccinated if it is intended that they go to school in Thailand. Tourists are not normally at risk. Adults should consult their doctors. Side effects Adverse reactions to the vaccine are very uncommon and usually consist of some soreness or redness at the injection site. More severe reactions are very rarely seen.

JAPANESE B ENCEPHALITIS

This is an uncommon disease caused by a virus which is transmitted by mosquitoes. The virus infects the brain and although few cases develop any significant symptoms, some cases are fatal or produce permanent brain damage. The disease is seen through out the Far East. It is especially common in rural rice-growing or pig-farming areas. The peak season for the disease is the rainy season. The vaccine The vaccine is given by injection at day 0, 7-14, and then a year later. The vaccine gives good protection but this may take one month to develop. In Thailand, many hospitals give the vaccine routinely to children over one year of age. Cost may be one reason why it is not given to all Thai children. The vaccine is not widely available in the West and most travelers to the Far East are not offered this vaccine. Its use in the Far East is well established however, and the vaccine seems to be quite safe to use. Recommendations Again, there is no absolute indication for vaccination. Clearly adults and children over one year of age who will be staying in rural areas especially between June and September should be vaccinated, but even in urban areas outside of the monsoon period, it is possible to contract the disease, although this is rare. It would seem reasonable to vaccinate children who will be staying in Thailand for more than a few months in view of the low risk of problems from the vaccine itself. Side effects Allergic reactions to the vaccine are very rare. Localised pain and redness occur very infrequently.

TYPHOID

This is a severe disease characterised by fever and diarrhoea. It is caused by the bacterium Salmonella typhi. There are many hundreds of other members of the Salmonella family and they may cause diarrhoea of varying severity with or without fever and blood in the stool, but they do not cause typhoid fever. Typhoid is transmitted by food and drinks which are contaminated by an infected person or carrier of the bacteria through poor hygiene. It is found in all parts of Asia. It is rarely seen in the expatriate community in Thailand, who do not often expose their children to unhygienic food. Cases in the West are rare and usually imported from Asia. The vaccine There are two main types: an injectable vaccine and an oral vaccine. The oral type consists of three capsules which are taken on alternate days. They must be kept refrigerated. They must be swallowed whole and are not suitable for children under three years of age. Up to 80% protection is given for at least three years. The injectable vaccine is produced by the Thai government pharmaceutical department. It gives up to 80 % protection for three years if two doses are given. Recommendations For adults and older children the oral vaccine is recommended and may be repeated every three years. For children under 18 months vaccination is not advised. Children 18 months to 3 years of age should have the injectable vaccine. Side effects The oral vaccine may produce transient mild nausea, stomach cramps and diarrhoea. The injectable vaccine OFTEN produces localised redness, swelling, pain and tenderness lasting for a few days.

RABIES

Rabies is a viral infection of the brain transmitted via contact with an infected animal. It is invariably fatal and although cases of rabies in human are rare, infected dogs are moderately common in Thailand. The vaccine If given after exposure to a suspect animal, six injections are given over a three months period. If given only as a safeguard before exposure three doses are required. Recommendation Because protection from rabies can be given after exposure, the vaccine is not normally given to persons who have not been in contact with a sick animal. Protective vaccination may be advisable if there is a special risk such as travel to very remote areas or for those who work with animals. However, vaccination is strongly advised if there is contact with a suspect animal whether the skin is broken or not. All dog bites should be regarded as suspect even if the dog is someone else's pet and is known to be immunised, as the vaccine for dogs is not fully reliable.

HAEMOPHILUS INFLUENZAE TYPE B (Hib)

This bacteria is a cause of meningitis (infection of the lining of the brain). Young children are at higher risk. The disease is not particularly common in Thailand. If contracted, the effects are often severe. In recent years the vaccine against this bacteria has become established as routine for children under four years of age in North America and Europe (in the UK from Oct '92). In Thailand the vaccine is currently NOT AVAILABLE although it may become available in mid-1993. The vaccine Three doses are given by injection one month apart to children aged two months and over up to 4 years of age. Those under 1 year are at special risk from the disease. It is important to use the same brand of vaccine for all three doses. Recommendation As the vaccine is now given to all children in the age group in the West, it would be equally advisable that all children of Western parents between 2 months and 4 years of age in Thailand are vaccinated. While the vaccine is not yet available in Thailand, parents should try to bring or obtain the vaccine from abroad.

HEPATITIS A

This disease of the liver is very common in Thailand and is transmitted mainly via unhygienic food. Although usually only moderately severe and self-limiting, cases with serious complications are sometimes seen. The vaccine for hepatitis A is only now becoming available in other parts of the world and should become available in Thailand soon. It is expected to be beneficial to expatriate children, amongst whom cases of hepatitis A are seen moderately frequently. Please note that this vaccine is not the same as immunoglobulin injections commonly given abroad to provide short-term protection from hepatitis A. CHOLERA The use of vaccination against this rare but severe illness was very commonplace at one time, but in recent years it has been shown that the vaccine is not very effective and complication rates are high. Cholera vaccine is now not advised, except for travel to a few countries which still require it.

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