IMMUNIZATIONS - OUCH!!

I thought shots were for kids and dogs! I’m 48 (oops 49), in good health (knock knock) and haven’t had a single shot since I was a kid! Then, I decided to hitch a ride on a cruise ship for 4 months to see the world!  And it was 2 shots in the left arm, 2 shots in the right arm, another shot in the left arm (5 total) - and Typhoid and Malaria pills to take later (along with other "travel meds", "just in case")!  This isn't the "fun" part of the cruise!!  But it beats getting a horrid disease ...

SAY, MY DOCTOR LOOKED KINDA LIKE THIS!

INFORMATION PROVIDED BY CRUISE LINE
          On Holland America’s web site, they tell us:  “International travelers can take a number of simple steps to avoid potential health problems before and during travel:
                     Contact your local physician ideally 4-6 weeks prior to departure.
                     It is important to receive current health information on the countries you plan to visit.
                     Obtain all necessary vaccinations and preventative medications. It is important to address any special needs.
                     Immunizations may be recommended or required for countries visited on your cruise itinerary. If you are traveling to (or transiting through) Africa or South America, for example, you may require a certificate of vaccination against yellow fever. This vaccination can be administered only by a state approved clinic.
                     It is also a good idea to bring along a record of your immunizations as requirements for immunizations may change."

FINDING A STATE-APPROVED CLINIC
          So I needed to find a "state approved clinic".  A general "Google" search for travel immunizations brought up a number of service providers in my area (San Diego), as well as a site for the County of San Diego’s Immunization Program. The County of San Diego’s Health & Human Services Agency does not provide travel vaccines. However, they directed us to a number of local fee-for-service “travel physicians”, who provide "comprehensive travel counseling". I was able to find someone there.

SEEING A “TRAVEL” PHYSICIAN AND RESEARCHING CDC REQUIREMENTS

          When I called for my doctor's appointment, I was taken aback when the lady asked me which vaccines I needed. How was I supposed to know? I was calling them for the “comprehensive travel counseling”. They told me they follow CDC guidelines, and I should go to the CDC’s web site to learn which vaccines I needed for the locations I would visit. Okay, fine.
          On the CDC’s web site, I learned that “CDC divides travel vaccines into 3 categories: routine, recommended, and required. See: http://wwwnc.cdc.gov/travel/page/vaccinations.htm . While your doctor will tell you which ones you should have [that’s what I thought, too], it’s best to be aware of them ahead of time.”  (I did receive the travel counseling at the appointment itself, after pointing out the unusual response when I called for the appointment.)
          • Routine: The CDC says, “Be sure that you and your family are up to date on your routine vaccinations. These vaccines are necessary for protection from diseases that are still common in many parts of the world even though they rarely occur in the United States. If you are not sure which vaccinations are routine, look at the schedules below.”
          Curious, I clicked on the link for “Recommended Adult Immunization Schedule – United States". This takes you to a sheet, “Vaccinations for Adults”. It lists different things, for different ages (19-49, 50-64, and 65 & older). I got (or considered) these shots:
                    • Influenza (flu): CDC says you need a dose every fall or winter. I’d never had one before, and my doctor didn’t insist, either (he said, “I’ll give it to you if you want it”). I decided to go ahead with it, since I’d be stuck on a ship for 4 months, where people have been known to get sick.✓ (This one stung the worst.)
                    • Pneumococcal: The vaccination page says you need 1-2 doses if you smoke cigarettes or have certain chronic medical conditions, or if you’re 65 or older and have never been vaccinated. I do smoke and thought this would be one I’d get, but the doctor said I didn’t need it - that the CDC says to only give to persons 65 or older. Who was I to argue?
                    • Tetanus, diphtheria, pertussis (whooping cough): CDC says get a 1-time dose of “Tdap” vaccine if younger than 65, or 65+ and have contact with an infant, are a healthcare worker, or simply want to be protected from whooping cough. It says you also need a Td booster dose every 10 years. So I got the Tdap vaccine.✓
                    • Other routine ones inapplicable. Each person should check the list for him/herself.
          • Recommended: Here’s where my own research, combined with speaking to the doctor, was very helpful. You can look up each country/destination on the CDC website here:
          http://wwwnc.cdc.gov/travel/destinations/list.htm


VACCINATION CERTIFICATE

          In addition to the routine vaccinations, the following are recommended for our travel destinations:
                    Hepatitis A, Hepatitis B and Typhoid: About 10 countries recommend these three. Many countries only recommend the Hep B. ✓
                    According to my doctor, Hep B is only transmitted through blood or sexual contact.  Since I'm not planning a sexual rendez vous or to share blood with any locals, I didn’t have to have it.  But the Hep A and Hep B can be combined into one shot/series, so I went ahead and got both. You don’t have to wait months for the series, either, because there’s an accelerated one, where you get the 2nd shot after 7 days and the 3rd/final shot after 3 weeks. The Typhoid comes in 4 small pills, which must remain refrigerated, and aren’t taken until 2 weeks before travel, one every other day for a week.
                     Add Polio booster w/IPV: India. ✓
                     Add Yellow Fever: Brazil and Argentina. ✓
                     Rabies: Several countries also recommend Rabies IF you’re a vet, live in a high-risk area or might be in direct contact with bats (or, in Indonesia, if you’ll be spending a lot of time outdoors, hiking, camping, biking) - I skipped
                     Several also recommend Japanese Encephalitis, e.g., Australia IF visiting Torres Straight or northern Australia, and Indonesia/Hong Kong/Vietnam/Singapore/Thailand/Sri Lanka IF visiting rural farming areas, or if there’s a known outbreak - I skipped

NO, I DON'T WANT TO!!

          • Required: According to the CDC, “The only vaccine required by International Health Regulations is yellow fever vaccination for travel to certain countries in sub-Saharan Africa and tropical South America.” (Since this can be dangerous for some people, e.g., older travelers, their doctors will need to complete the “Medical Contraindication to Vaccination” portion of the yellow “International Certificate of Vaccination”.)

MEDICATIONS
          In addition to the vaccines mentioned above, certain medications are recommended for our trip.
          • Malarone for Malaria: A prophylactic is required when traveling to countries where there is malaria. According to the CDC, malaria is a mosquito-borne disease, caused by a parasite. People with malaria often experience fever, chills and flu-like illness. Left untreated, they may develop severe complications and die. In 2008, an estimated 190 - 311 million cases of malaria occurred worldwide and 708,000 - 1,003,000 people died, most of them young children in sub-Saharan Africa.”  (What a tragedy - there's medication to prevent this!)

KILL THEM THERE MOSQUITOS!

                    In addition to avoiding mosquitos (using repellant), I am to take Malarone (generic is Atovaquone-Proguanil) 1 day before arriving in Belem, Indonesia and India, and continuing for 7 days after leaving these places. These were the locations my doctor was concerned about on our itinerary. He said this was the most expensive of the available meds, but one alternative, Doxycycline, requires a much longer dose, and another presents the risk of adverse reactions like suicide. All the agents can be studied on the CDC web site here:
http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/malaria.htm#1975.  And, as it turns out, the Malarone generic was only $11.80 (my insurance must have picked up most of the cost)
          • Ciprofloxacin (Cipro) for Traveler's Diarrhea: My doctor routinely prescribes this "just in case".  I only got one course (2 pills a day X 5 days), so let's hope I don't need it once, let alone twice!  This was only $4.75.
          • Transderm Patches for Motion Sickness:  I was told these patches are "the best" way to prevent motion sickness.  Since we're on a mid-sized ship, headed to some rough places (e.g., Cape Horn), I thought it best not to rely on Dramamine.  These were the most expensive, costing $48.20 for 4 patches (each lasting up to 3 days).  That's $4/day not to find myself praying to the Porcelain God - worth it, I'd say!

THE COSTS
          Here were the costs of these immunizations:
                    Hep A+B Combo - $107 (Dose 1), $132 (Dose 2)
                    Flu - $55
                    Polio booster w/IPV - $42
                    Tdap - $48
                    Typhoid oral vaccine - $60
                    Yellow fever - $105
                    Travel consult - $68
                            Total - $617
          For the meds, I paid a total of $64.76.


Update:  In a letter, just received today (10/17/11) from HAL, the cruise line tells us "At the time of publication, no specific vaccinations were required for this sailing."  Really?!  I'll rely on the CDC guidelines, which say yellow fever immunization is required for travel to tropical South America (we're going to the Amazon, Iguazu Falls in the jungle, etc.).