15 Oct 2015
Country specific information - RationaleEpidemiological rationale for recommendations
Cholera is considered to represent a potential risk to travellers if:
- a country had reported ≥100 cases to the WHO in at least 3 out of 5 years, 2010 to 2014 inclusive;
- a country had reported an outbreak of ≥1000 cases to the WHO in at least one year, 2010 to 2014 inclusive.
When there had been sporadic or absent reporting to WHO between 2010 and 2014, a consensus opinion was formed based on consideration of available data, and whether the country borders an country endemic for cholera [1,2].
Review in progress: coming soon
NaTHNaC country specific vaccine recommendations were based on the 2010, the World Health Organization (WHO) “The Global Prevalence of Hepatitis A Virus Infection and Susceptibility publication which classifies countries with different burdens of Hepatitis A disease. For countries with a high burden of hepatitis A disease, the recommendation was for most travellers to receive Hepatitis A vaccine; vaccine was not recommended for low burden countries.
For those countries with a burden of hepatitis A disease classified as “medium” or “low-medium”, two additional factors were considered to assess the need for a vaccine recommendation: sanitation levels in rural populations, and the economic development of that country.
Countries were divided into two groups based on the percentage of the rural population without access to improved sanitation as detailed in the WHO Progress on Drinking Water and Sanitation Report 2014:
(a) < 90% of rural population with access to improved sanitation
(b) ≥ 90% of rural population with access to improved sanitation
(2) Economic Development:
The World Bank classifies economies as low-income, middle-income (subdivided into lower-middle and upper-middle), or high-income based on gross national income (GNI) per capita. Countries with a high GNI per capita were classified as high economic development countries.
Using these additional sanitation and economic factors:
a. for countries with medium or low-medium burden of hepatitis A, high economic development, and ≥ 90% of the rural population with access to improved sanitation vaccine was recommended for some travellers.
b. for all other countries with medium or low-medium burden of Hepatitis A disease, vaccine was recommended for most travellers.
When there had been sporadic, absent or conflicting reports, national authorities were consulted and a consensus opinion was formed based on consideration of any additional available data for that country.
NaTHNaC vaccine recommendations have been made for countries where 2% or more of the population were known to be persistently infected with the hepatitis B virus (intermediate/high prevalence) [3-5]. When there was limited information about those who are persistently infected with the virus in a country, a consensus opinion was formed based on consideration of the available data.
Review in progress: coming soon
NaTHNaC country specific vaccine recommendations for meningococcal ACWY have made based on whether a country lies within the meningitis “belt” of sub-Saharan Africa, as defined by the World Health Organization. Additional vaccine recommendations for Saudi Arabia were made in accordance with the requirements of the Ministry of Health of the Kingdom of Saudi Arabia for those who will perform Hajj or Umrah, or undertake seasonal work.
NaTHNaC monitors the global polio situation, as detailed by the Global Polio Eradication Initiative and World Health Organization, and makes changes to country specific recommendations as new information becomes available.
NaTHNaC recommends that travellers visiting countries where cases of wild type polio have been reported since January 2012 should receive a booster dose of polio-containing vaccine if they have not received one within the past 10 years.
NaTHNaC also recommends that travellers to countries reporting wild type poliovirus in environmental samples in the last year or have reported circulating vaccine derived polio virus usually should receive a booster dose of polio-containing vaccine if they have not received one within the past 10 years.
When an environmental VDPV is reported in a country without human cases, expert advice will be sought to consider immunisation coverage and surveillance and whether a recommendation needs to change.
In addition, some countries have specific polio vaccination and certificate requirements.
NaTHNaC identified countries where rabies was currently a risk by reviewing data from the World Animal Health Information Database (OIE) 2011- 2012 and where country data was available in 2013. Reports on the Outbreak Surveillance database were reviewed regarding known or presumed cases in indigenous domestic and/or wild animals. Where data was lacking for a country, other verifiable sources were sought including personal communications with the national authorities. Where no or limited data was available, a consensus opinion was formed based upon the best available evidence.
NaTHNaC reviewed available information in order to identify countries where schistosomiasis may pose a risk to travellers. The primary resource used was the World Health Organization (WHO) report on the status of schistosomiasis in endemic countries in 2012 [6,7]. Where reporting was sporadic or absent, consensus expert opinion was formed based on consideration of available data.
Review in progress: coming soon
There is an increased risk of acquiring tuberculosis in countries where the annual incidence of all forms of tuberculosis (TB) is ≥40 cases per 100,000 population. Further information is available here.
NaTHNaC reviewed the average annual incidence of tuberculosis between 2012 and 2014 from the World Health Organization (WHO).
Some travellers may be recommended to receive BCG vaccination when a country has:
- reported an average annual incidence of tuberculosis of ≥40 cases per 100,000 population in the last five years
- reported an annual incidence of tuberculosis of ≥40 cases per 100,000 population at least once in the last five years
Where no or limited data was available for a country, expert consensus opinion is formed using the best available information. If the annual incidence is presumed to be ≥40 cases per 100,000 population, there is a recommendation for vaccination for some travellers to that country.
NaTHNaC typhoid vaccine recommendations were based on a review of country specific burden of typhoid disease using available resources [8,9] and Public Health England imported typhoid disease data. Where information was unavailable, the national authorities of a country were contacted for information and a consensus opinion was formed based on consideration of all available data for that country.
Country specific recommendations are based on collaborations with Public Health England and Centers for Disease Control, Atlanta (Hepatitis A).
First Published : 15 Oct 2015
Last Updated :  10 Nov 2016
- World Health Organization. Weekly epidemiological record: cholera 2014 [Accessed 21 September, 2016]
- Public Health England. Laboratory reports of Vibrio cholerae O1 and O139 in England and Wales: 2004 – 2013. [Accessed 21 September, 2016]
- World Health Organization & Centers for Disease Control and Prevention publication: J.J. Ott, G.A. Stevens, J. Groeger, S.T. Wiersma, Global epidemiology of hepatitis B virus infection: New estimates of age-specific HBsAg seroprevalence and endemicity, Vaccine. 2012. [Accessed 8 October 2015]
- Prevalence and estimation of hepatitis B and C infections in the WHO European Region: a review of data focusing on the countries outside the European Union and the European Free Trade Association. Hope VD, Eramova I, Capurro D, Donoghoe MC. Epidemiology and Infection, 2013, 29:1-17. [Accessed 8 October 2015]
- The State of Hepatitis B and C in the Mediterranean and Balkan Countries: Report from a Summit Conference Hatzakis 2013 et al. [Accessed 8 October 2015]
- World Health Organization. Status of Schistosomiasis endemic countries 2012. [Accessed 8 October 2015]
- World Health Organization. Weekly Epidemiological Record, 89, 21-28, 2014. Schistosomiasis: number of people receiving preventive chemotherapy in 2012. [Accessed 8 October 2015]
- Burden of typhoid fever in low-income and middle-income countries: a systematic, literature-based update with risk-factor adjustment. Mogsdale V, Maskery B, Ochiai Rl et al, 2015. The Lancet Global Health Oct; 2(10):e570-80.
- Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bulletin of the World Health Organisation, May 2004, 82(5), 346-353
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