Travel Health Consultation

Medical Directive — Blenheim Health Hub Pharmacy | YFVC Designated (ON-2125)

1. Patient Information

Patient Name *

Date of Birth

Health Card Number

Consultation Date

2. Eligibility Screening — Medical Directive

Inclusion Criteria (must confirm all three)

Age ≥ 2 years verified Patient requesting travel health advice Traveling to area with identified health risks (CDC/NACI)

Exclusion Criteria (any checked → REFERRAL REQUIRED)

Pregnant (any trimester) Complex medical history (malignancy, transplant, renal/hepatic/cardiac failure) Anaphylaxis history to vaccine components Currently symptomatic (fever >38°C or acute illness)

3. Medical History & Allergies

Medical History

Current Medications

Allergies / NKDA

4. Immunization History

Routine Vaccinations

Check each vaccine the patient has received and enter the most recent date.

Travel Vaccinations — Previously Received

Record prior doses. Duration of protection guides whether a booster is needed today.

⚠ Vaccination Gaps Identified

Select any routine gaps — these will appear in the physician note and patient summary.

Additional immunization notes

5. Trip Details

Departure Date

Return Date

Itinerary

Country *	City / Region	Days	Max Altitude (m)

Accommodation Type

Hotel (international chain) Guesthouse / local hotel Hostel / backpacker Camping / outdoor Rural village / local home Resort Cruise ship

Dining Habits

Western restaurants only Local restaurants Street food Rural / village food Mixed

Activities

6. Risk Assessment

Populates risk notes and pre-checks recommended vaccines/medications based on entered destinations.

Clinical Risk Assessment

6B. Yellow Fever Screening

Complete this section only if Yellow Fever risk was identified above. Implements the 4-step algorithm per SOP Section 16.5 and Medical Directive Appendix C.

Yellow Fever screening completed for this patient

7. Travel Vaccines — Plan

Check all vaccines being ordered. Auto-populated by Destination Analysis (Section 6), or select manually.

Hepatitis Vaccines 📖 NACI — Hep A 📖 NACI — Hep B

Hepatitis A — Havrix Day 0 + booster at 6–12 months · 0.5 mL IM · Protection 20+ yrs (lifelong with 2-dose series) 2 doses

Hepatitis A — Avaxim Day 0 + booster at 6–12 months · 0.5 mL IM · Protection 20+ yrs (lifelong with 2-dose series) 2 doses

Hepatitis B — Engerix-B Day 0, 1 month, 6 months · 20 mcg/1 mL IM · Accelerated: Day 0, 7, 21 + booster at 12 months · Lifetime protection 3 doses

Hepatitis B — Recombivax HB Day 0, 1 month, 6 months · 10 mcg/mL IM · >95% efficacy after 3-dose series · Lifetime protection 3 doses

Hep A+B — Twinrix Standard Day 0, 1 month, 6 months · 1 mL IM · Combined HAV + HBV · Lifelong protection 3 doses

Hep A+B — Twinrix Accelerated Day 0, 7, 21 + booster at 12 months · 1 mL IM · For urgent travel needing early protection 4 doses

Typhoid Vaccines 📖 NACI — Typhoid

Typhoid — Typhim Vi (IM) Single dose 0.5 mL IM · Booster every 2–3 years · Efficacy 50–80% · CI: prior anaphylaxis to phenol 1 dose

Typhoid — Vivotif (Oral) 1 capsule on Day 1, 3, 5, 7 · Complete ≥1 week before departure · Booster every 5–7 years · CI: immunocompromised, antibiotics within 3 days 4 capsules

Meningococcal Vaccines 📖 NACI — Meningococcal

Meningococcal ACWY — Menveo / Nimenrix Single dose 0.5 mL IM · Booster every 5 years if ongoing risk · > 85% efficacy vs serogroups A/C/W/Y · Required for Hajj/Umrah (Saudi Arabia) 1 dose

Meningococcal B — Bexsero 2 doses ≥1 month apart · 0.5 mL IM · > 90% efficacy vs serogroup B · CI: latex anaphylaxis · Administer in separate limb from other vaccines 2 doses

⚠ Yellow Fever 📖 NACI — Yellow Fever

Yellow Fever — YF-Vax Single dose 0.5 mL SC · Certificate valid from Day 10 post-vaccination · Lifelong immunity (WHO 2014) · 99% efficacy · Must be given at YFVC-designated site ⚠ Requires YF screening (Section 6B) before ordering. Do not check without completing screening above. 1 dose

Other Travel Vaccines 📖 NACI — Cholera/ETEC 📖 NACI — Japanese Encephalitis 📖 NACI — Rabies 📖 CATMAT — Chikungunya 📖 NACI — Polio

Cholera / ETEC — Dukoral 2 oral doses ≥1 week apart (adults) · Each dose: granule sachet dissolved in 150 mL water · Booster: 1 dose at 2 years · 85% efficacy vs cholera, 50–60% vs ETEC 2 doses

Japanese Encephalitis — Ixiaro Standard Day 0, Day 28 · 0.5 mL IM · >95% seroconversion · Booster at 12–24 months if ongoing risk · Rural/agricultural Asia ≥1 month, or high-risk outdoor activity 2 doses

Japanese Encephalitis — Ixiaro Accelerated Day 0, Day 7 · 0.5 mL IM · For urgent travel departing <4 weeks · Complete at least 1 week before arrival in risk area 2 doses

Rabies — Pre-Exposure Prophylaxis (Imovax / RabAvert) 2-dose series: Day 0 & Day 7 (WHO updated 2018) · Alt: Day 0/7/21–28 (3-dose) · 1 mL IM · Indicates: remote travel >1 month, animal handlers, cavers · Does NOT eliminate need for post-exposure PEP 2–3 doses

Chikungunya — Ixchiq Single dose 0.5 mL SC · Live attenuated · 98.9% seroresponse · Adults 18–64 yrs · CI: pregnancy, immunocompromised (CD4 <200), age ≥65 (caution) · Space ≥4 weeks from other live vaccines 1 dose

Polio Booster — IPV (IPOL / Imovax Polio) Single lifetime booster 0.5 mL IM or SC (if primary series complete) · ~100% protection · Indicated for: Pakistan, Afghanistan, Nigeria, conflict zones with circulating poliovirus 1 dose

Vaccine Selection Rationale

8. Travel Medications — Plan

Quantities are calculated automatically from trip duration and altitude days on note generation.

Malarone (Atovaquone/Proguanil) — Malaria Prophylaxis 1st line Doxycycline 100mg — Malaria Prophylaxis (cost-effective) Mefloquine 250mg — Malaria Prophylaxis 3rd line Azithromycin 250mg — Traveler's Diarrhea (1st line) Ciprofloxacin 500mg — Traveler's Diarrhea (alternate) Acetazolamide (Diamox) 250mg — Altitude Sickness