Disease Overview

• Yellow fever is an acute, mosquito-borne viral illness.
• It occurs predominantly in tropical and subtropical regions of:
  • Sub-Saharan Africa.
  • South America.
• Clinical infection ranges from:
  • Asymptomatic infection.
  • Mild, non-specific febrile illness.
  • Severe haemorrhagic disease with acute liver failure, multiorgan failure, shock and death.
• Jaundice is characteristic of severe disease and gives yellow fever its name.
• No specific antiviral treatment is available.
• Prevention depends on:
  • Yellow fever vaccination.
  • Avoidance of mosquito bites.
  • Public health measures that prevent infected people from exposing mosquitoes during viraemia.

Aetiology

• Yellow fever is caused by an enveloped, positive-sense, single-stranded RNA virus.
• It belongs to:
  • Family: Flaviviridae.
  • Genus: Flavivirus.
• Related flaviviruses include:
  • Dengue virus.
  • West Nile virus.
  • Japanese encephalitis virus.
  • Zika virus.
  • St Louis encephalitis virus.
• Seven major yellow fever virus genotypes have been identified:
  • Five African genotypes.
  • Two South American genotypes.
• Current yellow fever vaccines provide protection across the recognised genotypes.

Mosquito Vectors

• Yellow fever virus is transmitted through the bite of an infected mosquito.
• Important vectors include:
  • Aedes aegypti.
  • Other Aedes species.
  • Haemagogus species.
  • Sabethes species.
• Aedes aegypti:
  • Is adapted to domestic and urban environments.
  • Commonly breeds in artificial water containers.
  • Is the main vector in the urban transmission cycle.
• Haemagogus and Sabethes mosquitoes:
  • Are primarily forest-dwelling vectors.
  • Maintain sylvatic transmission in South America.
• Yellow fever vectors generally bite during daylight hours, although exposure can also occur around dawn and dusk.

Transmission

• Mosquitoes become infected by feeding on a viraemic:
  • Human.
  • Non-human primate.
• After an extrinsic incubation period, the mosquito can transmit the virus to another host through subsequent bites.
• Humans have the highest level of viraemia:
  • Shortly before fever begins.
  • During approximately the first 3–5 days of illness.
• A viraemic person may therefore infect local mosquitoes, which can subsequently transmit the virus to other people.
• Ordinary direct person-to-person transmission has not been demonstrated.
• Direct transmission from a non-human primate to a human does not occur without a mosquito vector.
• Rare non-vector routes have included:
  • Perinatal transmission.
  • Theoretical or reported blood-borne transmission through transfusion, transplantation or needlestick exposure.
• Vertical transmission can occur within mosquito populations when an infected female transmits the virus to her eggs.

Transmission Cycles

Jungle or sylvatic cycle

• Virus circulates between:
  • Non-human primates.
  • Forest-dwelling mosquitoes.
• Humans become incidental hosts when they:
  • Enter forested areas.
  • Work in forest environments.
  • Are bitten by infected forest mosquitoes.
• This is the predominant transmission cycle in South America.

Intermediate or savannah cycle

• Occurs in Africa.
• Semi-domestic mosquitoes transmit the virus among:
  • Non-human primates.
  • Humans living or working near forest and savannah boundaries.
• Several villages may be affected simultaneously.
• Transmission remains mosquito-mediated; it is not direct monkey-to-human or person-to-person transmission.

Urban cycle

• Begins when a viraemic person enters a populated area containing competent mosquitoes, particularly Aedes aegypti.
• Urban mosquitoes acquire the virus from the infected person.
• The infected mosquitoes subsequently transmit the virus between humans.
• This cycle can result in large urban epidemics.

Regional distribution of cycles

• Jungle, intermediate and urban cycles may occur in Africa.
• South American transmission is predominantly sylvatic.
• Urban transmission occurs periodically in Africa and sporadically in the Americas.
• Naturally occurring endemic yellow fever transmission remains concentrated in Africa and South America despite the wider global distribution of Aedes aegypti.

Epidemiology

• Yellow fever is endemic and intermittently epidemic in Africa and South America.
• The burden is greatest in Africa, particularly West Africa.
• Surveillance figures substantially underestimate the true burden because:
  • Many infections are asymptomatic or mild.
  • Cases may be misdiagnosed as other febrile illnesses.
  • Laboratory and surveillance systems may be limited.
• Current WHO modelling estimates approximately:
  • 67,000–173,000 severe infections annually.
  • 31,000–82,000 deaths annually.
• Most disease and deaths occur in Africa.

Seasonal risk

Africa

• Transmission is generally highest during and shortly after the rainy season.
• In West Africa:
  • Transmission generally increases around the middle of the rainy season.
  • Risk commonly peaks at the beginning of the dry season.
  • The higher-risk period is broadly July–October, often peaking around October.
• Transmission may still occur during the dry season, particularly where Aedes aegypti is established.

South America

• Sylvatic transmission is most frequent during the rainy season:
  • Generally January–May.
  • Peak incidence commonly occurs in February and March.

Risk to Travellers

• Individual traveller risk depends on:
  • Vaccination status.
  • Exact destination and local transmission intensity.
  • Current outbreaks.
  • Season.
  • Duration of travel.
  • Forest, rural or savannah exposure.
  • Occupational and recreational activities.
  • Accommodation.
  • Ability to avoid mosquito bites.
• The absence of reported cases does not necessarily indicate absence of transmission because surveillance may be incomplete.
• Estimated risks for an unvaccinated traveller during a two-week stay in an endemic area are:

West Africa

• Yellow fever illness: approximately 50 per 100,000 travellers.
• Death from yellow fever: approximately 10 per 100,000 travellers.

South America

• Yellow fever illness: approximately 5 per 100,000 travellers.
• Death from yellow fever: approximately 1 per 100,000 travellers.
• These estimates are derived from local population risk, often during peak transmission periods.
• They may not accurately represent an individual traveller’s risk.
• Risk increases considerably during active outbreaks.

Pathophysiology

• Following inoculation through a mosquito bite, the virus initially replicates locally and in regional lymphatic tissue.
• Viraemia then develops, allowing rapid dissemination to multiple organs.

Liver

• The liver is one of the principal organs affected.
• Hepatocellular injury may cause:
  • Marked transaminase elevation.
  • Impaired synthetic function.
  • Coagulopathy.
  • Hyperbilirubinaemia.
  • Severe jaundice.
  • Fulminant hepatic failure.

Kidneys

• Renal involvement may result from:
  • Direct tissue injury.
  • Hypoperfusion.
  • Shock.
  • Multiorgan dysfunction.
• Manifestations include:
  • Proteinuria.
  • Oliguria.
  • Acute kidney injury.
  • Acute renal failure.

Gastrointestinal tract

• Gastrointestinal mucosal bleeding can cause:
  • Haematemesis.
  • Melaena.
  • Epigastric pain.
• “Black vomit” refers to altered blood mixed with gastric contents.

Cardiovascular system

• Severe disease may cause:
  • Hypotension.
  • Shock.
  • Myocarditis.
  • Cardiac dysrhythmias.

Central nervous system

• Severe disease may be associated with:
  • Encephalopathy.
  • Cerebral oedema.
  • Intracranial haemorrhage.
  • Seizures.
  • Coma.

Incubation and Clinical Course

• The usual incubation period is 3–6 days.

Initial febrile phase

• Illness usually begins abruptly with:
  • Fever.
  • Chills.
  • Severe headache.
  • Malaise.
  • Marked fatigue or weakness.
  • Myalgia.
  • Severe lower back pain.
  • Nausea.
  • Vomiting.
  • Dizziness.
• Most symptomatic patients improve after approximately 3–4 days.

Remission phase

• A brief improvement or remission may occur.
• This generally lasts no more than approximately 24–48 hours.
• Most patients then recover fully.

Toxic phase

• Approximately 12–15% of infected patients progress to severe disease after the brief remission.
• Features may include:
  • Recurrent high fever.
  • Jaundice.
  • Acute liver failure.
  • Acute kidney injury.
  • Epigastric pain.
  • Persistent vomiting.
  • Haematemesis or “black vomit.”
  • Petechiae.
  • Epistaxis.
  • Gingival or mucosal bleeding.
  • Melaena.
  • Disseminated intravascular coagulation.
  • Encephalopathy.
  • Shock.
  • Multiorgan failure.
• Death commonly occurs within 7–10 days of disease onset in fatal cases.
• The case-fatality rate among people who develop severe yellow fever is approximately 30–60%.

History and Examination

History

• Establish:
  • All countries visited.
  • Exact provinces, states and regions visited.
  • Dates of travel.
  • Date of departure from the risk area.
  • Urban, rural, forest or savannah exposure.
  • Mosquito bites and use of mosquito precautions.
  • Occupational or recreational forest exposure.
  • Yellow fever vaccination history.
  • ICVP documentation.
  • Recent live-virus vaccination.
  • Airport transit through yellow fever risk countries.
  • Exposure to sick people, animals or healthcare settings.
  • Other potential infections associated with the itinerary.
• Determine the timing of symptoms in relation to:
  • Travel.
  • Mosquito exposure.
  • Vaccination.

Examination findings

• Possible findings include:
  • Fever.
  • Facial flushing.
  • Conjunctival injection.
  • Jaundice.
  • Dark urine.
  • Hepatic tenderness.
  • Epigastric tenderness.
  • Mucosal bleeding.
  • Petechiae or ecchymoses.
  • Haematemesis or melaena.
  • Oliguria.
  • Hypotension.
  • Altered mental state.
  • Shock.

Faget sign

• Faget sign refers to relative bradycardia or pulse–temperature dissociation:
  • The pulse is slower than expected for the degree of fever.
• It may occur in yellow fever but is neither sufficiently sensitive nor specific to confirm the diagnosis.

Diagnosis

• Suspect yellow fever in a person with:
  • Compatible acute febrile illness.
  • Recent travel to or residence in an endemic or outbreak area.
  • Potential mosquito exposure.
  • No effective yellow fever vaccination.
• Diagnosis depends on:
  • Epidemiological exposure.
  • Clinical presentation.
  • Vaccination history.
  • Laboratory confirmation.
• Testing should be arranged urgently in consultation with:
  • The local Public Health Unit.
  • Infectious diseases or microbiology specialists.
  • The relevant public health reference laboratory.

Laboratory confirmation

Early illness

• Reverse-transcription polymerase chain reaction, or RT-PCR, may detect:
  • Yellow fever viral RNA.
  • Viral genomic sequences.
• Viral isolation may be available through specialised reference laboratories.
• Molecular tests are most useful early in the illness while viraemia is present.
• A negative PCR later in the illness does not exclude yellow fever.

Serology

• Yellow fever-specific IgM and IgG may be detected using serological assays.
• Interpretation may be complicated by cross-reactivity with:
  • Dengue.
  • Zika.
  • West Nile.
  • Japanese encephalitis.
  • Other flaviviruses.
  • Previous flavivirus vaccination.
• Confirmatory neutralisation testing may be required.

Routine laboratory findings

• Possible abnormalities include:
  • Leukopenia.
  • Neutropenia.
  • Thrombocytopenia.
  • Elevated transaminases.
  • Hyperbilirubinaemia.
  • Prolonged coagulation studies.
  • Elevated creatinine.
  • Proteinuria.
  • Metabolic acidosis.
  • Hypoglycaemia in severe hepatic failure.

Additional assessment

• Urgently test for malaria in any febrile returned traveller from a malaria-endemic area.
• Other investigations should be guided by the presentation and may include:
  • Full blood count.
  • Electrolytes, urea and creatinine.
  • Liver function tests.
  • INR, aPTT, fibrinogen and D-dimer.
  • Blood glucose.
  • Lactate.
  • Blood cultures.
  • Malaria microscopy and rapid diagnostic testing.
  • Dengue and other arboviral testing.
  • Hepatitis testing.
  • Leptospira testing.
• Chest imaging, ECG, echocardiography, CT or MRI should be used when clinically indicated to assess complications.
• Lumbar puncture is not a routine diagnostic test for yellow fever and should only be considered when:
  • CNS infection is suspected.
  • It is clinically safe.
  • Coagulopathy and thrombocytopenia have been excluded.

Differential Diagnosis

The differential diagnosis is broad and should be directed by the itinerary, incubation period and clinical syndrome.

Priority diagnoses

• Malaria, particularly Plasmodium falciparum malaria.
• Dengue.
• Viral hepatitis.
• Leptospirosis.
• Enteric fever.
• Severe bacterial sepsis.

Other arboviral infections

• Chikungunya.
• Zika virus infection.
• West Nile virus infection.
• Japanese encephalitis.
• Other mosquito-borne encephalitides.

Viral haemorrhagic fevers

Depending on the itinerary and exposures:

• Ebola virus disease.
• Marburg virus disease.
• Lassa fever.
• Crimean–Congo haemorrhagic fever.

Other infections

• Rickettsial infection.
• Relapsing fever.
• Acute HIV infection.
• Herpes simplex encephalitis.
• Bacterial or viral meningoencephalitis.
• Cytomegalovirus infection in an immunocompromised person.
• Tuberculosis involving the CNS.
• Nipah virus infection where epidemiologically relevant.
• Fungal meningitis in an immunocompromised person.

Non-infectious conditions

• Drug-induced liver injury.
• Acute liver failure from another cause.
• Disseminated intravascular coagulation.
• Haemolysis.
• Thrombotic microangiopathy.
• Toxic ingestion.
• Heat-related illness.

Treatment and Management

General principles

• There is no proven specific antiviral treatment for yellow fever.
• Management is supportive.
• Patients with suspected severe disease require:
  • Urgent hospital assessment.
  • Infectious diseases consultation.
  • Early intensive care involvement where indicated.

Supportive management

• Monitor:
  • Airway and respiratory status.
  • Haemodynamic status.
  • Fluid balance.
  • Urine output.
  • Blood glucose.
  • Renal function.
  • Liver function.
  • Coagulation profile.
  • Neurological status.
• Provide:
  • Careful fluid and electrolyte replacement.
  • Oxygen and ventilatory support when required.
  • Haemodynamic support for shock.
  • Correction of hypoglycaemia.
  • Renal replacement therapy for severe acute kidney injury.
  • Blood products for clinically significant bleeding or coagulopathy when indicated.
• Fresh frozen plasma should not be given routinely solely because coagulation tests are abnormal; use should be guided by bleeding, planned procedures and specialist advice.
• Manage disseminated intravascular coagulation according to standard critical-care and haematological principles.
• Avoid:
  • Aspirin.
  • Non-steroidal anti-inflammatory drugs.
  • Other medicines that increase bleeding risk.
  • Unnecessary intramuscular injections.
• Use analgesics and antipyretics cautiously, particularly when significant hepatic dysfunction is present.

Infection Control and Public Health Management

• Yellow fever is a notifiable and quarantinable disease throughout Australia.
• A suspected case should prompt urgent consultation with:
  • The local Public Health Unit.
  • Infectious diseases services.
  • The hospital infection-control team.
• Diagnostic testing should be coordinated with public health authorities.
• Prevent the patient from being bitten by mosquitoes during the viraemic period, particularly during the first 3–5 days of illness.
• Measures may include:
  • Keeping the patient indoors.
  • Using screened or air-conditioned accommodation.
  • Using an insecticide-treated mosquito net.
  • Applying an appropriate insect repellent.
  • Implementing local mosquito-control measures.
• Yellow fever is not ordinarily transmitted through casual contact, droplets or aerosols.
• Standard precautions are appropriate for yellow fever itself.
• Additional transmission-based precautions may be required until other serious infectious diagnoses, particularly quarantinable viral haemorrhagic fevers, have been excluded.
• Routine isolation alone does not prevent transmission unless mosquito exposure is also prevented.

Complications

• Fulminant hepatitis.
• Severe jaundice.
• Acute liver failure.
• Acute kidney injury or renal failure.
• Haematemesis and gastrointestinal haemorrhage.
• Disseminated intravascular coagulation.
• Severe thrombocytopenia.
• Shock.
• Multiorgan failure.
• Acute respiratory distress syndrome.
• Respiratory failure.
• Myocarditis.
• Cardiac dysrhythmia.
• Encephalopathy.
• Cerebral oedema.
• Encephalitis.
• Seizures.
• Secondary bacterial infection or sepsis.
• Death.

Risk-Area Assessment

Australian border screening

• Border screening is streamlined by assessing travellers according to the countries they have visited.
• This approach does not necessarily reflect the traveller’s actual exposure within a country.

Clinical assessment

• Clinical assessment should examine more detail than the country alone.
• Risk may be restricted to:
  • Particular provinces.
  • Particular states.
  • Rural or forested areas.
  • Areas at specific elevations.
• Assess the exact itinerary using current WHO or CDC:
  • Country recommendations.
  • Regional descriptions.
  • Risk maps.
  • Outbreak information.
• Consider:
  • Destination.
  • Season.
  • Length of stay.
  • Urban versus rural travel.
  • Forest or jungle exposure.
  • Occupational activities.
  • Planned outdoor activities.
  • Accommodation.
  • Mosquito-avoidance measures.
• This individualised assessment is important when balancing:
  • Risk of yellow fever exposure.
  • Risk of serious vaccine adverse effects.

Vaccination

• Yellow fever is preventable through vaccination.
• Vaccination has two main purposes:
  • Protecting the vaccinated person from infection.
  • Reducing international spread of the virus.
• The vaccine used in Australia is Stamaril™.
• Rare but potentially serious vaccine adverse events can occur.
• Vaccination decisions should therefore be based on an individual risk–benefit assessment.

Mosquito-bite prevention

All travellers to yellow fever risk areas should be advised to:

• Use mosquito repellent containing:
  • DEET.
  • Picaridin.
  • IR3535.
  • Oil of lemon eucalyptus, according to product directions.
• Apply permethrin-containing products to clothing where appropriate.
• Wear:
  • Light-coloured clothing.
  • Long-sleeved shirts.
  • Long trousers.
• Minimise exposed skin.
• Avoid mosquito breeding areas.
• Prevent mosquitoes from entering accommodation.
• Stay in:
  • Air-conditioned rooms.
  • Well-screened accommodation.
• Use an insecticide-treated mosquito net when adequate screening or air conditioning is unavailable.
• Continue precautions during daytime, including dawn and dusk, because yellow fever mosquito vectors commonly bite during the day.

International Health Regulations

• Under the International Health Regulations 2005, countries may impose yellow fever vaccination entry or exit requirements.
• These requirements are intended to prevent international spread of yellow fever.
• Some countries require proof of vaccination when a traveller:
  • Arrives directly from a yellow fever risk country.
  • Has recently travelled through a yellow fever risk country.
  • Has had a prolonged transit in a risk country.
• Entry requirements and clinical recommendations are not always the same:
  • An entry requirement protects the destination country.
  • A clinical recommendation protects the individual traveller.

International Certificate of Vaccination or Prophylaxis

• The International Certificate of Vaccination or Prophylaxis is commonly called:
  • ICVP.
  • Yellow Card.
  • Carte Jaune.
• It is the official certificate used to document yellow fever vaccination under the International Health Regulations.

Requirements for a valid Australian ICVP

• The vaccine must be WHO-approved.
• Stamaril™ is the WHO-approved yellow fever vaccine available in Australia.
• The certificate must include:
  • Vaccine manufacturer.
  • Vaccine batch number.
  • Date of vaccination.
  • Details of the administering or supervising clinician.
• The certificate must comply with Annex 6 of the International Health Regulations.
• It must be signed by:
  • A medical practitioner; or
  • Another authorised health worker, such as a nurse practitioner, supervising the vaccination.
• It must contain:
  • Official stamp of the administering centre.
  • Unique identification number of the authorised centre.
• It must be an individual certificate:
  • Family or collective certificates are not valid.
  • Each child requires a separate certificate.
• The vaccinated person must sign the certificate.
• For a child unable to sign:
  • A parent or guardian signs.
• For a person unable to write:
  • The person may make a mark.
  • Another person must identify it as the vaccinated person’s mark.
• The certificate must be completed in:
  • English; or
  • French.
• Another language may also be included in addition to English or French.
• The month must be written in words rather than numerals.
• All sections must be completed accurately.
• Amendments, erasures or incomplete sections may invalidate the certificate.
• For certificates issued before 11 July 2016:
  • The existing “valid to” date should not be removed or crossed out.
  • The certificate remains valid for life despite the older printed expiry date.

Certificate validity

• The ICVP becomes valid 10 days after the first yellow fever vaccination.
• It remains valid for the lifetime of the vaccinated person.
• Since 11 July 2016, the International Health Regulations recognise lifetime validity.
• Countries should not require a yellow fever booster solely as an entry condition when a valid lifetime certificate is held.
• Some people may require an additional vaccine dose for medical protection, even though their certificate remains legally valid for life.

Issuing the certificate

• The name on the ICVP should match the name on the traveller’s passport.
• Although this is not necessarily a legal requirement, discrepancies may cause problems at international borders.
• The traveller should be advised to:
  • Keep the original certificate with their passport.
  • Store it safely.
  • Scan or photocopy it.
• A scan or photocopy is generally not accepted as a valid border document.
• However, a copy may assist an authorised centre to reissue a replacement certificate if the original is lost.

Armed Forces documentation

• An equivalent document issued to an active member of the Armed Forces may be accepted when:
  • It contains substantially the same medical information as the ICVP.
  • It records the nature and date of vaccination.
  • The relevant statement is written in English or French, with another language added where appropriate.

Australian Yellow Fever Risk Countries and Areas

Legislative basis

• The Biosecurity (Entry Requirements) Determination 2025
  • provides Australia’s current legal framework for yellow fever entry screening.
• Schedule 1 specifies the current countries and areas treated as yellow fever risk locations for Australian border purposes.
• Schedule 2 repeals the former Biosecurity (Entry Requirements) Determination 2016. (This is a legislative housekeeping provision. It means that the old 2016 instrument was removed and replaced by the 2025 Determination)

Australian border implications

• Travellers arriving in Australia must declare relevant recent travel to a listed yellow fever risk country or area.
• A traveller may be subject to yellow fever screening when they have:
  • Stayed overnight or longer in a listed country or area.
  • Done so within the six days before arriving in Australia.
• They may be asked to present an International Certificate of Vaccination or Prophylaxis, or ICVP.
• Australia does not refuse entry solely because the traveller is unvaccinated or cannot produce an ICVP.
• A traveller without acceptable evidence may be issued a Yellow Fever Action Card, explaining what to do if symptoms develop.

Schedule 1 Countries and Areas

Africa — 29 countries

• Angola.
• Benin.
• Burkina Faso.
• Burundi.
• Cameroon.
• Central African Republic.
• Chad.
• Democratic Republic of the Congo.
• Republic of the Congo.
• Côte d’Ivoire.
• Equatorial Guinea.
• Ethiopia.
• Gabon.
• The Gambia.
• Ghana.
• Guinea.
• Guinea-Bissau.
• Kenya.
• Liberia.
• Mali.
• Mauritania.
• Niger.
• Nigeria.
• Senegal.
• Sierra Leone.
• South Sudan.
• Sudan.
• Togo.
• Uganda.

Central America, South America and the Caribbean — 13 countries or areas

• Argentina:
  • Misiones Province.
  • Corrientes Province.
• Bolivia.
• Brazil.
• Colombia.
• Ecuador, excluding the Galápagos Islands.
• French Guiana.
• Guyana.
• Panama.
• Paraguay.
• Peru.
• Suriname.
• Trinidad and Tobago.
• Venezuela.

Important geographic qualifications

• Inclusion in Schedule 1 does not necessarily mean that every part of each country has the same transmission risk.
• Two entries contain explicit Australian legislative geographic qualifications:
  • Argentina is limited to Misiones and Corrientes Provinces.
  • Ecuador excludes the Galápagos Islands.
• For clinical travel-vaccination decisions, assess the traveller’s precise:
  • Province or state.
  • Urban, rural or forest destination.
  • Season of travel.
  • Duration of exposure.
  • Activities and occupational exposure.
  • Current outbreak conditions.

Six-day rule for entry into Australia

• A traveller may be asked to provide an International Certificate of Vaccination or Prophylaxis if they have stayed overnight or longer in a Schedule 1 yellow fever risk country or area within the six days before arriving in Australia.
• If the traveller spends more than six days in a non-yellow-fever-risk country before entering Australia, they will generally not be required to present the ICVP at the Australian border.
• However, the intermediate or transit country may have its own yellow fever certificate requirements.

Example: A traveller who spends four weeks in Uganda and then seven days in Malaysia will generally not need to show an ICVP when entering Australia, because more than six days have passed since leaving Uganda. The traveller may still need to present the certificate when entering Malaysia.

WHO Country List

• WHO’s Countries with risk of yellow fever transmission and countries requiring yellow fever vaccination, published in November 2022, is a broader international travel-health reference.
• It includes:
  • Countries and areas with recognised yellow fever transmission risk.
  • Individual countries’ vaccination certificate requirements.
  • WHO recommendations for yellow fever vaccination.
  • Information regarding poliomyelitis vaccination and malaria prophylaxis.
• The information was compiled following consultation with States Parties to the International Health Regulations and WHO regional and technical units.

Australian Schedule versus WHO list

• The Australian Schedule 1 list determines which travel locations trigger Australian border declaration and screening requirements.
• The WHO list provides international recommendations and the entry requirements reported by individual destination countries.
• These lists serve related but different purposes:
  • Australian Schedule 1: entry into Australia.
  • WHO list: assessment of disease risk and international destination requirements.
• A country may require an ICVP even where the traveller’s individual exposure risk is low.
• Conversely, vaccination may be clinically recommended because of exposure risk even when it is not an entry requirement.

Need for current checking

• Yellow fever vaccination requirements may change at any time.
• Temporary requirements may also be introduced because of:
  • Outbreaks.
  • Mass gatherings.
  • Changes in transmission risk.
  • Changes in national border policy.
• Before travel, check:
  • Current WHO travel advice.
  • The destination country’s embassy or consulate.
  • Transit-country requirements.
  • Current outbreak information.
  • Australian re-entry requirements.

Vaccination

The Yellow Fever Vaccine

Background

• Yellow fever vaccine has been used since the 1930s.
• Approximately one billion doses have been administered worldwide.
• Yellow fever vaccine is a live-attenuated viral vaccine.

Vaccine available in Australia

• Stamaril® is the only WHO-approved yellow fever vaccine currently available in Australia.
• It is supplied by Sanofi-Aventis Australia Pty Ltd.
• Only approved Yellow Fever Vaccination Centres may purchase Stamaril® for administration.
• The vaccine must generally be administered at the approved centre where it was purchased.
• Administration outside an approved centre is permitted only in exceptional circumstances authorised under the National Guidelines.

Vaccine composition

• Stamaril® contains live-attenuated yellow fever virus, 17D strain.
• It provides protection against all yellow fever virus strains circulating in nature.
• The virus is propagated in avian leucosis-free chick embryos.
• Each reconstituted 0.5 mL dose contains:
  • At least 1,000 IU of live-attenuated yellow fever virus.
  • Lactose.
  • Sorbitol.
  • L-histidine hydrochloride.
• Traces of egg protein may be present.
• Stamaril® does not contain:
  • Antibiotics.
  • Preservatives.
  • Gelatin.

Storage and Reconstitution

• Store Stamaril® at +2°C to +8°C.
• Do not freeze.
• Protect the vaccine from light.
• Transport and store according to the current National Vaccine Storage Guidelines: Strive for 5.
• Reconstitute the vaccine using the full contents of the supplied diluent syringe.
• Gently shake until the freeze-dried powder has completely dissolved.
• Use the reconstituted vaccine within one hour.
• Discard any vaccine not used within one hour.

Recommendations

Yellow fever vaccination is recommended for:

• People aged nine months or older who are travelling to, or living in, an area with a risk of yellow fever virus transmission.
• Expatriates and people visiting friends and relatives in risk areas.
• Laboratory personnel who routinely work with yellow fever virus.

Vaccination may also be required to meet a destination or transit country’s entry requirements, even when the traveller will not enter an area with a significant clinical risk of yellow fever exposure.

Vaccination is generally not recommended when:

• The itinerary is limited to an area with no or very low yellow fever transmission risk.
• The only potential exposure is a brief transit that does not trigger the destination country’s entry requirements.
• The vaccine is contraindicated.
• The risk of a serious vaccine adverse event outweighs the likelihood of yellow fever exposure.

The decision should distinguish between:

• Clinical indication: protection of the traveller from yellow fever.
• Administrative indication: satisfying the entry requirements of a destination or transit country.

Dose and Administration

• Dose: 0.5 mL for adults and children.
• Route:
  • Intramuscular injection; or
  • Subcutaneous injection.
• One dose provides lifelong protection for most immunocompetent people.
• The vaccination must be:
  • Prescribed or supervised by an accredited yellow fever vaccination practitioner.
  • Administered at an approved Yellow Fever Vaccination Centre, except in specifically authorised exceptional circumstances.
• Record the vaccination in:
  • The International Certificate of Vaccination or Prophylaxis.
  • The Australian Immunisation Register, including the vaccine batch number.

Co-administration with Other Vaccines

Inactivated vaccines

• Yellow fever vaccine can be given:
  • At the same visit as an inactivated vaccine.
  • At any time before an inactivated vaccine.
  • At any time after an inactivated vaccine.
• This includes vaccines such as tetanus-containing vaccines.

Oral live vaccines

• Oral live vaccines relevant to travel, such as oral typhoid vaccine, can generally be given:
  • At the same time.
  • At any time before yellow fever vaccine.
  • At any time after yellow fever vaccine.

Other parenteral live vaccines

• Yellow fever vaccine and most other injectable live vaccines should be given:
  • On the same day, using separate syringes and injection sites; or
  • At least four weeks apart.
• This includes:
  • BCG.
  • Live Japanese encephalitis vaccine.
  • MMR and other measles-containing vaccines.

Yellow fever and MMR vaccines

• Where time allows, it is preferable to give yellow fever and MMR vaccines at least four weeks apart.
• Studies have found that same-day administration may result in lower antibody concentrations or seroconversion to some antigens.
• However, when:
  • Protection is required rapidly; or
  • There is a risk of a missed vaccination opportunity, the vaccines may be administered at the same visit.
• An additional MMR dose or yellow fever revaccination may be considered case by case in people with ongoing risk.

Tuberculin Skin Testing

• Live viral vaccines may temporarily suppress the response to a tuberculin skin test.
• Where a Mantoux test is required, it should preferably be performed:
  • Before yellow fever vaccination; or
  • On the same day as vaccination.
• If yellow fever or another live viral vaccine has already been administered, consider delaying tuberculin skin testing for approximately 4–6 weeks.
• Where BCG is also required:
  • Perform any indicated pre-BCG tuberculin testing before vaccination.
  • Give BCG and yellow fever vaccine on the same day or at least four weeks apart.

Contraindications

A person with a true contraindication should generally be advised not to travel to an area with a high risk of yellow fever transmission.

Anaphylaxis

Yellow fever vaccine is contraindicated in people with:

• Anaphylaxis following a previous dose of yellow fever vaccine.
• Known anaphylaxis to any vaccine component.
• Known anaphylaxis to eggs or egg products.

People with egg allergy who require vaccination should be referred to:

• An immunologist or allergist.
• A specialised immunisation clinic.
• A specialist travel medicine service.

Specialist-supervised vaccination may be possible in selected circumstances.

Age under nine months

• Routine yellow fever vaccination is contraindicated in infants younger than nine months because of the increased risk of vaccine-associated neurotropic disease.
• Do not administer the vaccine to an infant younger than six months.
• In exceptional circumstances, such as a major outbreak with unavoidable exposure, vaccination may be considered in infants aged 6–8 months following specialist risk assessment.

Severe immunocompromise

Yellow fever vaccine should generally not be given to people who are severely immunocompromised because the vaccine virus can disseminate.

Potential causes include:

• Severe primary or acquired immunodeficiency.
• Active haematological or other malignancy associated with immunosuppression.
• Immunosuppressive chemotherapy.
• Radiotherapy causing significant immune suppression.
• Solid-organ transplantation with ongoing immunosuppression.
• Haematopoietic stem cell transplantation before immune recovery.
• High-dose systemic corticosteroids.
• Conventional immunosuppressants.
• Biological or targeted immunomodulatory therapy.

Examples of potentially relevant immunosuppressive therapies include:

Mechanism or class	Examples
Anti-TNF therapy	Etanercept, infliximab, adalimumab
IL-1 inhibition	Anakinra
Costimulation blockade	Abatacept
B-cell depletion or inhibition	Rituximab
Antimetabolites	Azathioprine, mercaptopurine, methotrexate
Corticosteroids	High-dose prednisone or equivalent
T-cell activation inhibition	Tacrolimus, ciclosporin
Other immunosuppressants	Cyclophosphamide, mycophenolate

This is not an exhaustive list.

• Review the precise medication, dose, duration and date of cessation.
• Live vaccines should ideally be administered at least four weeks before commencing immunosuppressive treatment.
• The required interval after stopping treatment varies considerably between agents.
• Obtain advice from the treating specialist or immunologist where immune status is uncertain.
• Household contacts of an immunocompromised person can receive yellow fever vaccine if they have no personal contraindication.

Thymus disorders

Yellow fever vaccine is contraindicated in people with a current or previous thymus disorder because of the increased risk of vaccine-associated viscerotropic disease.

Relevant conditions include:

• Thymoma.
• Myasthenia gravis associated with thymic disease.
• Previous thymectomy.
• DiGeorge syndrome.
• Thymic damage caused by chemoradiotherapy.
• Thymic damage associated with graft-versus-host disease.

Precautions

Adults aged 60 years or older

• Adults aged 60 years or older have a higher risk of severe yellow fever vaccine adverse events.
• Risk appears to increase further with advancing age.
• Vaccination should follow an individual risk–benefit assessment considering:
  • Exact itinerary.
  • Local yellow fever activity.
  • Season.
  • Duration of exposure.
  • Planned activities.
  • Previous yellow fever vaccination.
  • Age and frailty.
  • Comorbidities.
  • Current medicines and treatments.
  • Likelihood of complying with mosquito precautions.
• The risks of vaccination and non-vaccination should be discussed and documented.
• If travel is unavoidable but vaccination risk exceeds benefit:
  • Issue a medical exemption where appropriate.
  • Advise strict mosquito-bite precautions.
  • Explain that the destination country may not accept the exemption.

Mild or moderate immunocompromise

• Vaccination may be considered following an individual risk–benefit assessment.
• Consider:
  • The nature and severity of immune compromise.
  • The medication involved.
  • Timing of treatment.
  • Risk of yellow fever exposure.
  • Availability of safer itinerary alternatives.
• Seek specialist advice where necessary.

People living with HIV

• Vaccination decisions should be made with the person’s HIV-treating clinician.
• Yellow fever vaccine can generally be considered in people with well-controlled HIV who are not severely immunocompromised.
• This includes:
  • Adults with a CD4 count of at least 200 cells/µL.
  • Asymptomatic children older than 12 months with an age-appropriate CD4 percentage of at least 15%.
• Vaccine immune responses may be reduced.
• People with a CD4 count below 200 cells/µL should generally not be vaccinated unless yellow fever exposure cannot be avoided and specialist assessment supports vaccination.
• When vaccination is required only to satisfy entry requirements and there is no meaningful exposure risk, consider a medical exemption instead.

Possible IFNAR1 deficiency

• People with confirmed or suspected interferon-alpha/beta receptor subunit 1 deficiency require specialist immunological advice before vaccination.

Pregnancy

• Yellow fever vaccine is not routinely recommended during pregnancy because it is a live vaccine.
• Pregnant women should be advised to avoid or postpone travel to a yellow fever risk area where possible.
• If travel is unavoidable and meaningful exposure risk exists, vaccination may be recommended after informed risk–benefit discussion.
• Available experience has not demonstrated a substantial risk of adverse pregnancy outcomes.
• Inadvertent vaccination in early pregnancy is not an indication for pregnancy termination.
• Women receiving their first yellow fever dose during pregnancy may have a reduced immune response and may require a booster dose after 10 years if they remain at risk.
• Advise women to avoid becoming pregnant for 28 days after vaccination.

Breastfeeding

• Women breastfeeding an infant younger than nine months should generally avoid yellow fever vaccination.
• Rare transmission of vaccine virus through breast milk has caused probable vaccine-associated neurotropic disease in infants.
• Where exposure cannot be avoided or postponed, vaccination may still be appropriate following specialist risk–benefit assessment.
• Options may include:
  • Postponing travel.
  • Postponing vaccination until breastfeeding has ceased.
  • Vaccinating the mother and child once the child reaches nine months, where appropriate.

Haematopoietic stem cell transplant recipients

• Yellow fever vaccination may be considered at least two years after transplantation only when:
  • There is no chronic graft-versus-host disease.
  • Immunosuppressive therapy has been stopped for at least three months.
  • The treating specialist considers the person immunocompetent.
• A person who received yellow fever vaccine before a subsequent stem cell transplant requires an additional dose if travelling to a yellow fever risk area, regardless of the date of the previous dose.

Adverse Events Following Immunisation

Mild adverse events

Common mild reactions include:

• Low-grade fever.
• Headache.
• Myalgia.
• Malaise.
• Asthenia or fatigue.
• Injection-site pain, redness or inflammation.

These reactions:

• Usually begin within the first five days.
• May persist for up to two weeks.
• Are reported by up to approximately 25% of vaccine recipients when actively sought.
• Restrict usual activities in up to approximately 1%.

Immediate hypersensitivity

• Immediate hypersensitivity reactions, including anaphylaxis, are very rare.
• The reported frequency is less than one per million doses.
• Most cases occur in people with anaphylactic sensitivity to eggs.
• Stamaril® does not contain gelatin.
• All vaccinations must be administered in a setting equipped to recognise and treat anaphylaxis.

Yellow fever vaccine-associated neurotropic disease

Yellow fever vaccine-associated neurotropic disease, or YF-AND, is a rare but potentially serious neurological adverse event.

Clinical syndromes include:

• Meningoencephalitis.
• Guillain–Barré syndrome.
• Acute disseminated encephalomyelitis.
• Bulbar palsy.

Key points:

• Direct CNS infection with vaccine virus may cause meningoencephalitis.
• Other manifestations are thought to be immune-mediated.
• Risk is higher in:
  • Very young infants.
  • Adults aged 60 years or older.
• Onset may occur up to approximately 30 days after vaccination.
• Suspected cases require:
  • Urgent neurological assessment.
  • Infectious diseases advice.
  • Cerebrospinal-fluid testing where clinically appropriate.
  • AEFI reporting.

Yellow fever vaccine-associated viscerotropic disease

Yellow fever vaccine-associated viscerotropic disease, or YF-AVD:

• Is rare but potentially fatal.
• Causes uncontrolled replication and dissemination of the vaccine virus.
• Resembles naturally acquired severe yellow fever.
• Is characterised by multiorgan failure.
• Occurs at an estimated rate of approximately 3–4 cases per million doses.
• Has a high case-fatality rate.

Recognised risk factors include:

• Older age.
• Previous thymus disease.
• Previous thymectomy.

Possible associations with autoimmune disease have been reported, but the independent level of risk remains uncertain.

Reporting adverse events

• Report suspected significant AEFI according to the relevant state or territory reporting process.
• Reports may also be made to the Therapeutic Goods Administration.
• Serious events should be managed urgently and not delayed while causality is being assessed.

Onset and Duration of Protection

• The ICVP becomes valid 10 days after the first yellow fever vaccination.
• Protection is accepted as commencing from this time for international certification purposes.
• Approximately 90% of healthy vaccine recipients develop protective neutralising antibodies by day 14.
• Virtually all healthy recipients develop protective levels by day 28.
• A single dose provides lifelong protection for most people.
• The ICVP remains legally valid for life.

Booster Doses and Revaccination

Routine 10-yearly booster doses are not required for most people.

A booster dose may be recommended when the previous dose was at least 10 years ago and the person:

• Received their first dose while pregnant.
• Was living with HIV when they received their first dose.
• Will be staying for an extended period in a high-risk location.
• Is travelling to an area with an ongoing yellow fever outbreak.
• Has another clinical reason to suspect a suboptimal immune response.

Laboratory workers

• Laboratory workers with ongoing yellow fever virus exposure should have neutralising antibody titres checked when their last dose was at least 10 years ago.
• If antibody testing is unavailable, a booster dose every 10 years is recommended while exposure continues.

Stem cell transplantation

• A person who has undergone haematopoietic stem cell transplantation after yellow fever vaccination requires an additional dose before future risk-area travel once they meet criteria for live vaccination.

Reissue of the ICVP

A new or replacement ICVP may be issued when:

• The original certificate has been lost or damaged.
• The person has changed their name.
• The accredited practitioner is satisfied that the person previously received yellow fever vaccine.
• All information required to complete the certificate is available, including:
  • Date of vaccination.
  • Vaccine name.
  • Manufacturer.
  • Batch number.
  • Relevant vaccination-centre details.

Evidence may be obtained from:

• The Australian Immunisation Register.
• The original vaccination centre.
• Other reliable medical records.
• A scan or photocopy of the original certificate.

Older certificates containing an expiry date

• Yellow fever certificates issued before 11 July 2016 remain valid for life, even where a printed “valid until” date has passed.
• Reissue is not required solely because the printed expiry date has passed.
• Do not:
  • Cross out the expiry date.
  • Alter the certificate.
  • Erase any entry.
• Altering an older certificate may invalidate it.
• A replacement may be issued if all original vaccination information is available.

Inadequate evidence

• A verbal history alone is insufficient to reissue an ICVP.
• If the vaccination date, vaccine and batch details cannot be established:
  • Do not issue a replacement certificate as though the previous vaccination were documented.
  • Reassess the indication for vaccination.
  • Revaccinate if clinically appropriate.
  • Provide a medical exemption if vaccination is contraindicated.

Medical Exemptions

A medical exemption may be issued when:

• Yellow fever vaccine is contraindicated; or
• A precaution is present and the risk of vaccination outweighs the likely benefit.

General principles

• Avoiding or postponing travel to a yellow fever risk area is the safest option.
• Exemptions should be issued only for the current trip.
• The traveller must be counselled regarding:
  • Risk of yellow fever.
  • Consequences of remaining unvaccinated.
  • Strict mosquito-bite precautions.
  • The possibility that the destination country may not accept the exemption.
  • Possible quarantine or refusal of entry under the destination country’s laws.

Medical exemption documentation

Provide a dated and signed medical exemption letter on the letterhead of an approved Yellow Fever Vaccination Centre.

Include:

• Traveller’s full name exactly as shown on the passport.
• Date of birth.
• Relevant identification details where appropriate.
• A statement that yellow fever vaccination is contraindicated on medical grounds.
• Dates and destinations for the current trip.
• Signature of the accredited practitioner.
• Official centre stamp.
• Unique state or territory centre identification number.

The medical contraindication section of the ICVP should also be completed, stamped and signed where required.

The Pre-Travel Consultation: An Overview

Purpose

• Yellow fever vaccination should be provided as part of a broader, destination-specific pre-travel health assessment.
• Completion of the yellow fever vaccination course does not by itself provide the knowledge and skills required for a comprehensive travel consultation.
• Clinicians should identify:
  • Knowledge gaps requiring further education.
  • Complex clinical situations requiring specialist advice.
  • Travellers who may benefit from referral to a specialist travel medicine clinic.
• Up to 50% of international travellers develop a health problem during travel or after returning.
• Common travel-related syndromes include:
  • Travellers’ diarrhoea.
  • Respiratory tract infections.
  • Skin conditions.
  • Febrile illness.
• Approximately 10 million Australian residents return each year after short-term international travel of less than three months.
• About 1.5% return from areas of South America or sub-Saharan Africa where yellow fever transmission may occur.

Travel Risk Assessment

Information to obtain

Itinerary

• Countries and regions to be visited.
• Urban, rural or remote travel.
• Elevation and planned high-altitude exposure.
• Modes of transport.
• Accommodation type.
• Planned and possible activities.
• Length of travel.
• Stopovers and transit countries.

Purpose of travel

• Leisure or tourism.
• Visiting friends and relatives.
• Work or occupational travel.
• Health care or humanitarian work.
• Adventure or high-risk activities.

Traveller-related factors

• Age.
• Pregnancy or plans for pregnancy.
• Medical history.
• Current medications.
• Immunocompromising conditions or treatment.
• Recent surgery or significant health events.
• Previous vaccination history.
• Previous adverse vaccine reactions.
• Past travel experiences.
• Traveller’s perception of risk.
• Attitudes, concerns and fears.

Advice to Consider for All Travellers

Vaccination

• Routine vaccine boosters or catch-up vaccination, including:
  • Tetanus.
  • Measles.
  • Influenza.
• Destination- and itinerary-specific travel vaccines, including where indicated:
  • Yellow fever.
  • Typhoid.
  • Hepatitis A.
  • Hepatitis B.
  • Meningococcal disease.
  • Rabies.
  • Japanese encephalitis or other destination-specific vaccines.

Vector-borne disease prevention

• Prevention of mosquito-borne illnesses, including:
  • Malaria.
  • Dengue.
  • Zika.
  • Chikungunya.
  • Yellow fever.
• Discuss:
  • Appropriate insect repellent.
  • Protective clothing.
  • Bed nets.
  • Accommodation precautions.
  • Malaria chemoprophylaxis where indicated.

Tick-borne disease prevention

• Discuss avoidance and prevention of tick bites.
• Consider destination-specific risks such as:
  • Lyme disease.
  • Tick-borne encephalitis.

Rabies

• Assess the risk of animal exposure.
• Discuss:
  • Avoiding contact with animals.
  • Pre-exposure rabies vaccination where appropriate.
  • Immediate wound washing after an exposure.
  • Urgent access to post-exposure prophylaxis.

Food- and water-borne illness

• Safe food and drinking-water practices.
• Prevention and management of travellers’ diarrhoea.
• When to use oral rehydration.
• When medical assessment is required.
• Consideration of standby treatment where clinically appropriate.

Parasitic infections

• Prevention of infections such as:
  • Schistosomiasis.
  • Hookworm.
• Avoid:
  • Swimming or wading in unsafe freshwater.
  • Walking barefoot where soil-transmitted parasites are a risk.

Environmental risks

• Heat, sun and dehydration precautions.
• Cold exposure where relevant.
• Altitude illness prevention and management.
• Gradual ascent where possible.
• Recognition of altitude-related red flags.

Long-distance travel risks

• Deep vein thrombosis prevention.
• Encourage:
  • Regular mobilisation.
  • Leg exercises.
  • Adequate hydration.
• Assess whether additional preventive measures are appropriate for travellers at increased thromboembolic risk.

Sexual health

• Prevention of sexually transmitted infections.
• Prevention of blood-borne viruses.
• Condom use.
• Avoiding unsafe medical, tattooing or piercing procedures.
• Consider hepatitis B vaccination where indicated.

Personal safety

• Road and traffic safety.
• Appropriate helmet and seatbelt use.
• Avoiding driving while fatigued or intoxicated.
• Personal security and situational awareness.
• Risks from conflict, civil unrest or violence.
• Water and recreational safety.

Animal safety

• Avoid touching or feeding unfamiliar animals.
• Consider risks from:
  • Dogs.
  • Monkeys.
  • Bats.
  • Other mammals.
• Discuss rabies risk and post-exposure action.

General travel preparation

• Travel insurance, including cover for:
  • Pre-existing conditions.
  • Medical evacuation.
  • Adventure activities.
  • Pregnancy where relevant.
• First-aid kit.
• Emergency and regular medicines.
• Medication documentation.
• Jet lag prevention and management.
• Destination-specific outbreaks and health alerts.

Special-Risk Travellers

Groups requiring additional assessment

• Young children.
• Older travellers.
• Pregnant travellers.
• Immunocompromised people due to disease or treatment.
• People with significant comorbidities.
• People with mental health conditions.
• Travellers who have recently undergone surgery or another significant health event.
• People visiting friends and relatives.
• Health care or humanitarian workers.
• Travellers undertaking high-risk or adventure activities.
• Travellers going to areas affected by conflict or a high threat of violence.

Additional advice may include

• How the traveller’s condition affects travel-related risk.
• How risks can be reduced or managed.
• Ensuring an adequate supply of regular medication.
• Carrying medicines in original labelled packaging.
• Contingency plans for deterioration or complications.
• Letters describing:
  • Medical diagnoses.
  • Current treatment.
  • Medication requirements.
  • Medical devices where relevant.
• Access to medical care at the destination.
• Specific risks related to:
  • Planned activities.
  • Remote travel.
  • Climate.
  • Altitude.
  • Local health infrastructure.

Referral considerations

• Refer or seek specialist advice when:
  • The traveller has complex medical needs.
  • There are significant vaccine contraindications or precautions.
  • The itinerary is complex.
  • The traveller is immunocompromised.
  • Pregnancy creates uncertainty regarding vaccination or destination risk.
  • Specialist input is required for a particular condition.
  • Comprehensive travel medicine advice cannot be safely provided within the consultation.

Pre-Vaccination Screening Checklist

Before vaccination, assess whether the person:

• Is currently unwell.
• Has a condition that lowers immunity, including:
  • Leukaemia.
  • Cancer.
  • HIV.
• Is receiving immunosuppressive treatment, including:
  • Systemic corticosteroids.
  • Biological therapy.
  • Radiotherapy.
  • Chemotherapy.
• Is an infant whose mother received highly immunosuppressive treatment during pregnancy.
• Has had a severe reaction following a previous vaccine.
• Has any severe allergy.
• Carries an adrenaline autoinjector for an underlying allergic or immunological disorder.
• Has received another vaccine within the previous month.
• Has received:
  • Immunoglobulin.
  • Blood products.
  • Whole-blood transfusion within the previous year.
• Is pregnant.
• Is planning pregnancy or anticipating parenthood.
• Has a history of Guillain–Barré syndrome.
• Was born prematurely.
• Has a severe or chronic illness.
• Has a bleeding disorder.
• Identifies as Aboriginal or Torres Strait Islander.
• Does not have a functioning spleen.
• Is a parent, grandparent or carer of an infant aged six months or younger.
• Lives with someone who is immunocompromised.
• Is planning travel.
• Has an occupational or lifestyle indication for vaccination.

Before giving the vaccine, confirm:

• The person understands the information provided.
• They have had the opportunity to ask questions.
• They do not require further information before deciding.
• Valid consent has been obtained.
• Their vaccination record is available where possible.
• A personal vaccination record will be provided or updated.

Vaccination Administration: Best Practice

• Use a systematic, standardised vaccination process.
• Confirm:
  • Correct patient.
  • Correct vaccine.
  • Correct indication.
  • Correct dose.
  • Correct route.
  • Correct injection site.
  • Correct timing and schedule.
  • Expiry or use-by date.
  • Vaccine integrity and storage conditions.
• Double-check the vaccine name and expiry date with another person where possible.
• Exercise particular caution when:
  • Vaccinating multiple members of the same family.
  • There has been a delay between prescribing and administration.
  • The vaccine is unfamiliar to the administrator.
  • Several vaccines are being administered at the same visit.
• Follow Australian Immunisation Handbook guidance for:
  • Vaccine preparation.
  • Route of administration.
  • Injection technique.
  • Appropriate injection sites.
  • Patient positioning.
  • Distraction techniques.

Post-Vaccination Care

Immediate observation

• Advise the vaccinated person or parent/carer to remain nearby for at least 15 minutes.
• The observation area should allow:
  • Prompt recognition of an immediate reaction.
  • Rapid medical assessment.
  • Immediate emergency treatment.
• Be able to distinguish:
  • Anaphylaxis.
  • Vasovagal reactions.

Adverse-event preparedness

• All vaccination services must be able to:
  • Recognise anaphylaxis.
  • Provide immediate treatment.
  • Access appropriate emergency equipment and medicines.
• Follow the Australian Immunisation Handbook guidance on anaphylaxis management.

Vaccination Documentation

Record every vaccine in:

• The practice medical record.
• A written or personal record provided to the traveller.
• The Australian Immunisation Register.

For each vaccine, record as applicable:

• Date of administration.
• Vaccine name and brand.
• Batch number.
• Dose.
• Route.
• Site of administration.
• Provider details.
• Whether and when another dose or booster is required.

Yellow fever-specific documentation

• Create a permanent AIR record because yellow fever vaccination generally provides lifelong protection.
• Record the batch number accurately.
• The batch number may be needed to replace a lost or damaged yellow fever certificate.
• AIR batch numbers:
  • Are entered under the vaccine or brand field.
  • Can be viewed online in the immunisation encounter details.
  • Do not appear on printed or downloaded AIR Immunisation History Statements.
• Yellow fever vaccination records should be readily retrievable.
• Keep a separate searchable register where practice software cannot provide this function.
• Records should include the traveller’s destination or destinations.
• Retrievable records may be required for surveys or audits by state or territory health authorities.

Reporting Adverse Events Following Immunisation

• Adverse events following immunisation should be reported according to applicable state, territory and national requirements.
• The TGA monitors:
  • Adverse-event rates.
  • Safety trends.
  • Administration errors.
  • Manufacturing issues.
  • Vaccine storage and delivery problems.

Jurisdictional reporting contacts shown in the course material

• ACT: ACT Health Department — 02 6205 2300.
• NSW: Local Public Health Unit — 1300 066 055.
• NT: NT Immunisation Program — 08 8922 8044.
• Queensland: Queensland Health — 07 3328 9724, or complete the Queensland adverse-event following immunisation initial report form.
• South Australia: Immunisation Section, Department of Health and Welfare — 1300 232 272.
• Tasmania: Department of Health adverse-event reporting service — 1800 044 114.
• Victoria: SAEFVIC — 03 9345 4143.
• Western Australia: WAVSS — 08 9321 1312.

Yellow Fever Vaccination Accreditation

Yellow Fever Vaccination Centres

• Yellow fever vaccine can only be:
  • Supplied to designated Yellow Fever Vaccination Centres.
  • Purchased by approved centres.
  • Administered at an accredited centre, except in rare circumstances where hospital administration may be authorised.
• Centres are approved by the relevant state or territory health authority.
• Practices should consult:
  • National Guidelines for Yellow Fever Vaccination Centres and Providers.
  • Their state or territory health authority regarding approval criteria and applications.
• Lists of approved centres are maintained by jurisdictional health authorities.

Requirements for medical practitioners

To become an accredited yellow fever vaccine provider, a medical practitioner must:

• Successfully complete the approved online module.
• Provide the completion certificate to the accredited Yellow Fever Vaccination Centre where they intend to practise.
• Administer yellow fever vaccine only at an accredited centre, except in rare approved hospital circumstances.

Requirements for nurse practitioners

A nurse practitioner must:

• Ensure yellow fever vaccination is within their scope of practice.
• Have yellow fever vaccine included in their prescribing formulary.
• Successfully complete the approved online module.
• Provide the completion certificate to the Yellow Fever Vaccination Centre where they intend to practise.
• Administer the vaccine only at an accredited centre, except in rare approved hospital circumstances.

Centre and health-authority responsibilities

• Yellow Fever Vaccination Centres must notify their state or territory health authority of practitioners who have completed the module.
• The relevant health authority may revoke an individual practitioner’s accreditation.
• The practitioner must be notified in writing of the date on which they must cease administering yellow fever vaccine.
• The Commonwealth Department of Health, Disability and Ageing maintains a national record of accredited practitioners.
• The national record assists with practitioners who:
  • Move between practices.
  • Move between jurisdictions.

Maintenance of Accreditation

• Yellow fever provider accreditation is valid for three years.
• The approved Yellow Fever Vaccination Course must then be completed again.
• Yellow fever providers are encouraged to undertake further education in travel medicine.
• Nursing staff working in accredited centres are encouraged to undertake continuing professional development in:
  • Yellow fever vaccination.
  • Travel medicine.

Recommended Information Sources

Australian resources

• Australian Immunisation Handbook.
• Smartraveller.
• Relevant state or territory health authority.
• TGA vaccine safety information.

International resources

• CDC Yellow Book.
• WHO Disease Outbreak News.
• TravelHealthPro.

Journals

• Journal of Travel Medicine.
• Travel Medicine and Infectious Disease.
• Australian Family Physician or relevant RACGP publications.
• Australasian Society of Clinical Immunology and Allergy resources.

Pre-Travel Consultation Scenarios

Individual 1 — Nathan

22 years old; Machu Picchu five-day trek, remote Amazonian community, traditional tattoo and scooter traveNathan is a 22-year-old travelling to Machu Picchu for a five (5) day walk. He also plans to visit a remote Amazonian tribe which hosts a traditional tattoo artist and tour La Paz by scooter.

What travel advice is Nathan potentially going to need?l in La Paz

Potential advice includes:

• Yellow fever
  • Assess destination-specific transmission risk and entry requirements.
  • Offer vaccination if indicated and no contraindication.
• Routine and travel vaccinations
  • Review routine vaccinations and provide catch-up or boosters as required.
  • Consider hepatitis A, hepatitis B, typhoid and other itinerary-specific vaccines.
• Mosquito- and insect-borne illness
  • Malaria risk assessment and chemoprophylaxis where indicated.
  • Prevention of dengue, Zika, chikungunya and other vector-borne infections.
  • Repellent, protective clothing, bed nets and accommodation precautions.
• Altitude illness
  • Machu Picchu and La Paz involve significant altitude exposure.
  • Discuss gradual ascent, hydration, activity modification and recognition of acute mountain sickness.
  • Explain red flags requiring descent and urgent medical assessment.
• Rabies and animal safety
  • Assess likelihood of exposure to dogs, bats, monkeys and other mammals.
  • Consider pre-exposure rabies vaccination because of remote travel.
  • Avoid animal contact and seek urgent post-exposure management after a bite, scratch or mucosal exposure.
• Traditional tattoo
  • Risk of hepatitis B, hepatitis C, HIV and bacterial infection.
  • Avoid tattooing unless sterile, single-use equipment and appropriate infection-control standards can be assured.
  • Confirm hepatitis B vaccination status.
• Sexual health
  • Discuss prevention of sexually transmitted infections and blood-borne viruses where relevant.
  • Condom use and avoidance of high-risk exposures.
• Road and scooter safety
  • Helmet use.
  • Local licensing and international driving permit requirements.
  • Travel-insurance exclusions for scooter or motorcycle use.
  • Avoid alcohol or drugs when riding.
  • Consider unfamiliar traffic conditions, road quality and altitude-related impairment.
• Food and water precautions
  • Safe food and drinking-water practices.
  • Prevention and management of travellers’ diarrhoea.
• Long-haul travel
  • Assess individual venous thromboembolism risk.
  • Encourage mobility, leg exercises and hydration during prolonged travel.
• Remote-area preparation
  • Travel insurance including evacuation.
  • First-aid supplies and emergency medications.
  • Communication and evacuation plan.

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Individual 2 — Sarah

Sarah is a 35 year old who works for an NGO. She has a planned three (3) week work trip to inspect a medical facility in Kampala, Uganda for a time when she will be 15 weeks pregnant. It is important that this trip is completed before she goes on maternity leave.

What advice specific to Sarah’s situation should be covered?

Advice specific to her situation includes:

• Consider avoiding or postponing travel
  • The safest option may be not to travel to a malaria-endemic area during pregnancy.
  • Explore whether the work can be deferred, delegated or completed remotely.
  • Discuss that occupational importance does not remove the maternal and fetal risks.
• Shared risk–benefit discussion
  • Document the reasons for travel.
  • Discuss maternal, fetal, infectious, obstetric and occupational risks.
  • Consider review by an obstetrician and/or specialist travel medicine clinic.
• Malaria
  • Pregnancy increases the risk of severe malaria and adverse pregnancy outcomes.
  • Discuss rigorous mosquito-bite prevention.
  • Select only an antimalarial regimen considered appropriate for pregnancy and the destination.
  • Explain the need for urgent assessment of any febrile illness during travel or after return.
• Yellow fever
  • Yellow fever vaccine is a live vaccine and requires an individualised risk–benefit assessment during pregnancy.
  • Consider:
    • Actual exposure risk.
    • Entry requirements.
    • Possibility of changing the itinerary.
    • Whether a medical exemption would be accepted.
  • Seek specialist advice where uncertainty exists.
• Tuberculosis and occupational exposure
  • Assess anticipated contact with patients and the infection-control standards at the medical facility.
  • Discuss ventilation, respiratory protection and avoidance of high-risk clinical areas.
  • Establish a plan for assessment if a significant exposure occurs.
• Pregnancy complications
  • Review current pregnancy status and obstetric risk factors.
  • Explain warning symptoms requiring urgent care, including:
    • Vaginal bleeding.
    • Significant abdominal pain.
    • Fluid loss.
    • Severe vomiting or dehydration.
    • Fever.
    • Severe headache or neurological symptoms.
  • Identify suitable medical and obstetric facilities before departure.
• Gastrointestinal illness
  • Strict food- and water-hygiene measures.
  • Early oral rehydration.
  • Avoid medications that are unsuitable during pregnancy.
  • Seek medical care promptly for persistent diarrhoea, blood in the stool, fever or dehydration.
• Vaccination review
  • Review routine and pregnancy-recommended vaccinations.
  • Avoid contraindicated live vaccines unless specialist risk–benefit assessment supports their use.
• Air travel and venous thromboembolism
  • Assess individual VTE risk.
  • Encourage mobility, hydration and appropriate preventive measures.
• Travel insurance
  • Confirm explicit cover for:
    • Pregnancy-related complications.
    • Neonatal care.
    • Medical evacuation.
    • Pre-existing pregnancy.
• Medication and documentation
  • Carry an adequate medication supply.
  • Carry antenatal records and a medical letter.
  • Develop a contingency plan for deterioration or early return.

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Individual 3 — Jasmine

Jasmine is a 25-year-old with type 1 diabetes and GORD. She is taking insulin in a basal and bolus schedule via a pump and is also on a protein pump inhibitor. She has had all her childhood and adolescent vaccinations but no further vaccines since she completed high school. She is visiting Brazil for 4 weeks, staying with family, attending Carnival Rio and doing a boat trip down the Amazon.

In addition to standard travel advice, what special risk factors does Jasmine have?

Type 1 diabetes

• Time-zone changes
  • Requires a written plan for adjusting basal insulin, bolus timing and meal-related dosing.
  • Pump time settings may need to be changed deliberately rather than automatically.
• Changes in meals and activity
  • Unpredictable meal timing, unfamiliar carbohydrate content and increased physical activity may alter insulin requirements.
  • Increased risk of hypoglycaemia during walking, dancing, heat exposure or missed meals.
  • Illness and dehydration may increase insulin requirements and risk of ketosis.
• Insulin-pump failure
  • Carry:
    • Spare infusion sets and reservoirs.
    • Batteries or charging equipment.
    • Backup insulin pens or syringes.
    • Long-acting insulin and a written backup regimen where prescribed.
  • Never rely on the pump as the only insulin-delivery method during remote travel.
• Glucose and ketone monitoring
  • Carry additional glucose-monitoring supplies.
  • Carry blood or urine ketone testing.
  • Have a written sick-day management plan.
  • Seek urgent care for persistent hyperglycaemia, ketones, vomiting or suspected diabetic ketoacidosis.
• Hypoglycaemia preparation
  • Carry rapid-acting carbohydrate and glucagon.
  • Ensure companions can recognise and treat hypoglycaemia.
  • Consider a medical identification bracelet or card.
• Insulin storage
  • Protect insulin from freezing and excessive heat.
  • Keep insulin, pump supplies and monitoring equipment in hand luggage.
  • Carry sufficient extra supplies for delays or loss.
• Airport and security issues
  • Carry a medical letter explaining:
    • Type 1 diabetes.
    • Insulin and sharps.
    • Pump and continuous glucose-monitoring equipment.
  • Check manufacturer advice before exposing devices to security scanners.

Proton-pump inhibitor use

• Reduced gastric acidity may increase susceptibility to some food- and water-borne infections.
• Emphasise:
  • Safe drinking water.
  • Food hygiene.
  • Hand hygiene.
  • Early management of diarrhoea and dehydration.
• Gastrointestinal illness is particularly important because it can destabilise glucose control and precipitate ketosis.

Visiting friends and relatives

• Travellers staying with relatives may:
  • Stay longer.
  • Eat locally prepared food.
  • Stay in homes without screened or air-conditioned accommodation.
  • Travel to rural or remote areas.
  • Underestimate familiar-country risks.
• A full destination-specific assessment remains necessary despite family familiarity.

Carnival and crowded events

• Increased exposure to:
  • Respiratory infections.
  • Sexually transmitted infections.
  • Alcohol-related harm.
  • Theft, assault and crowd-related injury.
• Alcohol may impair recognition and treatment of hypoglycaemia.

Amazon boat travel

• Potential exposure to:
  • Yellow fever.
  • Malaria and other mosquito-borne infections.
  • Rabies and animal contact.
  • Food- and water-borne disease.
  • Limited access to emergency care.
• Requires:
  • Destination-specific vaccination review.
  • Mosquito precautions and possible malaria chemoprophylaxis.
  • Adequate diabetes supplies.
  • Emergency evacuation and communication planning.

Vaccination history

• Review routine vaccine status because she has had no vaccines since completing high school.
• Consider routine boosters and itinerary-specific vaccines, including yellow fever and other vaccines indicated by the precise destinations and activities.

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Individual 4 — The Jones Family

The Joneses are a family of five (5), including three (3) children, aged five (5), three (3) and six (6) months. They go to the nurse for vaccination. Their vaccination needs for their upcoming holiday have been determined to be slightly different for each person due to their age and previous vaccination. Yellow fever vaccine is being given to the father and the older two (2) children. The mother and baby are being given a yellow fever vaccine medical exemption due to breastfeeding and age. The family attends together for vaccination, piling all their vaccines brought in from the pharmacy on the nurse’s desk. Additional vaccines are needed from the practice fridge.

What systems and policies are in place in your practice to ensure that each member of this family receives the appropriate vaccines and documentation? 

How could this be improved?

Systems that should be in place

Before preparing any vaccines

• Create a separate vaccination plan for each family member, showing:
  • Full name and date of birth.
  • Vaccines required.
  • Dose and schedule.
  • Previous vaccination history.
  • Contraindications and precautions.
  • Vaccines to be administered versus medical exemptions.
  • Required travel documentation.
• Confirm the identity of each person using at least two identifiers.
• Perform and document individual pre-vaccination screening and consent before removing or preparing vaccines.
• Check:
  • Age eligibility.
  • Previous vaccine doses and intervals.
  • Allergies and previous reactions.
  • Pregnancy or breastfeeding.
  • Immunocompromising conditions or treatment.
  • Current illness.
  • Relevant travel itinerary.
• Verify that pharmacy-supplied vaccines:
  • Match the prescription and intended recipient.
  • Are unopened, in date and correctly labelled.
  • Have remained within the required cold chain during transport.
• Do not administer a vaccine when its identity, prescription or cold-chain history cannot be established. Australian guidance requires comprehensive screening, confirmation of the correct person and vaccine, assessment of age and contraindications, and valid consent before vaccination.

Vaccine separation and administration

• Do not leave all family members’ vaccines mixed together on the desk.
• Use a separate labelled tray or container for each person.
• Keep pharmacy-supplied and practice-supplied vaccines clearly identified.
• Prepare vaccines for one person at a time.
• Complete that person’s administration and documentation before moving to the next family member.
• Immediately before each injection, check:
  • Correct patient.
  • Correct vaccine and indication.
  • Correct dose.
  • Correct route and anatomical site.
  • Correct timing and interval.
  • Expiry date.
  • Batch number.
  • Vaccine appearance and integrity.
  • Prescription or written vaccination plan.
• Use an independent second-person check, particularly because:
  • Several family members are being vaccinated.
  • Their vaccine requirements differ.
  • Multiple vaccines have been supplied from different sources.
• Record the injection site of each vaccine where multiple vaccines are given.

The Australian Immunisation Handbook specifically recommends preparing vaccines for only one person at a time when several family members are vaccinated at the same visit.

Documentation

For the father and older children:

• Record each administered vaccine in:
  • The individual clinical record.
  • The Australian Immunisation Register, as applicable.
  • The person’s vaccination record.
• Record:
  • Vaccine brand.
  • Batch number.
  • Dose number.
  • Date and time.
  • Route and site.
  • Vaccinator.
  • Any next dose required.
• Complete a separate International Certificate of Vaccination or Prophylaxis for each person receiving yellow fever vaccine.
• Ensure the certificate details correspond exactly with the traveller’s passport.

For the mother and baby:

• Record:
  • That yellow fever vaccine was not administered.
  • The clinical reason.
  • The individual risk–benefit assessment.
  • Mosquito-avoidance advice.
  • Advice regarding possible border implications.
• Complete the appropriate individual yellow fever medical exemption documentation.
• Do not use one combined family exemption or certificate.

All vaccinations should be recorded in the clinical file and personal vaccination record, with relevant vaccines reported to AIR.

How the process could be improved

• Complete travel assessment, AIR review, screening and prescriptions before the vaccination appointment.
• Ask the family to keep each person’s pharmacy-supplied vaccines in a separate labelled cold-chain bag.
• Use:
  • Individual vaccination checklists.
  • Colour-coded or clearly labelled trays.
  • Printed family-member vaccine plans.
  • Barcode scanning where available.
• Allocate one staff member to prepare and another to independently verify.
• Introduce a mandatory “pause before injection” in which the vaccinator verbally confirms the patient, vaccine and dose.
• Avoid interruptions and unrelated telephone calls while vaccines are being prepared.
• Schedule a longer family vaccination appointment or stagger family members where necessary.
• Audit:
  • Vaccine administration errors.
  • Near misses.
  • Documentation completion.
  • AIR submissions.
  • Yellow fever certificate completion.
• Conduct regular staff training using simulated multi-person vaccination scenarios.

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Individual 5 — Jeff

Jeff, a 70 year man, comes to see the nurse for his yellow fever vaccine. At the pre vaccine check, it is discovered that he has recently started high dose oral steroids. It is decided not to give the vaccine at this time. A vaccine had been readied for him and had been out of the fridge for 70 minutes.

Should this vaccine be used for another person? What processes are in place in your practice to ensure the cold chain is maintained?

Should the prepared vaccine be given to another person?

• No.
• Assuming the yellow fever vaccine had been reconstituted, it should be discarded.
• Current Australian Stamaril product information states:
  • Use immediately after reconstitution.
  • It is a single-use product for one patient only.
  • Any residue must be discarded.
• It should not be reassigned to another patient after being prepared for Jeff and left for 70 minutes.

Important distinction: if the vaccine had merely been removed from the refrigerator but remained unopened and unreconstituted, management would depend on documented time and temperature exposure and the cold-chain breach protocol—not simply the passage of 70 minutes.

Why Jeff should not receive the vaccine

• Yellow fever vaccine is a live attenuated vaccine.
• High-dose systemic corticosteroid treatment may cause significant immunosuppression.
• Yellow fever vaccination should be postponed when the patient is receiving immunosuppressive doses of systemic corticosteroids.
• Reassess after the steroid treatment and immunosuppressive effect have resolved, taking account of:
  • Dose.
  • Duration.
  • Underlying condition.
  • Departure date.
  • Yellow fever exposure risk.
  • Border requirements.
• Consider specialist travel medicine or immunisation advice where timing is uncertain.

Cold-chain systems

• Complete pre-vaccination screening before removing or reconstituting the vaccine.
• Reconstitute yellow fever vaccine only when:
  • Eligibility has been confirmed.
  • Consent has been obtained.
  • The patient is ready for immediate administration.
• Store vaccines in a purpose-built vaccine refrigerator between +2°C and +8°C, aiming for approximately +5°C.
• Maintain:
  • Temperature monitoring and documentation.
  • A data logger and alarm system.
  • Clear responsibility for reviewing temperatures.
  • Procedures for power failure and refrigerator malfunction.
  • An up-to-date cold-chain breach protocol.
  • Staff training and competency records.
• During a suspected breach:
  • Label and isolate affected stock.
  • Do not use or discard it until advice is obtained.
  • Record the duration and temperature excursion.
  • Contact the relevant health authority for funded vaccines or the manufacturer/supplier for privately purchased vaccines.
• Check cold-chain transport arrangements for vaccines brought from a pharmacy.
• Document vaccine wastage, including:
  • Vaccine and batch number.
  • Reason for disposal.
  • Time reconstituted.
  • Time discarded.

Australian vaccine storage guidance requires vaccines to remain between +2°C and +8°C and recommends managing any excursion through a formal cold-chain breach process.

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Individual 6 — Nigel

5 minutes following vaccination, Nigel, 39, feels faint and reports that his lips and mouth feel strange.

What systems does your practice have in place to manage post vaccine reactions?

Immediate clinical concern

• Feeling faint could represent a vasovagal episode.
• However, an abnormal sensation involving the lips or mouth within five minutes of vaccination may indicate an evolving allergic reaction.
• Treat Nigel as having possible anaphylaxis until rapidly assessed rather than assuming simple fainting.

Immediate response

• Stop other clinical activity and call for assistance.
• Do not allow Nigel to stand or walk.
• Lie him flat, preferably with legs elevated.
  • Allow a supported sitting position only if breathing is significantly impaired when lying down.
• Assess:
  • Airway and voice change.
  • Lip, tongue or throat swelling.
  • Breathing, wheeze or stridor.
  • Skin flushing, urticaria or angioedema.
  • Pulse, blood pressure and oxygen saturation.
  • Level of consciousness.
• If anaphylaxis is suspected:
  • Call 000.
  • Give adrenaline 1:1000, 0.5 mL IM into the mid-outer thigh for an adult of more than approximately 50 kg.
  • Repeat every five minutes if required.
  • Give high-flow oxygen when available.
  • Continue airway, breathing and circulation support.
  • Arrange ambulance transfer.
• Do not rely on antihistamines or corticosteroids as first-line treatment.
• If uncertain whether the reaction is anaphylaxis, Australian guidance supports giving IM adrenaline rather than delaying treatment.

Practice systems for post-vaccination reactions

• Advise every vaccinated person to remain under observation for at least 15 minutes.
• Provide a clearly designated waiting area:
  • Visible to staff.
  • Close to the treatment room.
  • With a process to prevent patients leaving unnoticed.
• Record the time vaccination was given and when the observation period ends.
• Maintain an immediately accessible emergency trolley containing:
  • Adrenaline 1:1000.
  • Appropriate syringes and needles.
  • Oxygen and masks.
  • Airway equipment.
  • Blood-pressure and oxygen-saturation monitoring.
  • AED and basic resuscitation equipment.
• Check and document emergency equipment and adrenaline expiry dates regularly.
• Display current anaphylaxis algorithms and adrenaline dosing tables.
• Ensure staff receive:
  • Basic life-support training.
  • Anaphylaxis-recognition and management training.
  • Training to distinguish anaphylaxis from vasovagal syncope.
  • Regular emergency simulations.
• Allocate emergency roles in advance:
  • Clinical lead.
  • Adrenaline administration.
  • Calling 000.
  • Monitoring and documentation.
  • Directing ambulance access.
• After the event:
  • Document symptoms, observations, vaccine details, batch numbers, treatment and response.
  • Arrange appropriate medical observation and follow-up.
  • Report the adverse event through the relevant jurisdictional AEFI process.
  • Review the incident as a team and identify system improvements.

Australian guidance requires at least 15 minutes of observation and states that immunisation providers must be able to recognise and distinguish anaphylaxis from fainting and provide immediate treatment.