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The most recent childhood immunization schedule released by the Centers for Disease Control in February has important new recommendations for vaccines prior to travel, including some that conflict with the traditional endorsed vaccine schedules for the first year of life. This can be confusing for physicians, as they may not realize that they can (and should) administer some vaccines early and some vaccines on an accelerated schedule for infants and children traveling to at-risk areas.
Providing immunizations for traveling children makes the already complex and crowded immunization schedule even more so. Fortunately, there are several online resources available that can provide rapid and up to date consultations for busy physicians. CDC has a website dedicated to travel recommendations, as well as tools providers can download on their mobile devices, including the TravWell app and CDC Health Information for International Travel (known as the Yellow Book).
Over 2.5 million children travel internationally each year, including increasing numbers of adolescents traveling abroad with school groups. When families request pretravel consultation, some practitioners may prefer to refer them to a travel clinic, but not all travel clinics will care for young infants and children, and often the need to provide immunizations prior to travel requires more-immediate action.
Suppose your last patient of the morning is a 9-month-old girl brought in for a well-child visit by her parents and 4-year-old sister. Her father mentions that the family is travelling to Nigeria at the end of the month for a 2-week trip to visit family and friends. The infant is up to date for age on her routine immunizations, given at 2, 4, and 6 months, but should now receive the following immunizations to protect her during her trip abroad:
Hepatitis A vaccine (HAV): In a new recommendation, infants 6 to 11 months of age traveling outside the U.S. should receive HAV prior to travel. Vaccine administered before 12 months of age is not considered to provide long-term protection and needs to be repeated after 1 year of age, with a second vaccine 6 months later to complete the series.
Measles Mumps Rubella (MMR) vaccine: Similar to the HAV recommendation, infants 6 to 11 months of age should also receive a dose of MMR vaccine. For infants vaccinated at <12 months of age, MMR needs to be repeated when the child is aged ≥12 months, with a second dose administered after a minimum of 28 days. If this infant's 4-year-old sibling has not received two doses of a measles-containing vaccine, she should also receive a dose of MMR prior to travel. HAV and MMR vaccine can be administered at the same visit.
Meningococcal vaccine: Children ≥2 months of age traveling to the meningitis belt of Africa during the dry season (December to June) should receive vaccine. For this 9-month-old infant, a conjugate meningococcal vaccine — MenACWY-CRM (Menveo) or MenACWY-D (Menactra) — is recommended in a two-dose series. The infant's 4-year-old sibling should receive one dose of meningococcal conjugate vaccine prior to travel.
Other things to discuss with this family include:
Malaria prophylaxis: In addition to a review of mosquito bite avoidance, CDC provides a detailed reference for malaria prophylaxis for children of all ages.
Safe food and water consumption: These recommendations are especially relevant given the evidence that the highest-risk travelers are those whose travels include staying with friends and relatives. Children older than 2 years should receive typhoid vaccine.
Although we typically think of travel medicine when patients have planned travel to under-resourced countries, it is important to remember that vaccine-preventable diseases do not respect borders. There are currently six ongoing measles outbreaks in the U.S., with 372 cases in 2018, and 314 cases so far this year. This includes an outbreak in Washington State, which at latest count is up to 74 cases, 86% of which have occurred in unimmunized individuals. Children who are unvaccinated either because of parental choice or young age should avoid travel to outbreak areas; if travel is unavoidable, those >6 months of age should receive MMR vaccine.
Pretravel visits can be lengthy, and parents may not have anticipated the administration of additional vaccinations, or the need to repeat some vaccines when the child is older. Providing families with parent-friendly materials on CDC's website can be helpful as we aim to keep all children safe from preventable diseases as they travel.