Chapter 7 International Travel with Infants & Children
Vaccine Recommendations for Infants & Children
Vaccinating children for travel requires careful evaluation. Whenever possible, children should complete the routine immunizations of childhood on a normal schedule. However, travel at an earlier age may require accelerated schedules. Not all travel-related vaccines are effective in infants, and some are specifically contraindicated.
The recommended childhood and adolescent immunization schedule is available at www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-schedule.pdf. The catch-up schedule for children and adolescents who start their vaccination schedule late or who are >1 month behind can also be accessed at www.cdc.gov/vaccines/schedules/downloads/child/catchup-schedule-pr.pdf. This table also describes the recommended minimum intervals between doses for children who need to be vaccinated on an accelerated schedule, which may be necessary before international travel.
Country-specific vaccination recommendations and requirements for departure and entry vary over time. For example, at the time of this publication, proof of yellow fever vaccination is required for entry into certain countries. Meningococcal vaccination is required for travelers entering Saudi Arabia for the annual Hajj. The World Health Organization issued temporary vaccination requirements for residents of and long-term visitors to countries with active wild poliovirus transmission. Clinicians should check the CDC website for up-to-date requirements and recommendations (www.cdc.gov/travel).
Additional information about diseases and routine vaccination is available in the disease-specific sections in Chapter 3. Interactive tools for determining routine and catch-up childhood vaccination are available at www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html.
MODIFYING THE IMMUNIZATION SCHEDULE FOR INADEQUATELY IMMUNIZED INFANTS AND YOUNGER CHILDREN BEFORE INTERNATIONAL TRAVEL
Several factors influence recommendations for the age at which a vaccine is administered, including age-specific risks of the disease and its complications, the ability of people of a given age to develop an adequate immune response to the vaccine, and potential interference with the immune response by passively transferred maternal antibodies.
The routine immunization schedules for infants and children in the United States do not provide specific guidelines for those traveling internationally before the age when specific vaccines and toxoids are routinely recommended. Recommended age limitations are based on potential adverse events (yellow fever vaccine), lack of efficacy data or inadequate immune response (polysaccharide vaccines and influenza vaccine), maternal antibody interference (measles-mumps-rubella [MMR] vaccine), or lack of safety data. In deciding when to travel with a young infant or child, parents should be advised that the earliest opportunity to receive routinely recommended immunizations in the United States (except for the dose of hepatitis B vaccine at birth) is at age 6 weeks.
Routine Infant and Childhood Vaccinations
Children should receive routine vaccination for hepatitis A virus; hepatitis B virus; diphtheria, tetanus, pertussis; Haemophilus influenzae type b (Hib); human papillomavirus; influenza; MMR; Neisseria meningitidis; polio; rotavirus; Streptococcus pneumoniae; and varicella. In order to complete vaccine series before travel, vaccine doses can be administered at the minimum intervals. Parents should be informed that infants and children who have not received all recommended doses might not be fully protected. Rotavirus vaccine is unique among the routine vaccines given to US infants because it has maximum ages for the first and last doses; specific consideration should be given to the timing of an infant’s travel so that the infant will still be able to receive the vaccine series, if at all possible.
Travel-specific vaccine considerations include the following:
- Hepatitis A vaccine: Although hepatitis A is often not severe in infants and children aged <5 years, infected children may transmit the infection to older children and adults, who are at risk for severe disease. Vaccination should be ensured for all children traveling to areas where there is an intermediate or high risk of hepatitis A. Because of the potential interference by maternal antibodies, the hepatitis A vaccine is not approved for children aged <1 year. The vaccine series consists of 2 doses ≥6 months apart. One dose of monovalent hepatitis A vaccine administered at any time before departure can provide adequate protection for most healthy children. The second dose is necessary for long-term protection.
- Immune globulin (IG) for hepatitis A protection: Children aged <1 year or who are allergic to a vaccine component and who are traveling to high-risk areas can receive IG. One dose of 0.02 mL/kg intramuscularly provides protection for up to 3 months, and 1 dose of 0.06 mL/kg IM provides protection for 3–5 months. Children should receive a second dose after 5 months if travel continues. For optimal protection, children aged ≥1 year who are immunocompromised or have chronic medical conditions and who are planning to depart to a high-risk area in <2 weeks should receive the initial dose of vaccine along with IG at a separate anatomic injection site. IG does not interfere with the response to yellow fever vaccine but can interfere with the response to other live injected vaccines (such as MMR and varicella vaccines). Administration of MMR and varicella vaccines should be delayed for >3 months after administration of IG for hepatitis A prophylaxis. IG should not be administered <2 weeks after MMR or varicella vaccines unless the benefits exceed those of vaccination. If IG is given during this time, the child should be revaccinated with the live MMR or varicella vaccines but not sooner than 3 months after IG administration. When travel plans do not allow adequate time to administer live vaccines and IG before travel, the severity of the diseases and their epidemiology at the destination will help determine the course of preparation.
- Hepatitis B vaccine: Vaccine can be administered with an accelerated schedule of 4 doses of vaccine given at 0, 1, 2, and 12 months; the last dose may be given on return from travel.
- Influenza vaccine: Influenza viruses circulate predominantly in the winter months in temperate regions (typically November–April in the Northern Hemisphere and April–September in the Southern Hemisphere) but can occur year-round in tropical climates. Since influenza viruses may be circulating at any time of the year, travelers aged ≥6 months who were not vaccinated during the influenza season of their country of residence should be vaccinated ≥2 weeks before departure if vaccine is available. Children aged 6 months through 8 years who are receiving influenza vaccine for the first time require 2 doses administered ≥4 weeks apart. For 2014–2015, Advisory Committee on Immunization Practices (ACIP) has recommended that live, attenuated influenza vaccine is preferred for healthy children 2–8 years if it is readily available. Check the CDC website annually for updated recommendations about seasonal influenza vaccination.
- MMR or MMRV vaccine: Children traveling abroad may need to be vaccinated at an earlier age than is routinely recommended. Infants aged 6–11 months should receive 1 dose of MMR vaccine before departure, then be vaccinated with MMR or MMRV (measles-mumps-rubella-varicella) vaccine at 12–15 months (≥28 days after the initial dose) and again at 4–6 years, according to the routinely recommended schedule. Children aged ≥12 months need 2 doses of MMR vaccine before traveling overseas. Children who have received 1 dose should receive their second dose before departure, provided the 2 doses are separated by ≥28 days.
- Meningococcal vaccine: Epidemics of meningococcal disease, caused by the bacterium Neisseria meningitidis, occur in sub-Saharan Africa during the dry season, December through June (see Map 3-11). CDC recommends that travelers be vaccinated before traveling to this region. Meningococcal vaccination is a requirement to enter Saudi Arabia when traveling to Mecca during the annual Hajj. Health requirements and recommendations for US travelers to the Hajj are available each year on the CDC Travelers’ Health website (www.cdc.gov/travel). Meningococcal vaccine is also recommended for children aged 2 months through 18 years who travel to or reside in areas where N. meningitidis is hyperendemic or epidemic; for these children, providers should take care to use a meningococcal vaccine that is licensed for the child’s age group and contains all 4 serotypes (A, C, Y, W-135). The schedule for the primary series and booster doses varies depending on which meningococcal vaccine is administered (see CDC’s Immunization Schedules webpage at www.cdc.gov/vaccines/schedules for additional information).
- Polio vaccine: Polio vaccine is recommended for travelers to countries with evidence of wild poliovirus (WPV) circulation (during the last 12 months) and for travelers with a high risk of exposure to someone with imported WPV infection when traveling to some countries that border areas with WPV circulation. Refer to the CDC Travelers’ Health website destination pages for the most up-to-date polio vaccine recommendations (wwwnc.cdc.gov/travel/destinations/list). Clinicians should ensure that travelers have completed the recommended age-appropriate polio vaccine series and have received a single lifetime booster dose, if necessary. See Chapter 3, Poliomyelitis and CDC’s Immunization Schedules webpage (www.cdc.gov/vaccines/schedules) for information about accelerated schedules for completing the routine series. Young adults (≥18 years of age) who are traveling to areas where polio vaccine is recommended and who have received a routine series with either inactivated polio vaccine (IPV) or live oral polio vaccine in childhood should receive a single lifetime booster dose of IPV before departure. Available data do not indicate the need for more than a single lifetime booster dose with IPV. However, requirements for long-term travelers may apply when departing certain countries.
- In May 2014, the World Health Organization (WHO) declared the international spread of polio to be a Public Health Emergency of International Concern (PHEIC) under the authority of the International Health Regulations (2005). To prevent further spread of disease, WHO issued temporary polio vaccine recommendations for long-term travelers (staying >4 weeks) and residents departing from countries with WPV transmission (“exporting WPV” or “infected with WPV”). Clinicians should be aware that long-term travelers and residents may be required to show proof of polio vaccination when departing from these countries. All polio vaccination administration should be documented on an International Certificate of Vaccination or Prophylaxis (ICVP). The polio vaccine must be received between 4 weeks and 12 months before the date of departure from the polio-infected country. Country requirements may change, so clinicians should check for updates on the CDC Travelers’ Health website. Refer to the Clinical Update: Interim CDC Guidance for Travel to and from Countries Affected by the New Polio Vaccine Requirements (wwwnc.cdc.gov/travel/news-announcements/polio-guidance-new-requirements) for a list of affected countries, guidance on meeting the vaccination requirements, and instructions on how to order and fill out the ICVP.
Japanese Encephalitis Vaccine
Japanese encephalitis (JE) virus is transmitted by mosquitoes and is endemic throughout Asia. The risk can be seasonal in temperate climates and year-round in more tropical climates. The risk to short-term travelers and those who confine their travel to urban centers is low. JE vaccine is recommended for travelers who plan to spend a month or longer in endemic areas during the JE virus transmission season. JE vaccine should be considered for short-term (<1 month) travelers whose itinerary or activities might increase their risk for exposure to JE virus. The decision to vaccinate a child should follow the more detailed recommendations in Chapter 3, Japanese Encephalitis.
An inactivated Vero cell culture– derived JE vaccine (Ixiaro [Valneva]) was licensed by the Food and Drug Administration in 2009 for use in the United States for travelers aged ≥17 years. In 2013, the recommendations were expanded and the vaccine was licensed for use in children starting at age 2 months.
The primary series is 2 intramuscular doses administered 28 days apart. Information on age-appropriate dosing is available at www.cdc.gov/japaneseencephalitis/vaccine/vaccineChildren.html. For people aged ≥17 years, ACIP recommends that if the primary series was administered >1 year previously, a booster dose may be given before potential JE virus exposures. Although studies are being conducted on the need for a booster dose following a primary series of Ixiaro in children, data are not yet available.
Rabies virus causes an acute viral encephalitis that is virtually 100% fatal. Traveling children may be at increased risk of rabies exposure, mainly from dogs who roam the streets in developing countries. Bat bites carry a potential risk of rabies throughout the world. There are 2 strategies to prevent rabies in humans:
- Avoiding animal bites or scratches.
- A 3-shot preexposure immunization series on days 0, 7, and 21 or 28. In the event of a subsequent possible rabies virus exposure, the child will require 2 more doses of rabies vaccine on days 0 and 3. The decision whether to obtain preexposure immunization for children should follow the recommendations in Chapter 3, Rabies.
For children who have not received preexposure immunization and may have been exposed to rabies, a weight-based dose of human rabies immune globulin and a series of 4 rabies vaccine injections are required on days 0, 3, 7, and 14.
Typhoid fever is caused by the bacterium Salmonella enterica serotype Typhi. Vaccination is recommended for travelers to areas where there is a recognized risk of exposure to Salmonella Typhi.
Two typhoid vaccines are available: Vi capsular polysaccharide vaccine (ViCPS) administered intramuscularly and oral live attenuated vaccine (Ty21a). Both vaccines induce a protective response in 50%–80% of recipients. The ViCPS vaccine can be administered to children who are aged ≥2 years, with a booster dose 2 years later if continued protection is needed. The Ty21a vaccine, which consists of a series of 4 capsules (1 taken every other day) can be administered to children aged ≥6 years. A booster series for Ty21a should be taken every 5 years, if indicated. The capsule cannot be opened for administration but must be swallowed whole. All 4 doses should be taken ≥1 week before potential exposure.
Yellow Fever Vaccine
Yellow fever, a disease transmitted by mosquitoes, is endemic in certain areas of Africa and South America (see Maps 3-15 and 3-16). Proof of yellow fever vaccination is required for entry into some countries (see Chapter 3, Yellow Fever & Malaria Information, by Country). Infants and children aged ≥9 months can be vaccinated if they travel to countries within the yellow fever–endemic zone. More information, including how to access yellow fever vaccine in the United States, is available in Chapter 3, Yellow Fever.
Infants aged <9 months are at higher risk for developing encephalitis from yellow fever vaccine, which is a live virus vaccine. Studies conducted during the early 1950s identified 4 cases of encephalitis out of 1,000 children aged <6 months vaccinated with yellow fever vaccine. An additional 10 cases of encephalitis associated with yellow fever vaccine administered to infants aged <4 months were reported worldwide during the 1950s.
Travelers with infants aged <9 months should be advised against traveling to areas within the yellow fever–endemic zone. ACIP recommends that yellow fever vaccine never be given to infants aged <6 months. Infants aged 6–8 months should be vaccinated only if they must travel to areas of ongoing epidemic yellow fever and if a high level of protection against mosquito bites is not possible. Clinicians considering vaccinating infants aged 6–8 months may contact their respective state health departments or CDC toll-free at 800-CDC-INFO (800-232-4636) or www.cdc.gov/cdc-info/requestform.html.
- CDC. General recommendations on immunization—recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011 Jan 28;60(2):1–64.
- CDC. Interim CDC guidance for polio vaccination for travel to and from countries affected by wild poliovirus. MMWR Morb Mortal Wkly Rep. 2014 Jul 11;63(27):591–4.
- CDC. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013 Mar 22;62(RR-2):1–28.
- CDC. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006 May 19;55(RR-7):1–23.
- CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007 Jun 22;56(RR-4):1–40.
- CDC. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices. MMWR Recomm Rep. 2010 Mar 19;59(RR-2):1–9.
- CDC. Use of Japanese encephalitis vaccine in children: recommendations of the Advisory Committee on Immunization Practices, 2013. MMWR Morb Mortal Wkly Rep. 2013 Nov 15;62(45):898–900.
- CDC. Yellow fever vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 Jul 30;59(RR-7):1–27.
- Global Polio Eradication Initiative. Polio public health emergency: temporary recommendations to reduce international spread of poliovirus. Geneva: Global Polio Eradication Initiative; 2014 [cited 2014 Sep 22]. Available from: http://www.polioeradication.org/infectedcountries/polioemergency.aspx.
- Pickering LK, editor. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
- Page created: July 10, 2015
- Page last updated: July 10, 2015
- Page last reviewed: July 10, 2015
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