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Chapter 2 The Pre-Travel Consultation

Perspectives: Fear of Vaccines

Paul Offit

Pre-travel consultations often provide the opportunity to update routine vaccinations for both children and adults. One of the first topics covered in such sessions is whether the traveler is immune to diseases such as measles and varicella. Unfortunately, in some circumstances, providers may be surprised to find that travelers have no interest in being vaccinated or in having their children vaccinated, whether for measles or other potentially life-threatening, travel-related infections, such as yellow fever.

Although travel-related vaccines may not have implications for community health, such as providing herd immunity, they can protect people against severe and occasionally fatal illness. For these vaccines, the discussion between clinicians and patients is one of weighing the risks and benefits of travel-related vaccines for particular destinations. Travelers are often at a higher risk of exposure to diseases for which routine vaccines provide protection, even when traveling to countries in Europe. For example, measles outbreaks of 27,134 cases were reported in the World Health Organization’s European Region in 2012, and an additional 31,520 cases were reported in 2013. The European measles outbreak belied a common belief that severe and occasionally fatal vaccine-preventable diseases are the province of the developing world.

Because so much is at stake, the travel health provider should educate all travelers, and especially parents, about the use of vaccines. Those providing travel health advice should familiarize themselves with the literature on the safety of both routine and travel-related vaccines, so they can address any concerns that their patients may have.

The history of the development of vaccination complacency and avoidance is a curious one. During the 1940s, parents in the United States did not hesitate to get the diphtheria, tetanus, and pertussis vaccines; they knew that diphtheria and pertussis were common killers of young children, and they had watched tetanus claim the lives of soldiers in World Wars I and II. During the 1950s, the polio vaccine was a godsend; everyone knew what poliovirus could do. During the 1960s, parents gladly accepted the measles, mumps, and rubella vaccines. They knew that measles caused tens of thousands of hospitalizations and hundreds of deaths every year, mostly from pneumonia; that mumps was a common cause of deafness and a rare cause of sterility; and that rubella caused thousands of children to suffer severe birth defects of the eyes, ears, and heart.

The widespread use of vaccines caused a dramatic decrease—and in some cases a virtual elimination—of several diseases. Parents, no longer compelled by fear of the diseases around them, became complacent. Immunization rates plateaued. Now, the United States (as well as many European countries) finds itself in a situation where vaccine safety issues, real or imagined, are a primary concern. Parents confront a flood of misinformation from radio and television programs, magazine and newspaper articles, antivaccine blogs, YouTube, and Twitter. Vaccines—considered mankind’s greatest lifesaver—are now feared by some to cause a variety of chronic diseases, including autism, diabetes, allergies, asthma, learning disabilities, multiple sclerosis, and attention deficit disorder. As a consequence, some parents are choosing not to immunize their children according to recommended schedules. Travel health providers must be aware of these issues and arm themselves with accurate information to properly educate their patients.

In addition to protecting the health of the vaccine recipient, vaccination safeguards the health of entire communities, both at home and possibly at travel destinations. Predictably, in communities with clusters of underimmunized children, there is increased risk of vaccine-preventable diseases. Some of the outbreaks in these communities have been linked to international travel to the United States. More measles cases were reported in the United States in 2014 than in any year since 1994. Many of the cases in 2014 were associated with people returning to the United States from the Philippines. Pertussis outbreaks have swept the nation, fueled in part by inadequately vaccinated children. Haemophilus influenzae type b meningitis has claimed the lives of several children in Minnesota and Pennsylvania, deaths that could have easily been avoided if parents had not feared vaccines more than the diseases they prevent.

So, where do we go from here? How do we again inspire people to vaccinate themselves and their children? One way would be to make parents aware of the impact of vaccine-preventable diseases and to provide the science that supports the safety of vaccines in a manner that is compelling and easily understood. Some of this information is available from CDC (, the American Academy of Pediatrics (, the Immunization Action Coalition (, the Vaccine Education Center at the Children’s Hospital of Philadelphia (, Every Child By Two (, the National Network for Immunization Information (, the Institute for Vaccine Safety at Johns Hopkins Hospital (, and Parents of Kids with Infectious Diseases (, among other groups.

But is it enough? As providers whose job it is to protect people against vaccine-preventable diseases, travel-related or otherwise, we need to enhance our efforts to educate ourselves and our patients, so that we will not once again be compelled to vaccinate after witnessing the suffering, hospitalization, and death caused by vaccine-preventable diseases—an unwanted return to an earlier and darker phase in history.


  1. Atwell JE, Van Otterloo J, Zipprich J, Winter K, Harriman K, Salmon DA, et al. Nonmedical vaccine exemptions and pertussis in California, 2010. Pediatrics. 2013 Oct;132(4):624–30.
  2. CDC. Invasive Haemophilus influenzae type b disease in five young children—Minnesota, 2008. MMWR Morb Mortal Wkly Rep. 2009 Jan 30;58(3):58–60.
  3. CDC. Measles—United States, January 1–May 23, 2014. MMWR Morb Mortal Wkly Rep. 2014 Jun 6;63(22):496–9.
  4. CDC. Notes from the field: outbreak of pertussis in a school and religious community averse to health care and vaccinations—Columbia county, Florida, 2013. MMWR Morb Mortal Wkly Rep. 2014 Aug 1;63(30):655.
  5. Chen RT, Mootrey G, DeStefano F. Safety of routine childhood vaccinations. An epidemiological review. Paediatr Drugs. 2000 Jul–Aug;2(4):273–90.
  6. Muscat M, Shefer A, Ben Mamou M, Spataru R, Jankovic D, Deshevoy S, et al. The state of measles and rubella in the WHO European Region, 2013. Clin Microbiol Infect. 2014 May;20 Suppl 5:12–8.

Perspectives sections are written as editorial discussions aiming to add depth and clinical perspective to the official recommendations contained in the book. The views and opinions expressed in this section are those of the author and do not necessarily represent the official position of CDC.