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Chapter 7 Family Travel

Vaccine Recommendations for Infants & Children

Michelle S. Weinberg

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/hcp/imz/child-adolescent.html. The catch-up schedule for children and adolescents who start their vaccination schedule late or who are >1 month behind can be accessed at www.cdc.gov/vaccines/schedules/hcp/imz/catchup.html. These tables also describe 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, 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 and Umrah pilgrimages. The World Health Organization issued temporary vaccination recommendations for residents of and long-term visitors to countries with active circulation of wild or vaccine-derived poliovirus. 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 4. 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 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 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 and immaturity of the immune system (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 and age 1 month) is at age 6 weeks. In general, live-virus vaccines (MMR, varicella, yellow fever) should be administered on the same day or spaced ≥28 days apart.

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 ages and dose 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 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 did not receive at least 2 doses of influenza vaccine before July 1 of the fall influenza season should receive 2 doses separated by at least 4 weeks. Check the CDC website annually for updated recommendations about seasonal influenza vaccination.
  • MMR or MMRV vaccine: Children traveling abroad need to be vaccinated at an earlier age than is routinely recommended. Infants aged 6–11 months should receive 1 MMR dose. Infants vaccinated before age 12 months must be revaccinated on or after the first birthday with 2 doses of MMR or MMRV separated by ≥28 days. Children aged ≥12 months should be given 2 MMR or MMRV doses separated by ≥28 days.
  • Meningococcal vaccine: Children aged 2 months to 18 years who travel to or reside in areas of sub-Saharan Africa known as the “meningitis belt” (see Map 4-10) during the dry season (December through June) should receive quadrivalent meningococcal conjugate (MenACWY) vaccine.

    Meningococcal vaccination is a requirement to enter Saudi Arabia when traveling to Mecca during the annual Hajj or Umrah pilgrimages. Health requirements and recommendations for US travelers to the Hajj or Umrah are available each year on the CDC Travelers’ Health website (www.cdc.gov/travel).

    The schedule for the primary series and booster doses varies depending on which meningococcal vaccine is administered (see CDC’s Immunization Schedules website at www.cdc.gov/vaccines/schedules for additional information).

    Vaccination with a serogroup B meningococcal (MenB) vaccine is not routinely recommended for travel to the meningitis belt or other regions of the world unless an outbreak of serogroup B disease has been reported. Although MenB vaccine is not licensed in the United States for children <10 years of age, some European countries have recently introduced MenB vaccine as a routine immunization for infants. Infants who will be residing in these countries may consider MenB vaccination according to the routine infant immunization recommendations of that country.
  • Polio vaccine: Polio vaccine is recommended for travelers to countries with evidence of wild poliovirus (WPV) or vaccine-derived poliovirus 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. Infants and children should receive an accelerated schedule to complete the routine series. See Chapter 4, Poliomyelitis, and CDC’s Immunization Schedules website (www.cdc.gov/vaccines/schedules) for information about accelerated schedules.

    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”) or with circulating vaccine-derived polioviruses types 1 or 3. 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 for a list of affected countries, guidance on meeting the vaccination requirements, and instructions on how to order and fill out the ICVP.

     

Other Vaccines

JAPANESE ENCEPHALITIS

Japanese encephalitis (JE) virus is transmitted by mosquitoes and is endemic throughout most of Asia and parts of the western Pacific. 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 4, 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.

For children aged 2 months through 17 years, the primary series consists of 2 intramuscular doses administered 28 days apart. For travelers who received their primary JE vaccine series ≥1 year prior to potential JE virus exposure, ACIP recommends providing them with a booster dose before departure. Information on age-appropriate dosing is available at www.cdc.gov/japaneseencephalitis/vaccine/vaccineChildren.html.

RABIES

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 that 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.
  • Use of preexposure and postexposure prophylaxis. A 3-dose preexposure immunization series may be given 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 4, Rabies. Children who have not received preexposure immunization and may have been exposed to rabies require a weight-based dose of human rabies immune globulin and a series of 4 rabies vaccine doses on days 0, 3, 7, and 14.
TYPHOID

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 and must be swallowed whole. All 4 doses should be taken ≥1 week before potential exposure.

YELLOW FEVER

Yellow fever, a disease transmitted by mosquitoes, is endemic in certain areas of Africa and South America (see Maps 4-13 and 4-14). Proof of yellow fever vaccination is required for entry into some countries (see Chapter 2, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country). Infants and children aged ≥9 months can be vaccinated if they travel to countries within the yellow fever–endemic zone. In February 2015, the CDC Advisory Committee on Immunization Practices (ACIP) approved a new recommendation that a single dose of yellow fever vaccine provides long-lasting protection and is adequate for most travelers. The updated recommendations also identify specific groups of travelers who should receive additional doses and others for whom additional doses may be considered. More information, including how to access yellow fever vaccine in the United States, is available in Chapter 4, 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 wwwn.cdc.gov/dcs/ContactUs/Form.

BIBLIOGRAPHY

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