Author(s): Michelle Weinberg

Vaccinating children for travel requires careful evaluation. Whenever possible, children should complete routine childhood immunizations on a normal schedule. Travel at an earlier age, however, might require accelerated vaccine schedules. Not all travel-related vaccines are effective in infants, and some are specifically contraindicated.

See recommended childhood and adolescent immunization schedules. The Centers for Disease Control and Prevention (CDC) provides a catch-up schedule for children and adolescents who start a vaccination schedule late or who are >1 month behind. Tables also describe the recommended minimum intervals between doses for children who need to be vaccinated on an accelerated schedule, which could 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 Umrah or the annual Hajj pilgrimage. The World Health Organization (WHO) has issued temporary vaccination recommendations for residents of and long-term visitors to countries with active circulation of wild or vaccine-derived poliovirus. Some countries might require coronavirus disease 2019 (COVID-19) vaccine, testing, or both for entry. Check the CDC Travelers’ Health website for current requirements and recommendations.

Additional information about diseases and routine vaccination is available in the disease-specific chapters in Section 5. See tools for determining routine and catch-up childhood vaccination.

Modifying Immunization Schedules for Infants & Young Children Before International Travel

Several factors influence recommendations for the age at which a vaccine is administered, including age-specific risks for the disease and its complications, age-dependent ability to develop an adequate immune response to a vaccine, and potential interference with the immune response by passively transferred maternal antibodies.

Immunization schedules for infants and children in the United States do not provide guidance on modifications for people traveling internationally before the age when specific vaccines are routinely recommended. Age limits for vaccine administration are based on the risk for potential adverse events (e.g., yellow fever vaccine), lack of efficacy data or inadequate immune response (e.g., influenza vaccine, polysaccharide vaccines), maternal antibody interference and immaturity of the immune system (e.g., measles-mumps-rubella [MMR] vaccine), or lack of safety data.

To help parents decide when to travel with an infant or young child, advise them that the earliest opportunity to receive routinely recommended immunizations in the United States (except for doses of hepatitis B vaccine at birth and age 1 month) is when the baby is 6 weeks old. In general, live-virus vaccines (MMR, varicella, yellow fever) should be administered on the same day or spaced ≥28 days apart.

Routine Infant & Childhood Vaccines

Children should be vaccinated against diphtheria, Haemophilus influenzae type b (Hib), hepatitis A and hepatitis B virus, human papillomavirus, influenza, measles, mumps, Neisseria meningitidis, pertussis, polio, rotavirus, rubella, Streptococcus pneumoniae, tetanus, and varicella. To complete a vaccine series before travel, doses can be administered at the minimum ages and dose intervals. Inform parents that infants and children who have not received all recommended vaccine doses might not be fully protected. Rotavirus vaccine is unique among the routine vaccines given to infants in the United States because it has maximum ages for both the first and last doses; specifically consider the timing of travel so that the infant will be able to receive the complete vaccine series, if possible.

Coronavirus Disease 2019

The COVID-19 pandemic continues to evolve, and CDC’s vaccination recommendations are updated regularly. See the most current recommendations for children and teens. COVID-19 vaccines available for use in the United States can be administered simultaneously with all other vaccines.

Hepatitis A

Hepatitis A infection is usually mild or asymptomatic in infants and children <5 years old. Infected children can, however, transmit the infection to older children and adults, age groups at greater risk for severe disease. Ensure vaccination for all children traveling to areas with an intermediate or high risk for hepatitis A (see Sec. 5, Part 2, Ch. 7, Hepatitis A). Routine hepatitis A vaccination for children aged ≥12 months consists of 2 doses, separated by ≥6 months. Ideally, the first dose should be administered ≥2 weeks before travel. When protection against hepatitis A is recommended, infants aged 6–11 months should receive 1 dose of hepatitis A vaccine before travel outside the United States.

Hepatitis A vaccine is considered safe and immunogenic in infants; doses administered before 12 months of age, however, can result in a suboptimal immune response, particularly in infants with passively acquired maternal antibody. Therefore, doses administered to infants <12 months old are not considered to provide long-term protection; initiate the 2-dose hepatitis A vaccine series at age 12 months according to the routine immunization schedule.

Hepatitis A Immune Globulin

When protection against hepatitis A is recommended, infants <6 months old should receive immune globulin (IG) before travel. One dose of 0.1 mL/kg intramuscularly provides protection for ≤1 month. Infants who do not receive vaccination who will be traveling for >1 month but ≤2 months should receive an IG dose of 0.2 mL/kg. If the traveler remains in a high-risk setting, IG (0.2 mL/kg) should be administered every 2 months until hepatitis A vaccine can be given at ≥6 months of age, if not contraindicated.

For optimal protection, children aged ≥1 year who are immunocompromised or who have chronic medical conditions, and who will be traveling to a high-risk area in <2 weeks, should receive the initial dose of hepatitis A vaccine and IG at separate anatomic injection sites.

Recommended Dosing Intervals for Coadministration of Live-Virus Vaccines

Hepatitis A IG is an antibody-containing product that does not interfere with the immune response to yellow fever vaccine but can inhibit the response to other injected live-virus vaccines (e.g., MMR, varicella) for up to 6 months after administration (see Sec. 2, Ch. 3, Vaccination & Immunoprophylaxis—General Principles).

MMR vaccine is recommended for all infants aged 6–11 months traveling internationally. Because measles in infancy is a more severe disease than hepatitis A, administer hepatitis A vaccine and MMR vaccine simultaneously to infants aged 6–11 months to provide protection against hepatitis A and measles, but do not give hepatitis A IG.

If the interval between MMR or varicella vaccine administration and subsequent administration of an antibody-containing product is <14 days, repeat vaccination after the recommended interval unless serologic testing indicates a protective antibody response. For information about dosing intervals, see The Timing and Spacing of Immunobiologics, General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices, Table 3-4) and Table 3-5.

Hepatitis B

For certain age groups, hepatitis B vaccine can be administered with an accelerated schedule of 4 doses of vaccine given at 0, 1, 2, and 12 months; the last dose can be given after the child returns from travel (see Sec. 5, Part 2, Ch. 8, Hepatitis B, for details).

Influenza

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 (see Sec. 5, Part 2, Ch. 12, Influenza). Because influenza viruses can circulate any time of the year, travelers aged ≥6 months who were not vaccinated during the influenza season in their country of residence should be vaccinated ≥2 weeks before departure if vaccine is available.

Children aged 6 months–8 years who have never received influenza vaccine, or who have not previously received a lifetime total of ≥2 doses, should receive 2 doses separated by ≥4 weeks. See annually updated recommendations about seasonal influenza vaccination.

Measles-Mumps-Rubella or Measles-Mumps-Rubella-Varicella

Children traveling abroad need to be vaccinated against measles, mumps, and rubella at an age earlier than what is routinely recommended. Infants 6–11 months old should receive 1 MMR vaccine dose. Infants vaccinated before age 12 months must be revaccinated on or after their first birthday with 2 doses of MMR vaccine (separated by ≥28 days) or measles-mumps-rubella-varicella (MMRV) vaccine (separated ≥3 months). The minimum interval between any varicella-containing vaccine (MMRV or monovalent varicella) is 3 months.

MMRV vaccine is licensed for use in children aged 12 months–12 years and should not be given outside this age group. Recipients of a first dose of MMRV vaccine have a greater risk for febrile seizures compared with recipients of MMR and varicella vaccines administered concomitantly. Unless the caregiver expresses a preference for MMRV, CDC recommends administering separate MMR and varicella vaccine for the first dose of MMR and varicella vaccination for children 12–47 months.

Meningococcal

Quadrivalent Conjugate

Children aged 2 months–18 years who travel to or reside in areas of sub-Saharan Africa known as the meningitis belt during the dry season (December–June) should receive quadrivalent meningococcal conjugate (MenACWY) vaccine (see Sec. 5, Part 1, Ch. 13, Meningococcal Disease). In addition, travelers are required to have meningococcal vaccination to enter Saudi Arabia when traveling to Mecca for Umrah or the annual Hajj pilgrimage. The CDC Travelers’ Health website provides annual health requirements and recommendations for US travelers going to Mecca for Umrah or Hajj (also see Sec. 10, Part 1, Ch. 2, Saudi Arabia: Hajj & Umrah Pilgrimages).

The schedule for primary series meningococcal vaccine and booster doses varies depending on the vaccine administered.

Meningococcal B

Unless an outbreak of serogroup B disease has been reported, vaccination with a serogroup B meningococcal (MenB) vaccine is not routinely recommended for travel to the meningitis belt or other regions of the world. Although MenB vaccine is not licensed in the United States for children <10 years of age, some European countries recently introduced MenB vaccine as a routine immunization for infants. Some countries might have other meningococcal vaccines available. Consider meningococcal vaccination for infants residing in these countries according to the routine infant immunization recommendations of that country.

Polio

Polio vaccine is recommended for travelers going to countries with evidence of wild poliovirus (WPV) or vaccine-derived poliovirus circulating during the last 12 months, and for travelers with a high risk for 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 current polio vaccine recommendations.

Ensure that travelers complete the recommended age-appropriate polio vaccine series and receive a single lifetime booster dose, if necessary. Infants and children should receive an accelerated schedule to complete the routine series. See Sec. 5, Part 2, Ch. 17, Poliomyelitis, and CDC’s Immunization Schedules website for information about accelerated schedules.

People ≥18 years of age 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. Requirements for long-term travelers might apply, however, when departing from certain countries.

Long-Term Travelers to Countries With Poliovirus Transmission

In May 2014, the World Health Organization (WHO) declared the international spread of polio to be a Public Health Emergency of International Concern 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.

Long-term travelers and residents could be required to show proof of polio vaccination when departing from these countries for any destination. All polio vaccination administration should be documented on an International Certificate of Vaccination or Prophylaxis (ICVP). See ordering information and instructions on how to fill out the ICVP. The polio vaccine must be received 4 weeks–12 months before the date of departure from the polio-infected country.

Country requirements can change, so clinicians should check for updates on the CDC Travelers’ Health website.

Travel Vaccines for Infants & Children

Dengue

Dengue can cause mild to severe illness (see Sec. 5, Part 2, Ch. 4, Dengue). Although many people have asymptomatic infections, for some children dengue can be life-threatening. Travelers should adhere to mosquito protection measures during travel to dengue-endemic areas (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).

In June 2021, the Advisory Committee on Immunization Practices (ACIP) recommended the use of a live attenuated dengue virus vaccine, Dengvaxia (Sanofi Pasteur), to prevent disease in children aged 9–16 years. Children eligible to receive the vaccine include those with laboratory-confirmed previous dengue virus infection who live in areas of the United States, including the US territories of American Samoa, Puerto Rico, and the US Virgin Islands; and freely associated states, the Federated States of Micronesia, the Republic of Marshall Islands, and the Republic of Palau. Dengvaxia is not approved for use in US travelers who are visiting but who do not live in areas where dengue is endemic.

Only people who test positive for previous dengue infection or who have other laboratory-confirmed evidence of a previous dengue infection are eligible for vaccination with Dengvaxia. In people without previous dengue infection, Dengvaxia can increase the risk for severe illness and hospitalization if the person gets infected after vaccination. Serodiagnostic tests recommended by health authorities with acceptable performance (≥75% sensitivity, ≥98% specificity) are available to test for evidence of previous dengue infection.

The vaccine is a series of 3 doses, administered 6 months apart at month 0, 6, and 12 months.

Japanese Encephalitis

Japanese encephalitis (JE) virus is transmitted by mosquitoes and is endemic throughout most of Asia and parts of the western Pacific. JE risk can be seasonal in temperate climates and year-round in more tropical climates. Risk to short-term travelers and those who confine their travel to urban centers is considered low. JE vaccine is recommended for travelers who plan to spend ≥1 month in endemic areas during JE virus transmission season. Consider JE vaccine for short-term (<1 month) travelers whose itinerary or activities could increase their risk for JE virus exposure. The decision to vaccinate a child should follow the more detailed recommendations found in Sec. 5, Part 2, Ch. 13, Japanese Encephalitis.

An inactivated Vero cell culture–derived JE vaccine (IXIARO) was licensed by the US Food and Drug Administration (FDA) 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 ≥2 months of age. For children aged 2 months–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 a booster dose before departure. See information on age-appropriate dosing.

Rabies

Rabies virus causes an acute viral encephalitis that is virtually 100% fatal. Traveling children can be at increased risk for rabies exposure, mainly from dogs that roam the streets in low- and middle- income countries. Bat bites carry a potential risk for rabies throughout the world. In addition to taking measures to avoid animal bites and scratches (see Sec. 4, Ch. 7, Zoonotic Exposures: Bites, Stings, Scratches & Other Hazards), preexposure and postexposure rabies prophylaxis is part of a broader approach to preventing this disease. Follow the recommendations in Sec. 5, Part 2, Ch. 18, Rabies, when making decisions about whether to provide rabies preexposure prophylaxis for children.

Preexposure Prophylaxis

In June 2021, to align with the recently revised adult schedule, ACIP adjusted the number of recommended doses of rabies preexposure prophylaxis in children downward, from 3 to 2. For immunocompetent children <18 years old, administer the first dose of vaccine on day 0 and a second dose 7 days later (see Sec. 5, Part 2, Ch. 19, . . . perspectives: Rabies Immunization).

The advantages of the revised schedule are that it is both less expensive and easier to complete prior to travel. There are, however, no data on the duration of protection afforded by this 2-dose series. Because of this uncertainty, travelers with a sustained risk for rabies exposure should either have a titer drawn or receive a third dose of vaccine within 3 years of the initial series. Travelers unlikely to visit an at-risk destination after 3 years require no further titers or boosters unless they have a subsequent exposure.

Postexposure Prophylaxis

Children who have not received preexposure immunization and who might have been exposed to rabies require a weight-based dose of human rabies immune globulin (RIG) and a series of 4 rabies vaccine doses on days 0, 3, 7, and 14. Decisions about any changes in how to manage postexposure prophylaxis, schedule deviations for pre- or postexposure prophylaxis, and postexposure prophylaxis initiated abroad are expected from the ACIP.

Tick-Borne Encephalitis

Tick-borne encephalitis (TBE) is a viral disease transmitted by Ixodes ticks in parts of Asia and Europe. Rare in US travelers, TBE is usually asymptomatic but can appear as a biphasic illness with central nervous system involvement (see Sec. 5, Part 2, Ch. 23, Tick-Borne Encephalitis). Although TBE infection tends to be less severe in children, residual symptoms and neurologic deficits have been described.

Most infections result from the bite of infected tick, typically acquired when a person is bicycling, camping, hiking, or participating in other outdoor activities in brushy or forested areas. TBE also can be acquired by ingesting unpasteurized dairy products from infected animals, or, rarely, from direct person-to-person spread via blood transfusion, solid organ transplantation, or breastfeeding.

In August 2021, the FDA approved a TBE vaccine for people aged ≥1 year; in February 2022, ACIP approved recommendations for vaccine use among people traveling or moving to a TBE-endemic area who will have extensive tick exposure based on planned outdoor activities and itinerary. Primary vaccination consists of 3 doses; the schedule varies by age. For children 1–15 years old, give the second dose 1–3 months after the first dose; for children aged ≥16 years, give the second dose 14 days–3 months after the first dose. All children should receive the third dose 5–12 months after receiving their second dose of the vaccine. A booster (fourth) dose can be given ≥3 years after completion of the primary immunization series if ongoing exposure or reexposure is expected.

Typhoid

Typhoid fever is caused by the bacterium Salmonella enterica serotype Typhi (see Sec. 5, Part 1, Ch. 24, Typhoid & Paratyphoid Fever). Travelers can avoid typhoid fever by following safe food and water precautions and frequently washing hands. Typhoid vaccine is recommended for travelers going to areas with a recognized risk for Salmonella Typhi exposure.

Two typhoid vaccines are licensed for use in the United States: 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 aged ≥2 years, who should receive a booster dose 2 years later if continued protection is needed. The Ty21a vaccine consists of a series of 4 capsules (1 taken orally every other day), which can be administered to children aged ≥6 years. Do not open capsules for administration; capsules must be swallowed whole. All 4 doses should be taken ≥1 week before potential exposure. A booster series for Ty21a should be taken every 5 years, if indicated.

Yellow Fever

Yellow fever, a disease transmitted by mosquitoes, is endemic to certain areas of Africa and South America (see Sec. 5, Part 2, Ch. 26, Yellow Fever). Proof of vaccination against yellow fever is required for entry into some countries (see Sec. 2, Ch. 5, Yellow Fever Vaccine & Malaria Prevention Information, by Country). Infants and children ≥9 months old and without contraindications should be vaccinated before traveling to countries where yellow fever is endemic.

Infants aged <9 months are at greater 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 who received 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.

Advise travelers with infants aged <9 months against traveling to areas where yellow fever is endemic. ACIP advises against administering yellow fever vaccine 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 can consult their respective state health departments or CDC toll-free at 800-CDC-INFO (800-232-4636).