Technically Speaking: Vaccinations in Preparation for Travel — Test Yourself!

As summer 2022 arrives, many people are excited for a return to international travel, especially since the CDC recently lifted the COVID-19 testing requirement for entry into the U.S. If a patient (or family member) announced their intention to travel abroad, would you be ready to advise them about vaccination? Outside of infectious disease or travel medicine specialists, few of us are well versed in the details of vaccinations needed for travel. The topic of vaccination for travel is broad because it often is destination- and activity-specific, and it can change based on outbreaks or situations occurring during the period of travel. For this reason, it is often useful to work with (or send patients to) local public health officials or formal travel clinics (See resources later in this article). However, it is important for all providers to be aware of certain key concepts, so let’s test your knowledge.

Question 1: Which of the following are TRUE?

(Choose all of the true statements.)

1. The CDC’s Pink Book is published every two years as a resource for health professionals providing care to international travelers.
2. Travel health notices inform travelers and clinicians about current health issues that impact travelers’ health (e.g., outbreaks and natural disasters) around the world.
3. Most internal medicine offices can give the yellow fever vaccine.
4. The CDC maintains a website that lists COVID-19 travel information, travel health notices, and necessary vaccines and medicines by country.
5. The Pre-Travel Providers’ Rapid Evaluation Portal (Pre-Travel PREP) is a free clinical tool for preparing U.S. travelers for a safe and healthy international trip.

Answer — True statements include B, D, and E:

1. False. While the CDC’s Pink Book is a wonderful resource regarding routine vaccinations, the CDC’s Yellow Book focuses on care for international travelers.
2. True. Travel health notices include:
   1. Warnings (Level 3 — Avoid nonessential travel)
   2. Alerts (Level 2 — Practice enhanced precautions)
   3. Watches (Level 1 — Practice usual precautions)
   For example, “Monkeypox in Multiple Countries” was listed as an alert as of June 7, 2022.
3. False. Only an authorized yellow fever vaccine clinic can give the yellow fever vaccine. Certified providers can be identified using the “Search for Yellow Fever Vaccination Clinics” webpage.
4. True. The CDC maintains an extensive travel website that includes COVID-19 travel information, travel health notices, and health-related considerations and vaccinations based on a traveler’s destination country. It also offers a “Disease Directory” and a “Frequently Asked Questions” section.
5. True. The Pre-Travel PREP webpage is interactive. After a clinician submits (deidentified) details, such as the traveler’s age, destination and medical conditions, they receive situation- and (deidentified) patient-specific recommendations.

“Take Action” Challenge: Try this sample patient using the Pre-Travel PREP (or dream a little and put in your bucket list trip!):

You are a primary care physician in a hospital-based clinic in Philadelphia (zip code 19104). The patient is a 20-year-old female with psoriasis who is traveling from Philadelphia to Malawi, which is in southeastern Africa. She is going for a study abroad semester.

If you ran this sample, you likely found the following recommendations:

• If the patient thinks she has protection based on a previous hepatitis A exposure, that should be confirmed by serology. It’s just as safe, and usually more efficient, to give the hepatitis A vaccine if it is unclear whether the patient was previously vaccinated.
• Yellow fever (YF) vaccine is not required for entry to Malawi. However, this vaccine would be required if she were traveling from a country with risk of YF virus transmission, such as if she has a layover of more than 12 hours in an airport located in a country with risk of YF virus transmission.
• The patient should receive either of the two typhoid vaccines available in the U.S.
• Dengue vaccine would not be needed. ACIP recommends dengue vaccine for residents of, but not visitors to, areas with endemic dengue.
• Rabies vaccine should be considered under special circumstances, but usually rabies disease can be avoided by not touching animals, including dogs, monkeys and bats.

Refer to the Malawi destination page on the CDC’s travel website to see more details about considerations and recommendations for this patient. In addition to vaccination recommendations, this page includes information related to water-related concerns, bug bites, airborne and droplet considerations, and additional information and advice for before, during and after travel.

Question 2: Let’s get specific about ACIP recommendations for travel vaccines in the last few years. Which of the following are TRUE?

(Choose all of the true statements.)

1. Eight hours should separate the oral cholera vaccine and the first dose of oral typhoid vaccine, Ty21a.
2. For pre-exposure prophylaxis to prevent rabies infection, ACIP now recommends a two-dose (days 0 and 7) intramuscular rabies vaccination series instead of a the three-dose schedule (days 0, 7, and 21 or 28).
3. Pre-exposure vaccination with Ebola vaccine is now also recommended for U.S. adults 18 years of age and older who are at high risk for potential occupational exposure to Ebola virus.
4. Healthy persons between 12 months and 40 years of age who are planning travel to an area with high or intermediate hepatitis A endemicity and who have not received hepatitis A vaccine should receive a single dose of this vaccine as soon as travel is considered and should complete the series with the appropriate dose and schedule as recommended.
5. Although influenza vaccine should be considered for travelers, most Southern Hemisphere influenza vaccine formulations are not licensed in the U.S., and they generally are not commercially available. 

Answer — True statements include A, B, C, D, and E:

1. True. For more details go to Immunize.org’s “Ask the Experts” section and refer to the “Travel Vaccines” questions.
2. True. This change was published in the May 6, 2022, issue of Morbidity & Mortality Weekly Report (MMWR).
3. True. This updated guidance was published in the Feb. 25, 2022, issue of MMWR.
4. True. This update was published in the July 3, 2020, issue of MMWR.
5. True. This guidance was published in the August 27, 2021, issue of MMWR.

Of course, the elephant in the room is COVID-19. The recommendations continue to evolve rapidly. For the latest information on U.S. travel recommendations regarding COVID-19, check the CDC’s updated information.

Bon voyage!

Travel vaccine resources

The Vaccine Education Center has several resources related to travel:

• Check the travel subheading on the “Vaccine Considerations for Specific Groups” webpage.
• Download “Infectious Diseases and Travel” (PDF).
• Install “Vaccines on the Go,” the VEC’s free mobile app for information on travel vaccines. Check out the “Special Populations” section and refer to travel or search for a specific vaccine or disease in the “Vaccines” section of the app. Available for Android or Apple devices.
• Find out more about travel vaccines on these dedicated webpages:
  • Cholera
  • Japanese Encephalitis Virus (JEV)
  • Rabies
  • Typhoid
  • Yellow Fever

Immunize.org posts all CDC Vaccine information Statements and many translations, including those for travel vaccines. You can also find ACIP recommendations in order of publication.

The Vaccine Handbook App, available at no charge for iOS and Android devices, includes chapters on each travel vaccine.

The Pediatric Infectious Disease Society’s “Comprehensive Vaccine Education Program” has an interactive module on travel vaccines that includes memorable graphics and helpful explainer videos.