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Many vaccine-preventable diseases remain prevalent in developing countries, and outbreaks still occur in areas where these diseases are considered rare. The schedule for some vaccines may be accelerated for travel, and some vaccines can be given earlier than the recommended age. Vaccination pertaining to children traveling follows the routine vaccination schedule as outlined in Chapter 10. The recommended intervals balance the high-risk age for disease with infant immunologic responses. The recommended minimum interval between doses is listed in Table 45–3. Barriers to some early immunizations are antibody from the mother interfering with an infant’s ability to mount an antibody response, particularly to live vaccines, and the lack of a T-cell–dependent immune response to certain immunogens in those younger than 2 years. Minor febrile illnesses are not a contraindication to routine or travel vaccines and should not lead to their postponement. Live vaccines should be given together or separated by 30 days or more.
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Diphtheria-Tetanus-Acellular Pertussis Vaccine
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Immunization is recommended prior to travel to developing countries because of the greater risk of disease from diphtheria, tetanus, and pertussis. Tetanus risk is high in several areas of the developing world where fecal contamination of soil is extensive. Infants should receive their first diphtheria-tetanus-acellular pertussis (DTaP) at 6 weeks of age for an adequate immune response, with a 4-week interval between the subsequent two doses. Adequate protection is achieved after the third dose. The fourth dose may be given 6–12 months after the third dose provided that the child is 12 months of age or older. Tdap is licensed for children at least 11 years of age. Adolescents and adult caretakers, who are prominent vectors in the spread of pertussis to young children, should receive a single Tdap booster. If more than 5 years have elapsed since the last dose, a booster should be considered for children and adolescents to minimize tetanus risk. Tdap is preferred to Td in children older than 11 years if they have not received Tdap previously.
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Haemophilus influenzae Type b Vaccine
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The indications for vaccination of Haemophilus influenzae type b (Hib) in children traveling are the same as for the US residents. If previously unvaccinated, infants younger than 15 months should receive at least two doses prior to travel. An accelerated schedule can start at a minimum of 6 weeks of age, with a 4-week interval between the first, second, and third doses, and at least 8 weeks between third and fourth doses.
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Hepatitis A is one of the most common vaccine-preventable illnesses globally, and vaccination should be provided prior to travel to developing countries. Hepatitis A is much less common in the developed world, so children from these areas are likely to be susceptible when traveling to high-risk areas. Although two doses of the vaccine are recommended 6–12 months apart, a single dose will provide protection during the trip if given at least 2 weeks prior to departure. The earliest age of administration is 1 year in the United States. If travel will occur within 2 weeks of travel consultation, immune globulin (IG) (0.1 mL/kg IM) can be given simultaneously with hepatitis A vaccine, or for protection of children younger than 1 year traveling for up to 1 month or 0.2 mL/kg if traveling up to 2 months. Additional doses can be given every 2 months (0.2 mL/kg) for ongoing travel in a high-risk setting until 1 year of age, after which time vaccination should be encouraged. IG interferes with measles-mumps-rubella (MMR) and varicella vaccination, so these vaccines should be given 2 weeks prior to immunoglobulin.
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Areas of high endemicity for hepatitis B include most of Asia, the Middle East, Africa, and the Amazon Basin. Unimmunized children are at risk if they receive blood transfusions that have not been screened for HBV surface antigen (HBsAg) or are exposed to unsterilized medical or dental equipment. Children traveling to developing countries should be vaccinated before departure. An accelerated schedule is possible, with the second dose given with a minimum 4-week interval and the third dose given at least 8 weeks after the second dose. The third dose should not be given before 24 weeks of age.
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Children are at high risk of respiratory infection during travel. The influenza vaccine is recommended for travel during the influenza season, which is between September and March in the Northern Hemisphere, and between April and August in the Southern Hemisphere, and year round in the tropics. The vaccine available in the United States may not protect against new strains circulating in the Southern Hemisphere. Influenza vaccine is recommended for children at least 6 months of age; those younger than 9 years will need two doses of vaccine administered at least 4 weeks apart if they have received zero or one dose in prior seasons. The current vaccines are the trivalent or quadrivalent inactivated vaccine (IIV) given intramuscularly and the quadrivalent live attenuated vaccine (LAIV) given intranasally. It is preferable to be vaccinated at least 2 weeks prior to departure. The annual seasonal influenza vaccine may not be routinely available in the United States from the late spring to early fall, when it may be needed for travelers but may be available at some travel clinics. Revaccination is not recommended for those who will be traveling during April through September and were vaccinated the preceding fall.
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Measles-Mumps-Rubella Vaccine
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Measles remains endemic in many parts of the world, including Europe, Africa, and Asia, and outbreaks continue to occur worldwide. Susceptible travelers represent an important cause of outbreaks imported into the United States. Children as young as 6 months traveling outside the United States are recommended to receive the vaccine at least 2 weeks before departure, but any doses given prior to 12 months do not count toward an adequate two-dose series, as maternal antibodies may interfere with the immune response. These infants will still require one dose of measles-mumps-rubella (MMR) at 12–15 months of age and a second dose at 4–6 years of age. The second dose aims to protect those individuals (~ 5%) who did not respond the first time. If an accelerated schedule is required, two doses must be separated by a minimum of 4 weeks.
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Meningococcal Vaccine
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The highest risk for meningococcal disease is for travelers to the meningitis belt of Africa, (sub-Saharan region) especially during the dry season, and travelers on the Hajj or Umrah pilgrimage to Mecca. Notably, meningococcal disease is decreasing in this region due to vaccination against type A. Vaccination is recommended for those who live or travel to these areas with high rates of meningitis for children 2 months of age and older. The vaccine must be given at least 10 days before international travel. For children younger than 9 months, MenACWY-CRM should be used, and for those 9 months of age and older, either MenACWY or MenACWY-D can be used. Vaccination commencing at 2–6 months of age requires a four-dose series; children aged 7–23 months require a two-dose series at least 8 weeks apart, and those 2–55 years of age require one dose. The duration of protection is 3 years in children and 5 years in adults, and boosters are indicated for ongoing exposure and at-risk hosts.
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Hib-MenCY-TT is approved for vaccination of children aged 6 weeks to 9 months. A combined Hib and Neisseria meningitidis serogroup C conjugate vaccine is licensed for infants younger than 6 weeks. These two vaccines should not be used for children traveling to the meningitis belt or the Hajj, as serogroup A is the predominant organism in these regions.
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A previously vaccinated infant reaching the age of 9 months and traveling to endemic areas should be revaccinated with MCV4. MPSV4 should be used for persons older than 56 years. Meningococcal vaccination is required by the Saudi Arabian government for pilgrims undertaking the Hajj or Umrah pilgrimage to Mecca and Medina, because of pilgrimage-related international outbreaks of N meningitidis A in 1987 and W-135 in 2000 and 2001. Further information concerning geographic areas recommended for meningococcal vaccination can be obtained from http://www.cdc.gov/travel.
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The indications for vaccination against Streptococcus pneumoniae in children traveling are the same as for routine vaccination. The 13-valent pneumococcal conjugate vaccine (PCV 13) is recommended for children aged 5 years or younger. For children aged 5 years or younger who have completed the PCV 7 series, a single additional dose of PCV 13 is recommended. The minimal interval is 4 weeks between the first three doses and 8 weeks between the third and fourth doses. In addition, the pneumococcal polysaccharide (PPSV23) is recommended for children and adults aged 2 years or older who have certain underlying medical conditions and for all adults aged 65 years or older.
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Transmission of wild-type polio still occurs in regions of Asia and Africa, and endemic transmission continues in Afghanistan and Pakistan; vaccine-derived polio is transmitted in other regions. Adequate immunization with inactivated polio vaccine (IPV) should be completed prior to travel to developing countries. The minimum age of administration is 6 weeks of age for IPV. The recommended interval between each dose is 4 weeks. One additional lifetime dose (a fifth dose) of the IPV should be given to caretakers who are traveling to areas with recent circulating polio.
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Rotavirus is the most common cause of severe gastroenteritis in infants and young children worldwide, and vaccination with the complete series is recommended prior to travel if age-appropriate. The minimum and maximum age for the first dose is 4 weeks and 14 weeks, 6 days, respectively. There are insufficient data on the safety of older infants. The minimum interval between doses is 4 weeks.
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