Vaccines are important, especially when traveling internationally. Pharmacists should advise families to ensure that they are up-to-date on all routine US vaccines. The CDC’s Adult Vaccine Assessment Tool is a great way for patients to begin determining which immunizations they may need before traveling, as it provides a survey that includes medical history, potential travel outside the United States, and risk factors.1



VALUABLE RESOURCES
The CDC’s online Yellow Book helps determine which vaccines are recommended and required prior to international travel.2 It also includes the various diseases that the vaccines protect against. Pharmacists can choose the country that the patient is visiting through a drop-down menu, and the vaccine list with descriptions is generated. Travel health notices on the CDC website should always be consulted for the latest information on disease outbreaks to determine if supplementary vaccines are needed.3

PATIENT RECOMMENDATIONS
In general, patients should be vaccinated at least 1 month before travel, as the body needs adequate time to build up immunity, and some immunizations require multiple doses.4 It is especially important for patients to ensure that they are up-to-date on their measles, mumps, and rubella (MMR) vaccine, as most measles cases in the United States result from international travel.5 Many countries are experiencing measles outbreaks, including Israel, Japan, the Philippines, Thailand, Ukraine, and Vietnam.5 Patients should be vaccinated with the MMR at least 2 weeks before traveling. Infants under 12 months traveling internationally should receive a dose of the MMR at 6 to 11 months of age, another dose at 12 to 15 months of age, and a final dose at 4 to 6 years of age. Children older than 12 months who are traveling should get their first dose immediately, followed by a second dose 28 days later. Adults and teens with no evidence of immunity should receive their first dose immediately, followed by a second dose 28 days later. The CDC’s online tool can help determine whether patients are up-to-date on the MMR.5

With hepatitis A outbreaks on the rise, encourage patients to get the vaccine prior to travel. The recommendations have been updated to suggest that everyone 2 to 18 years of age should get vaccinated if they missed the recommended window at 12 to 23 months of age.6 The hepatitis A vaccine is given as 2 shots, 6 months apart.6

Yellow fever virus is spread by infected mosquitos and is typically found in subtropical and tropical areas of Africa and South America.7 Vaccination is recommended for individuals 9 months and older living in or traveling to at-risk areas, and proof of immunization may be required to enter certain countries.7 Patients should receive the vaccine at least 10 days prior to travel. There is a shortage of YF-Vax, which is manufactured by Sanofi Pasteur and is the only yellow fever vaccine licensed in the United States.7 Stamaril is an investigational new drug and yellow fever vaccine manufactured by Sanofi Pasteur in France that is provided to a limited number of US clinics.7 Help patients locate the vaccine through the CDC’s yellow fever vaccination clinic search page.7

With flu season in swing, individuals should get vaccinated at least 2 weeks prior to traveling to prevent influenza.

Typhoid fever is spread through contaminated food, and patients should receive the vaccine at least 1 to 2 weeks prior to travel.8 The oral vaccine series should be completed at least 1 week before travel, and a booster is needed every 5 years. The injection should be completed at least 2 weeks before travel, and a booster is recommended every 2 years.8

Recommendations for who should receive the Japanese encephalitis (JE) vaccine have recently been updated based on particular risk factors.9 The JE virus spreads through mosquito bites and is a seasonal risk throughout most of Asia and parts of the western Pacific.9 Patients moving to risk areas to live, longterm (1 month or longer) travelers to risk areas, and frequent travelers to risk areas should receive the JE vaccine.9 The JE vaccine can be considered for other patients, but it is not recommended for travelers with low-risk itineraries or for those who travel outside the JE transmission season.9

There is an FDA-approved single-dose oral cholera vaccine (Vaxchora) recommended for adults 18 to 64 years traveling to an area of active transmission.10 However, the vaccine is not routinely recommended, because most travelers do not visit affected areas.


REFERENCES
  1. CDC. The adult vaccine assessment tool. www2a.cdc.gov/nip/adultimmsched/. Updated February 5, 2019. Accessed November 9, 2019.
  2. CDC. CDC Yellow Book.  wwwnc.cdc.gov/travel/page/yellowbook-home/. Updated July 18, 2019. Accessed November 9, 2019.
  3. CDC. Travel health notices. wwwnc.cdc.gov/travel/notices.  Updated December 4, 2019. Accessed December 6, 2019.
  4. CDC. Get vaccinated before you travel.  cdc.gov/vaccines/parents/travel-vaccines.html. Updated August 1, 2019. Accessed November 9, 2019.
  5. CDC. Plan for travel. cdc.gov/measles/plan-for-travel.html. Updated June 18, 2019. Accessed December 6, 2019.
  6. Jenco M. ACIP approves recommendations on MenB, HepA, flu vaccines. American Academy of Pediatrics website. aappublications.org/news/2019/06/28/acip062819. Published June 28, 2019.  Accessed November 9, 2019.
  7. CDC. Clinical update announcement: temporary total depletion of US licensed yellow fever vaccine addressed by availability of Stamaril vaccine at selected clinics. https://wwwnc.cdc.gov/travel/news-announcements/yellow-fever-vaccine-access. Updated April 30, 2019. Accessed November 10, 2019.
  8. CDC. Typhoid fever and paratyphoid fever. cdc.gov/typhoid-fever/typhoid-vaccination.html. Updated January 3, 2019. Accessed November 10, 2019.
  9. Hills SL, Walter EB, Atmar RL, Fischer M, ACIP Japanese Encephalitis Vaccine Work Group. Japanese encephalitis vaccine: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2019;68(2):1-33.  doi: 10.15585/mmwr.rr6802a1.
  10. CDC. Clinical update cholera vaccine for travelers. wwwnc.cdc.gov/travel/news-announcements/cholera-vaccine-for-travelers. Updated October 23, 2019.  Accessed November 10, 2019.