Current Infectious Disease Reports

, Volume 1, Issue 5, pp 417–426

Vaccination in travelers

  • David R. Hill


Vaccination of populations throughout the world has led to dramatic decreases in morbidity and mortality from many infectious diseases, including poliomyelitis and measles. In the United States, for example, morbidity and mortality from invasive disease from Haemophilus influenzae type b has decreased more than 99%. International travelers should ensure that they are up-to-date on their routine immunizations and then consider vaccination against other diseases based on risk. This article reviews new vaccines such as those against rotavirus, Lyme disease, and enterotoxigenic Escherichia coli and provides updated information on the risk of typhoid fever and the efficacy of vaccination against it. The use of hepatitis A vaccine in outbreak control, the safety of yellow fever vaccine, and the importance of protecting travelers against rabies exposure are also discussed. Vaccination is an important way for travelers to maintain their health before, during, and after travel.


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References and Recommended Reading

  1. 1.
    Centers for Disease Control and Prevention: Impact of vaccines universally recommended for children—United States, 1990–1998. MMWR CDC Surveill Summ 1999, 48:243–248. This report documents the dramatic decrease in vaccine-preventable disease from before the vaccine era to 1998. Eradication of smallpox and wild-type polio and decreases of more than 95% in diphtheria, tetanus, pertussis, measles, mumps, rubella, and H. influenzae type b virus are some of the achievements.Google Scholar
  2. 2.
    Centers for Disease Control and Prevention: Recommended childhood immunization schedule—United States, 1999. MMWR CDC Surveill Summ 1999, 48:12–16.Google Scholar
  3. 3.
    Centers for Disease Control and Prevention: Progress toward global poliomyelitis eradication, 1997–1998. MMWR CDC Surveill Summ 1999, 48:416–421. This report details the accomplishments of the global effort to eradicate polio by the year 2000. Civil conflict in Africa and large reservoirs of infection in the Indian subcontinent, where over 50% of the world’s polio cases occur, present challenges to ultimate eradication.Google Scholar
  4. 4.
    Centers for Disease Control and Prevention: Recommendations of the Advisory Committee on Immunization Practices: revised recommendations for routine poliomyelitis vaccination. MMWR CDC Surveill Summ 1999, 48:590.Google Scholar
  5. 5.
    Centers for Disease Control and Prevention: Progress toward global measles control and regional elimination, 1990–1997. MMWR CDC Surveill Summ 1998, 47:1049–1054.Google Scholar
  6. 6.
    World Health Organization: Smallpox eradication: destruction of variola virus stocks. Wkly Epidemiol Rec 1999, 74:188–191. This is an interesting review of the postponed destruction of variola virus that was to take place in the United States and Russia. Destruction was originally planned for 1993, then 1995, and finally June 30, 1999, but has been delayed until 2002. Concern about loss of the virus for scientific study and fears that countries other than the United States and Russia hold the virus have led to this latest delay.Google Scholar
  7. 7.
    Centers for Disease Control and Prevention: Rotavirus vaccine for the prevention of rotavirus gastroenteritis among children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR CDC Surveill Summ 1999, 48 (No. RR-2):1–20. These statements from the ACIP are the expert opinion on the rotavirus vaccine and form the basis for its administration in the United States.Google Scholar
  8. 8.
    World Health Organization: Rotavirus vaccines: WHO position paper. Wkly Epidemiol Rec 1999, 74:33–38. The WHO has begun a series of position papers on vaccines that present the epidemiology of disease on a global basis, the status of vaccine development, and the role that vaccination will have in control of disease. Readers can access these series via the WHO’s web site ( Scholar
  9. 9.
    Cama RI, Parashar UD, Taylor DN, et al.: Enteropathogens and other factors associated with severe disease in children with acute watery diarrhea in Lima, Peru. J Infect Dis 1999, 179:1139–1144.PubMedCrossRefGoogle Scholar
  10. 10.
    Tucker AW, Haddix AC, Bresee JS, et al.: Cost-effectiveness analysis of a rotavirus immunization program for the United States. JAMA 1998, 279:1371–1376.PubMedCrossRefGoogle Scholar
  11. 11.
    Centers for Disease Control and Prevention: Intussusception among recipients of rotavirus vaccine—United States, 1998–1999. MMWR CDC Surveill Summ 1999, 48:577–581.Google Scholar
  12. 12.
    Centers for Disease Control and Prevention: In Health Information for International Travel, 1999–2000. Atlanta: US Department of Health and Human Services; 1999. This is the definitive resource for US health personnel in deciding about the prevention of illness in travelers. Newly updated, the publication provides information on vaccine safety, schedules, and indications; malaria and yellow fever epidemiology on a countryby-country basis; and a wealth of information on the prevention of other travel-related illness.Google Scholar
  13. 13.
    Engles EA, Falagas ME, Lau J, Bennish ML: Typhoid fever vaccines: a meta-analysis of studies on efficacy and toxicity. BMJ 1998, 316:110–115. This paper is the first effort in recent years to analyze the efficacy of the three typhoid fever vaccines—WC inactivated, oral attenuated, and Vi polysaccharide. Although vaccine efficacy appeared low (50%-70%), differences in patient populations, the eras of study, and the number of doses and schedule made direct comparisons difficult. Travelers should always exercise caution when eating and drinking in foreign countries, regardless of whether they have received vaccine.Google Scholar
  14. 14.
    Cryz SJ: Patient compliance in the use of Vivotif Berna vaccine, typhoid vaccine, live oral Ty21a. J Travel Med 1998, 5:14–17.PubMedCrossRefGoogle Scholar
  15. 15.
    Mermin JH, Townes JM, Gerber M, et al.: Typhoid fever in the United States, 1985–1994: changing risks of international travel and increasing antimicrobial resistance. Arch Intern Med 1998, 158:633–638. This is an update of typhoid fever in the United States, with particular emphasis on imported cases, which now account for 72% of US typhoid cases.PubMedCrossRefGoogle Scholar
  16. 16.
    Ryan CA, Hargrett-Bean NT, Blake PA: Salmonella typhi infections in the United States, 1975–1984: increasing role of foreign travel. Rev Infect Dis 1989, 11:1–8.PubMedGoogle Scholar
  17. 17.
    Rowe B, Ward LR, Threfall EJ: Multidrug-resistant Salmonella typhi: a worldwide epidemic. Clin Infect Dis 1997, 24(suppl 1):S106-S109.PubMedGoogle Scholar
  18. 18.
    Committee to Advise on Tropical Medicine and Travel (CATMAT): Statement on oral cholera vaccine. Can Commun Dis Rep 1998, 24:1–4.Google Scholar
  19. 19.
    Naficy A, Rao MR, Paquet C, et al.: Treatment and vaccination strategies to control cholera in sub-Saharan refugee settings: a cost-effectiveness analysis. JAMA 1998, 279:521–525. Although cholera does not present a risk to most travelers, cholera resulting from crowded and unsanitary conditions in refugee camps can be devastating and account for thousands of deaths within weeks. The analysis provided by these authors provides the basis on which to make life-saving decisions in the event of an outbreak of diarrheal illness. Vaccination against cholera is not as effective as having in place a rehydration therapy protocol.PubMedCrossRefGoogle Scholar
  20. 20.
    Murray J, McFarland DA, Waldman RJ: Cost-effectiveness of oral cholera vaccine in a stable refugee population at risk for epidemic cholera and in a population with endemic cholera. Bull WHO 1998, 76:343–352.PubMedGoogle Scholar
  21. 21.
    Waldman RJ: Cholera vaccination in refugee settings [editorial]. JAMA 1998, 279:552–553.PubMedCrossRefGoogle Scholar
  22. 22.
    Clemens JD, Sack DA, Harris JR, et al.: Cross-protection by B subunit-whole cell cholera vaccine against diarrhea associated with heat-labile toxin-producing enterotoxigenic Escherichia coli: results of a large-scale field trial. J Infect Dis 1988, 158:372–377.PubMedGoogle Scholar
  23. 23.
    Peltola H, Siitonen A, Kyrönseppä H, et al.: Prevention of travellers’ diarrhoea by oral B-subunit/whole-cell cholera vaccine. Lancet 1991, 338:1285–1289.PubMedCrossRefGoogle Scholar
  24. 24.
    Savarino SJ, Brown FM, Hall E, et al.: Safety and immunogenicity of an oral, killed enterotoxigenic Escherichia coli-cholera toxin B subunit vaccine in Egyptian adults. J Infect Dis 1998, 177:796–799.PubMedCrossRefGoogle Scholar
  25. 25.
    Savarino SJ, Hall ER, Bassily S, et al.: Oral, inactivated, whole cell enterotoxigenic Escherichia coli plus cholera toxin B subunit vaccine: results of the initial evaluation in children. J Infect Dis 1999, 179:107–114. This paper reports on the efforts to develop a vaccine against ETEC, the most common cause of traveler’s diarrhea and of childhood diarrhea in the developing world. This oral vaccine consists of killed E. coli organisms that express colonization antigens combined with rCTB. Although not an efficacy trial, this study examined immunogenicity in 2- to 12-year-old children and paved the way for studies in infants and then efficacy trials.PubMedCrossRefGoogle Scholar
  26. 26.
    World Health Organization: New frontiers in the development of vaccines against enterotoxinogenic (ETEC) and enterohaemorrhagic (EHEC) E. coli infections: Part 1. Wkly Epidemiol Rec 1999, 74:98–101. This is an excellent review of the status of vaccination against diarrheagenic E. coli.Google Scholar
  27. 27.
    Tacket CO, Mason HS, Losonsky G, et al.: Immunogenicity in humans of a recombinant bacterial antigen delivered in a transgenic potato. Nat Med 1998, 4:607–609.PubMedCrossRefGoogle Scholar
  28. 28.
    Werzberger A, Mensch B, Kuter B, et al.: A controlled trial of a formalin-inactivated hepatitis A vaccine in healthy children. N Engl J Med 1992, 327:453–457.PubMedCrossRefGoogle Scholar
  29. 29.
    Sagliocca L, Amoroso P, Stroffolini T, et al.: Efficacy of hepatitis A vaccine in prevention of secondary hepatitis A infection: a randomised trial. Lancet 1999, 353:1136–1139. In this study, the administration of hepatitis A vaccine to case contacts within 8 days of exposure helped to control infection, suggesting that travelers who receive vaccine just before departure will be protected.PubMedCrossRefGoogle Scholar
  30. 30.
    Robertson SE, Hull BP, Tomori O, et al.: Yellow fever: a decade of reemergence. JAMA 1996, 276:1157–1162.PubMedCrossRefGoogle Scholar
  31. 31.
    Van der Stuyft P, Gianella A, Pirard M, et al.: Urbanisation of yellow fever in Santa Cruz, Bolivia. Lancet 1999, 353:1558–1562. This study analyzes the introduction of yellow fever into an urban area of Brazil. Infestation of the city with the A. aegypti mosquito and low vaccination rates led to the outbreak. Ongoing public health efforts are needed to prevent this from happening in other areas of South America and Africa.PubMedCrossRefGoogle Scholar
  32. 32.
    McFarland JM, Baddour LM, Nelson JE, et al.: Imported yellow fever in a United States citizen. Clin Infect Dis 1997, 25:1143–1147.PubMedGoogle Scholar
  33. 33.
    Kelso JM, Mootrey GT, Tsai TF: Anaphylaxis from yellow fever vaccine. J Allergy Clin Immunol 1999, 103:698–701.PubMedCrossRefGoogle Scholar
  34. 34.
    Tsai TF, Kollaritsch H, Que JU, et al.: Compatible concurrent administration of yellow fever 17D vaccine with oral, live, attenuated cholera CVD 103-HgR and typhoid Ty21a vaccines [letter]. J Infect Dis 1999, 179:522–524.PubMedCrossRefGoogle Scholar
  35. 35.
    Nishioka SD, Nunes-Araujo FRF, Pires WP, et al.: Yellow fever vaccination during pregnancy and spontaneous abortion: a case-control study. Trop Med Int Health 1998, 3:29–33.CrossRefGoogle Scholar
  36. 36.
    Liu Z-L, Hennessy S, Strom BL, et al.: Short-term safety of live attenuated Japanese encephalitis vaccine (SA145-14-2): results of a randomized trial with 26,239 subjects. J Infect Dis 1997, 176:1366–1369.PubMedGoogle Scholar
  37. 37.
    World Health Organization: Japanese encephalitis vaccines: WHO position paper. Wkly Epidemiol Rec 1998, 73:337–344. This is an excellent summary of the epidemiology of Japanese encephalitis and the role of vaccination in controlling the infection. The paper also reviews the status of vaccines other than the mouse brain-derived vaccine (currently the only product available in the United States).Google Scholar
  38. 38.
    Franklin QJ: Sudden death after typhoid and Japanese encephalitis vaccination in a young male taking pseudoephedrine. Mil Med 1999, 164:157–159.PubMedGoogle Scholar
  39. 39.
    Steere AC, Sikand VK, Meurice F, et al.: Vaccination against Lyme disease with recombinant Borrelia burgdorferi outer-surface lipoprotein A with adjuvant. N Engl J Med 1998, 339:209–215. The development of a vaccine against Lyme disease is encouraging for prevention of this infection, which is common in the northeast and upper midwest United States. The vaccine uses recombinant OspA of Borrelia. It provides modest protection for individuals against clinical illness (49% efficacy in the first season and 76% in the second) and is even more effective against asymptomatic infection. However, the ultimate role will need to be decided because regular booster doses may be necessary.PubMedCrossRefGoogle Scholar
  40. 40.
    Sigal LH, Zahradnik JM, Lavin P, et al.: A vaccine consisting of recombinant Borrelia burgdorferi outer-surface protein A to prevent Lyme disease. N Engl J Med 1998, 339:216–222.PubMedCrossRefGoogle Scholar
  41. 41.
    Centers for Disease Control and Prevention: Recommendations for the use of Lyme disease vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR CDC Surveill Summ 1999, 48 (No. RR-7):1–25. This is an excellent, balanced statement on the use of vaccine for the prevention of Lyme disease.Google Scholar
  42. 42.
    Dumpis U, Crook D, Oksi J: Tickborne encephalitis. Clin Infect Dis 1999, 28:882–890. This is an excellent review of tick-borne encephalitis, an arthropodtransmitted viral infection. Although vaccination is not available in the United States, and a year is generally required for full immunization, the vaccine can be considered for long-term travelers and expatriates to endemic areas of central and eastern Europe and Russia.PubMedGoogle Scholar
  43. 43.
    Noah DL, Drenzek CL, Smith JS, et al.: Epidemiology of human rabies in the United States, 1980–1996. Ann Intern Med 1998, 128:922–930. This paper reviews the epidemiology and clinical presentations of human rabies since 1980.PubMedGoogle Scholar
  44. 44.
    Centers for Disease Control and Prevention: Human rabies prevention—United States, 1999: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR CDC Surveill Summ 1999, 48 (No. RR-1):1–21. This paper provides newly updated recommendations for pre- and postexposure prevention of rabies. Important changes include the availability of a third tissue culture vaccine (purified chick embryo cell), the use of serologic testing in deciding whether booster doses are needed, the importance of infiltrating bite wounds with the complete volume of RIG, and lowering the threshold of PET following exposure to a bat.Google Scholar
  45. 45.
    Kositprapa C, Wimalratna O, Chomchey P, et al.: Problems with rabies postexposure management: a survey of 499 public hospitals in Thailand. J Travel Med 1998, 5:30–32.PubMedCrossRefGoogle Scholar
  46. 46.
    Parviz S, Luby S, Wilde H: Postexposure treatment of rabies in Pakistan. Clin Infect Dis 1998, 27:751–756. This study highlights the difficulty in obtaining safe vaccines that are properly administered in the event of a potential rabid exposure.PubMedGoogle Scholar
  47. 47.
    Case records of the Massachusetts General Hospital: Case 21-1998. N Engl J Med 1998, 339:105–112. This is an excellent clinical summary of a case of rabies following a dog bite in Nepal.Google Scholar
  48. 48.
    Strady A, Lang J, Lienard M, et al.: Antibody persistence following preexposure regimens of cell-culture rabies vaccines: 10-year follow-up and proposal for a new booster policy. J Infect Dis 1998, 177:1290–1295.PubMedGoogle Scholar
  49. 49.
    Lodmell DL, Ray NB, Parnell MJ, et al.: DNA immunization protects nonhuman primates against rabies virus. Nat Med 1998, 4:949–952.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 1999

Authors and Affiliations

  • David R. Hill
    • 1
  1. 1.Division of Infectious DiseasesUniversity of Connecticut Health CenterFarmingtonUSA

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