Why Aren't International Travelers Vaccinated for Measles?
Authors: Lori K. Handy, Paul A. Offit
Journal: Annals of Internal Medicine (2017)

Editorials18 July 2017Why Aren't International Travelers Vaccinated for Measles?FREELori K. Handy, MD, MSCE and Paul A. Offit, MDLori K. Handy, MD, MSCEFrom Thomas Jefferson University and University of Pennsylvania, Philadelphia, Pennsylvania.Search for more papers by this author and Paul A. Offit, MDFrom Thomas Jefferson University and University of Pennsylvania, Philadelphia, Pennsylvania.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M17-1044 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Before a vaccine against measles was introduced, 500 000 cases occurred each year in the United States, resulting in 500 deaths, 48 000 hospitalizations, and 1000 cases of permanent brain damage from encephalitis (1). Endemic measles was eliminated from the United States in 2000 (2), but sporadic outbreaks have occurred since then because of importation of the virus from other countries. These cases occur in travelers as well as their contacts in the United States, many of whom are unvaccinated themselves (3). In 2014, the United States had the largest single outbreak of measles (667 cases) in more than 20 years because of infected travelers returning from abroad combined with the low vaccination rate of certain U.S. populations (4). This outbreak was linked to travel to the Philippines, which was in the midst of a measles epidemic. In 2015, a multistate outbreak associated with Disneyland likely was the result of a park visitor who had traveled overseas; 188 cases were reported that year (5). Importations remain the source of measles transmission in the United States, and persons visiting travel clinics present an opportunity to reduce or eliminate these cases.The measles, mumps, rubella (MMR) vaccine is recommended for all persons traveling internationally (6). Although efforts to increase MMR immunization rates are focused mainly on young children, an often-overlooked population is unvaccinated travelers at risk for transmitting measles within the United States after returning home. To prevent endemic measles from recurring in the United States, we must be vigilant about ensuring that travelers do not bring the virus back from overseas.In their current Annals article, Hyle and colleagues (7) report that fewer than half the adults eligible for MMR vaccine at a pretravel clinic visit were vaccinated. The authors conducted a retrospective study of pretravel consultations with Global TravEpiNet, a nationwide network of travel clinics associated with a Centers for Disease Control and Prevention–funded consortium. Of 40 810 adults who visited the clinics, 6612 (16%) were considered eligible for MMR vaccine; however, only 47% of those eligible received a vaccination during the consultation. Reasons for individuals not being vaccinated were patient refusal (48%), provider decision (28%), and health system barriers (24%).Although these results may not be representative of all travelers, individuals who visit travel clinics presumably are highly motivated to seek protection from infectious diseases while abroad. Therefore, it is surprising that the MMR vaccination rates at these visits were not higher. Vaccine eligibility in this study population was based on self-reported disease and immunization history, which is less strict than the criteria of the Advisory Committee on Immunization Practices. Although these more lenient standards may have influenced one's perception of whether vaccination was needed—or not—previous studies estimated that measles seroprevalence is greater than 75%—and likely closer to 90%—in agreement with the authors' findings (8). Many departing U.S. travelers attend travel clinics or visit their own physician to take appropriate precautions before leaving the country. Conversely, many others are not motivated to visit a travel clinic or are logistically unable to do so; travelers overall may have even lower immunization rates.Because these data are from surveys, information is incomplete regarding the reason for traveler refusal, the drivers of provider decisions, and the measures taken to encourage vaccination. The study included sites at both academic and nonacademic institutions in various regions of the country. Variability by clinic is one factor that may be addressed to try to standardize care among clinics. Travelers did have the opportunity to report why they refused the MMR vaccine, and most stated they did so because they were “not concerned about illness.” Exotic infections, such as malaria and yellow fever, preoccupy travelers; measles should be just as feared, and vaccination should be strongly encouraged. Because of the low incidence of measles in the United States, few persons understand the severity of the disease for themselves, the contagiousness of the virus, or the implications for society at large on their return. Providers must play a role in helping travelers understand the seriousness of this infection.All unvaccinated travelers who are medically able to receive MMR vaccine should do so. The risks are minimal for the individual who receives the vaccine and are greatly outweighed by the benefit to the traveler, as well as to society, on his or her return (9). Furthermore, travel clinics present an additional contact with the health care system, through which adults and children may receive recommendations regarding all vaccinations, not only those recommended for travel. If persons traveling abroad continue to underestimate the importance of pretravel MMR vaccination, our society is destined to be affected by imported cases of measles, leading to morbidity and mortality from this disease.References1. Bloch AB, Orenstein WA, Stetler HC, Wassilak SG, Amler RW, Bart KJ, et al. Health impact of measles vaccination in the United States. Pediatrics. 1985;76:524-32. [PMID: 3931045] MedlineGoogle Scholar2. Katz SL, Hinman AR. Summary and conclusions: measles elimination meeting, 16-17 March 2000. J Infect Dis. 2004;189 Suppl 1:S43-7. [PMID: 15106088] MedlineGoogle Scholar3. Centers for Disease Control and Prevention (CDC). Measles imported by returning U.S. travelers aged 6-23 months, 2001-2011. MMWR Morb Mortal Wkly Rep. 2011;60:397-400. [PMID: 21471945] MedlineGoogle Scholar4. Gastañaduy PA, Budd J, Fisher N, Redd SB, Fletcher J, Miller J, et al. A measles outbreak in an underimmunized Amish community in Ohio. N Engl J Med. 2016;375:1343-54. [PMID: 27705270] doi:10.1056/NEJMoa1602295 CrossrefMedlineGoogle Scholar5. Centers for Disease Control and Prevention. Measles Cases and Outbreaks. Accessed at www.cdc.gov/measles/cases-outbreaks.html on 1 May 2017. Google Scholar6. McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS; Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62:1-34. [PMID: 23760231] MedlineGoogle Scholar7. Hyle EP, Rao SR, Jentes ES, Parker A, Hagmann SHF, Taylor A, et al. Missed opportunities for measles, mumps, rubella vaccination among departing U.S. adult travelers receiving pretravel health consultations. Ann Intern Med. 2017;167:77-84. doi:10.7326/M16-2249 LinkGoogle Scholar8. Rosario-Rosario G, Gareca M, Kincaid H, Knouse MC. Using locally derived seroprevalence data on measles, mumps, rubella, and varicella by birth cohort to determine risks for vaccine-preventable diseases during international travel. J Travel Med. 2015;22:396-402. [PMID: 26412393] doi:10.1111/jtm.12235 CrossrefMedlineGoogle Scholar9. Sukumaran L, McNeil MM, Moro PL, Lewis PW, Winiecki SK, Shimabukuro TT. Adverse events following measles, mumps, and rubella vaccine in adults reported to the Vaccine Adverse Event Reporting System (VAERS), 2003-2013. Clin Infect Dis. 2015;60:e58-65. [PMID: 25637587] doi:10.1093/cid/civ061 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Vinu ArumughamIndependent Researcher6 June 2019 Sweeping safety claims are based on a flimsy piece of evidence Drs. Handy and Offit claim: "The risks are minimal for the individual who receives the vaccine and are greatly outweighed by the benefit to the traveler, as well as to society, on his or her return." They cite Sukumaran et al. to support the claim. Sukumaran et al. reviewed VAERS for reports of adverse events in adults following MMR administration over a 10 year period. Passive surveillance systems such as VAERS are widely known to underreport. A major safety concern with the MMR vaccine is type 1 diabetes (T1D) as I explain in my comment here:https://annals.org/aim/fullarticle/2626466/missed-opportunities-measles-mumps-rubella-vaccination-among-departing-u-sCorrelation of type 1 diabetes trends in European countries to the number of bovine insulin and GAD65 contaminated chick embryo cell culture containing vaccines in the schedule, as predicted by the autoimmunity mechanism involving immunization with homologous xenogeneic antigens and EPIT as a potential treatmenthttps://doi.org/10.5281/zenodo.1870364T1D can take years or even decades to manifest following MMR vaccine administration. The chance of such events being reported to VAERS are practically zero.Therefore Drs. Handy and Offit should refrain from making such sweeping safety claims based on such a flimsy piece of evidence. Author, Article, and Disclosure InformationAffiliations: From Thomas Jefferson University and University of Pennsylvania, Philadelphia, Pennsylvania.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1044.Corresponding Author: Lori K. Handy, MD, MSCE, Children's Hospital of Philadelphia, Abramson Research Building, Room 1202, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104; e-mail, [email protected]chop.edu.Current Author Addresses: Drs. Handy and Offit: Children's Hospital of Philadelphia, Abramson Research Building, Room 1202, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104.This article was published at Annals.org on 16 May 2017. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoMissed Opportunities for Measles, Mumps, Rubella Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health Consultations Emily P. Hyle , Sowmya R. Rao , Emily S. Jentes , Amy Parker Fiebelkorn , Stefan H.F. Hagmann , Allison Taylor Walker , Rochelle P. Walensky , Edward T. Ryan , and Regina C. LaRocque Metrics Cited byMeasles Hospitalizations at a United States Children’s Hospital 2011–2017 18 July 2017Volume 167, Issue 2Page: 127-128KeywordsChildrenMMR vaccineMalariaMeaslesMorbidityMortalityPerceptionPopulation statisticsRetrospective studiesVaccines ePublished: 16 May 2017 Issue Published: 18 July 2017 Copyright & PermissionsCopyright © 2017 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...