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CDC Health Information for International Travel 2008

Chapter 8
International Travel with Infants and Young Children

Vaccine Recommendations for Infants and Children

For all children, decisions regarding vaccinations should be made in cooperation with a health-care provider who will review the traveler’s medical history and itinerary. Each traveler should be up to date with their routine childhood vaccinations because many of the diseases prevented by these vaccines are rare or non-existent in the United States but are still common in other parts of the world (1) The recommended childhood and adolescent immunization schedules are depicted in Tables 8-2 and 8-3. Table 8-4 depicts the catch-up schedule for children and adolescents who start their vaccination schedule late or who are more than 1 month behind. This table also describes the recommended minimal intervals between doses for children who need to be vaccinated on an accelerated schedule, which is sometimes required for international travel. Proof of yellow fever vaccination is required for entry into certain countries (see Chapter 5). Recommendations for other vaccines and immunobiologics depend on the traveler’s medical history and itinerary and do not alter the schedule for recommended childhood immunizations.

Modifying the Immunization Schedule for Inadequately Immunized Infants and Younger Children Before International Travel

Several factors influence recommendations for the age at which a vaccine is administered, including age-specific risks of the disease and its complications, the ability of people of a given age to develop an adequate immune response to the vaccine, and potential interference with the immune response by passively transferred maternal antibody. Vaccines are recommended for the youngest age group at risk for developing the disease whose members are known to develop an adequate antibody response to vaccination.

The routine immunization recommendations and schedules for infants and children in the United States do not provide specific guidelines for those traveling internationally before the age when specific vaccines and toxoids are routinely recommended. When deciding when to travel with a young infant or child, parents should be advised that the earliest opportunity to receive routinely recommended immunizations in the United States (except for the dose of hepatitis B vaccine at birth) is at 6 weeks of age. Because additional vaccinations may be recommended for international travel, parents should also be aware of the youngest age at which these vaccinations can be administered. The following section provides guidance for active and passive immunization of such infants and children. Additional information about all the diseases and vaccines mentioned below can be found in Chapters 1 and 4.

ROUTINE INFANT AND CHILDHOOD VACCINATIONS

Hepatitis B Vaccine

Hepatitis B virus (HBV) is a cause of acute and chronic hepatitis, cirrhosis, and hepatocellular carcinoma. There are more than 200 million chronically infected persons worldwide; the risk of chronic infection is highest when infection occurs in infancy or childhood and declines with age (2). Infants and children who have not previously been vaccinated and who are traveling to areas with intermediate and high HBV endemicity are at risk if they are directly exposed to blood (or body fluids containing blood) from the local population. Circumstances in which HBV transmission could occur in children include receipt of blood transfusions not screened for HBV surface antigen (HBsAg), exposure to unsterilized medical or dental equipment, or continuous close contact with local residents who have open skin lesions (impetigo, scabies, or scratched insect bites).

Hepatitis B vaccine is recommended for all infants in the United States, with the first dose administered soon after birth and before hospital discharge (3). Infants and children who will travel should receive the three doses of HBV vaccine before traveling. The interval between doses one and two should be at least 4 weeks. Between doses two and three, the interval should be a minimum of 8 weeks; the interval between doses one and three should be at least 16 weeks. The third dose should not be given before the infant is at least 24 weeks of age. Adolescents not previously vaccinated with hepatitis B vaccine should be vaccinated at 11-12 years of age. For adolescents, the usual schedule is two doses separated by at least 4 weeks, followed by a third dose 4-6 months after the second dose.

Diphtheria and Tetanus Toxoid and Pertussis Vaccine

Diphtheria, tetanus, and pertussis each occur worldwide and are endemic in countries with low immunization levels. Infants and children leaving the United States should be immunized before traveling. Optimum protection against diphtheria, tetanus, and pertussis is achieved with at least three but preferably four doses of diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP). The usual primary series includes four doses given at 2, 4, 6, and 15-18 months of age (2). A fifth (booster) dose is recommended when the child is 4-6 years of age. The fifth dose is not necessary if the fourth dose in the primary series was given after the child’s fourth birthday.

For infants and children younger than 7 years of age, if an accelerated schedule is required to complete the series before travel, the schedule may be started as soon as the infant is 6 weeks of age, with the second and third doses given 4 weeks after each preceding dose. The fourth dose should not be given before the infant is 12 months of age and should be separated from the third dose by at least 6 months. The fifth (booster) dose should not be given before the child is 4 years of age. Two doses of DTaP received at intervals at least 4 weeks apart can provide some protection; however, a single dose offers little protective benefit. Parents should be informed that infants and children who have not received at least three doses of DTaP might not be fully protected against pertussis.

Haemophilus influenzae Type b Conjugate Vaccine

Haemophilus influenzae type b (Hib) is an endemic disease worldwide that can cause fatal meningitis, epiglottitis, and other invasive diseases. Infants and children should have optimal protection before traveling. Routine Hib vaccination beginning at 2 months of age is recommended for all U.S. children (2). The first dose may be given when an infant is as young as 6 weeks of age. Vaccination before age 6 weeks may induce immune tolerance to subsequent vaccines and should never be done. A primary series consists of two or three doses (depending on the type of vaccine used) with a minimum interval of 4 weeks between doses. A booster dose is recommended when the infant is at least 12 months of age, at least 8 weeks after the previous dose.

If Hib vaccination is started when the infant or child is 7 months of age or older, fewer doses are required. If different brands of vaccine are administered, a total of three doses of Hib conjugate vaccine completes the primary series. After completion of the primary infant vaccination series, any of the licensed Hib conjugate vaccines may be used for the booster dose when the infant is 12-15 months of age.

If previously unvaccinated, infants younger than 15 months of age should receive at least two vaccine doses before travel. An interval as short as 4 weeks between these two doses is acceptable. Unvaccinated infants and children 15-59 months of age should receive a single dose of Hib vaccine. Children older than 59 months of age, adolescents, and adults do not need to be vaccinated unless a specific condition exists such as functional or anatomic asplenia, immunodeficiency, immunosuppression, or HIV infection.

Polio Vaccine

While polio has been eliminated in the US, poliovirus continues to circulate in parts of Africa and Asia, including South Asia. In the US, all infants and children should receive four doses of inactivated poliovirus vaccine (IPV) at 2, 4, 6-18 months, and 4-6 years of age. If accelerated protection is needed, the minimum interval between doses is 4 weeks. The minimum age for the fourth dose is 18 weeks. Infants and children who had initiated the poliovirus vaccination series with one or more doses of oral poliovirus vaccine (OPV) should receive IPV to complete the series. Proof of vaccination is required to enter Saudi Arabia for the Hajj.

Rotavirus Vaccine

Rotavirus is the most common cause of severe gastroenteritis in infants and young children worldwide. In developing countries rotavirus gastroenteritis is responsible for approximately 500,000 deaths per year among children younger than 5 years. Routine rotavirus vaccination beginning at about 2 months of age is recommended for all U.S. children (5). The first dose of the series must be administered between 6 and 12 weeks of age. The vaccination series should not be initiated for children 13 weeks of age or older because of a lack of safety data when the series is begun after 12 weeks of age. Two additional doses are recommended at 4 and 6 months of age. A minimum interval of 4 weeks between doses can be used if an accelerated schedule is needed. All three doses of the series should be administered no later than 32 weeks of age (about 71⁄2 months). Rotavirus vaccine should not be administered to infants older than 32 weeks of age even if the 3-dose series has not been completed.

Measles, Mumps, and Rubella Vaccine

Measles is an endemic disease in areas where measles immunization levels are low, and outbreaks occur even in developed countries. International travelers are at increased risk for measles exposure. Infants and children should be as well protected as possible against measles and should complete the immunization series before traveling. While the risk for serious disease in infants from either mumps or rubella is low, these diseases do circulate in many parts of the world and vaccination is recommended.

In addition to the measles, mumps, and rubella vaccine (MMR), monovalent measles, monovalent mumps, monovalent rubella, and combinations of the components are available from the manufacturer. A combined measles, mumps, rubella, and varicella vaccine (MMRV) was also licensed by the U.S. Food and Drug Administration in 2005 for children age 12 months-12 years (6). The Advisory Committee on Immunization Practices (ACIP) recommends that MMR be administered when any of the individual components is indicated as part of the routine immunization schedule (MMRV can be used if varicella vaccine is also indicated). Two doses of MMR are routinely recommended for all children, usually at age 12 months and again at age 4-6 years. The second dose can be given as soon as 28 days after the first dose. If MMRV is used, note that two varicella-containing vaccines should be separated by at least 3 months.

Before travel outside the U.S., children 12 months of age and older should receive two doses of MMR separated by at least 28 days. Children age 6-11 months, if they must travel outside the U.S., should receive monovalent measles vaccine before departure if it is available, or MMR if monovalent measles vaccine is not available. However, MMR given before age 12 months should not be counted as part of the series. Children who receive MMR before age 12 months will need two more doses of MMR, the first of which should be administered at 12 months of age.

Varicella Vaccine

Varicella (chickenpox) is an endemic disease throughout the world. Two doses of varicella vaccine are recommended for all susceptible children 12 months of age and older. The first dose is recommended at age 12-15 months. The second dose is routinely recommended at age 4-6 years but can be given earlier, provided that at least 3 months have passed since the first dose.

Efforts should be made to ensure varicella immunity before age 13 years, because varicella disease can be more severe among older children and adults. Children 13 years of age and older should receive two doses of varicella vaccine 4-8 weeks apart (7).

Vaccination is not necessary for children with health care provider-diagnosed chickenpox. When a prior history of chickenpox is uncertain, the vaccine should be given.

Meningococcal Vaccine

Meningococcal disease (including meningococcal meningitis) is caused by the bacterium Neisseria meningitidis and has high morbidity and mortality rates. Epidemics occur in sub-Saharan Africa during the dry season (December through June) (See Map 4-10), and CDC recommends travelers be vaccinated before traveling to this region. Meningococcal vaccination is a requirement to enter Saudi Arabia when traveling to Mecca during the annual Hajj

Two vaccines are available in the U.S. that protect against four serogroups of N. meningitidis (A, C, Y, and W-135): the meningococcal conjugate vaccine (MCV4) and the meningococcal polysaccharide vaccine (MPSV4). MCV4 is approved for use in persons 2-55 years of age and is recommended by the ACIP for routine vaccination of adolescents at 11-18 years of age (8, 14, 15). MCV4 is also recommended for persons 2-55 years of age who travel to or reside in areas where N. meningitidis is hyperendemic or epidemic. MPSV4 can be used when MCV4 is not available. The serogroup A polysaccharide in MPSV4 induces an antibody response in some children as young as 3 months. Thus, vaccinating infants traveling to high-risk areas can provide some degree of protection. For children vaccinated at younger than 4 years of age, revaccination in 2-3 years should be considered if they remain at high risk for infection. For children vaccinated at 4 years of age and older, revaccination should be considered in 5 years if they remain at high risk. (Section Updated February 15, 2008)

Pneumococcal Vaccine

Streptococcus pneumoniae causes substantial morbidity and mortality throughout the world each year. The vaccine is available in two forms: the pneumococcal conjugate vaccine (PCV7) and the pneumococcal polysaccharide vaccine (PPV23).

All infants should be vaccinated with PCV7 (9). Infant vaccination provides the earliest protection, and infants younger than 23 months of age have the highest incidence of pneumococcal disease. The primary series for PCV7 includes three doses given at 2, 4, and 6 months of age with a fourth (booster) dose at 12-15 months of age. Children 24 months of age and older who are at high risk for pneumococcal disease (e.g., those with sickle cell disease, asplenia, HIV, chronic illness, or immunocompromising conditions) should receive a dose of PPV23 at least 2 months following their last dose of PCV7. If the child is 10 years of age or younger, one revaccination with PPV23 should be considered 3-5 years after the first dose of PPV 23.

Unvaccinated children 7-11 months of age should receive two doses of PCV7 at least 4 weeks apart and a booster dose at age 12-15 months. Unvaccinated children 12-23 months of age should receive two doses at least 8 weeks apart. Vaccination with a single dose of PCV7 should be considered for previously unvaccinated healthy children 24-59 months of age. Previously unvaccinated children 24-59 months of age at high risk for pneumococcal disease (as previously described) should receive two doses separated by at least 8 weeks. Children 24-59 months of age who are at increased risk for pneumococcal disease and who were previously vaccinated with PPV23 should receive two doses of PCV7 separated by at least 8 weeks. The PCV7 vaccine is not routinely recommended for children older than 59 months (5 years) of age.

Influenza Vaccine

Influenza vaccine can reduce the risk of influenza infection in transmission sea-son (typically November-February in the Northern Hemisphere, April-September in the Southern Hemisphere, and throughout the year in the tropics). The vaccine is prepared in two forms: an intramuscular trivalent inactivated vaccine (TIV) and a live, attenuated, intranasal vaccine (LAIV).

All children 6-59 months of age should receive TIV annually, as should all children at risk for complicated influenza infection due to chronic medical conditions (10), including but not limited to asthma, cardiac disease, sickle cell disease, HIV, and diabetes. In addition, all persons who have close contact with healthy children younger than 59 months of age (particularly infants younger than 6 months of age) or with persons at increased risk of influenza complications should be vaccinated annually. For healthy children 5 years of age and older, LAIV is an acceptable alternative to TIV. (LAIV can be given to healthy persons 5-49 years of age.)

Children receiving TIV should be administered an age-appropriate dose (0.25 mL for those 6-35 months of age and 0.5 mL for those 36 months of age and older). Children 8 years of age and younger who are receiving influenza vaccine for the first time should receive two doses (separated by at least 4 weeks for TIV and 6-10 weeks for LAIV). Children 9 years of age and older should receive one injection of the 0.5-mL dose.

Hepatitis A Vaccine or Immune Globulin for Hepatitis A

Hepatitis A virus (HAV) is endemic in most parts of the world, and infants and children traveling to these areas are at increased risk for acquiring HAV infection. Although HAV is often not severe in infants and children younger than 5 years of age, those infected efficiently transmit infection to older children and adults, who are at higher risk of severe disease.

Hepatitis A vaccine is recommended for all children at age 1 year (i.e., 12-23 months) (11). Vaccination should be ensured for all susceptible children traveling to areas where there is an intermediate or high risk of HAV infection. The HAV vaccine series consists of two doses at least 6 months apart. The first dose should be administered 4 weeks before travel to allow time for an adequate immune response to develop. The second dose is necessary for long-term protection.

The vaccine is not approved for children younger than 1 year of age. Children less than 1 year of age who are traveling to high-risk areas should receive immune globulin (IG) (see Chapter 4). For optimal protection, IG may also be given to children older than 1 year who will be traveling less than 4 weeks after receipt of the first dose of hepatitis A vaccine. The vaccine and IG can be administered at the same time at different anatomic sites.

IG does not interfere with the response to yellow fever vaccine but can interfere with the response to other live injected vaccines (e.g., measles, mumps, rubella (MMR), and varicella vaccines). Administration of MMR should be delayed for at least 3 months and varicella for more than 5 months after administration of IG. Moreover, IG should not be administered for 2 weeks after measles-, mumps-, and rubella-containing vaccines and for 3 weeks after vaccination with varicella vaccine. If IG is given during this time, the child should be revaccinated with the live vaccine at least 3 months after administration of IG. When travel plans do not allow adequate time for administration of live vaccines and IG before travel, the severity of the diseases and epidemiology of the diseases at destination points will help determine the most appropriate course of preparation.

OTHER VACCINES

Yellow Fever Vaccine

Yellow fever, a disease transmitted by mosquitoes, is endemic in certain areas of Africa and South America (Maps 4-15 and 4-16). Proof of yellow fever vaccination is required for entry into some countries (see Chapter 5).

Infants are at high risk for developing encephalitis from yellow fever vaccine, a live virus vaccine. Vaccination of infants should be considered on an individual basis. Although the incidence of these adverse events has not been clearly defined, 14 of 18 reported cases of post-vaccination encephalitis were in infants younger than 4 months old. One fatal case confirmed by viral isolation was in a 3-year-old child.

Travelers with infants younger than 9 months of age should be strongly advised against traveling to areas within the yellow fever-endemic zone. The ACIP recommends that yellow fever vaccine never be given to infants younger than 6 months of age (12). Infants 6-8 months of age should be vaccinated only if they must travel to areas of ongoing epidemic yellow fever and a high level of protection against mosquito bites is not possible. Infants and children older than 9 months of age can be vaccinated if they travel to countries within the yellow fever-endemic zone. Physicians considering vaccinating infants younger than 9 months of age should contact the Division of Vector-Borne Infectious Diseases (970-221-6400) or the Division of Global Migration and Quarantine (404-498-1600) at CDC for advice.

Typhoid Vaccine

Typhoid fever is an acute, life-threatening febrile illness caused by the bacterium Salmonella enterica Typhi. Vaccination is recommended for travelers to areas where there is a recognized risk of exposure to S ser. Typhi.

Two typhoid vaccines are available: a Vi capsular polysaccharide vaccine (ViCPS) administered intramuscularly and an oral, live, attenuated vaccine (Ty21a). Both vaccines induce a protective response in 50%-80% of recipients. The ViCPS vaccine can be administered to children who are at least 2 years of age, with a booster dose 2 years later if continued protection is needed. The Ty21a vaccine, which consists of a series of four capsules ingested every other day, can be administered to children 6 years of age and older. All the capsules should be taken at least 1 week before potential exposure. A booster series for Ty21a should be taken every 5 years if indicated.

Because neither vaccine is fully protective, preventing contamination of food and beverages remains extremely important.

Japanese Encephalitis Vaccine

Japanese encephalitis (JE) is transmitted by primarily night-biting mosquitoes in rural areas of Asia and the Pacific Rim. In temperate climates, their numbers are greatest from June through September; they are inactive during the winter. Most reported cases occur in children. Although most infections are asymptomatic, when encephalitis occurs, the mortality rate can be as high as 30%; neurologic sequelae occur in 50% of survivors and are more common in the very young. The risk to short-term travelers and those who confine their travel to urban centers is very low. Expatriates and travelers living for prolonged periods in rural areas where JE is endemic or epidemic are at greatest risk. The decision to vaccinate a child should take into consideration the itinerary, expected activities, and level of JE activity in the country (see Chapter 4).

JE vaccine is administered as a series of three injections on days 0, 7, and 30. A booster dose is administered at least 24 months later. Children 1-2 years of age receive 0.5 mL of vaccine per dose; those 3 years of age and older receive 1.0 mL of vaccine per dose. No data are available on vaccine efficacy for infants younger than 1 year of age.

JE vaccine is associated with local reactions in approximately 20% of vaccinees and mild systemic reactions (e.g., fever, headache, myalgias, and rash) in approximately 10% (13). Serious allergic reactions, including generalized urticaria and angioedema of the extremities, face, and oropharynx have been reported in up to 0.6% of vaccinees, with accompanying respiratory distress or hypotension in a small number of these cases. Importantly, these hypersensitivity reactions can be delayed for 1 to 2 weeks after receipt of the vaccine. Children receiving the vaccine series should be observed for 30 minutes after immunization. Moreover, the series should be completed at least 10 days before departure, and during that time, vaccine recipients should be remain in areas with access to medical care.

Rabies Vaccine

Rabies is an acute, fatal encephalomyelitis usually transmitted by the bite of an infected mammal. Rabies occurs throughout the world and is endemic in most countries. As with other vaccines, the decision to vaccinate will depend on the itinerary and expected activities during international travel. The decision should also be guided by the availability of appropriate antirabies biologics at the destination (see Chapter 4). Children should always be instructed to report all bites and to avoid contact with animals other than their own pets.

Two rabies vaccines are licensed for use in the United States. Each may be administered to infants and children. All the rabies vaccines, when used in a preexposure regimen, are given as a series of injections on days 0, 7, and 21 or 28. Even if a child has completed the preexposure vaccine series, any mammal bite warrants immediate medical evaluation to determine the need for postexposure immunization.

References

 

  1. Mackell SM. Vaccinations for the pediatric traveler. Clin Infect Dis. 2003;37:1508-16.
  2. Epidemiology and prevention of vaccine-preventable diseases. Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. 9th ed. Washington, DC: Public Health Foundation, 2006.
  3. Mast EE, Margolis HS, Fiore AE, Brink EW, Goldstein ST, Wang SA, et al.; Advisory Committee on Immunization Practices (ACIP). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. MMWR Recomm Rep. 2005;54(RR-16):1-31.
  4. Broder KR, Cortese MM, Iskander JK, Kretsinger K, Slade BA, Brown KH, et al.; Advisory Committee on Immunization Practices (ACIP). Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-3):1-34.
  5. Parashar UD, Alexander JP, Glass RI; Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC). Prevention of rotavirus gastroenteritis among infants and children. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-12):1-13.
  6. Centers for Disease Control and Prevention. Licensure of a combined live attenuated measles, mumps, rubella, and varicella vaccine. MMWR Morbid Mortal Wkly Rep. 2005;54:1212-14.
  7. Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the advisory committee on immunization practices (ACIP). MMWR Morbid Mortal Wkly Rep. 1996; 45(RR11):1-25.
  8. Bilukha OO, Rosenstein N; National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC). Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54(RR-7):1-21.
  9. Centers for Disease Control and Prevention. Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep. 2000;49(No. RR-9):1-35.
  10. Advisory Committee on Immunization Practices (ACIP); Smith NM, Bresee JS, Shay DK, Uyeki TM, Cox NJ, Strikas RA. Prevention and Control of Influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-10):1-42.
  11. Advisory Committee on Immunization Practices (ACIP); Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-7):1-23.
  12. Advisory Committee on Immunization Practices (ACIP); Cetron MS, Marfin AA, Julian KG, Gubler DJ, Sharp DJ, Barwick RS, et al. Yellow fever vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2002. MMWR Recomm Rep. 2002;51(RR-17):1-11.
  13. Plesner AM. Allergic reactions to Japanese encephalitis vaccine. Immunol Allergy Clin North Am. 2003;23:665-97.
  14. CDC. Notice to Readers: Recommendation from the Advisory Committee on Immunization Practices (ACIP) for Use of Quadrivalent Meningococcal Conjugate Vaccine (MCV4) in Children Aged 2-10 Years at Increased Risk for Invasive Meningococcal Disease. MMWR 2007;56(48):1265-1266.
  15. CDC. Notice to Readers: Revised Recommendations of the Advisory Committee on Immunization Practices to Vaccinate All Persons Aged 11-18 Years with Meningococcal Conjugate Vaccine. MMWR 2007;56(31):794-795.
HENRY BAGGETT

 

TABLE 8-2. Recommended Immunization Schedule for Ages 0 to 6 Years-United States, 2008

Table 8-2
(Table Updated February 15, 2008)

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TABLE 8-3. Recommended Immunization Schedule for Ages 7 to 18 Years-United States, 2008

Table 8-3
(Table Updated February 15, 2008)

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TABLE 8-4. Recommended Childhood Immunization Schedule — United States, 2008. Children and Adolescents Who Start Late or Who Are More Than 1 Month Behind

Table 8-4
(Table Updated February 15, 2008)

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  • Page last updated: February 15, 2008
  • Content source:
    Division of Global Migration and Quarantine
    National Center for Preparedness, Detection, and Control of Infectious Diseases
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