Chapter 2The Pre-Travel Consultation

Perspectives: Vaccine Recommendations of the ACIP

Amanda Cantor, Jean Clare Smith

The Advisory Committee on Immunization Practices (ACIP) is a federal advisory committee, the purpose of which is to advise and provide guidance to the Secretary of the US Department of Health and Human Services (HHS), the Assistant Secretary for Health (the primary advisor to the Secretary), and the Director of CDC regarding the use of vaccines and related agents to control vaccine-preventable diseases in the civilian population. The committee meets 3 times annually and is made up of 15 members who are selected by the HHS Secretary. These members are considered to be authorities knowledgeable in immunization practices and public health, who have expertise in the use of vaccines and other immunobiologic agents in clinical practice or preventive medicine, have expertise with clinical or laboratory vaccine research, or have expertise in assessing vaccine efficacy and safety.

ACIP advises specifically for the control of diseases for which a vaccine is licensed in the United States. This guidance covers the appropriate use of the licensed vaccine, and can include recommendations for administration of immune globulin preparations or antimicrobial therapy shown to be effective in controlling the same disease. For each recommended vaccine, ACIP advises on population groups or circumstances in which a vaccine or related agent is recommended, and develops guidance on the route, dose, and frequency of administration of the vaccine, immune globulin, or antimicrobial agent. In addition, the committee provides recommendations on contraindications and precautions for use of the vaccine and related agents, as well as information on recognized adverse events. All deliberations on the appropriate use of vaccines include consideration of population-based studies, such as efficacy, cost-benefit, and risk-benefit analyses. As new information becomes available regarding a particular vaccine, or if the risk of disease changes, ACIP can alter or withdraw their recommendations. ACIP recommendations, provisional recommendations, and immunization schedules, along with additional useful information published in Morbidity and Mortality Weekly Report, are listed on the CDC website (www.cdc.gov/vaccines/recs/acip).

In exceptional circumstances, ACIP guidance for use of unlicensed vaccines may be developed. For example, in the late 1980s, the Japanese manufacturer Biken produced an inactivated mouse brain–derived Japanese encephalitis vaccine. The vaccine was not licensed in the United States, but after a US student died in Beijing from Japanese encephalitis, ACIP/CDC formulated recommendations for the use of the Biken vaccine to US travelers and to the military under an investigational new drug application. ACIP/CDC reacted in a flexible way to provide guidance for preventing a serious disease that could affect US citizens.

ACIP also establishes, reviews, and, as appropriate, revises the list of vaccines for administration to children and adolescents who are eligible to receive vaccines through the Vaccines for Children Program. The Vaccines for Children Program is an entitlement program with an annual budget of $3 billion that provides vaccines free of charge to underinsured, uninsured, Medicaid-eligible, and American Indian/Alaska Native children. It also provides schedules regarding the appropriate dose and dosing interval and contraindications to administration of the pediatric vaccines.

Although some of the vaccine recommendations include guidance pertaining to travelers, not all ACIP guidelines specifically address travel. These recommendations are meant to be for the use of vaccines to benefit public health in the most cost-effective manner possible. Many of the routine vaccinations that are considered in the pre-travel consultation do not relate to diseases that are unique to the country of destination, but are included to ensure that travelers are protected against routine vaccine-preventable diseases (such as tetanus or measles). Table 2-04 provides a list of the vaccines listed in the Yellow Book, and a short assessment of the guidance for travelers detailed by ACIP. Instances where ACIP recommendations differ from the prescribing information are indicated.

Other ACIP recommendations are provided for: General recommendations on immunizations
Immunization of health care personnel
Anthrax
Haemophilus influenzae type B
Hib and DTP
Vaccinia (smallpox)
Herpes zoster (shingles)

For more information regarding the ACIP and to access each ACIP vaccine recommendation, visit www.cdc.gov/vaccines/recs/acip/#recs. To access current prescribing information for FDA-licensed vaccines, visit www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm093830.htm.

Table 2-04. Vaccines described in the CDC Yellow Book and recommendations by ACIP

VACCINE IN THE YELLOW BOOK	BRIEF REVIEW OF TRAVEL ADVICE PROVIDED BY ACIP	DIFFERENCE BETWEEN ACIP GUIDANCE AND FDA LICENSE
Hepatitis A	People traveling to or working in intermediate- to high-endemicity areas	None
Hepatitis B	Not specific to travelers	FDA has not approved accelerated schedules in which hepatitis B vaccine is administered more than once in 1 month. If an accelerated schedule (such as doses at 0, 7, and 14 days) is used, the patient also should receive a booster dose ≥6 months after the start of the series to promote long-term immunity.
Human papillomavirus	Not specific to travelers	None
Influenza	Any traveler who wants to reduce the risk for influenza infection should consider influenza vaccination, preferably ≥2 weeks before departure. In particular, people at high risk for complications of influenza and who were not vaccinated with influenza vaccine during the preceding fall or winter should consider receiving influenza vaccine before travel if they plan to travel to the tropics, with organized tourist groups at any time of year, or to the Southern Hemisphere during April–September.	None
Japanese encephalitis	Japanese encephalitis vaccine is recommended for travelers who plan to spend ≥1 month in endemic areas during the JEV transmission season. This includes long-term travelers, recurrent travelers, or expatriates who will be based in urban areas but are likely to visit endemic rural or agricultural areas during a high-risk period of JEV transmission. Vaccination should be considered for: Short-term (<1 month) travelers to endemic areas during the JEV transmission season, if they plan to travel outside an urban area and have an increased risk for JEV exposure Travelers to an area with an ongoing JEV outbreak Travelers to endemic areas who are uncertain of specific destinations, activities, or duration of travel	None
Measles, mumps, and rubella	Protection against measles is especially important for people planning foreign travel, including adolescents and adults who have not had measles and have not been adequately vaccinated, and infants aged 6–11 months. Similarly, protection against rubella is especially important for women of childbearing age who are not immune to the disease. Children who travel or live abroad should be vaccinated at an earlier age than recommended for children remaining in the United States. Parents who travel or reside abroad with infants aged <12 months should have acceptable evidence of immunity to rubella and mumps, as well as measles.	None
Meningococcal	For travelers, vaccination is especially recommended for those visiting the parts of sub-Saharan Africa known as the “meningitis belt” during the dry season (December–June). Vaccination is required by the government of Saudi Arabia for all travelers to Mecca during the annual Hajj. Advisories for travelers to other countries are issued when epidemics of meningococcal disease, caused by vaccine-preventable serogroups, are detected.	The FDA has licensed the qaudrivalent meningococcal conjugate vaccine as a single dose for people 2–55 years (MenACWY-D) and (MenACWY-Crm). (Updated January 25, 2012)
Pertussis vaccine (acellular)	Not specific to travelers	None
Pneumococcal conjugate	Not specific to travelers	On February 24, 2010, a 13-valent pneumococcal conjugate vaccine (PCV13) was licensed by FDA to prevent invasive pneumococcal disease caused by the 13 pneumococcal serotypes covered by the vaccine, and to prevent otitis media caused by serotypes in the 7-valent pneumococcal conjugate vaccine formulation. PCV13 is licensed for use among children aged 6 weeks– 71 months, and succeeds PCV7, which was licensed by FDA in 2000.
Pneumococcal polysaccharide 23-valent	Not specific to travelers	None
Polio	IPV is recommended for travelers to areas or countries where polio is epidemic or endemic.	None
Rabies	Not specific to travelers	None
Rotavirus	Not specific to travelers	None
Tdap vaccine	Not specific to travelers	None
Typhoid	Travelers to areas in which there is a risk of exposure to S. Typhi. Risk is highest for travelers to developing countries who have prolonged exposure to potentially contaminated food and drink.	None
Varicella (chickenpox)	Adults who might be at increased risk for exposure or transmission and who do not have evidence of immunity should receive special consideration for vaccination, which includes international travelers.	None
Yellow fever	People aged ≥9 months who are traveling to or living in areas at risk for YF virus transmission in South America and Africa. In addition, some countries require proof of YF vaccination for entry.	The manufacturer and FDA state that vaccination of infants aged <9 months is contraindicated because of the risk for encephalitis. ACIP considers ages 6–8 months to be a precaution for YF vaccination. Whenever possible, travel by children ages 6–8 months to YF-endemic countries should be postponed or avoided. If travel is unavoidable, vaccination decisions for these infants need to balance the risk of YF virus exposure with the risk for adverse events following vaccination. (The administration of YF vaccine to infants <6 months is contraindicated by both FDA and ACIP guidelines.)

Abbreviations: ACIP, Advisory Committee on Immunization Practices; FDA, Food and Drug Administration; IPV, inactivated polio vaccine; JEV, Japanese encephalitis virus; OPV, oral polio vaccine; Tdap, tetanus and diphtheria toxoids and acellular pertussis vaccine; YF yellow fever.

BIBLIOGRAPHY

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CDC. ACIP Recommendations: Advisory Committee on Immunization Practices (ACIP). Atlanta: CDC; 2010 [updated Nov 3; cited 2010 Sep 16]. Available from: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm.
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