Chapter 2The Pre-Travel Consultation

Paul Offit

Pre-travel counseling visits often provide the opportunity to update routine vaccinations for both children and adults. Thus, one of the first topics covered in such sessions is whether the traveler is immune to diseases such as measles and varicella. Unfortunately, in some circumstances, providers may be surprised to find out that the travelers have no interest in being vaccinated or in having their children vaccinated, whether for measles or other potentially life-threatening, travel-related infections, such as yellow fever.

Although vaccines geared for international travelers may not have implications for community health, such as providing herd immunity, they can protect individuals against severe and occasionally fatal illness. For these vaccines, the discussion between clinicians and patients is by nature one of weighing risks and benefits of administering travel-related vaccines for the particular destination. Travelers are often at a higher risk of exposure to diseases for which routine vaccines provide protection, even when traveling to countries in Europe. During this discussion, the travel health provider should seize the opportunity to educate all travelers, and especially parents, about the use of those vaccines. Those providing travel health advice should familiarize themselves with the literature on vaccine safety of both routine and travel-related vaccines, so they can appropriately address any concerns that their clients may have.

The history of the development of vaccination complacency and perhaps, following that, vaccination avoidance is a curious one. During the 1940s, parents in the United States did not hesitate to get the diphtheria, tetanus, and pertussis vaccines; they knew that diphtheria and pertussis were common killers of young children, and they had watched tetanus claim the lives of soldiers in World Wars I and II. During the 1950s, the polio vaccine was a godsend; everyone knew what poliovirus could do. During the 1960s, parents gladly accepted the measles, mumps, and rubella vaccines. They knew that measles caused thousands of hospitalizations and hundreds of deaths every year, mostly from pneumonia; that mumps was a common cause of deafness and a rare cause of sterility; and that rubella caused thousands of children to suffer severe birth defects of the eyes, ears, and heart.

The widespread use of vaccines caused a dramatic decrease—and in some cases a virtual elimination—of several diseases. Parents, no longer compelled by the diseases around them, became complacent. Immunization rates plateaued. Now, the United Sates (as well as many European countries) finds itself in a situation where vaccine safety issues, real or imagined, are a primary concern. Parents confront a flood of misinformation from radio and television programs, magazine and newspaper articles, anti-vaccine blogs, YouTube, and Twitter. Vaccines—considered mankind’s greatest lifesaver—are now feared by some to cause a variety of chronic diseases, including autism, diabetes, allergies, asthma, learning disabilities, multiple sclerosis, and attention deficit disorder, among others. As a consequence, many parents are choosing not to immunize their children according to recommended schedules. Travel health providers must be aware of these issues and arm themselves with accurate information to properly educate their clients.

In addition to protecting the health of the vaccinee, vaccination of individuals helps safeguard the health of entire communities, both at home and possibly at travel destinations. Predictably, in communities with clusters of underimmunized children, the incidence of vaccine-preventable diseases has risen. A measles epidemic in 2008 was larger than any measles epidemic in the previous 10 years. Pertussis outbreaks have swept the nation. Increased numbers of cases of Haemophilus influenzae type b meningitis have claimed the lives of several children in Minnesota and Pennsylvania, deaths that could have easily been avoided if parents had not feared vaccines more than the diseases they prevent. Some of these outbreaks have been linked to international travel to the United States.

So, where do we go from here? How do we again compel people to vaccinate themselves and their children? One way would be to make parents aware of the impact of vaccine-preventable diseases and to provide the science that exonerates vaccines as a cause of chronic diseases in a manner that is compelling and easily understood. Some of this information is available from CDC (www.cdc.gov/vaccines/recs/acip/default.htm), the American Academy of Pediatrics (www.aap.org), the Immunization Action Coalition (www.immunize.org), the Vaccine Education Center at the Children’s Hospital of Philadelphia (www.vaccine.chop.edu), Every Child By Two (www.ecbt.org), the National Network for Immunization Information (www.immunizationinfo.org), the Institute for Vaccine Safety at Johns Hopkins Hospital (www.vaccinesafety.edu), and Parents of Kids with Infectious Diseases (www.pkids.org), among other groups.

But is it enough? As providers whose job it is to protect individuals against vaccine-preventable diseases, whether they be travel-related infections or otherwise, we need to enhance our efforts to educate ourselves and our patients, so that we will not once again be compelled to vaccinate after witnessing the suffering, hospitalization, and death caused by vaccine-preventable diseases—an unwanted return to an earlier phase in history.

BIBLIOGRAPHY

1. CDC. Invasive Haemophilus influenzae type B disease in five young children—Minnesota, 2008. MMWR Morb Mortal Wkly Rep. 2009 Jan 30;58(3):58–60.
2. CDC. Pertussis outbreak in an Amish community—Kent County, Delaware, September 2004–February 2005. MMWR Morb Mortal Wkly Rep. 2006 Aug 4;55(30):817–21.
3. CDC. Update: measles—United States, January–July 2008. MMWR Morb Mortal Wkly Rep. 2008 Aug 22;57(33):893–6.
4. Chen RT, Mootrey G, DeStefano F. Safety of routine childhood vaccinations. An epidemiological review. Paediatr Drugs. 2000 Jul–Aug;2(4):273–90.