Chickenpox (Varicella) Vaccine
Chickenpox vaccine is a routine immunization for all children in the USA. All children should receive one dose of chickenpox vaccine between 12 and 18 months of age, or at any age after that, if they have never had chickenpox. Adults and adolescents 13 years of age or older should receive 2 doses of the vaccine, 4-8 weeks apart. Chickenpox vaccine should not be given during pregnancy, and female patients should not become pregnant for at least 1 month after immunization.

Chickenpox is a viral infection that is highly contagious and usually quite mild, but it can be serious, especially in young infants and adults. Any person who has ever had chickenpox in the past has lifelong immunity and does not need this vaccine. Once otherwise healthy people contact chickenpox, the disease rarely ever occurs a second time. Before the availability of the vaccine in 1995, approximately 10,000 persons with chickenpox required hospitalization every year in the USA; close to 100 deaths from chickenpox occurred annually.

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Cholera Vaccine
Effective June of 2000, cholera vaccine is no longer manufactured in the USA.

Cholera vaccine (injectable) has been available for nearly a century, but Wyeth-Ayerst Laboratories stopped manufacturing it in the summer of 2000. Many countries, including Canada, license an oral cholera vaccine, although there is no evidence that it is more effective than the injectable formulation. The oral vaccine is not available in the USA. Cholera vaccine is no longer listed in a separate section in the International Certificate of Vaccination and is not officially required for entry into any country. The vaccine is a 2-dose series separated by 1-4 weeks. Booster doses for travelers at high-risk are recommended every 6 months. It is not recommended for children younger than 6 months of age.

Cholera is a potentially life-threatening, tropical disease that causes severe and profuse diarrhea. Because it is an extremely rare disease in international travelers from the USA, and the vaccine may have significant side effects and is probably not more than 50% effective, it is not recommended by the World Health Organization. The Centers for Disease Control (CDC) recommends it only for travelers at high risk who work and live in highly endemic areas under less than adequate sanitary conditions.

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Diphtheria-Tetanus-acellular Pertussis (DTaP); Diphtheria-Tetanus (DT) Vaccines
DTaP vaccine is a routine childhood immunization in the USA. This is a 5-dose series starting at 2 months of age and finishing at 4-6 years of age. It is frequently given in combination with Haemophilus influenzae (Hib) vaccine. It is never administered after the 7th birthday. Following completion of the DTaP series (by the 7th birthday), Td vaccine is given at 11-12 years of age if at least 5 years have elapsed since the last dose of DTaP.

Diphtheria is a serious disease characterized by a very sore throat, difficulty breathing, paralysis, and heart failure. It is very rare in the USA because of the high immunization rates in children and young adults. Pertussis, or whooping cough, may be a serious disease, especially in infants. It is characterized by choking and coughing - often prolonged. It is highly contagious. Tetanus, or lockjaw, is a very serious disease that may follow a cut, burn, or wound. It causes serious muscle spasms and frequently ends in death. In the USA it is a very rare disease because almost all children and young adults have received the vaccine.

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Haemophilus influenzae type b (Hib) Vaccine
Hib vaccine is a routine childhood immunization in the USA. This is a 4-dose series (it may be a 3-dose series depending on the brand of Hib vaccine used) starting at 2 months of age and finishing at 12-15 months of age. Many health care providers give this vaccine in combination with DTaP vaccine. It is not generally recommended for children after the 5th birthday.

Haemophilus influenzae type b disease is a serious, contagious bacterial infection. Before the availability of the Hib vaccine in 1987, Haemophilus influenzae was the leading cause of bacterial meningitis among children under 5 years of age in the USA. Haemophilus influenzae infection may also cause pneumonia, ear infections, sinus infections, and other severe infections. Because infection with Hib is rare after 5 years of age, older children and adults do not routinely need this vaccine.

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Hepatitis A Vaccine
In 2000, hepatitis A vaccine became a routine immunization for some children in the United States who are 2-12 years of age. In 2001, the recommendation is extended to age 2-18 years of age. This vaccine is recommended for routine immunization in this age group only for selected states (Alaska, Arizona, California, Idaho, Oklahoma, Oregon, Nevada, New Mexico, South Dakota, Utah, and Washington) and should be considered for routine immunization in a few other states (Arkansas, Colorado, Missouri, Montana, Texas, and Wyoming).Hepatitis A vaccine is a 2-dose series with a minimum of 6 months recommended between doses. The duration of protection is many years and there is no specific booster recommendation at this time.

Hepatitis A is a serious, contagious viral infection of the liver, most commonly transmitted person-to-person between close contacts or by contaminated food and water (such as uncooked fruits and vegetables, shellfish, and ice). The disease is very common in developing countries but also occurs in the USA. In the USA approximately one-third of all cases occur in children under 15 years of age. Children are frequently not very ill with the disease and recover quickly, but they may spread it to other people, especially household members and playmates. Once a person contracts a hepatitis A infection, they have lifelong immunity and will never need the vaccine.

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Hepatitis B Vaccine
Hepatitis B vaccine is a routine immunization for all children and adolescents in the USA who are 18 years of age and younger. Hepatitis B vaccine is a 3-dose series with 1 month recommended between dose 1 and 2, and 5 months recommended between dose 2 and 3. The duration of protection is many years and there is no specific booster recommendation at this time.

Hepatitis B is a serious viral infection of the liver transmitted by blood, blood products, objects contaminated with blood, and sexual contact. It can also be transferred from mother to infant at the time of birth, but it is not transmitted by breastfeeding. Hepatitis B infection can cause chronic liver disease, including cancer of the liver. When an infant contracts the disease at birth, it will cause a chronic carrier state up to 90% of the time and serious liver disease up to 25% of the time.

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Immune Serum Globulin

Travelers seeking immediate protection against hepatitis A and travelers too young to receive the hepatitis A vaccine should receive a single dose of immune globulin (also known as IG, immune serum globulin, ISG, or gamma globulin). This gives protection for 3-5 months, depending on the amount of IG given. IG is administered deep intramuscularly in larger children, adolescents, and adults .

IG is not a vaccine. Although IG contains human blood products, it has never been shown to transmit infectious disease. It is effective for the prevention of hepatitis A for international travelers and it is also effective if used for the prevention of hepatitis A immediately after a known exposure. Since the introduction of hepatitis A vaccine (for persons over age 2) in 1995, the use of IG has markedly decreased.

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Influenza Vaccine
Immunization is also recommended for people aged 6 months-49 years that are at high risk for influenza infections. The optimum time to receive this vaccine is annually from October 1 until mid-November. Infants and children 6 months-8 years of age who have never been vaccinated should receive 2 doses at least 1 month apart, while infants and children who have previously received the vaccine need only a single dose. The vaccine is inactivated and cannot cause influenza.

Influenza is a contagious, and sometimes very serious, viral disease. It is a particularly serious disease in people with chronic disease, residents of long-term care facilities, pregnant women, and people 6 months-18 years of age receiving chronic aspirin therapy. Most candidates for influenza vaccine are also candidates for pneumococcal vaccine.

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Japanese Encephalitis Vaccine
Japanese encephalitis (JE) vaccine is a 3-dose series administered on days 0, 7, and 30. Because of the potential for adverse and allergic reactions, patients should remain in areas with access to medical care for 10 days after each injection, and the last dose should be given a minimum of 10 days before travel.

JE is a severe inflammation of the brain transmitted by mosquitoes. JE vaccine should be considered by people who plan to live in areas of Asia where JE is endemic or epidemic (the Indian subcontinent, Japan, Guam, the former USSR, Malaysia, and the Western Pacific Islands) and for travelers whose activities include trips into rural, farming areas. JE is typically found seasonally in areas where pigs are raised and where rice paddies, marshes, and standing pools of water provide breeding grounds for mosquitoes and feed for birds.

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Lyme Disease Vaccine
Lyme disease vaccine was licensed in the USA in 1998. It should be considered for persons from 15-70 years of age who have frequent or prolonged exposure to outdoor, wooded areas infested with deer ticks. The highest risk of Lyme disease occurs in just eight states: Connecticut, Delaware, Maryland, New Jersey, New York, Pennsylvania, Rhode Island, and Wisconsin. Lyme disease vaccine is a 3-dose series: 1 dose initially, followed by a second dose 1 month later, and a third dose 12 months after the initial dose. At this time there is no recommendation for additional, or booster doses, after the initial 3-dose series. The vaccine is considered about 75-80% effective. It is not protective for strains of Lyme disease found outside the USA.

Lyme disease is a disease of the skin, joints, muscles, nerves, and heart that is transmitted by the bite of deer ticks. Almost 25% of the cases occur in children. The disease can be prevented with a combination of immunization, protective clothing, insect repellents, and prompt removal of ticks from the body. Lyme disease can be treated with antibiotics.

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Measles-Mumps-Rubella (MMR) Vaccines
MMR vaccine is a routine childhood immunization in the USA. This is a 2-dose series given initially on or after the 1st birthday and again at 4-6 years of age, but it is acceptable to give the 2 doses any time with as little as 1 month between them. The MMR vaccine should not be given during pregnancy, and female patients should not become pregnant for at least 3 months after immunization. For babies age 6-11 months traveling to countries where measles is endemic (e.g., India), a single dose of monovalent measles vaccine (MMR is acceptable) is recommended. If the vaccine is given at age 6-11 months, a routine MMR is still recommended at age 1 year or as soon after as practical.

Measles, mumps and rubella (German measles) are highly contagious, viral diseases that are rare in the USA because of the high level of childhood immunization rates. Immunization of adolescents and young adults with a rubella-containing vaccine is especially important in preventing congenital rubella syndrome (CRS).

It has been suggested that the MMR vaccine is a cause of autism; however, the results of a study published in the New England Journal of Medicine (November 7, 2002) provides strong evidence against the hypothesis that MMR causes autism.

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Meningococcal Vaccine
Meningococcal vaccine should be considered for college freshmen, particularly those that plan to live in dormitories. Some colleges require meningococcal vaccine for entering freshmen. All colleges should provide information about meningococcal disease and the availability of the vaccine.

Meningococcal vaccine is a single dose injection. It is recommended for international travelers to the "meningitis belt" of Africa from December through June and pilgrims returning to the Hajj or Umra in Saudi Arabia. Outbreaks occur intermittently in India, Mongolia, Nepal, and Pakistan. It is also indicated for people 2 years of age or older who lack a spleen or suffer from some immune deficiencies. A booster dose, when indicated, is recommended 2-5 years later.

Meningococcal infections, usually meningitis, are serious bacterial infections with a 10% fatality rate. The infection is most common in children and young adults and people living in crowded conditions. Intimate contact and airborne contamination from infected individuals spread the disease. Some people are carriers of the disease but are not sick themselves.

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Pneumococcal Vaccines
In 2000, pneumococcal conjugate vaccine (PCV) became a routine childhood immunization in the USA for children 2-23 months of age.

Pneumococcal conjugate vaccine is a 4-dose series given at 2, 4, and 6 months of age with a booster at 12-15 months of age. PCV is also recommended for children 2-5 years of age who have sickle cell disease, have a damaged spleen or no spleen, have HIV/AIDS, have other diseases that affect the immune system, i.e., diabetes or cancer, or take medications that affect the immune system, i.e., chemotherapy or steroids. PCV should be considered for children 2-5 years of age who are 24 - 35 months of age, are of Alaska Native, American Indian or African-American descent, or attend group child care. It is not recommended for children after the 5th birthday.

Another pneumococcal vaccine, called pneumococcal polysaccharide vaccine (PPV23), is a routine immunization for all adults over age 65. It is never used in children under 2 years of age, but it is sometimes recommended for people over 2 years of age who are at risk for pneumococcal bacterial infections.

Pneumococcal disease may cause meningitis, pneumonia, middle ear infections, and other serious infections. The highest rates of these pneumococcal infections occur in children under 2 years of age and adults over 40 years old.

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Polio Vaccines
Effective 2000, Oral polio vaccine (OPV) is no longer recommended as a routine vaccine in the USA; only injectable polio vaccine is used. OPV is no longer manufactured in the USA. It is still widely used in the rest of the world.

Polio vaccine is a routine childhood immunization in the USA. This is a 4-dose series starting at 2 months of age and finishing at 4-6 years of age. To eliminate the risk of serious side effects of the oral polio vaccine (OPV), injectable polio vaccine (IPV) is the recommended vaccine for all doses of the series. There is no recommendation for routine booster immunization for children or adults after completion of the 4-dose series.

Polio is a serious viral infection that was very common before the introduction of polio vaccine in 1955. Since that time, polio has essentially disappeared in the USA. No wild (infectious) case of polio has been reported in the USA during the last 20 years and there has not been a case of wild polio in the entire Western Hemisphere in almost 10 years. It is expected that polio, like smallpox before it, will be eradicated worldwide within the next 5 years.

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Rabies Vaccines
Rabies vaccine is indicated for international travelers venturing into areas of possible rabies exposure, particularly if post-exposure treatment is not available, and for any person exposed to the rabies virus. The primary series of intramuscular vaccine is a total of three injections given at 0, 7, and 21 or 28 days. A single booster dose is recommended for persons in high-risk categories as often as every 2 years.

Rabies is a viral infection of the central nervous system. Dogs are the most common source of rabies, especially in Latin America, Africa and Asia (except Taiwan, Hong Kong, Singapore, Brunei, Maldives, and Japan). More than 30% of rabies cases in the USA occur in returning travelers and immigrants who received dog bites while abroad. Almost 60% of the human cases of rabies diagnosed in the USA have been associated with exposure to bats. In the case of a bat bite, inhalation of aerosolized bat secretions (e.g., spelunkers), scratch or mucous membrane exposure, post-exposure treatment is recommended even if evidence of exposure is not visible but there is reasonable probability that an exposure may have occurred. Other sources of rabies are skunks, raccoons, foxes, jackals, groundhogs, domestic cats, mongooses and, particularly in countries in southwestern Asia, wolves. It is rare to find rabies in rabbits, squirrels, gerbils, rats, mice, chipmunks, or guinea pigs.

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Tetanus-Diphtheria (Td) Vaccine
There is currently a severe shortage of all tetanus-containing (tetanus-diphtheria or Td) immunizations. For many people that means a routine tetanus booster (every 10 years) may not be available. Until the shortage is resolved (probably not until 2002), Td immunization, if available, must be prioritized. Travelers to countries where the risk of diphtheria is high should be given top priority (e.g., Newly Independent States of the former Soviet Union). Other travelers at risk for diphtheria include those traveling for long periods of time, those with extensive contact with children, and those exposed to poor hygiene.

Persons needing Td after suffering a wound are the second level of priority. The lowest priority is adolescents and adults who have not been vaccinated with Td within the preceding 10 years.

Td vaccine is a routine childhood immunization in the USA for those 7 years of age and older. Following completion of the DTaP, DTP, or DT series (by the 7th birthday), Td is given at 11-12 years of age if at least 5 years have elapsed since the last dose of DTaP, DTP or DT. Subsequent Td boosters are recommended every 10 years.

Tetanus, or lockjaw, is a very serious disease that may follow a cut, burn or wound. It causes serious muscle spasms and frequently ends in death. Diphtheria is a serious disease characterized by a very sore throat, difficulty breathing, paralysis, and heart failure. Both diseases are very rare in the USA because of the high immunization rates in children and young adults.

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Typhoid Fever Vaccines
Oral typhoid vaccine is no longer available in the USA. It will probably be re-introduced in 2001. Injectable typhoid vaccine for children 6 months to 2 years of age is no longer available in the USA.

Typhoid fever vaccine has at least 4 formulations (oral suspension, oral capsule, and 2 injectable formulations) worldwide, but only the injectable Typhim Vi is currently available in the USA. Typhim Vi is a single dose vaccine used in persons 2 years of age or older. A booster dose is recommended every 2 years. Oral typhoid vaccine is taken on alternate days for a total of 4 capsules. It is only approved for persons 6 years of age and older. A booster dose is recommended every 5 years. The capsules must be refrigerated and taken with a cool liquid approximately 1 hour before eating.

Typhoid fever is an acute, life-threatening bacterial disease introduced into the body from contaminated food and water. It presents as a febrile infection of the intestinal tract, but it is not necessarily associated with diarrhea. It is a concern particularly in India, Mexico, and Peru.

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Yellow Fever Vaccine
Yellow fever vaccine is a single dose injection. Per international regulation, a booster dose is required every 10 years and the vaccine must be given not less than 10 days prior to date of entry. It should not be given to children under 9 months of age unless they are at very high risk. The vaccine is only available at federal centers or vaccination centers designated by state health departments.

Yellow fever is a severe viral infection of the liver transmitted by mosquitoes. International regulations require proof of yellow fever vaccination for travel to and from certain countries in South America and Africa. Because of the international regulation of this vaccine, all vaccinees should receive an International Certificate of Vaccination (the small, yellow immunization book) completed, signed, and validated with the center's stamp where the vaccine was given. It is a good habit to carry the International Certificate of Vaccination with your passport at all times when traveling. In practice, international regulations for yellow fever vaccine may be strictly, but randomly, enforced, particularly for persons traveling from South America or Africa to Asia.

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Vaccines No Longer Available in the USA
Cholera Vaccine
Diphtheria, Tetanus, Pertussis (DTP)
Plague Vaccine
Polio Vaccine, Oral (OPV)
Rabies ID
Rotavirus Vaccine
Smallpox Vaccine
Tick-Borne Encephalitis Vaccine
Typhoid, injectable (Wyeth-Ayerst Laboratories)
Typhoid, Oral
Typhus Fever Vaccine

Based on: CDC, Health Information for International Travel 2000-2001, DHHS, Atlanta, GA, 1999; CDC, Epidemiology and Prevention of Vaccine-Preventable Diseases, 6th Edition, DHHS, Atlanta, GA, 2000; and Dr. Richard Thompson's book - Travel and Routine Immunizations - A Practical Guide for the Medical Office, 2001, Shoreland, Inc.