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Many travelers behind on routine vaccinations before leaving United States

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Multicenter study suggests one-half of those eligible for MMR don’t get immunized

Many adults who travel outside the United States are behind on routine immunizations and risk bringing diseases like measles back home to their communities, say researchers in a study published online in the Annals of Internal Medicine.

In a study spanning 24 sites associated with the CDC-funded consortium Global TravEpiNet, researchers analyzed the records of 40,810 adults born after 1956 who had pretravel consultations between 2009 and 2014. They found that 6,612 were eligible for MMR vaccination, yet fewer than one-half received immunizations. Of the 3,477 who did not get vaccinated, 48% refused, 28% were not vaccinated because the provider decided against it, and 24% were not vaccinated because of barriers in the health system. Furthermore, of those who refused vaccination between 2012 and 2014 (when providers began asking why patients chose to decline immunization), 74% did so because they were not concerned about illness.

These figures indicate a need for provider intervention and counseling, said Emily Hyle, MD, infectious disease specialist at Massachusetts General Hospital in Boston and the study’s lead author. “It’s an opportunity to engage patients in what measles is and how it can affect the surrounding communities when travelers bring it back home.”

Hyle added that it’s important to be clear with patients about the immunization process because some may wonder about the frequency of the vaccinations. “We’re not talking about a pre-travel booster every time the person travels. It’s two lifetime MMR vaccinations.”

The European challenge

According to CDC, many measles outbreaks in the United States can be attributed to travelers who bring the disease back from overseas, most of whom were unvaccinated. But travelers who visit western Europe present a particularly tough challenge, said Jeffery A. Goad, PharmD, MPH, FAPhA, FISTIM, professor and chair of the department of pharmacy practice at Chapman University School of Pharmacy in Irvine, CA. “The vast majority of the travel population doesn’t go to a travel clinic, and of those who go, it’s not really because they’re traveling to western Europe. They think that if they’re going to England or Germany that they don’t need to go to a travel clinic. But we know that most of our [measles] outbreaks are imported, and we should be making a point to ensure all international travelers are up to date on their MMR vaccinations.”

Hyle agreed. “Europe is not a destination people consider to be a risk for measles, but in reality, it is. This is just more opportunity for discussion with travelers because the Advisory Committee on Immunization Practices guidelines don’t differentiate by itinerary. For any international travel, the risk is high enough to merit making sure travelers have measles immunity before they travel.”

When the system is the problem

In the study, 822 eligible travelers were not vaccinated because of barriers in the health system. For 1% of those patients, the MMR vaccine was unavailable at the clinic. The rest were referred to another provider, which would have required another appointment.

“There may have been concerns that the vaccinations wouldn’t be covered [by insurance] for the travel clinic, but would be covered for a primary care visit,” said Hyle. “We would advocate that vaccinations be covered in travel clinics because having another stop makes it more difficult for patients.”

Relying on memory

Hyle and her colleagues noted one limitation of the study: the providers assessed measles immunity as it’s carried out in clinical practice, but their estimates may be imprecise because at times they had to rely on patient recall when determining eligibility.

“Adult patients usually do not have their childhood vaccination records with them. It’s rare that they’re explicit and say they got both doses. They’ll say they got whatever was recommended at the time,” Hyle said.

“This is the dilemma we are all faced with,” said Goad. “You have a limited amount of information, you don’t always have records or what immunizations patients have obtained. You often only have what patients tell you.”

How pharmacists can help

Hyle said pharmacists are well positioned to provide travel immunization counseling. “Pharmacists are a fantastic group to engage patients. They staff the travel clinics and know the guidelines. If you see a patient for whom you can’t confirm MMR vaccination or other forms of immunization, and they don’t have a contraindication to the vaccine, have an informative conversation about the risks to their own health, the ease with which measles is transmitted among people who are not immune, and the risk to the community when the traveler returns.”

As a member benefit, APhA offers the Travel Health Pocket Guide, a condensed resource for pharmacists providing travel health services. The quick reference chart presents CDC information on immunizations by patient population, with color coding and notes, and includes a reminder to inquire about routine vaccinations. APhA also offers the Pharmacy-Based Travel Health Services advanced competency training program for pharmacists to gain the knowledge and skills needed to provide optimal care to the traveling population.

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