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Clinical Practices for Measles-Mumps-Rubella Vaccination Among US Pediatric International Travelers.

  • Hyle, Emily P1, 2, 3, 4
  • Rao, Sowmya R5, 6
  • Bangs, Audrey C2
  • Gastañaduy, Paul7
  • Fiebelkorn, Amy Parker8
  • Hagmann, Stefan H F9, 10
  • Walker, Allison Taylor11
  • Walensky, Rochelle P2, 3, 4
  • Ryan, Edward T1, 3, 4
  • LaRocque, Regina C1, 3, 4
  • 1 Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston.
  • 2 Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston.
  • 3 Division of Infectious Diseases, Massachusetts General Hospital, Boston.
  • 4 Harvard Medical School, Boston, Massachusetts.
  • 5 Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital, Boston.
  • 6 Department of Global Health, Boston University School of Public Health, Boston, Massachusetts.
  • 7 Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia. , (Georgia)
  • 8 Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia. , (Georgia)
  • 9 Division of Pediatric Infectious Diseases, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park.
  • 10 Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.
  • 11 Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia. , (Georgia)
Published Article
JAMA pediatrics
Publication Date
Feb 01, 2020
DOI: 10.1001/jamapediatrics.2019.4515
PMID: 31816033


The US population is experiencing a resurgence of measles, with more than 1000 cases during the first 6 months of 2019. Imported measles cases among returning international travelers are the source of most US measles outbreaks, and these importations can be reduced with pretravel measles-mumps-rubella (MMR) vaccination of pediatric travelers. Although it is estimated that children account for less than 10% of US international travelers, pediatric travelers account for 47% of all known measles importations. To examine clinical practice regarding MMR vaccination of pediatric international travelers and to identify reasons for nonvaccination of pediatric travelers identified as MMR eligible. This cross-sectional study of pediatric travelers (ages ≥6 months and <18 years) attending pretravel consultation at 29 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention-supported consortium of clinical sites that provide pretravel consultations, was performed from January 1, 2009, through December 31, 2018. Measles-mumps-rubella vaccination among MMR vaccination-eligible pediatric travelers. Of 14 602 pretravel consultations for pediatric international travelers, 2864 travelers (19.6%; 1475 [51.5%] males; 1389 [48.5%] females) were eligible to receive pretravel MMR vaccination at the time of the consultation: 365 of 398 infants aged 6 to 12 months (91.7%), 2161 of 3623 preschool-aged travelers aged 1 to 6 years (59.6%), and 338 of 10 581 school-aged travelers aged 6 to 18 years (3.2%). Of 2864 total MMR vaccination-eligible travelers, 1182 (41.3%) received the MMR vaccine and 1682 (58.7%) did not. The MMR vaccination-eligible travelers who did not receive vaccine included 161 of 365 infants (44.1%), 1222 of 2161 preschool-aged travelers (56.5%), and 299 of 338 school-aged travelers (88.5%). We observed a diversity of clinical practice at different GTEN sites. In multivariable analysis, MMR vaccination-eligible pediatric travelers were less likely to be vaccinated at the pretravel consultation if they were school-aged (model 1: odds ratio [OR], 0.32 [95% CI, 0.24-0.42; P < .001]; model 2: OR, 0.26 [95% CI, 0.14-0.47; P < .001]) or evaluated at specific GTEN sites (South: OR, 0.06 [95% CI, 0.01-0.52; P < .001]; West: OR, 0.10 [95% CI, 0.02-0.47; P < .001]). The most common reasons for nonvaccination were clinician decision not to administer MMR vaccine (621 of 1682 travelers [36.9%]) and guardian refusal (612 [36.4%]). Although most infant and preschool-aged travelers evaluated at GTEN sites were eligible for pretravel MMR vaccination, only 41.3% were vaccinated during pretravel consultation, mostly because of clinician decision or guardian refusal. Strategies may be needed to improve MMR vaccination among pediatric travelers and to reduce measles importations and outbreaks in the United States.

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