Clinical Practices for Measles-Mumps-Rubella Vaccination Among US Pediatric International Travelers | Pediatrics | JAMA Pediatrics | JAMA Network
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    Original Investigation
    December 9, 2019

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

    Author Affiliations
    • 1Travelers’ Advice and Immunization Center, Massachusetts General Hospital, Boston
    • 2Medical Practice Evaluation Center, Department of Medicine, Massachusetts General Hospital, Boston
    • 3Division of Infectious Diseases, Massachusetts General Hospital, Boston
    • 4Harvard Medical School, Boston, Massachusetts
    • 5Massachusetts General Hospital Biostatistics Center, Massachusetts General Hospital, Boston
    • 6Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
    • 7Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 8Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 9Division of Pediatric Infectious Diseases, Steven and Alexandra Cohen Children’s Medical Center of New York, New Hyde Park
    • 10Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
    • 11Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia
    JAMA Pediatr. 2020;174(2):e194515. doi:10.1001/jamapediatrics.2019.4515
    Key Points

    Question  Are there missed opportunities for measles-mumps-rubella (MMR) vaccination at pretravel consultations for US pediatric international travelers?

    Findings  In this cross-sectional study of 14 602 pediatric travelers, 91.7% of infants, 59.6% of preschool-aged travelers, and 3.2% of school-aged travelers were eligible for MMR vaccination; however, 44.1% of MMR vaccination–eligible infants, 56.5% of MMR vaccination–eligible preschool-aged travelers, and 88.5% of MMR vaccination–eligible school-aged travelers were not vaccinated at the consultation. Clinician decision and guardian refusal were the most common reasons for nonvaccination.

    Meaning  The findings suggest that opportunities exist for clinicians to provide pretravel MMR vaccination to US pediatric travelers and that additional education of clinicians and guardians may be needed.


    Importance  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.

    Objective  To examine clinical practice regarding MMR vaccination of pediatric international travelers and to identify reasons for nonvaccination of pediatric travelers identified as MMR eligible.

    Design, Setting, and Participants  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.

    Main Outcomes and Measures  Measles-mumps-rubella vaccination among MMR vaccination–eligible pediatric travelers.

    Results  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%]).

    Conclusions and Relevance  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.