Measles and pertussis outbreaks: An important role for travel clinics.

Although measles transmission was effectively eliminated in the United States by 1998, the Centers for Disease Control and Prevention have regularly reported cases of measles throughout 2011 and 2012. There is considerable cost to conduct a response to a single case of measles: $799,136 in 1 report of a travel-associated measles outbreak in Arizona.1 Also, in 2012 the United States recorded the most cases of pertussis compared with the previous 50 years, including a large outbreak in Washington State.2 This was despite expanded recommendations for combined tetanus, diphtheria, and acellular pertussis (Tdap) vaccination by the Advisory Committee on Immunization Practices. It would appear logical that the solution to these outbreaks is to improve vaccination with the measles, mumps, and rubella (MMR) and Tdap vaccines. Unfortunately there are practical challenges to implementation of vaccine guidelines, including safety concerns and public misconceptions.3 In addition, Tdap is not covered by many state vaccine programs. It is also difficult to capture healthy individuals who may not visit their physicians on a regular basis and do not believe they have a need for vaccines. A unique opportunity to increase uptake of these vaccines exists when otherwise healthy persons make plans to travel out of the country. Travelers are already primed to receive “travel vaccines” like hepatitis A, typhoid, and yellow fever.

Our travel clinic is a specialized service offered by the Division of Infectious Diseases of the Reliant Medical Group, a private multispecialty group in Central Massachusetts. The clinic is staffed by 4 providers—3 infectious disease-certified physicians and 1 nurse practitioner. In addition to face-to-face evaluation and counseling, telephone consults are also offered for patients who had been previously evaluated at this clinic. Travel vaccines offered include hepatitis A, typhoid, polio, meningitis, yellow fever, Japanese encephalitis, and rabies. In addition, routine vaccines (eg, hepatitis B, varicella, influenza, pneumococcus, MMR, Tdap, and tetanus and diptheria toxoids vaccine) are available. Counseling regarding mosquito-borne illnesses, diarrheal diseases, and other travel-related issues is also part of the visit. Recommendations are individualized and guided by Centers for Disease Control and Prevention information available for the respective country of travel.

In response to the increased incidence of measles and pertussis, there was an added emphasis by our travel clinic on measles serotesting and vaccination, and Tdap vaccination in those travelers without documented evidence for the same. A total of 1,261 patients were evaluated in person at Reliant Medical Group’s travel clinic during 2011. This compares very favorably with the number of travelers seen over a 2-year period by Global TravEpiNet, a large consortium of 18 travel clinics in the United States, where the median number of travelers per site was 201.4 At our travel clinic, traditionally administered so-called travel vaccines included typhoid (n = 993), hepatitis A (n = 547), polio (n = 287), and yellow fever (n = 273). With the added emphasis on measles and pertussis protection, review of patients’ records before their travel indicated lack of documented protection against measles in a large number of travelers, indicating an at-risk population in the community. This resulted in serotesting in 416 travelers and MMR vaccination in 133 individuals. In addition, 397 travelers received the Tdap vaccine. This represented indirect evidence that a considerable number of healthy persons in the community remain at risk for pertussis. Our data have interesting implications regarding the gap between MMR and Tdap vaccine recommendations and the implementation of these guidelines. Addressing this gap will involve increasing awareness among physicians and patients of the ongoing epidemics. Public policy and resources should be directed toward improving the uptake of these established vaccines with emphasis on vaccination opportunities at any and all physician visits—including travel clinics. MMR and Tdap vaccination at a travel clinic represents a significant opportunity to increase the uptake of these vaccines in otherwise healthy individuals. Thus, travel clinics represent an important contact point to achieve improved vaccination and hence prevent the spread of these 2 infectious diseases.

Authors:Rapose A.

Journal:Am J Infect Control. 2013