Pre-Exposure Rabies Vaccination among US International Travelers: Findings from the Global TravEpiNet Consortium

Abstract

Background: People who travel to areas with high rabies endemicity and have animal contact are at increased risk for rabies exposure. We examined characteristics of international travelers queried regarding rabies vaccination during pretravel consultations at Global TravEpiNet (GTEN) practices during 2009-2010. Material and Methods: We performed bivariate and multivariable analyses of data collected from 18 GTEN clinics. Travel destinations were classified by strength level of rabies vaccination recommendation. Results: Of 13,235 travelers, 226 (2%) reported previous rabies vaccination, and 406 (3%) received rabies vaccine at the consultation. Common travel purposes for these 406 travelers were leisure (26%), research/education (17%), and nonmedical service work (14%). Excluding the 226 who were previously vaccinated, 8070 (62%) of 13,009 travelers intended to visit one or more countries with a strong recommendation for rabies vaccination; 1675 (21%) of these 8070 intended to travel for 1 month or more. Among these 1675 travelers, 145 (9%) were vaccinated, 498 (30%) declined vaccination, 832 (50%) had itineraries that clinicians determined did not indicate vaccination, and 200 (12%) remained unvaccinated for other reasons. In both bivariate and multivariate analyses, travelers with trip durations > 6 months versus 1-3 months (adjusted odds ratio [OR] = 4.9 [95% confidence interval [CI] 2.1, 11.4]) and those traveling for ''research/education'' or to ''provide medical care'' (adjusted OR = 5.1 [95% CI 1.9, 13.7] and 9.5 [95% CI 2.2, 40.8], respectively), compared with leisure travelers, were more likely to receive rabies vaccination. Conclusions: Few travelers at GTEN clinics received rabies vaccine, although many planned trips 1 month long or more to a strong-recommendation country. Clinicians often determined that vaccine was not indicated, and travelers often declined vaccine when it was offered. The decision to vaccinate should take into account the strength of the vaccine recommendation at the destination country, duration of stay, availability of postexposure prophylaxis, potential for exposure to animals, and likelihood of recurrent travel to high-risk destinations.

Refusal of recommended travel-related vaccines among U.S. international travellers in Global TravEpiNet

“…Vaccine recommendations were continuously updated in accordance with guidance issued by the CDC Travellers’ Health Branch (www.cdc.gov/travel). Clinicians were prompted to consider administration of each of these vaccines in the following circumstances: hepatitis A, influenza, meningococcal, tetanus-diphtheria/tetanus-diphtheria-acellular pertussis, and typhoid fever vaccines for all travellers;rabies vaccine for all travellers to a high-risk country with duration of travel greater than 28 days; 8 , 14 polio vaccine for travellers to countries where polio vaccine was indicated, as defined by CDC recommendations current at the time of the visit; 8 Japanese encephalitis vaccine for individuals travelling to countries endemic for Japanese encephalitis; or 15 yellow fever vaccine for travellers to countries entirely endemic or partially endemic for yellow fever, as defined by CDC recommendations current at the time of the visit 8 …”

“…rabies vaccine for all travellers to a high-risk country with duration of travel greater than 28 days; 8 , 14 …”

Perceptions of rabies risk: a survey of travellers and travel clinics from Canada, Germany, Sweden and the UK

“…This rate is however consistent with previous reports from a study in international travellers attending a travel clinic in the Netherlands (7.8%) 14 or travellers from the USA travelling for 1 month or more in countries with a strong recommendation for rabies (2%). 15 In our study, awareness of rabies PrEP and PEP vaccination in Sweden was relatively low compared with the other countries. This is similar with data published by Angelin et al , which sampled people attending a travel clinic in Sweden.…”

Intradermal pre-exposure rabies vaccination in a Canadian travel clinic: 6-year retrospective observational study

“…The observed low rate of pretravel vaccination is consistent with other studies. 13,14 Factors contributing to the low uptake of pre-exposure prophylaxis reported in the literature include low perception of benefit, concern about adverse reactions and belief that vaccination is not necessary, 14 but the main barrier to vaccination cited by travellers was cost. 13 Recognized risk factors for animal-associated rabies exposure in travellers include travel to Southeast Asia, India and North Africa, young age and travelling for tourism.…”