Travel Vaccine Recommendations for Infants and Children

Introduction

Vaccinating children (i.e., age <18 years old) for travel requires careful evaluation to determine whether acceleration of routine childhood immunizations is needed and to address indications, precautions, or contraindications of specific travel vaccines based on age. See recommended childhood and adolescent immunization schedules. These schedules indicate the recommended minimum intervals between doses for children who need to be vaccinated on an accelerated schedule and provide catch-up schedules for children and adolescents who start a vaccination schedule late or who are >1 month behind.

Country-specific vaccination requirements and recommendations for departure and entry vary over time. For example, proof of yellow fever vaccination is required for entry into certain countries. Meningococcal vaccination is required for travelers entering Saudi Arabia for Umrah or the annual Hajj pilgrimage (see Meningococcal Disease and Saudi Arabia: Hajj and Umrah Pilgrimages chapters). The World Health Organization (WHO) has issued temporary vaccination recommendations for residents of and long-term visitors to countries with active circulation of wild or vaccine-derived poliovirus (see Poliomyelitis chapter).

Additional information about diseases and routine vaccination is available in the disease-specific chapters in Section 4. See tools for determining routine and catch-up childhood vaccination.

Modifying immunization schedules for infants and young children before international travel

Several factors influence recommendations for the age at which a vaccine is administered, including age-specific risks for the disease and its complications (e.g., Haemophilus influenzae type B vaccine [Hib] vaccine), age-dependent ability to develop an adequate immune response to a vaccine (e.g., typhoid polysaccharide vaccine), potential interference with the immune response by passively transferred maternal antibodies (e.g., measles, mumps, and rubella [MMR] vaccine), and age-specific risks of vaccine adverse events (e.g., yellow fever vaccine).

Immunization schedules for infants and children in the United States provide information about minimum intervals between doses in a vaccine series; these can be used to guide accelerated schedules for vaccination of children with upcoming departures. Specific guidance is provided in the schedule footnotes about modifications in the schedule for international travel for MMR, hepatitis A, and meningococcal vaccines. Discussions with parents about reasons for altering the routine vaccine schedule and why certain vaccines are appropriate only at specific ages help parents to make decisions about immunization of their children before travel.

Recommended dosing intervals for co-administration of live-virus vaccines

In general, non-live and live vaccines may be administered together or at any interval; 2 or more live vaccines (MMR, varicella, yellow fever) should be administered together or at an interval of ≥28 days. An exception is live oral vaccines, which may be given at any interval from other vaccines. Immune globulin given for protection against hepatitis A does not interfere with the immune response to yellow fever vaccine but can inhibit the response to other injected live-virus vaccines (e.g., MMR, varicella) for up to 6 months after administration (see Vaccination and Immunoprophylaxis—General Principles chapter).

If the interval between MMR or varicella vaccine administration and subsequent administration of an antibody-containing product is <14 days, repeat vaccination after the recommended interval unless serologic testing indicates a protective antibody response. The immune response to a live virus injectable or nasally administered vaccine may be impaired if the vaccine is given <28 days from another injectable or nasally administered live-virus vaccine. A dose of the second vaccine should be repeated at least 28 days later to assure adequate immune response. For information about dosing intervals, see The Timing and Spacing of Immunobiologics, General Best Practice Guidelines for Immunization: Best Practices Guidance of the Advisory Committee on Immunization Practices.

Routine infant and childhood vaccines

Immunizations recommended routinely for children include COVID-19, diphtheria, Hib, hepatitis A, hepatitis B, human papillomavirus, influenza, measles, mumps, Neisseria meningitidis, pertussis, polio, rotavirus, rubella, Streptococcus pneumoniae, tetanus, and varicella vaccines. Doses can be administered at the minimum ages and dose intervals to facilitate completion of a series before travel; inform parents that infants and children who have not received all recommended vaccine doses might not be fully protected. Rotavirus vaccine is unique among the routine vaccines given to infants in the United States because it has maximum ages for both the first and last doses; specifically consider the timing of travel so that the infant will be able to receive the complete vaccine series, if possible.

Coronavirus disease 2019

Children aged 6 months and older should remain up to date with the COVID-19 vaccine schedule based on the latest Advisory Committee on Immunization Practices (ACIP) recommendations. Children aged 5 years and older should receive 1 dose of the current seasonal COVID-19 vaccine. Children aged 6 months through 4 years should receive 1–3 doses depending on their prior vaccination history and the COVID-19 vaccine brand. CDC's COVID-19 vaccination recommendations are updated regularly, including for children and teens. COVID-19 vaccines available for use in the United States can be administered simultaneously with all other vaccines.

Hepatitis A

Hepatitis A virus infection is usually mild or asymptomatic in infants and children <5 years old, but children can transmit the infection to older children and adults, who are at greater risk for severe disease. Vaccination is recommended for all children traveling to areas with an intermediate or high risk for hepatitis A beginning at 6 months of age (see Hepatitis A chapter). Ideally, the first dose should be administered ≥2 weeks before travel but providing a dose as late as the day of travel is acceptable. Routine hepatitis A vaccination is recommended for children aged ≥12 months of age. Hepatitis A vaccine is considered safe and immunogenic in infants, but doses administered before 12 months of age can result in a suboptimal immune response, particularly in infants with passively acquired maternal antibody, and do not count toward the routine 2-dose series. Therefore, 2 doses of vaccine should be administered according to the routine immunization schedule of 2 doses, separated by ≥6 months, to infants who received a dose of hepatitis A vaccine before 1 year of age.

For optimal protection, children aged ≥6 months who are immunocompromised or who have chronic medical conditions, and who will be traveling to a high-risk area in <2 weeks, should receive the initial dose of hepatitis A vaccine and receive an immune globulin dose at a separate anatomic injection site.

Hepatitis B

Hepatitis B vaccine can be administered with a schedule of 4 doses of vaccine given at 0, 1, 2, and 12 months to children who require an accelerated schedule before travel.

Influenza

Influenza viruses circulate predominantly in the winter months in temperate regions (typically November–April in the Northern Hemisphere and April–September in the Southern Hemisphere) but can occur year-round in tropical climates (see Influenza chapter). Travelers aged ≥6 months who were not vaccinated during the influenza season in their country of residence should be vaccinated ≥2 weeks before departure if vaccine is available.

Children aged 6 months to 8 years who have never received influenza vaccine, or who have not previously received a lifetime total of ≥2 doses, should receive 2 doses separated by ≥4 weeks. See annually updated recommendations about seasonal influenza vaccination.

Measles-mumps-rubella or measles-mumps-rubella-varicella

Children traveling abroad need to be vaccinated against measles, mumps, and rubella at an age earlier than what is routinely recommended (see Measles [Rubeola] chapter). Infants 6–11 months old should receive 1 MMR vaccine dose. Infants vaccinated before age 12 months should be revaccinated on or after their first birthday with 2 doses of MMR vaccine (separated by ≥28 days). Children 12 months of age and older should receive 2 doses of MMR vaccine, separated by at least 28 days, prior to travel; this may require giving the second dose before it would have been given routinely.

Measles-mumps-rubella-varicella (MMRV) vaccine is licensed for use in children aged 12 months to 12 years and should not be given outside this age group. Recipients of a first dose of MMRV vaccine have a greater risk for febrile seizures compared with recipients of MMR and varicella vaccines administered concomitantly. Administering separate MMR and varicella vaccine for the first dose of MMR and varicella vaccination for children 12–47 months is recommended unless the caretaker expresses a preference for MMRV. If an accelerated schedule of 2 doses of MMRV is chosen, doses should be separated by an interval of 3 months.

Meningococcal

Quadrivalent conjugate

Children aged 2 months to 18 years who travel to or reside in areas of Sub-Saharan Africa known as the meningitis belt during the dry season (December–June) should receive quadrivalent meningococcal conjugate (MenACWY) vaccine (see Meningococcal Disease chapter). Travelers are required to have meningococcal vaccination to enter Saudi Arabia when traveling to Mecca for Umrah or the annual Hajj pilgrimage. Annual health requirements and recommendations for U.S. travelers going to Mecca for Umrah or Hajj are available in Saudi Arabia: Hajj and Umrah Pilgrimages chapter.

The schedule for primary series meningococcal vaccine and booster doses varies depending on the vaccine administered.

Meningococcal B

Vaccination with a serogroup B meningococcal (MenB) vaccine is not routinely recommended for travel to the meningitis belt or other regions of the world unless an outbreak of serogroup B disease has been reported. Although MenB vaccine is not licensed in the United States for children <10 years of age, some European countries recently introduced MenB vaccine as a routine immunization for infants. Some countries might have other meningococcal vaccines available. Consider meningococcal vaccination for infants residing in these countries according to the routine infant immunization recommendations of that country.

Pentavalent meningococcal conjugate (MenACWY-TT/MenB-FHbp)

A new pentavalent conjugate vaccine (MenABCWY) was licensed in 2023 and can be used for travelers aged 10 years and older who are recommended to receive both MenACWY and MenB.

Polio

Polio vaccine is recommended for travelers going to countries with evidence of wild poliovirus (WPV) or vaccine-derived poliovirus circulating during the last 12 months and for travelers with a high risk for exposure to someone with imported WPV infection when traveling to some countries that border areas with WPV circulation (see Poliomyelitis chapter). Current polio vaccine recommendations are available on the CDC Travelers' Health website destination pages.

Infants and children should complete as much of the recommended, age-appropriate polio vaccine series as possible before departure, by an accelerated schedule if necessary. See CDC's Immunization Schedules website for information about accelerated schedules.

People ≥18 years of age traveling to areas where polio vaccine is recommended and who have received a routine series with either inactivated polio vaccine (IPV) or live oral polio vaccine in childhood should receive a single lifetime booster dose of IPV before departure. Available data do not indicate the need for more than a single lifetime booster dose with IPV. Requirements for long-term travelers might apply, however, when departing from certain countries.

Long-term travelers to countries with poliovirus transmission

In May 2014, WHO declared the international spread of polio to be a Public Health Emergency of International Concern under the authority of the International Health Regulations. To prevent further spread of disease, WHO issued temporary polio vaccine recommendations for long-term travelers (staying >4 weeks) and residents departing from countries with WPV transmission ("exporting WPV" or "infected with WPV") or with circulating vaccine-derived poliovirus types 1 or 3.

Long-term travelers and residents could be required to show proof of polio vaccination when departing from these countries for any destination. All polio vaccination administration should be documented on an International Certificate of Vaccination or Prophylaxis (ICVP). See ordering information and instructions on how to fill out the ICVP. The polio vaccine must be received 4 weeks to 12 months before the date of departure from the polio-infected country.

Country requirements can change, so healthcare professionals should check for updates on the CDC Travelers' Health website.

Travel vaccines for infants and children

Cholera

Cholera, a toxin-mediated bacterial gastrointestinal illness, causes acute, watery diarrheal illness that can be severe and fatal without proper treatment (see Cholera chapter). Cholera is rare in pediatric U.S. travelers. During 2012–2018 in the United States, 5 cases of travel-associated cholera occurred in children and adolescents aged 2–17 years. Cholera is more common in persons living in or traveling to cholera-affected areas for extended periods, travelers visiting friends and relatives, healthcare professionals, and cholera outbreak response workers. In February 2022, ACIP voted to recommend the use of a single-dose, live attenuated oral cholera vaccine, CVD 103-HgR, for children and adolescents aged 2–17 years traveling to an area with active toxigenic Vibrio cholerae 01 transmission. The vaccine should be given at least 10 days before travel. Vaccination against cholera is not routinely recommended because cholera is rare in travelers, and most travelers do not visit areas of active transmission. Additional information to guide healthcare professionals is available at Cholera Vaccine: Recommendations of the Advisory Committee on Immunization Practices, 2022. A list of areas with active cholera transmission is available at Cholera Information for Health Care Professionals.

Administration instructions differ for children aged 2–5 years versus people aged 6 years and older. Follow package insert instructions for additional recommendations. Recipients should avoid consuming food or drinks for 60 minutes before and after vaccine administration. Palatability can be improved by administering the vaccine with sucrose or stevia sweetener (additional instructions available at Cholera Vaccine: Recommendations of the Advisory Committee on Immunization Practices, 2022). Duration of protection beyond the 3-month period evaluated in immunogenicity studies is unknown; ACIP does not have a recommendation regarding booster doses at this time.

Dengue

Dengue can cause mild to severe illness (see Dengue chapter). Although many people have asymptomatic infections, for some children dengue can be life-threatening. Travelers should adhere to mosquito-protection measures during travel to dengue-endemic areas (see Mosquitoes, Ticks, and Other Arthropods chapter). There are no dengue vaccines approved for use in U.S. travelers who are visiting but do not live in areas where dengue is endemic.

Japanese encephalitis

Japanese encephalitis (JE) virus is transmitted by mosquitoes and is endemic throughout most of Asia and parts of the western Pacific. JE risk can be seasonal in temperate climates and year-round in more tropical climates. Risk to short-term travelers and those who confine their travel to urban centers is considered low. JE vaccine is recommended for travelers who plan to spend ≥1 month (consecutive or cumulative) in endemic areas during JE virus transmission season and can be considered for short-term (<1 month) travelers whose itinerary or activities could increase their risk for JE virus exposure. The decision to vaccinate a child should follow the more detailed recommendations found in Japanese Encephalitis chapter.

An inactivated Vero cell culture-derived JE vaccine (IXIARO) was licensed by the U.S. Food and Drug Administration in 2009 for use in travelers aged ≥2 months of age. For children aged 2 months to 17 years, the primary series consists of 2 intramuscular doses administered 28 days apart (doses may be given at an interval of 7 days in travelers ≥18 years of age). The last dose of IXIARO should be given at least 1 week before travel. A booster dose (third dose) may be given 1 or more years after the initial series for travelers remaining at risk for JE. See information on age-appropriate dosing at Japanese Encephalitis Vaccine.

Rabies

Rabies virus causes an acute viral encephalitis that is nearly 100% fatal. Traveling children can be at increased risk for rabies exposure, mainly from dogs that roam the streets in low- and middle-income countries. Bat bites carry a potential risk for rabies throughout the world. In addition to taking measures to avoid animal bites and scratches, pre-exposure and post-exposure rabies prophylaxis is part of a broader approach to preventing this disease (see Zoonotic Exposures: Bites, Scratches, and Other Hazards chapter). Follow the recommendations in Rabies chapter when making decisions about whether to provide rabies pre-exposure prophylaxis for children.

Pre-exposure prophylaxis

The number of recommended doses of rabies pre-exposure prophylaxis was adjusted downward in 2021, from 3 to 2 doses, administered at an interval of at least 7 days (see Rabies chapter).

The advantages of the revised schedule are that it is both less expensive and easier to complete prior to travel. Because there are no data on the duration of protection afforded by this 2-dose series, travelers with a sustained risk for rabies exposure (i.e., >3 years after receipt of the 2-dose series) should, within 3 years of the 2-dose series either: (1) have a titer drawn to determine if it is >0.5 IU/mL (and receive a booster dose if it is <0.5 IU/mL but no vaccination if >0.5 IU/mL); or (2) pre-emptively receive a third dose of vaccine. Travelers unlikely to visit an at-risk destination after 3 years require no further titers or boosters unless they have a subsequent risk of exposure. Immunocompromised persons should have a titer drawn 1–2 weeks after completion of the 2-dose series to ensure that the titer is ≥0.5 IU/mL.

Post-exposure prophylaxis

Children who have not received pre-exposure immunization and who might have been exposed to rabies require a weight-based dose of human rabies immune globulin and a series of 4 rabies vaccine doses on days 0, 3, 7, and 14. Children who did receive pre-exposure immunization and might have been exposed to rabies require only 2 doses of rabies vaccine on days 0 and 3 post-exposure (additional details are provided in Rabies chapter).

Tick-borne encephalitis

Tick-borne encephalitis (TBE) is a viral disease transmitted by Ixodes ticks in parts of Asia and Europe that is rare in U.S. travelers. TBE is usually asymptomatic but can appear as a biphasic illness with central nervous system involvement (see Tick-Borne Encephalitis chapter). Although TBE virus infection tends to be less severe in children, residual symptoms and neurologic deficits have been described.

Most infections result from the bite of an infected tick, typically acquired when a person is bicycling, camping, hiking, or participating in other outdoor activities in brushy or forested areas. TBE also can be acquired by ingesting unpasteurized dairy products from infected animals or, rarely, from direct person-to-person spread via blood transfusion, solid organ transplantation, or breastfeeding.

TBE vaccine is approved for people aged ≥1 year and is recommended for use among people traveling or moving to a TBE-endemic area who will have extensive tick exposure based on planned outdoor activities and itinerary. Primary vaccination consists of 3 doses; the schedule varies by age. The second dose is given 1–3 months after the first for children 1–15 years old, and 14 days to 3 months after the first for individuals aged ≥16 years. All children should receive the third dose 5–12 months after receiving their second dose of the vaccine. A booster (fourth) dose can be given ≥3 years after completion of the primary immunization series if ongoing exposure or re-exposure is expected. An algorithm for decision-making for TBE vaccination for U.S. travelers is available at Tick-borne Encephalitis Vaccine Information for Healthcare Providers.

Typhoid

Typhoid fever is caused by the bacterium Salmonella enterica serotype Typhi (see Typhoid and Paratyphoid Fever chapter). Travelers can reduce risk of typhoid fever by following safe food and water precautions (see Food and Water Precautions for Travelers chapter) and frequently washing hands. Typhoid vaccine is recommended for travelers going to areas with a recognized risk for Salmonella Typhi exposure.

Two typhoid vaccines are licensed for use in the United States: Vi capsular polysaccharide vaccine (ViCPS) administered intramuscularly and oral live attenuated vaccine (Ty21a). Both vaccines induce a protective response in 50%–80% of recipients. The ViCPS vaccine can be administered to children aged ≥2 years, who should receive a booster dose 2 years later if continued protection is needed. The ViCPS vaccine should be administered ≥2 weeks before potential exposure. The Ty21a vaccine consists of 4 capsules (1 taken orally every other day), which can be administered to children aged ≥6 years. Capsules should be swallowed whole and taken ≥2 hours after eating or drinking and 1 hour before subsequent eating or drinking. All 4 capsules should be taken ≥1 week before potential exposure. A booster dose of Ty21a should be taken every 5 years, if indicated.

Yellow fever

Yellow fever, a disease transmitted by mosquitoes, is endemic to certain areas of Africa and South America (see Yellow Fever chapter). Proof of vaccination against yellow fever is required for entry into some countries (see Yellow Fever Vaccine and Malaria Prevention Information, by Country chapter). Infants and children ≥9 months old and without contraindications should be vaccinated before traveling to countries where yellow fever is endemic.

Infants aged <9 months are at greater risk for developing encephalitis from yellow fever vaccine, which is a live-virus vaccine. Studies conducted during the early 1950s identified 4 cases of encephalitis out of 1,000 children aged <6 months who received yellow fever vaccine. An additional 10 cases of encephalitis associated with yellow fever vaccine administered to infants aged <4 months were reported worldwide during the 1950s. Yellow fever vaccine is contraindicated in infants <6 months of age and should be administered to children 6–8 months of age after careful consideration of risk at destination and ability of caregivers to prevent mosquito bites. Delay of travel until the infant is older and able to receive yellow fever vaccine more safely can be considered. Additional information is available through healthcare professionals' respective state health departments or CDC toll-free at 800-CDC-INFO (800-232-4636).