People On The Move:

1

• People On The Move
• Immunization issues for refugees, immigrants and
  travelers

Donna L. Weaver, RN, MN National Immunization
Program
Greensboro, NC October 2, 2003
2

• The sponsor of this event has not contributed to
  the content of this presentation. The content
  was developed entirely by the National
  Immunization Program of the Centers for Disease
  Control and Prevention. The presenter receives
  no financial support of any kind from the sponsor.

3

• The use of trade names and commercial sources
  during this presentation is for identification
  only, and does not imply endorsement by the U.S.
  Department of Health and Human Services, the U.S.
  Public Health Service, or the Centers for Disease
  Control and Prevention.

4
Disclosures

• The speaker has no financial conflict with the
  manufacturer of any product named in this
  presentation
• The speaker will not discuss any product not
  currently licensed by the FDA

5
Immigrants and Refugees
6
Vaccines Received Outside the U.S.

• Many immigrants do not have vaccination records
• May not be age-appropriately vaccinated
• Vaccination records may not accurately reflect
  vaccination status

7
Vaccines Received Outside the U.S.

• Documented immigrants
• Other immigrants and refugees
• Adoptees

8
Documented Immigrants

• 1996 revision of the Immigration and
  Naturalization Act requires people applying for
  permanent residency to show evidence of
  age-appropriate vaccination
• Adoptees exempt from regulation

9
www.cdc.gov/ncidod/dq/health.htm
10
(No Transcript)
11
(No Transcript)
12
Other Immigrants and Refugees

• Accept doses if
• written, dated record
• age, spacing, and timing comparable with that
  recommended in the U.S.
• Vaccinate according to age

13
General Recommendations on Immunization
1994 www.cdc.gov/mmwr/PDF/rr/rr4301.pdf
14
www.health.state.mn.us/divs/dpc/adps/forgnvac.htm
15
www.who.int/vaccines/GlobalSummary/Immunization/Co
untryProfileSelect.cfm
16
(No Transcript)
17
Recommended Minimum Ages Intervals Between
Vaccine Doses(Can be used to evaluate number,
age, spacing of doses received outside U.S.)
General Recommendations on Immunization
1994 www.cdc.gov/mmwr/PDF/rr/rr5102.pdf
18
Children Adopted from Outside the United States

• Immigration and Naturalization Act does not apply
• Special consideration of vaccination history for
  adopted children, particularly those adopted from
  orphanages

19
International Adoptions in the U.S.
20
Age Distribution of U.S. International Adoptees
21
Birth Countries of U.S. International Adoptees
22
Geographic Distribution of Chronic HBV Infection
HBsAg Prevalence
³8 - High
2-7 - Intermediate
lt2 - Low
23
Evaluation of International Adoptees

• Concern about the validity of written vaccination
  records
• Early studies suggested serologic evidence of
  protection not consistent with recorded doses
• Studies using more sensitive serologic tests have
  not confirmed these observations

24
HBV Prevalence Among Adopted Children

• 1999 study from Columbia University and CDC
• 498 children adopted primarily from from China
  and Russia
• 2.8 HBsAg (range, 1-8)

25
Does Hepatitis B Vaccination History Predict
Protection?

• 96 children adopted primarily from China and
  Russia with gt2 doses of hepatitis B vaccine
  recorded
• Serology results
• 53 anti-HBsAg
• 45 anti-HBsAg-
• 2 HBsAg

26
Hepatitis B Vaccination of Internationally-Adopted
Children
Doses Recorded Any lt3 gt3 gt3
Anti-HBs lt10 gt10 gt10 gt10
Action 3 doses Remaining doses None 1 dose gt6 mos
if gt1 dose given gt6 months of age if all
doses given lt6 months of age
27
General Recommendations on Immunization
2002 www.cdc.gov/mmwr/PDF/rr/rr5102.pdf
28
www.cdc.gov/mmwr/PDF/rr/rr5102.pdf
29
Evaluation of International Adoptees

• Careful evaluation of vaccination record with
  attention to age/date of doses
• Discard suspicious and invalid doses
• Age-appropriate vaccination and/or revaccination

30
Evaluation of International AdopteesHepatitis B

• Routine testing for HBsAg, anti-HBs, and anti-HBc
• Appropriate management of HBsAg-positive children
  and contacts
• Vaccination recommendations based on written
  record and serology

31
Evaluation of International Adoptees
Recommended Approach Vaccinate Vaccinate Vaccinate
Vaccinate Vaccinate Vaccinate
Vaccine Polio Hib PCV Varicella MMR DTaP
serologic testing followed by age-appropriate
vaccination is an option, particularly for DT
32
www.cdc.gov/nip/recs/child-schedule.htmPrintable
33
(No Transcript)
34
www.cdc.gov/nip/recs/child-schedule.htmcatchup
35
(No Transcript)
36
Evaluation of International AdopteesSummary

• Adoption of children from outside the U.S.
  increasing, particularly from eastern Europe and
  Asia
• Vaccination records may not accurately reflect
  protection
• Routine HBV serologic testing and selected
  revaccination recommended

37
International Travelers
38
Factors to Consider

• Immunization history
• Current health status
• Travel itinerary
• Length of stay
• Activities planned during visit
• Time of year for travel

39
www.cdc.gov/nip/recs/child-schedule.htmPrintable
40
(No Transcript)
41
Recommended Minimum Ages Intervals Between
Vaccine Doses(Can be used to accelerate the
schedule if necessary for international travel)
General Recommendations on Immunization
1994 www.cdc.gov/mmwr/PDF/rr/rr5102.pdf
42
www.cdc.gov/nip/recs/adult-schedule.htm
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
Vaccines for Many Adults
Vaccine
Indications

• Tetanus and diphtheria All-every 10 yrstoxoids
• Influenza Vaccine All gt50 yrs
  Underlying Illness
• Contacts
• Pneumococcal Vaccine All 65 yrs
• Underlying Illness

47
Vaccines for Some Adults
Vaccine
Indications

• Hepatitis B Vaccine Increased Risk
• MMR Vaccine Born after 1956
• Varicella Vaccine Susceptible

48
Vaccines for a Few Adults
Vaccine
Indications

• Meningococcal Asplenic
• Travel
• Hib Asplenic
• IPV
• Typhoid
• Hepatitis A Travel
• Yellow Fever
• Other

49
Travel Vaccines
www.cdc.gov/travel/ www.cdc.gov/travel/yb/index.ht
m
50
www.cdc.gov/travel/icv.htm
51
www.who.int/ith/
52
www.who.int/ith/chapter06_01.html
53
www.immunize.org/catg.d/2019prod.pdf
54
www.cdc.gov/health/default.htm
55
www.cdc.gov/ncidod/dvbid/jencephalitis/index.htm f
tp//ftp.cdc.gov/pub/Publications/mmwr/rr/rr4201.p
df
56
www.cdc.gov/ncidod/dvrd/rabies/ www.cdc.gov/mmwr/p
review/mmwrhtml/00056176.htm
57
http//www.cdc.gov/ncidod/dbmd/diseaseinfo/typhoid
fever_g.htm ftp//ftp.cdc.gov/pub/Publications/mmw
r/rr/rr4314.pdf
58
http//www.cdc.gov/ncidod/dvbid/yellowfever/index.
htm http//www.cdc.gov/mmwr/preview/mmwrhtml/rr511
7a1.htm
59
The Blue Sheet
www.cdc.gov/travel/blusheet.htm
60
The Green Sheet
www2.cdc.gov/nceh/vsp/vspmain.asp
61
Questions???