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9 common questions about vaccines and travel

Joel Streed

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Travel does more than just transport you to a different place. It can broaden your perspective, increase your happiness, give you a chance to try new things, boost your creativity and help you recharge. Even planning a trip can be an exciting task. The anticipation of mapping an itinerary and scheduling your must-see attractions can bring a lot of joy and happiness.

One of the most important tasks before taking a trip is to make an appointment with a travel medicine specialist. These health care professionals help keep travelers safe and happy before and after their journeys.

Here are answers to common questions about travel medicine:

1. who should make an appointment with a travel medicine specialist.

Anyone planning a trip overseas can benefit from seeing a travel medicine specialist. However, a travel clinic appointment is critical if you are traveling to underdeveloped or developing countries where there's a higher risk of contracting severe communicable illnesses while abroad. It is also important for patients with certain medical conditions that make their immune systems weaker and more vulnerable to infectious diseases.

2. What vaccinations do I need to travel overseas?

All travelers should be vaccinated against the flu and current with COVID-19 vaccines and boosters.

In addition, it's important to complete the adult vaccination schedule that includes vaccinations for:

• Chickenpox (varicella)
• Diphtheria, tetanus and pertussis (DTP)
• Pneumococcal
• Measles, mumps and rubella (MMR)

Additional vaccines may be recommended depending on your travel itinerary. For example, hepatitis A vaccination is recommended if you are traveling to Southeast Asia. During your appointment, we can discuss which vaccines are appropriate for your itinerary.

3. Are there travel destinations that have different vaccination recommendations?

Yes. Infectious diseases thrive in different climates. If you travel to a new climate, you may be exposed to diseases to which you don't have any immunity.

Some infections are more prevalent in tropical settings compared to temperate climates. For example, typhoid and hepatitis A are more common in Southeast Asia because these communicable diseases can be spread through contaminated water. Some areas of Africa and South America have a higher prevalence of yellow fever and malaria, which are mosquito-borne infections.

The  Centers for Disease Control and Prevention (CDC)  has good information online for travelers for each travel destination.

Recommended vaccines may include:

• Hepatitis A
• Hepatitis B
• Japanese encephalitis
• Yellow fever

4. Can my primary care provider give me travel vaccinations?

It depends on your travel destinations and vaccine recommendations. I recommend starting the conversation with your primary care provider and reviewing the  CDC recommendations .

If you have a complex itinerary with multiple countries or are traveling to Southeast Asia or Africa, it's better to make an appointment at the travel clinic. I also would recommend patients with organ transplants and immunocompromising conditions seek travel medicine consultation to reduce the risk of illness during travel. During that appointment, we will review your itinerary, provide necessary vaccinations and discuss ways to prevent mosquito-borne or tick-borne diseases.

5. How long before my trip should I go to the travel clinic?

Plan to have an appointment at least four weeks before you travel. Some vaccines require several weeks for immunity to develop, while others require more than one dose of vaccine for full protection.

If your trip is to an underdeveloped or developing country, you may need to schedule an appointment up to two months in advance to receive a complete set of immunizations. This gives your body time to produce the protective antibodies, so you are well protected when you land at your destination.

6. Can I only go to the travel clinic before I travel?

No. The Travel and Tropical Medicine Clinic is available before or after travel. The team can provide consultative services and treatment if you get sick after you return home.

7. I'm going to an all-inclusive resort. Will I have a lower risk of getting sick?

Maybe, but no traveler should take safety for granted. Even in an all-inclusive resort, knowing how food is prepared or the water supply quality is not possible. Mosquitos and other insects could still be a concern. It's important to take all necessary precautions and follow vaccination recommendations when you travel, regardless of your accommodations.

8. How do I lower my risk of malaria when traveling?

Malaria is a disease caused by a parasite. It's spread to humans through the bites of infected mosquitoes. Prophylactic malaria medications are available and are started before the travel, continued during the stay and for a certain duration after returning home. A travel medicine specialist can review the risks and benefits of all prevention and treatment options.

9. How do I stay healthy while traveling?

Nothing can ruin a trip like illness. Make sure all your vaccinations and boosters are up to date, and get any new vaccinations recommended for your destinations.

Food and water safety is important while traveling. Only eat well-cooked food. Avoid eating from roadside stands and uncooked foods, like salad and raw vegetables. Drink bottled beverages only, including bottled water. This is especially important if you travel in resource-limited regions, such as Southeast Asia or Africa.

Hand hygiene is important at home and overseas. Wash your hands often using soap and hot water. Avoid crowded places, follow respiratory etiquette and consider optional masking. Mosquitos and bugs can transmit parasites and diseases, like yellow fever and malaria. Use mosquito repellents. Mosquito nets may be appropriate in some parts of the world, as well.

As you make travel plans, schedule an appointment with a travel medicine specialist to get the vaccinations and information you need to be healthy and safe on your journey.

Raj Palraj, M.D. , is a physician in  Infectious Diseases  and  Travel and Tropical Medicine  in  La Crosse , Wisconsin.

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Travel & Immunization Center

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Travel & Immunization Center

Cox Building, 5th Floor 55 Fruit Street Boston , MA   02114

Phone: 617-724-6454

Hours: Monday, 5:00 pm – 7:30 pm Tuesday, 8:30 am – 4:00 pm Wednesday, 8:30 am – 4:00 pm Thursday, 9:00 am – 3:30 pm Friday, 8:30 am – 11:30 am" itemprop="openingHours"> By appointment only Monday, 5:00 pm – 7:30 pm Tuesday, 8:30 am – 4:00 pm Wednesday, 8:30 am – 4:00 pm Thursday, 9:00 am – 3:30 pm Friday, 8:30 am – 11:30 am

Please call 866-211-6588 to register with the hospital before calling to make an appointment.

Explore This Center

About the program.

Our Travelers' Advice and Immunization Practices provide complete pre-travel medical evaluation, including education about prevention of illness (food and water precautions, mosquito precautions, precautions for altitude sickness) and immunizations and prophylaxis. Immunizations which are available include yellow fever, Japanese encephalitis, typhoid, hepatitis A, rabies, meningococcal meningitis, tetanus/diphtheria/pertussis and others. We also offer prophylaxis for malaria and diarrheal diseases. We provide care to adults, children and families.

These practices also serve as full immunization centers for routine and specialty vaccines unrelated to international travel, including vaccines against chicken pox (varicella), zoster (shingles), pneumococcus (pneumonia vaccine), Haemophilus influenzae b (Hib), meningococcus (meningitis vaccine), hepatitis B, rabies (pre- and post-exposure prophylaxis), measles/mumps/rubella, tetanus/diphtheria/pertussis, polio, human papillomavirus (HPV) and others.

Many immunizations require multiple injections and take weeks to reach full effectiveness, so please make your appointment as soon after you make your travel plans as possible.

The Travel & Immunization Center is a Member of the Global TravEpiNet Program . Global TravEpiNet is a national network of travel clinics across the United States. The network is supported by the Centers for Disease Control and Prevention and is aimed at advancing the health of individuals who travel internationally. The network is coordinated by Massachusetts General Hospital. The MGH Travel & Immunization Center is also a Member of the Heading Home Healthy Program, also supported by the US Centers for Disease Control and Prevention and coordinated by Mass General. The Heading Home Healthy Program includes a number of free resources, including web tools that allow you to generate CDC-based recommendations based on your proposed international travel.

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Where to Go

You can get most recommended vaccines at your doctor’s office, and many recommended vaccines are also available at local pharmacies, health centers, health departments, and travel clinics. Below you’ll find information and tools to help you find out where to get vaccinated near you—and some tips for making an appointment.

Find vaccines near you!

How do I get a COVID-19 vaccine?

COVID-19 vaccines are safe, effective, and free for everyone age 12 and older living in the United States, regardless of insurance or immigration status. To find a COVID-19 vaccination location near you:

• Text your zip code to 438829
• Call 1-800-232-0233
• Visit Vaccines.gov

Your doctor’s office

If you have a doctor who you see regularly, you can schedule an appointment to talk about vaccines you and your family may need — and to get vaccinated.

Many local pharmacies offer most recommended vaccines for adults, as well as some travel vaccines. If you plan on getting vaccinated at a pharmacy, consider calling ahead to:

• Find out if the pharmacy has the vaccine you need . This is an especially good idea if you need a travel-related vaccine.
• Ask what you will need to pay . Many vaccines are covered by health insurance. But if you don’t have insurance, try calling a few pharmacies and ask what they charge for vaccines — prices can vary.

Health centers

Federally funded health centers provide a variety of health care services, including vaccination. You can go to a health center even if you don’t have health insurance — and some may offer sliding fees based on your income.

Use the Health Center Finder to find a list of health centers near you.

State and local health departments

State and local health departments are a great resource for finding out where to get vaccinated. They may also have information about state vaccine requirements and free and low-cost vaccines, including vaccines for travel.

Click on your state to explore your state health department’s vaccine information.

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Travel clinics

Planning a trip outside the United States? Travel clinics are a great resource for getting pre-travel health advice and vaccines for travelers. Travel clinics have doctors and nurses who specialize in travel health and vaccines. They may also stock vaccines that doctor’s offices and pharmacies don’t have.

Always call a travel clinic before you go — you’ll need an appointment at most of them, and you may need to see a doctor before you get vaccinated. Use the resources below to find a travel clinic.

To find a travel clinic near you, visit:

• International Society of Travel Medicine (ISTM) — travel medicine specialists
• American Society of Tropical Medicine and Hygiene (ASTMH) — infectious disease specialists who may practice travel medicine

Yellow fever clinics

Only certain travel clinics stock the yellow fever vaccine, which is required to travel in some countries. If you need the yellow fever vaccine, find a clinic that offers the yellow fever vaccine .

Learn more about vaccines for travelers .

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Getting immunized is easy. Vaccines and preventive antibodies are available at the doctor’s office or pharmacies — and are usually covered by insurance.

Find out how to get protected .

Want to learn about the journey of your child’s vaccine?

See how vaccines are developed, approved, and monitored .

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What vaccines do you need to travel?

The vaccines you need will depend on where you’re traveling and what you will be doing during your travels. Walgreens pharmacists are able to assist in helping you determine which vaccines you may need.

Which travel vaccines are available at Walgreens?

Travel vaccines Walgreens offers include: Yellow Fever, Meningitis, Polio, Typhoid, Japanese Encephalitis, Tick-Borne Encephalitis, Hepatitis A, Hepatitis B and Rabies*.

*Vaccines offered at Walgreens vary by state, age and health conditions. Talk to your local pharmacist about availability.

What other vaccines should I have before traveling?

It’s important to be up-to-date on routine vaccinations before traveling as well—like Measles-Mumps-Rubella (MMR), Tetanus, Flu and COVID-19.

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We provide routine and travel immunizations to the UNH community. This service is available by appointment only.

A fee is charged for this service and varies based on which immunizations you obtain. Please check with your health insurance plan to see if they will cover this service.

Note: Health & Wellness will no longer be providing travel clinic services to individuals outside the UNH community starting November 28, 2022.

Available Immunizations

The Centers for Disease Control and Prevention (CDC)  offers information about vaccinations by age or for special populations, such as travelers.  You can also  search for vaccine information by disease.

• COVID-19 We offer Moderna and Bivalent booster doses. Find out more information on our COVID-19 Frequently Asked Questions page.
• Influenza This is a seasonal vaccination and should be updated yearly.
• Hepatitis A This is a 2-shot series, given over a 6-month period. This is considered a lifetime vaccination.
• Hepatitis B  This is a 3-shot series, given over a 6-month period. For most, this is a lifetime vaccination.
• HPV This vaccination is for men and women. It is given as a 3-shot series, over a 6-month period. This is considered a lifetime vaccination.
• Japanese Encephalitis Available by special order. 
• Meningococcal  This is considered effective for approximately 5 years, and might need to be updated for travel to endemic areas.
• MMR (measles, mumps, rubella) 2 MMRs are considered a lifetime vaccination. This immunization is required by UNH. 
• Polio  This inactivated injectable Polio vaccination is considered a one-time adult booster for those who have received the Polio series as a child.
• Pneumococcal 
• Rabies This is a 3-shot series. For continued risk/exposure to potential rabies, titer levels should be checked approximately every 2 years to determine booster needs  
• Shingles This vaccination is recommended for people 60 years old and older to prevent shingles. This is a one-time vaccination. There is no maximum age for getting the vaccine.
• TD  (Tetanus, Diphtheria) or  Tdap  (Tetanus/Diphtheria/Acellular Pertussis) Recommended to booster every 10 years.
• Typhoid  This is available in either the oral or injectable vaccination. The oral vaccine is effective for 5 years and the injectable vaccine is effective for 2 years.
• Yellow Fever  Needed for travel into countries of Yellow Fever transmission. This vaccine is effective for 10 years. Call (603) 862-1094 for availability.

Travel Immunization Clinic

We provide a state-approved travel clinic that provides immunizations needed for academic, professional or personal travel.

• The Travel Clinic is available during the academic year and is not available during the summer or semester breaks.
• We recommend that you schedule your travel clinic visit at least 4-6 weeks before your travel departure date.
• Make an appointment  for travel vaccinations and/or HIV/AIDS testing.
• If you paid your health fee, co-pays for visits to the travel clinic are covered. Immunizations are chargeable, but are less expensive than most external providers. Check with your health insurance provider to determine if immunizations at our clinic are covered by your plan.
• If you have not paid the health fee, the visit and immunizations are chargeable. Check with your health insurance provider to determine if visits and immunizations at our clinic are covered by your plan.

Employees and Dependents (18+ years old)

• All services are chargeable, but most are less expensive than most external providers. Check with your health insurance provider to determine if visits and immunizations at our Travel Clinic are covered by your plan.

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Vaccine clinic on wheels: Rockland adds ways to get immunized amid national measles surge

Rockland County has added a mobile vaccination unit to its childhood vaccination efforts.

The new vaccination clinic on wheels comes as cases of measles are climbing worldwide, in the U.S. and in New York.

While Rockland has not seen a case of measles this year, the county managed a measles outbreak in 2018 and 2019. In 2022, Rockland County also saw the first case of polio in the U.S. in decades.

The van, purchased with federal COVID funds, is already up and running. The idea, county spokesperson Beth Cefalu has said, is to get the shots to where they're needed.

Plans for community visits could include sites in East Ramapo school district, county officials said. The greater Spring Valley area is home to a large new immigrant community and the district has reported many new enrollees from Haiti, Central and South America. Often, kids arrive without vaccination records from their home country. Providing on-site shots could help kids catch up and ensure they meet state vaccination regulations for school attendance.

Vaccination rates have slipped in recent years, for various reasons, all over.

Rockland County, though, has long had its own challenges with pockets of low childhood vaccination rates.

Urgency amid Rockland's vulnerability

As of April 18, the U.S. Centers for Disease Control and Prevention had documented 125 measles cases across the U.S. in 2024. That includes three cases in New York; two in NYC and one in Nassau County, according to the New York State Department of Health.

Rockland County remains vulnerable, county officials have said.

In 2018-2019, Rockland witnessed a measles outbreak that ultimately sickened 312; there were 649 cases found in New York City.

“To successfully prevent measles from resurfacing in this county we need cooperation from all communities,” County Executive Ed Day said in a statement.

Polio: Rockland hits full year with no virus found in wastewater

In July 2022, a Monsey man suffered permanent paralysis from polio, an outcome often feared before a vaccine came into use in the early 1960s. The man had not traveled outside the U.S.

Wastewater testing showed the polio virus had been present for months. Subsequent testing of sewage treatment systems around downstate New York have not shown the virus' presence since February 2023.

Focus on upping immunization numbers

County officials have been focused on upping immunization rates since the measles outbreak in the last teens, throughout COVID and through the recent polio scare.

The county's health department recently launched a childhood immunization campaign .

Cefalu said that Rockland Health Department clinics have seen an increase in visits by 50% between 2021 and 2023.

Still, as of Aug. 1, 2023, New York state health records showed pockets of low polio vaccination rates among Rockland County children age 2 and under. For example, in the 10952 ZIP code, which covers the greater Monsey area, just 41.4% of babies and toddlers were vaccinated against polio; in the 10977 postal code, the Spring Valley area, the polio vaccination rate was 55.9%.

How to get vaccinated

Rockland County clinics provide free vaccines through the Vaccines for Children and Vaccines for Adults programs. Find out about eligibility at 845-364-2520/2524. 

Clinic appointments are available by appointment (call 845-364-2520 to schedule) at the following times and locations:

• 8:30-11 a.m. Mondays and Wednesdays at Rockland County Department of Health Clinic, Yeager Center Building A, 2nd floor Rotunda area, 50 Sanatorium Road, Pomona, NY 10970.
• 8:30-11 a.m. Tuesdays and Thursdays at Rockland County Department of Health Spring Valley Clinic, 14 S. Main St., Spring Valley, NY 10977.

Go to health.ny.gov/prevention/immunization for more information about vaccines.

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‘This is life and death’: inside a Florida clinic after the six-week abortion ban

State’s fall as the last bastion of access to the procedure in the deep south means women will have to travel farther for care

Rose hadn’t even missed her period when the thought hit her: “I need to take a test.”

The Florida resident, who has two kids, had given birth just three months ago. She thought that she and her husband were being careful. But the pregnancy test confirmed her suspicion: she was pregnant and, she realized, didn’t want to be.

“It would just be a very big financial, physical, emotional strain,” said Rose, who asked to be identified by a nickname. Her last two pregnancies were enormously difficult and she feared for her health. She wants to be a tattoo artist, but she’s not working at the moment. Her husband has only recently started a new job. Rose continued: “I want to start a career and go to school and learn new things and it’s a lot harder with more kids. It’s already more difficult with the kids that I have.”

By the time she took a pregnancy test, Rose estimates that she was maybe four weeks into her pregnancy. She was lucky: many people don’t realize they’re pregnant that early. Rose also moved swiftly to secure an appointment at a Florida abortion clinic. Still, by Tuesday, when Rose sat in a dimly lit room decorated with butterfly collages and a doctor pressed a white pill into her hand to start a medication abortion, Rose was six weeks and four days into her pregnancy.

Had Rose arrived at the clinic a single day later, she would not have been able to get an abortion in Florida. On Wednesday, Florida banned abortion past six weeks of pregnancy.

“There’s still a lot I can do at my age, and that I want to do at my age and that I’m not really gonna get a chance to do if I’m continuing to be pregnant and have more kids,” she said.

Rose is 19 years old.

For nearly two years after the US supreme court overturned Roe v Wade , Florida stood as the last bastion of abortion access in the US deep south. Even though the state had a 15-week abortion ban, providers there performed more than 84,000 abortions in 2023, including almost 9,000 on out-of-state patients. But on 1 April, the Florida supreme court ruled to uphold the 15-week ban – and, due to legislative maneuvering by Florida’s Republican-controlled state legislature, that decision paved the way for the six-week ban to take effect on Wednesday.

The impact of the ban will ripple across the US. Women who are past six weeks – about 60% of Florida abortions take place after that point in pregnancy – will have to travel at least several states away for abortions, further burdening the relatively few abortion clinics that have survived Roe’s fall. Women who can’t afford to travel may self-manage their abortions, a process that, if undertaken early enough in pregnancy, is medically safe but legally fraught.

Women may also be forced to remain pregnant against their will.

The phone rang off the hook on Tuesday, the last day before the ban took effect, at the abortion clinic that performed Rose’s abortion, Bread and Roses Women’s Health Center in swampy Gainesville, Florida. A squat building nearly hidden behind a lush wall of ivy, Bread and Roses’s walls are decorated in butterfly motifs and motivational posters. One small, framed poster featured a uterus-shaped American flag under the stark word: “vote”.

Bread and Roses normally sees somewhere between 20 and 30 patients a day, but throughout April, as the ban neared, the clinic added extra hours and started to see closer to 40 patients a day. Desperate to squeeze in as many patients as possible on Tuesday, staffers barely had time to even eat. The doctor who was performing abortions kept attempting to heat up her pasta lunch, only to be repeatedly interrupted. Kristin, the clinic director, made toast but was pulled away to do ultrasounds; by the time she remembered to return to it, hours later, the bread had hardened into a hockey puck. (Kristin asked to be identified by her first name due to safety concerns.)

Almost every phone call seemed to include some version of the same conversation, as clinic staffers asked would-be patients: do you know about the six-week abortion ban? When was your last menstrual period? Do you think you’re less than six weeks along?

If a caller seemed like they were past that limit, staffers steered them towards resources to help them find an abortion clinic in another state. One woman, pregnant from her husband’s repeated sexual assaults, cried on the phone on Wednesday as a staffer told her that she likely couldn’t get an abortion in Florida. The woman, who lived in a state with a near-total abortion ban, was confused by Florida’s ban and overwhelmed by the difficulty of having to travel even farther than she had imagined.

“This law is changing everything,” a Bread and Roses staffer told another, baffled caller. “If you are over six weeks, we just would not be able to move forward with an abortion.

“It’s horrible,” the staffer added. “It’s not fair at all.”

Yet another woman who called Bread and Roses on Wednesday had accidentally gone to a crisis pregnancy center, an anti-abortion facility that aims to convince people to continue their pregnancies. They’re often located close enough to abortion clinics to confuse people. (A similar facility was located just two doors down from Bread and Roses.) People at the crisis pregnancy center told the woman that taking abortion pills could lead her to give birth on the toilet, according to a Bread and Roses staffer, who was enraged by the sheer misinformation. How could this be legal, but an abortion past six weeks was not?

Complicating everything is the fact that Florida also requires patients to go to an abortion clinic for a consultation at least 24 hours before they actually get the procedure or pills. That restriction further cuts down on the amount of time that women have to recognize they are pregnant, realize they want an abortion and get to a clinic.

Floridians past six weeks of pregnancy may have to venture to clinics in states like New Mexico, Kansas and Illinois. North Carolina is a closer option for many Floridians – but that state only permits abortions until 12 weeks of pregnancy and its waiting period is also even more onerous than Florida’s. It requires people to show up at a clinic for an initial consultation at least 72 hours before their abortion.

One patient at Bread and Roses on Tuesday, who asked to be identified by her initial A, was little more than five weeks into her pregnancy. A new mom with a months-old baby at home, A had always opposed abortion, but she had developed heart failure during her last pregnancy. Then she had a seizure about a week after giving birth.

“After my condition after my last pregnancy, I realized it’s something people should have a right to if need be,” A said of abortion. “I feel like women should have rights to their bodies. I think it’s cruel, honestly, for people with health conditions, like myself.”

A, who isn’t working right now, didn’t know what she would do if she had been unable to get an abortion in Florida. With a sigh, she suggested: “I would have been stressed out and delivered the baby.”

Rose already knows what it’s like to be denied an abortion. When she got pregnant with her son at 16, she considered having an abortion, but her deeply conservative mom refused to let her get one, she said. Then, due to an injury sustained at birth, Rose’s son was born with severe disabilities.

“I was a 17-year-old kid taking care of a heavily disabled child,” Rose said. “I love my son very much. I don’t regret him.”

But, she added: “It’s not okay to force somebody to do that with their body.”

Most minors involve parents in their decision to get an abortion, but minors in Florida who cannot or will not do so must, instead, go to court to convince a judge that they are mature enough to get an abortion. (The default assumption is that they are mature enough to give birth.) Their victory is far from guaranteed: in the two years before Roe’s demise, Florida judges denied more than 12% of 200-plus minors’ requests . Even if a minor succeeds, the court process can also take days, if not weeks.

Under a six-week ban, minors will likely be unable to surmount these legal hurdles in time. But even if they can secure a parent’s permission for an abortion, minors are especially likely to be denied them under Florida’s six-week ban. Two in three 15- to 19-year-olds realize they are pregnant after six weeks.

Because Bread and Roses staffers prioritized patients who seemed like they were less than six weeks into their pregnancy, all of the patients who showed up for consultations on Tuesday could legally get an abortion by Wednesday. But on Wednesday, the clinic had to tell three or four people that they were past Florida’s legal limit, according to the doctor performing abortions on Wednesday.

The clinic did not track how many people called but seemed beyond the six-week limit already. Kristin, the clinic director, estimated that about half of callers were not able to be scheduled.

Kristin suspects that, in the coming days, Bread and Roses will be forced to turn away even more. As the ban made headlines so much in April, she thinks people might be paying more attention than normal to their periods and pregnancies; if the ban falls out of headlines, people may forget about it until it’s too late. On Wednesday afternoon, Kristin sat in the clinic’s parking lot, clad in black scrubs, and scrunched her knees to her chest.

“I feel exhausted today. I feel incredibly sad and angry. I’m so angry,” Kristin said. “I’m so naive. I want to think that people have the best intentions and this law is just so harmful. I don’t understand how somebody can’t see how harmful this law is. This is life and death for some people.

“In the deep places of my heart, I don’t understand it,” she repeated.

There is a sliver of hope for Bread and Roses staffers: in November, Florida is set to vote on a ballot measure that would enshrine abortion rights in the state constitution, making the six-week ban unconstitutional. Similar measures have already triumphed in states across the country, including Republican strongholds like Kansas and Ohio.

Notably, ballot measures in increasingly red Florida must garner 60% of the vote to pass. Even if abortion rights supporters do win in November, Florida’s abortion laws would not officially change until January. Floridians will have to live under the six-week ban for months.

Clinics may also not survive the ban. Unable to perform most abortions, they’re facing a devastating financial hit – but it’s impossible to map its exact blast radius.

“How do you plan for it, when you don’t know what to expect?” Kristin said. “We’ll be fine. We’re not closing. We’ll figure it out.”

Like many other patients at Bread and Roses, Rose had never heard of the ballot measure before her abortion appointment. She is not registered to vote, but she does want to vote for the ballot measure.

The six-week ban, she said, is “evil”.

“Florida, along with the United States, is going downhill,” Rose said. “I used to like living here, but I’m planning on moving out as soon as I can.”

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• Section 5 - Rubella
• Section 5 - Smallpox & Other Orthopoxvirus-Associated Infections

Rubeola / Measles

Cdc yellow book 2024.

Author(s): Paul Gastañaduy, James Goodson

Infectious Agent

Transmission, epidemiology, clinical presentation.

INFECTIOUS AGENT: Measles virus

TRAVELER CATEGORIES AT GREATEST RISK FOR EXPOSURE & INFECTION

PREVENTION METHODS

Rubeola is a vaccine-preventable disease

DIAGNOSTIC SUPPORT

Measles virus is a member of the genus Morbillivirus of the family Paramyxoviridae .

Measles is transmitted from person to person via respiratory droplets and by the airborne route as aerosolized droplet nuclei. Infected people are usually contagious from 4 days before until 4 days after rash onset. Measles is among the most contagious viral diseases known; secondary attack rates are ≥90% among susceptible household and institutional contacts. Humans are the only natural host for sustaining measles virus transmission, which makes global eradication of measles feasible.

Measles was declared eliminated (defined as the absence of endemic measles virus transmission in a defined geographic area for ≥12 months in the presence of a well-performing surveillance system) from the United States in 2000. Measles virus continues to be imported into the country from other parts of the world, however, and recent prolonged outbreaks in the United States resulting from measles virus importations highlight the challenges faced in maintaining measles elimination.

Given the large global measles burden and high communicability of the disease, travelers could be exposed to the virus in any country they visit where measles remains endemic or where large outbreaks are occurring. Most measles cases imported into the United States occur in unvaccinated US residents who become infected while traveling abroad, often to the World Health Organization (WHO)–defined Western Pacific and European regions. These travelers become symptomatic after returning to the United States and sometimes infect others in their communities, causing outbreaks.

Nearly 90% of imported measles cases are considered preventable by vaccination (i.e., the travelers lacked recommended age- and travel-appropriate vaccination). Furthermore, observational studies in travel clinics in the United States have shown that 59% of pediatric and 53% of adult travelers eligible for measles-mumps-rubella (MMR) vaccine at the time of pretravel consultation were not vaccinated at the visit, highlighting a missed opportunity to reduce the likelihood of measles introductions and subsequent spread. Encourage all eligible travelers to receive appropriate MMR vaccination. Outbreak investigations are costly and resource intensive, and infected people—in addition to productivity losses—can incur direct costs for the management of their illness, including treatment, quarantine, and caregiving.

The incubation period averages 11–12 days from exposure to onset of prodrome; rash usually appears ≈14 days after exposure. Symptoms include fever, with temperature ≤105°F (≤40.6°C); conjunctivitis; coryza (runny nose); cough; and small spots with white or bluish-white centers on an erythematous base appearing on the buccal mucosa (Koplik spots). A characteristic red, blotchy (maculopapular) rash appears 3–7 days after onset of prodromal symptoms. The rash begins on the face, becomes generalized, and lasts 4–7 days.

Common measles complications include diarrhea (8%), middle ear infection (7%–9%), and pneumonia (1%–6%). Encephalitis, which can result in permanent brain damage, occurs in ≈1 per 1,000–2,000 cases of measles. The risk for serious complications or death is highest for children aged ≤5 years, adults aged ≥20 years, and in populations with poor nutritional status or that lack access to health care.

Subacute sclerosing panencephalitis (SSPE) is a progressive neurologic disorder caused by measles virus that usually presents 5–10 years after recovery from the initial primary measles virus infection. SSPE manifests as mental and motor deterioration, which can progress to coma and death. SSPE occurs in ≈1 of every 5,000 reported measles cases; rates are higher among children <5 years of age.

Measles is a nationally notifiable disease. Laboratory criteria for diagnosis include a positive serologic test for measles-specific IgM, IgG seroconversion, or a significant rise in measles IgG level by any standard serologic assay; isolation of measles virus; or detection of measles virus RNA by reverse transcription PCR (RT-PCR) testing. The Centers for Disease Control and Prevention’s Measles Virus Laboratory is the national reference laboratory; it provides serologic and molecular testing for measles and technical assistance to state public health laboratories for the collection and shipment of clinical samples for molecular diagnostics and genetic analysis. See detailed information on diagnostic support .

A clinical case of measles illness is characterized by generalized maculopapular rash lasting ≥3 days; temperature ≥101°F (38.3°C); and cough, coryza, or conjunctivitis. A confirmed case is one with an acute febrile rash illness with laboratory confirmation or direct epidemiologic linkage to a laboratory-confirmed case. In a laboratory-confirmed or epidemiologically linked case, the patient’s temperature does not need to reach ≥101°F (38.3°C) and the rash does not need to last ≥3 days.

Treatment is supportive. The WHO recommends vitamin A for all children with acute measles, regardless of their country of residence, to reduce the risk for complications. Administer vitamin A as follows: for infants <6 months old, give 50,000 IU, once a day for 2 days; for infants 6 months old and older, but younger than 12 months, give 100,000 IU once a day for 2 days; for children ≥12 months old give 200,000 IU once a day for 2 days. For children with clinical signs and symptoms of vitamin A deficiency, administer an additional (i.e., a third) age-specific dose of vitamin A 2–4 weeks following the first round of dosing.

Measles has been preventable through vaccination since a vaccine was licensed in 1963. People who do not have evidence of measles immunity should be considered at risk for measles, particularly during international travel. Acceptable presumptive evidence of immunity to measles includes birth before 1957; laboratory confirmation of disease; laboratory evidence of immunity; or written documentation of age-appropriate vaccination with a licensed, live attenuated measles-containing vaccine 1 , namely, MMR or measles-mumps-rubella-varicella (MMRV). For infants 6 months old and older, but younger than 12 months, this includes documented administration of 1 dose of MMR; for people aged ≥12 months, documentation should include 2 doses of MMR or MMRV (the first dose administered at age ≥12 months and the second dose administered no earlier than 28 days after the first dose). Verbal or self-reported history of vaccination is not considered valid presumptive evidence of immunity.

1 From 1963–1967, a formalin-inactivated measles vaccine was available in the United States and was administered to ≈600,000–900,000 people. It was discontinued when it became apparent that the immunity it produced was short-lived. Consider people who received this vaccine unvaccinated.

Vaccination

Measles vaccine contains live, attenuated measles virus, which in the United States is available only in combination formulations (e.g., MMR and MMRV vaccines). MMRV vaccine is licensed for children aged 12 months–12 years and can be used in place of MMR vaccine if vaccination for measles, mumps, rubella, and varicella is needed.

International travelers, including people traveling to high-income countries, who do not have presumptive evidence of measles immunity and who have no contraindications to MMR or MMRV, should receive MMR or MMRV before travel per the following schedule.

Infants (6 months old and older, but younger than 12 months): 1 MMR dose. Infants vaccinated before age 12 months must be revaccinated on or after the first birthday with 2 doses of MMR or MMRV separated by ≥28 days. MMRV is not licensed for children aged <12 months.

Children (aged ≥12 months): 2 doses of MMR or MMRV separated by ≥28 days.

Adults born in or after 1957: 2 doses of MMR separated by ≥28 days.

One dose of MMR is ≈85% effective when administered at age 9 months; MMR and MMRV are 93% effective when administered at age ≥1 year. Vaccine effectiveness of 2 doses is 97%.

Adverse Reactions

In rare circumstances, MMR vaccination has been associated with anaphylaxis (≈2–14 occurrences per million doses administered); febrile seizures (≈1 occurrence per 3,000–4,000 doses administered, but overall, the rate of febrile seizures after measles-containing vaccine is much lower than the rate with measles disease); thrombocytopenia (≈1 occurrence per 40,000 doses during the 6 weeks after immunization); or joint symptoms (arthralgia develops among ≈25% of nonimmune postpubertal females from the rubella component of the MMR vaccination, and ≈10% have acute arthritis-like signs and symptoms that generally persist for 1–21 days and rarely recur; chronic joint symptoms are rare, if they occur at all). No evidence supports a causal link between MMR vaccination and autism, type 1 diabetes mellitus, or inflammatory bowel disease.

Contraindications

People who experienced a severe allergic reaction (difficulty breathing, hives, hypotension, shock, swelling of the mouth or throat) following a prior dose of MMR or MMRV vaccine, or who had an anaphylactic reaction to topically or systemically administered neomycin, should not be vaccinated or revaccinated. People who are allergic to eggs can receive MMR or MMRV vaccine without prior routine skin testing or the use of special protocols.

Immunosuppression

Enhanced replication of live vaccine viruses can occur in people who have immune deficiency disorders. Death related to vaccine-associated measles virus infection has been reported among severely immunocompromised people; thus, severely immunosuppressed people should not be vaccinated with MMR or MMRV vaccine. For a thorough discussion of recommendations for immunocompromised travelers, see Sec. 3, Ch. 1, Immunocompromised Travelers .

MMR vaccination is recommended for all people with HIV infection aged ≥12 months who do not have evidence of measles, mumps, and rubella immunity, and who do not have evidence of severe immunosuppression. The assessment of severe immunosuppression can be based on CD4 values (count or percentage); absence of severe immunosuppression is defined as CD4 ≥15% for ≥6 months for children aged ≤5 years, or CD4 ≥15% and CD4 count ≥200 cells/mL for ≥6 months for people aged >5 years.

People with leukemia in remission and off chemotherapy, who were not immune to measles when diagnosed with leukemia, may receive MMR vaccine. At least 3 months should elapse after termination of chemotherapy before administering the first dose of vaccine.

Steroids & Other Immunosuppressive Therapies

Avoid vaccinating people who have received high-dose corticosteroid therapy (in general, considered to be ≥20 mg or 2 mg/kg body weight of prednisone, or its equivalent, daily for ≥14 days) with MMR or MMRV for ≥1 month after cessation of steroid therapy. Corticosteroid therapy usually is not a contraindication when administration is short-term (<14 days) or a low to moderate dose (<20 mg of prednisone or equivalent per day).

In general, withhold MMR or MMRV vaccine for ≥3 months after cessation of other immunosuppressive therapies and remission of the underlying disease. See Sec. 3, Ch. 1, Immunocompromised Travelers , for more details.

MMR vaccines should not be administered to pregnant people or people attempting to become pregnant. Because of the theoretical risk to the fetus, people should be counseled to avoid becoming pregnant for 28 days after receiving a live-virus (e.g., MMR) vaccine.

Precautions

Personal or family history of seizures of any etiology.

Compared with administration of separate MMR and varicella vaccines at the same visit, use of MMRV vaccine is associated with a higher risk for fever and febrile seizures 5–12 days after the first dose among children aged 12–23 months. Approximately 1 additional febrile seizure occurs for every 2,300–2,600 MMRV vaccine doses administered. Use of separate MMR and varicella vaccines avoids this increased risk for fever and febrile seizures.

Thrombocytopenia

The benefits of primary immunization are usually greater than the potential risks for vaccine- associated thrombocytopenia. Avoid giving subsequent doses of MMR or MMRV vaccine, however, if an episode of thrombocytopenia occurred ≤6 weeks after a previous dose of vaccine.

Postexposure Prophylaxis

Measles-containing vaccine or immune globulin (IG) can be effective as postexposure prophylaxis. MMR or MMRV administered ≤72 hours after initial exposure to measles virus might provide some protection. If the exposure does not result in infection, the vaccine should induce protection against subsequent measles virus infection.

When administered ≤6 days of exposure, IG can be used to confer temporary immunity in a susceptible person. If the exposure does not result in modified or typical measles, vaccination with MMR or MMRV is still necessary to provide long-lasting protection. Six months after receiving intramuscularly administered IG, or 8 months after receiving intravenously administered IG, administer MMR or MMRV vaccine, provided the patient is aged ≥12 months and the vaccine is not otherwise contraindicated.

CDC website: Measles

The following authors contributed to the previous version of this chapter: Paul A. Gastañaduy, James L. Goodson

Bibliography

Centers for Disease Control and Prevention. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-04):1–34.

 Gastañaduy P, Redd S, Clemmons N, Lee AD, Hickman CJ, Rota PA, et al. Measles. In: Roush SW, Baldy LM, Kirkconnell Hall MA, editors. Manual for the surveillance of vaccine-preventable diseases. Atlanta: Centers for Disease Control and Prevention; 2019. Available from: www.cdc.gov/vaccines/pubs/surv-manual/chpt07-measles.html .

Hyle EP, Fields NF, Fiebelkorn AP, Taylor Walker A, Gastañaduy P, Rao SR, et al. The clinical impact and cost-effectiveness of measles-mumps-rubella vaccination to prevent measles importations among US international travelers. Clin Infect Dis. 2019;69(2):306–15.

Hyle EP, Rao SR, Bangs AC, Gastañaduy P, Parker Fiebelkorn A, Hagmann SHF, et al. Clinical practices for measles-mumps-rubella vaccination among US pediatric international travelers. JAMA Pediatr. 2020;174(2):e194515.

Hyle EP, Rao SR, Jentes ES, Parker Fiebelkorn A, Hagmann SHF, Taylor Walker A, et al. Missed opportunities for measles, mumps, rubella vaccination among departing U.S. adult travelers receiving pretravel health consultations. Ann Intern Med. 2017;167(2):77–84.

Lee AD, Clemmons NS, Patel M, Gastañaduy PA. International importations of measles virus into the United States during the post-elimination era, 2001–2016. J Infect Dis. 2019;219(10):1616–23.

National Notifiable Diseases Surveillance System. Measles (rubeola): 2013 case definition. Atlanta: CDC; 2013. Available from: https://ndc.services.cdc.gov/conditions/measles/ .

Patel MK, Goodson JL, Alexander JP Jr., Kretsinger K, Sodha SV, Steulet C, et al. Progress toward regional measles elimination—Worldwide, 2000–2019. MMWR Morb Mortal Wkly Rep. 2020;69(45):1700–5.

Pike J, Leidner AJ, Gastañaduy PA. A review of measles outbreak cost estimates from the US in the post-elimination era (2004–2017): Estimates by perspective and cost type. Clin Infect Dis. 2020;1(6):1568–76.

World Health Organization. Measles vaccines: WHO position paper—April 2017. Wkly Epidemiol Rec. 2017;92(17):205–27.

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Togliatti: A city shaped by cars, mountains and Italian Communist

The city's surroundings also have their places of interest. The great Russian river Volga amazes with its breadth, loftiness, expanse and beauty. A cruise around will be a real pleasure, as Zhiguli mountains are exceptionally picturesque in the background.

Togliatti is the second largest city in the Samara region, 500 miles southeast of Moscow. At the moment it has a population of about 720 thousand people.

The city's name was changed to Togliatti in 1964, after Palmiro Togliatti, the longest-serving secretary of the Italian Communist Party. Prior to this, it was known as Stavropol-on-Volga.

The city's main claim to fame has been automobile manufacturing by AvtoVAZ's Lada (Zhiguli) car plants, employing some 110,000 people: in cooperation with Italy's Fiat since 1970 and with General Motors since 2001.

In 2011 the Togliatti Special Economic Zone was first introduced to further develop the region and diversify the economy of the city. Several auto-component producers have since been registered, as well as large industrial manufacturers.

Togliatti has been considered as Russia's automotive capital. The car manufacturing company, covering an area of 500 hectares, was constructed in a record short time.

This particular car was promoted by the Russian President himself. Vladimir Putin make 2,000-kilometer drive across Siberia in this canary-yellow Lada Kalina in 2010.

The culture in the City of Togliatti is the unique phenomenon for a young Russian city that has an interesting 272 – year history.

Taking a bird-eye's view and you will admire how generous nature is to the city. Togliatti lies on vast steppes, on the bank of the Volga the great Russian river, close to the ancient Zhiguli mountains.

The city blends well with the surrounding land, keeping the harmony of nature.

The city's transport infrastructure is linked to the international airport Kurumoch, situated about 60 km outside Togliatti. Two railway stations and a river port are also available for external transportation.

Due to its unique geographic position Togliatti can be a continental level hub, connecting North and South Eurasia by waterway.

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