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Clinical Policy Bulletin:
Vaccines for Travel
Number: 0473


Policy

Notes: Most Aetna HMO plans exclude coverage of vaccines for travel.  Most Aetna traditional plans cover medically necessary travel vaccines for members of plans with preventive services benefits.  Please check benefit plan descriptions.

The following table lists vaccines that may be required for travel, and their medically necessary indications, standard administration schedule, and contraindications:

Vaccine Standard Schedule Indications Precautions and Contraindications
Cholera

Primary: 0.5 ml intramuscularly or subcutaneously, or 0.2 ml intradermally, 2 doses 1 week to 1 month apart at least 6 days before travel.

Booster: 0.5 ml intramuscularly or subcutaneously or 0.2 ml intradermally every 6 months.

Travel to endemic areas. No longer required under international health regulations. Safety in pregnancy unknown; previous severe local or systemic reaction.

Meningococcal polysaccharide (see CPB 0356 - Meningococcal Vaccine)

Primary: 1 dose (0.5 ml) subcutaneously or intramuscularly.

Booster: not recommended

Travel to areas with epidemic meningococcal disease. Safety in pregnancy unknown.
Typhoid, inactivated bacteria

Primary: 2 doses (0.5 ml) subcutaneously given 4 or more weeks apart.

Booster: 0.5 ml subcutaneously or 0.1 ml intradermally, every 3 years.

Risk of exposure to typhoid fever. Previous severe local or systemic reaction.
Typhoid, attenuated live bacteria Primary: 4 oral doses; re-immunize every 5 years. Risk of exposure to typhoid fever. Immuno-compromised host ; enteric illness; concurrent antimicrobial treatment.
Oral polio (see CPB 0402 - Polio Vaccine)

Childhood dose: injectable vaccine is preferred; 4 doses administered before school entry, at 2, 4 and 6 to 18 months and 4 to 6 years.

Adult dose: 1 oral dose.

One-time booster for previously immunized persons; complete the series in partially immunized adults; alternative to inactivated vaccine when there is less than 1 month before travel exposure; not used for primary immunization in persons 18 years old or older. Immuno-compromised host or immuno-compromised contacts or recipients.
Yellow fever

Primary: 1 dose (0.5 ml) subcutaneously, 10 days to 10 years before travel.

Booster: every 10 years.

As requested by individual countries. Avoid in pregnant women, unless engaged in high-risk travel; immuno-compromised host; hypersensitivity to eggs.
Hepatitis B (see CPB 0410 - Hepatitis B Vaccine)

Primary: 2 doses (10 mg/dose) intramuscularly in deltoid, 1 month apart; third dose 5 months after second.

Booster: not routinely recommended.

For health care workers* in contact with blood; persons residing for more than 6 months in areas of high endemnicity of hepatitis B surface antigen; others at risk. Safety to fetus is unknown; pregnancy not a contraindication in high-risk persons.
Hepatitis A (see CPB 0048 - Hepatitis A Vaccine)

Primary: 2 doses, 0 and 6 to 12 months.

Booster: The need for periodic booster doses has not been established.

Men who have sex with men; IV drug users; certain populations (e.g., Pacific Islander, Native Americans, and Alaska Native Populations); institutionalized persons and workers in these institutions*; travelers to endemic countries.  
Inactivated polio (see CPB 0402 - Polio Vaccine)

Childhood dose: 4 doses administered before school entry, at 2, 4 and 6 to 18 months and 4 to 6 years.

Adult primary dose: 2 doses (0.5 ml) subcutaneously, 4 to 8 weeks apart; third dose 6 to 12

Preferred for primary immunization; one-time booster dose for travelers. Safety in pregnancy unknown; anaphylactic reactions to streptomycin and neomycin.
Japanese B encephalitis Primary: 3 doses (1.0 ml) subcutaneously on days 0, 7, and 30 or at weekly intervals. Travel to areas of risk with rural exposure or prolonged residence. Pregnancy; allergy to mice or rodents; immuno-compromised host.
Rabies (human diploid-cell vaccine)

Pre-exposure: 1 ml intramuscularly in deltoid on days 0, 7, and 21 or 28; or 0.1 ml intradermally, on days 0, 7, and 21 or 28.

Booster: every 2 years or when antibody titer falls below acceptable level.

For persons at high-risk of rabies exposure including international travelers who are likely to come in contact with animals in areas where dog rabies is enzootic. Allergy to previous doses; may be given in pregnancy if indicated; intradermal route should be completed 30 days or more before travel; intradermal route should not be used with concurrent chloroquine administration.
Lyme vaccine (LYMErix)††

Primary: 3 doses, 30 mg/0.5 ml, with the second dose 1 month after the first, and the third dose given at 1 year.

Booster: The need for periodic booster doses has not been established.

Age 15 to 70 and live, work,* or travel or take part in regular recreational activities that make them likely to come into contact with infected deer ticks. Hypersensitivity to vaccine; safety in pregnancy unknown; not tested in pediatric patients less than 15 years of age.

Persons who are immunocompromised because of immune deficiency diseases, leukemia, lymphoma, generalized cancer, or the acquired immunodeficiency syndrome, or who are receiving immunosuppressive therapy with corticosteroids, alkylating agents, anti-metabolites, or radiation.

†† LYMErix was withdrawn from the U.S. market in February 2002.

* Most Aetna benefit plans exclude coverage of vaccines for work.  Please check benefit plan descriptions.

Note: Many of these vaccines may also be considered medically necessary for reasons other than travel, and may be covered when medically necessary in members with preventive benefits, regardless of whether the plan excludes coverage of travel vaccines.

Note: Malaria vaccine for travel is considered experimental and investigational because an effective malaria vaccine has yet to be developed.

Note: The Advisory Committee on Immunization Practices (1996) states that plague vaccination is not indicated for most travelers to countries in which cases of plague have been reported.



Background

The Centers for Disease Control and Prevention (CDC)'s recommended vaccinations for travelers can be found at the following website: http://wwwn.cdc.gov/travel/contentVaccinations.aspx.

In a Cochrane review on vaccines for preventing malaria, Graves and Gelband (2006a) concluded that there is no evidence for protection by SPf66 vaccines against P. falciparum in Africa.  There is a modest reduction in attacks of P. falciparum malaria following vaccination with SPf66 in South America.  There is no justification for further trials of SPf66 in its current formulation.  Further research with SPf66 vaccines in South America or with new formulations of SPf66 may be justified.

In another Cochrane review, Graves and Gelband (2006b) concluded that the MSP/RESA (Combination B) vaccine shows promise as a way to reduce the severity of malaria episodes, but the effect of the vaccine is MSP2 variant-specific.  Pre-treatment for malaria during a vaccine trial makes the results difficult to interpret, particularly with the relatively small sample sizes of early trials.  The results show that blood-stage vaccines may play a role and merit further development.

Vaughan et al (2009) presented a comprehensive meta-analysis of more than 500 references, describing nearly 5,000 unique B cell and T cell epitopes derived from the Plasmodium genus, and detailing thousands of immunological assays.  This was the first inventory of epitope data related to malaria-specific immunology, plasmodial pathogenesis, and vaccine performance.  The survey included host and pathogen species distribution of epitopes, the number of antibody versus CD4(+) and CD8(+) T cell epitopes, the genomic distribution of recognized epitopes, variance among epitopes from different parasite strains, and the characterization of protective epitopes and of epitopes associated with parasite evasion of the host immune response.  The results identified knowledge gaps and areas for further investigation.  This information has relevance to issues, such as the identification of epitopes and antigens associated with protective immunity, the design and development of candidate malaria vaccines, and characterization of immune response to strain polymorphisms.

Currently, there is an ongoing phase III clinical trial of a candidate vaccine for malaria, but the study has not been completed (Birkett, 2010).

The Advisory Committee on Immunization Practices (ACIP) of the CDC provided the following recommendations regarding the prevention of plague (1996):

  • Routine plague vaccination is not necessary for individuals living in areas in which plague is enzootic.
  • Plague vaccination is not indicated for hospital staff or other medical personnel in such areas.
  • Plague vaccination is not indicated for most travelers to countries in which cases of plague have been reported.
 
CPT Codes/ HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
90632
90633
90634
90636
90675
90676
90690
90691
90692
90712
90713
90717
90725
90733
90734
90735
90738
90740
90743
90744
90746
90747
90748
Other CPT codes related to the CPB:
90460
+90461
90471
+ 90472
90473
+ 90474
90644
90727
HCPCS codes covered if selection criteria are met:
G0010 Administration of hepatitis B vaccine
ICD-9 codes covered if selection criteria are met:
V03.0 Need for prophylactic vaccination and inoculation against cholera alone
V03.1 Need for prophylactic vaccination and inoculation against typhoid-paratyphoid alone [TAB]
V04.0 Need for prophylactic vaccination and inoculation against bacterial diseases, poliomyelitis
V04.4 Need for prophylactic vaccination and inoculation against yellow fever
V04.5 Need for prophylactic vaccination and inoculation against rabies
V04.89 Need for prophylactic vaccination and inoculation against other viral diseases
V05.0 Need for prophylactic vaccination and inoculation against arthropod-borne viral encephalitis
V05.3 Need for prophylactic vaccination and inoculation against viral hepatitis
V06.0 Need for prophylactic vaccination and inoculation against cholera with typhoid-paratyphoid [cholera+TAB]
V06.2 Need for prophylactic vaccination and inoculation against diphtheria-tetanus-pertussis, with typhoid-paratyphoid [DTP+TAB]
V06.3 Need for prophylactic vaccination and inoculation against combinations of diseases, diphtheria-tetanus-pertussis with poliomyelitis [DTP-polio]
Other ICD-9 codes related to the CPB:
001.0 - 001.9 Cholera
002.0 Typhoid and paratyphoid
042 Human immunodeficiency virus [HIV] disease
045.0 - 045.9 Acute poliomyelitis
060.0 - 060.9 Yellow fever
062.0 Japanese encephalitis
070.0 - 070.1 Viral hepatitis A
070.20 - 070.23, 070.30 - 070.33 Viral hepatitis B
071 Rabies
088.81 Lyme disease
140.0 - 208.91 Malignant neoplasm
279.00 - 279.09 Disorders involving the immune mechanism
V08 Asymptomatic human immunodeficiency virus [HIV] infection status
V58.0 Encounter for radiotherapy
V58.69 Long-term (current) use of other medications


The above policy is based on the following references:
  1. Centers for Disease Control and Prevention (CDC). Recommendations for the use of Lyme disease vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1999;48(RR-7):1-17, 21-25.
  2. Centers for Disease Control and Prevention (CDC). Update: Recommendations to prevent hepatitis B virus transmission -- United States. MMWR Morbid Mortal Wkly Rep. 1995:44(30):574-575.
  3. Centers for Disease Control and Prevention (CDC). Update: Recommendations to prevent hepatitis B virus transmission -- United States. MMWR Morbid Mortal Wkly Rep. 1999;48(2):33-34.
  4. Centers for Disease Control and Prevention (CDC). Prevention of hepatitis A through active or passive immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep. 1999;48(RR-12):1-37.
  5. Centers for Disease Control and Prevention (CDC). Prevention and control of meningococcal disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep. 2000;49(RR-7):1-10.
  6. Centers for Disease Control and Prevention (CDC). Recommendations of the Advisory Committee on Immunization Practices: Revised recommendations for routine poliomyelitis vaccination. MMWR Morbid Mortal Wkly Rep. 1999;48(27):590.
  7. Centers for Disease Control (CDC). Rabies prevention -- United States, 1984. MMWR Morbid Mortal Wkly Rep. 1984;33(28):393-402, 407-408.
  8. No authors listed. Cholera vaccine. MMWR Morbid Mortal Wkly Rep. 1988;37(40):617-618, 623-624.
  9. Centers for Disease Control and Prevention (CDC). Typhoid immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morbid Mortal Wkly Rep. 1990;39(RR-10):1-5.
  10. Cetron MS, Marfin AA, Julian KG, et al. Yellow fever vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2002. MMWR Morbid Mortal Wkly Rep. 2002;51(RR-17):1-11.
  11. Centers for Disease Control and Prevention (CDC). Inactivated Japanese encephalitis virus vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1993;42(RR-1):1-15.
  12. Marfin AA, Eidex RS, Kozarsky PE, Cetron MS. Yellow fever and Japanese encephalitis vaccines: Indications and complications. Infect Dis Clin North Am. 2005;19(1):151-168, ix.
  13. Wilder-Smith A. Meningococcal disease in international travel: Vaccine strategies. J Travel Med. 2005;12 Suppl 1:S22-S29.
  14. Arguin PM, Kozarsky PE, Reed C, eds. CDC Health Information for International Travel, 2008. St. Louis, MO: Mosby; 2007. Available at: http://wwwn.cdc.gov/travel/contentYellowBook.aspx. Accessed July 16, 2007.
  15. Graves PM, Deeks JJ, Demicheli V, Jefferson T. Vaccines for preventing cholera: Killed whole cell or other subunit vaccines (injected). Cochrane Database Syst Rev. 2001;(1):CD000974.
  16. Fraser A, Goldberg E, Acosta CJ, et al. Vaccines for preventing typhoid fever. Cochrane Database Syst Rev. 2007;(3):CD001261.
  17. Schiøler KL, Samuel M, Wai KL Vaccines for preventing Japanese encephalitis. Cochrane Database Syst Rev. 2007;(3):CD004263.
  18. Carroll ID, Williams DC. Pre-travel vaccination and medical prophylaxis in the pregnant traveler. Travel Med Infect Dis. 2008;6(5):259-275.
  19. Ritz N, Connell TG, Curtis N. To BCG or not to BCG? Preventing travel-associated tuberculosis in children. Vaccine. 2008;26(47):5905-5910.
  20. Graves P, Gelband H. Vaccines for preventing malaria (SPf66). Cochrane Database Syst Rev. 2006a;(2):CD005966.
  21. Graves P, Gelband H. Vaccines for preventing malaria (blood-state). Cochrane Database Syst Rev. 2006b;(4):CD006199.
  22. Vaughan K, Blythe M, Greenbaum J, et al. Meta-analysis of immune epitope data for all Plasmodia: Overview and applications for malarial immunobiology and vaccine-related issues. Parasite Immunol. 2009;31(2):78-97.
  23. Jelinek T. Ixiaro: A new vaccine against Japanese encephalitis. Expert Rev Vaccines. 2009;8(11):1501-1511.
  24. Fischer M, Lindsey N, Staples JE, Hills S; Centers for Disease Control and Prevention (CDC). Japanese encephalitis vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-1):1-27.
  25. Birkett A. MVI discusses what's on the horizon for malaria vaccine development. Bethesda, MD: The PATH Malaria Vaccine Initiative; 2010. Available at: http://www.malariavaccine.org/RD_Strategy_QA.php. Accessed April 30, 2010.
  26. Gautret P, Wilder-Smith A. Vaccination against tetanus, diphtheria, pertussis and poliomyelitis in adult travellers. Travel Med Infect Dis. 2010;8(3):155-160.
  27. Staples JE, Gershman M, Fischer M; Centers for Disease Control and Prevention (CDC). Yellow fever vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-7):1-27.
  28. Centers for Disease Control and Prevention (CDC). The Yellow Book. CDC Health Information for International Travel 2012. New York, NY: Oxford University Press; 2011.
  29. Centers for Disease Control and Prevention. Prevention of plague: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 1996;45(No. RR-14). Available at: ftp://ftp.cdc.gov/pub/Publications/mmwr/rr/rr4514.pdf. Accessed April 26, 2012.
  30. American Academy of Pediatrics Committee on Infectious Diseases. Poliovirus. Pediatrics. 2011;128(4):805-808.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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