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:

Table: List of Vacccines

Vaccine	Standard Schedule	Indications	Precautions and Contraindications
Cholera	Single dose of lyophilized CVD 103-HgR (Vaxchora, PaxVax, Redwood City, California), a single-dose, live attenuated oral cholera vaccine.	Travel to endemic areas. No longer required under international health regulations.	Safety in pregnancy unknown.
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 hostFootnotes for Persons who are immunocompromised†; 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 hostFootnotes for Persons who are immunocompromised† 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 hostFootnotes for Persons who are immunocompromised†; 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 workersFootnotes for Aetna benefit plans* 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 institutionsFootnotes for Aetna benefit plans*; 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.Footnotes for Persons who are immunocompromised†
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)Footnotes for 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,Footnotes for Aetna benefit plans* 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.
Measles	Infants 6 months through 11 months of age should receive 1 dose of MMR vaccine.  Infants who get 1 dose of MMR vaccine before their 1st birthday should get 2 more doses (1 dose at 12 through 15 months of age and another dose at least 28 days later). Children 12 months of age and older should receive 2 doses of MMR vaccine separated by at least 28 days. Teenagers and adults who do not have evidence of immunity against measles should get 2 doses of MMR vaccine separated by at least 28 days.  Acceptable presumptive evidence of immunity against measles includes at least one of the following: written documentation of adequate vaccination, laboratory evidence of immunity, laboratory confirmation of measles, or birth in the United States before 1957.	Risk of exposure to measles.	Contraindications: Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapy or patients with human immunodeficiency virus [HIV] infection who are severely immunocompromised).  Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered.  HIV-infected children may receive varicella and measles vaccine if CD4+ T-lymphocyte count is greater than 15 %. Pregnancy Precautions: Moderate or severe acute illness with or without fever Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product).  Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered History of thrombocytopenia or thrombocytopenic purpura Need for tuberculin skin testing.  Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be administered on the same day as tuberculin skin testing. If testing cannot be performed until after the day of MMR vaccination, the test should be postponed for at least 4 weeks after the vaccination. If an urgent need exists to skin test, do so with the understanding that reactivity might be reduced by the vaccine.

Footnotes^† 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.

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

Footnotes^* 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.

Note: Oral or skin-patch cholera vaccine for prevention of entero-toxigenic Escherichia coli diarrhea is considered experimental and investigational because their clinical value has not been established.

Note: Dengue vaccine for travel is considered experimental and investigational because its clinical value has not been established, and there is no FDA-approved vaccine available in the United States.

Background

The Centers for Disease Control and Prevention (CDC)'s recommended vaccinations for travelers can be found at the following website: Destinations and Travelers Health.

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.

In a Cochrane review, Ahmed et al (2013) evaluated the safety, effectiveness, and immunogenicity of vaccines for preventing entero-toxigenic Escherichia coli (ETEC) diarrhea.  These investigators searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and ClinicalTrials up to December 2012.  Randomized controlled trials (RCTs) and quasi-RCTs comparing use of vaccines to prevent ETEC with use of no intervention, a control vaccine (either an inert vaccine or a vaccine normally given to prevent an unrelated infection), an alternative ETEC vaccine, or a different dose or schedule of the same ETEC vaccine in healthy adults and children living in endemic regions, intending to travel to endemic regions, or volunteering to receive an artificial challenge of ETEC bacteria were included for analysis.  Two authors independently assessed each trial for eligibility and risk of bias.  Two independent reviewers extracted data from the included studies and analyzed the data using Review Manager (RevMan) software.  They reported outcomes as risk ratios (RR) with 95 % confidence intervals (CI) and assessed the quality of the evidence using the GRADE approach.  A total of 24 RCTs, including 53,247 participants, met the inclusion criteria – 4 studies assessed the protective efficacy of oral cholera vaccines when used to prevent diarrhea due to ETEC and 7 studies assessed the protective efficacy of ETEC-specific vaccines.  Of these 11 studies, 7 studies presented efficacy data from field trials and 4 studies presented efficacy data from artificial challenge studies.  An additional 13 trials contributed safety and immunological data only.  The currently available, oral cholera killed whole cell vaccine (Dukoral^®) was evaluated for protection of people against "travelers' diarrhea" in a single RCT in people arriving in Mexico from the USA.  These researchers did not identify any statistically significant effects on ETEC diarrhea or all-cause diarrhea (1 trial, 502 participants; low-quality evidence).  Two earlier trials, one undertaken in an endemic population in Bangladesh and one undertaken in people travelling from Finland to Morocco, evaluated a precursor of this vaccine containing purified cholera toxin B subunit rather than the recombinant subunit in Dukoral^®.  Short-term protective efficacy against ETEC diarrhea was demonstrated, lasting for around 3 months (RR 0.43, 95 % CI: 0.26 to 0.71; 2 trials, 50,227 participants).  This vaccine is no longer available.  An ETEC-specific, killed whole cell vaccine, which also contains the recombinant cholera toxin B-subunit, was evaluated in people traveling from the USA to Mexico or Guatemala, and from Austria to Latin America, Africa, or Asia.  These investigators did not identify any statistically significant differences in ETEC-specific diarrhea or all-cause diarrhea (2 trials, 799 participants), and the vaccine was associated with increased vomiting (RR 2.0, 95 % CI: 1.16 to 3.45; 9 trials, 1,528 participants).  The other ETEC-specific vaccines in development have not yet demonstrated clinically important benefits.  The authors concluded that there is currently insufficient evidence from RCTs to support the use of the oral cholera vaccine Dukoral^® for protecting travelers against ETEC diarrhea.  Moreover, they stated that further research is needed to develop safe and effective vaccines to provide both short- and long-term protection against ETEC diarrhea.

Also, an UpToDate review on "Travelers' diarrhea" (Wanke, 2014) states that "Use of vaccines to protect against travelers’ diarrhea is hindered by the varied pathogens that can cause it. Although enterotoxigenic E. coli (ETEC) predominates as an etiology of travelers’ diarrhea, vaccination strategies that have focused on this pathogen as a target have been suboptimal.  Although vaccination to protect against cholera is not routinely recommended for travelers, a number of trials suggest that the oral, killed whole-cell vaccine given with the nontoxic B subunit of cholera toxin (Dukoral) provides protection for travelers against ETEC infection.  The rationale for such protection is that the B subunit of cholera is antigenically similar to the heat-labile enterotoxin of ETEC.  In two randomized trials, the killed whole-cell vaccine combined with the B subunit of cholera toxin reduced the incidence of diarrhea caused by ETEC by 67 percent in a trial in Bangladesh and 52 percent among travelers to Morocco.  The Dukoral vaccine was approved in the United States in late 2006 for use as a travelers' diarrhea vaccine.  However, a conservative estimate that took into account the incidence of ETEC infection throughout the world and the efficacy of the vaccine suggested that it may prevent ≤7 percent of travelers' diarrhea cases.  The 2006 guidelines on travel medicine from the Infectious Diseases Society of America concluded that the decision to use the vaccine to prevent travelers' diarrhea must balance its cost, adverse effects, and limited utility against the known effectiveness and costs of self-treatment as described above.  A separate vaccination strategy for ETEC also appears to have limited utility.  Despite initial promising data on vaccination with heat-labile enterotoxin from ETEC via a skin patch, it was not effective in decreasing the incidence of moderate to severe diarrhea due to either ETEC or any cause in a randomized, placebo controlled trial that included 1,644 individuals who traveled to Mexico or Guatemala.  In a subgroup analysis, the vaccine provided modest protection against ETEC that produced only heat-labile enterotoxin (vaccine efficacy 61 percent [95 % CI, 7 to 84 percent]), but not ETEC that produced heat-stable toxin or both.  This highlights the limitations of a single-antigen vaccine for travelers’ diarrhea".

An UpToDate review on "Immunizations for travel" (Freedman and Leder, 2015) states that "In general, severely immunocompromised patients should not receive live vaccines.  Live vaccines include yellow fever vaccine, oral typhoid vaccine, nasal influenza vaccine, oral polio vaccine (OPV), MMR, and varicella vaccine.  Inactivated vaccines include meningococcal vaccine, parenteral typhoid vaccine, hepatitis A and B vaccines, rabies vaccine, Japanese encephalitis vaccine, inactivated influenza vaccine, inactivated polio vaccine (IPV), Tdap, and Td".

Measles

Jost and colleagues (2015) evaluated the relevance of travel-related measles, a highly transmissible and vaccine-preventable disease. Between 2001 and 2013, surveillance and travel-related measles data were systematically reviewed according to the PRISMA guidelines with extraction of relevant articles from Medline, Embase, GoogleScholar and from public health authorities in the Region of the Americas, Europe and Australia.  From a total of 960 records, 44 articles were included and they comprised 2,128 imported measles cases between 2001 and 2011.  The proportion of imported cases in Europe was low at 1 to 2 %, which reflected the situation in a measles-endemic region.  In contrast, imported and import-related measles accounted for up to 100 % of all cases in regions with interrupted endemic measles transmission; 11 air-travel related reports described 132 measles index cases leading to 47 secondary cases.  Secondary transmission was significantly more likely to occur if the index case was younger or when there were multiple infectious cases on board.  Further spread to health care settings was found.  Measles cases associated with cruise ship travel or mass gatherings were sporadically observed.  The authors concluded that within both, endemic and non-endemic home countries, pre-travel health advice should assess MMR immunity routinely to avoid measles spread by non-immune travelers.  They stated that to identify measles spread as well as to increase and sustain high vaccination coverages, joint efforts of public health specialists, health care practitioners and travel medicine providers are needed.

An UpToDate review on "Immunizations for travel" (Freedman and Leder, 2016) states that "Children traveling outside the United States should receive MMR vaccination sooner than the standard immunization schedule. Prior to departure, children 12 months of age or older should have received 2 doses of MMR vaccine separated by at least 28 days, with the first dose administered on or after the first birthday.  Children aged 6 to 11 months should receive 1 dose of MMR before departure.  MMR vaccination for adults is indicated for individuals born in 1957 or later in the United States (before 1970 in Canada; before 1966 in Australia) without evidence of immunity or without evidence of 2 doses of an adequate live vaccine at any time after age 12 months.  Although individuals born before 1957 in the United States are presumed to be immune (exceptions include United States healthcare workers and women of childbearing age), 2 doses of MMR vaccine spaced by 1 month should be strongly considered for unvaccinated individuals without other evidence of immunity who were born before 1957 (in the United States) and are traveling for purposes of healthcare or humanitarian work potentially entailing close contact with ill individuals.  MMR vaccination is contraindicated in pregnant and immunocompromised patients".

The CDC (2015) states that anyone who is not protected against measles is at risk of getting infected when they travel internationally. It recommends the following: Centers for Disease Control and Prevention.

• Infants 6 months through 11 months of age should receive 1 dose of MMR vaccineFootnotes for MMR vaccines for infants^†
• Children 12 months of age and older should receive 2 doses of MMR vaccine separated by at least 28 days.
• Teenagers and adults who do not have evidence of immunityFootnotes for Acceptable presumptive evidence of immunity against measles^* against measles should get 2 doses of MMR vaccine separated by at least 28 days.

Footnotes^† Infants who get 1 dose of MMR vaccine before their first birthday should get 2 more doses (1 dose at 12 through 15 months of age and another dose at least 28 days later).

Footnotes^* Acceptable presumptive evidence of immunity against measles includes at least one of the following: written documentation of adequate vaccination, laboratory evidence of immunity, laboratory confirmation of measles, or birth in the United States before 1957.

Contraindications and Precautions: Vaccine Recommendations and Guidelines of the ACIP.

Contraindications

• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
• Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, or long-term immunosuppressive therapyFootnotes for deferred vaccine^† or patients with human immunodeficiency virus [HIV] infection who are severely immunocompromised)Footnotes for HIV infected children^*
• Pregnancy

Footnotes^† Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered.

Footnotes^* HIV-infected children may receive varicella and measles vaccine if CD4+ T-lymphocyte count is greater than 15 %.

Precautions

• Moderate or severe acute illness with or without fever
• Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product)Footnotes for immune globulin products^†
• History of thrombocytopenia or thrombocytopenic purpura
• Need for tuberculin skin testingFootnotes for Measles vaccination^*

Footnotes^† Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered

Footnotes^* Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be administered on the same day as tuberculin skin testing. If testing cannot be performed until after the day of MMR vaccination, the test should be postponed for at least 4 weeks after the vaccination. If an urgent need exists to skin test, do so with the understanding that reactivity might be reduced by the vaccine.

Dengue Vacine

Dengue is a mosquito-borne flavivirus disease that has spread to several tropical and subtropical areas. The disease is caused by four closely related viruses, the Dengue viruses 1-4. Per the CDC Health Information for International Travel (2018), there is no vaccine against dengue available in the United States, and no prophylaxis treatment available to prevent dengue. There is one vaccine licensed for use in Mexico, the Philippines, Brazil and Thailand (CDC, 2018; WHO, 2018).

The first dengue vaccine, Dengvaxia (CYD-TDV) by Sanofi Pasteur, was first registered in Mexico in December, 2015. CYD-TDV is a live recombinant tetravalent dengue vaccine that has been evaluated as a 3-dose series on a 0/6/12 month schedule in Phase III clinical studies. It has been registered for use in individuals 9-45 years of age living in endemic areas (WHO, 2018) and 9-60 years of age for those living in high dengue endemic areas (Scott, 2016). Approximately five additional dengue vaccine candidates are in clinical development, with two candidates (developed by Butantan and Takeda) that are currently in Phase III trials (WHO, 2018). Butantan’s trial is being carried out in multiple sites in Brazil, whereas Takeda’s trial is being conducted worldwide; however, does not include the United States (Clinicaltrial.gov, NCT02406729 and NCT02747927). WHO recommends that countries should consider introduction of the dengue vaccine CYD-TDV only in geographic settings (national or subnational) where epidemiological data indicate a high burden of disease. Although dengue rarely occurs in the continental United States, it is endemic in Puerto Rico and in many popular tourist destinations in Latin America, Southeast Asia and the Pacific islands (CDC, 2018).

Contraindications include severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component, pregnancy and breastfeeding. Precautions include individuals on immunosuppressive therapy.

Japanese Encephalitis Vaccine for Pediatric Travelers

Taucher and colleagues (2020) stated that in an initial study among children from non-Japanese encephalitis (JE)-endemic countries, sero-protection rates (SPRs) remained high 6 months following completion of the primary series with IXIARO. In an open-label, follow-up study, a subset of 23 children who received a 2-dose primary series of IXIARO in the parent study, were examined for safety and neutralizing antibody persistence for 36 months.  SPRs remained high but declined from 100 % 1 month after primary immunization to 91.3 % at month 7 and 89.5 % at month 36. Geometric mean titers (GMTs) declined considerably from 384.1 by day 56-60.8 at month 36.  No long-term safety concerns were identified.  The authors concluded that the substantial decline in GMT observed in this study, together with previously published data on children vaccinated with IXIARO supported the recommendation for a booster dose in children who remain at risk of JE from 1 year after the primary series of IXIARO, consistent with the recommendation for adults.

Vaccines for Pregnant Travelers

Nasser and colleagues (2020) noted that pregnant travelers and their offspring are vulnerable to severe outcomes following a wide range of infections. Vaccine-preventable diseases can have a particularly severe course in pregnant women, but little is known about the safety of travel vaccines in pregnant women. These investigators carried out a systematic review of all published literature concerning the safety of vaccines frequently given to travelers such as yellow fever, MMR (mumps, measles and rubella), influenza, Tdap (tetanus, diphtheria and pertussis), meningococcus, hepatitis A and B, rabies, polio, typhoid fever, tick-borne encephalitis and Japanese encephalitis vaccines.  They included case series, cohort studies and RCTs. For the meta-analysis, these researchers included only RCTs that compared the administration of a vaccine to placebo or to no vaccine.  Outcome measures included severe systemic adverse events (AEs), maternal outcomes related to the course of pregnancy, neonatal outcomes and local AEs. They calculated the RR and its 95 % CI as the summary measure. The safety of influenza vaccine is supported by high-quality evidence.  For Tdap vaccine, no evidence of any harm was found in the meta-analysis of RCTs. A slight increase in chorioamnionitis rate was reported in 3 out of 12 observational studies.  However, this small possible risk is far out-weighed by a much larger benefit in terms of infant morbidity and mortality. Meningococcal vaccines are probably safe during pregnancy, as supported by RCTs comparing meningococcal vaccines to other vaccines.  Data from observational studies support the safety of hepatitis A, hepatitis B and rabies vaccines, as well as that of the live attenuated yellow fever vaccine.  The authors found little or no data about the safety of polio, typhoid, Japanese encephalitis, tick-borne encephalitis and MMR vaccines during pregnancy.

Table: CPT Codes/ HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
CPT codes covered if selection criteria are met:
90632	Hepatitis A vaccine (HepA), adult dosage, for intramuscular use
90633	Hepatitis A vaccine (HepA), pediatric/adolescent dosage-2 dose schedule, for intramuscular use
90634	Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for intramuscular use
90636	Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use
90675	Rabies vaccine, for intramuscular use
90676	Rabies vaccine, for intradermal use
90690	Typhoid vaccine, live, oral
90691	Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use
90707	Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use
90710	Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use
90713	Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use
90717	Yellow fever vaccine, live, for subcutaneous use
90733	Meningococcal polysaccharide vaccine, serogroups A, C, Y, W-135, quadrivalent (MPSV4), for subcutaneous use
90734	Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent, for intramuscular use
90738	Japanese encephalitis virus vaccine, inactivated, for intramuscular use
90740	Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use
90743	Hepatitis B vaccine (HepB), adolescent, 2 dose schedule, for intramuscular use
90744	Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use
90746	Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use
90747	Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4 dose schedule, for intramuscular use
90748	Hepatitis B and Haemophilus influenzae type b vaccine (Hib-HepB), for intramuscular use
CPT codes not covered for indications listed in the CPB:
90587	Dengue vaccine, quadrivalent, live, 3 dose schedule, for subcutaneous use
90625	Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use
Other CPT codes related to the CPB:
90460	Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component
+90461	each additional vaccine/toxoid component
90471	Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
+ 90472	each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)
90473	Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)
+ 90474	each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)
90644	Meningococcal conjugate vaccine, serogroups C & Y and Haemophilus influenzae type b vaccine (Hib-MenCY), 4 dose schedule, when administered to children 6 weeks-18 months of age, for intramuscular use
HCPCS codes covered if selection criteria are met:
G0010	Administration of hepatitis B vaccine
ICD-10 codes covered if selection criteria are met:
Z23	Encounter for immunization

The above policy is based on the following references: