title: Refusal of recommended travel-related vaccines among U.S. international travellers in Global TravEpiNet.
abstract: BACKGROUND
  International travellers are at risk of travel-related, vaccine-preventable diseases. More data are needed on the proportion of travellers who refuse vaccines during a pre-travel health consultation and their reasons for refusing vaccines.
  
  
  METHODS
  We analyzed data on travellers seen for a pre-travel health consultation from July 2012 through June 2014 in the Global TravEpiNet (GTEN) consortium. Providers were required to indicate one of three reasons for a traveller refusing a recommended vaccine: (1) cost concerns, (2) safety concerns or (3) not concerned with the illness. We calculated refusal rates among travellers eligible for each vaccine based on CDC recommendations current at the time of travel. We used multivariable logistic regression models to examine the effect of individual variables on the likelihood of accepting all recommended vaccines.
  
  
  RESULTS
  Of 24 478 travellers, 23 768 (97%) were eligible for at least one vaccine. Travellers were most frequently eligible for typhoid (N = 20 092), hepatitis A (N = 12 990) and influenza vaccines (N = 10 539). Of 23 768 eligible travellers, 6573 (25%) refused one or more recommended vaccine(s). Of those eligible, more than one-third refused the following vaccines: meningococcal: 2232 (44%) of 5029; rabies: 1155 (44%) of 2650; Japanese encephalitis: 761 (41%) of 1846; and influenza: 3527 (33%) of 10 539. The most common reason for declining vaccines was that the traveller was not concerned about the illness. In multivariable analysis, travellers visiting friends and relatives (VFR) in low or medium human development countries were less likely to accept all recommended vaccines, compared with non-VFR travellers (OR = 0.74 (0.59-0.95)).
  
  
  CONCLUSIONS
  Travellers who sought pre-travel health care refused recommended vaccines at varying rates. A lack of concern about the associated illness was the most commonly cited reason for all refused vaccines. Our data suggest more effective education about disease risk is needed for international travellers, even those who seek pre-travel advice.
authors: Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, MA, USA.
authors: Sara M
authors: SM
authors: Lammert
authors: Department of Surgery, Boston University Medical Center, Boston, MA, USA.
authors: Sowmya R
authors: SR
authors: Rao
authors: Division of Global Migration and Quarantine, Travelers' Health Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors: Emily S
authors: ES
authors: Jentes
authors: Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA.
authors: Jessica K
authors: JK
authors: Fairley
authors: Division of Global Migration and Quarantine, Travelers' Health Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors: Stefanie
authors: S
authors: Erskine
authors: Division of Global Migration and Quarantine, Travelers' Health Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors: Allison T
authors: AT
authors: Walker
authors: Division of Pediatric Infectious Diseases, Bronx-Lebanon Hospital Center, Bronx, NY.
authors: Stefan H
authors: SH
authors: Hagmann
authors: Division of Global Migration and Quarantine, Travelers' Health Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
authors: Mark J
authors: MJ
authors: Sotir
authors: Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, MA, USA.|Harvard Medical School, Boston, MA.
authors: Edward T
authors: ET
authors: Ryan
authors: Travelers' Advice and Immunization Center, Massachusetts General Hospital, Boston, MA, USA rclarocque@partners.org.|Harvard Medical School, Boston, MA.
authors: Regina C
authors: RC
authors: LaRocque
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D014195:Travel; D016312:Treatment Refusal / Q000706:statistics & numerical data*; D014481:United States; D014611:Vaccination / Q000706:statistics & numerical data*
keywords: International travel; vaccine refusal