Immunizations — required vaccines

by Alan M. Spira, M.D.

(Third of three parts)

In the prior two issues, routine and travel-specific immunizations held our attention. Now we turn to immunizations which are “required” and relevant to travelers.

There is good news, here. The only immunization mandated by international law is that for yellow fever, through the International Health Regulations (IHR) of the United Nations via the World Health Organization. This document was reratified in 2005 at the World Assembly of the U.N.

So immunization with yellow fever vaccine can be required by international law. In the IHR, all signatories to the United Nations charter are obliged to follow all directives, including immunization requirements.

Yellow fever is a dangerous viral disease found only in tropical America south of the Panama Canal and sub-Saharan Africa; it is endemic in 11 countries in Latin America and 33 countries in Africa. There is no yellow fever virus in Asia.

This disease was once widespread, even in the United States, with large outbreaks occurring in Philadelphia in 1793 and many in New Orleans up to the 20th century. This disease, along with malaria, kept the French from building the Panama Canal.

It is estimated that there are over 200,000 cases of yellow fever annually, with 30,000 deaths, most occurring in sub-Saharan Africa. There have been several deaths in travelers from yellow fever infection in the past several years, all in cases where the travelers were not immunized. It is estimated that the real number of yellow fever cases is substantially underreported and that the virus may be found beyond the officially designated zones.

Visitors to countries are more likely to face hassles at Immigration stations of airports and ports than the risk of contracting this bad disease. There are many countries which require yellow fever immunization of travelers who either transit through or arrive from countries with infected areas (even if the traveler did not enter those areas aside from a refueling stop at an airport!).

If a traveler has been through a yellow fever endemic area, a country has the right to refuse passage or demand immunization (with a 10-day “quarantine”) upon arrival. Sometimes, the Immigration officials are looking for baksheesh rather than proof that the traveler is truly immunized. To avoid this aggravation, travelers should keep their International Certificate of Vaccination (ICV) in their passports.

The ICV must be filled out exactly as directed on the form and signed in ink (not a stamp signature) or it is not valid. The vaccine should be given at least 10 days prior to entry. Only health providers with specific licenses issued by state medical boards can administer this vaccine. Once given, it is officially valid for 10 years.

As it is a live vaccine, there are several health considerations, such as not giving it to immunocompromised travelers, but it has nonetheless been safely used for over 75 years.

Cholera used to be a required immunization, but the World Health Organization no longer endorses it and travelers do not need it.

Meningitis vaccine is required by the government of Saudi Arabia for all pilgrims who are partaking in the Hajj or Umra. Those travelers who arrive without proof of immunization will be forced into getting it there.

Travel medicine specialists will know about any disease outbreaks around the globe, what precautions to take and which vaccines to recommend. You can find a list of such specialists online at and ITN

Dr. Spira is medical director of the Travel Medicine Center, 131 N. Robertson Blvd., Beverly Hills, CA 90211; visit