The COVID-19 pandemic and monkeypox outbreak highlight a fundamental truth: communicable diseases cross borders readily, and vaccines, if accessible and not cost-prohibitive, present a critical strategy for limiting their impact.
Concern about global transmission of infectious diseases has risen — outbreaks since 2000 include SARS, H1N1 influenza, MERS, Ebola, chikungunya and Zika viruses, and of course, the COVID-19 pandemic and monkeypox. The U.S. Government Accountability Office (GAO) in July reported on air travel-related contact tracing in order to respond effectively to public health threats posed by international travel and stated specifically what travel medicine practitioners and the traveling public have seen first-hand in the last few years — that “air travel creates the potential for infectious diseases to move quickly from one part of the world to another.”
A National Academies of Sciences, Engineering, and Medicine Committee concluded recently that the Centers for Disease Control and Prevention (CDC) Division of Global Migration and Quarantine “should create an effective and innovative quarantine station model to confront new challenges in preventing the spread of infectious diseases in the U.S.” and commented that “the pace and variance of global infectious disease emergence has been accelerating at an alarming rate. This likely reflects a range of factors, including mass travel and migration, close animal/human interchange, and climate change.”
As clinician-educators, we take pride in recommending vaccines following guidance from the Advisory Committee on Immunization Practices Centers (ACIP) of the CDC. For those who cross borders, special vaccines protect against vaccine-preventable diseases to which travelers may be exposed during their journeys, and also prevent travelers from inadvertently bringing diseases home — thus reducing the risk of a domestic public health threat.
We know firsthand how some travelers forego vaccines to avoid incurring prohibitive out-of-pocket costs. A wide range of travelers, including missionaries, students, families, researchers, business and leisure travelers, are at risk for emerging and re-emerging infectious diseases endemic to their destinations. Non-travelers may also be at risk when infected travelers return home. We do not know when, or from where, the next outbreak will arise, but we know for certain that one will occur.
The time is now for the Biden administration’s Department of Health and Human Services (HHS) to endorse a scientifically sound, forward-thinking clarification of regulatory policy that has the support of bipartisan members of Congress and diverse public health stakeholders alike — by ensuring that all CDC-recommended, physician prescribed travel and other vaccines are covered by health insurance without patient cost-sharing. This is a matter of equity as well as individual and public health.
The U.S. government moved quickly and decisively to enact legislation that ensured ready availability of COVID-19 vaccines to all Americans without cost-sharing. Such legislation should not have been necessary, because existing law already requires that all CDC-recommended vaccines, without exception, be covered by health insurance with no cost sharing. Section 2713 of the Public Health Service Act, also known as the Preventive Care Mandate, addresses this coverage requirement. Unfortunately, the HHS regulations implementing the vaccine coverage mandate limited its scope to vaccines considered routine — effectively creating significant coverage gaps of important travel vaccines, such as hepatitis A, hepatitis B, yellow fever, typhoid and Japanese encephalitis, as well as occupational vaccines such as rabies. Public policy and public health should not be delayed when an outbreak occurs by having to pass legislation to ensure accessibility to critical vaccines without cost-sharing.
The need to harmonize the Preventive Care Mandate and current regulations has become apparent. Several key members of Congress and a key House committee as well as a broad group of public health stakeholders — representing travel, occupational and other interests — have urged the Biden administration to clarify the regulations to give full force and effect to the law that offers Americans the best protection against future vaccine-preventable communicable diseases.
Travel has resumed — inbound international travel to the U.S. in 2022 is expected to be at or near 2019 pre-COVID levels. High vaccination rates offer the best chance we have for people to resume some normalcy in their lives in the face of seemingly increasing risk of global infectious disease transmission.
Given the reality that additional contagious disease outbreaks are likely to occur, the U.S. must ensure that all CDC-recommended vaccines, including those used for travel and occupational health risks, are available and affordable, with insurance coverage for all. Finally, to improve our vaccination strategies, we must continue efforts toward equity, education and better communication.
Lin H. Chen, MD, is an associate professor of medicine in the Division of Infectious Diseases and Travel Medicine, Mount Auburn Hospital at Harvard Medical School.
Elizabeth Barnett, MD, is a professor of pediatric infectious diseases at the Boston University School of Medicine.
Phyllis Kozarsky, MD, is professor emerita with distinction at Emory University in the Department of Medicine and Division of Infectious Diseases.
Their views are their own and do not represent any affiliated institutions.