Diphtheria, tetanus, and pertussis immunizations were routinely given from 1968, and BCG vaccination

from as far back as 1954. Given that the mean age of our study participants was 36.4 years, it is likely that most will have received these vaccines but have no recollection of doing so. These findings may suggest that many Japanese tend to be indifferent to their immunization status. The vaccination uptake among Japanese travelers needs to be improved. Two issues affecting the uptake of vaccines in Japan are that hepatitis B vaccination is not part of the routine childhood immunization program, and that many of the travel vaccines are not MEK inhibitor licensed for use in Japan, eg, typhoid, oral cholera, meningococcal, and tick-borne

encephalitis (TBE) vaccines.15 Many vaccines, including travel vaccines, marketed in Japan are produced domestically, and as a result there is limited data on their way of use. In Western countries, a two-dose regimen has been introduced for hepatitis A vaccine, and accelerated schedules exist for hepatitis B, rabies, and TBE vaccines. Furthermore, several combination vaccines are available. All this makes compliance with vaccination schedules much easier. The introduction of such convenient injection schedules for domestically produced vaccines in Japan may well lead to improved uptake of travel vaccines among the Japanese population.16 Alternatively, the introduction of internationally used vaccines may be considered. There is another issue to address, which is the concern expressed by many individuals about potential adverse effects of immunization. Observations made by a Japanese Doxorubicin specialist in pediatric infectious diseases17 may help to clarify the reasons why so many people have formed these

beliefs. He has suggested that negative attitudes toward immunization by the government and some physicians may stem from previous legal cases where the causal relationship between a vaccination and an adverse event was uncertain. The court often ruled against the physician (ie, they were found to be negligent by not been sufficiently observant of contraindications to a vaccine) and the government was ordered to compensate the recipient for any resultant damage either to their health. He also stated that although in many of the cases the vaccine administration and adverse events were coincidental, the media reported it as if a true causal relationship had been proved, with, in some cases, tragic consequences. This may well have contributed to the undue concerns expressed by laypersons and travelers about the safety of vaccines. Providers of travel health information in Japan should help to minimize fears around vaccination and provide a more balanced picture of the risks and benefits of immunization. For most, the benefits of immunization may outweigh any rare serious adverse event that may be associated with it.