Recent reports  of counterfeit yellow fever vaccination certificates in Zambia follow reports of falsified proof of vaccination documents being used in other countries, including Ethiopia , India , Nigeria , Pakistan , Sudan , Uganda , Tanzania  and Zimbabwe . While the World Health Organization (WHO) published guidelines in 1999  to support countries in developing measures to combat counterfeit pharmaceutical products and issued a report in 2017  highlighting the public health and socioeconomic impacts of falsified medical products, neither publication discussed the current problem of false or fraudulently obtained proof of vaccination documentation. Counterfeit proof of vaccination in home-based records (HBRs), particularly those issued to provide documented proof of vaccination against yellow fever virus or polio virus , presents a threat to the health and security of countries and their citizens and warrants further discussion and action.
Given the imperative of preventing the spread of vaccine-preventable diseases at a time when increased air travel and globalization link communities worldwide as never before , efforts seem warranted to (1) understand the magnitude and impact of counterfeit proof of vaccination and (2) work with national health authorities to develop practical counterfeit-deterrent strategies as part of the Eliminate Yellow fever Epidemics (EYE) global strategy (2017–2026)  as well as ongoing WHO activity around protection of essential medicines and health products . Efforts to combat counterfeiting are also timely and urgent as part of the Global Health Security Agenda  as the likelihood of deadly, cross-border epidemics increases  and as countries continue to require international travelers to provide proof of vaccination as a prerequisite for entry (or exit) as part of international health regulations recommended by WHO . This directive combined with improved enforcement at ports of entry into a country and a global yellow fever vaccine shortage  could further drive the demand for counterfeit vaccination documents.
As providing proof of vaccination for travelers is one of several important HBR functions , HBRs deserve particular attention. For many travelers, proof of vaccination status is provided through a duly completed version of the International Certificate of Vaccination or Other Prophylaxis  recommended by the World Health Organization. In June 2007, a revised international certificate of vaccination was adopted following the 2005 revision of the International Health Regulations . The revised certificate replaced the International Certificate of Vaccination or Revaccination Against Yellow Fever but did not include any anti-counterfeit guidelines or recommendations.
The prevalence and impact of counterfeit medical products highlighted in the 2017 WHO report  point to a very real public health problem: a counterfeit problem that is not limited to medicines . In Nigeria counterfeit proof of yellow fever vaccination records have been noted since at least 2012 when travelers from the country holding alleged counterfeit documents were denied entry by officials on arrival in Ghana  and South Africa . As a result, the Federal Ministry of Health has attempted to curb the problem by issuing documents that included additional security features; however, a November 2018 report from Lagos airport highlights opportunities for further improvement as the problem of counterfeit documentation may continue .
It is far too easy to dismiss HBR counterfeit incidents as a trivial matter. Such incidents are anything but trivial. More must be done to investigate HBR counterfeiting incidents with local authorities. Additionally, we must leverage existing knowledge and explore novel approaches to combat counterfeit proof of vaccination while also exploring design-related solutions to better ensure the integrity of HBRs. The risks of spread of vaccine-preventable diseases by international travelers is a public health concern , placing increased importance on safeguarding HBRs as a verified source of travelers’ vaccination status.
The author acknowledges the editorial support of Ms Stacy Young of Applied Scientific Consulting in preparing this work.
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