Healthcare providers should be aware of important updates to vaccine recommendations that could affect patients preparing to travel internationally this summer. This includes information about:
New Guidelines for Pre-Exposure Rabies Prevention (PrEP);
new tick-borne encephalitis (TBE) vaccine; And the
Update cholera vaccine recommendations and resume manufacture and distribution of Vacchora.
International travelers are the largest group for which the Advisory Committee on Immunization Practices (ACIP) recommends pre-exposure prophylaxis (PrEP). International travelers may be at risk of contacting the rabies virus when traveling to areas where rabies is common in dogs. In the past, at-risk travelers may not have been able to obtain PrEP as recommended because PrEP for rabies consisted of a three-dose vaccine series—usually at high out-of-pocket costs—that required at least 21 days to complete. The new PrEP schedule is shorter and therefore less expensive. There are also more options for maintaining long-term protection which may allow more at-risk people to be vaccinated.
In May 2022, ACIP updated its rabies PrEP recommendations based on newly published data. Consistent with recent changes in WHO guidelines, the two-dose PrEP rabies schedule (days 0 and 7) has replaced the previous three-dose series. For travelers with only a short-term (3-year) risk of rabies who complete the two-dose series, no additional titer or booster doses are required. However, for travelers who could be at long-term (>3 years) risk of rabies, one of the additional steps below is needed to maintain protection beyond 3 years:
Healthcare providers should check rabies antibody titers one time within 1-3 years after the two-dose series (and provide a booster dose if titer <0.5 IU/mL); or
Healthcare providers should proactively administer a one-time booster dose 21 days to 3 years after completion of the two-dose series.
Some patients may prefer the first option because it may save money. Others may prefer the second option because it may save them time to get the booster regardless of titer results. By providing options, the revised recommendations allow for more flexibility in the management of PrEP, which will facilitate ensuring that international travelers at risk are protected from rabies.
Persons who have already received the previous three-dose series do not need the one-time titer check or booster dose recommended above. While PrEP for rabies is recommended for a small subset of international travelers, it can be a vital part of preparing for travel for travelers at risk of exposure. Providers should encourage at-risk international travelers to receive PrEP when indicated, and to follow the additional precautions outlined in the new recommendations for travelers with compromised immune systems. Even if travelers are receiving PrEP treatment, they should still take steps to protect against rabies while traveling, such as avoiding unnecessary contact with wild animals, dogs, pets, and other wild animals that can carry rabies.
For additional information:
Latest guidelines for pre-exposure rabies prevention
General information on pre-exposure prophylaxis for rabies
Rabies status: assessment by country | Center for Disease Control
rabies | Information for travelers | Center for Disease Control
Rabies – Chapter 4 – Yellow Book 2020 | Travelers Health | Center for Disease Control
Rabies and travel information
Tick-borne encephalitis (TBE) is a rare but potentially serious disease found in parts of Europe and Asia and is most commonly transmitted through tick bites. The risk of developing TBE is very low for most travelers. However, those who plan to visit TBE-endemic areas and participate in outdoor activities that will expose them to ticks (eg, hiking, camping, hunting, and bird watching) may be at increased risk. The main way to prevent TBE is to avoid tick bites (eg, using insect repellent, treating clothing and gear with products containing 0.5% permethrin, and checking for ticks during and after outdoor activities).
In February 2022, ACIP approved recommendations for the use of the TBE vaccine among travelers visiting countries where TBE is endemic. The TBE vaccine has been available in Europe for more than 20 years but has never been seen before in the United States. The vaccine can be given to adults and children 1 year of age and older as a series of three doses. Healthcare providers should review and closely follow the administration instructions in the package leaflet, which differ for recipients aged 1-15 years versus those 16 years of age or younger.
When talking to patients, you should discuss:
Where and when will they travel?
What activities are they planning?
Rare occurrence of TBE, but potential for severe consequences of the disease
Vaccine dose, cost and possible side effects
Ways to avoid tick bites
The TBE vaccine is recommended for those who will have extensive exposure to ticks in TBE-endemic areas. It may be considered for those with lower exposure, with the decision to vaccinate based on various factors (eg, presence of risk factors for worse medical outcomes, subjective perception, risk tolerance).
For additional information:
The CDC recently revamped its TBE website where you can find more information about risk factors for infection, countries at risk for TBE, a vaccination decision tree, and a TBE vaccine schedule. Take a look now to learn about new recommendations and ways all travelers can prevent tick bites.
Additional information, especially for travelers, is available on the CDC’s Traveler Health website.
Cholera is an acute watery diarrheal disease that can be severe and rapidly fatal without proper treatment. Most cases of cholera in the United States are related to travel to cholera-endemic countries. Lyophilized CVD 103-HgR (Vaxchora), Single Live Dose Attenuated Oral Cholera Vaccine Derived from cholera vibrio O1 is the only cholera vaccine licensed for use in the United States. In June 2016, ACIP recommended lyophilized CVD 103-HgR for adults aged 18 to 64 years traveling to an area with active transmission of cholera. The CDC maintains an updated list of countries believed to have areas of active cholera transmission. Cholera vaccine recommendations are also available on the Centers for Disease Control and Prevention (CDC) destination pages.
In February 2022, ACIP extended the CVD 103-HgR recommendation for children and adolescents ages 2 to 17 who are traveling to an area with active transmission of cholera. Distribution of CVD 103-HgR has been temporarily halted due to the COVID-19 pandemic and is expected to resume later in 2022. Healthcare providers should review and follow the administration instructions in the package appendix, which differ for recipients aged 2-5 years vs. Those aged 6-64 years.
For additional information:
cholera: cholera vibrio infection
Travelers’ health: cholera
Vaccora (live oral cholera vaccine)
ACIP cholera vaccine recommendations
Travel-related infectious diseases: cholera
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