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Travel advice for immunocompromised hosts

Camille N Kotton, MD
Section Editor
Karin Leder, MBBS, FRACP, PhD, MPH, DTMH
Deputy Editor
Elinor L Baron, MD, DTMH


Immunocompromised hosts represent a broad spectrum of immune compromise. Severely immunocompromised patients include individuals with active leukemia or lymphoma, generalized malignancy, aplastic anemia, graft-versus-host disease, HIV with CD4 count <200, congenital immunodeficiency, current or recent radiation therapy, solid organ transplant within a year, or bone marrow transplant within two years, or individuals whose transplants occurred >2 years ago but who are still taking immunosuppressive drugs [1]. Moderately immunocompromised patients include individuals with asplenia, renal failure, chronic liver disease, diabetes, or HIV with CD4 count >200. Perhaps the largest growing population of immunocompromised hosts is those on biologic therapy and other immunomodulatory treatments for autoimmune and other chronic inflammatory diseases who have a broad range of immunosuppression. The overall risk for travel-related (and other) infections must be considered on an individual basis.

Immunocompromised hosts traveling overseas are at risk for exposure to endemic pathogens. In general, the vaccine response rate in these patients is diminished and they may be more likely to have adverse effects from vaccines containing live attenuated virus.

Issues related to travel-related vaccines in adult immunocompromised hosts without HIV will be reviewed here. Issues related to travel-related vaccines in immunocompetent hosts are discussed separately, as are issues related to routine immunizations for these groups. (See "Immunizations for travel" and "Immunizations in hematopoietic cell transplant candidates and recipients" and "Immunizations in patients with cancer" and "Immunizations in HIV-infected patients" and "Immunizations in solid organ transplant candidates and recipients".)


Immunocompromised hosts planning to travel overseas should be evaluated by a travel medicine specialist familiar with the patient's immunocompromised state and medications [2,3]. Travel health specialists for complex patients should confer with the traveler's other providers as needed to develop an appropriate plan. Given the broad spectrum of immune compromise, an assessment of risk is an important part of the pretravel visit (table 1) [1,4]. Some immunocompromised hosts may wish to defer travel until they are less immunocompromised (eg, delay until one year after solid organ transplant or two years after hematopoietic stem cell transplant).

Among 95 transplant recipients with recent travel outside North America, 66 percent of travelers sought pretravel advice from their transplant physician and many of the recommended preventative measures were overlooked: 63 percent traveled to areas where hepatitis A is endemic, but only 5 percent had received hepatitis A immunization; 50 percent traveled to dengue- and malaria-endemic areas, but only 25 percent adhered to mosquito prevention measures; and 10 percent reported behaviors that exposed them to blood or body fluids [2].


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Literature review current through: Sep 2016. | This topic last updated: Aug 26, 2015.
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  1. Centers for Disease Control and Prevention. Health Information for International Travel 2016: The Yellow Book. Chapter 8 - Advising Travelers with Specific Needs: Immunocompromised Travelers. http://wwwnc.cdc.gov/travel/yellowbook/2016/advising-travelers-with-specific-needs/immunocompromised-travelers (Accessed on October 06, 2016).
  2. Boggild AK, Sano M, Humar A, et al. Travel patterns and risk behavior in solid organ transplant recipients. J Travel Med 2004; 11:37.
  3. Roukens AH, van Dissel JT, de Fijter JW, Visser LG. Health preparations and travel-related morbidity of kidney transplant recipients traveling to developing countries. Clin Transplant 2007; 21:567.
  4. Committee to Advise on Tropical Medicine and Travel (CATMAT). The immunocompromised traveller. An Advisory Committee Statement (ACS). Can Commun Dis Rep 2007; 33:1.
  5. Elkayam O, Caspi D, Reitblatt T, et al. The effect of tumor necrosis factor blockade on the response to pneumococcal vaccination in patients with rheumatoid arthritis and ankylosing spondylitis. Semin Arthritis Rheum 2004; 33:283.
  6. van der Velden AM, Claessen AM, van Velzen-Blad H, et al. Vaccination responses and lymphocyte subsets after autologous stem cell transplantation. Vaccine 2007; 25:8512.
  7. Fishman JA. Infection in solid-organ transplant recipients. N Engl J Med 2007; 357:2601.
  8. Kotton CN. Immunization after kidney transplantation-what is necessary and what is safe? Nat Rev Nephrol 2014; 10:555.
  9. Jaffe D, Papadopoulos EB, Young JW, et al. Immunogenicity of recombinant hepatitis B vaccine (rHBV) in recipients of unrelated or related allogeneic hematopoietic cell (HC) transplants. Blood 2006; 108:2470.
  10. Danziger-Isakov L, Kumar D, AST Infectious Diseases Community of Practice. Vaccination in solid organ transplantation. Am J Transplant 2013; 13 Suppl 4:311.
  11. Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2012; 61:816.
  12. Duchini A, Goss JA, Karpen S, Pockros PJ. Vaccinations for adult solid-organ transplant recipients: current recommendations and protocols. Clin Microbiol Rev 2003; 16:357.
  13. Avery RK, Ljungman P. Prophylactic measures in the solid-organ recipient before transplantation. Clin Infect Dis 2001; 33 Suppl 1:S15.
  14. Molrine DC, Hibberd PL. Vaccines for transplant recipients. Infect Dis Clin North Am 2001; 15:273.
  15. Centers for Disease Control and Prevention. Health Information for International Travel 2016: The Yellow Book. http://wwwnc.cdc.gov/travel/page/yellowbook-home (Accessed on August 19, 2015).
  16. http://www.merck.com/product/usa/pi_circulars/m/mmr_ii/mmr_ii_pi.pdf (Accessed on May 18, 2010).
  17. Hayney MS, Welter DL, Reynolds AM, et al. High-dose hepatitis B vaccine in patients waiting for lung transplantation. Pharmacotherapy 2003; 23:555.
  18. Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule, United States - 2016. http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf (Accessed on October 06, 2016).
  19. Filippelli M, Lionetti E, Gennaro A, et al. Hepatitis B vaccine by intradermal route in non responder patients: an update. World J Gastroenterol 2014; 20:10383.
  20. Harpaz R, Ortega-Sanchez IR, Seward JF, Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2008; 57:1.
  21. Ryan ET, Kain KC. Health advice and immunizations for travelers. N Engl J Med 2000; 342:1716.
  22. Günther M, Stark K, Neuhaus R, et al. Rapid decline of antibodies after hepatitis A immunization in liver and renal transplant recipients. Transplantation 2001; 71:477.
  23. Rendi-Wagner P, Korinek M, Winkler B, et al. Persistence of seroprotection 10 years after primary hepatitis A vaccination in an unselected study population. Vaccine 2007; 25:927.
  24. Arslan M, Wiesner RH, Poterucha JJ, Zein NN. Safety and efficacy of hepatitis A vaccination in liver transplantation recipients. Transplantation 2001; 72:272.
  25. Dumot JA, Barnes DS, Younossi Z, et al. Immunogenicity of hepatitis A vaccine in decompensated liver disease. Am J Gastroenterol 1999; 94:1601.
  26. Stark K, Günther M, Neuhaus R, et al. Immunogenicity and safety of hepatitis A vaccine in liver and renal transplant recipients. J Infect Dis 1999; 180:2014.
  27. Askling HH, Rombo L, van Vollenhoven R, et al. Hepatitis A vaccine for immunosuppressed patients with rheumatoid arthritis: a prospective, open-label, multi-centre study. Travel Med Infect Dis 2014; 12:134.
  28. Garcia Garrido HM, Wieten RW, Grobusch MP, Goorhuis A. Response to Hepatitis A Vaccination in Immunocompromised Travelers. J Infect Dis 2015; 212:378.
  29. World Health Organization. Immunization, Vaccines and Biologicals: Research and Development. http://www.who.int/vaccine_research/diseases/diarrhoeal/en/index7.html (Accessed on February 04, 2015).
  30. Begier EM, Burwen DR, Haber P, et al. Postmarketing safety surveillance for typhoid fever vaccines from the Vaccine Adverse Event Reporting System, July 1990 through June 2002. Clin Infect Dis 2004; 38:771.
  31. Centers for Disease Control and Prevention. Health Information for International Travel 2016: The Yellow Book. Chapter 3 - Infectious Diseases Related to Travel: Typhoid & Paratyphoid Fever. http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/typhoid-paratyphoid-fever (Accessed on August 19, 2015).
  32. Ljungman P, Aschan J, Gustafsson B, et al. Long-term immunity to poliovirus after vaccination of allogeneic stem cell transplant recipients. Bone Marrow Transplant 2004; 34:1067.
  33. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62:1.
  34. Centers for Disease Control and Prevention (CDC). Updated recommendation from the Advisory Committee on Immunization Practices (ACIP) for revaccination of persons at prolonged increased risk for meningococcal disease. MMWR Morb Mortal Wkly Rep 2009; 58:1042.
  35. Parkkali T, Käyhty H, Lehtonen H, et al. Tetravalent meningococcal polysaccharide vaccine is immunogenic in adult allogeneic BMT recipients. Bone Marrow Transplant 2001; 27:79.
  36. Patel SR, Ortín M, Cohen BJ, et al. Revaccination with measles, tetanus, poliovirus, Haemophilus influenzae type B, meningococcus C, and pneumococcus vaccines in children after hematopoietic stem cell transplantation. Clin Infect Dis 2007; 44:625.
  37. Yu JW, Borkowski A, Danzig L, et al. Immune response to conjugated meningococcal C vaccine in pediatric oncology patients. Pediatr Blood Cancer 2007; 49:918.
  38. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58:e44.
  39. Cetron MS, Marfin AA, Julian KG, et al. Yellow fever vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2002. MMWR Recomm Rep 2002; 51:1.
  40. Fishman JA. Smallpox and live-virus vaccination in transplant recipients. Am J Transplant 2003; 3:786.
  41. Ljungman P. Vaccination of Transplant Recipients. In: Transplant Infections, Bowden RA, Ljungman P, Paya CV (Eds), Lippincott Williams & Wilkins, Philadelphia 2003. p.611.
  42. Mileno M. Preparation of Immunocompromised Travelers. In: Travel Medicine, 1st ed, Keystone JS, Freedman DP, Nothdurft HD, Connor BA (Eds), Mosby, Edinburgh 2004. p.249.
  43. Centers for Disease Control and Prevention. Health Information for International Travel 2016: The Yellow Book. Chapter 3 - Infectious Diseases Related to Travel: Yellow Fever. http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/yellow-fever (Accessed on August 19, 2015).
  44. Domingo C, Niedrig M. Safety of 17D derived yellow fever vaccines. Expert Opin Drug Saf 2009; 8:211.
  45. Kengsakul K, Sathirapongsasuti K, Punyagupta S. Fatal myeloencephalitis following yellow fever vaccination in a case with HIV infection. J Med Assoc Thai 2002; 85:131.
  46. Kennedy SE, Shen Y, Charlesworth JA, et al. Outcome of overseas commercial kidney transplantation: an Australian perspective. Med J Aust 2005; 182:224.
  47. Gowda R, Cartwright K, Bremner JA, Green ST. Yellow fever vaccine: a successful vaccination of an immunocompromised patient. Eur J Haematol 2004; 72:299.
  48. Receveur MC, Thiébaut R, Vedy S, et al. Yellow fever vaccination of human immunodeficiency virus-infected patients: report of 2 cases. Clin Infect Dis 2000; 31:E7.
  49. Tattevin P, Depatureaux AG, Chapplain JM, et al. Yellow fever vaccine is safe and effective in HIV-infected patients. AIDS 2004; 18:825.
  50. Ho YL, Enohata T, Lopes MH, De Sousa Dos Santos S. Vaccination in Brazilian HIV-infected adults: a cross-sectional study. AIDS Patient Care STDS 2008; 22:65.
  51. Mota LM, Oliveira AC, Lima RA, et al. [Vaccination against yellow fever among patients on immunosuppressors with diagnoses of rheumatic diseases]. Rev Soc Bras Med Trop 2009; 42:23.
  52. Gibbons RV, Rupprecht CE. Postexposure rabies prophylaxis in immunosuppressed patients. JAMA 2001; 285:1574.
  53. Inactivated Japanese encephalitis virus vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1993; 42:1.
  54. Conlon CP. The Immunocompromised Traveler. In: Textbook of Travel Medicine and Health, 2nd ed, DuPont HL, Steffer R (Eds), BC Decker, 2001. p.464.
  55. Panackal AA, Hajjeh RA, Cetron MS, Warnock DW. Fungal infections among returning travelers. Clin Infect Dis 2002; 35:1088.
  56. Marin M, Güris D, Chaves SS, et al. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007; 56:1.
  57. Evans RW. Ethnocentrism is an unacceptable rationale for health care policy: a critique of transplant tourism position statements. Am J Transplant 2008; 8:1089.
  58. Merion RM, Barnes AD, Lin M, et al. Transplants in Foreign Countries Among Patients Removed from the US Transplant Waiting List. Am J Transplant 2008; 8:988.
  59. Participants in the International Summit on Transplant Tourism and Organ Trafficking Convened by the Transplantation Society and International Society of Nephrology in Istanbul, Turkey, April 30-May 2, 2008. The Declaration of Istanbul on organ trafficking and transplant tourism. Transplantation 2008; 86:1013.
  60. Martín-Dávila P, Fortún J, López-Vélez R, et al. Transmission of tropical and geographically restricted infections during solid-organ transplantation. Clin Microbiol Rev 2008; 21:60.
  61. Commercially motivated renal transplantation: results in 540 patients transplanted in India. The Living Non-Related Renal Transplant Study Group. Clin Transplant 1997; 11:536.
  62. Harling R, Turbitt D, Millar M, et al. Passage from India: an outbreak of hepatitis B linked to a patient who acquired infection from health care overseas. Public Health 2007; 121:734.
  63. Sever MS, Kazancioğlu R, Yildiz A, et al. Outcome of living unrelated (commercial) renal transplantation. Kidney Int 2001; 60:1477.
  64. Canales MT, Kasiske BL, Rosenberg ME. Transplant tourism: Outcomes of United States residents who undergo kidney transplantation overseas. Transplantation 2006; 82:1658.
  65. Geddes CC, Henderson A, Mackenzie P, Rodger SC. Outcome of patients from the west of Scotland traveling to Pakistan for living donor kidney transplants. Transplantation 2008; 86:1143.
  66. Gill J, Madhira BR, Gjertson D, et al. Transplant tourism in the United States: a single-center experience. Clin J Am Soc Nephrol 2008; 3:1820.