Immunocompromised Travelers

Immunocompromised Travelers is a topic covered in the CDC Yellow Book.

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Approach to the Immunocompromised Traveler

Immunocompromised travelers make up 1%–2% of travelers seen in US travel clinics and pursue itineraries largely similar to those of immunocompetent travelers. The pretravel preparation of travelers with immune suppression due to any medical condition, drug, or treatment must take into consideration several issues:

  • What is the cause of the immune suppression? Different conditions and medications produce widely varying degrees of immunocompromise, and there are many unknowns in this field. Guidance regarding vaccination of immunocompromised travelers is less evidence-based than with other categories of travelers; this section provides recommendations based on the best available data and the practices of experienced clinicians.
  • Is the traveler’s underlying medical condition stable? The travel health care provider may need to contact the traveler’s primary or specialty care providers (with the patient’s permission) to discuss the traveler’s fitness to travel, give specific medical advice for the proposed itinerary, verify the drugs and doses composing their usual maintenance regimen, and discuss whether any of the disease-prevention measures recommended for the proposed trip could destabilize the underlying medical condition, directly or through drug interactions.
  • Do the conditions, medications, and treatments of the traveler constitute contraindications to, decrease the effectiveness of, or increase the risk for adverse events of any of the disease-prevention measures recommended for the proposed trip? Depending on the destination, such measures may include immunizations and drugs used for malaria chemoprophylaxis and management of travelers’ diarrhea. Are there specific health hazards at the destination that would exacerbate the underlying condition or be more severe in an immunocompromised traveler? If so, can specific interventions be recommended to mitigate these risks?
  • If an immunocompromised traveler were to become ill while traveling, what are the health care options (see Chapter 6, Obtaining Health Care Abroad)? What would the traveler do should medical evacuation be required? An immunocompromised traveler should have a plan for when and how to seek care overseas and how to pay for it.

The traveler’s immune status is particularly relevant to immunizations. Overall considerations for vaccine recommendations, such as destination and the likely risk of exposure to disease, are the same for immunocompromised travelers as for other travelers. The risk of severe illness or death from a vaccine-preventable disease must be weighed against potential adverse events from administering a live vaccine to an immunocompromised patient. In some complex cases when travelers cannot tolerate recommended immunizations or prophylaxis, the traveler should consider changing the itinerary, altering the activities planned during travel, or deferring the trip.

For purposes of clinical assessment and approach to immunizations, immunocompromised travelers may be thought of as falling into 1 of 3 groups, based on mechanism and level of immune suppression. The 3 groups are people who have 1) medical conditions without significant immunologic compromise, 2) medical conditions and treatments associated with limited immune deficits, and 3) medical conditions or treatments associated with severe immune compromise. Vaccine recommendations for different categories of immunocompromised adults are shown in Table 5-1.

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Approach to the Immunocompromised Traveler

Immunocompromised travelers make up 1%–2% of travelers seen in US travel clinics and pursue itineraries largely similar to those of immunocompetent travelers. The pretravel preparation of travelers with immune suppression due to any medical condition, drug, or treatment must take into consideration several issues:

  • What is the cause of the immune suppression? Different conditions and medications produce widely varying degrees of immunocompromise, and there are many unknowns in this field. Guidance regarding vaccination of immunocompromised travelers is less evidence-based than with other categories of travelers; this section provides recommendations based on the best available data and the practices of experienced clinicians.
  • Is the traveler’s underlying medical condition stable? The travel health care provider may need to contact the traveler’s primary or specialty care providers (with the patient’s permission) to discuss the traveler’s fitness to travel, give specific medical advice for the proposed itinerary, verify the drugs and doses composing their usual maintenance regimen, and discuss whether any of the disease-prevention measures recommended for the proposed trip could destabilize the underlying medical condition, directly or through drug interactions.
  • Do the conditions, medications, and treatments of the traveler constitute contraindications to, decrease the effectiveness of, or increase the risk for adverse events of any of the disease-prevention measures recommended for the proposed trip? Depending on the destination, such measures may include immunizations and drugs used for malaria chemoprophylaxis and management of travelers’ diarrhea. Are there specific health hazards at the destination that would exacerbate the underlying condition or be more severe in an immunocompromised traveler? If so, can specific interventions be recommended to mitigate these risks?
  • If an immunocompromised traveler were to become ill while traveling, what are the health care options (see Chapter 6, Obtaining Health Care Abroad)? What would the traveler do should medical evacuation be required? An immunocompromised traveler should have a plan for when and how to seek care overseas and how to pay for it.

The traveler’s immune status is particularly relevant to immunizations. Overall considerations for vaccine recommendations, such as destination and the likely risk of exposure to disease, are the same for immunocompromised travelers as for other travelers. The risk of severe illness or death from a vaccine-preventable disease must be weighed against potential adverse events from administering a live vaccine to an immunocompromised patient. In some complex cases when travelers cannot tolerate recommended immunizations or prophylaxis, the traveler should consider changing the itinerary, altering the activities planned during travel, or deferring the trip.

For purposes of clinical assessment and approach to immunizations, immunocompromised travelers may be thought of as falling into 1 of 3 groups, based on mechanism and level of immune suppression. The 3 groups are people who have 1) medical conditions without significant immunologic compromise, 2) medical conditions and treatments associated with limited immune deficits, and 3) medical conditions or treatments associated with severe immune compromise. Vaccine recommendations for different categories of immunocompromised adults are shown in Table 5-1.

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