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How to Safely Travel This Summer If You're Immunocompromised

Hugo Lin / Verywell

Key Takeaways

To minimize risk, immunocompromised individuals and anyone who is traveling with them should be fully vaccinated before going on a trip.
The destination, mode of transportation, and activities should all be considered beforehand.
Plan ahead in case anyone in the travel party gets COVID-19 during the trip.

With summer quickly approaching, many Americans are already making plans for upcoming travels. Planning a trip can be arduous, but it’s even more taxing during a pandemic when you have to take more factors into consideration.

Instead of opting for the most convenient options, the focus needs to ultimately be on safety. This is even more crucial for immunocompromised and high-risk individuals who want to travel.

If you're immunocompromised, it doesn't mean you shouldn't travel, but there are extra precautions you can take to have fun and be safe. Here’s what you should factor into your plans this summer.

Factors to Consider When Planning a Trip

There are plenty of ways to minimize your risk of COVID-19 exposure and infection as much as possible. However, keep in mind that your risk is likely never zero.

Vaccination Status

Everyone is recommended to be up-to-date with their COVID-19 vaccinations, especially those who intend to travel.

“Immunocompromised folks can reduce the likelihood of severe illness with vaccination and boosters,” Keri Althoff, PhD, MPH , an epidemiologist at the Johns Hopkins Bloomberg School of Public Health, told Verywell. “These essential tools to staying healthy may not result in the same immune response as someone without immunosuppression, but immune responses are a dial, not a switch. Even a little response may help to confer protection against more severe illness.”

Experts advise immunocompromised people to talk to their healthcare providers before traveling and continue taking all precautions even after being fully vaccinated.

The timing of booster shots should also be considered, both for the people in the travel party and that of anyone you might visit, Stanley H. Weiss, MD , professor of medicine at the Rutgers New Jersey Medical School, told Verywell. Also, assess what the exposure levels will be for children if they are younger than 5 years old and have not been vaccinated, he added.

Destination

The community incidence rate of COVID-19 and other infections like influenza must be taken into account when choosing a destination, Weiss said. The prevention strategies in place at the destination and various points en route, such as masking and/or vaccination requirements, should also be considered, he added.

“Due to the various modalities of testing—including at-home tests that typically are not reflected in local and state COVID-19 data—it is important to look at how COVID-19 transmission rates are trending, not just the absolute COVID-19 transmission rate,” Althoff said. “If the rate is increasing, you may want to re-think your mitigation layers to increase your protection.”

According to the Centers for Disease Control and Prevention (CDC), restrictions and policies may change during the trip itself, so being flexible is necessary. Prevention strategies and COVID-19 response also vary across the country, so read up on those beforehand.

“Make sure you are aware of the local mitigation strategies and the metrics by which the local area may scale up or down mitigation strategies,” Althoff said. “This information should be available on a public health department website, but if you can’t find it, find the telephone number for the local health department at your destination and inquire.”

Accommodation

It may be best to choose an accommodation that will allow for a bit of seclusion from others, like a rental cabin or home instead of a hotel room, Althoff said.

Doing so would help minimize contact with other people who are not traveling with you.

Transportation

Going on a road trip is probably safer than taking a long-distance train or bus trip.

“A personal vehicle and traveling with people who you know are vaccinated, boosted and negative on a rapid test just before you leave will confer the lowest risk of exposure,” Althoff said.

For those going on a long drive, minimize stops along the way with a potential for exposure, Weiss said. In case you need to stay overnight anywhere before reaching the destination, evaluate how safe that facility might be, he added.

If traveling with a personal vehicle is not possible, make sure to wear well-fitting, high-quality masks to minimize transmission.

“Make sure you pack masks that fit well and have filtration that increases your protection, recognizing that in many places, including airplanes and public transportation, are no longer requiring masks,” Althoff said. “Your fellow passengers are likely to be unmasked.”

The day of the week and time of the day also matter since airports tend to be busier on weekends and public transport is more crowded during rush hour, she added.

It’s best to choose outdoor activities with adequate spacing, and make sure to avoid crowded areas, Weiss said. The risk of exposure to COVID-19 is lower when doing outdoor activities, even without wearing masks.

Outdoor recreation like cycling, kayaking, and camping is likely to be safe. Going on an outdoor walking tour or playing sports with the people from the same travel party are possible options as well.

“Go for a hike, enjoy a view from a mountain with a picnic, [or] sit by the water,” Althoff said. “Make sure you have backup options for uncooperative weather.”

What This Means For You

If you’re immunocompromised and you intend to go on a trip soon, make sure your travel companions are fully vaccinated against COVID-19. To minimize the infection risk as much as possible, check the virus transmission rates beforehand, choose a safer mode of transportation, and engage in outdoor activities.

Plan Ahead in Case You Get COVID-19

It’s important for anyone—especially immunocompromised individuals—to have a plan for where and how they would seek care at the intended destination in case they get infected.

“Identify pharmacies that are stocked with COVID-19 antivirals and/or hospitals or clinics that have monoclonal antibodies,” Althoff said. “Seek out the local health department’s information on how to access these should you need them.”

Although there’s no strict number of people in a travel group that’s considered “safe,” it helps if the people you’re traveling with are on the same page with you when it comes to COVID-19 precautions and agrees on the activities that you will and will not do.

“Even if others are not wearing masks, putting peer pressure upon [you] not to: decide in advance that you will not succumb, that you know you will nevertheless stay firm,” Weiss said. “Avoid situations where you might feel compelled not to take adequate precautions. Recognize that a person can be asymptomatic or rapid-antigen-test-negative yet still be infectious.”

The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page .

Centers for Disease Control and Prevention. Domestic travel during COVID-19 .

Centers for Disease Control and Prevention. Small and large gatherings .

By Carla Delgado Carla M. Delgado is a health and culture writer based in the Philippines.

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COVID-19 travel tips for people with weakened immune systems

DeeDee Stiepan

Kelsey Kloss

Home Living with Arthritis Coronavirus COVID-19 Vaccines

What the CDC’s New Guidance on Travel for Fully Vaccinated People Means If You’re Immunocompromised

PUBLISHED 04/15/21 BY Kelsey Kloss

Is it safe to travel if you’re fully vaccinated but have an autoimmune or inflammatory disease or take immunosuppressant medication? Here’s what experts say, plus tips for staying safe if you travel.

Learn more about our FREE COVID-19 Patient Support Program for chronic illness patients and their loved ones.

The U.S. Centers for Disease Control and Prevention recently released new guidance that state fully vaccinated Americans can travel. It’s less clear, however, as to what that means if you’re fully vaccinated but immunocompromised due to an autoimmune or inflammatory condition or taking immunosuppressant medication.

You are considered fully vaccinated if it’s been two or more weeks since you received the second dose of a two-dose vaccine ( Pfizer or Moderna ), or it’s been two or more weeks since you received a single-dose vaccine ( Johnson & Johnson ).

Generally, experts have recommended that patients who are immunocompromised continue to follow standard mitigation efforts until more data is available on how the COVID-19 vaccine works in immunosuppressed individuals.

“Vaccine response and vaccine durability [how long protection lasts] is not fully understood in immunocompromised patients,” says Jiha Lee, MD , a Clinical Assistant Professor specializing in rheumatology at Michigan Medicine. “Immunocompromised patients who are fully vaccinated should exercise caution when considering travel.”

The steps you take, however, may depend on your personal situation, such as your medications, underlying health issues, and degree of being immunocompromised. Here’s what to know if you need to travel and you’re fully vaccinated but immunocompromised.

What the CDC Guidance Says About Travel

The new CDC guidance does not include recommendations specific to immunosuppressed individuals, beyond noting that people should discuss with their doctor if they have any questions about their individual situation, such as immunocompromising conditions.

For the general population, the CDC says:

Fully vaccinated people can travel domestically and do not need to get tested before or after travel — or self-quarantine after travel.
Fully vaccinated people do not need to get tested before leaving the United States unless it’s required by the destination, and they do not need to self-quarantine after returning to the United States.

That said, other standard COVID-19 prevention measures still apply to travelers, even if they are fully vaccinated.

All travelers must wear a face mask on planes, buses, trains, and other forms of public transportation.
People traveling internationally should closely monitor the situation at their destination before traveling, due to the spread of new variants and the shifting burden of COVID-19 cases globally.

“COVID-19 disease activity varies a lot in different parts of the word, and the United States public health system can really only govern within the United States,” says David Aronoff, MD , Director of the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tennessee. “There are restrictions and requirements of other travel locations internationally that may also be very different. Countries may be banning people from going there, or you may have to quarantine or get tested.”

Fully vaccinated air travelers coming to the United States from abroad still need to have a negative SARS-CoV-2 viral test result or documentation of recovery from COVID-19 before boarding a flight.

What the Travel Guidance Means for Immunocompromised Patients

As the CDC guidance states, you should check with your doctor to gauge your personal situation and risk factors — and what that means for your vaccination status. Your doctor will consider factors such as the medications you take and the underlying conditions you have.

Taking certain immunosuppressant medications may mean you don’t generate as strong an immune response to the COVID-19 vaccine. The vaccine likely still provides protection, but it may be reduced compared to that of healthy adults.

“If your health care team thinks that you should have gotten an adequate immune response from vaccination, then you should be free to follow the same guidance around travel that has now been updated by the CDC related to fully vaccinated travelers,” says Dr. Aronoff. “But if you are immunocompromised such that there’s doubt as to whether the vaccine was fully able to induce a strong immune response, then you may want to continue to travel under the same guidance as people who are not vaccinated.”

Dr. Aronoff says it boils down to asking your doctor this question: “Do you think it’s likely that the vaccine did its job, and am I okay to behave like any other fully vaccinated person?”

If the answer to that is no or uncertain, then there may need to be further conversations about what that means for you in terms of travel.

In general, the CDC currently recommends against non-essential travel for those who are not fully vaccinated. Of course, the lowest-risk option is to avoid non-essential travel until more data is available, but that’s not always possible.

If you need or want to travel, it’s important to be careful to reduce your risk of contracting COVID-19. Don’t let your guard down just because you’ve gotten the vaccine.

“Although traveling is safer after vaccination, you may still be at increased risk of getting infected and spreading COVID-19, especially depending on your travel destination and type of activity planned during travel,” says Dr. Lee.

How to Stay Safe While Traveling If You’re Fully Vaccinated and Immunocompromised

The CDC recommends delaying travel until you’re fully vaccinated, and even then, you should take the everyday steps you know so well by now:

Wear a mask over your nose and mouth in public
Stay six feet away from anyone who’s not traveling with you and avoid crowds
Wash your hands often or use hand sanitizer (with at least 60 percent alcohol)

It may be worth it to double mask, which research has shown can reduce exposure to infectious particles by up to 96 percent . Double masking involves wearing a cloth mask over a medical procedure mask, which makes the fit of your mask tighter.

“Immunocompromised folks really should give thought to double masking with a medical mask under a cloth mask,” says Dr. Aronoff. “That’s good advice, independent of vaccine status, for people whose immune systems are not fully functional.”

According to a Global Healthy Living Foundation poll , more than 40 percent of chronic illness patients recently said that they always or usually double mask.

And despite the CDC stating that the risk of contracting COVID-19 from surfaces — called surface transmission — is low, continue to practice good hygiene, especially hand hygiene.

“As an infectious disease physician, I will never eschew hand hygiene because clean hands are important for limiting illness from lots of different diseases, including foodborne illnesses and viruses and bacteria,” says Dr. Aronoff. “While the risk of transmitting or getting infected from COVID-19 is much lower when it comes to touch than breathing, it’s always good to be limiting that risk to the extent possible, because it’s easy to do.”

As long as you are regularly cleaning your hands and not touching your eyes, nose, or mouth after touching public surfaces, you likely don’t need to sanitize everything in your vicinity. That said, if you think you might forget and, say, rub your nose after touching the tray table in a plane, then it might be worth doing a quick wipe-down for peace of mind.

Understanding Travel Risk Levels

There are three levels of risk when traveling, according to the CDC:

Safer: Short road trips with household members or fully vaccinated people with few stops along the way. If you must fly, try to take flights that have the fewest stops or layovers.
Less Safe: Longer trips by car or RV with many stops, trips by car or RV with people who are not from your household or who are not vaccinated, and flights with layovers.
Avoid: Long-distance train or bus trips and traveling on a cruise ship or river boat.

“Given how active COVID-19 is in the United States, it’s still prudent to limit travel to what you would consider to be essential if you’re unvaccinated or you may not have had a normal response to a vaccine,” says Dr. Aronoff. “Right now, we are seeing hot spots in the United States where disease activity is higher than it has been recently.”

If you’re trying to decide if your trip is essential, Dr. Aronoff recommends asking yourself this question: Is this trip necessary for my well-being in terms of my employment or my relationships? (For example, if a family member is very sick or there’s a pressing work-related issue.)

Watching for COVID-19 Symptoms After You Return from Travel

“You don’t necessarily need to get tested after travel if you are asymptomatic, but you should monitor to see if you develop any COVID-19 symptoms and get tested if you do,” says Lisa Zhu, MD , a rheumatologist at Ronald Reagan UCLA Medical Center.

Even if you are fully vaccinated, you should get tested for COVID-19 if you experience any symptoms, such as fever or chills, cough, shortness of breath or difficulty breathing, and new loss of taste or smell. Here is the latest list of COVID-19 symptoms from the CDC .

The Good News About the Future of Travel

Although any type of travel carries the potential for disease transmission, it may not be high-risk if you’re fully vaccinated and your doctor believes you mounted an adequate response to the virus.

“In the United States, we haven’t seen major point-source outbreaks associated with trains, busses, or airplanes,” says Dr. Aronoff. “I do think a lot of that is because people are being very careful about travel. And getting vaccinated absolutely reduces the risk of infection and the likelihood of severe infection, so that’s adding a whole new layer of safety to travel.”

More and more people are getting vaccinated every day, which will make traveling safer for those who don’t mount a full response to the vaccine.

“If we can get as many people as possible vaccinated this summer, and people can continue to do the things we need to do to limit the risk of transmission, my hope is that we really do reach the full benefit of herd immunity — where the immunity of the majority of people protects even those who cannot develop immunity to the virus,” says Dr. Aronoff.

That’s the purpose of vaccination on a societal level: to create enough immunity among the masses to help shield those who are still vulnerable.

“Things are headed in a great direction in terms of vaccination, and I think that’s really to be celebrated,” adds Dr. Aronoff. “The light at the end of the tunnel is starting to burn brighter for us, and we will get there.”

Get Free Coronavirus Support for Chronic Illness Patients

Join the Global Healthy Living Foundation’s free COVID-19 Support Program for chronic illness patients and their families. We will be providing updated information, community support, and other resources tailored specifically to your health and safety. Join now .

Interim Public Health Recommendations for Fully Vaccinated People. COVID-19. U.S. Centers for Disease Control and Prevention. April 2, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html .

Interview with David Aronoff, MD , Director of the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tennessee

Interview with Jiha Lee, MD , Clinical Assistant Professor specializing in rheumatology at Michigan Medicine

Interview with Lisa Zhu, MD , a rheumatologist at Ronald Reagan UCLA Medical Center

Science Brief: SARS-CoV-2 and Surface (Fomite) Transmission for Indoor Community Environments. COVID-19. U.S. Centers for Disease Control and Prevention. April 5, 2021. https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/surface-transmission.html .

Symptoms of COVID-19. COVID-19. U.S. Centers for Disease Control and Prevention. February 22, 2021. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html .

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Travelers with Chronic Illnesses

Cdc yellow book 2024.

Author(s): Noreen Hynes

Although traveling abroad can be relaxing and rewarding, the physical demands of travel can be stressful, particularly for travelers with underlying chronic illnesses. With adequate preparation, however, these travelers can have safe and enjoyable trips. For more detailed information on assisting immunocompromised travelers , travelers with disabilities , highly allergic travelers , and travelers with substance use disorders prepare for international travel, see the respective chapters in this section.

Patients should see their established health care providers well in advance of travel to ensure that all chronic conditions are controlled, and management is optimized. Clinicians should encourage patients to seek pretravel consultation prior to paying for nonrefundable trips, and at least 4–6 weeks before departure to ensure adequate time to respond to immunizations, try new medications before travel, or redefine the itinerary based upon pretravel consultation recommendations.

General Approach

Advising travelers.

Adequate preparation for patients with chronic illnesses for international travel requires the active participation of both the traveler and the travel health provider. Box 3-03 includes a checklist of pretravel activities for travelers with chronic illnesses.

Box 3-03 A checklist for travelers with chronic illnesses preparing for international travel

☐ Carry copies of all prescriptions.

☐ Check with the foreign embassy or consulate for your destination country in the United States to clarify whether any medication restrictions exist. Some countries do not allow visitors to bring certain medications into the country, especially narcotics and psychotropic medications.

☐ Favor travel to destinations that have access to quality care for your condition (see Sec. 6, Ch. 2, Obtaining Health Care Abroad )

☐ Obtain an established provider letter. The letter should be on office letterhead stationery and outline existing medical conditions, medications prescribed (including generic names), and any equipment required to manage the condition. By law, some states do not permit a travel health specialist to furnish such a letter if the specialist is not also the primary care provider or established provider of record.

☐ Pack a travel health kit (see Sec. 2, Ch. 10, Travel Health Kits ). Take health kits on board as carry-on luggage, and bring all necessary medications and medical supplies (e.g., pouching for ostomies) in their original containers.

☐ Select a medical assistance company that allows you to store your medical history so it can be accessed worldwide.

☐ Sign up for the Smart Traveler Enrollment Program , a free service of the US Department of State to US citizens and permanent residents, to receive destination-specific travel and security updates. This service also allows the Department of State to contact international travelers during emergencies.

☐ Stay hydrated, wear loose-fitting clothing, and walk and stretch at regular intervals during long-distance travel (see Sec. 8, Ch. 3, Deep Vein Thrombosis & Pulmonary Embolism ).

☐ Wear a medical alert bracelet or carry medical information on your person. Various brands of jewelry or tags, even electronic ones, are available.

Health Care Provider Roles & Responsibilities

Health care providers play a critical role in helping patients with chronic underlying conditions travel safely. Ask patients about previous health-related issues encountered during travel (e.g., complications during air travel). In addition to sharing the advice found in Box 3-03 , ensure the traveler has sufficient medication (and proper storage conditions) for the entire trip, plus extra in case of unexpected delays. Because medications should be taken based on elapsed time and not time of day, offering travelers guidance on scheduling when to take medications during and after crossing time zones might be needed. Educate travelers on possible drug interactions (see Sec. 2, Ch. 4, Interactions Between Travel Vaccines & Drugs ). Some medications used to treat chronic medical illnesses (e.g., warfarin) can interact with prescribed self-treatment for travelers’ diarrhea or malaria chemoprophylaxis. Discuss all medications patients use, including medications taken daily, those taken on an as-needed basis, and dietary supplements or herbal products. In addition, discuss supplemental insurance options for travelers, including policies that cover trip cancellation in the event of illness, supplemental medical insurance, and medical evacuation insurance. Supplemental medical insurance can reimburse travelers for money paid for health care abroad; most medical insurance policies do not cover the cost of health care received in other countries. Medical evacuation insurance covers moving the person from the place of illness or injury to a place where they can receive definitive care. Travelers might need assistance to identify supplemental insurance plans that will cover costs for preexisting conditions (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance ).

Help patients devise a Personal Travel Health Plan. This plan should give instructions for managing minor problems or exacerbations of underlying illnesses and should include information about medical facilities available in the destination country (see Sec. 6, Ch. 2, Obtaining Health Care Abroad ).

Specific Chronic Medical Conditions

Chronic illness or acute illness affecting underlying chronic disease might affect the recommendations clinicians make to a traveler after completing the risk assessment conducted as part of the pretravel consultation (see Sec. 2, Ch. 1, The Pretravel Consultation ). Some online resources for travelers who have ≥1 chronic medical conditions can be found in Table 3-05 (in Sec. 3, Ch. 2, Travelers with Disabilities ) and Table 3-07 .

Chronic conditions include those affecting the cardiovascular, endocrine, gastrointestinal, genitourinary, hematological, hepatic, neurologic, and respiratory systems. Table 3-08 addresses issues and recommendations related to specific chronic medical illnesses and should be used in conjunction with the other recommendations given throughout this book.

Travelers also might want to investigate international health care accreditation agencies to identify health care facilities at the travel destination that have received recognition or accreditation for high care standards and good patient safety records. If travelers or their health care providers have concerns about fitness for air travel or the need to obtain a medical certificate before travel, the medical unit affiliated with the specific airline is a valuable source for information.

Travelers who require service animals, including emotional support animals, should check with the airline and the destination country to ensure both the air carrier and the country will allow the animal; documentation and permits might also be required (see Sec. 7, Ch. 6, Traveling with Pets & Service Animals ). Travelers planning to use supplemental oxygen on the aircraft or needing other equipment (e.g., a wheelchair) must inform the airline far in advance of planned travel. The Transportation Security Administration (TSA) Cares Helpline (toll-free at 855-787-2227) or TSA Cares online assistance also can provide information on how to prepare for the airport security screening process for a particular disability or medical condition.

Table 3-07 Online resources for travelers with chronic illnesses: disease & condition-specific

DISEASE / CONDITION

ORGANIZATION / SOURCE

ANTICOAGULATION

Anticoagulation Forum

Centers of Excellence Resource Center

American Cancer Society

Eat Right and Stay Active while Traveling

CELIAC DISEASE

National Celiac Association

Eating GF when traveling abroad

CHRONIC PAIN

International Pain Foundation

Top Tips for Traveling Abroad with Chronic Pain

American Diabetes Association

Air Travel and Diabetes

Epilepsy Foundation

Travel and Holidays

Epilepsy Society (UK)

Travel and holidays for people with epilepsy

HEART CONDITIONS

American Heart Association

Healthy Travel

INFLAMMATORY BOWEL DISEASE

Crohn’s & Colitis Foundation

Traveling with IBD

KIDNEY DISEASE

American Association of Kidney Patients (AAKP)

International Travel while on Dialysis

National Kidney Foundation

Foreign Travel Tips for Dialysis Patients

Global Dialysis (UK)

Travel Advice

LUNGS & CHEST

American Lung Association

Traveling with Oxygen

MULTIPLE SCLEROSIS

Multiple Sclerosis Foundation

Tips for Traveling Abroad with MS

SLEEP APNEA

American Sleep Association

Travel: CPAP Machines

American Sleep Apnea Association

US Travel Tips for CPAP Users

Table 3-08 Special considerations for travelers with chronic illnesses

Abbreviations: AAKP, American Association of Kidney Patients; AICD, automatic implantable cardioverter defibrillator; CABG, coronary artery bypass graft; CHF, congestive heart failure; CKD, chronic kidney disease; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; COVID-19, coronavirus disease; CrCl, creatinine clearance; CVA, cerebrovascular accident; DVT, deep vein thrombosis; ECG, electrocardiogram; FSBG, fingerstick blood glucose; GI, gastrointestinal; Hgb, hemoglobin; HIV, human immunodeficiency virus; IGRA, interferon-γ release assay; INR, international normalized ratio; PNS, peripheral nervous system; PPIs, proton-pump inhibitors; PTX, pneumothorax; TD, travelers’ diarrhea; TIA, transient ischemic attack; TNF, tumor necrosis factor; TST, tuberculin skin test; YF, yellow fever.

a There is a spectrum of airline travel–related risk that depends on the cardiovascular disorder, the defined risk group within the disorder, and the time since the acute event (if applicable). Evidence basis for recommendations is suboptimal, however.

b See Sec. 5, Part 3, Ch. 16, Malaria , for additional details.

The following authors contributed to the previous version of this chapter: Deborah Nicolls Barbeau, Gail A. Rosselot, Sue Ann McDevitt

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Furuto Y, Kawamura M, Namikawa A, Takahashi H, Shibuya Y. Health risk of travel for chronic kidney disease patients. J Res Med Sci. 2020;25:22.

Heng S, Hughes B, Hibbert M, Khasraw M, Lwin Z. Traveling with cancer: A guide for oncologists in the modern world. J Glob Oncol. 2019;5:1–10.

International Air Transport Association. Medical manual, 12th edition; July 2020. Available from: www.iata.org/en/publications/medical-manual .

Josephs LK, Coker RK, Thomas M; British Thoracic Society Air Travel Working Group. Managing patients with stable respiratory disease planning air travel: a primary care summary of the British Thoracic Society recommendations. Prim Care Respir J. 2013;22(2):234–8.

McCarthy AE, Burchard GD. The travelers with pre-existing disease. In: Keystone JS, Kozarsky PE, Connor BA, Nothdurft HD, Mendelson M, Leder K, editors. Travel medicine, 4th edition. Philadelphia: Saunders Elsevier; 2018. pp. 263–6.

Pinsker JE, Becker E, Mahnke CB, Ching M, Larson NS, Roy D. Extensive clinical experience: a simple guide to basal insulin adjustments for long-distance travel. J Diabetes Metab Disord. 2013;12(1):59.

Ringwald J, Strobel J, Eckstein R. Travel and oral anticoagulation. J Travel Med. 2009;16(4):276–83.

Smith D, Toff W, Joy M, Dowdall N, Johnston R, Clark L, et al. Fitness to fly for passengers with cardiovascular disease. Heart. 2010;96(Suppl_2):ii1–16.

US Department of Justice. Exemption from import or export requirements for personal medical use. Title 21 CFR §1301.26. 2004 Sep 14. Available from: www.deadiversion.usdoj.gov/fed_regs/rules/2004/fr0914.htm .

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The Immunocompromised Traveler

Among immunocompromised travelers, the risk of acquiring travel-related infections may be higher due to deficits in their immune system and their potential to have attenuated responses to vaccines.

Table 1. Essential Competencies of a Pre-Travel Counseling Visit

Table 2. Some Vaccines Given in the Setting of International Travel

Table 3. Highly Immunocompromising Conditions in Cancer Patients

Introduction

More than 1 billion people worldwide crossed international borders in 2014.[1] International travelers, especially those visiting tropical and subtropical locations, are at increased risk for acquiring infections that may lead to adverse health events during or upon return from travel.[2,3] Among immunocompromised travelers, the risk of acquiring travel-related infections may be higher due to deficits in their immune system and their potential to have attenuated responses to vaccines.[4]

Furthermore, live attenuated vaccines may be contraindicated in certain immunocompromised patients. In the United States, as the prognosis of multiple cancer types has improved over the past few decades,[5] more people living with cancer are enjoying a better quality of life, which includes increased mobility and the ability to travel. Recent studies have highlighted that international travel is common among patients living with cancer, both during therapy and soon after therapy has concluded, even among highly immunocompromised hematopoietic stem cell transplant recipients.[6,7] Pre-travel health counseling and interventions should be optimized in these patients, and clinicians should consider referral to a travel medicine specialist for the provision of specific counseling and interventions.

A 52-year-old woman with a history of invasive ductal breast cancer, who underwent a mastectomy followed by chemotherapy 2 years prior and is currently on an aromatase inhibitor, is referred by her oncologist for a pre-travel consultation 2 months ahead of a trip to Ghana. She is traveling with her church group and will be staying in a hotel, although she will be visiting homes of local church members. Her only other international travel has been to Jamaica and Mexico; at the latter destination she experienced diarrhea. She does not recall receiving any recent vaccinations other than an annual flu shot.

Pre-Travel Consultation: The Essential Competencies

Preventive strategies in the form of proper planning, counseling, and vaccine and chemoprophylaxis interventions are helpful in ensuring a safe and healthy trip for cancer patients when they travel to international destinations (Table 1). In order to properly prioritize and customize pre-travel interventions, a structured risk assessment should be conducted based on the travel itinerary and nature of activities planned, as well as stratification of the patient according to degree of immunocompromise. Consultation should occur at least 4 to 6 weeks in advance of travel, although in certain cases, particularly when booster doses of vaccines are required for maximal protection, even more advanced planning is preferable.

Planning, Packing, and Getting There

Many websites offer comprehensive, up-to-date information on recommendations and requirements prior to embarkation. Both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) offer general and country-specific information about epidemiologic risks and related recommendations for vaccination and chemoprophylaxis.[8,9]

Patients should keep medications and supplies in their original packaging and pack them in their carry-on bags. A clinician letter detailing the medical condition(s) and prescribed medication(s), including generic names, should be provided. Patients should be advised on personal safety and the differences between trip, travel medical, and medical evacuation insurance.[10] In addition, patients should pack a travel health kit that includes additional over-the-counter medications and/or supplies that might be helpful in the setting of minor illness or injury, such as analgesics, antihistamines for allergy, and a first aid kit.

Patients with malignancy who are on active treatment are at increased risk for deep vein thrombosis,[11] and long-haul travel greater than 6 hours is also associated with increased risk.[12] Patients should be counseled on staying well hydrated, wearing loose-fitting clothing, and stretching while awake. For patients who are at particularly high risk, compression stockings can be prescribed.

In general, vaccines that should be considered prior to travel include: 1) routine vaccinations that would benefit the patient regardless of travel, particularly since certain routine vaccine-preventable illnesses like polio and measles are re-emerging in localized outbreaks[13,14]; 2) travel-related vaccinations, based on specific epidemiologic risks that may be encountered; and 3) vaccines that might be required prior to entry to certain countries. Table 2 contains a list of common vaccines given prior to international travel.

The risks associated with receipt of live attenuated vaccines must be carefully weighed against potential benefit, and are not advised in patients with severe immunologic compromise (Table 3).[15] It is very important that the effects of the increasingly diverse group of immunologics and biologics used in cancer therapy be well understood by the vaccine provider, since the spectrum and duration of immunosuppressive effects can vary widely. Since yellow fever is a live attenuated vaccine, the potential harms and benefits of vaccination in relation to underlying immune status must be carefully considered. For patients who cannot safely receive vaccination that is required for disembarkation but who will be visiting a location where little epidemiologic risk occurs, a waiver letter can be written by a certified yellow fever vaccine provider. For patients who are planning a trip that may result in natural exposure to disease, attendant risks and possibility of altering an itinerary to avoid natural exposure should be discussed.

Data regarding efficacy of travel vaccines in individuals who are immunosuppressed because of cancer or related therapy are limited.[16] Certain severely immunosuppressed patients (ie, those with recent receipt of monoclonal anti-CD20 antibodies) may be unlikely to respond to vaccinations, in which case alternate additional strategies, such as immune globulin for hepatitis A prevention, should be considered.

Protection From Insect Bites

Mosquitoes, ticks, and other arthropod vectors can transmit a number of infections. Vaccination or chemoprophylaxis strategies can protect travelers against several of these diseases, such as malaria, yellow fever, and Japanese encephalitis, among others. However, not all vector-borne infectious agents have vaccine or chemoprophylaxis options to reduce the incidence of disease acquisition (dengue virus, chikungunya virus, zika virus, among others); therefore, bite prevention strategies, such as the use of effective topical repellents, as well as permethrin-embedded clothing or bed netting in the appropriate setting, should be considered. I recommend that travelers utilize insect repellent that contains at least 25% DEET.[17] Sunscreen, when applied concurrently with insect repellent, should be applied first.[18]

Malaria prevention

Patients traveling to areas with malaria should obtain prophylactic medications prior to travel. The CDC maintains a comprehensive, up-to-date list of countries with malaria, and country-specific recommendations are well outlined.[19] Chloroquine remains the drug of choice for areas of the world where there is still chloroquine-sensitive malaria. For most areas with chloroquine-resistant malaria, atovaquone/proguanil, mefloquine, and doxycycline all have similar efficacy for malaria prevention; drug-drug interactions must be reviewed.

Watching What You Eat

Patients traveling to areas where food hygiene and water safety are concerns should be counseled to avoid tap water (including ice), as well as to generally avoid raw vegetables and unpasteurized dairy products. Cooked, steamed, or boiled food, and fruit that can be self-peeled, is generally considered to be safe.[20]

Traveler’s Diarrhea

Traveler’s diarrhea is usually a self-limited illness caused by viruses or noninvasive strains of Escherichia coli. Although much less common, enteroinvasive bacteria or parasites may be causative agents. Over-the-counter loperamide can be used for mild diarrhea without bloody stools or persistent fever (> 24 hours) and/or abdominal cramps. For more severe diarrhea, patients can be prescribed an antibiotic for initiation of self-treatment in the appropriate setting,[20] and this may be particularly important for immunocompromised patients who may experience more severe symptoms or a longer duration of symptoms.[21] Fluoroquinolones or macrolides are the most commonly prescribed antimicrobials, and the choice of which to use is dependent on destination-specific antimicrobial resistance patterns.[22]

Counseling, vaccination, and chemoprophylaxis strategies can help patients who are traveling during or after cancer treatment. My patient was counseled on optimal preparations prior to her trip to Africa. She received yellow fever, typhoid, hepatitis A, and tetanus-diphtheria-pertussis vaccinations prior to departure, and was given a certification stamp for yellow fever vaccination, as was required for entry to Ghana. She also received atovaquone/proguanil for malaria prophylaxis. She returned uneventfully and has plans to return next year.

Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1. United Nations. World Tourism Organization: Annual Report 2014. Madrid: United Nations; 2015.

2. Steffen R, Rickenbach M, Wilhelm U, et al. Health problems after travel to developing countries. J Infect Dis. 1987;156:84-91.

3. Hill DR. The burden of illness in international travelers. N Engl J Med. 2006;354:115-7.

4. Mileno MD, Bia FJ. The compromised traveler. Infect Dis Clin North Am. 1998;12:369-412.

5. American Cancer Society. Cancer facts & figures 2015. Atlanta: American Cancer Society; 2015.

6. Mikati T, Taur Y, Seo SK, Shah MK. International travel patterns and travel risks of patients diagnosed with cancer. J Travel Med. 2013; 20:71-7.

7. Mikati T, Griffin K, Lane D, et al. International travel patterns and travel risks for stem cell transplant recipients. J Travel Med. 2015; 22:39-47.

8. Centers for Disease Control and Prevention. Traveler’s health. http://wwwnc.cdc.gov/travel/destinations/list/ . Accessed January 8, 2016.

9. World Health Organization. International travel and health. http://www.who.int/ith/en/ . Accessed January 8, 2016.

10. Stoney RJ. Travel insurance, travel health insurance, & medical evacuation insurance. In Chapter 2: Obtaining health care for the traveler abroad. The CDC Health Information for International Travel (the Yellow Book); 2016. http://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/travel-insurance-travel-health-insurance-medical-evacuation-insurance . Accessed January 17, 2016.

11. Khorana AA, Kuderer NM, Culakova E, et al. Development and validation of a predictive model for chemotherapy-associated thrombosis. Blood. 2008;111:4902-7.

12. Philbrick JT, Shumate R, Siadaty MS, Becker DM. Air travel and venous thromboembolism: a systematic review. J Gen Intern Med. 2007;22:107-14.

13. Centers for Disease Control and Prevention. Measles (rubeola). http://www.cdc.gov/measles/travelers.html . Accessed January 8, 2016.

14. Aylward B, Yamada T. The polio endgame. N Engl J Med. 2011; 364:2273-5.

15. Kotton CN, Freedman DO. Immunocompromised travelers. In: Chapter 8, Advising travelers with special needs. The CDC Health Information for International Travel (the Yellow Book); 2016. http://wwwnc.cdc.gov/travel/yellowbook/2016/advising-travelers-with-specific-needs/immunocompromised-travelers . Accessed January 8, 2016.

16. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58:309-18.

17. Fradin MS, Day JF. Comparative efficacy of insect repellents against mosquito bites. N Engl J Med. 2002;347:13-8.

18. Sunscreen revisited. Med Lett Drugs Ther. 2011;53:17-8.

19. Arguin PM, Tan KR. Malaria. In: Chapter 3, Infectious diseases related to travel. The CDC Health Information for International Travel (the Yellow Book); 2016. http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/malaria . Accessed January 8, 2016.

20. Advice for travelers. Med Lett Drugs Ther. 2015;57:52-8.

21. Patel RR, Liang SY, Koolwal P, Kuhlmann FM. Travel advice for the immunocompromised traveler: prophylaxis, vaccination, and other preventive measures. Ther Clin Risk Manag. 2015;11:217-28.

22. Steffen R, Hill DR, DuPont HL. Traveler’s diarrhea: a clinical review. JAMA. 2015;313:71-80.

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You asked: I’m unvaccinated and immunocompromised. How can I travel safely?

This week’s by the way concierge gets advice for an immunocompromised traveler during the omicron surge.

Traveling has always come with complications, but the coronavirus pandemic has made it more challenging than ever. Our By The Way Concierge column will take your travel dilemmas to the experts to help you navigate the new normal. Want to see your question answered? Submit it here .

“I am a 65-year-old with underlying medical problems, and I am unvaccinated at my doctor’s recommendation. I am scheduled to fly to a large city airport after the holidays to visit with my specialist. What precautions can I take during this trip to minimize my risks?” — Krystalline, Roswell, N.M.

It sounds like you’re in a very small group of the population who would like to get vaccinated but can’t — such as people who are allergic to vaccine components or had severe allergic reactions after getting a first shot.

Given the omicron surge, it’s a very risky time to be traveling, particularly for people who are unvaccinated and/or at high risk for severe illness. Every one of the four experts who weighed in on your question started with the same advice: Postpone your trip if you can.

Syra Madad , a pathogen preparedness expert and infectious-disease epidemiologist who was featured in the Netflix docuseries “Pandemic: How to Prevent an Outbreak,” recommends putting off any nonessential travel until you can get vaccinated or transmission rates are lower.

What to do if your flight is delayed or canceled

The first question to ask yourself is whether your upcoming trip is absolutely necessary, says LetsGetChecked chief medical officer Robert Mordkin. Can you delay a month or at least a few weeks until the current surge wanes?

If the trip can’t wait, consider driving to your destination. You will be better able to control your environment and social distance from other people.

“Not traveling is choice number one. Traveling by car is choice number two,” says Katie Passaretti, medical director of infection prevention of health-care company Atrium Health .

Andrew Noymer, associate professor of population health and disease prevention at the University of California at Irvine, agrees — to an extent.

The best travel advice of 2021, from By The Way Concierge

“I wouldn’t suggest someone drive clear across the country,” he says. “But I think omicron is so contagious and there are too many opportunities for exposure at the airport, including when the TSA agent requests that you remove your mask [to confirm your identity].”

Again, all the experts say to avoid travel, but should you absolutely have to fly (or take a train or bus), remember that “any kind of enclosed public transportation — that carries increased inherent risk,” Passaretti says. That doesn’t mean you can’t improve the situation.

Step one: Get a good mask and make sure it fits correctly. Madad suggests an N95, KN95 or KN94 mask for travelers.

Because everyone has a unique face shape, Noymer says you may need to purchase multiple mask options from different brands to find one that seals your nose and mouth the best.

The airline lost your luggage. Now what?

While traveling, refrain from taking off the mask in shared public spaces, Madad says. If you need to eat or drink something, she recommends finding a less crowded place.

Passaretti also recommends booking a window seat , where you will be farther from passengers walking up and down the aisles, and turning on the overhead air vent to improve the air flow.

When you get to your destination, avoid crowded places such as restaurants and hotel lobbies, and spend as much time as you can outdoors. Depending on your destination, you may be limited in what you can do anyway as more cities require proof of vaccination for indoor activities.

These tips are, of course, in addition to coronavirus-prevention basics such as cleaning your hands often and social distancing from people when possible.

Finally, it may be worth having another conversation with your doctor about your vaccination status.

Mordkin recommends confirming with your physician that you are still not a candidate for coronavirus vaccination, as it remains the most effective defense against severe illness or death from a covid-19 infection.

Have a travel dilemma for By The Way Concierge? Submit it here.

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VINCENT LO RE, III, M.D., AND STEPHEN J. GLUCKMAN, M.D.

Am Fam Physician. 2004;70(1):89-99

A more recent article on pretravel consultation is available .

Patient information handout: A patient information handout on travel immunizations, written by the authors of this article, is provided on page 103.

Advising travelers on vaccine-preventable illnesses is increasingly becoming the responsibility of primary care physicians. The approach to vaccine recommendations should be based on a thorough assessment of the risks for travel-related diseases, the time available before trip departure, and current knowledge of the epidemiology of vaccine-preventable diseases. Routine childhood vaccinations should be reviewed in all travelers and updated as necessary. Yellow fever vaccination may be required for entry by countries that lie within a yellow fever zone or for travelers coming from an endemic area to prevent introduction of the disease. Immunization against hepatitis B virus should be considered in travelers who expect to have close contact with local populations that have high rates of hepatitis B transmission. Japanese encephalitis vaccine should be offered to travelers who plan prolonged trips to rural areas in southeast Asia or the Indian subcontinent during the transmission season. Typhoid fever immunization is recommended for travelers who may be exposed to potentially contaminated food and drink. Preexposure rabies vaccination should be considered in travelers who plan a prolonged duration of stay in a remote area or who engage in activities that might involve working near animals or that could attract animals. Physicians should be aware of the adverse events and contraindications associated with each travel vaccine.

As international travel to exotic locations becomes increasingly common, it is necessary for more physicians to maintain familiarity with current recommendations for travel health safety. Immunizations and preventive medicines are key parts of travel preparation, and careful attention to them can reduce the risks of infections acquired while abroad. Travel vaccines generally fall into one of three categories: (1) routine immunizations typically administered during childhood that should be updated or boosted, (2) legally required immunizations necessary for entry into certain countries, and (3) recommended immunizations that may be useful, depending on the risks of exposure at the travel destination. 1 – 3 Vaccines are not available for all travel-related infections (e.g., malaria). In these cases, preventive medication may be necessary to keep the traveler healthy.

Advising travelers on vaccine- and medication-preventable diseases is increasingly becoming the responsibility of primary care physicians. The approach to travel health recommendations should be based on an assessment of the risks for travel-related illnesses, the time available before trip departure, and the current epidemiology of preventable diseases. Physicians should take into account the adverse events and contraindications associated with each vaccine and medication. This article reviews the overall approach to travel immunizations and provides an overview of the immunizations that are recommended or required for international travel ( Table 1 ). Information about preventive medication has appeared previously in American Family Physician . 4

Risk Assessment

Immunizations should be recommended according to the patient’s risk of travel-related diseases and not solely according to geographic destination. A number of resources provide updated information about risks to travelers ( Table 2 ). 5 To properly assess a traveler’s risk of illness, the physician first should consider the details of the planned journey 5 – 7 : the exact itinerary, including all geographic destinations and possible stopovers; duration of stay in each location; type of lodging (urban or rural, hotel or tent); planned activities (animal contact, river- or lake-water exposure, eating habits); seasonal risks (time of year); and level of anticipated contact with local residents.

Physicians then should review the status of the traveler’s general health, focusing on underlying diseases that may have implications during the trip. 6 Previous immunizations, allergies to medications and vaccine components (especially eggs), and current medications also should be reviewed. 5 – 7 The physician should make a special effort to identify travelers who are at particularly high risk for travel-related illnesses ( Table 3 ). 3 , 6 An overall approach to vaccination of travelers based on risk assessment is presented in Figure 1 and Table 4 .

Travelers, particularly those going to developing countries, should be encouraged to seek medical advice early in their planning (at least four weeks in advance). Consultation with a travel clinic may be helpful if the destination is high risk. The amount of time remaining before departure determines whether the standard schedule for a primary immunization series can be used or whether an accelerated schedule, if one exists, should be offered. 2 When departure is imminent and an accelerated vaccine schedule is used, vaccine efficacy may not be maximal by the time of departure, and this fact must be discussed with the patient. 2

Physicians who provide consultations to travelers should base their recommendations on the current epidemiology of vaccine-preventable diseases at each destination. The Centers for Disease Control and Prevention (CDC) publication, “Health Information for International Travel,” is one of the standard references for travel immunization recommendations and is updated regularly. 8 Additional information may be obtained online from the CDC ( http://www.cdc.gov/travel ) and the World Health Organization (WHO) ( http://www.who.int/ith ).

Routine Immunizations

Travel provides an opportunity for the physician to review and update a patient’s routine immunizations. 1 , 6 Travelers to areas where postexposure tetanus immunization might be unavailable should consider receiving a booster dose of tetanus and diphtheria (Td) toxoids before departure if five or more years have elapsed since their last vaccination. 9

Measles is endemic in many developing nations, and a booster of measles-mumps-rubella (MMR) vaccine is warranted for any person born after 1956 who does not have documentation of two doses of the vaccine or immunity by serum antibody testing. 10 Children six to 11 months of age should receive one dose of MMR vaccine if traveling to highly endemic areas, but they still must receive two doses of the vaccine after 12 months of age to be considered fully immunized. 10

Polio is a good example of the need for physicians to keep current with changing epidemiology. Intensive immunization campaigns have resulted in a marked decrease in polio throughout the world. Polio remains endemic in seven countries: India, Nigeria, Pakistan, Egypt, Afghanistan, Niger, and Somalia. 11 Travelers to these countries are advised to receive a single booster of inactivated polio vaccine (IPOL) if the primary doses have already been administered.

Varicella (chickenpox) immunity should be reviewed and, if needed, children one through 12 years of age should receive a single dose of vaccine (Varivax), while those 13 years and older should receive two doses of vaccine administered four to eight weeks apart. 1 , 2 , 8 , 12 , 13 In particular, this vaccine should be considered for women of child-bearing age who do not have documented varicella disease before vaccination or antibody titers.

The pneumococcal vaccine (Pneumovax) should be considered for travelers who are older than 65 years as well as younger adults with chronic cardiopulmonary disease, asplenia, cirrhosis, or diabetes mellitus. 8 , 14

Finally, the influenza vaccine is recommended for all international travelers during influenza season. While influenza typically occurs from November until March in the northern hemisphere, the incidence of the disease peaks from April until September in the southern hemisphere. Patients should receive the most current vaccine available.

Required Immunizations

Yellow fever.

Yellow fever is a rare but potentially fatal viral infection that is endemic in equatorial Africa ( Figure 2 ) and South America ( Figure 3 ) , where the virus is transmitted by day-biting mosquito vectors. The clinical presentation of the disease ranges from a mild febrile illness to a life-threatening disease characterized by hepatitis, renal failure, hemorrhagic fever, and shock.

Yellow fever vaccination is recommended for patients older than nine months who are traveling to areas where yellow fever is reported. 15 It also is recommended for travelers to rural areas of countries that do not officially report yellow fever but are within the endemic zone. 15 Many yellow-fever endemic countries require proof of vaccination for entry. Other countries may require proof of vaccination if a person is traveling from an endemic area to prevent introduction of the disease. Yellow fever vaccination may be required even if the person merely passes through an endemic region while traveling to the final destination. Physicians can obtain country-specific requirements for yellow fever vaccination from the CDC. 8

The yellow fever vaccine (YF-Vax) is a live-attenuated virus preparation delivered in a single subcutaneous inoculation of 0.5 mL. It induces neutralizing antibodies in 99 percent of recipients within 30 days of receipt. 16 Immunity is likely to be lifelong, but revaccination is required at 10-year intervals. 15 For purposes of international travel, the vaccine must be administered at an approved yellow fever vaccination center. Proof of immunization should be documented on an Official International Certificate of Vaccination Against Yellow Fever, which becomes valid 10 days after vaccination to meet entry and exit requirements for all countries. Yellow fever immunization is usually available at local health departments, which are approved vaccination centers.

Reactions to the yellow fever vaccine are generally mild, but analysis of vaccine recipients in the United States from 1990 to 1998 found that persons 65 years or older were at an increased risk for neurologic and systemic reactions. 17 [Evidence level B, case series] Thus, its use should be considered carefully in this population.

Yellow fever vaccination is not recommended in pregnancy, and pregnant women who are not immune to yellow fever should delay their travel to any high-transmission area until after delivery. If the travel itinerary of a pregnant woman does not present a substantial risk, and immunization is required only for entry, the physician should provide the woman with a waiver letter. 8 , 15 [Evidence level C, consensus/expert guidelines] Pregnant women who must travel to areas with active transmission should be vaccinated because the small risk to the mother and fetus from the vaccine is believed to be outweighed by the risk of yellow fever. 15 [Evidence level C, consensus/ expert guidelines]

Recommended Immunizations

Hepatitis a.

The inactivated hepatitis A virus vaccines (Havrix, Vaqta) are recommended for all international travelers except those going to destinations in North America (except Mexico), western Europe, Japan, Australia, and New Zealand. 8 , 18 , 19 Travelers preferably should receive a single intramuscular dose of 1.0 mL four weeks before departure. Vaccination two weeks before travel still may be useful because up to 94 percent of patients develop protective antibodies within two weeks of the first dose. 19 [Evidence level A, randomized controlled trial (RCT)] A 1.0-mL booster given six to 12 months later can provide protective antibody levels for at least 10 years. 19 Both vaccines provide protective antibody levels in 94 to 100 percent of patients within four weeks of vaccination. 20 , 21 [References 20 and 21—Evidence level A, RCTs] The safety of the vaccine in pregnant women has not been determined.

Travelers who need optimal hepatitis A protection earlier than two weeks after the first dose of hepatitis A vaccine should receive immune globulin with the first vaccine dose but at a different injection site. 8 , 19 , 22 Those who receive vaccination less than two weeks before departure and who do not receive immune globulin are still at risk of infection, so administration of immune globulin should be considered. 8 , 19 [Evidence level C, consensus/expert opinion] Simultaneous receipt of hepatitis A vaccine and immune globulin results in lower antibody titers than occur when only hepatitis A vaccine is given, but protective antibody levels exceed those achieved when immune globulin is given alone. 2 , 23 Immune globulin also should be offered to travelers who are allergic to the vaccine, younger than two years, or pregnant. 19 It is given by intramuscular injection and can provide protection in 85 to 90 percent of patients for three to five months, depending on the dose used (0.02 mL per kg or 0.06 mL per kg). 19

HEPATITIS B

While childhood vaccination against hepatitis B now is routine in the United States, many adult travelers have never been immunized. 24 Hepatitis B vaccination should be considered for patients who have a potential for close contact with a local population that has a high rate of hepatitis B transmission, patients planning an extended stay (six months or longer) in an area where hepatitis B is endemic (e.g., South America, Africa, southeast Asia, South Pacific), those with a potential need for medical treatment while abroad, and those born overseas who are traveling back to their country of origin.

The standard schedule for administering the hepatitis B vaccine (Recombivax-HB, Engerix-B) in adults 20 years and older calls for three doses of vaccine (each 1.0 mL) at zero, one, and six months. An accelerated schedule with Engerix-B consists of vaccination at zero, one, and two months, with a booster given 12 months after the first dose. 8 , 25 The vaccine is not contraindicated in pregnancy. 8

COMBINED HEPATITIS A AND B

A combination hepatitis A and B vaccine (Twinrix) containing the same antigenic components as Engerix-B and pediatric Havrix is available for use in adults older than 18 years. It is as efficacious as each of the monovalent vaccines. 25 , 26 Primary immunization occurs at zero, one, and six months. An accelerated schedule of zero, one, and three weeks, with a fourth dose 12 months after the first dose, is as efficacious as the standard schedule. 26 Its safety in pregnancy has not been determined.

JAPANESE ENCEPHALITIS

Japanese encephalitis virus, an arboviral infection transmitted by day-biting mosquitoes, is prevalent in the Indian subcontinent, China, Korea, Japan, and other southeast Asian countries. 27 The majority of human cases are asymptomatic, but the virus can cause severe encephalitis with residual neuropsychiatric sequelae.

Japanese encephalitis vaccine (Je-Vax) should be offered to patients who plan to remain for 30 days or longer in endemic areas during the transmission season, particularly if travel destinations might include rural areas. Vaccination also should be considered for short-term travelers who engage in extensive outdoor activities or visit areas of epidemic transmission.

Primary immunization in patients three years or older consists of three doses of 1.0 mL, each given by subcutaneous injection on days zero, seven, and 30. An accelerated schedule, in which doses are given on days zero, seven, and 14, can be used when departure is imminent. 27 The vaccine’s efficacy is 91 percent after two doses. 28 [Evidence level A, RCT] A booster dose may be given three years after the primary series if continued exposure in high-risk areas is expected. Because generalized urticaria and angioedema of the face, lips, or oropharynx occasionally have occurred up to two weeks after immunization, the last dose of vaccine should be administered at least 10 days before trip departure. 27 , 29

The safety of the vaccine in pregnancy has not been determined. Pregnant women who must travel to an area where the risk of Japanese encephalitis is high should be vaccinated when it is thought that the risks of immunization are outweighed by the risk of infection to the mother and fetus. 27 [Evidence level C, consensus/expert guidelines]

TYPHOID FEVER

Typhoid fever immunization is recommended for travelers going to highly endemic areas in Central and South America, the Indian subcontinent, and Africa. 30 It also is recommended for travelers who may be exposed to potentially contaminated food and drink, such as those journeying beyond the usual tourist routes. 30 Typhoid vaccines (Vivotif Berna, a live-attenuated oral Ty21a vaccine, and Typhim VI) are approximately 50 to 80 percent effective and cannot substitute for careful selection of food and drink.

Primary vaccination with oral Ty21a consists of one enteric-coated capsule taken on alternate days for four doses. 30 Vaccine-elicited immunity occurs 14 days after receipt of the last vaccine dose, with an overall efficacy of approximately 50 to 80 percent. 30 [Evidence level A, RCT] A booster dose, consisting of the entire four-capsule regimen, is recommended every five years for those at continued risk. 30 The most common adverse effect reported is mild gastrointestinal upset. The vaccine is contraindicated in pregnant women, children under the age of six years, and immunocompromised patients. Care must be taken if this vaccine is given in association with antibiotics because they may kill the live-attenuated organisms.

Primary vaccination with Typhim VI in patients two years or older consists of a single 0.5-mL dose given intramuscularly. Protective immunity is elicited 14 days after vaccine receipt. 30 The efficacy of this vaccine has been reported to be 50 to 80 percent. 8 , 30 [Evidence level A, RCT] A booster dose given every two years is recommended for continued exposure. No data have been reported regarding its use in pregnant women or immunocompromised patients, although it theoretically is a safer alternative in these groups.

MENINGOCOCCAL

Meningococcal vaccine (Menomune) is recommended for travelers to sub-Saharan Africa, where epidemics of serogroups A or C meningococcal disease occur frequently from December through June in the “meningitis belt” from Senegal to Ethiopia 31 ( Figure 4 ) . The vaccine is required for pilgrims to Saudi Arabia during the Hajj and at other religious holidays. 8

The vaccine is effective only against sero-groups A, C, Y, and W-135. 25 , 31 Primary immunization in patients two years and older consists of a single 0.5-mL dose given by subcutaneous injection, and this dose confers immunity for at least three years. 31 Protective levels of antibody are achieved in seven to 10 days. 8 Vaccination is not contra-indicated in pregnancy. 31 Revaccination may be considered within three to five years for continued exposure. 31

Canine rabies remains endemic in the Indian subcontinent, China, southeast Asia, the Philippines, parts of Indonesia, Latin America, Africa, and countries of the former Soviet Union. 1 , 2 , 32 Postexposure prophylaxis, although effective, may not be readily available. 33 Preexposure rabies vaccination should be considered for travelers who plan a prolonged stay (more than 30 days) in an endemic region, who travel in remote areas, work near animals, engage in activities that could attract animals (e.g., hiking, cycling), or for persons who cannot report an exposure if bitten (e.g., young children).

In the United States, intramuscular formulations of the purified chick embryo cell vaccine (RabAvert) and human diploid cell vaccine (Imovax) are available. Preexposure rabies immunization consists of three 1.0-mL doses of one of the rabies vaccine formulations given on days zero, seven, and 21 or 28. 34 After a high-risk bite, travelers who received preexposure vaccination still require local wound care and two additional rabies vaccine doses (on the day of the bite and on day 3), but administration of rabies immune globulin is not necessary. 33

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Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP).MMWR Recomm Rep. 1997;46(RR-8):1-24 -

Yellow fever vaccine.Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep. 1990;39(RR-6):1-6 -

Monath TP, Cetron MS. Prevention of yellow fever in persons traveling to the tropics. Clin Infect Dis. 2002;34:1369-78 -

Martin M, Weld LH, Tsai TF, Mootrey GT, Chen RT, Niu M, et al. Advanced age a risk factor for illness temporally associated with yellow fever vaccination. Emerg Infect Dis. 2001;7:945-51 -

Steffen R, Kane MA, Shapiro CN, Billo N, Schoellhorn KJ, van Damme P. Epidemiology and prevention of hepatitis A in travelers. JAMA. 1994;272:885-9 -

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Werzberger A, Mensch B, Kuter B, Brown L, Lewis J, Sitrin R, et al. A controlled trial of a formalin-inactivated hepatitis A vaccine in healthy children. N Engl J Med. 1992;327:453-7 -

Innis BL, Snitbhan R, Kunasol P, Laorakpongse T, Poopatanakool W, Kozik CA, et al. Protection against hepatitis A by an inactivated vaccine. JAMA. 1994;271:1328-34 -

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Clemens R, Safary A, Hepburn A, Roche C, Stanbury WJ, Andre FE. Clinical experience with an inactivated hepatitis A vaccine. J Infect Dis. 1995;171(suppl 1):S44-9 -

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Infections in immunosuppressed travellers with autoimmune inflammatory diseases—a narrative review and advice for clinical practice

Victoria allen.

1 Department of Academic Rheumatology, King’s College London

Nicky Longley

2 Hospital for Tropical Diseases

3 London School of Hygiene and Tropical Medicine, London, UK

Associated Data

Data are available upon reasonable request by any qualified researchers who engage in rigorous, independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). All data relevant to the study are included in the article.

The management of autoimmune, inflammatory diseases has been revolutionized by biologic therapies. A beneficial consequence of better disease control is that more patients are well enough to travel the world. There is now a class of traveller, the significantly immunosuppressed person with autoimmune disease, with specific risks and requirements. This review introduces the concept of the pre-travel risk assessment and discusses the major vaccine-preventable and non-vaccine-preventable travel-associated infections. The challenges and controversies around vaccination and immunosuppression are reviewed with advice for clinical practice.

Rheumatology key messages

Immunosuppressed travellers need a multi-disciplinary risk assessment that includes their underlying condition and treatment.
Immunosuppressed travellers may develop more frequent, severe or atypical infections that can mimic underlying disease.
Evidence for vaccine response with immunosuppression is lacking but it is likely to be impaired.

Introduction

In 2018 there were an estimated 1.4 billion international tourist arrivals worldwide [ 1 ]. The COVID-19 pandemic has illustrated how travel can facilitate the spread of emerging diseases [ 2 ]. Although quarantine measures have decreased global travel, the pandemic is a reminder of the importance of travel-related infection.

The growth of international travel occurred alongside the advent of targeted therapies in autoimmune diseases. These drugs mean that those living with autoimmune conditions experience a better quality of life. Whereas before they might have been too unwell to travel, they are now able to visit a range of countries and enjoy diverse activities. Immunosuppressed travellers plan similar travel itineraries to non-immunocompromised travellers and around one-third visit low-income countries [ 3 ]. A growing population of immunosuppressed travellers now exists, and their physicians frequently receive questions regarding travel health advice.

Nationally, only a small number of dedicated travel clinics exist, and most pre-travel advice comes from primary care practitioners or autoimmune disease specialists in secondary care. The purpose of this review is to provide information tailored to the immunosuppressed host to aid clinicians in offering pragmatic advice. Immune modulation for autoimmune disease encompasses a large number of therapies spanning multiple diseases, and this review will not attempt to consider these individually. A common theme is that immune modulation carries a small, but significant increased risk of infection.

Pre-travel risk assessment

Risk may be defined as the likelihood that a person may be harmed or suffer an adverse health effect if exposed to a hazard [ 4 ]. The perceptions and realities of travel-associated risk will be different for each individual traveller. When evaluating risk, it is necessary to weigh the possibility of harm from a travel-related disease or event against harm from an intervention.

Suggested risk assessment framework

A simple question to start the risk assessment with is: ‘Who is this person and what will they be doing in this place at this time?’ These areas can then be considered in more detail as follows [ 5 ] ( Fig. 1 ).

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VFR: visiting friends and relatives.

Travellers visiting friends and relatives

Travellers visiting friends and relatives (VFR) are an important group to consider since they may have a different perception of travel-related risk as they are travelling to visit familiar places and people. They may have important personal reasons for travel at a particular time and may travel with significant co-morbidities. Lack of pre-travel healthcare may be more common due to incomplete childhood vaccinations or language barriers [ 6 ].

Malaria is an example of how an infectious disease may carry different risks in the VFR group. A VFR traveller who has grown up in a malaria-endemic area may have developed semi-immunity to malaria through repeated childhood exposures, meaning malaria may only cause a mild febrile illness in this group. A British study showed that although most imported malaria cases were seen in VFR travellers of African heritage, the greatest mortality was seen in the elderly, tourists and those seen in areas with few malaria cases [ 7 ].

VFR travellers are at higher risk of typhoid. Another British study showed that most imported typhoid cases were seen in VFR travellers and those visiting South Asia. This may be due to a difference in perception of risk and different behaviours around food and water hygiene [ 8 ].

Therapies for rheumatological conditions, immunosuppression and infection risk

The exact immune defect and resulting risk of infection depends on the immunosuppression used and the underlying autoimmune disease. Immunosuppressive therapies can be broadly divided into those causing non-significant and significant immunosuppression. Guidelines explaining these categories can be easily found online [ 9 ]. An overview of biologic therapies used in autoimmune diseases and their mechanisms of action is available [ 10 ].

Vaccinations in immunosuppressed travellers—general considerations

Significant immunosuppression is a contraindication to the use of live vaccinations. This is due to the risk of developing severe or fatal infection from the vaccine inoculum. In contrast, inactivated vaccinations are considered safe to use but the immune response may be impaired. Research has investigated temporary discontinuation of methotrexate around the time of influenza vaccination, demonstrating improved immunological response when methotrexate is withheld for 2 weeks following vaccination. Where vaccine response is particularly important, this strategy might be considered, although extrapolation to non-influenza vaccines is outside the evidence base [ 11 ].

All travellers should be up to date with their local routine vaccination schedule as well as any specific travel vaccinations. Infections such as measles remain common in parts of Asia and Africa [ 12 ].

Vaccine-preventable infections

A brief description of some of the most important infections and the vaccinations against them is given below. Immunosuppressed travellers should plan their trips well in advance to allow time for necessary vaccinations to be given.

Hepatitis A

Hepatitis A is an infection of the liver caused by hepatitis A virus. Disease is usually mild, but severity increases with age and jaundice may occur in 70–80% of infected adults [ 13 ]. Disease may be severe in immunocompromised states [ 14 ]. Fulminant hepatitis is unusual and there is no chronic carrier state. The overall case-fatality rate is low but is higher in people with underlying hepatic disease and older adults. Transmission is via the faecal–oral route and is common in areas with poor sanitation and food hygiene. Foreign travel associated cases are most frequent with travel to the Far East and South Asia. Vaccination is recommended for those aged 1 year and above travelling to areas of moderate or high disease prevalence [ 13 ].

There are several vaccines against hepatitis A including a monovalent vaccine and polyvalent vaccines combined with hepatitis B or typhoid. All are inactivated and may be given to immunosuppressed travellers. In immunocompetent people one dose of hepatitis A vaccine provides adequate protection before travel. A second booster dose is given at 6–12 months to provide longer lasting immunity for up to 25 years or more [ 13 ].

There may be an impaired serological response to hepatitis A vaccination with immunosuppression. A small study in rheumatoid arthritis patients treated with either TNF inhibitors or methotrexate found that two doses of hepatitis A vaccine provided adequate protection for most patients, but a single dose of vaccine was unlikely to provide sufficient protection [ 15 ]. Another study found 46% of patients on TNF inhibitors were protected after one dose of vaccine and 79% were protected after a second dose [ 16 ].

Enteric fever or typhoid is a systemic infection caused by Salmonella enterica , serotype typhi. Symptoms range from mild fever and gastrointestinal upset to severe disseminated infection with multi-organ involvement. Severe disease occurs in around 10–15% of cases. Paratyphoid, caused by S. paratyphi A, B and C, has a similar clinical presentation and is often less severe. Typhoid is spread via the faecal–oral route and is mainly a disease of poor sanitation and food hygiene [ 17 ]. It is common throughout South Asia, Southeast Asia and sub-Saharan Africa with an estimated 14.3 million cases per year. The estimated global case fatality rate is 1% [ 18 ].

Antibiotic resistant typhoid is rising in prevalence globally, largely due to widespread availability of over-the-counter antibiotics in countries with limited antimicrobial stewardship. A recent outbreak of extensively drug resistant (XDR) typhoid in Sindh, Pakistan [ 19 ], highlights the importance of vaccination against typhoid.

There are two types of vaccination available in the UK, the oral-live attenuated vaccine and the polysaccharide vaccine. The oral-live attenuated vaccine should be avoided in immunosuppressed people but the polysaccharide vaccine is safe. Studies in immunocompetent individuals estimate efficacy between 55 and 75% [ 17 ]. There are no data on immune response to typhoid vaccination in immunosuppressed patients but efficacy is likely to be lower [ 10 ]. There is no effective vaccination against paratyphoid, and so irrespective of vaccination good food hygiene remains important.

Meningococcal disease

Meningococcal disease is caused by Neisseria meningitidis . Meningococci colonize the nasopharynx in around 10% of the population. They can be spread through inhaling respiratory secretions or by direct contact [ 20 ]. A minority of people go on to develop invasive disease. The commonest presentations are meningitis, bacteraemia or meningitis with accompanying bacteraemia.

Meningococcal disease can occur as sporadic cases, outbreaks or epidemics. Most meningococcal infections occur in children and young adults, but all ages may be at risk during large epidemics. The serogroup of a meningococcal strain is determined by its polysaccharide capsule. Serogroups A, B, C, W-135 and Y cause most invasive infections [ 21 ].

There are different forms of meningococcal vaccine containing conjugated polysaccharides against one or more of serotypes A, W, C and Y and a multi-component protein vaccine. The vaccines are inactivated and may be given to immunosuppressed patients. Meningococcal vaccination forms part of the routine vaccination schedule in many countries [ 22 ].

The highest incidence of meningococcal disease worldwide occurs in the ‘meningitis belt’ of sub-Saharan Africa where large seasonal epidemics occur [ 21 ]. The Islamic Hajj and Umrah pilgrimages in Saudi Arabia have been associated with outbreaks of meningococcal disease. Saudi Arabia has made vaccination against meningococcal ACW135Y mandatory for pilgrims [ 23 ].

Unvaccinated travellers, including those who are immunosuppressed, should be vaccinated if travelling to high prevalence regions. Immunosuppressed travellers should be warned of the risk of an incomplete serological response. There is no evidence for efficacy of meningococcal vaccines in immunocompromised adults [ 24 ].

Human influenza A and B viruses cause seasonal outbreaks of influenza or ‘flu’. Influenza is a respiratory disease that is usually self-limiting. Severe disease with complications including pneumonia can occur and such cases can be life threatening or fatal. Those at increased risk of severe disease include the elderly, young children, pregnant women, people with certain chronic conditions and immunocompromised individuals. Influenza viruses are predominantly transmitted by droplet inhalation but may be transmitted via contaminated surfaces.

Influenza is one of the commonest vaccine preventable infections amongst travellers [ 25 ]. Cruise ships and attending mass gatherings such as The Hajj may increase the risk of disease [ 26 ]. Many national guidelines advise annual vaccination for those at risk of severe infection, including immunosuppressed patients. Many significantly immunosuppressed travellers will therefore have been vaccinated but influenza risk should be discussed as part of the pre-travel consultation. The live influenza vaccination should be avoided in significantly immunosuppressed patients. Inactivated influenza vaccines are safe but there may be an impaired serological response [ 27 ].

Yellow fever

Yellow fever virus is spread by the Aedes aegypti mosquito and is endemic in over 50 countries in sub-Saharan Africa and tropical South America. Outbreaks have occurred in recent years in Brazil, Nigeria, Angola and the Democratic Republic of Congo [ 28 ]. The incubation period is typically less than 7 days following a bite from an infected mosquito. The disease has a biphasic presentation with an initial short, febrile illness followed by a toxic phase that develops in up to 15% of patients. The toxic phase consists of fever, renal failure, hepatic failure, jaundice, haemorrhage and cardiovascular compromise. Multi-organ failure may develop and up to half of patients in the toxic phase die within 7–10 days [ 29 ].

Under the International Health Regulations (2005) a yellow fever vaccination certificate may be required as a condition of entry to a country. This aims to reduce the chance of viraemic individuals importing the virus and triggering a new outbreak. Guidance from the WHO suggests that one dose of yellow fever vaccination offers lifelong protection in most cases and a booster dose after 10 years is generally not required [ 30 ].

The risk of a traveller acquiring yellow fever is determined by their vaccination status, travel destination, season of travel, duration of exposure, activities undertaken and the rate of yellow fever transmission. The risk is estimated to be around 10 times higher in rural West Africa compared with South America [ 31 ].

Although an effective live attenuated vaccine is available, it is contraindicated in immunosuppressed patients due to the risk of vaccine-associated neurotropic and viscerotropic disease. Unvaccinated travellers should be discouraged from travelling to endemic areas. If travel is unavoidable, they should be informed of the risk of yellow fever and the importance of strict mosquito bite avoidance measures during both daytime and night-time, as Aedes mosquito species chiefly feast on humans during the day, but may also bite at night in well-lit areas.

If an immunosuppressed traveller requires an International Certificate of Vaccination or Prophylaxis (ICVP) then a Medical Letter of Exemption (MLoE) may be issued instead by their treating specialist or travel clinic [ 32 ]. This should be taken into consideration by their destination but patients should be aware that it may not guarantee entry.

MLoEs are valid for one trip and should be written on headed paper from the treating clinician’s hospital or clinic. A sample MLoE can be found at: https://nathnacyfzone.org.uk/factsheet/6/medical-letter-of-exemption .

Animal bites and rabies

Almost all human cases of rabies are caused by rabies virus genotype 1. Most cases are caused by bites from rabid dogs, often strays in urban areas, but any infected terrestrial mammal may act as a vector. The virus can be spread via scratches or through broken skin or mucus membranes. Other lyssaviruses, spread by bats, may cause an indistinguishable syndrome. Rabies causes an acute viral encephalomyelitis and established disease is fatal as there is no effective treatment. Death occurs from respiratory failure [ 33 ]. Most cases are reported in Africa and Asia and there are at least 60 000 deaths worldwide per year [ 34 ].

Rabies is rare in travellers, but animal bites and scratches are common. All travellers should be advised of the risks and to avoid contact with animals. Travellers deemed to be at higher risk, for example those travelling to high-risk areas for over a month, can be vaccinated with a course of pre-exposure vaccination [ 35 ].

Travellers who sustain a bite, scratch or exposure of animal saliva to broken skin or mucus membranes should be advised to wash the wound thoroughly as soon as possible. A disinfectant should be used along with a dressing. They should have an urgent risk assessment [ 33 ].

Pre-exposure vaccination primes the immune system to produce an antibody response following rabies exposure. Post-exposure vaccination is still required so travellers should seek medical attention quickly following an exposure.

The rabies vaccine is inactivated and safe in immunosuppressed people. The literature demonstrates that immunocompromised people may not mount an adequate serological response to a full course of post-exposure vaccination [ 36 ]. All immunosuppressed individuals should be warned of the risk of rabies if travelling to an endemic area and offered a pre-exposure vaccination course.

Non-vaccinated travellers require a longer course of post-exposure vaccination. They will also require human rabies immunoglobulin (HRIG) following a significant exposure. This is infiltrated around the wound and neutralizes rabies virus. Due to the risk of an impaired serological response, significantly immunosuppressed travellers should be managed as if they are unvaccinated regardless of their vaccination history. They will require a full course of post-exposure vaccination, HRIG and antibody testing post-treatment to assess their serological response [ 33 ]. All suspected cases of rabies should be discussed with specialist services.

Non-vaccine-preventable infections

Travellers’ diarrhoea.

Travellers’ diarrhoea (TD) is common in travellers from high-income countries to lower income countries, affecting 20–60%. It is defined as three or more loose stools in a 24-h period with or without other symptoms of fever, nausea or cramps [ 37 ]. TD is spread via the faecal–oral route due to poor food and water hygiene. It is caused by a variety of pathogens including bacteria (50–75% of cases), viruses (5–20%) and parasites (0–10%) [ 38 ].

The incidence of TD is not increased in patients on immunosuppressive therapies [ 39 ], but certain food or waterborne infections can be more severe or lead to chronic disease. These include salmonellosis, shigellosis, campylobacteriosis, giardiasis, listeriosis and cryptosporidiosis [ 9 ]. Cryptosporidum may cause chronic, intractable infection, including pancreato-biliary disease, in immunosuppressed patients. This can be very difficult to clear [ 40 ].

There is no strong evidence that dietary measures reduce the risk of TD [ 37 ], but travellers should be advised to follow good food and hygiene measures. Those with TD should maintain good hydration and use oral rehydration therapy. Short courses of antibiotics (1–3 days), taken at symptom-onset, reduce illness duration from 3 to 1.5 days [ 37 ].

Significantly immunosuppressed travellers can take an emergency pack of antibiotics for self-treatment of TD. Prophylactic antibiotics may be considered, especially for short-term travel to high-risk countries, but the risk of drug interactions and side effects should be considered. The choice of drug depends on the travel destination. For patients on biologic agents or Janus kinase inhibitors, azithromycin would be a suitable choice as it avoids the risk of antimicrobial resistance [ 41 ] and tendon rupture associated with fluoroquinolones and does not interact with commonly prescribed immunosuppressants.

Clinicians should be aware that travel has been associated with acquisition of multi-drug resistant Enterobacteriaceae (MDRE). These are increasingly common in low- and middle-income countries. Travel has been associated with MDRE acquisition rates of 21–51%. South Asia has the highest risk of MDRE acquisition with rates of up to 85%; other areas of Asia are also high risk. Antibiotic use during travel raises the risk MDRE carriage. MDRE carriage may persist for 6 months or more following a traveller’s return [ 42 ].

Clinicians should consider investigating TD lasting 14 days. Investigations may be sent sooner if there are concerning features such as fever or dysentery. Useful tests include full blood count, renal and liver function tests, inflammatory markers and stool for microscopy and culture, PCR and examination for ova, cysts and parasites. The presence of eosinophilia and a relevant travel history should prompt investigation for strongyloidiasis, schistosomiasis and other helminthic infections. Imaging may be performed in the presence of local tenderness or severe colitis. Non-infectious causes of chronic diarrhoea such as malignancy or inflammatory bowel disease should be considered [ 37 ].

Malaria is caused by the parasite Plasmodium . More than one hundred species have been described but only P. falciparum , P. vivax , P. ovale , P. malariae and P. knowlesi commonly cause human infection. The parasite is spread via the Anopheles mosquito. Malaria can be divided into uncomplicated and severe disease. Most severe malaria is caused by P. falciparum . There were an estimated 228 million cases worldwide in 2019, 93% of which were in Africa [ 43 ].

Effective chemoprophylaxis is available and should be offered to travellers to endemic areas. The choice of agent will depend on patient preference, the medical history and destination. Healthcare professionals should consult relevant local or national travel guidelines for malaria and be aware that these differ between countries [ 44 ].

Malaria should always be suspected in a febrile traveller returning from an endemic area. Suspected cases should be discussed with local infectious diseases specialists. Treatment depends on the infecting species and disease severity. There are no specific data on malaria severity in patients on immunosuppressive therapies. The immunosuppressed traveller should be advised on measures to avoid mosquito bites and prescribed prophylaxis. Care should be taken to avoid drug–drug interactions [ 24 ].

Tuberculosis

Tuberculosis (TB) is caused by bacteria of the Mycobacterium tuberculosis complex ( M. tuberculosis , M. bovis , M. africanum or M. microti ). An estimated 10 million people developed TB in 2019 and it caused ∼1.4 million deaths. TB rates are highest in Southeast Asia and sub-Saharan Africa [ 45 ].

Approximately one-quarter of the world’s population is infected with M. tuberculosis and their lifetime risk of developing active TB is ∼10% [ 45 ]. Most healthy people infected with M. tuberculosis never develop active TB. Immunosuppression raises the risk of latent disease progressing to active TB. Evidence suggests that anti-TNF-α therapies are associated with a 2- to 4-fold increased risk of active TB [ 46 ].

Most cases of active TB in people on biologic therapies will be due to reactivation of latent TB. Travellers are generally considered to be at low risk of acquiring TB and prolonged exposure to an infectious person is usually required . Travellers with extended stays in higher risk areas are at greater risk of infection with M. tuberculosis [ 47 ]. This includes VFR travellers, long-term travellers, healthcare workers and those with prolonged contact with an infectious individual.

The BCG vaccine forms part of the routine immunization schedule in the UK and is targeted at high-risk individuals. It is a live vaccine and is contra-indicated in significantly immunosuppressed individuals [ 48 ].

Travellers at high risk of TB infection, for example VFR travellers, should be advised to avoid prolonged contact with people with active TB. This advice is important for those who are immunosuppressed. They should also be advised to seek urgent medical advice if they become unwell with fever, cough or other constitutional symptoms.

All patients should be screened for latent TB infection before commencing a biologic although the optimal screening strategy remains uncertain. In the UK, guidelines recommend an IFN-γ release assay (IGRA) alone or in combination with a tuberculin skin test (TST) [ 49 ]. The use of serial IGRA testing whilst on a biologic is complex as IGRAs are inherently dynamic in a serial testing setting. This is demonstrated in the literature, which shows high rates of both conversions and reversions. This pattern is seen in low, intermediate and high TB incidence settings, suggesting that some of the observed variations may be due to the assay independent of exposure risk [ 50 ]. Repeat IGRA testing may be considered in travellers with a significant TB exposure and a previously negative IGRA result. This should be discussed with a local TB specialist.

Other infections

A discussion of other infections relevant to the immunosuppressed traveller can be found in the Supplementary data (available at Rheumatology online).

Limitations of this review

The most important limitation of this review is scope. This review is a narrative appraisal of the evidence base, and by the nature of its length, cannot cover all possible infections acquired abroad. However, we have signposted many external resources that offer further detail.

There is a recurring acknowledgement that vaccine efficacy may be lower in immunocompromised hosts, but this statement is largely based upon small studies of laboratory markers of seroconversion rather than true estimates of disease prevention. Consequently, clinicians should not interpret the statements regarding weaker vaccine responses as a reason to withhold vaccination.

Finally, it is relevant to note that whilst this review has intentionally focused on infection, one of the greatest risks to travellers remains road traffic accidents [ 51 ]. These are not specific to the immunosuppressed host, but nonetheless, every time a clinician offers travel advice, it is wise to remind people about the value of the seatbelt.

The true burden of travel-related infection amongst immunocompromised patients is not known. Future research is needed to quantify risks of travel and further evaluate the effectiveness of vaccinations.

Conclusions

Travel-related infections in the significantly immunocompromised traveller are complex and comprise vaccine-preventable and non-vaccine-preventable infections. A thorough risk assessment should be performed before travel. The risk assessment should include non-infection considerations, which are outside the scope of this review and take the patient’s preferences into account. Ideally significantly immunosuppressed travellers would benefit from a multi-disciplinary review from their treating rheumatologist and a travel medicine or infection specialist prior to travel, but this may not be practical due to a lack of local resources. Rheumatologists should consider discussing immunosuppressed patients at high risk of travel-related infections with local infection specialists where appropriate, including those travelling to tropical regions, VFR travellers and those planning extended trips abroad. The decision to travel is one that must be taken by the patient after a personalized assessment of the risks and benefits.

Funding : V.A. holds an Academic Clinical Fellowship funded by the National Institute for Health Research (NIHR) through the Integrated Academic Training (IAT) Programme.

Disclosure statement : Both authors declare no potential conflicts of interest.

Data availability statement

Supplementary data.

Supplementary data are available at Rheumatology online.

Supplementary Material

Keab445_supplementary_data.

Infections in immunosuppressed travellers with autoimmune inflammatory diseases-a narrative review and advice for clinical practice

Affiliations.

1 Department of Academic Rheumatology, King's College London.
2 Hospital for Tropical Diseases.
3 London School of Hygiene and Tropical Medicine, London, UK.
PMID: 34022043
PMCID: PMC8409992
DOI: 10.1093/rheumatology/keab445

Keywords: autoimmune disease; immunosuppressed travellers; immunosuppression; targeted therapies; travel medicine; travel risk assessment; travel vaccines; travel-related infections; vaccine responses; visiting friends and relatives.

Publication types

Research Support, Non-U.S. Gov't
Autoimmune Diseases / immunology*
Communicable Disease Control*
Immunocompromised Host / immunology*
Risk Assessment*
Travel-Related Illness*
Vaccine-Preventable Diseases / immunology*
Vaccine-Preventable Diseases / prevention & control*

Interim Effectiveness of Updated 2023–2024 (Monovalent XBB.1.5) COVID-19 Vaccines Against COVID-19–Associated Hospitalization Among Adults Aged ≥18 Years with Immunocompromising Conditions — VISION Network, September 2023–February 2024

Weekly / March 28, 2024 / 73(12);271–276

Ruth Link-Gelles, PhD 1 ; Elizabeth A.K. Rowley, DrPH 2 ; Malini B. DeSilva, MD 3 ; Kristin Dascomb, MD, PhD 4 ; Stephanie A. Irving, MHS 5 ; Nicola P. Klein, MD, PhD 6 ; Shaun J. Grannis, MD 7 ,8 ; Toan C. Ong, PhD 9 ; Zachary A. Weber, PhD 2 ; Katherine E. Fleming-Dutra, MD 1 ; Charlene E. McEvoy, MD 3 ; Omobosola Akinsete, MBBS 3 ; Daniel Bride, MS 10 ; Tamara Sheffield, MD 11 ; Allison L. Naleway, PhD 5 ; Ousseny Zerbo, PhD 6 ; Bruce Fireman 6 ; John Hansen, MPH 6 ; Kristin Goddard, MPH 6 ; Brian E. Dixon, PhD 7 ,12 ; Colin Rogerson, MD 7 ,13 ; William F. Fadel, PhD 7 ,14 ; Thomas Duszynski, PhD 7 ,15 ; Suchitra Rao, MBBS 9 ; Michelle A. Barron, MD 9 ; Sarah E. Reese, PhD 2 ; Sarah W. Ball, ScD 2 ; Margaret M. Dunne, MSc 2 ; Karthik Natarajan, PhD 16 ; Erica Okwuazi, MSc 1 ,17 ; Ami B. Shah, MPH 1 ,17 ; Ryan Wiegand, PhD 1 ; Mark W. Tenforde, MD, PhD 18 ; Amanda B. Payne, PhD 1 ( View author affiliations )

What is already known about this topic?

What is added by this report?

Among adults aged ≥18 years with immunocompromising conditions, receipt of an updated COVID-19 vaccine provided increased protection against COVID-19–associated hospitalizations compared with not receiving an updated COVID-19 vaccine. Few persons (18%) in this high-risk study population had received updated COVID-19 vaccine.

What are the implications for public health practice?

All persons with immunocompromising conditions should receive updated COVID-19 vaccination and may get additional updated COVID-19 vaccine doses ≥2 months after the last recommended COVID-19 vaccine.

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In September 2023, CDC’s Advisory Committee on Immunization Practices recommended updated 2023–2024 (monovalent XBB.1.5) COVID-19 vaccination for all persons aged ≥6 months to prevent COVID-19, including severe disease. As with past COVID-19 vaccines, additional doses may be considered for persons with immunocompromising conditions, who are at higher risk for severe COVID-19 and might have decreased response to vaccination. In this analysis, vaccine effectiveness (VE) of an updated COVID-19 vaccine dose against COVID-19–associated hospitalization was evaluated during September 2023–February 2024 using data from the VISION VE network. Among adults aged ≥18 years with immunocompromising conditions, VE against COVID-19–associated hospitalization was 38% in the 7–59 days after receipt of an updated vaccine dose and 34% in the 60–119 days after receipt of an updated dose. Few persons (18%) in this high-risk study population had received updated COVID-19 vaccine. All persons aged ≥6 months should receive updated 2023–2024 COVID-19 vaccination; persons with immunocompromising conditions may get additional updated COVID-19 vaccine doses ≥2 months after the last recommended COVID-19 vaccine.

Introduction

On September 12, 2023, CDC’s Advisory Committee on Immunization Practices recommended updated 2023–2024 COVID-19 vaccination with a monovalent XBB.1.5–derived vaccine for all persons aged ≥6 months to prevent COVID-19, including severe disease ( 1 ). Most persons aged ≥5 years are recommended to receive 1 updated dose. Persons with moderate or severe immunocompromising conditions, who are at higher risk for severe COVID-19 and might have a decreased response to vaccination, have the option to receive additional doses, guided by the clinical judgment of a health care provider and personal preference and circumstances* ( 2 ). Understanding vaccine effectiveness (VE) among persons with immunocompromising conditions is important to guiding vaccine policy and patient and provider decisions. This analysis estimated effectiveness of updated 2023–2024 COVID-19 vaccines against COVID-19–associated hospitalizations among adults aged ≥18 years with immunocompromising conditions during September 2023–February 2024.

Methods for Virtual SARS-CoV-2, Influenza, and Other respiratory viruses Network (VISION) VE analyses have been reported ( 3 ). VISION is a multisite † electronic health care records (EHR)–based network that utilizes a test-negative design to estimate COVID-19 VE. This analysis included hospitalizations among adults aged ≥18 years with immunocompromising conditions § and who had COVID-19–like illness ¶ with SARS-CoV-2 molecular testing during the 10 days preceding admission or up to 72 hours after admission. Case-patients were persons who received a positive SARS-CoV-2 test result using a molecular test and received a negative or indeterminate or had an unknown test result for both respiratory syncytial virus and influenza, and control patients were those who received a negative SARS-CoV-2 test result using a molecular test and received a negative influenza test result or had an unknown influenza test result. Nine persons who received >1 updated COVID-19 vaccine dose were included.** Odds ratios (ORs) and 95% CIs were estimated using multivariable logistic regression comparing persons who received an updated COVID-19 vaccine dose with those who did not, irrespective of the number of previous original or bivalent COVID-19 vaccine doses received (if any), among case- and control patients. Regression models were adjusted for age, sex, race and ethnicity, calendar time, and geographic region. VE was calculated as (1 − adjusted OR) × 100%. Analyses were conducted using R software (version 4.3.2; R Foundation). This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy. †† VISION activities were reviewed and approved by the Westat and site institutional review boards.

Among 14,586 patients with immunocompromising conditions who were hospitalized with COVID-19–like illness, 1,392 case-patients and 13,194 control patients were included ( Table 1 ). The most common immunocompromising conditions among both case-patients and control patients were solid organ malignancy (36% and 43%, respectively) and other intrinsic immune conditions or immunodeficiency (38% and 35%, respectively). A total of 195 (14%) case-patients had received an updated COVID-19 vaccine dose compared with 2,401 (18%) control patients. VE against COVID-19–associated hospitalization was 38% in the first 7–59 days after receipt of an updated COVID-19 vaccine dose and 34% in the 60–119 days after receipt of an updated dose ( Table 2 ).

In this multisite analysis among adults with immunocompromising conditions during September 2023–February 2024, receiving an updated 2023–2024 COVID-19 vaccine dose provided additional protection against COVID-19–associated hospitalizations, compared with not receiving an updated vaccine dose. Effectiveness estimates in this report were slightly lower than those in a recently published analysis from VISION and another CDC VE network showing COVID-19 VE against COVID-19-associated hospitalizations in adults without immunocompromising conditions was approximately 50%, but this report includes the analysis of an additional month of data compared with the previous report ( 3 ). However, lower COVID-19 VE among adults with immunocompromising conditions compared with adults without immunocompromising conditions has been previously reported ( 4 , 5 ); persons with moderate or severe immunocompromising conditions are at higher risk for severe COVID-19 and might have decreased response to vaccination ( 2 ).

Relatively few persons in this analysis had received an updated COVID-19 vaccine dose, despite those with immunocompromising conditions being at higher risk for severe COVID-19. For example, among those with an organ or stem cell transplant, a group known to be at particularly high risk for severe COVID-19 ( 6 ), only 18% had received an updated dose, representing a missed opportunity to prevent severe COVID-19.

Limitations

The findings in this report are subject to at least two limitations. First, the use of selected discharge diagnoses as surrogates for presumed immunocompromise status and the absence of medication and other relevant data might have led to misclassification of immunocompromise status, which might have biased estimated VE in either direction. Second, immunocompromising conditions are heterogeneous and likely to create differential risk for severe COVID-19, as well as differential response to vaccination ( 2 ). This analysis did not have statistical power to estimate VE by individual risk group or for those receiving more than one dose of the updated COVID-19 vaccine; however, CDC will continue to monitor VE in these groups. In addition, this analysis is subject to limitations similar to those in previous VISION VE analyses, including the potential that case-patients might have been hospitalized for reasons other than COVID-19, potential misclassification of vaccination status, no accounting for previous infection status, and potential residual confounding ( 3 ).

Implications for Public Health Practice

Receipt of an updated COVID-19 vaccine dose provided increased protection against COVID-19–associated hospitalization among adults with immunocompromising conditions compared with no receipt of an updated dose. CDC will continue to monitor VE of updated COVID-19 vaccines in populations at high risk, including those with immunocompromising conditions. All persons aged ≥6 months should receive updated 2023–2024 COVID-19 vaccination; persons with immunocompromising conditions may get additional updated COVID-19 vaccine doses ≥2 months after the last recommended COVID-19 vaccine.

Acknowledgments

Allison Ciesla, Monica Dickerson, Josephine Mak, Abby L. Martin, Morgan Najdowski, Caitlin Ray, Emily Reeves, Ralph D. Whitehead, Jr., CDC.

Corresponding author: Ruth Link-Gelles, [email protected] .

1 Coronavirus and Other Respiratory Viruses Division, National Center for Immunization and Respiratory Diseases, CDC; 2 Westat, Rockville, Maryland; 3 HealthPartners Institute, Minneapolis, Minnesota; 4 Division of Infectious Diseases and Clinical Epidemiology, Intermountain Health, Salt Lake City, Utah; 5 Kaiser Permanente Center for Health Research, Portland, Oregon; 6 Kaiser Permanente Northern California, Oakland, California; 7 Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, Indiana; 8 Department of Family Medicine, School of Medicine, Indiana University, Indianapolis, Indiana; 9 School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado; 10 Enterprise Analytics, Intermountain Health, Salt Lake City, Utah; 11 Immunization Programs, Intermountain Health, Salt Lake City, Utah; 12 Department of Health Policy and Management, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana; 13 Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana; 14 Department of Biostatistics and Health Data Science, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana; 15 Department of Epidemiology, Richard M. Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana; 16 Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York; 17 General Dynamics Information Technology, Falls Church, Virginia; 18 Influenza Division, National Center for Immunization and Respiratory Diseases, CDC.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Brian E. Dixon reports institutional support from the National Institutes of Health (NIH) and the U.S. Department of Veterans Affairs and royalties from Elsevier, Inc. for a book on health information technology and from Springer Nature for a book on health information technology. Nicola P. Klein reports institutional support from Sanofi Pasteur, Merck, Pfizer, Seqiris, and GSK; uncompensated membership on an expert panel for a planned Hepatitis E Phase II vaccine clinical trial among pregnant women in Pakistan, sponsored by the International Vaccine Institute; unpaid membership on the Western States COVID-19 Scientific Safety Review Workgroup, the Board on Population Health and Public Health Practice, the National Academies of Science, Engineering and Medicine, and the National Vaccine Advisory Committee Safety Subcommittee. Charlene E. McEvoy reports grants or contracts from NIH, the Department of Defense, Patient-Centered Outcomes Research Institute, Astra Zeneca, and GSK; payment or honorarium from Pri-Med for a lecture on incorporation of ACT and CAT into electronic health records to improve outcomes in patients with asthma and chronic obstructive pulmonary disease; and uncompensated participation on the American Lung Association of Minnesota Board, the Minnesota Department of Health Long COVID Advisory Committee, and the Minnesota Department of Health Asthma Care Advisory Committee. Tamara Sheffield reports uncompensated membership on CDC’s Advisory Committee on Immunization Practices Influenza Vaccine Work Group, chairmanship of the Utah Adult Immunization Coalition vaccine quality improvement and advocacy group, and membership on the Utah Department of Health and Human Services Scientific Advisory Committee on Vaccines. Ousseny Zerbo reports a grant from the National Institute of Allergy and Infectious Diseases. Suchitra Rao reports grants from Biofire and GSK. No other potential conflicts of interest were disclosed.

* https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html

† Sites from the CDC-funded VISION network that contributed data for this analysis were HealthPartners (Minnesota and Wisconsin), Intermountain Health (Utah), Kaiser Permanente Northern California (California), Kaiser Permanente Northwest (Oregon and Washington), Regenstrief Institute (Indiana), and University of Colorado (Colorado).

§ Immunocompromising conditions were obtained from International Classification of Diseases, Tenth Revision (ICD-10) discharge codes. The specific codes used were hematological malignancy: C81.*, C82.*, C83.*, C84.*, C85.*, C86.*, C88.*, C90.*, C91.*, C92.*, C93.*, C94.*, C95.*, C96.*, D46.*, D61.0*, D61.2, D61.9, D70.0, and D71.*; solid malignancy: C00.*, C01.*, C02.*, C03.*, C04.*, C05.*, C06.*, C07.*, C08.*, C09.*, C10.*, C11.*, C12.*, C13.*, C14.*, C15.*, C16.*, C17.*, C18.*, C19.*, C20.*, C21.*, C22.*, C23.*, C24.*, C25.*, C26.*, C27.*, C28.*, C29.*, C30.*, C31.*, C32.*, C33.*, C34.*, C35.*, C36.*, C37.*, C38.*, C39.*, C40.*, C41.*, C42.*, C43.*, C44.*, C45.*, C46.*, C47.*, C48.*, C49.*, C50.*, C51.*, C52.*, C53.*, C54.*, C55.*, C56.*, C57.*, C58.*, C59.*, C60.*, C61.*, C62.*, C63.*, C64.*, C65.*, C66.*, C67.*, C68.*, C69.*, C70.*, C71.*, C72.*, C73.*, C74.*, C75.*, C76.*, C77.*, C78.*, C79.*, C7A.*, C7B.*, C80.*, Z51.0, Z51.1*, and C4A.*; transplant: T86.0*, T86.1*, T86.2*, T86.3*, T86.4*, T86.5*, T86.81*, T86.85*, D47.Z1, Z48.2.*, Z94.*, and Z98.85; rheumatologic/inflammatory disorders: D86.*, E85.1, E85.2, E85.3, E85.4, E85.8*, E85.9, G35.*, J67.9.*, L40.54, L40.59, L93.0.*, L93.2.*, L94.*, M05.*, M06.*, M07.*, M08.*, M30.*, M31.3*, M31.5*, M32.*, M33.*, M34.*, M35.3*, M35.8*, M35.9*, M46.*, and T78.40*; other intrinsic immune condition or immunodeficiency: D27.9, D72.89, D80.*, D81.0, D81.1, D81.2, D81.4, D81.5, D81.6, D81.7, D81.8*, D81.9, D82.*, D83.*, D84.*, D87.89, D89.0, D89.1, D89.3, D89.4*, D89.8*, D89.9, K70.3*, K70.4*, K72.*, K74.3, K74.4, K74.5, K74.6, N04.*, R18.0; HIV: B20.*, B21.*, B22.*, B23.*, B24.*, B97.35, O98.7*, and Z21*. All ICD-10 codes with * include all child codes under the specific parent code.

¶ COVID-19–like illness diagnoses were obtained from ICD-10 discharge codes. The specific codes used were COVID-19 pneumonia: J12.81 and J12.82; influenza pneumonia: J09.X1, J10.0, J10.00, J10.01, J10.08, J11.0, J11.00, and J11.08; other viral pneumonia: J12*; bacterial and other pneumonia: J13, J14, J15*, J16*, J17, and J18*; influenza disease: J09*, J10.1, J10.2, J10.8*, J11.1, J11.2, and J11.8*; acute respiratory distress syndrome: J80; chronic obstructive pulmonary disease with acute exacerbation: J44.1; asthma acute exacerbation: J45.21, J45.22, J45.31, J45.32, J45.41, J45.42, J45.51, J45.52, J45.901, and J45.902; respiratory failure: J96.0*, J96.2*, and R09.2; other acute lower respiratory tract infections: B97.4, J20*, J21*, J22, J40, J44.0, J41*, J42, J43*, J47*, J85, J85.0, J85.1, J85.2, J85.3, and J86*; acute and chronic sinusitis: J01* and J32*; acute upper respiratory tract infections: J00*, J02*, J03*, J04*, J05*, and J06*; acute respiratory illness signs and symptoms: R04.2, R05, R05.1, R05.2, R05.4, R05.8, R05.9, R06.00, R06.02, R06.03, R06.1, R06.2, R06.8, R06.81, R06.82, R06.89, R07.1, R09.0*, R09.1, R09.2, R09.3, and R09.8*; acute febrile illness signs and symptoms: R50*, R50.81, and R68.83; acute nonrespiratory illness signs and symptoms: M79.10, M79.18, R19.7, R43*, R51.9, R65*, R53.81, R53.83, R57.9, R41.82, R40.0, R40.1, R53.1, R11.0, R11.10, R11.11, R11.15, R11.2, R21*, R10.0, R10.1*, R10.2, R10.3*, R10.81*, R10.84, and R10.9; respiratory failure, unspecified: J96.9*; febrile convulsions: R56.0; viral and respiratory diseases complicating pregnancy, childbirth, and puerperium: O98.5*, O98.8*, O98.9*, and O99.5*. All ICD-10 codes with * include all child codes under the specific parent code. One VISION site, representing 33% of case-patients, did not include the following codes in its definition: B97.4, J96.9*, O98.5*, O98.8*, O98.9*, O99.5*, and R56.0.

** The Advisory Committee on Immunization Practices recommendations allow optional additional doses for persons with moderate or severe immunocompromise. Because only nine persons in participating sites received >1 updated COVID-19 vaccine dose, statistical power to estimate VE separately in this group was insufficient.

†† 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

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Abbreviations: ICU = intensive care unit; KPNC = Kaiser Permanente Northern California; KPNW = Kaiser Permanente Northwest; NA = not applicable; SMD = standardized mean or proportion difference; VISION = Virtual SARS-CoV-2, Influenza, and Other respiratory viruses Network. * Patient received a positive SARS-CoV-2 test result using a molecular test and received a negative or indeterminate test result or had an unknown test result for both respiratory syncytial virus and influenza. † Patient received a negative SARS-CoV-2 test result using a molecular test and received a negative influenza test result or had an unknown influenza test result. § A larger SMD indicates a larger difference in variable distributions between hospitalizations for vaccinated versus unvaccinated patients, or for patients who received a positive SARS-CoV-2 test result versus patients who received a negative SARS-CoV-2 test result. For mRNA COVID-19 vaccination status, a single SMD was calculated by averaging the absolute SMDs obtained from pairwise comparisons of each vaccinated category versus unvaccinated. Specifically, SMD was calculated as the average of the absolute value of the SMDs for 1) updated dose, 7–59 days earlier versus no updated dose; and 2) updated dose, 60–119 days earlier versus no updated dose. ¶ The “no updated dose” group included all eligible persons who did not receive an updated COVID-19 vaccine dose, regardless of number of previous (i.e., original monovalent and bivalent) doses (if any) received. ** Date ranges of hospitalizations by site: HealthPartners (September 21, 2023–February 17, 2024), Intermountain Health (September 21, 2023–February 17, 2024), KPNC (September 21, 2023–February 17, 2024), KPNW (September 21, 2023–February 17, 2024), Regenstrief Institute (September 21, 2023–February 13, 2024), and University of Colorado (September 21, 2023–February 4, 2024). †† “Other, non-Hispanic” race persons reporting non-Hispanic ethnicity and any of the following options for race: American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, other races not listed, and multiple races; because of small numbers, these categories were combined. §§ “Unknown” includes persons with missing race and ethnicity in their electronic health records. ¶¶ Underlying condition categories included pulmonary, cardiovascular, cerebrovascular, musculoskeletal, neurologic, hematologic, endocrine, renal, and gastrointestinal. All persons in the analysis had one or more immunocompromising condition. *** Chronic respiratory condition was defined using International Classification of Diseases, Tenth Revision discharge codes for asthma, chronic obstructive pulmonary disease, cystic fibrosis, or other lung disease. ††† Persons included in the analysis might have one or more immunocompromising conditions; therefore, column totals might add to more than 100%. §§§ In-hospital death was defined as death while hospitalized within 28 days after admission. ¶¶¶ The JN.1 predominant period was considered to have started December 24, 2023.

Abbreviations: Ref = referent group; VE = vaccine effectiveness; VISION = Virtual SARS-CoV-2, Influenza, and Other respiratory viruses Network. * VE was calculated as (1 – odds ratio) × 100%, with odds ratios calculated using logistic regression. † The odds ratio was adjusted for age, sex, race and ethnicity, geographic region, and calendar time (days since January 1, 2021). § The “no updated dose” group included all eligible persons who did not receive an updated COVID-19 vaccine dose, regardless of number of previous (i.e., original monovalent and bivalent) doses (if any) received.

Suggested citation for this article: Link-Gelles R, Rowley EA, DeSilva MB, et al. Interim Effectiveness of Updated 2023–2024 (Monovalent XBB.1.5) COVID-19 Vaccines Against COVID-19–Associated Hospitalization Among Adults Aged ≥18 Years with Immunocompromising Conditions — VISION Network, September 2023–February 2024. MMWR Morb Mortal Wkly Rep 2024;73:271–276. DOI: http://dx.doi.org/10.15585/mmwr.mm7312a5 .

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FDA Authorizes COVID Drug Pemgarda for High-Risk Patients

BY CARRIE MACMILLAN April 5, 2024

woman removing mask after taking Pemgarda, which protects against COVID

The Food and Drug Administration (FDA) granted an emergency use authorization (EUA) to a medicine meant to protect certain immunocompromised people against COVID-19 .

The medicine, pemivibart (brand name Pemgarda™), is for people who are at least 12 years of age, weigh more than 88 pounds, and are moderately to severely immunocompromised.

An EUA is a tool the FDA uses to expedite the availability of drugs, vaccines , and other products during a public health emergency. While the public health emergency for COVID officially expired in May 2023, the FDA can still issue EUAs related to it.

“This medication provides important protection for the immunocompromised, a population that is more likely to have serious COVID illness and a higher mortality rate,” says Scott Roberts, MD , a Yale Medicine infectious diseases specialist.

Being immunocompromised means your immune system doesn’t work as well as it should to protect against infection because of a medical condition, such as cancer , that weakens immune function or because you receive medicines or treatments, such as immunotherapy , that suppress the immune system.

“The population identified as moderately to severely immunocompromised includes solid organ transplant recipients, stem cell transplant recipients, and those who are on chemotherapy for cancers such as lymphoma and leukemia, among many others,” Dr. Roberts explains. The Centers for Disease Control and Prevention (CDC) provides a list . Approximately 3% of adults in the United States are immunocompromised.

“This group is also less likely to build enough protection against COVID after vaccination. For these patients, the pandemic is not over,” says Dr. Roberts. “Hopefully, this new treatment will help the vulnerable feel safer.”

Below, we talk more about Pemgarda with Dr. Roberts.

Why isn’t COVID vaccination as effective in immunocompromised individuals?

Those who are not immunocompromised most likely have a strong mix of “hybrid” immunity to COVID at this point, both from vaccination and natural infection, Dr. Roberts explains.

“Most people should not be concerned when a new COVID variant arises because even if it bypasses some of their protection, it's not going to bypass all of it,” Dr. Roberts says. “But some immunocompromised people do not have that luxury. Any COVID infection is going to hit them the hardest. And vaccination is still the best tool we have to offer for the prevention of severe COVID.”

However, this drug is a new tool that can help immunocompromised patients feel safe going about daily activities as many other people do at this phase of the pandemic, he adds.

How does Pemgarda work?

Pemgarda is a type of medicine called pre-exposure prophylaxis (PrEP), which is taken to prevent COVID infection. Anyone with COVID—or who has a known recent exposure to someone with a COVID infection—cannot take Pemgarda.

Paxlovid and Remdesivir, conversely, are meant to be taken after a known COVID infection and are for anyone deemed high-risk for serious illness, including those who are immunocompromised.

Pemgarda is a type of monoclonal antibody (mAb), a drug therapy that uses antibodies made in a laboratory. These antibodies attach to the spike protein of SARS-CoV-2, the virus that causes COVID-19, and prevent the virus from entering the body’s cells.

“Despite vaccination, many immunocompromised patients are still unable to generate the antibodies necessary to block this entry; Pemgarda serves as a tool to increase SARS-CoV-2-specific antibodies to levels seen in nonimmunocompromised individuals after vaccination,” says Dr. Roberts.

It is given as an infusion in a medical setting and takes about an hour to complete. Patients can get a dose of the medication as often as every three months.

Is this the first preventive drug for COVID?

A previous mAb treatment, Evusheld™, was authorized by the FDA in 2021 to prevent COVID in immunocompromised patients. However, the medication proved ineffective against newer COVID variants and was taken off the market in January 2023.

Pemgarda is the only COVID PrEP drug on the market.

How effective is Pemgarda against COVID?

Pemgarda was granted an EUA based on data from an ongoing Phase 3 clinical trial, as well as data from previous clinical trials of a similar monoclonal antibody treatment.

In the trials, Pemgarda reduced the risk of developing symptomatic COVID-19 by 70%, according to Invivyd , the company that makes the drug. The studies were done when the JN.1 subvariant was circulating. JN.1 is still the predominant coronavirus subvariant.

Is Pemgarda safe?

In the trial, 623 participants received at least one dose of the drug. The most common side effects included skin reactions at the infusion site, cold and flu-like illness, headache, fatigue, and nausea. Four people experienced anaphylaxis (a severe allergic reaction).

“For patients who are worried about the trade-off, I think it requires a risk-benefit analysis,” says Dr. Roberts. “I think in most cases the benefit is going to outweigh the risk of anaphylaxis, especially if doctors can mitigate it by having medications such as an Epi-pen there in case a patient does have a severe allergic reaction.”

Where and when can patients get Pemgarda?

Immunocompromised people who are interested in taking Pemgarda should talk to their doctor. “It might be better for some patients to talk to a specialist first—for instance, if an individual has cancer, it might be best for them to talk to their oncologist about whether this drug is right for them,” Dr. Roberts advises.

The medication is expected to be available in April. The price has not yet been set, but Medicare and private insurance plans are expected to cover it, according to news reports.

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Guest Essay

I’m a Doctor. Dengue Fever Took Even Me by Surprise on Vacation.

A black-and-white illustration of an Aedes aegypti mosquito.

By Deborah Heaney

Dr. Heaney is a physician in Ann Arbor, Mich.

I hate mosquitoes so much that I take my own bug repellent to parties. But in early March, on a trip with my partner to the idyllic island of Curaçao off Venezuela, I was caught off guard by insect bites after our bed-and-breakfast hosts said that mosquitoes didn’t usually appear until late summer.

Near the end of the vacation, my legs began to ache. After I couldn’t keep up with my partner on a snorkeling adventure, he pulled me from the water. My ribs felt broken, as if I’d been smashed against large boulders in the sea. Later that day came intense fever, alternating with shaking chills.

Back in Michigan — weak, nauseated and dehydrated from explosive diarrhea — I ended up in the emergency department. Tests showed worrisome white blood cell levels and abnormal liver numbers. The physician assistant who saw me was perplexed; she gave me IV fluids and medication for nausea and sent me home.

A few days later I developed itching so severe that I couldn’t sleep. A bright red rash spread over both thighs and up my lower back. My brain was foggy, and my balance was so impaired that I would have failed a sobriety test. My primary care doctor had no answers. But as my head began to clear, it occurred to me to request a dengue fever test.

Two days later, the test was positive.

Despite my training in medicine, I was blindsided. Dengue, a mosquito-borne illness, is surging through Latin America and the Caribbean, including in Puerto Rico, where a public health emergency was declared last week. This year is likely to be the worst on record, in part because of El Niño-driven temperature spikes and extreme weather linked to climate change. As temperatures rise and precipitation patterns grow more erratic, the problem will get only worse.

But neither the traveling public nor our frontline health workers are prepared. Without urgent reforms to how we educate travelers, doctors, nurses and others — as well as reforms to public health surveillance and early warning systems — we will be doomed to miss textbook cases like mine. That means those infected with dengue will miss out on timely treatment, possibly even spreading the virus to areas where it was never found before.

The dengue virus, which is primarily transmitted by the Aedes aegypti mosquito, infects up to 400 million people every year in nearly every region of the world, but it is most prevalent in Latin America, South and Southeast Asia and East Africa. Most cases are asymptomatic or, like mine, are considered mild, although the aptly nicknamed breakbone fever often doesn’t feel that way. Some 5 percent of cases progress to a severe, life-threatening disease including hemorrhagic fever.

One malicious feature of dengue is that when someone is infected a second time with a different type of the virus, the risk of severe illness is higher. A vaccine exists, but the Centers for Disease Control and Prevention recommends it only for children ages 9 to 16 who had dengue before and live in places where the virus is common. That’s because, paradoxically, if you’ve never had dengue, the vaccine puts you at greater risk of severe illness your first time.

Dengue outbreaks, which, in the Americas, tend to occur every three to five years , now appear to be expanding their geographic reach as temperatures climb . The Aedes aegypti mosquito has typically had difficulty surviving and reproducing during the winter in temperate climates. But in parts of Brazil, which is experiencing a dengue emergency , the thermometer no longer dips as low in the winter as it once did, allowing the bugs to reproduce year-round. Overall, Latin America and the Caribbean have had three times the number of cases this year as reported for the same period in 2023, which was a record year. Higher temperatures are also helping the virus develop faster inside the mosquito, leading to a higher viral load and a higher probability of transmission. And mosquitoes are benefiting from standing water from rains and floods that are growing more extreme in a warming world.

As the virus spreads globally, travelers are bringing infections back to the continental United States. Based on 2024 numbers to date, this year should show a clear increase of cases here at home compared with 2023, given that the typical dengue season hasn’t even started yet. There could also be local outbreaks in places like Florida, Texas and California, which experienced small ones in the past. As Dr. Gabriela Paz-Bailey, the chief of the C.D.C.’s dengue branch, told me by email, “Increased travel to places with dengue risk could lead to more local transmission, but the risk of widespread transmission in the continental United States is low.”

But since testing is done only on a small fraction of cases, many are going uncounted. I was the one who requested that I be tested. Had I not been given a diagnosis, I would not be aware of my increased risk of severe illness if I am reinfected. Getting a diagnosis is crucial to inform those infected in areas where the Aedes mosquito lives so that the virus doesn’t spread further.

The growing risk means travelers to regions with dengue must be savvier: They can check local news and U.S. State Department advisories, bring an effective insect repellent and protective clothing and book lodging with air-conditioning or screens on the windows and doors. Though Aedes aegypti mosquitoes now live year-round in many locations and are pushing northward into new regions , thanks to climate change and other factors, there are still seasons when the risk is greater, and travelers might consider avoiding trips during those periods. Travel insurance with medical coverage may also be a useful precaution.

For medical professionals, this should be a warning. We need to start thinking about dengue as a possible diagnosis, not just a piece of textbook trivia. We should ask about recent travel when treating patients presenting with symptoms, especially symptoms not easily explained by other diagnoses.

Medical schools are gradually integrating climate change effects into curriculums . This is essential, since malaria, Lyme, West Nile and other insect-borne diseases are on the rise, as are other conditions like heat illness, asthma and allergies that are worsened by climate change. This work must accelerate, and training must include those of us who are already practicing. State medical boards should consider mandating continuing education on tropical emerging illnesses, as they do on many other pertinent topics.

After receiving my positive test result, I called the emergency department to leave a message for my previous provider about my diagnosis, assuming she had never before seen dengue. If we continue on this trajectory, I’m certain this won’t be her last case.

Deborah Heaney is a preventive, occupational and environmental health physician practicing in Ann Arbor, Mich. She also holds a master’s degree in public health.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

Follow the New York Times Opinion section on Facebook , Instagram , TikTok , WhatsApp , X and Threads .

An earlier version of this article included an incorrect reference to the mosquitoes that spread dengue. They are members of the Aedes genus, not species.

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Untangling Disinformation

How anti-vaccine activists and the far right are trying to build a parallel economy.

Attendees visit booths at the RePlatform conference in Las Vegas in March. The conference crowd was a hybrid of anti-vaccine activists, supporters of former President Donald Trump and Christian conservatives. Krystal Ramirez for NPR hide caption

Entrepreneurs and influencers from across a spectrum of conspiracist and religious communities gathered in Las Vegas in March to discuss building an "uncancellable" future together.

But the conference almost didn't happen. A few weeks before the RePlatform conference was scheduled to begin, the event organizers lost access to their money from ticket sales. Their payment processor, Stripe, had frozen their account.

"Stripe just said, well, we're going to hold 70%. And what they do is they say, we'll give it back to you after the show," speaker Dan Eddy told the audience from the Vegas stage.

Social Media Site Gab Is Surging, Even As Critics Blame It For Capitol Violence

Conveniently for everyone involved, Eddy is the chief operating officer of an alternative payment processor, GabPay . It's a third-party company that works with the social media platform Gab .

"We'll process for you. No problems, no questions asked. We'll do it," Eddy described telling the event organizers.

Dan Eddy (left), the chief operating officer of alternative payment processor GabPay, and Lonnie Passoff, who runs a payment processing company that works with the social media platform Gab, speak at the RePlatform conference in Las Vegas last month. Krystal Ramirez for NPR hide caption

For people in the business of opposing vaccination or unwelcome election results , mistrust of big financial institutions and tech companies is common. Increasingly, they can find alternatives being built by a community with a head start in developing the tools of the so-called freedom economy: the far right.

"Leave all these woke corporations behind"

At RePlatform in Las Vegas, GabPay got to be the hero. But it's also possible that the company was part of why Stripe froze the conference's money in the first place. A few weeks earlier, a news story by Mother Jones about the event highlighted a promotional appearance that GabPay's executives had made on far-right conspiracy theorist Stew Peters' streaming show.

GabPay founder Lonnie Passoff's interview with Peters included an exchange where the two sarcastically dismissed the idea that antisemitic conspiracy theories are hate speech.

The company also recently began processing payments for the prominent white nationalist website VDARE . But the audience at the RePlatform event in Vegas didn't hear any of this from the GabPay speakers. The crowd was a hybrid of anti-vaccine activists, supporters of former President Donald Trump and Christian conservatives. Most were entrepreneurs in these movements, looking for ways to build what they call the "freedom economy."

Chris Widener, founder of the Red Referral Network, speaks at the RePlatform conference. Krystal Ramirez for NPR hide caption

Chris Widener, founder of the Red Referral Network, speaks at the RePlatform conference.

"We are here together because we are people who have either been canceled or we really understand what is going on in America today as it relates to cancelization," conference emcee Chris Widener told the crowd.

While many of the event's panels delivered familiar complaints about "woke" culture and media, speakers from businesses sponsoring the event leaned into pitches aimed at drawing the audience away from the conveniences offered by large banks, financial institutions and tech providers.

"Leave Amazon, leave GoDaddy, leave all these woke corporations behind and start spending money with organizations that have your best interests in mind," said Megan Greene of Patmos, a web-hosting company named after the Greek island that the Christian apostle John is said to have been exiled to.

'Lex Luthor Of The Internet': Meet The Man Keeping Far-Right Websites Alive

It's hard to say just how large the market of conservative-focused businesses is. One recent report from a conservative shopping app estimated that there are at least 80,000 American small businesses in what it calls the "freedom economy," from coffee sellers and razor companies to dating apps and plumbers. Some of these businesses aren't small: At one point, pillow salesman turned pro-Trump conspiracy theorist Mike Lindell's MyPillow company had almost $300 million in revenue.

A matter of survival

In some religious communities, building a parallel society is an old idea, according to Amarnath Amarasingam, a professor of religion at Queen's University in Ontario. One example is fundamentalist Christians after the Scopes Monkey Trial in 1925.

"They got destroyed in kind of the media sphere. They were depicted as this kind of backwater, Bible-thumping dummies," he said. "They retreated from the public, and they created a kind of network, a kind of parallel society, their own publishing houses, their own media, their own magazines, newsletters and so on."

A woman sits at the Christian Chamber of Commerce booth at the RePlatform conference. Krystal Ramirez for NPR hide caption

A woman sits at the Christian Chamber of Commerce booth at the RePlatform conference.

But the entrepreneurs gathered in Vegas represent a broader fusion of communities reacting to years of COVID-19, stolen election narratives and transgender visibility, he said. A shared, embattled subculture.

"They feel like they're on the outs," said Amarasingam. "They believe that the governments are against them, intellectuals are against them, that science is moving in the opposite direction, that science education is moving in the opposite direction. So they just see a lot of trends that they feel are against traditional Christian values, family values."

And adding in a spoonful of current-day conspiracism helps to frame the building of a separate, untainted economy as a matter of survival.

"Tragedy in the real world"

The situation that the conference itself faced with Stripe was a fitting, if muddy, illustration of a concern often referred to as "debanking." The power that financial organizations have to freeze or shut down accounts is real. And while figures on the right have often framed debanking as political persecution, it's nearly impossible to know how often it happens. That's because banks and payment processors rarely spell out their reasons, according to Jessica Davis, who runs Insight Threat Intelligence .

Stripe, for instance, did not comment on what happened with the conference, citing customer privacy.

In many cases, Davis said, people are cut off over mundane , technical violations, such as someone using their account the wrong way.

"But there is social capital to be gained by a lot of these people who are claiming that they have their accounts closed," she added.

On the other hand, there is another category of very high-profile examples, in which extremists have lost access to payment services or social media accounts after violent events.

"The bulk of it happens as a response to some tragedy in the real world," said Megan Squire, a computer and data scientist tracking extremism with the Southern Poverty Law Center.

White nationalists, neo-Nazis and members of the alt-right clashed with counterprotesters during the Unite the Right rally in 2017. One aftermath of that event was that some far-right groups lost access to financial and technology platforms. Chip Somodevilla/Getty Images hide caption

She said waves of debanking and deplatforming have followed violent episodes like the deadly Unite the Right white nationalist rally in Charlottesville, Va., in 2017 and a number of mass shootings explicitly motivated by hate. Another big wave came after the Jan. 6, 2021, Capitol riot. Squire said that for years, she has watched some far-right extremists experiment with building infrastructure to get around these bans.

"They'll talk about how we need this payment [platform]. ... We need to make our own web-hosting companies. We need to make our own social media. We need to make our own domain registrars. We need to make our own computers," she said.

Building those tools is a huge challenge, requiring planning, technical skill, money and, crucially, finding a sustainable customer base. Squire says GabPay is one of many such experiments, born out of necessity. It's part of a dream that the founder of Gab has been promoting for years.

Dan Eddy (center) speaks to attendees at the GabPay booth. Krystal Ramirez for NPR hide caption

Dan Eddy (center) speaks to attendees at the GabPay booth.

"The broadest audience possible"

Gab is a glitch-prone alternative to X, formerly Twitter, that launched in 2016 in response to perceived anti-conservative censorship at major social media companies. It bans pornography but otherwise brands itself as a free-speech absolutist space by explicitly allowing hate speech that other mainstream platforms prohibit.

One of Gab's most notable active users was the man who shot and killed 11 people and wounded six at a Pittsburgh synagogue in 2018 . The platform's founder, Andrew Torba, has said he doesn't hate Jews but has also said they have no place in what he calls his conservative Christian movement.

National Security

Pittsburgh shooting and other cases point to rise in domestic extremism.

"And it's really thanks to the folks on Gab that I became aware of these issues: issues like [the] Jewish Question, issues like Zionist power and Zionist Occupied Government ," Torba said on an episode of his podcast in November 2023.

"'The Jewish Question' is literally a Nazi term," said religion professor Amarasingam, "about what to do with the Jewish population in areas controlled by the Third Reich."

Asked for comment, Torba responded, "Christ is King" to NPR in a post on X. The phrase is a common, uncontroversial expression of faith for many Christians, but in recent years it has also become popular among the far right and conspiracists . Torba says he uses it as a regular signoff on his emails after learning that his doing so offended Jonathan Greenblatt at the Anti-Defamation League.

Onstage at the RePlatform event in Las Vegas, GabPay's Eddy described Gab and Torba as "all about being First Amendment. And, yes, they have a Christian slant because the guy that built it is a Christian. So he goes out and says, 'I'm a Christian. I think you should have Christian values.'" He added, "Whether you agree with that or not is inconsequential to the fact that he can say it and so can you."

NPR spoke with several banks and other organizations at the conference about Gab and GabPay's background. But as brands there to promote free speech absolutism, none wanted to be seen as unwilling to engage or do business with them.

Eric Ohlhausen, chief strategy officer at Old Glory Bank, stands in front of his company's sign at the RePlatform conference. Krystal Ramirez for NPR hide caption

Eric Ohlhausen, chief strategy officer at Old Glory Bank, stands in front of his company's sign at the RePlatform conference.

Eric Ohlhausen, with the conservative Old Glory Bank, said his company will do business with anyone operating legally.

"Our whole premise is one to not censor, and there might be organizations who promote policies that maybe, personally, I don't adhere to, but we really welcome all as customers," said Ohlhausen.

Ashton Cohen is the creative manager of the conservative media nonprofit PragerU. Krystal Ramirez for NPR hide caption

Ashton Cohen is the creative manager of the conservative media nonprofit PragerU.

Ashton Cohen of the conservative media nonprofit PragerU told NPR that charges of antisemitism on the right are overblown.

"My mother was pushed out of her country because she was Jewish, because she was persecuted for being a Jew in Iran. And the very people who support that regime today and that mindset today are on the left," said Cohen.

Anti-vaccine activist Steve Kirsch helped organize the RePlatform conference. Krystal Ramirez for NPR hide caption

Anti-vaccine activist Steve Kirsch helped organize the RePlatform conference.

Wealthy anti-vaccine activist Steve Kirsch , who helped organize the RePlatform conference, said in a written statement: "I don't support racism and never have. People are dying, and lives are on the line. We want to reach the broadest audience possible."

Within each of these movements, the benefits of supporting each other appear to outweigh any reputational risks. There was a clear message at RePlatform: So long as you're not breaking laws, let's do business.

News | Why do so few in Southern California get…

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News | why do so few in southern california get updated covid vaccinations, column: politics and poor messaging seen as reasons why some will get flu shots but not the latest defense for the coronavirus.

The buds are blooming, the grass is green, the orange and palm trees sway — and those spring COVID vaccines are rolling out yet again.

This spring, the COVID booster is aimed at folks 65 and older and those who are immunocompromised, but we mostly stink at staying up-to-date on these vaccinations. Cutting-edge Californians are remarkably under-vaccinated — only 13.7% of Golden Staters are up to date, and that percentage shrinks as poverty levels increase.

In Orange County, 12.6% of folks were up-to-date on their COVID vaccines, compared to 12% in Los Angeles County, 8% in Riverside County, and 6.8% in San Bernardino County.

The most at-risk group is folks 65 and older, so it’s good that it’s also the most up-to-date age group. Still, the overwhelming majority of seniors are avoiding the shot: Statewide, 34.1% of folks 65 and older have had the most recent vaccine, compared to 32.2% in Orange County, 28.5% in Los Angeles County, 26.2% in Riverside County and 24.3% in San Bernardino County.

What gives?

“The messaging from the CDC is horrible,” said Eva Kohn of San Clemente. “Most people think COVID is over. As of late, the mRNA vaccines have some issues that can keep away potential takers.”

Among them, rare cardiac issues in young men. She opted for the Novavax shot, which is not an mRNA vaccine like Pfizer and Moderna. Novavax is a protein-based vaccine built on older technology; it includes protein fragments from the virus that can’t cause disease, but fire up the immune system.

Her college-aged kids got the Novavax shot as well, and they’ve been COVID-free this season.

“People are treating COVID-19 like the flu at this point; there are those who get flu shots every year and then there are the vast majority who don’t,” Julie Huniu Nolte said via Facebook. “People no longer view COVID-19 as a major threat.”

“The good news is that hospitalizations and deaths directly tied to COVID-19 are low, mainly due to initial vaccinations and herd immunity. Following the pandemic, most people were either vaccinated or were infected by the virus. Nevertheless, it’s important for seniors and immunocompromised individuals to get the COVID-19 booster vaccine at least once a year, as is the case with the flu shot, so that their protection remains high.”

Andrew Noymer, an epidemiologist and demographer at UC Irvine, lays much of the blame for low uptake on the Centers for Disease Control.

“You ask rhetorically, is COVID just flu now?” he said. “I think most Americans think so. Hard to blame them; this is what CDC has been telegraphing. Unfortunately, COVID is still more deadly on a case-by-case basis than influenza, and it has more severe sequelae. It ain’t flu.”

The CDC consistently minimizes COVID, data dashboards have been dismantled, briefings discontinued, and, “Most egregiously, its official guidance is not to let a positive COVID at-home test result keep us from going to work or school, as long as we are asymptomatic. Because, let’s infer, COVID is no big deal,” Noymer continued. “Yet some people are advised to re-up their vaccines every four months. While new guidance on a cadence of every-four-months vaccines for 65+ may make sense in light of data on fading antibodies, it’s not going to do anything to help vaccine uptake. Name another vaccine with a four-month cadence; I’ll wait.”

The federal government’s decision to stop buying COVID vaccines last year also has not helped, said Richard Carpiano, a public and population health scientist and medical sociologist at UC Riverside.

“This meant that the manufacturers sold directly to insurers, which shifted the cost to them,” he said. “This made it more likely that people who were under- or uninsured were less likely to get vaccinated. … Even for those with insurance, this policy change also made it more complicated to get vaccinated when the updated booster became available.”

The Biden administration created the Bridge Program to cover the cost for uninsured people, partnering with providers including pharmacies and public health departments, he said. That program rolled out in September, but the disparity data suggest it’s unclear how effective it has been, or what else may be at work (funding for targeted campaigns, education, outreach and community clinics).

Skepticism about vaccines in general is on the rise.

“During COVID, we were told that vaccines would end the pandemic. When breakthrough infections became apparent in July 2021… the CDC director at the time made great effort to stress that breakthroughs are unusual,” Noymer said. “Now we know that breakthrough infections are commonplace. ‘Why bother?’ many Americans are asking, and the CDC hasn’t made the case that we should bother.”

In December, a Gallup poll found that while 47% of adults said they’d gotten the flu shot, only 29% said they got the new COVID-19 shot.

Even though COVID is more dangerous and deadly than flu. State data show that:

• In mid-March, 158 Californians were hospitalized with COVID. Only 28 were hospitalized with flu.

• In the first three weeks of March, 138 Californians died of COVID. Only 10 died of flu.

Public health has become sadly politicized.

Nearly half of Democrats (48%) got the updated COVID-19 shot, while only 20% of independents and 10% of Republicans did. A stunning 82% of Republicans said they would not get the updated shot.

Flu shots are more popular, but politics is at work here as well: 61% of Democrats, 38% of independents and 35% of Republicans got the flu shot this year. More than half of Republicans, 52%, said nuts to that.

Why? Folks’ primary reason for skipping the COVID shot was because they had COVID-19 and believe they still have protective antibodies (27%), and because they have safety concerns about the vaccine (24%), Gallup found.

The effectiveness of the vaccine was questioned by 18%, and another 16% said they don’t believe they’d suffer serious health consequences from the coronavirus.

Smaller groups, less than 10%, say they distrust vaccines in general or are concerned about an allergic reaction.

FILE - A pharmacist injects a patient with a booster dosage of the Moderna COVID-19 vaccine at a vaccination clinic in Lawrence, Mass., on Wednesday, Dec. 29, 2021. U.S. regulators have authorized updated COVID-19 boosters, the first to directly target today's most common omicron strain. The move on Wednesday, Aug. 13, 2022, by the Food and Drug Administration tweaks the recipe of shots made by Pfizer and rival Moderna that already have saved millions of lives. (AP Photo/Charles Krupa, File)

The Orange County Health Care Agency said it continues to monitor COVID-19 vaccination coverage, and that the CDC continues to find that immunized folks are far less likely to need emergency care or hospitalization.

“Despite clear evidence pertaining to efficacy, we recognize vaccination coverage rates remain too low,” Dr. Regina Chinsio-Kwong, county health officer, said by email. “Contributing factors include vaccine fatigue, misinformation, and difficulty in accessing COVID-19 vaccine. As an agency, we remain steadfast in our commitment to address these challenges through ongoing education and outreach efforts.

“We continue to collaborate with stakeholders such as community-based organizations, medical professionals, and the Orange County Immunization Coalition, as well as through social media, to emphasize the benefits of COVID-19 vaccination as well as other vaccines. All these efforts are integral to disseminating accurate information and promoting vaccination uptake.”

UCI’s Noymer recommends a book on the American experience of the 1918 flu, called “America’s Forgotten Pandemic.” One of its themes is that people in the U.S. just wanted to turn their back on the whole painful experience. A similar social force is at work here, he said.

“Unfortunately,” he said, “we are throwing out the baby with the bathwater, and we have measles epidemics as a result.”

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The trains and stations of the Moscow Metro

2 Comments · Posted by Alex Smirnov in Cities , Travel , Video

The Moscow Metro is the third most intensive subway system in the world after Tokyo and Seoul subways. The first line was opened on May 15, 1935. Since 1955, the metro has the name of V.I. Lenin.

The system consists of 12 lines with a total length of 305.7 km. Forty four stations are recognized cultural heritage. The largest passenger traffic is in rush hours from 8:00 to 9:00 and from 18:00 to 19:00.

Cellular communication is available on most of the stations of the Moscow Metro. In March 2012, a free Wi-Fi appeared in the Circle Line train. The Moscow Metro is open to passengers from 5:20 to 01:00. The average interval between trains is 2.5 minutes.

The fare is paid by using contactless tickets and contactless smart cards, the passes to the stations are controlled by automatic turnstiles. Ticket offices and ticket vending machines can be found in station vestibules.

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Electrostal History and Art Museum

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The Moscow Metro Museum of Art: 10 Must-See Stations

There are few times one can claim having been on the subway all afternoon and loving it, but the Moscow Metro provides just that opportunity. While many cities boast famous public transport systems—New York’s subway, London’s underground, San Salvador’s chicken buses—few warrant hours of exploration. Moscow is different: Take one ride on the Metro, and you’ll find out that this network of railways can be so much more than point A to B drudgery.

The Metro began operating in 1935 with just thirteen stations, covering less than seven miles, but it has since grown into the world’s third busiest transit system ( Tokyo is first ), spanning about 200 miles and offering over 180 stops along the way. The construction of the Metro began under Joseph Stalin’s command, and being one of the USSR’s most ambitious building projects, the iron-fisted leader instructed designers to create a place full of svet (radiance) and svetloe budushchee (a radiant future), a palace for the people and a tribute to the Mother nation.

Consequently, the Metro is among the most memorable attractions in Moscow. The stations provide a unique collection of public art, comparable to anything the city’s galleries have to offer and providing a sense of the Soviet era, which is absent from the State National History Museum. Even better, touring the Metro delivers palpable, experiential moments, which many of us don’t get standing in front of painting or a case of coins.

Though tours are available , discovering the Moscow Metro on your own provides a much more comprehensive, truer experience, something much less sterile than following a guide. What better place is there to see the “real” Moscow than on mass transit: A few hours will expose you to characters and caricatures you’ll be hard-pressed to find dining near the Bolshoi Theater. You become part of the attraction, hear it in the screech of the train, feel it as hurried commuters brush by: The Metro sucks you beneath the city and churns you into the mix.

With the recommendations of our born-and-bred Muscovite students, my wife Emma and I have just taken a self-guided tour of what some locals consider the top ten stations of the Moscow Metro. What most satisfied me about our Metro tour was the sense of adventure . I loved following our route on the maps of the wagon walls as we circled the city, plotting out the course to the subsequent stops; having the weird sensation of being underground for nearly four hours; and discovering the next cavern of treasures, playing Indiana Jones for the afternoon, piecing together fragments of Russia’s mysterious history. It’s the ultimate interactive museum.

Top Ten Stations (In order of appearance)

Kievskaya station.

Kievskaya Station went public in March of 1937, the rails between it and Park Kultury Station being the first to cross the Moscow River. Kievskaya is full of mosaics depicting aristocratic scenes of Russian life, with great cameo appearances by Lenin, Trotsky, and Stalin. Each work has a Cyrillic title/explanation etched in the marble beneath it; however, if your Russian is rusty, you can just appreciate seeing familiar revolutionary dates like 1905 ( the Russian Revolution ) and 1917 ( the October Revolution ).

Mayakovskaya Station

Mayakovskaya Station ranks in my top three most notable Metro stations. Mayakovskaya just feels right, done Art Deco but no sense of gaudiness or pretention. The arches are adorned with rounded chrome piping and create feeling of being in a jukebox, but the roof’s expansive mosaics of the sky are the real showstopper. Subjects cleverly range from looking up at a high jumper, workers atop a building, spires of Orthodox cathedrals, to nimble aircraft humming by, a fleet of prop planes spelling out CCCP in the bluest of skies.

Novoslobodskaya Station

Novoslobodskaya is the Metro’s unique stained glass station. Each column has its own distinctive panels of colorful glass, most of them with a floral theme, some of them capturing the odd sailor, musician, artist, gardener, or stenographer in action. The glass is framed in Art Deco metalwork, and there is the lovely aspect of discovering panels in the less frequented haunches of the hall (on the trackside, between the incoming staircases). Novosblod is, I’ve been told, the favorite amongst out-of-town visitors.

Komsomolskaya Station

Komsomolskaya Station is one of palatial grandeur. It seems both magnificent and obligatory, like the presidential palace of a colonial city. The yellow ceiling has leafy, white concrete garland and a series of golden military mosaics accenting the tile mosaics of glorified Russian life. Switching lines here, the hallway has an Alice-in-Wonderland feel, impossibly long with decorative tile walls, culminating in a very old station left in a remarkable state of disrepair, offering a really tangible glimpse behind the palace walls.

Dostoevskaya Station

Dostoevskaya is a tribute to the late, great hero of Russian literature . The station at first glance seems bare and unimpressive, a stark marble platform without a whiff of reassembled chips of tile. However, two columns have eerie stone inlay collages of scenes from Dostoevsky’s work, including The Idiot , The Brothers Karamazov , and Crime and Punishment. Then, standing at the center of the platform, the marble creates a kaleidoscope of reflections. At the entrance, there is a large, inlay portrait of the author.

Chkalovskaya Station

Chkalovskaya does space Art Deco style (yet again). Chrome borders all. Passageways with curvy overhangs create the illusion of walking through the belly of a chic, new-age spacecraft. There are two (kos)mosaics, one at each end, with planetary subjects. Transferring here brings you above ground, where some rather elaborate metalwork is on display. By name similarity only, I’d expected Komsolskaya Station to deliver some kosmonaut décor; instead, it was Chkalovskaya that took us up to the space station.

Elektrozavodskaya Station

Elektrozavodskaya is full of marble reliefs of workers, men and women, laboring through the different stages of industry. The superhuman figures are round with muscles, Hollywood fit, and seemingly undeterred by each Herculean task they respectively perform. The station is chocked with brass, from hammer and sickle light fixtures to beautiful, angular framework up the innards of the columns. The station’s art pieces are less clever or extravagant than others, but identifying the different stages of industry is entertaining.

Baumanskaya Statio

Baumanskaya Station is the only stop that wasn’t suggested by the students. Pulling in, the network of statues was just too enticing: Out of half-circle depressions in the platform’s columns, the USSR’s proud and powerful labor force again flaunts its success. Pilots, blacksmiths, politicians, and artists have all congregated, posing amongst more Art Deco framing. At the far end, a massive Soviet flag dons the face of Lenin and banners for ’05, ’17, and ‘45. Standing in front of the flag, you can play with the echoing roof.

Ploshchad Revolutsii Station

Novokuznetskaya Station

Novokuznetskaya Station finishes off this tour, more or less, where it started: beautiful mosaics. This station recalls the skyward-facing pieces from Mayakovskaya (Station #2), only with a little larger pictures in a more cramped, very trafficked area. Due to a line of street lamps in the center of the platform, it has the atmosphere of a bustling market. The more inventive sky scenes include a man on a ladder, women picking fruit, and a tank-dozer being craned in. The station’s also has a handsome black-and-white stone mural.

Here is a map and a brief description of our route:

Start at (1)Kievskaya on the “ring line” (look for the squares at the bottom of the platform signs to help you navigate—the ring line is #5, brown line) and go north to Belorusskaya, make a quick switch to the Dark Green/#2 line, and go south one stop to (2)Mayakovskaya. Backtrack to the ring line—Brown/#5—and continue north, getting off at (3)Novosblodskaya and (4)Komsolskaya. At Komsolskaya Station, transfer to the Red/#1 line, go south for two stops to Chistye Prudy, and get on the Light Green/#10 line going north. Take a look at (5)Dostoevskaya Station on the northern segment of Light Green/#10 line then change directions and head south to (6)Chkalovskaya, which offers a transfer to the Dark Blue/#3 line, going west, away from the city center. Have a look (7)Elektroskaya Station before backtracking into the center of Moscow, stopping off at (8)Baumskaya, getting off the Dark Blue/#3 line at (9)Ploschad Revolyutsii. Change to the Dark Green/#2 line and go south one stop to see (10)Novokuznetskaya Station.

Check out our new Moscow Indie Travel Guide , book a flight to Moscow and read 10 Bars with Views Worth Blowing the Budget For

Jonathon Engels, formerly a patron saint of misadventure, has been stumbling his way across cultural borders since 2005 and is currently volunteering in the mountains outside of Antigua, Guatemala. For more of his work, visit his website and blog .

Photo credits: SergeyRod , all others courtesy of the author and may not be used without permission

Claudia Looi

Touring the Top 10 Moscow Metro Stations

By Claudia Looi 2 Comments

Komsomolskaya metro station looks like a museum. It has vaulted ceilings and baroque decor.

Hidden underground, in the heart of Moscow, are historical and architectural treasures of Russia. These are Soviet-era creations – the metro stations of Moscow.

Our guide Maria introduced these elaborate metro stations as “the palaces for the people.” Built between 1937 and 1955, each station holds its own history and stories. Stalin had the idea of building beautiful underground spaces that the masses could enjoy. They would look like museums, art centers, concert halls, palaces and churches. Each would have a different theme. None would be alike.

The two-hour private tour was with a former Intourist tour guide named Maria. Maria lived in Moscow all her life and through the communist era of 60s to 90s. She has been a tour guide for more than 30 years. Being in her 60s, she moved rather quickly for her age. We traveled and crammed with Maria and other Muscovites on the metro to visit 10 different metro stations.

Arrow showing the direction of metro line 1 and 2

Moscow subways are very clean

To Maria, every street, metro and building told a story. I couldn’t keep up with her stories. I don’t remember most of what she said because I was just thrilled being in Moscow. Added to that, she spilled out so many Russian words and names, which to one who can’t read Cyrillic, sounded so foreign and could be easily forgotten.

The metro tour was the first part of our all day tour of Moscow with Maria. Here are the stations we visited:

1. Komsomolskaya Metro Station is the most beautiful of them all. Painted yellow and decorated with chandeliers, gold leaves and semi precious stones, the station looks like a stately museum. And possibly decorated like a palace. I saw Komsomolskaya first, before the rest of the stations upon arrival in Moscow by train from St. Petersburg.

2. Revolution Square Metro Station (Ploshchad Revolyutsii) has marble arches and 72 bronze sculptures designed by Alexey Dushkin. The marble arches are flanked by the bronze sculptures. If you look closely you will see passersby touching the bronze dog's nose. Legend has it that good luck comes to those who touch the dog's nose.

Touch the dog's nose for good luck. At the Revolution Square station

Revolution Square Metro Station

3. Arbatskaya Metro Station served as a shelter during the Soviet-era. It is one of the largest and the deepest metro stations in Moscow.

Arbatskaya Metro Station

4. Biblioteka Imeni Lenina Metro Station was built in 1935 and named after the Russian State Library. It is located near the library and has a big mosaic portrait of Lenin and yellow ceramic tiles on the track walls.

Lenin's portrait at the Biblioteka Imeni Lenina Metro Station

5. Kievskaya Metro Station was one of the first to be completed in Moscow. Named after the capital city of Ukraine by Kiev-born, Nikita Khruschev, Stalin's successor.

Kievskaya Metro Station

6. Novoslobodskaya Metro Station was built in 1952. It has 32 stained glass murals with brass borders.

Novoslobodskaya metro station

7. Kurskaya Metro Station was one of the first few to be built in Moscow in 1938. It has ceiling panels and artwork showing Soviet leadership, Soviet lifestyle and political power. It has a dome with patriotic slogans decorated with red stars representing the Soviet's World War II Hall of Fame. Kurskaya Metro Station is a must-visit station in Moscow.

Ceiling panel and artworks at Kurskaya Metro Station

8. Mayakovskaya Metro Station built in 1938. It was named after Russian poet Vladmir Mayakovsky. This is one of the most beautiful metro stations in the world with 34 mosaics painted by Alexander Deyneka.

Mayakovskaya station

One of the over 30 ceiling mosaics in Mayakovskaya metro station

9. Belorusskaya Metro Station is named after the people of Belarus. In the picture below, there are statues of 3 members of the Partisan Resistance in Belarus during World War II. The statues were sculpted by Sergei Orlov, S. Rabinovich and I. Slonim.

10. Teatralnaya Metro Station (Theatre Metro Station) is located near the Bolshoi Theatre.

Teatralnaya Metro Station decorated with porcelain figures .

Taking the metro's escalator at the end of the tour with Maria the tour guide.

Have you visited the Moscow Metro? Leave your comment below.

January 15, 2017 at 8:17 am

An excellent read! Thanks for much for sharing the Russian metro system with us. We're heading to Moscow in April and exploring the metro stations were on our list and after reading your post, I'm even more excited to go visit them. Thanks again 🙂

December 6, 2017 at 10:45 pm

Hi, do you remember which tour company you contacted for this tour?

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