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Raj Palraj, M.B.B.S., M.D.

Infectious Diseases

9 common questions about vaccines and travel

Immunizations

Person sitting in wooden boat on the water in a tropical location

Travel does more than just transport you to a different place. It can broaden your perspective, increase your happiness, give you a chance to try new things, boost your creativity and help you recharge. Even planning a trip can be an exciting task. The anticipation of mapping an itinerary and scheduling your must-see attractions can bring a lot of joy and happiness.

One of the most important tasks before taking a trip is to make an appointment with a travel medicine specialist. These health care professionals help keep travelers safe and happy before and after their journeys.

Here are answers to common questions about travel medicine:

1. who should make an appointment with a travel medicine specialist.

Anyone planning a trip overseas can benefit from seeing a travel medicine specialist. However, a travel clinic appointment is critical if you are traveling to underdeveloped or developing countries where there's a higher risk of contracting severe communicable illnesses while abroad. It is also important for patients with certain medical conditions that make their immune systems weaker and more vulnerable to infectious diseases.

2. What vaccinations do I need to travel overseas?

All travelers should be vaccinated against the flu and current with COVID-19 vaccines and boosters.

In addition, it's important to complete the adult vaccination schedule that includes vaccinations for:

Chickenpox (varicella)
Diphtheria, tetanus and pertussis (DTP)
Pneumococcal
Measles, mumps and rubella (MMR)

Additional vaccines may be recommended depending on your travel itinerary. For example, hepatitis A vaccination is recommended if you are traveling to Southeast Asia. During your appointment, we can discuss which vaccines are appropriate for your itinerary.

3. Are there travel destinations that have different vaccination recommendations?

Yes. Infectious diseases thrive in different climates. If you travel to a new climate, you may be exposed to diseases to which you don't have any immunity.

Some infections are more prevalent in tropical settings compared to temperate climates. For example, typhoid and hepatitis A are more common in Southeast Asia because these communicable diseases can be spread through contaminated water. Some areas of Africa and South America have a higher prevalence of yellow fever and malaria, which are mosquito-borne infections.

The Centers for Disease Control and Prevention (CDC) has good information online for travelers for each travel destination.

Recommended vaccines may include:

Hepatitis A
Hepatitis B
Japanese encephalitis
Yellow fever

4. Can my primary care provider give me travel vaccinations?

It depends on your travel destinations and vaccine recommendations. I recommend starting the conversation with your primary care provider and reviewing the CDC recommendations .

If you have a complex itinerary with multiple countries or are traveling to Southeast Asia or Africa, it's better to make an appointment at the travel clinic. I also would recommend patients with organ transplants and immunocompromising conditions seek travel medicine consultation to reduce the risk of illness during travel. During that appointment, we will review your itinerary, provide necessary vaccinations and discuss ways to prevent mosquito-borne or tick-borne diseases.

5. How long before my trip should I go to the travel clinic?

Plan to have an appointment at least four weeks before you travel. Some vaccines require several weeks for immunity to develop, while others require more than one dose of vaccine for full protection.

If your trip is to an underdeveloped or developing country, you may need to schedule an appointment up to two months in advance to receive a complete set of immunizations. This gives your body time to produce the protective antibodies, so you are well protected when you land at your destination.

6. Can I only go to the travel clinic before I travel?

No. The Travel and Tropical Medicine Clinic is available before or after travel. The team can provide consultative services and treatment if you get sick after you return home.

7. I'm going to an all-inclusive resort. Will I have a lower risk of getting sick?

Maybe, but no traveler should take safety for granted. Even in an all-inclusive resort, knowing how food is prepared or the water supply quality is not possible. Mosquitos and other insects could still be a concern. It's important to take all necessary precautions and follow vaccination recommendations when you travel, regardless of your accommodations.

8. How do I lower my risk of malaria when traveling?

Malaria is a disease caused by a parasite. It's spread to humans through the bites of infected mosquitoes. Prophylactic malaria medications are available and are started before the travel, continued during the stay and for a certain duration after returning home. A travel medicine specialist can review the risks and benefits of all prevention and treatment options.

9. How do I stay healthy while traveling?

Nothing can ruin a trip like illness. Make sure all your vaccinations and boosters are up to date, and get any new vaccinations recommended for your destinations.

Food and water safety is important while traveling. Only eat well-cooked food. Avoid eating from roadside stands and uncooked foods, like salad and raw vegetables. Drink bottled beverages only, including bottled water. This is especially important if you travel in resource-limited regions, such as Southeast Asia or Africa.

Hand hygiene is important at home and overseas. Wash your hands often using soap and hot water. Avoid crowded places, follow respiratory etiquette and consider optional masking. Mosquitos and bugs can transmit parasites and diseases, like yellow fever and malaria. Use mosquito repellents. Mosquito nets may be appropriate in some parts of the world, as well.

As you make travel plans, schedule an appointment with a travel medicine specialist to get the vaccinations and information you need to be healthy and safe on your journey.

Raj Palraj, M.D. , is a physician in Infectious Diseases and Travel and Tropical Medicine in La Crosse , Wisconsin.

Person feeling sick, drinking beverage, holding tissue

Travel vaccination advice

If you're planning to travel outside the UK, you may need to be vaccinated against some of the serious diseases found in other parts of the world.

Vaccinations are available to protect you against infections such as yellow fever , typhoid and hepatitis A .

In the UK, the NHS routine immunisation (vaccination) schedule protects you against a number of diseases, but does not cover all of the infectious diseases found overseas.

When should I start thinking about the vaccines I need?

If possible, see the GP or a private travel clinic at least 6 to 8 weeks before you're due to travel.

Some vaccines need to be given well in advance to allow your body to develop immunity.

And some vaccines involve a number of doses spread over several weeks or months.

You may be more at risk of some diseases, for example, if you're:

travelling in rural areas
backpacking
staying in hostels or camping
on a long trip rather than a package holiday

If you have a pre-existing health problem, this may make you more at risk of infection or complications from a travel-related illness.

Which travel vaccines do I need?

You can find out which vaccinations are necessary or recommended for the areas you'll be visiting on these websites:

Travel Health Pro
NHS Fit for Travel

Some countries require proof of vaccination (for example, for polio or yellow fever vaccination), which must be documented on an International Certificate of Vaccination or Prophylaxis (ICVP) before you enter or when you leave a country.

Saudi Arabia requires proof of vaccination against certain types of meningitis for visitors arriving for the Hajj and Umrah pilgrimages.

Even if an ICVP is not required, it's still a good idea to take a record of the vaccinations you have had with you.

Find out more about the vaccines available for travellers abroad

Where do I get my travel vaccines?

First, phone or visit the GP practice or practice nurse to find out whether your existing UK vaccinations are up-to-date.

If you have any records of your vaccinations, let the GP know what you have had previously.

The GP or practice nurse may be able to give you general advice about travel vaccinations and travel health, such as protecting yourself from malaria.

They can give you any missing doses of your UK vaccines if you need them.

Not all travel vaccinations are available free on the NHS, even if they're recommended for travel to a certain area.

If the GP practice can give you the travel vaccines you need but they are not available on the NHS, ask for:

written information on what vaccines are needed
the cost of each dose or course
any other charges you may have to pay, such as for some certificates of vaccination

You can also get travel vaccines from:

private travel vaccination clinics
pharmacies offering travel healthcare services

Which travel vaccines are free?

The following travel vaccines are available free on the NHS from your GP surgery:

polio (given as a combined diphtheria/tetanus/polio jab )
hepatitis A

These vaccines are free because they protect against diseases thought to represent the greatest risk to public health if they were brought into the country.

Which travel vaccines will I have to pay for?

You'll have to pay for travel vaccinations against:

hepatitis B
Japanese encephalitis
tick-borne encephalitis
tuberculosis (TB)
yellow fever

Yellow fever vaccines are only available from designated centres .

The cost of travel vaccines that are not available on the NHS will vary, depending on the vaccine and number of doses you need.

It's worth considering this when budgeting for your trip.

Other things to consider

There are other things to consider when planning your travel vaccinations, including:

your age and health – you may be more vulnerable to infection than others; some vaccines cannot be given to people with certain medical conditions
working as an aid worker – you may come into contact with more diseases in a refugee camp or helping after a natural disaster
working in a medical setting – a doctor, nurse or another healthcare worker may require additional vaccinations
contact with animals – you may be more at risk of getting diseases spread by animals, such as rabies

If you're only travelling to countries in northern and central Europe, North America or Australia, you're unlikely to need any vaccinations.

But it's important to check that you're up-to-date with routine vaccinations available on the NHS.

Pregnancy and breastfeeding

Speak to a GP before having any vaccinations if:

you're pregnant
you think you might be pregnant
you're breastfeeding

In many cases, it's unlikely a vaccine given while you're pregnant or breastfeeding will cause problems for the baby.

But the GP will be able to give you further advice about this.

People with immune deficiencies

For some people travelling overseas, vaccination against certain diseases may not be advised.

This may be the case if:

you have a condition that affects your body's immune system, such as HIV or AIDS
you're receiving treatment that affects your immune system, such as chemotherapy
you have recently had a bone marrow or organ transplant

A GP can give you further advice about this.

Non-travel vaccines

As well as getting any travel vaccinations you need, it's also a good opportunity to make sure your other vaccinations are up-to-date and have booster vaccines if necessary.

Although many routine NHS vaccinations are given during childhood, you can have some of them (such as the MMR vaccine ) as an adult if you missed getting vaccinated as a child.

There are also some extra NHS vaccinations for people at higher risk of certain illnesses, such as the flu vaccine , the hepatitis B vaccine and the BCG vaccine for tuberculosis (TB) .

Your GP can advise you about any NHS vaccinations you might need.

Find out about NHS vaccinations and when to have them

Page last reviewed: 16 March 2023 Next review due: 16 March 2026

The website will be down for maintenance from 6:00 a.m. to noon CDT on Sunday, June 30.

CHRISTOPHER SANFORD, MD, MPH, ADAM MCCONNELL, MD, AND JUSTIN OSBORN, MD

Am Fam Physician. 2016;94(8):620-627

Patient information : See related handout on tips for international travel .

Author disclosure: No relevant financial affiliations.

Key components of the pretravel consultation include intake questions regarding the traveler's anticipated itinerary and medical history; immunizations; malaria prophylaxis; and personal protection measures against arthropod bites, traveler's diarrhea, and injury. Most vaccinations that are appropriate for international travelers are included in the routine domestic immunization schedule; only a few travel-specific vaccines must also be discussed. The most common vaccine-preventable illnesses in international travelers are influenza and hepatitis A. Malaria prophylaxis should be offered to travelers to endemic regions. Personal protection measures, such as applying an effective insect repellent to exposed skin and permethrin to clothing and using a permethrin-impregnated bed net, should be advised for travelers to the tropics. Clinicians should offer an antibiotic prescription that travelers can take with them in case of traveler's diarrhea. Additional topics to address during the pretravel consultation include the risk of injury from motor vehicle crashes and travel-specific risks such as altitude sickness, safe sex practices, and emergency medical evacuation insurance.

Data show that 1.1 billion persons crossed an international border in 2014, and this number is projected to increase to 1.8 billion persons in 2025. 1 Tourism is increasing in both high- and low-income destinations, and is the first- or second-largest source of revenue in 20 of the 48 least developed countries. 2

WHAT'S NEW ON THIS TOPIC: THE PRETRAVEL CONSULTATION

Pregnant women and women of childbearing age who are trying to conceive should postpone travel to Zika-endemic areas. If they do visit these areas, they should be vigilant about arthropod avoidance measures. Because Zika is also transmitted by sex, men who visit Zika-endemic areas should use condoms with pregnant sex partners.

Only a minority of international travelers—36% in one study—seek pretravel counseling; of those, 60% see a primary care clinician, 10% see a travel subspecialist, and 30% turn to friends and family. 3 Although research supports some portions of the pretravel encounter (e.g., malaria prophylaxis, immunizations), the benefit of counseling on other topics (e.g., motor vehicle crashes, safe sex) has not yet been demonstrated. 4

Although consulting a clinician is beneficial to patients at any time before international travel, pretravel visits should ideally occur at least six weeks before departure to maximize benefit of immunizations and other preventive measures. The pretravel consultation is likely to be particularly useful in those visiting low-income nations.

Table 1 outlines the recommended components of the pretravel consultation, 5 , 6 and Table 2 provides resources for clinicians who provide pretravel services. Physicians who perform pretravel consultations only occasionally or who have minimal training in travel medicine may want to refer complex cases to a clinician experienced in travel medicine.

The assessment should include dates of travel, anticipated itinerary, planned activities, mode of travel, and reason for travel. Additionally, clinicians should inquire about the traveler's acceptance level for health risks and budget for health care expenditures.

A full medical history should be elicited from the traveler, including immunization records, medications, allergies, and medical conditions. Certain conditions, if uncontrolled, may increase health risks in travelers and include congestive heart failure, hypertension, seizures, diabetes mellitus, and mental illness. Clinicians may recommend against particular trips or activities if they exceed the traveler's physical abilities or if there is a specific contraindication. Persons who have had a myocardial infarction or coronary artery bypass within the previous two weeks, or a complicated myocardial infarction within the previous six weeks, 7 are thought to be at higher risk of cardiovascular events when flying. Prior use of antimalarials and any adverse effects experienced should be recorded. Physicians should ask women about pregnancy status and birth control method, if applicable.

Selected travel hazards and risk reduction strategies are included in Table 3 . 8 – 12

Noninfectious Risks

The most common cause of death in nonelderly international travelers is motor vehicle crashes, which account for 18% to 24% of deaths in all travelers. Deaths from motor vehicle crashes are markedly more common in low-income nations. Other common causes of death in travelers include violence (e.g., homicide, suicide) and drowning. 13 , 14

Immunization-Preventable Diseases

eTable A summarizes immunizations recommended for international travelers. Live vaccines should be avoided in travelers who are pregnant or immunocompromised.

ROUTINE VACCINES

In general, the diseases on the routine domestic immunization schedule are more common in travelers than are the travel-specific illnesses; hence, travelers should be up to date on the routine vaccines recommended by the Advisory Committee on Immunization Practices. The most common vaccine-preventable illnesses in international travelers are influenza and hepatitis A. The influenza season is between April and September in the southern hemisphere, and it occurs year-round in locations near the equator. Immunization for influenza should be advised when available. Hepatitis A, transmitted by contaminated food and water, is ubiquitous in low-income nations, and the vaccine is appropriate for all travelers older than one year. 15

TRAVEL-SPECIFIC VACCINES

Travel-specific immunizations include those for typhoid fever, 16 yellow fever, Japanese encephalitis, rabies, and cholera. Travelers may be required to show proof of vaccination for yellow fever to enter or return from nations within endemic regions (tropical Africa and tropical South America). Physicians should document yellow fever vaccination on travelers' International Certificate of Vaccination or Prophylaxis (“yellow card,” as approved by the World Health Organization). An example of the vaccine certificate is available at http://www.who.int/ihr/IVC200_06_26.pdf?ua=1 . If travelers have a contraindication to the yellow fever immunization, clinicians should write a letter of exemption or complete the waiver section of the vaccine certificate; these are generally accepted at international borders. Travelers to Saudi Arabia for the annual hajj and umrah (Muslim pilgrimage) are required to show proof of immunization for meningococcal meningitis.

Protection Against Insects and Other Arthropods

Personal protection measures.

It is important to stress to travelers that taking antimalarials does not negate the need for personal protection measures ( Table 4 17 ) , which guard against malaria and numerous other arthropod-borne diseases (e.g., dengue fever, a common illness in most tropical countries). 18 , 19

Insect repellent should be applied to exposed skin. The most effective insect repellents contain 20% to 50% diethyltoluamide (DEET) 20 , 21 or 20% picaridin. Other effective insect repellents are oil of lemon eucalyptus (PMD) and IR3535. Insect repellent should not be applied onto or under clothing. Regular reapplication is important.

Applying permethrin to clothing markedly increases protection against insect bites. 22 , 23 Travelers to malaria-endemic regions should sleep under a bed net impregnated with permethrin unless there is air-conditioning. Wearing long sleeves and pants offers additional protection. The vector for malaria is the female Anopheles mosquito, which feeds at dusk, nighttime, and dawn; minimizing time outdoors during these times will reduce risk. IR3535 does not provide adequate protection against Anopheles mosquitoes and should not be used in malaria-endemic areas.

MALARIA PROPHYLAXIS

Travelers to endemic regions should receive malaria prophylaxis. 24 , 25 The choice of prophylactic medication ( Table 5 20 , 26 ) should be based on whether the patient is going to an area with chloroquine-sensitive or chloroquine-resistant malaria, whether there could be potential adverse effects or interactions with the patient's medical conditions or other medications, the convenience of dosing schedule, and the cost. A summary of countries where malaria is endemic and prophylaxis recommendations from the Centers for Disease Control and Prevention are available at http://www.cdc.gov/malaria/travelers/country_table/a.html . Recommendations from the World Health Organization are available at http://www.who.int/ith/2015-ith-chapter7.pdf?ua=1 .

Regions where chloroquine-sensitive malaria is endemic include Mexico and Central America (west of the Panama Canal), and the island of Hispaniola (Haiti and the Dominican Republic). Options for prophylaxis in these regions are chloroquine (Aralen) and hydroxychloroquine (Plaquenil). Potential adverse effects of these medications include blurred vision, headache, nausea, and vomiting. Hydroxychloroquine may be better tolerated than chloroquine. Primaquine may be used for prophylaxis in areas affected primarily by Plasmodium vivax malaria.

The options for travelers to chloroquine-resistant regions (including most of South America, Asia, and Africa) are doxycycline, atovaquone/proguanil (Malarone), and mefloquine; these agents are equally effective. Doxycycline, which is taken daily, is relatively inexpensive. Potential adverse effects include nausea, photosensitivity, vaginal yeast infections, and esophageal ulceration. Atovaquone/proguanil, also a daily medication, is the most expensive option but has the lowest incidence of adverse effects. Mefloquine, taken weekly, is well-tolerated by most patients, but has a U.S. Food and Drug Administration boxed warning because of its neurologic and psychiatric adverse effects. In some areas of Southeast Asia, malaria is resistant to mefloquine, and doxycycline or atovaquone/proguanil should be used. Antimalarials should not be purchased in low-income nations because there is a high risk of counterfeit, adulterated, or expired medications.

ZIKA VIRUS INFECTION

Zika virus infection is primarily transmitted by mosquitoes, but it can also be sexually transmitted. Since May of 2015, this disease has spread to Mexico and essentially every country in Central and South America and the Caribbean. Risk of microcephaly in the newborn if a woman is infected in the first trimester of pregnancy has been estimated at 1% to 13%. Pregnant women should avoid travel to areas with Zika transmission. Men who live in or visit a Zika-endemic area should use a condom or abstain from sex with a pregnant partner for the remainder of the pregnancy. 27 , 28

Traveler's Diarrhea

Traveler's diarrhea (TD) is by far the most common infection in international travelers, with a rate of 30% to 70% depending on destination and season of travel. The risk is highest in the first two weeks of travel and slowly declines thereafter. 29 Taking medications that reduce gastric acidity, including proton pump inhibitors and antacids, significantly increases the risk of TD. 10 Other risk factors include younger age, diabetes, and immunosuppression.

The etiology of TD is bacterial in 80% to 90% of cases; the remainder are caused by viral or protozoan organisms. Bacterial and viral TD usually present as the sudden onset of loose stools, cramping, and nausea. Other manifestations may include abdominal pain, fever, vomiting, and bloody stools. TD caused by protozoan organisms, such as Giardia , tends to have a more insidious onset and a longer duration of symptoms. 30

Traditional advice (e.g., avoiding food from street stands, tap water, raw foods, and ice) has not been shown to reduce the incidence of TD. 31 Hand washing reduces risk by 30%; alcohol-based hand sanitizer also significantly reduces risk. 32

Prophylactic antibiotics are not routinely recommended. For patients at particularly high risk, taking bismuth subsalicylate (Pepto-Bismol; two tablets four times daily for the duration of the trip) reduces risk by 50% to 65%. 20 , 33 Possible adverse effects of bismuth subsalicylate include a black tongue and dark stool, and contraindications include aspirin allergy, renal insufficiency, breastfeeding, and concurrent use of anticoagulants. There is insufficient evidence for the use of probiotics to prevent TD.

The primary supportive treatment for TD is rehydration. However, in general, TD is not dehydrating, except for in persons who are very young or old or who have chronic illnesses. If dehydration occurs, travelers can rehydrate with most fluids, including water, juice, soda pop, or tea.

Loperamide (Imodium) is a safe and effective antimotility agent that can be used with or without antibiotics. It should be avoided in persons with warning signs, such as blood in the stool or fever, and in children younger than six years. Diphenoxylate is an alternative antimotility agent.

Without treatment, TD usually lasts three to seven days. A short course of antibiotics usually shortens symptom duration to six to 24 hours. 34 , 35 Fluoroquinolones are effective for self-treatment of TD in Africa and Latin America. One regimen is ciprofloxacin taken as one 500-mg tablet followed by a second 500-mg tablet 12 hours later. However, a macrolide, such as azithromycin (Zithromax; 500 mg daily for one to three days or one 1,000-mg tablet [higher incidence of nausea]) is more effective in South and Southeast Asia because of the high prevalence of TD caused by fluoroquinolone-resistant Campylobacter . Given the recent warning by the U.S. Food and Drug Administration regarding adverse effects of fluoroquinolones, 36 clinicians may consider prescribing a macrolide for self treatment of TD regardless of destination. Rifaximin (Xifaxan), an antibiotic with minimal systemic absorption, can be used as a preventive medication (200 mg once or twice daily) or as treatment (200 mg three times daily for three days). It is not approved by the U.S. Food and Drug Administration for TD prophylaxis.

Because TD is usually self-limited, and antibiotics have potential adverse effects, a course of carry-along antibiotics should be prescribed for the patient to use only if needed. To reduce the risk of creating drug-resistant bacteria, antibiotics should be taken only for severe diarrhea. 37

Travelers with TD who develop syncope, dehydration, or symptoms lasting more than one week should seek medical care. Studies show that 3% to 17% of TD cases may result in chronic postinfectious irritable bowel syndrome; the risk increases with multiple bouts of TD. 38 , 39

Emergency Medical Evacuation Insurance

Emergent medical evacuation from a low-income nation can cost $50,000 to $75,000 or more. Emergency medical evacuation insurance is particularly important for older travelers, for those with chronic medical conditions, and for those engaged in high-risk activities, such as high-altitude climbing. Travelers can visit https://www.squaremouth.com/ to compare travel insurance options, including medical and emergency evacuation insurance.

Travelers with Chronic Medical Conditions

Persons with most medical conditions can travel without restriction, but additional advance preparation may be necessary. Medical conditions should be stable before travel, and patients requiring frequent medical interventions should postpone travel to low-income nations.

Travelers who have chronic medical conditions should carry a list of their medications and physician contact information. Medications should be transported in carry-on, not checked, luggage and remain in the labeled containers in which they were dispensed from the pharmacy. Travelers who have diabetes should accept somewhat higher than usual glucose values during travel days to avoid hypoglycemia. Those requiring oxygen should contact the airline several weeks in advance to arrange for oxygen during flights. The Federal Aviation Administration does not allow passengers to carry their own oxygen tanks; battery-powered portable oxygen concentrators approved by the Department of Transportation may be used. Travelers who have a significant history of cardiac events should travel with a recent electrocardiogram.

Pregnant Women

Most airlines allow pregnant women to fly until 36 weeks of gestation. Pregnant women should not scuba dive because of the potential risk of decompression sickness in the fetus and fetal malformations. 40

Data Sources: We searched PubMed, the Cochrane Database of Systematic Reviews, Essential Evidence Plus, AHRQ Evidence Reports, and BMJ Clinical Evidence. Key words: travel medicine, immunizations, malaria prophylaxis, traveler's diarrhea, motor vehicle injuries, pretravel consultation. Search dates: May and September 2015, and June 2016.

note: This review updates previous articles by Bazemore and Huntington , 26 Lo Re and Guzman , 41 and Dick . 42

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The vaccines you need will depend on where you’re traveling and what you will be doing during your travels. Walgreens pharmacists are able to assist in helping you determine which vaccines you may need.

Which travel vaccines are available at Walgreens?

Travel vaccines Walgreens offers include: Yellow Fever, Meningitis, Polio, Typhoid, Japanese Encephalitis, Tick-Borne Encephalitis, Hepatitis A, Hepatitis B and Rabies*.

*Vaccines offered at Walgreens vary by state, age and health conditions. Talk to your local pharmacist about availability.

What other vaccines should I have before traveling?

It’s important to be up-to-date on routine vaccinations before traveling as well—like Measles-Mumps-Rubella (MMR), Tetanus, Flu and COVID-19.

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Travel vaccinations

Measles cases are increasing worldwide.

Before travelling, check that you and your family have received the recommended measles vaccinations.

Do not travel if you have symptoms of measles or have been in contact with someone with measles.

If you develop symptoms of measles after your return to Canada, call a health care provider right away.

Global Measles Notice

When travelling outside Canada, you may be at risk for a number of vaccine preventable illnesses.

You should consult a health care provider or visit a travel health clinic preferably six weeks before you travel. This is an opportunity to:

review your immunization history
make sure your provincial/territorial vaccination schedule is up-to-date
discuss any trip-related health concerns you may have
assess your needs based on where you plan to travel and what you plan to do

You may need additional vaccinations depending on your age, planned travel activities and local conditions. Preventing disease through vaccination is a lifelong process.

Use the reference below to determine which vaccinations may be recommended or required for your destination.

Vaccination recommendations by destination

Yellow fever vaccination.

Some countries require proof that you have received a yellow fever vaccination before allowing you to enter the country. Consult an embassy or consulate of your destination country in Canada for up-to-date information on its entry and exit requirements before you travel abroad.

Other countries may require you to have been vaccinated for yellow fever if you have passed through an area where yellow fever may occur .

Proof of vaccination must be documented on an International Certificate of Vaccination or Prophylaxis . You must carry the original certificate with you.

In Canada, the vaccination is only given at designated yellow fever vaccination centres .

Immunization records

Download the free CANImmunize app from the iOS App Store or Google Play, and manage your family’s vaccination records on the go.
Carry copies of your family’s immunization records while you travel and leave the originals at home.
Sickness or injury
Travel Advice and Advisories
If you get sick after travelling
Receiving medical care in other countries
Travel health kit
Travel insurance
Well on Your Way - A Canadian’s Guide to Healthy Travel Abroad
Tips for healthy travel
Yellow Fever Vaccination Centres in Canada , Public Health Agency of Canada (PHAC)
Recommended Immunization Schedules , PHAC

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Clinical Overview
Investigating a Suspected Case of Polio
Health Departments: Reporting Cases
Lab Testing

Polio Vaccination Before Traveling

Polio, also called poliomyelitis, has been eliminated from most of the world, but it still occurs in some countries.
Some travelers may be eligible for a one-time booster vaccine before traveling.
Check the recommendations and make sure you and your family, including children, are fully vaccinated before traveling internationally.

Vaccination for international travelers

People who plan to travel internationally should make sure they are fully vaccinated against polio before departure.

When visiting a country where there is increased risk of exposure to poliovirus, the government of that country may require you to show proof of polio vaccination on your yellow International Certificate of Vaccination or Prophylaxis (ICVP) when departing that country.

Polio vaccination information for adults

Woman watching a movie on her laptop while traveling on a plane.

Adults who are unvaccinated against polio should complete a primary vaccination series of 3 doses:

The first dose at any time.
The second dose 1 to 2 months later.
A third dose 6 to 12 months after the second dose.

If an adult cannot complete the above series before traveling, an accelerated schedule (3 doses of IPV administered at least 4 weeks apart) is recommended.

Adults who are incompletely vaccinated (got only 1 or 2 doses of polio vaccine in the past) should get the remaining 1 or 2 doses of IPV (administered at least 4 weeks apart) before departure.

Adults who are fully vaccinated and who plan to travel to a country where there is an increased risk of exposure to poliovirus, may receive a one-time booster dose of IPV.

For more information on polio vaccine recommendations for travel, talk to your healthcare provider or visit Travelers' Health: Poliomyelitis .

Visit CDC's Travelers' Health Notices site to see the most current information about polio around the world and what special steps you need to take to protect yourself or a loved one from polio while traveling.

Polio vaccination information for infants and children

Happy toddlers playing a group on a mat.

CDC recommends that all infants and children in the United States are vaccinated against polio with 4 doses of IPV given at ages 2 months, 4 months, 6–18 months, and 4–6 years.

Keep in mind‎

If a child cannot complete the routine series before departure, an accelerated schedule is recommended as follows:

First dose at age 6 weeks or older.
A second dose 4 or more weeks after the first dose.
A third dose 4 or more weeks after the second dose.
A fourth dose 6 or more months after the third dose.

If the accelerated schedule cannot be completed before leaving, the remaining doses should be given in the visited country, or upon return home, at the intervals recommended in the accelerated schedule.

In addition, children completing the accelerated schedule should still receive a dose of IPV at 4 years old or older, as long as it has been at least 6 months after the previous dose.

More information about polio vaccination

Review these pages for more information about polio and polio vaccination:

Polio Vaccination: What Everyone Should Know
Polio Vaccines for Children
Polio Vaccine Information Statement

Polio was once one of the most feared diseases in the United States. Thanks to the polio vaccine, wild poliovirus has been eliminated in this country.

For Everyone

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Home / Ask the Experts / Travel Vaccines

Ask the Experts: Travel Vaccines

Note: The travel vaccines section of Ask the Experts contains information only on vaccines not routinely recommended in the United States.

What are the CDC recommendations for use of the oral cholera vaccine, CVD 103-HgR (Vaxchora, Emergent BioSolutions)?

The FDA-licensed cholera vaccine CVD 103-HgR (Vaxchora, by Emergent BioSolutions) is currently unavailable in the United States. The manufacturer temporarily halted production in December 2020. CDC published ACIP recommendations for its use in September 2022, available at www.cdc.gov/mmwr/volumes/71/rr/rr7102a1.htm .

CVD 103-HgR is recommended for travelers ages 2–64 years old going to areas of active toxigenic Vibrio cholerae O1 transmission. Criteria for “active” cholera transmission for a given country and a table classifying countries according to transmission levels are found at wwwnc.cdc.gov/travel/page/cholera-travel-information .

Vaccination against cholera is not routinely recommended because cholera is rare in travelers and most travelers do not visit areas of active transmission. However, disease is more likely to occur in travelers who may have limited access to safe food and water in outbreak settings, including outbreak response workers. Clinicians should consider these factors in addition to the level of cholera transmission in the destination country, length of stay, patient’s age and history of pre-existing medical conditions, and the availability of intravenous hydration when assessing a traveler’s risk for cholera infection and the need for vaccination. Other WHO-prequalified cholera vaccines not licensed in the United States may be available in the destination country.

All travelers to cholera-affected areas should follow safe food and water precautions and proper sanitation and personal hygiene measures as primary prevention strategies against cholera infection. Travelers who develop severe diarrhea should promptly seek medical attention for rehydration therapy.

Are there other cholera vaccines available outside the United States?

Other oral cholera vaccines have been prequalified by the World Health Organization (WHO). These vaccines are not available in the United States and ACIP has not provided recommendations on use of these vaccines. To learn more about these vaccines, visit the World Health Organization Cholera Vaccines page: www.who.int/news-room/fact-sheets/detail/cholera .

For further information from CDC about cholera vaccines and preventing cholera, visit www.cdc.gov/cholera/prevention/cholera-vaccines.html and wwwnc.cdc.gov/travel/page/cholera-travel-information .

The package insert for the oral cholera vaccine CVD 103-HgR (Vaxchora, Emergent BioSolutions) states that effectiveness and safety have not been established for revaccination. Does ACIP have any recommendations on revaccination?

ACIP has not made recommendation related to revaccination or booster doses with the FDA-licensed oral cholera vaccine, CVD 103-HgR. As more information becomes available, CDC will update its recommendations accordingly.

Does live oral cholera vaccine CVD 103-HgR (Vaxchora, Emergent BioSolutions) need to be administered at an interval from other live oral or injectable vaccines?

With one exception, you do not need to consider the timing of this vaccine relative to other vaccines. According to CDC’s “General Best Practice Guidelines for Immunization”, concerns about spacing between doses of live vaccines not given at the same visit applies only to live injectable or intranasal vaccines. The one exception is administration of Ty21a oral typhoid vaccine and oral cholera vaccine. The CVD 103-HgR buffer might interfere with the enteric-coated Ty21a formulation. For this reason, ACIP recommends that the cholera vaccine should be administered at least 8 hours before ingesting the first dose of Ty21a vaccine.

Can a traveler who is taking antibiotics also receive the FDA-licensed oral cholera vaccine, CVD 103-HgR (Vaxchora, Emergent BioSolutions)?

Antibiotics administered before or after receiving the CVD 103-HgR vaccine might diminish the effectiveness of the vaccine because the immune response to the vaccine relies on the live attenuated vaccine organisms replicating within the small intestine. We do not know what the optimal interval is between receipt of antibiotics and the Vaxchora vaccine. CDC refers clinicians to the package insert which specifies that CVD 103-HgR should not be given to patients who have received oral or parenteral antibiotics during the preceding 14 days. A duration of fewer than 14 days between stopping antibiotics and giving CVD 103-HgR might be acceptable under certain circumstances, such as if travel cannot be avoided during that 14-day interval.

The package insert, however, does not specify an optimal minimum duration between the completion of CVD 103-HgR vaccination and starting antibiotics. In certain circumstances, antibiotics might be clinically necessary after the vaccine (to treat an unrelated infection), thus clinical discretion is recommended.

Is there any concern with taking the FDA-licensed oral cholera vaccine (Vaxchora) and antimalarial medication?

Chloroquine might diminish the immune response to CVD 103-HgR. The vaccine manufacturer, Emergent BioSolutions, recommends that CVD 103-HgR be administered 10 days or more before starting chloroquine. Doxycycline, a tetracycline antibiotic, is often used for malaria prophylaxis. The manufacturer does not recommend administration of the vaccine with oral antibiotics and does not recommend administering CVD 103-HgR to a person within 14 days prior to vaccination. The optimal duration between completion of CVD 103-HgR and then starting doxycycline is unknown.

Is there a yellow fever vaccine shortage?

Following a multi-year shortage, in April 2021, the FDA-licensed yellow fever vaccine, YF-Vax (Sanofi) resumed availability for purchase in the United States. Providers with a current Yellow Fever Vaccination Stamp issued by their state or territorial health department may order YF-VAX from the manufacturer.

Locations that administer yellow fever vaccine can be found on CDC’s yellow fever vaccination clinic search page at wwwnc.cdc.gov/travel/yellow-fever-vaccination-clinics/search .

Healthcare providers should refer to the section titled “Yellow Fever and Malaria Information, by Country,” in CDC Health Information for International Travel 2024 (“The Yellow Book”) for information about the countries that require yellow fever vaccination for entry and the countries where CDC recommends yellow fever vaccination. If a country does not have an entry requirement, CDC does not recommend yellow fever vaccination if the traveler’s itinerary does not include travel to a yellow fever–endemic area. This section is available at wwwnc.cdc.gov/travel/yellowbook/2024/preparing/yellow-fever-vaccine-malaria-prevention-by-country .

When not given on the same day, is the interval between yellow fever and MMR vaccines 4 weeks (28 days) or 30 days? I have seen the yellow fever and live virus vaccine recommendations published both ways.

The CDC’s General Best Practice Guidelines for Immunization generally recommends that live parenterally or nasally administered vaccines not given on the same day should be separated by at least 28 days. Despite this general principle, limited data suggest that coadministration of yellow fever vaccine and MMR may diminish the immune response. The CDC travel health website recommends that yellow fever vaccine and other parenteral or nasal live vaccines should be separated by at least 30 days, if possible. If yellow fever vaccine and another injectable live-virus vaccine are not administered either simultaneously or at least 30 days apart, CDC advises that providers might consider measuring the patient’s neutralizing antibody response to vaccination before travel. CDC recommends contacting the state health department or the CDC Arboviral Disease Branch (970-221-6400) to discuss serologic testing. For details, see the 2024 Yellow Book section on spacing of vaccines and immunobiologics: wwwnc.cdc.gov/travel/yellowbook/2024/preparing/vaccination-and-immunoprophylaxis-general-principles#spacing .

Is a vaccine for tick-borne encephalitis (TBE) available in the United States?

Yes. TBE is caused by a flavivirus transmitted by ticks in certain regions of Asia and Europe. Most infections are asymptomatic, but it can cause meningitis and encephalitis. In August 2021, the FDA approved a TBE vaccine, Ticovac (by Pfizer), for people age 1 year or older. The dose for people age 16 years and older is 0.5mL, and for children and adolescents up to age 15 years is 0.25mL. The primary vaccination schedule includes 3 doses, and a booster dose can be given if ongoing exposure or re-exposure to TBE virus is expected. TBE vaccines are also available in many countries overseas where TBE virus is present. For more information from CDC about the TBE vaccine, visit www.cdc.gov/tick-borne-encephalitis/hcp/vaccine/index.html .

Travelers to what areas should consider vaccination against tick-borne encephalitis (TBE)?

Tick-borne encephalitis (TBE) is a disease caused by a flavivirus transmitted by tick bite in certain areas of Europe and Asia. It may also be transmitted through the consumption of unpasteurized milk or cheese from infected cows, goats, or sheep. CDC provides details of TBE-endemic areas, but notes that the risk of TBE in endemic areas is variable within risk areas and from year-to-year. Additional geographic information is available from CDC: www.cdc.gov/tick-borne-encephalitis/data-maps/ .

Travelers moving or traveling to a TBE-endemic area and likely to have extensive exposure to ticks based on their planned outdoor activities and itinerary should be vaccinated for TBE. TBE vaccination may be considered for other travelers to TBE-endemic areas based on their likely exposure to ticks during their activities, their risk of a poor health outcome, and their personal perception and tolerance of risk.

What are the ACIP recommendations for use of tick-borne encephalitis (TBE) vaccine (Ticovac, Pfizer)?

In February 2022, ACIP voted on the following recommendation or TBE vaccination: TBE vaccine is recommended for people who are moving or traveling to a TBE-endemic area and will have extensive exposure to ticks based on their planned outdoor activities and itinerary.

In addition, TBE vaccine may be considered for persons traveling or moving to a TBE-endemic area who might engage in outdoor activities in areas ticks are likely to be found. The decision to vaccinate should be based on an assessment of their planned activities and itinerary, risk factors for a poorer medical outcome, and personal perception and tolerance of risk. For more information about TBE vaccine from CDC, visit www.cdc.gov/tick-borne-encephalitis/hcp/vaccine/index.html .

This page was updated on August 21, 2023 .

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http://orcid.org/0000-0002-6663-0457 Matthew W McGarrity 1 , 2 ,
Ryan Lisk 3 ,
Paul MacPherson 4 , 5 ,
David Knox 6 ,
Kevin S Woodward 7 , 8 ,
Jeffrey Reinhart 9 ,
John MacLeod 10 ,
Isaac I Bogoch 11 ,
Deanna Clatworthy 12 ,
Mia J Biondi 13 ,
Sean T Sullivan 14 ,
Alan T W Li 15 ,
Garfield Durrant 16 , 17 ,
Andrew Schonbe 18 ,
Fanta Ongoiba 19 ,
Janet Raboud 20 ,
Ann N Burchell 2 , 21 ,
Darrell H S Tan 1 , 2 , 22 , 23
1 Division of Infectious Diseases , St Michael's Hospital , Toronto , Ontario , Canada
2 MAP Centre for Urban Health Solutions , St Michael's Hospital , Toronto , Ontario , Canada
3 AIDS Committee of Toronto , Toronto , Ontario , Canada
4 Ottawa Hospital , Ottawa , Ontario , Canada
5 University of Ottawa , Ottawa , Ontario , Canada
6 Maple Leaf Medical Clinic , Toronto , Ontario , Canada
7 Department of Medicine , McMaster University , Hamilton , Ontario , Canada
8 Hamilton PrEP Clinic , Hamilton , Ontario , Canada
9 Sherbourne Health , Toronto , Ontario , Canada
10 790 Bay Street Clinic , Toronto , Ontario , Canada
11 Infectious Diseases , Toronto General Hospital , Toronto , Ontario , Canada
12 ARCH Clinic , Guelph , Ontario , Canada
13 School of Nursing , York University , Toronto , Ontario , Canada
14 Reseau Access Network , Sudbury , Ontario , Canada
15 Community Alliance for Accessible Treatment , Toronto , Ontario , Canada
16 Black Coalition for AIDS Prevention , Toronto , Ontario , Canada
17 Health Outcome Promotion and Engagement Centre , Toronto Metropolitan University , Toronto , Ontario , Canada
18 The PrEP Clinic , Toronto , Ontario , Canada
19 Africans in Partnership Against AIDS , Toronto , Ontario , Canada
20 University of Toronto Dalla Lana School of Public Health , Toronto , Ontario , Canada
21 Department of Family and Community Medicine , University of Toronto , Toronto , Ontario , Canada
22 Department of Medicine , University of Toronto , Toronto , Ontario , Canada
23 Institute of Health Policy, Management and Evaluation , University of Toronto , Toronto , Ontario , Canada
Correspondence to Dr Darrell H S Tan, Division of Infectious Diseases, St Michael's Hospital, Toronto, Canada; darrell.tan{at}gmail.com

Objectives Populations who seek HIV pre-exposure prophylaxis (PrEP) are disproportionately affected by hepatitis A virus (HAV), hepatitis B virus (HBV) and human papillomavirus (HPV). We examined immunity/vaccination against these infections among participants in the Ontario PrEP cohort study (ON-PrEP).

Methods ON-PrEP is a prospective cohort of HIV-negative PrEP users from 10 Ontario clinics. We descriptively analysed baseline immunity/vaccination against HAV (IgG reactive), HBV (hepatitis B surface antibody >10) and HPV (self-reported three-dose vaccination). We further performed multivariable logistic regression to identify characteristics associated with baseline immunity/vaccination. We used cumulative incidence functions to describe vaccine uptake among participants non-immune at baseline.

Results Of 633 eligible participants, 59.1% were white, 85.8% were male and 79.6% were gay. We found baseline evidence of immunity/vaccination against HAV, HBV and HPV in 69.2%, 81.2% and 16.8% of PrEP-experienced participants and 58.9%, 70.3% and 10.4% of PrEP-naïve participants, respectively. Characteristics associated with baseline HAV immunity were greater PrEP duration (adjusted OR (aOR) 1.41/year, 95% CI 1.09 to 1.84), frequent sexually transmitted and bloodborne infection (STBBI) testing (aOR 2.38, 95% CI 1.15 to 4.92) and HBV immunity (aOR 3.53, 95% CI 2.09 to 5.98). Characteristics associated with baseline HBV immunity were living in Toronto (aOR 3.54, 95% CI 1.87 to 6.70) or Ottawa (aOR 2.76, 95% CI 1.41 to 5.40), self-identifying as racialised (aOR 2.23, 95% CI 1.19 to 4.18), greater PrEP duration (aOR 1.39/year, 95% CI 1.02 to 1.90) and HAV immunity (aOR 3.75, 95% CI 2.19 to 6.41). Characteristics associated with baseline HPV vaccination were being aged ≤26 years (aOR 9.28, 95% CI 2.11 to 40.77), annual income between CAD$60 000 and CAD$119 000 (aOR 3.42, 95% CI 1.40 to 8.34), frequent STBBI testing (aOR 7.00, 95% CI 1.38 to 35.46) and HAV immunity (aOR 6.96, 95% CI 2.00 to 24.25). Among those non-immune at baseline, overall cumulative probability of immunity/vaccination was 0.70, 0.60 and 0.53 among PrEP-experienced participants and 0.93, 0.80 and 0.70 among PrEP-naïve participants for HAV, HBV and HPV, respectively.

Conclusions Baseline immunity to HAV/HBV was common, and a sizeable proportion of non-immune participants were vaccinated during follow-up. However, HPV vaccination was uncommon. Continued efforts should be made to remove barriers to HPV vaccination such as cost, inclusion in clinical guidelines and provider recommendation.

pre-exposure prophylaxis
hepatitis A
hepatitis B
human papillomavirus
vaccination

Data availability statement

No data are available.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/sextrans-2023-055961

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Populations who typically seek HIV pre-exposure prophylaxis (PrEP) often have a higher incidence of hepatitis A virus (HAV), hepatitis B virus (HBV) and human papillomavirus (HPV).

There is little evidence on the immune/vaccine status of these infections in PrEP users.

WHAT THIS STUDY ADDS

Immunity to HAV and HBV was common in Ontario PrEP users and a sizeable proportion of non-immune individuals were vaccinated during follow-up.

Both baseline vaccination and vaccine uptake was low for HPV, even among those eligible for publicly funded vaccination.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

Efforts should be made to promote vaccination throughout the duration of PrEP care and remove barriers such as cost, eligibility for publicly funded vaccination, provider recommendation and access to sexual health services.

Introduction

Pre-exposure prophylaxis (PrEP) is a safe and highly effective intervention that decreases the risk of infection with HIV. 1 PrEP involves taking oral medication either daily or ‘on-demand’ before potential HIV exposures to prevent infection. In September 2017, the public drug formulary in Ontario, Canada (named the Ontario Drug Benefit) started covering the cost of PrEP for those aged ≥65 years, on social assistance, receiving home care or residing in long-term care facilities. 2 In January 2018, PrEP coverage was expanded to include all Ontarians aged <25 years through a programme called OHIP+. 2 Other Ontario residents can seek partial PrEP coverage by applying for a subsidy programme called Trillium. 2 With a 6.6-fold subsequent increase in the number of individuals dispensed PrEP between 2016 and 2019, PrEP has become an essential part of Ontario’s HIV prevention strategy. 3

According to the Canadian guideline on HIV PrEP and non-occupational post-exposure prophylaxis, laboratory screening for sexually transmitted and bloodborne infections (STBBIs) is recommended at baseline and quarterly follow-up visits. 4 Based on the results of serological screening, vaccination against hepatitis A virus (HAV) and/or hepatitis B virus (HBV) is recommended for non-immune PrEP users. 4 Because gay, bisexual and other men who have sex with men (GBM) are over-represented in outbreaks of viral hepatitis, make up the greatest proportion of PrEP patients and are eligible for publicly funded vaccination in Ontario, PrEP care presents an opportunity to promote HAV and HBV vaccination among this important group. 5–8 Other sexually active PrEP-using populations may derive benefit from these vaccines as well. This is especially important for HBV, since the most common PrEP medications (ie, tenofovir disoproxil fumarate, tenofovir alafenamide and emtricitabine) have anti-HBV activity, which could predispose those with chronic infection to hepatitis flares during sudden PrEP discontinuation. 4

Although not included in Canadian or international PrEP guidelines, experts also recommend vaccination against human papillomavirus (HPV) alongside HAV and HBV. 9 10 Since anal carriage of high-risk HPV is prevalent among GBM, integrating HPV vaccination within PrEP care may reduce the burden of HPV-related anal cancers in this over-represented population. 11 12 This may also further the reach of publicly funded vaccine programmes, since GBM aged ≤26 years are eligible for free HPV vaccination in Ontario. 8

To date, no study has investigated immunity to or vaccination against each of HAV, HBV and HPV among PrEP users in a Canadian context. Our objectives were to: (1) quantify the proportion of Ontario PrEP users who were immune to/vaccinated against HAV, HBV and HPV at study baseline; (2) identify participant characteristics that were associated with baseline immunity/vaccination and (3) measure vaccine uptake over time among individuals who were non-immune at baseline.

Study design

This study analysed data from the Ontario PrEP cohort study (ON-PrEP), an ongoing, prospective cohort of HIV-negative individuals using PrEP in Ontario. ON-PrEP involves follow-up visits every 6 months for 2 years. During each visit, participants completed a web-based questionnaire, which gathered data on biological, behavioural, experiential and engagement in care outcomes. Additionally, study staff entered clinical information into the study database, including results of STBBI testing performed at study sites. STBBI serological testing and vaccination was performed according to the judgement of treating clinicians and was not prescribed by the study protocol. To improve data capture for STBBI screening conducted outside of ON-PrEP, we asked participants for permission to access additional test results from the Public Health Ontario Laboratory (PHOL), whose records include the majority of STBBI testing done in the province. PHOL data covered the entire study period plus 5 years after enrolment. We deterministically linked PHOL and ON-PrEP data sources using provincial health card numbers. Participants were given CAD$30 at baseline and CAD$20 for follow-up visits as compensation.

Participants

Enrolment into ON-PrEP began in February 2018 with a target sample size of 800 individuals. Participants were recruited from 10 clinical facilities across Ontario, including 5 sites in Toronto and 1 site in each of Guelph, Hamilton, London, Ottawa and Sudbury. We also sought self-referrals through community outreach activities in collaboration with 20 community-based organisations. Eligible participants were aged ≥16 years, initiating or currently using any PrEP regimen, HIV-negative within 3 months before enrolment as documented by standard serology and had sufficient English language proficiency to complete study activities.

There were 713 participants enrolled in ON-PrEP at the time of data extraction (ie, 2 June 2023). However, laboratory data were not collected for 80 participants enrolled through the community outreach activities. Therefore, 633 participants were eligible for inclusion in our analysis. The first participant was enrolled on 28 February 2018 and the last study visit was on 18 April 2023. Participants completed a median of 3 (IQR 4) study visits and were followed for a median of 196 (IQR 462) days.

Outcome variables

Our outcomes of interest were immunity to/vaccination against each of HAV, HBV and HPV. We determined HAV and HBV immunity using both laboratory results (ie, HAV IgG reactive, hepatitis B surface antibody titre >10) and self-reported completion of vaccine series (ie, two doses for HAV, three doses for HBV) from the following data sources: (1) PHOL serology results; (2) laboratory testing conducted at ON-PrEP sites and (3) self-reported vaccination as recorded in the study database. However, participants had varying degrees of data completeness across these sources, especially since permission to access PHOL records was optional and 109 (17.2%) participants opted out.

To optimise the accuracy of our immunity measures, we created binary outcome variables that incorporated data from each of the three sources hierarchically, prioritising PHOL serological results over site-level screening and finally self-reported vaccination ( figure 1 ). Self-reported vaccine status was collected by study staff directly into the study database, as opposed to via participant-completed questionnaires. Therefore, those with unknown vaccine status were individuals in whom neither the participant nor the study staff (on review of available medical records) could ascertain the true vaccine status.

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Flow chart used to determine hepatitis A virus (HAV) and hepatitis B virus (HBV) immune status among participants in the Ontario pre-exposure prophylaxis (ON-PrEP) cohort study (n=633). Our hierarchical classification system used both laboratory results (ie, HAV IgG reactive, hepatitis B surface antibody (HBsAb) titre >10) and self-reported completion of vaccine series (ie, two doses for HAV, three doses for HBV). Data sources included Public Health Ontario Laboratory (PHOL) serology results, laboratory testing conducted at ON-PrEP sites and self-reported vaccination as recorded in the study database. Counts (n) represent the number of participants falling under each classification.

Unlike HAV and HBV, there are no readily available laboratory tests that can determine immunity towards HPV. Consequently, we used participants’ self-reported vaccine status to create a binary outcome variable for completion of HPV vaccine series (ie, two or less doses vs all three doses).

To explore participant characteristics associated with baseline immunity/vaccination, we pre-identified potential covariates through a combination of literature review and consultation with our multidisciplinary study team of sexual health providers, HIV researchers and community members. This process yielded the following list of candidate demographic variables: city of residence, age, region of birth, race, gender identity, sexual orientation, annual income and Drug Use Disorders Identification Test (DUDIT) score. 13 Since sexual behaviour may influence uptake of STBBI prevention measures, we further included the following variables: having a primary partner, having casual partners and number of male sex partners in the last 6 months. Likewise, we considered variables regarding participants’ healthcare access, including having a primary care provider, duration of PrEP use, frequency of STBBI testing in the year preceding enrolment and perceived discrimination in healthcare as represented by Discrimination in Medical Setting scores. 14 Recognising that STBBI vaccination may be performed simultaneously, we also included the HAV, HBV and HPV outcome variables as covariates in models where it was not the model outcome.

Statistical analysis

We descriptively analysed sociodemographic characteristics among eligible ON-PrEP participants, using counts and percentages for categorical variables and median and IQR for continuous variables. To achieve our first objective, we calculated the proportion of participants with baseline immunity/vaccination against each of HAV, HBV and HPV, stratified by PrEP status (ie, whether participants were PrEP-naïve or PrEP-experienced at the time of enrolment). Participants with unknown immune/vaccination status were reported for results up until this point but were excluded from all subsequent analyses henceforth.

For our second objective, we used the ‘purposeful selection of covariates’ model—building strategy from Hosmer-Lemeshow-Sturdivant to identify characteristics associated with baseline immunity/vaccination. 15 All models were constructed using a complete case analysis. First, we built univariable logistic regression models between each pre-identified covariate and the outcomes of interest. All univariable relationships with a p value <0.15 were included in preliminary multivariable models. Variables with >40% missing responses (eg, DUDIT score, HPV vaccination for HAV and HBV models) or limited variability (eg, gender identity, sexual orientation, having a primary provider, city of residence for the HPV model) were excluded. Within the preliminary multivariable models, covariates that produced a p value >0.05 were consecutively removed, but reintroduced if their deletion modified any beta-coefficient by >20%. 15 This iterative process was repeated until all essential variables were included in the model. We then performed diagnostic testing for multicollinearity using variance inflation factors ≥10 and non-linearity using partial residual plots; however, none of the included covariates suggested evidence of either phenomenon. Once elucidated, we used OR and 95% CI to quantify associations in the final multivariable logistic regression models.

To fulfil our third objective, we produced cumulative incidence functions (CIFs) to examine uptake of HAV, HBV and/or HPV vaccination among participants who were non-immune at baseline and in whom vaccination was indicated according to the Ontario public vaccination schedule (ie, GBM and transgender women for HAV and all adults beyond grade 7 for HBV/HPV). 16–18 One participant who was HAV non-immune at baseline was removed from the HAV CIF because vaccination was not indicated. Since the recommended vaccine schedules for HAV, HBV and HPV are typically completed in <12 months, we estimated the cumulative probability of vaccine series completion after 1 year in ON-PrEP. 16–18 We further estimated cumulative probabilities at the longest length of individual follow-up which was 730 days. Participants who were lost to follow-up were censored at their last date of observation. All analyses were conducted in R Studio V.2022.02.3.

Patient and public partnership

The ON-PrEP study team includes a multidisciplinary group of HIV researchers, sexual health providers and community members who were involved in identifying research questions, developing data collection instruments, recruiting participants and disseminating results. For this specific analysis, we consulted team members in identifying participant characteristics that may be associated with STBBI immunity/vaccination to leverage the perspectives of those with expertise or lived experience.

Of 633 eligible participants, 374 (59.1%) were white, 543 (85.8%) were male, 504 (79.6%) self-identified as gay and 396 (62.6%) were aged 27–49 years ( table 1 ). The majority resided in major cities, with 332 (52.4%) living in Toronto and 198 (31.3%) in Ottawa. In terms of PrEP initiation, 441 (69.7%) were already taking PrEP before entering the cohort (median duration of PrEP use was 1 year, IQR 1), whereas 192 (30.3%) initiated PrEP within a week after enrolment.

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Demographic characteristics of participants enrolled in the Ontario PrEP cohort study at baseline (n=633)

Among PrEP-experienced participants, 305 (69.2%) were HAV immune at baseline, 76 (17.2%) were non-immune and 60 (13.6%) had unknown status. For HBV, 358 (81.2%) were immune, 67 (15.2%) were non-immune and 16 (3.6%) had unknown status. For HPV, only 74 (16.8%) had completed the vaccine series, 77 (17.5%) had received two doses or fewer (ie, 53 completely unvaccinated) and the remaining 290 (65.8%) had unknown status. Of 41 PrEP-experienced participants who were eligible for publicly funded HPV vaccination (ie, GBM aged ≤26 years) at baseline, only 10 (24.4%) were fully vaccinated.

Among PrEP-naïve participants, 113 (58.9%) were HAV immune at baseline, 64 (33.3%) were non-immune and 15 (7.8%) had unknown status. For HBV, 135 (70.3%) had baseline immunity, 49 (25.5%) were non-immune and 8 (4.2%) had unknown status. For HPV, only 20 (10.4%) had completed the vaccine series, 33 (17.2%) had received two doses or fewer (ie, 20 completely unvaccinated) and the remaining 139 (72.4%) had unknown status. Of 30 PrEP-naïve participants who were eligible for publicly funded HPV vaccination at baseline, only 6 (20.0%) were fully vaccinated.

In multivariable analysis, the following variables were associated with baseline HAV immunity ( table 2 ): greater duration of PrEP use (aOR 1.41/year, 95% CI 1.09 to 1.84), testing for STBBIs three or more times in the year preceding enrolment (aOR 2.38, 95% CI 1.15 to 4.92) and HBV immunity (aOR 3.53, 95% CI 2.09 to 5.98). For HBV, the following variables were associated with baseline immunity: living in Toronto (aOR 3.54, 95% CI 1.87 to 6.70) or Ottawa (aOR 2.76, 95% CI 1.41 to 5.40), self-identifying as racialised (aOR 2.23, 95% CI 1.19 to 4.18), greater duration of PrEP use (aOR 1.39/year, 95% CI 1.02 to 1.90) and HAV immunity (aOR 3.75, 95% CI 2.19 to 6.41). Finally, the following variables were associated with baseline HPV vaccination: being aged ≤26 years (aOR 9.28, 95% CI 2.11 to 40.77), having an annual salary between CAD$60 000 and CAD$119 000 (aOR 3.42, 95% CI 1.40 to 8.34), testing for STBBIs three or more times in the year before enrolment (aOR 7.00, 95% CI 1.38 to 35.46) and HAV immunity (aOR 6.96, 95% CI 2.00 to 24.25).

Univariable and multivariable relationships between characteristics and baseline immunity/vaccination against HAV, HBV and HPV among participants in the Ontario PrEP cohort study

Using CIFs, we observed that the probability of becoming immune/vaccinated against each of HAV, HBV and HPV increased steadily over time for participants who were non-immune at baseline ( figure 2 ). However, the likelihood of vaccine series completion was lower for HPV. After 1 year, the cumulative probability of immunity/vaccination was 0.48 for HAV, 0.41 for HBV and 0.19 for HPV among non-immune PrEP-experienced participants compared with 0.37 for HAV, 0.32 for HBV and 0.36 for HPV among non-immune PrEP-naïve participants. At the longest length of individual follow-up, cumulative probabilities were 0.65 for HAV, 0.60 for HBV and 0.53 for HPV among PrEP-experienced participants compared with 0.93 for HAV, 0.80 for HBV and 0.70 for HPV among PrEP-naïve participants. Of 116 participants who were HBV non-immune at baseline, only 3 underwent HBV core antibody (HBcAb) testing during follow-up, and none were positive for HBcAb, suggesting that the vast majority of HBV immunity acquired during the study was attributable to vaccination rather than infection.

Cumulative incidence function (CIF) for hepatitis A virus (HAV), hepatitis B virus (HBV) and human papillomavirus (HPV) among participants non-immune/unvaccinated at baseline. CIFs included participants in the pre-exposure prophylaxis (PrEP) cohort study who had available data, who were non-immune/unvaccinated at baseline and in whom vaccination was indicated according to the Ontario public vaccination schedule (ie, gay, bisexual and other men who have sex with men and transgender women for HAV and all adults beyond grade 7 for HBV/HPV). CIFs were stratified by PrEP status. Coloured bands represent the 95% CI. Cumulative probabilities were reported from baseline to longest length of individual follow-up. Participants who were lost to follow-up were censored at their last date of observation.

In this analysis, we found that most ON-PrEP participants were immune to HAV and HBV at baseline. However, a sizeable proportion was non-immune, especially among those who were initiating PrEP for the first time (ie, 33.3% for HAV and 25.5% for HBV). HPV vaccination was particularly low in both PrEP-experienced and PrEP-naïve groups and the high prevalence of unknown vaccine status highlights important gaps in promoting comprehensive STBBI prevention within PrEP care. The proportions of non-immune/unvaccinated PrEP users observed in this study mirror those found in other settings. In a small cohort of GBM initiating PrEP at a primary care clinic in New York City, USA, 41.7% of participants were non-immune to HAV at baseline. 6 Likewise, among individuals initiating PrEP at a sexual health clinic in Paris, France, 42.3% were HAV non-immune, 26.6% were HBV non-immune and 98.8% were HPV unvaccinated. 19 Similar to our findings, baseline HPV vaccination was only slightly higher among those eligible for free vaccine coverage. 19

Promoting vaccination against HAV, HBV and HPV among PrEP users continues to be important. Clinically, HBV is treatable but not curable and there is currently no antiviral treatment for either HAV or HPV. At the population level, GBM (the most common PrEP-seeking group in our setting) have been over-represented in sporadic HAV outbreaks across Canada. For instance, during an outbreak of acute HAV in Toronto from January 2017 to November 2018, 80% of confirmed cases were male and 64% reported having sex with men. 20 Likewise, GBM have historically been disproportionately affected by HBV when compared with other Canadians; 9.9% of acute HBV infections in Canada between 2005 and 2010 were among GBM. 21 Given the emergence of novel PrEP medications that no longer function as HBV treatment, notably long-acting injectable cabotegravir, diligent HBV vaccination is essential to prevent increases in HBV infection in this important group. 22 Although previous studies indicate that knowledge of HPV vaccine is high among Canadian GBM eligible for publicly funded vaccination, rates of vaccine initiation and series completion are limited to 26%–35% and 43%–66%, respectively. 23

Our findings suggest that PrEP care presents a valuable opportunity for vaccination against these common infections. For HAV and HBV, greater duration of PrEP use was associated with increased odds of baseline immunity. Among those non-immune, the overall probability of immunity was 0.65 for HAV and 0.60 for HBV among PrEP-experienced participants and 0.93 for HAV and 0.80 for HBV among the PrEP-naïve group, suggesting that providers likely recommended vaccination and uptake was high. Nevertheless, PrEP-experienced participants having higher baseline prevalence of HAV/HBV immunity and subsequently lower likelihood of vaccine uptake during follow-up suggests a greater emphasis on STBBI prevention early in PrEP care. Continued effort should be made to promote vaccination among those already taking PrEP.

More work is needed to improve HPV vaccination in PrEP care, since the estimated probability of vaccine series completion at both 1 year and longest length of individual follow-up were low when compared with HAV and HBV. Although the stringent eligibility criteria for publicly funded vaccination in Ontario likely played a role, a previous study found that PrEP stakeholders (ie, providers, clinic staff, patients) perceived the exclusion of HPV vaccine in PrEP management guidelines to be the greatest barrier to integrating HPV vaccination within PrEP care. 24 Putting this into context, pooled estimates from a recent meta-analysis found that only 24% of patients initiated HPV vaccination without provider recommendations compared with 60% whose provider recommended getting vaccinated. 25 Including HPV vaccine in both Canadian and international PrEP guidelines and encouraging providers to recommend HPV vaccination during PrEP consultations are important strategies for improving vaccine uptake among PrEP users.

Findings from our multivariable modelling can inform hypotheses about how to increase the reach of vaccination in PrEP care. Like other investigators, we found that prior immunity to another STBBI increased the odds of being immune/vaccinated against each of HAV, HBV and HPV. 23 Additionally, more frequent STBBI testing was associated with higher odds of HAV and HPV immunity/vaccination. Taken together, our results suggest that greater involvement in sexual healthcare may be a strong predictor of baseline immunity/vaccination. Continued effort should be made to promote vaccination among those with infrequent access to sexual health services, including education to primary care providers about indications for publicly funded vaccine. Despite Ontario implementing universal HBV vaccination for all grade seven students in 1994, we found that living in major cities like Toronto or Ottawa increased the likelihood of baseline HBV immunity, highlighting potential geographic disparities in access to HBV vaccination outside of school-based programmes across Ontario. 26 For HPV, participants within the eligible age range for publicly funded vaccination had greater odds of baseline vaccination. Moreover, those with higher annual salaries had increased odds of HPV vaccination, suggesting that income may be a barrier among those not eligible for free vaccination. By combining these predictors with the observed low proportions of baseline HPV vaccination, our study highlights the need to remove financial barriers to HPV vaccination in Ontario. One strategy is to expand the eligibility criteria for publicly funded HPV vaccination to reflect that of other Canadian provinces; free HPV vaccine is offered to GBM aged ≤45 years in Nova Scotia and GBM of all ages in Prince Edward Island. 27

Interestingly, we observed that self-identifying as racialised was predictive of HBV immunity at baseline. The reasons for this association were unclear. Notably, we found no association between region of birth and baseline immunity during multivariable modelling. One possible explanation is a high prevalence of natural immunity due to over-representation of first-generation and second-generation newcomers to Canada from HBV-endemic countries within the cohort.

Our analysis had limitations that warrant consideration. First, our multivariable models were constructed using a complete case analysis which may have produced biased estimates as data may not have been missing completely at random. Second, our analysis has limitations in terms of generalisability, since included participants were largely born in Canada and self-identified as gay, white, males. Because viral hepatitis is most prevalent in sub-Saharan Africa and East Asia, and newcomers from these regions account for most infections in North America, our results may underestimate HAV and HBV immunity among PrEP users not reached in this sample. 28 Third, ON-PrEP took place during the COVID-19 pandemic which imposed unprecedented challenges for completing study activities, laboratory screening and vaccination due to the shift to virtual care. 29 Consequently, unavoidable missing data was a limitation and our CIFs may underestimate vaccine uptake during follow-up. However, creating binary variables that included a hierarchy of data sources reduced the severity of missingness for HAV and HBV immunity measures. Fourth, our definitions considered completion of the HBV vaccine series equivalent to lab-confirmed immunity, although we recognise that HBV vaccine non-responders account for roughly 5% of immunocompetent individuals receiving vaccination. 30 Finally, we included self-reported data which may have been subject to recall and social desirability biases.

Our analysis found that HAV and HBV immunity was common among ON-PrEP participants and vaccine uptake was high among non-immune individuals, suggesting that PrEP care presents a valuable opportunity for vaccination. Because both baseline vaccination and uptake were lower for HPV, continued effort should be made to remove barriers to HPV vaccination such as cost and inclusion in PrEP guidelines. By identifying characteristics associated with baseline immunity/vaccination, we generated hypotheses on populations that would benefit most from vaccination within PrEP care, such as those with infrequent healthcare access, who live outside major cities, with lower income and not eligible for publicly funded vaccination.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

ON-PrEP was granted ethical approval by the following research ethics boards: Hamilton Integrated (HiREB Project #4513), Ottawa Health Science Network (Protocol #20180306-01H), Public Health Ontario (File Number 2020-045.01), St. Michael’s Hospital (REB# 17-281), University Health Network (19-5062) and University of Toronto (RIS Protocol #35597). All participants provided informed consent before partaking in study activities. Study data were de-identified and kept confidential.

Acknowledgments

The authors wish to acknowledge that they live, work and play on the traditional territories of the 16 Mississaugas of the Credit, Haudenosaunee, Anishnaabe, Chippewa and Wendat Peoples. The authors would like to thank the ON-PrEP participants for making this work possible. The authors would like to thank the ON-PrEP study team for their contribution to the study. The authors would like to thank MR for the assistance during data cleaning. The authors would also like to thank the reviewers and editors for their constructive feedback.

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Handling editor Michael Traeger

Contributors MWMcG contributed to data collection, designed and implemented the statistical analysis, and wrote the first version of the manuscript; RL contributed to protocol development, project administration and data collection/recruiting study participants; PMacP, DK, KSW, JR, JMacL, IIB, DC, MJB, STS and the ON-PREP Study Team partook in data collection/recruited study participants; ATWL, GD, AS, FO, JR and ANB shared their expertise to inform the study methodology; DHST conceived the study, secured funding, oversaw study conduct and is responsible for the overall content as the guarantor. All authors critically reviewed and approved the final manuscript.

Funding ON-PrEP is funded by the Canadian Institutes of Health Research (CBR-151185), Canadian Foundation for AIDS Research (ROG-1077), Ontario HIV Treatment Network (ROG-1077) and REACH 2.0 (ROG-1077). DHST is supported by a Tier 2 Canada Research Chair in HIV Prevention and STI Research. PMacP is supported by a University of Ottawa Tier 1 Research Chair in Gay Men’s Health. IIB is supported by a research grant from CIHR. ANB is supported by a Tier 2 Canada Research Chair in Sexually Transmitted Infection Prevention.

Competing interests DHST’s institution has received support from Abbott and Gilead for investigator-initiated research grants and from GlaxoSmithKline for industry-sponsored clinical trials. PMacP has received speaker honoraria from Merck and Gilead. IIB has consulted to Intercept: Global Public Health & Health Security. The other authors have no conflicts of interest to declare.

Provenance and peer review Not commissioned; externally peer reviewed.

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New Drug Provides Total Protection From H.I.V. in Trial of Young African Women

An injection given just twice a year could herald a breakthrough in protecting the population that has the highest infection rates.

A close-up view of a pair of hands with pink painted nails drawing diluent from a tiny plastic test tube on a blue surface.

By Stephanie Nolen

Stephanie Nolen has covered the global H.I.V. pandemic for more than 25 years.

Researchers and activists in the trenches of the long fight against H.I.V. got a rare piece of exciting news this week: Results from a large clinical trial in Africa showed that a twice-yearly injection of a new antiviral drug gave young women total protection from the virus.

“I got cold shivers,” said Dr. Linda-Gail Bekker, an investigator in the trial of the drug, lenacapavir, describing the startling sight of a line of zeros in the data column for new infections. “After all our years of sadness, particularly over vaccines, this truly is surreal.”

Yvette Raphael, the leader of a group called Advocacy for Prevention of H.I.V. and AIDS in South Africa, said it was “the best news ever.”

The randomized controlled trial, called Purpose 1, was conducted in Uganda and South Africa. It tested whether the every-six-months injection of lenacapavir, made by Gilead Sciences, would provide better protection against H.I.V. infection than two other drugs in wide use in high-income countries, both daily pills.

The results were so convincing that the trial was halted early at the recommendation of the independent data review committee, which said all participants should be offered the injection because it clearly provided superior protection against the virus.

None of the 2,134 women in the arm of the trial who received lenacapavir contracted H.I.V. By comparison, 16 of the 1,068 women (or 1.5 percent) who took Truvada, a daily pill that has been available for more than a decade, and 39 of 2,136 women (1.8 percent) who received a newer daily pill called Descovy were infected.

The findings were announced by Gilead . The data has not yet been subject to peer review. A second trial, conducted in six other countries, including Brazil and the United States, is assessing the effectiveness of lenacapavir in men who have sex with men, in transgender people and in those who use injection drugs. Midterm review of those results will take place later this year.

While Truvada, taken daily, provides high levels of protection against H.I.V. infection and has been widely used by gay men in the United States and other high-income countries for years, it has not proved to be a potent prevention tool in Africa, where uptake has been low, particularly among young African women, the group with the highest rates of new infection.

The hope is that a twice-a-year injection, which women can put on their calendars and then not think about for months, will prove more effective.

“For a young woman who can’t get to an appointment at a clinic in a town, a young woman who can’t keep pills without facing stigma or violence — an injection just twice a year is the option that could keep her free of H.I.V.,” said Lillian Mworeko, who leads a group called the International Community of Women Living With H.I.V. Eastern Africa.

The outstanding question is access: Gilead charges $42,250 per patient per year for lenacapavir, in the United States, where it is approved as a treatment for H.I.V.

“Africa is excited, women are excited, we have waited long for this,” Ms. Mworeko said. “Now we need to know, how do we get this into the hands of people who need it? We need an answer to this yesterday.”

Gilead said it was committed to making large volumes of the drug available “at prices that enable widespread availability” as quickly as possible in low-income countries with H.I.V. incidence rates.

Janet Dorling, Gilead’s senior vice president for global patient solutions, said the company intended to sign voluntary licenses with generic drug makers in several regions, sharing its intellectual property in exchange for a licensing fee, so that eventually a cheaper generic product would become available for low- and middle-income countries.

It can take generic makers years to get ready to produce a drug, and they need to have a sense of the potential market in order to commit to investing in production. So, in the meantime, Gilead will aim to to ship “sufficient volumes” of lenacapavir to low-income countries as soon as it has regulatory approval, she said.

Lenacapavir and the two pills studied are all known as pre-exposure prophylaxis drugs, or PrEP. Another effective injectable PrEP drug is available in some African countries, but its rollout has been bedeviled by access questions. Long-acting cabotegravir, which is delivered as an injection every two months, also showed excellent results in clinical trials in Africa. It is made by ViiV Healthcare, which is majority owned by the pharmaceutical giant GSK; the company is charging $180 per patient per year for cabotegravir in developing countries, a price out of reach for most people and health systems in Africa.

South Africa’s current budget for oral PrEP is about $40 per patient per year.

Facing criticism by activists on pricing , ViiV granted a license to the Medicines Patent Pool, a United Nations-backed agency that tries to make medical technologies more accessible, and which subsequently contracted with three generic makers. But none is expected to have a product available before 2027.

“Gilead has to have an access plan that is bold — not countries weighting up who will get it because they can’t afford to give it to everyone — or else this amazing clinical trial will not translate into any impact on H.I.V.,” said Carmen Peréz Casas, who works on access to technologies to fight the virus at the global health initiative Unitaid.

The Purpose 1 trial is unusual for the young age of the participants, who were between 16 and 25, and for the fact that it enrolled pregnant and lactating women and kept women in the trial if they got pregnant. While pharmaceutical companies have historically been reluctant to test drugs in those groups, Ms. Mworeko said community participants were adamant that this trial must include those most at risk of new infection — that is, sexually active late-adolescent girls.

Lenacapavir is also the first H.I.V. prevention drug for which trial results have become available for women before men; most are tested in gay men in industrialized countries before trials reach African women, long the most vulnerable population.

An earlier version of this story misspelled the name of the twice-yearly injected H.I.V. drug that was the subject of a study in African women. It is lenacapavir, not lenacaprivir.

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Stephanie Nolen is a global health reporter for The Times. More about Stephanie Nolen

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Make sure you are up-to-date on all routine vaccines before every trip. Some of these vaccines include

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All eligible travelers should be up to date with their COVID-19 vaccines. Please see Your COVID-19 Vaccination for more information.

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There has been evidence of chikungunya virus transmission in India within the last 5 years. Chikungunya vaccination may be considered for the following travelers:

People aged 65 years or older, especially those with underlying medical conditions, who may spend at least 2 weeks (cumulative time) in indoor or outdoor areas where mosquitoes are present in India, OR
People planning to stay in India for a cumulative period of 6 months or more

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Cholera is presumed to be present in India. Cholera is rare in travelers. Certain factors may increase the risk of getting cholera or having severe disease ( more information ). Avoiding unsafe food and water and washing your hands can also help prevent cholera.

Vaccination may be considered for children and adults who are traveling to areas of active cholera transmission.

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Recommended for unvaccinated travelers one year old or older going to India.

Infants 6 to 11 months old should also be vaccinated against Hepatitis A. The dose does not count toward the routine 2-dose series.

Travelers allergic to a vaccine component or who are younger than 6 months should receive a single dose of immune globulin, which provides effective protection for up to 2 months depending on dosage given.

Unvaccinated travelers who are over 40 years old, immunocompromised, or have chronic medical conditions planning to depart to a risk area in less than 2 weeks should get the initial dose of vaccine and at the same appointment receive immune globulin.

Hepatitis A - CDC Yellow Book

Dosing info - Hep A

Hepatitis B

Recommended for unvaccinated travelers younger than 60 years old traveling to India. Unvaccinated travelers 60 years and older may get vaccinated before traveling to India.

Hepatitis B - CDC Yellow Book

Dosing info - Hep B

Japanese Encephalitis

Recommended for travelers who

Are moving to an area with Japanese encephalitis to live
Spend long periods of time, such as a month or more, in areas with Japanese encephalitis
Frequently travel to areas with Japanese encephalitis

Consider vaccination for travelers

Spending less than a month in areas with Japanese encephalitis but will be doing activities that increase risk of infection, such as visiting rural areas, hiking or camping, or staying in places without air conditioning, screens, or bed nets
Going to areas with Japanese encephalitis who are uncertain of their activities or how long they will be there

Not recommended for travelers planning short-term travel to urban areas or travel to areas with no clear Japanese encephalitis season.

Japanese encephalitis - CDC Yellow Book

Japanese Encephalitis Vaccine for US Children

CDC recommends that travelers going to certain areas of India take prescription medicine to prevent malaria. Depending on the medicine you take, you will need to start taking this medicine multiple days before your trip, as well as during and after your trip. Talk to your doctor about which malaria medication you should take.

Find country-specific information about malaria.

Malaria - CDC Yellow Book

Considerations when choosing a drug for malaria prophylaxis (CDC Yellow Book)

Malaria information for India.

Cases of measles are on the rise worldwide. Travelers are at risk of measles if they have not been fully vaccinated at least two weeks prior to departure, or have not had measles in the past, and travel internationally to areas where measles is spreading.

All international travelers should be fully vaccinated against measles with the measles-mumps-rubella (MMR) vaccine, including an early dose for infants 6–11 months, according to CDC’s measles vaccination recommendations for international travel .

Measles (Rubeola) - CDC Yellow Book

Dogs infected with rabies are commonly found in India.

Rabies is also present in some terrestrial wildlife species.

If rabies exposures occur while in India, rabies vaccines are typically available throughout most of the country.

Rabies pre-exposure vaccination considerations include whether travelers 1) will be performing occupational or recreational activities that increase risk for exposure to potentially rabid animals and 2) might have difficulty getting prompt access to safe post-exposure prophylaxis.

Please consult with a healthcare provider to determine whether you should receive pre-exposure vaccination before travel.

For more information, see country rabies status assessments .

Rabies - CDC Yellow Book

Recommended for most travelers, especially those staying with friends or relatives or visiting smaller cities or rural areas.

Typhoid - CDC Yellow Book

Dosing info - Typhoid

Yellow Fever

Arrive within 6 days of leaving an area with risk for YF virus transmission, or
Have been in such an area in transit (exception: passengers and members of flight crews who, while in transit through an airport in an area with risk for YF virus transmission, remained in the airport during their entire stay and the health officer agrees to such an exemption), or
Arrive on a ship that started from or touched at any port in an area with risk for YF virus transmission ≤30 days before its arrival in India, unless such a ship has been disinsected in accordance with the procedure recommended by the World Health Organization (WHO), or
Arrive on an aircraft that has been in an area with risk for YF virus transmission and has not been disinsected in accordance with the Indian Aircraft Public Health Rules, 1954, or as recommended by WHO.
Africa: Angola, Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Ethiopia, Gabon, The Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Liberia, Mali, Mauritania, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Sudan, Sudan, Togo, Uganda
Americas: Argentina, Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Panama, Paraguay, Peru, Suriname, Trinidad & Tobago (Trinidad only), Venezuela

Yellow Fever - CDC Yellow Book

Avoid contaminated water

Leptospirosis

How most people get sick (most common modes of transmission)

Touching urine or other body fluids from an animal infected with leptospirosis
Swimming or wading in urine-contaminated fresh water, or contact with urine-contaminated mud
Drinking water or eating food contaminated with animal urine
Avoid contaminated water and soil
Avoid floodwater

Clinical Guidance

Avoid bug bites.

Crimean-Congo Hemorrhagic fever

Tick bite
Touching the body fluids of a person or animal infected with CCHF
Avoid Bug Bites
Mosquito bite

Leishmaniasis

Sand fly bite
An infected pregnant woman can spread it to her unborn baby

Airborne & droplet

Avian/bird flu.

Being around, touching, or working with infected poultry, such as visiting poultry farms or live-animal markets
Avoid domestic and wild poultry
Breathing in air or accidentally eating food contaminated with the urine, droppings, or saliva of infected rodents
Bite from an infected rodent
Less commonly, being around someone sick with hantavirus (only occurs with Andes virus)
Avoid rodents and areas where they live
Avoid sick people

Tuberculosis (TB)

Breathe in TB bacteria that is in the air from an infected and contagious person coughing, speaking, or singing.

Avoid skin contact

Antimicrobial-resistant (ar) ringworm.

Close contact with infected person
Shared objects (e.g., towels, bed sheets)
Shared surfaces (e.g., locker room and shower floors)
Keep skin clean and dry.
Do not share bedding, towels, or clothes.
Avoid touching the infected area so it does not spread to other parts of your body.
Consult a healthcare provider for treatment and testing.
Avoid steroid creams, as they can make the ringworm worse.
Use prescribed or over-the-counter (OTC) antifungals exactly as directed and contact a healthcare provider if treatment is not working.
Topical antifungals and oral terbinafine are frequently ineffective against AR ringworm.

Emerging Severe and Antimicrobial-Resistant Ringworm | Ringworm | CDC

Learn actions you can take to stay healthy and safe on your trip. Vaccines cannot protect you from many diseases in India, so your behaviors are important.

Eat and drink safely

Food and water standards around the world vary based on the destination. Standards may also differ within a country and risk may change depending on activity type (e.g., hiking versus business trip). You can learn more about safe food and drink choices when traveling by accessing the resources below.

Choose Safe Food and Drinks When Traveling
Water Treatment Options When Hiking, Camping or Traveling
Global Water, Sanitation and Hygiene (WASH)
Avoid Contaminated Water During Travel

You can also visit the Department of State Country Information Pages for additional information about food and water safety.

Prevent bug bites

Bugs (like mosquitoes, ticks, and fleas) can spread a number of diseases in India. Many of these diseases cannot be prevented with a vaccine or medicine. You can reduce your risk by taking steps to prevent bug bites.

What can I do to prevent bug bites?

Cover exposed skin by wearing long-sleeved shirts, long pants, and hats.
Use an appropriate insect repellent (see below).
Use permethrin-treated clothing and gear (such as boots, pants, socks, and tents). Do not use permethrin directly on skin.
Stay and sleep in air-conditioned or screened rooms.
Use a bed net if the area where you are sleeping is exposed to the outdoors.

What type of insect repellent should I use?

FOR PROTECTION AGAINST TICKS AND MOSQUITOES: Use a repellent that contains 20% or more DEET for protection that lasts up to several hours.
Picaridin (also known as KBR 3023, Bayrepel, and icaridin)
Oil of lemon eucalyptus (OLE) or para-menthane-diol (PMD)
2-undecanone
Always use insect repellent as directed.

What should I do if I am bitten by bugs?

Avoid scratching bug bites, and apply hydrocortisone cream or calamine lotion to reduce the itching.
Check your entire body for ticks after outdoor activity. Be sure to remove ticks properly.

What can I do to avoid bed bugs?

Although bed bugs do not carry disease, they are an annoyance. See our information page about avoiding bug bites for some easy tips to avoid them. For more information on bed bugs, see Bed Bugs .

For more detailed information on avoiding bug bites, see Avoid Bug Bites .

Some diseases in India—such as dengue, Zika, filariasis, and leishmaniasis—are spread by bugs and cannot be prevented with a vaccine. Follow the insect avoidance measures described above to prevent these and other illnesses.

Stay safe outdoors

If your travel plans in India include outdoor activities, take these steps to stay safe and healthy during your trip.

Stay alert to changing weather conditions and adjust your plans if conditions become unsafe.
Prepare for activities by wearing the right clothes and packing protective items, such as bug spray, sunscreen, and a basic first aid kit.
Consider learning basic first aid and CPR before travel. Bring a travel health kit with items appropriate for your activities.
If you are outside for many hours in heat, eat salty snacks and drink water to stay hydrated and replace salt lost through sweating.
Protect yourself from UV radiation : use sunscreen with an SPF of at least 15, wear protective clothing, and seek shade during the hottest time of day (10 a.m.–4 p.m.).
Be especially careful during summer months and at high elevation. Because sunlight reflects off snow, sand, and water, sun exposure may be increased during activities like skiing, swimming, and sailing.
Very cold temperatures can be dangerous. Dress in layers and cover heads, hands, and feet properly if you are visiting a cold location.

Stay safe around water

Swim only in designated swimming areas. Obey lifeguards and warning flags on beaches.
Practice safe boating—follow all boating safety laws, do not drink alcohol if driving a boat, and always wear a life jacket.
Do not dive into shallow water.
Do not swim in freshwater in developing areas or where sanitation is poor.
Avoid swallowing water when swimming. Untreated water can carry germs that make you sick.
To prevent infections, wear shoes on beaches where there may be animal waste.

Schistosomiasis and leptospirosis, infections that can be spread in fresh water, are found in India. Avoid swimming in fresh, unchlorinated water, such as lakes, ponds, or rivers.

Keep away from animals

Most animals avoid people, but they may attack if they feel threatened, are protecting their young or territory, or if they are injured or ill. Animal bites and scratches can lead to serious diseases such as rabies.

Follow these tips to protect yourself:

Do not touch or feed any animals you do not know.
Do not allow animals to lick open wounds, and do not get animal saliva in your eyes or mouth.
Avoid rodents and their urine and feces.
Traveling pets should be supervised closely and not allowed to come in contact with local animals.
If you wake in a room with a bat, seek medical care immediately. Bat bites may be hard to see.

All animals can pose a threat, but be extra careful around dogs, bats, monkeys, sea animals such as jellyfish, and snakes. If you are bitten or scratched by an animal, immediately:

Wash the wound with soap and clean water.
Go to a doctor right away.
Tell your doctor about your injury when you get back to the United States.

Consider buying medical evacuation insurance. Rabies is a deadly disease that must be treated quickly, and treatment may not be available in some countries.

Reduce your exposure to germs

Follow these tips to avoid getting sick or spreading illness to others while traveling:

Wash your hands often, especially before eating.
If soap and water aren’t available, clean hands with hand sanitizer (containing at least 60% alcohol).
Don’t touch your eyes, nose, or mouth. If you need to touch your face, make sure your hands are clean.
Cover your mouth and nose with a tissue or your sleeve (not your hands) when coughing or sneezing.
Try to avoid contact with people who are sick.
If you are sick, stay home or in your hotel room, unless you need medical care.

Avoid sharing body fluids

Diseases can be spread through body fluids, such as saliva, blood, vomit, and semen.

Protect yourself:

Use latex condoms correctly.
Do not inject drugs.
Limit alcohol consumption. People take more risks when intoxicated.
Do not share needles or any devices that can break the skin. That includes needles for tattoos, piercings, and acupuncture.
If you receive medical or dental care, make sure the equipment is disinfected or sanitized.

Know how to get medical care while traveling

Plan for how you will get health care during your trip, should the need arise:

Carry a list of local doctors and hospitals at your destination.
Review your health insurance plan to determine what medical services it would cover during your trip. Consider purchasing travel health and medical evacuation insurance.
Carry a card that identifies, in the local language, your blood type, chronic conditions or serious allergies, and the generic names of any medications you take.
Some prescription drugs may be illegal in other countries. Call India’s embassy to verify that all of your prescription(s) are legal to bring with you.
Bring all the medicines (including over-the-counter medicines) you think you might need during your trip, including extra in case of travel delays. Ask your doctor to help you get prescriptions filled early if you need to.

Many foreign hospitals and clinics are accredited by the Joint Commission International. A list of accredited facilities is available at their website ( www.jointcommissioninternational.org ).

In some countries, medicine (prescription and over-the-counter) may be substandard or counterfeit. Bring the medicines you will need from the United States to avoid having to buy them at your destination.

Malaria is a risk in India. Fill your malaria prescription before you leave and take enough with you for the entire length of your trip. Follow your doctor’s instructions for taking the pills; some need to be started before you leave.

Select safe transportation

Motor vehicle crashes are the #1 killer of healthy US citizens in foreign countries.

In many places cars, buses, large trucks, rickshaws, bikes, people on foot, and even animals share the same lanes of traffic, increasing the risk for crashes.

Be smart when you are traveling on foot.

Use sidewalks and marked crosswalks.
Pay attention to the traffic around you, especially in crowded areas.
Remember, people on foot do not always have the right of way in other countries.

Riding/Driving

Choose a safe vehicle.

Choose official taxis or public transportation, such as trains and buses.
Ride only in cars that have seatbelts.
Avoid overcrowded, overloaded, top-heavy buses and minivans.
Avoid riding on motorcycles or motorbikes, especially motorbike taxis. (Many crashes are caused by inexperienced motorbike drivers.)
Choose newer vehicles—they may have more safety features, such as airbags, and be more reliable.
Choose larger vehicles, which may provide more protection in crashes.

Think about the driver.

Do not drive after drinking alcohol or ride with someone who has been drinking.
Consider hiring a licensed, trained driver familiar with the area.
Arrange payment before departing.

Follow basic safety tips.

Wear a seatbelt at all times.
Sit in the back seat of cars and taxis.
When on motorbikes or bicycles, always wear a helmet. (Bring a helmet from home, if needed.)
Avoid driving at night; street lighting in certain parts of India may be poor.
Do not use a cell phone or text while driving (illegal in many countries).
Travel during daylight hours only, especially in rural areas.
If you choose to drive a vehicle in India, learn the local traffic laws and have the proper paperwork.
Get any driving permits and insurance you may need. Get an International Driving Permit (IDP). Carry the IDP and a US-issued driver's license at all times.
Check with your auto insurance policy's international coverage, and get more coverage if needed. Make sure you have liability insurance.
Avoid using local, unscheduled aircraft.
If possible, fly on larger planes (more than 30 seats); larger airplanes are more likely to have regular safety inspections.
Try to schedule flights during daylight hours and in good weather.

Medical Evacuation Insurance

If you are seriously injured, emergency care may not be available or may not meet US standards. Trauma care centers are uncommon outside urban areas. Having medical evacuation insurance can be helpful for these reasons.

Helpful Resources

Road Safety Overseas (Information from the US Department of State): Includes tips on driving in other countries, International Driving Permits, auto insurance, and other resources.

The Association for International Road Travel has country-specific Road Travel Reports available for most countries for a minimal fee.

Traffic flows on the left side of the road in India.

Always pay close attention to the flow of traffic, especially when crossing the street.
LOOK RIGHT for approaching traffic.

For information traffic safety and road conditions in India, see Travel and Transportation on US Department of State's country-specific information for India .

Maintain personal security

Use the same common sense traveling overseas that you would at home, and always stay alert and aware of your surroundings.

Before you leave

Research your destination(s), including local laws, customs, and culture.
Monitor travel advisories and alerts and read travel tips from the US Department of State.
Enroll in the Smart Traveler Enrollment Program (STEP) .
Leave a copy of your itinerary, contact information, credit cards, and passport with someone at home.
Pack as light as possible, and leave at home any item you could not replace.

While at your destination(s)

Carry contact information for the nearest US embassy or consulate .
Carry a photocopy of your passport and entry stamp; leave the actual passport securely in your hotel.
Follow all local laws and social customs.
Do not wear expensive clothing or jewelry.
Always keep hotel doors locked, and store valuables in secure areas.
If possible, choose hotel rooms between the 2nd and 6th floors.

To call for emergency services while in India, dial 100 or, from a mobile phone, 112. Write these numbers down to carry with you during your trip.

Learn as much as you can about India before you travel there. A good place to start is the country-specific information on India from the US Department of State.

Healthy Travel Packing List

Use the Healthy Travel Packing List for India for a list of health-related items to consider packing for your trip. Talk to your doctor about which items are most important for you.

Why does CDC recommend packing these health-related items?

It’s best to be prepared to prevent and treat common illnesses and injuries. Some supplies and medicines may be difficult to find at your destination, may have different names, or may have different ingredients than what you normally use.

If you are not feeling well after your trip, you may need to see a doctor. If you need help finding a travel medicine specialist, see Find a Clinic . Be sure to tell your doctor about your travel, including where you went and what you did on your trip. Also tell your doctor if you were bitten or scratched by an animal while traveling.

If your doctor prescribed antimalarial medicine for your trip, keep taking the rest of your pills after you return home. If you stop taking your medicine too soon, you could still get sick.

Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the doctor about your travel history.

For more information on what to do if you are sick after your trip, see Getting Sick after Travel .

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COMMENTS

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