Update on Rabies, TBE, and Cholera Vaccines Before Travel

Healthcare providers should be aware of important updates to vaccine recommendations that could affect patients preparing to travel internationally this summer. This includes information about:

New rabies pre-exposure prophylaxis guidelines (PrEP);
The new tick-borne encephalitis (TBE) vaccine; and
Updated cholera vaccine recommendations and a restart of Vaxchora manufacturing and distribution.

Rabies

Background

International travelers are the largest group for whom the Advisory Committee on Immunization Practices (ACIP) recommends rabies pre-exposure prophylaxis (PrEP). International travelers may be at risk for contact with rabies virus when traveling to areas where rabies is common in dogs. In the past, at-risk travelers may not have been able to get PrEP as recommended because rabies PrEP consisted of a three-dose vaccine series — typically with high out-of-pocket costs — that required at least 21 days to complete. The new PrEP schedule is shorter, and for that reason, less expensive. There are also more options for maintaining long-term protection which might allow more people at risk to be vaccinated.

What's new?

In May 2022, ACIP updated rabies PrEP recommendations based on newly published data. Consistent with recent changes to the World Health Organization guidance, a two-dose rabies PrEP schedule (days 0 and 7) replaced the previous three-dose series. For travelers with only short-term (≤ 3 years) risk for rabies who complete the two-dose series, no additional titers or booster doses are needed. However, for travelers who could be at longer-term risk (> 3 years) for rabies, one of the additional steps below is needed to maintain protection beyond 3 years:

Healthcare providers should check a one-time rabies antibody titer during years 1-3 after the two-dose series (and provide a booster dose if the titer is <0.5 IU/mL); or
Healthcare providers should preemptively administer a one-time booster dose 21 days to 3 years after completing the two-dose series.

Some patients may prefer the first option because it could save money. Others may prefer the second option because it may save them time to get the booster regardless of the results of the titer check. By providing options, the revised recommendations allow more flexibility in the administration of PrEP, which will make it easier to ensure that at-risk international travelers are protected against rabies.

People who have already received the previous three-dose series do not need the one-time titer check or booster dose recommended above. While rabies PrEP is recommended only for a small subset of international travelers, it can be a vital part of travel preparation for travelers who are at risk of exposure. Providers should encourage at-risk international travelers to receive PrEP when indicated, and follow additional precautions outlined in the new recommendations for travelers with weakened immune systems. Even if travelers receive PrEP, they should still take steps to protect against rabies while traveling, such as avoiding unnecessary contact with wild animals, dogs, and other domestic and wild animals that can carry rabies.

For additional information:

Latest Guidance on Rabies Pre-exposure Prophylaxis

General Rabies Pre-exposure Prophylaxis Information

Rabies Status: Assessment by Country | CDC

Rabies | Information for Travelers | CDC

Rabies – Chapter 4 – 2020 Yellow Book | Travelers' Health | CDC

Rabies and Travel Information

Tick-borne Encephalitis

Background

Tick-borne encephalitis (TBE) is a rare but potentially severe disease found in parts of Europe and Asia that is most commonly transmitted through tick bites. Risk for TBE is very low for most travelers. However, those planning on visiting areas endemic for TBE and taking part in outdoor activities that will expose them to ticks (eg, hiking, camping, hunting, birdwatching) might be at increased risk. The main way to prevent TBE is avoiding tick bites (eg, using insect repellent, treating clothing and gear with products containing 0.5% permethrin, and inspecting for ticks during and after outdoor activities).

What's new

In February 2022, ACIP approved recommendations for use of TBE vaccine among travelers visiting countries where TBE is endemic. The TBE vaccine has been available in Europe for more than 20 years but never previously in the United States. The vaccine can be given to adults and children 1 year and older as a three-dose series. Healthcare providers should closely review and follow the administration instructions in the package insert, which differ for recipients aged 1-15 years vs those aged ≥ 16 years.

When talking to patients, you should discuss:

Where and when they will be traveling
What activities they are planning
The rare occurrence of TBE but the potential for severe outcomes from disease
Vaccine dosage, cost, and possible side effects
Ways to avoid tick bites

TBE vaccine is recommended for those who will have extensive exposure to ticks in TBE-endemic areas. It may be considered for those with less exposure, with the decision to vaccinate based on various factors (eg, having risk factors for a poorer medical outcome, personal perception, and tolerance of risk).

For additional information:

CDC has recently revamped its TBE website where you can find further information on risk factors for infection, countries with TBE risk, a vaccination decision tree, and the TBE vaccine schedule. Take a look now to familiarize yourself with the new recommendations and ways all travelers can prevent tick bites.

Additional information, specifically for travelers, is available on CDC's Travelers' Health website.

Cholera

Background

Cholera is an acute watery diarrheal illness that can be severe and rapidly fatal without proper treatment. Most US cholera cases are associated with travel to cholera-endemic countries. Lyophilized CVD 103-HgR (Vaxchora), a single-dose, live attenuated oral cholera vaccine derived from Vibrio cholerae O1, is the only cholera vaccine licensed for use in the United States. In June 2016, ACIP recommended lyophilized CVD 103-HgR for adults aged 18-64 years traveling to an area with active cholera transmission. CDC maintains an up-to-date list of countries considered to have areas of active cholera transmission. Cholera vaccine recommendations are also available on CDC's country-specific destination pages.

What's new

In February 2022, ACIP extended the recommendation of CVD 103-HgR for children and adolescents aged 2-17 years traveling to an area with active cholera transmission. Distribution of CVD 103-HgR has been temporarily discontinued due to the COVID-19 pandemic and is expected to resume later in 2022. Healthcare providers should closely review and follow the administration instructions in the package insert, which differ for recipients aged 2-5 years vs those aged 6-64 years.

For additional information:

Cholera: Vibrio cholerae infection

Travelers' Health: Cholera

Vaxchora (Cholera Vaccine Live Oral)

Cholera ACIP Vaccine Recommendations

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