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.
Last reviewed:
August 21, 2023
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.
Last reviewed:
August 21, 2023
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.
Last reviewed:
August 21, 2023
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.
Last reviewed:
August 21, 2023
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.
Last reviewed:
August 21, 2023
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.
Last reviewed:
August 21, 2023
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.
Last reviewed:
August 21, 2023
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/healthcare-providers/hcp-vaccine.html.
Last reviewed:
August 21, 2023
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/geographic-distribution/index.html.
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.
Last reviewed:
August 21, 2023
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/healthcare-providers/hcp-vaccine.html.
Last reviewed:
August 21, 2023
