Last Updated: 04/12/2018
Vaccinations, risk of travel-related infection and IBD
This information is to give you an overview of vaccinations in relation to inflammatory bowel disease and is not intended to replace the individual and comprehensive information that your travel clinic can provide.
Vaccination is a highly effective method of preventing certain travel-related infectious diseases but there is no single vaccination schedule that fits all travellers. This will vary according to your current medication, previous immunisations, countries to be visited, and type /duration of travel1
You should visit a travel clinic 8 weeks before your intended departure to get information regarding the risk of disease in the country or countries you plan to visit and the steps to be taken to prevent illness. Various travel clinics, such as Nomad Travel http://www.nomadtravel.co.uk/travel-vaccination-information offer expert advice to help with planning your trip and ensuring your safety whilst abroad.
Does having IBD make my immune system weaker?
No, having Crohn’s disease or ulcerative colitis does not make your immune system weaker (immunocompromised) but the medication you take to treat the IBD may do.3 This is not something that should prevent you from traveling or doing normal day-to-day things. People taking medication that weaken the immune system will always be closly monitored by the their IBD team and have regular blood tests to check for side-effects.
What is does immunocompromised mean?
The term immunocompromised means that your immune system has been weakened, making you more prone to picking up opportunistic infections. This means catching infections that you would perhaps normally not be at risk of when not taking this sort of medication.
You may be at risk of catching travel-associated diseases when you are taking certain medications (called Immunomodulators) that reduce your immune system, therefore immunisation against these is recommended3
IBD should not restrict foreign travel but avoiding travel to areas where certian infectious diseases are common may reduce your risk of infection if you are taking immunomodulator medication3
What are immunosuppressant / immunomodulator medications?
These are medications commonly used to treat crohn’s disease and ulcerative colitis that suppress the immune system.
These medications include:
(Please note the medications listed below are given as UK names- if you have been prescribed medication from another country this may be called something different):
- Corticosteroids* – Prednisolone, budesonide, hydrocortisone
- Azathioprine (immuran) / mercaptopurine (puri-nethol)
- Ciclosporin and tacrolimus
- Anti-TNF drugs: Remicade (infliximab); Adalimumab (humira)
* Total daily dose equivalent to ≥20 mg of prednisolone for ≥2 weeks3
If you are taking any of these medications and travel around the world frequently or plan to travel to a developing country then you should seek advice from your IBD specialist or travel clinic
Vaccinations- Things to consider11
There are several things to consider when planning your travel vaccinations, including:
- the country or countries you are visiting – some diseases are more common in certain parts of the world and less common in others
- when you are travelling – some diseases are more common at certain times of the year, for example during the rainy season
- where you are staying – in general, you will be more at risk of disease in rural areas than in urban areas, and if you are backpacking and staying in hostels or camping, you may be more at risk than if you were on a package holiday and staying in a hotel
- how long you will be staying – the longer your stay, the greater your risk of being exposed to diseases
- your age and health – some people may be more vulnerable to infection than others, while some vaccinations cannot be given to people with certain medical conditions
- what you will be doing during your stay – for example, whether you will be spending a lot of time outdoors, such as trekking or working in rural areas
- if you are working as an aid worker – you may come into contact with more diseases if you are working in a refugee camp or helping after a natural disaster
- if you are working in a medical setting – for example, a doctor or nurse may require additional vaccinations
- if you are in contact with animals – in this case, you may be more at risk of getting diseases that are spread by animals, such as rabies
If possible, see your GP or travel clinic at least eight weeks before you are due to travel, because some vaccinations need to be given well in advance to allow your body to develop immunity and some involve multiple doses spread over several weeks.
Types of Vaccinations
Vaccinations are available as either live (also called attenuated) or inactive2,4
- If you are taking immunomodulators you should not have ‘live’ vaccinations
- You should wait at least 3 weeks from the last immunisation with a live vaccine before you start immunomodulator treatment3. This should be discussed with with your IBD team.
If your IBD team have discussed that you may be starting immunosuppressive treatment then you should see your GP / travel clinic and get an update/ booster of all your vaccinations before you start treatment3.
Live vaccines- contain a version of the living bacteria that has been weakened in the lab so it can’t cause disease. They “teach” the immune system and give a strong antibody response.
People with weakened immune systems, such as those on immunosuppressive medication, cannot have live vaccines.
Inactive vaccines- The disease-causing bacteria has been killed in a lab and are safe to use in people with weakened immune systems.
Table showing Live (attenuated) vaccinations12
|Measles, mumps and rubella (MMR)|
|Chickenpox/ Shingles (Herpes Zoster)|
|Cholera (oral version also available as inactive)|
|Oral Typhoid (injectable version is inactive)|
|BCG (Tuberculosis Vaccination)|
|Flumist Influenza vaccine (nasal spray only)|
|Rotavirus (used in infants only)|
What do I do if I need a live vaccine but am already taking immunosuppressant medication?
Recently published International guidelines3 suggest that you can have live vaccines 3–6 months after stopping immunomodulator therapy. You should to seek advice from your IBD team and travel clinic regarding the medication you are taking and whether it is advised to stop your current treatment.
If you are unable to stop your medication but you have to have a live vaccine such as yellow fever (see below), a healthcare professional can write you a letter of exeption that can be used when entering the country that requires vaccination (Kenya is a common destination that requires this). A template for this letter can be found in a official International Certificate of Vaccination or Prophylaxis document available from travel clinics or GP surgeries.
How long should I wait before having a live vaccine and starting immunomodulator treatment?
You should wait at least 3 weeks from the last immunisation with a live vaccine before you start immunomodulator treatment.3 The exact timing of this should be discussed with your IBD team.
Never stop your medication without discussing this with your IBD team
The table below shows vaccinations that you may require1,5.
This is separated into:
- Routine vaccines (used in most UK routine programmes, particularly in children)
- Recommended vaccines (before travelling to particular countries or areas)
- Required vaccines (by the International Health Regulations for travel to certain countries)
Please note this list is taken from the World health organisation website1 and therefore may differ depending on each countries immunisation programme.
Always check with your GP/ local travel clinic.
Table of Vaccinations1,5
|Routine Vaccinations||Recommended vaccinations||Required vaccines|
|Diphtheria, tetanus, and pertussis
Hepatitis B (Hep B)
Haemophilus influenzae type b
Human papilloma virus
Measles, mumps, and rubella
For country specific vaccination advice, please see the interactive world map
Malaria is an infection of the red blood cells that is transmitted by mosquitoes. Exposure to malaria depends on the country visited, climate, season and altitude.
Bite prevention is the best way to avoid contracting malaria. Measures to prevent mosquito bites include:
- Use a repellent with 50% DEET. As a guide, duration of protection is 1 to 3 hours for 20%, up to 6 hours for 30% and up to 12 hours for 50% DEET. When both sunscreen and DEET are required, DEET should be applied afterwards as it reduces the efficacy of sunscreen, however sunscreens do not reduce the effectiveness of DEET
- Use a net if sleeping outdoors or in unscreened accommodation, insecticide-treated mosquito nets should ideally be used. Protective efficacy of nets against malaria for travellers has been estimated at 50%.6
- Wear protective clothing. Within the limits of practicality, cover up with loose-fitting clothing, long sleeves, long trousers and socks if outdoors after sunset, to minimise accessibility to skin for biting mosquitoes.
- Air conditioning and ceiling fans cool the room temperature and therefore reduce the likelihood of mosquito bites.
- Doors & windows should be screened with fine mesh netting which must be close-fitting and free from rips or tears.
Spray the room before dusk with insecticide to kill any mosquitoes which may have entered the accommodation during the day. Where electricity is available, use a heated liquid reservoir mosquito repellent device or coil containing insecticide.
Symptoms of Malaria7
The symptoms of malaria can develop 7-18 days after being bitten.
The initial symptoms of malaria can often be mild and difficult to identify and include:
- A high temperature (fever)
- Headache, sweats
- Chills and vomiting
- Muscle Pain
There are numerous types of medication for malaria chemoprophylaxis. The type you need will depend on the area you plan to visit. You should discuss this in detail with your GP or travel clinic and ensure that they are aware of your IBD and any other medication you are taking.
Anti-malarial medication’s Daraprim and Vibramycin (Doxycycline) may interact with methotrexate and cause increased toxicity.9,10
Consult your travel clinic if you are taking methotrexate and plan to travel to a high-risk malaria country.
Anti-malarial medication side-effects can include gastrointestinal upset and make you sensitive to the sun (photosensitive). It is important to use a high factor UVA/UVB sunscreen.
It is very important that you take the correct dose and that you finish the course of anti-malarial treatment. If you are unsure, check with your GP or pharmacist how long you should take your medication for.
People with IBD who plan extended trips such as a gap year, stay in cheap accommodation, or engage in welfare projects during the trip might put them at higher risk of some diseases such as Tuberculosis.
If you have IBD and are traveling for more than a month to a moderate/ high endemic area (see below) you should discuss screening for latent tuberculosis with your IBD team or GP. If the test is negative, the screening test should be repeated approximately 8–10 weeks after returning3
Areas that are considered to be moderately/highly endemic for tuberculosis include:
- Most of Africa
- Central America
- Parts of South America
- South and South east Asia
- Middle East
- Former states of the Soviet Union
Yellow fever virus is found in tropical and subtropical areas in South America and Africa. The virus is transmitted to humans by the bite of an infected mosquito7.
Yellow fever vaccination is required for travel to certain areas and you may not be allowed entry into that country without proof of vaccination (A vaccination certificate).
Certain countries will also require you to hold a proof of vaccination certificate if you are arriving from a country with a risk of yellow fever transmission.8 If you have a contraindication to having yellow fever vaccination this can be documented the certificate.
A detailed list of yellow fever risk areas and countries that require a vaccination certificate can be found on the following World Health organisation page http://www.who.int/ith/ITH_Annex_I.pdf?ua=1
Further information regarding Yellow Fever can be found on the World Health Organisation website http://www.who.int/mediacentre/factsheets/fs100/en/
Sources of information
- World health organisation http://www.who.int/ith/vaccines/en/
- National institute of allergy and infectious disease http://www.niaid.nih.gov/topics/vaccines/understanding/Pages/typesVaccines.aspx
- Rahier JF, et al, Second European evidence-based consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease, J Crohns Colitis (2014), http://dx.doi.org/10.1016/j.crohns.2013.12.013
- Viget N et al (2008) Opportunistic infections in patients with inflammatory bowel disease: prevention and diagnosis. Gut, 57, 549-558
- The Department of Health. Greenbook: immunisation against infectious disease. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/147827/Green-Book-Chapter-7.pdf
- The Health protection agency (2013). Guidelines for Malaria prevention for travellers from the UK. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1203496943523
- NHS choices. Symptoms of Malaria http://www.nhs.uk/Conditions/Malaria/Pages/Symptoms.aspx
- World Health Organisation Yellow fever fact sheet http://www.who.int/mediacentre/factsheets/fs100/en/
- Electronic medicines compendium Daraprim summary product characteristics information. http://www.medicines.org.uk/emc/medicine/729 last accessed 10/10/2014.
- Electronic medicines compendium Vibramycin (Doxycycline) summary product characteristics informatiom. http://www.medicines.org.uk/emc/medicine/20879. Accessed 10/10/2014.
- NHS Choices. Travel Immunisations http://www.nhs.uk/Conditions/Travel-immunisation/Pages/Introduction.aspx Accessed 10/7/2015
- Center for Disease Control and Prevention Epidemiology and Prevention of Vaccine-Preventable Diseases, 13th Edition http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/us-vaccines.pdf Accessed online 10/7/2015