Page 9: Canadian Immunization Guide: Part 3 - Vaccination of Specific Populations

Immunization of Travellers

Please Note: In response to the shortage of the yellow fever vaccine in Canada and globally, the CATMAT Yellow Fever working group has developed the Interim Canadian recommendations for the use of a fractional dose of yellow fever vaccine during a vaccine shortage.

Travel Health Information

Immunization to protect travellers can be life-saving and is a cornerstone of travel health protection. Other protective measures, such as sanitation and hygiene, food precautions, insect or animal bite prevention, and injury prevention, are also essential for health protection while travelling and are complementary to immunization. An understanding of the personal protective measures recommended for travellers is an integral part of travel preparation; refer to the Committee to Advise on Tropical Medicine and Travel (CATMAT) website for additional information.

Travellers can be exposed to different health risks abroad than they are at home. Information about immunization requirements and recommendations related to travel is available from travel health clinics or public health agencies. Extensive information regarding travel-related diseases and immunization of travellers is available from the Government of Canada's Travelling Abroad webpage. Additional information is available from the Centers for Disease Control and Prevention (CDC) in the United States and the World Health Organization (WHO).

This chapter update was conducted in collaboration with the Committee to Advise on Tropical Medicine and Travel (CATMAT). Recommendations relating to travel vaccines are based CATMAT Statements and Recommendations.

Immunization of Travellers

Travellers, in particular those travelling to countries with health risks that are greater than in Canada, should seek medical advice pre-departure. Pre-travel consultation affords an opportunity for health care providers to review the traveller's itinerary and to develop appropriate health protection recommendations. It also allows for the review of preventive measures for travel-related illnesses and is an opportunity to assess the overall immunization status of travellers. Unimmunized or incompletely immunized travellers should be offered vaccination as recommended in the routine immunization schedules (refer to Recommended Immunization Schedules in Part 1). A health care provider or travel health clinic should be consulted as early as possible, ideally at least 4 to 6 weeks in advance of travel, to provide sufficient time for completion of optimal immunization schedules. Even if a traveller is departing at short notice, a pre-travel consultation is recommended. In cases where there is insufficient time for the optimal immunization schedule, refer to the vaccine-specific chapters in Part 4 for the suggested rapid or accelerated schedule.

The immunizations recommended for travellers vary according to the: traveller's age, immunization history, and existing medical conditions; destination(s); planned activities; duration and nature of travel (for example, staying in urban hotels vs. visiting remote rural areas); legal requirements for entry into countries being visited; travellers' own concerns and preferences and the amount of time available before departure. Immunizations related to travel can be categorized as those that are considered routine (part of the recommended primary series of immunizations or routine booster doses); those required by international law; and those recommended for maintenance of health while travelling.

Refer to Immunization of Workers in Part 3 for additional information about immunization of travellers planning to work abroad in occupations with increased risk of exposure to vaccine preventable diseases (for example, humanitarian relief or refugee workers, health care workers). Refer to Immunization of Persons New to Canada for additional information about immunization of family members travelling outside of Canada to adopt a child.

Routine Immunizations

Unimmunized or incompletely immunized travellers should receive routine immunizations as appropriate for age and individual risk factors. Travellers may require additional doses or booster doses of routine immunizations, or a change in the routine immunization schedule. Refer to Recommended Immunization Schedules in Part 1 for a summary of the recommended immunization schedules for infants, children and adults. Recommendations for modification of the routine immunization schedule in relation to travel follow.

Accelerated primary vaccination schedule - infants

For infants who will be travelling, the primary vaccination series with diphtheria, tetanus, acellular pertussis, inactivated polio, Haemophilus influenzae type b, with or without hepatitis B (DTaP-IPV-Hib or DTaP-HB-IPV-Hib) vaccine and pneumococcal conjugate vaccine may be started at 6 weeks of age. Rotavirus vaccine may be given at 6 weeks of age concomitantly with these vaccines. The first dose of measles-mumps-rubella (MMR) vaccine should be given at an earlier age than usual for children travelling to countries outside of North America, or to regions in North America with ongoing outbreaks of measles (refer to Measles Vaccine in Part 4). Refer to vaccine-specific chapters in Part 4 and Timing of Vaccine Administration in Part 1 for additional information including the minimum interval between vaccine doses to achieve maximum vaccination protection prior to travel. Refer to the CATMAT Statement on International Travellers Who Intend to Visit Friends and Relatives for additional information on accelerated pediatric vaccine schedules.

Hepatitis B vaccine

Travel is a good opportunity to offer hepatitis B (HB) immunization to children and adults who have not been previously vaccinated. HB vaccine should be particularly recommended to travellers who will be residing in areas with high levels of HB endemicity or working in health care facilities, and those likely to have contact with blood or to have sexual contact with residents of such areas. HB immunization is recommended for children who will live in an area where HB is endemic. HB is endemic in the Far East, the Middle East, Africa, South America, Eastern Europe and Central Asia. Refer to a WHO map of countries and areas of risk for HB for additional information. Refer to Hepatitis B Vaccine in Part 4 and to the CATMAT Summary of Recommendations for the Prevention of Viral Hepatitis During Travel for additional information.

Concomitant immunization with hepatitis A (HA) and HB vaccines is recommended as HA vaccination is also indicated for travellers to endemic countries. For those who are susceptible to both HA and HB virus, a combined HAHB vaccine can be used. For travellers presenting less than 21 days before departure, monovalent HA and HB vaccines should be administered separately, with the completion of both vaccine series as recommended. Refer to Hepatitis A Vaccine in Part 4 for additional information.

Measles, mumps and rubella vaccine

Measles, mumps and rubella are endemic in many countries and therefore protection against these diseases is especially important for travellers.

Travellers born in or after 1970, who do not have documented evidence of receiving 2 doses of MMR vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed measles disease, should be vaccinated accordingly so that they have received 2 doses of MMR vaccine. MMR vaccine may be given as early as 6 months of age; however, 2 additional doses of measles-containing vaccine must be administered after the child is 12 months old to ensure long lasting immunity to measles.

Travellers born before 1970, who do not have documented evidence of receiving MMR vaccine on or after their first birthday, or laboratory evidence of immunity, or a history of laboratory confirmed measles or mumps disease, should receive 1 dose of MMR vaccine.

Refer to Measles Vaccine, Mumps Vaccine and Rubella Vaccine in Part 4 for additional information.

Varicella vaccine

It is important that people travelling or living abroad be immune to varicella. In tropical climates, varicella tends to occur at older ages and at any time of the year. Adolescent and adult immigrants born in tropical countries, therefore, are more likely to be susceptible to varicella as compared to the Canadian population.

Two doses of univalent varicella (chickenpox) vaccine or measles-mumps-rubella-varicella (MMRV) vaccine are recommended for immunization of healthy children aged 12 months to 12 years of age. Two doses of univalent varicella vaccine are recommended for susceptible adolescents (13 to 17 years of age) and susceptible adults (18 to 49 years of age). In the rare circumstance that an adult aged 50 years or older is known to be serologically susceptible to varicella, based on previous testing for another reason, and is without contraindications, the individual should be vaccinated with two doses of univalent varicella vaccine. For the prevention of shingles (reactivated varicella infection) the herpes zoster (shingles) vaccine is recommended for adults without contraindications if they are 60 years of age and older. Refer to Varicella (Chickenpox) Vaccine and Herpes Zoster (Shingles) Vaccine in Part 4 for additional information.

Pertussis vaccine - adults

For pertussis prevention, acellular pertussis-containing vaccine (tetanus, reduced diphtheria, reduced acellular pertussis [Tdap]) is recommended for adults who have not previously received a dose in adulthood, regardless of the interval from the last dose of tetanus and diphtheria toxoid-containing vaccine. The pre-travel consultation is an opportunity to give the adult booster to those who may not otherwise seek immunization from a vaccine provider. Refer to Pertussis Vaccine in Part 4 for additional information.

Poliomyelitis vaccine - adults

Adults travelling to areas where poliovirus is known or suspected to be circulating should be vaccinated with IPV-containing vaccine. Previously unvaccinated adults should receive 3 doses of IPV-containing vaccine; for adults previously immunized against polio, a single lifetime booster of IPV-containing vaccine is recommended. Refer to Poliomyelitis Vaccine in Part 4 for additional information.

Polio remains endemic in Afghanistan, Nigeria and Pakistan. Additional countries may be affected by outbreaks of imported wild poliovirus or circulating vaccine-derived poliovirus. Refer to the WHO Global Polio Eradication Initiative for up-to-date information about the current status of polio around the world, including any Temporary Recommendations which may require proof of polio vaccination for travellers entering affected countries.

Tetanus and diphtheria vaccine - adults

Travel is a good opportunity to provide tetanus and diphtheria immunization to adults who have not been previously vaccinated. A 3 dose primary series should be given to unimmunized adults; the first dose should contain acellular pertussis vaccine. For immunization of adults that have not been immunized against polio, all doses should contain polio vaccine. Previously immunized adult travellers should receive a booster dose of tetanus and diphtheria toxoid-containing vaccine every 10 years. Refer to Tetanus Toxoid and Diphtheria Toxoid in Part 4 for additional information.

Tetanus occurs worldwide and diphtheria is endemic throughout many regions of the world.

Required Immunizations

The following immunizations may be a requirement of international law or proof of immunization may be considered a visa requirement:

Meningococcal vaccine

As a condition of entry, Saudi Arabia requires proof of meningococcal immunization for travellers arriving for the purpose of Umrah or pilgrimage (Hajj) and for seasonal workers. Adults and children aged over 2 years must receive 1 dose of the quadrivalent (ACYW-135) meningococcal vaccine and show proof of vaccination on a valid International Certificate of Vaccination or Prophylaxis. Vaccination is to be administered no less than 10 days before arrival in Saudi Arabia.

Visit the Saudi Arabia Ministry of Health website for vaccination requirements.

Yellow fever vaccine

Yellow fever (YF) vaccine is unique amongst travel vaccines in that its use is governed by the International Health Regulations. Yellow fever immunization, documented by an International Certificate of Vaccination or Prophylaxis, is required to enter certain countries. The WHO publishes a list of yellow fever certificate requirements and recommendations. This country list is updated annually and can be found on the WHO International Travel and Health website.

YF vaccine is recommended for travellers to yellow fever risk areas in Africa and Central and South America. The decision to immunize a traveller against YF should take into account the traveller's itinerary and the associated risk for exposure to YF virus, the requirements of the country to be visited (including stopovers and airport transit), and individual risk factors for serious adverse events following vaccination.

The International Certificate of Vaccination or Prophylaxis is valid beginning 10 days after primary immunization. An important amendment was made in May 2014 to Annex 7 of the International Health Regulations (2005) which extended the validity of the International Certificate of Vaccination or Prophylaxis against yellow fever from 10 years to lifetime. This requirement came into force on 11 July 2016. The status of YF vaccination requirements is published in the WHO country list as stated above.

Travellers requiring the certificate but in whom the YF vaccine is medically contraindicated can be provided with an International Certificate of Medical Contraindication to Vaccination by a Yellow Fever Vaccination Centre following an individual risk assessment. Travellers without a valid International Certificate of Vaccination or Prophylaxis or an International Certificate of Medical Contraindication to Vaccination may be denied entry into a country requiring such documentation, may be quarantined, or may be offered immunization at the point of entry (for example, at the airport), potentially putting the health of the traveller at risk. Although usually accepted, the International Health Regulations do not compel any country to accept an International Certificate of Medical Contraindication to Vaccination.

In Canada, Yellow Fever Vaccination Centre clinics are designated by the Public Health Agency of Canada (or in the case of the Canadian Forces, by the Directorate of Force Health Protection) to provide the International Certificate of Vaccination or Prophylaxis, or the International Certificate of Medical Contraindication to Vaccination. Refer to the list of designated Yellow Fever Vaccination Centres in Canada.

Refer to Yellow Fever Vaccine in Part 4 and the CATMAT Statement for Travellers and Yellow Fever for additional information.

Recommended Immunizations

Based on a risk assessment of the travel itinerary, the nature of travel, and the traveller's underlying health, the following vaccines should be considered (also refer to Yellow Fever vaccine):

Hepatitis A vaccine

Protection against HA is recommended for all travellers to endemic countries, especially if they are travelling to rural areas or places with inadequate sanitary facilities. Hepatitis A is one of the most common vaccine preventable diseases in travellers. Hepatitis A containing vaccine is the preferred agent for pre-exposure prophylaxis of travellers 6 months of age and older. For pre-exposure prophylaxis of infants less than 6 months of age, immunocompromised persons, and people for whom HA vaccine is contraindicated, human immune globulin (Ig) may be indicated. Refer to Hepatitis A Vaccine in Part 4 for additional information. Refer to the CATMAT Summary of Recommendations for the Prevention of Viral Hepatitis During Travel for additional information on rapid dosing schedules.

Refer to a WHO map of countries or areas at risk for hepatitis A.

Influenza vaccine

All travellers are encouraged to receive influenza vaccine. Influenza occurs year-round in the tropics, while in temperate northern and southern countries, influenza activity peaks generally during the winter season (November to March in the Northern Hemisphere and April to October in the Southern Hemisphere). Vaccines prepared specifically for use in the Southern Hemisphere are not available in Canada, and the extent to which the recommended vaccine components for the Southern Hemisphere may overlap with those in available Canadian formulations will vary. Refer to Influenza Vaccine in Part 4 for additional information.

Japanese encephalitis vaccine

Japanese encephalitis (JE) vaccine is recommended for adult travellers with a high exposure risk going to JE endemic or epidemic areas during the transmission season. The risk for acquiring JE is low for most travellers, particularly for short-term visitors to major urban areas, because the mosquito vector for JE and its animal reservoir(s) are primarily found in rural agricultural areas. Japanese encephalitis occurs in many areas of Asia, especially in the south east and in parts of the western Pacific, and is the leading cause of viral encephalitis in Asia. Refer to Japanese Encephalitis Vaccine in Part 4 for additional information.

Refer to the WHO  map of the countries or areas at risk for JE.

Meningococcal vaccine

Travellers to destinations where risk of meningococcal transmission is high should be vaccinated with a meningococcal conjugate quadrivalent vaccine (Men-C-ACYW), multicomponent meningococcal vaccine (4CMenB), or both vaccines, depending on the risk of meningococcal disease in the area of travel.

Refer to Meningococcal above for information about the requirement for meningococcal vaccination as a condition to entry for certain travellers to Saudi Arabia. Refer to Meningococcal Vaccine in Part 4 for additional information.

Invasive meningococcal disease occurs sporadically worldwide and in focal epidemics. The traditional endemic areas of the world include the savannah areas of sub-Saharan Africa, extending from Gambia and Senegal in the west to Ethiopia and Western Eritrea in the east. Meningococcal disease is also associated with the Hajj, an Islamic pilgrimage to Mecca, Saudi Arabia. Refer to the CATMAT Statement on Meningococcal Disease and the International Traveller for additional information. Refer to the WHO meningococcal disease outbreak website for updates.

Rabies vaccine

Travellers to rabies endemic areas where there is poor or unknown access to adequate and safe post-exposure management, as well as frequent and long-term travellers to high-risk areas should be considered for pre-exposure rabies immunization. Children, especially those who are too young to understand either the need to avoid animals or to report a traumatic animal contact, should receive pre-exposure immunization when travelling to endemic areas.

Pre-exposure rabies vaccination obviates the requirement for rabies immune globulin if rabies exposure occurs, which may be unsafe or unavailable in many countries with high rabies risk. Refer to Rabies Vaccine in Part 4 for additional information including post-exposure prophylaxis.

Public health officials should be consulted regarding travellers who have had an exposure to a potentially rabid animal in a low resource country, even if the traveller has received a complete course of post-exposure prophylaxis in that country. The prevalence of rabies in low resource countries is often much higher than in Canada and there may be concerns about the efficacy of available vaccines in these countries.

To identify high-risk areas, refer to the WHO map of areas at risk for rabies transmission.

Typhoid vaccine

Travellers to South Asia (including Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka) 2 years of age and older should be offered typhoid vaccine.

Typhoid immunization is not routinely recommended for travel outside of South Asia, although, it might be considered for travellers to other areas, such as Africa. The decision of whether a traveller should be immunized when travelling to destinations other than South Asia should be carefully balanced against the presence of other factors that may increase the risk of travel-associated typhoid, such as visiting residents of the country in their homes, or longer duration of travel which may prolong exposure to potentially contaminated food and water. Immunization is not routinely recommended for short-term holidays in resort hotels.

Refer to CATMAT Statement on International Travellers and Typhoid and Typhoid Vaccine in Part 4 for additional information.

Bacille Calmette-Guérin (BCG) vaccine

In exceptional circumstances, immunization with BCG vaccine may be considered for travellers planning extended stays in areas or countries of high tuberculosis prevalence. Consultation with an infectious disease or travel medicine specialist is recommended. Refer to Bacille Calmette-Guérin Vaccine in Part 4, the CATMAT Statement on Risk Assessment and Prevention of Tuberculosis among Travellers and the Canadian TB Standards (Chapter 16) for additional information.

Cholera and travellers' diarrhea vaccine

Travellers to cholera-endemic countries who may be at significantly increased risk of exposure, for example, humanitarian workers or health care providers working in endemic countries, may benefit from cholera vaccination. Most travellers following the usual tourist itineraries in countries affected by cholera are at extremely low risk of acquiring cholera infection. For protection against travellers' diarrhea, vaccination with cholera and travellers' diarrhea vaccine is of limited benefit and is not routinely recommended, except for high-risk travellers who are 2 years of age and older.

Refer to Cholera and Enterotoxigenic Escherichia coli (ETEC) Diarrhea Vaccine in Part 4 and the CATMAT Statement on Traveller's Diarrhea for additional information. Refer to the WHO map of the areas reporting cholera outbreaks.

Immunocompromised Travellers

For information about immunization of travellers who are immunocompromised refer to Immunization of Immunocompromised Persons in Part 3, vaccine-specific chapters in Part 4, and the CATMAT Statement on the Immunocompromised Traveller.

Pregnant and Breastfeeding Travellers

For information about immunization of pregnant or breastfeeding travellers refer to Immunization in Pregnancy and Breastfeeding in Part 3, vaccine-specific chapters in Part 4, and the CATMAT Statement on Pregnancy and Travel.

Older Travellers

In older adults, both vaccine efficacy and the risk of adverse reactions may be affected by age. Declining cell-mediated and humoral immunity influence the response to immunization, potentially resulting in diminished, delayed, and less durable immune responses and greater susceptibility to adverse effects of some vaccines, especially yellow fever. Older adults may also be more vulnerable to disease and complications for some vaccine preventable illnesses, such as hepatitis A, typhoid fever, and yellow fever. For additional information refer to the CATMAT Statement on Older Travellers.

Pediatric Travellers

Travel immunization recommendations for children will vary with the individual risk of exposure and the severity of potential infection. Some travel-related infections, such as hepatitis A, typhoid, and rabies, are more likely to occur in pediatric travellers than in adult travellers. Children are at higher risk for meningococcal infections. For additional information regarding immunization of pediatric travelers, refer to the CATMAT Statement on Pediatric Travellers.

Travellers Who Visit Friends and Relatives

Those who travel with the intention of visiting friends and relatives or other residents of the country in their homes are at increased risk of travel-related infections. Adults, and particularly children, are at greater risk due to both demographic and travel-related characteristics such as travelling for longer periods, travelling to rural areas, travelling to destinations with higher risk for tropical diseases, and are less likely to seek pre-travel health advice. Refer to the CATMAT Statement on International Travellers Who Visit Friends and Relatives for additional information.

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