What immunizations are recommended for a 45-year-old female with rheumatoid arthritis (RA) traveling to Costa Rica and Panama?

Immunizations for Travel to Costa Rica & Panama in a 45-Year-Old Female with Rheumatoid Arthritis

For travel to Costa Rica and Panama, this patient should receive hepatitis A (with an extra priming dose if departure is imminent), typhoid, and ensure routine vaccinations are current, while avoiding live vaccines if she is on immunosuppressive therapy.

Critical Timing Consideration

• Start vaccinations 4-6 weeks before departure to ensure adequate immunity development 1
• If this patient is on immunosuppressive medications (DMARDs, biologics, or corticosteroids), she requires special vaccination timing considerations 2

Essential Travel-Specific Vaccines for Central America

Hepatitis A (Highest Priority)

• Hepatitis A vaccination is strongly recommended for travelers to Costa Rica and Panama due to foodborne and waterborne exposure risk 2, 1
• Critical caveat for RA patients on immunosuppression: A single dose does NOT provide adequate protection 2
• Give two doses of hepatitis A vaccine - either as a double dose or four weeks apart, followed by a booster at 6 months 2, 3
• If departure is imminent and she cannot receive two doses pre-travel, consider passive immunization with hepatitis A immunoglobulin 2
• Post-vaccination antibody titers should be checked to confirm seroconversion 2

Typhoid Fever

• Typhoid vaccination is recommended for travelers to Central America, especially those visiting smaller cities, rural areas, or consuming food from local markets 1, 4
• Use the inactivated (injectable) typhoid vaccine if she is immunosuppressed, NOT the oral live vaccine 2

Routine Vaccinations to Update

Tetanus-Diphtheria-Pertussis (Tdap)

• Update Tdap before travel 1
• RA patients show satisfactory immunogenicity to tetanus vaccination even on immunosuppressive drugs 2

Influenza

• Annual influenza vaccination is strongly recommended regardless of immunosuppressive therapy 2, 5
• For patients on immunosuppressive medications, high-dose or adjuvanted influenza vaccine is preferred over standard-dose 2
• If high-dose/adjuvanted vaccine is unavailable, give standard-dose rather than delaying 2
• If on methotrexate, consider holding it for 2 weeks after vaccination if disease activity allows 5

Pneumococcal

• Pneumococcal vaccination is strongly recommended for RA patients <65 years on immunosuppressive medications 2
• Follow CDC guidelines for PCV15 followed by PPSV23, or single-dose PCV20 2

Hepatitis B

• Consider hepatitis B vaccination if she may have sexual contact with new partners, receive medical/dental treatment, or have potential blood/bodily fluid exposure 1
• Note that RA patients on biologics may have insufficient humoral response to HBV vaccine 2

Vaccines to AVOID

Live Attenuated Vaccines

• Live attenuated vaccines should be avoided if she is on immunosuppressive therapy 2, 1
• This includes: oral typhoid, yellow fever (not required for Costa Rica/Panama), BCG, and live herpes zoster vaccine 2
• Yellow fever is NOT required for entry to Costa Rica or Panama 4

Medication-Specific Timing Considerations

If on Rituximab (B-cell depleting therapy)

• Ideally vaccinate BEFORE starting rituximab 2
• If already on rituximab, vaccinate at least 6 months after starting but 4 weeks before the next course 2
• Humoral responses are severely hampered 1-3 months after rituximab 2

If on TNF Inhibitors or Methotrexate

• Vaccinations can be administered during use of these medications 2
• Most patients develop protective antibody levels, though responses may be slightly reduced 2

If on Prednisone ≥20 mg Daily

• Administer influenza vaccination regardless of dose 5
• Consider deferring other non-live vaccinations until glucocorticoids are tapered to <20 mg daily 5

Additional Considerations

Rabies

• Consider rabies vaccination if she will be involved in outdoor activities, working with animals, or staying for extended periods 1
• Use inactivated rabies vaccine (safe in immunosuppressed patients) 1

Multiple Vaccine Administration

• Multiple vaccines can be administered simultaneously on the same day without reducing effectiveness 1, 5

Common Pitfalls to Avoid

• Failing to account for reduced vaccine efficacy in immunosuppressed patients - particularly for hepatitis A where a single dose is insufficient 2
• Giving live vaccines to immunosuppressed patients - verify immunosuppression status before any vaccination 2
• Not allowing adequate lead time - starting vaccinations <4 weeks before departure may not provide adequate immunity 1
• Assuming standard vaccination schedules apply - RA patients on immunosuppression require modified schedules for optimal protection 2, 3