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Travel Vaccine Recommendations after Pediatric Heart Transplantation


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Martin Schweiger, MD
Children's Hospital Zurich
Zurich, Switzerland
Martinschweig88@hotmail.com



If one is to believe the great German poet Johann Wolfgang Goethe, the wise man obtains the best education while traveling. It seems this message has been heard by a great number of people worldwide, when one looks at international travel statistics-which reported more than one billion tourist arrivals globally in 2013.

Heart transplantation is a life-saving treatment, and intends to improve quality of life and reintegration into social life. This might even be truer for children and teenagers, as traveling across different countries adds to their personal development. However, the need for continuous immunosuppressive therapy may result in restrictions on some social and recreational activities, including traveling. Nonetheless, immunocompromised patients are traveling at increasing rates. In a survey, published in 2008, of adult patients who had undergone solid organ transplantation at the Mayo Clinic-with regard to their travel behavior-it was revealed that over 25% traveled outside the US, with the majority traveling to destinations at low risk for infectious disease. Though the report showed that generally, transplant recipients were able to travel safely, travelers to destinations at high risk for infection (defined as Asia, Central and South America, Africa, Middle East in this article) had a significant rate of illness. The authors revealed a low number of counseling sessions and interventions prior to travels [1]. Therefore, physicians caring for (pediatric) transplant recipients must be knowledgeable about pre-travel consultations, and recognize when referral to an infectious disease specialist is warranted. Consultation of the patient should begin several months ahead of departure.

In general, inactive vaccines after transplantation may be considered safe, while the use of live attenuated vaccines is contraindicated. Therefore, every effort should be made to vaccinate prior to transplantation. It is pointed out that different countries will have slightly different recommendations for immunization of solid organ transplant candidates, as already emphasized in the article by Ranny Goldwasser in this issue of the LINKS newsletter.

A well-written summary concerning (travel) vaccination in solid organ transplantation was published by the AST infectious diseases community [2]. Two of the diseases that most frequently occur while traveling are diarrhea and cholera. There are oral inactive vaccines providing short-term protection against cholera and Enterotoxigenic E. coli. Likewise, there is an inactive vaccine for Japanese encephalitis. If traveling to a country where typhoid (Salmonella serotype Typhi) is common, the patient should be vaccinated against it. The live oral typhoid vaccine is contraindicated. Instead, the killed parenteral Vi polysaccharide vaccine should be administered [3].

No monitoring of vaccine titers is necessary for the immunizations named. For planned travel to high-risk areas of hepatitis A and B, vaccination status of the recipient should be checked prior to the journey (in all children on heart transplantation waiting list, hepatitis A/B vaccination is recommended). Vaccination status for tetanus should be checked as well (hepatitis A/B and tetanus are inactivated vaccines). Rabies vaccination is not routinely administered; it should be addressed individually, in accordance with the risk of exposure.

Nevertheless, it has to be stated that travel to certain destinations may not be recommended. Recipients planning to travel to destinations that present true risk of yellow fever (some countries of Africa and South America) should strongly be discouraged. Vaccination for yellow fever is a live attenuated vaccine, and the subject should be vaccinated prior to transplantation. If this is done, long-term persistence of antibodies to yellow fever (at least in renal and liver transplant recipients) has been observed [4].

Finally, the potential risks of poor vaccine responses have to be taken into account, especially in immunosuppressed patients.

We wish you a safe journey. ■

Disclosure Statement: The author has no conflicts of interest to disclose.


References:

  1. Uslan, D.Z., R. Patel, and A. Virk, International travel and exposure risks in solid-organ transplant recipients. Transplantation, 2008. 86(3): p. 407-12.
  2. Danziger-Isakov, L. and D. Kumar, Vaccination in solid organ transplantation. Am J Transplant, 2013. 13 Suppl 4: p. 311-7.
  3. Pirofski, L.A. and A. Casadevall, Use of licensed vaccines for active immunization of the immunocompromised host. Clin Microbiol Rev, 1998. 11(1): p. 1-26.
  4. Wyplosz, B., et al., Persistence of yellow fever vaccine-induced antibodies after solid organ transplantation. Am J Transplant, 2013. 13(9): p. 2458-61.



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