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When Your Transplant Recipient Travels Overseas


Marcus Pereira, MD, MPH
Columbia Univeristy Medical Center
New York, NY, USA
Mp2323@cumc.columbia.edu



"Thank you doc, I'm glad my heart transplant is doing fine. I'll see you next time. Oh and by the way, I'm travelling with my friends to the Brazilian Amazon in a month. Should I take anything for that?"

Most providers have been in that situation and that sense of bewilderment that takes you over is unshakeable. As the number of heart transplant recipients grows each year, with many of them living longer and healthier lives, travelling has become more frequent. In this globalized world, many transplant recipients are increasingly choosing international destinations [1]. While an exciting and rewarding undertaking, travelling overseas represents unique challenges to transplant recipients and must be carefully evaluated by the transplant team. For one, transplant recipients are at a significantly higher risk of contracting opportunistic and travel related infections [2-4]. Second, they are less likely to respond to important travel related vaccines [5]. Third, immunosuppressive drugs can have important drug interactions with common travel related medications.

Unfortunately, studies have shown that despite pitfalls many transplant recipients fail to seek timely or any pre-travel medical advice even when travelling to high risk areas [1, 6]. Some of the more common reasons included thinking that it is not necessary, not knowing about the need for pre-travel medical advice and not being advised by their physician or coordinator to seek medical advice. This leads to overall low rates of vaccination, poor adherence to safety measures such as mosquito precautions and basic food hygiene, among others. When problems occur, they not only lead to significant morbidity but also decrease quality of life.

It is therefore extremely important for the transplant team to alert their patients to the potential risks involved in overseas travel and seek expert advice well ahead of time. Travel related vaccines and prophylaxis, as well as important safety related tips are all best addressed during a dedicated pre-travel visit with a specialist familiar with transplant patients [5, 7]. The following are some of the most important topics that should be discussed with transplant recipients wishing to travel overseas.

When to travel after transplant? Whether to attend a wedding or visit a sick family member, patients don't always get to decide when to travel. Many do, however, so when possible patients should be discouraged from travelling to high risk areas during periods of greater immunosuppression. This not only generally includes the first year after transplant but also several months after treatment for rejection.

Where to go? links imageOnce again, patients don't always get to decide where to travel and with careful preparation many places are safe. However, some destinations should give the transplant recipient and the provider some pause. For example, destinations where yellow fever is endemic are not appropriate because transplant recipients cannot receive the yellow fever vaccine. Areas with active outbreaks of disease should also be avoided. Knowledge of these areas requires some continued updating from reliable epidemiological source. Cruise ships are generally thought of as safe however severe viral outbreaks occur and can severely affect the transplant recipient. Most significant at this time, the Zika virus outbreak in Central and South America as well as in many parts of the Caribbean (see figure) represents a major health risk and the majority of experts recommend that transplant recipients avoid travelling to these areas for the time being [8].

What is planned for the trip? This is a large topic and will vary with each circumstance but some basic common sense should prevail at all times. For example, because of poorer sanitation and decreased access to health care, backpacking through the countryside in many areas of the world is likely much riskier than staying at a big urban center. Visiting family and friends, although often thought of as safe, can actually increase risk for food/water borne infections.

What precautions should be taken? There is a long list of safety measures many depending on the destination. Because diarrhea is the most common illness affecting travelers, a detailed discussion on food and water precautions is essential. Transplant recipients should only drink boiled or bottled water and avoid ice, unpasteurized dairy products and raw/undercooked foods. Good hand hygiene might help prevent some respiratory viral infections. Mosquito precautions with bed nets, repellants and protective clothing might help with preventing malaria as well as dengue, Chikungunya and Zika viruses. In regions where Schistosoma species is endemic, travelers should avoid swimming in fresh water. Finally, travelers should be counseled on bloodborne and sexually transmitted infections including not sharing needles, acquiring tattoos or having unprotected sex with new partners.

What vaccines should be given? For many travel related vaccines, their efficacy in transplant recipients is diminished and thus it is strongly encouraged that patients complete each vaccine series well in advance of travelling. Vaccine boosters are sometimes necessary. Most importantly, all travel related live vaccines are deemed contraindicated for transplant recipients, including yellow fever, oral polio, Bacille Calmette-Guerin (BCG) and oral typhoid vaccines. Safe travel related vaccines include Hepatitis A and B, meningococcal conjugate, inactivated polio, rabies and Japanese encephalitis. The cholera vaccine is also safe but not available in the United States.

What prophylactic medications should be prescribed? Malaria prophylaxis should be given when indicated. The CDC's Yellow Book maintains a list of countries and regions where it is needed [9]. Further, drug resistant is a common and serious issue, dictating what prophylaxis regimen is effective. Because of its efficacy and minimal side effects, atovaquone-proguanil is the most common drug prescribed. Doxycycline is also effective and well tolerated, except when significant sun exposure is expected. Most transplant recipients are also usually prescribed antibiotics (either a fluoroquinolone or azithromycin) for empiric self-treatment of recurrent diarrhea associated with fevers and blood/pus in stools.

Where can one obtain more information? There are many online resources and guidelines available to the providers and patients. These include the Centers for Disease Control and Prevention travel website (http://wwwnc.cdc.gov/travel/), which maintains excellent and detailed information on infectious risks for each destination along with travel advisories and current outbreaks. For more specific discussion on transplant recipients, and directed for providers, the AST guidelines offer guidance on vaccines, prophylaxis and other issues.

Travel related infections represent a serious risk to transplant patients but a timely visit to a travel clinic can help prevent most of these complications. With those issues addressed, your patient can travel more confidently and enjoy the trip! ■

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


References:

  1. Hochberg, N.S., et al., International travel by persons with medical comorbidities: understanding risks and providing advice. Mayo Clin Proc, 2013. 88(11): p. 1231-40.
  2. Dekkiche, S., et al., Travel-related health risks in moderately and severely immunocompromised patients: a case-control study. J Travel Med, 2016. 23(3).
  3. Roukens, A.H., et al., Health preparations and travel-related morbidity of kidney transplant recipients traveling to developing countries. Clin Transplant, 2007. 21(4): p. 567-70.
  4. Wieten, R.W., et al., Health risks of travelers with medical conditions--a retrospective analysis. J Travel Med, 2012. 19(2): p. 104-10.
  5. Kotton, C.N., P.L. Hibberd, and A.S.T.I.D.C.o. Practice, Travel medicine and transplant tourism in solid organ transplantation. Am J Transplant, 2013. 13 Suppl 4: p. 337-47.
  6. 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.
  7. Aung, A.K., J.A. Trubiano, and D.W. Spelman, Travel risk assessment, advice and vaccinations in immunocompromised travellers (HIV, solid organ transplant and haematopoeitic stem cell transplant recipients): A review. Travel Med Infect Dis, 2015. 13(1): p. 31-47.
  8. Silveira, F.P. and S.V. Campos, The Zika epidemics and transplantation. J Heart Lung Transplant, 2016. 35(5): p. 560-3.
  9. CDC Health Information for International Travel 2016. Available from:http://wwwnc.cdc.gov/travel/yellowbook/2016/table-of-contents.



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