Transcript Interactive Guide to the Travel Medicine section of the ID Guidelines

©2014 American Society of Transplantation
American Society of Transplantation
Infectious Disease Guidelines, 3rd Edition
>>Interactive Guide<<
Travel Medicine Section
Developed by:
Robin Avery, MD, Johns Hopkins
John Baddley, MD, University of Alabama at Birmingham
AST Infectious Disease Community of Practice
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©2014 American Society of Transplantation
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DPT/Pertussis
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Vaccine
Preventable
Illness
Rabies/JE
Meningococcus
Typhoid
Yellow Fever
General Travel
Information
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Preventable
Illness
Influenza/Strep. pneumioniae
Traveler’s Diarrhea
Malaria and Dengue
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Post-travel
Illness
Patient Evaluation
Causes of Illness
Sexually Transmitted Diseases
Other Travel
Issues
Food/Water Exposure
Transplant Tourism
©2014 American Society of Transplantation
General Travel Information
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Many travel-related illnesses can be prevented with immunizations and/or appropriate education.
Comprehensive information is found in the CDC’s Yellow Book at:
http://wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm
Visit to dedicated travel clinic familiar with immunocompromised patients ≥2 – 3 months in advance of
planned trip
Avoid travel to high-risk destinations during
– the first post-transplant year
– times of intensified immunosuppression.
Travelers should carry
– summaries of their medical problems
– updated and accurate medication lists
– baseline EKG if abnormal
– contact information for their transplant clinicians
– adequate supplies of medications
Travelers should
– have evacuation insurance for transport to a major medical center in the event of severe illness.
– Check all new prescriptions with their transplant team or a clinician experienced in transplantation
issues.
Travelers should avoid
– clinical settings where non-sterile needles or equipment may be used
– blood transfusions or other blood products in areas of limited resources.
©2014 American Society of Transplantation
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Vaccine
Preventable
Illness
Non-vaccine
Preventable
Illness
Post-travel
Illness
Other Travel
Issues
©2014 American Society of Transplantation
Vaccine Preventable Illness
Immunizations should be administered:
• ≥ 2-3 months in advance of planned trip
• Preferably by a dedicated travel clinic familiar with immunocompromised patients
• General (routine) immunizations should be up to date
Check the CDC’s Yellow Book
• General travel information http://wwwnc.cdc.gov/travel/page/vaccinations.htm
• Destination-specific information http://wwwnc.cdc.gov/travel/destinations/list.htm
Check the AST ID Guidelines for recommended immunizations for SOT travelers (table 3)
Family members of transplant recipients should not receive
• Oral polio vaccine
• Nasal influenza vaccine
• Smallpox vaccine
DPT/Pertussis
Typhoid
Hepatitis A/B
Rabies/Japanese
encephalitis
Yellow Fever
Meningococcus
Influenza/Strep.
pneumoniae
©2014 American Society of Transplantation
DPT/Pertussis
DPT/Pertussis
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A tetanus/diphtheria booster should be administered if not
given within 10 years.
– If the patient has never received Tdap vaccine (tetanusdiphtheria-pertussis), substitute a 1-time Tdap dose for
protection against pertussis.
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Hepatitis A/B (1 of 2)
©2014 American Society of Transplantation
Hepatitis A vaccine
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Recommended for
– All travelers if not received pre-transplant.
– Vaccine administration
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2 doses should be administered 6 – 12 months apart.
Check antibody titers after second vaccine
If there is not enough time before planned travel for 2 doses of hepatitis A vaccine,
intramuscular gamma globulin can be given at a dose of 0.02 ml/kg for short-term protection
(up to 3 months), and at a dose of 0.06 ml/kg for longer-term protection, and should be
repeated every 4 – 6 months
Continued on next slide…
Hepatitis A/B (2 of 2)
©2014 American Society of Transplantation
Hepatitis B vaccine
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Recommended for:
– Not previously HBV immune and at least 1 of following:
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If they may have new sexual partners while traveling or
Will live in an endemic area for an extended period of time, or
May require transfusions or medical procedures while traveling.
Vaccine administration
– Administered at 0,1,6 months. However, accelerated schedules (such as 0,1,2 months, or
0,7,28 days could also be used; the benefit of these schedules is less well studied). Ideally,
seroconversion (anti-HBs) should be checked. Seroconversion may be suboptimal on posttransplant immunosuppression, so post-exposure prophylaxis may still be required in the
event of an exposure. Antibody titers can be checked to assess the adequacy of previous
vaccination, and a booster dose and/or enhanced potency dose administered to nonconverters.
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©2014 American Society of Transplantation
Rabies/JE
Rabies vaccine
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Pre-exposure prophylaxis (3 doses on days 0, 7, and 21 or 28) for
– Travelers who anticipate
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Frequent contact with animals or;
Will reside for a prolonged time in an endemic area and/or;
Will be far from medical care in area where rabies is endemic.
Post-exposure prophylaxis
– Travelers in the event of an exposure
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Days 0 and 3 for previously vaccinated versus days 0,3,7,21, and 28 for those without prior immunization
Rabies immunoglobulin can be given to SOT recipients even if they have received pre-exposure prophylaxis as they
may not have mounted an adequate response to the vaccine. In these cases, some experts recommend rabies
immunoglobulin in addition to vaccine.
– Information from CDC about use of a four-dose series (for immunosuppressed patients,
post-exposure prophylaxis is still 5 doses)
Japanese encephalitis vaccine
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For travelers to rural areas in certain parts of Asia
Administered on days 0 and 28
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©2014 American Society of Transplantation
Meningococcus
Meningococcal vaccine
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Administer to travelers to
– Sub-Saharan Africa, or
– Saudi Arabia for the hajj or umra (proof of vaccination within the past 3 years
is required)
Single dose Meningococcal conjugate vaccine
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©2014 American Society of Transplantation
Typhoid
Typhoid vaccine
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For travel to typhoid-endemic areas
Administer injected non-live typhoid vaccine, not the oral live vaccine
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©2014 American Society of Transplantation
Yellow Fever
• Yellow Fever Vaccine is contraindicated
• For countries that require yellow fever immunization for entry
– Provide letter of exemption from a physician
• Letters should have the stamp of an official yellow fever immunization
center
• Discuss safety of travel to area with transplant recipient prior
to travel
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©2014 American Society of Transplantation
Influenza/Strep. pneumoniae
Seasonal inactivated (injectable) influenza vaccine
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Should be administered if not already received, even if travel planned for outside
of the winter season
Pneumococcal vaccine
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For vaccine naïve patients:
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The 13-valent pneumococcal conjugate vaccine should be given if no prior pneumococcal vaccination
Following this, the 23-valent pneumococcal polysaccharide vaccine should be given at least 8 weeks
later
For those who have received previous pneumococcal polysaccharide vaccine:
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The 13-valent pneumococcal conjugate vaccine should be given at least one year after PPV
Following this, PPV booster should be given at least 5 years after the previous PPV
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©2014 American Society of Transplantation
Non-vaccine Preventable Illness
Traveler’s
Diarrhea
Malaria and
Dengue
©2014 American Society of Transplantation
Traveler’s Diarrhea (1 of 2)
Traveler’s diarrhea affects over half of travelers to some destinations
– Dehydration from diarrhea may result in compromise of renal function with altered
metabolism of immunosuppressive medications
Minimizing risk of diarrhea
– Instruct traveler in appropriate food and water precautions prior to international travel
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Summary of food and water precautions is available on the CDC website
– Patient instructions
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Drink only boiled or bottled water and beverages not containing local water or ice
Avoid unpasteurized dairy products and food sold by street vendors
Avoid raw or undercooked foods (except fruit and vegetables that can be peeled)
Fluid replacement with clean water and oral rehydration solution if they develop diarrhea
Continued on next slide…
©2014 American Society of Transplantation
Traveler’s Diarrhea (2 of 2)
• Antibiotics for traveler’s diarrhea
– Ciprofloxacin or azithromycin (depending on the local resistance patterns of
Campylobacter and Salmonella species) for self-treatment of diarrhea
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See AST ID Guidelines Table 4
– Start antibiotic therapy if more than 3 unformed stools in 24 hours and accompanying
symptoms:
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Fever or blood, pus or mucus in the stool
Seek medical attention as soon as possible if accompanying symptoms
– Consider drug interactions
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See AST ID Guidelines Table 5
• Avoid
– Doxycycline or trimethoprim/sulfamethoxazole for treatment of diarrhea (due to
resistance issues)
– Anti-motility agents
– Bismuth subsalicylate (i.e., Pepto Bismol), especially if renal dysfunction
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©2014 American Society of Transplantation
Malaria and Dengue (1 of 2)
(Arthropod-borne illnesses)
Travelers to endemic areas should be counseled about how to minimize insect
bites by utilizing all of the following:
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Repellents containing DEET (N,N-diethyl-3-methylbenzamide) or picaridin
Bed nets
Well-screened rooms or air conditioning
Protective clothing
Permethrin-impregnated clothing
Continued on next slide…
©2014 American Society of Transplantation
Malaria and Dengue (2 of 2)
(Arthropod-borne illnesses)
Dengue fever
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May result in severe illness in SOT
Check country-specific outbreak information
Avoid areas of outbreak
Malaria
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For prophylaxis against malaria, consult the CDC Yellow Book, which provides country-specific
guidelines
Malaria prophylaxis options can be found in the AST ID Guidelines Table 4
It is important to note that drug interactions of antimalarial medicines and transplant-related
medicines may be present, as summarized inAST ID Guidelines Table 5
Leishmania endemic regions
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Precautions should be taken against sand fly bites
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©2014 American Society of Transplantation
Post-travel Illness
• 15-70% of international travelers returning to the US have a travel-related
illness
– 5% will become sick enough to seek medical care, usually for
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Diarrhea
Fever
Respiratory symptoms, or
Skin lesions.
• Indications for post-travel follow-up at the transplant center or by a
healthcare provider specializing in travel medicine:
– If any new symptoms develop during or following their return or
– If away for prolonged periods or
– If potential exposure to blood-borne pathogens or other high-risk situations
• A summary of post-travel evaluation can be found in chapter 5 of the CDC
Yellow Book
Causes of
Illness
Patient
Evaluation
©2014 American Society of Transplantation
Patient Evaluation
• Transplant recipients should
– Report the details of their trip
– Consider the following factors when assessing risk:
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Past medical history and medications
Travel destinations and duration of visits;
Types of accommodation;
Pre-travel immunizations and prophylaxis (medications, insect repellant, etc.)
Activity and exposures (food and water consumptions, sexual contacts, insect bites,
Water exposures, animal exposures, hospitalization or medical care)
• Initial laboratory evaluation considerations in febrile returning travelers
(refer to Chapter 5 of CDC Yellow Book):
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Complete blood count with differential
General chemistries, liver-function studies
Urinalysis
Cultures of blood, urine, stool
Chest radiography
Malaria diagnostic testing (blood smears)
Risk-specific assays, dependent on travel (HIV testing, infection serologies, etc.)
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©2014 American Society of Transplantation
Causes of Illness (1 of 3)
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Even with careful precautions and full immunizations, infections can be acquired during travel,
and may not manifest until weeks or even months after return from the trip.
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Causes of fever in this setting include: malaria, dengue, typhoid, rickettsial diseases (including
Mediterranean spotted fever and typhus), acute schistosomiasis, filariasis, leptospirosis,
chikungunya virus infection, acute histoplasmosis, coccidioidomycosis, bartonellosis, Q fever,
legionellosis, African trypanosomiasis, brucellosis, tuberculosis, viral encephalitis, amebic liver
abscess, or visceral leishmaniasis.
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Additional information about causes of fever in returning travelers, including tables of common
causes of fever, may be found in the CDC Yellow Book in chapter 5.
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Hepatitis A, B, or E may be acquired during travel and may present with fatigue, nausea, and
jaundice 2 – 9 weeks after exposure.
Continued on next slide…
©2014 American Society of Transplantation
Causes of Illness (2 of 3)
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Malaria, especially falciparum malaria, can progress rapidly and should be sought immediately in
any febrile traveler in order to institute treatment promptly. Having taken malaria prophylaxis
does not rule out this diagnosis.
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Traveler’s diarrhea may manifest either during or after a trip, and may be due to a variety of viral,
bacterial, or parasitic pathogens. Patients should be aware of the need for prompt evaluation for
diarrhea that does resolve, as the dehydration that accompanies diarrhea may have harmful
effects particularly to a renal allograft.
•
However, a significant percentage of infections in returning travelers will be less exotic: urinary
tract infections, bronchitis, pneumonia, influenza. For SOT recipients, transplant pyelonephritis
(in kidney or kidney pancreas recipients), cytomegalovirus viremia, and other common causes of
fever should be suspected.
Continued on next slide…
©2014 American Society of Transplantation
Causes of Illness (3 of 3)
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Acute HIV infection may present with fever, with or without rash and a mononucleosis-like
syndrome. Patients with fever should report new sexual contacts that occurred during travel.
Primary Epstein-Barr virus infection, cytomegalovirus infection, and toxoplasmosis may also
present with a mononucleosis-like syndrome.
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Transplant recipients who acquire infection with Strongyloides stercoralis are at risk of
fulminant dissemination. Suspect strongyloidiasis in transplant recipients who have had
extensive rural tropical contact particularly with activities such as barefoot outdoor sports.
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Tuberculosis is unlikely to be acquired during a short trip to an endemic area, but may occur
in transplant recipients with protracted stays or residence in such area. TB may manifest in
atypical fashion (undifferentiated fever, gastrointestinal or central nervous system without
pulmonary manifestations, or dissemination). Tests for TB, including the PPD skin test and
interferon-gamma release assays (IGRA), may be less sensitive in patients with impaired
cellular immunity.
•
Noninfectious causes of fever in this setting may include pulmonary emboli (particularly after
lengthy air or ground travel) and medication reactions.
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©2014 American Society of Transplantation
Other Travel Issues
Sexually
Transmitted
Diseases
Food/Water
Exposure
Transplant
Tourism
©2014 American Society of Transplantation
Sexually Transmitted Diseases (1 of 2)
• STDs are an under-recognized cause of illness in travelers
– Transplant recipients are at higher risk for severe or atypical presentations
• Prior to travel, remind patients of risks of unprotected sexual intercourse
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HIV
HBV
Gonorrhea, chlamydia
Syphilis
HSV
Chancroid and lymphogranuloma venereum
• Prior to travel, remind patient to avoid
– Contact with commercial sex workers
– Going on trips for the purpose of sexual tourism
• Absence of visible genital lesions, or self-reported lack of an STD history, is
no guarantee of absence of an STD.
Continued on next slide…
©2014 American Society of Transplantation
Sexually Transmitted Diseases (2 of 2)
• Prevention of STDs
– Condoms should always be worn in sexual contacts outside of long-term monogamous
relationships
– Avoid use of illicit drugs and excessive consumption of alcohol
• Sexual assault is a risk in many parts of the world
– Avoid solitary travel, travel at night and secluded or poorly-lit areas
• Seek rapid medical attention at a reliable health care center with attention
to post-exposure prophylaxis including HIV post-exposure prophylaxis if
there is a concern for STD
– http://aidsinfo.nih.gov/contentfiles/NonOccupationalExposureGL.pdf
• Be aware of antimicrobial resistance issues when treating STDs
– Refer to CDC revised guidelines published in June 2015
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©2014 American Society of Transplantation
Food/Water Exposure
• Patients should be advised to avoid
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Food from street vendors
Fresh fruits and vegetables (unless these can be peeled or cooked)
Raw or undercooked foods
Unpasteurized dairy products
Tap water and ice cubes (unless made from safe water)
• Drink only boiled water or bottled beverages
• More information on food and water precautions is available on the CDC
website
See also: Traveler’s Diarrhea section
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©2014 American Society of Transplantation
Transplant Tourism
• “Transplant tourism” (involving travel of either the organ donor or
recipient strictly for purposes of organ transplantation), conveys
significant infectious disease risks
• Given their commercial and sometimes illegal nature, many of these organ
transplants are not recorded in databases, so the incidence of infection in
donors or recipients is unknown
• The extent and quality of the pretransplant evaluation of the donor and
recipient is likely to be quite variable
• Read full details in the AST ID Guidelines
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©2014 American Society of Transplantation
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©2014 American Society of Transplantation
References
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Comprehensive information is found in the CDC’s Yellow Book at: http://wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm
http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-8-advising-travelers-with-specific-needs/immunocompromised-travelers
http://wwwnc.cdc.gov/travel/page/traveler-information-center
Destination-specific information http://wwwnc.cdc.gov/travel/destinations/list.htm
Boggild AK, Sano M, Humar A, et al. Travel patterns and risk behavior in solid organ transplant recipients. J Travel Med 2004; 11:3743.
Uslan DZ, Patel R, Virk A. International travel and exposure risks in solid-organ transplant recipients. Transplantation 2008; 86: 407412.
Roukens AH, van Dissel JT, de Filter JW, Visser LG. Health preparations and travel-related morbidity of kidney transplant recipients
traveling to developing countries. Clin Transplant 2007; 21:567-570.
Danziger-Isakov L, Kumar D; AST Infectious Diseases Community of Practice. Vaccination in solid organ transplantation. Am J
Transplant. 2013 Mar;13 Suppl 4:311-7. doi: 10.1111/ajt.12122.
Rubin LG1, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, Bousvaros A, Dhanireddy S, Sung L, Keyserling H, Kang I, Infectious
Diseases Society of America. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis.
2014 Feb;58(3):309-18. doi: 10.1093/cid/cit816.
DuPont HL1. Systematic review: the epidemiology and clinical features of travellers' diarrhoea.See comment in PubMed Commons
below
Aliment Pharmacol Ther. 2009 Aug;30(3):187-96.
Al-Abri SS1, Beeching NJ, Nye FJ. Traveller's diarrhoea. See comment in PubMed Commons belowLancet Infect Dis. 2005
Jun;5(6):349-60.
http://www.cdc.gov/malaria/travelers/index.html
Travel-associated Dengue surveillance - United States, 2006-2008.See comment in PubMed Commons belowMMWR Morb Mortal
Wkly Rep. 2010 Jun 18;59(23):715-9. Centers for Disease Control and Prevention (CDC).
http://www.cdc.gov/Dengue/
Guidelines for the Treatment of Malaria. 2nd edition. Geneva: World Health Organization; 2010.
WHO Guidelines Approved by the Guidelines Review Committee.
©2014 American Society of Transplantation
References (continued)
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http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-5-post-travel-evaluation/general-approach-to-the-returned-traveler
Hagmann SH1, Han PV2, Stauffer WM3, Miller AO4, Connor BA5, Hale DC6, Coyle CM7, Cahill JD8, Marano C9, Esposito DH2, Kozarsky
PE10; GeoSentinel Surveillance NetworkTravel-associated disease among US residents visiting US GeoSentinel clinics after return
from international travel. Fam Pract. 2014 Dec;31(6):678-87.
Gautret P1, Gaudart J, Leder K, Schwartz E, Castelli F, Lim PL, Murphy H, Keystone J, Cramer J, Shaw M, Boddaert J, von Sonnenburg
F, Parola P; GeoSentinel Surveillance Network. Travel-associated illness in older adults (>60 y). J Travel Med. 2012 MayJun;19(3):169-77.
Zenilman J, “From Boudoir to Bordello: Sexually Transmitted Diseases and Travel.” In Infections of Leisure (4th Edition), ed. David
Schlossberg, ASM Press, Washington, DC, 2009.
http://www.cdc.gov/std/treatment/2010/default.htm
Matteelli A1, Schlagenhauf P, Carvalho AC, Weld L, Davis XM, Wilder-Smith A, Barnett ED, Parola P, Pandey P, Han P, Castelli F;
GeoSentinel Surveillance Network. Travel-associated sexually transmitted infections: an observational cross-sectional study of the
GeoSentinel surveillance database. See comment in PubMed Commons belowLancet Infect Dis. 2013 Mar;13(3):205-13.
http://wwwnc.cdc.gov/travel/page/food-water-safety
See comment in PubMed Commons below
Kotton CN1, Hibberd PL; AST Infectious Diseases Community of Practice. Travel medicine and transplant tourism in solid organ
transplantation. Am J Transplant. 2013 Mar;13 Suppl 4:337-47. doi: 10.1111/ajt.12125.
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