sy7-03 - special advice in immunocompromised travellers ... · •preventive measures that need to...

6/24/2019

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Special Advice for the Immunocompromised Traveller• Micha Loebermann

Department of Tropical Medicine and Infectious Diseases

University of Rostock

Universitätsmedizin Rostock

Objectives

• practical issues in the immuncompromised traveller to

be considered during pre‐travel asssessment

• options for medical care and insurance issues abroad

• symptoms immunosuppressed travellers need to be

aware of and their possible (self‐) management

• preventive measures that need to be considered.


Travel post stem-cell transplantation

Swiss Med Wkly. 2015 May 29;145:w14136. doi: 10.4414/smw.2015.14136Hollenstein et al. Travelling activity and travel‐related risks after allogeneic haematopoietic stem cell transplantation ‐ a single centresurvey.

118/153 (77.1%) travelled outside country of residence (> 1 week)

pre-travel vaccination n %

Tetanus 89 44.3%

Influenza 85 42.3%

Hepatitis B 63 31.3%

Streptococcuspneumoniae

50 24.9%

Poliomyelitis 40 19.9%

Hepatitis A 31 15.4%

Neisseria meningitidis 24 11.9%


Mayo Clinic ‐ Travel Counselling

Tan EM, Marcelin JR, Virk A. Pre‐travel counseling for immunocompromised travelers: A 12‐year single‐center retrospective review. Infection, disease & health. 2019;24(1):13‐22

Authors conclusions:‐ Low vaccination rates‐ Serologic pre‐travel testing uncommon‐ Early screening for travel plans advisable

Immunocompromisedtravellers

N 321

Malaria prophylaxis

Hep A vaccination

YF exemption

Solid organ transplant 134 33.6% 77.3% 16.4%

Connective tissue disease 121 46.3% 77.7% 22.3%

Inflammatory boweldisease

41 32.6% 76.1% 21.7%

HIV 21 45.0% 95% 20%


National travel advice UK

Immunosuppressivedrugs

N 160

%

Systemic steroids 71 44.3%

Methotrexate 43 26.9%

Azathioprine 22 13.6%

Monoclonal antibodies 21 13.1%

Mesalazine 13 8.1%

Sulphasalazine 10 6.3%

Ciclosporin 6 3.8%

Beta-interferon 5 3.0%

Tacrolimus 3 1.9%

Other/unknown 23 14.4%

Allen JE, Patel D. Enquiries to the United Kingdom National Travel Advice Line by healthcare professionals regarding immunocompromised travellers. Journal of travel medicine. 2016;23(3).

A Strangfeld et al. Ann Rheum Dis 2011;70:1914-1920

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Risk factors‐ age > 60 years‐ chronicpulmonary disease‐ Prevoius severeinfection

Serious infection rates in TNF inhibition

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Medical risk assessment for travellers

• infectious diseases

• environmental factors

• standard and availability of local

emergency medical and dental care

• access to quality pharmaceutical

supplies

• requirement for medical evacuation

• cultural, language or administrative

barriers

https://www.travelriskmap.com/#/planner/map/medical 2018 Universitätsmedizin Rostock

Medical risks and availability of care

https://www.travelriskmap.com/#/planner/map/medical 2018


Treatment costs in different regions

https://www.brokerfish.com/resources/expat‐health‐insurance‐cost‐by‐country; PO 13.04

https://wwwnc.cdc.gov/travel/yellowbook/2018/the‐pre‐travel‐consultation/obtaining‐health‐care‐abroad

Locate adequate medical care options: embassies and consulates, medical insurance or credit card companies; www.istm.org

Poster 13.04


Travel insurance

• Generally covers acute

illness

• May not cover

‐ preexisting diseases

‐ repatriation

‐medical prescriptions

‐ ambulance call outs

‐ optical/dental service

• Additional trip

cancellation insurancewww.tinz.co.nz


Immunocompromised Travellers ‐ symptoms

Dekkiche S, et al. Travel‐related health risks in moderately and severely immunocompromised patients: a case‐control study. Journal of travel medicine. 2016;23(3); Suryapranata Fet al. Symptoms of infectious diseases in HIV‐positive travellers: A prospective study with exposure‐matched controls. Travel medicineand infectious disease. 2019

N Any healthproblem

Significantclinical events*

Immunocompromisedtravellers

116 27 (23.3%) 9 (7.8%)

Solid organ transplant 4 2 (50%)Infection 66.6%Inflammatorydisease 11.1%Trauma 11.1%Cardivascularproblem 11.1%

systemic immuno‐suppressive med.

52 4 (7.7%)

Splenectomized 20 0%

HIV 15 3 (20%)

Active cancer 25 0%

Healthy controls 116 24 (20.7%) 2 (1.7%) Infection 100%

* repatriation, hospitalisation duuring/1 month after travel, medical consultation during travel52 HIV vs 52 healthy travellers: comparable diarrhoea, vomiting, cough, rhinitis, pruritus, fatigue, or nausea.


Travel with stable disease condition

Multiple Sclerosis (MS) pseudo‐relapse

(non‐inflammatory progression)

• Infectious

• Psychiatric

• Vertigo

• Temperature related

• Trauma

• Other neurological reasons

Rodriguez de Antonio LA et al. Non‐inflammatory causes of emergency consultation in patients with multiple sclerosis.

Neurologia 2018; Loebermann M, et al. . Vaccination against infection in patients with multiple sclerosis. Nat Rev

Neurol. 2011;8(3):143‐51

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Influenza

Metze C, et al. Immunogenicity and predictors of response to a single dose trivalent seasonal influenza vaccine in multiple sclerosis . CNS NeurosciTher. 2019 Feb;25(2):245‐254; Steffen R. Travel vaccine preventable diseases‐updated logarithmic scale with monthly incidence rates. Journal of travel medicine. 2018.

Influenza affects 1/100 travellers(most frequent vaccine preventable infection)- Group travel - Cruise ship- Elderly- Chronic medical

conditions

Annual relapsrate

months

Influenza vaccine in MS

Metze C, et al. Immunogenicity and predictors of response to a single dose trivalent seasonal influenza vaccine in multiple sclerosis . CNS NeurosciTher. 2019 Feb;25(2):245‐254; Steffen R. Travel vaccine preventable diseases‐updated logarithmic scale with monthly incidence rates. Journal of travel medicine. 2018.


Acute travel associated diarrhea

Increased risk

Previous severe course

Reduced gastric acidity(antacids, gastric surgery)

Immunodeficiency

„All‐inclusive“ tourism

IBD

Risk of complication

Dehydration: previousstroke, diabetes, young/oldage

Electrolyte imbalances: renal insufficiency, IBD

Steffen R et al. JAMA 2015;313:71‐80; Cook/Zumla. Tropical Diseases 2009 Universitätsmedizin Rostock

Diarrhoea – treatment

• Prophylaxis

• Not routinely recommended

• Cholera vaccine (cross immunity)?

• Bismuth subsalicylate (renal toxicity in renal tx)

• Rifaximin (cyclosporin interaction)

• Chinolons not recommended

• Empiric therapy

• Mild – symptomatic (rehydration, electrolyte substitution, anti‐

motility agents e.g. loperamide, bismuth)

• Moderat – chinolons??, azithomycin, rifaximin

• Severe – antibiotic therapy – microbiology testing

• Cave: invasive infections, developing resistance (campylobacter)

RiddleMS et al. J TravelMed. 2017;24(suppl_1):S57‐S74; Beeching NJ, et al.Traveler's Diarrhea

Recommendations for Solid Organ Transplant Recipients and Donors. Transplantation. 2018;102:S35‐s41

E. coli (ETEC) 40‐70%, Campylobacter, Shigella, Salmonella, Aeromonas etc.


Prophylactic measures against malaria

http://www.dtg.org; Boubaker R, et al. Malaria prevention strategies and recommendations, from chemoprophylaxis to stand‐by emergencytreatment: a 10‐year prospective study in a Swiss Travel Clinic. Journal of travel medicine. 2017;24(5)

mosquito avoidancechemoprophylaxisstand‐by emergency treatment (SBET)


Drug interactions

Mariano D, Smith DS. Safe Travel Preparation for HIV‐Infected Patients. Current infectious disease reports. 2019;21(4):15.https://www.hiv‐druginteractions.org; www.drugs.com/interaction

Co‐medication Possible effect

Doxycycline etravirine , nevirapine, efavirenz

CYP3A4/CYP450‐associated decreased doxy concentrations

calcineurin inhibitors(tacrolimus, cyclosporine)

Elevated calcineurin inhibitor levels

Proguanil‐Atovaquone

Efavirenz, rinonavir reduced proguanil metabolites, reduced atovaquon concentration

Mefloquine efavirenz, lopinavir inceased QT‐interval

calcineurin inhibitors(tacrolimus, cyclosporine)

Elevated calcineurin inhibitor levels

Chloroquine efavirenz, lopinavir inceased QT‐interval

Primaquine etravirine , nevirapine potentially increased primaquinehaemotoxicity

Tafenoquin as for primaquine?

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Practical issues

• Sufficient medical supply

• Carry‐on luggage & suitcase

• Special requirements for fluids and

syringes

• Cold‐chain (arrange with airline)

• Medical supply certificate

United Arab Emirates – drug restrictions

• psychotropic substances

• analgetics

• antitussives

• hormons

ISTM Pharmacist Professional Group Database on International RegulationsPoster 15.16


Countries with restrictions for HIV – short term travel

• Azerbaidjan

• Bhutan

• Brunei

• Egypt

• Equatorial Guinea

• Iran

• Iraq

• Jordan

• Kyrgyzstan

• Marshall Islands

• Russia

• Solomon Islands

• Suriname

• Syria

• Tunisia

• United Arab Emirates (UAE)

• Yemen

http://www.hivtravel.org 2019 Universitätsmedizin Rostock

Yellow fever required vaccinations

/who.maps.arcgis.com 20171201Schonenberger S, Hatz C, Buhler S. Unpredictable checks of yellow fever vaccination certificates upon arrival in Tanzania. Journal of travel medicine. 2016;23(5)


Summary – ideal traveller

• Early screening for travel plans done and vaccinations started

• All generally usefull vaccines completed: pneumococcus, meningococcus, HAV,

HBV, TdaP, Influenza etc. (ImmunoStart Poster 17.08)

• No drug interactions with antimalarials or other antibiotics

• Has medical care at travel destination if needed

• Has no legal travel restrictions

• Has stable disease, is educated about underlying diesase and is well insured

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sy7-03 - special advice in immunocompromised travellers ... · •preventive measures that need to...

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