Preparing Immunocompromised Patients for Risks of Traveling Abroad

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Summer is a season for travel, so if your immunocompromised patients plan to journey to regions where there are outbreaks of infections, such as chikungunya, tuberculosis, typhoid, yellow fever or other diseases, communication and preparation may prevent serious health events.

“The world teems with disease-causing organisms, and almost every infection is more serious in the immunocompromised,” says Amesh A. Adalja, MD, FACP, FACEP, senior associate, Center for Health Security at the University of Pittsburgh Medical Center and School of Medicine in Pittsburgh.

Whether for leisure or business, patients with autoimmune-related rheumatic diseases, such as rheumatoid arthritis, may want or need to travel to regions where infection risks may be high. However, these patients may be at significantly elevated risk for infections. A 2002 study published in Arthritis & Rheumatism looked at retrospective data on RA patients from 1955 to 1994 and found that this population’s infection risk was 19.64/100 person-years vs. 12.87/100 person-years for the general, healthy population.¹ Both the effects of their disease on their immune systems and immunosuppressant agents, such as methotrexate or anti-tumor necrosis factor biologic drugs, may put them at especial risk for viral, bacteria or fungal infections that could be life threatening.

Rheumatologists must work with their patients to assess the risks, suggest precautions or help prepare for illness related to travel abroad. “You can’t give live vaccines to people who are immunocompromised,” says Michael D. Lockshin, MD, director of the Barbara Volcker Center for Women and Rheumatic Disease at the Hospital for Special Surgery in New York. “If people want to go to the Amazon, you can’t give them the yellow fever vaccine. I might tell them to be careful and to use a lot of bug spray, but you can’t do much for this population” if they travel to risky regions.

Current Risks

Many destinations currently have outbreaks of infectious diseases that pose a risk for immunocompromised patients, says Dr. Adalja, who is a spokesman for the Infectious Diseases Society of America.

“The key risk for an immunocompromised traveler is that they may be exposed to an infectious disease that may be particularly severe because of their health status,” he says. “Tuberculosis is a risk throughout the world, dengue fever and chikungunya are particularly concerning because of their presence in the Caribbean, and many nations in Asia have a high prevalence of multi-drug resistant forms of bacteria that travelers can contract. Diarrheal diseases, yellow fever and malaria are also concerns in Africa and Asia.”

Immunocompromised patients are advised to avoid certain live vaccines, including Ty21a typhoid, measles-mumps-rubella, yellow fever and Bacillus Calmette Guérin (BCG) tuberculosis. These vaccines are recommended for the general population prior to travel to at-risk regions. Certain destinations may simply be off limits for some patients. “Because of the risk of yellow fever in certain parts of the African continent and the inability of immunocompromised patients to receive the yellow fever vaccine, these travelers may want to avoid those areas completely,” says Dr. Adalja.

If patients are planning international travel, they need to know the risks of both infections and preventive measures. For example, the anti-malarial drug chloroquine may decrease the bioavailability of methotrexate, which is a widely used therapy for RA and other rheumatic diseases.

The Centers for Disease Control and Prevention offers information and specific vaccine recommendations for immunocompromised travelers on its website, including the Yellow Book for physicians. This information can help rheumatologists stay informed so they can vaccinate or advise their patients prior to travel, says Dr. Lockshin.

“I try to stay reasonably on top of what’s happening in areas where patients are going,” he says. “I usually go on the CDC site or suggest that my patients do so if they are going to any exotic areas.”

Guidelines for vaccinations for immunocompromised patients may change, and new outbreaks of infectious disease in unexpected regions may occur with little warning. Establishing open communication with patients at the beginning of the relationship is important, he says. “I get to know people I am treating, and when I take their first medical history, I get an idea of how much they may travel. There are always those people who do a lot of international travel. I think few, if any, of my patients would travel without having that conversation with me first. We just have that kind of relationship.”

Rheumatologists should suggest that their patients review online travel risk information before booking any international trip, so they are aware of their particular infection risks, says Dr. Adalja.

“The CDC travel website is a great source. Additionally, they may want to meet with an infectious disease physician prior to travel in order to ensure that they take the appropriate precautions,” he says. Many people simply do not know current infection risks, which may rise quickly. “Travel-related illnesses are underappreciated. Many U.S.-based physicians do not have great knowledge about them. A proactive approach in which patients are counseled about the risks they face when immunosuppressants are used would go a long way toward empowering patients.”

Preventive Action

Before planning any travel, all patients should be up to date with the vaccinations they can take, such as hepatitis A and B, and pneumococcus, says Dr. Lockshin.

Vaccines are not the only way that rheumatologists may help their immunocompromised patients prepare for international travel. For example, chikungunya, a viral infection transmitted by mosquito bite that may cause fever, joint pain and swelling, and rash, has no vaccine at this time. In 2013, outbreaks of chikungunya were seen in the Caribbean, a popular vacation destination for Americans. The CDC recommends people traveling to regions affected by chikungunya use insect repellent, wear long sleeves and pants to reduce skin exposure to mosquitoes, and stay in accommodations with air conditioning or window screens.

Another relatively new infectious disease risk is Middle East Respiratory Syndrome (MERS), a novel coronavirus. According to the World Health Organization, MERS was first identified in Saudi Arabia in 2012, and cases have been reported in the Middle East, Europe, Africa, Asia and the Americas. Immunocompromised patients are at high risk of severe disease from MERS-CoV infection. MERS infection may cause fever, cough, shortness of breath, pneumonia or gastrointestinal symptoms, such as diarrhea. There is no vaccine for MERS-CoV, and transmission appears to occur during close contact with infected humans or animals, such as camels.

Rheumatologists can work with patients to prepare for travel-related illnesses or even disease flares that occur far from home, says Dr. Lockshin. “I warn people that they may have to go to a hospital or physicians’ offices where they don’t speak their language,” he says. He may provide contact information for rheumatologists in the area where his patients plan to travel or an explanatory letter with details about their diagnosis and current medications.

Some international destinations may have unclean food and water that carry Salmonella or other bacteria that could cause diarrhea. The CDC website offers guidelines for avoiding food- and water-borne infections while abroad, including:

• Eat foods that are cooked and served hot;
• Eat only fruits and vegetables that you have cleaned yourself or peeled;
• Consume only pasteurized dairy products;
• Avoid salads or other raw or undercooked foods;
• Avoid bushmeat, which includes monkeys, bats or other wild game;
• Drink only bottled, sealed liquids or water that has been disinfected;
• Avoid tap water, ice made with tap water or fountain sodas;
• Use bottled water for brushing teeth; and
• Use caution while bathing or swimming to avoid swallowing unclean water.

Rheumatologists may provide an anti-diarrheal prescription for their patients who plan to travel abroad, says Dr. Lockshin. Other precautions may help patients prepare for potential illnesses while they are away from home, he says.

“I pretty much insist that my patients take extra medications with them when they travel,” says Dr. Lockshin. In some areas, it may be hard to find a pharmacy to get a prescription refilled, he says. Patients should not pack prescriptions in checked baggage that could be lost by airlines or stolen.

Prior to travel, a rheumatologist’s recommendations may depend on the patient’s particular situation or diagnosis, says Dr. Lockshin. It’s helpful to talk about all the risks and what steps to take to avoid illness or discomfort while abroad.

“I tell my lupus patients, for example, about particular cautions for sun exposure. Patients with joint replacements may not be able to sit on a plane for a long time,” he says. Joint replacements may put patients at higher risk for deep vein thrombosis during lengthy flights, so these patients may need prophylaxis. “Also, injectable medications may be hard to get through security in some countries, and there are some medications that need to be kept on ice. You should be having a conversation with your patients so they know what to do when they travel.”

Susan Bernstein is a freelance medical journalist based in Atlanta.

Reference

1. Doran MF, et al. Frequency of infection in patients with rheumatoid arthritis compared with controls: A population-based study. Arthritis Rheum. 2002;46:2287–2293.