Advice for the Traveller “ Do you have the stomach to travel? ” Dr Raghu Gill
Case History of ASUC Now well on stable dose azathioprine Travel to US, Europe, South America and India Jiand ZD, J Infect Dis 2000
Case History of ASUC, now well Stable dose azathioprine Travel to US, Europe, South America and India Jiand ZD, J Infect Dis 2000
Recommendations • Section 8 of ECCO consensus on OI (www.ecco-ibd.eu) • CDC 2012 (google CDC yellow book)
Introduction • Importance of a pre-travel consultation • Main risks • Vaccine preventable diseases • Vaccinations • Traveller ’ s diarrhoea • Malaria • DVT risk • Logistics for travel • The returning traveller
Pre-travel consultation with you • Advise that patient is seen at a professional travel advisory clinic • Travel route • Immunisations • Safety: aware of risks • Adequate supply medication • Instructions for emergency self-treatment • Health insurance • Letter for airports re medications (sharps etc)
2 main risks • Relapse, exacerbation, or complications – Gastrointestinal infection – Dietary changes – Decreased compliance with medications – Lack of medications/inactivation of medication • Acquiring infectious disease endemic to that country which may be more severe due to immunosuppression Rahier JF, et al, JCC 2009 www.ecco-ibd.eu
IBD but no IM • Treat as everybody else and follow international guidelines • Frequently updated by the Infectious Diseases Society of America • Travel clinic pre-travel consultation
IBD and IM • Pre-travel consultation as usual but.............. NO LIVE VACCINES
Vaccine preventable diseases • Hepatitis A • Influenza • Typhoid fever • Measles • Yellow fever • Mumps • Japanese B • Diptheria encephalitis • Tetanus • Meningococcal • Poliomyelitis meningitis • Tick born encephalitis Rahier et al, JCC 2009 www.ecco-ibd.eu
2 principal questions 1. Do these diseases behave differently in IBD patients treated with IM/biologicals? 2. What influence does immunosuppression have on the success of preventative measures and on their safety?
Do these diseases behave differently in IBD patients treated with IM/biologicals? • Not fully known • Scant case reports • Impossible to extrapolate the effect of single drug on severity • However, intuition tells you that they may be more severe
Does immunosuppression influence the success of preventative measures and safety? • Vaccination best given before IM therapy • Inactivated vaccines: no reports of infectious complications however efficacy may be lower – DTP - Parenteral typhoid – IA parenteral polio - Meningococcal – Influenza - Oral killed cholera – Pneumovax - IA Japanese encephalitis – Hepatitis A and B - HPV
Live-attenuated vaccines • Considered unsafe for immunosuppressed patients - MMR - Typhoid Ty21a - Oral Polio - LAIV - BCG - Varicella - Yellow fever – Controversial – ECCO guidelines say to wait 3 months after ceasing, can start within 3 weeks Rahier JF, JCC 2009 www.ecco-ibd.eu
Yellow Fever: Africa and South America Maps : Yellow fever vaccine recommendations in the Americas, 2010. CDC 2012
Traveller ’ s Diarrhoea • 1-5 days disease in 95% of cases • 40% rate among travellers from low to high risk region, greater in those on IM • May provoke a relapse Jiand ZD, J Infect Dis 2000
Traveller ’ s diarrhoea - prevention • Hygiene precautions: • Cooked food • Boiled or bottled water • Careful choice of restaurants Jiand ZD, J Infect Dis 2000
Traveller ’ s diarrhoea in IBD • No data, but early initiation of treatment is warranted • Patient advised to carry antibiotics and to have a low threshold for starting them • Ciprofloxacin • Azithromycin (if on quinolones/high resistance areas, no response to quinolone, pregnancy) • Adjunct loperamide increases 24 hour cure rate (OR 2.6) Rahier JF, JCC 2009 Adachi JA, Cl Infect Dis 2003
Malaria • Unless pregnant, asplenic or HIV, no higher risk of malaria (acquisition or complications) • Follow malaria prophylaxis as per guidelines • Consider interactions – Eg maxolon decreases absorption of Malarone Rahier JF, JCC 2009 www.ecco-ibd.eu
DVT risk Data is variable – Increased DVT risk with travel – Not just ‘ economy class syndrome ’ Risk factors – Prior DVT – Thrombophilia (genetic or other RFs such as FV Liaden, Protein C, Antiphospholipid) – Surgery 2-4 weeks (esp major surgery)
DVT Prophylaxis Data is limited – Not aspirin for travel Where is the proof? – Graduated stockings – Aisle seat Fluids – 100ml per hour during the flight Mobilise and foot and ankle exercises
For higher risk patients Consider – LMWH • Day before, day of, day after • Use your “ clinical judgement ” • Dose up to 1mg/kg daily Jiand ZD, J Infect Dis 2000
Logistics • Enough medication • Emergency supply • Gastroenterologist contact in destination country • Letter summarising disease course and treatment • Pathology tests
The returning traveller • Should anything be done pre-emptively?
Parasites & Helminths • Can cause delayed symptoms in returning travellers especially after initiation of immunosupression • FBC & differential for eosinophila • Stool test for OCP (sens 1 stool specimen 80%) Rahier JF, JCC 2009 www.ecco-ibd.eu
Stronglyoides • Can persist in the returning traveller for life time • May mimic IBD exacerbation and can cause life-threatening infestation • Sensitivity of stool samples low • Serology Ben-Horin S, World J Gastro 2008 Leung VF, Am J gastro 1997
The flaring returning traveller – Work in co-operation with specialised travel clinic – High index of suspicion for intestinal parasites – Consider Albenazole 400mg x 2 for 3-5 days before initiation of immunosuppression Rahier JF, JCC 2009 www.ecco-ibd.eu
Summary • Pre-travel consultation (checklist) • No live vaccinations for those on IM • Encourage patient to pack antibiotics for TD & prednisone for a flare • TB screening • Travel Logistics • “ Phone a friend ”
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