Advice for the Traveller Do you have the stomach to travel? Dr - - PowerPoint PPT Presentation

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
• Typhoid fever
• Yellow fever
• Japanese B

encephalitis

• Meningococcal

meningitis

• Tick born encephalitis
• Influenza
• Measles
• Mumps
• Diptheria
• Tetanus
• Poliomyelitis

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
• n 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
• f 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”