6/24/2019 Objectives practical issues in the immuncompromised - PDF document

6/24/2019 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. Special Advice for the Immunocompromised Traveller • Micha Loebermann Department of Tropical Medicine and Infectious Diseases University of Rostock Universitätsmedizin Rostock 1 2 Travel post stem-cell transplantation Mayo Clinic ‐ Travel Counselling Immunocompromised N Malaria Hep A YF 118/153 (77.1%) travelled outside travellers 321 prophylaxis vaccination exemption country of residence (> 1 week) Solid organ transplant 134 33.6% 77.3% 16.4% Connective tissue disease 121 46.3% 77.7% 22.3% pre-travel vaccination n % Inflammatory bowel 41 32.6% 76.1% 21.7% Tetanus 89 44.3% disease Influenza 85 42.3% HIV 21 45.0% 95% 20% Hepatitis B 63 31.3% Streptococcus 50 24.9% Authors conclusions: pneumoniae ‐ Low vaccination rates Poliomyelitis 40 19.9% ‐ Serologic pre ‐ travel testing uncommon Hepatitis A 31 15.4% ‐ Early screening for travel plans advisable Neisseria meningitidis 24 11.9% Swiss Med Wkly. 2015 May 29;145:w14136. doi: 10.4414/smw.2015.14136 Hollenstein et al. Travelling activity and travel ‐ related risks after allogeneic haematopoietic stem cell transplantation ‐ a single centre Tan EM, Marcelin JR, Virk A. Pre ‐ travel counseling for immunocompromised travelers: A 12 ‐ year single ‐ center retrospective review. survey. Infection, disease & health. 2019;24(1):13 ‐ 22 Universitätsmedizin Rostock Universitätsmedizin Rostock 3 4 National travel advice UK Serious infection rates in TNF inhibition Immunosuppressive N % drugs 160 Systemic steroids 71 44.3% Methotrexate 43 26.9% (per 100 patients/year) Azathioprine 22 13.6% Serious infection s Monoclonal antibodies 21 13.1% Mesalazine 13 8.1% Sulphasalazine 10 6.3% Ciclosporin 6 3.8% Beta-interferon 5 3.0% 3 2 Risk factors Tacrolimus 3 1.9% 1 ‐ age > 60 years Other/unknown 23 14.4% 0 ‐ chronic pulmonary disease ‐ Prevoius severe infection Allen JE, Patel D. Enquiries to the United Kingdom National Travel Advice Line by healthcare professionals regarding immunocompromised A Strangfeld et al. Ann Rheum Dis 2011;70:1914-1920 Universitätsmedizin Rostock travellers. Journal of travel medicine. 2016;23(3). 5 6 1

6/24/2019 Medical risk assessment for travellers Medical risks and availability of care • 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 https://www.travelriskmap.com/#/planner/map/medical 2018 Universitätsmedizin Rostock 7 8 Treatment costs in different regions Travel insurance • Generally covers acute illness • May not cover ‐ preexisting diseases ‐ repatriation ‐ medical prescriptions Poster 13.04 ‐ ambulance call outs ‐ optical/dental service Locate adequate medical care options: embassies and consulates, • Additional trip medical insurance or credit card companies; www.istm.org cancellation insurance https://www.brokerfish.com/resources/expat ‐ health ‐ insurance ‐ cost ‐ by ‐ country; PO 13.04 Universitätsmedizin Rostock Universitätsmedizin Rostock https://wwwnc.cdc.gov/travel/yellowbook/2018/the ‐ pre ‐ travel ‐ consultation/obtaining ‐ health ‐ care ‐ abroad www.tinz.co.nz 9 10 Immunocompromised Travellers ‐ symptoms Travel with stable disease condition N Any health Significant Multiple Sclerosis (MS) pseudo ‐ relapse problem clinical events* (non ‐ inflammatory progression) Immunocompromised 116 27 (23.3%) 9 (7.8%) travellers • Infectious Solid organ transplant 4 2 (50%) Infection 66.6% • Psychiatric systemic immuno ‐ 52 4 (7.7%) Inflammatory suppressive med. • Vertigo disease 11.1% Trauma 11.1% Splenectomized 20 0% • Temperature related Cardivascular HIV 15 3 (20%) problem 11.1% • Trauma Active cancer 25 0% Healthy controls 116 24 (20.7%) 2 (1.7%) Infection 100% • Other neurological reasons * repatriation, hospitalisation duuring/1 month after travel, medical consultation during travel 52 HIV vs 52 healthy travellers: comparable diarrhoea, vomiting, cough, rhinitis, pruritus, fatigue, or nausea. Rodriguez de Antonio LA et al. Non ‐ inflammatory causes of emergency consultation in patients with multiple sclerosis. 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); Neurologia 2018; Loebermann M, et al. . Vaccination against infection in patients with multiple sclerosis. Nat Rev Suryapranata Fet al. Symptoms of infectious diseases in HIV ‐ positive travellers: A prospective study with exposure ‐ matched controls. Travel medicine Universitätsmedizin Rostock Universitätsmedizin Rostock Neurol. 2011;8(3):143 ‐ 51 and infectious disease. 2019 11 12 2

6/24/2019 Influenza Influenza vaccine in MS Influenza affects 1/100 travellers (most frequent vaccine preventable infection) - Group travel - Cruise ship Annual relaps rate - Elderly - Chronic medical conditions months Metze C, et al. Immunogenicity and predictors of response to a single dose trivalent seasonal influenza vaccine in multiple sclerosis . CNS Neurosci Metze C, et al. Immunogenicity and predictors of response to a single dose trivalent seasonal influenza vaccine in multiple sclerosis . CNS Neurosci Ther. 2019 Feb;25(2):245 ‐ 254; Steffen R. Travel vaccine preventable diseases ‐ updated logarithmic scale with monthly incidence rates. Journal of travel Ther. 2019 Feb;25(2):245 ‐ 254; Steffen R. Travel vaccine preventable diseases ‐ updated logarithmic scale with monthly incidence rates. Journal of travel medicine. 2018. medicine. 2018. 13 14 Acute travel associated diarrhea Diarrhoea – treatment E. coli (ETEC) 40 ‐ 70%, Campylobacter, Shigella, Salmonella, Aeromonas etc. Increased risk Previous severe course • Prophylaxis Not routinely recommended Reduced gastric acidity • (antacids, gastric surgery) Cholera vaccine (cross immunity)? • Immunodeficiency Bismuth subsalicylate (renal toxicity in renal tx) • Rifaximin (cyclosporin interaction) „All ‐ inclusive“ tourism • Chinolons not recommended • IBD • Empiric therapy Risk of complication Mild – symptomatic (rehydration, electrolyte substitution, anti ‐ • Dehydration : previous motility agents e.g. loperamide, bismuth) stroke, diabetes, young/old Moderat – chinolons??, azithomycin, rifaximin • age Severe – antibiotic therapy – microbiology testing • Electrolyte imbalances : renal • Cave: invasive infections, developing resistance (campylobacter) insufficiency, IBD Riddle MS et al. J Travel Med. 2017;24(suppl_1):S57 ‐ S74; Beeching NJ, et al.Traveler's Diarrhea Steffen R et al. JAMA 2015;313:71 ‐ 80; Cook/Zumla. Tropical Diseases 2009 Universitätsmedizin Rostock Recommendations for Solid Organ Transplant Recipients and Donors. Transplantation. 2018;102:S35 ‐ s41 Universitätsmedizin Rostock 15 16 Prophylactic measures against malaria Drug interactions Co ‐ medication Possible effect Doxycycline etravirine , nevirapine, CYP3A4/CYP450 ‐ associated efavirenz decreased doxy concentrations calcineurin inhibitors Elevated calcineurin inhibitor levels (tacrolimus, cyclosporine) Proguanil ‐ Efavirenz, rinonavir reduced proguanil metabolites, Atovaquone reduced atovaquon concentration Mefloquine efavirenz, lopinavir inceased QT ‐ interval calcineurin inhibitors Elevated calcineurin inhibitor levels (tacrolimus, cyclosporine) Chloroquine efavirenz, lopinavir inceased QT ‐ interval mosquito avoidance Primaquine etravirine , nevirapine potentially increased primaquine chemoprophylaxis haemotoxicity stand ‐ by emergency treatment (SBET) Tafenoquin as for primaquine? http://www.dtg.org; Boubaker R, et al. Malaria prevention strategies and recommendations, from chemoprophylaxis to stand ‐ by emergency Mariano D, Smith DS. Safe Travel Preparation for HIV ‐ Infected Patients. Current infectious disease reports. 2019;21(4):15. treatment: a 10 ‐ year prospective study in a Swiss Travel Clinic. Journal of travel medicine. 2017;24(5) Universitätsmedizin Rostock Universitätsmedizin Rostock https://www.hiv ‐ druginteractions.org; www.drugs.com/interaction 17 18 3