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.
