Safe Travels Post-Transplant: Navigating Travel Risks and Appropriate Guidelines

It is not uncommon for transplant recipients to decide to travel post-transplant, despite recommendations that they should not travel within the first year of transplant or within the first year after treatment, explained Heather J. Johnson, PharmD, FCCP, BCPS, during a presentation at the 2024 American College of Clinical Pharmacy (ACCP) Annual Meeting. When on vacation, transplant patients, like other people, may also be more likely to engage in high-risk behaviors.

“Travel is wonderful. It's empowering, and it's exciting, but we might go into vacation mode. We might do things we would not otherwise do when we're at home. There may be risks out there that we might not recognize in terms of the environment, and so we need to think about protecting ourselves and our transplant patients as they travel,” said Johnson, an assistant professor at the University of Pittsburgh in Pennsylvania, during the ACCP session. “Transplant is life changing, as we all know, and survey data shows us that transplant patients travel to a lot of places, and they may go intercontinental.”

Survey data show that transplant recipients may even use IV drugs when they're on vacation, engage in risky sexual practices, and may engage in risky food or hygiene practices, according to Johnson.

“We have to keep all those things in mind as we're thinking about our transplant patient who is traveling. And the alarming thing is also that some of the survey data show that over 15% of patients in some surveys required medical attention while they were traveling. So, these are real risks,” Johnson said. “In terms of immunization history, we're all really good about asking questions about those standard immunizations that we receive as either part of childhood or we receive as part of the transplant workup. We're probably not as good about asking about immunizations that patients might not routinely receive or have received as part of other parts of their care, but we do need to ask about both the routine and the atypical vaccinations.”

Johnson noted that it is important for pharmacists to be aware of the transplant date and the dates of rejection treatment, which will help inform guidance around patient-specific risks during travel. Additionally, pharmacists should ask about the locations and duration of travel.

“It matters if patients are staying with family or if they're staying in a 5-star hotel. It matters if they're going to the beach or climbing in the mountains. It matters what season they're going to visit for certain areas because of the risks involved, and it matters how long patients may be staying in specific places,” Johnson said.

Johnson explained further that there are great resources available for assessing the risks present in places that patients are intending to visit, with one of the best resources made available by the CDC.

“The CDC is the first place that I would go for travel information, and they provide information about specific countries and specific travel notices. The CDC Yellow Book dives a little bit deeper, but it isn't updated as frequently as the travel notices,” Johnson said. “The CDC also specifically has a section on mosquitoes, which are public enemy number 1.”

Additionally, Johnson noted that another resource available are the guidelines from American Society of Transplantation (AST), which provide information both about travel as well as safe living after transplant. Most recently, AST released a video for practitioners and patients about travel considerations that has valuable information, according to Johnson.

In the CDC resources, Johnson noted that the site also has a section on non-vaccine preventable diseases that may be high risk in certain areas.

“You get information about staying healthy and safe, as well as what might go into a travel list and even thoughts for what to do after your trip, because some of the risks that patients will have as they travel persist after they come home,” Johnson said. “The CDC Yellow Book has a specific chapter on travelers with additional considerations that includes immunocompromised travelers and travelers with chronic illnesses. They have lists that go into specific drugs and which drugs we should be aware of, so it's a very well-designed tool. They also have a specific chapter on environmental hazards and risks by location.”

The CDC also notes information about sun exposure, which patients might have more of if they're traveling to certain locations, as well as risks from mosquitoes, ticks, and other arthropods. Johnson noted that one of her patients, who she referred to as the Transplant Globetrotter, within the first year of transplant went to Iceland, which has lower risks, and India, which may have some risks depending on his history.

“He decided to climb Mount Kilimanjaro and shared the video of his flight there for the first year anniversary of his transplant,” Johnson said. “He's doing well, but he did this all without asking for medical advice, which up to a third of transplant patients do, according to the survey data. Now he's decided to disclose to us that he does want to go to Machu Picchu.”

Johnson explained that Transplant Globetrotter is on tacrolimus and mycophenolate, and his baseline disease was metabolic and alcohol related. He was transplanted just over almost a year and a half ago.

“Well, lucky for us, section 10 of the CDC Yellow Book has popular itineraries, and they divide those popular itineraries by continent, and one of those popular itineraries that you can click on is Cusco and Machu Picchu,” Johnson said. “So, the CDC Yellow Book has already done a lot of the work for us.”

Malaria is caused, like many of the other infectious diseases that are a concern while traveling, by public enemy number one—the mosquito. Image Credit: © nechaevkon - stock.adobe.com

In the CDC Yellow Book, it discusses antimicrobial prophylaxis, vaccines, and other preventative measures pharmacists can use for transplant patients based on travel location. Malaria is one such concern for Peru, as it tends to be present in tropical regions. Malaria is caused, like many of the other infectious diseases that are a concern while traveling, by public enemy number one—the mosquito.

“Mosquitoes have different patterns of feeding depending on what kind of mosquitoes they are, but the mosquitoes that cause malaria tend to like to feed at dusk and dawn, so that would be important for counseling for our patient, as the malaria lifetime cycle is complicated,” Johnson said. “It may be many, many days before symptoms present, and may even be days after the patient returns home when they develop any symptoms.”

The onset for malaria is between a week and 30 days after an infected mosquito bite. Malaria, as all as other infectious diseases, can be more severe in transplant patients, which is why it is important to think about these risks, according to Johnson. For malaria, the risk of severe disease depends on the mosquito species, the parasite load, the degree of immunosuppression, as well as the time between symptom onset and the time to diagnosis.

“The more time that passes between symptom onset and diagnosis, the more likely the patient will end up having severe disease. For transplant patients, severe disease is defined by having any 1 of a list of conditions, which includes thrombocytopenia and impaired consciousness,” Johnson said. “What we want to do is prevent severe disease, which is why we want to prevent disease in the first place. There are many, many agents available for antimalarial prophylaxis, and the recommendations for which antimalarial prophylaxis is appropriate for a patient, depending on where they're going, is ever changing according to the resistance patterns of malaria at present.”

There is also no vaccine for malaria available, and the ideal prophylaxis drug for a certain patient on a certain trip will differ greatly based on the amount of time they need to take the drug, whether it is taken prior to travel, and the amount of time it needs to be taken after travel. Antimicrobial prophylaxis also varies distinctly by the number of times per day, or number of times per week it needs to be taken while traveling. Some of the medications may also require pre-testing, such as for G6PD testing, because the medication cannot be taken by patients who are deficient.

“There are also drug interactions with some of these medications and the immunosuppressive agents we commonly use, so that will have to be checked before we decide on the optimal antimalarial prophylaxis for our patients,” Johnson said. “If you really drill down and pull up the map for Peru, which is where Machu Picchu and Cusco are, we can look and see that there are some more specifics that show Peru, in and of itself, is not all at the same risk. So, if we only had information about the country our patient was visiting, we would not have enough information to make decisions.”

According to CDC’s map of regions at risk of malaria, Cusco and Machu Picchu are actually indicated as very low malaria risk because of the high elevation, since most malaria transmission is at low elevations and low inland elevations. Because Transplant Globetrotter’s travel itinerary is predominantly Cusco and Machu Picchu, from what we know, he actually is listed as not being at malaria risk in this location.

“The CDC site also pushes us to think about other illnesses that patients may be at risk for on the vaccines and medicines page,” Johnson said. “There are vaccine-preventable illnesses such as chikungunya and yellow fever in Peru. There also are non-vaccine preventable infections listed on the CDC site, and some of these are more medicine preventable than others, such as dengue and Zika virus.”

Johnson explained further that patients should take extra medications with them as they travel, and they should think about establishing an arsenal of over the counter or other medications that they might want to have in case they may need it. Johnson explained further that pharmacists can advise patients around what they should pack and bring with them to be prepared, such as medications, vaccine records, a yellow card or waiver if the destination requires it, insect repellent, sunscreen, sanitary wipes, and a first aid kit.

“Because when you're prepared and think about the possibilities that things happen, you can confront those events in a much better way than you could had you not thought about it, and all of a sudden you're calling your transplant coordinator in the middle of the night because you don't know what you're supposed to do,” Johnson said. “We also do not travel alone, and so we might want to think about what the recommendations would be for those household contacts.”

Johnson explained that the guidelines suggest that household contacts and travel companions should be vaccinated against the same things the transplant patient needs to be vaccinated against.

“So, if they're traveling to a yellow fever country, their travel companions should be vaccinated for yellow fever. If there's an opportunity to choose the safer vaccine, we should choose the safer vaccine, but we should vaccinate those household contacts,” Johnson said. “We have lots of resources available at our fingertips to help Transplant Globetrotter during his travels.”

REFERENCE

Johnson HJ. Prevention of Infectious Diseases Acquired Via Travel in Persons Undergoing Solid Organ Transplantation: A Review of Malaria, Arboviruses, and Travel Vaccines​. Presented at: 2024 American College of Clinical Pharmacy Annual Meeting; October 12-15, 2024; Phoenix, Arizona.