Arden’s life dream is to study economics in Mali. She fell in love with the country after reading a book about a small village there as a child. Now in college, she is eligible for a study abroad program and wants you to provide travel vaccines and medications.
But there is a big problem. Arden developed autoimmune arthritis in her teens.
The problem is not the arthritis, but rather the methotrexate she uses to keep it under control. Arden is a model patient; she takes her immunosuppression as prescribed, gets all the follow up labs, and is under excellent control. In her mind she is far more responsible than her peers. She just knows she won’t get sick when she travels.
Arden’s mom is not so sure. She wants to bundle Arden up in a cocoon and keep her safe. She worries that her daughter will get sick or have a flare-up of her disease while traveling. Mom would really prefer that Arden stick to domestic travel.
If you have a large general medical practice chances are sooner or later one of your immnosuppressed patients will travel abroad.
Care for the immunocompromised traveler is challenging, but well within your scope of care. You will work in concert with your patient’s specialist; each of you has a different responsibility and together you help your patient stay healthy.
At first, you are likely to need guidance from travel medicine specialist. Hopefully you are fortunate enough to have one within your practice network, if not you can find one here.
As you develop more travel medicine skills you will have the confidence to manage immunosuppressed patients who travel yourself, in conjunction with their specialist.
When you join International Society of Travel Medicine (ISTM) you will have the support of the membership who can guide you through the learning process; really it’s the quickest way to get up to speed.
How to help your immunosuppressed patients travel
Start asking your patients if they are planning to travel. If they are feeling well it’s likely they are traveling, and you’ll never know if you don’t ask.
Over one-third of immunosuppressed patients who travel abroad fail to get any pre-travel advice.
A recent study highlighted the convergence of a tripling of international travel with the rapid rise in immunosuppressive therapies creating a dramatic rise in travel for people with organ transplantation, cancer, HIV and autoimmune diseases.
Surprisingly 20-45% of immnocompromised patients travel abroad, yet over a third fail to get any pre-travel advice.
It’s time for you to develop a strategy to provide effective pre-travel care for your medically fragile patients.
You role will be to be the ‘go between’ the specialist and your patient. This may take several phone calls or office visits. The GI, rheumatologist, or oncologist working with your patient is likely to be an expert in diseases and immunosuppression, but not travel health.
This is where you come in. You understand the vaccines and you can see the big picture. Most importantly you are an expert in anticipatory guidance, a big part of travel medicine. Having a collegial relationship with your colleagues will make the whole process go a lot smoother.
Communication and coordination of care is the hallmark of effective pre-travel healthcare. Discuss the level of immune suppression with your patient’s specialist. Assess the risk of disease from the available medical literature and peer forums. ProMED-mail is a good database to search.
You may find that CDC recommends vaccines for your patient. Take a moment to consider whether your patient can actually receive the recommended immunizations. Fortunately there is a comprehensive review of best practices for vaccination of the immunocompromised patient, which includes advice about travel vaccines.
One of your most difficult tasks is communicating risk of becoming ill while traveling to your patient. Risk, in general, is a very hard concept to communicate effectively and even more difficult with very little data. Don’t worry, you do this every day, and there are established best practices (here and here) to guide you.
What do you recommend?
Some of your advice may be uncomfortable. It may even put you in direct conflict with the desires of your patients. This is the difficult part of the job, but you are up to the task.
Suggestions may include:
- Picking a destination appropriate for the underlying disease.
- Providing extra protection from illness at the destination.
- Identifying healthcare providers at the destination able to help your patient with complex medical care.
- Managing recommended vaccines carefully, especially live vaccines.
Let’s look at these separately:
1. Picking a destination with less medical risk
This may be the best option, albeit unpopular. In many cases, the immune suppression makes your patient far more susceptible to infections or unable to get required vaccines.
Help your patient identify what is so attractive at the intended destination and see if there isn’t another country with similar offerings.
For example many immune suppressed patients cannot safely receive yellow fever vaccine and are rendered more susceptible to malaria. This makes travel to certain parts of Africa or South America rather risky.
In the case of yellow fever a medical exemption to vaccine can be provided. This will allow your patient to cross international borders, but does not protect them from yellow fever.
South Africa offers safaris without the need for a yellow fever vaccine and Costa Rica offers jungle excursions without malaria exposure or the need for yellow fever vaccine. Have your patients think deeply about this, they can often find a good substitute.
2.Providing extra protection
To offset increased susceptibility to infections it makes sense to protect your patients as much as possible.
Insects spread many diseases. In addition to detailed instruction about effective repellents you can provide an extra layer of protection by treating clothing with permethrin. For those in whom traveler’s diarrhea may set off a cascade of health problems, taking preventative Rifaximin may be a good option.
3.Identifying healthcare providers at the destination
Not all heath problems can be anticipated or prevented. The specialist can discuss how to manage a flare-up while traveling abroad and provide the needed medications and instructions for your patient.
But what if the flare up is too severe to handle alone?
Many specialists have systems for patients to contact them while traveling. Alternatively, the specialist can suggest a colleague at the destination, someone they know or from membership in a specialty society with the skills to help your patient.
International Association for Medical Assistance to Travelers (IAMAT) is a great source for generalists, they in turn, know the specialists in their locales.
Remember, there are some problems too complicated to be cared for in a resource-poor community. In that situation, your patient may need to change their travel plans.
4.Managing recommended vaccines
To administer live vaccines you may need to discuss the level of immune suppression with the specialist. Most live vaccines cannot be given to an immune suppressed patient. The Infectious Disease Society of America (IDSA) has a monograph with detailed guidance for vaccination of immunocompromised patients.
Sometimes, especially with mild disease, and always with the consent of the specialist, your patient can stop suppressive medications for a period of time to give needed vaccines. After an appropriate waiting period they resume their medications.
This is a difficult decision, and there are no reliable data to guide you. It will require clear and open discussions between you, your patient and their specialist.
Arden is caught between a rock and a hard place. On immunosuppression she cannot get the needed (live) yellow fever vaccine for travel, off immunosuppression her underlying disease may flare up.
After detailed discussion with her rheumatologist, Arden decides to discontinue her medication for 3 months, receive her yellow fever vaccine and resume her methotrexate a month later. If she is lucky her disease won’t flare-up. It is a calculated risk; one she is willing to take.
When most patients think about travel health they think about shots. But the data are clear that vaccines do not prevent most of the problems travelers face. Car accidents, digestive troubles, and respiratory infections top the list of common travel-related health problems.
This is where you, the medical generalist, come in.
After you have discussed travel vaccines and the appropriateness of the destination you will need to provide effective anticipatory guidance.
It’s important you remember to discuss personal safety issues, seat belts, sun protection, alcohol use and safer sex. These are the most likely problems your patients will face, and they are all topics you talk about everyday.
Can I really do this?
You might think, “Hey this sounds really complicated, I think I’ll send my patient to the health department to get this taken care of.”
That’s not going to work, since most health departments use protocols to provide vaccines to healthy people. Which means most immune suppressed patients cannot get their vaccines there.
Besides, they don’t prescribe medicine or provide anticipatory guidance, which is what your patient really needs. The specialist is not likely to be able to do this alone either.
You are part of a team and have an important role.
You are the one your patient trusts and you know how to communicate risk effectively; you do this all day, every day. You got this.
Arden really needs sound advice about insect bite avoidance, malaria prevention, personal safety, and plans to minimize or treat any flare-ups. The yellow fever vaccine question is just the start of the conversation, the issue that brings her into the office. You will expand her understanding of how to stay healthy while traveling, beyond a few shots.
Providing comprehensive pre-travel advice is part of general medicine.
You make an awesome team when you partner with your patient’s specialist.
The specialists provides management of the underlying disease and you provide the vaccines and anticipatory guidance for travelers.
It’s fun and rewarding to help your patient realize a dream. And it’s good medicine.