The Special Traveller: Immunosuppressed Traveller
Our immune system is one of the many things in life we take for granted. That is, until we no longer have a properly functioning one. This can come about for many reasons, but is usually the result of certain conditions or infections (e.g. leukemia, HIV/AIDS, removal of spleen) or the medications used to treat these and other conditions (e.g. chemotherapy, steroids, immune modulators). Many “autoimmune” diseases such as lupus erythematosus, inflammatory bowel disease and multiple sclerosis probably do not result in immunosuppression on their own, but their treatments often do.
An ever increasing number of travelers are immunosuppressed and require special consideration, preferably from a travel medicine specialist and/or their appropriate specialist.
Why are they different?
- They may be more susceptible to various infections while traveling. Some of these would be considered unusual or opportunistic infections (e.g. pneumocystis pneumonia, cryptosporidiosis). Others are available to everyone but may be more severe in someone who is immunosuppressed, such as malaria or diarrheal disease (Salmonella, Campylobacter).
- Live vaccines (e.g. yellow fever, oral typhoid, oral polio) are not recommended in these travelers. This may preclude visiting certain destinations.
- While most of the vaccines are “killed” or “inactivated” and considered safe, they may not produce the desired immune response and protection.
- Certain countries may require a negative HIV test as a condition of entry. This would more likely apply to longer stay travelers on a work permit.
Patients infected with HIV can assess their immune status by having their CD4 count checked. Anything under 200 is considered immunosuppressed. A count of between 200-500 may mean some extent of immunosuppression. In the case of oral steroids, a daily dose of 10 milligrams per day for more than two weeks would be significant. Steroid inhalers, creams and injections do not increase risk. Immune modulators, such as Humira®, Enbrel® and Remicade® are used for a number of conditions such as Crohn’s Disease, rheumatoid arthritis and psoriasis, and they do have the potential to lower immunity.
How can you minimize the risks?
- See a travel medicine specialist who can advise you regarding the safety, or lack thereof, of certain vaccines (mainly yellow fever, oral typhoid and polio).
- Delay travel to certain areas until your immunity has improved with time or treatment.
- Killed or inactivated vaccines are safe and you should receive the recommended ones.
- If you must travel to a country where yellow fever is a risk, you might want a Certificate of Medical Contraindication. You may also have to weigh the risk of the vaccine against the risk of disease. Perhaps visiting Machu Picchu in Peru but not the Amazon or other yellow fever areas would be the best idea.
- Travelers who have been on chemotherapy should delay receiving live vaccines for 3 months until after chemotherapy has been completed.
- If your spleen has been removed or you have sickle cell anemia, you should be immunized against Hemophilus influenza, pneumococcus and meningococcal disease.
- Pay particular attention to food and water precautions and insect avoidance.
- Consider using a prophylactic antibiotic such as ciprofloxacin (Cipro®) or rifaximin (Xifaxan®) for the short term prevention of Traveler’s Diarrhea.
- In the case of hepatitis B vaccine, a higher dose may be used to achieve good immunity.
- Take along your pertinent medical records should you need medical care abroad, and know where you will get your medical care before you need it.
- Ensure that your medical insurance covers your pre-existing conditions.