One of my transplant patients came to clinic last week excited about his trip to Tanzania. He had undergone kidney transplantation three years ago and has had an uneventful course.
As a transplant nephrologist, you kind of become a PCP for your patients and travel medicine advice must be an integral part of the visit. On a recent survey, more than 35% of transplant patients have reported recent travel outside Canada and USA. 63% of these patients had traveled to endemic areas of hepatitis A but only 5% did receive vaccination. An unacceptable ratio, especially since immunosuppressed patients are increasingly susceptible to enteric, vector-borne or bloodborne infections. Below, some pearls about vaccination/travel medicine in kidney transplant recipients:
Which vaccines are safe for transplant recipients?
- Inactivated vaccines are generally safe and do not seem to increase the risk of rejection, however transplant recipients have a lower rate of seroconversion.
- Live vaccines are contraindicated in transplant recipients – those include MMR, Varicella, Yellow fever and BCG.
What are the routine vaccines for adult transplant recipients?
- Influenza yearly (2011 flu vaccine will protect against H1N1)
- Pneumococcus every 5 years
- Tetanus every 10 years
Which vaccines should be tested for seroconversion?
- Hepatitis A, hepatitis B and pneumococcal vaccines. Seroconversion is defined as a 4-fold increase in titers over 4 weeks after vaccination.
When is it safe to give an inactivated vaccine after transplantation?
- In general, most centers wait 3-6 months after transplant day or after a rejection episode, based on the higher immunosuppressive use and possible lower efficacy of the vaccine. Nonetheless, it is especially important to ensure close contacts and family members have received influenza vaccine yearly!
When is it safe to travel abroad after transplantation?
- In general, traveling to ‘high risk’ areas should be avoided on the first year after transplantation or during the treatment of a rejection episode.
Your patient is heading to Tanzania. What should be your recommendations?
- The CDC Yellow book is a terrific site to obtain information and updates about travel destinations.
- For example in Tanzania, the general recommended vaccinations include hepA, hepB, typhoid, polio and yellow fever. The latter should not be given since it is a live attenuated vaccine. For polio, the inactivated Salk should be used and the TyphimVi (Aventis) for typhoid. On this case, it is worth a visit to a travel clinic in order to get all the required vaccinations (find one close to you here).
- This patient will also require anti-malarial drugs, since malaria is endemic in Tanzania – it is worth noting that most anti-malarial drugs may increase CNI level or increase toxicity of bactrim.
** Finally, Traveler’s diarrhea (TD) is the most common illness of travelers, affecting 10-60% of travelers to developing regions. TD may be life threatening in kidney recipients. In addition to food and water precautions, a five day prescription of Ciprofloxacin 500mg BID should be given to the patient. Threshold to self-treatment include more than 4 unformed stools/day, fever, blood, pus or mucus in the stool.
Kidney transplantation opens up the world to kidney patients but safety precautions should not be overlooked! Have a safe travel!
Picture: Wildbeest migration in Tanzani, one of the most spectacular wildlife events on Earth, when wildebeest and zebras migrate to greener pastures as the seasons change and predators follow them closely.
Posted by Leonardo Riella M.D.