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Keywords:

  • Travel medicine;
  • organ transplant;
  • vaccination

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Increasing numbers of solid organ transplant recipients are traveling to the developing world. Many of these individuals either do not seek or do not receive optimal medical care prior to travel. This review considers risks of international travel to adult solid organ transplant recipients and the use of vaccines and prophylactic agents in this population.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Many individuals travel to industrialized and developing/nonindustrialized regions for work and pleasure following solid organ transplantation (1,2). In 267 transplant patients from Toronto (2), 36% traveled outside of North America of whom 66% sought pretravel advice, primarily from their transplant physician. Of those who did not seek pretravel advice, the majority traveled to the developing world. Sixty-three percent traveled to areas where hepatitis A is endemic, with only 5% receiving hepatitis A immunization. Over half traveled to areas where malaria and dengue fever are endemic, but less than a quarter adhered to mosquito-avoidance measures. Ten percent reported behaviors that exposed them to blood-borne pathogens, including injections, body piercing and casual sexual activity. Only 18% carried antibiotics for self-treatment of diarrhea. Seventeen percent were sick enough to seek medical attention either during or immediately after the trip.

Organ transplant recipients should meet with their health care provider prior to travel to determine potential hazards associated with each region to be visited. A number of guidelines are available for general issues regarding travel medicine and prophylaxis (3–8), including the Center for Disease Control and Prevention (CDC) traveler's health web site (http://www.cdc.gov/travel) and destination link (http://www.cdc.gov/travel/destinat.htm). These links provide access to destination-specific information on risks for infection, recommended prophylaxis and vaccination strategies, current outbreak information, cultural issues and government travel advisories. The traveler should be referred to a travel medicine center if the clinician lacks relevant expertise. As immune suppression and metabolic derangements are usually most intense in the immediate posttransplant period or after treatment for rejection, travel to developing regions should be delayed, if possible, beyond 3–6 months after transplantation or treatment of rejection.

Traveler's Diarrhea

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Diarrhea is the most common illness of travelers, affecting 10–60% of travelers to developing regions. Traveler's diarrhea may be life-threatening to travelers with compromised immune systems. Dehydration may compromise renal function, and markedly increase toxicity of immunosuppressants. Complications of diarrhea may include bacteremia, metastatic seeding and altered intestinal absorption (with concomitant alterations in the absorption of oral immunosuppressive medications). Prior to international travel, organ recipients should be instructed in appropriate food and water precautions (http://www.cdc.gov/travel/food-drink-risks.htm) (6). In general, SOT recipients should be cautioned to drink boiled or bottled water and other beverages, and to avoid food sold by street vendors and raw foods (except fruit and vegetables that can be peeled).

If SOT recipients develop diarrhea for more than 1–2 days while traveling, especially with fever, vomiting and/or bloody stools, they should consider seeking medical attention. Immunocompromised travelers should carry appropriate antimicrobial agents for presumptive self-treatment (Table 1) (6). Fluoroquinolone antibiotics are the usual choice for empiric therapy of traveler's diarrhea. Alternatively, short courses of azithromycin may be an appropriate treatment option (3); although azithromycin may transiently increase levels of cyclosporine and tacrolimus (Table 2). Due to microbial resistance, trimethoprim-sulfamethoxazole is ineffective against traveler's diarrhea. There are no data regarding the use of antimotility agents (loperamide, atropine/diphenoxylate) in transplant recipients with diarrhea, but such agents may serve to delay clearance of toxins from the gut. Bismuth-containing therapies may also be used (6). In the gastrointestinal tract, bismuth subsalicylate is converted to salicylic acid and insoluble bismuth salts. SOT recipients with decreased renal function may be at higher risk for salicylate toxicity. Prophylaxis against bacterial traveler's diarrhea is rarely indicated and should only be considered for short-term use. Bismuth subsalicylate confers only moderate protection as a prophylactic agent (6).

Table 1.  Travel-related medications, adult dosages and duration
  Dose Duration Change for reduced GFRChange for hepatic dysfunction
Diarrhea treatment
 Ciprofloxacin500 mg bidfor 3–7 daysYesNo
 Levofloxacin500 mg qDfor 3–7 daysYesNo
 Azithromycin500 mg qDfor 3–7 daysUse caution if CrCl < 10 mL/minNo
Malaria prophylaxis
 Atovaquone-proguanilAtovaquone/proguanil 250 mg/100 mg, dailyStart 1–2 days prior to entering a malaria-endemic area, continue throughout the stay and for 7 days after leaving malarious areaNot for mild-to-moderate renal impairment; avoid if severe renal impairment (CrCl < 30 mL/min)No dosage adjustment required in mild-to-moderate hepatic impairment. No data for use in severe hepatic impairment.
 Mefloquine250 mg, weeklyBegin 2 weeks before, arrival in endemic area, continuing weekly during travel and for 4 weeks after leaving endemic areaNoHalf-life may be prolonged and plasma levels may be higher
 Doxycycline100 mg, dailyStart 1–2 days prior to entering a malaria-endemic area, continue throughout the stay and for 28 days after leaving malarious areaNoNo
 Chloroquine500 mg/week (300 mg base), weeklyBegin 1–2 weeks prior to exposure; continue for 4 weeks after leaving endemic areaAdminister 50% of dose if CrCl < 10 mL/minNo dosage adjustment required
Altitude illness prophylaxis
 Acetazolamide125–250 mg bidBegin 1–2 days before ascending and continue until 2 days after completing ascentYesNo
Table 2.  Interactions between transplant and travel-related medications
 Calcineurin inhibitors (CNI)Trimethoprim/ sulfamethoxazole
  1. *Significant interactions of travel medicines and azathioprine, mycophenolate mofetil and corticosteroids have not been reported; significant interactions of transplant medicines and levofloxacin, diphenoxylate hydrochloride and atropine sulfate tablets or loperamide have not been reported; minimal data available.

  2. Adapted from MicroMedex® DrugReax® interactive drug interactions and Lexi-Comp Online™ interaction analysis.

AzithromycinMay [UPWARDS ARROW]CNI levels 
MefloquineMay [UPWARDS ARROW]CNI levelsMay increase risk of cardiac toxicity, QT prolongation, torsades de pointes or cardiac arrest
Atovaquone/proguanil May increase risk of of bone marrow toxicity
DoxycyclineMay [UPWARDS ARROW]CNI levels 
ChloroquineMay [UPWARDS ARROW]CNI levelsMay increase risk of cardiac toxicity, QT prolongation, torsades de pointes or cardiac arrest
PrimaquineMay [UPWARDS ARROW]CNI levels 
Sulfadoxine/pyrimethamineMay [DOWNWARDS ARROW]CNI levelsMay increase risk of of bone marrow toxicity
AcetazolamideMay [UPWARDS ARROW]CNI levels 

Transplant recipients are at risk for additional water-borne diseases, including those caused by coccidian infections (isosporiasis, cryptosporidiosis, cyclosporiasis), microsporidiosis and giardiasis. Transplant recipients who have diarrhea refractory to standard treatment should be fully evaluated for intestinal parasitic infection.

Respiratory Infections

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Respiratory infections are the second most common infection affecting travelers (3). All transplant recipients should receive pneumococcal vaccination and yearly influenza immunization (Table 3) (6,7,9). The risk of influenza in tropical and subtropical climates is year-round; in the Southern hemisphere, peak influenza season is May–October. Endemic fungal pulmonary infections, such as histoplasmosis, coccidioidomycosis and penicilliosis, could be acquired during travel (10). SOT recipients are at higher risk for invasive fungal infection, and should avoid activities such as spelunking and excavating, activities that have been associated with exposure to Cryptococcus neoformans or endemic fungi.

Table 3.  Vaccination after solid organ transplantation (6,37)
VaccineRecommendation after transplantation
  1. *Live, attenuated.

  2. Adapted from the Centers for Disease Controls ‘Recommended Adult Immunization Schedule—United States, 2003—2004’ (37) and ‘Vaccine Recommendations for Travelers with Altered Immunocompetence, Including HIV’ in ‘Health Information for International Travel 2003–2004’ (6).

Routine vaccines
 Influenza-parenteralYearly
 Influenza-intranasal*Contraindicated
 PneumococcalRecommended, one time booster after 5 years
 Tetanus/diphtheriaRecommended
 MMR*Contraindicated
 Varicella*Contraindicated
Vaccines for selected travelers after solid organ transplant
 Hepatitis ARecommended
 Hepatitis BOccasionally recommended
 MeningococcalOccasionally recommended
 Typhim ViRecommended
S. typhi Ty21a*Contraindicated
 Oral polio (OPV)*Contraindicated in patients/family members
 Inactivated polio (IPV)Recommended
 RabiesOccasionally recommended
 BCG*Contraindicated
 Yellow fever*Contraindicated
 Japanese encephalitisOccasionally recommended

Malaria and Other Arthropod-Borne Illnesses

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Malaria and dengue fever are the most common arthropod-borne illnesses of travelers. Most cases of dengue fever are self-limited in the normal host; the risk for complications in transplant recipients is unknown. Malaria is a significant risk for all travelers to endemic areas. There is no evidence that malaria is significantly more common or severe in individuals with AIDS or in other immunocompromised hosts (4).

Prophylaxis against malaria should be based on the travel itinerary. Choloroquine should be considered the first-line agent to prevent malaria in individuals traveling to areas of the world endemic for chloroquine-sensitive malaria. Chloroquine may increase cyclosporine levels, thus levels should be monitored when administered to organ transplant recipients. For travel to areas of the world endemic for choloroquine-resistant malaria, three main chemoprophylactic options exist in the United States: atovaquone/proguanil, mefloquine and doxycycline; the latter two may have interactions with the common immunosuppressive medications (Table 2). Prophylactic medications should be started a few weeks prior to travel to permit measurement of immunosuppressive drug levels prior to travel (Table 1). Drug levels should be rechecked after stopping prophylaxis. For theoretical concerns, proguanil should be taken with care if the patient is taking another folate antagonist, such as prophylactic trimethoprim-sulfamethoxazole; some authorities suggest supplying folic acid supplements (4). Mefloquine should be avoided in patients with a history of convulsions, cardiac conduction abnormalities or psychiatric disorders. Atovaquone used for prophylaxis against PCP is inadequate as a single agent for protection against malaria. Proguanil is not commercially available as a single agent in the United States. Therefore, a separate antimalarial agent such as daily doxycycline should be provided. In addition to receiving chemoprophylaxis against malaria, organ transplant recipients traveling to the developing world should be instructed on ways to minimize insect bites, including use of repellents containing DEET (N,N-diethyl-3-methylbenzamide), protective clothing and permethrin-impregnated clothing and bed nets (6).

Sun Exposure and Altitude

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Transplant recipients have a major risk of skin cancer that correlates with the intensity of sun exposure. It is important to recommend the use of hats, sunglasses, protective clothing (also useful for arthropod-borne infections) and sunblocking agents with ultraviolet A and B protection.

Travelers who rapidly ascend to altitude are at risk for altitude sickness. Acetazolamide accelerates acclimatization and decreases the risk of altitude sickness (11); its use in organ transplant recipients is unstudied. Travelers to high attitude should be advised to avoid vigorous activities for the first few days at altitude. Acetazolamide should be offered to those travelers ascending rapidly to greater than 2500 m since there is at least a 15–25% risk of altitude sickness. Acetazolamide may increase cyclosporine trough concentrations. Corticosteroids have some efficacy for the symptoms of altitude sickness, but, unlike acetazolamide, steroids do not accelerate acclimatization. The recommended prophylactic dose of dexamethasone is 4 mg every 6 hours (11).

Vaccines: Evaluation and Timing

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Transplant recipients should be vaccinated prior to transplantation whenever possible, including vaccines for anticipated travel (Table 3). While metabolic dysfunction prior to transplantation may diminish responses, pretransplant immune memory boosted after organ transplantation is more effective than primary vaccination following transplantation (12). Vaccination is generally avoided in the first 6 months after organ transplantation to avoid confusion with early graft dysfunction or rejection. When possible, vaccination for travel should be started several months before the trip, to allow time for possible additional boosters and serologic evaluations. Emergency travel (such as international travel due to a personal crisis or death of family member) may present a potentially high-risk situation. In such a circumstance, passive immunization could be used, such as administration of intramuscular immunoglobulin to protect against hepatitis A virus infection.

Although there have been reports of graft rejection temporally associated with vaccination (13), others have not found evidence of such an association (14). Infections normally prevented by vaccination may themselves contribute to graft rejection and may be life-threatening in the immunocompromised host (6,9,15). Immune responses to vaccination may wane more rapidly in immunocompromised individuals than in other hosts. For some pathogens, antibody titers following immunization may be measured. Booster doses of vaccine are occasionally administered, but such practices have not been subjected to rigorous trials nor evaluated for protective efficacy. The efficacy of vaccine adjuvants have not been well studied in SOT recipients and have not been successful in increasing immunity to vaccines in normal hosts (16).

Routine Vaccines

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Recommendations for routine adult vaccinations, including immunizations for immunocompromised individuals, are available through the Centers for Disease Control and Prevention website (http://www.cdc.gov/nip/recs/adult-schedule.pdf). Diphtheria is common in the developing world with 5–10% mortality among normal hosts despite therapy. A diphtheria antibody level of >0.1 IU/mL suggests adequate protection. Patients with a lower titer and those vaccinated more than 10 years prior to travel should be revaccinated before entering an area in which diphtheria is endemic or resurgent. For immunocompromised travelers entering high-risk areas, diphtheria antibody levels may be measured a month or more after vaccination.

Approximately 30 million cases of measles occur each year globally, resulting in approximately 750,000 deaths. Measles vaccination in the United States is usually performed with a trivalent live viral vaccine (measles-mumps-rubella [MMR] vaccine). In general, live vaccines are contraindicated in immunocompromised individuals (6,8,9,17). In a small study of 18 pediatric patients vaccinated with MMR after liver transplantation, however, immunity developed in seven children by serologic criteria and there were no complications directly attributable to immunization (18). Prior to travel by transplant recipients, serologic evidence of immunity against measles, mumps, rubella and varicella should be evaluated. Immune globulin should be considered for measles-susceptible, immunosuppressed travelers who travel to measles-endemic countries (6).

Immunization against hepatitis B may be indicated for certain transplant recipients, including those with new sexual partners while traveling, and those living in endemic areas for extended periods. Compared to the immune response following immunization pretransplation (8,9), the efficacy of standard hepatitis B vaccination is reduced when the vaccine is administered posttransplantation (with response rates of 5–15%) (19). In comparison, 20 liver transplant patients given extra doses of hepatitis B vaccine with one of two new adjuvants demonstrated a serologic response rate of 80% (16). A group of 24 renal transplant patients who did not respond to intramuscular vaccine had a overall response rate of 63% to a series of eight intradermal vaccinations followed by an intramuscular vaccination (20). For immunocompromised persons, some authorities recommend immunization with a vaccine containing 40 mcg of hepatitis B surface antigen (i.e. two 1 ml Engerix-B® vaccines, each containing 20 mcg, or a special formulation of Recombivax-HB®) given at one site, in a four-dose schedule at 0, 1, 2, 6 months (6), although this regimen has been predominantly evaluated in dialysis patients.

Travel Vaccines

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Hepatitis A

The risk of hepatitis A in nonimmune travelers to the developing world is estimated to be 1 in 1000 per week for those on a usual tourist route, and 1 in 200 for those on more adventuresome travel (3). Immunoglobulin is 85–90% effective at protecting against infection, although this effect only lasts for 3–6 months. Hepatitis A vaccine is less effective in transplant recipients. In a study of 37 hepatitis A seronegative liver transplant recipients who were given hepatitis A vaccine 6 months apart, only 8% had seroconverted at 1 month following vaccination, and only 26% at 7 months (1 month after the second vaccination) (21). In another study, zero of eight liver transplant recipients responded to the two doses of vaccine given 2 months apart (22). In a third trial, liver and renal transplant recipients (39 in each group) received two doses of hepatitis A vaccine 6 months apart (23); response after the primary dose occurred in 41% of the liver transplant patients and 24% of the renal transplant patients, while after the second dose, the respective conversion rates were 97% and 72%. Two years after vaccination, organ transplant recipients had a more rapid antibody decline than controls, and only 59% of liver transplant and 26% of renal transplant seroconverters retained protective titers (24). No clear explanation is found for the discrepancies between studies, although differences exist in patient selection, severity of liver disease, immunosuppressive medications and type of vaccine used. For hepatitis A, if there is enough time before travel, it may be useful to vaccinate SOT-recipient travelers with two doses of vaccine 6–12 months apart when the transplant recipients are at least a year after transplantation and being treated with a modest dose immunosuppressive regimen. SOT recipients who do not have time or do not respond to active immunization should be given intramuscular immunoglobulin prior to travel (6).

Typhoid

An estimated 16 million cases of typhoid fever and 600,000 related deaths occur worldwide each year. Approximately 300–400 cases of typhoid fever are reported in the United States each year, with the majority related to international travel. Immunocompromised individuals are at risk for severe complications during infection with Salmonella enterica serovar Typhi and should be immunized against typhoid prior to travel to the developing world. There are currently two vaccines commonly available: TyphimVi® (Aventis Pasteur SA, Swiftwater, PA, USA), an injectable polysaccharide vaccine, and Vivotif® (Ty21a, Berna, Berne, Switzerland) an oral live, attenuated vaccine. The live oral typhoid vaccine is not known to cause disseminated disease; however, for theoretical reasons, the inactive parenteral vaccine should be administered to immunocompromised individuals. Immune response in immunocompromised hosts to either typhoid vaccine is usually poor; responses in organ transplant recipients have not been specifically studied. A study of HIV-positive patients vaccinated with TyphimVi found lower levels of antibody against S. enterica serovar Typhi in vaccinated HIV-infected individuals compared with vaccinated healthy controls (25).

Polio

Poliomyelitis caused by wild-type poliovirus has been eradicated from the Western hemisphere, but wild-type virus exists in sub-Saharan Africa and South Asia. In addition, outbreaks of vaccine-associated poliomyelitis remain possible due to neurovirulent reversion of live attenuated poliovirus from oral polio vaccine. There have been recent outbreaks of vaccine-associated poliomyelitis in Haiti, the Dominican Republic, the Philippines, Madagascar and Cape Verde. Worldwide, two forms of the polio vaccine are available: orally administered, live, attenuated virus (OPV or Sabin) and injected inactivated poliovirus vaccine (IPV or Salk). Since attenuated vaccine strain polioviruses may spread through fecal-oral contact, SOT recipients and household contacts of immunocomprised individuals should not receive OPV. OPV is no longer distributed in the United States. Travelers should have received a primary series of polio vaccine and at least one booster as an adult. Some authorities recommend booster immunization if more than 10 years have elapsed since administration of the last polio vaccine, especially for individuals traveling to areas of the world with a polio outbreak or with circulating wild-type polioviruses.

Meningococcus

Clinically evident meningococcal disease is associated with high case-fatality rates (5–15%), even when adequate medical services are available. In the United States, a quadrivalent polysaccharide (Neisseria meningitidis A, C, Y, W-135) vaccine is available. The meningococcal vaccine is indicated for individuals traveling to areas of the world with an outbreak of invasive meningococcal disease caused by a serogroup included in the vaccine, and for individuals traveling to the meningitis belt of sub-Saharan Africa, especially during the dry winter months of December through June. Proof of vaccination is required for travel to Saudi Arabia for Muslim pilgrims partaking in hajj or umra. There are no data regarding the response of solid organ transplant recipients to immunization with the polysaccharide meningococcal vaccine. The majority of 44 patients who were given the vaccine 8–20 months after bone marrow transplantation had significant immune responses to serogroups A and C; these responses were higher in individuals 20 months after transplantation than 8 months after transplantation (26). These responses declined sharply over the first 6–12 months after vaccination; revaccination should be considered for new or continuous risks of exposure to meningococcal infection.

Yellow fever

Yellow fever is a mosquito-borne viral hemorrhagic fever with a high case-fatality rate. The disease occurs in tropical regions of South America and sub-Saharan Africa, and kills an estimated 30,000 people every year. No specific treatment exists and case fatality may surpass 20%. Yellow fever may be a risk for travelers to endemic countries. The yellow fever vaccine contains a live attenuated viral strain and is distributed only through Department of Public Health-certified vaccination centers, including travel clinics and some county health departments. A listing of approved centers is available from local Departments of Public Health and the U.S. CDC (http://www2.ncid.cdc.gov/travel/yellowfever/).

As a general rule, the yellow fever vaccine should not be given to immunosuppressed individuals, including solid organ recipients (5–7,9,27,28). While a few mildly immunosuppressed travelers have tolerated the vaccine (including individuals with early HIV infection or a distant history of hematological malignancy not currently being treated with immunosuppressive agents) (29–31), complications including death have been reported in immunosuppressed individuals (32). Optimally, the SOT traveler should avoid regions where yellow fever is endemic; alternatively, SOT recipients should understand the risks of travel and minimize exposure to mosquitoes. A physician's letter stating contraindications to vaccination is acceptable to some governments. Such letters should bear the stamp of an official immunization center approved for distribution of the yellow fever vaccine. Some countries may deny entry without immunization; knowledge of the specific regulations is suggested (http://www.cdc.gov/travel/yb/outline.htm#2). Family members of immunosuppressed persons may receive yellow fever vaccine.

Rabies

Compared to the risk in the United States, many travelers are at an increased risk of exposure to rabid animals while traveling. Long-term travelers, individuals expecting intense animal exposure, and individuals who plan to be far from medical care should be considered candidates for pretravel immunization against rabies. Since SOT recipients may not mount adequate antibody responses to the rabies vaccine (titers >0.5 IU/mL are considered adequate), some authorities recommend administration of human rabies immunoglobulin (HRIG) after all at-risk exposures (normally, HRIG is only given to previously nonimmunized individuals) (33). Intradermal administration of rabies vaccines may result in variable immune responses even in immunocompetent individuals and is not recommended by most authorities. One study of seven HIV-positive patients with low CD4(+) T lymphocyte counts (<200 cells/μL) found poor neutralizing antibody responses to pre- and postexposure rabies vaccination (34) (with doubling of the intradermal doses of cell-culture rabies vaccine). Three HIV-infected patients with higher CD4 T lymphocyte (range 295–472 cells/μL) counts had better antibody responses to postexposure rabies vaccination.

Japanese encephalitis

Japanese encephalitis (JE) may cause up to 10,000 deaths annually in Asia. Immunization against JE should be considered for individuals with intense rural travel in areas of Asia endemic for JE, especially during periods of increased transmission (6,35). The JE vaccine is a killed viral vaccine and estimated to be 80–90% effective; hypersensitivity reactions in immunocompetent individuals occur in 0.6% of recipients and include generalized urticaria and/or angioedema, and less rarely neurologic adverse reactions including acute disseminated encephalomyelitis. The efficacy of the JE vaccine is unstudied in solid organ transplant recipients. In a study of HIV-infected Thai children who were given two doses of JE vaccine at 12 months of age, 5 of 14 (36%) HIV-infected children and 18 of 27 (67%) uninfected children had positive JE antibody titers after immunization (36).

Summary

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References

Pretravel counseling and vaccination is an important part of medical care for SOT recipients. As both international travel and the number of SOT recipients increases, transplant physicians and recipients need to have an increased awareness of travel health. There is a need for more data on vaccination and disease prevention in immunocompromised individuals, including solid organ transplant recipients. Drug interactions may have a major impact on the health of this vulnerable population and should be studied further. The impact of newer immunosuppressive regimens and tolerance-induction protocols on host responses to vaccination merits evaluation. Further data may serve to protect this high-risk population as they return to normal activities after organ transplantation.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Traveler's Diarrhea
  5. Respiratory Infections
  6. Malaria and Other Arthropod-Borne Illnesses
  7. Sun Exposure and Altitude
  8. Vaccines: Evaluation and Timing
  9. Routine Vaccines
  10. Travel Vaccines
  11. Summary
  12. References
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