Immunosuppression

This factsheet provides advice for immunosuppressed travellers on pre travel preparation, tips to stay healthy abroad and links to useful resources Immunosuppression

 

Key Messages


Pre travel planning is essential; immunosuppressed individuals should discuss their travel plans carefully with their hospital specialist and GP, ideally before booking travel. These individuals should be stable, know how to manage their condition, be prepared to manage minor illnesses, and know when and how to seek medical advice abroad.
All travellers should obtain comprehensive travel health insurance; immunosuppressed travellers should declare their full medical history to the insurers.
Immunosuppressed travellers are more likely to experience severe illness as a result of certain infections and extra precautions are recommended. They are also potentially at risk of a deterioration or exacerbation of their condition.
Additional vaccines should be offered to immunosuppressed individuals as per guidance from Public Health England (PHE) ‘Green book ‘chapter 7, see resources. Those who are severely immunosuppressed will not be able to have live vaccinations. Inactivated vaccines can be given safely, but may be less effective.
For immunosuppressed children, British Infection Association guidelines were published in 2016, by Pinto MV et al, see resources.

Overview

Immunosuppression is the suppression of the body’s normal immune response. This causes a reduced ability to fight infection. Immunosuppression can be caused by a variety of conditions, drugs or treatments.

Immunosuppressive conditions include:

  • Bone marrow transplant recipients (bone marrow or stem cell transplant) until at least 12 months after finishing all immunosuppressive treatment or longer where graft-versus-host disease has developed. Specialist advice is required as there will be variation based upon the type of transplant and the immune status of the individual.
  • Certain types of cancer and cancer treatments, such as chemotherapy and generalised radiotherapy, within at least the last six months.
  • Human immunodeficiency virus (HIV) infection (those living with HIIV, with a CD4 count >200/mm3 and no symptoms of disease are not usually considered to have severe immunosuppression) see our HIV/AIDS factsheet for details.
  • Individuals who had a solid organ transplant and are currently on immunosuppressive treatment to prevent rejection.
  • Severe primary (inherited) immunodeficiencies, such as DiGeorge’s syndrome, Wiskott-Aldrich syndrome and other combined immunodeficiency syndromes.
  • Asplenics (those with no spleen), and those with a dysfunctional spleen (e.g. some individuals with sickle cell disease or other haemoglobinopathies, some adults with Coeliac disease), are at increased risk of overwhelming infection with certain bacterial pathogens; additional vaccinations and standby antibiotics may be required. Live vaccinations can be offered unless the individual has another immunosuppressive condition/treatment. These travellers are also at particular risk of severe malaria, and where possible should avoid travel to malarious areas.
  • A number of chronic (long-term) medical conditions (and their treatments) may be may be associated with immune deficit (e.g. liver disease, kidney disease and diabetes). Additional vaccinations may be recommended for these individuals.

This list is not exhaustive; health professionals are encouraged to liaise with the supervising doctor where there is any concern about an underlying medical condition or treatment. For further details see PHE’s Green Book chapter 6 and 7.

Immunosuppressive medications include:

  • High dose steroids (e.g. budesonide, cortisone acetate, deflazacort, dexamethasone, hydrocortisone, methylprednisolone, prednisolone, triamcinolone). “High dose” is considered to be at least 40mg of prednisolone (or an equivalent drug) a day for more than one week in adults, and 2mg/kg/day of prednisolone (or an equivalent drug) for at least one week, or 1mg/kg/day for one month, in children. These are considered to be immunosuppressed during treatment and until at least three months after treatment has stopped. Occasionally, individuals on lower doses of steroids may also be immunosuppressed; when in doubt, discussion with a specialist is recommended. 
  • Antiproliferative drugs (e.g. azathioprine, mycophenolate mofetil). 
  • Anti-TNF drugs (e.g. etanercept, infliximab, adalimumab). 
  • Inhibitors (e.g. ciclosporin, tacrolimus, sirolimus). 
  • Monoclonal antibodies (e.g.adalimumab, basiliximab, bevacizumab, infliximab, rituximab, trastuzumab). 
  • Cytotoxic drugs including antimetabolites (e.g. methotrexate, 6-mercaptopurine) and other antineoplastic drugs (e.g. taxanes, cyclophosphamide). 
  • Disease modifying antirheumatic drugs (e.g. cyclophosphamide, leflunomide) 

This list is not exhaustive; health professionals should liaise with the supervising doctor where there is any concern about the possible immunosuppressive effects of a medication.

Medications not usually linked to immunosuppression include:

  • Non-systemic corticosteroids, such as aerosols, skin creams and intra-articular (joint) injections. 
  • Steroid replacement therapy for adrenal insufficiency. 
  • Other drugs used in autoimmune and inflammatory conditions include aminosalicylates (mesalazine and sulphasalazine), hydroxyurea (antineoplastic drug), and hydroxychloroquine (anti-inflammatory). These drugs are not considered directly immunosuppressive and do not usually contraindicate live vaccines. However, the traveller’s underlying medical condition must also be taken into account when considering if an individual is immunosuppressed.

For further details see contraindications and special considerations in PHE’s Green Book.

Pre-travel preparation

Immunosuppressed travellers should be advised to research their destination/s in detail and discuss their travel plans carefully with their supervising specialist, ideally before booking travel. Information can be found on our Country Information pages and the Foreign and Commonwealth office website.

Travellers should have a plan of what to do should they become ill whilst travelling and need to seek medical help. Travel insurance covering the immunosuppressive condition and/or treatment should be obtained. Support groups for the specific condition may be able to provide advice on where to obtain specialist insurance (see resources below for some of these groups).

Specific issues to address pre travel include:

  • Is the individual fit to travel/fly? Is the immunosuppressive condition and/or treatment stable?
  • Can specific interventions (e.g. behavioral measures, vaccination or preventative medication) be recommended to reduce disease risks?
  • Does the condition/treatment contraindicate or decrease effectiveness of any recommended vaccines and/or malaria chemoprophylaxis (antimalarials)
  • Is appropriate specialist emergency care available at the destination?
  • Does the individual have comprehensive travel insurance which covers travel when immunesuppressed?

Medication

Travellers should carry a first aid kit tailored to their destination to help them manage common issues such as insect bites, cuts and grazes, travellers’ diarrhoea or headache.

Travellers who take regular medication should plan well ahead. A letter from the GP or prescriber detailing the medicines is advised. Some countries may not allow the entry of certain types of medicines, and others may have regulations requiring specific permission for a medication to be brought in. These rules can also apply to medicines available over the counter in the UK. Counterfeit (fake) drugs are more common in certain regions and can be a significant health risk. Further information can be found in our travelling with medicines factsheet.

When prescribing antibiotics, antimalarials or any other medication, all potential interactions with immunosuppressive drugs (or antiretroviral medicines for those living with HIV) must be considered. The British National Formulary, the University of Liverpool HIV drug interactions website and the electronic medicines compendium are all useful tools for checking potential drug interactions. 

Vaccination

Individual assessment of a traveller’s immune status is required before planning travel vaccinations. Travellers with relatively minor immunodeficiencies can receive all recommended vaccinations,

including live vaccines. Live vaccines are however contraindicated for those who are severely immunosuppressed, as they can cause severe or fatal infections due to extensive replication of the vaccine strain following administration. Where there is doubt about an individual’s immune status, specialist advice should be obtained [1].

Live vaccines currently used in the United Kingdom include: Bacillus Calmette-Guérin (BCG for TB prevention), paediatric nasal influenza, mumps, measles and rubella (MMR), oral typhoid, rotavirus, shingles, varicella (chickenpox) and yellow fever (YF). 

YF vaccine can be considered for those living with HIV, if risk of YF exposure is high and unavoidable and the traveller is asymptomatic (without symptoms), has a suppressed viral load, and a stable CD4 count of > 200cells/µl [2, 3]. Reduced response to vaccine can occur; revaccination at 10 years should be offered for those at continued risk [4].

Inactivated vaccines can be safely offered to immunosuppressed travellers. However, the immune response may be compromised (reduced) resulting in less than optimal protection. Immunosuppressed individuals should be counselled about this and encouraged to further reduce their risk by taking additional preventative measures. For some travellers, additional doses of vaccine maybe recommended.

Individuals who receive bone marrow or stem cell transplants are likely to lose any natural or immunisation-derived protective antibodies against most vaccine-preventable diseases. All individuals should be considered for a re-immunisation programme, specialist advice should be sought [5].

Venous thromboembolism

Venous thromboembolism (VTE) (deep vein thrombosis or pulmonary embolism) can occur as a result of long periods of immobility associated with any form of travel. Some travellers are at increased risk e.g. older travellers, those with cancer or a previous history of VTE or recent surgery. Those at increased risk of VTE should seek advice from their health care provider and consider the use of properly fitted compression socks. Low molecular weight heparin therapy may also be recommended. Further information is available in our venous thromboembolism factsheet.

During travel

Food and water risks

Travellers’ diarrhoea is the most common illness that affects travellers to low-income regions of the world [6]. Some food and water borne illness such as those caused by Salmonella, Campylobacter, Giardia, Listeria and Cryptosporidium can be severe or become chronic (long-lasting) in immunosuppressed individuals [7].

Immunosuppressed travellers should take particular care with food and water hygiene and discuss the management of diarrhoea with their health care provider. Travellers should be given clear advice and written instructions on the appropriate use of self-treatment medication. A prescription for an antibiotic for self-treatment should be considered, details are available in our travellers’ diarrhoea factsheet. Prompt treatment of gastrointestinal infection is essential in immunosuppression and specialist advice should be sought, if available locally.

Prophylactic antibiotics may also be considered for some immunosuppressed travellers, especially for short-term travel. The choice of agent must be balanced with possible drug interactions and location of travel [8]. Potential drug interactions should be carefully checked by the prescriber.

Vector-borne risks

Immunosuppressed travellers should take particular care to avoid insect bites. Travellers should avoid scratching bites and keep them clean and dry to avoid infection. Antiseptic and basic wound dressings can be helpful if the bite is causing irritation. Prompt medical advice should be sought if signs of skin infection develop.

Travellers with immunosuppression may be at greater risk of severe disease if they contract malaria [7]. Travellers should be familiar with the ABCD of malaria prevention. When selecting an antimalarial medication, care must be taken to check interactions with any current medication.

Certain other insect borne diseases such as visceral leishmaniasis [7] and Chagas disease [8] may also be more severe for immunosuppressed travellers.

There is little published information on the risk of Zika virus for those with immunosuppression, guidance is available from Public Health England [9].

Ideally, severely immunosuppressed travellers should avoid travelling to yellow fever (YF) risk regions as the vaccine is contraindicated. Realistically, some may feel they have compelling reasons to travel and be determined to go. These travellers should be counselled about reducing their risk as much as possible by practising scrupulous mosquito bite avoidance and minimising time spent in risk areas. Where travel to a YF risk country cannot be avoided and where an International Certificate of Vaccination or Prophylaxis is needed for entry to that country, a Medical Letter of Exemption (MLoE) from YF vaccination can be offered when YF vaccination is contraindicated on medical grounds. A MLoE should be taken in to consideration by the destination country, but may not guarantee entry.

Other disease risks

Travellers with immunosuppression should be aware of diseases of close contact, respiratory infections such as tuberculosis and influenza and those transmitted by animal bites such as rabies and wound infections.

Respiratory fungal infections, such as Cryptococcus, Histoplasma, Paracoccidioides and Penicillium are rare, but can cause life-threatening opportunistic infections in immunosuppressed travellers. Caving and other outdoor activities that put travellers at risk should be avoided [8]. Exposure to dust, soil, and bird or bat droppings should also be avoided. Masks and gloves can help reduce exposure to fungal spores if working with plants, hay or peat moss.

Sun protection

Travellers with immune suppression should take particular care in the sun. Immunosuppressive treatments have the potential to impair the skin immune system leading to an increased incidence of skin cancer [10]. Certain medications can make skin more sensitive to the sun and more likely to burn. Travellers should seek urgent medical advice if they notice changes to moles, such as increasing size, itchiness, bleeding or oozing, or if a new mole develops very quickly.

Illness abroad

Travellers should know when and how to seek prompt medical advice, for example if they experience fever, prolonged diarrhoea, signs of dehydration, signs of skin infection such as swollen, painful / red skin around a wound with pus, or any other concerning symptoms. Keep any receipts for treatment and in EU countries an EHIC card should be carried, the travel insurance company should be informed as soon as possible.

Prophylaxis with immunoglobulins other antibiotic or antiviral drugs may be recommended for immunosuppressed individuals exposed to infections such as measles, chickenpox, hepatitis A, pertussis (whooping cough) or influenza. Advice on the management of exposed individuals can be found in Chapter 7 of the Green Book.

First Published :   13 Feb 2017
Last Updated :   14 Feb 2017

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