Travelers with Pre-Existing / Chronic Medical Conditions

Travelers with Pre-Existing / Chronic Medical Conditions Elaine C Jong MD Clinical Professor of Medicine UW Travel Clinic – Hall Health Center University of Washington, Seattle, WA ecjong@u.washington.edu May 4, 2008

Introduction • International travel continues to increase year by year • The global population is growing older • Increased numbers of senior travelers mean that more are likely to have pre-existing or chronic medical conditions • The Air Carrier Access Act of 1986 (U.S. Dept. Transportation Regulations) • Ensures people with disabilities are treated without discrimination • People with medical conditions who might not have chosen airline travel in the past now travel by airplane

International Tourist Arrivals-2004 www.world-tourism.org, accessed 042006

U.S. Growth of Elderly Population In 1997, one in eight Americans were elderly (age 65 and over). By 2030, one in five American’s could be elderly.

Three Centuries of World Population Aging Source: Long-Range World Population Projections: Based on the 1998 Revision. The Population Division, Department of Economic and Social Affairs, United Nations Secretariat

Preflight Medical Clearance* (Integrated Health Care, TAP Group, Lisbon, Portugal) • 1999-2001: 1,387 requests for medical clearance • Incidence=1/10,953 passengers • 32 (2.3%) denied • 25 (1.8%) unnecessary • 53.4% requests were males • 13.3% in age group 61 to 70 years *Jorge A, Pombal R, Peixoto H, Lima M. Preflight medical clearance of ill and incapacitated passengers: 3-year retrospective study of experience with a European airline. J Travel Med 2005:12:306-11.

Preflight Medical Clearance Results* *Jorge A, Pombal R, Peixoto H, Lima M. Preflight medical clearance of ill and incapacitated passengers: 3-year retrospective study of experience with a European airline. J Travel Med 2005:12:306-11.

Travel Health Objectives • Before Travel • Risk assessment—health and itinerary • Preventive measures • During Travel • Compliance with risk reduction advice • Ability to access medical care if necessary • After Return from Travel • When to check back with regular health care provider

Travel Health Preparation TRAVEL AGENT/ TRANSPORT OPERATOR/ TOUR OPERATOR TRAVELER REGULAR HEALTH CARE PROVIDER TRAVEL HEALTH CARE PROVIDER

BEFORE TRAVEL: Travelers with Special Needs • CONSULT TRAVEL AGENT • Explore destinations and itineraries • Become aware of special requirements for destination and itinerary • Consider travel with a companion or guided group • Request special diet, oxygen, wheelchair, gate-to-gate motorized cart transfers, special accommodations, etc. ahead of time, at the time of making airplane/ cruise/ train reservations

BEFORE TRAVEL: Travelers with Special Needs • CONSULT REGULAR HEALTH CARE PROVIDER • Stabilize chronic medical conditions • Pre-flight medical clearance may be required • Obtain adequate supplies of medications (depending on trip, 2-3x regular quantity) • Obtain copies of essential health documents • Consider pre-travel exercise conditioning program

BEFORE TRAVEL: Travelers with Special Needs • CONSULT TRAVEL HEALTH PROVIDER • Seek personalized pre-travel health advice • Vaccines • Malaria chemoprophylaxis • Travelers’ diarrhea and other common ailments • Become aware of special health concerns at destination • Identify medical consultants and medical facilities at destination • Discuss insurance coverage • Trip cancellation • Medical care abroad • Emergency evacuation insurance

BEFORE TRAVEL: Travelers with Special Needs • PERSONAL PREPARATION • Pack lightly • Carry snacks in hand luggage • Carry medicines in hand luggage (also carry a copy of all prescriptions plus health and insurance documents) • Arrive at airport early!

What types of medical emergencies are experienced by air travelers? • In the airport • Immediately prior to travel • Immediately post-travel • In flight • In a review of 754 traveler incidents, the majority of problems were medical • Medical (60%) • Trauma (25%) • Psychiatric (3%) • Obstetrics (2%) • Pediatrics (1%) • Other alarms Cummins R, Schubach J: Frequency and types of medical emergencies among commercial air travelers: in the air and at the airport, JAMA, 1989; 26l:1295-9.

Airport Medical Emergencies Cummins R, Schubach J: Frequency and types of medical emergencies among commercial air travelers: in the air and at the airport, JAMA, 1989.

Medical Guidelines for Airline Travel • Aerospace Medical Association • Complimentary copy of “Medical Guidelines for Airline Travel, 2nd Edition, 2003, available as PDF download: http://www.asma.org/publications/medicalguideline.php

Travel Health Care Provider T TRAVELER’S HEALTH STATUS TRIP-SPECIFIC RISKS INTERVENTIONS

General Approach—Travelers with Medical Conditions • Vaccinate if possible • Consider malaria chemoprophylaxis • Consider empiric self-therapy regimens • Consider drug/drug interactions • Consider drug dosage adjustments • Traveler education on risk reduction behaviors • List of physician contacts at destination(s) Adapted from: Ericsson CD, Travelers with pre-existing medical conditions. Int J of Antimicrobial Agents 2003: 21:181-188.

Travelers with Underlying Medical Conditions • Post cardiac event, surgery • Chronic diseases or infirmities • Compromised cardiac or pulmonary function • Gastrointestinal diseases • Diabetes mellitus • End-stage renal disease • Medical devices/ orthopedic hardware • Psychiatric disease • Compromised hosts • HIV-infected • Organ transplant • Malignancy & its treatment • IgA deficiency • Asplenia • Use of immunocompromising drugs

Travelers with Recent Surgery • Recent abdominal, central nervous system, ophthalmologic or thoracic surgery • Expansion of trapped gas at reduced cabin pressures • Intestinal gas may expand by 25% by volume at cabin altitude of 8000 feet • Risk tearing of suture lines, hemorrhaging or bowel perforation in passengers with recent abdominal surgery

Travelers with Recent Surgery • RECOMMENDATIONS • Awaiting period of at 1 to 2 weeks before airline travel after any laparoscopic or surgical procedure involving introduction of gas into the abdominal cavity • Patient is declared medically stable by attending surgeon

Travel with Cardiac Disease • Randomized, single-blind, controlled trial • 38 patients randomized to O2 at 2 L /min via nasal prongs or no O2, with Holter monitoring throughout the flight. • Recommendations: • Postpone travel by air 2-3 weeks after uncomplicated AMI • Avoid overexertion in immediate preflight and postflight phases • Neither supplemental oxygen nor medical escorts were needed for transportation of patients who fly 2 weeks after acute (uncomplicated) myocardial infarction Roby H, Lee A, Hopkins A. Safety of air travel following acute myocardial Infarction. Aviat Space Environ Med. 2002; 73:91-6.

Decline in Blood Oxygen Tension with Increase in Altitude 1 = Cabin altitude from 5000 to 8000 ft at 35,000 ft above sea level cruising altitude according to pressurization schedules. 2 = After 45 min steady-state hypobaric exposure, equivalent to 8000 ft above sea level. From: Dillard TA, Berg BW, Rajagopol KR et al. 1989. Ann Intern Med 111:362-367.

Travel with Pulmonary Disease-1 • Air cabin pressurized to altitude equivalent to 5000-8000 feet above sea level • Shift in oxygen/hemoglobin dissociation curve associated with high altitudes • Physiologically normal people experience a fall in PaO2 to 65-68 mm Hg at cabin pressure • Aim for PaO2 levels to remain above 50-55 mmHg • If resting PaO2 is 70 mm Hg or lower at mean sea level, then at 8000 ft the PaO2 may fall below 50 mm Hg– supplementary O2 during the flight may be recommended • Supplemental oxygen for patients with cardiac disease Seccombe LM, Peters MJ. Oxygen supplementation for chronic obstructive pulmonary disease patients during air travel. Current Opinion in Pulmonary Medicine. 2006; 12: 140-144.

Travel with Pulmonary Disease-2 • Light exercise during air flight worsens hypoxemia • Many patients tolerate significant hypoxemia without development of symptoms or adverse medical event • If exacerbations of underlying respiratory disease occur— person should not fly. Seccombe LM, Peters MJ. Oxygen supplementation for chronic obstructive pulmonary disease patients during air travel. Current Opinion in Pulmonary Medicine. 2006; 12: 140-144.

Travel with Gastrointestinal Disease • Higher risk for travelers’ diarrhea • Achlorhydria • Antacids • H2-blockers • Proton pump inhibitors • Consider antibiotic prophylaxis • Vaccines against GI pathogens • Typhoid • Cholera • Food & drink Precautions—smaller meals?

Traveler’s Diarrhea Etiology Cause % Isolation • BACTERIAL 50 - 75 • E. coli 5 – 70 • ETEC 5 – 70 • Campylobacter 0 – 30 • Salmonella 0 – 15 • Shigella 0 – 15 • Aeromonas 0 – 10 • Plesiomonas 0 – 5 • PROTOZOA 0 – 5 • VIRUSES 0 - 20 • Unknown: 10% - 40% of TD cases Adapted from Ansdell VE & Ericsson CD. Med Clin NA.1999;83:945-973.

Travelers’ Diarrhea Self-Treatment • Oral rehydration • Bismuth subsalicylate (pepto-bismol) • Anti-motility agents • natural opiates (paregoric, codeine) • synthetic opiates (diphenoxylate, loperamide) • Antibiotics • TMP/ SX (Bactrim™, Septra™, Co-Trimoxazole™) (widespread resistance) • Ciprofloxacin (Cipro™), or other quinolone antibiotics (resistance emerging) • Azithromycin (Zithromax™) • Rifaximin (Xifaximin™)

Traveling with Diabetes Mellitus • Metabolic dysregulation on long-haul flights • Eastwards—shorter day (2-4% insulin decrease) • Westwards—longer day (2-4% insulin increase) • Avoid hypoglycemia (less tight control during actual day of travel) • Increase glucose monitoring • Adjust insulin doses with short-acting insulin • Glucose monitoring devices • Low humidity & lower pressures in aircraft cabin • Low temperature & lower pressures at extreme altitude • Carry medications to treat infections (e.g. travelers’ diarrhea) Sane T, Kovisto VA, Nikkanen P, et al. Adjustment of insuline doses of diabetic Patients during long distance flights. Br Med J 1990; 301:421.

Altitude and Glucose Meters • Meters may underestimate glucose levels by ~1-2% for each 1000 ft gain in elevation • DKA could result from relying on falsely low blood glucose measurements • Supplement meter readings with urine ketone dipstick tests • Meters’ accuracy also affected by temperature and humidity Fink KS, Christensen DV, Ellsworth A. 2002 Effect of high altitude on blood glucose meter performance. Diabet Technol Ther 4:5.

Travelers with End-stage Renal Disease Potential Issues: • Supplies for peritoneal dialysis • Access to hemodialysis centers away from home, especially in foreign countries • Concerns about hepatitis C infection from HD in resource-limited countries* • Specialized Tours • Medical personnel • Expedite Equipment and Supplies • Dialysis cruises *Ghafur A, Raza M, Labbett W, et al. Travel-associated acquisition of Hepatitis C virus infection in patients receiving haemodialysis. Nephrol Dial Transplant. 2007; 22:2640-4.

Resources for Travelers with End-stage Renal Disease • Dialysis Facility Comparisons. www.medicare.gov/Dialysis/Home.asp • The Nephron Information Center (dialysis units in the U.S.) www.nephron.com • The Global Dialysis Directory 2007 (14,000 dialysis centers in 151 countries, 684 pp.) www.globaldialysis.com • The last 2 web sites have links to travel agencies specializing in travel for persons requiring dialysis

Travelers with Medical Devices • Travel with signed letter from his or her personal physician on letterhead stationery stating name of device (artificial joint components, internal fixation pins, pacemaker, ICD, insulin pump, etc.) and the location • Insulin pump wearers may be asked to open the back of the pump • Persons with pacemakers or ICDs may wish to request a hand search rather than a magnetic wand search going through airport security • Syringes, infusion sets, and other “sharps” should have original pharmacy label attached stating the health care provider’s name

Travelers with Psychiatric Disease • “Fear of Flying” factor • Before travel: • Discuss travel plans in advance with mental health provider • Stabilize mental health condition • Carry adequate supply of medications; may need supplemental medications for anxiety • During travel: • Travel with knowledgeable escort or friend • Avoid alcohol • Carry printed information about condition, drugs, and treatment for emergencies

HIV-infected Traveler • Advise travel when CD4 count > 200 • Risk of Salmonella typhimurium infection with low CD4 counts (100x) • Risk of respiratory infections • Risk of Mycobacterium tuberculosis • Risk of fungal infections Castelli F, Patroni A. The human immunodeficientcy virus-infected traveller. Clin Infect Dis 2000;31:1403-8.

HIV-infected Traveler • Give inactivated vaccines • Tetanus/diphtheria, polio (IPV) influenza, pneumococcal, hepatitis A, hepatitis B, typhoid Vi, meningococcal, rabies • Avoid live vaccines • OPV, VZV, BCG, oral Ty21a • Possible exceptions: Measles, (Yellow Fever) • Consider possible malaria and diarrhea drug reactions with HAART drugs Castelli F, Patroni A. The human immunodeficiency virus-infected traveller. Clin Infect Dis 2000;31:1403-8.

HIV Drug-Drug Interactions: Malaria* 1=nucleoside reverse transcriptase inhibitor 2=non-nucleoside reverse transcriptase inhibitor *Adapted from: Table 2. in Bhadelia N, Klotman M, Caplivski D. The HIV-Positive Traveler. Am J Med, 2007;120:574-80.

HIV Drug-Drug Interactions: TD* 1=nucleoside reverse transcriptase inhibitor 2=non-nucleoside reverse transcriptase inhibitor *Adapted from: Table 2. in Bhadelia N, Klotman M, Caplivski D. The HIV-Positive Traveler. Am J Med, 2007;120:574-80.

Resource for HIV-drug Interactions University of Liverpool, http://www.hiv-druginteractions.org/ Interactive web site allows customized searches on drug interactions and print-outs

HIV-infected Traveler & Parasites • Susceptibility not increased compared with non-infected travelers • Malaria • Helminthic infections • Onchocerciasis • Schistosomiasis • Increased susceptibility • Protozoan GI pathogens • Leishmaniasis

Travel after Heart Transplantation103 consecutive patients, 100 responded, 95 reported travel N=95 Kofidis T, Pethig K, Futher G, et al. Traveling after heart transplantation. Clin Transplant 2002;16:280-284.

Travel after Transplantation • Travel to locations removed from high-level medical care not recommended • Diminished T-cell immunity, similar to HIV-infected patient with CD4 count <100 • Prone to infection with intracellular microorganisms • Salmonella, Listeria, mycobacteria, fungi • Give Typhoid Vi Vaccine • Drug/drug interactions • Tacrolimus with erythromycin, clarithromycin • Cyclosporin with TMP/SX, erythromycin, azithromycin, fluoroquinolones • No data on rifaximin Kofidis T, Pethig K, Futher G, et al. Traveling after heart transplantation. Clin Transplant 2002;16:280-284

Travel with Malignancy & Other Conditions, or Treatment Associated with Immunosuppression • Active cancer chemotherapy– approach like HIV-infected patients with CD4 counts <200 with regard to vaccines • Recommend travel after chemotherapy completed & immune function recovered as much as possible • Neutropenic patients should probably not travel • Corticosteroid therapy >20mg/day associated with significant immunosuppression

Immune Modulation Induced by Anti-TNF and Methotrexate Therapy in Rheumatoid Arthritis Patients • Methotrexate and tumor necrosis factor (TNF) blockers are increasingly used for treatment of rheumatoid arthritis and seronegative arthritis • Adverse drug effects include lung disease and infections • The disease-modifying antirheumatic drugs affect responsiveness to vaccines, depending on what type of vaccine is used

Antirheumatic Drugs & Vaccines 1. Kapetanovic MC et al. 2007. Rheumatology, 46:608-11. 2. Brezinschek HP et al. 2008. Curr Opin Rhematol, 20:295-9.

Travel with IgA Deficiency • Risk is about 1 in 600 persons • Risk for diarrhea, lower respiratory tract infections • Consider TD antibiotic prophylaxis with fluoroquinolone, empirical self-treatment with azithromycin • Appropriate travel vaccines: 3 “R’s” • Immune globulin contraindicated

Asplenic Traveler • Risk 600 times for development of overwhelming sepsis with encapsulated bacteria • Response to S. pneumonia, H. influenzae, N. meningititis vaccines may be blunted, but give anyway • Consider routine antibiotic prophylaxis for trip • Supply of antibiotic to take at first sign of febrile illness while seeking medical care • Increased risk to Capnocytophagia infections from dog bites • Increased risk to serious infections with babesiosis and possibly malaria

AFTER RETURN FROM TRAVEL • Contact regular health care provider for fever, diarrhea, skin lesion, or any change in usual state of health. • Contact regular health care provider if asymptomatic upon return home, but had exposure to possible high-risk persons, animals, food, insects, treatments, or any unusual agent during the international trip. • Always mention history of international travel when seeking care for acute or new illness in the year following return.

Travelers with Pre-Existing / Chronic Medical Conditions