Pre-travel care for immunocompromised and chronically ill travellers: A retrospective study

Immunogenicity and one-year boostability of a 3-dose intramuscular rabies pre-exposure prophylaxis schedule in adults receiving immunosuppressive monotherapy: a prospective single-Centre clinical trial

BACKGROUND

For immunocompromised patients (ICPs), administration of rabies immunoglobulins (RIG) after exposure is still recommended regardless of prior vaccination, due to a lack of data. We aimed to assess the one-year boostability of a 3-dose rabies pre-exposure prophylaxis (PrEP) schedule in individuals using immunosuppressive monotherapy.

METHODS

In this prospective study, individuals on immunosuppressive monotherapy with a conventional immunomodulator (cIM) or a TNF-alpha inhibitor (TNFi) for a chronic inflammatory disease received a 3-dose intramuscular PrEP schedule (days 0,7,21-28) with 1 mL Rabipur®, followed by a 2-dose simulated post-exposure prophylaxis (PEP) schedule (days 0,3) after 12 months. Rabies neutralizing antibodies were assessed at baseline, on Day 21-28 (before 3rd PrEP dose), Day 60, Month 12 and Month 12 + 7 days. The primary outcome was one-year boostability, defined as the proportion of patients with a neutralizing antibody titre of ≥ 0.5 IU/mL at Month 12 + 7 days. Secondary outcomes were geometric mean titres and factors associated with the primary endpoint.

RESULTS

We included 56 individuals, of whom 52 completed the study. The one-year boostability was 90% (47/52) with a GMT of 6.16 (95% CI 3.83-9.91). All participants seroconverted at some point in the study. Early response to PrEP (at day 21-28) was significantly associated with 100% boostability (Odds ratio 51; 95% confidence interval [5.0-6956], p < 0.01). The vaccination schedule was safe and well tolerated. No vaccine-related serious adverse events occurred.

CONCLUSION

In patients using immunosuppressive monotherapy, a 3-dose rabies PrEP schedule followed by a 2-dose PEP schedule is immunogenic, with all patients seroconverting at some point in the study. Although boostability 7 days after PEP was not 100%, nobody would wrongly be denied RIG when only administered to those who responded early to PrEP, while reducing administration of RIG by 73%.

Travel-related infections presenting in Europe: A 20-year analysis of EuroTravNet surveillance data

Background

Disease epidemiology of (re-)emerging infectious diseases is changing rapidly, rendering surveillance of travel-associated illness important.

Methods

We evaluated travel-related illness encountered at EuroTravNet clinics, the European surveillance sub-network of GeoSentinel, between March 1, 1998 and March 31, 2018.

Findings

103,739 ill travellers were evaluated, including 11,239 (10.8%) migrants, 89,620 (86.4%) patients seen post-travel, and 2,880 (2.8%) during and after travel. Despite increasing numbers of patient encounters over 20 years, the regions of exposure by year of clinic visits have remained stable. In 5-year increments, greater proportions of patients were migrants or visiting friends and relatives (VFR); business travel-associated illness remained stable; tourism-related illness decreased. Falciparum malaria was amongst the most-frequently diagnosed illnesses with 5,254 cases (5.1% of all patients) and the most-frequent cause of death (risk ratio versus all other illnesses 2.5:1). Animal exposures requiring rabies post-exposure prophylaxis increased from 0.7% (1998–2002) to 3.6% (2013–2018). The proportion of patients with seasonal influenza increased from zero in 1998–2002 to 0.9% in 2013–2018. There were 44 cases of viral haemorrhagic fever, most during the past five years. Arboviral infection numbers increased significantly as did the range of presenting arboviral diseases, dengue and chikungunya diagnoses increased by 2.6% and 1%, respectively.

Interpretation

Travel medicine must adapt to serve the changing profile of travellers, with an increase in migrants and persons visiting relatives and friends and the strong emergence of vector-borne diseases, with potential for further local transmission in Europe.

Funding

This project was supported by a cooperative agreement (U50CK00189) between the Centers for Disease Control and Prevention to the International Society of Travel Medicine (ISTM) and funding from the ISTM and the Public Health Agency of Canada.

What do we know about travel for children with special health care needs? A review of the literature

BACKGROUND

Children travel with their families, including children with chronic illness. We know that adults with chronic illness who travel are more likely than their healthy peers to become sick while traveling. A review of the literature was undertaken to identify what is known about traveling with children with special health care needs and to identify gaps in our knowledge.

METHODS

An Online search of the PubMed, CINAHL and Google databases of English language literature was conducted June 2016, October 2017, June 2018 and April 2019 using the terms children and travel, air travel, travel health, disabled child, children with special healthcare needs, parents of disabled children, vacations, recreation, international, wheelchairs, planning techniques, asthma, diabetes, altitude, cystic fibrosis, inflammatory bowel disease, sickle cell disease, depression, food allergies, Attention Deficit Hyperactivity Disorder (ADHD), and seizures. The search was limited to years 2000-2019. A secondary search of relevant articles was conducted using the reference sections of articles identified in the primary search.

RESULTS

185 papers were examined for travel health related outcomes for children and adults with chronic diseases. Articles were excluded if they addressed the educational needs of students with disabilities traveling abroad, did not directly address travel health (e.g travel skills, travel itineraries), contained outdated policy statements, or were case reports of a single patient. The remaining 84 papers were organized and reviewed by organ systems. The articles were primarily descriptive and did not lend themselves to a systematic review.

CONCLUSION

Children traveling with chronic and complex health conditions are a heterogeneous group of vulnerable travelers. Closing the knowledge gap about how to best help these travelers requires a multipronged approach. Research is urgently needed to identify best practices for five of the most common chronic childhood diseases: asthma, depression, ADHD, food allergies and autism. For less common illnesses, ones typically cared for in specialty clinics, expert consensus opinion and multi-center studies are needed. Families and disease advocacy societies should be included in the research as they may have already identified the most pressing travel-related health concerns and solutions for these problems.

Travel-related health events and their risk factors in HIV-infected sub-Saharan migrants living in France and visiting their native country: The ANRS VIHVO cohort study

BACKGROUND

Literature on health events in HIV-infected travellers is scarce, particularly in sub-Saharan African (SSA) migrants.

METHODS

We investigated health events in HIV-infected SSA migrants living in France during and after travel to their native country. All had a pre-travel plasma viral load (pVL) below 200 copies/mL and were on stable combined antiretroviral therapy (cART). Logistic regression models were used to assess the risk factors for at least one adverse health event or febrile event.

RESULTS

Among 264 HIV migrants, pre-travel median CD4 count was 439/mm3 and 27 migrants (6%) experienced a low-level viremia between 50 and 200 copies/mL. One hundred (38%) experienced at least one event (13 experienced two events). The most common events were gastrointestinal, including diarrhoea (n = 29, 26%), respiratory events (n = 20, 18%), and malaria (n = 17, 15%; 1 death). In multivariable analysis, a pre-travel low-level viremia and a lack of pre-travel medical advice significantly increased the risk for any event (OR 4.31, 95% CI, 1.41-13.1; and OR 3.62, 95% CI, 1.38-9.47; respectively). A lack of pre-travel advice significantly increased the risk for febrile event.

CONCLUSIONS

Early and tailored counselling on pre-travel medical advice regarding diarrhoea and vector-borne diseases prophylactic measures in HIV-infected SSA migrants should be emphasised before travel to Africa.

Symptoms of infectious diseases in HIV-positive travellers: A prospective study with exposure-matched controls

BACKGROUND

Recently, the number of HIV-infected travellers to (sub)tropical areas has increased substantially. In the Netherlands, HIV-positive travellers with CD4-cells of <500/mm³ are advised to carry stand-by antibiotic treatment against travellers' diarrhoea. Our aim was to determine whether HIV infection is associated with travel-related symptomatic diseases.

METHODS

A prospective study was performed among HIV-infected travellers and age-matched HIV-uninfected travel companions serving as controls, attending two travel clinics in Amsterdam. Participants filled out daily questionnaires before, during, and after their trip.

RESULTS

Overall, 52 pairs were included. All participants were male, and 91.3% were born in a Western country. Prevalence of travel-related diarrhoea was 50% among HIV-positive travellers and 40% among controls. No significant differences were observed for incident travel-related diarrhoea (incidence rate ratio = 1.60, 95%CI = 0.79-3.27) or duration of symptoms (odds ratio = 1.49, 95%CI = 0.65-3.45). There were no significant differences in symptom incidence or duration for travel-related vomiting, cough, rhinitis, pruritus, fatigue, or nausea. Only 6.3% of HIV-positive travellers with CD4-cells of <500/mm³ and diarrhoea used their stand-by antibiotic treatment as recommended.

CONCLUSION

Travel-related symptoms were not significantly more frequent or longer lasting among HIV-infected travellers compared to controls. Most HIV-infected travellers with CD4-cells of <500/mm³ and diarrhoea did not take stand-by antibiotic treatment. These results may question the need for routine prescription of stand-by antibiotics among this specific risk group. Further research, especially among HIV infected VFR travellers and in larger study groups is needed.

Incidence of invasive pneumococcal disease in immunocompromised patients: A systematic review and meta-analysis

BACKGROUND

Invasive pneumococcal disease (IPD) is associated with high morbidity and mortality, with immunocompromised patients (ICPs) at particular risk. Therefore, guidelines recommend pneumococcal vaccination for these patients. However, guidelines are scarcely underpinned with references to incidence studies of IPD in this population. This, potentially results in unawareness of the importance of vaccination and low vaccination rates. The objective of this systematic review and meta-analysis was to assess the incidence of IPD in ICPs.

METHODS

We systematically searched PubMed and Embase to identify studies in English published before December 6th, 2017 that included terms related to 'incidence', 'rate', 'pneumococcal', 'pneumoniae', 'meningitis', 'septicemia', or 'bacteremia'. We focused on patients with HIV, transplantation and chronic inflammatory diseases.

RESULTS

We included 45 studies in the systematic review reporting an incidence or rate of IPD, defined as isolation of Streptococcus pneumoniae from a normally sterile site. Random effects meta-analysis of 38 studies showed a pooled IPD incidence of 331/100,000 person years in patients with HIV in the late-antiretroviral treatment era in non-African countries, and 318/100,000 in African countries; 696 and 812/100,000 in patients who underwent an autologous or allogeneic stem cell transplantation, respectively; 465/100,000 in patients with a solid organ transplantation; and 65/100,000 in patients with chronic inflammatory diseases. In healthy control cohorts, the pooled incidence was 10/100,000.

DISCUSSION

ICPs are at increased risk of contracting IPD, especially those with HIV, and those who underwent transplantation. Based on our findings, we recommend pneumococcal vaccination in immunocompromised patients.

PROSPERO REGISTRATION

ID: CRD42016048438.

Travel-related health problems in the immunocompromised traveller: An exploratory study

BACKGROUND

Immunocompromised travellers (ICTs) are at increased risk of travel-related health problems. Therefore, they are advised to attend specialised pre-travel clinics for advice on vaccination, malaria chemoprophylaxis and on-demand antibiotics. However, studies yield conflicting data regarding travel-related health problems encountered by ICTs; questioning the rationale for certain advices, and particularly the advice of on-demand antibiotics.

OBJECTIVE

To evaluate self-reported travel-related health problems, antibiotic use, medical visits and risk behaviours in ICTs and controls.

METHODS

We conducted a questionnaire-based observational study with pilot character. We recruited participants from a (medical) pre-travel clinic. Telephone interviews were conducted 2-4 weeks post-travelling, applying a structured questionnaire.

RESULTS

We included 30 ICTs and 30 controls. More ICTs than controls reported travel-related health problems, antibiotic use and medical visits, although not statistically significant. Travellers' diarrhoea appeared to be more severe in ICTs. Furthermore one ICT was hospitalized post-travel due to pneumonia. Of ICTs, 2/30 (7%) used on demand antibiotics while not indicated (according to the protocol of the Dutch national coordinating centre for travel advice or prescribed by a physician). Reversely, 6/30 (20%) did not use on demand antibiotics while actually indicated according to this protocol.

DISCUSSION

Our findings substantiate the recommendation of on demand antibiotics. However, ICTs did often not use on demand antibiotics correctly; they therefore need very careful instructions.