Vaccinations and travel

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Travelling after your transplant? Here’s what you need to know.

From strategies on forward planning so recipients don’t run out of scripts/medication while away; practical tips to avoid and manage travel sickness and bugs; travel insurance options for recipients; and which countries allow recipients to access basic medical care for free, this section provides a comprehensive overview for the transplant traveler.

It also includes downloadable vaccination resources; everything a transplant recipient needs to take to their GP detailing exactly what vaccinations they can have at home or while travelling; which they can’t, and what vaccinations their families/those close to them will need.

Transplant Australia wishes you safe and awesome adventures.

Vaccinations

Transplant recipients can receive inactivated vaccines to shield them from infectious diseases. For example, during the flu season, a recipient can get the flu vaccine. They’re also encouraged to vaccinate against Hepatitis A and B.

Recipients cannot receive live vaccines as they can activate the disease instead of shielding recipients from it. For example, the chicken pox vaccine is risky for you after a transplant, but won’t affect you if you’ve had it pre-transplant.

Quick checklist on what you should and should not receive:

Please Note: This is not an exhaustive list. If you have any concerns, please check with your transplant team.

SAFE to use vaccines

Pneumococcal vaccine
Diphtheria, tetanus, pertussis (DPT)
Influenza
Inactivated polio vaccine (IPV)
Hepatitis A & hepatitis B
Meningococcal vaccine
Human papillomavirus vaccine (HPV)
COVID
Shingles non live vaccine i.e Shingrix

UNSAFE vaccines (which contain live organisms)

BCG (Bacillus Calmette-Guérin)
Yellow fever
MMR (mumps, measles and rubella)
Varicella-zoster virus (also known as chicken pox)
Small pox
Oral polio (live) Sabin
Shingles live vaccine i.e Zostavax
Oral cholera vaccine (Vaxchora)
Some Japanese encephalitis virus vaccines
Rotavirus vaccine
Oral typhoid vaccine

Vaccine-related disease can be caused by unchecked infection (replication) by the live vaccine virus or bacteria. This is especially true for:

BCG vaccine^1,2
vaccines that contain measles, mumps, rubella^3,4 or varicella-zoster virus⁵

Download, print and take to your GP

Note: If you’ve been exposed to people who have chicken pox or other viruses, notify your transplant team immediately.

Travel

It is advisable for solid organ recipients to wait at least a year before embarking on overseas travel. Bone marrow recipients need to wait a minimum of 2 years before travelling.

Plan and consult your transplant doctor well in advance to be reviewed and assessed for risks associated with travelling. You will be at the highest risk of infections during periods of greater immunosuppression. This is usually during the first year following transplantation or during intense treatment for rejection.

Travel can be unsafe for recipients especially if you are travelling to places where infectious diseases are common, sanitation is poor and quality medical care is limited. Updated travel advisories can be obtained from the Department of Health or Centers for Disease Control and Prevention.

Six tips for smooth flying

Take enough medication in your hand luggage and in your checked-in baggage. If your luggage is lost, you have enough in your hand luggage, and if your hand luggage is stolen, you have enough in your checked-in luggage.

Keeping all medications in their original packs can help if you’re questioned by customs/baggage inspectors as you go through airport security.

Request a letter from your doctor specifying all medication you take, including the dosage and frequency. Carry this letter on you as you go through baggage screening.

Liquid medicines are subject to the same volume restrictions as any other liquids (100 ml per container). Carry a doctor’s letter if you need more than the allowable limit of medicines on-board.

While travelling overseas with PBS medicines use a medicine declaration form to declare the medicines you are carrying.

Consult your doctor for flexibility with taking medicines. Prepare a schedule to adapt to changes in time zones.

Stock up on medicines

Always take a greater supply of medicines than you need in case your trip is extended, you experience delays or miss flights. You can do this by renewing scripts in the minimum allowable time – some prescriptions include the date when the script can be next be ordered (approximately 21 days). When travelling overseas, talk to your doctor about stocking up. Your doctor can communicate with the pharmacist for extra supplies
Print a list of your medications, doses and include the names and contacts of your transplant doctor, transplant unit and other emergency details. Try to keep this list in a pocket or wallet at all times when travelling

Note: Keep your medicines in their original packs even if you’re tempted to put them in smaller containers to save space. Once medicines are taken out of their packaging, they’re affected by moisture. Remove them from their blister pack/foil only before using them.

Food safety

In developing countries like Africa, Latin America, Asia and the Middle East, where sanitation and hygiene standards are poor, you are at greater risk of water and foodborne bacteria.

Avoid ice cubes when travelling to countries with untreated tap water like Thailand. Stay away from uncooked foods like salads, and ensure you eat foods that are well cooked and heated through at the time of serving.

In many countries, foods containing raw or under-cooked meats and fish, such as sushi in Japan, can be risky for recipients. Stay away from shellfish like oysters, uncooked prawns and crabs as they can contain harmful bacteria. For more information on which foods to choose abroad, visit transplant-friendly foods.

Managing and preventing travel-related illness

Whether travelling by car, boarding a flight or on a cruise, you can overcome motion sickness with over-the-counter medications. Consult your transplant doctor to determine drugs and dosages that are safe to have with transplant medicines.

Some medications used to manage altitude sickness, like diamox (Acetazolamide), can have side effects that are risky for transplant recipients.

If travelling to high altitudes like Nepal or Peru, it’s advisable to avoid vigorous activities for the first few days. The chance of altitude sickness is greater if you ascend rapidly while hiking, or at altitudes over 2500m. The best way to manage this is by climbing slowly, stopping for 24 hours during the climb to allow the body to adjust to the height, and taking it easy the first couple of days.

Top three travel tips for motion sickness

Watch what you eat – Try to eat something light 45 to 60 minutes before traveling. A nutritious meal low in sodium and fat, like a turkey sandwich or crackers, can help settle your stomach. Avoid foods and drinks that might make you feel unusually full.

Where you sit – Plan in advance and choose a seat where you’ll experience the least motion. The front seat of the car is ideal. The middle of an airplane is the calmest area. On a ship, those in lower level cabins near the center experience less motion than passengers in higher or outer cabins.

How you sit – Sit facing the direction of travel. Facing backwards could make you sick.

Stomach bugs, insect/bloodborne diseases and STDs

Diarrhea is the most common condition among travellers. Dehydration from diarrhea can lead to anti-rejection drug toxicity. Ensure you carry the appropriate antibiotics for self-treatment along with electrolyte tablets and oral rehydration powders like hydralyte.

If unwell with diarrhea, avoid caffeine, dairy products, greasy, high-fibre or sugary foods. Instead, bland foods may help (eg. oatmeal, porridge, bread or toast, and boiled potatoes). It’s important to stay well hydrated with oral rehydration fluid.

Be aware that taking non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen used for pain relief can cause diarrhea.

You’ll need to take anti-diarrhea medicines if:

There are more than 3 unformed stools in 24 hrs
Blood, pus or mucous is in the stool
You experience nausea and vomiting
You experience fever

If fever, vomiting or bloody stools accompany the diarrhea, you must seek immediate medical attention. Anti-diahrrea drugs like loperamide that slow diahrrea must be used with caution because they can prevent your body from getting rid of the bacteria or virus that made you unwell.

Hand-washing thoroughly (after using the toilet, changing nappies and before meals) is one of the most effective ways of staying safe from the spread of viruses and bacteria that can cause diarrhea.

stomach-pain

Insect-borne diseases: malaria and dengue prevention: Consult your transplant doctor on anti-malarial medications that have a low impact on the efficacy of immunosuppressants.

In countries like India and Bangladesh where insect-borne diseases such as chikungunya and dengue fever are common, reduce the risk of bites by using repellents, bed nets, well-screened rooms or air-conditioning and protective clothing.

For up-to-date information on dengue, refer to the information on the dengue map.

Bloodborne and sexually transmitted diseases: Protect yourself from infections related to exposure to non-sterile needles, syringes and other medical equipment. Use clean injecting equipment, safe injecting practices and avoid sharing needles to avoid risk.

You can get bloodborne diseases like hepatits B, hepatitis C, and HIV by receiving infected blood or blood products, sharing injection equipment (including needles and syringes), the use of unsterile or contaminated medical equipment and unsterile body piercing or tattooing procedures.

Research the medical facilities available at your travel destination to ensure the safety of blood products which will be used in the event you may need transfusions.

Carry a supply of condoms. Why? Because you may face difficulties obtaining them on the road due to language barriers and differing sexual education/reproductive health mandates, so it’s always good to be as prepared as possible. In some countries like the Philippines and Nigeria, where the use of condoms is low, unprotected sex can lead to infections like HIV.

Remember to follow safe sexual health practices to reduce the risk of sexually transmitted diseases. Condoms, diaphragms and spermicidal jellies are safe for recipients to use as are some contraceptive pills, but you must clarify the brand.

If you’re a woman and already following a birth control plan (IUD or the pill), make sure you have enough protection or are up-to-date for the duration of your trip.

Travel insurance

Travel insurance is strongly recommended to cover you in case you require medical attention while overseas. Transplant recipients have some options although not all companies provide insurance, especially to those with multiple preexisting conditions.

Insurance companies are unlikely to cover recipients if they’ve had their transplant less than 12 months. Before buying insurance, it maybe helpful to get a ‘fit to fly’ letter from your GP or transplant specialist stating that you’ve had an up-to-date health check and are considered strong enough to travel.

Transplant recipients are more likely to receive travel insurance if their vaccinations are up-to-date.

Once you select your travel destination, talk to a GP about next steps. Remember, transplant recipients cannot take any live vaccine.

Vaccinations depend on the country of travel and the time lapsed after transplantation. Click to download a table of travel-related vaccinations.

Consider taking out basic travel insurance to cover emergencies. Pay for your trip with a credit card that offers some level of travel insurance, or consider organising general travel insurance through a union, bank or superannuation fund.

Contact The Department of Foreign Affairs and Trade (DFAT) for guidelines on buying travel insurance.

For information on precautions to take in the country you’re going to, refer to:

Reciprocal Health Care Agreements (RHCA)

Australia has reciprocal healthcare arrangements with certain countries which allows you to access basic medical treatment for free. If you’re an Australian citizen, this is available to you in the following countries: New Zealand, United Kingdom, Republic of Ireland, Sweden, Netherlands, Finland, Italy, Belgium, Malta, Slovenia and Norway.

To view more on RHCA and the details of entitlements in individual countries click here.

Arrangements with each country differ on the services and care available. To be eligible to receive this care, you must have a valid passport and Medicare card. For more information click here.

The RHCA is not intended to replace travel insurance because there are limits to the amount it will cover and type of conditions it will support. Multiple conditions, chronic conditions and related issues may fall outside the boundaries of this cover; hence, it is advisable to buy travel insurance that will give peace of mind.

References

Information sourced from THE AUSTRALIAN IMMUNISATION HANDBOOK 10TH EDITION; table 3.3.2 Recommendations for vaccinations for solid organ transplant (SOT) recipients and Table 3.3.3 and viewed on 23/05/2016 at http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home~handbook10part3~handbook10-3-3
Danzinger-Isakov L, Kumar D, AST Infectious Diseases Community of Practice. Guidelines for vaccination of Solid Organ Transplant Candidates and Recipients. American Journal of travel Medicine 2009; Volume 9, Issue Supplement s4, Version of Record online: 16 DEC 2009. Viewed on 1 November 2016. http://onlinelibrary.wiley.com/doi/10.1111/j.1600-6143.2009.02917.x/pdf
Kidney Health Australia. Transplant and Travel. Last reviewed on May 2016. http://kidney.org.au/cms_uploads/docs/kidney-health-australia-transplant-and-travel-information.pdf . Link viewed on November 7, 2016.
Cotton C, Hibberd P, the AST Infectious Disease Community of Practice. Travel Medicine and Transplant Tourism in Solid Organ Transplantation. American Journal of Transplantation – Wiley Online library. First published 6 March 2013. http://onlinelibrary.wiley.com/doi/10.1111/ajt.12125/full Link viewed on November 11, 2016
The Australian Immunisation Handbook 10^th Cholera. http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/content/Handbook10-home~handbook10part4~handbook10-4-1#4-1 Link viewed on November 7, 2016
Information Manual for Liver Transplant Recipients and their families – Jan 2009. Australian Liver Transplantation Unit
Allogenic Bone Marrow Transplant – A patient’s Guide. Blood and Bone Marrow Transplant Network, NSW, 2006
Information Manual for Heart, Heart-Lung and Lung Transplant Recipients. Heart and lung Transplant Unit. St. Vincents Health Network. Sydney. March 2014
K. Averya, M. G. Michaels,∗ and the AST Infectious Diseases Community of Practice “Strategies for Safe Living After Solid Organ Transplantation”; American Journal of Transplantation. Volume 13 Issue S4. Viewed on 13/05/2016 in http://onlinelibrary.wiley.com/doi/10.1111/ajt.12121/pdf

Acknowledgements

Transplant Australia acknowledges that each patient experience is different and in no way provides this information as a substitute for medical advice. Please contact your transplant unit if you have any questions or concerns regarding vaccinations and medication.

Transplant Australia gratefully acknowledges the valuable contribution of Elaine Chan, Renal Specialist Pharmacist, Department of Pharmacy at Westmead Hospital, in developing and reviewing the article on vaccinations.

Transplant Australia gratefully acknowledges the contribution of Michele Harvey, Nurse Practitioner at Doomadgee Community Health, Department of Health/North West Hospital and Health Service in developing and reviewing the article on travel.