COMMENTARY

Illness During Travel in Patients With IBD

David A. Johnson, MD

Disclosures

May 03, 2012

Travel-Associated Health Risks for Patients With Inflammatory Bowel Disease

Ben-Horin S, Bujanover Y, Goldstein S, et al
Clin Gastroenterol Hepatol. 2012;10:160-165

Study Summary

Background. Inflammatory bowel disease (IBD) has significant implications for the safety of travel. Often, patients with IBD are taking immunosuppressants or biologic agents; these create significant concerns in terms of travel, particularly international travel.

Many healthcare providers counsel patients with IBD to not travel, especially to more remote areas, where the risk for infection or disease flares is higher. Some insurance companies are reluctant to insure patients with IBD who are regular travelers.

Methods. This analysis from a group in Israel was a retrospective, case-control study of illness in 222 patients with IBD and 224 healthy individuals during a total of 1099 trips. Data were obtained by use of questionnaires, interviews, and chart review.

Results. These travelers experienced 142 illness episodes, 92% of which were enteric disease-related. An illness episode developed during 15.1% of trips taken by patients with IBD, compared with 10.9% of the healthy travelers (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.01-2.0; P = .04). This difference occurred during travel to industrialized countries; surprisingly, no difference in the incidence of illness was found during travel to developing countries.

To adjust for length of travel, the investigators analyzed risk per 10 days of traveling, stratified by developed and nondeveloped regions. The results were similar to those of the nonnormalized analyses and showed lack of increased risk for illness in patients with IBD when traveling to developing or tropical areas.

In multivariate analysis, factors associated with increased risk for travel illness included frequent flares of IBD (OR, 1.9; 95% CI, 1.1-3.4; P = .02) and previous hospitalizations due to IBD (OR, 3.5; 95% CI, 1.3-9.3; P =.01). No increased risk for illness was associated with the use of immunosuppressant or biologic therapies.

The investigators concluded that patients with IBD have a higher rate of illness flares when traveling to industrialized countries, but not when traveling to nonindustrialized or tropical areas. These illness episodes are attributable to IBD flares rather than an increased susceptibility to enteric infections.

Viewpoint

International travel is increasing, both for business and leisure pursuits, including among patients with IBD. In a recent survey,[1] more than 60% of patients with IBD reported that travel restrictions have a significant effect on their quality of life. Such restrictions are often self-imposed but are also frequently mediated by their healthcare providers. This study suggests that this advice is justified, at least from the standpoint of enteric infectious disease.

Before patients with IBD are given a "green light" for unrestricted travel, several words of caution are warranted. First, as the investigators acknowledge, this study was not powered to detect rare opportunistic infections, such as Strongyloides.

Second, travel to areas with a high prevalence of tuberculosis was not identified. This issue is important, in particular for patients receiving biologic agents.

Finally, vaccine recommendations for specific travel destinations must be considered. Clearly, the use of live attenuated vaccines, such as yellow fever, is contraindicated. In addition, bacille Calmette-Guérin vaccine is used in countries with a high endemic rate of tuberculosis. This vaccine is typically not recommended for travelers, but it may be considered for children younger than 5 years who are traveling to highly endemic areas for more than 1 year.[2]

Live vaccines should be avoided with in patients receiving medications or who have medical conditions that create an immunosuppressive state, defined by an expert consensus group[3] as:

  • Treatment with glucocorticoids (prednisone > 20 mg/day equivalent, or > 2 mg/kg/day in patients weighing < 10 kg, for 2 weeks or more and within 3 months of stopping therapy);

  • Ongoing treatment with effective doses of 6-mercaptopurine/azathioprine, or discontinuation of therapy within the previous 3 months;

  • Treatment with methotrexate or biologics (infliximab, adalimumab, certolizumab, and natalizumab), or discontinuation of therapy within the previous 3 months;

  • Treatment with infliximab, or discontinuation of therapy within the previous 3 months; and

  • Significant protein-calorie malnutrition.

Abstract

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