Travel Bugs

Been to Vancouver?
   

It used to be that a trip to Florida was a big deal, and a vacation in Europe a once in a lifetime occurrence.  No longer. Now it seems that every week I hear of patients packing up and flying off to climb Kilimanjaro or trek to Machu Picchu. There has been a recent surge in people heading off to Thailand and Vietnam.  All very exciting, but it seems few ever consider their medical condition before they book their exotic voyages.  They're are often disappointed and even mad at me when I suggest that more first-worldly destinations might be preferable.  Not long ago I had to convince a young woman who had just started on cyclophosphamide and high dose prednisone for a Wegener's vasculitis that Laos was not the optimal travel destination for her.  Three days later she called back to say he was going after all because he was feeling much better on the prednisone. 

There are many reasons for her and other rheumatological patients to be cautious in their globetrotting:

First of all, you are much more likely to get sick in a third world country.  30-50% of travelers to these places develop gastroenteritis and the risk is highest amongst the immunosuppressed . Even simple meds like proton pump inhibitors for reflux can increase the risk.  There are also many other nasty bugs out there, all more likely to infect patients on immunosuppressors.

You can't get all the vaccinations necessary if you are taking biologics or other immunosuppressors.  Yellow Fever, for example is a live vaccine and therefore contraindicated.  Fortunately, many countries deny entry without these vaccinces, preventing immunosuppressed patients from even getting in.

Tuberculosis.  As anybody who has taken a biologic knows, TB is a big concern and all patients are screened before treatment is started.  If their PPD test is positive, we treat them before starting.  This cures the infection that was there, but doesn't prevent a new infection from occurring, something that is a lot more likely to happen in a third world country.

If you do get sick, what kind of medical care is available.  I have no idea what the situation is in the vacation regions of Thailand.  It may be fine for all I know, but what I have noticed is that the traveling patients of mine don't know either.  

Even if there is medical care available, who's going to pay.  Some of my patients aren't aware that their insurance has specific clauses concerning prior illnesses.  Here, most insurances won't cover your illness or complications if there has been any modification in therapy in the three months prior to departure.

So now I include travel recommendations with my normal biologic blurb.  Florida sounds nice.  France is lovely.  Been to Vancouver?

Comments

[Helen]

I'll never go to a third world country - much too risky for me - but I'll admit the month I spent backpacking in Europe was, in large part, a way for me to say "screw you" to RA and my recently implanted defibrillator. I imagine some of that is going through these patients' heads, as well.

That said, it was complicated enough carting Enbrel around, avoiding metal detectors and having to know the location of a cardiac unit in every city. I can't imagine how difficult it would be outside the developed world.

[milkshake]

Patients born in Europe could have been vaccinated with the live TB vaccine in their childhood, which causes a significant fraction of them to still test positive in tuberculin test response in adulthood. I know this because I had to take TB test form my Green card, and I had to go to hassle of proving that I do not have TB even though my tuberculin response was positive. They really wanted to treat me with cycloserine and rifampicine for half a year, no matter that 5% of patients develop nasty liver reaction to the treatment, and that treatment ruins the efficacy of the TB vaccination...

[Julie]

Good point, and one I recently had to think about when a vasculitis pt announced a trip to Haiti.

[home page]

I have no idea what the situation is in the vacation regions of Thailand. It may be fine for all I know, but what I have noticed is that the traveling patients of mine don't know either.

[Manohar Singh]

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