Sunday, November 24, 2013

IBD and Travel

 Travelling with Crohn's Disease and Ulcerative Colitis

Tis the season … to travel.  Many of us will be travelling in November and December to visit friends and relations, or to take some long-needed vacation hours before they go away at the end of the year.  Travelling with IBD is different than travelling for others without the disease.  There are many sites good travel tips for those with IBD, ranging from getting extra meds to obtaining records from your doctor to finding restrooms.  Here are a few good links:

My own travel tip is to make use of hotel bathrooms.  They tend to be clean, readily accessible off the lobby, open 24 hours, and open to anyone who stops (its hard to know who is a guest and who isn’t).  But this site is above evidence-based IBD.  Are there increased risks for those with Crohn’s and Ulcerative Colitis?  How about hard numbers?  Fortunately, there has been some research into just these questions.

First off, travel has a bigger impact on individuals with IBD.  In a study of Crohn’s patients in remission, they found that 20.5% ended up with diarrhea while traveling, compared with 1.3% of healthy controls. Approximately 6% ended up in a flare post-travel. (1)  A second, larger study found a similar increase in risk with all IBD patients (both Crohn’s and UC), though not as extreme, finding that illness occurred in 15.1% of trips made by patients with IBD compared with 10.9% for controls.  This study differentiated travel in the developing world, and found that travel to high risk locations had equal risk for those with IBD, but travel to more industrialized areas put those with IBD at higher risk due to the underlying illness (and not local conditions).(2)

The second area that travel can have an impact is vaccinations – specifically international travel.  Those with IBD taking steroids, immunomodulators, or anti-TNF-alpha drugs are considered immunocompromised.  They should be vaccinated using any inactivated (dead virus) vaccines but not live virus vaccines prior to travel.(3)  There are two reasons that are given for avoiding live virus vaccines – 1) the efficacy may not be as great, 2) there may be a negative systematic response.  The first risk exists with any vaccine – the second only with live virus vaccines (Yellow Fever vaccine being the most often cited for travel reasons).  Despite the guidance provided, there is minimal evidence that rates of systemic infection are higher for those on anti-TNF-alpha drugs – this area requires further research, but avoidance of areas with endemic disease and the required vaccinations is the safer route until it occurs.

A final area of interest and the subject of recent research is high altitude travel (both in a plane and at higher altitude locations).  It is known that hypoxia can increase inflammation, and higher altitude environments can induce hypoxia in those not acclimated.  A research study out of Switzerland found an almost doubled risk of flare in IBD patients within four weeks of high altitude adventures (though pressurized, airplane cabin pressures are generally equivalent to an 8,000 foot altitude at their lowest pressure).  While avoiding air travel isn’t practical, individuals should be aware of the increased risk possible based on the preliminary data from this study.(4)  This may be the partial cause of the increased diarrhea and exacerbated illness risks noted above.

Whatever your travel plans, I wish everyone a fun an healthy holiday season.

Bottom Line

·         Those with IBD may have increased risk of diarrhea with travel.
·         Prolonged air travel or high-altitude vacation destinations may induce flares.
·         Live virus vaccines should be avoided, but more research needs to be done to confirm this.
1.       Ellul, Pierre, Valerie Anne Fenech, Christine Azzopardi, Lara Callus, Nicholas Delicata, Jeffrey Muscat, Neville Azzopardi, and Mario Vassallo. "Diarrhoeal episodes in travellers suffering from IBD." Frontline Gastroenterology 4, no. 2 (2013): 120-124.
2.       Ben–Horin, Shomron, Yoram Bujanover, Shulamit Goldstein, Moshe Nadler, Alon Lang, Uri Kopylov, Lior Katz, Adi Lahat, Eli Schwartz, and Benjamin Avidan. "Travel-associated health risks for patients with inflammatory bowel disease." Clinical Gastroenterology and Hepatology 10, no. 2 (2012): 160-165.
3.       Wasan, Sharmeel K., Jennifer A. Coukos, and Francis A. Farraye. "Vaccinating the inflammatory bowel disease patient: deficiencies in gastroenterologists knowledge." Inflammatory Bowel Diseases 17, no. 12 (2011): 2536-2540.
4.       Vavricka, Stephan R., Gerhard Rogler, Sandra Maetzler, Benjamin Misselwitz, Ekaterina Safroneeva, Pascal Frei, Christine N. Manser et al. "High altitude journeys and flights are associated with an increased risk of flares in inflammatory bowel disease patients." Journal of Crohn's and Colitis (2013).

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