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provide medical care for travel. Travel recommendations change frequently as inter-
national conditions change; therefore, prior to making recommendations, primary
care providers should check for updated guidelines, such as the CDC Yellow Book,
in particular, Section 3, “Immunocompromised Travelers.” [69] The 2019 AST travel
medicine guideline [68] also provides a checklist for pre-travel visits and packing
lists for traveling solid organ transplant recipients, which may be helpful resources.
14.5.1.1 Immunizations
All individuals should be up-to-date in routine immunizations (e.g., tetanus, inu-
enza, pneumococcal, and SARS-CoV-2). The specic vaccines needed for travel
will depend on the travel agenda, including the specic areas in the countries that
will be visited and associated exposure risks, and the patient’s vaccination status. In
general, solid organ transplant recipients should avoid traveling to countries with
yellow fever [46] or other endemic outbreaks such as typhoid, dengue, measles,
polio, Chikungunya, or Japanese encephalitis. Ideally, vaccines should be given sev-
eral months before travel to allow for an optimal immune response. The yellow
fever vaccine is a live-attenuated vaccine and therefore contraindicated in transplant
recipients. Comprehensive information regarding travel vaccines for solid organ
transplant recipients can be found at the CDC Traveler’s Health website [67], but a
few recommendations are highlighted here:
• Hepatitis A. Those who have not been vaccinated or are on higher levels of
immunosuppression and plan to travel within 2 weeks, should be given IM
pooled immunoglobulins as they provide 85–90% protection against hepatitis
A.A dose of 0.2ml/Kg provides up to 2months of protection. Alternatively, if
time allows, vaccination with two doses of the hepatitis A vaccine 6 to 12months
apart provides protection [68].
• Hepatitis B. Those not already vaccinated, should receive high-dose hepatitis B
(40 mcg). Accelerated schedules 0, 7, 21, and 28days or 0, 1, and 2months (both
with a booster at 6months) are acceptable.
• Salmonella enterica serovar Typhi. Typhim Vi®, an inactivated IM polysaccha-
ride vaccine, should be given at least 2weeks before departure and is protective
for 2years.
• Japanese encephalitis (JE). Consider immunization with the inactivated vaccine
(Jepect/Ixiaro) for individuals traveling to rural areas of Asia or other endemic
regions, although there is no available data on safety or efcacy of JE vaccination
in immunocompromised patients [69].
14.5.1.2 Travel Precautions
Ideally, solid organ transplant recipients should not travel for 1year after transplant
or during treatment for rejection [68, 70]. Once patients are on maintenance doses
of immunosuppressants and the allograft has stabilized, it may be safer to travel.
R. S. Gold and L. Marcotte
419
Patients should travel with adequate supply of medications and copies of
prescriptions.
It is important for patients to carefully follow food and water precautions to pre-
vent infections. They should drink only boiled or bottled water, and avoid ice in
drinks, raw food, and food rinsed with tap water [68]. Diarrhea, the most common
illness of travelers, can be life threatening for solid organ transplant recipients [71].
Dehydration can lead to decreased renal function, especially in those taking tacroli-
mus [68]. Complications include bacteremia and altered absorption and metabolism
of immunosuppressive drugs. Patients should be prescribed empiric antibiotic ther-
apy, such as azithromycin or ciprooxacin, to have available during travel; however,
these medications can potentially interact with transplant medications and should be
discussed with the transplant team rst. The threshold for treatment is three or more
unformed stools in 24 h, or any systemic symptoms (e.g., fever). Anti-motility
agents should be used with caution. Bismuth-containing antidiarrheal medications
should be avoided because they increase the risk for salicylate toxicity in the context
of decreased renal function. In general, it is not recommended for patients to take
antibiotics prophylactically due to increased risk for antibiotic resistance, C. dif-
cile infection, and drug interactions.
Patients should be instructed to minimize insect bites, including by use of repel-
lents, bed nets, and protective clothing [65, 68]. Careful discussion regarding need
for malaria prophylaxis is recommended [68], with particular counseling for
asplenic patients who may be at higher risk for morbidity and mortality. The CDC
suggests atovaquone-proguanil might be the most appropriate malaria prophylactic
agent for solid organ transplant recipients, because other antimalarials can interact
with calcineurin inhibitors and mTOR inhibitors [69].
Solid organ transplant recipients are at an increased risk for invasive fungal
infections and should avoid activities such as spelunking and excavating, which
Table 14.6 Travel advice for solid organ transplant recipients [69, 72]
Review Precautions
Food and water, mosquitos, traveler’s diarrhea (and when to take antibiotics), sun exposure,
sexually transmitted/blood-borne pathogens
Healthcare
Make a list of facilities where medical care can be obtained if needed, consider obtaining
evacuation insurance, carry a list of medications/medical conditions
Supplies
Insect repellent, sunscreen, basic rst aid kit, antibacterial hand wipes or an alcohol-based hand
cleaner
Medications
Malaria prophylaxis if indicated, all regular medications to cover the entire trip, antibiotics for
diarrhea, over-the-counter as needed medications
Care coordination
Discuss with the transplant team, we recommend at least 1–2months ahead of planned travel
Consider referencing the CDC Yellow Book, Section 3, “Immunocompromised Travelers:”
https://wwwnc.cdc.gov/travel/yellowbook/2024/additional- considerations/
immunocompromised- travelers
14 Preventive Health intheAdult Solid Organ Transplant Recipient
420
could lead to exposure to Cryptococcus neoformans or other endemic fungi [65]. At
a minimum, masking should occur during any high-risk activities. Table14.6 sum-
marizes the recommendations for solid organ transplant recipients who plan to
travel internationally.
14.6 Behavioral Health andSubstance Use
inTransplant Recipients
14.6.1 Behavioral Health
Behavioral health diagnoses are prevalent in solid organ transplant recipients,
although further research is needed to better characterize incidence and impact of
these following solid organ transplants. The most evidence is for depression. Solid
organ transplant recipients are at higher risk for developing depression post-
transplant compared to the general population. In a survey of liver transplant recipi-
ents, approximately 50% of those surveyed met criteria consistent with at least mild
depression based on Patient Health Questionnaire (PHQ)-9 responses [73]. A diag-
nosis of depression post-transplant is correlated with worse outcomes. A 2015 sys-
tematic review and meta-analysis found that post-transplant depression was
associated with a 65% greater risk of mortality. The same analysis examined impact
of anxiety on post-transplant mortality and found a non-signicant increased risk;
however, the authors noted these data were likely unreliable due to far fewer studies
and less precision of results as compared to those for depression [74].
There is emerging data regarding post-traumatic stress disorder (PTSD) follow-
ing solid organ transplant. A systematic review found 10–17% cumulative incidence
of post-transplant PTSD.Poor social support and pre-existing psychiatric diagnoses
were correlated with post-transplant PTSD.Post-transplant PTSD was associated
with worse mental health-related quality of life [75].
Poor sleep is a common experience among solid organ transplant recipients with
prevalence ranging from 39% to 52% among kidney, liver, and lung transplant
recipients; and it is associated with higher rates of depression, anxiety, restless leg
syndrome, comorbidity, and worse overall reported quality of life [76]. While ask-
ing about sleep is not part of formal guidelines, primary care providers could con-
sider it as part of mental health screening and evaluation.
No consensus guidelines exist for screening for psychiatric diagnoses post-
transplant, although many recommend at least regular interval screening for depres-
sion [77]. In 2023, the Academy of Consultation Liaison Psychiatry (ACLP)
published best practice guidance with the recommendation to screen adult solid
organ transplant recipients for depression within the rst 6months following trans-
plant, once more in the next 6months, and then annually thereafter [78]. The ACLP
recommended screening using the PHQ −2, −8, or−9 and referring patients who
screen positive for clinical assessment, preferably by a mental health practitioner
R. S. Gold and L. Marcotte
421
experienced in transplant psychiatry. These recommendations are aligned with the
USPSTF depression screening recommendations for the general population, how-
ever, are more specic with respect to screening intervals and tools [79].
See also Chap. 12.
14.6.2 Substance Use
Substance use is screened and monitored as part of pre-transplant evaluations. After
solid organ transplant, substance use (e.g., alcohol and tobacco) is associated with
higher rates of graft failure [80, 81]. Although precise estimates are unknown, a
meta-analysis of studies in solid organ transplant recipients found a 1–4% rate of
post-transplant substance use (dened as tobacco, alcohol, or illicit drug use) [82].
Still, comprehensive screening guidelines are lacking for the solid organ transplant
population.
Substance use after transplant is best studied in patients who received liver trans-
plant for alcohol-associated liver disease. In a study surveying 67 liver transplant
recipients, approximately 20% reported alcohol use; however only 4.5% reported
at-risk behavior (as dened by the Alcohol Use Disorders Identication Test
[AUDIT]); 30% reported tobacco use; and a minority (3%) reported non-marijuana
drug use [73].
Alcohol use after liver transplant is associated with worse outcomes regardless of
reason for transplant [83]. The AASLD and AST guidelines [17] recommend that
patients who receive a liver transplant for alcohol-associated liver disease should be
encouraged to abstain from alcohol. However, there are not specic guidelines for
screening and recommendations for patients who do not have a prior diagnosis of
alcohol-associated liver disease. Guidelines for care of kidney transplant recipients
include avoidance of alcohol and other behaviors associated with worse outcomes
in the evaluation of adherence, however no specic screening recommendations are
given [40].
Tobacco use in solid organ transplant recipients is associated with poorer graft
function and signicantly worse survival [84]. Currently, only lung transplant
guidelines cite tobacco use as an absolute contraindication to transplant [85]. While
there are not clear guidelines regarding screening for tobacco use in solid organ
transplant recipients, routine screening (e.g., annually) is recommended given the
clear correlation with worse outcomes and the demonstrated substantial rates of
recurrent use in recipients who smoked prior to transplant [80].
Increasingly states are legalizing medical and recreational cannabis, yet there is
little guidance as to how to screen and counsel solid organ transplant recipients
regarding use. Studies that have looked at the effect of cannabis use in solid organ
transplant recipients have not found signicant differences in graft function and/or
survival as compared to non-marijuana users [86–88]. However, there remain con-
cerns regarding marijuana’s potential inhibition of metabolic pathways that could
14 Preventive Health intheAdult Solid Organ Transplant Recipient
422
lead to medication toxicity, infectious risks in the context of immunosuppression,
end-organ risks that may be amplied in immunosuppression, as well as addiction
behaviors and impacts on cognition that might worsen adherence to medical ther-
apy [89]. At least one case report demonstrated three-fold increased tacrolimus
levels in a patient receiving cannabidiol (CBD) [90]. Another group of investiga-
tors sampled cannabis from several dispensaries in California and found several
pathogenic fungi and gram-negative bacteria [91]. Based on these concerns, the
AST Infectious Diseases Community of Practice recommends avoidance of can-
nabis use by smoking or vaporization [65]. While they noted oral ingestion is
likely safer from pathogenic exposure, it would still pose risk for medication
interactions.
AST also recommends transplant recipients avoid intravenous or intradermal
substance use, due to both the possible health consequences of these drugs, as
well as the increased risk of acquiring HIV, HCV, and HBV.Similarly, body pierc-
ings and tattoos cause breaks in the skin that can increase risk of infection, so
patients should ensure use of reputable centers with close attention to sterile tech-
nique [65].
14.7 Conclusion
Solid organ transplant recipients are at increased risk for a broad spectrum of com-
mon conditions, several of which are discussed in this chapter. We emphasize the
importance of cancer screening and vaccinations for all recipients. Travel planning
and precautions are also addressed.
For many of the conditions reviewed, there are still unclear or absent guidelines
with respect to screening. For example, we were unable to nd any guidelines for
screening for osteoporosis in lung transplant recipients, although there is an
increased risk. This can cause uncertainty, especially amongst primary care physi-
cians, as to what to recommend to patients. More frequently updated guidelines and
further research is needed to establish effective screening modalities and intervals
for different medical problems in the solid organ transplant population.
Primary care physicians play an important role in providing optimal healthcare
for solid organ transplant recipients. The checklist below (Table14.7) summarizes
R. S. Gold and L. Marcotte
423
Table 14.7
Preventive health checklist for solid organ transplant recipients (see text for details)
Screening/prevention
category Recommendations
Cancer ⧠ Skin cancer screening: annual skin exam
⧠ Anal cancer screening: annual cytology if risk factors
⧠ Cervical cancer screening: cytology +/− HPV at 1–3-year
intervals; continue after age 65
(see Table 14.1 for additional detail and age-specic
recommendations)
⧠ Other age-appropriate cancer screening as for the general
population
Cardiovascular disease and
diabetes
⧠ Monitor blood pressure each visit
⧠ Diabetes screening every 3months for rst year, then annually
⧠ Annual lipids if normal
⧠ Exercise, diet, and tobacco cessation counseling
Osteoporosis ⧠ DXA at least within the rst year of transplant
⧠ Consider calcium and vitamin D supplementation
⧠ Consider regular weight-bearing or resistance exercises
(see Table 14.3 for additional detail and transplanted organ
specic recommendations)
Immunizations ⧠ Inuenza: annually
⧠ PCV21: once
⧠ TdaP: every 10years
⧠ HPV: 3-doses total thru age 45yr (if not completed
pre-transplant)
⧠ Shingrix®: two doses (if not completed pre-transplant)
⧠ SARS-CoV-2: refer to CDC guidelines for
immunocompromised schedule
(see Table 14.4 for additional vaccine recommendations)
Safe living practices ⧠ Discuss hand hygiene, masking, protective clothing and
high-risk hobbies and exposures
⧠ Discuss food preparation and water precautions
Behavioral health ⧠ Depression screening (PHQ-2 and/or PHQ-9) at least annually
a
⧠ Monitor for signs of PTSD, poor sleep
Substance use ⧠ Alcohol screening at least annually
a
⧠ Tobacco screening at least annually
a
DXA dual-energy X-ray absorptiometry, HPV human papilloma virus, PHQ patient health ques-
tionnaire, PTSD post-traumatic stress disorder
a
No consensus guidelines
most topics covered in this chapter and can serve as a tool for primary care physi-
cians to ensure solid organ transplant recipients receive regular screening and
appropriate preventive care.
Acknowledgments Thank you to Heidi Powell for her contributions to the First Edition of this
book and chapter.
14 Preventive Health intheAdult Solid Organ Transplant Recipient
424
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14 Preventive Health intheAdult Solid Organ Transplant Recipient