Hematopoietic stem cell transplantation (HSCT) recipients and transplant candidates should pay attention to hand hygiene on a continuous and regular basis.

In Which Situations Should You Be Careful?

• Before preparing and eating food,
• After changing the diaper,
• After contact with plants or soil,
• After the toilet,
• After contact with animals,
• After contact with any item (clothing, bedding, toilet, or bed slide, etc.) that has come into contact with body fluids or wastes, or human or animal feces
• After going out or being in a public place,
• After the gloves are removed,
• After collecting or dropping litter,
• Before and after contact with catheters or wounds.

Protection from Infections Transmitted by Direct Contact

Hematopoietic stem cell transplantation (HSCT) recipients and transplant candidates should pay attention to hand hygiene on a continuous and regular basis.

In Which Situations Should You Be Careful?

• Before preparing and eating food,
• After changing the diaper,
• After contact with plants or soil,
• After the toilet,
• After contact with animals,
• After contact with any item (clothing, bedding, toilet, or bed slide, etc.) that has come into contact with body fluids or wastes, or human or animal feces
• After going out or being in a public place,
• After the gloves are removed,
• After collecting or dropping litter,
• Before and after contact with catheters or wounds.

Preventing Respiratory Transmitted Infections

• To prevent respiratory tract infections, hands should not be contacted with eyes, nose, and mouth without disinfecting.
• Close contact with people with respiratory tract disease should be avoided. The use of surgical masks is recommended in symptomatic cases. Although transplant recipients use masks to protect themselves during contact with symptomatic people, it is not yet known how protective the mask is.
• Before and after the visit, hands should be washed or sterilized with an alcohol-based cleaning gel.
• Direct contact with soil and plants, their pollen, and dust should be avoided in the first 6 months after transplantation and during the period of immunosuppression treatment. When using them, it is recommended to use gloves, surgical masks, or N95 masks to prevent scratches and tears. After contact, hands should be washed thoroughly with soap and water.
• Recipients are advised to stay away from dusty areas such as construction sites, excavations, etc., in the first 6 months after transplantation and during periods of significant immunosuppression treatment. When coming to the transplantation center, roads away from the construction sites should be preferred.
• Bird and bat droppings should be avoided in terms of histoplasmosis (a lung disease caused by a fungal infection known as Histoplasma capsulatum).
• Persons with active tuberculosis should not be contacted in the first 6 months after transplantation and during the periods of significant immunosuppression treatment.
• The risk of toxoplasmosis, Q fever, brucellosis, and other zoonotic (animal-transmitted) diseases increases in animal contact in the first 6 months after transplantation and during periods of significant immunosuppression treatment.
• Transplant recipients are required to use masks and gloves when handling waste.

Recommendations for People Living in the Same Household and Receiving Live Vaccination

It is recommended that people who share the same house with the transplant patient get inactivated vaccines against the possibility of transmission of the vaccine virus.

• Polio Vaccine: Inactivated Polio vaccine (IPV) is preferred. However, if for any reason a live Polio vaccine (OPV) is administered as an oral dropper, close contact should be avoided for approximately 4-6 weeks.
•  Rotavirus Vaccine: Standard routine prevention is recommended for newly vaccinated infants. It is recommended that babies not be brought to visit for 2-4 weeks after vaccination.
•  Live-Attenuated Influenza Vaccine: It takes about 3 days for the skin to renew itself in adults. However, it continues up to 7 days after vaccination. Trivalent (Triple) Inactivated Vaccine (TIV) is recommended for family members living with transplant recipients to avoid potential transmission. Visitors of transplant recipients should receive the Live-Attenuated vaccine and avoid close contact for 7 days.
• Zoster (Shingles) Vaccine: Transplant centers do not accept visitors who have varicella (chickenpox) and rashes like Zoster (shingles) after vaccination.
•  Varicella (Chickenpox) Vaccine: Since the virus in the vaccine has a low risk of contagiousness, households should be vaccinated to protect the transplant recipient against the wild type of this disease, especially if there are no vaccine-related rash.
• Measles-Rubella-Mumps (MMR) Vaccine: Those living in the same house should get the recommended MMR vaccine according to their age. However, if vaccinated individuals develop fever and/or rash after vaccination, they should not be taken to the transplant center and should avoid close contact with transplant recipients.

Sexually active, non-monogamous patients should use latex condoms during every intercourse to protect themselves from CMV, HSV, HIV, HPV, HBV, HCV, and other sexually transmitted diseases.

It is very important for patients who are in a monogamous relationship but who are seropositive to use latex condoms during sexual intercourse in terms of the risk of being exposed to sexually transmitted diseases again.

Immunosuppressed transplant recipients must avoid any unprotected sexual intercourse (activities involving contact of the transplant recipient's mucous surfaces with saliva, semen, or vaginal discharge) until they recover from immunosuppression.

Prevention of Zoonotic Infections Transmitted from Pets:

Immunocompromised transplant recipients and transplant candidates should pay attention to the following issues: 

• They should avoid adopting pets or any stray animals that are sick or younger (such as cats ≤6 months old).
• They should not be come into contact with reptile animals (lizards, snakes, turtles, and iguanas) due to the risk of salmonellosis. The food of these animals and everything they touch should be avoided. If contact occurs, the recipient or transplant candidate should thoroughly disinfect their hands.
• It is recommended not to feed or contact ducklings and chicks in order to prevent salmonella and campylobacter species infections.
• It is recommended not to feed or come into contact with exotic animals (chinchillas, monkeys, or other non-human primates). 
• People who have pets need to be much more careful.
• If a pet becomes ill, it should be taken to the veterinarian immediately to reduce the risk of transmission to the owner. If the pet has diarrhea, Cryptosporidium, Giardia species, Salmonella, and Campylobacter should be investigated.
• The necessary vaccinations of the animals should be performed, except for live vaccines.
• There is no need to routinely investigate healthy animals for zoonotic diseases.
• It is important to feed animals only with high-quality ready-made foods and to prevent infections from spoiled or contaminated food. Thus, transmission from animal to human is prevented.
• If eggs, chicken, or meat products are given to animals as supplementary food, they must be well-cooked. Milk and dairy products must also be pasteurized.
• Animals should be prevented from drinking toilet water, rummaging through trash, hunting, and eating the excrement of other animals.
• In order to reduce the risk of toxoplasmosis, cryptosporidiosis, salmonellosis, and campylobacteriosis, it is recommended that transplant recipients and transplant candidates do not come into contact with animal feces, do not clean cat litter or cages and dispose of animal wastes themselves.
• Gloves should be worn when touching items contaminated with bird droppings, because bird droppings can be the source of factors such as cryptococcus neoformans, mycobacterium avium, and Histoplasma capsulatum.
• Transplant candidates and recipients with compromised immune systems mustn't clean the aquarium in order to avoid encountering Mycobacterium marinum.

If these tasks cannot be delegated to others, patients should use disposable gloves and wash their hands thoroughly after the procedure.

Preventing Toxoplasmosis:

Patients should be informed that they may encounter toxoplasmosis with oocytes (eggs) from cat feces. In houses with cats, litter boxes should not be kept in the kitchen, dining room, or places where food is eaten or prepared.

• Litter boxes should be cleaned by someone other than the patient in order to reduce the risk of toxoplasmosis transmission. There is an incubation period of >1 day for fecal oocytes to become infectious (disease-causing).
• Transplant recipients and candidates who own cats should not take their cats outside and should not adopt or touch stray cats.
• Cats should be fed dry or wet ready-made food or well-cooked homemade food. Undercooked or raw meat should not be given to cats, as they may contain disease-causing factors that can be transmitted from cat to owner.
• Transplant recipients do not need to have their cats in the house tested for toxoplasmosis.
• Litter boxes in the playground should be kept covered so that when not in use, cats do not use them as a toilet. 
• Transplant recipients or candidates receiving preparation treatment should not drink raw goat's milk to reduce the risk of toxoplasmosis.
• Toxoplasmosis can also be transmitted from cat feces that are contacted during gardening activities.

Transplant recipients are advised to avoid activities such as walking, wading, swimming, or playing games in recreational areas such as ponds or lakes, as there may be a risk of contamination with Cryptosporidium, E.coli O157:H7, or animal or human feces. In such areas, there is a risk for patients to accidentally drink or swallow these waters. Therefore, they should be careful.

The use of water from private or public wells, which is rarely tested for sporadic bacterial contamination, is inconvenient in terms of bacterial, viral, and parasitic contamination.

If transplant recipients and candidates drink tap water, they should pay attention to the local or general administrator's instructions for boiling the water. Tap water should be boiled for at least 1 minute before drinking.

Although tap water is generally safe, it may not be completely free of cryptosporidium. In immunocompromised individuals, cryptosporidium can cause severe chronic diarrhea, malnutrition, and even loss of life.

Alternatively, some water filters or home distillers can be used to protect against cryptosporidium and waterborne pathogens. Household filters must be able to separate particles of 1 micron and above from water or must be a reverse osmosis filter.

Since the majority of these filters cannot filter out smaller-sized microbes, they should only be used with well-purified tap water.

Bottled water may be suitable for use if it has been purified by reverse osmosis, 1-micron particle filters, or distillation.

Drinks such as premixed drinks, ice made from tap water used in restaurants, bars, and cinemas, frozen fruit drinks mixed with tap water, iced tea, or iced coffee made with tap water should not be consumed.

Fizzy drinks, hot tea and coffee, bottled soda, mineral water, pasteurized fruit juices, and frozen fruit drink concentrates which are widely distributed and trusted throughout the country are generally recommended as safe drinks for transplant recipients in terms of cryptosporidium.

Unpasteurized milk, fruit, and vegetable juices should not be consumed in order to protect transplant recipients from Brucella, Salmonella, E Coli O157:H7, Cryptosporidium, and other pathogens. 

Safe Food Options Suitable for Everyone

• Raw chicken, red meat, fish, and all seafood should be prepared in a separate area from other foods.
• A different preparation board should be used for each prepared product or it should be washed with warm water and soap after each use.
• Raw meats should not come into contact with other food products in order to prevent food-borne diseases caused by factors that can cause serious and invasive diseases in immunocompromised patients such as Salmonella enteritidis and Campylobacter jejuni.
• Different types of meat should be cooked at different temperatures, hotter than 66°C.
• Casseroles or soufflés containing other meats and eggs should be cooked above 71°C.
• Cold foods should be stored below 4°C. Hot foods should be stored above 60°C.
• Food preparers should wash their hands before and after dealing with leftover foods, and use clean utensils and food preparation areas. Leftover foods should be cut into small pieces and stored in shallow containers that can cool quickly.
• Leftover foods should be placed in the refrigerator within 2 hours after cooking, and foods that remain at room temperature for more than 2 hours should not be consumed.
• If leftover food is to be reheated or partially cooked food is to be recooked, the temperature must be above 74°C when cooked. Leftover soups and sauces should be boiled thoroughly before eating. Food placed in the refrigerator should be dated and should not be stored for more than 72 hours.

Additional Practices for Transplant Recipients

• The diet of transplant recipients should be restricted to prevent infections such as bacteria, viruses, yeasts, molds, and parasites that may arise from food prior to engraftment.
• A low microbial diet is recommended for transplant recipients prior to engraftment, although there is no evidence of its efficacy for preventing infection.
• After engraftment in transplant recipients, it is necessary to provide adequate additional nutritional intake as well as to prevent food-borne infections.
• In autologous transplant recipients, this diet should be continued for 3 months, and in allogeneic transplant recipients, until all immunosuppressive drugs are discontinued and the recipient reaches a level where live-attenuated vaccines can be administered.
• Transplant recipients should not eat any raw or undercooked meat (beef, chicken, pork, lamb, deer, and other game meats) or those that contain raw meat or sweet bread of animals.
• Transplant recipients and candidates should take care to consume only well-cooked meat if the meal is being prepared by someone other than themselves or their caregivers (in restaurants, etc.).
• Transplant recipients and candidates should not consume sausages and delicatessen products unless they are heated until the smoke comes out.
• Due to the risk of Salmonella enteritidis infection, transplant recipients and candidates should not consume raw or undercooked eggs or foods containing them (such as hollandaise sauce, salad dressings such as caesar dressing, homemade mayonnaise).
• Raw or undercooked seafood should not be consumed to avoid infections caused by Vibrio species, viral gastroenteritis, and Campylobacter species.
• It is recommended to wash the shelled vegetables and fruits, organic foods, and packaged fruits and vegetables that are stated to have been previously washed with tap water.
• Foods such as raw cabbage (E.Coli, Salmonella), fruits such as strawberry and mulberry, unroasted, raw or shelled nuts, products containing fermented soybeans, raw grain products, unpasteurized milk, and dairy products, cheese containing raw vegetables, blue mold cheeses, soft cheeses, smoked or pickled seafood, and raw honey should not be consumed.

Transplant Recipients Should Not Consume Probiotics

Transplant candidates under preparation treatment, neutropenic (neutrophil count <1000/ml3) transplant recipients, or severely immunocompromised patients should not use naturopathic (herbal) medications as they may contain mold.

Transplant recipients should use naturopathic medications as recommended by transplant doctors or naturopathists working with infectious disease specialists.

• Traveling to underdeveloped countries, especially for chronic immunosuppressed allogeneic transplant recipients, poses a significant risk in terms of encountering infection.
• Transplant recipients should not plan their trips to underdeveloped countries without consulting their doctor and getting over the period of severe immunosuppression.
• Allogeneic recipients should not travel to underdeveloped countries during the 6-12 month post-transplant period and while they are receiving immunosuppressive therapy for GVHD.
• Autologous recipients, on the other hand, can travel to underdeveloped countries 3-6 months after transplantation, if their doctors approve.
• “Adventure” holidays (such as boating, and participating in triathlons) should be avoided as they cause epidemic infections (such as leptospirosis).
• Although air travel is known to rarely cause respiratory infections (influenza, tuberculosis, measles, etc.), it is generally safe. In this case, transplant recipients should stay away from passengers showing symptoms of respiratory tract infection and pay attention to hand hygiene.
• Cruise ships are also generally considered safe, but have been associated with gastrointestinal diseases (such as norovirus) and legionella infection. Transplant recipients should be very meticulous about hand washing while on tour and report any symptoms that may occur to the transplantation team.
• Prophylactic antibiotics are not required for diarrhea in travel to underdeveloped countries. However, the transplant doctor may recommend fluoroquinolone prophylaxis.
• Prior to travel, transplant recipients should check that their vaccinations are up to date.
• Antivirals recommended by the physician can be used during the holidays for influenza prophylaxis in transplant patients with compromised immune systems.
• Travelers should be on the alert for pandemic influenza and Severe Acute Respiratory Syndrome (SARS).