Chapter 8Advising Travelers with Specific Needs
Travelers with Chronic Illnesses
GENERAL TRAVEL PREPARATION: PRACTICAL CONSIDERATIONS
Although traveling abroad can be relaxing and rewarding, the physical demands of travel can be stressful, particularly for travelers with underlying chronic illnesses. With adequate preparation, however, those with chronic illnesses can have safe and enjoyable trips. The following is a list of recommendations for patients with chronic illnesses:
- Ensure that any chronic illnesses are stable. Patients with underlying illness should see their physicians to ensure that the management of their illness is optimized.
- Recommend seeking pre-travel consultation early, at least 4–6 weeks before departure, to ensure adequate time to respond to immunizations and, in some circumstances, to try medications before travel (see the Immunocompromised Travelers section earlier in this chapter).
- Provide a physician’s letter. The letter should be on office letterhead stationery, outlining existing medical conditions, medications prescribed (including generic names), and any equipment required to manage the condition.
- Advise travelers to pack medications in their original containers in carry-on luggage and to carry a copy of their prescriptions. Ensure sufficient quantities of medications for the entire trip, plus extra in case of unexpected delays. When crossing time zones, medications should be taken based on elapsed time, not time of day.
- Educate regarding drug interactions. Medications used to treat chronic medical illnesses (such as warfarin) may interact with medications prescribed for self-treatment of travelers’ diarrhea or malaria chemoprophylaxis. Discuss all medications used, either daily or on an as-needed basis.
- Recommend consideration of supplemental insurance. Consideration should be given for 3 types of insurance policies: 1) trip cancellation in the event of illness; 2) supplemental insurance so that money paid for health care abroad may be reimbursed, since most medical insurance policies do not cover health care in other countries; and 3) medical evacuation insurance (see Chapter 2, Travel Health Insurance and Evacuation Insurance).
- Help devise a health plan. This plan should give instructions for managing minor problems or exacerbations of underlying illnesses and should include information about medical facilities available in the destination country (see Chapter 2, Obtaining Health Care Abroad for the Ill Traveler).
- Recommend that the traveler wear a medical alert bracelet or carry medical information on his or her person (various brands of jewelry or tags, even electronic, are available).
- Always advise the traveler about packing a health kit (see Chapter 2, Travel Health Kits).
SPECIFIC CHRONIC MEDICAL ILLNESSES
Issues related to specific chronic medical illnesses are addressed in Table 8-04. These recommendations should be used in conjunction with the other recommendations given throughout this book. Additional resources for information include:
- American Diabetes Association (www.diabetes.org)
- American Heart Association (www.heart.org)
- American Lung Association (www.lungusa.org)
- Anticoagulation Forum (www.acforum.org)
- Crohn’s and Colitis Foundation of America (www.ccfa.org)
- Global Dialysis (www.globaldialysis.com)
- International Self-Monitoring Association of Oral Anticoagulated Patients (www.ismaap.org)
- National Kidney Foundation (www.kidney.org)
- US Department of State (www.state.gov)
Also, many health care facilities outside the United States are accredited by Joint Commission International, an affiliate of the Joint Commission, which is the largest accreditor of US-based health care organizations. A list of accredited international facilities is available at their website (www.jointcommissioninternational.org).
If travelers or their health care providers have concerns about fitness for air travel, the medical unit affiliated with the specific airline is also a valuable source for information.
Table 8-04. Special considerations for travelers with chronic medical illnesses
| CONDITION |
ABSOLUTE AND RELATIVE CONTRAINDI- CATIONS TO AIRLINE TRAVEL |
PRE-TRAVEL CONSIDERA- TIONS |
IMMUNIZA- TION CONSIDERA- TIONS |
MISCELLA- NEOUS |
|---|---|---|---|---|
| Cardiovascular diseases |
Uncomplicated MI within 2–3 weeks Complicated MI within 6 weeks Unstable angina CHF, severe, decompensated Uncontrolled hypertension CABG within 10–14 days CVA within 2 weeks Uncontrolled arrhythmia Eisenmenger syndrome Severe symptomatic valvular heart disease |
Supplemental oxygen Plan for self-management of dehydration and volume overload; may include adjusting medications Bring copy of recent EKG Bring pacemaker or AICD card DVT precautions |
Influenza Pneumococcal Consider hepatitis B |
Have sublingual nitroglycerine available in carry-on bag Mefloquine not recommended for persons with cardiac conduction abnormalities, particularly for those with ventricular arrhythmias Self-monitoring and management of INR should be tailored to the individual patient by the anticoagulant primary provider |
| Pulmonary diseases |
Severe, labile asthma Recent hospitalization for asthma Active respiratory infection Pneumothorax within 2–3 weeks Pleural effusion within 14 days High supplemental oxygen requirements at baseline Major chest surgery within 10–14 days |
Supplemental oxygen Discuss with airline need for other equipment on plane (such as nebulizer) Plan for self-management of exacerbations (including COPD, asthma) DVT precautions |
Influenza Pneumococcal Consider hepatitis B |
Consideration for carrying short course of antibiotics and steroids, as appropriate, for exacerbations Consider advising an inhaler available in a carry-on bag, even if not routinely used
|
| Gastrointestinal diseases |
Surgery, including laparoscopic, within 10–14 days Gastrointestinal bleed within 24 hrs Colonoscopy within 24 hrs Partial bowel obstruction Chronic liver disease (especially cirrhosis or heavy alcohol use) |
Emphasize food and water precautions Consider prescribing prophylactic antibiotic for TD Recommend avoiding undercooked seafood, if cirrhosis or heavy alcohol use (Vibrio vulnificus) |
Influenza Pneumococcal Hepatitis A Hepatitis B |
May experience increased colostomy output during air travel H2 blockers and PPIs increase susceptibility to TD Use mefloquine with caution in any chronic liver disease For YF vaccine, see the Immunocompromised Travelers section earlier in this chapter |
| Renal failure and chronic renal insufficiency |
None |
Emphasize food and water precautions Plan for self-management of dehydration, which can worsen renal function Arrange dialysis abroad, if needed Adjust medications for CrCl |
Influenza Pneumococcal Hepatitis B |
Know HIV, hepatitis C, and hepatitis B status Atovaquone-proguanil contraindicated when CrCl <30 mL/min Kidney Foundation and Global Dialysis websites can help with finding dialysis centers; check for JCI accreditation For YF vaccine, see the Immunocompromised Travelers section earlier in this chapter |
| Diabetes mellitus |
None |
Plan for self-management of dehydration, diabetic foot, and pressure sores Insulin adjustments Should check FSBG at 4- to 6-hour intervals during air travel Discuss changes in insulin regimen or oral agent with diabetes specialist Provide physician's letter stating need for all equipment, including syringes, glucose meter, and supplies |
Influenza Pneumococcal Consider hepatitis B |
Keep insulin and all glucose meter supplies in carry-on bag Bring food and supplies needed to manage hypoglycemia during travel Check feet daily for pressure sores For YF vaccine, see the Immunocompromised Travelers section earlier in this chapter |
| Severe allergic reactions | None |
Plan for managing allergic reaction while traveling and consider bringing short court of steroids for possible allergic reactions Should carry injectable epinephrine and antihistamines (H1 and H2-blockers)—always have on person |
Many airlines already have policies in place for dealing with peanut allergies Make sure to carry injectable epinephrine in case of severe reaction while in flight |
|
| Autoimmune and rheumatologic diseases | None | Should have a baseline TST or IGRA before starting TNF blockers |
Immunosuppressive medications and TNF blockers may alter response to immunizations Live attenuated vaccines may be contraindicated |
Particular emphasis should be placed on food and water precautions and hand hygiene |
Abbreviations: AICD, automatic implantable cardioverter defibrillators; CABG, coronary artery bypass graft; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CrCl, creatinine clearance; CVA, cerebrovascular accident; DVT, deep vein thrombosis; EKG, electrocardiogram; FSBG, fingerstick blood glucose; IGRA, interferon-γ release assay; INR, international normalized ratio; JCI, Joint Commission International; MI, myocardial infarction; PPIs, proton-pump inhibitors; TD, travelers’ diarrhea; TNF, tumor necrosis factor; TST, tuberculin skin test; YF, yellow fever.
BIBLIOGRAPHY
- Aerospace Medical Association. Medical Guidelines for Airline Travel. Alexandria, VA: Aerospace Medical Association; 2003 [cited 18 Nov 2010]. Available from: http://www.asma.org/pdf/publications/medguid.pdf.
- Bassetti M, Nicco E, Delfino E, Viscoli C. Disseminated Salmonella paratyphi infection in a rheumatoid arthritis patient treated with infliximab. Clin Microbiol Infect. 2010 Jan;16(1):84–5.
- Chandran M, Edelman SV. Have insulin, will fly: diabetes management during air travel and time zone adjustment strategies. Clin Diabetes. 2003;21(2):82–5.
- McCarthy AE. Travelers with pre-existing disease. In: Keystone JS, Kozarsky PE, Freedman DO, Nothdurft HD, Connor BA, editors. Travel Medicine. 2nd ed. Philadelphia: Mosby; 2008. p. 249–55.
- Ringwald J, Strobel J, Eckstein R. Travel and oral anticoagulation. J Travel Med. 2009 Jul–Aug;16(4):276–83.
- Schwartz M. Travel and oral anticoagulants. J Travel Med. 2009 Sep–Oct;16(5):369–70.
- Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2008 Feb;121(2 Suppl):S402–7.
Contact Us:
- Centers for Disease Control and Prevention
1600 Clifton Rd
Atlanta, GA 30333 - 800-CDC-INFO
(800-232-4636)
TTY: (888) 232-6348 - Contact CDC-INFO
