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Chapter 8Advising Travelers With Specific Needs

Travelers with Chronic Illnesses

Deborah Nicolls Barbeau

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 general recommendations for patients with chronic illnesses:

  • Ensure that any chronic illnesses are well controlled. Patients with an underlying illness should see their physicians to ensure that the management of their illness is optimized.
  • Recommend seeking pre-travel consultation early, ≥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).
  • Ask about previous health-related issues encountered during travel, such as complications during air travel.
  • 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. Travelers with underlying medical conditions should consider choosing a medical assistance company that allows them to store their medical history predeparture so it can be accessed worldwide if needed (see Chapter 2, Obtaining Health Care Abroad for the Ill Traveler).
  • Advise travelers to pack medications in their original containers in carry-on luggage and to carry a copy of their prescriptions. Ensure the traveler has sufficient quantities of medications for the entire trip, plus extra in case of unexpected delays. Since medications should be taken based on elapsed time and not time of day, travelers may need guidance on scheduling when to take medications during and after crossing time zones.
  • Educate regarding drug interactions (see Chapter 2, Interactions among Travel Vaccines & Drugs). Medications (such as warfarin) used to treat chronic medical illnesses 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.
  • Suggest supplemental insurance. Three types of insurance policies can be considered: 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 Insurance, Travel Health Insurance, & Medical 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).
  • Advise travelers to keep well-hydrated, wear loose-fitting clothing, and walk and stretch at regular intervals during long-distance travel (see Chapter 2, Deep Vein Thrombosis & Pulmonary Embolism).
  • Always advise the traveler about packing a health kit (see Chapter 2, Travel Health Kits).

SPECIFIC CHRONIC ILLNESSES

Issues related to specific chronic medical illnesses are addressed in Table 8-05. These recommendations should be used in conjunction with the other recommendations given throughout this book. Below is a noninclusive list of additional resources for information:

Also, many health care facilities outside the United States are accredited by the 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 or the need to obtain a medical certificate before travel, the medical unit affiliated with the specific airline is a valuable source for information. Remember to notify the airline in advance if oxygen or other equipment is needed on the plane. The TSA Cares Help Line (toll-free at 855-787-2227) can also provide information on how to prepare for the airport security screening process with respect to a particular disability or medical condition.

Table 8-05. 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

Following acute coronary syndrome:

  • those at very low risk—within 3 days after event
  • medium risk—within 10 days
  • high risk or awaiting further intervention or treatment—defer air travel until disease is stable

Unstable angina

CHF, severe, decompensated

Uncontrolled hypertension

CABG within 14 days

CVA within 2 weeks

Elective percutaneous coronary intervention within 2 days

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

Hepatitis B

Have sublingual nitroglycerine available in carry-on bag

Mefloquine not recommended for people 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 acute respiratory illness

Bullous lung disease

Active lower 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

Hepatitis B

Consider carrying a short course of antibiotics and steroids, as appropriate, for exacerbations

Consider advising an inhaler available in carry-on bag, even if not routinely used

 

Gastrointestinal diseases

Surgery, including laparoscopic, within 10–14 days

Gastrointestinal bleed within 24 hours

Colonoscopy within 24 hours

Partial bowel obstruction

Liver failure (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

AAKP 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

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 a short course 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 a 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: CHF, congestive heart failure; CABG, coronary artery bypass graft; CVA, cerebrovascular accident; EKG, electrocardiogram; AICD, automatic implantable cardioverter defibrillators; DVT, deep vein thrombosis; INR, international normalized ratio; COPD, chronic obstructive pulmonary disease; TD, travelers’ diarrhea; PPIs, proton-pump inhibitors; YF, yellow fever; CrCl, creatinine clearance; AAKP, American Association of Kidney Patients; JCI, Joint Commission International; FSBG, fingerstick blood glucose; TST, tuberculin skin test; IGRA, interferon-γ release assay; TNF, tumor necrosis factor.

BIBLIOGRAPHY

  1. Aerospace Medical Association. Medical Guidelines for Airline Travel. 2nd ed. Alexandria, VA: Aerospace Medical Association; 2003 [cited 2012 Sep 23]. Available from: http://www.asma.org/asma/media/asma/Travel-Publications/medguid.pdf.
  2. Aerospace Medical Association. Useful tips for airline travel. Alexandria, VA: Aerospace Medical Association; 2005 [cited 2012 Sep 23]. Available from: www.asma.org/asma/media/asma/Travel-Publications/HEALTH-TIPS-FOR-AIRLINE-TRAVEL-2013-Trifold.pdf.
  3. Ahmedzai S, Balfour-Lynn IM, Bewick T, Buchdahl R, Coker RK, Cummin AR, et al. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations. Thorax. 2011 Sep;66 Suppl 1:i1–30.
  4. 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.
  5. McCarthy AE, Burchard GD. The travelers with pre-existing disease. In: Keystone JS, Freedman DO, Kozarsky PE, Connor BA, Nothdurft HD, editors. Travel Medicine. 3rd ed. Philadelphia: Saunders Elsevier; 2013. p. 258–63.
  6. Ringwald J, Strobel J, Eckstein R. Travel and oral anticoagulation. J Travel Med. 2009 Jul–Aug;16(4):276–83.
  7. Schwartz M. Travel and oral anticoagulants. J Travel Med. 2009 Sep–Oct;16(5):369–70.
  8. Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2008 Feb;121(2 Suppl):S402–7.
  9. Smith D, Toff W, Joy M, Dowdall N, Johnston R, Clark L, et al. Fitness to fly for passengers with cardiovascular disease. Heart. 2010 Aug;96 Suppl 2:ii1–16.
 
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