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Chapter 5 Travelers with Additional Considerations

Travelers with Chronic Illnesses

Deborah Nicolls Barbeau, Gail A. Rosselot, Sue Ann McDevitt

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, such travelers can have safe and enjoyable trips. General recommendations for advising patients with chronic illnesses include:

  • Ensure that any chronic illnesses are well controlled. Patients with an underlying illness should see their health care providers to ensure that the management of their illness is optimized.
  • Encourage patients to seek pretravel consultation ≥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 in this chapter).
  • Advise patients to consider a destination where they have access to quality care for their condition (see Chapter 6, Obtaining Health Care Abroad).
  • Ask about previous health-related issues encountered during travel, such as complications during air travel.
  • Advise the traveler about packing a health kit (see Chapter 6, Travel Health Kits).
  • Advise travelers to pack medications and medical supplies (such as pouching for ostomies) in their original containers in carry-on luggage and to carry a copy of their prescriptions. Ensure the traveler has sufficient quantities of medications and proper storage conditions 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.
  • Advise travelers to check with the US embassy or consulate to clarify medication restrictions in the destination country. Some countries do not allow visitors to bring certain medications into the country, especially narcotics and psychotropic medications.
  • Educate travelers 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.
  • Provide a clinician’s letter. The letter should be on office letterhead stationery and should outline existing medical conditions, medications prescribed (including generic names), and any equipment required to manage the condition.
  • Discuss 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 6, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance). Travelers may need extra help in finding supplemental insurance, as some plans will not cover costs for preexisting conditions.
  • Encourage travelers with underlying medical conditions to consider choosing a medical assistance company that allows them to store their medical history so it can be accessed worldwide (see Chapter 6, Obtaining Health Care Abroad).
  • Help travelers 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 6, Obtaining Health Care Abroad).
  • Advise travelers to wear a medical alert bracelet or carry medical information on his or her person (various brands of jewelry or tags, even electronic [through medical records apps], are available).
  • Advise travelers to stay hydrated, wear loose-fitting clothing, and walk and stretch at regular intervals during long-distance travel (see Chapter 8, Deep Vein Thrombosis & Pulmonary Embolism).

SPECIFIC CHRONIC ILLNESSES

Issues related to specific chronic medical ill­nesses are addressed in Table 5-03. 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:

Considerations for travelers with allergies are shown in Box 5-02.

Travelers may also want to investigate international health care accreditation agencies for centers that have been awarded recognition for high standards and good patient safety records. 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.

Travelers who require service animals, including emotional support animals, should check with the airline and the destination country to ensure the destination country permits the animal and that all required documentation is available. Remember to notify the airline well in advance if oxygen or other equipment is needed on the plane. The TSA Cares Helpline (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 5-03. Special considerations for travelers with chronic medical illnesses

CONDITION ABSOLUTE AND RELATIVE CONTRAINDICATIONS TO AIRLINE TRAVEL PRETRAVEL CONSIDERATIONS IMMUNIZATION CONSIDERATIONS MISCELLANEOUS
Cancer

 

Severe anemia (Hg <8.5 g/dL)

Cerebral edema due to intracranial tumor
≤6 weeks since cranial surgery

Cardiovascular, pulmonary, or gastrointestinal complications referred to below

Emphasize food and water precautions

Plan for self-management of dehydration

DVT precautions

Supplemental oxygen

Wear loose-fitting clothing to prevent worsening of lymphedema

Immunosuppressive medications may alter response to immunizations

Live attenuated vaccines may be contraindicated

Revaccination may be necessary following cancer treatment

Check for medication restrictions in the destination country, especially if controlled medications are required for pain management

See the Immunocompromised Travelers section in this chapter

Cardiovascular diseases Following acute coronary syndrome:
  • those at very low risk and within 3 days after event
  • medium risk and within 10 days after event
  • high risk or awaiting further intervention or treatment—should 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 7 days(spontanous pneumothorax) or 14 days (traumatic pneumothorax)

Pleural effusion within 14 days

High supplemental oxygen requirements at baseline

Major chest surgery within 10 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 for exacerbations

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

Gastrointestinal diseases

Major surgery, within 10–14 days

Uncomplicated appendectomy or laparoscopic surgery within 5 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 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 accreditation

For YF vaccine, see the Immunocompromised Travelers section 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 in this chapter

Severe allergic reactions None

Plan for managing allergic reactions 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: DVT, deep vein thrombosis; CHF, congestive heart failure; CABG, coronary artery bypass graft; CVA, cerebrovascular accident; EKG, electrocardiogram; AICD, automatic implantable cardioverter defibrillators; 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; FSBG, fingerstick blood glucose; TST, tuberculin skin test; IGRA, interferon-γ release assay; TNF, tumor necrosis factor.

 

Box 5-02. Highly allergic travelers

Highly allergic travelers experience allergic reactions that can interrupt or alter planned activities or may require emergency medical care during travel. Language barriers, lack of emergency services, and unfamiliar environments and menus compound risk. Pretravel preparation and proactive communication can reduce the risk of severe allergic reactions (SARs), although travelers with a new severe allergy, recent SAR, or recurrent SARs warrant a specialist referral.

The travel medicine provider should assess and document the following:

  • Date of allergy onset; specific and related triggers, last date of any allergy workup or specialist consult.
  • Description of inhalation, ingested, contact, or injected (insects, snakes) allergy symptoms.
  • History of anaphylaxis emergency, urgent care visits, or hospitalizations.
  • Use of an epinephrine auto-injector, inhaler, inhaled or oral steroids; when and why last used.
  • Additional recognized risk factors for SARs while traveling: younger age, adolescence, history of SAR hospitalization, history of >3 days use of corticosteroids, asthma and food allergy comorbidity, solo travel, multiple destinations, remote destinations, longer duration of travel, outdoor activities (for inhalation and insect exposures), availability of specialist care at the destination, language barriers.

Providers should counsel travelers to:

  • Bring several copies of a written plan for responding to SARs; always carry a copy, including one in destination languages, if possible.
  • Research emergency services at destinations—where they are located and how to obtain them.
  • Never be too embarrassed to alert others about a severe allergy; inform traveling companions, tour leaders, flight attendants, seat mates, restaurant and hotel staff; share customized care plan.
  • Check expiration dates of prescriptions; carry extra supplies of all self-care therapies in carry-on luggage (antihistamines, inhalers, corticosteroids, epinephrine auto-injectors, nebulizers); medically necessary liquids and medications in excess of Transportation Security Administration limits are allowed in carry-on luggage; do not purchase medications abroad; bring a backpack or other bag to carry supplies at destination.
  • Wear a medical identification bracelet; carry a card listing all medical conditions and medications; carry a medical letter describing allergy, translated if possible.
  • Recognize SAR signs and symptoms; know when and how to correctly use epinephrine auto-injectors.
  • Purchase travel health insurance; confirm health insurance coverage for emergency services during travel.
  • Anticipate dietary and environmental allergies for trains, airlines, and ships; bring along snacks or meals, if needed; ask to be seated away from pets.
  • Food allergies: carry “chef cards” in English and destination languages (see www.foodallergy.org/life-food-allergies/managing-lifes-milestones/dining-out/food-allergy-chef-cards); bring a supply of nonperishable food in case safe food is not available; avoid “street food”; choose safe foods over exotic foods; consider eating at chain restaurants where ingredients may be more standardized; always remember that dietary vigilance is critical; when in doubt, avoid a food item.
  • Airborne allergies: minimize outdoor activity when air quality is poor or pollen count is high; identify and reserve smoke-free (pet-free) accommodations and restaurants; even if asthma is stable, travel may exacerbate the condition; be sure to pack all equipment including spacers, nebulizers, and peak flow meters.

BIBLIOGRAPHY

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