Travelers with Chronic Illnesses
CDC Yellow Book 2024
Travelers with Additional ConsiderationsAlthough 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, these travelers can have safe and enjoyable trips. For more detailed information on assisting immunocompromised travelers, travelers with disabilities, highly allergic travelers, and travelers with substance use disorders prepare for international travel, see the respective chapters in this section.
Patients should see their established health care providers well in advance of travel to ensure that all chronic conditions are controlled, and management is optimized. Clinicians should encourage patients to seek pretravel consultation prior to paying for nonrefundable trips, and at least 4–6 weeks before departure to ensure adequate time to respond to immunizations, try new medications before travel, or redefine the itinerary based upon pretravel consultation recommendations.
General Approach
Advising Travelers
Adequate preparation for patients with chronic illnesses for international travel requires the active participation of both the traveler and the travel health provider. Box 3-03 includes a checklist of pretravel activities for travelers with chronic illnesses.
Box 3-03 A checklist for travelers with chronic illnesses preparing for international travel
☐ Carry copies of all prescriptions.
☐ Check with the foreign embassy or consulate for your destination country in the United States to clarify whether any medication restrictions exist. Some countries do not allow visitors to bring certain medications into the country, especially narcotics and psychotropic medications.
☐ Favor travel to destinations that have access to quality care for your condition (see Sec. 6, Ch. 2, Obtaining Health Care Abroad)
☐ Obtain an established provider letter. The letter should be on office letterhead stationery and outline existing medical conditions, medications prescribed (including generic names), and any equipment required to manage the condition. By law, some states do not permit a travel health specialist to furnish such a letter if the specialist is not also the primary care provider or established provider of record.
☐ Pack a travel health kit (see Sec. 2, Ch. 10, Travel Health Kits). Take health kits on board as carry-on luggage, and bring all necessary medications and medical supplies (e.g., pouching for ostomies) in their original containers.
☐ Select a medical assistance company that allows you to store your medical history so it can be accessed worldwide.
☐ Sign up for the Smart Traveler Enrollment Program, a free service of the US Department of State to US citizens and permanent residents, to receive destination-specific travel and security updates. This service also allows the Department of State to contact international travelers during emergencies.
☐ Stay hydrated, wear loose-fitting clothing, and walk and stretch at regular intervals during long-distance travel (see Sec. 8, Ch. 3, Deep Vein Thrombosis & Pulmonary Embolism).
☐ Wear a medical alert bracelet or carry medical information on your person. Various brands of jewelry or tags, even electronic ones, are available.
Health Care Provider Roles & Responsibilities
Health care providers play a critical role in helping patients with chronic underlying conditions travel safely. Ask patients about previous health-related issues encountered during travel (e.g., complications during air travel). In addition to sharing the advice found in Box 3-03, ensure the traveler has sufficient medication (and proper storage conditions) for the entire trip, plus extra in case of unexpected delays. Because medications should be taken based on elapsed time and not time of day, offering travelers guidance on scheduling when to take medications during and after crossing time zones might be needed. Educate travelers on possible drug interactions (see Sec. 2, Ch. 4, Interactions Between Travel Vaccines & Drugs). Some medications used to treat chronic medical illnesses (e.g., warfarin) can interact with prescribed self-treatment for travelers’ diarrhea or malaria chemoprophylaxis. Discuss all medications patients use, including medications taken daily, those taken on an as-needed basis, and dietary supplements or herbal products. In addition, discuss supplemental insurance options for travelers, including policies that cover trip cancellation in the event of illness, supplemental medical insurance, and medical evacuation insurance. Supplemental medical insurance can reimburse travelers for money paid for health care abroad; most medical insurance policies do not cover the cost of health care received in other countries. Medical evacuation insurance covers moving the person from the place of illness or injury to a place where they can receive definitive care. Travelers might need assistance to identify supplemental insurance plans that will cover costs for preexisting conditions (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance).
Help patients devise a Personal Travel 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 Sec. 6, Ch. 2, Obtaining Health Care Abroad).
Specific Chronic Medical Conditions
Chronic illness or acute illness affecting underlying chronic disease might affect the recommendations clinicians make to a traveler after completing the risk assessment conducted as part of the pretravel consultation (see Sec. 2, Ch. 1, The Pretravel Consultation). Some online resources for travelers who have ≥1 chronic medical conditions can be found in Table 3-05 (in Sec. 3, Ch. 2, Travelers with Disabilities) and Table 3-07.
Chronic conditions include those affecting the cardiovascular, endocrine, gastrointestinal, genitourinary, hematological, hepatic, neurologic, and respiratory systems. Table 3-08 addresses issues and recommendations related to specific chronic medical illnesses and should be used in conjunction with the other recommendations given throughout this book.
Travelers also might want to investigate international health care accreditation agencies to identify health care facilities at the travel destination that have received recognition or accreditation for high care 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 both the air carrier and the country will allow the animal; documentation and permits might also be required (see Sec. 7, Ch. 6, Traveling with Pets & Service Animals). Travelers planning to use supplemental oxygen on the aircraft or needing other equipment (e.g., a wheelchair) must inform the airline far in advance of planned travel. The Transportation Security Administration (TSA) Cares Helpline (toll-free at 855-787-2227) or TSA Cares online assistance also can provide information on how to prepare for the airport security screening process for a particular disability or medical condition.
Table 3-07 Online resources for travelers with chronic illnesses: disease & condition-specific
DISEASE / CONDITION
ORGANIZATION / SOURCE
RESOURCE
DISEASE / CONDITION
ANTICOAGULATION
ORGANIZATION / SOURCE
Anticoagulation Forum
DISEASE / CONDITION
CANCER
ORGANIZATION / SOURCE
American Cancer Society
DISEASE / CONDITION
CELIAC DISEASE
ORGANIZATION / SOURCE
National Celiac Association
RESOURCE
DISEASE / CONDITION
CHRONIC PAIN
ORGANIZATION / SOURCE
International Pain Foundation
DISEASE / CONDITION
DIABETES
ORGANIZATION / SOURCE
American Diabetes Association
RESOURCE
DISEASE / CONDITION
EPILEPSY
ORGANIZATION / SOURCE
Epilepsy Society (UK)
DISEASE / CONDITION
HEART CONDITIONS
ORGANIZATION / SOURCE
American Heart Association
RESOURCE
DISEASE / CONDITION
INFLAMMATORY BOWEL DISEASE
ORGANIZATION / SOURCE
Crohn’s & Colitis Foundation
RESOURCE
DISEASE / CONDITION
KIDNEY DISEASE
ORGANIZATION / SOURCE
American Association of Kidney Patients (AAKP)
DISEASE / CONDITION
KIDNEY DISEASE
ORGANIZATION / SOURCE
National Kidney Foundation
DISEASE / CONDITION
KIDNEY DISEASE
ORGANIZATION / SOURCE
Global Dialysis (UK)
RESOURCE
DISEASE / CONDITION
LUNGS & CHEST
ORGANIZATION / SOURCE
American Lung Association
RESOURCE
DISEASE / CONDITION
MULTIPLE SCLEROSIS
ORGANIZATION / SOURCE
Multiple Sclerosis Foundation
RESOURCE
DISEASE / CONDITION
SLEEP APNEA
ORGANIZATION / SOURCE
American Sleep Association
RESOURCE
DISEASE / CONDITION
SLEEP APNEA
ORGANIZATION / SOURCE
American Sleep Apnea Association
RESOURCE
Table 3-08 Special considerations for travelers with chronic illnesses
| CONDITION | CONTRAINDICATIONS TO & TIMING OF AIRLINE TRAVEL | PRETRAVEL RECOMMENDATIONS & CONSIDERATIONS | IMMUNIZATION CONSIDERATIONS | ADDITIONAL CONSIDERATIONS & GUIDANCE |
|---|---|---|---|---|
| GENERAL CONSIDERATIONS |
Travelers unlikely to survive the flight due to preexisting condition Any traveler with serious and acute contagious disease (e.g., acute, untreated tuberculosis; COVID-19) |
|
|
|
| AUTOIMMUNE & RHEUMATOLOGIC DISEASES |
None |
Baseline TST or IGRA before starting TNF blockers |
Immunosuppressive medications including TNF blockers might alter response to immunizations Live attenuated vaccines might be contraindicated |
Emphasize safe food and water precautions and good hand hygiene |
| CANCER |
Anemia, severe (Hgb <8.5 g/dL)
|
Emphasize safe 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 might alter response to travel vaccines Live attenuated vaccines might be contraindicated Revaccination might be necessary after cancer treatment |
Check for medication restrictions at the destination (e.g., pain relief/control) See Sec. 3, Ch. 1, Immunocompromised Travelers, for additional recommendations |
| CARDIOVASCULAR & OTHER CIRCULATORY DISORDERSa |
Angina, unstable Arrhythmia, uncontrolled CHF, severe or decompensated Eisenmenger Syndrome Hypertension, uncontrolled Post–acute coronary syndrome Low risk: minimum 3 days before travel Moderate risk: minimum 10 days before travel High risk or awaiting further intervention or treatment: defer air travel until disease is stabilized Post–CABG: minimum 10 days, and improving, before travel Post–percutaneous coronary intervention (elective): minimum 2 days, and no complications, before travel Post–percutaneous pacemaker or implanted defibrillator placement: minimum 2–3 days, if uncomplicated, before travel Post–sickle cell crisis: minimum 10 days post-event, and improving, before travel Valvular heart disease, severe, symptomatic |
Supplemental oxygen Plan for self-management of dehydration and volume overload; may include adjusting medications Bring copy of recent ECG Bring pacemaker or AICD card DVT precautions |
Influenza Pneumococcal |
Have sublingual nitroglycerin available in carry-on bag Mefloquineb (antimalarial prophylaxis) not recommended for people with cardiac conduction abnormalities, particularly those with ventricular arrhythmias Provider primarily responsible for prescribing anticoagulation should tailor INR self-monitoring and management regimen |
| CNS & PNS DISORDERS |
Neurologic process, unstable Post–CVA: minimum 10–14 days, and improving, before travel Post–TIA: minimum 3 days, and no recurrence, before travel Post–cranial surgery: minimum 7–14 days, and improving, before travel Seizure disorder, poorly controlled |
Mefloquine antimalarial chemoprophylaxis is contraindicated in travelers with underlying seizure disorder; check for drug– drug interactions |
Patients with myasthenia gravis: mefloquine & chloroquine antimalarial chemoprophylaxis, and YF vaccine are all generally contraindicated |
|
| DIABETES MELLITUS | None |
Plan for self-management of dehydration, diabetic foot, and pressure sores Insulin adjustments Check FSBG at 4–6-hour intervals during air travel Discuss changes in insulin or oral agent regimen 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 guidance re: YF vaccine, see |
| GASTROINTESTINAL DISORDERS (INCLUDING LIVER DISEASE) |
Bowel obstruction GI bleed, active or recurrent Liver failure, uncompensated Post–major abdominal surgery: minimum 10–14 days, and improving, before travel Post–colonoscopy (uncomplicated): minimum 24 hours before travel Post–laparoscopic surgery: minimum 3–5 days, and improving, before travel |
Emphasize safe food and water precautions For travelers with chronic liver disease, cirrhosis, or heavy alcohol use, advise against eating raw or undercooked shellfish, due to possible overwhelming Vibrio vulnificus sepsis Consider prescribing prophylactic antibiotics for TD |
Influenza Pneumococcal Hepatitis A Hepatitis B |
Increased colostomy output might occur during air travel Patients with cirrhosis and history of hepatopulmonary syndrome or portopulmonary hypertension might be at increased risk for clinical deterioration with travel to high elevations H2-receptor antagonists and PPIs increase susceptibility to TD Use mefloquine with caution in travelers with chronic liver disease |
| RENAL FAILURE & CHRONIC RENAL INSUFFICIENCY | None |
Emphasize safe 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 pre-departure HIV, hepatitis C, and hepatitis B status Atovaquone-proguanil (Malarone) contraindicated when CrCl <30 mL/min CKD can predispose patients to increased risk of DVTs and altitude sickness For guidance re: YF vaccine, see Approach to Immunizations: Preparing Travelers with Severe Immune Compromise: Vaccine Considerations for Travelers with Severe Immune Compromise: Yellow Fever, in Sec. 3, Ch. 1, Immunocompromised Travelers |
| RESPIRATORY TRACT DISORDERS |
Asthma, severe or labile Bullous lung disease Lower respiratory tract infection, active Post–major chest surgery: minimum 10–14 days, and improving, before travel Post–PTX (spontaneous): minimum 7 days after full inflation before travel Post–PTX (traumatic): minimum 14 days after full inflation, before travel Pulmonary hypertension, severe Supplemental oxygen requirements: high, rapidly fluctuating, or increasing |
Supplemental oxygen Discuss with airline need for other equipment on plane (e.g., nebulizer) Plan for self-management of exacerbations (including asthma, COPD) DVT precautions |
Influenza Pneumococcal |
Consider carrying a short course of antibiotics and steroids for exacerbations Consider taking an inhaler in a carry-on bag, even if not used routinely |
Abbreviations: AAKP, American Association of Kidney Patients; AICD, automatic implantable cardioverter defibrillator; CABG, coronary artery bypass graft; CHF, congestive heart failure; CKD, chronic kidney disease; CNS, central nervous system; COPD, chronic obstructive pulmonary disease; COVID-19, coronavirus disease; CrCl, creatinine clearance; CVA, cerebrovascular accident; DVT, deep vein thrombosis; ECG, electrocardiogram; FSBG, fingerstick blood glucose; GI, gastrointestinal; Hgb, hemoglobin; HIV, human immunodeficiency virus; IGRA, interferon-γ release assay; INR, international normalized ratio; PNS, peripheral nervous system; PPIs, proton-pump inhibitors; PTX, pneumothorax; TD, travelers’ diarrhea; TIA, transient ischemic attack; TNF, tumor necrosis factor; TST, tuberculin skin test; YF, yellow fever.
aThere is a spectrum of airline travel–related risk that depends on the cardiovascular disorder, the defined risk group within the disorder, and the time since the acute event (if applicable). Evidence basis for recommendations is suboptimal, however.
bSee Sec. 5, Part 3, Ch. 16, Malaria, for additional details.
The following authors contributed to the previous version of this chapter: Deborah Nicolls Barbeau, Gail A. Rosselot, Sue Ann McDevitt