Chapter 5 Travelers with Additional Considerations
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, 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:
- American Association of Kidney Patients (www.aakp.org)
- American Diabetes Association (www.diabetes.org)
- American Heart Association (www.heart.org)
- American Lung Association (www.lung.org)
- American Society of Clinical Oncology (www.cancer.net)
- American Thoracic Society (www.thoracic.org)
- Anticoagulation Forum (www.acforum.org)
- British Thoracic Society (www.brit-thoracic.org.uk)
- Crohn’s and Colitis Foundation of America (www.ccfa.org)
- Global Dialysis (www.globaldialysis.com)
- International Narcotics Control Board (www.incb.org)
- National Multiple Sclerosis Society (www.nationalmssociety.org)
- Transportation Security Administration (www.tsa.gov)
- Department of State (www.state.gov)
- Department of Transportation (www.transportation.gov)
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 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:
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
- Exemption from import/export requirements for personal medical use. 21 CFR Part 1301;2004. [cited 2016 Sep, 27]. Available from: www.deadiversion.usdoj.gov/21cfr/cfr/1301/1301_26.htm
- Food allergy and anaphylaxis plan. FARE; 2018. [cited 2018 Apr 2]. Available from: www.foodallergy.org/life-with-food-allergies/food-allergy-anaphylaxis-emergency-care-plan.
- IATA. Medical Manual. 11th Edition. June 2018 [cited 2018 Oct 23]. Available from: www.iata.org/publications/Documents/medical-manual.pdf.
- Josephs LK, Coker RK, Thomas M, British Thoracic Society Air Travel Working Group. Managing patients with stable respiratory disease planning air travel: a primary care summary of the British Thoracic Society recommendations. Prim Care Respir J. 2013 Jun;22(2):234–8.
- 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. pp. 257–63.
- Pinsker JE, Becker E, Mahnke CB, Ching M, Larson NS, Roy D. Extensive clinical experience: a simple guide to basal insulin adjustments for long-distance travel. J Diabetes Metab Disord. 2013;12(1):59.
- Ringwald J, Strobel J, Eckstein R. Travel and oral anticoagulation. J Travel Med. 2009 Jul–Aug;16(4):276–83.
- School tools: Allergy & asthma resources for families, clinicians and school nurses. AAAAI; 2018. [cited 2018 Apr 2]. Available from: www.aaaai.org/conditions-and-treatments/school-tools.
- 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.