Severely Allergic Travelers

Introduction

Allergic conditions are among the most common chronic illnesses in the United States, with approximate prevalence rates for allergic rhinitis 25%, asthma 8%, food allergy 6%, and stinging insect allergy 3%. Additionally, asthma, food allergy, and stinging insect allergy cause significant morbidity and mortality. There also are rare conditions like mast cell disorders and idiopathic anaphylaxis that place patients at risk of life-threatening anaphylaxis. Severely allergic patients may be anxious about travel, but strategies exist to reduce risks for severely allergic travelers.

For severely allergic travelers, schedule pre-travel appointments at least 4–6 weeks prior to travel and recommend they schedule appointments with their allergist, immunologist, or other specialists. Advise travelers to purchase travel medical insurance that includes emergency services in the areas of travel (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter). Discuss medical alert identification items (bracelet, necklace, etc.) to identify conditions and allergies, including adding language(s) of travel destinations.

Travelers with allergic rhinitis and asthma

Pre-travel considerations

The pre-travel appointments for a traveler with allergic rhinitis and asthma should include a review of their current level of symptom control and medication regimen. Adjust medications to maximize symptom control prior to travel. Provide sufficient prescriptions for the duration of the trip. Instruct travelers to purchase sufficient over-the-counter medications in the United States prior to departure. Medications available in the United States may not be available in other countries. Medications outside the United States may have different names (e.g., salbutamol vs. albuterol), may be confused/mistaken in translation, and may be of uncertain quality. Provide an updated asthma action plan and oral steroids for use per the action plan. Administer all age- and condition-appropriate vaccinations, paying close attention to vaccines targeted at respiratory conditions, including influenza (consider Southern Hemisphere option as appropriate [see Influenza chapter]), respiratory syncytial virus, pneumococcal pneumonia, and COVID-19 (see Vaccination and Immunoprophylaxis—General Principles chapter).

Even in travelers who are well controlled at home, consider step-up or additional prophylactic therapy if a traveler will be exposed to reduced air quality (see Air Quality and Ionizing Radiation During Travel chapter) or differing active pollen seasons. Air quality and pollen counts at the destination can be researched in advance (Table 2.5.1). If preventive step-up therapy includes topical nasal corticosteroids, inhaled corticosteroids, and/or leukotriene modifiers, begin the dose change at least 2–4 weeks before departure. Remind travelers requiring nebulized therapy to investigate power conversion adaptors for nebulizer units or battery chargers. The Transportation Security Administration (TSA) allows larger amounts of medically necessary liquids (e.g., nebulized therapies) to be in carry-on luggage in reasonable quantities. Original containers with prescription information and a note from the physician, while not required by TSA or airlines, may prevent concerns arising at security or customs abroad. Instruct travelers on allergen immunotherapy or injectable biologics to work with their allergist, immunologist, or other subspecialists to determine timing and interval of dosing before travel to minimize lapses in therapy. Encourage travelers with allergic rhinitis and asthma to research lodging that mitigates exposure to known triggers, such as dust mite bedding covers, air filtration with or without air conditioning, pet-free rooms, smoke-free rooms, and carpet-free rooms.

During travel

Advise travelers with allergic rhinitis or asthma:

• Medications should be kept in carry-on luggage in the event of lost luggage and for access in-flight (in-transit on bus, ship, or train).
• Inquire with airlines (bus, ship, or train service) in advance regarding "buffer zones" from animals, ability to pre-board to clean seating area from prior passengers' animals, and ability to rebook (Table 2.5.1).
• Consider pre-medication if animal exposure is anticipated or known.

Upon arrival

Advise travelers with allergic rhinitis or asthma:

• Keep inhalers, other medications, asthma action plan, medical phrases card, and so on, in a medical kit or on their person.
• Confirm that accommodations have allergen mitigation, air conditioning, and/or smoke-free rooms as appropriate for the traveler's known triggers.
• Confirm location of nearby medical facilities and local contact phone numbers for emergency medical care.

Table 2.5.1: Online resources for severely allergic travelers

Travelers with food allergy, stinging insect allergy, and others at risk for anaphylaxis

Pre-travel considerations

The pre-travel appointments for a traveler with food allergy, stinging insect allergy, and others at risk for anaphylaxis should include a review of their current allergens and medication regimen. Provide sufficient prescriptions for the duration of the trip. Instruct travelers to purchase sufficient over-the-counter medications in the United States prior to departure. Medications available in the United States may not be available in other countries, may have different names, may be confused or mistaken in translation, and may be of uncertain quality. Provide an updated anaphylaxis action plan, review the proper use of their injectable epinephrine device, and ensure that expiration date exceeds period of travel. Instruct travelers to maintain original packaging with identifying information linking them to their injectable epinephrine. Although not required by TSA or airlines, provide a physician's note outlining the medical condition and requirement for injectable epinephrine to prevent concerns arising at security or customs abroad. Injectable epinephrine is generally available by prescription or over the counter in most of North America, Europe, and Australia. However, over half the countries of the world (concentrated in Africa, Central America, South America, and Asia) do not have injectable epinephrine easily available. As a result, prescribe extra injectable epinephrine devices if there is uncertainty regarding the availability of injectable epinephrine, availability of medical care, or language barriers that might limit access in areas of travel.

Advise all travelers at risk for anaphylaxis

• Obtain wallet cards with common emergency medical phrases in the language(s) where traveling (Table 2.5.1).
• Learn key medical phrases and allergen names in the language(s) where traveling.
• Inquire with airlines in advance regarding in-flight medical capabilities, including availability of stock epinephrine in on-board medical kits and policy for its use (see Perspectives: Responding to Medical Emergencies When Flying chapter). However, do not rely on the airline as the only source for injectable epinephrine; there may be a delay in having it available, and some airlines restrict the use to trained medical personnel that may not be available on every flight.

Added advice for travelers with food allergies

• Research local dietary customs, restaurant menus, and food allergy listings, common ingredients of signature local cuisine, and country-specific food allergen labeling regulations (Table 2.5.1).
• Investigate accommodations with self-meal preparation to the greatest extent practicable.
• Obtain chef cards in the language(s) where traveling (Table 2.5.1).
• Ask the airline (bus, ship, or train travel service) in advance about "buffer zones," nut or peanut exclusion from the flight, ability to pre-board to clean seating area, and in-flight medical capabilities; these policies vary widely among airlines (Table 2.5.1).
• Understand there are reassuring data from controlled research indicating that inhalation-only or incidental cutaneous-only exposures without ingestion of food allergens are unlikely to result in significant allergic reactions.

Added advice for travelers with stinging insect allergy

• Contact their allergist or immunologist to discuss prevalence of stinging insects of concern in area(s) of travel.
• For those on venom or fire ant immunotherapy, discuss with their allergist/immunologist the timing and interval of dosing before travel to prevent lapses in therapy.

During travel

Advise all travelers at risk for anaphylaxis

• Medications should be kept on the person or in immediately accessible carry-on luggage for access in-flight (in-transit on bus, ship, or train) and to prevent loss in lost checked baggage.

Added advice for travelers with food allergies

• Prepare safe snacks/meals at home and bring on-board.
• Arrive early and inform gate agents, flight attendants, and/or travel service personnel regarding relevant allergies to allow greater cooperation for safety.
• Request to pre-board to clean seating area.
• Do not use pillows or blankets provided by the airline/travel service.

Upon arrival

Advise all travelers at risk for anaphylaxis

• Keep injectable epinephrine, other medications, anaphylaxis action plan, medical phrases card, and so on, in a medical kit and/or on their person.
• Confirm location(s) of nearby medical facilities and local contact phone numbers for emergency medical care.

Added advice for travelers with food allergies

• Confirm that accommodations have self-meal preparation to the greatest extent practicable.
• Ensure that chef cards and cleaning wipes are included in the emergency kit above.
• Notify restaurant staff of food allergies and question staff regarding its ability to safely accommodate their food allergies.

Added advice for travelers with stinging insect allergy

• Choose appropriate protective clothing, such as closed-toe shoes, socks, long pants, and long-sleeved shirts in at-risk environments.

Immunization consideration for the severely allergic traveler

The pre-travel visit for the severely allergic traveler may reveal allergies to vaccine excipients or to allergens used in packaging. Primary allergens of concern are egg, gelatin, and latex. For perspective, anaphylaxis to vaccines is rare, occurring in less than 1 per 1,000,000 vaccinations. Reassuring data over time have demonstrated the safety of some vaccines with only trace amounts of egg protein and/or grown in chicken fibroblasts. For example, the Advisory Committee on Immunizations Practices no longer recommends additional safety measures for travelers with egg allergy (no matter how severe) when administering any influenza vaccine. Nevertheless, a few vaccines remain that contain larger amounts of egg allergen and/or where convincing safety data are not yet available (Table 2.5.2). For these vaccines, use alternatives or refer traveler to an allergist or immunologist for further evaluation.

After initial widespread concerns regarding anaphylaxis to the COVID-19 vaccines, reassuring data have evolved demonstrating the safety of these vaccines. Neither the Pfizer/BioNTech, AstraZeneca, Moderna, nor Janssen COVID-19 vaccine contains any egg proteins, and none of the vaccines are contraindicated in egg allergy. Only patients with anaphylactic or severe immediate reactions to prior doses of the COVID-19 vaccine or its excipients require referral to an allergist or immunologist. Anaphylaxis or severe immediate reactions to COVID-19 vaccine excipients such as polyethylene glycol and polysorbate are very rare in the population.

Gelatin is an uncommon food allergen, but it has been associated with anaphylaxis to gelatin-containing vaccines. For these vaccines, use alternatives or refer the traveler to an allergist or immunologist.

"Latex allergy" refers to different clinical syndromes. The most common form of latex allergy is contact dermatitis. Contact dermatitis to latex is not a contraindication to using vaccines that may have latex in their packaging and does not require additional safety measures. However, travelers who experienced anaphylaxis to latex have experienced anaphylaxis after receiving a vaccine packaged with latex. Studies linking cause and effect of latex exposure with threshold levels of latex have not been done. The potential risk comes from latex adsorption/leeching into the vaccine from vial stoppers, syringe plungers, and syringe tip caps or from exposure of the needle to the latex stopper. Most manufacturers have eliminated latex from their stoppers and many from all packaging. Some vaccines are still packaged with latex (Table 2.5.2). If a traveler has a history of an IgE-mediated reaction or anaphylaxis to latex, refer them to an allergist or immunologist.

Table 2.5.2: Allergens in vaccines