Travelers with Chronic Illnesses

CDC Yellow Book 2024

Travelers with Additional Considerations

Author(s): Noreen Hynes

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, 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

ANTICOAGULATION Anticoagulation Forum Centers of Excellence Resource Center
CANCER American Cancer Society Eat Right and Stay Active while Traveling
CELIAC DISEASE National Celiac Association Eating GF when traveling abroad
CHRONIC PAIN International Pain Foundation Top Tips for Traveling Abroad with Chronic Pain
DIABETES American Diabetes Association Air Travel and Diabetes
EPILEPSY Epilepsy Foundation Travel and Holidays
  Epilepsy Society (UK) Travel and holidays for people with epilepsy
HEART CONDITIONS American Heart Association Healthy Travel
INFLAMMATORY BOWEL DISEASE Crohn’s & Colitis Foundation Traveling with IBD
KIDNEY DISEASE American Association of Kidney Patients (AAKP) International Travel while on Dialysis
  National Kidney Foundation Foreign Travel Tips for Dialysis Patients
  Global Dialysis (UK) Travel Advice
LUNGS & CHEST American Lung Association Traveling with Oxygen
MULTIPLE SCLEROSIS Multiple Sclerosis Foundation Tips for Traveling Abroad with MS
SLEEP APNEA American Sleep Association Travel: CPAP Machines
  American Sleep Apnea Association US Travel Tips for CPAP Users


Table 3-08 Special considerations for travelers with chronic illnesses


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)






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


Anemia, severe (Hgb <8.5 g/dL)

Cardiovascular, gastrointestinal, or pulmonary/respiratory complications (see below for details)

Cerebral edema due to intracranial tumor

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


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



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


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


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



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
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


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



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


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



Hepatitis B

Know pre-departure HIV, hepatitis C, and hepatitis B status

Atovaquone-proguanil (Malarone) contraindicated when CrCl <30 mL/min
AAKP and Global Dialysis (see Table 3-07) can help locate dialysis centers; check accreditation

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


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



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

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