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:
Issues related to specific chronic medical illnesses are addressed in Table 5-3. 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 5-2.
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 precedes this section in the chapter |
Cardiovascular diseases | Following acute coronary syndrome:
Unstable angina CHF, severe, decompensated Uncontrolled hypertension CABG within 10 days CVA within 2 weeks Elective percutaneous coronary intervention within 2 days Uncontrolled arrhythmiaEisenmenger 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 cardDVT precautions | Influenza Pneumococcal Hepatitis B | Have sublingual nitroglycerin 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 (spontaneous pneumothorax) or 14 days (traumatic pneumothorax) | 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 |
Pleural effusion within 14 days High supplemental oxygen requirements at baseline Major chest surgery within 10days | ||||
Gastrointestinal diseases | Major surgery, within 10–14 days Uncomplicated appendectomy or laparoscopic surgery within 5 days Gastrointestinal bleed within 24 hoursColonoscopy 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 precedes this section in the 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 precedes this section in the chapter |
Diabetes mellitus | None | Plan for self-management of dehydration, diabetic foot, and pressure soresInsulin 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 precedes this section in the 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; Hg, hemoglobin; 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. |
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.
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:
Providers should counsel travelers to:
Deborah Nicolls Barbeau, Gail A. Rosselot, Sue Ann McDevitt