The Elderly Traveler

 The elderly are more prone to effects of jet lag, temperature change, motion sickness and dehydration. To minimize these symptoms:

  • Get plenty of rest prior to travel.
  • Carry extra layers of clothing to keep warm on the plane and while on the ground during layovers or transfers.
  • Drink plenty of fluids.
  • Carry extra snacks for unforeseen delays.

Plan ahead and always allow extra time:

  • To get to the airport, transfer to different terminals, counters and baggage claim areas.
  • Make use of available help by asking for wheelchairs and carts.

Should I avoid travel at this time?

Contraindications to air travel include but are not limited to:

  • Chest pain that is new, occurs at rest or with minimal effort
  • Had a heart attack in the past 6 weeks
  • Uncontrolled high blood pressure
  • Uncontrolled heart failure – breathless at rest
  • Had a collapsed lung in the past 3 weeks
  • Uncontrolled Asthma/COPD – breathless at rest
  • Active infection of the ear, nose, & throat
  • Surgery within the past 2 weeks
  • Had a stroke in the past 2 weeks
  • Been diving in the past 24 hours

Consult with your physician for your specific situation and any other contra-indications to air travel.

What if I have a chronic medical illness?

If you have other chronic medical conditions like diabetes, asthma or heart disease, there is specific advice for each illness, please go to any or all of those sections as needed with this link: traveler with diabetes, traveler with asthma and traveler with heart disease.

Will I need oxygen for flying?

Lists of conditions requiring supplemental oxygen while flying include, but not limited to, are:

  • You are currently on oxygen at home
  • Your blood oxygen level while breathing room air is less than 70 mmHg
  • Your finger probe oxygen saturation is less than 92% while at rest or less than 85% with exertion
  • if you are unable to walk 150 feet or climb a flight of 15 steps without becoming severely short of breath. 

Consult with your physician regarding whether you require oxygen during flight.

What is the risk of blood clots from travel or flying?

Factors that increase the risk of blood clots include but are not limited to:

  • Age > 75,
  • Previous history of blood clots,
  • Cancer,
  • Kidney failure,
  • Immobility,
  • Recent surgery,
  • Genetic susceptibility to clotting,
  • Prolonged air travel (> than 4 hours) etc.

Consult with your physician regarding your specific risk for developing blood clots.

Simple measures to prevent blood clots include but are not limited to:

  • Avoid dehydration by drinking plenty of fluids
  • Wear loose fitting clothes
  • Exercise in your seat by bending and straightening your feet and knees 15 times every 15 minutes.
  • Walk around the cabin every 30 minutes if safe and feasible
  • Wear properly fitted graduated compression stockings.
  • Consult your physician to see if you require medications to prevent blood clots.

Please go to our section on economy class syndrome for further details.

What about medical devices/records/drugs/supplies?

If you have implanted medical devices like defibrillators, medication infusion pumps, pace makers or artificial joints carry a letter from your physician to ease matters with security clearance.

Carry a copy of your EKG and a legible list of all your medical problems and medications with you in your carry on baggage or wallet/purse.

Carry all your medications, supplies and any blood sugar testing kits etc. with you in your carry on baggage. DO NOT put them in your checked luggage. If you are gone for a prolonged length of time, consider carrying a set of new prescriptions with you in your wallet or purse, incase you loose your luggage, so that you can have them refilled without problems.

How about travel vaccines and antibiotics?

Make sure you have received appropriate travel related and booster vaccines for the country you are traveling to and have necessary antibiotics for the prevention of malaria and treatment of diarrhea.

Be aware of the potential for newly prescribed medications like antibiotics, motion sickness pills etc to interact with your usual daily medications. Check with your physician or pharmacist about the need to adjust doses or alternatives.

If possible take a dose or two of the new medications prior to departure to make sure it will not cause any problems.

Should I wear a medical alert bracelet?

Wear a medical alert bracelet if you have diabetes, asthma, heart problems, seizures or psychiatric problems.

The Pregnant Traveler

If you are pregnant and considering international travel, you should evaluate the availability of quality care during travel and at your destination.

You should also investigate issues of insurance exclusions, medical evacuation costs, etc with your medical insurance carrier and have assurances in writing. This is of special importance if traveling to developing countries.

If your pregnancy is complicated for any reason, whether it be high blood pressure, diabetes, anemia or specific obstetrical issues you need to obtain permission from your OB/GYN physician.

The second trimester of pregnancy (weeks 18-24) is the safest for travel.

Any special precautions to take for air travel?

Avoid air travel:

  • From 32 weeks of gestation onward for multiple pregnancies (twins or more)
  • From 36 weeks of gestation onward for single pregnancy
  • Within 7 days of delivery
  • With complicated pregnancy

Prevent blood clots by frequently exercising the feet and legs, by walking in the cabin of the aircraft, and bending/straightening your feet and knees for 2 minutes every 10 minutes. Properly fitted graduated compression stockings may be appropriate for some. Pregnancy increases the risk of blood clots and preventive measure are crucial. Go to our economy class syndrome section for further details.

Avoid dehydration by drinking plenty of water or juice. Drink plenty and you will have to exercise the legs by going to the bathroom!!!

Wear seat belts at all times while seated, keep them at the level of your pelvis for a measure of comfort.

Any special advice for vaccinations during pregnancy?

Live bacterial and live viral vaccines are contra-indicated during pregnancy. These are: Bacille-Calamette-Guerin, Live Intra Nasal Influenza, Mumps-measles-rubella, oral typhoid –Ty 21a, Oral polio, Varicella and Yellow Fever.

In general, avoid vaccinations in the first trimester of pregnancy

The following vaccine preparations can be used form the 2nd trimester onward.

  • Immune globulin
  • Hepatitis B
  • Inactivated Influenza
  • Pneumovacc
  • Inactivated Polio
  • Rabies
  • Typhoid Vi

Data on safety in pregnancy is not available for Hepatitis – A and Japanese Encephalitis

Which antibiotics are safer during pregnancy? 

  • Traveler’s diarrhea: Azithromycin (Zithromax) and Cefixime (Suprax) are safe
  • Malaria prophylaxis: Mefloquine (Larium) and Atovaquone/Proguanil (Malarone) are CDC recommended after the 1st trimester. Chloroquine is safe, but should only be used in areas where Malaria parasite is known to be sensitive to it.

Avoid

  • Doxycycline
  • Primaquine
  • Pyremethamine
  • Trimethoprim-Sulfamethoxazole
  • Erythromycin
  • Quinolone class of antibiotics like Ciprofloxacin, Levofloxacin, Gatifloxacin and antifungal agents like fluconazole, itraconazole.

What do I do about water safety during my pregnancy and travel?

Boiling water for 3 minutes is the most safe and effective method to assure clean water.

Bottled juices, soft drinks and bottled water should be safe, make sure the cap is sealed when you buy it.

Avoid iodine tablets and iodine based water purification tablets due to risk of goiter in the fetus.

Since water filters do not filter viruses and one cannot use iodine to kill viruses, water filters are not of much use.

Brush your teeth with safe water.

Avoid ice.

See our water safety section for more details.

What do I do about food safety during pregnanacy and travel?

Always wash hands with soap and safe water

Strictly avoid all milk and dairy products. In the developing world pasteurization is not reliable. Risk of listeria, brucella etc are too great without this precaution

Avoid raw or undercooked meats, eggs and fish. Risk of Toxoplasmosis, salmonella etc are too great without this precaution.

Avoid salads, pre-cut vegetables and fruits for reasons of contamination.

If you must have a fruit, make sure the skin is undamaged and you peel the skin off yourself.

See our food safety section for more details.

What do I do if I develop traveler’s diarrhea while pregnant?

Dehydration can decrease placental blood flow; therefore one should aggressively drink fluids. Hot tea, 7-up, Ginger ale, Sports drinks or oral rehydration packets mixed in safe water are recommended.

Azithromycin(Zithromax) 500 mg once a day for 3 days or Cefixime(Suprax) 400 mg once a day for 3 days are safe antibiotics to use in pregnancy.

Combinations of Kaolin-Pectin and Imodium are safe if needed for symptom relief.

Avoid Pepto-Bismol or Bismuth salicylate products due to risk of birth defects and bleeding in the fetus.

See our traveler’s diarrhea section for more details.

What about malaria prevention while traveling and pregnant?

Wear long sleeve shirts and long pants.
Avoid outdoor activities at dusk and dawn.
Stay in accommodations with screens, fans or air-conditioning.
Use mosquito nets tucked into the mattress.
Use repellant containing DEET; use it directly onto clothing and only sparingly on skin exposed beyond long sleeve clothing.
Medications:

  • Mefloquine(Larium) is CDC recommended after the 1st trimester
  • Atovaquone/Proguanil is also considered safe after the 1st trimester
  • Chloroquine is safe, but ONLY use for areas where malaria parasites are known to be sensitive to it.
  • Avoid Doxycycline, Primaquine, Pyremethamine.

What do I do for motion sickness while pregnant?

  • Meclizine (Antivert) 25 mg three times a day is considered safe
  • Dimenhydrinate(Dramamine) 50 mg four times a day as needed is considered safe

What can I do about nausea while pregnant?

  • Promethazine (Phenergan) 25 mg three times a day as needed is considered safe

What can I take for pain while pregnant?

Acetaminophen (Tylenol) as directed is the safest
Avoid Aspirin and Non-steroidal agents like Ibuprofen

Traveler with Children

If children are traveling without their parents, the accompanying responsible adult or guardian should carry a notarized letter authorizing their travel, permission for any and all necessary medical treatment for them and evacuation if needed.

If children are traveling with a solo parent, a signed letter by the non-traveling parent, while not absolutely necessary, may speed up health care and services in countries with a legalistic bend.

Children with chronic heart, lung, blood or ear, nose and throat problems should be evaluated by their pediatrician prior to air travel.

Are there any special immunization requirements for children prior to travel? 

Update all recommended age appropriate vaccinations.

Accelerated vaccine administration schedules are available for special travel circumstances if the child is younger than recommended age, check with your pediatrician

Children should have at least 3 doses of tetanus toxoid and pertussis vaccine prior to travel.

Mumps-measles-rubella vaccine or monovalent measles vaccine (if the child is less than 12 months old) should also be given prior to travel.

Check with your pediatrician for specific recommendations for the country you are traveling to. Your child may need vaccines for Hepatitis A, Hepatitis B, Japanese encephalitis, Meningococcus, Rabies, Typhoid, and Yellow fever etc.

What should be done for malaria prevention in children during travel?

Stay in accommodations with screened windows and doors.

Use permethrin impregnated mosquito nets.

Avoid outdoor activities at dawn or dusk when mosquitoes are most active.

Wear long sleeve clothing.

Apply DEET (N, N-diethylmeta-toluamide) repellant on exposed skin and clothing as directed on the label for children.

Check with your pediatrician for specific weight based recommendation for medications like Atovaquone-proguanil, chloroquine, mefloquine etc.

See our malaria prevention section for further details.

How do I treat traveler’s diarrhea in children?

Follow general food safety and water safety recommendations.

Prepare formulas with safe water only.

Use oral rehydration solutions aggressively. If you are unable to find them or don’t have it, just mix 6 teaspoons of sugar and 1 teaspoon of salt in 1 liter of bottled, boiled or purified water.

Children should avoid lomotil, Pepto-Bismol or other anti-diarrhea medications, which could potentially cause blockage.

Take appropriate weight based antibiotics as directed by your pediatrician.

Traveler on Dialysis

Dialysis patients no longer need to be hooked to their hometowns. You can with some advance planning and preparation enjoy vacations, out of town business or pleasure engagements and even go on cruises or wilderness adventures. 

Who should consider travel?

Any hemodialysis or peritoneal dialysis patients who are medically stable and on a stable dialysis regimen can travel.

Who should avoid travel?

You should avoid travel if you are new to dialysis, your regimen and frequency are still being determined or your medical condition is unstable.

How should a hemodialysis patient start planning for a trip?

One should start planning at least 6-8 weeks in advance, perhaps longer for popular vacation destinations or during holidays. Discuss your plans with your kidney specialist (nephrologist) and obtain his approval from a medical standpoint.

Your local dialysis centers will sometime have a social worker or nurse who is familiar with arranging dialysis away from your home town and can assist you in finding a local hemodialysis center in the town you are visiting(travel dialysis center).

If your center is not able to do this, find out which national company is involved in your dialysis care and call their toll free number.   The 2 largest companies are: DaVita(1-800-244-0680 or davita.com) and Fresenius(1-866-889-6019 or fresinius.com).  They can help you find a dialysis center in the town you are visiting.

You can also go to www.globaldialysis.com to find local dialysis centers all over the world.

What if one has to travel in an emergency or short notice?

Most dialysis centers will be sympathetic and try to accommodate your needs.  Use your dialysis center staff, the above phone numbers and websites to make arrangements.

What adjustments will have to be made?

You may not always get into your first choice for dialysis center, you may have to drive a bit longer or take a different shift than you are used to. If you plan ahead none of the above may be an issue, but be prepared to be flexible, especially if on short notice.

What information will be needed at the travel dialysis center?

You will need to provide them with your name, address, contact information, your hometown dialysis center contact number, the dates you need dialysis, your vascular access type and dialysis prescription.

In addition they will need a copy of your medical history & physical, list of medications, laboratory results, EKG, CXR, 4-6 recent treatment records and any special dialysis requirements.

They will also need your insurance information, along with the name and contact number of your physician. Give them the address and local telephone number for the place you are staying at.

Are there extra costs out of my pocket for this?

Medicare will pay for 80% of the costs within the United States and its territories, but the patient is responsible for 20%. Your secondary insurance may cover this 20%, but travel dialysis centers may require you to pay this upfront and bill your insurance later.

Medicaid by and large will not pay for treatment outside your home state and you will be responsible for the costs.

If you have private insurance, it is best to have a letter in writing that they will pay for your treatment at the travel dialysis center.

Always inquire if the physician fee is your own responsibility or billed to the insurance.

What about peritoneal dialysis and travel?

Travel is usually quite a bit simpler since you don’t need a fixed appointment, but make sure to call the peritoneal dialysis center at your destination and see if they would be able to assist you if problems arose. Provide them with a copy of your pertinent medical records: history & physical, labs, EKG, CXR, dialysis prescription, list of medications etc.

You should carry enough supplies for the entire trip and some extra in case of problems.

If you are traveling for a prolonged period of time, have supplies delivered to your destination and make sure they have arrived prior to departure.

What if I get sick while traveling?

The travel dialysis center at your destination will be able to handle your needs through their physicians. Carry a complete legible copy of your pertinent medical records including medical problems, surgeries done, list of allergies, list of medications and contact information for your physician and family.

What about home hemodialysis and travel?

Most home hemodialysis patients get dialyzed in a local travel dialysis center at their destination, however some do travel in motor homes or go to campsites with electrical hook ups and are able to perform hemodialysis. Information can be found at travelingdialysisRVassociation.com.

What if I am on a transplant list?

If you are on a transplant list kindly inform your transplant coordinator about your travel plans and give contact information. If you wish to be “on hold” during the trip, please do so if you cannot get back in a reasonable amount of time.

What other resources are available?

Websites that maybe informative are:

Please visit the national kidney foundation local offices for list of camp grounds that are amenable to dialysis patients.

Traveler with Lung Problems

(COPD / ASTHMA / EMPHYSEMA / BRONCHITIS)

You should only travel if your medical condition is currently stable and doing well on current doses of oxygen, inhalers and other medications.

When should I not travel?

You should not travel:

  • If you have a new or ongoing infection.
  • If your doctor is still adjusting your doses of oxygen, inhalers and medications to help you breath better.
  • If you had lung surgery in the past 3 weeks.
  • If you had a collapsed lung in the past 3 weeks.

How can I best prepare for travel?

You should NOT be smoking if you have any breathing problems.

Consult with your pulmonologist regarding a pulmonary rehabilitation program like walking, to help you better adjust to the rigors of travel. Ideally this should be done 4-6 weeks prior to the trip.

What precautions do I take during travel?

Carry extra supply of inhalers, prednisone and an antibiotic that you have taken previously for any emergencies while traveling.

In addition to the long acting inhalers you might be on, take a short acting inhaler like albuterol with you to use as needed for quick relief of shortness of breath due to exertion, allergies, humidity, infection etc.

Arrive at the airport early to allow extra time for getting to terminals, gates etc.
Make use of services like wheelchairs and motorized transport to terminals and gates to decrease your exertion.

What about blood clots?

Prevent blood clots by:

  • Keeping well hydrated with water or juice.
  • Frequently exercising your legs by bending and straightening the feet and knees.
  • Wearing properly fitted graduated compression stockings.
  • Consult with your pulmonologist if you need medications to prevent blood clots.

Do I need oxygen for flying?

You will need oxygen on the flight if:

  • You use oxygen at home, and the dose or flow rate may need to be increased by1-2 L/min while in the air.
  • Your blood oxygen level is less than 70 mmHg on room air at rest.
  • Your blood oxygen saturation by pulse oximeter (finger probe) is less than 92% on room air or if it drops below 85% with activity.
  • You are unable to walk 150 feet or climb a flight of steps without getting short of breath.

Please consult your pulmonologist if you meet above criteria to make arrangements.

How do I arrange for oxygen on the flight and at airports?

The easiest way to arrange for oxygen on the flight, at airport terminals and during ground transport is to carry your own, Department of Transportation (DOT) pre-approved Portable Oxygen Concentrator (POC).

If you do not have your own DOT pre - approved portable oxygen concentrator, you should contact your airline to be sure they provide supplemental oxygen on ALL your flights including connecting flights, how much they charge and what documentation they need from your physician.

If your airline does provide supplemental in-flight oxygen on ALL your flights, make arrangements with them for this service when you book your flight and call again 72 hours prior to departure to re-confirm arrangements. Ideally, you should be on a direct, non-stop flight to your destination and sitting in an aisle seat to make transfers easier.

Airlines will only provide supplemental oxygen inside the aircraft. You will need to make separate arrangements with your home oxygen provider for needs at the arrival and departure terminals, any layover sites, baggage claim and during ground transfers.

In addition you will need to make arrangements for supplemental oxygen at your final travel destination.

See our section on oxygen.

Visit www.homeoxygen.org for further assistance regarding supplemental oxygen during air travel.

You can also visit the Transportation and Security Authority website at www.tsa.gov/travelers/index.shtm.

Traveler with Diabetes

How do I prepare for travel?

Take twice the quantity of medications, syringes, lancets, batteries and other supplies than you think you need for the trip and have it in your CARRY ON luggage.

Have new scripts written out by your physician to verify authenticity and to use incase you loose your medications and supplies.

Always carry extra supplies of food, glucose tablets, gel or glucagon with you for unexpected delays during travel with the potential for your blood sugars bottoming out.

Can I carry my insulin syringes and testing supplies on a flight?

It is prudent to carry documentation from your physician as to your diagnosis, treatment and the need to carry diabetic syringes, needles, and glucose monitoring instruments, insulin and / or insulin pump. Insulin and other medications should be clearly labeled as such.

You can check with the Department of Transportation Security  administration for the latest guidelines at www.tsa.gov/travelers-information/passengers-diabetes

What precautions do I take during travel?

DO NOT miss meals, if you are hungry, by all means eat!!

The greatest risk is that your blood sugars will go very low, therefore perform more frequent blood glucose measurements and accept moderately higher than usual glucose levels during air travel.

Be extra careful in drawing up insulin during flights, changes in air pressure may result in inaccuracies in measurements. Since the cabin is pressurized, you will only need to put half as much air into the syringe as you normally would to withdraw insulin.

Do I have to adjust my medications during travel?

In general traveling eastward shortens the day and you may need to decrease the dose of your medications and traveling westward lengthens the day and you may need to increase the dose of your medications. Frequent glucose measurements and use of short acting insulin is optimal.

Consult with your physician or visit www.diabetesmonitor.com for dosing regimens.

Once you have reached your destination, resume your normal meal schedules and medications dosing regimens.

Are there concerns for other diabetes related complications?

Foot infections are of special concern during travel. Make sure your shoes are broken in properly prior to departure. If you plan on having you nails trimmed, do so at least 2 weeks prior to your trip, not the day before, so that if infections were to develop you are not away from home.

DO NOT walk around barefoot, risk of injuries from innocuous objects like pebbles, sand and gravel to dangerous objects like needles, glass, etc and subsequent infections are too high. One is also at risk for contracting parasites through direct penetration. Do not wade in fresh or sea water if there are cuts, broken skin, cracked skin or even dry skin.

Diligently examine feet daily for evidence of skin breakdown. Any sign of infection is an indication for immediate medical attention and antibiotics.

What about complications related to eyes?

If you have had laser treatment of diabetes related eye problems within the previous year, check with your eye specialist prior to travel.

In addition, follow our country specific recommendations for immunization, malaria prevention, food safety, water safety, traveler’s diarrhea precautions and treatment by searching for your specific travel destination.

Traveler with Heart Disease

What if I had a heart attack?

Air travel is contraindicated within:

  • 2 weeks of an uncomplicated heart attack.
  • 8 weeks of a complicated heart attack that involved heart failure, shock or uncontrolled life threatening heart rhythms (ventricular fibrillation or ventricular tachycardia).

An exercise stress test that is performed 2 weeks after a heart attack or a more invasive tests like coronary angiogram to look at potential blockages in the blood vessels of your heart, maybe the best way to assess your safety for air travel. Check with your cardiologist.

What if I had heart surgery?

If you had coronary angioplasty and stent placement (opening of blocked blood vessels of the heart by balloon dilation), you need to wait 2 weeks prior to air travel.

If you had heart bypass (CABG – coronary artery bypass graft) or heart valve surgery, you need to wait at least 3 weeks prior to travel. If bypass surgery was complicated you need to wait longer and be cleared by your heart surgeon.

When should I not travel?

If you have the following diagnosis or symptoms you need to avoid travel and seek immediate medical help.

  • Unstable angina: chest pain that is new, at rest or with minimal exertion.
  • Uncontrolled high blood pressure: systolic >180, diastolic >100.
  • Uncontrolled heart failure: short of breath at rest or with minimal activity, waking up at night short of breath, short of breath when lying down in bed or increased swelling of legs.
  • Severe heart valve disease: short of breath at rest, with minimal activity, uncontrolled fast or slow heart rate.
  • Syncope: black out spells that have not been evaluated.
  • Uncontrolled arrhythmia: uncontrolled heart rate, whether too slow or too fast.

What is the most appropriate approach to go through airport security with implanted defibrillators and pacemakers?

  • If you have an implanted cardiac defibrillator or pacemaker it is prudent to carry a pacemaker or medical device ID card that documents the presence, make and model of your defibrillator or pacemaker and the telephone number for the manufacturer.
  • Inform the airport security officer that you have an implanted medical device and give them the pacemaker or medical device ID card.
  • Request a pat - down inspection rather than walking through the arched metal detector. Do not have the hand held security wand used to screen you, since it can interfere with the workings of your medical device.

Will my defibrillator or pacemaker set off the metal detector?

Yes, implanted cardiac defibrillators and pacemakers can trigger the alarm of metal detectors.

Will metal detectors harm my defibrillator or pacemaker?

Hand held security wands can interfere with implanted cardiac defibrillators. Travelers should carry a letter from your physician and request a physical pat down. Walk through metal detectors will not interfere with your device but will set off an alarm.

What else should I carry?

You should also carry a copy of your EKG with you, so physicians who are not familiar with you can compare EKG’s if an emergency situation developed while traveling. You should also consider having your cardiologist’s contact information (telephone/fax/email) with you for others to communicate with them.

For any questions regarding your defibrillator, pacemaker or stent please consult your cardiologist or company that made it.

What should I do about my medications?

You should carry all your medications with you in your CARRY ON luggage, keep a LEGIBLE list of your medical diagnosis, medications and carry a recent copy of your EKG (electrocardiogram).

Should I wear a medical bracelet?

It never hurts to have one, especially if you have an irregular heart rhythm that might cause you to pass out.

Are there any activities that I should be careful with?

One should be cautious with exertion at altitudes - either a sudden change of more than 3000 feet or activities at more than 5000 feet.
.
Avoid diving, bungee jumping, parachute jumping etc.

What about blood clots?

You can try to prevent blood clots with the following measures:

  • Keep well hydrated by drinking water or juice.
  • Wear loose fitting clothes.
  • Frequently exercise your legs by bending and straightening your feet and knees every 15 minutes for 30 seconds.
  • Walk around the cabin every half hour for a minute, if safe and feasible.
  • Wear properly fitted graduated intermittent compression stockings.
  • Check with your physician whether you need medications to prevent blood clots.

What about medication interactions?

Mefloquine (Larium), a medication prescribed to prevent malaria is contraindicated in patients with heart rhythm problems. Atovaquone-proguanil (Malarone) and Doxycycline are potential alternatives.

Antibiotics in the family of fluoroquinolones, especially moxifloxacin (Avelox) and gatifloxacin (Tequin) can also cause problems in patients with heart rhythm problems especially those on class I/III antiarrhythmic medications (Quinidine/Flecainide/Amiodarone etc). Check with your cardiologist.

Antibiotics in the fluoroquinolone family and erythromycin derivatives can interact with blood thinning medications (warfarin/coumadin). Consult with your cardiologist.

Traveler with HIV or AIDS

Can an individual with HIV travel to all countries?

Certain countries do not admit HIV infected individuals. Discovery of anti-retroviral medications in your luggage can lead to deportation. Check with the respective embassies or at the following website for the most current information: www.hivtravel.org.  

What sort of pre-travel preparations are needed?

If you are HIV positive or have AIDS and are considering international travel, you should evaluate the availability of quality care during travel and at your destination.

You should also investigate issues of insurance exclusions for care overseas; medical evacuation costs etc with your medical insurance carrier and have assurances in writing. Be aware that travel medical insurance may not cover pre-existing conditions and in any case overseas facilities expect payment prior to service, especially in third world countries.

We would strongly encourage separate medical evacuation insurance independent from your medical insurance. This is of special importance if traveling to developing countries.

Are vaccinations safe and effective with hiv/aids?

If you have symptomatic HIV infection or AIDS, the following vaccines are absolutely contra-indicated:

  • Bacille-Calamette-Guerin (BCG)
  • Live nasal influenza vaccine
  • Oral typhoid vaccine
  • Varicella vaccine
  • Yellow fever vaccines

The only exception being the mump-measles-rubella (MMR) vaccine, although with live virus is still recommended and felt to be safe by the CDC for those with asymptomatic HIV infection and CD4 counts greater than 200.

Some have suggested that yellow fever vaccine ( a live virus vaccine ) maybe safe in asymptomatic HIV patients with CD4 counts greater than 400/mm3.

However we urge extreme caution in this matter. You need to consult closely with your physician regarding actual risks versus benefit of taking the vaccine.

If the vaccine is required only for country requirements as opposed to true risk of infection consideration for a vaccine waiver letter is valid. However there is the possibility that the host country will not accept the waiver and is best to return home rather than be given the vaccine onsite in the host country. Bottom line: HIV infected individuals must seriously consider the risk versus benefit of visiting countries with risk of yellow fever.

All other vaccines are safe for aymptomatic HIV and AIDS patients.

Vaccines are most effective in individuals with a CD4 count greater than 200/mm3. If you are on anti-retroviral medications, make sure your counts have been over 200/mm3 for at least 3 months.

For specific vaccine recommendations for the country you are visiting, please search by country.

Are there significant drug interactions with anti-retrovirals?

There is always potential for medication interactions and additional side effects between anti-retroviral medications and prophylactic antibiotics for prevention of malaria or treatment of diarrhea. However these are not felt to be clinically significant at this time.

It is advisable to start the new medications prior to travel, to judge any reactions that you might have.

If going to the tropics or if there is significant sun exposure, see if your medications cause sunburn.

Are there any special malaria prophylaxis issues?

Malaria prevention is absolutely critical and recommendations should be diligently adhered to. The following steps are helpful:

  • Atovaquone-proguanil (Malarone) and Doxycycline maybe the best tolerated antibiotics from the perspective of efficacy and side effects.
  • Avoid outdoor activities at dawn and dusk when mosquitoes are most active
  • Stay in accommodations with screened windows and doors
  • Use permethrin impregnated mosquito nets
  • Wear long sleeve shirts and pants
  • Apply insect repellant containing DEET to exposed skin and clothing
  • Consider using mosquito repellant coils in your accommodation.

For specific recommendations for the country you are visiting, please search by country.

What can be done to prevent traveler’s diarrhea?

Traveler’s diarrhea maybe avoidable if you strictly adhere to food and water safety:

  • Use only bottled or boiled water for drinking and brushing your teeth.
  • Water purification filters may not protect against protozoan pathogens like cryptosporidium or microsporidium.
  • Do not use ice; it is made from contaminated water.
  • Bottled soft drinks, juices and alcohol that are drunk straight from the bottle, can or carton is safe.
  • Avoid salads, dairy products, already peeled fruits etc.
  • Only eat undamaged fruit that you peel yourself.
  • Only eat food that is cooked to order and brought to you hot.
  • Avoid buffets, undercooked meats, poultry and fish.

If your CD4 count is less than 200/mm3 and are on a short trip (less than 14 days) you may benefit from daily doses of preventive antibiotics like levafloxacin (Levaquin), moxifloxacin (Avelox) or azithromycin (Zithromax).

Go to our food safety, water safety and traveler’s diarrhea section for further details.

What is the risk for tuberculosis exposure?

There is a significant risk for exposure to individuals with tuberculosis in the developing world. If traveling to the developing world, TB skin testing before you travel and 6 weeks after travel should be performed to judge possible exposures and need for treatment.

Solid Organ Transplant: kidney, heart, liver, lung, pancreas

Solid Organ Transplants: kidney, heart, liver, lung, pancreas

When is it advisable to travel after solid organ transplantation?

The degree of immune compromise and thus the greatest risk of infections are within the first year after a transplant. In addition, the immunosuppressive medication that you take decreases the effectiveness of vaccines that are required for travel to developing nations. When considering overseas travel, you should not be experiencing active rejection or be on new medications to suppress rejection.

Therefore it is only advisable to travel overseas after the 1st year following an organ transplant, you should not be experiencing rejection and need to be on a fixed regimen of medications.

What vaccines are safe after organ transplantation?

Vaccines that are safe and possibly recommended depending on your travel destination are listed below. These are most effective when given 6-12 months AFTER your transplant

  • Hepatitis A Vaccine
  • Hepatitis B Vaccine 
  • Inactivated Influenza Vaccine 
  • Japanese encephalitis Vaccine
  • Meningococcal Vaccine
  • Pneumococcal Vaccine
  • Inactivated Polio Vaccine
  • Rabies Vaccine
  • Tetanus Vaccine
  • Inactivated Typhoid Vaccine

What vaccines are unsafe after organ transplantation?

Live bacterial and viral vaccines are ALWAYS contraindicated in patients with solid organ transplants. These are:

  1. BCG (Bacilli-Calamette-Guerin) Vaccine 
  2. Intranasal Influenza Vaccine 
  3. MMR  Vaccine
  4. Oral Polio Vaccine
  5. Oral Typhoid Vaccine
  6. Varicella Vaccine
  7. Yellow Fever Vaccine

Are there any special malaria prophylaxis issues?

  • Mefloquine (Larium) has potential for drug interactions and side effects.
  • Atovaquone/Proguanil (Malarone) has less chance of drug interactions however needs to be taken with meals for absorption.
  • Doxycycline is well tolerated but can cause sun burn.
  • Consult your physician and consider taking a dose or two prior to your trip to judge reactions.

Always take precautions to prevent insect bites as well and:

  • Wear long sleeve shirts and long pants
  • Avoid outdoor activities at dusk and dawn
  • Stay in accommodations with screens, fans or air-conditioning
  • Use mosquito nets tucked into the mattress.
  • Use insect repellant containing DEET; use it directly onto clothing and only sparingly on skin exposed beyond long sleeve clothing.

For specific malaria recommendations regarding your destination please search by country.

Are there any special traveler’s diarrhea issues?

Early treatment and aggressive hydration are crucial with immunocompromise.

  • Azithromycin (Zithromax) has the least risk of drug interactions.
  • Levofloxacin (Levaquin) is a potential option for those unable to take Azithromycin, however quinolone antibiotic like this has risk for drug interactions.
  • Cefexime (Suprax) is another option, however it may not cover some of the bacteria that cause traveler’s diarrhea and should not be taken without physician guidance.

Follow safe water precautions as follows:

  • Boiling water for 3 minutes is the most safe and effective method to assure clean water.
  • Bottled water, juices and soft drinks should be safe, make sure the cap is sealed when you buy it.
  • Water filters do not adequately remove viruses; need to use iodine tablets after filtering water.
  • Always brush your teeth with bottled or boiled water.
  • Do not use ice; they are made from contaminated water.

Follow safe food precautions as follows:

  • Always wash hands with soap and safe water and/or antibacterial liquid.
  • In the developing world pasteurization is not reliable therefore strictly avoid all milk and dairy products. The risk of contracting listeria, brucella etc is too great without this precaution.
  • Avoid raw or undercooked meats, eggs and fish. The risk of contracting Toxoplasmosis, Salmonella etc are too great without this precaution.
  • Avoid salads, pre-cut vegetables, and fruits and especially buffets where food temperatures and cleanliness are not assured.
  • If you must have a fruit, make sure the skin is undamaged and you peel the skin off yourself.
  • The best practice is to only eat well cooked foods, cooked to order and brought to you piping hot.

See our sections on safe food, safe water and traveler’s diarrhea for more recommendations.

For advice regarding your specific destination please search by country.

Bone Marrow Transplant

When is it safe to travel after bone marrow transplant?

Bone marrow transplant recipients usually reach status of normal immunocompetence at approximately 2 years after transplant.

Vaccines are administered to bone marrow transplant recipients beginning at 12 months after transplant and completed at 24 months after transplant.

Therefore it is advised to avoid travel to high-risk areas till 2 years after the bone marrow transplant.

Travel to high-risk areas should be avoided even 2 years after bone marrow transplant, if you are requiring high doses of immunosuppressive medications, being treated for rejection or you suffer from graft vs. host disease.

Are vaccines safe after bone marrow transplant?

Live viral and bacterial vaccines are ALWAYS contra-indicated in bone marrow transplant patients. These are

a. Bacille-Calamette-Guerin (BCG) Vaccine
b. Intranasal Influenza Vaccine
c. Mumps-Measles-Rubella Vaccine
d. Oral Polio Vaccine
e. Oral Typhoid Vaccine
f. Varicella Vaccine
g. Yellow fever Vaccine

Vaccines that are safe and possibly recommended depending on your travel destination are listed. For maximal effectiveness, these are administered beginning at 12 months AFTER transplant.Vaccines that are safe and possibly recommended depending on your travel destination are listed. For maximal effectiveness, these are administered beginning at 12 months AFTER transplant.

a. Hepatitis A Vaccine
b. Hepatitis B Vaccine
c. Inactivated Influenza Vaccine
d. Japanese Encephalitis Vaccine
e. Meningococcal Vaccine
f. Pneumococcal Vaccine
g. Inactivated Polio Vaccine
h. Rabies Vaccine
i. Tetanus Toxoid Vaccine
j. Inactivated Typhoid Vaccine

What do I need to do about malaria prophylaxis after bone marrow transplant?

a. Mefloquine (Larium): has potential for drug interactions
Atovaquone/Proguanil (Malarone): probably has the least potential for drug interactions however needs to be taken with meals for absorption.
b. Consider taking a dose or two of medications prior to your trip to assess tolerability.
c. Follow insect safety guidelines meticulously.

What do I do if I get travelers diarrhea after bone marrow transpant? 

a. Azithromycin (Zithromax): has the least risk of drug interactions and broadest spectrum of activity and least resistance at this time.
b. Levofloxacin (Levaquin): has less chance of drug interactions compared to others in the fluoroquinolone class however it is quite possible and should not be taken without physician guidance.
c. Cefixime (Suprax): is an option for those unable to take Azithromycin, however it does not cover many pathogens and should not be taken without physician guidance.
d. Follow safe food and safe water guidelines; see traveler’s diarrhea section as well for more information.


For country specific advise please click here.

Splenectomy (spleen removed)

Are there special precautions I should take regarding travel if I had a splenectomy?

The greatest risk of bacterial infections after removal of your spleen is within the first two years, however the risk remains elevated throughout life.
In addition to the usually recommended vaccinations for the destination you are traveling to, vaccinations against the following bacteria are strongly suggested.

Pneumococcus (pneumovacc)
Hemophilus influenza b (Hib)
Meningococcus (menomune, menactra, menveo)

These three bacteria can cause rapidly fatal infections in individuals who do not have a spleen and are possibly preventable with appropriate vaccinations.

There are other bacteria that can cause fatal infections as well.
Therefore, consider carrying a 7day supply of a broad-spectrum antibiotic that you have tolerated previously. Examples would be quinolones (Levafloxacin, gatifloxacin), cephalosporins (cefpodoxime, cefexime) or macrolide (azithromycin). Start a course of antibiotics with any signs of ear, nose, throat, respiratory or skin infection or fever.

Promptly seek medical attention from a physician for any signs of infection or fever and tell the caregiver that you do NOT have a spleen. DO NOT delay medical care just because you have started taking antibiotics.

Follow malaria prevention recommendations for your destination and insect safety guidelines. If you develop fever in a malaria prone area of the world, promptly seek medical attention.

Follow safe food and safe water guidelines and take antibiotics with the first instance of diarrhea. See our traveler’s diarrhea section for further details.

Traveler with Cancer

When is it advisable to travel after cancer treatment?

Vaccines are probably most effective a minimum of 3 months after the last session of chemotherapy and the cancer is in remission.

Therefore travel to high-risk areas are best advisable a minimum of 3 months after chemotherapy and after vaccinations.

All other recommendations are unchanged, just type in the destination of you travel for further information.

Consult with your cancer specialist prior to travel.

Traveler taking Prednisone

Are there special precautions I should take when traveling if I take prednisone?

Prednisone at a daily dose of 20 mg or greater for 2 weeks or more can compromise the immune system. Ideally for vaccines to be fully effective one should wait 4 weeks after the high dose usage period.

For purposes of travel and vaccinations the following usesof prednisone have no significant immune compromise.

a. Dose of 20 mg/day or less for less than 2 weeks
b. Dose of prednisone is for replacement of your daily requirements
c. Inhaled steroids for asthma or allergies
d. Injection of steroids into joints, tendons or use of steroid creams.

Consult with your physician prior to travel.

Traveler with Autoimmune Disease

Are there special precautions for travelers with autoimmune diseases?

Autoimmune Disease: Lupus, Rheumatoid arthritis, Crohn’s disease
Ulcerative colitis, Wegener’s, etc.

If you are currently not on immunosuppressive medications there are no definitive studies on one’s immune status and routine vaccinations, medications and safety and treatment guidelines should be adequate.

If you are on immunosuppressive medications (cytoxan, methotrexate, azothioprine, 6-mercaptopurine, etanercept, infliximab etc.) you are considered to be severely immunocompromised.

a) Live bacterial and viral vaccines are contraindicated. These are:

  • BCG (Bacille-Calamette-Guerin) Vaccine
  • Intranasal influenza Vaccine
  • Measles, mumps and rubella Vaccine
  • Oral Polio Vaccine
  • Oral Typhoid Vaccine
  • Varicella Vaccine
  • Yellow fever Vaccine

b) You should be off immunosuppressive medications for at least 3 months or if that is not possible, should be on the lowest possible maintenance doses prior to even considering travel.

c) You need a thorough discussion and evaluation by your physician regarding the benefits vs. risk of travel to high-risk areas and the potential effectiveness of vaccines etc.

Traveler with Multiple Sclerosis

Are there special precautions for travel if I have multiple sclerosis?

Individuals with multiple sclerosis should not receive any vaccinations a minimum of 6 weeks after a disease exacerbation.

Some experts have discouraged the use of live virus or even bacterial vaccines in the past, check with the National MS society or your neurologist for current advice.

You can go to www.nationalmssociety.org/sourcebook-vaccinations.asp)

Traveler with Seizures

When is it advisable to travel overseas?

You must have your seizures well controlled and be taking stable doses of medications prior to travel.

What precautions should one take prior to travel?

You should carry emergency anti-seizure medications and instructions for its use with you in case of unexpected breakthrough seizures.

You must wear a medical bracelet incase of emergency.

Can one experience more seizures at high altitude?

Seizure thresholds are reduced at high altitudes including in flight, but this should not be a problem for those on stable doses of medication.

Are there any prohibited activities with seizure disorders?

Diving is contraindicated because of the risk of seizure and death given the inability to deal with emergencies quickly underwater and the risk for life threatening decompression illness with rapid ascent.

Driving is contraindicated as well due to the risk of accidents and death unless you have been seizure free for two years.

What does one take for malaria prophylaxis?

The following anti-malaria medications are contraindicated in patients with seizures.

  • Mefloquine (Larium)
  • Chloroquine (Aralen)

For malaria prophylaxis Atovaquone-proguanil (malarone) and doxycycline are safe, IF they are appropriate for the country you are traveling to.

What about interactions involving seizure medications?

Medication interactions are very common and need to be carefully discussed with your physician.

  • Ciprofloxacin and other medications in the fluoroquinolone family reduce phenytoin (Dilantin) levels
  • Azithromycin (Zithromax) or Cefexime (Suprax) are safe to use for traveler’s diarrhea.
  • Salicylate (aspirin) containing products increase valproate (depokote) and phenytoin (Dilantin) levels

How soon after my illness / surgery can I fly

ILLNESSDelay travel by
Abdominal Surgery2 weeks
Chest Surgery2 weeks
Collapsed Lung Repair3 weeks
Heart Attack – uncomplicated3 weeks
Heart Attack – complicated 6 weeks
Heart Balloon Procedure (angioplasty)2 weeks
Heart Bypass Surgery2 weeks
Heart Valve Surgery2 weeks
Stroke2 weeks
Spinal Anesthesia2 weeks
Neurological Surgery2 weeks

These are general medical educational guides.Individual recommendations will vary depending on your specific circumstances, consult with your physicians for your specific condition.

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