CDC Health Information for International Travelers General Health Recommendation

TRAVELERS’ HEALTH KIT
PROTECTION AGAINST MOSQUITOES, TICKS, FLEAS AND OTHER INSECTS AND ARTHROPODS
INJURIES
SEEKING HEALTH CARE ABROAD
THE POST-TRAVEL PERIOD

Editor's note: The information presented in this section was condensed from the CDC's Health Information for International Travelers 2008, commonly referred to as the Yellow Book. For complete travel health information view CDC's website on the Internet at http://wwwn.cdc.gov/travel or call CDC's toll free voice information system at 1-877-394-8747.

TRAVELERS’ HEALTH KIT

The purpose of a Travel Kit is twofold: to allow the traveler to take care of minor health problems as they occur and to treat exacerbations of pre-existing medical conditions. Persons with pre-existing conditions, such as diabetes or allergies to envenomations or medications, should consider wearing an alert bracelet and making sure this information is on a card in their wallet and with their other travel documents. A variety of health kits are available commercially and may even be purchased over the Internet; however, similar kits can be assembled at home. The specific contents of the health kit are based on destination, duration of travel, type of travel, and the traveler's pre-existing medical conditions. Basic items that should be included are listed below.

Medications

• Personal prescription medications in their original containers (copies of all prescriptions should be carried, including the generic names for medications, and a note from the prescribing physician on letterhead stationery for controlled substances and injectable medications)
• Antimalarial medications, if applicable
• Over-the-counter antidiarrheal medication (e.g., bismuth subsalicylate, loperamide)
• Antibiotic for self-treatment of moderate to severe diarrhea
• Antihistamine
• Decongestant, alone or in combination with antihistamine
• Anti-motion sickness medication
• Acetaminophen, aspirin, ibuprofen, or other medication for pain or fever
• Mild laxative
• Cough suppressant/expectorant
• Throat lozenges
• Antacid
• Antifungal and antibacterial ointments or creams
• 1% hydrocortisone cream
• Epinephrine auto-injector (e.g., EpiPen), especially if history of severe allergic reaction. Also available in smaller-dose package for children

Other Important Items

• Insect repellent containing DEET (up to 50%)
• Sunscreen (preferably SPF 15 or greater)
• Aloe gel for sunburns
• Digital thermometer
• Oral rehydration solution packets
• Basic first-aid items (adhesive bandages, gauze, ace wrap, antiseptic, tweezers, scissors, cotton-tipped applicators)
• Antibacterial hand wipes or alcohol-based hand sanitizer containing at least 60% alcohol
• Moleskin for blisters
• Lubricating eye drops
• First aid quick reference card

Other items that may be useful in certain circumstances

• Mild sedative (e.g., zolpidem) or other sleep aid
• Anti-anxiety medication
• High-altitude preventive medication
• Water purification tablets
• Commercial suture/syringe kits (to be used by local health-care provider. These items will also require a letter from the prescribing physician on letterhead stationery.)
• Latex condoms
• Address and phone numbers of area hospitals or clinics

Commercial medical kits are available for a wide range of circumstances, from basic first aid to advanced emergency life support. Many outdoor sporting goods stores sell their own basic first aid kits. For more adventurous travelers, a number of companies produce advanced medical kits and will even customize kits based on specific travel needs. In addition, specialty kits are available for managing diabetes, dealing with dental emergencies, and handling aquatic environments. If travelers choose to purchase a health kit rather than assemble their own, they should be certain to review the contents of the kit carefully to ensure that it has everything needed; additional items may be necessary.

A final reminder: a health kit is useful only if it is available. It should be carried with the traveler at all times, e.g., in carry-on baggage when allowable, and on excursions. All medications, especially prescription medications, should be stored in carry-on baggage, in their original containers with clear labels. With heightened airline security, sharp objects and some liquids and gels will have to remain in checked luggage.

PROTECTION AGAINST MOSQUITOES, TICKS, FLEAS AND OTHER INSECTS AND ARTHROPODS

Although vaccines or chemoprophylactic drugs are available against important vector-borne diseases such as yellow fever and malaria, travelers still should be advised to use repellents and other general protective measures against biting arthropods. The effectiveness of malaria chemoprophylaxis is variable, depending on patterns of drug resistance and compliance with medication, and no similar preventive measures exist for other mosquito-borne diseases such as dengue or chikungunya. For many vector-borne diseases, no specific preventives are available.

The number of insect repellents available has been increasing, with several active ingredients now registered by the US Environmental Protection Agency (EPA). However, for travel to areas where the intensity of disease-transmitting vectors is high, it may be wise to use a product containing DEET or picaridin rather than an herbal product. DEET is the most studied repellent and travelers (military and civilian) have had the most experience with it.

General Preventive Measures

Tick-, mite-, and mosquito-borne parasitic and viral infections characteristically are diseases of “place” that are linked to known geographic or ecologic regions, and the amount of disease transmission in these areas often varies seasonally. Risk of infection increases when visiting areas of the world where these diseases occur and when epidemics are in progress. International travelers should consult CDC's Travelers’ Health web page for alerts and information on regional disease transmission patterns that may change periodically (http://www.cdc.gov/travel). Travelers to areas with identified risks should take the precautions described below to reduce the likelihood of acquiring a vector-borne disease. When possible, known foci of epidemic disease transmission should be avoided.

Travelers should be advised that exposure to arthropod bites can be minimized by modifying patterns of activity or behavior. Some vector mosquitoes are most active in twilight periods (i.e., dawn and dusk) or in the evening after dark. Avoidance of outdoor activity during these periods can reduce risk of exposure. Wearing long-sleeved shirts, long pants, and hats minimizes areas of exposed skin. Shirts should be tucked in. Repellents applied to clothing, shoes, tents, mosquito nets, and other gear will enhance protection.

When exposure to ticks, chigger mites, or biting insects is a possibility, travelers should be advised to tuck their pants into their socks and to wear boots, not sandals. Per-methrin-based repellents applied as directed to clothing or camping equipment will enhance protection. Travelers should be advised to inspect themselves and their clothing for ticks, both during outdoor activity and at the end of the day. Ticks are detected more easily on light-colored or white clothing. Prompt removal of attached ticks can prevent some infections.

When accommodations are not adequately screened or air conditioned, bed nets are essential to provide protection and to reduce discomfort due to biting insects. Bed nets are most effective when treated with a repellent such as per-methrin. Pre-treated, long-lasting bed nets can be purchased prior to traveling, or nets can be sprayed after purchase. The permethrin repellent will be effective for several months if the bed net is not washed. Bed nets should be tucked under mat-tresses. Aerosol insecticides can help to clear rooms of mosquitoes.

Repellents

Travelers should be advised that permethrin-containing repellents (e.g., Permanone) are recommended for use on clothing, shoes, bed nets, and camping gear, and are registered by the U.S. Environmental Protection Agency (EPA) for this use. Permethrin is highly effective both as an insecticide and as a repellent for ticks, mosquitoes, and other arthropods. Clothing treated according to label instructions should provide protection for up to 2 weeks and through several machine washings before re-treatment is required. Clothing pre-treated with permethrin is commercially available and should be used and washed according to the manufacturer's instructions. There appears to be little potential for toxicity from permethrin-treated clothing. Permethrin-treated clothing should be supplemented with topically applied repellents to protect exposed skin.

The EPA has registered several active ingredients for use in personal repellents applied to skin. EPA registration of repellent active ingredients indicates the materials have been reviewed and approved for efficacy and human safety if applied according to the instructions on the label. These active ingredients are DEET (N,N-diethylmetatoluamide), Picaridin (KBR 3023), IR 3535, p-menthane 3,8-diole (PMD or oil of lemon eucalyptus) and oil of citronella. Two additional compounds are also registered as repellents by EPA (MGK-326, MGK-264); however, they are generally formulated with other active ingredients to enhance repellent activity and are not found alone in repellent products.

All the EPA-registered active ingredients have some repellent activity. Published data indicate that repellent efficacy and duration of protection vary considerably among products and among mosquito species and are markedly affected by ambient temperature, amount of perspiration, exposure to water, abrasive removal, and other factors. In general, higher concentrations of active ingredient in a repellent formulation provide longer durations of protection, regardless of the active ingredient. Lower concentrations are not as long lasting, offering short-term protection only and necessitating more frequent reapplication.

DEET is the most common repellent active ingredient, and its efficacy and toxicity have been the subject of numerous scientific studies. Most authorities recommend repellents containing DEET (N,N-diethylmetatoluamide) as the most reliable and long-lasting active ingredient. DEET repels mosquitoes, ticks, and other arthropods when applied to the skin or clothing. In general, the more DEET a repellent contains, the longer it can protect against mosquito bites. Low concentrations provide shorter-duration protection than higher concentrations; however, there appears to be no added benefit of concentrations of more than 50% DEET. A microencapsulated, sustained-release formulation can have a longer period of activity than liquid formulations at the same concentrations.

DEET has been so widely used that a great deal of testing has been done. Over the long history of DEET use, very few confirmed incidents of toxic reactions to DEET have occurred when the product is used properly. No definitive studies have been published about what concentration of DEET is safe for children. However, reports of serious illness in children after the use of DEET are extremely rare; DEET was used inappropriately in most of these cases. DEET formulations as high as 50% are recommended for both adults and children >2 months of age. The recommendations for DEET use in pregnant women do not differ from those for nonpregnant adults.

Repellents that do not contain DEET have not been tested as thoroughly as DEET-based products, although available data indicate that many offer a duration of protection from biting mosquitoes similar to that provided by similar concentrations of DEET. Used according to label instructions and reapplied as necessary, EPA-registered non-DEET repellents can provide acceptable protection from biting insects and are not expected to pose health risks to people, including children and other sensitive populations. Similar to DEET, summaries from EPA indicate that Picaridin is slightly toxic by eye, dermal and oral routes. PMD (p-men-thane-3,8-diol) shows no adverse effects except for eye irritation. IR3535 has been used as an insect repellent in Europe for 20 years with no substantial adverse effects. Toxicity tests show that the IR3535 is not harmful when ingested, inhaled, or used on skin, although it may cause eye irritation if it enters a person's eyes. Oil of citronella shows little or no toxicity, but may cause skin irritation.

Repellents applied according to label instructions may be used with sunscreen with no reduction in repellent activity. Products that combine sunscreen and repellent are not recommended, as sunscreen may need to be re-applied with greater frequency and in greater amounts than are needed to provide protection from biting insects.

Travelers should be advised to check the container to ensure that the product bears an EPA-approved label and registration number. The entire label should be read and the directions followed carefully. For example, if a tick repellent is needed, the product label should list this use. If ticks are not listed, the product may not be formulated for that use. Repellents should be stored away from children's reach.

Travelers should be advised to use the following precautions when using repellents:

• Use enough repellent to cover exposed skin or clothing. Do not apply repellent to skin that is under clothing. Heavy application is not necessary to achieve protection.
• Do not apply repellent to cuts, wounds, or irritated skin.
• After returning indoors, wash treated skin with soap and water.
• Do not spray aerosol or pump products in enclosed areas; do not inhale the aerosol.
• Do not apply aerosol or pump products directly to the face. Spray hands and then rub them carefully over the face, avoiding eyes and mouth.
• When using repellent on a child, an adult should apply it to his or her own hands and then rub them on the child. Avoid the child's eyes and mouth and apply sparingly around the ears.
• Do not apply repellent to children's hands. (Children tend to put their hands in their mouths.)
• Do not allow children younger than 10 years old to apply insect repellent to themselves; an adult should do it for them. Keep repellents out of reach of children.

Protect infants younger than 2 months of age from biting mosquitoes by using an infant carrier draped with mosquito netting with an elastic edge for a tight fit.

Bed nets and repellents should be purchased before traveling and can be found in hardware, camping, sporting goods, and military surplus stores.

When purchasing repellents overseas, look for the EPA-registered active ingredients on the product labels. Per-methrin or a similar insecticide, deltamethrin, may be purchased to treat bed nets and clothes.

INJURIES

According to the World Health Organization, injuries are among the leading causes of death and disability in the world, and they are the leading cause of preventable deaths in travelers. An estimated 5 million people died from injuries in 2000, and more than 90% of these injury deaths occurred in lower and middle-income countries. Worldwide, among persons ages 5-44, injuries account for 6 of the 15 leading causes of death.

In 2005, just over 63.5 million Americans traveled outside the United States. The vast majority of these trips occurred without any serious health problems, but fatal and serious injuries occur to Americans every year while traveling internationally. Compared with injuries, infectious diseases, for example, only account for a small proportion (2%) of deaths of overseas travelers.

The U.S. State Department collects data for U.S. citizens who die in a foreign country from non-natural causes for the most recent 3-year period and makes these data available on the State Department website. These deaths are categorized by location where the death occurred, date of death, and cause of death. These deaths should be considered a conservative estimate of the true number of U.S. citizens who die in foreign countries, as some deaths may not be reported to the State Department. The data may not include some deaths of U.S. military or U.S. government officials. Road traffic crashes headed the list of causes (34%), followed by homicide (17%), and drowning (13%). (By comparison to U.S. injury fatalities in 2003, road traffic crashes accounted for 27%, homicide 11%, and drowning 2% of all injury deaths.

Depending on travel destination, duration, and planned activities, other common injury and safety concerns include natural hazards and disasters, civil unrest, terrorism, hate crimes against Americans, falls, burns, poisoning, drug-related overdose, and suicide. If a traveler is seriously injured, emergency care may not be available or acceptable by U.S. standards. Trauma centers capable of providing optimal trauma care are uncommon outside urban areas.

Males are more likely than females to die from injury causes while traveling internationally. Males account for 65% to 75% of all injury deaths to US citizens. Acquaintance rape and sexual assault are among the important risks to women travelers. Travelers should be aware of the increased risk of certain injuries while traveling abroad, particularly in low-income countries, and be prepared to take preventive steps to avoid them.

Road Traffic Injuries

Road traffic injuries are the leading cause of injury-related deaths worldwide. An estimated 3,000 people are killed each day in road traffic crashes involving cars, buses, motorcycles, bicycles, trucks or pedestrians. Each year, another 20 to 50 million people are seriously injured. In 2000, more than 1 million traffic-related deaths occurred in low-and middle-income countries, and that number is likely to double by 2020.

According to U.S. State Department data, road traffic crashes are also the leading cause of injury death in U.S. citizens while traveling internationally. An estimated 768 Americans were killed in road traffic crashes from 2003 to 2005. Approximately 13% of these road traffic deaths involved motorcycles, and 7% were pedestrians. A study from Bermuda reported that tourists sustain a much higher rate of motorbike injuries than the local population, with the highest rate in persons age 50-59. Loss of vehicular control, unfamiliar equipment, and inexperience with motorized two-wheelers contributed to crashes and injuries, even for travel at speeds less than 30 mph. Road traffic crashes are also a leading cause of nonfatal injury among U.S. citizens requiring emergency transport back to the United States.

Road traffic crashes are common in foreign tourists for a number of reasons: lack of familiarity with the roads, driving on the opposite side of the road than in one's home country, lack of universal safety standards in vehicles, travel fatigue, poor road surfaces without shoulders, unprotected curves and cliffs, and poor visibility due to lack of adequate lighting, both on the road and on the vehicle. In many low-income areas of the world, unsafe roads and vehicles and an inadequate transportation infrastructure contribute to the traffic injury problem. A safety concern in low-income countries is the mixing of motor vehicles with vulnerable road users such as pedestrians, bicyclists, and motorbike users. In low-income countries, cars, buses, and large trucks commonly all share the same road with pedestrians, motorbikes, bicycles, rickshaws, and even animals. This mixing of road users all in the same travel lane increases the risk for crashes and injuries.

Prevention of Road Traffic Injuries

Health advisors should counsel the traveler to:

• Use safety belts and child safety seats whenever possible. Safety belts reduce the risk of death in a crash by 45 to 60%, child safety seats by 54% and infant seats by 70%. When traveling, rent newer vehicles with safety belts and airbags, and bring your own child safety seats and booster seats from home.
• Rent larger vehicles if possible, for greater protection in a crash.
• Ride only in marked taxis with functional safety belts, ride in the rear seat and consider offering the driver a bonus for driving in a manner you determine “safe.”
• Be alert when crossing streets, looking right, left, and then right again and pay close attention to the correct side of the road when driving in countries that drive on the left.
• Wear helmets when riding motorcycles, motorbikes, and bicycles. If helmets are not available at the destination, consider bringing one. Bike riders should bring their own helmets from home. Recognize that unless you ride motorcycles regularly, you will be a novice rider competing in traffic with much more experienced drivers and riders who are familiar with the terrain and the driving culture.
• Avoid excessive alcohol. Alcohol is a risk factor for injuries, especially for pedestrians, drivers, and passengers riding with drinking drivers. Travelers may have a more carefree attitude while away from home that predisposes them to driving under the influence of alcohol. Research in the United States has shown an alcohol-impaired driver has a 17 times greater risk of being involved in a fatal crash.
• Avoid riding in overcrowded, overweight, or top-heavy buses or minivans.
• Check with the Association for International Road Travel for useful safety information for international travelers, including road safety checklists and country-specific driving risks. (www.asirt.org)
• Check with the US State Department which has safety information useful to international travelers, including road safety and security, international driving permits, and insurance. (www.travel.state.gov)
• Check the World Report on Road Traffic Injury Prevention which contains a section on interventions directed to the road, the vehicle and the driver that may help travelers select appropriate prevention strategies.
• Consider hiring a driver familiar with the city and expert in maneuvering through local traffic.

Other Unintentional Injuries

During 2003-2005, drowning, airplane crashes, natural disasters, and other unintentional injuries accounted for over a third of all injury deaths to Americans in foreign countries. Drowning was the leading cause of injury death to Americans visiting countries where water recreation was a major activity, such as Fiji, Dutch Antilles, Aruba, and Costa Rica. Risks for drowning and prevention measures are covered in the Swimming and Recreational Water Safety section. Studies have found that young men are particularly at risk of head and spinal cord injuries from diving into shallow water, with alcohol being a factor in some cases.

Fires can be a substantial risk in low-income countries, where building codes are not present or enforced, emergency access via 9-1-1 equivalent does not exist, and where fire departments are only involved in fire suppression (not fire prevention or victim rescue).

Travel by local commercial air carriers in many countries carries greater risk than appreciated. During 2003-2005, an estimated 83 Americans were killed in airplane crashes in foreign countries. Travel on unscheduled flights, in small aircraft, at night, in inclement weather, and with pilots who have limited flying hours carries the highest risk.

Prevention of Other Unintentional Injuries

• Injuries account for a substantial proportion of evacuations of tourists from low-income countries. Travelers should consider purchasing special health and evacuation insurance if their destinations include countries where there may not be access to good medical care.
• Because trauma care is poor in many countries, victims of injuries can die before reaching a hospital, and there may be no coordinated ambulance services. In remote areas, medical assistance, drugs, and medicines may be unavailable, and travel to the nearest medical facility can take a long time.
• Adventure travel activities, such as mountain climbing, whitewater rafting, and kayaking in low-income countries, are popular with Americans. Because quality emergency trauma care is lacking in many countries, travelers should consider this when planning the difficulty of their adventures.
• Travelers should avoid using local unscheduled small aircraft. Larger aircraft (greater than 30 seats), have usually undergone more strict and regular safety inspections and may provide more protection in the event of a crash. For country-specific airline crash events see www.airsafe.com.
• To prevent fire-related injuries, travelers should select accommodations on the 6th floor or below (fire ladders generally cannot reach above the 6th floor). If possible, hotels should be chosen that have smoke alarms and sprinkler systems. Improperly vented heating devices may cause poisoning from carbon monoxide (CO), a colorless, odorless gas and by-product of all fossil fuel combustions. Travelers should identify two escape routes from buildings and remember to escape a fire by crawling low under smoke, and covering the mouth with a wet cloth.

Violence-Related Injuries

Violence is a leading worldwide public health problem and a growing concern of travelers. In 2000, about 1.6 million persons lost their lives to violence and only 20% were casualties of armed conflicts. Rates of violent deaths in low- to middle-income countries are more than 3 times those in higher-income countries, although there are great variations within countries, depending on regional demographic differences.

Homicide was the second leading cause of injury death among American travelers in foreign countries, accounting for almost 400 deaths during 2003-2005. For some low-income countries, such as Honduras, Colombia, Guatemala, and Haiti, homicide was the leading cause of injury death for Americans, accounting for 43% to 65% of all injury deaths.

Terrorism-related deaths among U.S. citizens in foreign countries, while alarming, are still relatively rare events and accounted for only 2% of all injury deaths. The vast majority of terrorism deaths among Americans occurred in countries of the Middle East. According to data for 2003-2005 from the State Department, 82% of the injury deaths among Americans in Saudi Arabia and 55% of injury deaths in Israel/West Bank/Gaza were from terrorism.

Suicide is the fourth leading cause of injury death to U.S. citizens traveling abroad. Factors contributing to homicide and suicide may be different while traveling than at home. Unfamiliarity with a destination, not being vigilant to one's surroundings, and alcohol involvement may increase risk of assault and homicide. For longer-term travelers (e.g., missionaries and volunteers), social isolation and substance abuse, particularly in the face of poverty and rigid gender roles, may increase the risk of depression and suicide.

Prevention of Violence-Related Injuries

U.S. travelers are viewed by many criminals as wealthy, naïve targets, who are inexperienced and unfamiliar with the culture and inept at seeking assistance once victimized. Traveling in high poverty areas, those with civil unrest, or in unfamiliar environments at night, increase the likelihood that a U.S. traveler will be the victim of planned or random violence. Drug or alcohol use will also increase the risk.

To avoid violence travelers should limit travel at night, travel with a companion, and vary routine travel habits. They should wear locally available accessories that would associate you with the country-savvy expatriate community, and avoid expensive or provocative clothing or accessories. Avoiding accommodations on the ground floor of hotels and immediately next to the stairs as well as locking all doors and windows are helpful as well. Criminals are less likely to victimize upper-level floors. Travelers can carry a portable door intruder alarm, a smoke alarm, and a rubber door stop that can be used as a supplemental door lock. If confronted, travelers should not resist attackers, but rather give up their car and all valuables.

Other Injury Prevention Tips

The U.S. State Department maintains a website that features a section on International Travel both for tourists and business travelers, which covers current country-specific travel warnings, emergencies, physical security, safety tips, crisis awareness and preparedness, consular information, and special services. When traveling to countries with developing economies or through regions with the potential for geopolitical instability, travelers should check with the State Department or the country's US Embassy for Country-Specific Travel Warnings. These advisories are updated regularly. The State Department issues Consular Information Sheets for every country of the world that include information such as crime, areas of instability, and location of the nearest embassy or consulate in the subject country. Public announcements are used to disseminate information quickly about terrorist threats and other relatively short-term conditions that pose significant risks or disruptions to Americans overseas.

Summary

Injuries and violence are as much a public health problem to travelers overseas as are infectious and chronic diseases, and they are in many ways more deadly. Effective prevention strategies are available, particularly for travelers who find themselves in new environments and who may be more likely to be unaware of risks or complacent in exotic surroundings. Despite greater understanding and increased research efforts in this field, data on the magnitude and severity of injuries are still incomplete or unreliable in many countries. Travel health advisors and other health-care providers should alert the public to the known risks and especially about simple and effective preventive measures to implement during international travel.

SEEKING HEALTH CARE ABROAD

Preparation

In addition to ensuring that all necessary travel documents are complete before departure, travelers should learn what medical services their health insurance will cover overseas, as well as any policy exclusions. While some major health insurance carriers in the United States may provide coverage for emergencies that occur while traveling, most do not cover medical expenses due to exacerbations of pre-existing medical conditions while abroad. It is also important to know the insurance company's policy for “out-of-network” services, pre-authorization requirements, and need for a second opinion before obtaining treatment. Travelers should carry claim forms and a copy of their insurance policy card, if their insurance policy does provide coverage abroad. The Social Security Medicare program does not provide coverage for medical costs outside the United States, except under very limited circumstances; some Medigap plans available to people enrolled in the original Medicare plan provide limited coverage for emergency care abroad. Furthermore, very few health insurance companies cover the cost of medical evacuation, which can vary widely, ranging from a few thousand dollars to over $100,000, depending on the circumstances. Travelers who will be outside the United States for an extended period of time, who have underlying illnesses, or who are participating in activities involving greater risk for injury are encouraged to consider purchasing a supplemental health insurance policy that provides guaranteed medical payments, assistance via a 24-hour physician-backed support center, and emergency medical transport, including repatriation. A list of travel insurance and medical evacuation companies is available at the U.S. Department of State website at www.travel.state.gov. A brief list of additional assistance companies is also included below; this list is not all-inclusive.

International SOS: http://www.internationalsos.com. International SOS offers comprehensive 24-hour physician-backed medical and security assistance, for which members pay a fee. Membership provides access to on-line services, including medical and safety travel advisories, pre-travel itinerary-based recommendations, and computerized medical records. Insurance policies include medical evacuation and repatriation coverage, access to international clinics that provide primary care, diagnostic, and emergency services, and voluntary patient support programs to assist with medication compliance while abroad.

MEDEX: http://www.medexassist.com. MEDEX travel assistance services include 24-hour access to coordinators who can help locate appropriate medical care providers, coordinate direct payment of covered medical expenses, and assist in other medical, legal or travel situations. Insurance policies include medical evacuation and repatriation services, emergency dental coverage, and assistance with replacement of medications. For an additional fee, subscribers also have access to itinerary-based destination reports, which cover practical topics from local transportation and cultural norms to medical and security alerts.

International Association for Medical Assistance to Travelers: http://www.iamat.org. IAMAT is a nonprofit organization established to provide medical information to travelers and to make competent medical care available to them worldwide. IAMAT maintains an international network of physicians, hospitals, and clinics who have agreed to treat IAMAT members in need of medical care while abroad. Membership is free, although a donation to support IAMAT efforts is appreciated. Members receive a directory of participating physicians and medical centers and have access to a variety of travel-related informational brochures.

Travelers with underlying medical conditions also should consider choosing a medical assistance company that allows them to store their medical history before departure, so it can be accessed worldwide if needed. Alternatively, they may carry a letter from their physician listing underlying medical conditions and current medications (including their generic names). Travel insurance companies differ in their policies with regard to coverage for exacerbations of underlying medical conditions. Travelers are encouraged to research this carefully and understand the fine print.

Illness Abroad

If an American citizen becomes seriously ill or is injured abroad, a U.S. consular officer can assist in locating appropriate medical services and notifying friends, family, or employer. Additional resources include the clinic where the traveler received pre-travel health advice and immunizations, embassies and consulates of other countries, hotel doctors, credit-card companies, and multinational corporations, which may offer health-care services for their employees. For informational purposes, Travel Health Online (https://www.tripprep.com) provides a list of travel medicine providers from around the world. Wherever they are posted, lists of providers are obtained from a variety of sources, and the quality of services and the expertise of the providers are not guaranteed. The Inter-national Society of Travel Medicine and the American Society of Tropical Medicine and Hygiene also have directories of travel clinics available at their websites (www.istm.org and www.astmh.org, respectively). Although many of these clinics may only provide pre-travel services, some are located outside the United States and can see ill travelers.

The quality of health care from overseas medical centers can be variable, particularly in developing countries. Some foreign hospitals may have out-of-date facilities, while others have highly sophisticated diagnostic and therapeutic equipment similar to that found in the United States. Joint Commission International (JCI) is a division of Joint Commission Resources (JCR), a subsidiary of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which accredits hospitals in the U.S. JCI helps to improve the quality of patient care in more than 60 countries. Since 1998, 93 health-care facilities have been accredited by JCI in Europe, Africa, Asia, the Middle East, and the Americas. In 2005, WHO designated JCAHO and JCI as the world's first WHO collaborating center dedicated solely to patient safety (5). A list of accredited international health-care facilities is available at the JCI website: http://www.jcrinc.com. Physicians, hospitals, and most entities in other countries usually require payment in cash or credit card for services rendered rather than bill an insurance company. Travelers with health insurance coverage should carry their insurance card and claim forms, and they should obtain copies of all bills and receipts. If one needs financial assistance, the U.S. consular office can assist with transferring funds from the United States. In extreme circumstances, they may even be able to approve small government loans until private funds are available (7). Travelers must be aware, however, that they are responsible for paying all medical expenses they incur while abroad, including evacuation expenses.

In many developing countries, virtually any drug, including antibiotics and anti-malarial medications, can be purchased without prescription. Travelers should be advised, however, not to buy these medications unless they are familiar with the products. The quality of these drugs may not meet U.S. standards, and they may even be counterfeit or potentially hazardous because of contaminants. In addition, travelers requiring an injection overseas should consider bringing their own injection equipment. At the very least, they should ask if the injection equipment is disposable and insist, if possible, that a new needle and syringe be used.

Blood Transfusions

A blood transfusion can be a life-saving intervention when the blood supply has been appropriately screened and managed. For travelers, transfusion should be required only in rare and unexpected situations of massive hemorrhage, such as severe trauma, gynecologic and obstetric emergency, or gastrointestinal bleeding. Not all developing countries have accurate, reliable, and systematic screening of all blood donations for infectious agents such as malaria, HIV, and hepatitis viruses, which can result in transfusion-related transmission of these infections. According to WHO, more than 70 countries reported to the Global Database on Blood Safety that, during a 12-month period in 2000-2001, they did not test all donated blood for all the major infectious agents transmissible by transfusion, i.e., HIV, hepatitis B and C viruses, and Treponema pallidum (the etiologic agent of syphilis); 66 countries did not have nationally coordinated blood transfusion services or were unable to provide complete national data; and 39 countries reported that, because of interruptions to supplies of test kits, blood was released for clinical use without testing for transfusion-transmissible infections. Additionally, transfusion reactions can occur if the blood products are not adequately characterized for compatibility with the recipient before transfusion. Because of these inherent risks, transfusion should be prescribed only for conditions for which there is no other treatment. People who travel frequently to, or who spend a prolonged period of time in, developing countries, and those whose activities put them at higher risk for serious injury should consider being immunized against hepatitis B virus. When blood transfusion cannot be avoided, travelers should make every effort to ensure that the blood has been screened for transmissible diseases, including HIV. In many cases, resuscitation can be achieved by use of colloid or crystalloid plasma expanders instead of blood. Once stabilized, travelers should consider urgent evacuation for additional management

In the past, travelers planning international itineraries have requested to have their own blood or blood from their home country available to them in case of urgent need. There are no medical indications for travelers to take blood with them from their home countries. The international shipment of blood for transfusion is practical only when handled by agreement between two responsible organizations, such as national blood transfusion services. This mechanism is not useful for the emergency needs of individual travelers and should not be attempted by private travelers or organizations not operating recognized blood programs. The limited storage period of blood and the need for special equipment negate the feasibility of independent blood banking for individual travelers or small groups. Travelers should, however, carry a medical card or other document, showing their blood group and information about any current medical problems or treatment.

Health-Seeking Travel

Traveling abroad for the purpose of improving one's physical, mental, and spiritual well-being is increasing in popularity. Such “health tourism” includes, but is not limited to, traveling for alternative therapies, such as balneotherapy (treatment by baths) and thalassotherapy (treatment based on the use of sea water), religious pilgrimages, and modern medical treatments, including elective surgery.

Therapies that are considered “natural” are not without hazards. Mineral and “holy” waters may not be potable by U.S. standards and have been sources of infectious diseases. Moreover, pilgrims are subject to the same destination-associated risks as other travelers (e.g., heat and altitude-associated illnesses), but many may be traveling in ill-health. Outbreaks of meningitis due to Neisseria meningitidis have occurred in Hajj pilgrims, leading to the requirement that all pilgrims participating in the Hajj be immunized before their departure. With the shift in the timing of the Hajj to winter months, pilgrims may also be at increased risk for respiratory tract infections, such as influenza and a de no virus.

Medical tourism, traveling to another country for medical, dental, or surgical care, is a rapidly growing industry. Traditionally, people who could afford to do so traveled from lower-income counties to more developed countries in order to seek care not available in their home country. In recent years, however, people from higher-income countries have started traveling to lower income countries in seek of lower medical costs and shorter waiting times, Companies offering vacation packages bundled with medical consultations and financing options provide direct-to-consumer advertising over the internet. Enter “medical tourism” into any internet search engine and one will find a variety of tourism packages from travel agencies and health-care facilities worldwide. Recognizing the potential revenue to be gained through medical tourism, countries such as India, Thailand, Costa Rica, Turkey, and others have promotional campaigns to attract tourists seeking traditional and alternative therapies. Such medical packages often claim to provide high-quality care, but as mentioned above, the quality of health care in developing countries is highly variable, and only a handful of international health-care facilities are accredited by the Joint Commission International.

For the most part, medical insurance companies do not pay for medical procedures performed abroad, although some health insurance providers in the U.S, recognizing the cost benefits, allow policy holders to seek care in Mexico. Another problem with medical tourism is that there is little follow-up care. The patient usually is in the hospital for only a few days and then returns home. Complications are then the responsibility of the health-care system in the traveler's home country. For example, CDC received a number of reports of nontuberculous mycobacterial infections after elective cosmetic surgery abroad. In addition to these postoperative complications, procedures that result in significant blood loss and require transfusion subject the traveler to greater risk for blood-related complications, including compatibility errors and infection with hepatitis viruses or HIV. Finally, countries that offer medical tourism may have weaker malpractice laws than those in the U.S, giving the patient little recourse to local courts or medical boards if something goes wrong.

“Transplant Tourism,” a special type of medical tourism, has been increasing as the number of available organs, especially kidneys, is decreasing relative to the increasing demand. A number of international transplantation rings have been discovered, in which people from developing countries are paid for donating organs. This practice is considered legal in only a few countries. Recently the World Health Assembly met to discuss the challenges of transplantation and to address international transplantation guidelines. It encouraged countries to protect those most vulnerable to such exploitation, but there is still no international consensus on incentives for organ donation. In June 2006, the Organ Procurement and Transplantation Network (OPTN) and the United Network for Organ Sharing (UNOS) Board of Directors unanimously approved a statement opposing transplant tourism.

Regardless of the reason, people seeking health care abroad should understand that medical systems outside the United States may operate differently from those in the United States and are not subject to the same rules and regulations. Those who are considering seeking health care outside the United States should consult with their local physician before traveling.

THE POST-TRAVEL PERIOD

Many illnesses resulting from a particular exposure during travel may manifest clinically during travel, while others become clinically apparent after travelers have returned home (1-4). Some diseases present immediately after the traveler returns, while others may become evident weeks, months, or even years later. Therefore, obtaining a travel history is crucial when evaluating any ill patient and it is particularly important to obtain an exact itinerary and details of pre-travel preparation, whether chemoprophylaxis was taken, and what exposures the traveler encountered during the trip.

Risk for Travelers

The likelihood of a travel-related illness developing relates to the person's specific travel destination, duration of travel, level of accommodation, underlying medical condition, immunization history, adherence to indicated chemo-prophylactic regimens, and especially his or her history of exposure to potential infectious agents during travel. Eliciting a detailed history of the specific locales visited, the timing of travel relative to the onset of symptoms, and specific risk behaviors is essential in determining potential exposure to infectious pathogens and the likely incubation period. Particular groups of travelers are considered at higher risk of developing illness after returning to their place of residence. Adventure travelers and persons visiting friends and relatives overseas are at greater risk for becoming ill, in part because of increased exposure to pathogens. Travelers visiting friends and relatives are often also less likely to seek pretravel advice, obtain vaccinations or take antimalarial prophylaxis.

Clinical Presentation

Most travelers infected abroad become ill within 12 weeks after returning to the United States. However, some diseases, such as malaria, may not cause symptoms for as long as 6-12 months or more after exposure. If travelers become ill after they return home, even many months after travel, they should be advised to tell their physician where they have traveled. In particular, fever in a traveler returned from a malarious area should be considered a medical emergency. The possibility of malaria as a cause of the fever should be evaluated urgently by appropriate laboratory tests and qualified personnel, and testing should be repeated if the initial result is negative. In this regard, primary care physicians, general medicine practitioners, pediatricians, emergency medicine physicians and every health-care worker dealing with a febrile returned traveler from a malaria-endemic area should take the steps to ensure the patient has serial blood smears evaluated and consider hospitalization if there is any need for observation.

In evaluating patients seeking medical care, it is essential to obtain a detailed history of exposures such as insect bites, swimming in freshwater, animal bites, eating raw meat, seafood, or unpasteurized dairy products, and sexual contacts. Answers to these questions may provide important clues for diagnosis of a particular illness or syndrome in returned travelers. In addition, when suspecting an infectious disease, calculating an approximate incubation period is a useful step in ruling out possible etiologies. For example, fever beginning 3 weeks or longer after return greatly reduces the probability of dengue, rickettsial infections, and viral hemorrhagic fevers in the differential diagnosis. This important step helps focus the differential diagnosis on probable causative agents and eliminates unlikely considerations. As indicated by exposure history, time course of illness, and associated signs and symptoms, initial investigations for febrile travelers may include prompt evaluation of peripheral blood for Plasmodium species; a complete blood cell count with differential; liver enzymes; urinalysis; culture of blood, stool, and urine; and chest radiography. More specific diagnostic assays may be useful initially for diseases such as leptospirosis (serology) and acute HIV infection (RNA viral load). However, sometimes acute-and convalescent-phase serologies are required to confirm a particular diagnosis such as many rickettsial infections.

Since most primary-care physicians have little expertise in tropical diseases, a newly returned, ill international traveler should be evaluated by an infectious disease or tropical medicine practitioner. For assistance in finding a provider who practices clinical tropical medicine, one may access the American Society of Tropical Medicine website for a listing by state at http://www.astmh.org or the International Society of Travel Medicine at http://www.istm.org.

It may be prudent for asymptomatic international travelers who have been abroad for many months or longer, particularly in developing countries, to be screened for certain diseases. The decision to screen for particular pathogens will depend on the travel and exposure history. For example, travelers who have engaged in casual unprotected sex or have received an injection, a body piercing, or a tattoo may be screened for HIV, hepatitis C and other sexually transmitted diseases, and, if not immune, hepatitis B. Sometimes, testing for hepatitis C RNA viral load or HIV RNA viral load is recommended for travelers with high-risk factors presenting with a febrile illness. In addition, performing a tuberculin skin test to identify conversion in those travelers who were previously tuberculin negative is recommended, particularly after a prolonged stay in a developing country. Travelers who have been exposed to freshwater in areas endemic for schistosomiasis should be screened for this infection by serology and stool and/or urine tests. Eosinophilia in a returned traveler suggests the possibility of a helminth infection, of which the most important is strongyloidiasis. If left untreated, this infection may last for the lifetime of the host, and in an immuno-compromised person it has the potential to disseminate.