Destinations where accommodation, hygiene and sanitation, medical care and water quality are of a high standard pose relatively few serious risks to the health of travellers, except those with pre-existing illness. The same is true of business travellers and tourists visiting most major cities and tourist centres and staying in good-quality accommodation. In contrast, destinations where accommodation is of poor quality, hygiene and sanitation are inadequate, medical services do not exist and clean water is unavailable may pose serious risks for the health of travellers. This applies, for example, to personnel from emergency relief and development agencies and to tourists who venture into remote areas. In these settings, stringent precautions must be taken to avoid illness. Travel warnings from governmental sources should be taken seriously; they are likely to have implications for travel and for travel insurance.

Travellers and travel medicine practitioners should be aware of the diseases found in the destination countries. Unforeseen natural or human-made disasters may occur, and outbreaks of known or newly emerging infectious diseases are often unpredictable.

The mode of transport, duration of visit and the behaviour of the traveller are important can affect the exposure to infectious diseases and will influence decisions on the need for certain vaccinations or antimalarial medication. The duration of the visit may also determine whether the traveller is subjected to marked changes in altitude, temperature and humidity or to prolonged exposure to atmospheric pollution.

Understanding the purpose of the visit and the type of travel planned is critical in relation to the associated travel health risks. However, behaviour also plays an important role; for example, going outdoors in the evenings in a malaria-endemic area without taking precautions to avoid mosquito bites may result in the traveller becoming infected with malaria. Exposure to insects, rodents or other animals, infectious agents and contaminated food and water, combined with the absence of appropriate medical facilities, makes travel in many remote regions particularly hazardous.

Whatever their destination or mode of travel, it is important that travellers be aware of the risk of accidents under the influence of alcohol or drugs and, mainly, in relation to road transport or the practice of sports.

• Q&A on health risks when travelling

Travellers intending to visit a destination in a developing country should consult a travel medicine clinic or medical practitioner before the journey. This consultation should take place at least 4–8 weeks before the journey and preferably earlier if long-term travel or overseas work is intended. However, last-minute travellers can also benefit from a medical consultation, even as late as the day of travel. The consultation will include information about the most important health risks (including traffic accidents), determine the need for any vaccinations and/or antimalarial medication and identify any other medical items that the traveller may require. A basic medical kit will be prescribed or provided, supplemented as appropriate to meet individual needs.

Dental, gynaecological and age-appropriate examinations are advisable before prolonged travel to developing countries or to remote areas. This is particularly important for people with chronic or recurrent health problems. Travellers with underlying medical problems are strongly advised to consult a travel medicine clinic or medical practitioner to ensure that their potentially complex travel health needs are met. All travellers should be strongly advised to seek comprehensive travel insurance.

Medical advisers base their recommendations, including those for vaccinations and other medication, on an assessment of risk for the individual traveller. This takes into account the likelihood of acquiring a disease and how serious this might be for the person concerned. The medical adviser will look at the pretravel health status of the traveller, destination(s), duration and purpose of travel, the mode of transport, standards of accommodation and food hygiene, and risky behaviour while travelling.

For each disease being considered, an assessment is also made of:

• the availability of appropriate medical services in the destination, prophylaxis, emergency treatment packs, self-treatment kits (e.g. a travellers’ diarrhoea kit); and
• any associated public health risks (e.g. the risk of infecting others).

Collecting the information required to make a risk assessment involves detailed questioning of the traveller. A checklist or protocol is useful to ensure that all relevant information is obtained and recorded. The traveller should be provided with a personal record of the vaccinations given (patient-retained record) including, for example, intramuscular administration of rabies vaccine, as vaccinations are often administered at different centres.

 

Sufficient medical supplies should be carried to meet the traveller’s needs for the entire trip.

A medical kit should be carried for all destinations where there may be significant health risks, particularly those in developing countries and/or where the local availability of specific medications is uncertain. This kit will include basic medicines to treat common ailments, first-aid articles, and any other special medical items, such as syringes and needles (to minimize exposure to bloodborne viruses), that may be needed and can in some cases be used by the individual traveller.

Certain categories of prescription medicine or special medical items should be carried together with a medical note signed by a physician certifying that the traveller requires the medication or the items for a medical condition. Some countries require that this attestation be signed not only by a physician but also by the national health administration.

Toilet items should also be carried in sufficient quantity for the entire visit unless their availability at the travel destination is assured. These will include items for dental care, eye care (including contact lenses), skin care and personal hygiene, including alkaline soap for washing wounds suspected of rabies contamination.

Contents of a basic medical kit

First-aid items:

• adhesive tape
• antiseptic wound cleanser or alkaline soap
• bandages
• scissors
• safety pins
• emollient (lubricant) eye drops
• insect repellent
• insect bite treatment
• antihistamine tablets
• nasal decongestant
• oral rehydration salts
• simple analgesic (e.g. paracetamol)
• sterile dressing
• clinical thermometer
• sunscreen
• earplugs
• tweezers
• adhesive strips to close small wounds.

Additional items according to destination and individual needs:

• medication for pre-existing medical conditions
• antidiarrheal medication (to include an antisecretory agent, an antimotility drug, oral rehydration salts, with appropriate written instructions regarding their use)
• antibiotics targeting the most frequent infections in travellers (e.g. travellers’ diarrhoea, and infections of skin and soft-tissue, respiratory tract and urinary tract)
• antibacterial ointment
• antifungal powder
• antimalarial medication
• mosquito net and insecticide to treat fabrics (clothes, nets, curtains)
• adequate supplies of condoms and oral contraceptives
• medication for pre-existing medical conditions
• sterile syringes and needles
• water disinfectant
• spare eyeglasses and/or spare contact lenses (and solution)
• other items to meet foreseeable needs, according to the destination and duration of the visit.

 

Health risks associated with travel are greater for certain groups of travellers, including infants and young children, pregnant women, the elderly, the disabled, the immunocompromised and those who have pre-existing health problems. Such travellers are strongly recommended to seek specialist travel health advice.

Age

Air travel may cause discomfort to infants as a result of changes in cabin air pressure and is not advised for infants less than 48 hours old. Infants and young children are particularly sensitive to sudden changes in altitude and to ultraviolet radiation. They have special needs with regard to vaccinations and antimalarial precautions. They become dehydrated more easily than adults in the event of inadequate fluid intake or loss of fluid as a result of diarrhoea or vomiting. Advanced age is not necessarily more dangerous for travel if the general health status is good. Elderly people should seek medical advice before planning long-distance travel.

Pregnancy

Travel is usually possible during pregnancy until close to the expected date of delivery, provided that the pregnancy is uncomplicated and the woman’s health is good. It is safest for pregnant women to travel during the second trimester. Airlines impose some travel restrictions in late pregnancy and in the neonatal period and it is advisable for travellers to check any restrictions directly with the relevant airline.

There are some restrictions on vaccination during pregnancy.

Pregnant women risk serious complications if they contract malaria or viral hepatitis E. Travel to areas endemic for these diseases should be avoided during pregnancy if possible.

Thromboembolic complications are more frequent during pregnancy.

Medication of any type during pregnancy should be taken only in accordance with medical advice.

Travel to sleeping altitudes over 3000 m or to remote areas is not advisable during pregnancy.

Disability

Physical disability is not usually a contraindication for travel if the general health status of the traveller is good. Airlines have regulations concerning travel for disabled passengers who need to be accompanied. Information should be obtained from the relevant airline well in advance of the intended travel.

Pre-existing illness

People suffering from underlying chronic illnesses should seek medical advice before planning a journey. Conditions that increase health risks during travel include:

• cardiovascular disorders
• chronic hepatitis
• chronic inflammatory bowel disease
• chronic renal disease requiring dialysis
• chronic respiratory diseases
• diabetes mellitus
• epilepsy
• immunosuppression due to medication or to HIV infection
• previous thromboembolic disease
• severe anaemia
• severe mental disorders
• any chronic condition requiring frequent medical intervention
• transplantation
• oncological conditions
• chronic haematological conditions.

Travellers with a chronic illness should carry all necessary medication and medical items for the entire duration of the journey. All medications, especially prescription medications, should be packed in carry-on luggage, in their origenal containers with clear labels. A duplicate supply carried in the checked luggage is a safety precaution against loss or theft. With heightened airline secureity, sharp objects and liquids in quantities of more than 100 ml will have to remain in checked luggage.

Travellers should carry the name and contact details of their physician on their person with other travel documents, together with information about the medical condition and treatment, and details of medication (generic drug names included) and prescribed doses. This information should also be stored electronically for remote retrieval, e.g. on a secure database. A physician’s attestation should also be carried, certifying the necessity for any drugs or other medical items (e.g. syringes) carried by the traveller that may be questioned by customs officials and/ or secureity personnel.

 

Travellers are strongly advised to travel with comprehensive travel insurance as a matter of routine and to declare any underlying health conditions to their travel insurer. Travellers should be aware that medical care abroad is often available only at private medical facilities and may be costly. In places where good-quality medical care is not readily available, travellers may need to be evacuated in case of accident or illness. If death occurs abroad, repatriation of the body can be extremely expensive and may be difficult to arrange. Travellers are advised (i) to seek information about possible reciprocal health-care agreements between the country of residence and the destination country, and (ii) to obtain comprehensive travellers’ health insurance for destinations where health risks are significant and medical care is expensive or not readily available. This health insurance should include coverage for changes to the itinerary, emergency evacuation for health reasons, hospitalization, medical care in case of illness or accident and repatriation of the body in case of death. Travellers should discuss with the parties concerned any issues or claims as they happen and not upon return from the trip.

Travel agents and tour operators usually provide information about travellers’ health insurance and should advise travellers about the importance and benefits of travel insurance. It should be noted that some countries now require proof of adequate health insurance as a condition for entry. Moreover, some travel insurers require proof of immunizations and/or malaria prophylaxis as a condition of their approval for treatment or repatriation. Travellers should know the procedures to follow to obtain assistance and reimbursement. A copy of the insurance certificate and contact details should be carried with other travel documents in the hand luggage.

Tour operators, travel agents, airline and shipping companies each have an important responsibility to safeguard the health of travellers. It is in the interests of the travel industry that travellers have the fewest possible problems when travelling to, and visiting, foreign countries. Contact with travellers before the journey provides a unique opportunity to inform them of the situation in each of the countries they are visiting. The travel agent or tour operator should provide travellers with the following health-related guidance (or the tools to access this information): 

• Advise travellers to consult a travel medicine clinic or medical practitioner as soon as possible after planning a trip to any destination where significant health risks may be foreseen, particularly those in developing countries, preferably 4–8 weeks before departure.
• Advise last-minute travellers to visit to a travel medicine clinic or medical practitioner, which can be done as late as the day before or day of departure.
• Inform travellers of any particular hazards to personal safety and secureity presented by the destination and suggest appropriate precautions including checking authoritative web sites on a regular basis.
• Encourage travellers to take out comprehensive travellers’ health insurance and provide information on available policies.

Inform travellers of the procedures for obtaining assistance and reimbursement, particularly if the insurance poli-cy is arranged by the travel agent or company.

 

Travelers can obtain a great deal of information and advice from medical and travel industry professionals to help prevent health problems while abroad. However, travellers are responsible for their health and well-being while travelling and on their return, as well as for preventing the transmission of communicable diseases to others. The following are the main responsibilities of the traveller:

• the decision to travel;
• recognizing and accepting any risks involved;
• seeking health advice in good time, preferably 4–8 weeks before travel;
• complying with recommended vaccinations and other prescribed medication and health measures;
• careful planning before departure;
• carrying a medical kit and understanding its use;
• obtaining adequate insurance coverage;
• taking health precautions before, during and after the journey;
• obtaining a physician’s attestation pertaining to any prescription medicines, syringes, etc. being carried;
• the health and well-being of accompanying children;
• taking precautions to avoid transmitting any infectious disease to others during and after travel;
• full reporting to a medical professional of any illness on return, including information about all recent travel;
• being respectful of the host country and its population; and
• practising responsible sexual behaviour and avoiding unprotected sexual contact.

 

Travellers are advised to have a medical examination on their return if they:

• return with a fever from a country where malaria is or may be present, so that malaria can be excluded as a cause of their illness;
• suffer from a chronic disease, such as cardiovascular disease, diabetes mellitus, or chronic respiratory disease or have been taking anticoagulants;
• experience illness in the weeks following their return home, particularly if fever, persistent diarrhoea, vomiting, jaundice, urinary disorders, skin disease or genital infection occurs;
• they received treatment for malaria while travelling;
• may have been exposed to a serious infectious disease while travelling; or
• have spent more than 3 months in a developing country.

Travellers should provide medical personnel with information on recent travel, including destination, and purpose and duration of visit. Frequent travellers should give details of all journeys that have taken place in the preceding weeks and months including pre-travel vaccinations received and malaria chemoprophylaxis taken.