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Get Help with a Medical Emergency Abroad

If you or a U.S. citizen loved one become seriously ill or injured abroad, we can:

• Help locate appropriate medical services.
• Inform your family or friends, with your permission.
• Help  transfer funds  to U.S. citizens overseas.

The U.S. government does not pay overseas medical bills. The patient must pay all hospital and other expenses.

You can find lists of doctors and hospitals in the country you are visiting. Check the  website of the U.S. embassy in the country you are visiting. 

Check Your Health Insurance – Are You Covered Abroad?

Understand what medical services your health insurance will cover overseas before traveling. Carry your insurance card and a claim form if your policy covers you outside the United States. 

Medicare does not cover medical care when you travel the United States. Visit  Medicare.gov  for more information.

Some health insurance companies pay for “customary and reasonable” hospital costs abroad. Very few pay for your medical evacuation back to the United States. The cost may exceed $250,000, depending on your location and medical condition. Consider buying medical evacuation insurance. For more information, visit our webpage on Insurance Coverage Overseas . 

Traveling with Prescription Medications

• Check with the foreign embassy of the country you are visiting or passing through. Check to make sure your medications are allowed, particularly prescriptions for medical marijuana. You may need an import license or permit to travel with certain medications.
• Bring plenty of medicine for your trip. If possible, bring a few extra days’ worth in case of delays. You might not be able to get the same medication abroad.
• Carry a letter from the doctor. It should describe your medical condition. It should also list any prescription drugs and their generic names.
• Keep medications in their original, labeled containers.
• Entering a country with a prescription medication, even if legally obtained in the United States, could be illegal and result in your detention or arrest overseas.

Medical Tourism Abroad

Between 150,000 and 320,000 U.S. citizens travel abroad for medical care each year. Medical tourism includes cosmetic surgery, dentistry, and other surgical procedures. 

If you are a U.S. citizen considering travel abroad for medical care, you should:

• Verify the doctor’s training, qualifications, and reputation. 
• Visit the U.S. Centers for Disease Control and Prevention (CDC) Medical Tourism website for more information on medical tourism. 
• Check country information  for more information.

Inform Yourself About Vaccinations

Some Countries Require Vaccinations

Before you travel, check country information . You may need to carry an International Certificate of Vaccination, also called a Yellow Card. You may also need to show proof of other inoculations or medical tests. Check also current requirements directly with the foreign embassies of the countries you are visiting.

Recommended Vaccinations and Malaria Prevention

Check the  U.S. Centers for Disease Control (CDC)  and World Health Organization (WHO)  websites for recommended vaccinations and malaria prevention for your destination. Review the CDC’s webpage on Choosing a Drug to Prevent Malaria .

Travel Smartly with Prescription Medications

• Bring an ample supply of medication to cover you for your trip, and if possible, a few extra days in case there are delays.
• Carry a letter from the attending physician that describes your medical condition and any prescription medications, including the generic name of prescribed drugs.
• Check with the foreign embassy of the country you are visiting or transiting to make sure your medications are permitted in that country. Some countries require an import license or permit to travel with certain medications.

Being Prepared for a Pandemic

Review the  U.S. Centers for Disease Control and Prevention website for information about pandemics. In a pandemic, virus control measures could affect your travel:

• Travel restrictions may prevent U.S. citizens from traveling internationally.
• Foreign governments may close borders suddenly or with little advance warning.
• Commercial air, land, and sea carriers could suspend some or all transportation services.
• Some countries may quarantine people who appear sick or test positive with the virus.

These developments could delay your travel or your return to the United States.

Other Health Considerations Abroad

• Review the CDC’s Traveler Advice.
• Review Traveling With Disabilities .
• Review Considerations for Older Travelers .

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Health Guidelines for Travel Abroad

a CMO, SAC Health System, 250 South G Street, San Bernardino, CA 92410, USA

b Family Medicine Residency Program, Loma Linda University, 1200 California Street, Suite 240 Redlands, CA 92374, USA

Norman Benjamin Fredrick

c Family and Community Medicine and Public Health Sciences, Global Health Center, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA 17033, USA

Leesha Helm

d Department of Family Medicine, Pennsylvania State University College of Medicine, Penn State Health, PGY-3, 500 University Drive, Hershey, PA 17033, USA

Jeffrey Cho

Most travel medical care is provided by patients’ primary care physicians; only 10% of international travelers visit a travel clinic. The main purposes for travel include vacationing, visiting friends and family, business, and for educational purposes. The purposes of the pretravel consultation are to estimate risk and provide recommendations to mitigate risk.

• • Primary care providers manage the majority of travel medical care. The purpose of the pretravel visit are risk assessment and mitigation.
• • Encourage travelers to enroll in the Smart Traveler Enrollment Program for travel advisories.
• • The Centers for Disease Control and Prevention travel website offers destination-specific, point-of-care resources for clinicians and travelers.
• • Travelers who are visiting friends and relatives are a high-risk group.
• • The most common syndromes in returning travelers are gastrointestinal, febrile, and dermatologic.

Introduction

Most travel medical care is provided by patients’ primary care physicians; only 10% of international travelers visit a travel clinic. The main purposes for travel include vacationing, visiting friends and family, business, and for educational purposes.

Pretravel consultation

The purposes of the pretravel consultation are to estimate risk and provide recommendations to mitigate risk.

Traveler background

The initial pretravel assessment should focus on specific aspects regarding the health background of the traveler ( Box 1 ). A full history and physical examination, including a review of immunizations, allergies, medications, and chronic medical conditions should be explored. Special attention and tailored recommendations should be given to those with chronic disease states, including congestive heart failure, diabetes, mental health issues, and immunocompromised states. It is important to note recent hospitalizations and surgeries and to assess the risk associated with traveling after these events. Prior travel history may provide clues regarding intolerance to certain antimalarials or other medications.

Box 1

Risk assessment, medical history.

• • Medications
• • Allergies
• • Immunizations
• • Chronic disease states
• • Mental health
• • Hospitalizations
• • Surgeries
• • Pregnancy or breastfeeding
• • Previous travel
• • Previous use of antimalarials, antibiotics
• • Plans for repeat travel in next 1 to 2 years

Trip itinerary

• • Location
• • Dates and season
• • Activities, mass gatherings
• • Reasons for travel
• • Accommodations
• • Travel insurance

Trip specifics

Review the itinerary of the traveler, including types of travel, the reason for travel, and accommodations. Country-specific risks and travel advisories should be discussed in detail with the traveler by reviewing resources like the Smart Traveler Enrollment Program ( https://step.state.gov/ ) . By assessing these specific aspects, the provider can obtain a wealth of knowledge that can be synthesized to help the traveler manage possible risks.

Travel recommendations to reduce risk

Preparedness for exacerbations of chronic disease states.

Travel can be stressful and demanding for individuals with chronic disease states. Before travel, clinicians should direct travelers to recommendations provided by national associations related to their chronic medical states for travel guidelines. In addition, travelers should be directed to check in with the US embassy or consulate in their area of travel to clarify any restrictions on medications with which they may need to travel.

Travel Insurance and International Health Care

Many health insurances do not provide adequate coverage for international travel, including repatriation and medical evacuation. 1 The following resources can be used to help travelers make a decision regarding the need for travel insurance, travel health insurance, and medical evacuation insurance.

• • Department of State ( www.travel.state.gov )
• • International Association for Medical Assistance to Travelers ( www.iamat.org )

Accessing Local Reputable Medical Facilities

The International Association of Medical Assistance to Travelers maintains a list of clinics available to members: www.iamat.org/doctors_clinics.cfm . In addition, the Joint Commission International maintains a list of accredited, certified health care facilities: www.jointcommissioninternational.org .

Medications for chronic conditions and prevention of disease states specific to regions of travel should be procured before initiation of travel. Individuals with preexisting conditions or allergies should consider wearing a medical alert bracelet or card in their wallet. See Table 1 for a list of suggested travel health kit items.

Table 1

Health kit item checklist

Abbreviation: HIV, human immunodeficiency virus.

Providers should recommend travelers carry documentation of the following:

• • Health insurance, supplemental insurance,
• • Proof of vaccinations,
• • List of medications and preexisting conditions, and
• • Contact card with emergency contact, location of travel, hospitals and clinics, US embassy or consulate number, health care provider contact information.

Important Travel Risks

The World Health Organization has cited that, among deaths in travelers, 18% to 24% are caused by injuries, whereas only 2% are caused by infectious disease. 1

Motor vehicle safety

Among US travelers in foreign countries, motor vehicle accidents are the leading cause of death, making up approximately 27% of all nonnatural deaths in 1 study. 1  Contributing factors include lack of familiarity with infrastructure in the area of traveled, lack of seat belt use, alcohol use, travel fatigue, poor visibility, and increased risk for road-related accidents. 1 Prevention strategies include using seatbelts and child safety seats, avoiding night-time driving, increasing awareness of driving hazards, using helmets when driving motorcycles or motorbikes, avoiding alcohol or cellphone use before or during driving, using marked taxis for travel, avoiding travel in overcrowded buses, and remaining alert while crossing streets. 1

Drowning is the fourth leading cause of death of international US travelers. 1 Avoidance of swimming alone and the use of a life jacket with water-related activities should be encouraged. Swimming should be avoided when local water conditions or currents are unknown and if a traveler has recently used alcohol.

Crime and violence

Of nonnatural death causes in foreign travelers, 21% can be attributed to crime and violence. 1 Clinicians should encourage travelers to familiarize themselves with crime trends in the areas they are traveling to. Information can be accessed from the Overseas Security Advisory Council website ( www.osac.gov ) . Travelers can also familiarize themselves with security updates by accessing the Department of State’s Bureau of Consult Affairs recommendations for travel safety at http://travel.state.gov . Special precaution should be taken to protect against pickpocketing and individuals should attempt to keep money worn under clothing secured to the neck or waist. Travelers should limit traveling alone or at night time, keep all valuables secure, keep all doors and windows locked, use recommended safe modes of transportation, and avoid resistance if confronted in a robbery. The nearest US embassy should be contacted if concerns related to crime, violence, accidents, medical concerns, or specific travel questions arise.

Counterfeit, adulterated, or expired medications

Travelers should be educated about the risks of procuring medications while traveling including but not limited to medication side effects secondary to use of inappropriately compounded medications, counterfeit medications, and use of uncommon medication additives. 1 Clinicians should recommend obtaining all medications before travel to ensure that individuals are using authentic medications with known side effects and appropriate dosing.

Infections While Abroad

Immunizations.

Maintenance of an accurate immunization history is necessary to provide adequate protection for the traveler. Immunization records should be obtained and reviewed and, if unreliable, titers for measles, mumps, rubella, and hepatitis A should be obtained. Sufficient time should be taken before travel to ensure travel-specific vaccines can be administered and appropriate immunity achieved ( Table 2 ). The risks and benefits of immunizations should be discussed. In addition, vaccines with waning immunity should be addressed as well, especially in the case of immunocompromised travelers. Assessing return travel to similar areas with the next 1 to 2 years from the initial trip will help clinicians to assess the need for specific immunizations. Travelers should be given an updated immunization record to travel with. Country-specific recommendations for vaccines can be accessed by clinicians at the Centers for Disease Control and Prevention (CDC) travel website ( https://wwwnc.cdc.gov/travel ).

Table 2

Travel vaccines, including routine vaccines of high priority in travelers

Abbreviations: IM, intramuscularly; MPSV4, meningococcal polysaccharide vaccine.

Several important diseases are transmitted by mosquitos, of which malaria is among the most important. Most of the 1700 cases of malaria diagnosed in the United States annually are among returned travelers. 1 Box 2 outlines strategies for malaria prevention.

Box 2

Strategies to prevent malaria.

• Long-sleeved pants, shirts, and socks
• Permethrin-treated clothing
• Permethrin-treated bed nets
• Mosquito repellants (≥20% DEET)
• Chemoprophylaxis

From dawn to dusk, mosquitoes that transmit Dengue, Yellow Fever, Zika, and Chikungunya are active and bite whereas, from dusk to dawn, mosquitoes that carry malaria, West Nile, and Japanese encephalitis are active. Providers should review the CDC’s Malaria Maps, and Malaria Information by Country Table and take note of the special considerations mentioned on the drug selection guide: https://www.cdc.gov/malaria/travelers/drugs.html .

Antimalarials should always be purchased before travel, because in some countries drugs that are sold may be counterfeit. 1 Clinicians should also warn travelers that if symptoms of malaria occur, including flulike illness while traveling or after returning home, immediate medical attention should be sought. Antimalarials alone do not prevent transmission and should be used in conjunction with preventive measures, including repellants for skin and clothing in addition to appropriate clothing and mosquito netting. 1 , 6

Traveler’s diarrhea

Traveler’s diarrhea often occurs suddenly with loose, frequent stools in about 30% to 70% of travelers. 7 Poor food handling practices are thought to put travelers at highest risk for traveler’s diarrhea. Preventative measures include specific food and beverage selection, frequent handwashing, frequent use of alcohol-based hand sanitizers with greater than 60% alcohol content, and consideration of vaccination against typhoid and hepatitis A. 8 Table 3 contains recommendations for traveler’s diarrhea treatment based on severity.

Table 3

Treatment of traveler’s diarrhea based on severity

Respiratory illness

Respiratory illness occurs in 20% of returning travels, with upper respiratory infections being the most common respiratory illness. Risks include exposures in hotels, cruise ships, aircrafts and tour group. Individuals with comorbidities including asthma and chronic obstructive pulmonary disease are at higher risk for respiratory illnesses. 1 Prevention tips include minimizing contact with individuals with cough or congestive symptoms, frequent handwashing, and vaccination before travel. Viral etiologies such as rhinovirus, are more common causal agents, although coronaviruses (Middle East respiratory syndrome in the Arabian Peninsula) and avian influenza (Asia) should also be included in a clinician’s differential. 1 Viral causes can also put individuals at risk for superimposed bacterial infections.

Bloodborne illness

Travelers should be cautioned against obtaining tattoos and piercings in low-income areas of the world, because the risk of human immunodeficiency virus and hepatitis C transmission secondary to use of unclean needles is high in these areas. 1

Exposure to human immunodeficiency virus

Travelers should be cautioned about the risk of human immunodeficiency virus specifically associated with certain practices, including needle sharing, risky sexual behaviors, or exposure in a health care setting. In the case of health care workers or individuals who plan to be involved with high-risk behaviors, the physician should discuss having postexposure prophylaxis available to them in case of exposure. Preexposure prophylaxis can reduce the risk of human immunodeficiency virus infection by up to 70%. 1 Immediate attention by a physician should be sought out if concern for exposure arises to ensure appropriate counseling and the possible need for postexposure prophylaxis.

Sexual health

Travelers should be cautioned against high-risk sexual activities that may lead to the transmission of sexually transmitted infections, unwanted pregnancy, or bloodborne infections. Consistent contraceptive methods should be used in a traveler who does decide to be sexually active. Health care resources overseas should be provided for travelers, including reputable clinics to seek out if concerns for sexually transmitted infections and/or pregnancy arise.

Venous Thrombosis and Embolism

Travelers at increased risk for development of deep venous thrombosis who are traveling long distances should be advised to walk as often as possible, use appropriately fitted compression stockings that provide 15 to 30 mm Hg at the ankle, hydration, and to perform calf exercises as often as possible. The use of aspirin for deep venous thrombosis prevention is not recommended. 1

When traveling between time zones, travelers can often develop a mismatch between their natural 24-hour circadian rhythm and the time of day. When traveling through more than 3 time zones, sleep-related difficulty, mood changes, mental clarity, and gastrointestinal disturbance can occur with jet lag. During the pretravel assessment, the clinician can discuss this in detail with the traveler and set expectations. Changes to diet and physical activity, sunlight exposure, the use of melatonin and melatonin-receptor analogs, consideration of hypnotic medications with discussion of risks and benefits, and a combination of these therapies can be discussed with the traveler before initiation of travel. Avoidance of alcohol as a sleep aid should be discussed with travelers as well as encouraging hydration during the trip.

Special populations

Immunocompromised travelers.

According to the 2018 CDC Yellow Book, immunocompromised travelers make up 1% to 2% of travelers seen in US travel clinics. 1 The immunocompromised status may be due to a medical condition, medication, or treatment. Common examples are noted in Box 3 .

Box 3

Examples of immunocompromised travelers.

• Chronic oral steroids greater than or equal to 20 mg per day of prednisone or equivalent
• Posttransplant on medication
• Renal failure on dialysis
• Current or recent (<3 months) chemotherapy
• Chronic liver disease
• Human immunodeficiency virus infection with a CD4 count of less than 200
• Autoimmune diagnosis on biologics

Special points to remember for immunocompromised travelers:

• • Response to vaccines may be limited.
• • Live vaccines are contraindicated in severely immunosuppressed individuals.
• • Increased risk of foodborne and waterborne infections ( Salmonella , Shigella , Campylobacter , Giardia , Listeria , and Cryptosporidium ).
• • Avoid swallowing water during water-based activities.
• • Avoid eating raw seafood.

Traveling while pregnant

Key points for pregnant travelers 1 :

• • Obstetric emergencies are sudden and can be life threatening. Having an emergency plan and access to appropriate obstetric care is recommended.
• • Before booking, check with the airline or cruise ship regarding any limitations on travel. Some limit travel based on gestational age.
• • During air travel the cabin is pressurized to 6000 to 8000 feet. This will not affect a fetus in a normal pregnancy, but could cause fetal problems in women with cardiovascular conditions, sickle cell disease, or severe anemia (hemoglobin <8 g/dL).
• • During air travel, frequent stretching, walking, and isometric exercises are recommended to decrease risk of deep venous thrombosis, which is increased in pregnancy.
• • Treatment of choice for traveler’s diarrhea is hydration and, if indicated, azithromycin.
• • Owing to the risk of birth defects, the CDC recommends that pregnant women do not travel to areas where Zika is present. If travel cannot be avoided, avoidance of mosquito bites is extremely important. More information can be found at the CDC Zika website ( http://www.cdc.gov/zika/pregnancy/index.html ).
• • Most live virus vaccines are contraindicated during pregnancy except for yellow fever, for which pregnancy is considered a precaution by the Advisory Committee on Immunization Practices.
• • Malaria is more serious in pregnant than in nonpregnant women and puts both the mother and the fetus at risk. Malaria chemoprophylaxis is highly encouraged. Chloroquine and mefloquine (depending on the region) are the drugs of choice. Doxycycline and primaquine are contraindicated due to possible effects on the fetus, whereas atovaquone-proguanil lacks available safety data.

Traveling with Children

According to the CDC, an estimated 1.9 million American children travel internationally each year. 1 Typically, children are exposed to the same risks as adults, but the consequences can be more severe and children are less likely to receive travel advice than adults.

The most common health problems among child travelers were 1 :

• • Diarrheal illnesses,
• • Dermatologic diagnosis (animal/insect bites, cutaneous larva migrans, sunburn),
• • Febrile illnesses (malaria), and
• • Respiratory disorders.

Key points when traveling with children 1 :

• • Diarrheal diseases are more common and can be more likely to cause dehydration. Treatment should focus on oral rehydration solution and if indicated antibiotics for traveler’s diarrhea. Children should be given a nonfluoroquinolone such as azithromycin, which can be given as a single daily dose (10 mg/kg) for 3 days.
• • Car crashes and drowning are the leading 2 causes of death in children while traveling. Car seats are often not available so parents should bring their own. Life vests should always be used around water.
• • Avoidance of mosquito and other bug bites is critical, especially in malaria endemic areas. Repellents with DEET should not be used on infants less than 2 months and after 2 months, only repellents with 30% or less DEET should be used.
• • Malaria prophylaxis is also recommended for children in malaria endemic areas. Dosing will need to be adjusted based on weight. Doxycycline should not be given to children less than 8 years old because of the risk of teeth staining, and atovaquone-proguanil should not be used in children weighing less than 5 kg.
• • Rabies is more common in children owing to less fear in approaching animals. If there is exposure to any animal bite, seek medical care immediately. Consider rabies vaccine if planning to spend more than 3 months in endemic area.

Visiting Friends and Relatives

A traveler who is returning home to visit friends or relatives is considered a visiting friends and relatives traveler. Today, visiting friends and relatives travelers make up more than one-half of all international travelers. 1 They are least likely to seek pretravel advice and more likely to develop problems while traveling because they typically stay longer at a destination, eat local food in people’s homes, and often do not take the same precautions as other travelers.

Key points for visiting friends and relatives travelers 1 :

• • Malaria risk is 8 to 10 times higher than for a non-visiting friends and relatives traveler. Malaria immunity weans after living outside of a malaria endemic region, so when returning to the endemic region, malaria prophylaxis and mosquito bite avoidance is recommended. Malaria prevention medication should be started several weeks before international travel.
• • Foodborne illnesses are more common and any immunity to local bacteria can also wean with time after living outside the community. Avoidance of food at room temperature, raw fruits and vegetables, tap water, and ice from tap water is recommended.
• • These travelers are also at increased risk of tuberculosis and sexually transmitted diseases.

Posttravel assessment

General approach.

Worldwide, 8% of travelers develop illnesses severe enough to seek a health care provider. 1 The majority of travelers present to primary care for posttravel illnesses. Data gathered from a directed history can elucidate the cause of a traveler’s symptoms. Knowledge of the travel itinerary and incubation periods is essential to narrowing down a differential diagnosis based on geography and timing after travel.

Common Syndromes

According to a large-scale study by GeoSentinal, a global surveillance network, the most common syndromes in returned travelers are gastrointestinal (34.0%), febrile (23.3%), and dermatologic (19.5%). 9

Gastrointestinal Illness

Many cases of traveler’s diarrhea can be treated empirically, and 80% to 90% of cases are bacterial. See Table 4 for top infectious causes of persistent traveler’s diarrhea. Azithromycin should be preferentially used in travelers returning from South and Southeast Asia owing to the increasing resistance to fluoroquinolones. 7 Severe symptoms, including fever, tenesmus, and gross blood, should prompt further testing, including stool culture. If stool is tested for ova and parasites, 3 or more stool specimens should be collected to increase sensitivity. 7 Some organisms, such as Cryptosporidium and Cyclospora , require specific testing. Testing for Clostridium difficile should be performed if the traveler recently used antibiotics or malaria chemoprophylaxis. A minority of travelers have persistent diarrhea lasting more than 2 weeks, which can be from (1) persistent infection or an untreated coinfection, (2) postinfectious processes like postinfectious irritable bowel syndrome, which can be diagnosed using the Rome criteria, or (3) unmasking of a previously undiagnosed gastrointestinal disease. 7

Table 4

Top infectious causes of persistent traveler’s diarrhea listed in decreasing order of frequency in each column

Febrile Illness

Fever in a returned traveler needs to be evaluated immediately owing to the potential for a rapidly progressing, life-threatening illness like malaria. Those who arrive from areas where malaria is endemic should be evaluated with thick and thin blood films and malarial antigen tests, if available. Blood smears should be repeated if suspicion is high and initial smears are negative. Other important causes to consider include dengue fever, enteric fever (typhoid, paratyphoid), and rickettsial diseases (eg, African tick bite fever), among others. It is also important to keep in mind other common causes of fever including influenza, which occurs year round in tropical climates. See Table 5 for the top febrile illnesses to consider in returned travelers based on location. Those with fever accompanied by alarming symptoms should be thoroughly evaluated as soon as possible, which may be best conducted in the emergency department. In 25% to 40% of patients with fever, no specific cause was identified. 9 , 10

Table 5

Top febrile illnesses to consider in returned travelers based on location

Dermatologic Conditions

Rashes are common in returned travelers. One of the most common skin findings is the classic pruritic migratory serpiginous rash of cutaneous larva migrans. 11 Exposure occurs when skin (eg, bare feet) comes in contact with contaminated sand or soil. Animal bites and scratches, most commonly received from dogs and monkeys, are also common in returned travelers and may require rabies postexposure prophylaxis in up to 12% of cases. 9 See Box 4 for the top tropical dermatologic conditions to consider in returned travelers.

Box 4

Top 10 tropicala dermatologic conditions to consider in returned travelers.

• 1. Cutaneous larva migrans
• 2. Arthropod bite
• 3. Myiasis (bot fly, tumbu fly)
• 4. Injuries including animal bites
• 6. Cutaneous leishmaniasis
• 7. Tungiasis
• 8. Swimmer’s itch
• 9. Rickettsial infection
• 10. Dengue fever

a Many cosmopolitan causes (eg, cellulitis) excluded from this list.

Screening Asymptomatic Returned Travelers

Currently, there are no CDC guidelines for asymptomatic returned travelers.

Special circumstances section

Altitude illness.

Altitude illness is most common at altitudes of 8200 feet (2500 m) or more, although it can occur at lower elevations. 1 The main issue in altitude sickness is hypoxemia, which is exacerbated during sleep. Respiratory depressants such as alcohol and sleep medications should be avoided; acetazolamide and stimulants may speed acclimatization. Moderate-to-vigorous physical activity can exacerbate hypoxemia and should be avoided for the first 48 hours. Physical conditioning does not predict acclimatization. Contraindications to traveling to altitude include severe heart or lung disease, sickle cell anemia, high-risk pregnancy, and cerebral pathology.

There are 3 altitude syndromes: acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. Treatment involves immediate descent, medications ( Table 6 ), oxygen supplementation, and pressurization bags if rapid descent is not feasible.

Table 6

Common medications for altitude illness

Abbreviations: AMS, acute mountain sickness; BID, twice per day; HACE, high altitude cerebral edema; HAPE, high altitude pulmonary edema; PO, by mouth.

SCUBA Diving

SCUBA-related illnesses can be divided into 2 categories: barotrauma and decompression illness. The primary risk factors are dive depth, bottom time, and speed of ascent. 1 Decompression illness can occur even when all precautions are taken. The Divers Alert Network is a resource that can be accessed by both divers and health care providers at http://www.diversalertnetwork.org/ or at their 24-hour emergency hotline (919-684-9111).

Motion Sickness

Motion sickness is not a true pathology, but a normal response to the external stimulation that is created by the vestibular system. The most common forms are sea sickness, motor vehicle sickness, and air sickness. It has been noted to be more common in women and less common in frequent travelers either owing to habituation or self-selection. See Box 5 and Table 7 for recommendations for motion sickness prevention and management.

Box 5

Recommendations to prevent motion sickness, table 7.

Common preventive medications for motion sickness

Abbreviation: PO, by mouth.

Mass Gatherings

Defined as at least 1000, but can be more than 25,000, people gathered at a specific location for a specific purpose. 1 Often these gatherings can strain the local resources and increase the risk of disease transmission among the attendees. Common challenges among attendees are hypothermia, heat exhaustion, dehydration, sunburn, but worsening of underlying chronic diseases (eg, heart failure, diabetes) also occurs. And at times there can be other dangers such as unsafe transportation, stampedes, collapse of structures, fire, terrorism and other forms of violence. See Box 6 for examples of mass gatherings.

Box 6

Mass gathering examples.

• Measles exposure at amusement parks in the United States.
• Meningitis (meningococcal vaccine is required for the Hajj) and respiratory infections (Coronavirus) among Hajj pilgrims.
• Concern for Zika at Rio, Brazil Olympics.
• Exposure to flu during sports events, concerts, conventions.

Disclosure Statement: The authors have nothing to disclose.

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How to Travel With Medications

Stay Healthy and Save Money

If you plan to travel to a foreign country, it is important that you provide for your medication needs before leaving. An illness in the middle of your trip can ruin your vacation and cost you money to get needed medications.

Depending on the circumstances, buying medications in foreign countries can be expensive. Moreover, in some countries, you may be at risk of getting a counterfeit drug.

By thinking ahead and packing smart, you can stay healthy and enjoy your time. This article will help you understand what you need to know about traveling with over-the-counter and prescription medications.

Organize a Health Kit

The Centers for Disease Control and Prevention (CDC) recommends that travelers assemble a health kit containing current prescription medications and over-the-counter (OTC) drugs that can be used to treat minor problems. What you include in your travel health kit depends upon your destination and length of travel.

You also should anticipate some disruption in travel plans and take extra medication so you do not run out. For example, you do not want to be stuck in an airport for an extra day without your diabetes medication or pain medication used to treat arthritis.

Which OTC Medications Should I Pack?

Since it is not practical to pack your entire medicine cabinet, your travel destination and your itinerary may help you decide which over-the-counter medications to buy for your kit.

For example, you are less likely to have diarrhea from drinking water in Canada than in Mexico. And, if you are planning a walking trip in London, you are less likely to need an anti-motion sickness medication.

The following are some basic medications to consider:

• Anti-diarrhea medication: Foodborne illness is very common and may cause diarrhea in up to 30% of travelers. This is especially common in parts of Central and South America, Africa, and Asia. Pack Imodium (loperamide) or Pepto-Bismol (bismuth subsalicylate).
• Antihistamine: To treat an allergic reaction, pack an antihistamine that will not make you drowsy, such as Claritin (loratadine).
• Anti-motion sickness medication: For a bumpy plane or boat ride, pack some Dramamine (dimenhydrinate).
• Medicine for pain or fever: Pack your preferred painkiller, such as acetaminophen or ibuprofen.
• Mild laxative or stool softener: Changes in your eating routine and access to different foods can cause constipation . Pack a laxative containing bisacodyl such as Dulcolax or a stool softener such as Colace (docusate).
• Antifungal ointment or cream: Fungal infections of the skin, such as ringworm and athlete’s foot are common, especially in warm climates. Pack a tube of Tinactin (tolnaftate) or Lotrimin (clotrimazole).
• Antibacterial ointments or creams: To help prevent a skin infection from a minor cut or scrape, pack a tube of Neosporin Ointment (polymyxin B, bacitracin, and neomycin).

How Do I Manage My Prescription Medications on a Trip?

Before you leave for your trip, see your healthcare provider to get an ample supply of all your prescription medications. Also, talk to your practitioner about your change in schedule and ask when to take medications if you are moving through different time zones.

If you are traveling to a country with malaria , talk with your healthcare provider about getting a prescription for a medication to prevent malaria, such as Lariam (Mefloquine), Malarone (atovaquone, proguanil), or doxycycline (the CDC has a guide to each of the available medications, some of which are recommended for certain areas).

If your destination is a country that puts you at high risk of diarrhea or other bacterial infections, ask your practitioner about the possibility of getting a prescription for an antibiotic, such as Cipro (ciprofloxacin).

Talk to your pharmacist about drug-food interactions. Since your diet may change during your trip, your pharmacist can advise you about foods that could affect your medications.

Pack your travel health kit, including your prescription medications, in your carry-on luggage. Make copies of your prescriptions and pack them with your medications. You should also leave a copy of your prescriptions at home with a friend or family member.

Make a list of your medications, including the generic names and brand names, and what conditions the medications treat. That will make it easier to find a replacement if you run out of or lose your medications .

Will I Have Problems Crossing Borders With My Medications?

If you use a controlled substance, such as a sedative, tranquilizer or narcotic pain medication, make sure you obtain a letter from your healthcare provider, on the practitioner’s stationery, stating why you need the drug.

Without such a letter, these medications may not be allowed into another country or allowed back into the U.S. when you return.

Likewise, you should have a letter from your healthcare provider if you take any medication by injection and you have to carry needles and syringes.

Make sure that all medications are labeled properly. The safest way to carry your medications is in the original bottles, which will also speed the process if your carry-on bags are inspected (this applies to vitamins and supplements as well).

However, if you do not have enough space for the bottles in your carry-on, you can transfer them to small plastic bags. When you have your prescription filled, the pharmacy will give you a print-out that usually has a tear-off section on the top that has the same information as the label on your medication container. You can enclose this tear-off sheet in the plastic bag.

But note that the Transportation Security Administration—TSA— clarifies that although they do not require travelers to have medications in their original pharmacy-provided containers, "states have individual laws regarding the labeling of prescription medication with which passengers need to comply."

You'll also want to make sure that the name on your prescriptions , pill bottles (or tear-off sheet if you're packing your medications in a bag or pill sorter), and ID or passport all match.

If you have a liquid medication, TSA doesn't require it to be less than 3.4 ounces (the rule that applies to most other liquids), but you do need to tell the TSA agent that you have medically necessary liquids in your bag when you start the screening process at the airport.

Even with all of that planning, it's important to also have a clear understanding of the laws and regulations in your destination country. In some cases, you might find that a particular destination's rules simply aren't compatible with a medication that you take , and you may want to consider a different destination instead.

You can discuss the specifics with your healthcare provider, your pharmacist, and the U.S. embassy in the country you're considering visiting . The embassy will be able to tell you whether a medication you take is banned in the country or only allowed in limited quantities.

Where Can I Get More Information Before I Leave on My Trip?

Centers for Disease Control and Prevention: The CDC maintains an excellent Travelers’ Health website that includes a wide range of information about travel issues related to health. One section of the site has an interactive map that provides access to health information for each country. And their traveling abroad with medicine page is a must-read if you're planning a trip outside the U.S. and will need to bring medication with you.

Transportation Security Administration (TSA): The TSA provides online information for travelers with disabilities and medical conditions, and it explains the current requirements for how to go through airport security with medications.

U.S. Department of State: The State Department maintains a travel website that provides a profile about the current status of every country in the world. These profiles include information about health-related issues and often highlight issues with prescription medications.

Transportation Security Administration : TSA has a helpful page about disabilities and medical conditions . It includes a tool that allows you to select from among a range of common disabilities and medical conditions to see exactly what you need to know about the screening process and any steps you might want to take in advance to make it as smooth as possible.

Traveling with medications is common, but does require some advance planning. It's generally advisable to pack medications in your carry-on luggage, and to have copies of your prescriptions with you. Liquid medications can be brought onboard aircraft even in quantities greater than the limits that apply to other liquids, but you'll need to notify the TSA screening agent of your liquid medication. For controlled substances, you'll need a letter from your medical practitioner, explaining why you need the medication. And there are some countries where certain medications simply aren't allowed, even though they're prescribed in other countries.

A Word From Verywell

Staying healthy on your trip can save you a lot of money. Out-of-pocket medical expenses in a foreign country can be enormous. Make sure to purchase travel insurance before you leave and pack your medications !

Centers for Disease Control and Prevention. Travelers' Health .

Centers for Disease Control and Prevention. Choosing a Drug to Prevent Malaria .

Transportation Security Administration. Can You Pack Your Meds in a Pill Case and More Questions Answered .

Centers for Disease Control and Prevention. Traveling Abroad with Medicine .

Mohn, Tanya. New York Times. How to Make Sure You Travel with Medication Legally .

Transportation Security Administration. Disabilities and Medical Conditions ; and TSA Cares: Traveling with Medication ; and Can you pack your meds in a pill case and more questions answered .

By Michael Bihari, MD Michael Bihari, MD, is a board-certified pediatrician, health educator, and medical writer, and president emeritus of the Community Health Center of Cape Cod.

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• FDA Drug Info Rounds Video

Traveling with Prescription Medications

How can you avoid travel delays upon arrival to, and departure from, the United States? That’s a question patients often ask their local pharmacist or the FDA. FDA Drug Info Rounds pharmacists outline key points pharmacists should counsel their patients on prior to travel.

Video Transcript

Host:   Captain Mary Kremzner Pharmacist :  Lieutenant Lindsay Davison

CAPT Kremzner :  Traveling with prescription medications.  How can you avoid travel delays upon arrival to, and departure from, the United States?  That’s a question patients often ask their local pharmacist or the FDA. Hi, I’m Captain Mary Kremzner and this is Drug Info Rounds, brought to you by the pharmacists in FDA’s Division of Drug Information. I asked Lieutenant Lindsay Davison to outline key points pharmacists should counsel their patients on prior to travel. Let’s start by reviewing key precautions that travelers with prescription medications should know. LT Davison :  The first precaution is that patients should not assume that prescription medications that are approved in one country are approved in another.  Travelers coming into the U.S. should be aware that their products may be illegal here.  The same applies to travelers leaving for other countries.  They should contact the country they are traveling to for advice.  The second is to be aware that the approved indications for use may not be the same.  Just as the medication itself may not be approved in another country, the approved indication for use may differ as well. The third is to have information with you about your prescription medications.  Travelers should be aware that in the event they require medical attention, treatment could be delayed or made more difficult without sufficient information available about the product.  This includes the brand and generic name of the product, the dosage form and strength, and how often it is used.

CAPT Kremzner : Will you review some of the resources for travelers with prescription medications?

LT Davison :  A Travelers Alert is posted on FDA’s website with useful information.  This Alert lists two other agencies that offer advice to travelers:  U.S. Customs and Border Protection, also known as CBP, and the Drug Enforcement Administration, or DEA. CBP offers advice on their website for traveling with prescription medications and medical devices, such as oxygen tanks. They recommend: -    Prescription medications should be in their original containers with the doctor's prescription printed on the container.  -    Travel with no more than personal use quantities, a rule of thumb is no more than a 90 day supply.  -    If your medications or devices are not in their original containers, you should have a copy of your prescription with you or a letter from your doctor,  -    And a valid prescription or doctor’s note is required for all medications entering the U.S. CBP can be reached by email for medication questions not answered on their website. DEA enforces regulations for controlled substances in Schedules II through V, in the Code of Federal Regulations.  This is also available on their website.  DEA provides contact information to local Field Offices online.

CAPT Kremzner :  What about the Transportation Security Administration?

LT Davison :  Great point!  The TSA posts information for travelers who need medication on their website.  Passengers are allowed to bring medications in tablet or other solid form through security screening checkpoints, as long as they are screened.  Passengers should inform officers of medications and separate them from other belongings before screening begins. Medication is usually screened by X-ray; however, if a passenger does not want a medication X-rayed, they may ask for an inspection instead. Questions related to carrying prescription medications in luggage versus carry-on baggage should also be directed to TSA.

CAPT Kremzner :  This clears up a lot of questions that patients have for pharmacists about traveling with their prescription medications.  If you have questions, call or email FDA’s Division of Drug Information.

Related Resources

• FDA Drug Info Rounds Videos

A Travel Medicine Primer for the Pharmacist

Amber B. Giles, PharmD, BCPS, MPH, AAHIVP Assistant Professor of Pharmacy Practice Presbyterian College School of Pharmacy Clinton, South Carolina

USPharm. 2018;43(4):19-26.

ABSTRACT: With international travel increasing in past decades, pharmacists should be informed and stay up-to-date on the most pertinent travel-health information available. Preventive measures including prescriptions and other nonpharmacologic therapies are available to reduce the risk of acquiring an infectious disease while traveling internationally. Pharmacists in the community may be the last line of medication information and counseling available to the patient before travel, and they may be asked for recommendations about medications and OTC products to prevent travel-related illnesses such as traveler’s diarrhea, cholera, typhoid fever, malaria, and Zika.

International travel has dramatically increased in past decades, with over 80 million trips booked by Americans in 2016—8% more than in 2015. 1 Travelers should consult a medical professional weeks to months prior to international travel, especially when traveling to a tropical, subtropical, or developing country, in order to receive proper counseling and any prophylactic medications or vaccinations that may be recommended. 2 This article will focus on information pertinent to pharmacists in the United States in order to field questions about causes, preventive measures, and available treatment options for the most common travel-related illnesses that patients may experience abroad.

Important information to obtain from a patient seeking medical travel advice includes the travel destination, reason for travel (e.g., medical mission trip, work, or leisure), duration of travel, itinerary, and patient-specific health concerns. 2 Pharmacists can consult the CDC Travelers’ Health website for specific recommendations. 3 Pharmacists may also be instrumental in helping patients locate a travel-medicine clinic. The International Society of Travel Medicine has an online directory of available travel-medicine clinics, which can be searched by state in order to locate the nearest clinics. 4

Travel Vaccinations

Many diseases that travelers may be at higher risk for can be prevented with vaccinations. 5 Common routine vaccinations given at pretravel appointments include influenza, hepatitis A, hepatitis B, and tetanus, diphtheria, and pertussis. Specific travel-related vaccines should be administered based on risk of infection, patient-specific factors, and travel itinerary; further details about available travel vaccines may be found in Table 1 . 6-14 Many insurance companies do not cover the cost of travel vaccinations, so patients should contact a local travel-medicine clinic for specific information on pricing.

Prevention of Food and Waterborne Disease

Precautionary safety measures during travel are of utmost importance in preventing infectious diseases. Paying close attention to hygiene practices in international restaurants and avoiding places with poor hygiene practices are important. Travelers should avoid eating raw or undercooked foods, including meats, seafood, and raw fruits and vegetables, unless cooked or peeled by the traveler personally. Travelers should avoid purchasing foods and beverages from street vendors, drinking tap water and unpasteurized milk, and consuming ice and dairy products. Any water used for drinking or brushing teeth should either come from an unopened bottle or be boiled prior to use. Hand washing with soap and water should be practiced routinely while traveling abroad. Alcohol-based sanitizers may be used if soap and water are unavailable. 15

Traveler’s Diarrhea

Traveler’s diarrhea (TD) is the most common travel-related illness and is caused by consuming fecally contaminated food or water. TD is defined as three or more unformed stools within 24 hours plus one of the following symptoms: abdominal cramping, nausea, vomiting, fever, or fecal urgency. More than 80% of TD cases are caused by bacterial organisms, such as Escherichia coli , Campylobacter jejuni , Shigella spp . , or Salmonella spp . , but may also be caused by viral or protozoal infections. Norovirus is often associated with outbreaks in patients traveling on cruise ships. A higher incidence of TD is seen in patients traveling to countries in Central and South America, Asia, Africa, Mexico, and the Middle East. 16

Symptoms of TD can be mild, with some cramping and loose stools, or severe, with fever, bloody stools, vomiting, and intense abdominal pain. The food and water safety measures previously discussed should be practiced to prevent TD. Bismuth subsalicylate (BSS) has been studied, with success shown in reducing the risk of TD by approximately 50%. In patients wishing to use BSS for prophylaxis, proper counseling about the potential of BSS to blacken the tongue and stool is important. BSS prophylaxis should not be used in pregnant patients or children aged less than 3 years. Additionally, those who have an aspirin allergy, renal dysfunction, or a prescription for an anticoagulant should avoid BSS. Importantly, prophylactic antibiotic therapy is not indicated to prevent TD in most travelers because this practice may lead to further antibiotic resistance. 16

Counseling should be provided to patients about increasing oral fluid intake in the event of a TD episode during travel. Antimotility medications such as loperamide (maximum 8 mg per day) or BSS may be used to reduce the number of stools per day and allow patients to continue with travel plans. Antidiarrheals should be used only in patients who do not have concomitant fever or blood in the stool and who are not pregnant. 16 Antibiotics may be used to reduce the duration of moderate-to-severe TD. Azithromycin or fluoroquinolone antibiotics are recommended empiric therapy for infectious diarrhea. 17 Importantly, fluoroquinolones should not be used in cases of bloody diarrhea. 16 Additionally, fluoroquinolone resistance is increasing throughout the world, so these agents are no longer the preferred treatment options in some locations, as outlined on the CDC website. 3 Azithromycin is preferred in patients who are pregnant. 18  Single doses of antibiotics have been shown to be as efficacious as multidoses and are also more convenient for patients traveling abroad ( Table 2 ). 19

Typhoid and paratyphoid fever, also known as enteric fever , are bacterial infections caused by Salmonella enterica . Southern and Southeast Asia, as well as Africa, are the highest-risk regions for enteric fever. The Caribbean, East Asia, and South America are areas with a lower risk. Typhoid typically presents as a low fever in the morning followed by higher fever in the evening. Typhoid symptoms may last up to 1 month if left untreated, and complications associated with typhoid, such as intestinal perforation and hemorrhage, may present after several weeks of untreated illness. 13

Two vaccines are available for typhoid in the U.S. 13 Destination-specific vaccine recommendations may be found on the CDC Travelers’ Health website. 3 The traditional therapy of choice for enteric fever has been fluoroquinolone antibiotics; however, increasing resistance has been seen across the globe, especially in Southern and Southeast Asia. Third-generation cephalosporins and azithromycin are often used instead of fluoroquinolones owing to this resistance. After antibiotic initiation, patients could continue to spike fevers for several days, with an initial worsening of symptoms. 13  

Cholera is an infectious disease caused by a bacterium, toxigenic Vibrio cholerae . The highest incidence of cholera is found in regions of Africa and Southern and Southeast Asia. Cholera outbreaks have also been reported in parts of the Caribbean. Cholera typically presents as mild, watery diarrhea without fever and may also be asymptomatic. However, some patients may experience severe, profuse, watery diarrhea that appears like “rice-water stools.” This form of cholera may lead to very severe dehydration, shock, or even death if left untreated. 7

Owing to high quantities of fluid loss, aggressive rehydration is the key to treating patients with active cholera infections. Oral rehydration therapy may be used to treat moderate dehydration; however, IV fluids are needed in severe cases. Doxycycline is the agent of choice for adult patients in the majority of the world, and azithromycin is the treatment option preferred in pregnant women and children. 7 Other options for treatment include ceftriaxone or fluoroquinolone antibiotics, with increasing resistance to fluoroquinolones in many parts of the world. 7,17 In addition to safety precautions, an oral vaccine is now available in the U.S. for adults (ages 18-64) traveling to areas of active transmission of cholera. Currently, there are no safety or efficacy data for booster doses of the cholera vaccine. 20

Prevention of Insect-Borne Disease

Prophylactic medications and vaccinations are available in the U.S. to prevent vectorborne diseases. Lightweight long-sleeved shirts, long pants, closed-toe shoes, and hats should be worn when possible to minimize the amount of exposed skin. Permethrin may be used to treat clothing or gear but should not be applied directly to the skin. Any exposed skin should be treated with a mosquito repellent. Many commercially available insect repellents are EPA-registered, including DEET, picaridin, oil of lemon eucalyptus, and para-menthane-3,8-diol. Repellents containing less than 10% of the active ingredient are only minimally protective (providing coverage for 1-2 hours). Repellents should not be sprayed directly to the face, under clothing, or on cuts or irritated skin. Combination sunscreen and repellent products are not recommended by the CDC. In addition to wearing proper clothing and using insect repellents, travelers should sleep in screened-in and/or air-conditioned rooms as well as under an insecticide-pretreated bed net. 21

Malaria is a significant cause of morbidity and mortality in patients traveling internationally. 2 Malaria is caused by the Plasmodium parasite and transmitted by the Anopheles mosquito in areas of Africa, Asia, and Central and South America. Different species of Plasmodium are seen throughout the world, and each species and region have unique susceptibility to antimalarial agents. The CDC separates geographical regions into chloroquine-sensitive or chloroquine-resistant malaria, which helps physicians in choosing appropriate prophylaxis or treatment. 22

Malaria prophylaxis should be prescribed for patients traveling to high-risk areas and should be taken before, during, and after travel. The travel itinerary, remaining time before travel, age, weight, allergies, concomitant drug interactions, and pregnancy status are important factors to consider in order to choose the most appropriate prophylactic therapy for a patient. Several options for prophylaxis should be started 1 to 2 days prior to travel, while others must be started 1 to 2 weeks prior. In addition, the duration that prophylaxis must be continued post-travel is unique to each agent ( Table 3 ). Patients who believe that they may  have been infected with malaria while traveling should seek appropriate medical treatment as soon as possible. Treatment options depend on the severity of infection, area of travel, potential drug resistance, and patient-specific characteristics. 22 The CDC provides guidelines for the treatment of malaria in the U.S. 23

Zika is a viral infection that is transmitted by the Aedes mosquito. Zika virus was discovered in 1947 in Uganda; however, much attention has been focused on Zika in recent years owing to its association with severe effects on the fetuses of mothers infected with the virus. There are currently no available vaccinations or prophylactic therapies to prevent infection with Zika. Proper mosquito precautions are important for preventing the illness. The majority of patients infected with Zika remain asymptomatic, and any symptomatic infections are often mild and flulike. Supportive care is the mainstay of therapy in patients with symptomatic Zika infections. 24

An increased risk of microcephaly and other brain abnormalities in the fetus has been associated with Zika infection in pregnant women; therefore, the CDC recommends that pregnant women or those trying to become pregnant should not travel to areas of active local transmission. 24 Other potential birth defects linked to Zika are neural tube defects such as anencephaly, congenital cataracts, spina bifida, and hearing loss. 25 If travel to these areas cannot be avoided, the woman should speak with her healthcare provider and take very strict precautions to avoid mosquito bites. A male who has traveled to an area of local transmission should use condoms or abstain from sex with his partner, if the partner is pregnant, for the duration of the pregnancy. Couples wishing to conceive and who have recently traveled to an endemic area should first speak with a medical provider and wait until risks for transmission are minimized. 24

Yellow Fever

Yellow fever (YF) is caused by a virus and is endemic to sub-Saharan Africa and the tropics of Central and South America. YF is transmitted via the bite of Aedes or Haemagogus spp . mosquitoes. During the rainy season, there is an increased risk of infection; however, transmission may still occur outside of these months. The majority of patients infected with YF remain asymptomatic or may have mild flulike symptoms. Approximately 15% of patients infected with YF will progress to severe disease with liver dysfunction, hemorrhage, shock, and ultimately multiorgan failure. Supportive care with fluids, analgesics, and antipyretics is the standard of care. Because of the increased risk of bleeding, aspirin and nonsteroidal anti-inflammatory drugs should not be used in patients with suspected or confirmed YF. 14

YF prevention includes mosquito protection as well as the YF vaccine, which is a live attenuated vaccine. Some countries require proof of vaccination with the International Certificate of Vaccination or Prophylaxis, or “Yellow Card.”  In 2014, the World Health Organization determined that a single dose of the YF vaccine provides lifelong immunity, so a 10-year booster is no longer needed for most patients. 14 The Advisory Committee on Immunization Practices does recommend a one-time booster in patients who received their first vaccine while pregnant or who received a stem-cell transplant after the vaccination. Patients who are living with HIV should be given a booster every 10 years. 26 Owing to potential serious adverse effects of the YF vaccine, only certain healthcare providers are certified to administer the vaccine. 14 Information about providers who can administer the vaccine may be found via the CDC’s search engine. 27

Preventive measures including prescriptions, vaccinations, and other nonpharmacologic therapies are available to reduce the risk of acquiring an infectious disease while traveling internationally. Pharmacists in the community may be the last line of medication information and counseling available to the patient before travel, and they may be asked for recommendations about medications and OTC products to prevent travel-related illnesses such as traveler’s diarrhea, cholera, typhoid fever, malaria, and Zika (sidebar ). Pharmacists should be informed and stay up-to-date on the most pertinent travel health information.

1. National Travel and Tourism Office. 2016 outbound analysis. December 4, 2017. https://travel.trade.gov/outreachpages/download_data_table/2016_Outbound_Analysis.pdf. Accessed January 29, 2018. 2. Chen LH, Hochberg NS, Magill AJ. The pretravel consultation. In: CDC. Travelers’ Health—Yellow Boo k. Chapter 2. The pretravel consultation. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/the-pre-travel-consultation. Accessed January 25, 2018. 3. CDC. Travelers’ health. wwwnc.cdc.gov/travel. Accessed January 26, 2018. 4. International Society of Travel Medicine. Online clinic directory. www.istm.org/AF_CstmClinicDirectory.asp. Accessed January 26, 2018. 5. Boggild AK, Castelli F, Gautret P, et al. Vaccine preventable diseases in returned international travelers: results from the GeoSentinel Surveillance Network. Vaccine . 2010;28(46):7389-7395. 6. Kroger AT, Strikas RA. General recommendations for vaccination & immunoprophylaxis. In: CDC. Travelers’ Health—Yellow Book . Chapter 2. The pretravel consultation. Updated June 13, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/general-recommendations-for-vaccination-immunoprophylaxis. Accessed January 25, 2018. 7. Wong KK, Burdette E, Mintz ED. Cholera. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/cholera. Accessed January 25, 2018. 8. Nelson NP. Hepatitis A. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated June 12, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/hepatitis-a. Accessed January 25, 2018. 9. Averhoff F. Hepatitis B. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated June 13, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/hepatitis-b. Accessed January 25, 2018. 10. Hills SL, Rabe IB, Fischer M. Japanese encephalitis. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/japanese-encephalitis. Accessed January 25, 2018. 11. MacNeil JR, Meyer SA. Meningococcal disease. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/meningococcal-disease. Accessed January 25, 2018. 12. Petersen BW, Wallace RM, Shlim DR. Rabies. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/rabies. Accessed January 25, 2018. 13. Judd MC, Mintz ED. Typhoid & paratyphoid fever. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/typhoid-paratyphoid-fever. Accessed January 25, 2018. 14. Gershman MD, Staples JE. Yellow fever. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/yellow-fever. Accessed January 25, 2018. 15. Connor BA. Food & water precautions. In: CDC. Travelers’ Health—Yellow Book . Chapter 2. The pretravel consultation. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/food-water-precautions. Accessed January 25, 2018. 16. Connor BA. Travelers’ diarrhea. In: CDC. Travelers’ Health—Yellow Book . Chapter 2. The pretravel consultation. Updated June 13, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/travelers-diarrhea. Accessed January 25, 2018. 17. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis . 2017;65:e45-e80. 18. Morof DF, Carroll D. Pregnant travelers. In: CDC. Travelers’ Health—Yellow Book . Chapter 8. Advising travelers with specific needs. Updated June 13, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/advising-travelers-with-specific-needs/pregnant-travelers. Accessed January 25, 2018. 19. Steffen R, Hill DR, Dupont HL. Traveler’s diarrhea: a clinical review. JAMA . 2015;313(1):71-80. 20. Advisory Committee on Immunization Practices. Summary report, February 24, 2016. Atlanta, GA: US Department of Health and Human Services, CDC. Advisory Committee on Immunization Practices; 2016. www.cdc.gov/vaccines/acip/meetings/downloads/min-archive/min-2016-02.pdf. Accessed January 31, 2018. 21. Mutebi J, Hawley WA, Brogdon WG. Protection against mosquitoes, ticks, & other arthropods. In: CDC. Travelers’ Health—Yellow Book . Chapter 2. The pretravel consultation. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/protection-against-mosquitoes-ticks-other-arthropods. Accessed January 25, 2018. 22. Arguin PM, Tan KR. Malaria. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated June 12, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/malaria. Accessed January 25, 2018. 23. CDC. Malaria diagnosis and treatment in the United States. Updated February 23, 2017. www.cdc.gov/malaria/diagnosis_treatment/treatment.html. Accessed January 25, 2018. 24. Chen T, Staples JE, Fischer M. Zika. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/zika. Accessed January 25, 2018. 25. Fitzgerald B, Boyle C, Honein MA. Birth defects potentially related to Zika virus infection during pregnancy in the United States. JAMA . January 25, 2018. https://jamanetwork.com/journals/jama/fullarticle/2671017. Epub ahead of print. Accessed January 25, 2018. 26. CDC. Yellow fever vaccine booster doses: recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR . June 19, 2015. www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a5.htm. Accessed January 30, 2018. 27. CDC. Search for yellow fever vaccination clinics. wwwnc.cdc.gov/travel/yellow-fever-vaccination- clinics/search. Accessed January 30, 2018.

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Your Ultimate Guide To Traveling & Prescription Medications

• July 24, 2023
• Lauren Stuttaford

Traveling with prescription drugs internationally requires some extra planning and consideration. So, whether you’re exploring a foreign country or going on a business trip, it’s essential to know how to travel with prescription medication to ensure a smooth journey and uninterrupted health management.

In this guide, we’ll cover everything you need to know about traveling with prescription medicine, from international regulations to obtaining prescriptions abroad and more.

Can you travel internationally with prescription drugs?

Can you travel with prescription medicine? Yes, you can generally travel with prescription meds. However, it’s important to be aware of the specific regulations and restrictions of your destination country. Different countries have different rules about what medications are allowed, and what documentation you need to have with you.

For example, some countries require travelers to carry a doctor’s note, a translated prescription, or even a specific import permit for certain medications. It’s important to do your research and understand the specific rules of your destination country before traveling with prescription drugs internationally.

How to check local regulations for traveling with prescription medications?

Traveling with prescription medication can be a daunting task, especially if you’re not sure what the local regulations are in your destination country. To avoid any potential problems, it’s important to do your research and understand the specific rules of the country you’re visiting.

If you need information about traveling with prescription drugs internationally, here are a few tips on how to check local regulations for traveling with prescription drugs internationally:

• Contact the embassy or consulate of your destination country. This is the best way to get up-to-date information on the country’s medication importation policies. They will be able to tell you what medications are allowed, what documentation you need to have with you, and any other important information you need to know.
• Consult with a travel health specialist. A travel health specialist can help you understand the local regulations for your destination country and make sure you have everything you need to travel safely.
• Check the website of the Centers for Disease Control and Prevention (CDC). The CDC website has a wealth of information on traveling with prescription medications, including a list of countries with specific regulations.
• Do a Google search. A simple Google search can often turn up helpful information on the local regulations for traveling with prescription medications.

Once you’ve done your research, you’ll be well on your way to traveling with prescription medications safely and legally.

How to travel with prescription drugs internationally: flying with prescribed medication

Traveling with prescription drugs internationally can be a daunting task, but it doesn’t have to be. By following a few simple guidelines, you can ensure that you have everything you need during your journey and avoid any potential problems with the TSA.

Tips for flying with prescription medications:

• The best way to travel with prescription medication is to keep your medications in their original packaging, labeled with your name, prescription details, and dosage instructions.
• Pack your medications in your carry-on bag. This will help prevent loss or delays.
• Bring extra medications. Pack more than enough medication to cover your trip in case of unexpected delays or extensions.
• Store medications properly. Ensure medications are stored at the appropriate temperature, especially if some require refrigeration.
• Check the rules for liquids and gels, as some countries have restrictions on the amount of these items you can bring into the country.
• Contact the embassy or consulate of your destination country for up-to-date information on the country’s medication importation policies.

Familiarize yourself with TSA regulations for traveling with prescription medications:

When it comes to traveling with prescriptions TSA allows you to bring prescription medications in your carry-on bag or your checked luggage. However, there are some specific requirements that you must follow:

• Medications must be in their original containers, labeled with your name and prescription details.
• Liquid medications must be in containers that are 3.4 ounces or less and placed in a single, clear, quart-sized zip-top bag.
• If you have more than 3.4 ounces of a liquid medication, you can bring it with you if you have a doctor’s note or prescription.
• Controlled substances must be declared to the TSA at the security checkpoint.

Check out our comprehensive guide on Flying with Prescribed Drugs: How-to Pack, Tips & More! [Ultimate Travel Guide] . This guide covers essential tips on organizing your medications, packing them securely, and carrying the necessary documentation.

What should you do when you need to fill a prescription abroad?

When it comes to international travel with prescription meds, the thought of running out of medication while abroad can be stressful. If you find yourself in this situation, there are a few things you can do.

Can you fill prescriptions abroad?

In most cases, you can fill prescriptions abroad. However, there are some important factors to consider, like medication importation policies of your destination country and the availability of your medication in that country.

How to fill prescriptions abroad:

Here are some tips on how to fill prescriptions abroad:

• Do your research. Before you travel, it’s a good idea to do some research on the medication importation policies of your destination country. This will help you understand what medications are allowed and what documentation you need to have with you.
• Contact your doctor. If you’re not sure whether you can fill your prescription abroad, contact your doctor. They may be able to prescribe the medication you need or recommend a local healthcare provider who can help you.
• Bring a copy of your prescription. It’s always a good idea to bring a copy of your prescription with you when you travel. This will make it easier to fill your prescription if you need to.
• Be prepared to pay out of pocket. Even if your insurance company covers the cost of filling a prescription abroad, you may still have to pay a copayment or deductible. It’s important to be prepared to pay out of pocket for your medication if necessary.

Running out of medication while abroad can be stressful. Check out our guide on

Filling Prescriptions Abroad: When Travelling Internationally for step-by-step instructions on obtaining prescription medications in a foreign country.

How to get prescriptions abroad:

If you need a new prescription while traveling, it’s essential to know the options available to you. Here are some tips to help you prepare before your trip when traveling with prescriptions internationally, and even how you can get prescriptions when traveling.

The importance of being prepared:

Preparing before your trip, like arranging prescriptions for medications, is crucial because regulations vary from country to country. When it comes to traveling with prescription drugs internationally, you’ll want to make sure you have the required documentation and understand local laws. This guarantees a smooth journey and ensures you can maintain your medication management. If you don’t prepare you could face unexpected hurdles and potential health risks, so research and plan for a safe and enjoyable travel experience.

Taking prescription drugs abroad – preparing before your trip:

• Talk to your doctor. Before you travel, talk to your doctor about your medication needs. They can help you understand the medication importation policies of your destination country and recommend a course of action if you need to get a new prescription while you’re abroad.
• Get a copy of your prescription. Make sure you have a copy of your prescription with you when you travel. This will make it easier to fill your prescription if you need to.
• Research the medication importation policies of your destination country. Different countries have different rules about what medications are allowed and what documentation you need to have with you. Do some research before you go to make sure you know what to expect.

How to get prescriptions when traveling:

When it comes to international travel prescriptions, there are a few different ways to get prescriptions when you’re traveling abroad:

• Contact your doctor or a local healthcare provider. Your doctor or a local healthcare provider may be able to prescribe the medication you need.
• Visit a local pharmacy. Many pharmacies in foreign countries can fill prescriptions from doctors in other countries. However, it’s important to check with the pharmacy before you go to make sure they can fill your prescription.
• Use a travel health clinic or medical tourism company. Travel health clinics and medical tourism companies can help you get prescriptions while you’re abroad. They often have a network of doctors and pharmacies that they work with, so they can help you find the best option for your needs.

Head to our blog post: Prescriptions While Traveling: Your Guide to Getting Medication Abroad , for the ultimate guide on getting prescriptions while abroad. It explains various ways to obtain necessary prescriptions in different countries and more useful tips for international travel and prescription medication.

What to do if you lose your medication while abroad

• Take a deep breath and stay calm. It’s okay to be upset, but it’s important to stay calm so you can think clearly.
• Retrace your steps. Go back to the last place you remember having your medication and thoroughly search the area.
• If you’re traveling, report the loss to the local police. You can also ask them for a written report for documentation.
• Contact your doctor and pharmacy. Let them know that you’ve lost your medication and see if they can help you get a replacement.
• If it’s a critical medication, contact your doctor immediately. They can advise you on the next steps, which may include getting an emergency prescription or switching to a different medication.
• Consider using a pill organizer or keeping your medications in a secure location. This can help prevent future losses.

What to consider when traveling with prescription drugs

• Check the local regulations: Research the specific country’s laws and regulations regarding prescription medications to ensure compliance.
• Carry a doctor’s note: Obtain a letter from your healthcare provider stating your medical condition, prescribed drugs, and their purpose for customs clearance.
• Make sure you have sufficient supply: Carry an adequate amount of medication for the entire trip, including extra for unexpected delays.
• Don’t throw away original packaging: Keep medications in their original labeled containers to avoid confusion and prove legitimacy.
• Translation services if needed: If traveling to a country with a different language, have a translated copy of your prescription and medical documents.
• Always declare at customs: Disclose your prescription drugs to customs officials, if required, to prevent any issues at the border.
• Secure storage: Keep medications in a safe and cool place to maintain their efficacy throughout the journey.

Dealing with travelers’ diarrhea & getting prescription meds abroad

While traveling, a common health concern many people experience is travelers’ diarrhea. Changes in diet, water quality, and exposure to new bacteria can lead to this uncomfortable condition. Make sure you’re prepared and know what to do by reading our blog post on Traveler’s Diarrhea: Getting Prescribed Medicine Abroad .

Remember, seeking medical help can make a significant difference in quickly overcoming this temporary health issue and getting back to enjoying your travel adventures.

How Air Doctor can help you

Air Doctor is a valuable resource for travelers. The easy-to-use app instantly and seamlessly connects travelers to a global network of over 20,000 multi-lingual doctors and specialists so they can access trusted, quality medical care anywhere, anytime.

If you ever find yourself in need of medical assistance during your journey, you can use Air Doctor (with or without insurance) to find a doctor that meets your preferences (like language, gender, specialty, and more), and choose from clinic, at-home (hotel), and video consultations.

The Air Doctor solution accommodates multiple languages – with 24/7 multi-lingual support, doctors proficient in multiple languages, and an app which supports various major languages – in addition to video consultations in up to 21 languages.

Plus, we’re able to provide valid, local prescriptions through our cross-border telemedicine services.

The service makes it easier to manage any health-related concerns while traveling.

Download the app before your next trip.

Safe travels!

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Jenny Cohen Derfler

Air dr ceo & co-founder.

Jenny is the CEO and one of the Co-Founders at Air Doctor. She spent more than 20 years at Intel, most recently as general manager of its manufacturing facility in Israel and before that in various engineering and manufacturing roles in Silicon Valley. Air Doctor is her second startup having previously founded electric vehicle company ElectRoad.

CHRISTOPHER SANFORD, MD, MPH, ADAM MCCONNELL, MD, AND JUSTIN OSBORN, MD

Am Fam Physician. 2016;94(8):620-627

Patient information : See related handout on tips for international travel .

Author disclosure: No relevant financial affiliations.

Key components of the pretravel consultation include intake questions regarding the traveler's anticipated itinerary and medical history; immunizations; malaria prophylaxis; and personal protection measures against arthropod bites, traveler's diarrhea, and injury. Most vaccinations that are appropriate for international travelers are included in the routine domestic immunization schedule; only a few travel-specific vaccines must also be discussed. The most common vaccine-preventable illnesses in international travelers are influenza and hepatitis A. Malaria prophylaxis should be offered to travelers to endemic regions. Personal protection measures, such as applying an effective insect repellent to exposed skin and permethrin to clothing and using a permethrin-impregnated bed net, should be advised for travelers to the tropics. Clinicians should offer an antibiotic prescription that travelers can take with them in case of traveler's diarrhea. Additional topics to address during the pretravel consultation include the risk of injury from motor vehicle crashes and travel-specific risks such as altitude sickness, safe sex practices, and emergency medical evacuation insurance.

Data show that 1.1 billion persons crossed an international border in 2014, and this number is projected to increase to 1.8 billion persons in 2025. 1 Tourism is increasing in both high- and low-income destinations, and is the first- or second-largest source of revenue in 20 of the 48 least developed countries. 2

WHAT'S NEW ON THIS TOPIC: THE PRETRAVEL CONSULTATION

Pregnant women and women of childbearing age who are trying to conceive should postpone travel to Zika-endemic areas. If they do visit these areas, they should be vigilant about arthropod avoidance measures. Because Zika is also transmitted by sex, men who visit Zika-endemic areas should use condoms with pregnant sex partners.

Only a minority of international travelers—36% in one study—seek pretravel counseling; of those, 60% see a primary care clinician, 10% see a travel subspecialist, and 30% turn to friends and family. 3 Although research supports some portions of the pretravel encounter (e.g., malaria prophylaxis, immunizations), the benefit of counseling on other topics (e.g., motor vehicle crashes, safe sex) has not yet been demonstrated. 4

Although consulting a clinician is beneficial to patients at any time before international travel, pretravel visits should ideally occur at least six weeks before departure to maximize benefit of immunizations and other preventive measures. The pretravel consultation is likely to be particularly useful in those visiting low-income nations.

Table 1 outlines the recommended components of the pretravel consultation, 5 , 6 and Table 2 provides resources for clinicians who provide pretravel services. Physicians who perform pretravel consultations only occasionally or who have minimal training in travel medicine may want to refer complex cases to a clinician experienced in travel medicine.

The assessment should include dates of travel, anticipated itinerary, planned activities, mode of travel, and reason for travel. Additionally, clinicians should inquire about the traveler's acceptance level for health risks and budget for health care expenditures.

A full medical history should be elicited from the traveler, including immunization records, medications, allergies, and medical conditions. Certain conditions, if uncontrolled, may increase health risks in travelers and include congestive heart failure, hypertension, seizures, diabetes mellitus, and mental illness. Clinicians may recommend against particular trips or activities if they exceed the traveler's physical abilities or if there is a specific contraindication. Persons who have had a myocardial infarction or coronary artery bypass within the previous two weeks, or a complicated myocardial infarction within the previous six weeks, 7 are thought to be at higher risk of cardiovascular events when flying. Prior use of antimalarials and any adverse effects experienced should be recorded. Physicians should ask women about pregnancy status and birth control method, if applicable.

Selected travel hazards and risk reduction strategies are included in Table 3 . 8 – 12

Noninfectious Risks

The most common cause of death in nonelderly international travelers is motor vehicle crashes, which account for 18% to 24% of deaths in all travelers. Deaths from motor vehicle crashes are markedly more common in low-income nations. Other common causes of death in travelers include violence (e.g., homicide, suicide) and drowning. 13 , 14

Immunization-Preventable Diseases

eTable A summarizes immunizations recommended for international travelers. Live vaccines should be avoided in travelers who are pregnant or immunocompromised.

ROUTINE VACCINES

In general, the diseases on the routine domestic immunization schedule are more common in travelers than are the travel-specific illnesses; hence, travelers should be up to date on the routine vaccines recommended by the Advisory Committee on Immunization Practices. The most common vaccine-preventable illnesses in international travelers are influenza and hepatitis A. The influenza season is between April and September in the southern hemisphere, and it occurs year-round in locations near the equator. Immunization for influenza should be advised when available. Hepatitis A, transmitted by contaminated food and water, is ubiquitous in low-income nations, and the vaccine is appropriate for all travelers older than one year. 15

TRAVEL-SPECIFIC VACCINES

Travel-specific immunizations include those for typhoid fever, 16 yellow fever, Japanese encephalitis, rabies, and cholera. Travelers may be required to show proof of vaccination for yellow fever to enter or return from nations within endemic regions (tropical Africa and tropical South America). Physicians should document yellow fever vaccination on travelers' International Certificate of Vaccination or Prophylaxis (“yellow card,” as approved by the World Health Organization). An example of the vaccine certificate is available at http://www.who.int/ihr/IVC200_06_26.pdf?ua=1 . If travelers have a contraindication to the yellow fever immunization, clinicians should write a letter of exemption or complete the waiver section of the vaccine certificate; these are generally accepted at international borders. Travelers to Saudi Arabia for the annual hajj and umrah (Muslim pilgrimage) are required to show proof of immunization for meningococcal meningitis.

Protection Against Insects and Other Arthropods

Personal protection measures.

It is important to stress to travelers that taking antimalarials does not negate the need for personal protection measures ( Table 4 17 ) , which guard against malaria and numerous other arthropod-borne diseases (e.g., dengue fever, a common illness in most tropical countries). 18 , 19

Insect repellent should be applied to exposed skin. The most effective insect repellents contain 20% to 50% diethyltoluamide (DEET) 20 , 21 or 20% picaridin. Other effective insect repellents are oil of lemon eucalyptus (PMD) and IR3535. Insect repellent should not be applied onto or under clothing. Regular reapplication is important.

Applying permethrin to clothing markedly increases protection against insect bites. 22 , 23 Travelers to malaria-endemic regions should sleep under a bed net impregnated with permethrin unless there is air-conditioning. Wearing long sleeves and pants offers additional protection. The vector for malaria is the female Anopheles mosquito, which feeds at dusk, nighttime, and dawn; minimizing time outdoors during these times will reduce risk. IR3535 does not provide adequate protection against Anopheles mosquitoes and should not be used in malaria-endemic areas.

MALARIA PROPHYLAXIS

Travelers to endemic regions should receive malaria prophylaxis. 24 , 25 The choice of prophylactic medication ( Table 5 20 , 26 ) should be based on whether the patient is going to an area with chloroquine-sensitive or chloroquine-resistant malaria, whether there could be potential adverse effects or interactions with the patient's medical conditions or other medications, the convenience of dosing schedule, and the cost. A summary of countries where malaria is endemic and prophylaxis recommendations from the Centers for Disease Control and Prevention are available at http://www.cdc.gov/malaria/travelers/country_table/a.html . Recommendations from the World Health Organization are available at http://www.who.int/ith/2015-ith-chapter7.pdf?ua=1 .

Regions where chloroquine-sensitive malaria is endemic include Mexico and Central America (west of the Panama Canal), and the island of Hispaniola (Haiti and the Dominican Republic). Options for prophylaxis in these regions are chloroquine (Aralen) and hydroxychloroquine (Plaquenil). Potential adverse effects of these medications include blurred vision, headache, nausea, and vomiting. Hydroxychloroquine may be better tolerated than chloroquine. Primaquine may be used for prophylaxis in areas affected primarily by Plasmodium vivax malaria.

The options for travelers to chloroquine-resistant regions (including most of South America, Asia, and Africa) are doxycycline, atovaquone/proguanil (Malarone), and mefloquine; these agents are equally effective. Doxycycline, which is taken daily, is relatively inexpensive. Potential adverse effects include nausea, photosensitivity, vaginal yeast infections, and esophageal ulceration. Atovaquone/proguanil, also a daily medication, is the most expensive option but has the lowest incidence of adverse effects. Mefloquine, taken weekly, is well-tolerated by most patients, but has a U.S. Food and Drug Administration boxed warning because of its neurologic and psychiatric adverse effects. In some areas of Southeast Asia, malaria is resistant to mefloquine, and doxycycline or atovaquone/proguanil should be used. Antimalarials should not be purchased in low-income nations because there is a high risk of counterfeit, adulterated, or expired medications.

ZIKA VIRUS INFECTION

Zika virus infection is primarily transmitted by mosquitoes, but it can also be sexually transmitted. Since May of 2015, this disease has spread to Mexico and essentially every country in Central and South America and the Caribbean. Risk of microcephaly in the newborn if a woman is infected in the first trimester of pregnancy has been estimated at 1% to 13%. Pregnant women should avoid travel to areas with Zika transmission. Men who live in or visit a Zika-endemic area should use a condom or abstain from sex with a pregnant partner for the remainder of the pregnancy. 27 , 28

Traveler's Diarrhea

Traveler's diarrhea (TD) is by far the most common infection in international travelers, with a rate of 30% to 70% depending on destination and season of travel. The risk is highest in the first two weeks of travel and slowly declines thereafter. 29 Taking medications that reduce gastric acidity, including proton pump inhibitors and antacids, significantly increases the risk of TD. 10 Other risk factors include younger age, diabetes, and immunosuppression.

The etiology of TD is bacterial in 80% to 90% of cases; the remainder are caused by viral or protozoan organisms. Bacterial and viral TD usually present as the sudden onset of loose stools, cramping, and nausea. Other manifestations may include abdominal pain, fever, vomiting, and bloody stools. TD caused by protozoan organisms, such as Giardia , tends to have a more insidious onset and a longer duration of symptoms. 30

Traditional advice (e.g., avoiding food from street stands, tap water, raw foods, and ice) has not been shown to reduce the incidence of TD. 31 Hand washing reduces risk by 30%; alcohol-based hand sanitizer also significantly reduces risk. 32

Prophylactic antibiotics are not routinely recommended. For patients at particularly high risk, taking bismuth subsalicylate (Pepto-Bismol; two tablets four times daily for the duration of the trip) reduces risk by 50% to 65%. 20 , 33 Possible adverse effects of bismuth subsalicylate include a black tongue and dark stool, and contraindications include aspirin allergy, renal insufficiency, breastfeeding, and concurrent use of anticoagulants. There is insufficient evidence for the use of probiotics to prevent TD.

The primary supportive treatment for TD is rehydration. However, in general, TD is not dehydrating, except for in persons who are very young or old or who have chronic illnesses. If dehydration occurs, travelers can rehydrate with most fluids, including water, juice, soda pop, or tea.

Loperamide (Imodium) is a safe and effective antimotility agent that can be used with or without antibiotics. It should be avoided in persons with warning signs, such as blood in the stool or fever, and in children younger than six years. Diphenoxylate is an alternative antimotility agent.

Without treatment, TD usually lasts three to seven days. A short course of antibiotics usually shortens symptom duration to six to 24 hours. 34 , 35 Fluoroquinolones are effective for self-treatment of TD in Africa and Latin America. One regimen is ciprofloxacin taken as one 500-mg tablet followed by a second 500-mg tablet 12 hours later. However, a macrolide, such as azithromycin (Zithromax; 500 mg daily for one to three days or one 1,000-mg tablet [higher incidence of nausea]) is more effective in South and Southeast Asia because of the high prevalence of TD caused by fluoroquinolone-resistant Campylobacter . Given the recent warning by the U.S. Food and Drug Administration regarding adverse effects of fluoroquinolones, 36 clinicians may consider prescribing a macrolide for self treatment of TD regardless of destination. Rifaximin (Xifaxan), an antibiotic with minimal systemic absorption, can be used as a preventive medication (200 mg once or twice daily) or as treatment (200 mg three times daily for three days). It is not approved by the U.S. Food and Drug Administration for TD prophylaxis.

Because TD is usually self-limited, and antibiotics have potential adverse effects, a course of carry-along antibiotics should be prescribed for the patient to use only if needed. To reduce the risk of creating drug-resistant bacteria, antibiotics should be taken only for severe diarrhea. 37

Travelers with TD who develop syncope, dehydration, or symptoms lasting more than one week should seek medical care. Studies show that 3% to 17% of TD cases may result in chronic postinfectious irritable bowel syndrome; the risk increases with multiple bouts of TD. 38 , 39

Emergency Medical Evacuation Insurance

Emergent medical evacuation from a low-income nation can cost $50,000 to $75,000 or more. Emergency medical evacuation insurance is particularly important for older travelers, for those with chronic medical conditions, and for those engaged in high-risk activities, such as high-altitude climbing. Travelers can visit https://www.squaremouth.com/ to compare travel insurance options, including medical and emergency evacuation insurance.

Travelers with Chronic Medical Conditions

Persons with most medical conditions can travel without restriction, but additional advance preparation may be necessary. Medical conditions should be stable before travel, and patients requiring frequent medical interventions should postpone travel to low-income nations.

Travelers who have chronic medical conditions should carry a list of their medications and physician contact information. Medications should be transported in carry-on, not checked, luggage and remain in the labeled containers in which they were dispensed from the pharmacy. Travelers who have diabetes should accept somewhat higher than usual glucose values during travel days to avoid hypoglycemia. Those requiring oxygen should contact the airline several weeks in advance to arrange for oxygen during flights. The Federal Aviation Administration does not allow passengers to carry their own oxygen tanks; battery-powered portable oxygen concentrators approved by the Department of Transportation may be used. Travelers who have a significant history of cardiac events should travel with a recent electrocardiogram.

Pregnant Women

Most airlines allow pregnant women to fly until 36 weeks of gestation. Pregnant women should not scuba dive because of the potential risk of decompression sickness in the fetus and fetal malformations. 40

Data Sources: We searched PubMed, the Cochrane Database of Systematic Reviews, Essential Evidence Plus, AHRQ Evidence Reports, and BMJ Clinical Evidence. Key words: travel medicine, immunizations, malaria prophylaxis, traveler's diarrhea, motor vehicle injuries, pretravel consultation. Search dates: May and September 2015, and June 2016.

note: This review updates previous articles by Bazemore and Huntington , 26 Lo Re and Guzman , 41 and Dick . 42

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• 2024 Oropouche Outbreak
• Causes and Spread
• Health Effects
• Data and Maps
• Clinical Overview
• Clinical Care
• Testing and Reporting
• Response to Oropouche virus disease

Related Topics:

• View All Home
• Oropouche and Pregnancy
• From late 2023-2024, outbreaks of Oropouche virus disease (Oropouche) have been reported in several countries in South America and the Caribbean.
• Travel-associated cases among U.S. residents have been reported, but local transmission has not been detected in the United States.
• Oropouche virus is spread to people by the bites of infected biting midges. Some mosquitoes can also spread the virus.
• Travelers to affected areas should protect themselves from bug bites.
• Pregnant people should avoid non-essential travel to areas with an Oropouche virus Level 2 Travel Health Notice.

Situation summary

Numbers reported to arbonet as of september 17, 2024..

*Total human disease cases include neuroinvasive and non-neuroinvasive disease cases. Neuroinvasive disease occurs when the virus causes inflammation of the brain (encephalitis) or inflammation of the tissues around the brain (meningitis).

For more information on Oropouche ArboNET data and limitations of these data, please visit our Current Year Data page.

Why Oropouche is of concern

• Oropouche virus is an emerging virus in the Americas. The virus is spread to people by infected biting midges and some mosquito species.
• Oropouche is occurring outside the Amazon basin in areas where it hasn't previously been found.
• Several deaths have been reported in people with Oropouche.
• Infection during pregnancy has been linked to fetal death and possible birth defects.

Oropouche in pregnancy

• Oropouche virus can be passed from a pregnant person to their fetus.
• This type of spread has been linked to poor pregnancy outcomes such as fetal deaths, stillbirths, and birth defects.
• The risk of an infected pregnant person passing the virus to their fetus is not currently known.
• CDC is working to understand the potential risks of Oropouche during pregnancy and will share updates as we learn more.

Likelihood of spread to United States

Continental united states.

• Although the likelihood of Oropouche spreading widely in the continental United States is low because of differences in climate, types of biting midges and mosquitoes, and lifestyles (such as the use of air conditioning), some cases may occur in limited areas.
• CDC continues to evaluate the possibility of spread in the continental United States and we will update as we know more.

U.S. territories, such as Puerto Rico and U.S. Virgin Islands

It is unknown how widely Oropouche virus could spread in Puerto Rico and U.S. Virgin Islands.

What you should do

• Use Environmental Protection Agency (EPA)-registered insect repellents.
• Wear loose-fitting, long-sleeved shirts and pants.
• Wear clothing and gear treated with permethrin.
• Control biting insects in and around your home.
• Travelers to areas with Oropouche should use prevention measures to avoid biting midge and mosquito bites during travel and for 3 weeks after travel to prevent additional spread of the virus into unaffected areas in the United States.

If you're a pregnant traveler

• Talk to your healthcare provider about travel plans, why you're traveling, steps to prevent insect bites, and potential risks.
• If you're pregnant and considering travel to areas with an Oropouche Level 2 Travel Health Notice , reconsider nonessential travel.
• If you must travel, strictly follow steps to prevent insect bites during travel.

Prevent bug bites!‎

What cdc is doing.

• Working with state public health and international partners to enable rapid disease detection and surveillance of Oropouche, which will guide prevention measures.
• Providing guidance to state and local public health departments on how to respond to cases that might be identified in the United States or its territories.
• Assisting health departments and medical practitioners with clinical consultation and testing for suspected Oropouche cases.
• Developing and validating new tests for diagnosing Oropouche.
• Working with other federal and state agencies to learn more about the insects that spread Oropouche.
• Funding research in Florida to inform regional capacity to prevent and respond to Oropouche by conducting vector competence studies on local potential vectors using virus strain currently circulating in Cuba.
• Funding communication research to help learn what questions people have about Oropouche.
• Sharing information with partners such as clinicians, public health departments, and community organizations through newsletters, websites, and partner calls and meetings.
• Keeping the public informed through CDC websites and social media platforms as information about Oropouche evolves.
• Updating CDC's Travel Health Notices as new information becomes available.
• Providing clinical consultation and guidance for healthcare providers and tracking the impact of Oropouche virus on pregnant people and infants.

Health Advisory‎

Oropouche virus is spread primarily by midges. Learn about areas at risk, the illness it causes, and ways to prevent becoming infected.

For Everyone

Health care providers, public health.