HEART DISEASE AND TRAVEL

SUMMARY

Persons traveling with heart disease should take the following precautions.

PRE-TRAVEL PLANNING

Weigh the risks of traveling if your condition is unstable (an increase in underlying angina, shortness of breath, edema, or other associated new or worsening complaints, for example). An individual with advancing or unstable heart disease should think very carefully about planning a major international trip, especially if the destination is at a high elevation.

Well before your departure date, consult your physician and/or travel medicine advisor. Obtain adequate protection for infectious diseases, including use of preventive medication as needed, all appropriate vaccines ( influenza – pneumococcal), and a good supply of medication to be used for traveler's diarrhea.

Carry a recent EKG and, if you have a pacemaker, carry a pacemaker card with an EKG.

Contact airlines and hotels well in advance of travel to alert them of any specific dietary needs (i.e., a low sodium or low cholesterol diet); you may be less successful in meeting such needs in developing countries.

MEDICATIONS

Obtain and carry an adequate supply of necessary cardiac medication from your personal physician. You should never anticipate that the same formulation of medications will be available abroad.

Carry a letter on your physician's letterhead stationery, appropriately signed and dated, which states your underlying medical condition and the need for the use of supplies and medications. Also keep all medications in their original containers to avoid having them confiscated at certain border crossings.

Have all prescriptions written using generic names, since trade names vary in different parts of the world. Take along duplicate copies of prescriptions in case you should misplace or lose the drugs you brought with you.

Carry your drugs with you rather than packing them in luggage, in view of the ever-present problem of misplaced baggage.

Some drugs used to prevent malaria ( mefloquine)  may interact adversely with your cardiac medication or may be contraindicated because of a particular heart condition..

AIR TRAVEL

Some airlines do not provide oxygen and none provide oxygen for use in terminals or on stopovers. If you need supplemented oxygen during flight, check with the airline in advance for availability, policies, and cost. Passengers are not permitted to use their own oxygen.

Oxygen must be prescribed by a physician (who often must complete a form obtained from the airline medical office) at least 3 working days before departure; the request must be evaluated by the airline before oxygen will be provided.

If recent blood oxygen levels are not available you may have to see your physician to have the levels measured. For individuals who are already oxygen dependent, the vendor that supplies your home oxygen may be able to arrange for oxygen to be provided at your stopover airports by an affiliated dealer.

Because of flight cancellations and potential delays in aircraft departures and arrivals it is critical that travelers requiring oxygen have made appropriate arrangements prior to travel to ensure a continued supply of supplemental oxygen at all times. Whenever possible, try to obtain non-stop flights (no layovers). If that is not possible, try to use the same carrier for all legs of a trip in order to minimize the possibility of a glitch in the provision of oxygen at all stopovers.

To avoid delays, arrive early to pay service charges at the ticket counter. A prescription at check-in may also be required, specifying the method of administration and the flow rate (which is often limited to either 2 or 4L per minute). Some airlines may require a written order from your physician for you to be able to use oxygen during takeoff and landing, as well as in flight.

Most airlines supply face masks that are not very comfortable. Personal nasal prongs, extra connectors, and scissors (assuming that they won't be confiscated) should be carried aboard as a back-up.

Check with your cardiologist if you are wearing an implantable defibrillator to determine whether portable airport security magnets can interfere with its function. You may need to carry a letter from your physician (on letterhead) warning of this potential problem.

Walk through the cabin at least every 2 hours, carry out foot exercises, and wear support hose to prevent clots from developing in your legs during flight.

Passengers with previous confirmed  Deep Vein Thrombosis may consider an injection of Low molecular heparin prior to taking flights longer than 6 hours duration  ( if no contraindication).

MEDICAL CARE ABROAD

Wear a Medical Alert wrist band or carry other information at all times that identifies your underlying disease and all medications you are currently taking. Include a history of all known allergies or sensitivities, especially to medications.

Obtain names of physicians in the cities you will be visiting in case complications should arise. Also make sure adequate facilities exist to take care of any problem which may arise. IAMAT membership.

PULMONARY DISEASE AND TRAVEL

SUMMARY

Persons traveling with pulmonary disease should take the following precautions:

PRE-TRAVEL PLANNING

Consult with your physician and/or a travel medicine advisor well before your departure date, to make sure your health is stable, all necessary medications and immunizations have been provided, and any special needs (oxygen, face masks, respirators, etc.) can be met. Some individuals who are not oxygen-dependent on the ground may require oxygen during air travel due to the lower cabin pressure and hence oxygen levels.

Patients should have annual influenza vaccines and have a pneumococcal vaccine. 

If you need supplemental oxygen, verify that supplies of oxygen are available in specific areas where you will be traveling.

Inquire about the amount of walking, climbing, and high-altitude exposure that might be required by your itinerary.

AIR TRAVEL AND OXYGEN

Consult your physician and/or travel medicine advisor to make sure that traveling by aircraft does not jeopardize your oxygen requirements. Some airlines do not provide oxygen and none provide oxygen for use in terminals or on stopovers.

Passengers are not permitted to use their own oxygen. Investigate airline policies and costs for providing oxygen.

Oxygen must be prescribed by a physician (who often must complete a form provided by the airline medical office) at least 3 working days before departure; the request must be evaluated by the airline before oxygen will be provided.

If recent blood oxygen levels are not available you may have to see your physician to have the levels measured. For individuals who are already oxygen dependent, the vendor that supplies your home oxygen may be able to arrange for oxygen to be provided at your stopover airports by an affiliated dealer.

Because of flight cancellations and potential delays in aircraft departures and arrivals, it is critical that travelers requiring oxygen have made appropriate arrangements prior to travel to ensure a continued supply of supplemental oxygen at all times. Whenever possible, try to obtain non-stop flights without layovers. If this is not possible, try to use the same carrier for all legs of a trip in order to minimize the possibility of a glitch in the provision of oxygen at all stopovers.

To avoid delays, arrive early to pay service charges at the ticket counter. A prescription at check-in may also be required, specifying the method of administration and the flow rate (which is often limited to either 2 or 4L per minute). Some airlines may require a written order from your physician for you to be able to use oxygen during takeoff and landing, as well as in flight.

Most airlines supply face masks that are not very comfortable. Personal nasal prongs, extra connectors, and scissors (assuming that they won't be confiscated) should be carried aboard as a back-up.

MEDICATIONS

Obtain and carry a letter from your physician on letterhead stationery, appropriately signed and dated stating your medication requirements and other accompanying equipment such as supplemental oxygen. Keep all medications in their original containers. Consider switching inhalers to diskus or turbohaler  form. Certain countries have a ban in gas powered inhalers.

Take along duplicate copies of prescriptions (in generic rather than trade names), in case you should misplace or lose the drugs you brought with you.

Carry your drugs with you rather than packing them in luggage, in view of the ever-present problem of misplaced baggage.

Carry a sufficient quantity of your required medication and inhalers if you have asthma. Certain locations such as China , Cairo, Sao Paulo ( Brazil) and Mexico City may have pollution problems in major cities and may pose special risks for the individual with lung disease.

Carry a supply of medication for the recurrences of bronchitis ( Keflex- Biaxin- Tetracyclyine. The antibiotics that you customarily take for bronchitis may not be available in the particular country you are visiting.

RESPIRATORS AND MASKS

Obtain a special filtration mask and avoid outside exposure when pollution, humidity, and pollen are severe in areas of travel.

Check with your physician about the advisability of traveling while using a respirator or nebulizer.

Check voltage/amperage in locations you will be visiting (if you use a respirator- nebulizer) to make sure you have proper power transformers.

MEDICAL CARE ABROAD

Carry some medical alert information, preferably a Medical Alert wristband containing the diagnosis of your pulmonary disease. Also include your history of any known allergies or sensitivities, especially to medications.

If possible, obtain the names and contact information of physicians and preferred medical facilities in the cities you will be visiting, in case complications should arise. IAMAT membership.

DIABETIC TRAVELERS

SUMMARY

Persons with diabetes who plan to travel should take the following planning steps.

PRE-TRAVEL PLANNING

Weigh the risks of international travel

Avoid travel to developing countries if you have complications of diabetes that are unstable.

Contact airlines and hotels to notify them of any specific meal plan requirements;

Carry preferably a Medical Alert wristband.

Obtain and carry a letter from your physician on letterhead stationery, appropriately signed and dated, stating your medical history and your requirements for insulin or oral hypoglycemic agents and other accompanying equipment.

 Keep all medications in their original containers.

Carry  drugs in carry on luggage.

Take along duplicate copies of prescriptions in case of loss.

Prescriptions written using generic names

Carry extra supplies.

Carry a supply of glucose tablets or gel in the event of a low blood sugar reaction and a supply of non-perishable snacks such as boxed juices, peanut butter, fruit trail mix, crackers, etc.

Before leaving, obtain (IAMAT) membership.

Make sure that your travel insurance covers overseas care and medical evacuations.

TRAVELING WITH INSULIN

Depending on the manufacturer, opened vials of insulin can be stored for 30 days at room temperature or for up to 32 to 90 days when refrigerated. Insulin that is stored at temperatures above 86°F will deteriorate

Aircraft cabin pressure is often lower than that in the insulin vial.

Air should not be injected into the vial. Also, at lower pressures and oxygen levels in aircraft, glucose meters may underestimate blood glucose

Most manufacturers of glucose meters indicate that this should not be a problem; however, it would be prudent to check with the customer service representative of your meter manufacturer before travel.

There are no simple sets of rules to deal with the problem of glucose control through many time zones. The key is to avoid hypoglycemia. Traveling east shortens the day and therefore lowers insulin requirements. Traveling west lengthens the day, requiring additional insulin and snacks. No matter which direction you travel, test your sugar more often.

Remember to adjust your insulin for changes in activity level.

In North America, insulin syringes are designed to be used with u100 insulins. If you purchase u40 insulin, which is available in other countries, you will also need to purchase u40 syringes in order to get the correct dose. Many countries do not have 70/30 or 50/50 insulin or insulin pens.

AIR TRAVEL

On an aircraft, don't take your pre-meal insulin until the meal is on your tray in case turbulence interrupts the meal service. Also, be prepared for flight delays and lost luggage.

Teach your traveling companion how to deal with an emergency, especially low blood sugar, and how to give glucagon.

Ensure that you remain well hydrated since the aircraft often has low humidity.

On long flights, exercise your legs every two hours if possible and walk in the aircraft to prevent a clot developing in your legs.

STAYING HEALTHY ABROAD: SPECIAL PRECAUTIONS

Particular attention to food and water precautions is important to avoid traveler's diarrhea and its adverse effect on diabetic control. Carry loperamide and an antibiotic (e.g., ciprofloxacin, levofloxacin, azithromycin) for self-treatment of traveler's diarrhea, and consider carrying oral rehydration salts. Those with type 1 or difficult-to-control diabetes may want to consider taking an antibiotic to prevent traveler's diarrhea for trips of less than 4 weeks.

Some oral hypoglycemic agents (e.g., glyburide, glipizide) may increase sun sensitivity, and additional sun protection may be necessary.

Foot care is important. Carry a spare pair of shoes, inspect feet daily, don't walk barefoot, and don't break in a pair of shoes during travel.

Acclimatization to hot climates may be impaired with diabetes. Frequent rest stops, adequate hydration with extra salt, and a reasonable pace of activity are important to prevent dehydration and heat illness.

Urinary tract infections can be reduced by staying well hydrated, and yeast infections of the skin can be prevented by frequent bathing and keeping the skin dry.

Dr Assad

Elderly traveler

Increase availability of time – resources – and packages directed to senior travelers will expose seniors to a variety of destinations and health risks.

The elderly  special health concerns that are impacted by travel.

Insurance considerations:

• A comprehensive travel insurance plan is needed as for  all travelers.
• The senior with pre-existing medical conditions may have difficulty obtaining a reasonably priced insurance. The senior’s health condition must be stable ( no change in condition or therapy ) for at least 3 months before departure. Upcoming travel plans should be communicated to traveler’s family physician in order to avoid minor elective changes in therapy that could compromise insurance coverage.
• Medical care overseas should be sought usual. Dialysis units catering to travelers can be booked in many parts of the world.

Medical kit:

Fully stocked medical kit with extra medications ( see Medical Kit Outline)

Copy of medical chart – Recent ECG-waivers. Fiber supplements laxatives should be included.

Acclimatization

• Avoid transdermal scopolamine: mental changes – constipation-dry mouth common. Meclizine (Bonamine) – Diphenhydramine (Gravol) better.

• Internal temperature control, and perspiration mechanism are altered in the elderly leading to increase heat exhaustion and stroke.

• Sedatives for jet lag should be used with caution – Increase CNS suppression- decrease memory .

• High altitude travel is possible in the elderly without severe disability at sea level. However pre trip considerations such as hydration, TD prevention, calorie intake should be stressed.

Immunization:

• Differ very little from general population : Annual influenza -  Adequate pneumococcal coverage for > 65 years old and chronic illness history.

• Live vaccines such as Yellow Fever may place the elderly with depressed immunity at risk of actually contracting the disease from the vaccines. Several such deaths have been recorded. Therefore the actual risk must be carefully weighted before vaccination. Dispensation waivers should be considered when the risk level does not warrant  vaccination.

• Routine immunization coverage and titers have shown to be low in the elderly ( in 40%) . Travel offers a good opportunity for boosters for Td-Polio.

• Seniors from developing countries may have natural immunity to hepatitis A.

Risk of injury:

Poor  muscle tone - coordination-balance – vision – disabilities:  may lead to increase risk of falls and injury. Osteoporosis will increase risk of fractures.

Malaria Prophylaxis:

• No increase in side effects

• Mefloquine may affect conduction disorders- exacerbate preexisting insomnia and depression.

Traveler’s Diarrhea:

• Incidence same as general travelers- Morbidity from TD may be increased : Changes in renal function – electrolyte imbalance – use of diuretics- disabled compensatory mechanisms- make prevention and urgent re hydration  critical in the elderly .
• Loperaminde is preferred over atropine ( Lomotil) because of reduced anticholinergic activity.
• The elderly may benefit from prompt introduction of antibiotics ( Cipro).
• Dehydration may precipitate kidney stones in predisposed patients.

Elderly with Pulmonary – Cardiovascular – Diabetes disease.

See dedicated outlines

Dr Assad

Re: Travel Advisor