PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
Global travel trends have meant a huge increase in the numbers of people travelling abroad, and to increasingly remote countries. In the 1960s, international travellers numbered <100 million. Now over 900 million people travel abroad every year.
There are no published figures for the number of these travelling 'off the beaten track', but it is clear that such destinations are increasingly popular. It's also clear that their (paradoxical) accessibility means they attract a new breed of traveller - those who are not young or particularly fit. It is not unusual to find travellers in their 80s and travellers with significant physical disabilities trekking in the Everest Base Camp region of Nepal, when nocturnal temperatures are beneath -20ºC and the partial pressure of oxygen only 50% of that at sea level. Doctors are increasingly called upon to advise such patients on the safest way to manage their journey.
Issues commonly arise for travellers. For those travelling to a developing country for one month:
- Injury, usually due to road traffic accidents (RTAs), is the most common cause of mortality and morbidity.
- 50% will develop a health problem during their trip.
- 8% will see a doctor.
- 5% will be sufficiently ill to have to stay in bed.
- 0.3% will require hospital admission (either abroad or on return).
- 0.05% will require air evacuation.
- 0.001% will die.
- Only 1-4% of travel-related deaths are due to infectious disease.
Increasingly - and sensibly - travellers visit their doctor before departure asking for advice and support. This usually falls into several categories:
- Malaria prevention.
- Advice on eating and drinking and staying well.
- Contraception and sexual health for travel.
- Advice on personal fitness to travel, including concurrent diseases.
- Advice on specific physical challenges of planned trip - eg, altitude, heat, exercise.
- Advice and help in preparing first aid/medical kit, including issuing prescriptions.
- Advice on whether to travel at all.
The patient's own doctor is well placed to advise on these matters. Knowledge of the patient's medical history including medication and allergies is an essential part of advising them on management of illness abroad.
The consultation should be approached as any other, with careful questions about the planned nature and timing of travel making up the risk assessment and providing the bases for advice and management decisions.
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It is essential to determine where, when and how the patient is travelling, and for how long. What activities are planned (walking, climbing, base-jumping)? What sort of conditions will they face? Are they travelling in a supported group or alone? If in a group, will there be a first-aider or doctor present?
- Mode of transport - risks of overland, sea or air travel differ.
- Destination: this leads on to assessment of expected conditions of hygiene, sanitation, access to medical care and water quality.
- Destination (and stop-overs) also allows assessment of the risk of exposure to infectious disease, including those which may be emergent, endemic or epidemic.
- Duration of visit - risk increases with length of stay in general.
- Contact with local population (this is significant when considering the risk of acquiring tuberculosis).
- Likely contact with animals (eg, risk of rabies for volunteers working at animal rescue centres).
- Purpose of travel - tourists may be likely to stay in better-quality accommodation than aid or emergency relief workers or those visiting friends and relatives in developing countries.
- Behaviour and lifestyle of traveller - riskier activities increase the chances of mishap.
- Pre-existing medical conditions - doctors may be consulted to assess an individual's fitness to travel. Ideally the patient should be as stable as possible, with arrangements made in advance to reduce/eliminate foreseeable difficulties.
- Physical challenges of the environment (eg, altitude, humidity, temperature, UV exposure).
- Planned social behaviour - sexually transmitted and blood-borne disease (eg, HIV, hepatitis B and hepatitis C) represent avoidable risks.
Advising against travelling
It is sometimes necessary to advise against travel altogether. The accessibility of remote destinations in challenging environments means that patients often book trips for which they are not physically prepared. If the doctor believes the risk of travel is unacceptably high then they have a professional obligation to say so. This can be difficult as patients will be deeply disappointed. Advising against travel will also make it difficult if not impossible for patients to obtain health insurance. There are clear published guidelines in some areas - for example, around fitness to fly or to dive. It is obvious that a patient with unstable ischaemic heart disease is at risk from exertion at altitude, and a patient with alcohol dependency is unlikely to manage the privations of remote trekking. However, most patients wishing to travel do not fall into such obviously high-risk categories, and it is not always easy to determine the point at which the risk of travel becomes too significant.
A review of vaccination status is an essential part of pre-travel advice. Patients should carry a copy of their travel vaccination history and, where applicable, a copy of their yellow fever vaccination certificate.
Follow up-to-date guidelines:
- Ensure routine immunisations are up-to-date.
- Plan an immunisation programme based on recommendations and compulsory vaccines.
- Recommended intervals between doses and vaccines should be followed to allow optimal antibody production prior to travel. At least 10 days (ideally three weeks) should ideally separate all travel vaccinations so that any adverse reaction can be correctly attributed; however, in practice, many vaccines are often given simultaneously due to time constraints, without ill effect or loss of efficacy. Live vaccines should be administered at least three weeks apart or on the same day.
See separate article Malaria Prophylaxis.
Advice on eating and drinking and staying well
Guidance on eating and drinking is provided in the separate article Traveller's Diarrhoea. However, in many areas and with many types of trip, traveller's diarrhoea is inevitable, occurring, for example, in 100% of trekkers in the Annapurna region of Nepal.[
Constipation is also common in travellers, often triggered by dehydration, lack of fresh vegetables (due to sensible caution) or over-use of loperamide. Travellers should be advised to increase their fluid intake and if not passing a daily stool, use oral senna tablets (two daily at first, increasing to 3-4 if not effective in 24 hours) to try to re-establish a comfortable pattern.
- This results from the ingestion of food containing toxin-producing bacteria.
- Onset is very swift and it classically affects multiple people who ate the same meal, within a fairly short time.
- Nausea, vomiting and cramps may be severe.
- Patients are pale, sweaty and unwell.
- Diarrhoea may start with or after the vomiting.
- Recovery is usually within 24 hours with supportive treatment only.
Contraception and sexual health for travel
- Sexually active patients will need advice on contraception for travel.
- Doctors should offer advice regarding how to manage oral contraception in the event of vomiting and diarrhoea.
- Women taking oral contraception should be made aware of the increased DVT risk associated with long-haul travel by air and prolonged periods of coach or car travel, particularly if dehydrated. Patients should be advised of symptoms to look out for and on the use of preventative flight socks.
- Women of menstrual age may seek advice on postponement of periods with progesterone. Hormones for postponement of menses do not offer contraceptive protection, and may increase the risk of DVT.
- Doctors should advise patients of both sexes to take condoms on their trip and engage in safe sex. Patients should by advised against sexual contact with high-risk individuals such as sex workers in developing countries. Condoms purchased abroad may not be manufactured to the same protective standards as those in the UK. In a Dutch study, 4.7% of individuals who were seen in a pre-travel clinic had casual sexual contact whilst abroad, usually not anticipated prior to travel and frequently without protection (condoms, hepatitis B immunisation). An individual's sexual risk-taking may increase with travel, increasing their risk of contracting HIV, hepatitis B or other sexually transmitted infections. Inhibitions are further reduced by alcohol and drug taking.
- Availability of emergency contraception in the destination country should be considered. Patients might wish to take a 'morning after' pill.
- The safest sexual practice when travelling to remote locations is no sex, or at least, no sex with anyone who is not already the established and trusted sexual partner.
Advice on personal fitness to travel including concurrent diseases
- See separate article Flying with Medical Conditions for information on assessing fitness to fly.
- Patients must inform companies providing medical travel insurance of any pre-existing medical conditions when the policy is obtained.
- Doctors should discuss and assess the patient's fitness for the activities and environment they plan for their trip
- Exercise, particularly strenuous exercise, is a greater strain on the heart at altitude (where blood oxygen saturation is lowered) and in extreme heat.
- Advising against travel will almost certainly invalidate their insurance.
- Patients on prescribed medication should carry a medical letter with details of the condition and any treatment (ideally, a list of any drug therapy with generic names and dosages).
- Patients should carry sufficient medication to cover the entire duration of the trip and any possible delays, and to keep this in their hand luggage for the journey.
- There are fluid restrictions in hand luggage on most flights, so liquid medication may need to be well insulated in the checked luggage. Some medications such as medium- and long-acting insulins should not be allowed to freeze.
- Not all medications can be carried across all borders, even if prescribed. The carriage of controlled drugs across borders is a particularly difficult issue. Most countries will allow patients to bring in packaged medication clearly prescribed for them. Travelling medics may obtain Home Office letters of 'authorisation' to carry specific medications for medical use. However, such letters do not have legal status in other jurisdictions. In the USA, for example, medical diamorphine is an illegal substance in all circumstances.
- Patients should keep a list of routine prescriptions (generic names and doses). Be aware that some countries restrict drugs, even where prescription. All medications should be carried in pharmacy-labelled bottles.
- Treatment for certain conditions (eg, insulin-treated diabetes mellitus) will require adjustment over travel periods.
- Immunosuppressed patients should not receive live vaccines.
- If a patient experiences infrequent but recurrent issues such as vaginal thrush, cystitis or migraine, they should take a course of their usual treatment for this in addition to any first aid kit.
Special patient groups
Remote travel advice to patients with diabetes
Patients with diabetes who use insulin can be referred to the Diabetes UK website for specific advice on caring for insulin when travelling.
- Remote locations may present a particular challenge to keeping equipment clean.
- If exercise levels increase, calorie intake may need to increase and insulin requirements may fall.
- At high altitudes absorption of calories is reduced so the usual diet may not need the usual insulin dose - patients with diabetes will need to monitor their glucose levels carefully to avoid 'hypos'.
- Patients with insulin-dependent diabetes should be advised that they are at particularly high risk of becoming unwell if they develop severe traveller's diarrhoea. They need to continue taking insulin (possibly at a reduced dose) to avoid ketosis, and they also need to be able to take in calories in order to avoid becoming 'hypo'. This is a difficult situation to manage and they should make sure they are in a position to obtain advice and help should difficulties arise.
- Patients should carry a letter explaining their need to keep insulin and injection equipment in their hand luggage
- Crossing time zones means adjusting insulin.
- Travelling from East to West means lengthening days. If the time zone change lengthens the day by four hours or more there is likely to be an extra meal which is covered by extra insulin. The dose will be patient-specific. Many patients, particularly those with type I diabetes, cover the extra meal with an extra dose of rapid-acting insulin.
- Patients should be reminded that running slightly high will do them no harm whilst running too low is potentially harmful, as it may result in a 'hypo' when travelling.
- Travelling from West to East shortens the day. If the difference is more than four hours, adjustment is usually advised. This normally entails reducing insulin dosage. Some patients may be advised to leave out medium-acting insulins altogether and switch to short-acting insulins for the period of travel.
- Diabetes tablets do not normally need adjustment for travel, unless the time difference is very great.
Remote travel advice to pregnant women
- No pregnancy can be assumed to be risk-free and travel may hamper access to healthcare, records and good communication in the event of complications.
- Some infectious diseases, such as malaria and hepatitis E, are more serious in pregnant women.
- All pregnant women travelling to malarial zones should take chemoprophylaxis and avoid being bitten by mosquitoes:
- Chloroquine and proguanil (usually combined) are suitable for areas at lower risk of chloroquine resistance. A supplement of folic acid 5 mg daily should be taken with proguanil.
- Mefloquine is suitable for women in their second or third trimesters.
- Doxycycline is contra-indicated in pregnancy.
- Atovaquone-proguanil (Malarone®) is not recommended due to a lack of safety data.
- Seek specialised advice if a woman is in her first trimester (or intends to become pregnant whilst travelling) and chloroquine-proguanil provides inadequate protection.
- Immunisations are generally avoided in pregnancy, although inactivated vaccines may be used if the risk of disease exceeds the potential risk to the fetus.
- The best window of opportunity for flying in pregnancy is usually suggested as 18 to 24 weeks. Most airlines will allow pregnant women to fly up to 36 weeks, with a doctor's note beyond 28 weeks.
- Check that travel insurers are aware of the pregnancy.
Remote travel with children
Increasingly, more families are travelling to more exotic destinations for leisure purposes or to visit relatives. Parents travelling with children may be referred to the patient leaflet: Advice for Travelling to Remote Locations. A discussion of risk is essential, to make sure that parents understand what they are taking on on behalf of their child.
- Children can become swiftly unwell and that an unwell adult may have difficulty caring for them. The doctor may prescribe specific paediatric formulations in the travel first aid kit and advise on issues such as management of diarrhoea in children. Parents should be advised that unexplained fever in a child travelling remotely always needs urgent medical review.
- Those visiting family in countries with a malarial risk may assume that they have 'inherited' immunity. However, they will have lost their acquired immunity within several weeks of leaving their 'home' country, and their children, living in the UK, will not have it.
- Routine infant immunisations may be brought forward if children are travelling to high-risk countries for prolonged periods and may have close contact with the indigenous population. Consult product information as to the lower age limit for travel vaccines and the varying ages at which the paediatric dose changes to the adult dose.
- Malarial chemoprophylaxis can be difficult due to issues of compliance:
- A combination of chloroquine and proguanil is suitable in some areas with low or absent Plasmodium falciparum resistance to chloroquine.
- Mefloquine or Malarone® (atovaquone-proguanil) may be suitable in areas with a high risk of chloroquine-resistance P. falciparum but mefloquine should not be used in children weighing less than 5 kg and Malarone® in those weighing less than 11 kg.
- Doxycycline is contra-indicated in children aged under 12 years.
- Compliance with antimalarial drugs is likely to be more difficult in children.
Remote travel advice to patients with mental health issues
- Remote travel can pose significant stress (separation from family and existing social support networks, bewilderment and alienation in foreign culture, difficulties with communication).
- This can exacerbate a pre-existing mental disorder or precipitate one for the first time.
- Attitudes and facilities for caring for those with mental illness vary considerably around the world.
- Patients with ongoing mental health issues may be best advised to postpone their challenging travel until they are stable and well.
Remote travel advice for patients with drug or alcohol dependency
Patients with dependency on alcohol or illegal drugs would be ill-advised to travel to remote locations where they may find themselves either in withdrawal without support, or in very difficult legal trouble for possession of illegal substances.
Remote travel advice to aid workers and those providing disaster relief
This group is at particular risk of ill health. They may be staying in difficult conditions, may themselves be subject to contact with the diseases encountered following a natural disaster, and will be in close contact with local populations.
- Patients should be advised to travel with a recognised aid organisation rather than going it alone. This ensures the most effective help and provides support and, if necessary, evacuation.
- For those offering aid to others, keeping themselves well is clearly essential. If they don't do so they become part of the problem and may themselves require evacuation.
- Travellers should attend any relevant briefings on health and personal safety.
- They may need to pack more than other travellers: items such as goggles, protective gloves and a torch, candles, malaria nets and water purification tablets (bottled water may not be available).
- Aid workers visiting situations of natural disaster, famine, war or other chaotic or disturbing situations should seek medical advice on their return, even if they feel well. This may be an opportunity not only to make sure that they remained healthy but also to discover that they have had difficult or upsetting experiences and need counselling or support.
Risks of high-altitude travel
Patients travelling to altitude may be advised to read the section on altitude illness in a recommended textbook such as First Aid and Wilderness Medicine before they depart. See separate article High-altitude Illness for further information.
Risks of travel in very hot climates
Significant problems associated with travel to very hot climates are:
- The risk of dehydration increases with the increase in temperature, and this is particularly so in patients with diarrhoea and vomiting.
- Children are at particularly high risk.
- Patients could carry oral rehydration salts in their first aid kit.
- Symptoms: weakness, dizziness and nausea.
- Treatment: rest out of the heat until recovered, sipping water.
Heat exhaustion (exercise-related collapse)
- Symptoms: tiredness, dizziness, feeling faint, nausea and vomiting, cramp, rapid pulse.
- Distinguished from heat stroke in part by the fact that the patient is still sweating.
- Treat with shade, rest, rehydration and cooling with fanning or sponging.
- This is a life-threatening condition, when the protective processes which prevent overheating start to fail and body temperature rises.
- Symptoms: fever, with rapid pulse; the patient feels dry and hot, and stops sweating.
- They may lose consciousness or fit.
- Treatment is rapid cooling with sponging, wet sheets, iced water, and fanning.
- Patients also need oxygen and rapid rehydration.
Sun protection and sunburn
80% of skin cancers are thought to be preventable. Excessive sun exposure, and sunburn in children, are a major risk factor for later skin cancer. Skin protection in children and adolescents is crucial. Sun-induced damage is cumulative over a lifetime.
To avoid sun damage patients should:
- Keep out over the 'midday' sun period (from 11 am to 3 pm).
- Stay in the shade.
- Dress to screen from the sun, including wearing T-shirts, long-sleeved shirts and hats.
- Use a broad-spectrum, high-factor sunscreen and replenish it according to instructions.
If burned, apply cold compresses, aloe vera gel or hydrocortisone 1% cream. Painkillers may be needed
Personal first aid kit for a remote trip
The following is a fairly comprehensive first aid kit for two people travelling together to a remote environment. It is based on advice given in 'Pocket First Aid and Wilderness Medicine', a book written by two well-established expedition doctors with experience of looking after travellers in remote locations.
Some doctors may feel uncomfortable at prescribing drugs for patients to treat conditions they don't yet have, which will be taken outside the doctor's 'jurisdiction'. The intention is not to encourage patients to bypass medical help and self-treat when unwell. Self-diagnosis and self-medication should be strongly discouraged. A reasonable first aid kit enables them to seek medical help from other travelling doctors and nurses. They may be advised on what to take from a treatment kit pre-approved as being safe (in keeping with their personal health history) by their own doctor. It also means that the drugs are available when needed, as it is unlikely that a passing travelling doctor will carry spare drugs with which to supply others
Recommended reference book:
- Pocket First Aid and Wilderness Medicine: Drs Jim Duff and Peter Gormly (2007). This is an excellent handbook covering what to do as a layperson in most medical situations you might encounter.
- Thermometer (or 'FeverScan'®)
- Tweezers (pointed-end)
- Sewing needle
- Safety pins x 2
- 10 ml syringe, 2 ml syringe and needles (in packets, sterile)
- Protective gloves - 1 pair
- Sticking plasters - 1 pack
- Blister plasters - 1 pack assorted
- Gauze squares 5 cm x 5
- Sterile non-stick dressings x 5
- Sanitary pad x 1 (for absorbent padding)
- Cotton bandage 10 cm x 1.5 cm
- Crepe bandage 10 cm x 1.5 cm
- Duct tape - 1 small roll
- Wound closures (Steri-Strips®) - 1 packet
- Alcohol swabs x 5
- Sunscreen (high-factor if at altitude)
- Burn cream - eg, silver sulfadiazine or aloe vera gel
- Insect repellent (ideally containing at least 20% DEET)
- Lavender oil - mild antiseptic for wound sterilisation
- Antihistamine tablets - eg, chlorphenamine 4 mg x 10
- Hydrocortisone cream 1% 15 g tube
- Single course of one broad-acting antibiotic - eg, azithromycin 500 mg 3 tabs or ciprofloxacin 500 mg 10 tabs (take your doctor's advice - some antibiotics cannot be taken by children or pregnant women): for severe bacterial diarrhoea
- Single course of co-amoxiclav or amoxicillin: for chest infections
- Metronidazole 400 mg 15 tablets (for stays of more than 3-4 weeks); for gastroenteritis caused by giardia or amoeba (a doctor needs to advise you if you may have this sort of diarrhoea)
- Antibiotic ointment (eg, fusidic acid) 15 g tube
- Antifungal cream (eg, clotrimazole) 15 g tube
- Loperamide 2 mg (for diarrhoea) - pack of 10
- Senna tablets x 5
- Small bottle of antiseptic (eg, Dettol® or Savlon®)
- Antibiotic eye ointment (eg, chloramphenicol)
- Indigestion remedy (eg, ranitidine) 150 mg: 10 tabs
- Buccastem® antisickness tablets x 5
- Paracetamol 500 mg x 10
- Ibuprofen 400 mg x 20
- Oral rehydration salts x 10 sachets
- Throat lozenges - 1 packet (eg, Strepsils®, Vocalzone®)
Additional medication for very high-altitude trekking
- Acetazolamide 250 mg tablets (Diamox® - for prevention and management of altitude sickness) x 10-20.
- Discuss with your GP and trekking group whether your very high-altitude trek also necessitates carrying dexamethasone tablets or nifedipine tablets, both used in altitude sickness emergencies by doctors and nurses experienced in altitude medicine.
Travel insurance varies considerably: travellers should be advised to investigate different providers, to ensure that they have adequate medical insurance to cover emergency repatriation, and ideally the maximum amount of coverage for potential medical, surgical and dental costs.
Illness on return
See separate article Diagnosing The Tropical Traveller.
Infectious disease epidemiology, drug resistance patterns and political situations change rapidly. It is essential that those intending to travel have access to up-to-date advice. Sources include:
- The National Travel Health Network and Centre (NaTHNaC) Health Professionals Advice Line - can be contacted on 0845 602 6712 (calls cannot be taken from the general public), or advice found on the web. It provides comprehensive information on travel-related issues.
- NaTHNaC also run an excellent Travellers Information website.
- Patients should be advised to consult the Foreign and Commonwealth Office's 'Travelling and Living Overseas' website page, for up-to-date advice on safety issues in particular countries.
- Travax offers guidance on UK immunisation schedules and the Health Protection Agency on malaria prevention.
Further reading & references
- Air Travel and Pregnancy, Scientific Impact Paper No. 1; Royal College of Obstetricians and Gynaecologists, May 2013
- Assessing fitness to fly; Aviation Health Unit, UK Civil Aviation Authority (2012)
- Fit for travel; Health Protection Scotland
- Leggat PA; Assessment of febrile illness in the returned traveller. Aust Fam Physician. 2007 May;36(5):328-32.
- Spira AM; Assessment of travellers who return home ill. Lancet. 2003 Apr 26;361(9367):1459-69.; Includes useful management algorithms
- Goldsmid JM, Leggat PA; The returned traveller with diarrhoea. Aust Fam Physician. 2007 May;36(5):322-7.
- Immunizations - travel; NICE CKS, August 2012
- Health Information for Overseas Travel 'Yellow Book'; National Travel and Health Network and Centre (NaTHNaC)
- International Travel and Health; World Health Organization
- Spira AM; Preparing the traveller. Lancet. 2003 Apr 19;361(9366):1368-81.
- Fenner P; Fitness to travel - assessment in the elderly and medically impaired. Aust Fam Physician. 2007 May;36(5):312-5.
- Immunisation against infectious disease - the Green Book (latest edition); Public Health England
- Duff J; Pocket First Aid and Wilderness Medicine, 10th edition, 2007
- Croughs M, Van Gompel A, de Boer E, et al; Sexual risk behavior of travelers who consulted a pretravel clinic. J Travel Med. 2008 Jan-Feb;15(1):6-12.
- Advice to Patients with Type I and Type II Diabetes on Travel and Insurance; Diabetes UK
- Health Information for Overseas Travel 'Yellow Book'; National Travel and Health Network and Centre (NaTHNaC)
- Travellers; National Travel Health Network and Centre (NaTHNaC)
- Travelling and Living Overseas; Foreign and Commonwealth Office
- The A to Z of Healthy Travel; Travax
- Guidelines for malaria prevention in travellers from the United Kingdom; Health Protection Agency (January 2007)
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Hayley Willacy
Dr Mary Lowth
Dr Hayley Willacy