trip health problems

• COVID-19 travel advice

Lower your risk of COVID-19 as you travel for a safe and fun adventure.

Successful travel starts with being prepared for the unexpected. Coronavirus disease 2019, known as COVID-19, is now a part of standard travel planning.

As you choose a destination, travel group or event, add COVID-19 to the list of things to research. When packing for yourself or anyone you're caring for on the trip, consider COVID-19 prevention and testing.

No one wants to plan for the worst. But having a plan in case you catch the COVID-19 virus while traveling can save time if you need medical care.

To start, it can help to ask these basic questions as you make plans.

Am I up to date with my COVID-19 vaccine?

Staying up to date on your COVID-19 vaccine helps prevent serious illness, the need for hospital care and death due to COVID-19 .

If you need a vaccine, plan to get it at least a few weeks before you travel. Protection from the vaccine isn't immediate.

Am I, a travel companion or a person I live with at high risk of serious COVID-19 illness?

Many people with COVID-19 have no symptoms or mild illness. But for older adults and people of any age with certain medical conditions, COVID-19 can lead to the need for care in the hospital or death.

If you or those around you are at high risk of serious COVID-19 illness, take extra safety measures during or after travel.

Ask a healthcare professional if there are any specific actions you should take.

Does my destination, tour group or event need proof that I had a COVID-19 vaccine? Do I need to show proof of a negative COVID-19 test?

The country you travel to may not need to know your COVID-19 status. But you might need the information for other reasons.

Events, venues or tour groups might require proof that you are COVID-19 negative or are up to date on a COVID-19 vaccine. Check before you go so you have all the paperwork you need.

What's the plan if I get COVID-19 on my trip?

No one wants to get sick while traveling. But in case you do, it helps to know where you can get medical care and whether you'll be able to stay apart from others while you have symptoms.

Put together a COVID-19 kit with rapid home tests, masks, a thermometer, disinfectant wipes and hand sanitizer that contains at least 60% alcohol.

Before you leave, gather health information from your healthcare professional. Make sure it gives the details on any health conditions you're managing and medicine you take.

COVID-19 spread during travel

The virus that causes COVID-19 spreads mainly from person to person. When the virus is spreading, spending time indoors with a crowd of people raises your risk of catching it. The risk is higher if the indoor space has poor airflow.

The coronavirus is carried by a person's breath.

The virus spreads when a person with COVID-19 breathes, coughs, sneezes, sings or talks. The droplets or particles the infected person breathes out could possibly be breathed in by other people if they are close together or in areas with low airflow.

The virus carried by a person's breath can land directly on the face of a nearby person, after a sneeze or cough, for example. And people may touch a surface that has respiratory droplets and then touch their faces with hands that have the coronavirus on them.

Clean hands

While you travel, one way to lower your risk of COVID-19 is to clean your hands often.

Wash your hands after using the bathroom, before making food or eating, and after coughing, sneezing or blowing your nose. If you touch something that others regularly touch, such as an elevator button or a handrail, make sure to clean your hands afterward.

Also, try to avoid touching your eyes, nose or mouth.

Wearing a face mask is another way to lower your risk of COVID-19 .

Travel brings people together from areas where viruses may be spreading at higher levels. Masks can help slow the spread of respiratory viruses in general, including the COVID-19 virus.

Masks help the most in places with low airflow and where you are in close contact with other people. Also, masks can help if viruses are spreading at high levels in the places you travel to or through.

Masking is especially important if you or a companion have a high risk of serious COVID-19 illness. Choose the most protective mask that fits well and is comfortable.

Get the COVID-19 vaccine

As the virus that causes COVID-19 changes, COVID-19 vaccines are updated, so stay up to date with the recommended shots.

Know when the COVID-19 virus is spreading in your area

Check with health agencies in the area to see where the COVID-19 virus is spreading. Information about the spread of the virus may include the number of people in the hospital with COVID-19 or the number of people who test positive for the disease.

Keep some space around you

Choose outdoor activities and keep some distance between yourself and others. Poor airflow plus lots of people crowded together equals a higher chance you'll come in contact with the virus that causes COVID-19 .

If you can, try to avoid spending time with people who have COVID-19 symptoms or who are sick.

There will likely be times during travel when you don't have a choice about how close you are to others. Here are some tips for air travel, public transportation and lodging.

The risk of catching the virus that causes COVID-19 from air travel is thought to be low.

Air in the plane's cabin changes over quickly during the flight, being replaced every few minutes in some planes. Airplane air also is often filtered. So germs, including viruses, are trapped before they spread.

The air flowing down from vents above the seats in each row may help keep germs from spreading. Seats also may act as a barrier to germ spread on a plane, unless the person who is ill is sitting close to you.

You can help lower your risk by spreading out to keep distance between you and others when you can and cleaning your hands regularly.

Wearing a mask in crowded areas, such as security lines and bathrooms, can help protect you from COVID-19 and other respiratory illnesses.

Trains, buses and cars

Trains and buses may have good airflow and air filtering. But check before you travel so you know what to expect. When a vehicle is crowded, wear a face mask and take other steps, such as cleaning your hands.

Taxis and private cars used for ride-sharing may not have air filtering. But in most cases, rolling down a window could be an option to improve airflow.

Rental car companies may post their cleaning policies on the internet, or you can ask directly when you book the vehicle.

Hotels and other lodging

Cleaning protocols at hotels, vacation rentals and other lodging have largely returned to the way they were before the COVID-19 pandemic. If you have questions about how hosts or businesses protect guests, contact them directly. In public areas of hotels, take steps to lower your risk of catching the virus that causes COVID-19 .

Put safety first

Despite your planning, an illness may delay or cancel your trip. Stay home if you or anyone you're traveling with has:

• Symptoms of COVID-19 , such as fever or new loss of taste or smell.
• Taken a COVID-19 test and is waiting for results.
• Been diagnosed with COVID-19 .

Keep watch for serious symptoms of COVID-19 , such as trouble breathing or chest pain. If you or a person you're taking care of has symptoms that worry you, get help.

Once the fever is gone and symptoms are getting better, you may choose to travel. But for about five days after feeling better, you could still give others the virus that causes COVID-19 . Take extra actions to protect the people around you.

• Wear a mask.
• Keep your distance from others, especially when indoors.
• Clean your hands regularly.
• Keep the air flowing by turning on fans or opening windows when you can.

If you start to feel worse or your fever comes back, avoid being around others again until you feel better.

Stay flexible

With COVID-19 vaccinations, testing and treatment, events and travel are back to typical levels in many places. But as waves of COVID-19 outbreaks happen, it's important to stay flexible with your plans. Knowing whether the COVID-19 virus is spreading in your area or in places where you're traveling can help you make decisions about whether to go and what to put on your agenda.

• Stay up to date with COVID-19 vaccines. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html. Accessed May 15, 2024.
• Understanding how COVID-19 vaccines work. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/how-they-work.html. Accessed May 15, 2024.
• People with certain medical conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html. Accessed May 15, 2024.
• Coronavirus disease (COVID-19): Travel advice for the general public. World Health Organization. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19-travel-advice-for-the-general-public. Accessed May 15, 2024.
• Centers for Disease Control and Prevention. COVID-19. In: CDC Yellow Book 2024. https://wwwnc.cdc.gov/travel/yellowbook/2024/infections-diseases/covid-19. Accessed May 15, 2024.
• Centers for Disease Control and Prevention. Obtaining health care abroad. In: CDC Yellow Book 2024. https://wwwnc.cdc.gov/travel/yellowbook/2024/health-care-abroad/health-care-abroad. Accessed May 15, 2024.
• Goldman L, et al., eds. COVID-19: Epidemiology, clinical manifestations, diagnosis, community prevention, and prognosis. In: Goldman-Cecil Medicine. 27th ed. Elsevier; 2024. https://www.clinicalkey.com. Accessed May 16, 202.
• Taking steps for cleaner air for respiratory virus prevention. Centers for Disease Control and Prevention. https://www.cdc.gov/respiratory-viruses/prevention/air-quality.html. Accessed May 16, 2024.
• How COVID-19 spreads. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html. Accessed May 16, 2024.
• COVID-19 overview and infection prevention and control priorities in non-U.S. healthcare settings. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html. Accessed May 16, 2024.
• Hygiene and respiratory viruses prevention. Centers for Disease Control and Prevention. https://www.cdc.gov/respiratory-viruses/prevention/hygiene.html. Accessed May 14, 2024.
• About handwashing. Centers for Disease Control and Prevention. https://www.cdc.gov/clean-hands/about/index.html. Accessed May 16, 2024.
• Masking during travel. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/page/masks. Accessed May 16, 2024.
• Masks and respiratory virus prevention. Centers for Disease Control and Prevention. https://www.cdc.gov/respiratory-viruses/prevention/masks.html. Accessed May 16, 2024.
• How to protect yourself and others. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html. Accessed May 16, 2024.
• About physical distancing and respiratory viruses. Centers for Disease Control and Prevention. https://www.cdc.gov/respiratory-viruses/prevention/physical-distancing.html. Accessed May 16, 2024.
• How can ventilation reduce the risk of contracting COVID-19 on airplanes? World Health Organization. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19-travel-advice-for-the-general-public. Accessed May 16, 2024.
• Bielecki M, et al. Air travel and COVID-19 prevention in the pandemic and peri-pandemic period: A narrative review. Travel Medicine and Infectious Disease. 2021; doi:10.1016/j.tmaid.2020.101915.
• Symptoms of COVID-19. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed May 16, 2024.
• Preventing spread of respiratory viruses when you're sick. Centers for Disease Control and Prevention. https://www.cdc.gov/respiratory-viruses/prevention/precautions-when-sick.html. Accessed May 16, 2024.

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• Research article
• Open access
• Published: 13 July 2016

Travelers’ health problems and behavior: prospective study with post-travel follow-up

• Katri Vilkman 1 , 2 ,
• Sari H. Pakkanen 1 ,
• Tinja Lääveri 2 ,
• Heli Siikamäki 2 &
• Anu Kantele   ORCID: orcid.org/0000-0002-0004-1000 2 , 3 , 4 , 5  

BMC Infectious Diseases volume  16 , Article number:  328 ( 2016 ) Cite this article

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The annual number of international tourist arrivals has recently exceeded one billion, yet surprisingly few studies have characterized travelers’ behavior, illness, and risk factors in a prospective setting. Particularly scarce are surveys of data spanning travel, return, and follow-up of the same cohort.

This study examines behavior and illness among travelers while abroad, after return home, and at follow-up. Patterns of behavior connected to type of travel and illness are characterized so as to identify risk factors and provide background data for pre-travel advice.

Volunteers to this prospective cohort study were recruited at visits to a travel clinic prior to departure. Data on the subjects’ health and behavior were collected by questionnaires before and after journeys and over a three-week follow-up. In addition, the subjects were asked to fill in health diaries while traveling.

The final study population consisted of 460 subjects, 79 % of whom reported illness during travel or on arrival: 69 % had travelers’ diarrhea (TD), 17 % skin problems, 17 % fever, 12 % vomiting, 8 % respiratory tract infection, 4 % urinary tract infection, 2 % ear infection, 4 % gastrointestinal complaints other than TD or vomiting, and 4 % other symptoms. Of all subjects, 10 % consulted a doctor and 0.7 % were hospitalized; 18 % took antimicrobials, with TD as the most common indication (64 %). Ongoing symptoms were reported by 25 % of all travelers upon return home.

During the three-week follow-up (return rate 51 %), 32 % of respondents developed new-onset symptoms, 20 % visited a doctor and 1.7 % were hospitalized.

Factors predisposing to health problems were identified by multivariable analysis: certain regions (Southern Asia, South-Eastern Asia, and Eastern Africa), female gender, young age, and long travel duration.

Conclusions

Despite proper preventive measures like vaccinations, malaria prophylaxis, and travel advice, the majority of our subjects fell ill during or after travel. As the symptoms mostly remained mild, health care services were seldom needed. Typical traveler profiles were identified, thereby providing a tool for pre-travel advice. The finding that one third reported new-onset illness during follow-up attests to the importance of advising clients on potential post-travel health problems already during pre-travel visits.

Peer Review reports

According to travel records for 2015, the number of international tourist arrivals exceeded one billion, and half a billion people headed to emerging economies [ 1 ]. Less than half of the visitors to poor regions have been shown to seek pre-travel health advice, as exemplified by only 15 % of Canadians visiting hepatitis A endemic countries [ 2 ] and 31 % of Australasians traveling to Asia, Africa, or South America [ 3 ]. This is surprising, considering the high morbidity rates (64–70 %) reported for visitors to developing regions [ 4 , 5 ].

Investigations addressing travelers’ health have generally been retrospective and/or conducted among those seeking medical care after their journeys [ 6 – 21 ]. Not many prospective studies focus on the spectrum of travelers’ diseases [ 4 , 5 , 22 – 27 ]. Among these we found only one that looks at the same cohort during and after travel and also includes a post-travel follow-up [ 4 ]. The principal findings of the prospective studies are mildness of symptoms [ 4 , 22 ] and small proportion of those falling ill who seek medical care: 2–33 % of the total study population visit a physician and 0.1–4 % are hospitalized [ 4 , 5 , 22 , 24 , 25 , 27 ] during travel. After returning home, 9–20 % of all travelers have been reported to see a doctor [ 4 , 5 , 22 , 25 ] and 0.0–1.0 % to be hospitalized [ 4 , 22 , 27 ]. Even though those with the most severe symptoms probably seek medical care, it should be noted that they represent only the tip of the iceberg among travelers falling ill. To get a comprehensive view of travel-associated health problems, prospective study designs should be employed for collecting data on illness while abroad, after return, and at follow-up.

To examine the health problems of travelers overseas, we recently conducted a nation-wide study of a large Finnish database provided by an assistance organization [ 21 ]. While these data presumably cover cases with the most severe symptoms, we sought to complete them with a prospective study that would comprise even mild illness. By including a post-travel follow-up, we extended the research to symptoms not developing until after return.

Volunteers and study design

Volunteers to this prospective study cohort were enrolled at the Travel Clinic of Aava Medical Centre among travelers planning a journey outside the Nordic countries for a minimum of four days and a maximum of six months (Fig.  1 ). The only exclusion criterion was non-compliance in returning questionnaires. The subjects were recruited among consecutive clients at pre-travel appointments between December 2008 and February 2010. At the initial visit, they filled out a pre-travel questionnaire (Q1), on return home a post-travel questionnaire (Q2), and about three weeks later a follow-up questionnaire (Q3). Those who failed to return both Q1 and Q2 were excluded. In addition to the questionnaires, the subjects were asked to complete a structured diary on a voluntary basis. All volunteers were given pre-travel advice by a health care professional.

Study protocol, population, and information collected by questionnaires of a total of 524 travelers recruited at the pre-travel consultation

We have earlier reported risk factors for acquiring resistant intestinal microbes in the same population [ 28 ], and, data on diarrheal pathogens, first in our methodological investigation [ 29 ] and, recently, in an etiological study [ 30 ].

Questionnaires

The questionnaires consisted of 134 multiple-choice or open-ended questions: Q1 comprised 47, Q2 60, and Q3 27 questions. These questionnaires were modified from a set of survey questions routinely used for more than 10 years for ill travelers admitted to the Clinic of Infectious Diseases at HUCH. All items covered are listed in Fig.  1 . The structured diary contained more specific questions on duration and severity of symptoms, and use of antibiotics.

Definitions

Subjects were classified as ill if they reported symptoms implying health problems which could be travel-related. Diarrhea was defined according to WHO criteria, i.e. passage of 3 or more loose or liquid stools per day, or more frequently than is normal for the individual (World Health Organization [ 31 ]). At follow-up, symptoms which had set in more than two days after a journey and could be travel-related were categorized as newly onset.

Destinations

The countries visited were grouped into nine geographic regions (UN categorization, modified [ 32 ]): Southern Asia, South-Eastern Asia, Eastern Asia and Central Asia, Southern Africa, Eastern Africa, Western Africa and Middle Africa, Northern Africa and Western Asia, Latin America and the Caribbean, and Europe and Northern America (Table  1 ). The destination with the greatest health risk was considered primary for subjects traveling to several places. Here we used a rating based on the risk map drawn up by International SOS (Additional file 1 : Figure S1 HealthMap 2010) which takes into account a range of factors: the standard of local medical and dental care, access to prescription drugs, the possible prevalence of serious infectious diseases, and known cultural, linguistic and administrative barriers.

Univariable, bivariable and multivariable models were used. The p-value of Pearson Chi-square tests and Fisher’s exact test < 0.05 was considered statistically significant. If bivariable p-value was less than 0.10, the factor was chosen to the multivariable logistic regression model, and its adjusted odds ratios and 95 % confidence intervals were calculated. Missing data were assumed to be missing at random (MAR) and missing values were imputed using multiple imputations in SPSS. The statistical analyzes were carried out with SPSS Statistics (version 22.0.0.2, IBM Corp., USA).

Cohort population and prophylactic measures

Of the 524 initially recruited travelers, 88 % completed both pre- and post-travel questionnaires. The final study population thus consisted of 460 volunteers (Fig.  1 , Table  1 ). A total of 233 (51 %) returned follow-up questionnaires and 295 (64 %) filled in diaries. An underlying disease or condition was recorded for 192 (42 %)(Table  1 ), more frequently among the oldest subjects (56– years, 73 %; p  < 0.001), and females (45 %; p  = 0.046) than in other age groups (0–55 years, 23–38 %) or among males (36 %). Data on vaccinations are presented in Table  2 and on antimalarials in Table  3 .

Travel information and behavior

The 460 travelers visited 77 countries altogether (UN definition); India (64), Thailand (60), Gambia (50), Tanzania (48), and Kenya (40) ranking as their most popular destinations. Overall 662 country visits were made (average 1.45 per person; range 1–8). The 30 most favored countries accounted for 560 journeys (85 %); only three destinations were in developed regions (UN definition [ 33 ]): USA (8), Spain (7), and the Netherlands (5).

Uncooked meat/fish (Table  4 ) was eaten more frequently by young adults (18–35 years, 17 %) and the middle-aged (36–55 years, 13 %) than children (0–17 years, 6 %) and older travelers (56– years, 6 %) ( p  = 0.016). Young adults proved more likely than the others to have freshwater contact, neglect hand washing, and not to shun salads or eating without utensils. Men consumed more alcohol than women ( p  < 0.001).

Traveler profiles

Traveler profiles by age.

The median duration of travel was 23 days for the young adults and 15 days for others (age group vs travel duration group p  < 0.001). Young adults and children stayed most often in guest houses, while the others preferred hotel accommodation (Table  4 ).

Traveler profiles by destinations

To obtain data on typical travelers to the two most preferred geographic regions, Africa and Asia, the destinations were categorized into three subgroups: Africa ( n  = 212), Asia ( n  = 192), and others ( n  = 56). Their characteristics are presented in Table  4 . In bivariable analysis, distribution of age and duration of journey differed between those heading for Africa and those favoring Asia. The median age was higher for those visiting Africa, and the journey was shorter. Likewise, compared to Asia, visitors to Africa had less frequent freshwater contact and ate uncooked meat/fish less often.

Factors with p  < 0.1 in the bivariable analyses (Table  5 ) were included in the multivariable analyses (Table  6 ). Destination associated strongly with health problems. Females were more predisposed to falling ill. Overall, the risk was greatest at 31.5 years of age. The longer the travel, the greater the risk of contracting an illness – it increased each day by 2.5 %. Eating raw meat/fish was associated with healthier travelers.

Geographic regions with demographics and proportions of sick travelers are presented in Fig.  2 . Illness rates by geographic regions were found to accord with respective risk ratings by International SOS (Additional file 2 : Figure S2).

Demographics and illnesses of the 460 travelers. Each box presents data from one of the nine destinations by reporting the number of visitors, their median age in years, median duration of travel in days, and percentages of traveler with diarrhea (TD), respiratory tract infection (RTI), fever, or any symptom while traveling / on arrival. Map graphics devised by Helena Schmidt, HumanArt. N/A = not applicable.1 Europe and Northern America. 2 Latin America and the Caribbean. 3 Western Africa and Middle Africa. 4 Northern Africa and Western Asia. 5 Southern Africa. 6 Eastern Africa. 7 Southern Asia. 8 South-Eastern Asia. 9 Eastern Asia and Central Asia

Health care was sought by 10 % of all subjects and by 13 % of those fallen ill during travel; 10 % and 13 % visited a physician and 0.7 % and 0.9 %, respectively, were hospitalized (Table  7 ). The most common reason for consulting health care professionals while abroad was TD – 4 % of all travelers visited a doctor, and 0.4 % were subsequently admitted to hospital because of this illness.

During follow-up, about one-third reported new-onset health problems (Table  7 ). Their most common single symptom was fever, followed by respiratory tract infection, skin problems, and TD.

Introduction

Investigations addressing travelers’ health have generally been retrospective and/or conducted on those seeking medical care after their journeys, whereas prospective studies are scarce. Furthermore, research tends to focus on the effects that one or just a few specific factors have on travelers’ behavior and illness: destination [ 4 , 26 , 27 ], length of journey [ 4 , 5 , 26 , 27 ], purpose of travel [ 27 ], gender [ 4 , 5 , 26 , 27 ], age [ 4 , 5 , 26 , 27 ], risk behavior [ 5 ], and particular diseases, such as TD [ 34 – 41 ]. We are not aware of any earlier investigations into all these factors with a single prospective cohort of travelers; only one [ 4 ] provides data on the same subjects during and after travel, and at follow-up.

Morbidity during travel and on return

A central finding of our work is high morbidity rate. Despite efficient prophylactic measures taken before travel – exemplified by our vaccination data – the amount of health problems proved striking: as many as 76 % of our subjects reported illness while abroad, and 25 % still had ongoing symptoms or new complaints within two days after returning home. The overall proportion of our subjects with any symptoms while overseas (76 %) correspond to that reported for American (64 %; [ 4 ]), U.K. (64 %; [ 25 ]), and Israeli travelers (70 %; [ 5 ]), but proved higher than percentages presented for German (10-43 %; [ 26 , 27 ]), Swiss (38 %; [ 24 ]), and Swedish travelers (49 %; [ 23 ]). As all these investigations are based on questionnaires, the format of the various questions concerning symptoms may account for the differences.

As regards morbidity in different geographic regions, the percentage of illness proved, as expected, significantly smaller for travelers to advanced countries (20 %) than those visiting developing regions (81 %); the rates were highest for visitors to Southern Asia, South-Eastern Asia, and Eastern Africa. TD accounted for the majority of health problems while abroad / after return (69 %). This result accords with several previous studies [ 4 – 6 , 8 , 10 , 21 – 24 , 26 , 27 , 42 – 44 ].

Morbidity at follow-up

While the symptoms of illness mostly set in abroad, the figures proved unexpectedly high also during the follow-up: new health problems were reported by 32 % of our subjects. This percentage slightly exceeds the result of the only previous study exploring illness on return and at follow-up; the morbidity rate reported by Hill is 26 % [ 4 ]. The duration of follow-up may account for the small difference. In our study it was somewhat shorter (three weeks vs two months). But since the subjects were not asked to give exact dates for their symptoms, the onset could afterwards not be limited to 14 days in cases of TD, respiratory illness, and skin disorders, like in Hill’s report.

At follow-up, the four leading symptoms were fever, skin problems, respiratory illness, and TD, a finding according with Hill’s results [ 4 ]. In our study, fever was the most frequent single symptom – often associated with TD. Diarrhea remained the most common cause for seeking health care.

The data revealed regional differences which enabled profiling our subjects: travelers to Africa tended to be older and more cautious than those visiting Asia, whereas visitors to Asia were typically younger and favored longer trips. Likewise, the data show differences between travelers by age: the young traveled for longest and stayed in guest houses more frequently than the others, were the most likely to eat uncooked meat/fish and salads, not to use utensils, to follow a vegetarian diet, to neglect hand washing, and not to avoid freshwater contact. Not surprisingly, the longer the stay overseas, the lower the degree of travelers’ compliance with hygiene instructions. Such traveler profiles can be used as a tool to target advice at various groups according to their special characteristics.

• Risk factors

Destination, gender, age, and duration of travel were shown by multivariable analysis to be factors predisposing to illness. Southern Asia proved the riskiest resort, as also reported in earlier studies [ 4 , 26 ]. Female travelers proved to be at greater risk of acquiring symptoms (OR 1.7), a finding according with the results published by Hill [ 4 ]. In the present data, each day increased the risk of contracting illness by 2.5 %; the respective figure obtained by Hill was 3.1–3.7 % [ 4 ]. Young age has often been reported to be associated with illness [ 4 , 5 , 8 , 23 , 26 , 27 ]; in our cohort the risk was highest at 31.5 years. Eating raw meat or fish proved to be a protective factor. The reasons for this are not obvious and can only be speculated on.

Limitations of the study

The present investigation has some limitations which deserve to be discussed. Firstly, the results are not representative of all travelers, but of volunteers with pre-travel appointments at a travel clinic. Thus visitors to Africa and other developing regions were overrepresented. Secondly, due to small sample size, statistical analyses of some subgroups were poorly powered. The third limitation concerns the follow-up: the reliability of the conclusions suffers from the fact that only 51 % of our volunteers completed the questionnaire, and many delivered it later than requested. Importantly, however, even if it could be assumed that none of the remaining 49 % had been ill, the number of newly onset symptoms during follow-up remains substantial. The data would have benefited from a comparison to non-traveling controls. Our data collection can also be regarded as a limitation, for questionnaire-based studies may distort the results in various ways. Due to the common use of questionnaires, this tends to be characteristic of research into travelers’ health problems [ 3 , 4 , 6 , 22 – 27 , 42 , 44 – 48 ]; a few previous reports include data collected by telephone surveys [ 2 , 4 , 5 , 8 , 27 ]. In our study, travel diaries may have improved the accuracy of data to some degree. The exact number of clients declining to participate was not recorded. However, based on the number of clients seen by the recruiting doctor and number of those recruited, we estimate that at the maximum 10 % of the potentially eligible clients declined.

Our data in relation to previous estimates of travelers’ health problems

We recently reported incidences of illness and injury among more than 50 000 Finnish travelers visiting various regions [ 21 ] by relating cases recorded by an assistance organization to numbers of travelers to each region. The results were considered to cover the most severe cases. The present data complete that picture by showing even the mildest symptoms contracted. This puts the two studies into perspective. Since 90 % of our travelers did not contact health care, the proportion covered by our previous report may not amount to more than 10 % of the illness altogether – slightly less than estimated in that study [ 21 ]. The strengths of the present research include the prospective study design and the fact that we combined data of three time points (pre-travel, travel/return, and follow-up) for a single cohort. Interestingly, the rate of health problems per region presented in our study accords with risk estimates presented by International SOS (Additional file 2 : Figure S2).

Aspects related to malaria prophylaxis and treatment

Advice on malaria prophylaxis is a cornerstone of pre-travel appointments. In our data, 289 of the 296 travelers (98 %) taking malaria prophylaxis reported compliance. Interestingly, however, four of them, all diagnosed in Africa, were also treated for malaria while abroad. One case was microbiologically verified, two reported a negative malaria test, and one had taken medication without laboratory diagnostics. Our earlier data collected by the assistance organization shows malaria to be rare in travelers (8/50000 cases; Siikamäki, personal communication). Indeed, the diagnoses of our cases may not be correct, as presumptive treatment is often given in Africa [ 49 ], and malaria diagnostics may not always be accurate [ 50 ].

This study with most of its subjects visiting (sub)tropical regions shows that, despite efficient preventive measures like vaccinations, malaria prophylaxis, and travel advice, the majority fall ill during or after travel. TD is the most common disease while abroad, followed by skin problems and fever. After travel, the most frequent complaints are fever, respiratory tract infections, and skin problems. Symptoms generally remain mild, not requiring medical care. The proportion of newly onset illness among returning travelers is considerable: one-third get health problems after their journeys. Advice regarding this should be given already at pre-travel appointments.

Abbreviations

TD, Travelers’ diarrhea

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Acknowledgements

We express our gratitude to the late Dr Jukka Riutta for recruiting the patients. We thank the nurses at the Travel Clinic of Aava Medical Centre for help in recruiting the volunteers, and the personnel of Helsinki University Hospital Laboratory for assistance with the collection of questionnaires. Jukka Ollgren (National Institute for Health and Welfare, Helsinki, Finland) is acknowledged for advice in statistical analyses.

The work was supported by the Finnish Governmental Subsidy for Health Science Research and by the Scandinavian Society for Antimicrobial Chemotherapy Foundation. The funding sources had no involvement in study design, data collection, analysis, data interpretation, writing of the report, and the decision to submit the article for publication.

Availability of data and materials

Data not available.

Authors’ contributions

Study concept and design, KV, AK; acquisition of data, KV, SHP, TL, AK; analysis and interpretation of data, KV, SHP, TL, AK; statistical analysis, KV; drafting of the manuscript, KV, AK; critical comments on the manuscript, SHP, TL, HS; final approval of the version published, KV, SHP, TL, HS, AK. All authors have read and approved the final version of the manuscript.

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Competing interests

The authors declare that they have no competing interests.

Consent for publication

Ethics approval and consent to participate.

The study protocol was approved by the Ethics Committee of Helsinki University Hospital. Written informed consent was obtained from all subjects.

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Department of Bacteriology and Immunology, University of Helsinki, Haartmaninkatu 3, (P.O. Box 21), 00014, Helsinki, Finland

Katri Vilkman & Sari H. Pakkanen

Inflammation Center, Clinic of Infectious Diseases, Helsinki University Hospital and University of Helsinki, Aurora Hospital, Nordenskiöldinkatu 20, (P.O. Box 348), Helsinki, Finland

Katri Vilkman, Tinja Lääveri, Heli Siikamäki & Anu Kantele

Institute of Clinical Medicine, University of Helsinki, Helsinki, Finland

Anu Kantele

Aava Travel Clinic, Medical Centre Aava, Annankatu 32, 00100, Helsinki, Finland

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Correspondence to Anu Kantele .

Additional files

Additional file 1: figure s1..

HealthMap 2010 by International SOS. Medical risk ratings are based on the standard of local medical and dental care, access to prescription drugs, the possible prevalence of serious infectious diseases, and known cultural, linguistic and administrative barriers. Map printed with the written permission of International SOS. This map has been developed for illustrative purposes only. It is a global illustration of medical risk for travellers. For detailed information, please refer to the country guides at internationalsos.com © International SOS, 2010. All rights reserved. Unauthorized copy or distribution prohibited. (PDF 3143 kb)

Additional file 2: Figure S2.

HealthMap 2010 by International SOS presented together with demographics and illnesses of our 460 travelers. Each box presents data from one of the nine destinations by reporting the number of visitors, their median age in years, median duration of travel in days, and percentages of traveler with diarrhea (TD), respiratory tract infection (RTI), fever, or any symptom while traveling / on arrival. Map printed and modified with the written permission of International SOS. This map has been developed for illustrative purposes only. It is a global illustration of medical risk for travellers. For detailed information, please refer to the country guides at internationalsos.com © International SOS, 2010. All rights reserved. Unauthorized copy or distribution prohibited. 1 Europe and Northern America. 2 Latin America and the Caribbean. 3 Western Africa and Middle Africa. 4 Northern Africa and Western Asia. 5 Southern Africa. 6 Eastern Africa. 7 Southern Asia. 8 South-Eastern Asia. 9 Eastern Asia and Central Asia. (TIF 604 kb)

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Vilkman, K., Pakkanen, S.H., Lääveri, T. et al. Travelers’ health problems and behavior: prospective study with post-travel follow-up. BMC Infect Dis 16 , 328 (2016). https://doi.org/10.1186/s12879-016-1682-0

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DOI : https://doi.org/10.1186/s12879-016-1682-0

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ONE CHEL OF AN ADVENTURE

10 common travel problems (and how to solve/prevent them).

Traveling is undoubtedly exhilarating, but let’s be real—it’s not always smooth sailing. From unexpected mishaps to downright frustrating situations, we’ve all encountered our fair share of travel woes. With that in mind, here are some tried-and-true tips to help you navigate through 10 common travel problems and their solutions!

Most Common Travel Issues + Problems

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1. Getting Lost While Traveling

Whether it’s wandering aimlessly in a maze-like city or taking the wrong turn on a remote hiking trail, getting lost is practically a rite of passage for travelers. 

Sometimes, getting lost can lead to some of the most memorable experiences! Embrace the moment, ask locals for directions, use maps (both digital and paper), and consider downloading offline maps  to your phone before setting off.

2. Getting Mugged While Traveling

Safety should always be a top priority while traveling. Unfortunately, muggings can happen, especially in tourist-heavy areas. Stay vigilant, avoid flashing valuables, use discreet/theft-proof bags , and trust your instincts. It’s also wise to split your cash and keep copies of important documents in a separate location. 

Men: You should definitely think twice about wearing a nice watch if traveling to Europe (and in general) — there has been a rise in luxury watch theft lately !

In case the worst happens and you do find yourself in this situation, cooperate and prioritize your safety above all else .

Related Post:   How to Stay Safe While Traveling

3. Losing Your Phone

In today’s digital age, losing your phone can feel like losing a limb. But fret not, there’s hope! Before departing, install tracking apps and enable remote wiping features on your device, especially if you store banking info and other sensitive info on your device (as most of us do). 

Additionally, keep a physical backup of important information such as emergency contacts and reservation details. I typically bring one of my old phones with me as a back up just in case. 

4. Getting Sick in an Unfamiliar Place

Nothing puts a damper on travel plans like falling ill. To prevent sickness , stay hydrated, eat well-balanced meals, and get plenty of rest. Pack a small first-aid kit with essential medications, and consider purchasing travel insurance for added peace of mind. 

If you do fall ill, don’t hesitate to seek medical assistance or rest until you’re feeling better. Don’t make the same mistake I did in  Southeast Asia , it could have been really bad! 

5. Language Barrier

Ah, the beauty of language diversity! While it enriches our travel experiences, it can also pose challenges. To avoid issues, try learning a few basic phrases in the local language, utilize translation apps , and embrace non-verbal cues like gestures and smiles. Remember, a genuine effort to connect goes a long way!

6. Feeling Lonely

Solo travel can be incredibly rewarding, but it’s not uncommon to feel lonely at times. Combat loneliness by staying in social accommodations like hostels or joining group tours and activities. Embrace opportunities to meet fellow travelers, strike up conversations with locals, and stay connected with loved ones back home. 

7. Running Out of Money

Budgeting woes can put a damper on even the most meticulously planned trips. To avoid running out of funds, create a realistic budget before departure and track your expenses along the way. Look for ways to save money , such as cooking your meals or opting for budget accommodations.

And always have a backup plan, whether it’s a stash of emergency cash or access to financial assistance.

8. Missing a Flight

Missed flights are every traveler’s nightmare, but they’re not the end of the world. Stay calm, contact your airline immediately, and inquire about alternative options.

  Travel insurance  can often cover additional expenses incurred due to missed flights, so be sure to review your policy. 

9. Travel Sickness

Motion sickness can turn even the most scenic journey into a nauseating ordeal. To combat travel sickness, sit in the front or middle of vehicles, focus on the horizon, and avoid heavy meals before travel. 

Over-the-counter medications like Dramamine can also provide relief for mild cases. And don’t forget to take breaks and get some fresh air whenever possible.

10. Losing Luggage

Arriving at your destination only to find your luggage missing is undoubtedly frustrating. To minimize the risk, pack essentials in your carry-on and use luggage tags with your contact information. And I always, always, ALWAYS have an Apple Airtag in my luggage so I can see exactly where it is at all times! 

If your luggage goes astray, file a report with the airline immediately and keep all relevant documentation. Most airlines have protocols in place to track and reunite lost luggage with its owner.

Traveling is a rollercoaster ride filled with highs and lows, but it’s the challenges that make the journey worthwhile. By arming yourself with knowledge, preparation, and a positive attitude, you can overcome these Common Travel Problems. 

So, embrace the adventure, stay curious, and remember that the best stories often arise from the most unexpected moments. Safe travels, fellow adventurers!

If you have a question, leave a comment below or send me a DM on Instagram ! 

Related Posts:

• How to Stay Safe While Traveling
• 12 Tips for Overcoming Anxiety While Traveling
• How to Stay Healthy While Traveling

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• Caused a person to seek medical examination, diagnosis, care, or treatment by a doctor;
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It’s important to know that the illness, injury, or medical condition does not need to be formally diagnosed in order to be considered a pre-existing medical condition.

Let’s consider a few scenarios:

• Sudden, debilitating pain in an arthritic knee forces you to cancel your planned trekking tour of Iceland. Because you consulted your doctor about knee twinges three months ago, it’s considered a pre-existing condition.
• While sightseeing in Shanghai, you suffer a mild heart attack. Because you were diagnosed with coronary heart disease three weeks before purchasing travel insurance, this is considered a pre-existing condition.
• You were diagnosed with lupus many years ago, but it’s been in remission. You feel pretty good when you book your cruise to Bermuda, except for some fatigue and a rash. Then the Caribbean sun triggers a serious lupus flare, sending you to the hospital. Because you had symptoms when you booked your trip, this is considered a pre-existing condition.

2. Travel insurance requirements for covering pre-existing medical conditions 

If you’re dealing with a pre-existing medical condition, that does not mean you can’t get travel insurance, or that you shouldn’t travel at all. You just have to read the insurance policy documents very carefully to make sure you meet all the requirements. As Conde Nast Traveler puts it , “it’s best not to make assumptions. Returning home in pain is bad enough. Don’t intensify it by unnecessarily paying thousands of dollars you could use on your next trip.”

Certain Allianz Global Assistance plans can include pre-existing medical condition coverage as long as you:

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• Are a U.S. resident.
• Make sure you’re medically able to travel on the day you purchase the plan. Don’t assume you’re cleared to travel just because you feel OK that day. If you’re living with a chronic condition, or if you’ve recently had surgery or cancer treatment, it’s wise to get written approval to travel from your doctor.
• On the policy purchase date, insure the full non-refundable cost of your trip with Allianz Global Assistance — including trip arrangements that will become non-refundable or subject to cancellation penalties between the policy purchase date and the departure date. Make sure you include your airfare, hotel reservations, tour bookings and any other nonrefundable costs when you’re insuring your trip. If you incur additional non-refundable trip expenses after you purchase your policy, you must insure them with us within 14 days of their purchase. If you do not, those expenses will still be subject to the pre-existing medical condition exclusion.

3. What’s excluded from travel insurance coverage for pre-existing conditions

While most pre-existing conditions are covered by Allianz Global Assistance travel insurance, there are a few exceptions. Mental and nervous health disorders and normal pregnancy aren’t covered, for instance. If you want to make sure your particular condition is covered, speak with an insurance specialist before you buy.

Also, check the cap on trip costs. For the OneTrip Prime Plan , for instance, the total cost of your trip must be no more than $50,000 per person.

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If you have any kind of chronic health problem, travel insurance can save your vacation — or even your life. The best travel insurance for pre-existing conditions is the OneTrip Prime Plan from Allianz Global Assistance, which includes abundant coverage for covered emergency medical expenses overseas (up to $50,000). You also get emergency medical transportation benefits up to $500,000 to travel to the nearest appropriate medical facility or to return home. This is huge, especially if you suffer from a serious condition that might require advanced treatment. The OneTrip Premier Plan doubles these amounts.

Travel insurance from Allianz Global Assistance also can include trip cancellation and interruption benefits to reimburse you for non-refundable trip payments, in case you have to cancel your travel because of your covered pre-existing medical condition or another covered reason. You also get personalized, one-on-one help in emergencies from our hotline staff. Every day they help travelers who are suffering medical emergencies, lost documents, travel delays and other crises, all around the globe. But, our hotline experts say, the toughest thing they deal with is having to tell a customer who’s seriously ill that their pre-existing medical condition's not covered. That’s why it’s so important to follow the rules and meet the requirements.

Have questions about how to choose the best travel insurance for your covered pre-existing medical condition? Call our travel insurance advisers anytime at 1-866-884-3556. Travel happy!

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Insurance benefits underwritten by BCS Insurance Company (OH, Administrative Office: 2 Mid America Plaza, Suite 200, Oakbrook Terrace, IL 60181), rated “A” (Excellent) by A.M. Best Co., under BCS Form No. 52.201 series or 52.401 series, or Jefferson Insurance Company (NY, Administrative Office: 9950 Mayland Drive, Richmond, VA 23233), rated “A+” (Superior) by A.M. Best Co., under Jefferson Form No. 101-C series or 101-P series, depending on your state of residence and plan chosen. A+ (Superior) and A (Excellent) are the 2nd and 3rd highest, respectively, of A.M. Best's 13 Financial Strength Ratings. Plans only available to U.S. residents and may not be available in all jurisdictions. Allianz Global Assistance and Allianz Travel Insurance are marks of AGA Service Company dba Allianz Global Assistance or its affiliates. Allianz Travel Insurance products are distributed by Allianz Global Assistance, the licensed producer and administrator of these plans and an affiliate of Jefferson Insurance Company. The insured shall not receive any special benefit or advantage due to the affiliation between AGA Service Company and Jefferson Insurance Company. Plans include insurance benefits and assistance services. Any Non-Insurance Assistance services purchased are provided through AGA Service Company. Except as expressly provided under your plan, you are responsible for charges you incur from third parties. Contact AGA Service Company at  800-284-8300 or 9950 Mayland Drive, Richmond, VA 23233 or [email protected] .

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It’s the Grim Reality of Frequent Work Travel: Health Problems

By Tammy La Gorce

• Nov. 27, 2017

Their lives may be portrayed as glamorous. In fact, they’re often the opposite. Pity frequent business travelers.

Doctors at organizations including the Centers for Disease Control and Prevention and the International Society of Travel Medicine say they are hearing of a range of health problems in frequent travelers, from insomnia and weight gain to viruses. And they said they see a need for more comprehensive research into the health compromises made by business travelers, both short haul and long haul.

“The whole noncommunicable disease side of travel health is something that’s been under-researched,” said Dr. Martin Cetron , director of the division of global migration and quarantine at the C.D.C.

Lin Chen, the incoming president of the International Society of Travel Medicine and an associate professor of medicine at Harvard Medical School, said that jet lag, combined with a lack of access to exercise and fresh food while on the road and sporadic engagement at home, needs rigorous study. “Right now, it’s hard to know the impact because not enough research has been done,” she said. “But certainly it’s significant.”

Dr. Cetron said the image of the jet-setter who flies around making million-dollar deals no longer reflects the experience of most business travelers. “The reality is that the full spectrum of the work force now travels. Not just C.E.O.s but the more modest businessperson — think of junior employees at multinational companies, or aid workers who are called to respond to international crises. Some of these people have to travel on really shoestring budgets.” For them, flying business class or staying in fancy hotels is not an option.

In 2011, Catherine Richards, a doctor at Boston Health Economics , and Dr. Andrew Rundle , a professor of epidemiology at Columbia University, wrote a report, “Business Travel Linked to Obesity and Poor Health,” published by the Mailman School of Public Health at Columbia.

That study tracked the body mass index; levels of low-density lipoprotein cholesterol, what’s known as “bad” cholesterol; and self-rated healthiness of more than 13,000 business travelers. Dr. Rundle has just completed a follow-up study, and the new findings, currently under peer review, “are pretty much the same as the old ones,” he said. “What we’re seeing is kind of like a U-shaped curve. People who travel the most and people who don’t travel at all have the worst health.”

An explanation for nontravelers’ poor health may be that chronic conditions prevent them from boarding planes in the first place, he said. The culprits of the poor health among constant travelers are the usual suspects: bad airport food, uneven exercise habits and jet lag. If there is a sweet spot, Dr. Rundle said, it may be with those who travel for work only a few times a year.

Dr. Rundle, who lives in western Massachusetts and commutes to Manhattan about five days a month, said he was inspired to look into the health effects of professional travel by his own experience. On a business trip, he said, he learned his options were limited to ordering dinner from a Cheesecake Factory restaurant . “I was just, like, this is not good,” he said. “Catherine and I started looking at business travelers’ B.M.I. data.”

What they found in the initial study was that the average body mass index of travelers who are on the road 21 or more nights a month was higher than in travelers who were away from home one to six nights per month. For a 6-foot-tall person, the difference amounted to a 10-pound difference in weight.

That finding supports what Dr. Rundle said he suspected was a problem for traveling employees. “If you’re in your 30s and you’re traveling a lot and you’re eating poorly and you have poor access to physical activity, that starts to catch up with you,” he said. “Over the next 10 years or so, the consequences start to become things like high blood pressure and diabetes and obesity. Long-term chronic issues.”

His yet-unpublished sequel study looks more closely at business travelers’ mental health — an area both Dr. Cetron at the C.D.C. and Dr. Chen at the International Society of Travel Medicine said was important but fell outside their purview. It includes factors like alcohol abuse and accidents and injuries caused by lack of sleep and jet lag. “These are things that can have really immediate consequences for yourself and your career,” he said.

A Harvard Business Review article in 2015 noted that frequent business travel accelerates aging and increases the likelihood of suffering a stroke or heart attack, and that more than 70 percent of business travelers report some symptoms of an unhealthy lifestyle, including poor diet, lack of exercise, excess drinking, stress, mood swings and gastrointestinal problems. “All of which impair job performance,” it said.

If corporations are taking note, they’re not always taking action. “Travelers themselves are concerned about their health and the amount of time they’re away from home,” said Greeley Koch, executive director of the Association of Corporate Travel Executives , a nonprofit organization with board members from companies including Mastercard and Tesla . Policies to limit travel, or to make it less toxic through measures like upgrades to business class or added time for taking in fresh air during a work trip, depend on bosses and are entirely unregulated, he said. “It’s really a mixed bag when it comes to addressing these issues. It depends on the company.”

Doctors like Phyllis Kozarsky , a professor of medicine in the division of infectious diseases at Emory University School of Medicine and the medical director of TravelWell , a clinic in Atlanta for international travelers, said they see the need for more company attention to the issue.

“A lot of times, I’ll have people come in and say, ‘I was in so-and-so country, and I think I have a sinus infection,’” she said. “Then when I close the door to the exam room, they’ll burst out crying. They made the appointment ostensibly for a sinus infection, but they’re so tired and worn out from traveling that they just need to see someone and talk about it. They don’t want to share it with their business because they’re concerned about walking up the corporate ladder and their ability to succeed.”

Sharing tales of travel weariness at home may not be an option, either.

“I’ll hear things like, ‘My kid had a performance last week and my husband’s upset with me because I wasn’t there,’ or ‘I can’t do this any more and I don’t know how to tell my family,’” Dr. Kozarsky said. “You’re leaving people at home who are not happy you’re gone for a number of reasons, and when you get home you’re trying to catch up on all the things that happened while you were gone, but all you can think about is how tired you are. The only thing you can do as a doctor is to reassure them, to give people permission to feel the way they’re feeling.”

A frequent traveler, Brian Kelly, founder of the Points Guy , a digital platform for travel tips, said his world had been “flipped upside-down” when his dog had an illness recently. “It makes me sick to my stomach to think of leaving him. I have this business, and I have all these events I need to go to, but all I want to do is stay home and take care of my dog. In the back of my mind I know I need to take a 30-day health break,” he said.

Such a break would set off its own work-related stressors, though, he said.

And that is in keeping with what Dr. Cetron of the C.D.C. has been seeing.

“Things are merging and changing in the world of business travel,” he said. “Whether trips are frequent short ones or long ones, the intensity of travel schedules is putting people under a lot of pressure.”

Inside the Biden Administration

Here’s the latest news and analysis from washington..

Blocking U.S. Steel Takeover:  As the Biden administration nears a decision to block the proposed acquisition  of U.S. Steel, the debate over national and economic security  is being dwarfed by presidential politics.

Asylum Restrictions:  The Biden administration is considering actions that would make the president’s tough but temporary asylum restrictions almost impossible to lift , essentially turning what had been a short-term fix into a central feature of the asylum system in America.

Student Loan Debt Plan:  The Supreme Court maintained a temporary pause  on a new effort by President Biden to wipe out tens and perhaps hundreds of billions of dollars of student debt. Here’s what the ruling means for borrowers .

Undocumented Spouses:  A federal judge temporarily blocked a Biden administration program that could offer a path to citizenship for up to half a million undocumented immigrants  who are married to U.S. citizens.

Secret Nuclear Strategy:  In a classified document approved in March, the president ordered U.S. forces to prepare  for possible coordinated nuclear confrontations with Russia, China and North Korea.

U.S. News takes an unbiased approach to our recommendations. When you use our links to buy products, we may earn a commission but that in no way affects our editorial independence.

The Best Travel Medical Insurance of 2024

Allianz Travel Insurance »

Seven Corners »

GeoBlue »

WorldTrips »

Why Trust Us

U.S. News evaluates ratings, data and scores of more than 50 travel insurance companies from comparison websites like TravelInsurance.com, Squaremouth and InsureMyTrip, plus renowned credit rating agency AM Best, in addition to reviews and recommendations from top travel industry sources and consumers to determine the Best Travel Medical Insurance Plans.

Table of Contents

• Allianz Travel Insurance
• Seven Corners

Buying travel insurance is a smart move for any type of trip, but you may not need a policy that covers everything under the sun. If you don't need coverage for trip cancellations or delays because you're relying on your travel credit card to offer these protections, for example, you may find you only need emergency medical coverage that works away from home.

Still, travel medical coverage varies widely based on included benefits, policy limits and more. If you're comparing travel insurance plans and hoping to find the best option for unexpected medical expenses, read on to learn which policies we recommend.

Frequently Asked Questions

The term travel insurance usually describes a comprehensive travel insurance policy that includes coverage for medical expenses as well as trip cancellations and interruptions, trip delays, lost baggage, and more. Meanwhile, travel medical insurance is coverage that focuses on paying for emergency medical expenses and other related care.

Travelers need international health insurance if they're visiting a place where their own health coverage will not apply. This typically includes all international trips away from home since U.S. health plans limit coverage to care required in the United States.

Note that if you don't have travel health insurance and you become sick or injured abroad, you'll be responsible for paying back any health care costs you incur.

Many travel insurance policies cover emergency medical expenses you incur during a covered trip. However, the included benefits of each policy can vary widely, and so can the policy limits that apply.

If you're looking for a travel insurance policy that offers sufficient protection for unexpected medical expenses, you'll typically want to choose a plan with at least $100,000 in coverage for emergency medical care and at least that much in protection for emergency medical evacuation and transportation.

However, higher limits can provide even more protection from overseas medical bills, which can become pricey depending on the type of care you need. As just one example, Allianz says the average cost of emergency medical evacuation can easily reach up to $200,000 or more depending on where you’re traveling.

Your U.S. health insurance policy almost never covers medical expenses incurred abroad. The same is true for most people on Medicare and especially Medicaid. If you want to ensure you have travel medical coverage that applies overseas, you should purchase a travel insurance plan with adequate limits for every trip. Read the U.S. News article on this topic for more information.

The cost of travel medical insurance can vary depending on the age of the travelers, the type of coverage purchased, the length of the trip and other factors. You can use a comparison site like TravelInsurance.com to explore different travel medical insurance plans and their cost.

• Allianz Travel Insurance: Best Overall
• Seven Corners: Best for Families
• GeoBlue: Best for Expats
• WorldTrips: Best Cost

Coverage for preexisting conditions is available as an add-on

Easy to purchase as needed for individual trips

Relatively low limits for medical expenses

No coverage for trip cancellations or trip interruption

• Up to $50,000 in emergency medical coverage
• Up to $250,000 in emergency medical evacuation coverage
• Up to $2,000 in coverage for baggage loss and damage
• Up to $600 in baggage delay insurance
• Up to $1,000 for travel delays
• Up to $10,000 in travel accident insurance
• 24-hour hotline assistance
• Concierge services

SEE FULL REVIEW »

Purchase comprehensive medical coverage worth up to $5 million

Coverage for families with up to 10 people

Low coverage amounts for trip interruption

Medical coverage options vary by age

• Up to $5 million in comprehensive medical coverage
• Up to $500,000 in emergency evacuation coverage
• Up to $10,000 in coverage for incidental trips to home country
• Up to $25,000 in coverage for terrorist activity
• Up to $500 in accidental dental emergency coverage
• Up to $100 per occurrence in coverage for emergency eye exams
• $50,000 in coverage for local burial or cremation
• 24/7 travel assistance
• Up to $25,000 in coverage for accidental death and dismemberment per traveler
• Up to $500 for loss of checked baggage
• Up to $5,000 for trip interruptions
• Up to $100 per day for trip delays
• Up to $50,000 for personal liability

Qualify for international health insurance with no annual or lifetime caps

Use coverage within the U.S. with select providers

Deductible from $500 to $10,000 can apply

Doesn't come with any nonmedical travel insurance benefits

• Up to $250,000 in coverage for emergency medical evacuation
• Up to $25,000 for repatriation of mortal remains
• $50,000 in coverage for accidental death and dismemberment

High limits for medical insurance and emergency medical evacuation

Covers multiple trips over a period of up to 364 days

Deductible of $250 required for each covered trip

Copays required for medical care received in the U.S.

• Up to $1,000,000 of maximum coverage
• Up to $1,000,000 for emergency medical evacuation
• Up to $10,000 for trip interruptions
• Up to $1,000 for lost checked luggage
• Up to $100 per day for travel delays
• Up to $25,000 in personal liability coverage
• Medical coverage for eligible expenses related to COVID-19
• Ability to add coverage for your spouse and/or child(ren)
• Repatriation of remains coverage up to overall limit
• Up to $5,000 for local burial or cremation 
• $10,000 to $50,000 for common carrier accidental death

Why Trust U.S. News Travel

Holly Johnson is an award-winning content creator who has been writing about travel insurance and travel for more than a decade. She has researched travel insurance options for her own vacations and family trips to more than 50 countries around the world and has experience navigating the claims and reimbursement process. In fact, she has successfully filed several travel insurance claims for trip delays and trip cancellations over the years. Johnson also works alongside her husband, Greg, who has been licensed to sell travel insurance in 50 states, in their family media business.

You might also be interested in:

9 Best Travel Insurance Companies of 2024

Holly Johnson

Find the best travel insurance for you with these U.S. News ratings, which factor in expert and consumer recommendations.

8 Cheapest Travel Insurance Companies Worth the Cost

U.S. News rates the cheapest travel insurance options, considering pricing data, expert recommendations and consumer reviews.

How to Get Airport Wheelchair Assistance (+ What to Tip)

Suzanne Mason and Rachael Hood

From planning to arrival, get helpful tips to make the journey easier.

Is Travel Insurance Worth It? Yes, in These 3 Scenarios

These are the scenarios when travel insurance makes most sense.

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Fall is a great time to travel overseas — especially because you can avoid the high summer prices — but most people don't realize your health insurance doesn't travel with you when you leave the country.

If something happens, it can turn a dream vacation into a costly nightmare.

A 2022 survey found that nearly 1 in 4 Americans have faced health issues while traveling abroad.

It can be difficult to get quick help from your health insurance back home, and your policy might not even cover you abroad.

Most U.S. insurance providers, including Medicare, offer little to no medical coverage outside the country, which can lead to hefty medical bills if you need care.

To protect yourself, Consumer Reports recommends considering a travel medical insurance policy. These plans can cost less than $100 per trip, depending on the provider and what's covered.

Be sure to shop around. Websites like InsureMyTrip and Squaremouth make it easy to compare different policies. Pick a provider with strong ratings from the Better Business Bureau and A.M. Best, a credit rating agency for insurance companies.

Before buying, check for exclusions, coverage limits, and deductibles. Verify that the plan includes any pre-existing conditions and prescriptions.

It’s also a good idea to have a policy that covers medical evacuation, especially if you’re heading to remote areas with limited access to major hospitals.

Now that you have insurance in place, remember to check your passport's expiration date. Many countries require it to be valid for at least six months past the date of your trip. Regular processing takes six to eight weeks by mail, but you can speed it up for an extra fee. Book an in-person appointment if you need to travel abroad within 14 days.

Watch CBS News

Pope Francis, 87, appears sprightly after health troubles as epic Asia trip gets underway with Indonesia visit

By Anna Matranga

September 4, 2024 / 9:51 AM EDT / CBS News

Jakarta, Indonesia —  Pope Francis appeared in good health and good humor Wednesday on the first full day of what will be a marathon trip for the 87-year-old leader of the Catholic Church to Southeast Asia and Oceania. Over 12 days, Francis is scheduled to travel more than 20,000 miles and visit four countries — Indonesia, Papua New Guinea, East Timor and Singapore.

It is scheduled to be the longest and most challenging trip of Francis' 11-year papacy. He has suffered health issues over the past few years and now uses a wheelchair. 

The Vatican said no special precautions were being taken for this trip, but, as usual, Francis was traveling with a doctor and two nurses.

Speaking with CBS Evening News anchor and managing editor Norah O'Donnell in May, Francis said the idea of stepping down had never occurred to him, and he described his health as "fine" despite a recent bout with the flu  and two rounds of  intestinal surgery . The pope has also had only one full  lung  since undergoing surgery as a young man in Argentina, leaving him susceptible to respiratory illness.

In his first speech in Indonesia, the world's most populous Muslim country, Francis condemned religious extremism, saying it distorted religion by using deception and violence.

"There are times when faith can be manipulated to foment divisions and increase hatred," the pope told Indonesian politicians and religious leaders gathered at the presidential palace in Jakarta. He urged them to fight religious intolerance through dialogue. 

"In this way," he said, "prejudices can be eliminated, and a climate of mutual respect and trust can grow."

Religious freedom is protected by the Indonesian constitution and the country prides itself on its diversity and tolerance, but Islamic fundamentalism has made inroads, and there have been incidents of religious violence in recent years.

Francis also met Wednesday with Indonesian Catholic priests and nuns at the cathedral in Jakarta, offering words of encouragement and support.

On Thursday, Francis is scheduled to celebrate mass in Jakarta with the country's Catholics, a tiny but vibrant minority of barely 3% of the population. The Asia Pacific region is one of the few areas of the world where Catholicism is growing, both in terms of baptized faithful and in vocations.

The pope is also expected to meet Thursday with Indonesia's top Muslim leader, and the two will sign a joint declaration on humanitarian and environmental issues, and religious tolerance.

• Pope Francis
• Catholic Church

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This Vitamin Reduces Mental Health Problems By 50%

Around half the world’s population are thought to have an insufficiency of this vitamin.

A triple dose of vitamin D3 supplementation in the first two years of life reduces the chance of mental health problems later on by around 50 percent, a high-quality experiment finds.

Infants who were given 30 µg of vitamin D daily, which is three times the recommended dose, were only half as likely to have internalising problems by age 6-8.

Internalising problems are those in which a person keeps their problems to themselves, including depression, anxiety, loneliness and withdrawal.

Dr Samuel Sandboge, the study’s first author, said:

“Our results suggest that a higher dose of vitamin D3 supplementation during the first years of life may reduce the risk of internalizing psychiatric symptoms in late preschool and early school age.”

Vitamin D and mental health

The randomised controlled trial, which was carried out in Finland, was inspired by the link found between low childhood vitamin D levels and mental health problems.

Almost 350 children were given either a dose of 10 µg or 30 µg of vitamin D from age 2 weeks until 2-years-old.

The results showed that at 6- to 8-years-old, almost 12 percent of children given 10 µg had significant internalising problems.

In the 30 µg group, though, this figure was under 6 percent.

No differences were seen in the number of externalising problems.

Externalising disorders include ADHD and conduct disorder.

Later in life externalising disorders include substance abuse, antisocial personality disorders and even psychopathy.

Dr Samuel Sandboge warned that the study has drawbacks:

“The results and their potential implications are interesting, but further research is needed to confirm the results. In the interpretation of the results, we must note, among other things, that we studied the psychiatric symptoms only as parent-reported. Furthermore, the participants of the study were children with Nordic ancestry living in Finland who had good levels of vitamin D.”

Widespread deficiency

Around half the world’s population are thought to have an insufficiency of vitamin D, and 10 percent are deficient.

Vitamin D plays an important role in the development of the brain.

It is notable that a rise in autism and ADHD rates has happened at a time when there have been significant drops in average levels of vitamin D.

• A mother’s deficiency in vitamin D may contribute to the development of autism in her children .
• Zinc deficiency could be involved in the development of autism .
• Vitamin D activates a gene which produces an enzyme leading to higher levels of serotonin.

The study was published in JAMA Network Open ( Sandboge et al., 2023 ).

Author: Dr Jeremy Dean

Psychologist, Jeremy Dean, PhD is the founder and author of PsyBlog. He holds a doctorate in psychology from University College London and two other advanced degrees in psychology. He has been writing about scientific research on PsyBlog since 2004. View all posts by Dr Jeremy Dean

Join the free PsyBlog mailing list. No spam, ever.

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• Section 4 - Scuba Diving: Decompression Illness & Other Dive-Related Injuries
• Section 4 - Mosquitoes, Ticks & Other Arthropods

High Elevation Travel & Altitude Illness

Cdc yellow book 2024.

Author(s): Peter Hackett, David Shlim

Acclimatization

Altitude illness, medications, preventing severe altitude illness or death.

Typical high-elevation travel destinations include Colorado ski resorts with lodgings at 8,000–10,000 ft (≈2,440–3,050 m); Cusco, Peru (11,000 ft; ≈3,350 m); La Paz, Bolivia (12,000 ft; ≈3,650 m); Lhasa, Tibet Autonomous Region (12,100 ft; ≈3,700 m); Everest base camp, Nepal (17,700 ft; ≈5,400 m); and Mount Kilimanjaro, Tanzania (19,341 ft; ≈5,900 m). High-elevation environments expose travelers to cold, low humidity, increased ultraviolet radiation, and decreased air pressure, all of which can cause health problems. The biggest concern, however, is hypoxia, due to the decreased partial pressure of oxygen (PO2). At 10,000 ft (≈3,050 m), for example, the inspired PO2 is only 69% of that at sea level; acute exposure to this reduced PO2 can lower arterial oxygen saturation to 88%–91%.

The magnitude and consequences of hypoxic stress depend on the elevation, rate of ascent, and duration of exposure; host genetic factors may also contribute. Hypoxemia is greatest during sleep; day trips to high-elevation destinations with an evening return to a lower elevation are much less stressful on the body. Because of the key role of ventilation, travelers must avoid taking respiratory depressants at high elevations.

The human body can adjust to moderate hypoxia at elevations ≤17,000 ft (≈5,200 m) but requires time to do so. Some acclimatization to high elevation continues for weeks to months, but the acute process, which occurs over the first 3–5 days following ascent, is crucial for travelers. The acute phase is associated with a steady increase in ventilation, improved oxygenation, and changes in cerebral blood flow. Increased red cell production does not play a role in acute acclimatization, although a decrease in plasma volume over the first few days does increase hemoglobin concentration.

Altitude illness can develop before the acute acclimatization process is complete, but not afterwards. In addition to preventing altitude illness, acclimatization improves sleep, increases comfort and sense of well-being, and improves submaximal endurance; maximal exercise performance at high elevation will always be reduced compared to that at low elevation.

Travelers can optimize acclimatization by adjusting their itineraries to avoid going “too high too fast” (see  Box 4-08 ). Gradually ascending to elevation or staging the ascent provides crucial time for the body to adjust. For example, acclimatizing for a minimum of 2–3 nights at 8,000–9,000 ft (≈2,450–≈2,750 m) before proceeding to a higher elevation is markedly protective against acute mountain sickness (AMS). The Wilderness Medical Society recommends avoiding ascent to a sleeping elevation of ≥9,000 ft (≈2,750 m) in a single day; ascending at a rate of no greater than 1,650 ft (≈500 m) per night in sleeping elevation once above 9,800 ft (≈3,000 m); and allowing an extra night to acclimatize for every 3,300 ft (≈1,000 m) of sleeping elevation gain. These reasonable recommendations can still be too fast for some travelers and annoyingly slow for others.

Box 4-08 Acclimatization tips: a checklist for travelers

☐ Ascend gradually. ☐ Avoid going directly from low elevation to >9,000 ft (2,750 m) sleeping elevation in 1 day. ☐ Once above 9,000 ft (≈2,750 m), move sleeping elevation by no more than 1,600 ft (≈500 m) per day, and plan an extra day for acclimatization every 3,300 ft (≈1,000 m). ☐ Consider using acetazolamide to speed acclimatization if abrupt ascent is unavoidable. ☐ Avoid alcohol for the first 48 hours at elevation. ☐ If a regular caffeine user, continue using to avoid a withdrawal headache that could be confused with an altitude headache. ☐ Participate in only mild exercise for the first 48 hours at elevation. ☐ A high-elevation exposure (> 9,000 ft [≈2,750 m]) for ≥2 nights, within 30 days before the trip, is useful, but closer to the trip departure is better.

Risk to Travelers

Susceptibility and resistance to altitude illness are, in part, genetically determined traits, but there are no simple screening tests to predict risk. Training or physical fitness do not affect risk. A traveler’s sex plays a minimal role, if any, in determining predisposition. Children are as susceptible as adults; people aged >50 years have slightly less risk. Any unacclimatized traveler proceeding to a sleeping elevation of ≥8,000 ft (≈2,450 m)—and sometimes lower—is at risk for altitude illness. In addition, travelers who have successfully adjusted to one elevation are at risk when moving to higher sleeping elevations, especially if the elevation gain is >2,000–3,000 ft (600–900 m).

How a traveler previously responded to high elevations is the most reliable guide for future trips, but only if the elevation and rate of ascent are similar, and even then, this is not an infallible predictor. In addition to underlying, inherent baseline susceptibilities, a traveler’s risk for developing altitude illness is influenced by 3 main factors: elevation at destination, rate of ascent, and exertion ( Table 4-04 ). Creating an itinerary to avoid any occurrence of altitude illness is difficult because of variations in individual susceptibility, as well as in starting points and terrain. The goal for the traveler might not be to avoid all symptoms of altitude illness but to have no more than mild illness, thereby avoiding itinerary changes or the need for medical assistance or evacuation.

Table 4-04 Risk categories for developing acute mountain sickness (AMS)

RISK CATEGORY

DESCRIPTION

PROPHYLAXIS RECOMMENDATIONS

• People with no prior history of altitude illness ascending to <9,000 ft (2,750 m)
• People taking ≥2 days to arrive at 8,200–9,800 ft (≈2,500–3,000 m), with subsequent increases in sleeping elevation <1,600 ft (≈500 m) per day, and an extra day for acclimatization every 3,300 ft (1,000 m) increase in elevation

Acetazolamide prophylaxis generally not indicated

• People with prior history of AMS and ascending to 8,200–9,200 ft (≈2,500–2,800 m) elevation (or above) in 1 day
• People with no history of AMS ascending to >9,200 ft (2,800 m) elevation in 1 day
• All people ascending >1,600 ft (≈500 m) per day (increase in sleeping elevation) at elevations >9,900 ft (3,000 m), but with an extra day for acclimatization every 3,300 ft (1,000 m)

Acetazolamide prophylaxis would be beneficial and should be considered

• People with a history of AMS ascending to >9,200 ft (≈2,800 m) in 1 day
• All people with a prior history of HAPE or HACE
• All people ascending to >11,400 ft (≈3,500 m) in 1 day
• All people ascending >1,600 ft (≈500 m) per day (increase in sleeping elevation) at elevations >9,800 ft (≈3,000 m), without extra days for acclimatization
• People making very rapid ascents (e.g., <7-day ascent of Mount Kilimanjaro)

Acetazolamide prophylaxis strongly recommended

Abbreviations: HACE, high-altitude cerebral edema; HAPE, high-altitude pulmonary edema

Destinations of Risk

Some common high-elevation destinations require rapid ascent by a non-pressurized airplane to >11,000 ft (≈3,400 m), placing travelers in a high-risk category for AMS. A common travel medicine question is whether to recommend acetazolamide for travelers when gradual or staged acclimatization is not feasible. With rates of altitude illness approaching 30%–40% in these situations, a low threshold for chemoprophylaxis is advised. In some cases (e.g., Cusco and La Paz), travelers can descend to elevations much lower than the airport to sleep for 1–2 nights and then begin their ascent, perhaps obviating the need for medication.

Itineraries along some trekking routes in Nepal, particularly Everest base camps, push the limits of many people’s ability to acclimatize. Even on standard schedules, incidence of altitude illness can approach 30% at the higher elevations. Whenever possible, adding extra days to the trek can make for a more enjoyable and safer climb.

Altitude Illness Syndromes

Altitude illness is divided into 3 syndromes: acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE). Some clinicians consider high-altitude headache a separate entity because isolated headache can occur without the combined symptoms that define AMS.

Acute Mountain Sickness

AMS is the most common form of altitude illness, affecting 25% of all visitors sleeping at elevations >8,000 ft (≈2,450 m) in Colorado.

Diagnosis of AMS is based on a history of recent ascent to high elevation and the presence of subjective symptoms. AMS symptoms are like those of an alcohol hangover; headache is the cardinal symptom, usually accompanied by ≥1 of the following: anorexia, dizziness, fatigue, nausea, or, occasionally, vomiting. Uncommonly, AMS presents without headache. Symptom onset is usually 2–12 hours after initial arrival at a high elevation or after ascent to a higher elevation, and often during or after the first night. Preverbal children with AMS can develop loss of appetite, irritability, and pallor. AMS generally resolves within 12–48 hours if travelers do not ascend farther.

The condition is typically self-limited, developing and resolving over 1–3 days. Symptoms starting after 3 days of arrival to high elevation and without further ascent should not be attributed to AMS. AMS has no characteristic physical findings; pulse oximetry is usually within the normal range for the elevation, or slightly lower than normal.

The differential diagnosis of AMS is broad; common considerations include alcohol hangover, carbon monoxide poisoning, dehydration, drug intoxication, exhaustion, hyponatremia, and migraine. Travelers with AMS will improve rapidly with descent ≥1,000 ft (≈300 m), and this can be a useful indication of a diagnosis of AMS.

Although rarely available, supplemental oxygen at 1–2 liters per minute will relieve headaches within about 30 minutes and resolve other AMS symptoms over hours. The popular small, handheld cans of compressed oxygen can provide brief relief, but contain too little oxygen (5 liters at most) for sustained improvement. Travelers with AMS but without HACE or HAPE (both described below) can remain safely at their current elevation and self-treat with non-opiate analgesics (e.g., ibuprofen 600 mg or acetaminophen 500 mg every 8 hours) and antiemetics (e.g., ondansetron 4 mg orally disintegrating tablets).

Acetazolamide speeds acclimatization and resolves AMS, but is more commonly used and better validated for use as prophylaxis. Dexamethasone is more effective than acetazolamide at rapidly relieving the symptoms of moderate to severe AMS. If symptoms worsen while the traveler is at the same elevation, or despite supplemental oxygen or medication, descent is mandatory.

High-Altitude Cerebral Edema

As an encephalopathy, HACE is considered “end stage” AMS. Fortunately, HACE is rare, especially at elevations <14,000 ft (≈4,300 m). HACE is often a secondary consequence of the severe hypoxemia that occurs with HAPE.

Unlike AMS, HACE presents with neurological findings, particularly altered mental status, ataxia, confusion, and drowsiness, similar to alcohol intoxication. Focal neurologic findings and seizures are rare in HACE; their presence should lead to suspicion of an intracranial lesion, a seizure disorder, or hyponatremia. Other considerations for the differential diagnosis include carbon monoxide poisoning, drug intoxication, hypoglycemia, hypothermia, and stroke. Coma can ensue within 24 hours of onset.

In populated areas with access to medical care, HACE can be treated with supplemental oxygen and dexamethasone. In remote areas, initiate descent for anyone suspected of having HACE, in conjunction with dexamethasone and oxygen, if available. If descent is not feasible, supplemental oxygen or a portable hyperbaric device, in addition to dexamethasone, can be lifesaving. Coma is likely to ensue within 12–24 hours of the onset of ataxia in the absence of treatment or descent.

High-Altitude Pulmonary Edema

HAPE can occur by itself or in conjunction with AMS and HACE; incidence is roughly 1 per 10,000 skiers in Colorado, and ≤1 per 100 climbers at >14,000 ft (≈4,300 m).

Early diagnosis is key; HAPE can be more rapidly fatal than HACE. Initial symptoms include chest congestion, cough, exaggerated dyspnea on exertion, and decreased exercise performance. If unrecognized and untreated, HAPE progresses to dyspnea at rest and frank respiratory distress, often with bloody sputum. This typical progression over 1–2 days is easily recognizable as HAPE, but the condition sometimes presents only as central nervous system dysfunction, with confusion and drowsiness.

Rales are detectable in most victims. Pulse oximetry can aid in making the diagnosis; oxygen saturation levels will be at least 10 points lower in HAPE patients than in healthy people at the same elevation. Oxygen saturation values of 50%–70% are common. The differential diagnosis for HAPE includes bronchospasm, myocardial infarction, pneumonia, and pulmonary embolism.

In most circumstances, descent is urgent and mandatory. Administer oxygen, if available, and exert the patient as little as possible. If immediate descent is not an option, use of supplemental oxygen or a portable hyperbaric chamber is critical.

Patients with mild HAPE who have access to oxygen (e.g., at a hospital or high-elevation medical clinic) might not need to descend to a lower elevation and can be treated with oxygen over 2–4 days at the current elevation. In field settings, where resources are limited and there is a lower margin for error, nifedipine can be used as an adjunct to descent, oxygen, or portable hyperbaric oxygen therapy. A phosphodiesterase inhibitor can be used if nifedipine is not available, but concurrent use of multiple pulmonary vasodilators is not recommended. Descent and oxygen are much more effective treatments than medication.

Recommendations for use and dosages of medications to prevent and treat altitude illness are outlined in  Table 4-05 .

Table 4-05 Recommended medication dosing to prevent & treat altitude illness

Abbreviations: AMS, acute mountain sickness; HACE, high-altitude cerebral edema; HAPE, high-altitude pulmonary edema; IM, intramuscular; IV, intravenous; PO, by mouth; SR, sustained release. 1 This dose can also be used as an adjunct to dexamethasone for HACE treatment; dexamethasone remains the primary treatment for HACE. 2 Use only in conjunction with oral medications and not as monotherapy for HAPE prevention.

Acetazolamide

Mechanism of action.

When taken preventively, acetazolamide hastens acclimatization to high-elevation hypoxia, thereby reducing occurrence and severity of AMS. It also enhances recovery if taken after symptoms have developed. The drug works primarily by inducing a bicarbonate diuresis and metabolic acidosis, which stimulates ventilation and increases alveolar and arterial oxygenation. By using acetazolamide, high-elevation ventilatory acclimatization that normally takes 3–5 days takes only 1 day. Acetazolamide also eliminates central sleep apnea, or periodic breathing, which is common at high elevations, even in those without a history of sleep disorder breathing.

An effective dose for prophylaxis that minimizes the common side effects of increased urination and paresthesia of the fingers and toes is 125 mg every 12 hours, beginning the day before ascent and continuing the first 2 days at elevation, and longer if ascent continues. Acetazolamide can also be taken episodically for symptoms of AMS, as needed. To date, the only dose studied for treatment is 250 mg (2 doses taken 8 hours apart), although the lower dosage used for prevention has anecdotally been successful. The pediatric dose is 5 mg/kg/day in divided doses, up to 125 mg, twice a day.

Adverse & Allergic Reactions

 Allergic reactions to acetazolamide are uncommon. Since acetazolamide is a sulfonamide derivative, cross-sensitivity between acetazolamide, sulfonamides, and other sulfonamide derivatives is possible.

Dexamethasone

Dexamethasone is effective for preventing and treating AMS and HACE and might prevent HAPE as well. Unlike acetazolamide, if the drug is discontinued at elevation before acclimatization, mild rebound can occur. Acetazolamide is preferable to prevent AMS while ascending, and dexamethasone generally should be reserved for treatment, usually as an adjunct to descent. The adult dose is 4 mg every 6 hours; rarely is it needed for more than 1–2 days. An increasing trend is to use dexamethasone for “summit day” on high peaks (e.g., Aconcagua and Kilimanjaro) to prevent abrupt altitude illness.

Recent studies have shown that taking ibuprofen 600 mg every 8 hours helps prevent AMS, although not quite as effectively as acetazolamide. Ibuprofen is, however, available over the counter, inexpensive, and well tolerated.

Nifedipine both prevents and ameliorates HAPE. For prevention, nifedipine is generally reserved for people who are particularly susceptible to the condition. The adult dose for prevention or treatment is 30 mg of extended release every 12 hours, or 20 mg every 8 hours.

Phosphodiesterase-5 Inhibitors

Phosphodiesterase-5 inhibitors selectively lower pulmonary artery pressure, with less effect on systemic blood pressure than nifedipine. Tadalafil, 10 mg taken twice a day during ascent, can prevent HAPE. It is also being studied as a possible treatment.

The main point of instructing travelers about altitude illness is not to eliminate the possibility of mild illness but to prevent death or evacuation. Because the onset of symptoms and the clinical course are sufficiently slow and predictable, there is no reason for anyone to die from altitude illness unless they are trapped by weather or geography in situations where descent is impossible. Travelers can adhere to 3 rules to help prevent death or serious consequences from altitude illness:

• Know the early symptoms of altitude illness and be willing to acknowledge when symptoms are present.
• Never ascend to sleep at a higher elevation when experiencing symptoms of altitude illness, no matter how minor the symptoms seem.
• Descend if the symptoms become worse while resting at the same elevation.

For trekking groups and expeditions going into remote high-elevation areas, where descent to a lower elevation could be problematic, a pressurization bag (e.g., the Gamow bag) can be beneficial. A foot pump produces an increased pressure of 2 lb/in2, mimicking a descent of 5,000–6,000 ft (≈1,500–1,800 m) depending on the starting elevation. The total packed weight of bag and pump is about 14 lb (6.5 kg).

Preexisting Medical Conditions

Travelers with preexisting medical conditions must optimize their treatment and have their conditions stable before departure. In addition, these travelers should have plans for dealing with exacerbation of their conditions at high elevations. Travelers with underlying medical conditions (e.g., coronary artery disease, any form of chronic pulmonary disease or preexisting hypoxemia, obstructive sleep apnea [OSA], or sickle cell trait)—even if well controlled—should consult a physician familiar with high-elevation medical issues before undertaking such travel ( Table 4-06 ).

Clinicians advising travelers should know that in most high-elevation resorts and cities, “home” oxygen is readily available. In North America, this requires a prescription that the traveler can carry, or oxygen can be arranged beforehand. Supplemental oxygen, whether continuous, episodic, or nocturnal, depending on the circumstances, is very effective at restoring oxygenation to low elevation values and eliminates the risk for altitude illness and exacerbation of preexisting medical conditions.

Table 4-06 Ascent risk associated with various underlying medical conditions & risk factors

LIKELY NO EXTRA RISK

CAUTION REQUIRED 1

ASCENT CONTRAINDICATED

• Asthma (well-controlled)
• Children and adolescents
• Chronic obstructive pulmonary disease (mild)
• Coronary artery disease (following revascularization)
• Diabetes mellitus
• Hypertension (controlled)
• Neoplastic diseases
• Obesity (Class 1/Class 2) 2
• Obstructive sleep apnea (mild/ moderate)
• Pregnancy (low-risk)
• Psychiatric disorders (stable)
• Seizure disorder (controlled)
• Angina (stable)
• Arrhythmias (poorly controlled)
• Chronic obstructive pulmonary disease (moderate)
• Coronary artery disease (nonrevascularized)
• Cystic fibrosis (FEV1 30%–50% predicted)
• Heart failure (compensated)
• Hypertension (poorly controlled)v Infants <6 weeks old
• Obesity (Class 3) 3
• Obstructive sleep apnea (severe)
• Pulmonary hypertension (mild)
• Radial keratotomy surgery
• Seizure disorder (poorly controlled)
• Sickle cell trait
• Angina (unstable)
• Asthma (unstable, poorly controlled)
• Cerebral space–occupying lesions
• Cerebral vascular aneurysms or arteriovenous malformations (untreated, high-risk)
• Chronic obstructive pulmonary disease (severe/very severe)
• Cystic fibrosis (FEV1 <30% predicted)
• Heart failure (decompensated)
• Myocardial infarction or stroke (<90 days before ascent)
• Pregnancy (high-risk)
• Pulmonary hypertension (pulmonary artery systolic pressure >60 mm Hg)
• Sickle cell anemia

Abbreviations: : FEV1, forced expiratory volume in 1 second

1 Travelers with these conditions most often require consultation with a physician experienced in high-altitude medicine and a comprehensive management plan.

2 Class 1 obesity: Body Mass Index (BMI) of 30 to <35; Class 2 obesity: BMI of 35 to <40

3 Class 3 obesity: BMI of ≥40.

Diabetes Mellitus

Travelers with diabetes can travel safely to high elevations, but they must be accustomed to exercise if participating in strenuous activities at elevation and carefully monitor their blood glucose. Diabetic ketoacidosis can be triggered by altitude illness and can be more difficult to treat in people taking acetazolamide. Not all glucose meters read accurately at high elevations.

Obstructive Sleep Apnea

Travelers with sleep disordered breathing who are planning high-elevation travel should receive acetazolamide. Those with mild to moderate OSA who are not hypoxic at home might do well without a continuous positive airway pressure (CPAP) device, while those with severe OSA should be advised to avoid high-elevation travel unless they receive supplemental oxygen in addition to their CPAP. Oral appliances for OSA can be useful adjuncts when electrical power is unavailable.

There are no studies or case reports describing fetal harm among people who briefly travel to high elevations during their pregnancy. Nevertheless, clinicians might be prudent to recommend that pregnant people do not stay at sleeping elevations >10,000 ft (≈3,050 m). Travel to high elevations during pregnancy warrants confirmation of good maternal health and verification of a low-risk gestation. Advise pregnant travelers of the dangers of having a pregnancy complication in remote, mountainous terrain.

Radial Keratotomy

Most people do not have visual problems at high elevations. At very high elevations, however, some people who have had radial keratotomy procedures might develop acute farsightedness and be unable to care for themselves. LASIK and other newer procedures may produce only minor visual disturbances at high elevations.

The following authors contributed to the previous version of this chapter: Peter H. Hackett, David R. Shlim

Bibliography

Bartsch P, Swenson ER. Acute high-altitude illnesses. N Engl J Med. 2013;369(17):1666–7. 

Hackett PH, Luks AM, Lawley JS, Roach RC. High-altitude medicine and pathophysiology. In: Auerbach PS, editor. Wilderness medicine, 7th edition. Philadelphia: Elsevier; 2017. pp. 8–28. 

Hackett PH, Roach RC. High altitude cerebral edema. High Alt Med Biol. 2004;5(2):136–46. 

Luks AM, Auerbach PS, Freer L, Grissom CK, Keyes LE, McIntosh SE, et al. Wilderness Medical Society clinical practice guidelines for the prevention and treatment of acute altitude illness: 2019 update. Wilderness Environ Med. 2019;30(4S):S3–18. 

Luks AM, Hackett PH. High altitude and preexisting medical conditions. In: Auerbach PS, editor. Wilderness medicine, 7th edition. Philadelphia: Elsevier; 2017. pp. 29–39. 

Luks AM, Hackett PH. Medical conditions and high-altitude travel. N Engl J Med. 2022;386(4):364–73. 

Luks AM, Swenson ER.Medication and dosage considerations in the prophylaxis and treatment of high-altitude illness. Chest. 2008;133(3):744–55. 

Meier D, Collet TH, Locatelli I, Cornuz J, Kayser B, Simel DL, Sartori C. Does this patient have acute mountain sickness? The rational clinical examination systematic review. JAMA. 2017;318(18):1810–19. 

Roach RC, Lawley JS, Hackett PH. High-altitude physiology. In: Auerbach PS, editor. Wilderness medicine, 7th edition. Philadelphia: Elsevier; 2017. pp. 2–8. 

Woolcott OO. The Lake Louise Acute Mountain Sickness score: still a headache. High Alt Med Biol. 2021;22(4):351–2.

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Wisconsin health officials recall eggs after multistate salmonella outbreak.

Wisconsin health officials initiated a recall of eggs following an outbreak of salmonella infections among 65 people in nine states that originated on a Wisconsin farm.

The Wisconsin Department of Health Services said in a statement Friday that among those infected by salmonella are 42 people in Wisconsin, where the eggs are believed to have been sold.

“The eggs were distributed in Wisconsin, Illinois and Michigan through retail stores and food service distributors,” the department said. “The recall includes all egg types such as conventional cage-free, organic, and non-GMO, carton sizes, and expiration dates in containers labeled with ‘Milo’s Poultry Farms’ or ‘Tony’s Fresh Market.’”

The U.S. Centers for Disease Control and Prevention confirmed in a statement on its website that 65 people in nine states were infected by a strain of salmonella, with 24 hospitalizations and no deaths as of Friday.

The states include Wisconsin, Illinois, Michigan, Minnesota, Iowa, Virginia, Colorado, Utah and California, the agency said.

The egg recall was undertaken by Milo’s Poultry Farms LLC of Bonduel, Wisconsin, the CDC said.

“Anyone who purchased the recalled eggs is advised to not eat them or cook with them and to throw them away. Restaurants should not sell or serve recalled eggs,” the Wisconsin health department said.

The department advised anyone who ate the eggs and is experiencing symptoms to contact a health care provider.

Symptoms include diarrhea, abdominal pain, fever and vomiting lasting for several days, the statement said.

The U.S. Department of Agriculture in July announced new measures to limit salmonella in poultry products.

The proposed directive included requiring poultry companies to keep salmonella levels under a certain threshold and test for the presence of six particularly sickening forms of the bacteria, three found in turkey and three in chicken.

Bacteria exceeding the proposed standard and identification of any of the strains would prevent poultry sales and leave the products subject to recall.

The CDC estimates salmonella causes 1.35 million infections annually, most through food, and about 420 deaths. The Agriculture Department estimates there are 125,000 infections from chicken and 43,000 from turkey each year.

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