You are the expedition physician for a group of 10 scientists on a two-week trek to a remote area of the Nepali Himalaya. You and your group will be transporting medications across international borders and in the wilderness. A sample list of medications in your medical kit is provided in Table 1. What are the most common issues encountered during medication transport and storage and how can you best prepare for them?

Table 1: Sample medical kit on expedition to Nepal

• Allergic reaction: EpiPen, diphenhydramine, prednisone, hydrocortisone cream
• GI: Imodium, H2 blockers, PPI, laxatives, ondansetron, oral rehydration
• Antibiotics: to cover respiratory, GI, GU, skin/soft tissue infections
• Analgesics: ibuprofen, acetaminophen, narcotics, lidocaine
• Altitude illness: acetazolamide, dexamethasone, nifedipine
• Regional: antimalarial and antihelmithic
• Cardiovascular: aspirin, nitroglycerin, antihypertensives
• Respiratory: oxygen concentrator, inhalers
• Diabetes: insulin, glucometer
• Intravenous medications: IV fluids, pain medicines, antiemetics
• Splinting material/suture material/Dermabond

Bring a full supply from home and start planning early

Instruct each of the group members to carry a full supply of their own medications for the duration of the trip. Advise them to speak to their physicians prior to the trip regarding packaging, storage, and obtaining permits - if required - for their medical supplies. All prescription medications should have a full supply for the duration of the trip.

Make sure that the medications do not reach their expiration date during the trip.

Protect from the environment

You and your group may be exposed to the extremes of temperature, humidity, and excessive sunlight during travel in the wilderness. These conditions can also damage medications and potentially ruin your trip. Pressure changes during air travel can also damage certain medications such as inhalers and oxygen.

It is important to familiarize yourself with the manufacturer’s recommendations for the particular device or specific medication storage and plan accordingly. It is often acceptable to be outside of recommended temperature ranges if done so for brief periods of time. Some common ways to combat the elements are listed in Table 2.

Table 2 Ways to protect your medications from the elements

1) Protect from heat

• Use ice packs and insulated containers as temporizing measures
• Submerge in cold water or snow in a water tight bag
• Refrigerate if available, consider solar power
• Maximize protection from sunlight and humidity as listed below

2) Protect from cold

• Keep product indoors or inside tent, inside sleeping bag
• Use chemical heat packs and insulating containers as temporizing measure

3) Protect from humidity

• Ensure ventilation (open windows)
• Ensure circulation (create breeze, use fan to circulate fresh air if available)
• Use air tight caps
• Store in zip-lock or water proof bags to protect from accidental exposure to moisture

4)Protect from sunlight

• Use opaque dark bottles
• Do not take product into direct sunlight
• Store in shade

5) Air travel

• Check with manufacturer of oxygen concentrator and other products of concern to make sure they can be used  “in-flight”
• Most inhalers are safe to be used during flight

Other packaging tips

Ideally medications should be transported and stored in the original manufacturer’s packaging for identification, to ease clearing customs, and to preserve them. However, the packaging may be bulky and inconvenient for wilderness travel. Placing the needed amount of medications in well-labeled waterproof, airtight plastic bottles not containing polyvinylchloride (PVC) are appropriate. The label should contain the patient’s name, prescribing physician’s name, medication name, dosing schedule, indications, and warnings.

Keep medications well-organized. Use of watertight plastic or aluminum containers is preferred. For wilderness travel, a duffle bag style or other soft-sided medical kit may be more convenient. Medications in glass containers should be well-padded and handled carefully. Keep them on the top of your luggage or backpack.

If you are flying, try to fit all medications into your carry-on bag. If you are planning to check luggage or are traveling with multiple bags and must check medications, spread them out into multiple bags in case one of them gets stolen or lost.

Crossing borders

Travelers transporting personal medications in well-labeled containers usually do not encounter problems traveling internationally. If you are a group leader carrying a medical kit, you should carry appropriate documentation indicating this from your company.

Transportation of controlled substances may require advanced permission or a license for travel, although at most borders small amounts of prescribed narcotic medication for personal use is allowed. Refer to the U.S. Department of Justice’s Drug Enforcement Agency to find out if any of your medications are controlled. Agreements about transport of narcotic and amphetamine substances exist among some countries. The website for International Narcotics Control Board contains more information, including the forms you might need to fill out prior to travel. It is also prudent to contact the consulate or embassy of the destination country prior to travel if the group will be carrying large amounts of controlled substances.

Quality control in developing countries

It is best to bring a full supply of medications for the duration of your trip. However, if medications get lost or stolen, or if the travel is prolonged, one might need to rely on local pharmacies. Remember that quality control in many developing countries is not as vigorous as it is in the United States and other parts of the developed world. There is a risk of acquiring a damaged, counterfeit, or sometimes toxic medications. Refer to Table 3 for possible indicators of damaged medications. Any medications showing signs of poor quality control should be discarded immediately.

Table 3 Indicators of quality problems

General

• Broken or ripped packaging
• Missing or unreadable labels

Liquids

• Discoloration
• Cloudiness
• Sediment
• Broken seal on bottle
• Cracks in ampule, bottle, or vial
• Dampness or moisture in the packaging

Pills (tablets)

• Discoloration
• Crumbled pills
• Stickiness (especially coated tablets)
• Unusual smell
• Missing pills (from blister pack)
• Moisture inside the packaging
• Stained packaging

Injectables

• Liquid does not return to suspension after shaking

Capsules

• Discoloration
• Stickiness
• Crushed capsules

Tubes

• Sticky tube(s)
• Leaking contents
• Perforations or holes in the tube

Planning ahead and responsibly carrying all medications are important factors in avoiding an expensive or possibly trip-ending experieince, such as running out of medications or becoming ill with a chronic problem overseas. In particular, attention should be paid to devices such as glucometers and pulse oximiters for their suitability in extreme cold or hot climates, as well as oxygen concentrators or personal continuous positive airway pressure (CPAP) devices for those with pulmonary disease. Travelers should read all manufacturers recommendations and have a contingency plan for keeping their needed devices at the appropriate temperature.

As an expedition physician leader, pre-trip counseling and preparation are the most important factors in ensuring your group will be adequately prepared and that individuals will be aware of how to keep their medications from environmental damage. It is also your responsibility to ensure the group medical supplies are packaged securely, safely, and well-protected. With a little advanced preparation, you should be able to avoid many preventable problems and have a successful expedition!

References:

Briese B,  Marmer M. (2011). Appendix: Drug Stability in the Wilderness. In P. Auerbach (Ed.), Wilderness Medicine, 6th Edition. (pp. 2206-214). Philadelphia, PA: Mosby.

 “Medications when traveling internationally.” (n.d.) Mobility International USA.  Retrieved January 15, 2014.

“Travelers with disability and  medical conditions.” (n.d.) U.S. Department of Homeland Security.  Retrieved January 15, 2014.

Eutermoser E., Cushing T, Little C. “Go Bag: Travel Preparation.” Wilderness Medicine Magazine. 2013. Retrieved January 15, 2014.

“Controlled substance schedules.” Drug Enforcement Organization. U.S. Department of Justice. Retrieved January 15, 2014.

“International guidelines for national regulations concerning travellers under treatment with internationally controlled drugs.” International Narcotics Control Board. Retrieved January 15, 2014.

John Snow, Inc./DELIVER in collaboration with the World Health Organization. Guidelines for the Storage of Essential Medicines and Other Health Commodities. 2003. Arlington, Va.: John Snow, Inc./DELIVER.