Volume , Issue

The previous installment of this mini-series discussed Vaccines for Travel: The 3 Rs.

This segment will discuss other risks to which travelers are susceptible and for which drugs may be needed for prevention or treatment. As with the previous article on vaccines, this is intended to be a brief overview only--- if you’re planning extensive travel, especially internationally, it’s highly recommended that you consult a specialist in travel medicine/travel health for comprehensive information on how to keep safe on your trip. The Resources section of this article offers tips on how to find travel-related information and a provider.

Routine

Routine drugs for travel can be considered those already being taken for preexisting medical conditions. Usually routine drugs require that, a supply must go on the trip.

Recommended

There are many drugs that are recommended for travel. And as with vaccines, several things need to be considered before the decision is made about which drugs are needed. These are similar to the ones for vaccines and include:

Regions of travel --- travel occurs throughout prety much every region of the world 24/7, so where is the travel occurring?
Reasons for travel --- major reasons for travel include:

            o Tourism/adventure travel

            o Business/Conference

            o Student/Education

            o Medical/Humanitarian

            o Missionary

            o Visiting Friends and Relatives

            o Research

            o Migration

            o Migrant Worker

            o Military

            o Mass gathering

            o Medical Tourism

            o International Adoption

Adapted from: Harvey K, Esposito DH, Han P, Kozarsky P, Freedman DO, Plier DA, Sotir MJ; Centers for Disease Control and Prevention (CDC). Surveillance for travel-related disease —GeoSentinel Surveillance System, United States, 1997–2011. MMWR Surveill Summ. 2013 Jul 19; 62:1–23.

Risks

Considering the regions and reasons for travel, the risks of that travel can be assessed, taking into account the activity being undertaken and possible exposures with that activity. The table below lists risks and drugs that are recommended for prophylaxis or self-treatment. This list includes only those diseases for which a drug is available by prescription (written ideally by a travel medicine provider after a pre-travel consultation), or if available, bought over-the-counter (OTC) before the trip and carried in a personal medical kit (ie, BYO). These are for the routine traveler. For an extended expedition or medical/humanitarian aid work for example, a comprehensive medical kit will be carried, and medical consultation is necessary.

See: WMS Magazine, Medication Transport 

Sources: https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/the-pre-travel-consultation, Gundacker ND et al. Infections associated with adventure travel: A systematic review. Trav Med Infect Dis 2017;16:3-10.

*A reliable supply of standby emergency treatment (SBET) for malaria

Required

No drugs are technically required for travel, except those that are needed for preexisting medical conditions and exacerbations of these conditions during travel. 

Risky

Beware of counterfeit drugs. See the Ready? Section below.
As with any medication, the contraindications, warnings, precautions, and adverse reactions should be discussed by the provider with the traveler before drugs are prescribed or OTC drugs are recommended. As well, there may be possible drug interactions with the travel drugs prescribed, for example, some interact with each other, such as mefloquine for malaria and azithromycin for traveler’s diarrhea. There may be interactions with travel drugs and drugs for medical conditions already being taken, such as atovaquone-proguanil for malaria and warfarin. And there may be interactions with OTC medications, such as doxycycline for malaria or leptospirosis and bismuth subsalicylate for traveler’s diarrhea. 

https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/interactions-among-travel-vaccines-and-drugs

Ready?

Packing A Personal Medical Kit

The CDC offers the following tips for packing a travel health kit:

  •   Required: Bring supplies of medications for preexisting medical conditions and for treatment of exacerbations of these conditions 
  •   Risks: Bring supplies of prescription medications to prevent any illness due to traveling (table above)
  •   Minor health problems: bring a supply of OTC drugs for any minor illness or injury that may be sustained during travel such as:

o Pain: acetaminophen, aspirin, NSAID

o Gastrointestinal: laxative, antacid, famotidine (Pepcid)

o Insomnia: diphenhydramine (Benadryl), doxylamine (Unisom)

o Upper respiratory tract symptoms: antihistamine, decongestant

o First Aid: antibacterial, antifungal cream/ointment/spray, hydrocortisone cream

Traveling with medications 

If you bring a supply of medications from home, you are guaranteed that they will be of a reliable quality if they have domestic quality assurances in the United States. However, if you decide that you can just get whatever you need in a pharmacy in a foreign country, or you do not have medication with you for a disease you picked up on the trip, like an antibiotic for traveler’s diarrhea, you may be putting yourself at risk.

The CDC has advice for traveling with medication. Every country has their own regulations governing drugs, and some medications that may be OTC in the US may be unlicensed, illegal, or controlled substances in other countries.

Don’t end up getting your medications confiscated, leaving you without important control of your blood pressure or diabetes, or possibly worse, having you end up facing a large fine or ending up in jail— (who doesn’t remember “Midnight Express”). Although admittedly smuggling drugs out of a country is a bit different than trying to get your albuterol inhaler into a country).

The CDC also advises travelers to check with the foreign embassy of the country they will be visiting to see if the medications are permitted. If they are not permitted, the healthcare provider may need to prescribe an alternative or provide you with a written explanation to take with you as to why a certain medication is needed for your care. This is especially important for narcotics; the International Narcotics Control Board has guidelines on traveling with controlled substances, but not all countries and territories may be listed. Be extremely cautious when carrying narcotics, even though you have a prescription for them. 

U.S. Customs and Border Protection offers clear guidelines on how to travel with drugs: “Prescription medications should be in their original containers with the doctor’s prescription printed on the container. It is advised that you travel with no more than a 90 day supply. If your medications or devices are not in their original containers, you must have a copy of your prescription with you or a letter from your doctor.” 

[Resist the urge to dump all of your medications in one bottle for convenience (even if you can tell the blue ones from the pink ones from the yellow ones) in case your luggage is searched.]

The Pharmacist Professional Group of the International Society of Travel Medicine (ISTM) has put together an extensive list on importing medicines for personal use into about 100 countries. 

ISTM Pharmacist Professional Group Database on International Regulations on Importation of Medicines for Personal Use 

Buying medications overseas

Don’t depend on buying medications, whether prescription or over-the-counter in another country unless you can confirm it’s a reliable source, and don’t depend on buying drugs that are only sold by prescription in the US behind the counter over over-the-counter in another country, for the same reason. Counterfeits abound: they may look similar to the real thing, but contain an incorrect or substandard active ingredient or ingredients that may actually be toxic. So not only will you lose money, you may end up harming yourself by not treating the illness properly or suffering a toxic effect. According to the CDC, it is estimated that 10-30% of drugs in developing countries may be counterfeit (compared to <1% in developed countries). 

If a medication needs to be purchased in another country, the CDC advises US travelers to contact their nearest embassy or consulate for reliable doctors or pharmacies. 

Other tips from the CDC to avoid counterfeits:

-Buy medicines from licensed pharmacies only and get a receipt

-Do not buy from open markets

-Ask the pharmacist if the drug has the same active ingredient as the drug you are taking

-The drug should be in the original packaging

-Examine the packaging carefully - if the printing looks like poor quality or strange, it could be counterfeit

Longer Trips

If you plan to stay longer than 30 days, the CDC advises speaking to your doctor before your trip to arrange for a larger quantity of medication to be dispensed, as insurance companies often will not pay for a greater than 30 day supply. 

Packing Medications

CDC advises to bring enough supply of medication to last the entire trip plus a few extra doses in case of travel delays.

Storage of medication is important, especially for drugs like insulin or others that need to be refrigerated. 

If using drugs such as marijuana or injectable medications like epinephrine or insulin, it is best to have a letter from your doctor on official stationery from the office.

Resources/References for Travel Health 

CDC Travelers’ Health site.

The CDC Yellow Book 2018

Other travel resources include the World Health Organization, The Committee to Advise on Tropical Medicine and Travel (CATMAT) [Canada] and EuroTravNet and TropNet [Europe] , International Association for Medical Assistance to Travellers (IAMAT)  [International].

The International Society of Travel Medicine website has a Global Travel Clinic Directory, which provides a list of clinicians offering travel health services. Even though some general or family practitioners offer travel medicine services, a visit to a specialist in travel health is well worth it, especially for a complicated itinerary. However, the visit is not usually covered by insurance and may range in cost depending where the traveler is seen. 

The latest edition of “Travel Medicine” (2019) has just been released. Written by travel medicine experts, it contains a wealth of information for clinicians and travelers.

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