What if I get sick abroad?
This item appears on page 55 of the May 2014 issue.
What would you do if you got sick abroad or if your previously stable medical condition worsened abroad?
While much has been printed in ITN about travel health insurance, little has been written about the measures you should take proactively to get the best medical care when abroad. Below, I will indicate these measures.
Parts of the following information have been paraphrased from http://wwwnc.cdc.gov/travel and other CDC sites. I purposely have omitted information about travel insurance.
PREVENTION
Contact card
Prepare a contact card with the email addresses, physical addresses and phone numbers of the following:
• US embassy or consulate(s) in the destination country (countries)
• At least one family member or close contact who is physically present in the US or Canada or with whom you easily can get in touch at any time
• Health-care providers at home
• Area hospitals and/or clinics in countries to be visited
Inquire, read and study
• Inquire about needed immunizations and booster shots at least three months before traveling. Get a tetanus shot every 10 years, even if you don’t travel.
• Read the appropriate articles on the website wwwnc.cdc.gov/travel.
• Study your disease(s) on such websites as www.mayoclinic.com, medicine.net, etc.
• Read appropriate chapters in the reference “CDC Health Information for International Travel 2014” (commonly called the Yellow Book), online.
• Consult a travel health clinic or your local health department or contact the Centers for Disease Control & Prevention (CDC) at 800/232/4636.
• From your doctor, get a letter with your diagnoses and the medications you take with their generic names. (Include over-the-counter drugs.)
• Note that outside the US, Tylenol® (acetaminophen generic) is known as paracetamol. (FYI, the maximal 24-hour dose of paracetamol is 3,000mg.)
• Talk to your doctor about the most likely scenarios that might occur in the course of your disease and which medicines you might need if your condition worsened.
• Ask your doctor for the appropriate antimalarial drug, if indicated. For the best preventive advice and care, visit a travel health clinic.
Telephone help
It is vital that you know the location of the nearest phone in every place where you spend the night. You also should have the coins or a telephone card specific for that phone.
If you use a cell phone, make sure you have service at your accommodation. Test the phone as soon as you enter each lodging. If an emergency should occur, you will be happy that you can call for help. Ensure that you are in possession of the local number to call (such as “911”) in the event of an emergency.
Preventive measures
• Postpone air travel if you suddenly are short of breath or develop a communicable disease. Don’t travel to an area far from appropriate medical care.
• Reexamine your insurance coverage and increase the amount where necessary.
• Keep in mind that air carriers may decline the boarding of an obviously sick passenger.
• Before leaving, locate physicians and health-care facilities abroad by contacting one or more of the following:
A. The International Society of Travel Medicine, or ISTM — The preeminent multinational organization dealing exclusively with travel medicine, ISTM has about 3,000 members worldwide, slightly fewer than half of whom are located in the United States. For a worldwide directory of its travel health professionals, see the website.
B. The American Society of Tropical Medicine & Hygiene, or ASTMH — At its website, the ASTMH maintains a worldwide directory of providers specializing in tropical medicine, medical parasitology and travelers’ health. A subsection, dealing exclusively with tropical and travel medicine, is known as the American Committee on Clinical Tropical Medicine and Travelers’ Health.
Both the ISTM and ASTMH websites contain the names of non-US-based clinics and health-care providers affiliated with members of these organizations. Travelers are advised to review these lists before departure to identify health-care resources at their destination(s).
C. The Wilderness Medical Society — It focuses on adventure travel, including wilderness travel and diving medicine.
D. The Infectious Diseases Society of America, or IDSA — This is the largest organization representing infectious diseases clinicians in the United States. Although IDSA does not deal exclusively with travel medicine, it has many active members with expertise in tropical and travel medicine and has strong interests in these disciplines.
E. The International Society for Infectious Diseases, or ISID — It has approximately 20,000 members in 155 countries around the world.
Like IDSA, ISID does not specifically focus on travel medicine. However, its international reach, particularly in low-resource countries, makes travel medicine an important topic in ISID and a valuable source of information for infectious-diseases clinicians in many overseas travel destinations.
The society has a Program for Monitoring Emerging Diseases, ProMED, an open-source electronic system for reporting emerging infectious diseases and toxins, including outbreaks.
F. The International Association for Medical Assistance to Travelers, or IAMAT
a. IAMAT maintains an international network of physicians, hospitals and clinics who have agreed to treat IAMAT members in need of medical care while abroad.
b. Membership is free, although a donation to support IAMAT’s efforts is suggested. Members each receive a directory of participating physicians and medical centers and have access to a variety of travel-related informational brochures.
G. Travel Health Online — This resource maintains a list of travel medicine providers worldwide. Information is obtained from a variety of sources, so the quality of services and the expertise of the providers cannot be guaranteed.
H. In a number of countries, there are national travel medicine societies that maintain websites related to travel medicine and that also provide access to clinicians, including the following:
• Canada — Health Canada
• Great Britain — National Travel Health Network & Centre and British Global & Travel Health Association
• South Africa — South African Society of Travel Medicine
• Australia — Travel Medicine Alliance
• China — China International Travel Healthcare Association
The China ITHA website only shows a number of travel clinics in various large cities. The provided information is in English.
I. Private companies
Emergency travel-related medical care and medical evacuation may also be accessed through a number of private companies. One example is International SOS, which operates throughout the world. Provider locations and details may be found at the website.
J. In addition, travelers who obtain evacuation insurance before travel will have access to a 24-hour hotline for help in any medical emergency. This is your best bet to get the appropriate specialist for your particular condition.
K. In other countries, travelers may also get information about local health care from the local US embassies and consulates as well as from hotel doctors, credit card companies and, lastly, multinational corporations, which may offer health-care services for their employees.
L. Those with underlying medical conditions may want to take extra precautions. They should choose a medical assistance company that allows customers to store their medical history before departure so that it can be accessed from anywhere in the world, if needed. Examples are MedicAlert Foundation®, Access My Records and MedeFile.
Travelers each should carry a letter from their physician listing underlying medical conditions and all current medications (including their generic names).
If possible, they may want to carry with them the names of their medical conditions and medications written in the local languages of the areas they plan to visit.
Accreditation of health facilities
To get the best possible care, you may want to ascertain whether an overseas health facility is accredited or not. To do this, go to the website of Joint Commission International.
Obtaining pharmaceuticals abroad
It is, of course, best to take all needed medications with you.
Alternatively, if you do need additional medication, your insurance provider will be able to get the medicine to you or will be able to steer you to the right pharmacy.
If you are on your own, be careful what you buy. Even brand-name drugs having the same name as a US drug may have an entirely different formulation and may be used for entirely different conditions.
Take your own injection supplies. If you don’t have your own injection supplies, ask if the equipment to be used is disposable, and insist that a new needle and syringe be used.
Refuse blood transfusions in countries where the blood is not tested for contaminants and infections.
Getting instant emergency care abroad
In the event of an emergency…
• Contact your travel insurance and/or emergency-medical evacuation insurance company.
• Ask hotel staff. Ask expatriates.
• Be sure to have access to a workable phone and/or phone card and/or cell phone with an accessible network.
• As I indicated before, have the local 911-equivalent number available.
Note that although Medicare doesn’t pay for medical expenses outside the US except in very well-defined conditions, some private Medigap plans available to people enrolled in the original Medicare plan provide limited coverage for emergency care abroad.
Original Medicare consists of Plan A (hospital coverage) and Plan B (doctor’s coverage). (A later combination of these marketed as Medicare Advantage, with an entirely different set of rules, does not allow enrolling in Medigap.) To see if you are covered for care outside the US, read your private Medigap policy or call your Medigap insurer.
ILLNESS AFTER RETURNING HOME FROM A TRIP
While most of us arrive home in good health after a trip, a number of international travelers returning to the United States have travel-related illnesses. While some of these illnesses may begin during the travel period, others may occur weeks, months or even years after return.
Thus, a history of travel, particularly within the previous six months, should be part of the routine medical history for every ill patient, especially those with a febrile illness.
Travelers who visit friends and relatives are at greater risk for becoming ill, as they are often less likely to seek pretravel advice.
Types of illnesses
• Travelers may have persistent gastrointestinal illnesses (10%), skin lesions or rashes (8%), respiratory infections (5%-13%, depending on season of travel) and fever (up to 3%).
• The most frequent “tropical” causes of fever in returned travelers are malaria, dengue, invasive bacterial diarrhea, hepatitis A, typhoid and rickettsial infections. However, nontropical entities such as respiratory or urinary tract infections account for a large proportion of febrile illnesses in returned travelers.
• In terms of gastrointestinal illnesses, acute bacterial gastroenteritis or parasitic diarrhea caused mostly by Giardia represents the most common conditions reported by travelers.
• Most US travelers infected abroad become ill within 12 weeks after returning to the US. However, some diseases, such as malaria, may not cause symptoms for as long as six to twelve months or more after exposure.
• If a traveler becomes ill after returning home, even many months after travel, he/she should be advised to tell his/her physician where he/she has traveled. In particular, fever in a traveler returned from a malaria area should be considered a medical emergency.
• It would be best if patients who have symptoms after returning home were referred to a tropical medicine specialist. To locate one, access the website of the American Society of Tropical Medicine & Hygiene, for a listing by state, or of the International Society of Travel Medicine (www.istm.org).
I hope that the information provided above will be of help to you.
REFERENCES
FYI, I include the following references.
A. Destination-specific webpages
The CDC’s Travelers’ Health website features destination-specific pages with information on current CDC assessments of disease risk and recommendations for healthy travel. Destination pages contain information about endemic diseases and health risks, with links to travel notices.
B. Selected topics
The following are the titles of articles on the Web and where to find them.
• “Altitude Illness”
• “Deep Vein Thrombosis & Pulmonary Embolism”
• “Plan Ahead for Illnesses or Injuries During Your Trip”
• “Know What To Do if You Become Sick or Injured on Your Trip”
• “Pay Attention to Your Health During Your Trip”
• “Post-Travel Evaluation” on
1. this page
2. this page, and
3. “Pay Attention to Your Health When You Come Home”
• “Travel Health Kits” (putting together a kit to take care of minor health problems and treat preexisting medical conditions while abroad)