All travellers abroad, especially the elderly, should prepare to manage any health problems- should they arise - alone. Aged travellers must assume an inability to communicate with their own doctor, an inability of the attending doctor to speak English or, even with the best intention, achieve familiarity with the medical history or of the medications carried by the traveller. Sometimes, there is no doctor at all.
Unfortunately, in some cases, there is no travelling companion familiar with the health of our aged traveller.
With these thoughts in mind, the following are suggestions for a safe and healthy trip.
1. ROUTINE MEASURES a. Pre-trip physical conditioning:
Most travellers will exert themselves more than usual on their holiday. They should therefore, 3-4 weeks prior to departure, embark on a routine of walking, with some strengthening and flexibility exercises in preparation for their trip. b. Pre-trip medical exam / documents:
All aged travellers, especially those over 75 and those taking medications, should arrange a full health assessment by their own GP. (This takes time and the traveller should arrange for a prolonged consultation.)
Always collect, and carry with you, a copy of your past medical history and current treatment from your doctor. This, together with other relevant history – such as allergies to medications - should be taken with you on your trip. c. Medical attention in a foreign land
Aged travellers may need to consult a doctor or visit a hospital in a foreign land. Lists of recommended hospitals are obtainable through the web site of the International Society of Travel Medicine.
2. MEDICATIONS
Always take enough medicines to cover the duration of your trip. Leave medications in original packaging. Do not carry loose tablets. Your list of medications should include the generic names of medications, as brand names differ from country to country.
If you need to take restricted drugs and syringes, a certifying letter from your doctor is essential.
Before leaving home, you should check that your medications are legal in the country you are visiting. You can do this by contacting the embassy or high commission of the country you are visiting.
3. INSURANCE
Remember the first rule of travel: if you can't afford travel insurance, you can 't afford to travel.
Australia has health care agreements with other countries including Finland, Italy, Ireland, Malta, the Netherlands, New Zealand, Norway, Sweden and the United Kingdom. Australians can be provided with urgent or emergency medical treatment in these countries. To receive medical services under the agreements, you need to advise local medical staff you wish to be treated under the Reciprocal Health Care Agreement with Australia.
Medicare does not cover the cost of health care incurred while in transit to or from these countries. Nor does it cover cancellation of trip, loss or theft of items or the cost of medical evacuation or repatriation of a body.
In these cases, and for all costs related to health care in other countries, it is essential to purchase travel insurance from a reputable insurer.
Additionally, ready access to cash or credit is essential to facilitate emergency services.
4. MEDICAL TRAVEL KITS
Since heart attack and stroke pose the greatest risk to travelling elders, aspirin should be used and carried. Medications directed at gastrointestinal illness, mild to moderate pain, motion sickness, fever, infection, and skin problems are best included. Diarrhoea should be dealt with aggressively since elderly individuals are often on vital medications, which must be effectively absorbed from the bowel.
Medications, such as scopolamine, may be prescribed or bought over the counter for the management of motion sickness but should be used with care in the elderly, as they may cause severe constipation, urinary retention, and/or mental confusion.
Finally, anti-malarial preventive and treatment medications are indicated for certain destinations.
5. IMMUNISATIONS
Vaccine recommendations for those over 65 years are the same as those for younger travellers, except that influenza and pneumococcal pneumonia vaccines are recommended to all older Australians, travelling or not.
Older people may have let their routine vaccinations, such as diphtheria and tetanus, fall away. The pre-travel check should include a reappraisal of these vaccines, as well as those indicated for the trip.
6. SPECIAL CONSIDERATIONS a. Vision
Falls must be avoided at all costs and an eye examination before leaving is worthwhile. Consider taking spare glasses with you, preferably not bifocal if you will be walking a lot. A copy of your prescription should be carried. Do not clean glasses in water treated with iodine.
Travellers with low vision and needing a guide dog must make special arrangements with the airline and agencies in the country of destination. b. Hearing
Hearing is essential in unfamiliar environments, especially in noisy cities or airport transit areas. Existing deafness may be exacerbated by barotrauma, by the changes in pressure experienced while flying, by concurrent ear infections or allergies.
People with middle ear infections or eustachian tube malfunction are advised to defer travel until fully recovered. Check with your GP if this may be a problem.
Earplanes are available and help with pressure changes. Don’t forget to take extra batteries for your hearing aides. c. Eating and diets
Dentures sometimes cause difficulties in foreign countries. Make sure they are well fitted and not newly acquired on the day of departure. Always carry extra denture adhesive, if this is used.
Special diets are often essential for travellers. For instance, diabetics, sufferers from food allergy, vegetarians or those with religious objections to certain foods should notify airlines 1–2 days before departure. Others with heart disease, high blood pressure, kidney disease, etc. may also require special diets. d. Foot care
The feet of the aged traveller may be affected by chronic illness such as diabetes, poor circulation, peripheral neuritis or conditions affecting the feet. Minor lacerations or injuries will become a serious problem in the aged traveller.
Never walk in the open in bare feet. Elderly travellers are advised to wear comfortable shoes, not a new untried pair, while travelling. Excessive walking may produce blisters, strains or stress fractures. Moderation is in order.
Excessive sweating may lead to fungal infections and anti-fungal powders may be useful. Diabetics should inspect their feet every day. e. Deep vein thrombosis
Calf exercise and frequent walking about the cabin of the aircraft helps reduce the risk of deep vein thrombosis (DVT). Drugs such as diuretics, alcohol and caffeine are best avoided while flying. If you have an increased risk of thrombosis, supportive stockings (eg JetSox) and anti-clotting agents should be considered and discussed with your doctor.
7. ACCLIMITISATION
The ability to adapt to heat and cold is diminished with ageing. The presence of disease such as diabetes, heart failure or obesity, exacerbates this problem. A number of medications, such as beta-blockers, calcium-channel blockers, antidepressants, antihistamines, and anti-Parkinsonian drugs, interfere with body temperature responses.
In a hot climate, the traveller is advised to take frequent rests, drink more non-alcoholic fluids, wear loose clothing, access air-conditioned rooms and take cool baths / showers.
Adaptation to altitudes above 3000 metres is often a problem for the intrepid traveller and the elderly are more at risk. Health problems, such as anaemia, heart disease and lung disease, may cause serious problems at high altitudes. Certain drugs, such as betablockers, may slow the adaptation of heart rate to the lower oxygen levels and result in severe incapacity. Elderly people contemplating trekking in Nepal or Peru should seek appropriate assessment. The key to avoiding symptoms is gradual and slow ascent to allow the body time to acclimatise.
8. AIRLINE and CRUISE SHIP TRAVEL
Portable Oxygen -- Airlines may or may not accommodate a medical condition requiring supplemental oxygen in transit. Implementing this is laborious, often taking 3-4 weeks to arrange.
The airline will probably require independently arranged oxygen in place up to the time of boarding and at the disembarkation point.
9. POST-TRAVEL EXAMINATION
If an elderly person has been overseas for over 3 months, it is prudent to consider a brief check-up with their personal physician upon return home.
If there had been fever, diarrhoea, or other unexplained persistent or protracted medical problems associated with traveling, medical evaluation is advisable.
If you are pregnant and considering international travel, you are strongly advised to evaluate the potential problems associated with international travel as well as the quality of medical care available while travelling and at your destination. You should have a clear plan of action in the event of complications during travel or at your destination, and the names of doctors and hospitals able to handle these complications.
The safest time for a pregnant woman to travel is during the second trimester (18–24 weeks) when she is least likely to experience premature birth. A woman in the third trimester is advised to remain in close contact with medical care throughout her travels and, if there is any suggestion of serious complications, should not travel to developing countries.
Airline policy
From the QANTAS website:
There is no restriction for a normal uncomplicated pregnancy for domestic travel, but medical clearance is required if you wish to travel past the 36th week for uncomplicated multiple pregnancy or if you are having complications of pregnancy. International travel is not permitted after the 36th week for routine pregnancies or the 32nd week for routine multiple pregnancies. Some countries place limitations on the entry of non-national pregnant women. It is best to check with the local consulate if in any doubt.
Preparation for travel
The pregnant traveller, like all travellers, should carry a first aid/medical kit appropriate to her destination. However, the following items should be added to the kit: antenatal folic acid and minerals if prescribed, antifungal creams for vaginal thrush infections, talcum powder, sunscreen with high SPF, and paracetamol (rather than aspirin). Most medications should be avoided, if possible. Antimalarials and other medications should be included only on the advice of the travel health doctor. If travelling during the third trimester, a blood pressure monitor and urinary dipsticks, for the detection of urinary protein, may prove to be very useful.
Over the counter (OTC) self-treatment medications should be discussed with the attending doctor.
General Recommendations for Travel
Pregnant travellers are best to travel with a companion able to access medical care if problems arise. Travelling companions should recognise the signs and symptoms indicating the need for immediate medical attention. These include vaginal bleeding or the passage of clots or tissue, abdominal pain or cramps, contractions, ruptured membranes, excessive leg swelling or pain, headaches, or visual problems.
They should also be aware that pregnant travellers may experience common less serious problems such as heartburn, fatigue, indigestion, constipation, vaginal discharge, leg cramps, frequency of urination and haemorrhoids. Travel insurance is essential, particularly so for the pregnant traveller. Insurance should cover the whole pregnancy; including labor, delivery and medical care available at the destination.
Medical reasons to avoid travel
Pregnant women should consult with their health-care providers before making any travel decisions. In general, pregnant women with serious underlying illnesses should be advised not to travel to developing countries.
Any pregnancy may experience complications such as hypertension, phlebitis, miscarriage or premature labour, urinary infections, etc. These complications may become a serious issue in countries lacking standard health care.
The following table is adapted from CDC: Health Information for International Travel 2003-2004, and lists relative contraindications to international travel during pregnancy.
Obstetrical risk factors
General medical risk factors
Travel to potentially hazardous destinations
History of miscarriage
Incompetent cervix
History of ectopic pregnancy (ectopic with current pregnancy should be ruled out before travel)
History of premature labor or premature rupture of membranes
History of or existing placental abnormalities
Threatened abortion or vaginal bleeding during current pregnancy
Multiple gestation in current pregnancy
Fetal growth abnormalities
History of toxemia, hypertension, or diabetes with any pregnancy
Primigravida at 35 years of age and older, or 15 years of age and younger
History of thromboembolic disease
Pulmonary hypertension
Severe asthma or other chronic lung disease
Valvular heart disease (if NYHA class III or IV heart
failure)
Cardiomyopathy
Hypertension
Diabetes
Renal insufficiency
Severe anemia or hemoglobinopathy
Chronic organ system dysfunction requiring frequent
medical interventions
High altitudes
Areas endemic for or with ongoing outbreaks of life-threatening
food- or insect-borne infections
Areas where chloroquine-resistant Plasmodium falciparum
malaria is endemic
Areas where live virus vaccines are required and recommended
A few issues for pregnant travellers
Calf exercise and frequent walking about the cabin of the aircraft helps reduce the risk of deep vein thrombosis. Drugs such as diuretics, alcohol and caffeine are best avoided while flying. If you have an increased risk of thrombosis, supportive stockings (eg JetSox) and anti-clotting agents should be considered and discussed with your doctor. Seat belts in cars should always be used even in countries where they are not compulsory. Should an accident occur, a doctor should be consulted. Contaminated food and water are potentially more harmful to pregnant women and must be carefully avoided. Severe traveller's diarrhoea may lead to premature labor and shock. (Azithromycin is the treatment of choice for traveller’s diarrhoea in pregnancy. Loperamide is thought to be safe for the control of diarrhœa during pregnancy but available data is minimal.) Hepatitis E (sometimes seen in Asia or Africa) has a case fatality rate of 17-33% in pregnancy and there is no vaccine available. Scuba diving at any depth should be avoided in pregnancy because of the risk of decompression syndrome in the fœtus.
Vaccines
Pregnant travellers should avoid the use of live vaccines. These include MMR or Priorix, chickenpox vaccine, the live influenza vaccine (FluMist – not available in Australia), Sabin polio, the live cholera vaccine (Orochol), the live typhoid vaccine (Typh-Vax), BCG and the yellow fever vaccine. If these vaccines are considered essential, the risks must be weighed against the benefits. Alternatives may be available. The yellow fever vaccine should be used in pregnancy only if travel to an infected area cannot be avoided. Ideally, vaccination should be deferred for nine months after delivery.
Most killed vaccines are considered safe during pregnancy, but should be avoided during the first trimester. The benefits and risks of vaccination should be discussed with the attending doctor. In some instances, little information is available.
Travel to malarial areas
Because malaria carries a significant morbidity and mortality for both mother and foetus and no prophylactic medication is guaranteed to be effective, the pregnant traveller is advised not to travel to malarial areas.
If travel cannot be delayed, the following suggestions from the CDC Yellow Book will reduce the risk of disease.
Reducing the risk
1. Remain indoors between dusk and dawn;
2. If outdoors at night, wear light-coloured clothing, long sleeves, long pants, and shoes and socks;
3. Stay in well-constructed housing with air-conditioning and/or screens;
4. Use permethrin-impregnated bed nets; and
5. Use insect repellents containing DEET as recommended for adults, sparingly, but as needed.
Prophylactic medication
It is important to understand that the malaria parasites are often unaffected by some medications. Doctors often refer to falciparum malaria as being ‘chloroquine-sensitive’ or ‘chloroquine-resistant’. Pregnant women are encouraged not to visit areas where chloroquine-resistant P.falciparum occurs. Additionally, some malaria is resistant to other drugs.
You should discuss with your travel doctor or GP, the nature of the malaria at your destination and the best medication, if any, for you.
Additionally, some medications have been shown to be safe during the latter stages of pregnancy while others are definitely not safe. Never take medications recommended by friends or locals, without first consulting with your doctor.
The following are brief notes on commonly prescribed medications for the prevention of malaria. Chloroquine(Chlorquin) – category D
Avoid during conception. Safe during pregnancy. Ineffective in most areas. Taken weekly. Commence 1 week before departure and continue for 4 weeks after leaving malarial area. Mefloquine(Lariam) – category B3
Not recommended in 1st trimester, otherwise safe. Taken weekly. Commence 1-2 weeks before travelling and continue for 4 weeks after leaving malarial area. Proguanil(Paludrine) – category B2
Safe during pregnancy. Use only in combination with chloroquine.
Atovaquone-proguanil combination(Malarone) – category B2 Not recommended during pregnancy. Data not available. Doxycycline(Doryx, Doxy-100, Vibramycin) - category D Not safe during pregnancy. Dangers for mother and foetus.
Treatment medication
The treatment of malaria during pregnancy requires urgent and specialised care.
Clearly, children are subject to the same range of health problems as are their accompanying adults. They often adapt well, but have their own specific needs, which may require some preparation.
IN GENERAL:
1. Never leave children alone.
2. Carry food and drinks, especially for babies and the very young, which may not be available at your destination.
3. Take clothing appropriate for the climate and season.
4. Check that all medications and mosquito protection are suitable for children.
5. Ensure that all routine vaccinations are up to date and others recommended for your destination have been given.
The protection of children
1. In Australia, each child must have his or her own passport and cannot be included on the passport of a parent.
2. It is a criminal offence to have sex with a child under the age of 16 and parents seeking childcare facilities should research the standards applying in their country of destination. Children under six must be accompanied by an adult, on international flights. Do not allow nametags to be visible to strangers.
3. Children under the age of 18 may require special documentation in some countries. Travellers are advised to check the entry requirements of their intended destination before travelling.
4. Airlines have different regulations for the safety of children. The regulations set down by QANTAS may be found at their web site.
5. Accidents and injuries account for more deaths than do infectious diseases. Parental monitoring is essential as drowning is a common occurrence.
6. Adolescents in particular should be cautioned about engaging in body piercing, tattooing, and casual sexual activity in foreign countries due to the risk of blood-borne and body fluid-transmitted infections. Also, they should be discouraged from unaccompanied activities in urban areas, especially at night.
Food and drinks for children
1. Parents of children with food allergies should discuss their requirements with the airline at the time of booking
2. Commonly acquired gastrointestinal infections may be rapidly life threatening to children and should be avoided at all costs. Parents, especially when travelling in third world countries, should be familiar with food and water precautions, the management of diarrhoea and the frequent cleaning of toys and pacifiers.
3. Oral rehydration solutions are often available in developing countries, but parents are advised to carry their own.
4. Antibiotics, such as azithromycin (10 mg/kg/day orally for 3 days) are of secondary importance, but shown to be effective.
5. Anti-protozoal therapy will be prescribed in certain areas.
6. Anti-diarrhoeals such as loperamide and bismuth subsalicylate are not advised for children less than 3 years of age.
7. Vaccines: Dukarol is available to children over the age of two and protects against bacterial diarrhoea. Discuss with your TCA doctor.
More information is available in the “Traveller’s Pocket Medical Guide and International Certificate of Vaccination” available from Travel Clinics Australia, throughout Australia.
Appropriate clothing, footwear and protection.
1. Avoid over exposure to the sun with sun protection. If sun block is used with insect repellent, it should be applied first.
2. Clothing and netting, which protect against mosquitoes and other insects should be utilised in appropriate destinations. DEET to a concentration of less than 30% should be considered. Permethrin impregnated external clothing and nets have an excellent safety profile.
3. Children should avoid walking barefoot in rural areas of the tropics and in many developing countries.
4. Children are susceptible to altitude sickness (acute mountain sickness (AMS)) and may require Diamox (acetazolamide).
Medications for children
1. Children recovering from otitis media will need particular care while in the air. Earache may be reduced by chewing or swallowing. Pseudoephedrine is ineffective and should avoided. Sedatives should be avoided.
2. A medical kit for children might include rehydration powder, an antihistamine, paracetamol, sun protection and anti-malarial medication.
Vaccinations
1. Ensure all routine vaccinations are up to date. Sometimes these will need to be started earlier than usual.
2. Special vaccinations, such as those for yellow fever, must be discussed with your Travel Clinic doctor.
3. Some vaccinations, such as the quadrivalent meningococcal vaccines are not recommended for children under two years.
4. In older children and adolescents, hepatitis B and meningococcal vaccination is necessary, especially if sexual activity or tattooing is a possibility.
Malarial protection
1. All children travelling to malaria risk areas, including young or breastfed infants, should use personal protection methods to avoid mosquito bites.
2. Preventive drugs (eg chloroquine, proguanil, Malarone Junior) are used in the same way as for adults, but care with dosing and the avoidance of toxicity is essential. Drugs will be recommended according to the sensitivity of the malaria parasite in the destination country and your travel health doctor will discuss these. Antimalarial medications should be stored in childproof containers, out of reach of children, to avoid accidental overdose.
3. Some drugs are unsuitable for children and the medications prescribed will take into account the destination and its associated risks.
4. As for adults, prophylaxis should begin before entering the malarial area; continue for the duration and for some time after leaving the malarial area.
A good idea with special problems:
When the decision is made to travel with an infant, breast-feeding reduces many of the concerns about nutrition and hygiene and, when appropriate, should be encouraged. It should be continued as long as possible because of its safety and the resulting lower incidence of infant diarrhea.
THE PLUSES
Breast milk has nutritional and anti-infective properties and does not require reconstitution, sterilizing of bottles or the availability of clean water. It offers excellent nutrition for the infant, even when the mother has diarrhoea and considerably reduces the incidence of gastrointestinal infections. Supplementary feeding is usually not needed for the very young child but older infants will require powdered milk products and boiled water.
The atmospheric pressure changes during flight often produce pain and suffering in young children with eustachian tube malfunction. Breast-feeding provides comfort and relief when alternative feeding may be difficult to obtain.
THE MINUSES
Unfortunately, the flow of milk may be reduced by disruptions to eating and sleeping patterns, as well as other stressors. Mothers may need to increase their fluid intake, especially in the presence of diarrhoea, avoid excess alcohol and caffeine, and, as much as possible, avoid exposure to tobacco smoke.
VACCINES
There is no evidence of risk to the breastfeeding baby if the mother is vaccinated with either a live or inactivated vaccine. However, the CDC in Atlanta recommends the avoidance of the yellow fever vaccine (Stamaril) in nursing mothers because of a theoretical risk for transmission of the live vaccine virus to the infant. There is no data available for the newly released (in the USA) intranasal influenza vaccine.
Breast-feeding does not adversely affect immunisation and is not a contraindication for the administration of any vaccine to the baby.
FOOD AND WATERBORNE ILLNESS during breast-feeding
A nursing mother with travelers' diarrhoea should not stop breast-feeding, but should increase her fluid intake.
MALARIAL PROPHYLAXIS
Nursing mothers should take the usual adult dose of antimalarial appropriate for the country to be visited, with the knowledge that data on safety to the infant are lacking.
It must also be understood that the amount of medication in breast milk will not protect the infant from malaria who will require his or her own prophylaxis.
The drugs
Data are available for some antimalarial agents on the amount of drug excreted in breast milk of lactating women.
1. There is very limited information about the use of doxycycline (Doryx, Doxy) in lactating women. Although most experts consider the theoretical possibility of adverse events to be remote, doxycycline is usually best avoided when breast-feeding.
2. Very small amounts of chloroquine and mefloquine (Lariam) are excreted in the breast milk of lactating women. Little information is available and these drugs are therefore best avoided, although the amount of drug transferred is not thought to be harmful to a nursing infant.
3. Proguanil (Paludrine) is excreted in human milk in small quantities, but it is not known whether atovaquone is excreted in human milk. Because data are not yet available on the safety and efficacy of the atovaquone/proguanil combination (Malarone) in infants weighing <11 kg, it is not currently recommended for the prevention of malaria in women breast-feeding infants weighing <11 kg.
4. Information is not available on the amount of primaquine (Primacin) that enters human breast milk; the infant should be tested for G6PD-deficiency before primaquine is given to a woman who is breast-feeding.
All travellers abroad, especially the elderly, should prepare to manage any health problems- should they arise - alone.
If you are pregnant and considering international travel, you are strongly advised to evaluate the potential problems associated with international travel as well as the quality of medical care available while travelling and at your destination. You should have a clear plan of action in the event of complications during travel or at your destination, and the names of doctors and hospitals able to handle these complications.
1. Never leave children alone. 
THE PLUSES