Holiday destinations should be chosen and decisions to visit friends and relatives, or travel on business, taken with regard to fitness for travel, likely health risks and medical facilities at the destinations. Travellers should allow adequate time for medical preparation for such trips.

Travel medical insurance companies need to be aware of the medical conditions when the policy is obtained.

The traveller should carry a medical letter containing details of the condition or at least a list of any drug therapy with generic names and dosages. Any medication should be carried in hand luggage, or, preferably, divided between that of the traveller and a companion.

14.2  Additional notes on travel with certain conditions

14.2.1  Type 1 diabetes (Insulin dependent diabetes)

•   diabetic meals for air travel can be ordered but are not considered necessary.

•   for long haul east or west flights, instruction should be given on how to adjust insulin requirements during flight .

•   sufficient insulin needs to be carried in a cool box in hand luggage. It should not be allowed to become frozen eg if in aircraft hold.

•   injecting equipment and disposal method, blood monitoring equipment and test strips should be carried.

•   instruction should be given on regular monitoring whilst travelling and especially in case of illness.

•   advise to include snacks (eg cereal bars, biscuits, unsweetened fruit juice, sandwiches, glucose tablets etc) in hand luggage.

•   those who have poor warning signs of hypoglycaemia are advised to travel with a companion trained in early recognition of hypo or hyperglycaemia.

•   identification as a diabetic eg diabetic card or inscribed bracelet or medical letter should be carried at all times.

•   advise on prevention of travel infections, especially skin and gastrointestinal, and consider whether a course of antibiotics should be carried.

•   remind about the importance of keeping hydrated with plenty of non-alcoholic drinks in hot climates and the increased difficulty of early recognition of hypo and hyperglycaemia in such situations.

•   hot climates increase susceptibility to hypoglycaemia. Diabetics may need to decrease insulin dose on arrival and monitor blood glucose more closely.

•   Diabetes UK supplies useful information on many destinations, insulin type availability etc (see useful addresses).

14.2.2   Immunocompromised travellers (see below for additional notes on HIV infected travellers)

•   live vaccines (yellow fever, oral typhoid, oral polio, BCG) should be avoided (see 8.3 and Immunisation against Infectious Disease).

•   yellow fever infected areas should be avoided or the risk of travel without yellow fever protection should be assessed. In some cases the wisdom of travel may be questioned. Precautions should be advised to reduce mosquito bites dawn to dusk ie day biting mosquitoes (see 7.5).

•   an exemption from yellow fever vaccination on medical grounds may be issued. Such letters are usually acceptable for entry directly from the UK, however they are less likely to be acceptable for travel between several different countries within the yellow fever zones. Although the advice to check with embassies may be given, in practice there is no absolute guarantee of acceptance in every situation overseas.

•   inactivated vaccines can be administered although efficacy may be reduced.

•   consider whether a course of early treatment antibiotics should be carried.

14.2.3   Additional information for HIV infected travellers

In addition to the advice given for immunocompromised travellers above:

•   some countries require evidence of a negative HIV test as an entry requirement for certain categories of visitors, usually long-term visitors or students. Information is available from the Foreign and Commonwealth Office but these arrangements are liable to change and should be checked with the Embassy of the country concerned.

•   inactivated vaccines should be administered as required but could be less effective, especially in those with a low CD4 lymphocyte count.

•   vaccines may be more effective in those with higher CD4 counts who are taking anti-retroviral therapy. Although increases in viral load have been shown after administration of certain vaccines, these are generally thought to be transient and not clinically significant.

•   MMR vaccine, a live vaccine, has been used safely in HIV infected individuals (see Immunisation against Infectious Disease) and may be appropriate for travellers going to regions where the risk of measles may be increased.

•   yellow fever vaccination should be avoided as for other immunocompromised travellers (see above) on theoretical grounds. There is a lack of safety and efficacy data in HIV infected recipients, and this should be explained to asymptomatic HIV infected individuals who are determined to visit yellow fever risk areas whilst assessing the comparative risks of travelling with or without vaccine. A yellow fever waiver letter may be issued.

•   the risk of opportunistic infections in HIV infected travellers may be increased (eg cryptosporidial diarrhoea). Advice about food and water hygiene should be offered, and patients may wish to carry antibiotics for rapid treatment (until they receive medical advice) or occasionally for prophylaxis.

•   travellers intending to visit countries where TB prevalence is high, may be at increased risk of acquiring tuberculosis. Isoniazid chemoprophylaxis may be considered for those intending to stay for long periods.

•   there are few data regarding interactions between anti-retroviral drugs and malaria chemoprophylaxis. One study has shown that mefloquine reduces protease inhibitor levels and it is possible that protease inhibitors could increase the blood levels of mefloquine and quinine. The clinical significance of this is, however, unclear. Mefloquine should probably not be offered to HIV infected travellers until more information is available. There are no reports of adverse interactions between chloroquine, proguanil or doxycycline and anti-retroviral drugs.

14.2.4  Splenectomised/asplenic travellers

•   asplenic individuals are at increased risk of certain bacterial infections - pneumococcal, Hib and meningococcal C conjugate vaccines should be considered routinely. Meningococcal A&C or quadrivalent vaccine should be advised for travel to any suspected risk area.

•   flu vaccine is recommended annually.

•   risk from malaria is increased: high risk areas should be avoided if at all possible and meticulous care taken over prophylaxis.

•   risk from babesiosis* is increased.

•   check whether immunocompromised due to underlying condition (if so, see above).

•   consider antibiotic prophylaxis (penicillin V, amoxycillin or erythromycin) or as immediate standby treatment to be taken if symptoms develop (pyrexia, malaise or shivering) until medical help is obtained.

*Babesiosis is caused by a protozoan parasite transmitted by ticks. It occurs in the north eastern coastal region of USA plus Wisconsin and sporadically in California and Georgia; also some areas of Europe. Prevention is by tick avoidance measures (see 7.5).