Travellers with Special Needs

These include:

Children
Elderly Travellers
Pregnant Women
Disabled Travellers
Diabetes
IBD
Adoption purposes
HIV/AIDS

1. Children

Parents should take special care when travelling with young children and being prepared in advance is important.

Vaccinations are important and schedules can differ for children so seek advice from your doctor or nurse. Doses of malaria tablets are usually less than for adults. Special seating arrangements in planes can often be arranged if advance notice is given. Prepare for possible travel sickness. Boredom during travel can be relieved by books or toys.

Remember to avoid contaminated food and water. If your child has vomiting or diarrhoea lost fluid and salts must be replaced. It may be helpful to take rehydration tablets or powders for reconstituting with boiled water. You can usually buy these at your local chemist.

Infections such as tuberculosis and diphtheria, spread from close personal contact with those infected, can be more serious in young children.

Childrens' skin burns easily in the sun. Take sensible clothing, high factor sun screens and avoid exposure to 'mid-day' sun.

Keep children well away from stray or sick animals and seek medical advice without delay if any illness persists.

2. Elderly Travellers

More and more elderly people are now travelling abroad for holidays and to visit relatives. Special holidays can be arranged but age does not give natural protection against disease.

Take adequate personal medications. These must be clearly labelled and carried in hand luggage for easy access in case of delays or loss of luggage. While abroad store your medicines in a cool dry place. If you are crossing time zones, do not miss out doses especially if you are diabetic or have a heart condition.

If you suffer from any recurrent illness or are on regular medication check with your general practitioner. You may find a check-up helpful to ensure that you are fit to travel. A referral letter can be useful in case you you need treatment while abroad.

Immunizations are important at all ages. Having had a disease previously, such as polio or diphtheria, does not always mean you are immune. If you are prescribed anti malaria tablets, be sure to mention if you are on any other medication.

Read the small print of your insurance policy which should include repatriation in case of illness and ensure there are no important exclusion clauses.

Remember to take care to with food and water hygiene and to avoid insect and animal bites.

3. Pregnant Women

Travelling during pregnancy is usually possible but there are important things to keep in mind:

Always seek a medical check-up before planning your trip and again shortly before departure. It is important to get the 'all clear' from your own doctor or obstetrician before departure.
Most airlines will not accept a pregnant traveller after 28-32 weeks gestation and long air flights in the later stages can be very uncomfortable. The most risky times for travel are during the first 12-15 weeks of pregnancy when miscarriage is more likely.

Ante-natal facilities vary greatly between countries and you should think carefully before travelling to a country with poor medical facilities or where there are major cultural and language differences from home. This could be important if you have health problems such as threatening to miscarry or going into early labour.

Illness during pregnancy can be more severe so take special care to avoid contaminated food and water and insect and animal bites. Avoid partially cooked meat, unpasteurized milk products and soft cheeses. In some countries infections such as tuberculosis or meningitis can be spread from close personal contact with locals and these can be serious during pregnancy both to yourself and your unborn child.

Appropriate immunization and malaria prevention is sometimes different during pregnancy so seek advice. Some vaccines are best avoided during pregnancy, for example those that contain live organisms. However vaccination may be safer than travelling to some high risk areas without protection. Discuss this carefully with your doctor or nurse.

Ensure your insurance policy covers pregnancy but remember insurance policies are only as good as the facilities available.

4. Disabled Travellers

Travelling with a disability is now commonplace and there is no reason why this should pose serious problems if good preparations are made. Adapting to unexpected situations is a part of the challenge of travelling but advance knowledge of facilities available, during travel and at your destination, can be very important. Some organizations and tour companies arrange trips for the disabled when mobility problems, for example, are taken into account.

Airlines are usually helpful and provide assistance at airports and offer special facilities on aircraft if advised in advance. However this may not be the case with some airlines and at small airports especially in African, Asian and South American countries.

When selecting accommodation check good lifts are available, the condition of staircases and bathroom equipment. Ask in advance if special food requirements are necessary.
Make sure that you have comprehensive health insurance with no important exclusion clauses which affect disability and which includes repatriation if necessary.

Cruising the Nile... trekking in Nepal... elephant rides in Thailand... the Taj Mahal. The places to go are endless, as are the reasons for going. But regardless of where and why you go, travel should be relaxing, stimulating and fulfilling. Diabetes should not be a barrier to travelling. However the diabetic traveller's planning needs to go well beyond the usual itinerary and clothing list. If you use Murphy's Law (i.e. "whatever can go wrong will go wrong") as your guide, you will realize what I mean.

Imagine the following scenario. Your early morning flight to Greece sits on the runway for three hours in a snowstorm. The lovely breakfast you anticipate never materializes. You forgot to pack the granola bars 'just in case'. The flight attendant seems to ignore your requests for orange juice. What about the time zones? When should I take my next dose of insulin? How much? Where is my insulin? Great! It's in my suitcase in the hold! It'll freeze. Finally you land in Athens. Your baggage lands in Tokyo! The lovely customs agent takes away your syringes. What do you mean there's no Diet Coke in Greece! A lovely cruise through the Greek Islands. Motion sickness! I wonder what my blood sugar is now... Get the picture?

Close control of blood glucose is paramount in the treatment of diabetes. However while travelling, particularly during long flights, the goal should be to avoid any extremes that might result in symptomatic hypo- or hyperglycemia. Once you have arrived at your destination, you may then get back to a pattern of tighter control. But in order to achieve this, you must plan ahead.

Diabetic Supplies
Skimp on your underwear and socks, but not on your supplies. You never know when something might get damaged, lost or stolen. It is probably prudent to carry double the supplies that you will actually require. That goes for your insulin, syringes, batteries for your blood glucose monitor and alcohol swabs. It may not always be possible to purchase the same supplies abroad. For example the U-100 strength insulin you use here may not be available in certain countries. The same goes for your syringes or the insulin cartridges for your "pen". It is worthwhile, however, to check with the manufacturer of your insulin regarding the availability at your destination. Premixed combinations of insulin are available, and might be appropriate for someone with stable insulin requirements.

Insulin "pens" are perhaps ideal for travel. There is less risk of damage or theft Many patients with diabetes find them a lot easier and quicker to use, which can be particularly important for the traveller who may require more frequent injections and adjustments than usual. Finally, there is no need to carry syringes and vials.

Carry your supplies in your hand baggage. Insulin that travels in the baggage compartment may freeze and lose its potency. Or it may end up in Tokyo! Consider giving a bottle of insulin to your travelling companion, just in case you become separated from your hand luggage. It is important to carry some identification such as a Medic Alert bracelet or a wallet card' and a letter from your doctor explaining that you have diabetes. A written prescription for your insulin, needles and other supplies will smooth your passage through customs, as well as help you out should you require more supplies abroad. A list of English-speaking doctors around the world, which is available through IAMAT (International Association for Medical Assistance to Travellers) might also prove useful.

Remember that mealtime while travelling may be anytime. Flight delays, flat tires, power failures, long-winded tour guides and coup d'etats are only a few of the factors that will conspire against you and your ideal schedule. So always be prepared. Pack some cheese, crackers or dried fruit at all times, as well as some hard candy should you require a fast-acting source of sugar. A Glucagon Kit, for treatment of severe hypoglycemia, might be a good idea for someone with "brittle" diabetes, or for someone going a bit farther off the beaten path. Check this one out with your doctor. If you do take one along, be sure to instruct a travelling companion on its use.

Don't neglect other precautions which might be worthwhile before you travel. Certain inoculations may be required or recommended. Antimalarials may be needed. And go prepared for motion sickness, cuts and bruises, Montezuma's Revenge, and all of those other inevitable joys of travel!

Insulin Storage
The insulin you are using should be comfortable going wherever you go. It does not need to be refrigerated. However, it must be protected from temperature extremes and direct sunlight, or it may lose its potency. Crossing the Sahara in a Land Rover while your insulin swelters in the glove compartment is not ideal! And remember, unpressurized airline baggage compartments may lead to your insulin freezing. Unopened bottles of insulin should be refrigerated as soon as possible.

Insulin may be protected from temperature extremes by carrying it in an insulated container such as a thermos. Cool down the thermos, put the bottle in a plastic bag, and line the thermos with a wet washcloth. This will ensure that your insulin remains effective and unbroken.

Specially designed kits for carrying diabetic supplies and for protecting insulin are available and may simplify your life while travelling.

Blood Sugar Control
When we travel, we are looking for a change from our everyday routine. Whether this involves reading spy novels on the beach all day or climbing pyramids is up to you. Regardless, your diet and your activity will change. Throw in a 14-hour flight across eight time zones, and it becomes evident that blood sugar control will take some extra planning.

Firstly, let's cross the ocean. Schedules for insulin dosage are based on a 24 hour day. But when we fly eastward, to Europe, for example, we cross 5 time zones, and our day in fact becomes shorter. Conversely, on a westward flight, say to Hawaii, the day is lengthened by several hours. Flights to destinations north and south do not present the same problem. In addition to the time changes, the nature and timing of your meals is often a bit unpredictable, and your level of physical activity dwindles to nothing as you recline in your crowded airline seat for what seems like an eternity. Obviously, adjustments need to be made to your customary insulin schedule.

The keys to avoiding significant hypo- or hyperglycemia during travel are frequent self-monitoring of blood glucose, and flexibility. There are several ways to calculate insulin requirements, and it is best that you discuss this with your doctor or staff of a diabetes education unit. What you choose to do will depend upon the duration and direction of your flight, your time of departure, as well as your usual regime, i.e. single daily vs. twice daily injections and the type or types of insulin you use. People on oral hypoglycemics do not usually have to make any adjustments in their dosage, though they should be aware of all of the potential problems that can arise.

Eastward travel results in a shorter day and hence lower insulin requirements. You may choose to give yourself a smaller dose of your intermediate-acting insulin in the morning, and then supplement it later in the day with short-acting insulin, according to your glucose readings. You may simplify things a bit by calculating your usual "hourly" insulin dose. For westward travel with a longer day, your requirement will increase depending upon how many time zones you are crossing. This may be achieved simply by the addition of some short-acting insulin late in your day to cover the extra hours. Some people find a split dosage, i.e. twice daily, easier for travel and may switch to this prior to their departure if they are not already on such a regime. Never take your insulin unless your next meal is in sight, and don't forget to carry your own sources of carbohydrate and sugar. Again, insulin dosages and schedules need to be individualized. Discuss your plans with your doctor or diabetes educator.

With all of the newer insulins and monitors available, control of diabetes during travel should be much easier than it used to be.

Diet
A word about your diet while travelling. Certainly you will not have your usual control over what, where and when you eat. But do your best to keep to your customary meal plan. Foods that can substitute for your usual choices should not be hard to find.

It is also possible to alter slightly the timing of your meals, when possible. For example, if you take off for France at 0800 hours, it may be best to eat breakfast and take your insulin at 0600, rather than risk that breakfast will be delayed on the plane. If at times your sugar tests on the low side, than grab a quick snack. If you're running high, maybe it's because you need to get off of your sun cot (butt) and get some exercise. While some travellers prefer to stick to their "home time" for their insulin injections, it is probably best to switch over to "local time" as soon as you arrive. Once you are in the swing of things at your destination, remember that adjustments still may need to be made according to your differing activities and food intake. If you are in a very hot climate, you may find that your insulin gets absorbed more quickly and can result in hypoglycemia.

Once again, there are countless ways of managing your blood sugar during a prolonged flight and on vacation. But there is no 'right way'. It is probably best to sit down with your diabetes educator and organize a chart of your insulin and meal plans for your trip. It really needs to be individualized to each traveller. With a bit of experience, you will discover which methods work best for you, and you can learn to do your own planning.

There are many sources of information for the diabetic traveller. They include your diabetic education unit, your pharmacist, and the manufacturer of your insulin. The Canadian Diabetes Association site should be of help. With a little bit of advice, lots of planning, frequent blood sugar testing and flexibility, the traveller with diabetes should be able to choose where, when and how to travel. So good luck, enjoy, and stay healthy!

The Special Traveller: Inflammatory Bowel Disease

There are many medical conditions which make us think twice before travelling, particularly to the tropics. Inflammatory Bowel Disease (Crohn's Disease and Ulcerative Colitis) is one of them. Just the thought of Montezuma's Revenge might be enough to change one's destination from Acapulco to Arizona, or even decide to stay home. But by sticking to the following suggestions, that trip of your dreams might be a lot closer to reality.

Take along a few rolls of toilet paper.
Carry an address book with the name and phone number of your doctor, as well as that of a doctor abroad whom you could contact in an emergency.
Take more medication and other supplies than you really need. Keep your medications in their original labelled containers. Pack them with your carry on baggage, or you might never see them again
Purchase medical insurance. Don't skimp on this item.
Always know the location of the next toilet, and how to ask for it in several languages.
Consider the use of Dukoral for the prevention of traveller's diarrhea.
Read the section on Traveller's Diarrhea, twice!
Boil it, Bottle it, Peel it, Cook it...OR FORGET IT! (especially in the tropics)
Ice cubes are a no-no. Also, watch what you eat in the days preceding your trip.
Take along medications such as Imodium, as well as an antibiotic such as Cipro, for the prompt treatment of Traveller's Diarrhea. Consider using a "preventative" Imodium before a long flight, drive, or camel ride.
Be prepared to recognize danger signals which might suggest a flare-up of your Crohn's Disease or Ulcerative Colitis.
Know how to deal with these flare-ups, e.g. Prednisone, fluids, etc.
Eat lightly and sensibly, especially on the airplane. Gases expand as the plane ascends. So will your intestines.
Plan your visits to the washroom to avoid peak times, such as after meals, after the movie, and before landing.
Don't forget the other health risks of travelling, such as bugs, the sun, exotic infections, and more.
Travel only with understanding, patient people.

The Special Traveller: HIV and AIDS

Planning a trip when you have an underlying medical problem sometimes presents problems. When that medical problem is infection with HIV or AIDS, it can be quite a challenge, particularly when your destination is tropical. Food and water borne diseases, vector borne infections, and the inoculations themselves may pose important risks to this group of travellers. Aside from the medical concerns, just the logistical problems of crossing borders or carrying medications may also a formidable task.

The role of the travel medicine advisor is not to judge whether certain individuals should travel. Rather, it is to explain the risks, offer measures to minimize those risks, and to educate the traveller as to how to deal with medical problems should they arise. Prevention and anticipation are the keys.

From the point of view of pre-travel inoculation, the risk factors such as destination, duration and style of travel should be considered as with any other traveller. However, there are a few points to keep in mind when immunizing the HIV infected traveller. Firstly, live vaccines should be avoided, especially in anyone who is immunosuppressed as evidenced by a CD4 count of less than 200. This would preclude yellow fever vaccine, oral typhoid (Vivotif) and oral polio vaccine and measles vaccine. Typhim Vi, an inactivated vaccine, is a safe alternative for typhoid, as is IPV for polio. For those who must venture to an area of high risk for yellow fever, one might consider administering the shot, as while the risk is theoretical, it has been given in the past without adverse effects. Where the risk is likely low, a certificate of exemption may be given.

Tuberculosis is usually of little threat to the average traveller. But HIV infected patients are at significantly greater risk. Therefore TB skin testing should be performed prior to and after any extended travel where exposure is likely. BCG, a live vaccine with questionable efficacy against TB, is contraindicated. Another concern is whether or not the immunosuppressed patient will respond adequately to any particular vaccine. In the case of hepatitis B, a double dose has been advocated. Because of this possible limitation, personal measures to avoid disease are critical.

This is exceedingly important with respect to food and water borne disease. While Traveller's Diarrhea is usually but an inconvenience, it may be debilitating and life threatening to someone with AIDS. Patients with AIDS often have a decrease in stomach acid, which reduces their defences against gastrointestinal infections. It takes a much smaller inoculum, or a smaller mistake, to become ill.

Bacterial infections such as salmonella, shigella and campylobacter are often much more severe and prolonged in AIDS patients, sometimes leading to a chronic carrier state. They may spread to the bloodstream as well. A group of "spore forming" protozoa, including cryptosporidia, microsporidia, isospora and cyclospora may also lead to severe, dehydrating, and sometimes fatal diarrhea. The severity of the infection is proportional to the immune status of the individual. Effective treatment for these infections particular infections is unfortunately lacking.

The Special Traveller: Travelling to Adopt

There are countless reasons why people travel, and I've heard them all... to lounge by the ocean, climb a mountain, pray at holy shrines, visit friends and family, conduct business or volunteer their time and skills. But perhaps the most exciting, both for both me and the traveler, is to adopt a child from a completely different country and culture. The commonest destinations for adoptive parents tend to be eastern Europe (Romania, Ukraine), Asia (China, Korea, Vietnam, India) and Latin America (Guatemala, Peru). But, it could be anywhere!

Several factors have led to the upsurge in international adoption, not the least of which are the extremely long waiting times to adopt a child locally. But perhaps the most important is the desire of adoptive parents to be able to provide a loving home and endless opportunity for a child who would never get to experience this in their native country.

Adoptive parents share some of the same health-related anxieties as do all travelers, such as "Do I need any shots?" "Can I drink the water?" "What about malaria?" and "What do I do if I get sick?" The answer to many of these questions can be found by reading this book. But a visit to your local travel clinic is still a good idea.

The shots you may receive will depend upon your particular destination, how long you plan to be there and whether you will be visiting rural areas. At a minimum, you will need to be up to date with your routine inoculations such as tetanus-diphtheria-polio and measles. Protection against hepatitis A and typhoid fever might also be recommended assuming you are traveling to a lesser developed country where the safety of the food and water might be suspect. And don't forget your Imodium!

Hepatitis B is a very important issue. The first concern is the fact that you might become ill and require medical care that is less than sterile in the middle of China. Added to this is the worry that the baby you adopt might in fact be a carrier of the hepatitis B virus, and hence be infectious to you. As you recall, hepatitis B is transmitted via bodily fluids, and such contact is usually an occupational hazard of parenting! These children may have become infected directly from their mother during pregnancy, or from contaminated needles or blood, that is often commonplace in their country of origin. The bottom line here is that you should be immunized against hepatitis B! Also consider vaccinating siblings and grandparents eagerly waiting at home.

Whether you will need any other vaccines or malaria prophylaxis will depend mainly upon your destination. You should also be aware of the non-infectious risks where you are going, whether it be the buses in Guatemala or the pollution in Beijing. Many excellent organizations now exist to help adoptive parents through every step of their incredible journey.

Having looked after yourself, your concerns should then focus on the soon-to-be your baby. New questions should enter your minds, such as:

How will I know if my baby / child is healthy?
What tests should he or she have done when we return home?
Could the baby be carrying any diseases that might be a risk to friends and family back home?

Ideally, there will be a complete written record of your baby's and the birth mother's medical history. This can hopefully answer some of the following questions:

Is there a family history of any medical problems?
Were there any problems during pregnancy or surrounding the delivery?
Did the mother smoke, take any drugs or drink alcohol during pregnancy?
What inoculations, if any, has the baby received to date?
What were the results of testing for hepatitis B and HIV, stools for parasites, etc.?
Has the baby had any medical problems or required hospitalization to date?
Has he grown well and passed the usual milestones such as smiling or sitting at the appropriate times?
Under what sort of conditions has he been brought up so far, i.e. living with his birth family, foster care or an orphanage, and what was the quality of caring?

That was ideally! It is quite conceivable that any records will be few and far between, and what is available could even be fraudulent. Certain infections, such as hepatitis B and HIV have a long incubation period, so a negative test when you meet your baby could subsequently become positive in the months ahead. There is no guarantee that the vaccines your baby "received" were actually given, and if they were, the vaccines may not have met our standards. As well, a malnourished child might not respond adequately to immunization. What this usually means is that you will repeat the appropriate tests when you return home, and consider repeating some or all of the vaccinations.

Upon return, your baby should obviously have a medical examination. This need not be on the way home from the airport, but preferably within two weeks of arriving home. Should there be any acute illness, however, it should be attended to immediately. Remember that a child adopted from a malarious country may develop malaria days, weeks or even months after their arrival home. Respiratory infections, diarrhea and skin problems such as scabies and impetigo are common conditions in these children.

Aside from performing a thorough general examination, the doctor should be on the lookout for any sign of growth disturbance (height, weight, head circumference), malnutrition, hearing and visual problems. A developmental assessment is crucial in order to detect signs of past emotional deprivation or abuse. This may require a referral to a specialized facility.

Routine investigations might vary according to the age and origin of the child, but should probably include most of the following:

CBC (complete blood count, to detect anemia, sickle cell disease and other inherited conditions)
Urinalysis
Chest X-ray
TB skin test (if negative, repeat in 6 months)
Stool for culture and sensitivity (to test for bacterial infections such as Salmonella and Shigella)
Stool for ova and parasites (to detect protozoal infections such as giardiasis, and amebiasis, and helminthic or worm infections)
VDRL (for syphilis)
HIV (should be repeated in 6 months if negative)
Hepatitis B screen (for antigen and antibodies - should be repeated in 6 months if negative)

Any further testing or treatment will depend upon the results of the above assessment.
If it is felt that your child needs to be reimmunized, the exact schedule for those vaccines might depend upon the child's age and past records. The routine vaccines that will be necessary are DPTP(diphtheria, polio,tetanus, pertussis), MMR (measles, mumps, rubella) and HiB (haemophilus influenza). If there is no evidence of past exposure to hepatitis B, this vaccine should also be given. Newer vaccines against varicella, meningitis and pneumoccocal infections might also be worthwhile. Just as there are organizations specializing in international adoption, there are also medical clinics across North America that have expertise in assessing your new bundle of joy. He or she might not appreciate all of the probing, prodding and needling, but you will rest easier after it has all been done. Go to the COMEUNITY website listed below to find a clinic near you.

I suppose there are certain health risks involved in adopting a child from a lesser developed country. But if you and your family are properly immunized, and take sensible precautions such as washing your hands after changing a diaper, these are really quite negligible. Some babies may be harboring intestinal worms. These are generally not contagious to others in North America as the life cycle of most worms requires some time spent outside the body in a different home (e.g. in the soil) before they become infectious to others. This is quite unlikely in countries with indoor plumbing and three feet of snow!

For further information on the subject of international adoption, browse through the following websites:

COMEUNITY
Children's Bridge
Open Arms to International Adoption
International Adoption for Canadians (information for Americans too!)

Traveling is stressful, and I would assume that traveling to a foreign country to adopt a child must be very stressful. But imagine how it must be for the child. Giant, strange-looking humans staring and making silly faces and noises at you, and then whisking you to a foreign country by airplane, where you receive a multitude of needles. But I am sure that for all parties involved, things get better and better. Good luck!

Key Points:

Take the appropriate medical precautions for yourself before and during your trip
Assume that your child will need to be retested and reimmunized when you arrive back home