cdc travel for healthcare providers

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• Section 6 - Perspectives : Avoiding Poorly Regulated Medicines & Medical Products During Travel
• Section 7 - Pregnant Travelers

Medical Tourism

Cdc yellow book 2024.

Author(s): Matthew Crist, Grace Appiah, Laura Leidel, Rhett Stoney

• Categories Of Medical Tourism

The Pretravel Consultation

Risks & complications, risk mitigation, additional guidance for us health care providers.

Medical tourism is the term commonly used to describe international travel for the purpose of receiving medical care. Medical tourists pursue medical care abroad for a variety of reasons, including decreased cost, recommendations from friends or family, the opportunity to combine medical care with a vacation destination, a preference to receive care from a culturally similar provider, or a desire to receive a procedure or therapy not available in their country of residence.

Medical tourism is a worldwide, multibillion-dollar market that continues to grow with the rising globalization of health care. Surveillance data indicate that millions of US residents travel internationally for medical care each year. Medical tourism destinations for US residents include Argentina, Brazil, Canada, Colombia, Costa Rica, Cuba, the Dominican Republic, Ecuador, Germany, India, Malaysia, Mexico, Nicaragua, Peru, Singapore, and Thailand. Categories of procedures that US medical tourists pursue include cancer treatment, dental care, fertility treatments, organ and tissue transplantation, and various forms of surgery, including bariatric, cosmetic, and non-cosmetic (e.g., orthopedic).

Most medical tourists pay for their care at time of service and often rely on private companies or medical concierge services to identify foreign health care facilities. Some US health insurance companies and large employers have alliances with health care facilities outside the United States to control costs.

Categories of Medical Tourism

Cosmetic tourism.

Cosmetic tourism, or travel abroad for aesthetic surgery, has become increasingly popular. The American Society of Plastic Surgeons (ASPS) reports that most cosmetic surgery patients are women 40–54 years old. The most common procedures sought by cosmetic tourists include abdominoplasty, breast augmentation, eyelid surgery, liposuction, and rhinoplasty. Popular destinations often are marketed to prospective medical tourists as low cost, all-inclusive cosmetic surgery vacations for elective procedures not typically covered by insurance. Complications, including infections and surgical revisions for unsatisfactory results, can compound initial costs.

Non-Cosmetic Medical Tourism

Cancer treatment.

Oncology, or cancer treatment, tourism often is pursued by people looking for alternative treatment options, better access to care, second opinions, or a combination of these. Oncology tourists are a vulnerable patient population because the fear caused by a cancer diagnosis can lead them to try potentially risky treatments or procedures. Often, the treatments or procedures used abroad have no established benefit, placing the oncology tourist at risk for harm due to complications (e.g., bleeding, infection) or by forgoing or delaying approved therapies in the United States.

Dental Care

Dental care is the most common form of medical tourism among US residents, in part due to the rising cost of dental care in the United States; a substantial proportion of people in the United States do not have dental insurance or are underinsured. Dentists in destination countries might not be subject to the same licensure oversight as their US counterparts, however. In addition, practitioners abroad might not adhere to standard infection-control practices used in the United States, placing dental tourists at a potential risk for infection due to bloodborne or waterborne pathogens.

Fertility Treatments

Fertility tourists are people who seek reproductive treatments in another country. Some do so to avoid associated barriers in their home country, including high costs, long waiting lists, and restrictive policies. Others believe they will receive higher quality care abroad. People traveling to other countries for fertility treatments often are in search of assisted reproductive technologies (e.g., artificial insemination by a donor, in vitro fertilization). Fertility tourists should be aware, however, that practices can vary in their level of clinical expertise, hygiene, and technique.

Physician-Assisted Suicide

The practice of a physician facilitating a patient’s desire to end their own life by providing either the information or the means (e.g., medications) for suicide is illegal in most countries. Some people consider physician-assisted suicide (PAS) tourism, also known as suicide travel or suicide tourism, as a possible option. Most PAS tourists have been diagnosed with a terminal illness or suffer from painful or debilitating medical conditions. PAS is legal in Belgium, Canada, Luxembourg, the Netherlands, Switzerland, and New Zealand, making these the destinations selected by PAS travelers.

Rehab Tourism for Substance Use Disorders

Rehab tourism involves travel to another country for substance use disorder treatment and rehabilitation care. Travelers exploring this option might be seeking a greater range of treatment options at less expense than what is available domestically (see Sec. 3, Ch. 5, Substance Use & Substance Use Disorders , and Box 3-10 for pros and cons of rehab tourism).

Transplant Procedures

Transplant tourism refers to travel for receiving an organ, tissue, or stem cell transplant from an unrelated human donor. The practice can be motivated by reduced cost abroad or an effort to reduce the waiting time for organs. Xenotransplantation refers to receiving other biomaterial (e.g., cells, tissues) from nonhuman species, and xenotransplantation regulations vary from country to country. Many procedures involving injection of human or nonhuman cells have no scientific evidence to support a therapeutic benefit, and adverse events have been reported.

Depending on the location, organ or tissue donors might not be screened as thoroughly as they are in the United States; furthermore, organs and other tissues might be obtained using unethical means. In 2009, the World Health Organization released the revised Guiding Principles on Human Cell, Tissue, and Organ Transplantation, emphasizing that cells, tissues, and organs should be donated freely, in the absence of any form of financial incentive.

Studies have shown that transplant tourists can be at risk of receiving care that varies from practice standards in the United States. For instance, patients might receive fewer immunosuppressive drugs, increasing their risk for rejection, or they might not receive antimicrobial prophylaxis, increasing their risk for infection. Traveling after a procedure poses an additional risk for infection in someone who is immunocompromised.

Ideally, medical tourists will consult a travel medicine specialist for travel advice tailored to their specific health needs 4–6 weeks before travel. During the pretravel consultation, make certain travelers are up to date on all routine vaccinations, that they receive additional vaccines based on destination, and especially encourage hepatitis B virus immunization for unvaccinated travelers (see Sec. 2, Ch. 3, Vaccination & Immunoprophylaxis & General Principles , and Sec. 5, Part 2, Ch. 8, Hepatitis B ). Counsel medical tourists that participating in typical vacation activities (e.g., consuming alcohol, participating in strenuous activity or exercise, sunbathing, swimming, taking long tours) during the postoperative period can delay or impede healing.

Advise medical tourists to also meet with their primary care provider to discuss their plan to seek medical care outside the United States, to address any concerns they or their provider might have, to ensure current medical conditions are well controlled, and to ensure they have a sufficient supply of all regular medications to last the duration of their trip. In addition, medical tourists should be aware of instances in which US medical professionals have elected not to treat medical tourists presenting with complications resulting from recent surgery, treatment, or procedures received abroad. Thus, encourage medical tourists to work with their primary care provider to identify physicians in their home communities who are willing and available to provide follow-up or emergency care upon their return.

Remind medical tourists to request copies of their overseas medical records in English and to provide this information to any health care providers they see subsequently for follow-up. Encourage medical tourists to disclose their entire travel history, medical history, and information about all surgeries or medical treatments received during their trip.

All medical and surgical procedures carry some risk, and complications can occur regardless of where treatment is received. Advise medical tourists not to delay seeking medical care if they suspect any complication during travel or after returning home. Obtaining immediate care can lead to earlier diagnosis and treatment and a better outcome.

Among medical tourists, the most common complications are infection related. Inadequate infection-control practices place people at increased risk for bloodborne infections, including hepatitis B, hepatitis C, and HIV; bloodstream infections; donor-derived infections; and wound infections. Moreover, the risk of acquiring antibiotic-resistant infections might be greater in certain countries or regions; some highly resistant bacterial (e.g., carbapenem-resistant Enterobacterales [CRE]) and fungal (e.g., Candida auris ) pathogens appear to be more common in some countries where US residents travel for medical tourism (see Sec. 11, Ch. 5, Antimicrobial Resistance ).

Several infectious disease outbreaks have been documented among medical tourists, including CRE infections in patients undergoing invasive medical procedures in Mexico, surgical site infections caused by nontuberculous mycobacteria in patients who underwent cosmetic surgery in the Dominican Republic, and Q fever in patients who received fetal sheep cell injections in Germany.

Noninfectious Complications

Medical tourists have the same risks for noninfectious complications as patients receiving medical care in the United States. Noninfectious complications include blood clots, contour abnormalities after cosmetic surgery, and surgical wound dehiscence.

Travel-Associated Risks

Traveling during the post-operative or post-procedure recovery period or when being treated for a medical condition could pose additional risks for patients. Air travel and surgery independently increase the risk for blood clots, including deep vein thrombosis and pulmonary emboli (see Sec. 8, Ch. 3, Deep Vein Thrombosis & Pulmonary Embolism ). Travel after surgery further increases the risk of developing blood clots because travel can require medical tourists to remain seated for long periods while in a hypercoagulable state.

Commercial aircraft cabin pressures are roughly equivalent to the outside air pressure at 6,000–8,000 feet above sea level. Medical tourists should not fly for 10 days after chest or abdominal surgery to avoid risks associated with changes in atmospheric pressure. ASPS recommends that patients undergoing laser treatments or cosmetic procedures to the face, eyelids, or nose, wait 7–10 days after the procedure before flying. The Aerospace Medical Association published medical guidelines for air travel that provide useful information on the risks for travel with certain medical conditions.

Professional organizations have developed guidance, including template questions, that medical tourists can use when discussing what to expect with the facility providing the care, with the group facilitating the trip, and with their own domestic health care provider. For instance, the American Medical Association developed guiding principles on medical tourism for employers, insurance companies, and other entities that facilitate or incentivize medical care outside the United States ( Box 6-07 ). The American College of Surgeons (ACS) issued a similar statement on medical and surgical tourism, with the additional recommendation that travelers obtain a complete set of medical records before returning home to ensure that details of their care are available to providers in the United States, which can facilitate continuity of care and proper follow-up, if needed.

Box 6-07 American Medical Association’s guiding principles on medical tourism 1

• Employers, insurance companies, and other entities that facilitate or incentivize medical care outside the United States should adhere to the following principles:
• Receiving medical care outside the United States must be voluntary.
• Financial incentives to travel outside the United States for medical care should not inappropriately limit the diagnostic and therapeutic alternatives that are offered to patients or restrict treatment or referral options.
• Patients should only be referred for medical care to institutions that have been accredited by recognized international accrediting bodies (e.g., the Joint Commission International or the International Society for Quality in Health Care).
• Prior to travel, local follow-up care should be coordinated, and financing should be arranged to ensure continuity of care when patients return from medical care outside the United States.
• Coverage for travel outside the United States for medical care should include the costs of necessary follow-up care upon return to the United States.
• Patients should be informed of their rights and legal recourse before agreeing to travel outside the United States for medical care.
• Access to physician licensing and outcome data, as well as facility accreditation and outcomes data, should be arranged for patients seeking medical care outside the United States.
• The transfer of patient medical records to and from facilities outside the United States should be consistent with Health Insurance Portability and Accountability Action (HIPAA) guidelines.
• Patients choosing to travel outside the United States for medical care should be provided with information about the potential risks of combining surgical procedures with long flights and vacation activities.

1 American Medical Association (AMA). New AMA Guidelines on Medical Tourism . Chicago: AMA; 2008.

Reviewing the Risks

Multiple resources are available for providers and medical tourists assessing medical tourism–related risks (see Table 6-02 ). When reviewing the risks associated with seeking health care abroad, encourage medical tourists to consider several factors besides the procedure; these include the destination, the facility or facilities where the procedure and recovery will take place, and the treating provider.

Make patients aware that medical tourism websites marketing directly to travelers might not include (or make available) comprehensive details on the accreditations, certifications, or qualifications of advertised facilities or providers. Local standards for facility accreditation and provider certification vary, and might not be the same as those in the United States; some facilities and providers abroad might lack accreditation or certification. In some locations, tracking patient outcome data or maintaining formal medical record privacy or security policies are not standard practices.

Medical tourists also should be aware that the drugs and medical products and devices used in other countries might not be subject to the same regulatory scrutiny and oversight as in the United States. In addition, some drugs could be counterfeit or otherwise ineffective because the medication expired, is contaminated, or was improperly stored (for more details, see the previous chapter in this section, . . . perspectives: Avoiding Poorly Regulated Medicines & Medical Products During Travel ).

Table 6-02 Online medical tourism resources

Checking credentials.

ACS recommends that medical tourists use internationally accredited facilities and seek care from providers certified in their specialties through a process equivalent to that established by the member boards of the American Board of Medical Specialties. Advise medical tourists to do as much advance research as possible on the facility and health care provider they are considering using. Also, inform medical tourists that accreditation does not guarantee a good outcome.

Accrediting organizations (e.g., The Joint Commission International, Accreditation Association for Ambulatory Health Care) maintain listings of accredited facilities outside of the United States. Encourage prospective medical tourists to review these sources before committing to having a procedure or receiving medical care abroad.

ACS, ASPS, the American Society for Aesthetic Plastic Surgery, and the International Society of Aesthetic Plastic Surgery all accredit physicians abroad. Medical tourists should check the credentials of health care providers with search tools provided by relevant professional organizations.

Travel Health Insurance

Before travel, medical tourists should check their domestic health insurance plan carefully to understand what services, if any, are covered outside the United States. Additionally, travelers might need to purchase supplemental medical insurance coverage, including medical evacuation insurance; this is particularly important for travelers going to remote destinations or places lacking medical facilities that meet the standards found in high-income countries (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance ). Medical tourists also should be aware that if complications develop, they might not have the same legal recourse as they would if they received their care in the United States.

Planning for Follow-Up Care

Medical tourists and their domestic physicians should plan for follow-up care. Patients and clinicians should establish what care will be provided abroad, and what the patient will need upon return. Medical tourists should make sure they understand what services are included as part of the cost for their procedures; some overseas facilities and providers charge substantial fees for follow-up care in addition to the base cost. Travelers also should know whether follow-up care is scheduled to occur at the same facility as the procedure.

Health care facilities in the United States should have systems in place to assess patients at admission to determine whether they have received medical care in other countries. Clinicians should obtain an explicit travel history from patients, including any medical care received abroad. Patients who have had an overnight stay in a health care facility outside the United States within 6 months of presentation should be screened for CRE. Admission screening is available free of charge through the Antibiotic Resistance Laboratory Network .

Notify state and local public health as soon as medical tourism–associated infections are identified. Returning patients often present to hospitals close to their home, and communication with public health authorities can help facilitate outbreak recognition. Health care facilities should follow all disease reporting requirements for their jurisdiction. Health care facilities also should report suspected or confirmed cases of unusual antibiotic resistance (e.g., carbapenem-resistant organisms, C. auris ) to public health authorities to facilitate testing and infection-control measures to prevent further transmission. In addition to notifying the state or local health department, contact the Centers for Disease Control and Prevention at [email protected] to report complications related to medical tourism.

The following authors contributed to the previous version of this chapter: Isaac Benowitz, Joanna Gaines

Bibliography

Adabi K, Stern C, Weichman K, Garfein ES, Pothula A, Draper L, et al. Population health implications of medical tourism. Plast Reconstr Surg. 2017;140(1):66–74.

Al-Shamsi, H, Al-Hajelli, M, Alrawi, S. Chasing the cure around the globe: medical tourism for cancer care from developing countries. J Glob Onc. 2018;4:1–3.

Kracalik I, Ham C, Smith AR, Vowles M, Kauber K, Zambrano M, et al. (2019). Notes from the field: Verona integron-encoded metallo-β-lactamase–producing carbapenem-resistant Pseudomonas aeruginosa infections in U.S. residents associated with invasive medical procedures in Mexico, 2015–2018. MMWR Morb Mortal Wkly Rep. 2019;68(20):463–4.

Pavli A, Maltezou HC. Infectious complications related to medical tourism. J Travel Med. 2021;28(1):taaa210.

Pereira RT, Malone CM, Flaherty GT. Aesthetic journeys: a review of cosmetic surgery tourism. J Travel Med. 2018;25(1):tay042.

Robyn MP, Newman AP, Amato M, Walawander M, Kothe C, Nerone JD, et al. Q fever outbreak among travelers to Germany who received live cell therapy & United States and Canada, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(38):1071–3.

Salama M, Isachenko V, Isachenko E, Rahimi G, Mallmann P, Westphal LM, et al. Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review). J Assist Reprod Genet. 2018;35(7):1277–88.

Schnabel D, Esposito DH, Gaines J, Ridpath A, Barry MA, Feldman KA, et al. Multistate US outbreak of rapidly growing mycobacterial infections associated with medical tourism to the Dominican Republic, 2013–2014. Emerg Infect Dis. 2016;22(8):1340–7.

Stoney RJ, Kozarsky PE, Walker AT, Gaines JL. Population-based surveillance of medical tourism among US residents from 11 states and territories: findings from the Behavioral Risk Factor Surveillance System. Infect Control Hosp Epidemiol. 2022;43(7):870–5.

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A Travel Medicine Primer for the Pharmacist

Amber B. Giles, PharmD, BCPS, MPH, AAHIVP Assistant Professor of Pharmacy Practice Presbyterian College School of Pharmacy Clinton, South Carolina

USPharm. 2018;43(4):19-26.

ABSTRACT: With international travel increasing in past decades, pharmacists should be informed and stay up-to-date on the most pertinent travel-health information available. Preventive measures including prescriptions and other nonpharmacologic therapies are available to reduce the risk of acquiring an infectious disease while traveling internationally. Pharmacists in the community may be the last line of medication information and counseling available to the patient before travel, and they may be asked for recommendations about medications and OTC products to prevent travel-related illnesses such as traveler’s diarrhea, cholera, typhoid fever, malaria, and Zika.

International travel has dramatically increased in past decades, with over 80 million trips booked by Americans in 2016—8% more than in 2015. 1 Travelers should consult a medical professional weeks to months prior to international travel, especially when traveling to a tropical, subtropical, or developing country, in order to receive proper counseling and any prophylactic medications or vaccinations that may be recommended. 2 This article will focus on information pertinent to pharmacists in the United States in order to field questions about causes, preventive measures, and available treatment options for the most common travel-related illnesses that patients may experience abroad.

Important information to obtain from a patient seeking medical travel advice includes the travel destination, reason for travel (e.g., medical mission trip, work, or leisure), duration of travel, itinerary, and patient-specific health concerns. 2 Pharmacists can consult the CDC Travelers’ Health website for specific recommendations. 3 Pharmacists may also be instrumental in helping patients locate a travel-medicine clinic. The International Society of Travel Medicine has an online directory of available travel-medicine clinics, which can be searched by state in order to locate the nearest clinics. 4

Travel Vaccinations

Many diseases that travelers may be at higher risk for can be prevented with vaccinations. 5 Common routine vaccinations given at pretravel appointments include influenza, hepatitis A, hepatitis B, and tetanus, diphtheria, and pertussis. Specific travel-related vaccines should be administered based on risk of infection, patient-specific factors, and travel itinerary; further details about available travel vaccines may be found in Table 1 . 6-14 Many insurance companies do not cover the cost of travel vaccinations, so patients should contact a local travel-medicine clinic for specific information on pricing.

Prevention of Food and Waterborne Disease

Precautionary safety measures during travel are of utmost importance in preventing infectious diseases. Paying close attention to hygiene practices in international restaurants and avoiding places with poor hygiene practices are important. Travelers should avoid eating raw or undercooked foods, including meats, seafood, and raw fruits and vegetables, unless cooked or peeled by the traveler personally. Travelers should avoid purchasing foods and beverages from street vendors, drinking tap water and unpasteurized milk, and consuming ice and dairy products. Any water used for drinking or brushing teeth should either come from an unopened bottle or be boiled prior to use. Hand washing with soap and water should be practiced routinely while traveling abroad. Alcohol-based sanitizers may be used if soap and water are unavailable. 15

Traveler’s Diarrhea

Traveler’s diarrhea (TD) is the most common travel-related illness and is caused by consuming fecally contaminated food or water. TD is defined as three or more unformed stools within 24 hours plus one of the following symptoms: abdominal cramping, nausea, vomiting, fever, or fecal urgency. More than 80% of TD cases are caused by bacterial organisms, such as Escherichia coli , Campylobacter jejuni , Shigella spp . , or Salmonella spp . , but may also be caused by viral or protozoal infections. Norovirus is often associated with outbreaks in patients traveling on cruise ships. A higher incidence of TD is seen in patients traveling to countries in Central and South America, Asia, Africa, Mexico, and the Middle East. 16

Symptoms of TD can be mild, with some cramping and loose stools, or severe, with fever, bloody stools, vomiting, and intense abdominal pain. The food and water safety measures previously discussed should be practiced to prevent TD. Bismuth subsalicylate (BSS) has been studied, with success shown in reducing the risk of TD by approximately 50%. In patients wishing to use BSS for prophylaxis, proper counseling about the potential of BSS to blacken the tongue and stool is important. BSS prophylaxis should not be used in pregnant patients or children aged less than 3 years. Additionally, those who have an aspirin allergy, renal dysfunction, or a prescription for an anticoagulant should avoid BSS. Importantly, prophylactic antibiotic therapy is not indicated to prevent TD in most travelers because this practice may lead to further antibiotic resistance. 16

Counseling should be provided to patients about increasing oral fluid intake in the event of a TD episode during travel. Antimotility medications such as loperamide (maximum 8 mg per day) or BSS may be used to reduce the number of stools per day and allow patients to continue with travel plans. Antidiarrheals should be used only in patients who do not have concomitant fever or blood in the stool and who are not pregnant. 16 Antibiotics may be used to reduce the duration of moderate-to-severe TD. Azithromycin or fluoroquinolone antibiotics are recommended empiric therapy for infectious diarrhea. 17 Importantly, fluoroquinolones should not be used in cases of bloody diarrhea. 16 Additionally, fluoroquinolone resistance is increasing throughout the world, so these agents are no longer the preferred treatment options in some locations, as outlined on the CDC website. 3 Azithromycin is preferred in patients who are pregnant. 18  Single doses of antibiotics have been shown to be as efficacious as multidoses and are also more convenient for patients traveling abroad ( Table 2 ). 19

Typhoid and paratyphoid fever, also known as enteric fever , are bacterial infections caused by Salmonella enterica . Southern and Southeast Asia, as well as Africa, are the highest-risk regions for enteric fever. The Caribbean, East Asia, and South America are areas with a lower risk. Typhoid typically presents as a low fever in the morning followed by higher fever in the evening. Typhoid symptoms may last up to 1 month if left untreated, and complications associated with typhoid, such as intestinal perforation and hemorrhage, may present after several weeks of untreated illness. 13

Two vaccines are available for typhoid in the U.S. 13 Destination-specific vaccine recommendations may be found on the CDC Travelers’ Health website. 3 The traditional therapy of choice for enteric fever has been fluoroquinolone antibiotics; however, increasing resistance has been seen across the globe, especially in Southern and Southeast Asia. Third-generation cephalosporins and azithromycin are often used instead of fluoroquinolones owing to this resistance. After antibiotic initiation, patients could continue to spike fevers for several days, with an initial worsening of symptoms. 13  

Cholera is an infectious disease caused by a bacterium, toxigenic Vibrio cholerae . The highest incidence of cholera is found in regions of Africa and Southern and Southeast Asia. Cholera outbreaks have also been reported in parts of the Caribbean. Cholera typically presents as mild, watery diarrhea without fever and may also be asymptomatic. However, some patients may experience severe, profuse, watery diarrhea that appears like “rice-water stools.” This form of cholera may lead to very severe dehydration, shock, or even death if left untreated. 7

Owing to high quantities of fluid loss, aggressive rehydration is the key to treating patients with active cholera infections. Oral rehydration therapy may be used to treat moderate dehydration; however, IV fluids are needed in severe cases. Doxycycline is the agent of choice for adult patients in the majority of the world, and azithromycin is the treatment option preferred in pregnant women and children. 7 Other options for treatment include ceftriaxone or fluoroquinolone antibiotics, with increasing resistance to fluoroquinolones in many parts of the world. 7,17 In addition to safety precautions, an oral vaccine is now available in the U.S. for adults (ages 18-64) traveling to areas of active transmission of cholera. Currently, there are no safety or efficacy data for booster doses of the cholera vaccine. 20

Prevention of Insect-Borne Disease

Prophylactic medications and vaccinations are available in the U.S. to prevent vectorborne diseases. Lightweight long-sleeved shirts, long pants, closed-toe shoes, and hats should be worn when possible to minimize the amount of exposed skin. Permethrin may be used to treat clothing or gear but should not be applied directly to the skin. Any exposed skin should be treated with a mosquito repellent. Many commercially available insect repellents are EPA-registered, including DEET, picaridin, oil of lemon eucalyptus, and para-menthane-3,8-diol. Repellents containing less than 10% of the active ingredient are only minimally protective (providing coverage for 1-2 hours). Repellents should not be sprayed directly to the face, under clothing, or on cuts or irritated skin. Combination sunscreen and repellent products are not recommended by the CDC. In addition to wearing proper clothing and using insect repellents, travelers should sleep in screened-in and/or air-conditioned rooms as well as under an insecticide-pretreated bed net. 21

Malaria is a significant cause of morbidity and mortality in patients traveling internationally. 2 Malaria is caused by the Plasmodium parasite and transmitted by the Anopheles mosquito in areas of Africa, Asia, and Central and South America. Different species of Plasmodium are seen throughout the world, and each species and region have unique susceptibility to antimalarial agents. The CDC separates geographical regions into chloroquine-sensitive or chloroquine-resistant malaria, which helps physicians in choosing appropriate prophylaxis or treatment. 22

Malaria prophylaxis should be prescribed for patients traveling to high-risk areas and should be taken before, during, and after travel. The travel itinerary, remaining time before travel, age, weight, allergies, concomitant drug interactions, and pregnancy status are important factors to consider in order to choose the most appropriate prophylactic therapy for a patient. Several options for prophylaxis should be started 1 to 2 days prior to travel, while others must be started 1 to 2 weeks prior. In addition, the duration that prophylaxis must be continued post-travel is unique to each agent ( Table 3 ). Patients who believe that they may  have been infected with malaria while traveling should seek appropriate medical treatment as soon as possible. Treatment options depend on the severity of infection, area of travel, potential drug resistance, and patient-specific characteristics. 22 The CDC provides guidelines for the treatment of malaria in the U.S. 23

Zika is a viral infection that is transmitted by the Aedes mosquito. Zika virus was discovered in 1947 in Uganda; however, much attention has been focused on Zika in recent years owing to its association with severe effects on the fetuses of mothers infected with the virus. There are currently no available vaccinations or prophylactic therapies to prevent infection with Zika. Proper mosquito precautions are important for preventing the illness. The majority of patients infected with Zika remain asymptomatic, and any symptomatic infections are often mild and flulike. Supportive care is the mainstay of therapy in patients with symptomatic Zika infections. 24

An increased risk of microcephaly and other brain abnormalities in the fetus has been associated with Zika infection in pregnant women; therefore, the CDC recommends that pregnant women or those trying to become pregnant should not travel to areas of active local transmission. 24 Other potential birth defects linked to Zika are neural tube defects such as anencephaly, congenital cataracts, spina bifida, and hearing loss. 25 If travel to these areas cannot be avoided, the woman should speak with her healthcare provider and take very strict precautions to avoid mosquito bites. A male who has traveled to an area of local transmission should use condoms or abstain from sex with his partner, if the partner is pregnant, for the duration of the pregnancy. Couples wishing to conceive and who have recently traveled to an endemic area should first speak with a medical provider and wait until risks for transmission are minimized. 24

Yellow Fever

Yellow fever (YF) is caused by a virus and is endemic to sub-Saharan Africa and the tropics of Central and South America. YF is transmitted via the bite of Aedes or Haemagogus spp . mosquitoes. During the rainy season, there is an increased risk of infection; however, transmission may still occur outside of these months. The majority of patients infected with YF remain asymptomatic or may have mild flulike symptoms. Approximately 15% of patients infected with YF will progress to severe disease with liver dysfunction, hemorrhage, shock, and ultimately multiorgan failure. Supportive care with fluids, analgesics, and antipyretics is the standard of care. Because of the increased risk of bleeding, aspirin and nonsteroidal anti-inflammatory drugs should not be used in patients with suspected or confirmed YF. 14

YF prevention includes mosquito protection as well as the YF vaccine, which is a live attenuated vaccine. Some countries require proof of vaccination with the International Certificate of Vaccination or Prophylaxis, or “Yellow Card.”  In 2014, the World Health Organization determined that a single dose of the YF vaccine provides lifelong immunity, so a 10-year booster is no longer needed for most patients. 14 The Advisory Committee on Immunization Practices does recommend a one-time booster in patients who received their first vaccine while pregnant or who received a stem-cell transplant after the vaccination. Patients who are living with HIV should be given a booster every 10 years. 26 Owing to potential serious adverse effects of the YF vaccine, only certain healthcare providers are certified to administer the vaccine. 14 Information about providers who can administer the vaccine may be found via the CDC’s search engine. 27

Preventive measures including prescriptions, vaccinations, and other nonpharmacologic therapies are available to reduce the risk of acquiring an infectious disease while traveling internationally. Pharmacists in the community may be the last line of medication information and counseling available to the patient before travel, and they may be asked for recommendations about medications and OTC products to prevent travel-related illnesses such as traveler’s diarrhea, cholera, typhoid fever, malaria, and Zika (sidebar ). Pharmacists should be informed and stay up-to-date on the most pertinent travel health information.

1. National Travel and Tourism Office. 2016 outbound analysis. December 4, 2017. https://travel.trade.gov/outreachpages/download_data_table/2016_Outbound_Analysis.pdf. Accessed January 29, 2018. 2. Chen LH, Hochberg NS, Magill AJ. The pretravel consultation. In: CDC. Travelers’ Health—Yellow Boo k. Chapter 2. The pretravel consultation. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/the-pre-travel-consultation. Accessed January 25, 2018. 3. CDC. Travelers’ health. wwwnc.cdc.gov/travel. Accessed January 26, 2018. 4. International Society of Travel Medicine. Online clinic directory. www.istm.org/AF_CstmClinicDirectory.asp. Accessed January 26, 2018. 5. Boggild AK, Castelli F, Gautret P, et al. Vaccine preventable diseases in returned international travelers: results from the GeoSentinel Surveillance Network. Vaccine . 2010;28(46):7389-7395. 6. Kroger AT, Strikas RA. General recommendations for vaccination & immunoprophylaxis. In: CDC. Travelers’ Health—Yellow Book . Chapter 2. The pretravel consultation. Updated June 13, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/general-recommendations-for-vaccination-immunoprophylaxis. Accessed January 25, 2018. 7. Wong KK, Burdette E, Mintz ED. Cholera. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/cholera. Accessed January 25, 2018. 8. Nelson NP. Hepatitis A. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated June 12, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/hepatitis-a. Accessed January 25, 2018. 9. Averhoff F. Hepatitis B. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated June 13, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/hepatitis-b. Accessed January 25, 2018. 10. Hills SL, Rabe IB, Fischer M. Japanese encephalitis. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/japanese-encephalitis. Accessed January 25, 2018. 11. MacNeil JR, Meyer SA. Meningococcal disease. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/meningococcal-disease. Accessed January 25, 2018. 12. Petersen BW, Wallace RM, Shlim DR. Rabies. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/rabies. Accessed January 25, 2018. 13. Judd MC, Mintz ED. Typhoid & paratyphoid fever. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/typhoid-paratyphoid-fever. Accessed January 25, 2018. 14. Gershman MD, Staples JE. Yellow fever. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/yellow-fever. Accessed January 25, 2018. 15. Connor BA. Food & water precautions. In: CDC. Travelers’ Health—Yellow Book . Chapter 2. The pretravel consultation. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/food-water-precautions. Accessed January 25, 2018. 16. Connor BA. Travelers’ diarrhea. In: CDC. Travelers’ Health—Yellow Book . Chapter 2. The pretravel consultation. Updated June 13, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/travelers-diarrhea. Accessed January 25, 2018. 17. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis . 2017;65:e45-e80. 18. Morof DF, Carroll D. Pregnant travelers. In: CDC. Travelers’ Health—Yellow Book . Chapter 8. Advising travelers with specific needs. Updated June 13, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/advising-travelers-with-specific-needs/pregnant-travelers. Accessed January 25, 2018. 19. Steffen R, Hill DR, Dupont HL. Traveler’s diarrhea: a clinical review. JAMA . 2015;313(1):71-80. 20. Advisory Committee on Immunization Practices. Summary report, February 24, 2016. Atlanta, GA: US Department of Health and Human Services, CDC. Advisory Committee on Immunization Practices; 2016. www.cdc.gov/vaccines/acip/meetings/downloads/min-archive/min-2016-02.pdf. Accessed January 31, 2018. 21. Mutebi J, Hawley WA, Brogdon WG. Protection against mosquitoes, ticks, & other arthropods. In: CDC. Travelers’ Health—Yellow Book . Chapter 2. The pretravel consultation. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/protection-against-mosquitoes-ticks-other-arthropods. Accessed January 25, 2018. 22. Arguin PM, Tan KR. Malaria. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated June 12, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/malaria. Accessed January 25, 2018. 23. CDC. Malaria diagnosis and treatment in the United States. Updated February 23, 2017. www.cdc.gov/malaria/diagnosis_treatment/treatment.html. Accessed January 25, 2018. 24. Chen T, Staples JE, Fischer M. Zika. In: CDC. Travelers’ Health—Yellow Book . Chapter 3. Infectious diseases related to travel. Updated May 31, 2017. wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/zika. Accessed January 25, 2018. 25. Fitzgerald B, Boyle C, Honein MA. Birth defects potentially related to Zika virus infection during pregnancy in the United States. JAMA . January 25, 2018. https://jamanetwork.com/journals/jama/fullarticle/2671017. Epub ahead of print. Accessed January 25, 2018. 26. CDC. Yellow fever vaccine booster doses: recommendations of the Advisory Committee on Immunization Practices, 2015. MMWR . June 19, 2015. www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a5.htm. Accessed January 30, 2018. 27. CDC. Search for yellow fever vaccination clinics. wwwnc.cdc.gov/travel/yellow-fever-vaccination- clinics/search. Accessed January 30, 2018.

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Is It Worth Traveling Abroad for Healthcare?

T he CDC uses the phrase “medical tourism” to describe the act of leaving the country for medical care — and millions of Americans do it every year . Unsurprisingly, the most common destinations are Canada and Mexico, but U.S.-based medical tourists also commonly travel to the Caribbean, Central America, South America and beyond.

See: Why Nobody Is Buying Vacation Homes Anymore

Learn: How To Build Your Savings From Scratch

But, considering that your life might depend on the outcome, is it worth traveling for treatment — and in a country where medical debt is the leading cause of bankruptcy , can you afford not to?

In America, the Cost of Care and the Consequences of Debt Are Both Very High

The Peterson-KFF Health Care Tracker states, “The U.S. has higher prices for most health care services and prescription drugs, according to available internationally comparable data.” 

Costs are so high, in fact, that Americans would face financial ruin seeking treatment at home. According to RetireGuide, two out of three bankruptcies are directly caused by medical debt, and 17% of adults with healthcare debt have lost a home or have had to declare bankruptcy because of it. The system is as unforgiving as it is expensive.

According to the Texas Tribune, one in seven people with debt has been denied access to doctors or hospitals because of unpaid medical bills, even when suffering from severe conditions.

Take Our Poll: Who Has Given You the Best Money Advice You Have Ever Received?

“Right now, one of the driving factors causing Americans to seek care outside of the United States is the cost, particularly as we experience inflation,” said Dr. Latonya Dunlow, DHA, MPH and president of Premier Health Destinations , a concierge health and wellness facilitation company that connects Americans with international medical care.

“The thought that you can receive care without having to face years of medical debt motivates many — including insured individuals — to turn to international experts for their health needs.”

If You or Your Treatment Aren’t Covered, You Can Save a Bundle

Dunlow says her clients save at least 20% and often as much as 50% by seeking treatments and services overseas. While some medical tourists are uninsured, the CDC says many people travel for procedures and therapies that are unapproved or unavailable in the United States — with or without coverage.

Many others are insured but travel for care that insurance doesn’t typically cover or that’s more expensive in the States, even with insurance. That includes dental surgery, cosmetic surgery, cancer treatments, organ and tissue transplants and fertility treatments.

“In the U.S., IVF treatment can cost upwards of $10,000, while in Spain the process is about half the cost,” Dunlow said. “Even if you travel business class round trip, you would fare better financially.”

MedicalTourism.com says IVF treatment costs $15,400 in the U.S., but just $6,500 in Mexico.

“For some, joint replacement surgery is the equivalent of a year’s worth of their mortgage after spending only a few days recovering in the hospital,” Dunlow said.

According to Axa Global Healthcare, a hip replacement costs $39,313 in the U.S. compared to $22,408 in France and $12,420 in neighboring Belgium.

Axa states that heart bypass surgery costs $95,282 in the U.S. but just $29,470 in the U.K. — an incredible $65,812 difference.

The Overall Experience Can Be Not Just Cheaper, But More Pleasant

It’s not just the procedures and treatments. Recovery is often less expensive and stressful overseas, too.

“Internationally, you can receive the same treatment and care often for much less while recovering in a relaxing location,” Dunlow said.

David Walls, owner of D&D Insurance , which specializes in the Medicare market in Ocala, Florida, has several medical tourist clients. One, from Gotha, Florida, recently traveled to Panama for dental care that was one-third the cost of the $10,000 she would have paid in Orlando.

“The most interesting thing about her experience was the waiting room for this particular dentist,” Walls said. “It did not exist. The dentist owned a hotel built on the side of his practice that his customers stayed in — apparently, he catered to United States citizens. When it was her turn to see the dentist, the receptionist simply called her on her hotel room phone and asked her to come down to see the dentist.”

Travel blogger and registered nurse Mina Coleman and her family have long traveled to their native Bulgaria for dental care.

“I had a tooth implant a couple of years ago, which cost around $2,000 for everything — surgery, exams, X-rays, etc.,” she said. “Excellent dental work — and my round-trip ticket was around $650.”

Are You Comfortable Getting Surgery in Bulgaria?

Medical care isn’t always a get-what-you-pay-for situation — and medical tourism can be risky. U.S. insurance almost never covers care abroad, and navigating a foreign legal system for redress in cases of fraud or malpractice can be nearly impossible.

Also, prepare to navigate a patchwork of unfamiliar laws and regulations. Axa Global Healthcare states, “If you move to France, for example, you can register for public healthcare after you’ve lived there for three months. But in Singapore, public healthcare is only available to citizens and long-term permanent residents. Thailand, meanwhile, has public healthcare but it’s only accessible to expats through an employer, while in Sweden, all residents are eligible for subsidized healthcare, including expats.”

The Direct Risks Are the Most Consequential of All

According to the CDC, the likelihood of complications depends on the country, facility, treatment and your physical and mental condition. Risk factors include:

• Quality of care: In many countries, the standards for licensure, accreditation and credentialing are lower than in the U.S., and medicines and devices might be inferior.
• Language barriers: Communication challenges can lead to misunderstandings about your condition and care.
• Infectious disease: Some countries pose an especially high risk of infectious diseases and antibiotic-resistant infections.
• Air travel: Flying after certain treatments can be dangerous because of the increased risk of blood clots.

The CDC recommends protecting yourself by:

• Getting a pre-travel consultation with your healthcare provider four to six weeks before you leave.
• Investing in travel insurance that covers medical evacuation to the United States.
• Maintaining your medical records, bringing copies with you and returning home with any documents you receive overseas.
• Packing a travel health kit with enough of all your medicines to last the entire trip plus a few days.
• Arranging for follow-up care in the U.S.

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This article originally appeared on GOBankingRates.com : Is It Worth Traveling Abroad for Healthcare?

CHILL’D-Out: A Heat and Health Risk Factor Screening Questionnaire

CHILL’D OUT. Use this questionnaire with your patients to assess risk factors for health harms from heat or poor air quality. Then, create a Heat Action Plan with your patient. If there is limited time, cover the bolded questions.

• Does your patient have working air conditioning?
• Can they check and control indoor temperatures where they live?
• Do they have an electric fan?
• Do they know how to locate a cooling center if needed?
• Does your patient have stable housing?
• Do they live on a higher floor of a multi-story building where they may be exposed to more heat?
• Are they regularly exposed to indoor air pollutants such as secondhand smoke or mold?
• Do they have a portable air purifier or a filter in their HVAC system?

& mobility

• Does your patient have a neighbor, friend, or family member who can check on them during hot days?
• Does their mobility limit their ability to seek cooling in their home or elsewhere?

e L ectricity

• If heat leads to a power outage, does your patient have a plan for refrigerated medications and/or electric medical devices?
• Does your patient check the daily and hourly weather forecast to know the hottest time of the day? Can they access the HeatRisk tool?
• Where does your patient get information about how to protect their health from heat? What measures do they take to do so?
• Does your patient take medications that increase risk from heat exposure?
• How much time does your patient spend outdoors on hot days for work, sports, or recreation?
• Are they exposed to outdoor air pollution at home, work, or elsewhere, such as a major roadway, construction site, industrial facility, or frequent wildfire smoke?
• Do they have allergies to grass, weeds, and tree pollens?

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Heat-Related E.R. Visits Rose in 2023, C.D.C. Study Finds

By Noah Weiland

Reporting from Washington

The rate of emergency room visits caused by heat illness increased significantly last year in large swaths of the country compared with the previous five years, according to a study published on Thursday by the Centers for Disease Control and Prevention.

The research, which analyzed visits during the warmer months of the year, offers new insight into the medical consequences of the record-breaking heat recorded across the country in 2023 as sweltering temperatures stretched late into the year.

What the Numbers Say: People in the South were especially affected by serious heat illness.

The researchers used data on emergency room visits from an electronic surveillance program used by states and the federal government to detect the spread of diseases. They compiled the number of heat-related emergency room visits in different regions of the country and compared them to data from the previous five years.

Nearly 120,000 heat-related emergency room visits were recorded in the surveillance program last year, with more than 90 percent of them occurring between May and September, the researchers found.

The highest rate of visits occurred in a region encompassing Arkansas, Louisiana, New Mexico, Oklahoma and Texas. Overall, the study also found that men and people between the ages of 18 and 64 had higher rates of visits.

How It Happens: Heat can be a silent killer, experts and health providers say.

Last year was the warmest on Earth in a century and a half, with the hottest summer on record . Climate scientists have attributed the trend in part to greenhouse gas emissions and their effects on global warming, and they have warned that the timing of a shift in tropical weather patterns last year could foreshadow an even hotter 2024.

Heat illness often occurs gradually over the course of hours, and it can cause major damage to the body’s organs . Early symptoms of heat illness can include fatigue, dehydration, nausea, headache, increased heart rate and muscle spasms.

People do not typically think of themselves as at high risk of succumbing to heat or at greater risk than they once were, causing them to underestimate how a heat wave could lead them to the emergency room, said Kristie L. Ebi, a professor at the University of Washington who is an expert on the health risks of extreme heat.

“The heat you were asked to manage 10 years ago is not the heat you’re being asked to manage today,” she said. One of the first symptoms of heat illness can be confusion, she added, making it harder for someone to respond without help from others.

What Happens Next: States and hospitals are gearing up for another summer of extreme heat.

Dr. Srikanth Paladugu, an epidemiologist at the New Mexico Department of Health, said the state had nearly 450 heat-related emergency room visits in July last year alone and over 900 between April and September, more than double the number recorded during that stretch in 2019.

In preparation for this year’s warmer months, state officials are working to coordinate cooling shelters and areas where people can be splashed by water, Dr. Paladugu said.

Dr. Aneesh Narang, an emergency medicine physician at Banner-University Medical Center in Phoenix, said he often saw roughly half a dozen heat stroke cases a day last summer, including patients with body temperatures of 106 or 107 degrees. Heat illness patients require enormous resources, he added, including ice packs, fans, misters and cooling blankets.

“There’s so much that has to happen in the first few minutes to give that patient a chance for survival,” he said.

Dr. Narang said hospital employees had already begun evaluating protocols and working to ensure that there are enough supplies to contend with the expected number of heat illness patients this year.

“Every year now we’re doing this earlier and earlier,” he said. “We know that the chances are it’s going to be the same or worse.”

Noah Weiland writes about health care for The Times. More about Noah Weiland

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2024 National Viral Hepatitis Progress Report

The Centers for Disease Control and Prevention (CDC) strives to prevent viral hepatitis and eliminate disease and death caused by viral hepatitis. The 2024 Viral Hepatitis National Progress Report provides information on progress toward 2025 goals for new viral hepatitis infections and viral hepatitis–related deaths, overall and for key populations. In 2020, CDC modified the goals and associated targets from previous reports to align them with CDC’s Division of Viral Hepatitis 2025 Strategic Plan and the US Department of Health and Human Services’ Viral Hepatitis National Strategic Plan for 2021–2025.