Overview of Travel Health and Safety

General Health and Safety Concerns

Accidents

Transportation-related injuries are the leading cause of preventable deaths among travelers. Road conditions and traffic-law enforcement may be poor in some countries, and vehicles may lack adequate safety equipment. Cars with seat belts might not be readily available at all destinations. The tips below can help prevent transportation-related injuries:

• Do not drink and drive; some countries have a "zero tolerance" policy, with severe penalties for driving under the influence of alcohol or drugs.
• Seek vehicles with seat belts, which may result in extra expense; decline vehicles without seat belts unless no choice is available.
• Decline transportation in vehicles with worn tires, worn brakes, or inoperative lights.
• Decline water transportation in vessels without personal flotation devices or life jackets.
• Avoid using overcrowded public vehicles if possible.
• Ask drivers to slow down if they are driving recklessly.
• Avoid driving at night, especially in rural areas.
• Remain alert and drive slowly; roads could be damaged or too narrow for passage, animals might be gathering up ahead, or people could be hiking or crossing, even in remote areas.
• Be aware of the appropriate side of the road on which to drive because it can vary from country to country.
• Research where to find fuel, food, and assistance if traveling away from urban centers.
• Make note of the nearest regional medical facility on maps.
• Bring a high-quality helmet from home if planning on using motor scooters, bikes, and other such vehicles on unfamiliar and potentially unsafe terrain. Avoidance of these vehicles is the best course of action because unfamiliar language and rules of the road pose significant risk to the driver.

Slips and falls can be prevented by taking some common-sense precautions:

• Organize hotel rooms. Return chairs and drawers to their proper places and keep belongings off the floor. Keep a soft light on at night to see. Take extra care in the bathroom, where hard surfaces, water, and electricity can combine to cause serious injuries.
• Be careful when moving around on planes. Narrow aisles, food carts, and improperly stored luggage can be hazardous, especially during turbulence.
• Watch out for the most common shipboard mishaps: falling over storm steps, tripping over bulkheads, and catching fingers in doors that swing shut when the ship moves. The ship's doctor often treats on-board accidents before ever leaving port.
• Wear low-heeled, slip-proof shoes while traveling to help reduce fatigue and the risk of injury.

Altitude Illness

Travelers going to mountain areas should be prepared to recognize and respond to the symptoms of altitude illness, which are caused by the lower level of oxygen in the air at high elevations. Although the human body can adjust to changes in altitude, the process (called acclimatization) takes time.

Each person has his or her own "acclimatization line." Below it, travelers probably won't experience altitude illness, but going above it causes symptoms to begin. For most people, this line initially lies somewhere near 2,800 m (9,200 ft), but it can be adjusted by following preventive techniques. Travelers who have had altitude problems previously, have heart or lung problems, are unable to acclimatize on the way to higher elevations, or plan to go to extremely high elevations should discuss prevention and treatment options with a health care provider.

Altitude illness is generally divided into 3 syndromes, and symptoms range from mild to life threatening; serious syndromes are rarely seen below 2,500 m to 3,000 m (8,200-9,800 ft).

1. Acute mountain sickness (AMS) typically appears at altitudes above 2,500 m (8,200 ft), although illness can begin at elevations as low as 1,500 m (4,900 ft) in some individuals. Symptoms usually appear within a few hours of ascent and may include the following symptoms: headache, insomnia, irritability, dizziness, muscle aches, fatigue, loss of appetite, nausea or vomiting, and swelling of the face, hands, and feet. Travelers who experience mild AMS symptoms should limit their activity level and remain at the same altitude for 1 to 2 days before ascending any farther. Ibuprofen is best for an altitude headache. If symptoms become worse during a day of rest, descend until symptoms begin to improve.
2. High altitude cerebral edema (HACE) is a dangerous form of altitude illness that can lead to coma and death and is a medical emergency. HACE can be thought of as a worsening of AMS symptoms, with additional changes in consciousness and/or coordination. HACE is rare at altitudes typically attained on conventional tourist itineraries. Persons affected may hallucinate, appear confused, and begin to stumble or stagger, and they can have severe headaches and extreme fatigue. Helping affected persons descend to receive drug and oxygen treatment is crucial because they may be too confused to see the problem themselves. Persons who have recently experienced HACE should not ascend again, even if they have improved.
3. High altitude pulmonary edema (HAPE) is a buildup of fluid in the lungs that can occur along with HACE (or separately) and is a medical emergency. Some shortness of breath with significant exertion is to be expected at altitude. HAPE-affected persons become breathless and very tired when walking on a level surface and may experience a sense of fullness or pressure in the chest. Eventually, they are short of breath even while resting. Affected persons must be guided down to receive drug and oxygen treatment as soon as the illness is recognized as HAPE. They should be kept warm and assisted as much as possible because exertion will make the condition worse. Some people have chosen to ascend again after recovering from HAPE (not recommended).

Altitude Illness Prevention and Treatment

Preventive Behaviors

Consult a health care provider before leaving and discuss personal needs for medications to prevent and/or treat altitude illness. Remember, the same advice that applies to climbers applies to anyone at a high altitude: watch for signs of altitude illness, drink extra water, don't do too much too fast, and avoid alcohol and unnecessary medications.

Travelers who are climbing to high altitudes have options that those who are flying or driving may not have. Climbers can use these preventive techniques to acclimatize and reduce their chances of altitude illness:

• "Climb high, sleep low." Altitude illness occurs during ascent, not descent. The simplest way to avoid or reduce symptoms is to ascend slowly to give the body time to become accustomed to changes in oxygen concentration. Travelers who begin to feel mild symptoms of altitude illness, or reach an altitude of 3,000 m (9,800 ft), should keep total daily altitude gain under 300 m (1,000 ft). Travelers can exceed 300 m of altitude during the day's climb but should descend to sleep at an altitude that is no more than 300 m above the previous night's altitude.
• Increase fluid intake to counteract symptoms of dehydration induced by dry mountain air and increased respiratory rate.
• Avoid using alcohol or any unnecessary medications because their effects may be increased at high altitudes. Sleeping pills, tranquilizers, and narcotic-based pain relievers (in particular) can cause serious problems because they can decrease breathing rates. Consult a health care provider about any required medications.
• Do not push past the limits of individual climbers in a group; those who are most susceptible may experience altitude illness. Illness during ascent should be assumed to be altitude related and treated accordingly.
• Keep a log of the altitude at which each trip begins, the amount gained each day, and the altitude slept at each night. If anyone becomes ill, this information will be very important.
• Consult a health care provider to discuss options for prevention and treatment of illness if planning to go to extremely high altitudes or if a history of heart or lung problems or previous altitude problems exists.

Medications

Available drugs that can help with altitude illness include:

• Acetazolamide: has been shown to prevent or lessen AMS symptoms by increasing breathing rate and helping with acclimatization. Side effects may include tingling in hands and feet, nausea, and increased urination.
• Dexamethasone: can improve AMS and HACE symptoms long enough for severely ill travelers to descend to safety and medical help, but is not curative and does not promote acclimatization. Side effects may include sweating, flushing, and nausea.
• Nifedipine: often included in treatment for HAPE and improves blood flow and reduces the need for oxygen. Side effects may include headache, nausea, weakness, dizziness, and edema.

Depending on the severity of illness, additional drugs and oxygen treatment may be necessary. Always ask a health care provider for written information on dosages, scheduling, side effects, and precautions for all medications.

Beaches and Swimming

Being caught off guard is easy while enjoying oneself. Unfortunately, play can be serious business for those unaware of the dangers at recreational areas.

When possible, limit swimming to chlorinated pools and unpolluted ocean beaches far from the mouths of streams. Avoid water where algae are present. Avoid freshwater lakes and rivers in the tropics because they may contain the snails that transmit schistosomiasis to humans. (See Schistosomiasis.)

Walking barefoot exposes individuals to poisonous plants and animals, parasite and fungal infections, puncture wounds, and cuts and bruises. Rubber sandals, flip-flops, or shoes made to be worn in water can offer some protection when wading or swimming.

In areas frequented by animals, sand and soil may be contaminated. As a precautionary measure, consider sitting on a towel, blanket, or piece of clothing if chairs or hammocks are not available. Shake out all fabrics thoroughly after use to avoid transporting any unwanted guests.

In tropical waters, watch for jellyfish, sea anemones, and corals, all of which can give severe and painful stings. If stung, rinse the affected body part with vinegar or seawater, and scrape or shave the area gently to remove any remaining stingers. Do not rub the area or rinse with fresh water or tap water. Acetaminophen, aspirin, or ibuprofen will help ease pain, and antihistamines such as diphenhydramine (Benadryl) can relieve itching and swelling. If symptoms are severe or if signs of severe allergic reaction are present, seek medical help immediately. (See Pests.)

Strong currents, tides, and underwater hazards can cause injury and drowning. Before diving into unfamiliar waters, check water depth to avoid spinal injury. Beaches in tropical and developing countries are usually unsupervised: Never swim alone or at night and know what to do to help someone who is injured or in danger.

Scuba dive only with PADI- or NAUI-certified divers and only used equipment from PADI- or NAUI-certified dive shops. Follow timetables for air travel after diving.

Children and Travel

Traveling with children can be more rewarding by taking some extra preparations. Plan a pace that accommodates children without hurrying and include frequent food, beverage, and rest stops. Have toys, books, and games available to keep children quietly occupied when necessary.

Each traveling parent should have a photo or digital image of each child on their person at all times. Give children an identification necklace or card to keep with them at all times. It should include an address and phone number while abroad (but no names), as well as medical or emergency information.

Prearrange a meeting place in case of separation. Some people have children carry whistles to use if they become lost. Make sure children know the name and number of the person or place they should call if they become lost and their parents are not available. Teach them how to use foreign phones and let them practice making several calls.

When booking air travel, check the airline's website for seating charts or see www.seatguru.com. Many airlines will allow travelers to carry an infant safety seat or collapsible stroller on board, but travelers should check the airline's policy prior to travel. Many airlines require that an infant be placed in an approved infant seat or child restraint device, which is then secured with the safety belt of the aircraft seat. Most airlines require infants older than 2 years to occupy a regular airline seat. In some cases, airlines will allow a child younger than 2 years in a child-restraint system to occupy an empty airplane seat without having to pay the airline fare for the child. However, purchasing an airline ticket for the child is the only way to guarantee that a seat will be available.

Call the airline in advance to order special meals for children if they might not like the food offered. Bring along familiar foods or snacks and a 24-hour supply of food for infants in case of extensive delays.

Traffic regulations at various destinations may be different than those at home. Be sure children understand the rules in the countries they will visit, especially if traffic lights or signs are different than those they already know.

Do not assume child or infant car seats can be rented at each destination; bring one along unless a safe one will definitely be available. Travelers may also need a length of climbing rope or some other means of fastening the child's seat to the car's seat in case seat belts are not present or are inadequate.

Ensure that all routine vaccinations are up to date and that any needed travel-related vaccines are given, if appropriate. As with adults, infants and children need to be protected against diseases caused by physical contact (such as rabies) and insects (such as malaria) and should observe strict food and beverage precautions. Additionally, travelers should be prepared to handle any diarrhea that might occur while traveling.

A parent traveling alone with a child should carry a medical consent form for the child that has been presigned by the absent parent. Many countries require for entry a notarized letter from the absent parent authorizing the child to travel with the other parent.

Cold Weather

If travel plans include outdoor activities in a chilly environment, it may be necessary to pack water-resistant shoes or boots, a hat or face mask, and mittens or gloves. The tips below will help travelers cope with the cold.

• Dress in layers of loose, soft clothing for warmth; pockets of air between the layers create additional insulation, and layers can be added or removed if the weather changes.
• Wear an outer layer of windbreaker-type material. A chilling wind can pull away generated body heat and turn a cold day into a dangerous one.
• If any chance of precipitation exists, wear a moisture-resistant covering as an outer layer.

Hypothermia is a dangerous drop in the body's core temperature. It can occur even on days that seem mild, especially if the weather is damp. Many hypothermia deaths have occurred in weather that is between -1°C and 10°C (30°F and 50°F). Children and the elderly are particularly vulnerable. Symptoms include slurred speech, decreased awareness, shivering, irritability, or stumbling. Be especially concerned if shivering stops because this is a sign of exhaustion.

Frostbite is an actual freezing of body tissues. Symptoms include pain, numbness, swelling, itching, and changes in skin color. Do not thaw a frozen body part unless it can be kept thawed. For example, if a hiker must still be able to walk to help, don't start the warming process. Refreezing causes damage that is even worse than the original frostbite. Frostnip on the other hand is simply the formation of ice crystals over cold-exposed skin (usually the cheeks, ears, and nose) and does not cause tissue damage if rewarmed.

Travelers who suspect frostbite or hypothermia should find warm shelter and seek medical attention. Remove cold, damp clothing and place the affected person between blankets until help arrives. Avoid interim measures such as rubbing or rapid rewarming, which can lead to complications.

Crime

Many countries have government offices (such as the US Department of State) that supply information for travelers. Check for advisories on political or civil unrest, criminal activity against tourists, and other travel concerns before each trip. Know the phone number and location of the closest embassy or consulate and always carry this information. A duty officer is usually on call in case of crime or other emergencies. Know how local law enforcement agencies operate and where to go for help.

Tips for Avoiding Crime

Out and about

• Prepare tour routes before setting out. Avoid studying maps or mobile devices in the street because this will attract unnecessary attention.
• Lock rooms before setting out and inform at least 1 other person about individual daily schedules at all times.
• Consider a smartphone app that will allow designated others to track the phone's location.
• Become familiar with common local scams and distraction techniques. Ask at hotels if any areas are dangerous. Use extra caution in tourist sites, marketplaces, elevators, crowded subways, train stations, and festivals, and avoid marginal areas of cities.
• Be constantly attentive to surroundings and be wary of any stranger who engages in any form of conversation or makes physical contact in any way, no matter how accidental the contact appears to be. Especially beware of pickpockets around train stations and other crowded areas. Groups of small children sometimes act as distractions so travelers can be robbed.
• Give up all valuables if confronted. Money and passports can be replaced, life cannot.

Valuables, money, and dress

• Do not wear expensive clothing or jewelry and avoid carrying expensive cameras, computers, or luggage. Avoid clothing that declares nationality or political beliefs.
• Never carry valuables or large amounts of cash. Use credit cards for large purchases, but first make sure they are accepted at each destination.
• Learn about local exchange rates and pay close attention to all monetary transactions. Exchanging money is sometimes seen as an easy way to deceive tourists. Avoid black market exchanges.
• Carry only a passport face page and legal entry stamp photocopy while out. Leave the passport in a hotel safe unless local law requires travelers to carry a passport. Have a digital image of the passport face page stored in an e-mail inbox or accessible server in case of passport loss.
• Do not carry purses or money belts that can be cut or torn off.
• Wear handbags across the chest or under a jacket or shirt.
• Keep passports and most cash and credit cards in a neck pouch with a metal cable reinforced strap that is worn under a shirt.

Traveling by car, taxi, or public transport

• Keep suitcases locked and out of sight. Do not leave valuables in the car.
• Keep car doors locked and windows rolled up when driving. Use cars with air conditioning. Carjacking and thefts happen when stopped at gas stations, parking lots, or in slow city traffic.
• Avoid driving at night or alone, and never drive outside urban areas after dark. Do not pick up hitchhikers.
• Avoid rental cars with rental markings.
• Arrange for local mobile phone service (either a personal phone with a local plan or a locally purchased phone) to be kept in the vehicle when traveling (especially for business and long-stay travelers).
• Use taxis from official ranks or dispatched via a smartphone app or radio. Negotiate the fee before entering the taxi and carry small denominations for the taxi bill. Avoid sharing taxis with strangers.
• Avoid overcrowded public transport if possible.
• Decline food offerings because they may contain sedatives to induce sleep and make it easier to be robbed.
• Disembark at the next stop if the driver is acting in an unsafe manner or appears to be intoxicated.
• Beware of bogus porters who may disappear with luggage.

In the hotel

• Choose rooms on the third through sixth floors, which are generally regarded as optimal for safety and security.
• Lock rooms when heading out. When in the hotel, be sure to keep the hotel door locked at all times.
• Meet visitors in the lobby. Do not advertise personal room numbers. Inform someone, including the front desk, of an expected return time.
• Look for fire safety instructions in each hotel room and become familiar with escape routes upon arrival.
• Keep valuables in the hotel safe. Room safes are less secure.

Dental Care

Travelers who have a current dental concern or any pending dental work should take care of it before leaving home because it could be difficult to find a dentist in a foreign country. Also, dental care in most developing countries can be very poor, and travelers should avoid the risk of problems from inadequate treatment, improperly sterilized dental instruments, or infectious disease.

Emergencies

Prepare for emergencies by knowing how to handle problems before leaving on a trip. Determine personal needs in advance using thorough research. Because all insurance policies are not created equal, check with a medical insurance provider to determine coverage while out of the country and consider supplemental travel insurance if necessary. Some travelers may already have partial travel coverage or the option to purchase it through travel-related memberships. Some credit card companies include travel insurance if charging a trip; many international auto and touring clubs offer policies along with the usual provisions for car towing and accident assistance. Some tour packages also include insurance. Check carefully to determine what is covered. Frequent travelers may want a yearly policy; others may choose coverage only for the length of a one-time trip. Policies may or may not cover air rescue, ambulance transport, help in making hospital arrangements, coverage of medical or hospital bills, cash advances, evacuation to a home country, or 24-hour telephone assistance. Know how to reach a representative while traveling abroad and how to obtain compensation for any care received.

Increasingly, major insurance carriers have cashless agreements with major private hospitals in most foreign countries. However, many foreign medical providers still require cash payment up front, ranging from a deposit to the full amount of the anticipated care. Before leaving home, ensure access to funds while abroad.

Try to have an advocate present while receiving medical care, for example, a health care provider who will represent a traveler's best interests, a traveling companion, or, at a minimum, someone who speaks the local language and can serve as an ally in an emergency.

Ask health care providers if they can recommend providers or hospitals in each destination country, if possible. Most major insurers have websites with listings of affiliated medical providers at all destinations.

Those with a medical condition should wear medical alert tags and carry a list of important foreign words related to their condition.

Travelers with a condition requiring injections should consider bringing a supply of needles and syringes. Carry a letter from a doctor explaining the specific medical needs. If injected medications are advised during travel, ask whether an oral formulation is available that can be taken instead. If injections are necessary during travel, insist on individually wrapped, disposable needles. If an injection/vaccination offered abroad is likely unnecessary (especially if circumstances are questionable or if the injection/vaccination is to be given by nonmedical personnel), ask whether alternative arrangements can be made in lieu of receiving the shot.

Eye Care

Travelers who have eye or vision problems should see an eye care specialist before departing. Bring an extra pair of glasses or contact lenses as well as any necessary cleaning or wetting solutions. Travelers who wear contact lenses should wash hands with purified water before inserting contacts. Consider switching to eyeglasses if traveling to remote areas.

Protect eyes by wearing sunglasses when outdoors, especially at high altitudes or if the sunlight is intensified by water, sand, or snow.

Keep a written copy of any lens prescriptions with all other health information.

Flying with a Cold

Traveling by airplane with swollen mucous membranes can cause pain during ascent and descent or, in rare cases, may even result in permanent damage. Travelers who are very ill and have ear or sinus pain or a high fever should consider postponing air travel until they have recovered. Those who must travel with a cold should drink plenty of fluids and use a decongestant or nasal spray before takeoff and landing. Over-the-counter cold remedies work effectively for most people, but in addition to a decongestant, they commonly contain antihistamines, which can cause drowsiness. Ask a health care provider for specific recommendations on treatment and dosages.

Heat and Sun

Travelers who are visiting a country where temperatures or humidity exceed normal exposure should take extra precautions to guard against skin damage from ultraviolet (UV) radiation or heat-related illnesses.

• Wear sunscreen every day to prevent skin damage. Use a sunscreen with a sun protection factor (SPF) of 30 or more and choose a broad-spectrum that protects against both UVA1, UVA2, and UVB rays. Reapply if swimming or perspiring. Remember to apply sunscreen to ears and neck and to use lip protection as well. If choosing sunscreen for a child, select one without PABA, which can cause rashes or other problems.
• Where sunlight is very strong, wear sunglasses that have side shields and block 99% to 100% of both UVA and UVB radiation and block 75% to 90% of visible light. UV radiation from the sun increases the risk of cataracts.
• While in the sun, wear light-colored, lightweight, synthetic loose-fitting long sleeve shirts and long pants to cover as much skin as practicable. Ultraviolet protection factor (UPF)-rated clothing (UPF 30+ is preferred) enhances protection against UVA and UVB radiation and is especially helpful for children and persons with increased sun sensitivity due to fair skin or medications. Clothing with a UPF 25 rating blocks 96% of UV radiation and UPF 50 rating (recommended) blocks 98% of UV radiation. Wear a loose-fitting, light-colored hat with a wide all-around brim, preferably with some form of neck coverage. Wear a UPF-rated face shield (balaclava) for protection against reflected UV radiation when on snow or water.
• Avoid outdoor activities between 10:00 a.m. and 2:00 p.m., when the sun is strongest.
• If taking any medications, be extra careful about sun exposure. Determine whether the medications cause photosensitivity (which will increase the risk of sunburn).
• Decrease alcohol intake and increase intake of other fluids.

Mild sunburn discomfort can be relieved by bathing in cool water or applying cool compresses to affected areas and by taking oral anti-inflammatory drugs such as aspirin or ibuprofen.

Heat rash can appear as an area of raised spots or as reddened, sensitive skin, usually in body areas that are not exposed to air, such as underarms and groin. Cool baths or compresses can help soothe irritated skin, and hydrocortisone cream will decrease itching.

Heat exhaustion results from elevation of core body temperature (hyperthermia). Symptoms include dizziness, nausea, rapid pulse, and headache. If these symptoms occur, immediately take the person to a cool spot to rest and give plenty of liquids. If untreated, heat exhaustion can lead to heat stroke.

Heat stroke is extreme hyperthermia (core body temperature of 40°C/104°F or higher) and is very serious and can be fatal. Symptoms include headache, confusion, irrational behavior, low blood pressure, shock, vomiting, shortness of breath, and unconsciousness. Cool victims as quickly as possible: remove their clothing, wet them down, fan them, and get medical help immediately. If they are able to drink, give them water.

Jet Lag

Many people experience jet lag as a result of traveling across multiple time zones. Jet lag is usually more obvious when flying east and less so when flying west. The range of symptoms includes sleep disturbances, daytime fatigue, weakness, headache, sleepiness, and irritability. Most symptoms disappear by the fifth day after traveling across a 6-hour time zone. Jet lag is difficult to compensate for on trips shorter than 3 days.

Tips for reducing jet lag:

• When possible, choose daytime flights to minimize loss of sleep and fatigue.
• Eat lightly and drink lots of water.
• Avoid large fatty meals, caffeine, and alcohol during the flight.
• Adjust meal and sleeping times to those of the destination upon arrival. It may be even more effective to begin the process gradually several days before the trip, if possible.
• Get daylight exposure as soon as possible upon arrival.
• If traveling to the east, get exposure to morning light; if traveling to the west, get exposure to afternoon light. This will help the body adjust to the changed sleep-wake cycle.

Prevention of Jet Lag with Drugs

Consult a health care provider about the use of medications such as melatonin or zolpidem (Ambien) and the timing of their use, if appropriate. Sedatives are no longer recommended on airline flights due to the risk of blood clots in the legs during prolonged immobility.

• Zolpidem (Ambien) is a hypnotic that has been shown to be as effective as melatonin. It can be used to induce sleep after arrival at the appropriate destination time-zone sleeping time, when the body is jet lagged and cannot fall asleep. It can be used for up to 2 to 3 nights at each end of the trip. Some persons, and especially women, may experience morning impairment in activities that require full alertness (e.g., driving). Extended-release formulations can result in day-long impairment. Use the lowest effective dose.
• Melatonin is a natural hormone in the body that aligns sleep cycles and other physiological functions. In the US, melatonin supplements are not regulated by the FDA, so their purity and potency cannot be guaranteed. Melatonin can cause sleepiness and reduced alertness. Do not drive, operate heavy machinery, or perform tasks requiring alertness for 4 to 5 hours after taking melatonin. Timing of the dose of melatonin must be precise or it can actually worsen symptoms. Persons who suffer from psychiatric problems or migraine headaches or who may be pregnant should use melatonin with caution, if at all.

Medications

Depending on destination, familiar medications and health-related products may not be available, or they could be marketed using different names or formulations. Some medications might not meet the standards for safety, quality, and consistency found at home.

Before departing, make a list of all medications and their generic names in case replacement medications are needed and keep this list close at hand. Also keep a copy of the drug information leaflets (package inserts) from the manufacturers.

Bring an adequate supply of all the over-the-counter and prescription medications that are needed, preferably split up into 2 separate bags. Leave them in their original containers and keep a record of their generic names. Carry copies of prescriptions for the most important drugs and have all prescriptions written using generic names (because trade names vary in different parts of the world). Obtain and carry a letter from a physician on letterhead stationery, appropriately signed and dated, containing a medical history and medication requirements.

A number of countries have very strict laws about importing medications. Research importation restrictions prior to travel if bringing certain medications. Medications commonly restricted include, but are not limited to, controlled substances, injected medications, HIV drugs, and some over-the-counter cold medications. Failure to secure importation certificates can result in arrest and detention. Visit http://www.incb.org/incb/en/psychotropics/index.html for more information. Never hide medications in luggage.

Travelers who are allergic to any drugs should carry medical alert information, preferably a medical alert wristband or tags listing the allergy.

Remember to pack products for skin care, hygiene, and birth control if depending on certain brands.

Motion Sickness

Motion sickness can result from exposure to movement or from visual suggestion of movement. Traveling through water, on land, in air, or even in space can trigger motion sickness. Symptoms of include fatigue, headache, dizziness, a sensation of body warmth, pallor, cold sweating, nausea, and vomiting. Some people are more prone to this condition than others, but factors such as turbulence, anxiety, and illness can also trigger motion sickness.

Antihistamines can prevent or relieve motion sickness, especially if taken 30 to 60 minutes before travel and continued during the trip. Over-the-counter medications approved for this use in the US are cyclizine (Marezine), dimenhydrinate (Dramamine), diphenhydramine (Benadryl), and meclizine (Bonine and Dramamine II). Side effects may include drowsiness, dizziness, or dry mouth. Antihistamines should not be used by persons with glaucoma, breathing problems such as asthma, or urinary difficulties caused by an enlarged prostate. Check labels carefully for appropriate dosages, precautions, and age restrictions.

Some people may require prescription drugs such as scopolamine if over-the-counter medications are not effective. Discuss the options with a health care provider and make sure to ask about precautions and drug interactions. Other tips:

• Eat lightly before and during travel. Do not drink alcohol.
• Sit in the most stable section of a moving vehicle to help reduce symptoms. The best seats are those over the wings on an airplane; in the front seat of a car (except infants and children); near the front of trains; amidships, on deck if possible; and just forward of the midsection on buses.
• Face forward and look out a window, keeping the eyes fixed on the horizon or on a stationary point in the distance. Stay as still as possible and avoid any rapid head movement.
• Sleep if possible. If not, it may help to wear dark glasses or keep the eyes closed to reduce visual stimulation.

Children are more prone to motion sickness than adults are. For symptomatic treatment of motion sickness, dimenhydrinate or diphenhydramine may be considered for children 12 years and older. The first dose should be given 1 hour before travel and then every 6 hours. A test dose should be given in advance because these medications can cause excitability rather than drowsiness in some children. The advice that applies to adults is also valid for children, with 1 exception: the front seat of a car is not safe for children. Make sure children are secured in the back seat with a seat belt or child car seat. Give them sunglasses to wear and make a game out of watching a fixed object on the horizon.

Packing for Travel

Start early! As soon as possible, start an ongoing list of everything necessary to bring; check off each item as it's packed. A number of things can be forgotten when relying only on memory, particularly if packing in a hurry.

Luggage may be misplaced or stolen. Therefore, items that travelers may have trouble replacing or can't do without for a day should be kept in a carry-on bag, for example, valuables, traveler's checks or credit cards, important documents, medications, eyeglasses, toiletries, and so forth. Also pack a change of clothing in the event of delayed luggage arrival.

In an environment with high levels of viral/bacterial contamination, hand hygiene (frequent, thorough handwashing) can help lower the risk of infection. Bring disposable antibacterial wipes or alcohol-based hand sanitizer if soap and clean water will not be available.

If clothes need to be kept unwrinkled, lay them flat and slip them inside plastic dry-cleaning bags or jumbo garbage bags; fold them as few times as possible. The plastic bags reduce wrinkling. Keep each pair of shoes in a plastic or cloth bag, which protects the shoes and the clothes.

Pack heavy items at the bottom of the suitcase so they don't wrinkle the lighter items. Travelers who are using wheeled luggage should pack heavy items closest to the wheels to help keep the luggage upright.

When all packing is finished, take a final step (or several). Walk around with all luggage to mimic practices while traveling. Are the cases too heavy or unwieldy to carry for a moderate distance? Are objects shifting or falling out? Are items such as plane tickets and passports safe in a zippered pocket yet easily accessible?

Passports and Visas

A passport is issued by a home country as proof of citizenship. Visas are stamped into passports to allow entry into other countries. Although exceptions exist, travelers are usually required to display passports when entering or leaving a country. Travelers should also carry a photocopy of their passport and keep the original in a safe place at destination.

A visa is an endorsement or stamp entered into a passport by a foreign government. It allows a traveler to enter a country for a specific reason and period. Start applying for visas as soon as possible so that all necessary documentation is completed well before the departure date.

To receive a visa, a passport must usually be sent to the embassy or consulate of the country that will be visited. Increasingly, visas may be obtained directly from the consular websites of the country to be visited, but this remains the exception at present. Some countries (for example Australia) have an online registration process that must be completed prior to boarding any flight destined for that country. Most countries have embassies and consulates worldwide, and travel agents can usually tell travelers where the nearest ones are located.

Keep in mind that a passport may be tied up for days or weeks until the paperwork is done, so plan accordingly. Additionally, some countries require proof of yellow fever vaccination before they will issue a visa. The amount of time spent mailing a passport to the various agencies involved can add up if several countries are on an itinerary. Plan ahead. For travelers who only have a few weeks to prepare, a commercial visa service can often speed up the process.

Travelers' Thrombosis

Blood clots, called deep vein thrombosis (DVT), can occur in the large veins of the leg or pelvic area during or after long trips by air, bus, or train. Sitting still for long periods of time, especially with knees bent, can cause blood to pool in the legs, which increases the risk of a clot forming. Overall risk is extremely low in those without risk factors; see underlying risk factors for DVT, listed below. For air travel, the risk of DVT, sometimes called travelers' thrombosis, increases with the length of the flight. If not treated, DVT can lead to pulmonary embolism (PE), a potentially life-threatening condition in which part of the clot in the leg dislodges, travels to the lungs, and blocks a blood vessel.

Risk Factors for DVT

Some of the major risk factors include a personal or family history of previous DVT, PE, or blood-clotting disorder; recent major surgery, trauma, or immobilization (e.g., being in a leg cast); cancer within the last 2 years or current chemotherapy; late pregnancy or the first 6 weeks after childbirth; estrogen-containing medications; being older than 50 years; severe obesity; recent heart attack or congestive heart failure; large varicose veins or chronic venous insufficiency.

Symptoms of DVT

Symptoms of DVT can occur during or after a long flight or trip. Travelers should consult a health care provider if they develop leg pain, ache, or discomfort; leg swelling; increased warmth in the leg; leg skin discoloration (red); joint pain.

Symptoms of Pulmonary Embolism

Travelers should seek immediate medical attention if they develop chest pain, shortness of breath, or difficulty breathing.

Prevention of DVT

Preventive measures that can be taken (mainly to prevent blood from pooling in the legs during travel) include:

• Wearing loose, comfortable clothing that is not tight at the knees or waist.
• Wearing graded compression stockings (15-30 mm Hg at the ankle level).
• Walking around in the aircraft cabin at least every hour and at transit stops.
• Standing up and stretching the arms and legs periodically.
• Exercising leg and calf muscles frequently by flexing and extending the ankles and knees.
• Avoiding crossed legs because it decreases blood circulation.
• Using a footrest (or elevating feet on a briefcase or small bag) to reduce pressure on the back of the thighs from the seat, which can decrease circulation to the legs.
• Drinking plenty of water to prevent dehydration. Moderate alcohol or coffee intake is not a risk factor.
• Avoiding sleeping pills during a long flight.
• Choosing an aisle seat, if possible.
• Checking with a travel medicine specialist to determine if injectable heparin may be of benefit to those with significant preexisting risk factors; aspirin is of no benefit in preventing DVT.