cdc travel medications

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Before You Travel

Before you travel, take steps to prepare so you can stay safe and healthy during your trip.

Check CDC’s destination pages for travel health information . Check CDC’s webpage for your destination to see what vaccines or medicines you may need and what diseases or health risks are a concern at your destination.

Make sure you are up-to-date on all of your routine vaccines . Routine vaccinations protect you from infectious diseases such as measles that can spread quickly in groups of unvaccinated people. Many diseases prevented by routine vaccination are not common in the United States but are still common in other countries.

Know Your Health Status

Make an appointment with your healthcare provider or a travel health specialist  that takes place at least one month before you leave. They can help you get destination-specific vaccines, medicines, and information. Discussing your health concerns, itinerary, and planned activities with your provider allows them to give more specific advice and recommendations.

Learn About Blood Clots

Airplane travel, especially flights longer than 4 hours, may increase your risk for blood clots, including deep vein thrombosis and pulmonary embolism. Learn how to prevent blood clots during travel.

Share the following information about yourself or your trip with your provider:

• Special conditions such as pregnancy, allergies, or chronic health problems.
• Destinations on your itinerary.
• Type of accommodations (hotels, hostels, short term rentals).
• Type of travel (cruise, business, adventure travel).
• Timing and length of your trip.
• Planned activities.

Take recommended medicines as directed. If your doctor prescribes medicine for you, take the medicine as directed before, during, and after travel. Counterfeit drugs are common in some countries, so only take medicine that you bring from home and make sure to pack enough for the duration of your trip, plus extra in case of travel delays. Learn more about traveling abroad with medicine .

Plan for the Unexpected

Sometimes unexpected issues occur during travel. Learn what you can do before you leave to protect yourself and your travel companions.

Get travel insurance.  Find out if your health insurance covers medical care abroad. Travelers are usually responsible for paying hospital and other medical expenses out of pocket at most destinations. Make sure you have a plan to  get care overseas , in case you need it. Consider buying  additional insurance  that covers health care and emergency evacuation, especially if you will be traveling to remote areas.

There are different types of travel insurance such as trip cancellation insurance, travel health insurance and medical evacuation insurance. Learn more about travel insurance .

Enroll with the Department of State’s  Smart Traveler Enrollment Program  (STEP) . Check for and monitor any travel advisories for your destination. Enrolling also ensures that the  US Department of State  knows where you are if you have serious legal, medical, or financial difficulties while traveling. In the event of an emergency at home, STEP can also help friends and family contact you.

Prepare for emergencies. Leave copies of important travel documents (e.g. itinerary, contact information, credit cards, passport, proof of school enrollment) with someone at home, in case you lose them during travel. Make sure someone at home knows how to reach you in an emergency. Carry your emergency contacts with you at all times.

Some other tips to prepare for emergencies:

• Write down the contact information of people or services you may need while abroad.
• Check in with someone regularly during your trip.
• Dial 1-888-407-4747 if calling from the United States or Canada,
• Dial 00 1 202-501-4444 if calling from overseas, or
• Let family members know they can contact the embassy or consulate for help if they are worried about your safety while abroad.

Prepare a  travel health kit  with items you may need, especially those items that may be difficult to find at your destination. Include your prescriptions and over-the-counter medicines in your travel health kit and take enough to last your entire trip, plus extra in case of travel delays. Depending on your destination you may also want to pack a mask ,  insect repellent , sunscreen (SPF15 or higher), aloe, alcohol-based hand sanitizer, water disinfection tablets, and your health insurance card.

More information for some travelers who may need to take extra precautions:

• Traveling with a disability
• Travelers with a weakened immune system
• Traveling with a chronic illness
• Pregnant travelers

Follow CDC’s guidance on how to stay safe during travel and after travel .

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#PrepYourHealth: Tips for Holiday Travel

Holiday travel often includes visiting loved ones or taking a vacation. Whether you’re seeking a winter wonderland or an escape from subzero temperatures, follow these travel tips to stay healthy and safe during the holiday travel season.

Before Your Trip

No matter where you plan to travel, check CDC’s destination pages for travel health information . These pages include information about

• vaccines and medicines you may need, and
• diseases or health risks that are a concern at your destination.

Get up to date with your COVID-19 vaccines and seasonal flu vaccine. CDC recommends getting the  flu  vaccine every year.

Get up to date on routine vaccines. Routine vaccinations protect you from infectious diseases such as measles that can spread quickly in groups of unvaccinated people. Many diseases prevented by routine vaccination are uncommon in the United States but common in other countries.

Prepare a  travel health kit that includes personal needs, especially those items that may be difficult to find at your destination. Take enough of your prescription and over-the-counter medicines to last your entire trip, plus extra in case of travel delays. You may also want to pack  insect repellent ,  sunscreen  (SPF 15 or higher), aloe, alcohol-based hand sanitizer, water disinfection tablets, and important paperwork like your health insurance card.

Make sure you have a plan for  getting health care during travel . Find out if your health insurance covers medical care abroad. Travelers are usually responsible for paying hospital and other medical expenses out of pocket at most destinations. Consider buying  additional insurance  that covers health care and emergency evacuation, especially if you will travel to remote areas.

During Your Trip

Choose safe transportation. Always wear your seat belt. If you are traveling with children ages 12 and younger, make sure they are properly buckled in a car seat, booster seat, or seat belt—whichever is appropriate for their age, weight, and height—in the back seat.

Motor vehicle crashes are the leading cause of death among healthy travelers. Be alert when crossing the street, especially in countries where people drive on the left side of the road.  Find out other steps  you can take to stay safe on the roads.

Protect yourself from the sun. Apply sunscreen with SPF 15 or higher when traveling.  Protecting yourself from the sun  isn’t just for tropical beaches. You can sunburn even if it’s cloudy or cold. You are at the highest risk for ultraviolet light exposure during summer months, near the equator, at high altitudes, and between 10 a.m. to 4 p.m.

Stay alert in crowded areas. Does your holiday travel involve markets, festivals, or other activities that involve a large number of people at the same place (mass gathering)? If so, learn some tips to stay safe at a mass gathering.

Considerations for cold weather travel

Wear warm clothing in several loose layers when traveling in cold weather or climates. Learn practical skills and lessons like how to prevent hypothermia and frostbite .

Considerations for warm weather travel

If you are traveling in hot weather or to a hot climate, wear loose, lightweight, light-colored clothing.

Your chances of getting heat stroke, heat exhaustion, or other heat-related illness during travel depend on your destination, activities, level of hydration, and age. The more active you are in high temperatures, the more likely you are to get a heat-related illness. Learn how to prevent  heat-related illness .

Use   insect repellent  and take steps to avoid bug bites. Bugs, including mosquitoes, ticks, and flies, can spread diseases such as Zika, dengue, Lyme, and others. These bugs are typically more active during warm weather. Check your destination’s  page to determine what you need to do to protect yourself from diseases spread through bug bites, including medications or vaccines when recommended.

After Your Trip

If you recently traveled and feel sick , particularly if you have a fever, talk to a healthcare professional. Tell them about your travel. Be prepared to answer questions about your vaccination history, destination(s), reasons for traveling, itinerary, and other aspects of your trip.

• Travelers’ Health | CDC
• Traveler Advice | Travelers’ Health | CDC
• COVID-19: International Travel to and from the United States | CDC
• Cruise Ship Travel During COVID-19| CDC

Thanks in advance for your questions and comments on this Public Health Matters post. Please note that CDC does not give personal medical advice. If you are concerned you have a disease or condition, talk to your doctor.

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Update April 12, 2024

Information for u.s. citizens in the middle east.

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Get Help with a Medical Emergency Abroad

If you or a U.S. citizen loved one become seriously ill or injured abroad, we can:

• Help locate appropriate medical services.
• Inform your family or friends, with your permission.
• Help  transfer funds  to U.S. citizens overseas.

The U.S. government does not pay overseas medical bills. The patient must pay all hospital and other expenses.

You can find lists of doctors and hospitals in the country you are visiting. Check the  website of the U.S. embassy in the country you are visiting. 

Check Your Health Insurance – Are You Covered Abroad?

Understand what medical services your health insurance will cover overseas before traveling. Carry your insurance card and a claim form if your policy covers you outside the United States. 

Medicare does not cover medical care when you travel the United States. Visit  Medicare.gov  for more information.

Some health insurance companies pay for “customary and reasonable” hospital costs abroad. Very few pay for your medical evacuation back to the United States. The cost may exceed $250,000, depending on your location and medical condition. Consider buying medical evacuation insurance. For more information, visit our webpage on Insurance Coverage Overseas . 

Traveling with Prescription Medications

• Check with the foreign embassy of the country you are visiting or passing through. Check to make sure your medications are allowed, particularly prescriptions for medical marijuana. You may need an import license or permit to travel with certain medications.
• Bring plenty of medicine for your trip. If possible, bring a few extra days’ worth in case of delays. You might not be able to get the same medication abroad.
• Carry a letter from the doctor. It should describe your medical condition. It should also list any prescription drugs and their generic names.
• Keep medications in their original, labeled containers.
• Entering a country with a prescription medication, even if legally obtained in the United States, could be illegal and result in your detention or arrest overseas.

Medical Tourism Abroad

Between 150,000 and 320,000 U.S. citizens travel abroad for medical care each year. Medical tourism includes cosmetic surgery, dentistry, and other surgical procedures. 

If you are a U.S. citizen considering travel abroad for medical care, you should:

• Verify the doctor’s training, qualifications, and reputation. 
• Visit the U.S. Centers for Disease Control and Prevention (CDC) Medical Tourism website for more information on medical tourism. 
• Check country information  for more information.

Inform Yourself About Vaccinations

Some Countries Require Vaccinations

Before you travel, check country information . You may need to carry an International Certificate of Vaccination, also called a Yellow Card. You may also need to show proof of other inoculations or medical tests. Check also current requirements directly with the foreign embassies of the countries you are visiting.

Recommended Vaccinations and Malaria Prevention

Check the  U.S. Centers for Disease Control (CDC)  and World Health Organization (WHO)  websites for recommended vaccinations and malaria prevention for your destination. Review the CDC’s webpage on Choosing a Drug to Prevent Malaria .

Travel Smartly with Prescription Medications

• Bring an ample supply of medication to cover you for your trip, and if possible, a few extra days in case there are delays.
• Carry a letter from the attending physician that describes your medical condition and any prescription medications, including the generic name of prescribed drugs.
• Check with the foreign embassy of the country you are visiting or transiting to make sure your medications are permitted in that country. Some countries require an import license or permit to travel with certain medications.

Being Prepared for a Pandemic

Review the  U.S. Centers for Disease Control and Prevention website for information about pandemics. In a pandemic, virus control measures could affect your travel:

• Travel restrictions may prevent U.S. citizens from traveling internationally.
• Foreign governments may close borders suddenly or with little advance warning.
• Commercial air, land, and sea carriers could suspend some or all transportation services.
• Some countries may quarantine people who appear sick or test positive with the virus.

These developments could delay your travel or your return to the United States.

Other Health Considerations Abroad

• Review the CDC’s Traveler Advice.
• Review Traveling With Disabilities .
• Review Considerations for Older Travelers .

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Learn about your destination

Make two copies of all of your travel documents in case of emergency, and leave one with a trusted friend or relative.

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Emergency Support

In case of emergency abroad, first call the local equivalent of 911 listed in the global 911 directory .

You may also contact International SOS by phone at +1-617-998-0000 or through the Assistance App .

IEMT Portal

Access your International Emergency Management Team (IEMT) portal for information.

Tips for Traveling with Medication

Photo via Tomek Baginski/Unsplash

Many common U.S. medications and supplements are illegal abroad or require government authorization before your arrival.

Drug Facts: Traveling with Medication

Adderall. Benadryl. Birth control. Protein powder. These are just a few of the common U.S. medications and supplements that are illegal in some countries or require government authorization prior to your arrival.

Travelers are often caught off guard by the wide variance of laws regulating the importation of and access to medications across borders, whether mailed or hand carried. Depending on your destination, you could be subject to increased scrutiny from customs officials ( not a big deal, you think ) or confiscation and imprisonment ( that escalated quickly ). In Turkey, Egypt, and Malaysia, for example, a drug offense conviction can result in the death penalty.

Know Before You Go

Be aware of your destination’s banned and restricted medications. The US embassy website of your destination country is a good place to start—a quick query in the search bar should do the trick. You can also check your airline's website to see if things like flying with Adderall, for example, are prohibited.

If any of your medications are on the embassy's or airline's list of banned or restricted substances, you'll need to talk with your health care provider about suitable alternatives. Make sure the alternative medications are legally permitted and readily available in your destination.

Common Restrictions

• Narcotics and psychotropic medications (e.g. Adderall and Ambien)
• Over-the-counter medications and nutritional supplements (e.g. protein powder)
• Hormone medications (e.g. birth control pills, morning after pills, and hormone therapy medication for gender transition)
• Certain ingredients or quantities of ingredients (e.g. pseudoephedrine found in Sudafed, and diphenhydramine HCI found in Benadryl and Tylenol PM)

Ignorance isn’t an Excuse

Take this example of an American Toyota executive arrested in Tokyo after Japanese customs officials found a controlled pain medication in a package she mailed to herself. Japanese authorities can detain suspects without charge for up to 23 days, and the executive spent almost three weeks in jail before being released without charge. At a press conference, Toyota explained that their executive did not intentionally violate local laws; however, ignorance, in this case, had serious repercussions .

Chronic Conditions

For travelers with chronic physical or mental health conditions, anticipate how your new environment can affect your health. For example, if you have asthma and are traveling to areas with high levels of air pollution, you’ll want to discuss mitigation strategies with your health care provider. If you require injections, you’ll need to review airline and country-specific regulations for traveling with needles or syringes. Many airlines, like Emirates, have a list of prohibited goods on their website, as well as guidelines for traveling with a chronic health condition.

Mental Health

Practice self-care; difficulty in adjustment can be mitigated by trying to maintain your daily routine while abroad. If there are aspects of your routine that keep you happy at home—for example, working out—try to find facilities in your destination by which you can continue them.

Preexisting mental health conditions can be intensified by living in a different culture, and local resources may be less than or different from those to which you’re accustomed to at home. Discuss these concerns with your health care provider and know the counseling resources available to you abroad—including International SOS —should you need help.

Sexual and Reproductive Health

Cultural norms and laws that impact individuals’ access to sexual and reproductive health vary by country (and by state in the US). Consider bringing personal care and health-related items that may be unavailable or difficult to obtain in your destination, including menstruation products and contraceptives; as with your prescription and over-the-counter medications, make sure any contraceptives you bring with you are legal in your destination country.

Before You Leave

• Research your destination and transit locations. The International SOS destination guides, available in the Assistance App and member portal , include medical information such as vaccines, documentation, medication, clinics, and hospitals. Log in with your HarvardKey.
• If you're traveling to a region with a high risk of malaria, review the CDC's malaria advice and assess whether you'd like to carry preventative medication with you. Speak to your doctor about obtaining malaria medication, and treat it during travel just like you would any other prescription.
• Obtain necessary permits or government authorization.
• Ask your doctor for a letter on their letterhead explaining your medical treatment and necessity, translated into the host country’s language, if necessary.
• If you have to take your medication at a specific time, talk with your doctor about adjusting your schedule accordingly based on your travel time and time zone changes.
• Pack enough medication to last the length of your trip—plus extra in case of delays, but no more than personal-use quantities.

During Travel

• Keep all medications in your carry-on luggage and in their original, labeled containers; do not combine multiple medications into one container.
• The name on the prescription should match the name on travel documents and identification.
• Be prepared for additional screening.
• Carry a written prescription and a letter from your doctor explaining the medication and medical condition.
• Do not have banned or controlled substances mailed to you.
• In case of an emergency, contact International SOS if you are sick, injured, or need medical advice.

Returning to the U.S.

• If you're prescribed medication abroad, review U.S. Customs & Border Patrol's list of restricted and prohibited items to certify that medication obtained abroad may be brought back into the country.
• Declare all medication and associated items at customs.
• Carry medication obtained abroad in its original container.

Further Reading

Coronavirus: Advice for Travelers

Food and Drink Safety While Abroad

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Unsure of what meds you need before an international trip? Here's how your pharmacist can help.

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If you ever stop by the pharmacy before a trip, you might be grabbing plastic bags for airport security , travel-size toiletries or picking up medication before you leave home.

But pharmacists can do much more than just fill prescriptions: For travelers going abroad, they can provide a range of services, from health consultations before their trip to administering vaccines.

"Pharmacists who have training in travel health will likely be much more up to date (than the average primary care provider), not just on the clinical aspects of some of these specialized vaccines and medications, but also access to information that's very itinerary specific," Dr. Keri Hurley-Kim, an associate clinical professor at the University of California, Irvine School of Pharmacy & Pharmaceutical Sciences, told USA TODAY.

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What kinds of services can pharmacists provide to travelers?

Pharmacists that offer travel medicine services can provide travelers with consultations before their trip to help them prepare.

They can then administer vaccines, initiate prescriptions and dispense medications, and even order labs, though the scope of what they can offer varies by state. In California, for instance, pharmacists can independently provide any travel-related prescription medications like antimalarial drugs or antibiotics, said Dr. Jeff Goad, a professor of pharmacy practice and Associate Dean of Academic Affairs at the Chapman University School of Pharmacy.

That may not be the case depending where travelers live, and the types of vaccines pharmacists can give varies, too. "All states allow pharmacists to give vaccines, but not all states allow pharmacists to give all vaccines," he said.

Some large chain pharmacy locations have trained travel health pharmacists, Hurley-Kim said, and independent pharmacies may advertise those services as a specialized part of their business. The International Society of Travel Medicine also maintains a directory of travel clinics , she noted.

When in doubt about what services a pharmacist offers, Goad recommended calling to ask.

Do chain pharmacies offer assistance to travelers?

Walgreens pharmacists, for instance, can help travelers determine what vaccines they may need and can administer doses of polio, typhoid and Japanese  encephalitis  vaccines, among others. Some vaccines may not be available at all stores, according to a spokesperson. The vaccines are also subject to state and age restrictions.

"Walgreens pharmacists are trained via a 3hr CE course about travel health created by the clinical team," the spokesperson said in an email.

Travelers can also find information about Walgreens's services and schedule vaccine appointments via the pharmacy chain's website .

While CVS Pharmacy offers a range of vaccines it does not have a "formal travel health offering," a spokesperson said by email.  MinuteClinic locations do  offer travel health services , however.

What are the other benefits of seeing a pharmacist before traveling?

Pharmacies can also offer convenience. Some stock items that can come in handy during travel, such as bug spray, insect nets or remedies for ailments like traveler's diarrhea, Goad said.

If a trip is coming up soon, travelers may also be able to get into see a pharmacist faster than a primary care doctor, for instance. "Generally, in a pharmacy, you can get an appointment within 48 hours," said Goad. "That's the norm."

When should travelers see a pharmacist before traveling?

Just because travelers can get an appointment quickly doesn't mean they should wait until the last minute.

Hurley-Kim recommended coming in one to two months before a trip, particularly because some vaccines require multiple doses. "Four to eight weeks is a really kind of sweet spot where we know we're probably going to be able to get in all of the vaccines and medications that you need without it being so soon that things may change by the time you go," she said.

Pharmacists can help you determine whether you may need a consultation and other services before travel and will consider some key factors:

►  Where you are going: "For example, a trip to West Africa is a very different trip than to Mexico in terms of the disease risk, the range of diseases, those kinds of things," said Goad.

Hurley-Kim said the vast majority of travel health patients are visiting Africa, Central America, South America and Southeast Asia.

►  Your risk factors:  "If you are an 85 year old with chronic heart disease, versus a 20 year old with no medical problems, you also have a very different trip ahead of you," said Goad.

► What you are doing when you get there: Consider your itinerary, as well. Someone taking a business trip may need to prepare differently than someone planning to climb mountains, for instance.

The Centers for Disease Control and Prevention recommends travelers be up to date on their routine vaccinations. "If you are not vaccinated, international travel increases your chances of getting and spreading diseases that are not common in the United Sates," the agency said on its website .

Some countries may also require travelers to show proof of certain vaccinations on arrival, such as the yellow fever vaccine , according to the CDC. Travelers can find destination-specific recommendations and requirements on the agency's website .

How much does seeing a pharmacist before travel cost?

The cost of travel health services can vary widely, according to Hurley-Kim. She said a pharmacist will typically charge an appointment fee for the first visit, and she has historically charged around $60, though she offers discounts for groups like students and senior citizens. Health insurance providers are unlikely to cover that cost.

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Routine vaccines, like those for hepatitis A and hepatitis B, that are also commonly used in travel medicine are likely to be covered, she said. Whether specialty vaccines are covered depends on the individual insurance plan.

The price of vaccines ranges depending on the type and how many doses are in a series. The rabies vaccine, which Hurley-Kim said is "kind of infamously expensive," may cost between $300 and $400 per dose and travelers need at least two doses. Others can run between $50 and $200 and may require fewer doses.

Health insurance will generally cover medications provided by pharmacists as part of these services, according to Goad.

Even if you don't think you need to talk to a pharmacist before your trip, you may find it useful. "It never hurts to ask," said Hurley-Kim.

Do you consult your doctor or pharmacist before a trip? Why or why not?

Nathan Diller is a consumer travel reporter for USA TODAY based in Nashville. You can reach him at [email protected].

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• Patient Care & Health Information
• Diseases & Conditions
• Traveler's diarrhea

Traveler's diarrhea may get better without any treatment. But while you're waiting, it's important to try to stay hydrated with safe liquids, such as bottled water or water with electrolytes such as an oral rehydration solution (see below). If you don't seem to be improving quickly, several medicines are available to help relieve symptoms.

Anti-motility agents. These medicines — which include loperamide and drugs containing diphenoxylate — provide prompt but temporary relief by:

• Reducing muscle spasms in your gastrointestinal tract.
• Slowing the transit time through your digestive system.
• Allowing more time for absorption.

Anti-motility medicines aren't recommended for infants or people with a fever or bloody diarrhea. This is because they can delay clearance of the infectious organisms and make the illness worse.

Also, stop using anti-motility agents after 48 hours if you have stomach pain or if your symptoms worsen and your diarrhea continues. In such cases, see a doctor. You may need blood or stool tests and treatment with an antibiotic.

• Bismuth subsalicylate. This nonprescription medicine can decrease the frequency of your stools and shorten the length of your illness. However, it isn't recommended for children, pregnant women or people who are allergic to aspirin.
• Antibiotics. If you have more than four loose stools a day or severe symptoms, including a fever or blood, pus or mucus in your stools, a doctor may prescribe a course of antibiotics.

Before you leave for your trip, talk to your doctor about taking a prescription with you in case you get a serious bout of traveler's diarrhea.

Avoiding dehydration

Dehydration is the most likely complication of traveler's diarrhea, so it's important to try to stay well hydrated.

An oral rehydration salts (ORS) solution is the best way to replace lost fluids. These solutions contain water and salts in specific proportions to replenish both fluids and electrolytes. They also contain glucose to enhance absorption in the intestinal tract.

Bottled oral rehydration products are available in drugstores in developed areas, and many pharmacies carry their own brands. You can find packets of powdered oral rehydration salts, labeled World Health Organization (WHO)- ORS , at stores, pharmacies and health agencies in most countries. Reconstitute the powder in bottled or boiled water according to the directions on the package.

If these products are unavailable, you can prepare your own rehydrating solution in an emergency by mixing together:

• 3/4 teaspoon table salt.
• 2 tablespoons sugar.
• 1 quart uncontaminated bottled or boiled water.
• Sugar-free flavor powder, such as Crystal Light (optional).

You or your child can drink the solution in small amounts throughout the day as a supplement to solid foods or formula, as long as dehydration persists. Small amounts reduce the likelihood of vomiting. Breastfed infants also can drink the solution but should continue nursing on demand.

If dehydration symptoms — such as dry mouth, intense thirst, little or no urination, dizziness, or extreme weakness — don't improve, seek medical care right away. Oral rehydration solutions are intended only for urgent short-term use.

Lifestyle and home remedies

If you do get traveler's diarrhea, avoid caffeine, alcohol and dairy products, which may worsen symptoms or increase fluid loss. But keep drinking fluids.

Drink canned fruit juices, weak tea, clear soup, decaffeinated soda or sports drinks to replace lost fluids and minerals. Later, as your diarrhea improves, try a diet of easy-to-eat complex carbohydrates, such as salted crackers, bland cereals, bananas, applesauce, dry toast or bread, rice, potatoes, and plain noodles.

You may return to your normal diet as you feel you can tolerate it. Add dairy products, caffeinated beverages and high-fiber foods cautiously.

Preparing for your appointment

Call a doctor if you have diarrhea that is severe, lasts more than a few days or is bloody. If you are traveling, call an embassy or consulate for help locating a doctor. Other signs that you should seek medical attention include:

• A fever of 102 F (39 C) or higher.
• Ongoing vomiting.
• Signs of severe dehydration, including a dry mouth, muscle cramps, decreased urine output, dizziness or fatigue.

If you have diarrhea and you've just returned home from a trip abroad, share that trip information with your doctor when you call to make an appointment.

Here's some information to help you get ready, and what to expect.

Information to gather in advance

• Pre-appointment instructions. At the time you make your appointment, ask whether there are immediate self-care steps you can take to help recover more quickly.
• Symptom history. Write down any symptoms you've been experiencing and for how long.
• Medical history. Make a list of your key medical information, including other conditions for which you're being treated and any medicines, vitamins or supplements you're currently taking.
• Questions to ask your health care professional. Write down your questions in advance so that you can make the most of your time.

The list below suggests questions to ask about traveler's diarrhea.

• What's causing my symptoms?
• Are there any other possible causes for my symptoms?
• What kinds of tests do I need?
• What treatment approach do you recommend?
• Are there any possible side effects from the medicines I'll be taking?
• Will my diarrhea or its treatment affect the other health conditions I have? How can I best manage these conditions together?
• What is the safest way for me to rehydrate?
• Do I need to follow any dietary restrictions and for how long?
• How soon after I begin treatment will I start to feel better?
• How long do you expect a full recovery to take?
• Am I contagious? How can I reduce my risk of passing my illness to others?
• What can I do to reduce my risk of this condition in the future?

In addition to the questions that you've prepared, don't hesitate to ask questions as they occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to talk about in-depth. Your doctor may ask:

• What are your symptoms?
• When did you first begin experiencing symptoms?
• Have you traveled recently?
• Where did you travel?
• Have you taken any antibiotics recently?
• Have your symptoms been getting better or worse?
• Have you noticed any blood in your stools?
• Have you experienced symptoms of dehydration, such as muscle cramps or fatigue?
• What treatments have you tried so far, if any?
• Have you been able to keep down any food or liquid?
• Are you pregnant?
• Are you being treated for any other medical conditions?
• Feldman M, et al., eds. Infectious enteritis and proctocolitis. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 25, 2021.
• LaRocque R, et al. Travelers' diarrhea: Microbiology, epidemiology, and prevention. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Ferri FF. Traveler diarrhea. In: Ferri's Clinical Advisor 2023. Elsevier; 2023. https://www.clinicalkey.com. Accessed April 28, 2023.
• Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed April 27, 2023.
• Travelers' diarrhea. Centers for Disease Control and Prevention. https://wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea. Accessed April 28, 2023.
• LaRocque R, et al. Travelers' diarrhea: Clinical manifestations, diagnosis, and treatment. https://www.uptodate.com/contents/search. Accessed May 26, 2021.
• Khanna S (expert opinion). Mayo Clinic. May 29, 2021.

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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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