Table of Contents

1. What to Know Before You Go!
2. Vaccinations
3. Jet Lag
4. Food and Water Precautions
5. Traveler's Diarrhea
6. Altitude Sickness
7. Sun Exposure
8. Parasites, Bacteria and Viruses
9. Insect Bites and Insect Bourne Diseases
10. Other Travel Related Illnesses/Diseases
11. Diabetes and Travel
12. Pregnancy and Travel
13. Traveling with Children
14. What to Do if You Get Sick
15. Global Warming and Its Effect on World Health

1. What to Know Before You Go!
Traveling to another country may involve lengthy preparations or may be quite spontaneous. Whatever the nature of your trip, confirm that your passport is current, and, that you apply for any necessary visas well before your departure. Make two photocopies of the photo page of your passport. Leave one copy at home and keep the other with you in a safe place, separate from your passport. Keep your important documents, including your passport and return tickets with you or in your carry-on luggage. Do not pack these in a bag that you are planning to check as baggage. Prescription medications should be clearly labeled and kept with you at all times. It’s always a good idea to keep toiletries and a change of clothes in your carry-on bag in the event that your checked luggage is misplaced, lost or stolen. Be sure that all luggage conforms to weight and size restrictions set by your airline. When feasible, try to prepay any known expenses such as car rentals, lodging costs, or tour fees, before leaving the United States to avoid any sudden surprise charges upon arriving at your destination. Traveler’s checks are often more easily replaced than cash if lost, but may not be accepted in all locations, particularly in developing countries.
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2. Vaccinations
Completing a vaccination (immunization) schedule before departure is one of the most important steps you can take to prevent a travel-related disease. Once you have decided on a destination be sure to call a travel medicine specialist and find out which vaccinations are required (if any) and how much time you’ll need to complete the series (if required). 
One common mistake that travelers make is not allowing enough time to be vaccinated according to established schedules. This lack of foresight could force you to delay your trip, or worse, you could end up traveling without the essential protection you need. Generally speaking, you should see your specialist eight weeks prior to departure, as this will give you enough time to take multiple doses of a vaccination if required, get up-to-date if you’ve had vaccinations within the past few years but aren’t sure if you need a booster and to plan out a vaccination schedule that works best for your busy life. This “eight weeks before you go” rule-of-thumb will keep your pre-travel time stress free and you healthy and safe. 
Once you meet with your travel specialist, choosing the vaccinations that are best suited for you will be determined by several factors. Some of the details you and your physician will be taking into consideration include the following:

• Age, medical history, vaccination history, travel history, country of birth, and country where he or she was raised.
• Duration of travel, lifestyle activities during travel, occupation during travel (e.g., health-care or relief worker). 
• Present health status. Individuals who have immunodeficiency diseases (such as /HIVAIDS) or who are taking immunosuppressive medications require an individualized approach to vaccinations. Such individuals may be more susceptible to vaccine-preventable diseases, are at increased risk of uncontrolled virus replication due to their inability to produce antibodies, or may have a less than optimal immune response to vaccines.
• Current disease patterns in specific localities for the country to be visited. 
• Types of accommodations and restaurants to be frequented.
• Planned associations with indigenous peoples.
• Cost of vaccines in general. Unfortunately, for “budget” travelers, the cost of vaccines can be expensive. However, some vaccines recommended for travelers may be reimbursed by insurance coverage, but that is the exception, not the rule. Do keep in mind that you will be spending a substantial sum on your vacation and consultation with a travel medicine specialist is only a small part of your budget.
• Susceptibility to diseases such as polio that one might assume they are protected against.
• Vaccine effectiveness -- some vaccines are currently more effective and have fewer side effects (such as typhoid) or can be given over a shorter period of time (e.g., hepatitis A), making them more efficient in more travel scenarios.

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3. Jet Lag
The term Jet Lag is used to describe the symptoms of fatigue and disorientation experienced by airline passengers who rapidly cross three or more time zones, resulting in a disruption of the body’s internal sleep cycle. It is generally more pronounced in persons traveling west to east than vice versa, primarily because it is easier to stay awake when traveling east to west than to sleep when traveling in the opposite direction. Jet Lag before or during travel may be avoided by modification of diet, sleep cycles, and exposure to daylight. A traveler's usual sleeping hours can be adjusted to conform to those of the travel destination by gradually changing bedtimes during the week before travel. Persons traveling from east to west should retire an hour or two earlier each night; while those traveling west to east should stay awake an extra hour or two each night. Travelers who lack flexibility in their pre-travel schedule may consult their Travel Medicine specialist about prescribing a mild sleeping pill, enabling sleep during travel and an easier adaptation upon arrival. Adjusting to foreign time zones can begin right after boarding the plane by setting watches, sleeping and taking meals accordingly. Travelers are encouraged to steer clear of alcohol or caffeine during their flight as either can disrupt normal sleep habits and, if possible, avoid strenuous exertion, long driving plans, or other important tasks on arrival day. Additionally, melatonin, an over-the-counter remedy, can help when taken at the destination’s bedtime.
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4. Food and Water precautions
New and exotic foods can make any trip interesting, but travelers should remember a few important guidelines about what to eat and drink, especially in developing countries. As foods are potential sources of contamination that can lead to diarrhea, travelers should beware of raw or uncooked foods, including fruits, vegetables, salads, meats, seafood and shellfish. All foods should be cooked thoroughly and served piping hot, as even properly cooked dishes can become contaminated when left at room temperature for too long. In general, travelers should avoid raw fruits and vegetables unless they have thick, intact skins that can be peeled. Because lettuce is difficult to disinfect, travelers should be advised not to eat salads. Additionally, it is advised to steer clear of un-pasteurized dairy products such as milk, soft cheese, yogurt, ice cream and cream sauces. For drinking or brushing teeth, use bottled water obtained from a reliable source. Never drink tap water or water that is otherwise unpurified. Bottled soft drinks or alcoholic beverages are usually safe, but avoid the ice cubes. Words to live by while on the road: cook it, boil it, peel it, or forget it!

Safe Foods

• Well-cooked foods, served piping hot
• Breads, tortillas and other baked goods
• Freshly-boiled foods such as beans, rice and pasta, served hot
• Canned foods

Foods to Avoid

• Leafy or uncooked vegetables and salads. They may have been washed in untreated water or contain bacteria and parasites.
• Fruits, nuts and vegetables, unless they have a thick skin or shell which you can peel like oranges, bananas or melons.
• Undercooked or cold meat and fish can contain parasites.
• Large fish, especially from reef areas may contain toxins.
• Unpasteurized dairy products such as cheese or yogurt, while are ideal breeding grounds for germs.
• Food from street vendors or from restaurants that appear unclean.
• Buffet foods, unless you know they are safe.

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5. Traveler's Diarrhea
Unfortunately, diarrhea is a common occurrence for world travelers. Drastic changes in our diet and sleep cycles can all affect our sensitive systems. Add foreign bacteria into the mix and you have a recipe for a very inconvenient and uncomfortable problem. The good news is that in most cases traveler’s diarrhea rarely causes dehydration and/or serious health consequences in otherwise healthy adults. However, children and adults with underlining health problems may be at risk for traveler’s diarrhea to escalate into something more dangerous.
When your average traveler’s diarrhea is untreated, the symptoms will usually last three to four days before the infection resolves itself. If there is blood or mucus in the stool, a high volume, or fever, it suggests some form of dysentery. 

Dysentery: Dysentery is a disease involving the inflammation in the lining of the large intestines. Travelers may catch dysentery from consuming contaminated water/food or through personal contact with a contagious person. Dysentery often poses a major threat in crowded areas with inadequate sanitation, poor hygiene and limited supplies of safe water. In adults, dysentery may or may not subside spontaneously. In the event it does not adults, children and other vulnerable groups, can be treated with antibiotics or drugs for parasites to alleviate the condition. 

In any case, dehydration is the most dangerous possible outcome of dysentery and can be fatal if ignored. While traveling, if you think you have dysentery you should seek medical attention as soon as possible and receive oral re-hydration salts or intravenous fluids to help replenish what your body has lost due to diarrhea in addition to appropriate medication.
For your comfort, convenience and safety, speak with your Travel Medicine specialist before you leave about which medications to take with you so that you don't have to buy these while traveling. Most importantly adhere to the food and water precautions outlined in the previous section, as they are the most effective way to prevent all types of diarrhea.
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6. Altitude Sickness
Many medical problems can result from travel to destinations that are at altitudes over 4900 feet (1500 meters). Such rapid ascents can result in acute mountain sickness (AMS). The lower oxygen pressures found at high altitudes can produce dizziness, faintness, headaches, or breathing difficulties. In more serious cases, swelling of the brain or accumulation of fluid in the lungs can cause serious or even fatal illness. 
If you are planning a trip to a high-altitude destination, acclimate yourself by spending one to three nights at an intermediate altitude. There are medications available that may be prescribed by your specialist to help your body adjust to rapid changes in altitude – but – slow ascent is the most effective way to acclimate and prevent serious illness. 

While at a high altitude, travelers should:

• Keep in mind that different people will acclimatize at different rates. Make sure all of your party is properly acclimatized before going higher.
• Eat a moderate carbohydrate diet with complex carbohydrate supplements.
• Avoid excess dietary salt and drink EXTRA FLUIDS (at least 3-4 quarts per day) to help prevent dehydration. 
• During your first few days in high altitude overexertion should also be avoided and adequate physical fitness preparation is recommended.
• Avoid tobacco and alcohol and other depressant drugs including, barbiturates, tranquilizers, and certain sleeping pills. These depressants further decrease the respiratory drive during sleep.

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7. Sun Exposure
When traveling to a destination where the temperature and humidity surpass that of the region you are traveling from, it is important to safeguard against exposure to these sometimes-extreme conditions.
For best protection, a UVA and UVB-protective sunscreen with a SPF of 30 or higher should be applied to clean, dry skin 30 to 60 minutes before exposure to UV-rays. If outdoor activity involving swimming or excess sweating is planned, a water-resistant formula should be used. Sunscreen should be reapplied every one to three hours and after swimming or excessive sweating.
If you are using any medications or prescriptions, consult the packaging and/or your specialist to see if they may cause reactions from exposure to sunlight.

Other strongly recommended sun protective measures include avoiding mid-day sun exposure, wearing a broad-brimmed hat, wearing loose-fitting tightly woven light-colored clothing and changing into dry clothes immediately following swimming to allow for less penetration of UV radiation. Sunbathers should also remember that large beach umbrellas reduce exposure by only 50%.

Sunglasses serve an important purpose beyond using them to make a fashion statement, such as protection against glare and squinting. UV radiation from the sun may damage the cornea, choroid, conjunctiva, lens and retina of the eyes. Chronic exposure to solar UV radiation also is a significant risk factor for development of cataracts. Wearing sunglasses is the best way to prevent ocular phototoxicity. There are three classes of nonprescription sunglasses:

• Cosmetic Models - must block at least 70% of UVB light and 20% of UVA light. 
• General Purpose - must block at least 95% of UVB light and 60% of UVA light.
• Special Purpose - must block 99% of UVB and 60% of UVA light.

Travelers who desire the maximum protection should look for a label on the sunglasses indicating absorption of UV up to 400 nm (complete UVA and UVB blockage).

Sunstroke or Heatstroke is a condition in which the thermoregulatory mechanism of the body fails, sweating stops and body temperature rises above 105 F. Sunstroke is usually the last stage of a series of heat and sun related problems (including heat stress and heat exhaustion), during which dehydration, fever and low blood pressure become important. Sunstroke is life threatening. Victims of sunstroke are confused and need immediate medical care; evacuation may be required.
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8. Parasites, Bacteria and Viruses
GIARDIASIS -- The parasite that causes giardiasis (Giardia lamblia) is found in contaminated water as a result of fecal contamination from humans or animals (mostly dogs, beavers, and cattle). Giardiasis is also known as backpacker’s diarrhea because these parasites may be found in ponds, lakes and streams in rural or mountainous areas. Giardia cysts can easily spread from person-to-person within households and in day care centers. Poor personal hygiene, lack of hand washing and close physical/sexual contact may promote transmission. Symptoms can be sudden and severe or occur gradually. Some travelers may have no complaints except one large, loose bowel movement daily. Nausea, fatigue, weight loss, abdominal cramps, non-bloody diarrhea, excessive gas, abdominal rumblings and bloating can also occur to varying degrees. If you suffer from diarrhea lasting more than 2–3 weeks, you should be tested for intestinal parasites. Your Travel Medicine specialist can determine if taking along medication for Giardia is a good idea after reviewing your travel plans. 
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TYPHOID FEVER -- Typhoid fever (sometimes called enteric fever) is a serious, sometimes life-threatening disease caused by one particular species of salmonella bacteria (Salmonella typhi) and is contracted by the consumption of contaminated food or water, or by contact with an infected person. Untreated, typhoid lasts 2–6 weeks and can have a mortality rate of up to 30%. Salmonella typhi bacteria are transmitted by human carriers of the organisms and in all countries with substandard sanitation; there is risk of typhoid transmission. 

Pay close attention to food and water precautions when traveling anywhere where poor sanitation may be an issue. Especially avoid raw vegetables and salads because these items are often grown in contaminated irrigation water. Speak with your travel specialist about where you’re headed and find out if a typhoid vaccination is suggested or required.

9. Insect Bites and Insect Bourne Diseases
Bites and stings by insects are often annoying and can occasionally cause serious illnesses, including malaria, yellow fever, dengue, or life-threatening allergic reactions. While most of these illnesses can be safely treated if properly diagnosed, avoidance of insect bites remains the most important means of staying healthy. Your risk for developing these diseases depends on a number of factors, including your specific destination, your type of accommodations while abroad and the specific activities in which you engage. Your Travel Medicine specialist will look over your travel plans and help determine if specific preventive medicines are needed and can direct you to the most effective insect repellants for your body and clothes. If you suffer from serious allergic reactions to insect bites, you will need to carry a self-treatment kit to be used as necessary such as Epi-Pen (more commonly known as an Epi-Kit).
Below are some insect borne diseases to be aware of while putting together your travel itinerary. Your travel specialist has up-to-date information on which insects are in which regions of the world and will administer and educate you on the appropriate vaccines, medications and preventative measures you will need to take to ensure a safe and healthy trip. 

MALARIA: Malaria is the most important parasitic disease that you will face in most tropical and subtropical countries. A delay in diagnosis and treatment can lead to fatal consequences. If you travel to a malarious region, there are five things you must do: 

• Become informed about your risk of acquiring malaria in that particular region.
• Take measures to prevent mosquito bites. This very important malaria prevention measure is often underutilized and underestimated in its value. 
• Talk with your specialist about prescribing a prophylactic drug and don’t skip prescribed doses.
• Know the symptoms of malaria. 
• Seek immediate medical treatment if symptoms of malaria occur, especially if you are in, or have returned from, a country where malaria is endemic. Always consider malaria if you develop a fever after returning home from a malarious area. Be aware that the symptoms of malaria can be delayed for weeks, months, and sometimes years after exposure and that you can still get malaria even if you took an effective prophylactic drug. Ninety percent of U.S. and Canadian travelers who acquire malaria don’t develop symptoms until after they’ve returned home. 
• Transmission – Inoculation via the bite of infected blood feeding female mosquitoes of the genus Anopheles, transfer parasites called sporozoites from human to human. When the anopheles mosquito bites a victim it infects that person with parasites, called sporozoite that enter the bloodstream and travel rapidly (within 30 minutes) to the liver multiplying exponentially, producing daughter cells called merozoites. Approximately six to fourteen days later, the liver cells burst, releasing huge numbers of merozoites to invade the red blood cells, where they multiply again, rupturing the red cells and releasing even more merozoites triggering an attack of malaria.

DENGUE FEVER – Dengue fever (a flu-like viral illness) and dengue hemorrhagic fever (a severe, often fatal, complication of dengue fever) has emerged as major public health problems in urban-tropical areas. The primary vector mosquito bites by day and thrives in tropical temperatures even in cities. When they are close to their food source they breed near human dwellings in discarded tires, flowerpots, old oil drums and water storage containers. The urbanization process, which has left many without adequate water, sewer systems or waste-management has created the perfect environment for these mosquitoes and has hastened the spread of the disease. 

• Transmission: The viruses are transmitted via the bite of day-feeding mosquitoes of the subgenus Stegomyia. Once infected, a mosquito remains infective for life. Infected humans circulate the virus in their blood and mosquitoes in turn ingest the viruses when feeding on the infective individual. This way, humans serve as an amplifying host, though some monkeys may also serve as a source of the virus. Female mosquitoes can also transmit the virus transovarially, passing it down to the next generation.

YELLOW FEVER -- Yellow fever is another viral illness transmitted by mosquitoes. The disease is so named because jaundice (a condition that leaves the skin yellowish in color), is a common sign of this illness. While jaundice is a result of some damage to the liver, most yellow fever infections are mild and go unrecognized, but severe, life-threatening illness occurs in about 15% of people exposed to the disease.

• Transmission: There are two distinct cycles of transmission, but the resulting disease is the same. Urban yellow fever is transmitted by the bite of an Aedes aegypti mosquito, which goes from an infected person to another person. In jungle yellow fever, mosquitoes transmit the infection between nonhuman primates (e.g., monkeys) and humans or vice versa. It is a potentially fatal disease.
  

LYME DISEASE -- Lyme disease, also known as borreliosis, is an emerging infectious disease caused by bacteria from the genus Borrelia. People most at risk are those engaged in outdoor activities—campers, hikers, mountain bikers, hunters, fishermen, farmers, gardeners, telephone line workers, foresters, and military personnel on training maneuvers. If untreated, you can develop prolonged arthritic attacks in one or multiple joints (often the knees), chronic fatigue, and disorders of the nervous system such as polyneuritis, paralysis and encephalopathy.

• Transmission: The vector of infection is typically the bite of an infected black-legged or deer tick, but other carriers (including other ticks in the genus Ixodes) have been implicated. Borrelia burgdorferi is the predominant cause of Lyme disease in the U.S. and Borrelia afzelii and Borrelia garinii are most often found in Eastern Europe.

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10. Other Travel Related Illnesses/Diseases
HEPATITIS -- Hepatitis is a generic term for inflammation of the liver. It is caused by a large number of viruses, other infectious agents and toxins. However, for the traveler, viral hepatitis is the major concern. There are four hepatitis viruses of which all travelers should be particularly aware: A, B, C, and E. The means of transmission and long-term effects vary, depending upon which virus causes the disease. Hepatitis A and Hepatitis B can be prevented through vaccination and are therefore also referred to as vaccine-preventable hepatitis (VPH). There is no vaccination available for Hepatitis C at present, nor are there commercially available vaccines available for the prevention of Hepatitis E. However, several studies for the development of an effective vaccine against Hepatitis E are in being researched.

• Hepatitis A and E: Hepatitis A and E are transmitted primarily by contaminated food and water. High-risk areas are lesser-developed countries where poor sanitation results in fecal contamination of groundwater, tap water, and well water. Outbreaks of hepatitis A are also caused by food that has been contaminated by an infected food handler.
• Hepatitis B and C: Hepatitis B and C are spread by sexual contact, exchange of body fluids, injections from contaminated needles and syringes, and unscreened blood transfusions.
  Washing your hands regularly and adhering to food and water precautions will decrease your chances of contracting Hepatitis A and E while traveling. Being sexually responsible by wearing a condom with new sexual and/or non-tested partners and avoiding previously used needles are rules of conduct you should ALWAYS follow whether at home or abroad for your general health and safety.

RABIES -- Rabies is a serious but preventable viral disease that causes acute encephalitis (inflammation of the brain). The virus exists in the saliva of mammals and is transmitted from animal to animal or from animal to human by biting and/or scratching. *The virus can also be spread by licking, when infected saliva makes contact with open cuts, wounds or with the mouth, eyes and nose. If left untreated in humans and animals, rabies is fatal. There is a treatment for rabies but it is expensive and rarely available in clinics throughout the developing world. The best way to survive rabies exposure is to complete a rabies vaccination schedule administered by your Travel Medicine specialist. The vaccine is highly recommended for anyone traveling off-the-beaten-path or in countries where dogs are not typically vaccinated such as in Nepal and other developing countries. In these areas dogs are the most common carriers of the disease. In the United States, Canada and most of Western Europe where dogs are routinely vaccinated, animals such as skunks, raccoons, foxes, coyotes, bats and other wild carnivores are the primary transmitters of the disease. Many other animals around the world can carry rabies, so at the very least, travelers should take care not to approach or pet stray dogs or cats and never approach or touch wild animals.

BACTERIAL MENINGITIS -- Acute bacterial meningitis usually occurs when bacteria enter the bloodstream and migrate to the brain and spinal cord. It can also occur when bacteria invade the meninges directly, as a result of an ear or sinus infection or a skull fracture. Left untreated, bacterial meningitis can cause death. Some of the symptoms appear flu-like in nature and can include a high fever, vomiting and loss of appetite. If you or someone you know experience severe flu-like symptoms coupled with confusion, severe headaches/neck aches or seizures, seek medical care right away. 

Meningitis typically results from contagious infections and can be spread through coughing, sneezing, kissing, sharing eating utensils, a toothbrush or a cigarette. As many as one out of three people may be carrying the bacteria (which causes meningitis), though they are healthy or appear to be healthy. Meningitis can strike at any age but young people from fifteen to twenty four are most at-risk for contracting the disease. People living communally are a high-risk group as well. 

Need another good reason to give up smoking? It has recently been shown that smoking cigarettes and exposure to secondhand smoke is a risk factor for contracting meningitis.

Proper hygiene and common sense about sharing items like toothbrushes and utensils are always a good rule-of-thumb whether at home or abroad.
As for keeping informed about those places around the world experiencing sporadic meningitis outbreaks, ask your Travel Medicine specialist. This information is key as to whether you will require a meningitis vaccination before your trip.

HIV/AIDS -- Human immunodeficiency virus (HIV) is a retrovirus that can lead to acquired immunodeficiency syndrome (AIDS), a condition in humans in which the immune system begins to fail, leading to life-threatening opportunistic infections. HIV is spread by sexual contact with an infected person, by sharing needles and/or syringes with someone who is infected, or, less commonly (and now very rarely in countries where blood is screened for HIV antibodies), through transfusions of infected blood or blood clotting factors. Babies born to HIV-infected women may become infected before or during birth or through breast-feeding after birth.
How Can I Avoid HIV/AIDS while traveling?

• Don't have sex (vaginal, oral or anal) with strangers or commercial sex workers and avoid casual sexual contacts.
• If you are going to have sex with a new partner, use latex (or if allergic, use polyurethane) condoms consistently and correctly for every sexual contact. Before departure, pack your own supply of high-quality latex condoms and make sure they are new and have not expired.
• Don't share needles or syringes.
• Don't share razors, toothbrushes or shavers.
• Don't receive tattooing, body piercing, acupuncture or other skin-piercing treatments and cosmetic procedures.
• Don't receive injections or transfusions unless it is an emergency. If you must receive blood while traveling, try to ensure the donated blood has been tested for HIV. If you cannot ensure the blood has been screened, and you do not require emergency care, return home for treatment.
• Pack a supply of syringes, needles and blood products to cover the length of your trip if you require any of those for regular treatment. Also carry a medical certificate explaining the supply.
• Consider packing a suture kit containing sterile needles, syringes and suture material for emergencies.
• Traveling HIV Positive -- If you are HIV positive make sure to get all the facts before you go. Travel is physically taxing and that alone may compromise your immune system and increase your risk of getting opportunistic infections. It is imperative to discuss your travel plans with a specialist skilled in travel medicine before you leave so you know the medical risks and understand the steps to take to protect yourself.

In most countries, tourists staying less than one month do not need to show evidence of an HIV test. But dozens of countries—including the United States—do require an HIV test for those coming to study, work, and stay for long periods, or apply for immigrant status. Those who test HIV positive usually are denied entry, although sometimes a waiver may be issued. The World Health Organization regards HIV screening as discriminatory and unnecessary from a public health perspective yet several countries retain their policies of rejecting or expelling all foreigners with AIDS. If you are HIV positive and looking to study or live abroad speak with your travel physician about which countries screen immigrants for the virus and which country’s visa forms ask whether a visitor has any infectious or communicable diseases. 
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11. Diabetes and Travel
The thought of traveling with diabetes can discourage the most confident of travelers. Although with the proper preparation and common sense, the two are very compatible. Anticipating and avoiding common health problems in both tropical and temperate climates and being able to manage them on your own, will ensure a more pleasurable, healthier journey.

• Preparing for Your Trip -- Visit your diabetes physician at least 4–6 weeks before the trip. Ask for a signed and dated letter on official letterhead outlining your diabetes care, any other medical conditions and the need for you to carry medications and equipment such as syringes/needles. Obtain a summary of your medical history as well, including allergies and prescriptions. You should carry double the amount of needed medication and monitoring supplies for your planned length of stay (the latter to allow for increased testing).
• Travel With a Buddy -- Teaching your travel companion to carry a snack for you and to keep an eye out for signs that you may be low on sugar is one way to make sure you stay safe while traveling. You can also teach your travel mate what your medications are, when you need them, how much you need and how to administer them. Just knowing that there is someone looking out for you while abroad may make your travel experience more enjoyable.
• Be Well-Informed -- Visit your travel physician to begin working out the details of traveling with diabetes. Getting a professional opinion can help you organize a safe and well thought out vacation and help you better manage your medical needs within different environments.
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12. Pregnancy and Travel
If you are a healthy woman with an uncomplicated pregnancy, you do not necessarily need to curtail reasonable travel. According to the American College of Obstetricians and Gynecologists, the best time for travel is during the second trimester when your body has adjusted to the pregnancy but is not so bulky that moving about is difficult. The second trimester is also safer because the probability of miscarriage is less. After the sixth month, the risk of premature labor and other complications increase.

• When to Limit Travel -- A brief trip to major European cities during the second trimester represents a far safer scenario than an extended trip to a developing country where you might have potential exposure to exotic illnesses, as well limited access to medical care. If you will be far away from expert medical and obstetrical care, and/or have increased exposure to travel-related diseases, such as malaria, then you should consider deferring travel until after delivery. 
• After the 28th Week -- Most obstetricians advise their patients not to travel beyond a 100-mile radius after the 28th week. Problems after this time include increased risk of premature labor, preterm rupture of membranes, development of hypertension, phlebitis, and increased risk of uterine and placental injury should you be involved in a motor vehicle accident.

Pre-Travel Checklist: A careful assessment of your medical and obstetrical history, and your current state of health, is mandatory prior to departure. It should include the following:

• Spontaneous Abortion (miscarriage)
• Ectopic Pregnancy
• Toxemia 
• Premature Labor
• Incompetent Cervix 
• Prolonged Labor 
• Caesarean Section
• Premature Rupture of Membranes
• Uterine or Placental Abnormalities 
• Hypertension 
• Pelvic Inflammatory Disease 
• Phlebitis or Pulmonary Embolism 
• Rh Negative Blood Group
• Severe Morning Sickness 

• Have diabetes? 
• Take insulin? 
• Take medication for any other illness? 
• Have symptomatic congenital or acquired heart disease? 
• Have anemia, asthma, epilepsy, phlebitis, or any other significant medical illnesses?
• Get severe motion sickness? 
• Have significant allergies? 

• Personal comfort? 
• The duration of your trip—Will it be more than a few days? Will travel require prolonged sitting?
• The destination—Is it more than 100 miles from home? 
• The quality and availability of medical and obstetrical care in the countries on your itinerary—Is it available and adequate? 

After reviewing the foregoing checklists, your Travel Medicine specialist will be able to discuss with you the relative safety of your travel plans and offer appropriate advice. Airlines will require a letter from your obstetrician if you are in your 35th week of pregnancy (or beyond). 
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13. Traveling with Children
With the increasing mobility of families, more children are traveling to developing countries. A visit to a pediatrician or a Travel Medicine specialist should be scheduled at least one month before departure to allow for pre-travel preparation and any required vaccinations. Parents of children with food allergies should be reminded that adherence to special diets may be impossible in certain settings.

A leading cause of death in travelers is vehicular injury. Automobile seat belts are sometimes unavailable in developing countries, and infant car seats are often nonexistent. Whenever possible, parents should bring their own car-seats and try to obtain seat belts that can be attached to rental or available vehicles.

Make sure you supervise your child at all times. A common cause of hospitalization of children in the tropics is ingestion of poisonous plants or easily accessible drugs (especially antimalarials). For teens and young adults, routine counseling on sexually transmitted diseases and HIV infection should be reemphasized.

Remember that young children require frequent rest and refreshment stops, especially for fluid replacement in hot climates. Children also don't seem to tolerate heat as well as adults. Air conditioned hotels may be preferable to accommodations that are more desirable for adults that want to experience the "real outdoors."

A sanity saving tip for parents is to keep in mind that children are likely to get bored during long periods of travel, be it by plane, train or automobile. Make sure that you bring some of their "essential" items like favorite toys, games and books.
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14. What to Do if You Get Sick
Before leaving on your trip, discuss with your specialist what to do in case you become ill while abroad. It may be useful to carry certain medications for treating common illnesses, such as respiratory infections or diarrhea. A small first aid kit is easily packed and can often be invaluable for managing minor cuts, scrapes, insect bites or other problems. If you have chronic medical illnesses, such as asthma, heart disease or diabetes, be certain to carry adequate supplies of your regular medications. All medications should be clearly labeled and carried in prescription bottles and should always be kept with you rather than in checked luggage. If you have any special health needs or conditions, your physician can provide a letter of explanation for you to carry, which may aid you in obtaining appropriate health care while traveling. An area’s local U. S. Consulate will usually provide travelers with information about obtaining medical assistance while abroad. Your personal physician may be able to suggest other medical resources, such as The International Association for Medical Assistance to Traveler’s (IAMAT), a worldwide network of English-speaking physicians who provide acute care to travelers.

• Expect the Unexpected When Traveling Internationally -- Most insurance companies will not cover the costs of an injury while traveling abroad. It is important to consult with an insurance representative before you leave for your trip to see what kind of coverage is available.
• Patients with chronic medical conditions who are stable at the time of their departure may undergo a change in health status while away. Such patients should always travel with enough medical supplies and a current set of their medical records.
• Travelers (especially those with unusual travel plans or significant chronic illness) should also be counseled to routinely contact the US embassy upon arrival at each destination; the embassy can provide names of physicians who are available for consultation with tourists. Most tourist hotels in major cities have physicians on-call for guests who become ill or injured. The US State Department, through its overseas citizen emergency centers, provides assistance to tourists who are experiencing medical, legal, or financial difficulties.
• Because of the variable quality of health care services that are available abroad, hospitalization and treatment may be associated with a risk of disease or infection from contaminated blood supplies. If at all possible, avoid any dental work or injections that are not done with a syringe that is individually sealed.
• Emergency Medical Transport (MED EVAC) -- Should air evacuation be necessary, it’s much easier to have an insurance company make these arrangements through an assistance company than for you to make them yourself. Without an assistance policy, you’ll have to make all the transport arrangements yourself, pay up front, and hope your insurance policy or medical plan will reimburse you for costs up to the policy limit.
• The cost of stretcher transport on a commercial airliner is usually nine to ten times the cost of a one-way economy seat (or four times the cost of a first-class seat). Oxygen, nurse’s or doctor’s fees, and ground transport will be extra. Before paying you, the insurance company or your HMO will insist on knowing if the transport was “medically necessary,” and for this you will need a letter or other documentation from your physician or treatment facility.
• Scheduling normally takes 48 to 72 hours, or more, and is dependent upon seat availability as well as the airline’s acceptance of the transport. Some airlines will not transport stretcher patients. In general, only patients with stable, non-critical medical conditions will be accepted by airlines that do provide stretcher transport. Your Travel Medicine specialist can direct you to a travel insurance plan that will take all this into consideration. 
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15. Global Warming and Its Effect on World Health
The science behind Global Warming is conclusive and well documented. For over fifty years, scientists have been measuring the concentrations of carbon dioxide in the atmosphere from the Mauna Loa laboratory in Hawaii. They have found that the concentration of CO2 has been increasing by about one part per million every year - an increase that is caused by the burning of unprecedented amounts of fossil fuels over the last two hundred years of industrialization. We are already seeing this trend of warming today - the ten hottest years on record have all occurred within the last fifteen years.

Although Global Warming is not universally accepted, there have been regional climate changes that have affected the spread of disease. Both the increase in average temperatures and the lengthening of warmer seasons along with increases in humidity and rainfall have led to expansion of insect vectors and the diseases they carry. Mosquitoes are expanding their territory and are now found at higher altitudes, previously free of malaria.

• Global Warming and Dengue Fever -- Temperature limits the range of the mosquito, which carries dengue fever. Frost kills both adults and larvae. In the past, this has prevented the disease from spreading from the tropics, but rising temperatures are changing that pattern. It has moved steadily north in recent decades, and to higher elevations. In the United States the mosquito, which carries dengue, has reached as far north as Chicago.
• Global Warming and Malaria -- Like dengue fever, malaria is a mosquito borne illness normally limited by temperature. Rising temperatures have expanded its range, and exposed new populations to infection. IPCC (Intergovernmental Panel on Climate Change) scientists project that as warmer temperatures continue to spread north and south from the tropics and to higher elevations, malaria-carrying mosquitoes will spread with them. They project that global warming could put as much as 65 percent of the world’s population at risk of infection by malaria.
• Global Warming and Tick-Borne Encephalitis: Tick-borne encephalitis, a disease that was mostly confined to Eastern Europe has now made its way into France, Switzerland and even Sweden. Lyme disease is also tick-borne and has basically followed the same distribution pattern.
  

It is incumbent upon Travel Medicine specialists to inform their patients regarding the potential diseases and risks stemming from ongoing weather changes and natural disasters as related to the results of continuing climate change.
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