International Travel Preparation: Health and Safety Guide for Nurses

Exposure to infectious diseases during international travel has been in the news recently and it’s important to be aware of the types of risk posed by international travel as well as recommended pre- and post-travel interventions. Nurses, as a trusted health care voice, may receive questions from patients, family members, and others within their community—and nurses themselves may be preparing for international travel.

Therefore, how individuals can be be best prepared for international travel should be a point in patient education and personal education for nurses. International travel can be an enriching experience, but it also comes with certain health and safety risks. Proper preparation helps mitigate these risks and ensures a smoother and safer journey. The following information provides essential information on

• risk assessment
• food and water safety
• insect protection
• general safety considerations
• and medical preparedness, including vaccines and travel-related medications.

More detailed information can be obtained by going to the Centers for Disease Control and Prevention (CDC) website and consulting the Yellow Book, a recognized authority document freely available for access and download.

Risk Assessment

Before international travel, individuals should receive a comprehensive risk assessment to identify health and safety conditions associated with the trip and the anticipated itinerary. This risk assessment is ideally conducted by a health care provider with expertise in travel health and travel medicine.  However, information is available on the CDC website and can be a useful first step in this initial risk assessment. Key components of a risk assessment should include:

• Destination-specific risks: Use reliable sources like the CDC, World Health Organization (WHO), and the U.S. Department of State’s foreign office travel advisories. Consider political stability, disease prevalence, climate, natural disasters, political and medical infrastructure.
• Personal health: Review your medical history with a health care provider. Discuss any chronic conditions, medications, allergies, or immune-compromising conditions.
• Duration and purpose of travel: Whether your travel plans involve business, tourism, long-term stay, study abroad, staying with friends or relatives, or humanitarian work will influence your risk level.
• Activities planned: Outdoor activities, rural travel, or adventure sports are examples of how international travel can increase exposure to injury or disease.
• Health care access: Identify nearby clinics or hospitals in the country in advance. Some regions may lack advanced medical care and this may be relevant particularly if the traveler or their family members have chronic medical conditions or if unanticipated injuries occur.

A travel medicine clinic visit four to six weeks before departure is highly recommended by the CDC to allow time for consultation, planning, and vaccination.

Food and Water Safety

Contaminated food and water are leading causes of travel-related illness, especially traveler’s diarrhea. Contamination occurs through contact with sewage that may be present in the soil, water, or on the hands of individuals preparing or handling food. A travel health consultation should review food and water safety and provide specific activities to help prevent illness.

Food Safety Tips

• Eat food that is thoroughly cooked and served hot.
• Peel uncooked items (e.g., fresh fruits, vegetables) to reduce contact with contaminants that may be present on the outside of that item.
• Avoid leafy vegetables that are difficult to clean.
• Avoid street food unless it’s cooked fresh in front of you.  Even then, be aware that the hands of the individual handling that food may be unwashed and therefore represent transmission risk to the food and to you.
• Stick to sealed or packaged snacks.
• Avoid raw or undercooked meat, fish, and eggs.
• Be cautious with dairy products, especially if unpasteurized.

Water Safety Tips:

• Routinely drink bottled, boiled, or filtered water.
• Avoid tap water, even for brushing teeth in high-risk areas.
• Use high filtration water filters or iodine/chlorine tablets for purification if bottled water is not available
• Avoid ice cubes made from tap water.
• Be aware that coffee and tea are made with hot water, but not necessarily water that has been boiled. This makes coffee and tea risky to consume.

Insect Precautions

Mosquitoes and other insects can transmit serious diseases such as malaria, dengue, chikungunya, yellow fever, and Japanese encephalitis. Vaccines are available for chikungunya, yellow fever and Japanese encephalitis and should be considered based upon travel itinerary and length of time in risk areas.

Prevention Strategies:

• Use insect repellent with at least 30% DEET.  100% DEET is not necessary and may expose the user to unnecessarily high level of chemical contact exposure.
• Wear long-sleeved shirts, long pants, and light-colored clothing when outside during times mosquitos are active.
• Not all mosquitos are active only at dusk. Some mosquito species are active throughout the day, so DEET should be worn during those times.
• Sleep under mosquito nets in areas where insects are prevalent.
• Stay in air-conditioned or well-screened accommodations.
• Treat clothing and gear (not skin) with permethrin for added protection.

Check if your destination has malaria risk, and consider antimalarial prophylaxis.

General Safety Considerations

Health and safety extend beyond disease prevention. Be vigilant and aware of your surroundings.

Personal Safety

• Keep passport and important documents in a safe place.
• Keep photos of those documents in your phone or cloud-based files so they can be accessed, if needed.
• Avoid flashing valuables, expensive jewelry, or large amounts of cash.
• Use hotel safes, and carry only what you need.
• Stay in well-lit and populated areas, especially at night.
• Avoid demonstrations or political gatherings or large crowds that may be focused on social or political issues.

Transportation Safety

• Use licensed taxis or rideshares.
• Wear seatbelts, and avoid overcrowded or poorly maintained vehicles.
• Be aware of moving vehicles including cars, motorcycles, motorized carts, bicycles, or other moving devices. Stop and look for those vehicles/devices before stepping into traffic areas.
• In developing countries, road accidents are a leading cause of traveler injury.

Natural Hazards

• Know the local weather and environmental risks like extreme heat, altitude, or natural disasters.
• Prepare accordingly with sunscreen, hydration, and proper clothing.

Emergency Readiness

• Register with your embassy or consulate.
• Have access to emergency contact numbers, including local emergency services, embassy, and travel insurance provider.

Vaccinations

Vaccines are crucial in preventing potentially life-threatening diseases. Required and recommended vaccines vary by destination, but selection should be based upon country/countries visited, activities and itinerary, underlying health conditions, and assessed risk of the diseases the vaccines are designed to prevent or mitigate. Travel-related vaccine decisions can be complex, so use of a health care provider with specific expertise is important.

Routine Vaccines

Ensure your routine adult vaccines and those recommended for children are up to date, including:

• MMR (Measles, Mumps, Rubella)
• Diphtheria-Tetanus-Pertussis
• Polio
• Influenza
• COVID-19

Travel-Specific Vaccines

Based on the destination, the following provides some vaccination considerations and some of the rationales:

• Hepatitis A: Recommended for most travelers.
• Hepatitis B: Especially for long stays, medical exposure to blood/body fluids.
• Typhoid: Important for regions with poor sanitation and concerns about access to clean drinking water and clean water to wash foods.
• Yellow fever: Required for some countries in Africa and South America. Proof of vaccination may be mandatory for entry into the country. Areas where yellow fever is endemic may not require vaccination, so travelers may get a false sense of low risk.
• Japanese encephalitis: For long-term stays, particularly in rural Asia.
• Rabies: For high-risk travelers or areas with poor post-exposure care. Longer stays in high-risk areas are particularly problematic when children are traveling.
• Cholera: For high-risk areas, especially in humanitarian or outbreak settings.
• Meningococcal vaccine: Required for Hajj pilgrims and recommended in some areas of Africa.

Consult a travel health professional to determine which vaccines are necessary for your trip.

Preventive and Treatment Medications

Preventive Medications:

• Antimalarials: Depending on your destination, options include atovaquone-proguanil, doxycycline, Start before travel to the risk area and continue for some period of time post-return.
• Altitude sickness medications: For high-altitude destinations, acetazolamide may be prescribed.
• Traveler’s diarrhea prevention: Some travelers may benefit from over the counter loperamide, but azithromycin may also be beneficial.

Treatment Medications

Prepare a travel health kit that includes:

• Antibiotics (e.g., azithromycin) for moderate-to-severe traveler’s diarrhea.
• Oral rehydration salts (ORS) for dehydration.
• Anti-motility agents (e.g., loperamide) for symptom control of diarrhea (use cautiously).
• Antihistamines for allergic reactions.
• Analgesics like acetaminophen or ibuprofen for pain or fever.
• Antacids or anti-nausea medications for stomach upset.
• Motion sickness pills (e.g., dimenhydrinate or meclizine).
• Topical antibiotic ointments for cuts and scrapes.
• Prescription medications in original packaging with documentation.

Also bring extra doses of regular medications, as availability and quality abroad may vary. Check to make sure the country you are visiting does not have additional requirements for entry with medication (e.g., controlled substances, including ADHD medication).

Final Tips

• Purchase comprehensive travel insurance that covers medical emergencies, evacuation, and trip cancellation.  This is different from routine travel insurance that covers interruption of the trip flights or hotel.
• Maintain a copy of your health records, prescriptions, and vaccination records.
• Stay updated on health alerts or outbreaks in your destination.
• Stay hydrated, eat cautiously, and protect against bug bites and injuries.
• Trust your instincts and stay informed.

Conclusion

The information provided here is an overview and may not address all risks associated with an individual international travel itinerary. This is why an expert in travel health and travel medicine can be a valuable ally in protecting the health of the nurse, their families, and communities. International travel requires thorough preparation to stay safe and healthy. By evaluating risks, securing proper vaccinations prior to the trip, practicing food and water safety, protecting against insect bites, and bringing necessary medications, you reduce the likelihood of health issues occurring during your trip and, perhaps, upon return.

A proactive approach enables you to focus on enjoying your travels while minimizing avoidable health risks. Nurses have several critical roles when considering travel health. First, nurses represent one of the most critical professions for maintenance of the U.S. health care infrastructure, so our safety is vital. Second, protection of our families depends upon recognizing risk and taking steps to protect them and ourselves. Lastly, our communities may reach out to nurses for advice and recommendation, so expanding our knowledge and sharing that knowledge with others may have a profound impact on the health and well-being of others.

Ruth Carrico, PhD, FNP-C, CIC, FSHEA, FNAP, FAAN, is an adjunct professor in the Division of Infectious Diseases at the University of Louisville School of Medicine and a board certified family nurse practitioner. She has worked in the field of infection prevention and control for more than 30 years and is also board certified in infection prevention and control. Her research and clinical practice focus on disease prevention in all settings where care is delivered and involves public health and care of vulnerable populations.