Preparation

In addition to ensuring that all necessary travel documents are complete before departure, travelers should learn what medical services their health insurance will cover overseas, as well as any policy exclusions. While some major health insurance carriers in the United States may provide coverage for emergencies that occur while traveling, most do not cover medical expenses due to exacerbations of pre-existing medical conditions while abroad. It is also important to know the insurance company’s policy for “out-of-network” services, pre-authorization requirements, and need for a second opinion before obtaining treatment. Travelers should carry claim forms and a copy of their insurance policy card, if their insurance policy does provide coverage abroad. The Social Security Medicare program does not provide coverage for medical costs outside the United States, except under very limited circumstances (1); some Medigap plans available to people enrolled in the original Medicare plan provide limited coverage for emergency care abroad (2). Furthermore, very few health insurance companies cover the cost of medical evacuation, which can vary widely, ranging from a few thousand dollars to over $100,000, depending on the circumstances. Travelers who will be outside the United States for an extended period of time, who have underlying illnesses, or who are participating in activities involving greater risk for injury are encouraged to consider purchasing a supplemental health insurance policy that provides guaranteed medical payments, assistance via a 24-hour physician-backed support center, and emergency medical transport, including repatriation. A list of travel insurance and medical evacuation companies is available at the U.S. Department of State website (3). A brief list of additional assistance companies is also included below; this list is not all-inclusive:

• International SOS: http://www.internationalsos.com. International SOS offers comprehensive 24-hour physician-backed medical and security assistance, for which members pay a fee. Membership provides access to on-line services, including medical and safety travel advisories, pre-travel itinerary-based recommendations, and computerized medical records. Insurance policies include medical evacuation and repatriation coverage, access to international clinics that provide primary care, diagnostic, and emergency services, and voluntary patient support programs to assist with medication compliance while abroad.
• MEDEX: http://www.medexassist.com. MEDEX travel assistance services include 24-hour access to coordinators who can help locate appropriate medical care providers, coordinate direct payment of covered medical expenses, and assist in other medical, legal or travel situations. Insurance policies include medical evacuation and repatriation services, emergency dental coverage, and assistance with replacement of medications. For an additional fee, subscribers also have access to itinerary-based destination reports, which cover practical topics from local transportation and cultural norms to medical and security alerts.
• International Association for Medical Assistance to Travelers: http://www.iamat.org. IAMAT is a nonprofit organization established to provide medical information to travelers and to make competent medical care available to them worldwide. IAMAT maintains an international network of physicians, hospitals, and clinics who have agreed to treat IAMAT members in need of medical care while abroad. Membership is free, although a donation to support IAMAT efforts is appreciated. Members receive a directory of participating physicians and medical centers and have access to a variety of travel-related informational brochures.

Travelers with underlying medical conditions also should consider choosing a medical assistance company that allows them to store their medical history before departure, so it can be accessed worldwide if needed. Alternatively, they may carry a letter from their physician listing underlying medical conditions and current medications (including their generic names). Travel insurance companies differ in their policies with regard to coverage for exacerbations of underlying medical conditions. Travelers are encouraged to research this carefully and understand the fine print. See also the Travelers’ Health Kit section in this Chapter for more suggestions on travel preparation.

Illness Abroad

If an American citizen becomes seriously ill or is injured abroad, a U.S. consular officer can assist in locating appropriate medical services and notifying friends, family, or employer (3). Additional resources include the clinic where the traveler received pre-travel health advice and immunizations, embassies and consulates of other countries, hotel doctors, credit-card companies, and multinational corporations, which may offer health-care services for their employees. For informational purposes, Travel Health Online (https://www.tripprep.com) provides a list of travel medicine providers from around the world. Wherever they are posted, lists of providers are obtained from a variety of sources, and the quality of services and the expertise of the providers are not guaranteed. The Inter-national Society of Travel Medicine and the American Society of Tropical Medicine and Hygiene also have directories of travel clinics available at their websites (www.istm.org and www.astmh.org, respectively). Although many of these clinics may only provide pre-travel services, some are located outside the United States and can see ill travelers.

The quality of health care from overseas medical centers can be variable, particularly in developing countries. Some foreign hospitals may have out-of-date facilities, while others have highly sophisticated diagnostic and therapeutic equipment similar to that found in the United States. Joint Commission International (JCI) is a division of Joint Commission Resources (JCR), a subsidiary of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which accredits hospitals in the U.S. (4). JCI helps to improve the quality of patient care in more than 60 countries. Since 1998, 93 health-care facilities have been accredited by JCI in Europe, Africa, Asia, the Middle East, and the Americas. In 2005, WHO designated JCAHO and JCI as the world’s first WHO collaborating center dedicated solely to patient safety (5). A list of accredited international health-care facilities is available at the JCI website: http://www.jcrinc.com (6).

Physicians, hospitals, and most entities in other countries usually require payment in cash or credit card for services rendered rather than bill an insurance company. Travelers with health insurance coverage should carry their insurance card and claim forms, and they should obtain copies of all bills and receipts. If one needs financial assistance, the U.S. consular office can assist with transferring funds from the United States (3). In extreme circumstances, they may even be able to approve small government loans until private funds are available (7). Travelers must be aware, however, that they are responsible for paying all medical expenses they incur while abroad, including evacuation expenses.

In many developing countries, virtually any drug, including antibiotics and anti-malarial medications, can be purchased without prescription. Travelers should be advised, however, not to buy these medications unless they are familiar with the products. The quality of these drugs may not meet U.S. standards, and they may even be counterfeit or potentially hazardous because of contaminants (8). In addition, travelers requiring an injection overseas should consider bringing their own injection equipment (see Travel Health Kit section). At the very least, they should ask if the injection equipment is disposable and insist, if possible, that a new needle and syringe be used.

Blood Transfusions

A blood transfusion can be a life-saving intervention when the blood supply has been appropriately screened and managed. For travelers, transfusion should be required only in rare and unexpected situations of massive hemorrhage, such as severe trauma, gynecologic and obstetric emergency, or gastrointestinal bleeding. Not all developing countries have accurate, reliable, and systematic screening of all blood donations for infectious agents such as malaria, HIV, and hepatitis viruses, which can result in transfusion-related transmission of these infections. According to WHO, more than 70 countries reported to the Global Database on Blood Safety that, during a 12-month period in 2000-2001, they did not test all donated blood for all the major infectious agents transmissible by transfusion, i.e., HIV, hepatitis B and C viruses, and Treponema pallidum (the etiologic agent of syphilis); 66 countries did not have nationally coordinated blood transfusion services or were unable to provide complete national data; and 39 countries reported that, because of interruptions to supplies of test kits, blood was released for clinical use without testing for transfusion-transmissible infections (9). Additionally, transfusion reactions can occur if the blood products are not adequately characterized for compatibility with the recipient before transfusion. Because of these inherent risks, transfusion should be prescribed only for conditions for which there is no other treatment. People who travel frequently to, or who spend a prolonged period of time in, developing countries, and those whose activities put them at higher risk for serious injury should consider being immunized against hepatitis B virus. When blood transfusion cannot be avoided, travelers should make every effort to ensure that the blood has been screened for transmissible diseases, including HIV. In many cases, resuscitation can be achieved by use of colloid or crystalloid plasma expanders instead of blood. Once stabilized, travelers should consider urgent evacuation for additional management

In the past, travelers planning international itineraries have requested to have their own blood or blood from their home country available to them in case of urgent need. There are no medical indications for travelers to take blood with them from their home countries. The international shipment of blood for transfusion is practical only when handled by agreement between two responsible organizations, such as national blood transfusion services. This mechanism is not useful for the emergency needs of individual travelers and should not be attempted by private travelers or organizations not operating recognized blood programs. The limited storage period of blood and the need for special equipment negate the feasibility of independent blood banking for individual travelers or small groups (10). Travelers should, however, carry a medical card or other document, showing their blood group and information about any current medical problems or treatment.

Health-Seeking Travel

Traveling abroad for the purpose of improving one’s physical, mental, and spiritual well-being is increasing in popularity. Such “health tourism” includes, but is not limited to, traveling for alternative therapies, such as balneotherapy (treatment by baths) and thalassotherapy (treatment based on the use of sea water), religious pilgrimages, and modern medical treatments, including elective surgery.

Therapies that are considered “natural” are not without hazards. Mineral and “holy” waters may not be potable by U.S. standards and have been sources of infectious diseases (11). Moreover, pilgrims are subject to the same destination-associated risks as other travelers (e.g., heat and altitude-associated illnesses), but many may be traveling in ill-health. Outbreaks of meningitis due to Neisseria meningitidis have occurred in Hajj pilgrims (12), leading to the requirement that all pilgrims participating in the Hajj be immunized before their departure (see Chapter 4). With the shift in the timing of the Hajj to winter months, pilgrims may also be at increased risk for respiratory tract infections, such as influenza and adenovirus (13).

Medical tourism, traveling to another country for medical, dental, or surgical care, is a rapidly growing industry. Traditionally, people who could afford to do so traveled from lower-income counties to more developed countries in order to seek care not available in their home country. In recent years, however, people from higher-income countries have started traveling to lower income countries in seek of lower medical costs and shorter waiting times (14,15), Companies offering vacation packages bundled with medical consultations and financing options provide direct-to-consumer advertising over the internet. Enter “medical tourism” into any internet search engine and one will find a variety of tourism packages from travel agencies and health-care facilities worldwide. Recognizing the potential revenue to be gained through medical tourism, countries such as India, Thailand, Costa Rica, Turkey, and others have promotional campaigns to attract tourists seeking traditional and alternative therapies (14,15). Such medical packages often claim to provide high-quality care, but as mentioned above, the quality of health care in developing countries is highly variable, and only a handful of international health-care facilities are accredited by the Joint Commission International (6).

For the most part, medical insurance companies do not pay for medical procedures performed abroad, although some health insurance providers in the U.S, recognizing the cost benefits, allow policy holders to seek care in Mexico (14-16). Another problem with medical tourism is that there is little follow-up care. The patient usually is in the hospital for only a few days and then returns home. Complications are then the responsibility of the health-care system in the traveler’s home country. For example, CDC received a number of reports of nontuberculous mycobacterial infections after elective cosmetic surgery abroad (17,18). In addition to these postoperative complications, procedures that result in significant blood loss and require transfusion subject the traveler to greater risk for blood-related complications, including compatibility errors and infection with hepatitis viruses or HIV. Finally, countries that offer medical tourism may have weaker malpractice laws than those in the U.S, giving the patient little recourse to local courts or medical boards if something goes wrong (14,15).

“Transplant Tourism,” a special type of medical tourism, has been increasing as the number of available organs, especially kidneys, is decreasing relative to the increasing demand. A number of international transplantation rings have been discovered, in which people from developing countries are paid for donating organs (19). This practice is considered legal in only a few countries. Recently the World Health Assembly met to discuss the challenges of transplantation and to address international transplantation guidelines (20). It encouraged countries to protect those most vulnerable to such exploitation, but there is still no international consensus on incentives for organ donation. In June 2006, the Organ Procurement and Transplantation Network (OPTN) and the United Network for Organ Sharing (UNOS) Board of Directors unanimously approved a statement opposing transplant tourism (21).

Regardless of the reason, people seeking health care abroad should understand that medical systems outside the United States may operate differently from those in the United States and are not subject to the same rules and regulations. Those who are considering seeking health care outside the United States should consult with their local physician before traveling.

References

1. Medicare: The Official U.S. Government Site for People with Medicare. Available at: http://www.medicare.gov/Coverage. Accessed 31 Oct 2006.
2. Centers for Medicare & Medicaid Services. 2006. Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare. Available at: http://www.medicare.gov/Publications/Pubs/pdf/02110.pdf (PDF 464 KB/56 pages). Accessed 31 Oct 2006.
3. U.S. Department of State. Medical information for Americans traveling abroad. Available at: http://travel.state.gov/travel/tips/health/health_1185.html. Accessed 31 Oct 2006.
4. Joint Commission Resources. Available at: http://www.jcrinc.com. Accessed 31 Oct 2006.
5. Joint Commission International Center for Patient Safety. Available at: http://www.jcipatientsafety.org. Accessed 31 Oct 2006.
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17. CDC. Nontuberculous mycobacterial infections after cosmetic surgery— Santo Domingo, Dominican Republic, 2003-2004. MMWR. Morbid Mortal Wkly Rep 2004;53:509.
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21. Organ Procurement and Transplantation Network (OPTN). “OPTN/UNOS Board Opposes ‘Transplant Tourism.’” Available at: http://www.unos.org/news/newsDetail.asp?id=641. Accessed 31 Oct 2006.