Highly Allergic Travelers
CDC Yellow Book 2024
Travelers with Additional ConsiderationsAllergies are the 6th leading cause of chronic illness in the United States, and >50 million Americans experience allergies each year. Food allergies affect 8%–11% of children and adults in the United States; other major allergen categories include dust, insect venom, latex rubber, medications, mold, pets, and pollen. Highly allergic travelers might experience severe allergic reactions that could interrupt or alter planned activities or require emergency medical care during travel. Pay special attention to travelers with a history of anaphylaxis (see Box 3-04).
Travelers with severe allergies face health and safety risks during their journeys, and international itineraries expose travelers to numerous possible allergy triggers. Comprehensive lists of transportation-related and country-specific triggers are not typically available, and language barriers, lack of 9-1-1–like emergency services, and unfamiliar environments and menu items can compound the risk. Any environmental or food allergy can affect the success or pleasure of a trip, but severe reactions can be trip-altering and life-threatening.
Help travelers reduce their chances of being exposed to allergy triggers and having a (severe) reaction by emphasizing proactive communication and providing pretravel services that include careful assessment and prevention counseling. Assist highly allergic travelers in creating a written emergency action plan, a critical element of their pretravel preparation. Even during the shortest office visit, confirm allergies and provide guidance to help travelers respond appropriately to severe reactions. Early recognition of anaphylaxis and prompt self-administration of epinephrine and other medications can be lifesaving.
Box 3-04 Anaphylaxis: key points for travelers & health care providers
Anaphylaxis is an acute, life-threatening systemic allergic reaction; it can have a wide range of clinical manifestations, including cardiac (heart), dermatologic (skin), gastrointestinal (digestive tract), and respiratory (lungs)
Main risks for anaphylaxis in adults: medications and stinging insect venom
Main risks for anaphylaxis in children and adolescents: foods and stinging insect venom Among patients with a history of severe allergic reactions, approximately 1 in 4 have never had a specialist consult
Although the first-line medication for anaphylaxis is epinephrine, auto-injectors are available in only approximately 1 in 3 countries around the world
The lifetime risk for anaphylaxis is 1%–5%; studies suggest increasing incidence
Pretravel Assessment
During the pretravel assessment, routinely ask travelers about vaccine and vaccine-component, medication, food, and environmental allergies. At each visit, inquire about all drugs, including prescribed, over-the-counter, herbal, recreational, and international brands. Patients’ allergies can worsen or improve over time, and new allergies might develop. Check vaccine ingredients listed in the manufacturer’s product insert to appropriately care for individuals with history of allergic reactions.
Asthma and food and insect venom allergies are as likely to occur among international travelers as they are among the general population. Review the nature and extent of any reported allergy and the traveler’s experience with allergies and self-care management skills.
Preparation
Travelers with severe allergies might need extra pretravel preparation. Clinicians can provide customized self-care plans that include suggestions for extra travel medical kit items, travel medical insurance recommendations, country-specific information (where available), guidelines for communication about severe allergies, and referral to a specialist, if warranted (see Box 3-05).
Suggest travelers view information from organizations with resources that promote safe international travel for people with allergies, such as the American Academy of Allergy, Asthma, and Immunology (AAAAI), Asthma and Allergy Foundation of America (AAFA), and the Food Allergy and Research Foundation (FARE). These organizations publish websites, educational materials, template allergy action plans, and communication tools that can help travelers reduce their chances of exposure to allergic triggers.
Encourage travelers with severe allergies to seek pretravel care well in advance of departure. In particular, consider providing a specialist referral to any traveler with a history of idiopathic anaphylaxis, new severe allergies, and recent or recurrent severe allergic reactions; help travelers understand that a specialist might generate additional recommendations that could delay or reroute their travel.
Box 3-05 Allergy self-care management plan: a checklist for travelers
☐ Identify allergy triggers and learn how to avoid them.
☐ If you have a history of anaphylaxis, see an allergy specialist before you travel.
☐ Research emergency services at your destination: where are they located, how to contact them.
☐ Anticipate and research dietary and environmental allergy triggers for airplanes, cruise ships, and trains.
☐ Ask about airline allergy policies in advance of travel; alert gate and onboard personnel about specific allergy triggers.
☐ Bring along allergy-safe food and snacks, if indicated.
☐ Bring several copies of a written emergency action plan for preventing and responding to reactions; keep a copy with you at all times. Consider having a copy translated into the destination language.
☐ Buy travel medical assistance insurance and confirm coverage for medical and emergency services overseas.
☐ Check your prescriptions, confirm expiration dates, and carry extra medical supplies of all self-care therapies (e.g., antihistamines, inhalers, prednisone) in your carry-on luggage; medically necessary liquids and medications in excess of Transportation Security Administration (TSA) limits are allowed.
☐ Epinephrine
- Keep your epinephrine auto-injector supply (2 or more) on your person, not in overhead bins.
- Never rely on an airline having epinephrine readily available.
- Recognize signs of a severe allergic reaction and know when to use medications and epinephrine auto-injectors; get additional training if needed.
- If you use epinephrine to self-treat an allergic reaction, you must go to an emergency room for evaluation and monitoring until you are fully stable.
☐ Share action plans with guides and traveling companions; never be too embarrassed or hesitant to alert others about a severe allergy.
☐ Wear a medical identification bracelet; carry a card or electronic equivalent listing all medical conditions and medications.
Box 3-06 Food allergies: a checklist for travelers
☐ Ask about menu items, ingredients, and preparations; sauces are often a cause of reaction due to hidden ingredients.
☐ Bring along nonperishable food supply in case safe food cannot be located during travel.
☐ Carry “chef cards” or equivalents (Allergy Translation; Select Wisely) in English and the languages of destination countries to communicate food allergies to all restaurant staff.
☐ Carry a supply of sanitary wipes to clean hands and wipe down tray tables and eating utensils.
☐ Consider staying in accommodations that provide small refrigerators or kitchens for self-catering.
☐ Dietary vigilance is critical; when in doubt, avoid a food item.
☐ European Union countries and some others mandate menu labeling for 8–14 different allergens (e.g., shellfish, soy, tree nuts, wheat).
☐ FARE’s website has food allergy guidelines for 13 countries.
☐ International travel raises the risk for trying foods that could contain allergy triggers; avoid “street food” and consider eating at chain restaurants where ingredients and food preparation are more standardized.
☐ Main food allergens: dairy products and milk; eggs; fish and shellfish; peanuts; sesame; soy; tree nuts; wheat.
☐ Research destinations for in-country allergy websites and “allergy aware” restaurants and grocery stores.
☐ When purchasing food during travel, read food labels carefully, and seek language assistance, if needed.
Box 3-07 Airborne allergies: a checklist for travelers
☐ Review Box 3-05 (Allergy self-care management plan: a checklist for travelers).
☐ Consider packing pillow and mattress covers.
☐ Use a well-fitting face mask to minimize particulate matter exposure.
☐ Ensure easy cancellation policies with your host or property owner in advance; on arrival you might find your accommodations put you at increased risk for exposure to airborne allergens (e.g., tiled or wood flooring is preferable to carpeting to minimize dust allergen reactions).
☐ Identify and reserve smoke free (pet free) accommodations and restaurants when possible.
☐ If you have asthma, pack all equipment including spacers, nebulizers, and peak flow meters.
☐ Minimize outdoor activity when air quality is poor, or pollen count is very high.
☐ Research air quality and pollen counts at destinations.
Box 3-08 Skin & contact allergies: a checklist for travelers
☐ Hiking boots and backpacks can have allergens or irritants in the manufacture or gluing process.
- Try out equipment before departure to see if you have a reaction.
☐ Test any product applied to the skin (e.g., insecticides, repellents, and sunscreens) before travel.
- Try on all clothing items pretreated with these products to see if you have a reaction.