Medical Considerations for Domestic and International Travel During the Holidays

Many Americans will travel either domestically or internationally during the upcoming holiday season, either for business, vacation or to visit family and friends.  Unfortunately, in my experience, most people do not consider the potential for getting ill while away from home, where they would go for health care if they became ill especially on a holiday, how they would communicate their health history and medications to health care providers who may not speak English if travelling abroad, and how they would pay to be medically transported to another hospital if they or a family member was seriously ill and hospitalized, but wanted or needed care at a more advanced or specialized hospital or one closer to home. Often, international travelers are not aware of health threats that they may encounter in countries they plan to visit that are different than those we face in the U.S.

Just as you would plan the itinerary for your travels, one should plan ahead for the unexpected, especially, if you will be traveling with young children or persons who are at high risk for health problems. Most calls I receive for help when people are away from home are actually cases in which no one imagined the family member would suffer a serious illness and is now hospitalized in another country, where the hospital is demanding cash payments, the family member is having to pay for their own extended lodging, and no one understands what is wrong with their family member. These are heart-breaking situations.

Additionally, people who might decide that under normal circumstances that their health is excellent and therefore they would pass on certain vaccines such as influenza or COVID-19 (not something I would advise, yet I understand that many people do think like this) should reconsider when travel is involved. First, it is always disappointing when you have looked forward to a trip, visiting family or a vacation, and likely spent a lot of money arranging it, to then get sick. That disappointment can turn to fear when the illness is severe enough that medical attention is needed and you are away from home and uncertain as to where to turn.

Second, if you are visiting friends and family, even if you do not become severely ill, you now may be the source for infecting a young child or an elderly person who very well might become severely ill. I have read heart-wrenching stories of people who did not take precautions, became ill and may have merely experienced a cold-like illness, but realize they likely infected a parent or grandparent or other family member who developed severe illness, required hospitalization, and in some cases died.

Finally, it can certainly be a desperate situation to be trying to find health care for a child or other family member at night, on a weekend or on a holiday even in the U.S., not to mention when you are away from home and not familiar with the health care system in the city you are visiting and, in the case of international travel, don’t speak their native language.

Here are my tips and recommendations:

Domestic Travel within the U.S.

• Check with your doctor’s office to make sure you and all the family members who will be traveling with you are up-to-date with all your immunizations. In addition to the regularly scheduled immunizations:
  • Most everyone over 6 months of age should get the influenza vaccine. Those who are 65 years and older should get the high-dose flu vaccine.
  • Everyone over 6 months of age should also consider getting a COVID-19 updated booster shot (or your first, if you have never received one).
  • If you are traveling with a child under the age of 1 or if any travelers are over the age of 60, be sure to check with their doctors as to whether they should get the RSV vaccine.

• If you want to check your immunizations for yourself, if you have received them all from a single health care provider, they may be listed on that provider’s patient portal if they have one (e.g., myChart if the provider is on the Epic electronic health record system). But, if you received some of these vaccines from a pharmacy or if you have received them from a number of providers who are not all on Epic, you can get a complete list of the vaccines you have received and the dates you received them by downloading the free app Docket https://docket.care/, as long as the providers who gave you the vaccines participate in and report to the Idaho Immunization Reminder Information System (IRIS). That app will also indicate if you are due for certain vaccines.

• If any of the travelers have multiple medical conditions, an unusual medical condition and/or take medications on a regular basis, consider printing out a list of those medical conditions and medications.

You might be surprised to know how many patients I have seen who tell me, “I take a small white pill for my blood pressure, and a big yellow pill for ….” First of all, these descriptions don’t narrow down the range of possibilities of medications much and rarely will a description like that inform us as to the dosage of the medication. Further, patients might often call a capsule a pill, when a doctor or pharmacist would not. So, be sure to list the name of the medication (if you have the generic and the brand name, provide both, but either one will be fine if you don’t), the dosage and the unit (e.g., most pills you take probably are measured in milligrams, referred to as “mg” following the number, but children often take solutions of medications and they are sometimes labeled with the dose (e.g., 250 mg), but other times with the volume (e.g., my youngest grandson spent the night with me this week and I had to give him his medication and the direction was to give 1.88 cc or ml).

It is fine if you don’t know what the abbreviation on the bottle stands for because the doctors and pharmacists will, but in some cases the dose and the volume can be the same or close numbers, therefore, we want to make sure we know what abbreviation follows the number because that will tell us whether we are looking at the dose or the volume to be administered). Finally, be sure to write down how often you are taking the medication– e.g., twice daily, at bedtime, with meals, or as needed.

• If you are high risk for severe disease with COVID-19 (see https://www.cdc.gov/coronavirus/2019-ncov/your-health/risks-getting-very-sick.html for factors that increase your risk for severe disease) or traveling with someone who is, now that Paxlovid is approved by the FDA, you may wish to discuss with your physician whether you are a candidate for Paxlovid (anti-viral medication) if you get infected while away from home, and if so, whether your physician will prescribe it so that you can take the medication with you. Given the need to start Paxlovid soon after detection of infection, and the challenges you may face while out of town in getting a medical evaluation and a prescription for the medication in a timely manner over the holidays, and if out of the country, the fact that Paxlovid may not be available, having the medication to take with you may come in handy. However, do not take the medication unless and until you have a positive test for COVID-19.

• If you or a family member requires oxygen on a flight, be sure to check that the oxygen concentrator you are bringing is TSA approved https://www.faa.gov/about/initiatives/cabin_safety/portable_oxygen.

• Consider whether you should purchase a family medical evacuation/air transport plan. (see below under international travel). While you may think this would only be needed for international travel, consider what you would do if you were out of state and a family member became very ill and required a prolonged hospitalization.

• I recommend that you carry medication in your carry-on bag rather than your luggage. First, probably everyone who is reading this has had the experience of lost luggage. Therefore, if you are not going to take all of your medication in your carry-on, at least carry an extra day or two of medication in the event your luggage is delayed. Further, some medications can be temperature sensitive and lose effectiveness if exposed to extremes of temperature for an extended period of time. Cargo bay temperatures can get as low as 45 degrees Fahrenheit. If you do plan to pack medications in your luggage, be sure to check with your pharmacist whether that might create any problems.

• I also recommend packing a few days of extra medication just in case your plans change or there are unforeseen weather events or other circumstances that would delay your return home.

• It may be prudent to take an adequate supply of at-home COVID tests with you that would allow you to test each person who is traveling with you. There are still significant transmission levels of the SARS-CoV-2 virus, and transmission levels may be higher during the holidays.

Every household still has the opportunity to order 4 free at-home rapid antigen tests (2 boxes each containing 2 tests) if you have not already ordered them in the past two months. You can order these free tests at https://special.usps.com/testkits while supplies last.  I am not sure you will receive yours in time for your holiday travel, but it is worth a try, and even if not, these can be used to replenish your current supply.

If you already have a supply of tests, check the expiration dates to make sure that the tests are current. However, the FDA has recently extended the expiration dates for a number of home tests based on more testing since the agency issued their authorization for the tests. So, before tossing any of your current tests in the trash, check the FDA’s website at https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/home-otc-covid-19-diagnostic-tests#list to see if your test’s expiration date has been extended.

If you are out of tests and don’t receive your free tests in the mail in time, you can find tests at most pharmacies and many grocery stores. You may be glad you traveled with some tests if there is significant transmission wherever it is you are traveling to, as pharmacy inventory can quickly be exhausted when there is sudden demand. Plus, it is not fun to have to be contacting multiple stores to find out which has tests when you are not feeling well.

A certain number of tests per month are covered under many insurance plans, so if you go to the pharmacy itself to make the purchase, they can determine your insurance coverage for the tests https://www.cms.gov/how-to-get-your-at-home-OTC-COVID-19-test-for-free.

Many of the COVID-19 tests are also sensitive to temperature extremes, so I also recommend that you place these in your carry-on luggage rather than your checked bags. Keep in mind that the most important thing in in relying on the result of an at-home COVID-19 is the control line (often indicated by a “C” on the test strip where the line should appear) showing up. If it does not show up, discard the test and get another one.

• It also may be advisable to take a supply of over-the-counter fever-reducing medicines, cold-symptom relieving medicines, and high-quality masks with you. Be aware that there have been shortages in many parts of the country of children’s over-the-counter medicines from time-to-time, and this will be worse if there are significant levels of COVID-19, RSV, influenza and other respiratory viruses circulating. Also keep in mind that some pharmacies and grocery stores may have reduced business hours on the holidays.

• You would be well advised to wear a high-quality mask in airports and at least while boarding the aircraft and deplaning. While airplanes generally do have good ventilation and filtration of air, we have a number of well-documented transmissions of SARS-CoV-2 on flights, even to passengers who are not seated close to the index case. Further, keep in mind that ventilation is poor prior to the captain turning the engines on and they are frequently off during boarding. In addition, sometimes the captain will turn the engines off on the tarmac if there is going to be a significant delay in order to conserve fuel. It only takes seconds for the virus to transmit to a passenger when another passenger walks by who is infected, and the passenger may not even be aware that he or she is infected.

• Make a plan. Check with your doctor and your children’s doctors’ offices about (1) what their holiday hours will be and (2) whether someone will be available to help you if you or your child gets sick when the office is closed and you are out of town. However, you also need to plan ahead for emergency rooms and hospitals in the area where you will be staying in case the medical issue cannot be handled over the phone and requires urgent attention.

Beware that some urgent care clinics may not be open on holidays or may have limited hours. Also beware that emergency rooms are often extremely busy during the height of respiratory virus season (including during the holidays) and may also have reduced staff on the holidays. Therefore, there may be significant delays. Remember that many of the people in the emergency room are likely there for respiratory infections, so you will be wise to wear a high-quality mask at all times other than when the physician is examining your nose or throat, when they are obtaining a sample from you for testing or in the event that they need to place oxygen on you. Since waits can sometimes be many hours, you may want to take your next dose of medications with you.

• Know where to go for medical attention. Identify one or more urgent care centers near where you will be visiting. Check their website to verify days and hours of operation and check to see if they have reduced hours of operation on the holidays. If yours or your child’s illness does not seem to be severe, urgent care centers will likely be your best bet in that wait times are generally shorter and co-pays through your insurance are likely to be less than for an emergency room visit.

• Have a plan in the event of an emergency. In some parts of the country, the high volumes of illness, the increase in injuries that we see this time of year, and the reduced staffing due to illness and holiday scheduling will lead to the overwhelming of ERs and to delays in EMS response times. Therefore, know where the nearest hospital is, and if you have small children, where the nearest pediatric hospital is.

If there is more than one hospital near where you will be visiting for the holidays, you can check with your doctor to see if he or she is familiar with them and can make a recommendation. If not, there is no single best source to identify the highest quality hospitals in your area, so I use a couple of websites.

The first is the LeapFrog Hospital Safety Grades https://www.hospitalsafetygrade.org/search?findBy=state&zip_code=&city=&state_prov=ID&hospital=, which I use to get a sense of the hospital’s commitment and efforts towards ensuring patient safety. You can search hospitals by state to allow you to compare. I strongly prefer hospitals with an “A” grade for patient safety, but there may not be one near where you will be staying.

I then look at quality scores and awards, and I like the HealthGrades website for this: https://www.healthgrades.com/find-a-hospital. When you go to this webpage, type in hospitals and the city and state you will be visiting. The hospitals in that area should pop up in descending order of overall quality. When you click on the hospital, you will see recent quality awards, if any. Then, given that you most likely would need a hospital for a respiratory illness, you can click under the areas of pulmonary (lung diseases) and critical care (how well the hospital, its doctors, nurses and therapists perform in caring for patients in the intensive care unit) to see how that hospital’s quality outcomes are.

Another indicator of the best hospitals that I use is Magnet status – a very difficult to achieve status, and even more difficult to maintain, for excellence in nursing that has been correlated with quality of care. You can go to https://www.nursingworld.org/organizational-programs/magnet/find-a-magnet-organization/ and scroll down to select the state you are visiting, and the list of Magnet designated hospitals and the years in which they have been redesignated, if applicable, will appear.

Of course, if you did not plan your choice of hospital in advance and you have an emergency, just go quickly to your nearest hospital.

• Plan for an extended wait time in the ER and the potential that you or your child might have to be admitted to the hospital. Given the back-up in hospitals and the extraordinary time that you may have to spend in the ER with your child or family member even if they are not admitted, plan for who will care for your other children on short notice while you are at the hospital, especially if you or a family member must be admitted as an inpatient?

• Who will care for any pets you traveled with if you are tied up in the ER or hospital for more than a day?

• In the event of the need for hospitalization, if the hospitalized family member is a child and you are far from home, you can check to see if there is a local Ronald McDonald House that can provide your family members with lodging while your child is hospitalized https://rmhc.org/our-core-programs?c_src=paid&c_src2=23AOPMsearch_google&&msclkid=36e13d7f148b123697ad5828dc8971a6&gclid=36e13d7f148b123697ad5828dc8971a6&gclsrc=3p.ds. If the hospitalized family member is an adult, you can check with the hospital to see if there is any subsidized lodging or financial assistance for lodging. Alternatively, many hospitals have arrangements with local hotels that will provide discounts or reduced rates to out-of-town family members of patients.

International Travel

• Check with your doctor’s office to make sure you and all the family members who will be traveling with you are up-to-date with all your immunizations. In addition to the regularly scheduled immunizations:
  • Everyone over 6 months of age should get their influenza vaccine. Those who are 65 years and older should get the high-dose flu vaccine. There won’t be significant influenza activity in the southern hemisphere during our upcoming holiday if that is your destination, however, you will face exposure risks while at airports and on airplanes on the way.
  • Everyone over 6 months of age should also consider getting a COVID-19 updated booster shot (or your first, if you have never received one). There are some countries that are having significant surges in COVID-19 at the present time, (e.g., Australia, Germany and Sweden), but like the U.S., most countries are no longer reporting their cases. Consider that the country you are traveling to may have higher transmission rates than the U.S. at the time you travel, so take steps to protect yourself.
  • If you are traveling with a child under the age of 1 or if any travelers are over the age of 60, be sure to check with their doctors as to whether they should get the RSV vaccine.

• If you want to check your immunizations for yourself, if you have received them all from a single health care provider, they may be listed on that provider’s patient portal if they have one (e.g., myChart if the provider is on the Epic electronic health record system). But, if you received some of these vaccines from a pharmacy or if you have received them from a number of providers who are not all on Epic, you can get a complete list of the vaccines you have received and the dates by downloading the free app Docket https://docket.care/, as long as the provider who gave you the vaccine participates in and reports to the Idaho Immunization Reminder Information System (IRIS). That app will indicate if you are due for a vaccine and list the vaccines that you have already received and the date received.

• Travel Agent – optional

If you are using a travel agent to plan international travel, ask for any information they can provide you as to vaccines you will need, documentation of vaccines any of the countries you are traveling to might require, restrictions on medications you can take with you to those countries (see below), as well as medical care resources in the cities you will be visiting.

• Travel Medicine Clinic – optional    At least 6 weeks prior to travel

You can do the necessary research for yourself (see below), but I personally like the ease of going to a travel medicine clinic (the one my family uses is https://www.stlukesonline.org/communities-and-locations/facilities/clinics/st-lukes-clinic–travel-medicine-and-immunizations, but you can research other options in your area. Saint Alphonsus also has a travel medicine clinic https://www.saintalphonsus.org/specialty/travel-medicine/). During your travel medicine consultation, they will identify all the vaccines you might need for the countries you are traveling to, administer those vaccines and give you vaccine certificates for any countries that require them. Travel medicine clinics may be an especially good option if the people traveling are at high medical risk or if you need a vaccine that is not commonly available in most doctor’s offices or pharmacies, such as yellow fever vaccine. In addition, they can identify health threats in those countries such as infections transmitted by mosquitos, ticks or fleas and provide you with information as to how to avoid or minimize those exposures.

You also can consider public health departments that offer travel medicine services, however, many don’t and some have discontinued these services with the onset of the COVID-19 pandemic, so be sure to check their websites (e.g., Central District Health no longer offers this service) to see if they do offer the service and to schedule an appointment.

If you are uninsured or may experience high out of pocket expenses for vaccines, many public health departments will have immunization hotlines (e.g., in Ada and Boise Counties 208-327-7400, Valley County 208-634-7194, and Elmore County 208-587-4407) that you can call to get information as to the immunizations they offer (they may also list these on their websites, e.g., you can go to https://cdh.idaho.gov/hl-immunizations-adults.php for the list of vaccines offered through Central District Health) and schedule an appointment to receive your necessary vaccinations.

There are programs available to cover the cost of many vaccines (but not those that would not be routine vaccines in the U.S.) for those who are uninsured or for those with insurance plans that are not ACA-qualified plans for which the insured is required to make an out-of-pocket payment. For example, the Vaccines for Children program https://www.cdc.gov/vaccines/programs/vfc/index.html will cover the cost of all routine vaccines for children who are uninsured, including the COVID-19 vaccines, and the Bridge Access Program will cover the costs for COVID-19 vaccines for uninsured adults.

• Go to the CDC’s travel website and enter the name of the country or countries that you will be visiting. https://wwwnc.cdc.gov/travel/destinations/list. This will provide you with any travel health notices, including particular health risks in those countries and alerts relating to disease outbreaks. That site will also list recommended and required vaccinations for travelers to those countries. While most countries are no longer requiring COVID tests, immunization records of COVID-19 vaccines or quarantine for travelers, foreign countries can often make changes very quickly in response to outbreaks in their own countries, and so it is best to check to be sure there is no requirement that might catch you by surprise, and depending on the country you are traveling to, there might be requirements related to other diseases.

Pay particular attention to the section entitled “Healthy Travel Packing List,” especially if you plan to travel with medications and/or medical supplies. Some countries require medications to be in their original, labelled prescription bottles rather than in a pill box organizer. There are some over-the-counter and prescription medications that are perfectly fine to travel with inside the U.S., but are outlawed in certain other countries, and could even land you in prison. People are often surprised that certain cold medicines and over-the-counter medications to treat diarrhea are outlawed in certain countries. Be sure to check with the U.S. Embassy website https://www.usembassy.gov/ for each country you will be visiting to ensure that you are permitted to travel with the medications you plan to take with you, as well as any restrictions regarding syringes needed to administer those medications or any other medical supplies you plan to take to ensure they are permitted and that you have any required medical documentation. Also, be mindful of dosage limits. For example, diphenhydramine (commonly sold under the brand Benadryl) is available in the U.S. in 25 mg tablets and capsules. However, at least one country makes it illegal to have this medication in more than 10 mg formulations.

There are currently 31 countries that have circulating poliovirus (see https://wwwnc.cdc.gov/travel/notices/level2/global-polio for a complete list). Be sure that you have been fully vaccinated, and keep in mind that if you are traveling with a young child under the age of 6, that child may not yet be fully vaccinated against polio under the current schedule of vaccines. Therefore, check the immunization records yourself for IPV or inactivated polio vaccine to be sure your child has had a total of four shots. If not, check with your pediatrician’s or family medicine physician’s office as to the risks for the child or if the child is old enough to receive the 4^th shot before you depart. If adults will be traveling to one of the 31 countries listed above, check with your physician or travel medicine clinic to determine whether you should receive a one-time IPV booster prior to your travel.

• There are currently 39 countries that have been experiencing outbreaks of measles. You can check the current list of those countries at https://wwwnc.cdc.gov/travel/notices/level1/measles-globe. Measles is the most contagious virus that we know of, and exposure can occur more than an hour after the infected person leaves a room and a susceptible person enters.

If an adult becomes infected with the rubeola (measles) virus who has not had measles and has not been vaccinated against measles, there is a significant chance for severe illness that would require hospitalization. I promise you that you do not want to be hospitalized overseas, and obviously, this situation will be worse if you are the only adult traveling with a young child without someone to care for the child if you need to be hospitalized. Further, if the child you are traveling with is under the age of 6, he or she may not yet have been fully vaccinated against measles. Therefore, be sure to check the vaccination record for the child or talk to the child’s physician to determine whether the child is fully vaccinated, and if not, whether the child is old enough to be given the second dose of vaccine (called MMR for measles, mumps and rubella) at least two weeks prior to your departure.

• If any of the travelers have multiple medical conditions, an unusual medical condition and/or take medications on a regular basis, consider printing out a list of those medical conditions and medications. You might be surprised to know how many patients I have seen who tell me, “I take a small white pill for my blood pressure, and a big yellow pill for ….” First of all, these descriptions don’t narrow down the range of possibility of medications much. Further, patients might often call a capsule a pill, when a doctor or pharmacist would not.

Be sure to list the name of the medication (if you have the generic and the brand name, provide both, but of the two, the generic name is likely to be most helpful to health care professionals in another country), the dosage and the unit (e.g., most pills you take probably are measured in milligrams, referred to as “mg” after the number, but children often take solutions of medications and they are sometimes labeled with the dose (e.g., 250 mg), but other times with the volume (e.g., my youngest grandson spent the night with me this week and I had to give him his medication and the direction was to give 1.88 cc or ml). It is fine if you don’t know what the abbreviation on the bottle stands for because the doctors and pharmacists will, but in some cases the dose and the volume can be the same or close numbers and we want to make sure we know what abbreviation follows the number because that will tell us whether we are getting the dose or the volume to be administered. Be sure to write down how often you are taking the medication– e.g, twice daily, at bedtime, with meals, or as needed.

If you are not traveling to an English-speaking country, be sure to have a copy of the list of medical problems and medications that is translated into the native language for that particular country. Google and Adobe can both be used to translate your document into the language(s) of the country(ies) you are visiting. However, medical jargon is not always accurately translated, so it can be helpful to ask someone who speaks that language to review the translated version to make sure it accurately reflects what you meant to write. There are also some professional services that offer this service that you can find online. It also may be that the translation services department of your local hospital would be willing to review the document for you.

Finally, keep in mind that not all medications you are taking may be available in that country, and even if they are, they may go by a different name. So, when traveling to a non-English speaking country, add what you take the medication for to the list since they may need to change you to a medication that is available in their country.

• It also may be advisable to take a supply of over-the-counter fever-reducing medicines, cold-symptom relieving medicines, and high-quality masks with you. You are unlikely to be familiar with the over-the-counter medications in other countries, and if it is a non-English speaking country, you may have difficulty reading the labels and understanding the instruction for use and dosing of the medications.

• If you are high risk for severe disease with COVID-19 (see https://www.cdc.gov/coronavirus/2019-ncov/your-health/risks-getting-very-sick.html for factors that increase your risk for severe disease) or traveling with someone who is, now that Paxlovid is approved by the FDA, you may wish to discuss with your physician whether you are a candidate for Paxlovid (anti-viral medication) if you get infected while away from home, and if so, whether your physician will prescribe it so that you can take the medication with you. Given the need to start Paxlovid soon after detection of infection, and the challenges you may face while out of town in getting a medical evaluation and a prescription for the medication in a timely manner over the holidays, and if out of the country, the fact that Paxlovid may not be available, having the medication to take with you may come in handy. However, do not take the medication unless and until you have a positive test for COVID-19.

• If you or a family member requires oxygen on a flight, be sure to check that the oxygen concentrator you are bringing is TSA approved https://www.faa.gov/about/initiatives/cabin_safety/portable_oxygen.

• When traveling to a non-English speaking country, strongly consider identifying a website or app (e.g., Google translate) on your iPhone that you can use to translate to and from that country’s native language, or you can certainly purchase hand-held devices that will translate speech as well. This can be important if you need to request medical services and need directions or help, and this can be invaluable if you are in an urgent care clinic or emergency room and need to communicate to the health care providers and no translator is available.

• If you need to travel with medical devices (e.g., a CPAP machine, a nebulizer, etc.) that require electrical power, be sure that the country you are traveling to uses the same kind of plugs and outlets as the U.S. (many don’t), or you may need to take a converter with you. Here is a website you can use to determine the different electrical standards countries use https://www.worldstandards.eu/electricity/plug-voltage-by-country/ and I found a helpful picture guide to the different types of plugs here https://www.skyscanner.net/news/international-travel-plug-adapter-guide. You likely can find converters at stores like Walmart or quite a number of options online. Keep in mind that if you are taking a cruise, the plug outlets are likely to be the ones used by the country of origin of the ship rather than the country you are traveling to. Be sure to check with the cruise line or your travel agent.

• Consider whether you should purchase a family medical evacuation/air transport plan. I have unfortunately been called a few times over my career by a distressed family member, most often a spouse of someone who very unexpectedly became severely ill and required a prolonged hospitalization. While insurance may cover part or all of the hospitalization abroad, unlike in the U.S. where hospitals accept most insurance plans and don’s submit bills until after discharge from the hospital, foreign hospitals often require cash payments on a daily or weekly basis. Further, not that American doctors aways do a good job of explaining what is wrong with the family member, but I am often told that family members abroad don’t get to talk to the doctor regularly or don’t understand what the doctor is saying. For these, and other reasons, these family members are often desperate to have the patient transported home to a local hospital or at least to a different hospital in an English-speaking country or one with greater capabilities to treat their loved one.

Unfortunately, when patients are very ill, they need to be transported with a medical team that can care for the patient in air and handle any emergencies that might occur en route. Travel more than 150 miles requires a jet. These transports are very expensive (in my experience, even relatively short transports are in excess of $10,000.00. Overseas transports will obviously be far more expensive.

Most often, your medical insurance will only cover air transport if it is not possible for your family member to get the needed care at the hospital where they are. Issues with communication or the hospital requiring cash up front would generally not qualify for coverage under many insurance policies, nor would a request to transport the patient so that you can be closer to home, where there is more family support and doctors who have previously cared for the patient.

Therefore, you may wish to purchase a medical evacuation/transport plan. I have a plan that costs less than $400 per year to cover all members of my household. If you wish to purchase a plan, it is important to understand that not all of these plans are the same, and there are some important questions you should ask prior to purchasing your plan.

Most plans that I reviewed will only provide transportation to the nearest suitable U.S. hospital. For example, if your family member was hospitalized in Mexico, you would most likely be transported to a hospital in South Texas or Southern California, which may feel like a big improvement, but may still be far from home, may cause difficulties for your children who need to get back to school, and is almost certain to be far away from other family and friend support, all while incurring ongoing lodging costs for yourself away from home. There are plans that will cover transportation back to Boise or whatever your nearest local hospital that has the capacity and capability to care for your family member is located.

Another factor in your choice of plan would be whether they will guarantee your ability to fly back with your family member. Many plans will indicate that they may accommodate a family member with a patient, but don’t guarantee it. Obviously, it can be distressing for both family members to be separated from each other, and it is always more difficult for the receiving hospital and doctors when there is no family member available to provide information. Similarly, not all plans will ensure that your luggage will be accommodated on the flight. That may seem like a minor detail, but there are a lot of headaches and expense when you have to arrange for your luggage to be flown to the city you are being transported to and then from that airport to wherever you will be staying, all while you are worried about the welfare of your family member.

Finally, another thing that I like about my plan is that even if my wife and I are travelling domestically, if we were out of state and I wanted to get her back to Boise or she wanted to transport me, this plan would cover that transport.

• You would be well advised to wear a high-quality mask in airports and at least while boarding and deplaning. While airplanes generally do have good ventilation and filtration of air, we have a number of well-documented transmissions of SARS-CoV-2 on flights, even to passengers who are not seated close to the index case. Further, keep in mind that ventilation is poor prior to the captain turning the engines on, and often the engines are not on during boarding. Sometimes the captain turns the engines off on the tarmac if there is going to be a significant delay in order to conserve fuel. It only takes seconds for the virus to transmit to a passenger when another passenger walks by who is infected, and that passenger may not even be aware that he or she is infected.

• If hospitalization becomes necessary, and the hospitalized family member is a child and you are far from home in another country, you can check to see if there is a local Ronald McDonald House that can provide your family members with lodging while your child is hospitalized https://rmhc.org/our-core-programs?c_src=paid&c_src2=23AOPMsearch_google&&msclkid=36e13d7f148b123697ad5828dc8971a6&gclid=36e13d7f148b123697ad5828dc8971a6&gclsrc=3p.ds. If the hospitalized family member is an adult, you can check with the hospital to see if there is any subsidized lodging or financial assistance for lodging. Alternatively, many hospitals have arrangements with local hotels that will provide discounts or reduced rates to out-of-town family members of patients.

• I recommend that you carry medication in your carry-on bag rather than your luggage. First, probably everyone who is reading this has had the experience of lost luggage. Therefore, if you are not going to take all of your medication in your carry-on, at least carry an extra day or two of medication in the event your luggage is delayed. Further, some medications can be temperature sensitive and lose effectiveness if exposed to extremes of temperature for an extended period of time. Cargo bay temperatures can get as low as 45 degrees Fahrenheit. If you do plan to pack medications in your luggage, be sure to check with your pharmacist whether that might create any problems.

• I also recommend packing at least a few days of extra medication just in case your plans change or there are unforeseen weather events or other circumstances that would delay your return home.

• It may be prudent to take an adequate supply of at-home COVID tests with you that would allow you to test each person who is traveling with you. There are still significant transmission levels of the SARS-CoV-2 virus, and transmission levels may be higher during the holidays.

Every household still has the opportunity to order 4 free at-home rapid antigen tests (2 boxes each containing 2 tests) if you have not already ordered them in the past two months. You can order these free tests at https://special.usps.com/testkits while supplies last.  I am not sure you will receive yours in time for your holiday travel, but it is worth a try, and even if not, these can be used to replenish your supply.

If you already have a supply of tests, check the expiration dates to make sure that the tests are current. However, the FDA has recently extended the expiration dates for a number of home tests based on more testing since the agency issued their authorization for the tests. So, before tossing any of your current tests in the trash, check the FDA’s website at https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/home-otc-covid-19-diagnostic-tests#list to see if your test’s expiration date has been extended.

If you are out of tests and don’t receive your free tests in the mail in time, you can find tests at most pharmacies and many grocery stores, and may be better off purchasing them prior to departure rather than searching for them in another country. Moreover, you may be glad you traveled with some tests if there is significant transmission wherever it is you are traveling to, as pharmacy inventory can quickly be exhausted when there is sudden demand. Plus, it is not fun to have to be contacting multiple stores to find out which has tests when you are not feeling well.

A certain number of tests per month is covered under many insurance plans, so if you go to a pharmacy in the U.S. to make the purchase, they can determine your insurance coverage for the tests https://www.cms.gov/how-to-get-your-at-home-OTC-COVID-19-test-for-free.

Many of the COVID-19 tests are also sensitive to temperature extremes, so I also recommend that you place these in your carry-on luggage rather than your checked bags.

• Prior to your travel, try to identify a hospital wherever your destination will be. Unfortunately, there are fewer options of rigorous quality and safety rankings for hospitals outside the U.S. Nevertheless, I have looked to those hospitals that are accredited by Joint Commission International (see here for list as well as the hospital’s website https://www.jointcommissioninternational.org/who-we-are/accredited-organizations/#sort=%40aoname%20ascending) or by DNV (https://www.dnv.co.uk/assurance/healthcare/accredited-hospitals.html). There are limited hospital ratings available for international hospitals, but here is one that while it does not appear particularly rigorous, it nevertheless may be helpful in choosing among hospitals in the area of your destination: https://r.statista.com/en/hospitalrating/ranking/#hospitals and here is the latest list of the “World’s Best Hospitals” as determined by Newsweek https://www.newsweek.com/rankings/worlds-best-hospitals-2023.

I hope this is helpful. I wish you all happy and safe holidays!