Research the following before you go:

• Travel insurance
• Health care in other countries
• Climates you are expected to encounter
• Languages spoken where you are going
• Clean water supplies and uncontaminated food

Find detailed information below.

Plan your trip and medical supplies:

•  Medical check-up
•  Doctor's letter
•  Sick day management plan
•  Medication and insulin dose travel plan
•  Anti-embolic stockings
•  Vaccinations
•  Storage of insulin

Find detailed information below including an extensive supply and packing list.

Information for while you travel

• Air travel
• Sea travel
• Car/camping trips
• Other considerations
•  Useful links

 Find detailed information below.

Consider the following when choosing a policy:

• Type of cover – cover health care and belongings
• Covers you for the whole time you are away
• Epatriation back to Australia in case of emergency
• Clauses and exclusions - look closely and read the fine print
• Fully disclose your status, e.g. type 1 diabetes and other pre-existing               conditions
• You may need to pay a little more excess because of diabetes
• If the insurance company is reviewing your case make sure they give you a date for response otherwise you may be waiting until the last moment for approval.

Health care in other countries

•  If you become unwell overseas and are unsure where to seek medical care, contact the Australian consulate. In medical emergencies they can provide lists of local doctors and hospitals and assistance in arranging a medical evacuation (at your expense) if required. Contact details for Australian missions overseas are available on the Department of Foreign Affairs and Trade website.
• Travel insurance companies often have 24-hour assistance centres that you can contact from anywhere in the world. If you get sick overseas or are involved in a medical emergency, you should contact your travel insurance provider as soon as possible.
• Australia has reciprocal health care agreements with some countries for emergency medical treatment. This is available for Australian citizens and permanent residents. Refer to Medicare Australia's website for further details.
• International Association for Medical Assistance to Travellers (IAMAT) maintain a network of general practitioners and specialists, hospitals and clinics around the world - who have agreed to treat IAMAT members in need of medical care during their journey. Their aim is to make competent care available to travellers anywhere in the world, even in very remote locations, by doctors who speak English and have had medical training in North America or Europe.
• No other country in the world appears to have the equivalent of a subsidised diabetes supplies scheme (NDSS). The cost of diabetes supplies can be very expensive overseas.
• Find out if the insulin you are taking is available in the country that you are visiting. Also check to see if it is sold under the same name or a different name.
• Insulins used in Australia are all of the strength U-100. In some foreign countries, insulins may come as U-40 or U-80. If you need to use these insulins, you must make sure that the syringes match to avoid making a mistake with your insulin dose. If you use U-100 syringes for U-40 or U-80 insulin, you will take much less insulin than your correct dose. If you use U-100 insulin in a U-40 or U-80 syringe, you will take too much insulin.
• If you use insulin it is a good idea that you know how to inject it using a syringe as insulin pens might not be available in all countries.
• If you monitor your blood glucose levels it is a good idea to find out which unit of measurement is used in the country where you are visiting. In Australia we use mmol/L but in other countries they use mg/dL. A conversion chart is available.

Climates you expect to encounter

This will help you to prepare for appropriate temperature to store your insulin and supplies. Even places like North America don't have fridges available to store your insulin (refer to storage of insulin topic below for more information).

High blood glucose levels can lead to dehydration especially in hot climates. People with peripheral vascular disease (poor circulation) or peripheral neuropathy (nerve damage) need to take extra care to keep feet and hands warm in cold climates.

Languages spoken where you are going

Learn the phrase "I have diabetes" in the language of countries you are going in case of emergency.

Clean water supplies and uncontaminated food

Diarrhoea from eating contaminated food or water is the most frequent health problem encountered by travellers. Gastroenteritis can lead to unstable blood glucose levels and diabetic ketoacidosis. Use bottled or boiled water or water purification tablets if you are travelling to developing countries or camping. Even brushing your teeth with tap water can cause problems.

Common problems when travelling with diabetes are:

• Lost supplies/luggage or running out of supplies before the trip has ended
• Insufficient level of travel insurance
• No doctor's letter when needed at customs etc
• Hospitalisation, infection or other illness
• Hypoglycaemia
• Blisters to feet or wounds due to poor sensation or circulation
• Dehydration.

Medical check up

See your general practitioner (GP) or diabetes specialist at least 8 to12 weeks before you travel to review your diabetes and general health. If seeing your GP make a double appointment to allow sufficient time. Make sure you discuss:

• Current diabetes managment
• Sick-day managment plan
• Presciptions up to date
• Complication screening-up to-date
• Discuss any hypoglycaemia, impaired awareness of hypoglycaemia, hyperglycaemia, infections and/or complications you are experiencing.

Doctor's letter

You may need a doctor's letter for customs officials regarding your medical supplies and in case you need medical treatment overseas. Make sure you make extra copies. The letter should contain the following information:

• Your full name and address as it is on your passport, medication boxes and prescription
• The type of diabetes you have
• Insulin/s and medications that you take (generic not brand names, and dosages)
• Name of insulin injection device
• List the accessories you need such as needles, lancets, blood glucose meter, pump and accessories
• If you need to use an ice pack or gel pack to store your medication
• If you have a pump and that it should not be detached from your body
• If you are unable to get a letter from your doctor, Medicare Australia's medicine export declaration form may be sufficient to satisfy customs that the medicine is for your personal use.

Individualised sick day management plan

You will need an individualised sick day management plan from your doctor or diabetes educator. The NDSS has general information on sick days for both type 1 and type 2 diabetes. If you have recurring infections such as bladder infections or thrush, take antibiotics or antifungal creams/tablets with you. If you take insulin, prepare a sick day management kit with the following items:

• Copy of sick day guidelines/plan
• Short or rapid acting insulin
• Insulin syringes or pen
• Food for sick days and fluids (sweetened and diet drinks or water)
• Glucose containing food or gel
• Glucagon and ketone testing strips (for people with type 1 diabetes)
• Blood glucose meter and strips
• Ihermometer.

Medication management

Take extra prescriptions for your insulin and medications:

• In case you lose your medication or it is damaged
• If a doctor needs to write you a new prescription
• It will reassure customs officers that the medication is yours.

Keep all medication in the original packaging or keep the packaging with you to show to customs officers if required.

The Medicare Australia website provides information about taking and sending PBS medication overseas. The National Prescribing Service has an informative article for people who want to know more.

Insulin dose travel plan

When crossing time zones you may lose or gain time so your insulin dose or medication may need some adjustment. As everyone is different it is impossible to have a 'one rule fits all' approach. Take your itinerary to your doctor or diabetes educator to have an individualised travel plan made for you. If you use an insulin pump:

• Find out the contact details of your pump company in the countries you are travelling to in case you need assistance while overseas.
• Some pump companies will loan you a spare pump while travelling.
• Always carry syringes or insulin pen and needles and insulin as a back-up.
• Take a written copy of your pump settings.

Anti-embolic stockings

Anti-embolic stockings used for people who are lying in bed are not appropriate for travelling because the compression grading is too high. Flight stockings should be individually measured and fitted to the size of your calves to prevent complications such as pressure ulcers or impaired circulation. People with diabetes should have the circulation checked (Ankle Brachial Index - ABI) in their lower legs before being supplied with compression stockings. Check whether your podiatrist can do an ABI test (not all podiatrists do).

Vaccinations

Some health problems associated with international travel are vaccine preventable. Travellers should consult a travel medical centre, or their local doctor, at least 6–12 weeks before departure, for a check-up and to discuss required and recommended vaccinations for specific regions. The websites below provide information about vaccinations and tips for staying healthy while overseas:

• Travel Doctor
• Travel Clinics Australia
• World Health Organization

Packing

The following list is the minimum you should include (this is a guide only)

• All medication
• If using insulin:

          Short and long acting insulin
           Insulin delivery device (pens/pump/lines)
           Syringes/ spare pen
           Pen needles
           Cool pack (Frio) for storage of insulin
           Hypo kit (refer to 'hypo kit' information below)
           Carbohydrate snacks
           Ketone test strips (type 1 diabetes)
           Glucagon (type 1 diabetes only)
 
  If using other injectable medications       
             Pen needles
             Cool pack (Frio) for storage

• Blood glucose meter
• Spare batteries for meter
• Blood glucose monitoring strips. Take double what you need.
• Sharps disposal container/needle cutter/SafeClip
• Emergency Kit (refer to 'emergency kit' information below)
• Travel alarm clock
• MedicAlert bracelet
• Identification stating you have diabetes (NDSS card)
• Emergency contact number in mobile (store ICE in case of emergency into phone)
• GP/endocrinologist/diabetes educator's contact details including their email address
• List of medication
• Copy of prescriptions
• Doctor's letter
• All medications
• Resealable transparent plastic bags
• Name and address of diabetes services available at your destination

Take double the medication and supplies you need as unexpected events may occur such as losing luggage, delays and needing to stay overseas longer than expected.

Hypo kit (if you take diabetes medications or insulin)

• Quick acting carbohydrates (glucose gel, jelly beans or Lucozade)
• Long acting carbohydrates (muesli bar, crackers, biscuits)
• Glucagon (type 1 diabetes - your travel companion should carry)

Diabetes emergency kit

    Antiseptic cream or lotion/ betadine
    Icepack that does not need refrigeration

• Anti-nausea and anti-diarrhoeal medication
• Treatment for gastro (gastrolite)
• Paracetamol or ibuprofen
• Canesten/antifungal cream if prone to thrush
• Hermometer
• Telephone number of your GP and endocrinologist/DNE
• Ketone strips
• Glucagon injection kit (for your travelling companion to administer)

Storage of insulin

Insulin pens

If you use disposable insulin pens such as FlexPen or SoloStar you may find that they take up quite a bit of space in your hand luggage. Non-disposable pens may take up less room (note: not all insulins are available in cartridges). Ask your doctor if your insulin is available in disposable or reusable cartridges.

Storage of insulin

Unopened insulin should be stored in the fridge, between 2–8 degrees Celsius. Once opened, insulin may be kept at room temperature (below 25–30 degrees Celsius) for one month and then discarded. Insulin can be damaged by extreme temperatures. It must not be left where temperatures reach over 30 degrees, eg. in the car or in direct sunlight. Insulin should not be allowed to freeze (such as the cargo hold area of a plane)  as it will lose its potency, and must be discarded.

When travelling, you will need a cool pack to keep your insulin supplies cold. You will need to provide your own cool pack to regulate the temperature of your medication.  Most airlines have a policy in place that clearly states that they will not store patient medications in their refrigerator throughout the flight.

The Frio pack is an insulin travel wallet that can be used in the absence of refrigeration. There are crystals in the panels that are activated to become a cooling gel when immersed in water. These packs can keep insulin (and other medication) cool for up to 45 hours, after which they can be reactivated. They are reusable and have a life of 18-24 months. You can purchase a Frio pack at DA–Vic either online or at the retail shop.

Another option is an insulated travel bag and ice bricks. However, the insulin must not come into direct contact with the ice otherwise as it may freeze, which will damage it.

Note: Ice packs and gel packs (such as Frio) are exempt from the liquids, aerosol and gels regulations if they are included on your doctor's letter as being a necessary part of your diabetes supplies and equipment.

Cold or freezing climates

There is no product that can stop insulin from freezing in very cold environments. The safest thing to do is keep your  insulin close to your body to prevent it from freezing. Similarly, your strips and blood glucose meter can also be protected by your body temperature by keeping them close to you. If you are sleeping in sleeping bags, bring your insulin, meter and strips in the sleeping bag with you.

Arrive early at the airport to allow extra time for customs inspections. Advise the customs officers that you have diabetes and that you have supplies with you. Make sure you have the following with you:

• Doctor's letter (give them a copy only and always keep original)
• NDSS card. 

Take all your diabetes supplies and medication in your carry on luggage and share the spare supplies amongst your partner or friends in case one bag is misplaced or stolen. All diabetes supplies and equipment are allowed through customs.

• Find out more information about medication exemptions onboard flights.
• Find out more information on what you can bring on board with you.  

Should you encounter any problems with customs ask for the shift supervisor. The supervisor is employed by The Department of Infrastructure and Regional Development and is aware of laws, rules and regulations.

There are restrictions on the amount of PBS medicine that you can take overseas. Staff within the Australian Customs Service advise that generally you are allowed to take a three month supply of medication with you. For further information about taking PBS medication overseas, visit the Medicare Australia website or call the Travelling with PBS medication enquiry line on 1800 500 147.

Airport security and insulin pumps

If you have an insulin pump let the security officer know that you cannot remove it because it is attached to you. You can have it inspected by a security officer in a private room. Metal detectors will not harm your pump or the insulin within it.

X-rays and insulin

It is considered safe for your insulin to be exposed to mild x-ray when going through customs and therefore should not produce any change in the quality of your insulin. However, if you are concerned you may have it visually inspected by a security officer in a private room rather than going through x-ray. Security staff members are obliged to respond to such a request.

It is thought that the x-rays for checked-in luggage is much stronger than that used when going through the hand luggage check point and is one of the reasons why insulin should not be stored in checked-in luggage.

• During the flight
• Keep your blood glucose monitoring kit and hypo treatment within arms reach. On a turbulant flight you might not be able to get out of your chair to get belongings out of the overhead storage compartment.
• You will need to monitor BGLs more often to assess how your diabetes is travelling. Several factors may affect your BGL during air travel:
• Different foods
• Long periods of inactivity
• Altitude
• Dehydration due to air conditioning
• Change in time zones
• Stress/hectic pace of travelling.
• Drink plenty of sugar-free fluids.
• Avoid alcohol.
• Perform your leg and foot exercises to stop swelling and clots.
• Stand up and walk around as often as possible to increase circulation, keep blood glucose levels stable and prevent clots.

If you take insulin

• Never stop taking your long acting insulin and take your quick acting insulin when your meal arrives.
• Wait until your meal arrives in front of you before giving your quick acting or mixed insulin.
• Do not inject air into an insulin vial when drawing up insulin (air on plane is pressurised).
• You cannot store insulin in the plane's fridge due to food hygiene regulations and the airline will not take responsibility for insulin storage.
• Keep your watch on the time at home so you know when your insulin would have been due. Change the time when you arrive at your destination. 

If you have a pump

• You do not need to turn it off, however, a continuous blood glucose monitor must be turned off at take off and on landing just like you would any other electronic device.
• You do not need to change the rate on your pump until you arrive at your destination. Change your pump's clock when you get to your destination.
• Take a bolus dose with snacks and meals as usual
• Make sure you take back up insulin pens/ syringes. Don't forget to take a long acting insulin too.
• Take a written record of your pump settings.

Staying in contact

• Have an email address to keep in touch with family and friends.
• Prepare a package of supplies ready for couriering to you in case you lose your supplies.
• Advise the department of Foreign Affairs and Trade of your itinerary via their website.

Hypoglycaemia

Hypos are a common side effect of insulin therapy and some medications to lower blood glucose levels. However, due to the unpredictability of travelling hypos can occur more frequently. Some reasons may be:

• Meals may be delayed
• Foods may have different amounts of carbohydrates
• Increased activity - sightseeing, walking, hiking
• Stress/excitement
• Vomiting and inability to tolerate carbohydrates if unwell.

Have with you at all times:

• Quick acting carbohydrates (glucose gel, jelly beans or Lucozade)
• Long acting carbohydrates (muesli bar, crackers, biscuits)
• Glucagon injection (type 1 only - for your travelling companion to administer).

Sea travel

Sea travel is similar to air travel in terms of customs regulations. You will need your doctor's letter and NDSS card to be allowed to carry supplies and equipment on board with you. All the supplies mentioned for air travel will be the same.

Take motion sickness or anti-nausea medication during sea travel if needed.

Vaccinations are also important even if you are stopping at certain countries only for the day. Check with your doctor or travel clinic.

Travel insurance is still required.

We strongly recommend you inform the crew of your diabetes and remember that there is a doctor and nurse on board in case you need help.

Do not leave insulin supplies in the car once you've reached your destination. Heat and cold can affect your insulin. Your insulin, meter and strips should also not be exposed to direct sunlight.

If you take insulin or diabetes medications:

• Check blood glucose levels before leaving. Make sure your glucose level is above 5mmol/L. A two point check is a good way of knowing whether your blood glucose level is on its way up or down. For example check 30 minutes before you leave and then again just before you drive off. This can give you an indication whether you blood glucose level is dropping. You should check your glucose levels regularly whilst driving to make sure you continue to be safe to drive.
• Always carry quick acting carbohydrates in the car with you in case you are hypo. If you do become hypo, pull over to the side of the road as soon as you can safely do so. Turn off the ignition and take the keys out of the ignition. Treat your hypo and follow it up with long acting carbohydrates. Ensure that you are safe to drive by re-checking your blood glucose level. Do not drive until your blood glucose level is above 5mmol/L and you feel better.

More information abour driving and diabetes is available.

Camping

Camping is often not considered travelling because most people do not go overseas for it, but it still requires preparation and planning for a successful trip.

• Be cautious about camping alone in case of emergencies.
• Let someone at home know where you're going and your location.
• Consider the amount of activity you will be doing as you may need to adjust your insulin accordingly (discuss with your diabetes team).

    Remember the following:

• Diabetes emergency kit
• Hypo kit (including glucagon if prescribed by doctor)
• Frio pack/ cooler
• Protective shoes
• Supplies of drinking water and water purification tablets
• Sunscreen, mosquito repellent, hat etc.

Useful travel resources and websites

• Travel and diabetes information sheet
• Travel checklist
• Smart Traveller
• Diabetic Traveller
• Medtronic - Travelling with an insulin pumpMedtronic - Travelling with an insulin pump
• 'The Diabetes Travel Guide - second edition' by Davida F. Kruger