Study Abroad and Other International Student Travel

Introduction

Students travel internationally for many reasons, including studying abroad, leisure travel during a gap year, participating in medical rotations, volunteering, and visiting friends and relatives. Before the COVID-19 pandemic, nearly 350,000 U.S. students studied abroad annually. Study abroad notably declined by 53% in the 2019–2020 academic year and by 91% in the 2020–2021 academic year. Numbers are expected to rebound to pre-pandemic levels in the coming years. The most common destination for U.S. students to study abroad is Europe, but they also study in low- or middle-income countries.

Travel-associated morbidity and mortality is a concern for all destinations. The purpose of travel and the student's planned activities should be captured at the pre-travel consultation as part of the risk assessment. Medical, nursing, or veterinary students studying abroad can be at risk for acquiring blood-borne pathogens or zoonotic infections, and students participating in humanitarian activities could experience stress-related problems and environmental hazards. Short- or long-term travel for non-academic reasons, including leisure, athletics, volunteer work, and gap year experiences, can also be associated with travel-related risks.

Resources for students preparing to travel abroad include their institution's international program office, study abroad administrators, healthcare professionals at a pre-travel consultation either at their institution or in the community, international students from their intended destinations, and other students who have returned from a similar trip (see Table 8.5.1 for additional online study abroad resources). Appropriate preparation can help students stay healthy during travel and reduce the chance they will become ill or engage in behaviors abroad that can place their health at risk.

Table 8.5.1: Online health and safety information for students, healthcare professionals, and international program office professionals

Pre-departure preparation

Healthcare professionals: roles and responsibilities

Healthcare professionals preparing students for travel should have appropriate travel medicine training (see Travel Medicine Resources for Healthcare Professionals chapter). When conducting pre-travel consultations with student travelers, cover the core topics of risk assessment, risk mitigation, and preparation to respond effectively to health and safety problems while abroad (see The Pre-Travel Consultation chapter). Ensure that students have received all appropriate pre-departure health trainings for their institution or program. Make recommendations about vaccines, prophylaxis, and self-treatment medications; provide information on country-specific health risks; and give guidance on how to obtain medical and dental care while abroad. Remind students to pack a travel health kit (see Travel Health Kits chapter).

Advance planning is important for students who are taking prescription medication. The travel health professional should work closely with the student's prescribing healthcare professionals to facilitate coordination of medication management during travel. Considerations to address include plans for procuring medications while abroad, insurance coverage, continuity of care while abroad, and medication letters (with names of medications, supplies, and equipment) to accompany the traveler. Special consideration should be given to learning about the regulations in the destination countries regarding amount of medication allowed, controlled or regulated substances, and required documentation (see Traveling with Prohibited or Restricted Medications chapter); resources include International Narcotics Control Board and the destination's embassy or ministry of health. The International Association of Medical Assistance to Travelers (IAMAT) offers a valuable free interactive Guide to Traveling with Medications.

Other relevant topics to discuss include alcohol and illicit drug use and dependency (see Substance Use and Substance Use Disorders in Travelers chapter); blood-borne pathogen precautions (e.g., avoiding acupuncture, blood products, needles, piercings and tattoos, surgeries) while traveling; sexual orientation-related health issues, including information for lesbian, gay, bisexual, and other sexual minority (LGB+) students (see LGB+ Travelers chapter); managing stress and other mental health issues (see Mental Health in Travelers chapter) associated with international travel (e.g., culture shock); and practicing safer sex, including what to do in the event of pregnancy. Share information on risk mitigation of unintentional injuries (see Injury and Death During Travel chapter). Provide additional recommendations for students with disabilities or special needs (see Travelers with Disabilities chapter), students with preexisting health conditions (see Travelers with Chronic Illnesses chapter), and students participating in humanitarian activities (see Humanitarian Aid Workers chapter).

Students should purchase travel insurance that covers major medical, evacuation, and repatriation (see Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapter) for the duration of travel; "study abroad" insurance plans might be available through the school or parent institution and could provide a reasonable, cost-effective option. Encourage student travelers planning adventure activities (e.g., kayaking, mountaineering, spelunking) to include extreme sports coverage on their health insurance policy (see Adventure Travel chapter). All students should register with the Department of State's Smart Traveler Enrollment Program (STEP). They should also check the U.S. Department of State Bureau of Consular Affairs website for country-specific safety guidance and the Centers for Disease Control and Prevention (CDC) Travelers' Health website destination pages and Travel Health Notices for destination-specific health advice (e.g., best practices for disease prevention, outbreak information).

International program office and institute of higher education: roles and responsibilities

The international program office plays a crucial role in supporting the health and safety of student travelers. Coordinating and ensuring robust pre-travel preparation, including relevant health and safety information, is essential. Information to cover includes, but is not limited to, emergency protocols, seeking assistance abroad, and communication procedures. Staff should encourage students to seek pre-travel health visits for any personal physical or mental health concerns related to their travels, as well as for any destination-specific needs. Staff should encourage students to familiarize themselves with codes of conduct for their home and host institutions, as well as local health and safety issues, cultural norms, laws, and political climate. Pre-travel health and safety orientations should be provided and mandatory; it is also important for faculty and staff accompanying group travel to attend. Students should work with the international programs office to develop an individual communications plan that outlines both who a student should inform in the event of an urgent health issue and how they can reach them.

Institutes of higher education should establish a travel registry for all institution-related international travel, which includes information regarding all travelers' destinations, contact information, dates of travel, and emergency contact information. Establishment of an international travel committee may be useful to review proposed travel to higher-risk destinations or travel which involves higher-risk activities (e.g., adventure travel). This committee may also serve as an established group of campus personnel who can respond in the case of an emergency abroad.

Specific issues

Alcohol and illicit drugs

A lower minimum drinking age and cultural acceptability of alcohol consumption in the host country, combined with stress or mental health issues, can lead to increased alcohol consumption among students when abroad. Use and abuse of alcohol or illicit drugs pose serious health consequences, can increase the risk for accidents and injuries, and make students potential targets for crime or incarceration (see Substance Use and Substance Use Disorders in Travelers). Moreover, availability of recreational drugs (e.g., cannabis) or their use by citizens of host countries might not necessarily mean that their use is legal for international travelers.

Although cannabis is legal under certain U.S. state laws, its use continues to be illegal under U.S. federal law. U.S. airports and airlines operate under federal jurisdiction and, as such, do not recognize the medical marijuana laws or cards of any state. In countries outside the United States where cannabis is illegal, students found in possession of the drug—even those with a valid U.S. prescription—can be arrested; if found guilty, they could be deported, fined, or imprisoned.

Both healthcare professionals and international program office personnel should counsel students about the consequences of alcohol and illicit drug use, which may include expulsion from the program if substance use guidelines are not followed. Advise students who are planning to drink alcohol to do so responsibly and in moderation and to seek medical attention if they feel ill after drinking. Programs should strongly discourage all illicit drug use.

Blood-borne pathogens

Students planning to provide medical, nursing, or veterinary care overseas should receive hepatitis B vaccination or have evidence of immunity. Ask students about the availability of personal protective equipment at their destination and discuss the possibility of bringing their own. Inform these travelers about what to do in the event of a needlestick injury. At the pre-travel consultation, consider providing post-exposure HIV prophylaxis for students to carry with them in the event of a blood-borne exposure if they will be providing health care in a country with high HIV prevalence (see International Travel to Deliver Health Care in Resource-Limited Settings chapter).

Provide information on blood safety in the event the traveler has an emergency, has an unexpected blood-borne exposure, or needs a blood transfusion (see What to Do When Sick Abroad chapter). Warn students of the risks associated with getting acupuncture, piercings, or tattoos while abroad; sterility of needles or ink cannot be guaranteed. Psychological counseling is essential after a blood-borne exposure.

Emergency contact information

Students should always carry their personal information and important telephone numbers as hard copies and electronically in their mobile devices. The Center for Global Education offers a printable sample emergency contact card. For students with additional mental health or physical needs, provide written documentation of all health issues, prescribed medications, and recommended care plans as well as the contact information for their healthcare professionals at home; students should ensure that this letter gets translated accurately into the local language(s). Students should leave photocopies of all travel documents at home with their emergency contacts, with the international program office, and with group travel trip leaders (if applicable).

Sexual orientation-related issues

Discussing sexual orientation topics in pre-travel discussions can positively impact a student's international travel experience (see LGB+ Travelers chapter).

Students, including those who identify as lesbian, gay, bisexual, or other sexual minorities (LGB+), should familiarize themselves with cultural attitudes, local laws, and tolerance in their host country. Check the U.S. Department of State website and specific U.S. embassy or consulate websites in countries and cities around the world to obtain information on host country laws.

Equaldex publishes maps of sexual orientation laws by country, including protection against discrimination and criminalization of same-sex sexual acts. Additional research and planning might be needed to identify healthcare professionals in the host country with experience working with LGB+ students, if needed.

Mental health

Mental health issues are prevalent among students, irrespective of plans for international travel. International travel can be stressful for students who might be inexperienced travelers, reliant on their home support systems (which may not be readily accessible while abroad), or traveling for longer periods of time. Culture shock, fear, insecurity, isolation, and loneliness can exacerbate existing mental health issues or unveil new ones (see Mental Health in Travelers chapter). When deciding on a destination for study, students should consider their preexisting level of mental (and physical) well-being and the availability of local resources. Encourage students to take an active role in planning for care abroad by disclosing all chronic mental health conditions and support needs during the pre-travel consultation and to the international programs office before departure.

Advise students to continue their routine medications while abroad; assist with developing a plan to manage an exacerbation of symptoms while traveling with their prescribing providers (e.g., how to contact their prescribing provider, therapist, and support community; where to seek local care; how to repatriate in the event of severe mental health issues). Students should confirm that mental health services are covered by their travel health insurance. Recommend that students engage in self-care abroad by getting regular exercise, establishing good sleep patterns, joining interest groups (e.g., organizations at the destination for LGB+ students), and maintaining meaningful contact with family and friends at home.

Safer sex

Discuss safer sex practices (e.g., birth control, condom use, emergency contraception, HIV pre-exposure prophylaxis [PrEP]) with international student travelers and discourage sexual encounters with strangers (see Sex and Travel chapter). Provide information about the prevalence of sexually transmitted infections (STIs) or other diseases that may have negative outcomes in the event of pregnancy (e.g., Zika; see Zika chapter). Students should follow local social norms about public displays of affection and dating to avoid possible adverse consequences; they also should be empowered and encouraged to report any episode of sexual harassment or assault to local authorities, emergency contacts, the international program office, or the nearest U.S. consulate or embassy.

During and after travel considerations

During their time abroad, students should adhere to food and water precautions (see Food and Water Precautions for Travelers chapter), and use insect repellent (see Mosquitoes, Ticks, and Other Arthropods chapter) to prevent vector-borne diseases. Students should seek health care immediately and refer to their individual communications plan with the international program office if they become ill, injured, or have a bloodborne pathogen exposure.

Students who become ill after returning home should alert healthcare professionals about their international travel. Students with fever ≤1 year after returning from study or travel in malaria-endemic areas warrant testing for malaria (see the Yellow Fever Vaccine and Malaria Prevention Information, by Country and Malaria chapters). Students with new sexual partners while abroad should be tested for STIs if they develop symptoms while abroad or after they return home; they also should be screened for STIs when they return home.

After returning home, students will undergo a period of readjustment. All students should have access to mental health services after return to help cope with events that occurred overseas and to assist with reverse culture shock.

Acknowledgements

The following authors contributed to the previous version of this chapter: Sarah Kohl.