Travel medicine--prevention based on epidemiological data

Traveler's knowledge, attitude, and practice about travel health insurance: A community-based questionnaire study

BACKGROUND

Travel, especially international travel, has become one of the most popular leisure activities in the world. The risk of accidents and travel-related illnesses, including infectious and non-communicable diseases, should not be neglected. To provide a more comprehensive pre-travel consultation to international travelers, this study aimed to investigate the knowledge, attitude, and practice of travelers about travel health insurance.

METHODS

This was a cross-sectional study. Anonymous structured questionnaires were distributed to 1000 visitors to the Taiwan International Travel Fair in May 2019.

RESULTS

The top three important travel health insurances were accidental death and disablement insurance (92%), accidental medical reimbursement (90.4%), and 24-hour emergency assistance (89%). In addition to education level, travel-associated illness, and special activities during travel, a significant association was observed between the willingness to buy various travel health insurances and the willingness of pre-travel consultation.

CONCLUSIONS

Most travelers would buy travel health insurance; however, disproportional respondents understood the content of travel health insurance. Most travelers considered travel clinics to be the most reliable information source regarding travel health insurance. Therefore, travel medicine specialists are encouraged to offer more information about travel health insurance during pre-travel consultation.

Knowledge, attitudes, and practices of primary health care physicians regarding the pre-travel counselling of patients with type 2 diabetes in Riyadh, Saudi Arabia

Background

Travel has become an integral part of Saudi life. People with diabetes face many challenges while travelling that can have detrimental effects on glycaemic control. However, no previous studies have investigated pre-travel counselling in Saudi Arabia. This study aims to assess the knowledge, attitudes and practices of primary health care (PHC) physicians regarding pre-travel counselling for patients with type 2 diabetes.

Methods

This cross-sectional study was conducted in PHC centres under the Ministry of Health in Riyadh, Saudi Arabia, during the period 2018–2019. A cluster multistage random sampling technique was used to recruit physicians. The data were collected through a self-administered questionnaire.

Results

Three hundred and eighty-five primary health care physicians were recruited. This study showed that more than half (57.9%) of PHC physicians had poor knowledge scores. Additionally, the following characteristics were significantly associated with poor knowledge: being younger in age, being male, being Saudi, being a general practitioner, and having limited (0–5 years) experience. A total of 183 (47.5%) subjects showed disagreement attitudes towards the importance of pre-travel counselling among patients with diabetes. Furthermore, these disagreement attitudes were significantly associated with being older and having more years of experience. The majority (62.6%) of the physicians had poor practice scores. Poor practices were detected among physicians who were younger, male, and Saudi and who had a general practitioner specialty and degree.

Conclusions

It could be concluded that a gap was detected in the knowledge and practices of primary health care physicians regarding pre-travel counselling for people with type 2 diabetes. Therefore, it is necessary to create easily accessible travel medicine education programmes for Saudi PHC providers to improve the management of travellers with diabetes.

Non-vaccine-Preventable Infections

There are many potentially serious infections that may pose a risk to travellers for which no vaccines are available. Following discussions on vaccines, malaria prevention and travellers’ diarrhoea at the consultation, the travel-medicine practitioner should identify other infectious risks that may apply to the traveller, whether because of destination/s and duration of travel, occupational or other activities, or individual susceptibility. Information should be provided about these infections, their relevance, modes of transmission and methods of prevention, or the traveller should be referred to an authoritative source of information. In this chapter, advice will be given on both destination- and activity-related infections. The risk, distribution, clinical features and methods of prevention of a number of specific infections for which no vaccines are available are then outlined. This includes information on emerging viral infections such as Zika, MERS, Ebola and Chikungunya.

Identification of a Syndrome Class of Neuropsychiatric Adverse Reactions to Mefloquine from Latent Class Modeling of FDA Adverse Event Reporting System Data

Introduction

Although mefloquine use is known to be associated with a risk of severe neuropsychiatric adverse reactions that are often preceded by prodromal symptoms, specific combinations of neurologic or psychiatric reactions associated with mefloquine use are not well described in the literature. This study sought to identify a distinct neuropsychiatric syndrome class associated with mefloquine use in reports of adverse events.

Methods

Latent class modeling of US Food and Drug Administration Adverse Event Reporting System (FAERS) data was performed using indicators defined by the Medical Dictionary for Regulatory Activities neurologic and psychiatric high-level group terms, in a study dataset of FAERS reports (n = 5332) of reactions to common antimalarial drugs.

Results

A distinct neuropsychiatric syndrome class was identified that was strongly and significantly associated with reports of mefloquine use (odds ratio = 3.92, 95% confidence interval 2.91–5.28), defined by a very high probability of symptoms of deliria (82.7%) including confusion and disorientation, and a moderate probability of other severe psychiatric and neurologic symptoms including dementia and amnesia (18.6%) and seizures (18.1%). The syndrome class was also associated with symptoms that are considered prodromal including anxiety, depression, sleep disturbance, and abnormal dreams, and neurological symptoms such as dizziness, vertigo, and paresthesias.

Conclusions

This study confirms in FAERS reports the existence of a severe mefloquine neuropsychiatric syndrome class associated with common symptoms that may be considered prodromal. Clinical identification of the characteristic symptoms of this syndrome class may aid in improving case finding in pharmacovigilance studies of more serious adverse reactions to the drug.

Repatriation of human remains following death in international travellers

BACKGROUND

Death during international travel and the repatriation of human remains to one's home country is a distressing and expensive process. Much organization is required involving close liaison between various agencies.

METHODS

A review of the literature was conducted using the PubMed database. Search terms included: 'repatriation of remains', 'death', 'abroad', 'tourism', 'travel', 'travellers', 'travelling' and 'repatriation'. Additional articles were obtained from grey literature sources and reference lists.

RESULTS

The local national embassy, travel insurance broker and tour operator are important sources of information to facilitate the repatriation of the deceased traveller. Formal identification of the deceased's remains is required and a funeral director must be appointed. Following this, the coroner in the country or jurisdiction receiving the repatriated remains will require a number of documents prior to providing clearance for burial. Costs involved in repatriating remains must be borne by the family of the deceased although travel insurance may help defray some of the costs. If the death is secondary to an infectious disease, cremation at the site of death is preferred. No standardized procedure is in place to deal with the remains of a migrant's body at present and these remains are often not repatriated to their country of origin.

CONCLUSIONS

Repatriation of human remains is a difficult task which is emotionally challenging for the bereaving family and friends. As a travel medicine practitioner, it is prudent to discuss all eventualities, including the risk of death, during the pre-travel consultation. Awareness of the procedures involved in this process may ease the burden on the grieving family at a difficult time.

Are French general practitioners consulted before travel to developing countries? A cross-sectional study conducted in a French airport

BACKGROUND

General practitioners (GPs) could play a central role in preventing travel-related health issues. The aim of this study was to assess, in travellers departing to developing countries from a French airport, the proportion of individuals having sought GP counseling before departure and to identify determinants for having consulted a GP.

METHODS

Cross-sectional study conducted between November 2012 and July 2013, in all adults living in France. Sociodemographic, health characteristics, type of travel and resources consulted before departure were collected. A descriptive analysis was performed. Determinants for having consulted a GP before departure were investigated using a logistic regression analysis.

RESULTS

Of the 360 travellers included, 230 (64%) sought health counseling before departure. GPs were the main source of information for 134 (58%) travellers having sought health information and the only one for 49 (21%). Almost half of the travellers (48%) departing to sub-Saharan countries did not seek health counseling from a medical doctor (GP, non-GP specialist, specialist consulted in an international vaccination center or occupational physician). Individuals significantly more likely to travel without having consulted a GP were young and male, held foreign nationality, had travelled more than five times before, rarely consulted their GP and were travelling to a non-malarious area.

CONCLUSION

GPs were the main but not the only source of information and counseling before traveling to a developing country. This study helps identify the characteristics of individuals likely to travel without having consulted a GP before departure.

Reiseimpfungen und allgemein empfohlene Impfungen

Nach Schätzungen der World Tourism Organisation (WTO) verreisen jedes Jahr ca. 7,2 Millionen Deutsche nach Übersee. Hiervon entfällt ein Großteil auf Reisen in nicht tropische Gebiete: die USA, gefolgt von der Türkei und Tunesien, sind die häufigsten Ziele von Interkontinentalreisenden (www.world-tourism.org). Im Gegensatz hierzu sind Ost- und vor allem Westafrika, die von erkrankten Tropenrückkehrern am häufigsten als Infektionsgebiete genannt werden, bei den Reisezielen nur zu einem sehr geringen Ausmaß vertreten. Die internationale Reisetätigkeit boomt weltweit und gerade in Deutschland genießen Auslandsreisen einen besonderen Stellenwert. Die Forschungsgruppe Urlaub und Reisen gibt die Gesamtzahl der grenzüberschreitenden Reisen, die von Deutschen getätigt wurden, mit 56–63 Millionen pro Jahr an. Von den geschätzten 7,2 bis 7,8 Millionen interkontinentalen Reisen führten ca.4 Millionen in die Tropen.

Health risks and risk-taking behaviors among International Committee of the Red Cross (ICRC) expatriates returning from humanitarian missions

OBJECTIVE

To assess self-reported health risk and risk-taking behavior of humanitarian expatriates.

METHODS

A self-administered anonymous questionnaire was completed by International Committee of the Red Cross (ICRC) expatriates returning during May 2003 to September 2004, covering perceived health status before and after mission, malaria prevention, prevalence of exposure to stress, accidents and violence, and risk-taking behaviors.

FINDINGS

More than one-third (36.4%) reported worse health on return from the mission. A third (35%) of expatriates returning from Sub-Saharan Africa excl. South Africa reported not having followed ICRC's recommendation on taking malaria prophylaxis in spite of stating a high degree of awareness of the risks and availability of effective drugs. Over 40% reported the mission having been more stressful than expected, mostly due to the working environment; 10% reported injury or accidents and 16.2% exposure to at least one act of violence. Almost one-third of the respondents reported having engaged in casual sexual relationships. Of these, 64% reported using condoms at every sexual contact, and women reported lower usage of condoms than men. Many (27%) reported involvement in risk-taking behavior.

CONCLUSION

This study shows that humanitarian aid workers experience significant worsening of their health during overseas missions. Many are at risk of experiencing violence, accidents, or injuries. Despite awareness of the risks, many expatriates engage in behaviors that could endanger their health. Improved selection of expatriate staff, training programs emphasizing areas of concern, strengthening social support locally, and follow-up in field may help to alleviate these problems.

The role of the traveler in emerging infections and magnitude of travel

Travel and trade have grown immensely. Travelers interact with people and microbes during their journeys, and can introduce infectious agents to new areas and populations. Studying illnesses in travelers is a source of knowledge into diseases of resource-poor regions and the control of these diseases. Travel-associated illnesses also serve to detect emerging infections.

Recreational travel fatalities in US national parks

BACKGROUND

Injuries are a public health problem affecting traveling populations such as tourists visiting National Parks. This study investigates the distribution of visitor fatalities in US National Park Service (NPS) units and identifies the predeath activities and contributing factors associated with them.

METHODS

A retrospective study was conducted of visitor fatalities from all NPS units during 2003 and 2004.

RESULTS

There were 356 reported fatalities during 2003 and 2004. Fatalities were most common during the summer months and on weekends. Males accounted for 75% of the reported fatalities, and visitors aged 20 to 29 and 50 to 59 years accounted for 51% of all deaths. Only 99 of 388 (26%) NPS units reported at least 1 fatality, and only 10 units reported 10 or more fatalities. However, these 10 units were responsible for 36% of all fatalities. Lake Mead National Recreation Area, Blue Ridge Parkway, Grand Canyon National Park, Great Smoky Mountains National Park, and Yosemite National Park reported the highest number of fatalities. Domestic visitors accounted for 73% of the fatalities, and European visitors accounted for 13%. Transportation and water-based activities recorded the highest number of fatalities. Motor vehicle crashes accounted for 20% of fatalities and was followed by suicide (17%), swimming (11%), hiking (10%), plane crashes (9%), climbing (6%), and boating (5%) incidents.

CONCLUSIONS

Fatalities in NPS units are not widespread and are related to more common events such as motor vehicle crashes, suicide, swimming, and hiking rather than exotic causes such as bears or other wildlife. It is recommended that preventive techniques first be developed in the 10 NPS units responsible for 36% of the total NPS-wide fatalities.

Illness in returned travellers presenting at GeoSentinel sites in New Zealand

OBJECTIVE

To describe illnesses of returned travellers presenting at GeoSentinel sites in New Zealand.

METHODS

Record data for all patients presenting for travel-related illnesses seen at two GeoSentinel sites, operating as commercial travel clinics, in Auckland and Hamilton, NZ, were extracted for the period November 1997 to December 2001.

RESULTS

205 patients were identified with 262 diagnoses. Just over half were females (54.21%) and nearly half were in the 25-35 years age group (47.3%). About two-fifths of patients reported a pre-travel health consultation (41.0%). The commonest diseases diagnosed were diarrhoeal illnesses (23%), dermatological diagnoses (16%, excluding animal bites), animal bites (10%), and non-specific viral illnesses (8%), many of which manifest as respiratory infections. Tropical diseases, such as schistosomiasis (4%) malaria (2%) and dengue fever (0.5%), were not common.

CONCLUSIONS

Information on travel-related illnesses, when reported through a global reporting system, can be useful for the travel health adviser in identifying issues of current concern. Although the frequency of tropical disease is low, it remains important to prevent these potentially fatal diseases.

IMPLICATIONS

GeoSentinel makes a global contribution to the surveillance of emerging and re-emerging infectious diseases through a network of individual sites in various countries including New Zealand. This information can be used to help provide preventive advice for travellers as well as help in assessing illness in post-travel patients and potentially assist in preventing the secondary spread of some diseases acquired abroad following return.

Immunogenicity study of abbreviated rabies preexposure vaccination schedules

OBJECTIVE

To evaluate abbreviated preexposure rabies vaccination schedules that would reduce cost and shorten time required for completion.

METHOD

A random prospective immunogenicity study, using a group of 96 volunteer preclinical veterinary students, primary school children, and hospital-based health care workers. They were divided into six groups and administered abbreviated schedules of preexposure tissue culture rabies vaccines. Neutralizing antibodies were determined on days 0 and 360, and following boosters on days 367 and 374.

RESULTS

All subjects, including one group that received only 0.1 mL intradermally at two sites on one day, had detectable neutralizing antibody titers 1 year later and responded with an accelerated antibody response when given booster injections.

CONCLUSION

It might be possible to develop a 1-week and even one clinic visit preexposure vaccine schedule that would provide at least 1 year of immune memory.

Level of concern and sources of information of a group of Brisbane hostelers for personal safety and terrorism when traveling abroad

BACKGROUND

Little is known about the level of concern and sources of information of hostelers concerning personal safety and terrorism. This study was designed to investigate these in the Australian context.

METHODS

In 2006, self-administered questionnaires were distributed to hostelers attending a travelers' information evening in Brisbane.

RESULTS

Forty questionnaires (60.8%) were returned. Over two thirds of attendees were women (71.4%). About two thirds of the hostelers attending the travelers' information evening reported being aged 29 years or younger (64.2%). Anticipated main destinations were Europe (68.3%), Asia (14.3%), and North America (11.9%). Nearly two thirds (63.4%) intended to travel in more than 8 weeks time or were not sure. Of those departing within 8 weeks, only 40% had sought travel health advice from their general practitioner and/or travel clinic. Nonmedical sources of information on travel health included travel books and guides (40.5%), Internet (35.7%), and travel agents (19.0%). On a five-point rating scale (1 being not concerned to 5 being extremely concerned), median ratings of hostelers' concern for personal safety (4.0) was significantly higher than for terrorism (2.5), with the range being 1 to 5 in each case (p < 0.001). Nearly three quarters (73.8%) of hostelers would seek personal safety advice from multiple sources, and sources of information included the Internet (69.0%, 29), travel books and guides (59.5%), physicians (57.1%), and travel agents (45.2%). Only three (7.1%) nominated the physician as their only source of personal safety advice.

CONCLUSIONS

Hostelers attending a travelers' information night in Australia expressed more concern for their personal safety when traveling than for terrorism. Since this group of travelers uses multiple sources of information with the Internet most commonly used, Web sites that provide accurate and relevant information in an acceptable format could play an important role in supporting this group. It is important that policies being promoted by travel health advocacy groups in Australia continue to advocate that travelers seek travel health advice from a qualified source early, preferably around 6 to 8 weeks before travel, and that personal safety be discussed as part of the travel health consultation.

Assistance provided abroad to insured travellers from Australia following the 2004 Asian tsunami

BACKGROUND

On 26 December 2004, the Asian tsunami hit countries around the Indian Ocean rim, particularly around its earthquake-associated epicentre off Indonesia. A number of popular tourist destinations for Australian travellers are located in this region. This study was designed to investigate travel insurance claims reported by travellers from Australia following the Asian tsunami and to examine the role of travel insurance and emergency assistance companies.

METHODS

In December 2005, all claims reported, following the Asian tsunami on 26 December 2004, to a major Australian travel insurance company were examined for those claims associated with the Asian tsunami.

RESULTS

Twenty-two tsunami-related claims were submitted of which nine travellers (40.9%) used the travel insurance company's emergency assistance service. Four travellers (18.2%) cancelled their trip to Asia, mainly to Thailand. Five travellers (27.3%), who were already abroad, also curtailed their trip as a result of the tsunami. Half of travellers (50.0%) were claiming loss of personal belongings. Of those using the emergency assistance service, five travellers (22.7%) sought policy and claiming advice, two (9.1%) sought assistance with flight rearrangements, and one (4.5%) sought situation advice. There was also assistance provided following the death of one insured traveller as a direct consequence of the tsunami, which included a lump sum payment to the deceased estate. The mean refund, where a travel insurance claim was paid, was Australian dollars (AUD)2234 (SD=AUD5755).

CONCLUSIONS

This study highlights the importance of travellers taking out appropriate travel insurance, which provides for emergency assistance. Travel insurance agencies do play some role after emergencies, such as the Asian tsunami. This assistance predominantly involves dealing with cancellation of travellers' intended visits to the affected area, but does also involve some assistance to travellers affected by the crisis. Travellers should be advised to seek travel health advice well before departure overseas and to ensure that they are aware of travel advisories for their destination.

Awareness of rabies risks and knowledge about preventive measures among experienced German travel health advisors

BACKGROUND

Every year, millions of people travel to countries where rabies is enzootic. However, the quality of rabies-specific information provided by travel health advisors and the extent of their knowledge about pre- and postexposure prophylaxis have not been examined on a large-scale basis up to now.

METHODS

5,780 German physicians and pharmacists, who identified themselves as active travel health advisors, were chosen from a database. The selected providers were asked to complete an Internet-based questionnaire. The form requested both demographic information and the assessment of different concrete scenarios, each of which featured individuals seeking pre-travel advice on rabies or appropriate postexposure treatment after returning from abroad.

RESULTS

Overall, 496 physicians and pharmacists completed the questionnaire. Almost all respondents indicated that they would mention the risk of rabies and appropriate preventive measures to long-term travelers and tourists planning to visit rural areas. However, only 35% to 60% of the advisors would provide this information to individuals on business trips, package tours, or travelers in urban centers as well. The assessment of the scenarios yielded 51% to 98% of adequate advice. Potentially harmful decisions included, for instance, the failure to recommend further prophylactic measures after exposure of already vaccinated people or the fact that the necessary postexposure prophylaxis was inappropriately withheld in cases where treatment had been initially delayed.

CONCLUSIONS

Although the participants of this study were well aware of the travel-associated rabies risks and provided adequate information about this health hazard to most of their clients, evident flaws exist regarding the correct assessment of specific situations in pre- and postexposure rabies prophylaxis. Our findings therefore provide important cues on topics that should be more intensely covered during future postgraduate training in travel medicine and also underline the need for more practically orientated, readily available information on specific prophylactic treatment against rabies.

Accidents and repatriation

Accidents and injury contribute greatly to the morbidity and mortality of travellers worldwide, with road traffic accidents being a major contributer. Those travelers with serious illness and injury may need specialised medical evacuation services, which may involve an air ambulance and a specialised medical team. Such aeromedical repatriations require considerable organisation and liaison between the sending and receiving medical services and other interested parties. However, the majority of travellers requiring emergency assistance are stable patients requiring referral for medical or dental attention or special requirements for carriage on scheduled aircraft.

Risk assessment in travel medicine

Risk assessment is an integral part of pre-travel and post- assessment. Risk assessment largely determines what health and safety advice and interventions are given within the relevant prevailing travel health guidelines. Risk assessment needs time and depends on information, including that given by the traveller. Risk assessment also needs to be documented. Risk assessment of the traveller preferably starts before they enter the consulting room, where travellers may complete a pre-travel health questionnaire. Armed with this information, risk assessment may be assisted by access to computerised travel health databases and the published literature. Experience of travel to the destination may also assist in risk assessment and the tour operator, overseas employer or agency, the traveller or even the travel health advisers themselves may provide this information.

Travel and health status: a survey follow-up study

BACKGROUND

To date there is little sound knowledge on the relationship between travel and health status as perceived by the traveller. Our aim was to investigate the frequency and risk factors of travel-associated illnesses and injuries and identify potential protective factors.

METHODS

All adults enrolled in a health insurance scheme who planned to travel in 2002 were eligible for participation in a baseline survey. Pre-travel written questionnaires and post-travel telephone interviews were conducted with responders. We analysed travel-associated health problems using descriptive methods and multivariate logistic regression.

RESULTS

From 8316 persons who returned a pre-travel questionnaire, a sample of 2384 were chosen, of whom 1471 completed post-travel interviews. 10.1% of all travellers reported travel-associated illnesses, and 1.8% suffered from injuries during travel. Among travellers to European destinations, 6.0% reported an illness as opposed to 16.2% of travellers to overseas destinations. Predictors for travel-associated illness were age <30 years (OR 1.48), duration of travel >4 weeks (OR 3.35) and travel destination. Perceived health status as scored by the travellers improved after travel. The frequency of medical consultations and personal health-related expenses decreased significantly shortly after travel.

CONCLUSIONS

In this study, travel had a positive effect on the perceived health status of the traveller. The positive effects of travel seemed to outweigh the impact of health problems. Travel did not lead to increased health-related costs, neither in individual health expenses nor indirectly through increased medical consultation rates.

Traveller's diarrhoea

Traveller's diarrhoea affects over 50% of travellers to some destinations and can disrupt holidays and business trips. This review examines the main causes and epidemiology of the syndrome, which is associated with poor public health infrastructure and hygiene practices, particularly in warmer climates. Although travellers may be given common sense advice on avoidance of high-risk foods and other measures to prevent traveller's diarrhoea, adherence to such advice is sometimes difficult and the evidence for its effectiveness is contradictory. However, non-antimicrobial means for prevention of traveller's diarrhoea are favoured in most settings. A simple stepwise approach to the management of traveller's diarrhoea includes single doses or 3-day courses of antimicrobials, often self administered. The antibiotics of choice are currently fluoroquinolones or azithromycin, with an emerging role for rifaximin. In the long term, there will be greater benefit and effect on the health of local inhabitants and travellers from improving public health and hygiene standards at tourist destinations.

Efficacy of antimalarial chemoprophylaxis among French residents travelling to Africa

Controversy exists about which antimalarial chemoprophylaxis regimen should be used among travellers to Africa: the WHO and other experts recommend the use of mefloquine throughout sub-Saharan Africa, whereas French experts still support the combination of chloroquine and proguanil in most of West Africa (the so-called zone 2 countries). In this case-control study based at a travel clinic, we examined the compliance with antimalarial chemoprophylaxis and its efficacy among travellers to tropical areas. Cases were patients with Plasmodium falciparum malaria (n = 131). Controls were patients who had a negative malaria film (n = 158). Of all controls, only 36 (22.8%) were adequately protected (i.e. compliant with an adapted regimen of chemoprophylaxis). In zone 2 countries, the efficacy of the combined chloroquine and proguanil was 58% (95% CI 22-78%) for all users, but increased to 100% (95% CI 89-100%) for compliant users. In zone 3 countries, the efficacy of mefloquine was 90% (95% CI 51-98%) and 100% (95% CI 58-100%) for all users and compliant users, respectively.

Travel medicine: an Australian perspective

Travel medicine is emerging as a new multidisciplinary specialty area catering for an increasing number of travellers worldwide. Travel health advisers are engaged in the provision of pre-travel health advice, chemoprophylaxis against travel-related diseases, traveller's medical kits, and post-travel assessments and eradication treatment for various travel-related diseases. They are also in a key position to liaise with public health authorities on possible imported disease risks. In terms of risk assessment and provision of preventive measures, vector-borne diseases, in particular malaria and the arboviral diseases, stand out as major concerns for travellers, however, common problems, such as travellers' diarrhoea and respiratory tract infection, also need to be addressed. Travel and aviation medicine have many linkages, especially in terms of fitness to fly and dealing with problems that may arise in travellers due to physiological and psychological stresses of travel. In the face of recent terrorism and conflict, travel advisories have assumed great importance in travellers planning. Travel insurance remains an important safety net for travellers, which provides coverage for medical and dental treatment abroad as well as an emergency assistance service, which may include aeromedical evacuation.

Mefloquine versus quinine plus sulphalene-pyrimethamine (metakelfin) for treatment of uncomplicated imported falciparum malaria acquired in Africa

We conducted a multicenter, randomized, open-label trial to compare mefloquine with a 3-day quinine plus sulphalene-pyrimethamine (SP) regimen for the treatment of imported uncomplicated malaria acquired in Africa. The end points of the study were efficacy, tolerability, and length of hospital stay. From July 1999 to February 2003, 187 patients were enrolled in five centers in Italy, of whom 93 were randomized to receive mefloquine (the M group) and 94 were randomized to receive quinine plus SP (the QSP group). Immigrants and visiting relatives and friends represented 90% of the cases and were mainly from western African countries. A slightly increased proportion of cases in the QSP group had abnormal alanine aminotransferase levels at the baseline. The early cure rate was similar in the two groups: 98.9% (confidence interval [CI] = 97 to 100%) in the M group and 96.8% (CI = 93 to 100%) in the QSP group. The extended follow-up was completed by 135 subjects (72.2%), and no case of recrudescence was detected. There were no differences in the parasite clearance time, but patients in the M group had shorter mean fever clearance time (35.9 h versus 44.4 h for the QSP group; P = 0.05) and a shorter mean hospital stay (3.9 days versus 4.6 days for the QSP group; P = 0.007). The overall proportions of reported side effects were similar in the two groups, but patients in the M group had a significantly higher rate of central nervous system disturbances (29.0% versus 9.6% for the QSP group; P < 0.001).

Emergency assistance provided abroad to insured travellers from Australia

BACKGROUND

Emergency assistance provided on behalf of travel insurance companies may include direct services such as medical advice, referral for local medical or dental treatment abroad, or aeromedical evacuation (AME) back to Australia or a third country. Little is known about the nature of these services provided by emergency assistance services on behalf of travel insurance companies. This study is designed to investigate the nature of emergency assistance provided abroad to travellers from Australia.

METHODS

All travel insurance claims reported during 2001 to a major Australian travel insurance company were examined for those claims utilising the insurer's emergency assistance service.

RESULTS

Four hundred claims (25.3%) reported utilising emergency assistance Medical and dental claims made up over two thirds of claims requiring emergency assistance (275, 69.3%), with cancellation and curtailment, mostly for medical reasons, making up more than one eighth of claims (59, 14.8%). The most common nature of illness requiring emergency assistance was musculoskeletal disorders (87, 28.2%), followed by gastrointestinal disorders (45, 14.6%), dental conditions (42, 13.6%) and respiratory problems (36, 11.7%). The problem reportedly occurred at a median of 19.5 (range=281.0) days into travel. Emergency assistance provided included policy advice (395, 99.0%), claiming advice (394, 98.7%), civil advice or assistance (79, 19.8%), medical advice or GP referral (22, 5.5%), hospital emergency room (ER) review (58, 14.5%), hospital admission (46, 11.5%), medical or dental follow-up (25, 6.3%) and AME (10, 2.5%).

CONCLUSIONS

Use of the travel insurer's emergency assistance service was reported by about one quarter of claimants. In most cases, travellers sought simple claiming and policy advice, however, the emergency assistance service occasionally co-ordinated the provision of direct medical services. AME was an uncommon but expensive form of emergency assistance. Further research is needed into how useful the services provided by emergency assistance services of travel insurance companies were to the travellers that use these services.

A description of travel medicine in general practice: a postal questionnaire survey

BACKGROUND

Travel-related diseases are important aspects of public health. The number of UK residents traveling abroad is increasing at a rate of 16% a year, thereby increasing exposure to travel-related morbidity. Provision of comprehensive pretravel health advice is essential to reduce this trend. In the UK, pretravel health advice is predominantly provided through general practices.

METHODS

A postal questionnaire was sent to all 91 general practices in South Cheshire Health Authority. The questionnaires were to be completed by the lead advisor in travel medicine for each practice. Questions were asked on service provision, training and reference resources used, subjects advised on, and health promotion material used. Nonresponders were contacted and sent a further questionnaire.

RESULTS

A response rate of 86% (78/91) was achieved. Of the lead advisors, 97% were nurses and 3% general practitioners. Thirty-eight sources of advice were quoted, the commonest of which comprised wall immunization charts (72%). Duration of consultation ranged from less than 5 min to over 30 min, with a median and mode of 11 to 15 min. Most respondents reported advising on most travel-associated risks, 40% of practices lacked a protocol, and 83% of providers had attended a training course on travel medicine for 2 days or less.

CONCLUSIONS

This survey identified inadequacies of training and use of multiple sources of reference which may lead to inconsistencies in advice. Most practitioners could not define their workload in travel medicine. For effective protection of travelers, a careful risk assessment, clear risk communication and health education with detailed health promotion are necessary, but these are not likely to be provided within an average consultation time of 11 to 15 min. There is no evidence of consistent governance, planned training and monitoring of service quality of travel medicine practice. This may be due to lack of a national policy on best practice and guidance in this subject. National protocols with validated information resources, set standards of training, along with adequate consultation time for educating, advising, and prescribing, will lead to improved health of the traveling public.

Travel counsellors and travel health advice

BACKGROUND

Travel Counsellors may be a source of health advice to travellers and might influence travellers' decisions to seek consultation from health professionals. We examined the travel health advice that Alberta travel counsellors currently provide their clients and assessed their health knowledge and practices.

METHODS

Cross-sectional postal survey of travel counsellors who book international trips identified from a random sample of Alberta travel agencies in 2000.

RESULTS

The response rate was 54.4%. Over 80% of respondents routinely provide clients with general health advice, and approximately 70% advise on malaria risk and vaccines required for travel. The risk of malaria was correctly identified by 72% of the respondents who frequently book clients to malarious destinations. Most respondents (79%) thought they should be involved in promoting the health of international travellers. Their preference was to provide health advice to their clients (90%) rather than refer them to a health professional (67%).

CONCLUSIONS

A large proportion of Alberta travel counsellors provided travel-related health advice to clients. Their preferred role of counselling rather than referring conflicts with the recommendations of the International Society of Travel Medicine.

Emergency assistance provided abroad to insured travellers from Australia following the Bali bombing

Background. On 12 October 2002, terrorist bombs detonated in the Kuta entertainment district of Bali, Indonesia, a popular tourist destination for Australian travellers. This study was designed to investigate travel insurance claims reported by travellers from Australia requiring emergency assistance and/or aeromedical evacuation, as well as to examine the role of travel insurance and emergency assistance companies, following the Bali bombing. Methods. In 2003, all claims reported, following the Bali bombing attack on 12 October 2002, to a major Australian travel insurance company were examined for those claims that described the use of the insurer's emergency assistance contractor by travellers in Bali following the bombing. Results. Thirteen insured travellers used the emergency assistance service following the Bali bombing. Six travellers cancelled their trip to Bali. Five travellers, who were already abroad cancelled their trip to Bali and one was given evacuation assistance. One traveller required aeromedical evacuation by scheduled aircraft with glass injuries resulting from the bomb blast, and there was also assistance provided to significant others following the death of one insured traveller as a direct consequence of the bombing. Two travellers sought only claiming and policy advice and no claim was made. The mean refund, where a travel insurance claim was made, was AUD1185.09 (SD=AUD3047.31). Conclusions. This study highlights the importance of travellers taking out appropriate travel insurance, which provides for emergency assistance. Travel insurance agencies do play some role after emergencies such as the Bali bombing. This assistance involves predominantly dealing with cancellation of travellers' intended visits to the affected area, but does also involve some assistance to travellers evacuating from the crisis, including some who require aeromedical evacuation. Travellers should be advised to seek travel health advice well before departure overseas and to ensure that they are aware of travel advisories for their destination.

Health-related challenges in United States Peace Corps Volunteers serving for two years in Madagascar

BACKGROUND

The United States Peace Corps has nearly 8000 Volunteers (PCVs) working in more than 70 countries, predominantly in the developing part of the world. The volunteers are challenged by many new and unfamiliar health problems, as a result of change in living conditions during their service. The goal of this study was to assess the health problems of PCVs in Madagascar, and to use this information to evaluate the effectiveness of the current PCV health support program.

METHODS

PCVs, finalizing their 2 years of service, were enrolled in the study. Data were retrieved from individual Peace Corps service medical records, the close of service (COS) physical evaluation, and a PCV questionnaire, which elicited additional self-reported health problems and concerns.

RESULTS

Sixty-nine PCVs took part in the study. Median age at COS was 24 years (95% CI 23-26 years), and the male/female ratio was 1 : 3.6 (15 males and 54 females). Skin, gastrointestinal and respiratory infections constituted the three most common reported health problems. Among the registered parasitic infections were ova and parasites in the stool (42.0%), confirmed and presumptive malaria (15.9%) and schistosomiasis (11.6%). Female PCVs more frequently reported dermatologic manifestations than male PCVs: postadolescent acne (48.2% vs. 13.3%) and telogen hair loss (33.3% vs. 6.7%). Amenorrhea, as the most commonly reported menstrual alteration during service, was reported by 15 (27.7%) female PCVs.

CONCLUSIONS

The PCVs in Madagascar encounter a broad range of health-related problems, most of which are preventable infectious diseases. Reinforcement of the preservice personal health-training curriculum later during service is needed. Reported dermatologic and menstrual disturbances in female subjects may be associated with stress-related estrogen imbalance. More studies are warranted to assess the stress impact of long-term travel on the female physiology.

Reported fatal and non-fatal incidents involving tourists in Thailand, July 1997–June 1999

Objectives. To examine fatal and non-fatal incidents involving tourists in Thailand. Methods. Press records from a major English language newspaper for the period from July 1997 to June 1999 were examined for reports of fatal and non-fatal incidents involving tourists. Results. From July 1997 to June 1999, up to 233 deaths were reported and up to a further 216 were reported injured in incidents involving tourists. One hundred and one deaths and 45 injured were reported following one major domestic jet aircraft crash in southern Thailand, however, it was not stated what proportion of casualties were tourists. Approximately 90 people perished in a single hotel fire in southeast Thailand. Most of the victims were local travellers attending meetings of two Thai companies. Sixteen deaths and 86 injured resulted from five road accidents. The majority of deaths and injuries involved foreigners. Twelve deaths and at least 33 injured resulted from three ferry and tour boat accidents. Most victims were reported to be foreigners. Three deaths and 35 injured resulted from a single cable car accident in northern Thailand. Most of these were Thai tourists, however, four of the injured were foreigners. Eight deaths and six injured resulted from 11 muggings and other violent incidents. All were foreigners. Six deaths were reportedly connected to a scam at the airport in Bangkok involving unlicensed airport taxis. Three deaths and four injured were due to other reported incidents. Conclusions. Newspaper reports of fatal and non-fatal incidents involving tourists in Thailand were probably uncommon, particularly given the volume of tourists entering the Kingdom, although better reporting mechanisms are needed. With the exception of the unusual major incidents, most reported fatal and non-fatal incidents involving tourists were due to road trauma and other transportation accidents, muggings, and occasional water sports and other accidents, which could occur at any major tourist destination. Travel health advisers should include advice concerning personal safety abroad and tourist authorities should endeavour to promote and advocate for tourism safety.

Country profile: travelling to Australia

Australia has a well-developed tourism industry and health care system. Despite the precautions recommended in this paper, Australia has been virtually free of local outbreaks of life threatening tropical diseases in recent decades. This paper focuses on health and safety issues for travellers to Australia, especially the special precautions for those travelling to more rural and remote areas in outback Australia. Travellers to Australia should be advised that, in general, Australia is a relatively safe country in which to travel, and it has high standards of health and hygiene.

Assessment of travellers who return home ill

Every year, millions of people travel abroad, exposing themselves to various diseases. Advice on risk avoidance and on self-medication is not always successful; sometimes travellers return home ill or become unwell soon afterwards. There are many possible causes for such illnesses, and physicians should try to establish whether the disease is specifically associated with the recent journey. The approach to assessment of the ill traveller should make use not only of signs and symptoms, but also of geography and epidemiology. Travellers with fever need immediate attention to rule out serious and potentially life-threatening conditions. Faced with a difficult diagnosis, physicians should consult with experts in tropical and travel medicine.

Sexually transmitted diseases and travel

Sexually transmitted diseases (STDs) are infections and resulting clinical syndromes caused by more than 25 infectious organisms transmitted through sexual activity. International travellers are at great risk of contracting any of these STDs, including HIV, if they have been sexually exposed to persons with any of these diseases. Population movement has been shown to be a major contributing factor in the global spread of STDs. Increased sexual promiscuity and casual sexual relationships tend to occur during travel abroad to foreign countries. Travellers should be aware that the risk of STDs is high especially in the developing countries and sexual encounter with casual partners or commercial sex workers (CSWs) carries a high risk of infection. Prevention of STDs during travel can be achieved by complete abstinence from sexual exposure or adopting safe sexual practices such as consistently and correctly using a latex condom during sexual contact.

Unintentional injury during foreign travel: a review

Unintentional injury is a global public health problem. In 1990, an estimated 5 million people worldwide died as a result of an injury or poisoning. This accounted for 10% of deaths from all causes that year, and over half of the estimated 900 million years of life lost in 1990 due to premature death. Although mortality rates for ischemic heart disease, cerebrovascular disease, and cancer are higher, the majority of people dying of these causes are elderly, with far fewer potential years of life to live. Reasons for the increasing public health importance of injury include the decline of infectious disease, the processes of urbanization, industrialization, motorization, and increased opportunities to travel.

Incidence and precipitating factors of morbidity among Israeli travelers abroad

BACKGROUND

During recent years international travel, including visits to the developing world, has become increasingly popular. Many of these travelers suffer from some sort of health problem during their trip or after their return. Travelers clinics that give pretravel immunization and counseling have emerged. This study analyzes the incidence and risk factors for health problems among Israelis traveling abroad.

METHODS

The study surveyed by telephone 200 people who visited the traveler's clinic at Soroka Medical Center in Beer-Sheva during the years 1998 to 1999. The travelers were questioned after returning from their journey about the type and duration of the trip, compliance with medical advice given in the travel clinic, and health problems during the trip.

RESULTS

The mean age was 26.4 +/- 9.4 years, 7% went on an organized tour, 23% traveled alone, and 77% traveled with a friend. The mean duration of the trip was 14.7 +/- 13.4 weeks. Of the travelers, 70% reported some health impairment. Problems reported most frequently were gastrointestinal tract diseases (43%), respiratory tract diseases (25%), and injuries (10%). Only 4% were admitted to a hospital during their trip. After their return, 19.5% consulted a physician. Comparing the group of travelers who were sick with the rest, a correlation between noncompliance with the keeping of food hygiene and illness was found (p =.008). Additional risk factors for illness were long duration (p <.001), solitary trip (p =.04), and young age (p <.001). Of the people who were advised to take antimalaria chemoprophylaxis, 55% reported regular use of these drugs. Compliance with treatment correlated with older age (p <.001), short duration of stay (p =.01), previous experience, and travel to Africa (p <.001).

CONCLUSIONS

Most of the travelers to developing countries are young, travel for long periods, and live in basic conditions during their stay abroad. For these reasons travelers are at increased risk for morbidity. High risk travelers should be identified and counseled in order to increase their compliance with the medical advice and immunizations. A screening program for returning travelers should be considered.

How useful is PCR in the diagnosis of malaria?

Polymerase chain reaction (PCR) assays are the most sensitive and specific method to detect malaria parasites, and have acknowledged value in research settings. However, the time lag between sample collection, transportation and processing, and dissemination of results back to the physician limits the usefulness of PCR in routine clinical practice. Furthermore, in most areas with malaria transmission, factors such as limited financial resources, persistent subclinical parasitaemia, inadequate laboratory infrastructures in the poorer, remote rural areas preclude PCR as a diagnostic method. Even in affluent, non-endemic countries, PCR is not a suitable method for routine use. Nonetheless, PCR could be clinically useful in selected situations.

Infectious diseases in air travellers arriving in the UK

The ease of access to air travel and its increased popularity over the last 30 years have led to a significant incidence of imported infectious diseases and potential infectious hazards. The commonest type of illness found is acute gastroenteritis. Tuberculosis and malaria are not currently common conditions encountered in the UK, but medical vigilance is increasingly necessary as a result of these and other infectious diseases being carried by arriving air travellers. Risks of transmission to other passengers have been considered, and tuberculosis has been shown to have relatively low infectivity on commercial flights. Incidence of serious communicable disease occurring in arriving passengers is low, and should be referred to communicable disease specialists for advice on management. High standards of precautionary hygiene measures are mandatory to commercial aircraft to prevent spread of infectious agents. Disease vectors and products of animal origin pose additional potential threats to public health. Vigilance by environmental health specialists helps maintain national defences against this group of threats. Alertness to recent travel history and awareness of international public health concerns is essential for clinicians likely to encounter sick members of the travelling public. The largest commercial airports have health surveillance units, tasked with acting as a first line of defence against infectious disease. The majority of cases do not present in flight or at the airport, so they can present to any primary care clinician or emergency department. An integrated strategy for health protection will be developed in the UK with the setting up of a Health Protection Agency.

Travel insurance claims made by travelers from Australia

BACKGROUND

Little is known about travel insurance claims made by travelers returning from abroad. This study was designed to investigate travel insurance claims made by travelers from Australia, particularly examining demographic factors, type of travel insurance coverage, nature and duration of travel, when treatment was sought during travel or when the problem arose, use of emergency assistance, nature of claim, and claim outcome, including cost.

METHODS

A random sample of approximately one in five claims reported during the period 1996 to 1998 to a major Australian travel insurance company were examined.

RESULTS

A total of 855 claims were examined, of which 42.6% (356/836) were made by male travelers and 57.1% (477/836) were made by female travelers. The majority of claimants were in the 55 years and over age groups (445/836, 53.2%). Medical and dental conditions accounted for 66.6% of claims (569/854), with the remainder associated with loss, theft, and damage (285/854, 33.4%). The most common medical conditions were respiratory (110/539, 20.4%), musculoskeletal (90/539, 16.7%), gastrointestinal (75/539, 13.9%), ear, nose, and throat (67/539, 12.4%), and dental conditions (39/539, 7.2%). Only one case of venous thrombosis was reported, secondary to a lower limb infection. Use of the travel insurance company's emergency telephone service was reported in 17.1% of claims (146/853). Almost two-thirds (559/853, 65.5%) of claims were fully accepted. Those who claimed medical treatment, assault, and theft were significantly more likely to have their claims accepted compared to those claiming dental conditions, cancellation, curtailment, loss and damage (chi2 = 127.78, df = 40, p <.00001). The majority of medical and dental conditions did not require further medical investigations (427/569, 75.0%). The mean cost of claim refunds was Australian dollars (AUD)991.31 (standard deviation [SD] 6 AUD5400.76) for males and AUD508.90 (SD 6 AUD1446.10) for females. Claims for assault, cancellation, and curtailment were significantly more expensive than other types of claims (Kruskal-Wallis one way analysis of variance [ANOVA]; chi2 = 106.87, df = 8, p <.00001). Claims for treatment of gastrointestinal, cerebrovascular, cardiovascular, musculoskeletal conditions, and pyrexias of unknown origin were significantly more expensive than other medical and dental claims (Kruskal-Wallis one way ANOVA; x2 = 61.68, df = 15, p <.00001).

CONCLUSIONS

This explorative study highlights the importance of travelers taking out appropriate travel insurance. Claims for medical and dental conditions represent the majority of travel insurance claims made by Australian travelers returning from abroad, although travel insurance also covers against such contingencies as loss, theft, and cancellation. The most common medical conditions claimed were respiratory, musculoskeletal, and gastrointestinal disorders. Travelers should be advised to take out appropriate travel insurance before departure overseas and to take care with preexisting medical and dental conditions, which may not be able to be claimed against travel insurance.