Risk factors and pre-travel healthcare of international travellers attending a Dutch travel clinic: a cross-sectional analysis

Burden of dog bite injuries and wound management practices to prevent rabies among dog owners

Background

Despite members of dog-owning families being at a higher risk of dog bites owing to their proximity to dogs in their household, there are hardly any studies from India which focus on the burden of dog bites among them and their rabies control and prevention practices. This study aimed to estimate the burden of dog bites among dog owners and their wound management practices to prevent rabies.

Materials and Methods

A cross-sectional study was conducted among pet dog owners in a high-end housing society of National Capital Region of Delhi. A pre-tested and pre-validated schedule was used to collect data by consecutive sampling through community survey. Data were analyzed using R software. The incidence of dog bites and the status of rabies prevention practices adopted by the participants are presented as proportions. Chi-square test was applied to compare proportions.

Results

A total of 100 families were studied, which covered 355 family members. The incidence of dog bites in the past 1 year was found to be 44/355, 12.4% (95% confidence interval 9.2-16.3%). Pet dogs were responsible for 31/44 (70.5%) bites. Among 44 dog bite incidents, 30 (68.2%) reported taking any injection after the incident, and 10 (22.7%) reported receiving an anti-rabies vaccine. Only six out of 100 families reported at least one family member covered by rabies pre-exposure prophylaxis.

Conclusion

The incidence of dog bites among the dog owners was high. The rabies pre- and post-exposure prophylaxis practices adopted by the participants were found to be inadequate.

Travel vaccines-priorities determined by incidence and impact

BACKGROUND

Infectious disease epidemiology is continuously shifting. While travel has been disrupted by the COVID-19 pandemic and travel-related epidemiological research experienced a pause, further shifts in vaccine-preventable diseases (VPDs) relevant for travellers have occurred.

METHODS

We conducted a literature search on the epidemiology of travel-related VPD and synthesized data for each disease with a focus on symptomatic cases and on the impact of the respective infection among travellers, considering the hospitalization rate, disease sequela and case fatality rate. We present new data and revised best estimates on the burden of VPD relevant for decisions on priorities in travel vaccines.

RESULTS

COVID-19 has emerged to be a top travel-related risk and influenza remains high in the ranking with an estimated incidence at 1% per month of travel. Dengue is another commonly encountered infection among international travellers with estimated monthly incidence of 0.5-0.8% among non-immune exposed travellers; the hospitalized proportion was 10 and 22%, respectively, according to two recent publications. With recent yellow fever outbreaks particularly in Brazil, its estimated monthly incidence has risen to >0.1%. Meanwhile, improvements in hygiene and sanitation have led to some decrease in foodborne illnesses; however, hepatitis A monthly incidence remains substantial in most developing regions (0.001-0.01%) and typhoid remains particularly high in South Asia (>0.01%). Mpox, a newly emerged disease that demonstrated worldwide spread through mass gathering and travel, cannot be quantified regarding its travel-related risk.

CONCLUSION

The data summarized may provide a tool for travel health professionals to prioritize preventive strategies for their clients against VPD. Updated assessments on incidence and impact are ever more important since new vaccines with travel indications (e.g. dengue) have been licensed or are undergoing regulatory review.

Hospital-based care and/or death followed by repatriation in Dutch travelers: The HAZARD study

BACKGROUND

Travelers can experience health problems while abroad. This descriptive study aimed to quantify the disease burden leading to hospital-based care, repatriation or death in Dutch travelers during a stay in a foreign country, including Europe.

METHODS

Retrospective study of demographic and clinical data from three medical assistance centers (MACs) and the Dutch Ministry of Foreign Affairs on Dutch travelers receiving hospital-based care or who died abroad in the years 2010-2014. Diagnoses were coded according to the International Classification of Diseases (ICD) and classified using the Global Burden of Disease tool.

RESULTS

Data was available for 77,741 travelers' incidents: 75,385 medical consultations and 2356 deaths. Four in five travelers received inpatient care, of which 36% concerned older travelers (65+) who had significantly longer hospital stays. Overall the top three diagnoses were: injuries (29%), infectious diseases (17%), and cardiovascular diseases (17%). Mental illness was reported in nearly 1.5% of the travelers. Incidence proportions were highest in South-Eastern Asia, with enteric infections as most common diagnosis. Injuries and communicable diseases occurred most often in South-Eastern Asia, while non-communicable diseases were mostly reported in South America. One in five travelers who consulted a physician was repatriated back home, mostly on a scheduled flight with or without medical escort. Cardiovascular diseases and injuries were the leading causes of death.

CONCLUSIONS

Not only communicable diseases, but also injuries and chronic diseases (in particular cardiovascular diseases) frequently affected travelers' health while staying abroad and frequently necessitated hospital-based care. This should be addressed during the pre-travel counseling.

Profile and complexity of travel medicine consultations in Chile: unicentric cross-sectional study

OBJECTIVE

To analyse the spectrum, vaccination needs and pretravel advice complexity of travellers presenting at a travel medicine clinic in Santiago, Chile.

DESIGN

Cross-sectional study.

SETTING

Pretravel consultations in a private healthcare centre in Chile, an 'emerging market' country in South America.

PARTICIPANTS

Travellers (n=1341) seeking pretravel advice at the Travel Medicine Program of Clínica Alemana, Santiago, from April 2016 to March 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

Demographical and travel characteristics, indications for travel vaccines and malaria prophylaxis, and complexity of travel consultations.

RESULTS

Of 1341 travellers, 51% were female; the median age was 33 years. Most frequent travel reasons were tourism (67%) and business (20%). Median travel duration and time to departure were 21 days and 28 days, respectively. Most destinations were located in America (41%), followed by Asia (36%) and Africa (26%); 96% visited less developed countries, mostly in tropical regions, with risk of arboviral infections (94%) and malaria (69%). The indicated vaccine indications comprised hepatitis A (84%), yellow fever (58%), typhoid fever (51%), rabies (29%), polio (8%), Japanese encephalitis (6%) and meningococcal meningitis (5%). More than 60% of consultations were classified as complex.

CONCLUSION

The studied population mostly visited less developed tropical regions, resulting in a high requirement of yellow fever and other travel-related vaccinations. Most consultations were complex and required a comprehensive knowledge and training in travel medicine.

Experiences and Attitudes of International Travelers with Cardiovascular Disease: A Qualitative Analysis

Cardiovascular disease (CVD) is the leading cause of death among international travelers. It is unknown whether CVD is a barrier to international travel. The purpose of this study was to describe the travel experiences of a cohort of individuals with CVD, to identify their perceived barriers to travel, and to generate recommendations for CVD travelers, medical practitioners, and the travel industry. Semi-structured interviews were conducted with CVD patients who had attended either a regional, structured, multidisciplinary CVD prevention program or a cardiac rehabilitation program. Coding and thematic analysis of the transcripts were supported by NVivo® computer software. Peer debriefing with an independent researcher was undertaken. Demographic and clinical data such as gender, age, and types of cardiovascular condition were also recorded. Twelve patients (eight males), with a mean age of 68 ± 7.58 years, agreed to semi-structured interviews (26-78 minutes duration). The key themes emerging from the interviews included altered travel perception, accessing medical care overseas, issues with medications, medical device concerns at airports, restricted leisure travel activities, and optimal self-care. All interviewees perceived a health benefit to travel and did not regard CVD as a significant barrier to international travel. Certain cardiovascular conditions precipitated more travel anxiety. These findings highlight the unique experiences of CVD patients when engaging in international travel. Cardiovascular disease optimization and responsible travel health behaviors would facilitate medically uneventful overseas travel. The results may inform pretravel health advice given to CVD travelers. Further studies on issues relating to air travel in CVD are warranted.

Perceptions of rabies risk: a survey of travellers and travel clinics from Canada, Germany, Sweden and the UK

BACKGROUND

Extensive global experience shows that rabies pre-exposure prophylaxis (PrEP) through vaccination is effective and well tolerated, yet many travellers opt not to be vaccinated when travelling to rabies-endemic countries. Previous research has identified several factors influencing the choices travellers make to reduce the risk of rabies, including cost, time constraint and perspective on the importance of vaccination. The objectives of this study were to assess travellers' awareness of rabies and advice-seeking attitudes and to evaluate travel clinics practices regarding rabies pre-travel advice.

METHODS

We surveyed individuals aged 18-65 years residing in the UK, Germany, Canada and Sweden who had travelled to rabies-endemic countries between 2013 and 2016 and defined this as the rabies visit-risk sample. The first 850 respondents from the visit-risk sample who had undertaken pre-defined at-risk activities (e.g. contact with animals during the trip) completed an additional 15-min online questionnaire and were included in the activity-risk subsample. We also interviewed travel clinic personnel using a 25-min online or phone questionnaire.

RESULTS

The visit-risk sample included 4678 individuals. Many sought pre-travel health information online (33%) or talked to a family doctor (24%). Within the activity-risk subsample, 83% of travellers were aware of at least a few basic facts about rabies, and 84% could identify at least one correct rabies prevention measure; 49% were aware of a rabies vaccine, however, only 8% reported receiving PrEP vaccination within the past 3 years. Among 180 travel clinic respondents, 21% reported recommending PrEP against rabies to all travellers to rabies-endemic countries. Travel clinics estimated that 81% of travellers complete their travel vaccination schedules and reported sending reminders by e-mails (38%), text (38%), phone calls (37%) or by using vaccination cards (37%).

CONCLUSIONS

These findings suggest that although travellers had frequently heard of rabies, awareness of the risks of this serious infectious disease was relatively low. 5975671594001tay062media15975671594001.

A challenging entanglement: health care providers' perspectives on caring for ill and injured tourists on Cozumel Island, Mexico

Purpose: Despite established knowledge that tourists often fall ill or are injured abroad, little is known about their treatment. The intent of this study was to explore health care professionals’ treatment provision experiences on Cozumel Island, Mexico. Methods: 13 semi-structured interviews were undertaken with professionals across a number of health care vocations on Cozumel Island. Interviews were transcribed and thematically analysed to determine common challenges faced in the provision of treatment for transnational tourists. Results: Three thematic challenges emerged from the data: human and physical resource deficiencies, medical (mis)perceptions held by patients and complexities surrounding remuneration of care. Health care providers employ unique strategies to mitigate these challenges. Conclusion: Although many of these challenges exist within other touristic and peripheral spaces, we suggest that the challenges experienced by Cozumel Island’s health care professionals, and their mitigation strategies, exist as part of a complex entanglement between the island’s health care sector and its dominant tourism landscape. We call on tangential tourism services to take a larger role in ensuring the ease of access to, and provision of quality health care services for tourists on Cozumel Island.

Pre-travel care for immunocompromised and chronically ill travellers: A retrospective study

BACKGROUND

Immunocompromised and chronically ill travellers (ICCITs) are susceptible to travel related diseases. In ICCITs, pre-travel care regarding vaccinations and prophylactics is complex. We evaluated the protection level by preventive measures in ICCITs by analysing rates of vaccination protection, antibody titres, and the prescription of standby antibiotics.

METHODS

We analysed, and reported according to STROBE guidelines, pre-travel care data for ICCITs visiting the medical pre-travel clinic at the Academic Medical Centre, The Netherlands from 2011 to 2016.

RESULTS

We analysed 2104 visits of 1826 ICCITs. Mean age was 46.6 years and mean travel duration 34.5 days. ICCITs on immunosuppressive treatment (29.7%), HIV (17.2%) or diabetes mellitus (10.2%) comprised the largest groups. Most frequently visited countries were Suriname, Indonesia, and Ghana. Most vaccination rates were >90%. Of travellers in high need of hepatitis A and B protection, 56.6 and 75.7%, underwent titre assessments, respectively. Of ICCITs with a respective indication, 50.6% received a prescription for standby antibiotics.

CONCLUSION

Vaccination rates in our study population were overall comparable to those of healthy travellers studied previously in our centre. However, regarding antibody titre assessments and prescription of standby antibiotics, this study demonstrates that uniform pre-travel guidelines for ICCITs are highly needed.

Initial experience with imported Zika virus infection in Spain

INTRODUCTION

A considerable increase of imported Zika virus (ZIKV) infection has been reported in Europe in the last year. This is the result of the large outbreak of the disease in the Americas, along with the increase in the numbers of travellers and immigrants arriving from ZIKV endemic areas.

METHODS

A descriptive study was conducted in the Tropical Medicine Unit of Hospital La Paz-Carlos III in Madrid on travellers returning from an endemic area for ZIKV from January to April 2016. Demographic, clinical and microbiological data were analyzed.

RESULTS

A total of 185 patients were screened for ZIKV (59.9% women, median age of 37.7±10.3 years). Main purpose of the travel was tourism to Colombia, Brazil, and México. Just under three-quarters (73%) were symptomatic, mostly with fever and headache. A total of 13 patients (7% of those screened) were diagnosed with ZIKV infections, of which four of them were pregnant. All of them were symptomatic patients, the majority immigrants, and mainly from Colombia. Diagnostic tests were based on positive neutralization antibodies (8 cases, 61.6%) and a positive RT-PCR in different organic fluids (7 cases, 53.8%) The four infected pregnant women underwent a neurosonography every 3 weeks, and no alterations were detected. RT-PCR in amniotic fluid was performed in three of them, with negative results. One of the children has already been born healthy.

CONCLUSIONS

Our cases series represents the largest cohort of imported ZIKV to Spain described until now. Clinicians must increase awareness about the progression of the ZIKV outbreak and the affected areas so that they can include Zika virus infection in their differential diagnosis for travellers from those areas.

Travel health attitudes among Turkish business travellers to African countries

BACKGROUND

The number of international travellers is increasing worldwide. Although health risks related to international travel are important and generally well-understood, the perception of these risks was unclear among Turkish travellers. We aimed to evaluate the attitudes and health risk awareness of Turkish travellers travelling to African countries.

METHOD

A survey was performed of Turkish travellers bound for Africa from Istanbul International Ataturk Airport in July 2013.

RESULTS

A total of 124 travellers were enrolled in the study. Among them, 62.9% had information about their destination but only 11.3% had looked for information on health problems related to travel and their destination. Of all travellers, 53.2% had at least one vaccination before travelling. The most commonly administered vaccine was for typhoid. Among the travellers, 69.3% and 80.6% had "no idea" about yellow fever vaccination and malaria prophylaxis, respectively. A positive correlation was found between a higher level of travellers' education and receiving the recommended vaccination for the destination.

CONCLUSIONS

Our study revealed significant gaps in the vaccination and chemoprophylaxis uptake of Turkish travellers departing to Africa. An awareness and training program should be developed for travellers, as well as public health workers, to address health risks related to travel.

Characteristics and pre-travel preparation of travelers at a Canadian pediatric tertiary care travel clinic: A retrospective analysis

BACKGROUND

International travelers are susceptible to a wide spectrum of travel related morbidities. Despite rising number of international travelers in Canada, the demographics, risk profiles, and preventative strategies of high-risk traveler groups, including pediatric travelers visiting friends and relatives (VFRs) are not well described.

METHODS

A descriptive analysis was conducted on pre-travel consultations completed between January 2013 and August 2014 at a large pediatric tertiary care center in Toronto, Canada. Data on demographics, travel characteristics, and pre-travel interventions were extracted from 370 pre-travel consultations. Results were compared between all VFR and non-VFR travelers, as well as between children traveling to visit friends and relatives, for vacation, and for education and/or volunteer purposes.

RESULTS

Forty-eight percent of consultations were for children <18 years of age (n = 177), of which 31% were for young children (<5 years of age). Young children were more likely to travel to visit friends and/or relatives than for other purposes (29% vs 9%, p < 0.0001). Children VFRs (cVFRs) were more likely to travel for >28 days than children traveling for vacation (43% vs 1%, p < 0.0001), and children traveling for education/volunteer purposes (43% vs 21%, p = 0.03). Around half of cVFRs traveled to destinations in Asia (51%). The majority stayed with locals, friends and/or relatives (85%), and nearly all traveled to urban destinations (98%). The most prescribed interventions for children were azithromycin (84%), Dukoral (66%), and the hepatitis A vaccine (60%). Atovaquone/proguanil was the most commonly prescribed antimalarial for children.

CONCLUSION

Children that travel to visit friends and relatives represent a unique travel group and may require specific considerations during pre-travel preparations. Our findings can help develop targeted pre-travel strategies for children VFRs.

The elderly, the young and the pregnant traveler -- A retrospective data analysis from a large Swiss Travel Center with a special focus on malaria prophylaxis and yellow fever vaccination

BACKGROUND

Vulnerable individuals such as elderly, children/adolescents and pregnant/breastfeeding women increasingly travel overseas. We describe the travel and vaccination patterns of these groups at the largest Travel Clinic in Switzerland especially focusing on travel to yellow fever and malaria-endemic countries, and yellow fever vaccination (YFV) and malaria medications.

METHOD

An analysis of pre-travel visits between 2010 and 2012 at the Travel Clinic of the University of Zurich, was performed assessing differences between the elderly, young and middle-aged travelers as well as between pregnant/breastfeeding and other female travelers.

RESULTS

Overall, the vulnerable groups did not differ from other travelers regarding their travel patterns. YFV was the most often administered vaccine to elderly travelers; half of them received it for the first time. More than 30% of children/adolescents received YFV, but no child below six months was vaccinated. 80% of young travelers and a similar percentage of pregnant women went to malaria-endemic regions. Twenty-five pregnant/breastfeeding women traveled to YF endemic areas.

CONCLUSIONS

Travel patterns of vulnerable travelers are comparable to those of other travelers. In view of the limited data on malaria medications and precautions against YFV during pregnancy and at the extreme ages of life, giving travel advice to these groups is challenging.