Preparing the traveller

Global health governance for travel health: lessons learned from the coronavirus disease 2019 (COVID-19) outbreaks in large cruise ships

Background

The outbreak and global pandemic of coronavirus disease 2019 (COVID-19) attracts a great deal of attentions to the problem of travel health. Cruise tourism is increasingly popular, with an estimated 30 million passengers transported on cruise ships worldwide each year. Safeguarding the health of cruise travelers during the entire travel is of ultimate importance for both the industry and global public health.

Objective

This study aimed to explore the challenges and opportunities in travel health from the perspective of global health governance.

Methods

The global governance framework including problems, values, tools or regulations, and actors related to travel health were used to analyze the issues involved.

Results

Up to April 2020, nearly thirty cruise ship voyages reported COVID-19 cases. The Diamond Princess, Grand Princess and Ruby Princess cruise ship had over 1,400 total reported COVID-19 cases, and more than 30 deaths. A community with a common future in travel health is the core value of global health governance for travel health. The travel-related international regulations, including the International Health Regulation (IHR [2005]), United Nations Convention on the Law of the Sea (UNCLOS) and the International Maritime Organization (IMO) conventions should be further updated to deal with the travel health problems. The roles and responsibilities and the cooperation mechanisms of different actors are not clear in relation to the public health emergencies during the travel.

Conclusion

Travel health transcends national borders and involves multilevel actors, thus needs global cooperation and governance. Regulations and legislation at global and country level are required to prevent large-scale humanitarian crisis on travel health. Multilateral coordination, cooperation and collaboration mechanisms between governments, intergovernmental organizations, non-governmental organizations and industry are needed to build a better community of common destiny for travel health.

Travel/Tropical Medicine and Pandemic Considerations for the Global Surgeon

International travel goes hand in hand with medical delivery to underserved communities. The global health care worker can be exposed to a wide range of infectious diseases during their global experiences. A pretravel risk assessment visit and all appropriate vaccinations and education must be performed. Universal practices of water safety, food safety, and insect avoidance will prevent most travel-related infections and complications. Region-specific vaccinations will further reduce illness risk. An understanding of common travel-related illness signs and symptoms is helpful. Emerging pathogens that can cause a pandemic should be understood to avoid health care worker infection and spread.

Australian Pharmacists' Perceptions and Practices in Travel Health

Worldwide, pharmacists are playing an increasing role in travel health, although legislation and funding can dictate the nature of this role, which varies from country to country. The aim of this study was to explore the current and potential future practices in travel health for pharmacists in Australia, as well as the perceived barriers, including training needs, for the provision of services. A survey was developed and participation was sought from a representative sample of Australian pharmacists, with descriptive statistics calculated to summarise the frequency of responses. A total of 255 participants, predominantly female (69%), below 50 years (75%) and registered less than 30 years completed the survey. Although over two-thirds (68%) provided travel-related advice in their current practice, the frequency of advice provision was low (less than 2 travellers per week) and limited to responding to travellers questions. Although Australian pharmacists are currently unable to administer travel vaccines and prescription only medications without prescription, they still consider travel health to be an appropriate role and that their clients would seek travel health advice from pharmacies if offered. Currently, key roles for Australian pharmacists are advising travellers who do not seek advice from other practitioners, reinforcing the advice of other health practitioners and referring travellers needing vaccinations and antimalarials. In order to expand these services, the barriers of workload, time, staffing and the need for training in travel health need to be addressed. In summary, the travel health services provided by pharmacies in Australia still have a way to go before they match the services offered by pharmacies in some other countries, however Australian pharmacist are keen to further develop their role in this area.

Attitudes and awareness of medical assistance while traveling abroad

BACKGROUND

With globalization, more and more people travel to countries where they are at risk of injuries and travel-related diseases. To protect travelers' health, it is crucial to understand whether travelers accurately perceive medical assistance resources before and during their trips. This study investigated the need, awareness, and previous usage of overseas emergency medical assistance services (EMAS) among people traveling abroad.

METHODS

Anonymous questionnaires were distributed to patients (n = 500) at a travel clinic in Taipei, Taiwan.

RESULTS

The results showed that EMAS were important, especially in the following categories: 24-h telephone medical consultation (91.8%), emergent medical repatriation (87.6%), and assistance with arranging hospital admission (87.4%). Patients were less aware of the following services: arrangement of appointments with doctors (70.7%) and monitoring of medical conditions during hospitalization (73.0%). Less than 5% of respondents had a previous experience with EMAS.

CONCLUSIONS

EMAS are considered important to people who are traveling abroad. However, approximately 20-30% of travelers lack an awareness of EMAS, and the percentage of travelers who have previously received medical assistance through these services is extremely low. The discrepancy between the need and usage of EMAS emphasizes the necessity to adapt EMAS materials in pre-travel consultations to meet the needs of international travelers.

Non-pharmacotherapeutic interventions in travellers diarrhoea (TD)

BACKGROUND

This is a review of some of the non-pharmacotherapeutic interventions in travellers diarrhoea (TD) looking particularly at the role of pre and probiotics, the evidence behind water purification and the impact of advice given and its adherence by travellers.

METHOD

A systematic review of the research completed under section using the listed key words and searched using the databases of Google Scholar, Journal of Travel Medicine, QxMD, ReadCube and The Knowledge Network.

RESULTS AND CONCLUSIONS

Travellers' diarrhoea and use of pre/probiotics: There is no significant evidence to suggest the benefit of using pre or probiotics to prevent or treat TD. A new second generation of B-GOS prebiotics shows some potential in preventing the incidence and symptoms of TD but lack high levels of graded evidence. Recent reports from the biotics industry suggest that a review of the above issues is being addressed and in the future more robust studies may be completed. The evidence behind water purification and diarrhoeal disease: Evidence suggests there is no direct correlation that water purification has an impact on diarrhoeal disease, although some studies underline the value of water purification. The use of bottled water is questioned as being unreliable due to the inconsistencies of microbiological safety. With new water purification products and methods being introduced a benefit could be found for publishing effectiveness against pathogen groups to improve comparison. Are travellers given good sanitary advice and do they follow it? The advice given to travellers by non-clinical sources is unregulated and not a statutory obligation of a reservation to travel. Within the clinical sector the advice provided and the outcomes of advice provision do not correlate with a reduction in TD as a variance can occur by travellers' changes and behaviours towards the advice given. Following recommended advice and consuming higher risks foods do not correspond directly with levels of reported TD, suggesting attitudes and practices deviate away from this advice when travelling.

Travel medicine: Part 2-Special situations

Travel should be educational, fun, and safe if the appropriate care is rendered by counseling physicians and travelers take an active role in their health. In the second paper of the 2‐part special articles, we provide a practical summary of up‐to‐date travel medicine about special situations for primary care physicians. We focus on in‐flight emergencies, pregnancy, and specific precautions for injury and infectious disease as special situations. Physicians are frequently called upon to examine patients with in‐flight emergencies, and thus, they should have knowledge and skills for effectively caring patients. Common health problems over the flights include syncope, chest pain, dyspnea, and gastrointestinal symptoms. Cautious and prudent behaviors should be recommended for travelers to prevent injury and infectious disease. Follow‐up after the return home optimizes a positive outcome.

Travel health and pretravel preparation in the patient with inflammatory bowel disease

BACKGROUND AND AIMS

Foreign travel for people with inflammatory bowel disease (IBD) carries an increased risk of travel-related morbidity. There is limited research looking specifically at travel-associated health risks and travel preparation in patients with IBD. The aims of this study are to explore the experience of travel, pretravel preparation undertaken by the patient with IBD and examine IBD healthcare professionals' (HCP) confidence at providing travel advice and the content of that advice.

METHODS

A survey of patients with IBD attending an outpatient clinic with a separate online survey sent to IBD HCPs recruited using regional and international network databases.

RESULTS

A total of 132 patients with IBD, Crohn's disease (67/132, 51%), male (60/132, 45%) and 128 HCPs (IBD nurse specialist 113, 88%; IBD physician 15, 12%) completed the questionnaires. IBD affected travel to some extent in 62% (82/132) of patients, and 64% (84/132) had experienced an IBD flare, of whom 64% still travelled overseas during this time. Only 23% (31/132) travellers sought pretravel medical advice and 40% (53/132) obtained travel insurance. Forty-eight per cent of respondents on immunomodulator therapy were unaware of the need to avoid live vaccines. Twenty-seven per cent (34/128) of IBD HCPs are not confident at providing pretravel advice; vaccination advice (54%), obtaining travel insurance (61%) and healthcare abroad (78%) are the areas of most uncertainty.

CONCLUSIONS

Patients do not seek adequate pretravel advice and consultations for those who do are often deficient. The majority of IBD professionals are not confident to provide comprehensive travel advice. Greater IBD-specific travel education and awareness is needed for both patients with IBD and professionals.

Counseling for the Wilderness Athlete and Adventurer During a Preparticipation Evaluation for Preparation, Safety, and Injury Prevention

Wilderness sports and adventures continue to increase in popularity. Counseling is an essential element of the preparticipation evaluation (PPE) for athletes in traditional sports. This approach can be applied to and augmented for the wilderness athlete and adventurer. The authors reviewed the literature on counseling during PPEs and gathered expert opinion from medical professionals who perform such PPEs for wilderness sports enthusiasts. The objective was to present findings of this review and make recommendations on the counseling component of a wilderness sports/adventure PPE. The counseling component of a PPE for wilderness sports/adventures should take place after a basic medical evaluation, and include a discussion on sport or activity-specific injury prevention, personal health, travel recommendations, and emergency event planning. Counseling should be individualized and thorough, and involve shared decision making. This should take place early enough to allow ample time for the athlete or adventurer to further prepare as needed based on the recommendations. Resources may be recommended for individuals desiring more information on selected topics.

Effectiveness of pre-travel consultation in the prevention of travel-related diseases: a retrospective cohort study

BACKGROUND

This study aims to evaluate the effectiveness of pre-travel counselling carried out in Travel Clinics.

METHODS

This is a retrospective cohort. Three hundred international travellers were enrolled; 150 people were from users of Bari Travel Clinic, 150 were users of a travel agency. Enrolled subjects were interviewed using a questionnaire.

RESULTS

The average age of the enrolled subjects was 37.5 ± 13.9, without statistically significant differences between the two groups. 86% of cases and 19.3% of the controls reported the use of anti-malaria prophylaxis (p < 0.0001). Vaccination against cholera was given to 62% of cases and 7.3% of the controls (p < 0.001). Travel Clinic users, 6% reported diarrhoea and these figures were 27% in the control group (p < 0.0001). The proportion of those interviewed who reported fever (3.7) or insomnia (1.3) did not differ between the two groups. Mosquito bites were reported by 8% of cases and 20% of the controls (p = 0.003). Three cases of malaria were reported among the controls but no cases were detected among the cases (chi-square = 3.03; p = 0.08).

CONCLUSIONS

Our study demonstrated the effectiveness of pre-travel counselling; in the future, new studies must investigate the cost-effectiveness of pre-travel prevention measures.

Counseling for the Wilderness Athlete and Adventurer During a Preparticipation Evaluation for Preparation, Safety, and Injury Prevention

Wilderness sports and adventures continue to increase in popularity. Counseling is an essential element of the preparticipation evaluation (PPE) for athletes in traditional sports. This approach can be applied to and augmented for the wilderness athlete and adventurer. The authors reviewed the literature on counseling during PPEs and gathered expert opinion from medical professionals who perform such PPEs for wilderness sports enthusiasts. The objective was to present findings of this review and make recommendations on the counseling component of a wilderness sports/adventure PPE. The counseling component of a PPE for wilderness sports/adventures should take place after a basic medical evaluation, and include a discussion on sport or activity-specific injury prevention, personal health, travel recommendations, and emergency event planning. Counseling should be individualized and thorough, and involve shared decision making. This should take place early enough to allow ample time for the athlete or adventurer to further prepare as needed based on the recommendations. Resources may be recommended for individuals desiring more information on selected topics.

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.

Pharmaceutical care model to assess the medication-related risks of travel

BACKGROUND

People are at greater risk of health problems when travelling and a significant number of travel-related health problems are associated with the effects of travel on pre-existing chronic diseases. Medications play a key role in the management of these conditions. However, there is a notable lack of research evaluating the potential medication-related risks associated with travel.

OBJECTIVE

To apply a systematic pharmaceutical care model developed to evaluate potential pharmaceutical risks (PPRs) and pharmaceutical care issues (PCIs) in travellers.

SETTING

Adult travellers leaving Cairns International Airport, Australia, for an international destination.

METHOD

A cross-sectional survey using semi-structured interviews, including a systematic medication history, followed by the application of a pharmaceutical care model to evaluate each participant for PPRs and PCIs.

MAIN OUTCOME MEASURE

Evaluation of standard clinical and travel-related PPRs and PCIs.

RESULTS

Medications for chronic diseases were being taken by 47.7% of the 218 travellers interviewed. Although 75.2% of participants presented with no PPRs, a total of 274 PCIs were identified across 61.5% of the participants, with an average of 2.04 PCIs per participant. The most prevalent PCIs related to the inadequate precautions taken by some travellers visiting malaria-endemic regions. Although 91 participants recognised that they were travelling to malaria-endemic regions, 65.9% of these participants were not using malarial chemoprophylaxis, and only 16.5% were using chemoprophylaxis that fully complied with standard recommendations. The second most prevalent PCI was the need for 18.8% of participants to be educated about their medications. Other PCIs identified have the potential to increase the risk of acute, travel-related conditions, and complicate the care of travellers, if they inadvertently became unwell while overseas.

CONCLUSION

PPRs and PCIs were not identified in all participants. However, the impact of many of the identified medication-related issues could be substantial to the traveller. This study represents the novel application of a pharmaceutical care model to identify potential PPRs and PCIs in travellers that may not be identified by other pre-travel risk assessment methods.

Infections in travelers

Travel medicine continues to grow as international tourism and patient medical complexity increases. This article reflects the state of the current field, but new recommendations on immunizations, resistance patterns, and treatment modalities constantly change. The US Centers for Disease Control and the World Health Organization maintain helpful Web sites for both patient and physician. With thoughtful preparation and prevention, risks can be minimized and travel can continue as safely as possible.

The reliability of pre-travel history to decide on appropriate counseling and vaccinations: a prospective study

BACKGROUND

Although medical and travel plans gathered from pre-travel interviews are used to decide the provision of specific pre-travel health advice and vaccinations, there has been no evaluation of the relevance of this strategy. In a prospective study, we assessed the agreement between pre-travel plans and post-travel history and the effect on advice regarding the administration of vaccines and recommendations for malaria prevention.

METHODS

We included prospectively all consenting adults who had not planned an organized tour. Pre- and post-travel information included questions on destination, itineraries, departure and return dates, access to bottled water, plan of bicycle ride, stays in a rural zone, and close contact with animals. The outcomes measured included: agreement between pre- and post-travel itineraries and activities; and the effect of these differences on pre-travel health recommendations, had the traveler gone to the actual versus intended destinations for actual versus intended duration and activities.

RESULTS

Three hundred and sixty-five travelers were included in the survey, where 188 (52%) were males (median age 38 years). In 81(23%) travelers, there was no difference between pre- and post-travel history. Disagreement between pre- and post-travel history were the highest for stays in rural zones or with local people (66% of travelers), close contact with animals (33%), and bicycle riding (21%). According to post-travel history, 125 (35%) travelers would have needed rabies vaccine and 9 (3%) typhoid fever vaccine. Potential overprovision of vaccine was found in <2% of travelers. A change in the malaria prescription would have been recommended in 18 (5%) travelers.

CONCLUSIONS

Pre-travel history does not adequately reflect what travelers do. However, difference between recommendations for the actual versus intended travel plans was only clinically significant for the need for rabies vaccine. Particular attention during pre-travel health counseling should focus on the risk of rabies, the need to avoid close contact with animals and to seek care for post-exposure prophylaxis following an animal bite.

Quality of travel health advice in a French travel medicine and vaccine center: a prospective observational study

BACKGROUND

The number of international trips undertaken by French citizens is rising and we wished to assess the appropriateness of advices given to travelers in a vaccine and travel medicine center in France.

METHODS

We conducted a 3-month prospective study in one center in Paris where prescriptions and advice to travelers are given by trained physicians in travel medicine who have access to a computerized decision support system (Edisan). A questionnaire was used to record trip characteristics, patients' demographics, and prescriptions. Main outcome measure was the adequacy of prescriptions for malaria prophylaxis, yellow fever, and hepatitis A vaccines to French guidelines.

RESULTS

A total of 730 subjects were enrolled in this study, with a median age of 28 years. Travel destinations were sub-Saharan Africa (58%), Asia (21%), and South America (18%). Among the 608 patients (83%) traveling to malaria-endemic areas, malaria prophylaxis was in accordance with guidelines in 578/608 patients (95.1%, 95% CI: 93-96.5), and doxycycline was the regimen of choice (48%). Inappropriate malaria prophylaxis was given to eight patients, one of whom developed plasmodium falciparum malaria. All 413 patients (100%, 95% CI: 99-100) traveling to yellow fever-endemic areas who needed vaccination were correctly vaccinated. However, three patients received yellow fever vaccination without indication. Also, 442 of 454 patients (97.4%, 95% CI: 95.4-98.5) eligible to receive hepatitis A vaccination were immunized.

CONCLUSION

Appropriate advice for malaria prophylaxis, yellow fever, and hepatitis A vaccinations was provided in a travel medicine and vaccine center where trained physicians used a computerized decision support system. Even in this setting, however, errors can occur and professional practices should be regularly assessed to improve health care.

A comparison of pharmacist travel-health specialists' versus primary care providers' recommendations for travel-related medications, vaccinations, and patient compliance in a college health setting

BACKGROUND

Pretravel medication and vaccination recommendations and receipt were compared between primary care providers (PCPs) without special training and clinical pharmacists specializing in pretravel health.

METHODS

A retrospective chart review of patients seen for pretravel health services in a pharmacist-run travel clinic (PTC) compared to PCPs at a University Student Health Center. Vaccine/medication recommendations were assessed for consistency with national/international guidelines. Medical/pharmacy records were queried to determine the receipt of medications/vaccinations.

RESULTS

The PTC recommended antibiotics for travelers' diarrhea were given more often when indicated (96% vs 50%, p < 0.0001), and patients seen in the PTC received their medications more often (75% vs 63%, p = 0.04). PCPs prescribed more antibiotics for travelers' diarrhea that were inconsistent with guidelines (not ordered when indicated 49% vs 6%, p < 0.0001 and ordered when not indicated 21% vs 3%, p < 0.0001). The PTC prescribed antimalarials more often when indicated (98% vs 81%, p < 0.0001), while PCPs prescribed more antimalarials that were inconsistent with guidelines (not ordered when indicated 15% vs 1%, p < 0.0001 and ordered when not indicated 19% vs 2%, p < 0.0001). The PTC ordered more vaccines per patient when indicated (mean = 2.77 vs 2.31, p = 0.0012). PTC patients were more likely to receive vaccines when ordered (mean = 2.38 vs 1.95, p = 0.0039). PCPs recommended more vaccines per patient that were inconsistent with guidelines (not ordered when indicated: mean = 0.78 vs 0.12, p < 0.0001, ordered when not indicated: mean 0.18 vs 0.025, p < 0.0001).

CONCLUSIONS

A pharmacist-run pretravel health clinic can provide consistent evidence-based care and improve patient compliance compared to PCPs without special training. Pretravel health is a dynamic and specialized field that requires adequate time, resources, and expertise to deliver the best possible care.

A questionnaire study of Voluntary Service Overseas (VSO) volunteers: health risk and problems encountered

BACKGROUND

Every year several hundred Voluntary Service Overseas (VSO) volunteers are placed in developing countries where they live and work among the local population. This study analyzes the risk and problems encountered by VSO volunteers overseas.

METHODS

Information was collected from 219 returned VSO volunteers (out of 609; response rate 36%) recruited in the United Kingdom, using a self-administered questionnaire. During the period April 2006 to March 2007 volunteers were given a questionnaire by the VSO medical unit in London with a return envelope.

RESULTS

Diarrhea was the most prevalent problem (79.9%), especially for the younger volunteers. Skin and dental problems were next most prevalent. More than one in six had experienced accidents and nearly one-fourth acts of aggression (including verbal) or violence. Most (87.5%) lived in regions with mosquito-borne diseases, 11.6% of these had smear positive malaria. Of all volunteers, 11.0% had placed themselves at risk of HIV and sexually transmitted infections (STIs). Unprotected sexual intercourse (45.0%) and split condoms (30.0%) were the main sexual health risk factors. Just over one-fourth of volunteers reported ongoing medical/psychological problems on return, the most common being diarrhea (25.0%), skin disease (15.4%), gynecological problems (13.5%), and injuries (9.6%).

CONCLUSION

Volunteers experience a range of health problems during and after their placement in the developing world. Our study shows the importance of (1) predeparture health preparation of volunteers and (2) medical care and advice for volunteers. This advice is also important for travelers in similar conditions such as those visiting relatives, long-term backpackers, and students working in or traveling to developing countries. Further research is needed to help explain some of the findings and study ways of preventing accidents and illness.

[Infectious diseases transmission during air travel: from myth to reality]

En pocas horas el transporte aéreo puede diseminar enfermedades infecto-contagiosas alrededor del mundo. Aunque se considera uno de los medios de transporte más seguros, poco se conoce sobre qué tanto lo es para la salud pública internacional, teniendo en cuenta que se está expandiendo e incrementando la cantidad de usuarios que pueden llegar a adquirir y diseminar este tipo de enfermedades.

El punto crítico para evitar una pandemia es prever y estar preparados; esto se logra con el entrenamiento del personal de la salud y el de aviación. Por estas razones, este manuscrito busca mostrar el panorama general del impacto que tiene el ambiente aeronáutico sobre la transmisión de enfermedades infecciosas y las estrategias que se han ideado para lograr activar las alertas epidemiológicas tempranamente y controlar un posible brote, las cuales abarcan la educación del personal de salud, el de vuelo y el pasajero en tierra, la prevención, profilaxis e identificación temprana de la enfermedad y el manejo inmediato y retrospectivo del evento después del vuelo.

A retrospective study of 230 consecutive patients hospitalized for presumed travel-related illness (2000-2006)

A good knowledge of morbidity profiles among ill-returned travelers is necessary in order to guide their management. We reviewed the medical charts of 230 patients hospitalized in one infectious diseases department in France for presumed travel-related illnesses. The male-to-female ratio was 1.6 and the median age was 33 years (interquartile range [IQR], 25–50). Most patients (70.9%) were returning from sub-Saharan Africa. The median duration of travel was 28 days (IQR, 15–60) and the median time from return of travel to hospitalization was 13 days (IQR, 7–21). Malaria was the most frequent diagnosis (49.1%), which was especially encountered in patients returning from sub-Saharan Africa (95.6%), without adequate chemoprophylaxis (78.2%). Imported diseases at risk of secondary transmission were also diagnosed, including pulmonary tuberculosis (n = 8), viral hepatitis (n = 8), typhoid fever (n = 6), human immunodeficiency virus (HIV) (six new diagnosis), non-typhoid salmonellosis (n = 5), severe acute respiratory syndrome, and Crimean-Congo hemorrhagic fever. This study underlines the need to maintain tropical expertise for infectious diseases physicians, even in Europe.

Safety of Typhim Vi vaccine in a postmarketing observational study

BACKGROUND

Typhoid fever is endemic in many parts of the world. In the United States, nearly three quarters of all cases are contracted by persons who traveled to regions with endemic disease. Typhim Vi, a vaccine containing the purified cell surface Vi polysaccharide of the Salmonella enterica serovar Typhi, was developed to provide protection against typhoid fever. We present the results of the largest safety study of this Vi vaccine to date.

METHODS

This open-label, descriptive study assessed safety and reactogenicity following the Vi vaccine administration. Coadministration of other vaccines (at separate sites) was permitted, consistent with clinical practice. Participants aged 2 years or older with no known sensitivities to any vaccine component, who received the Vi vaccine, according to label directions, at a participating travel clinic, were eligible to participate. Information was collected on concurrent medications and medical conditions. The occurrence of solicited injection site reactions and systemic reactions was recorded on diary cards for 7 days following vaccination, along with any unsolicited medical events. Serious adverse events were reported for 30 days postimmunization.

RESULTS

A total of 1,204 participants (mean age: 37.2 y, range: 2-82 y, 55% female) were enrolled into the study, and 1,111 completed the 7-day follow-up. The most common solicited reactions were injection site pain [850 of 1,111 (76.5%)], tenderness [838 of 1,111 (75.4%)], and muscle aches [434 of 1,111 (39.1%)]. Fever was reported in 18 (1.6%) of 1,111 participants. Coadministration of other common travel vaccines did not affect reactogenicity profiles, except for an increase in the Vi vaccine injection site redness when two vaccines were administered in the same limb.

CONCLUSIONS

The Vi vaccine was well tolerated in an unselected population, aged 2 to 82 years, presenting to a travel clinic for vaccination.

Illness and injury presenting to a Norwegian travel insurance company's helpline

INTRODUCTION

Travel abroad is increasing, yet little attention has been paid to the use of health services by specific groups of travellers. This study describes the prevalence of illness, injury and subsequent changes to homeward bound travel and the costs for a group of Norwegian travellers.

METHODS

In 2003, 1787 cases were registered in the data base of the helpline of Norway's largest insurance company. This data were analyzed for prevalence of illness and injury according to age, gender, type of illness or injury, travel destination, type of travel, and the impact on return travel.

RESULTS

Illness and injury accounted for 76.2% and 23.8% of the notifications, respectively. Travellers over the age of 60 accounted for 32.3% of the total number of illnesses. The illness reported most frequently was infection (20.3%), with the highest prevalence of infections occurring in Southern and Eastern Europe (10.2%). The results obtained in this study were compared with studies of other populations of European travellers, revealing that infectious diseases are the most prevalent illness. Differences were noted in the incidence of cardiovascular disease and the destinations where this occurred, and of fatality.

CONCLUSION

The results of this study when compared with those of other European travellers revealed that sufficient difference occurs. As a consequence pre-departure information needs to target better specific population groups with respect to minimizing the risk of illness and injury. As well, the collection of data by the insurance company misses the opportunity of acquiring data of real value for future travellers, the insurance company and the medical profession. It is argued that there is a need to develop a comprehensive data base of greater use than available currently.

Travel Characteristics and Health Practices Among Travellers at the Travellers’ Health and Vaccination Clinic in Singapore

Introduction: Singapore has a fast-growing travel industry, but few studies have been done on travel characteristics and travel health practices. This study describes the profile and health-seeking behaviour of travellers attending a travel health clinic in Singapore. Materials and Methods: A cross-sectional survey was conducted on travellers attending the Traveller’s Health and Vaccination Centre (THVC) between September and November 2002 using a standardised questionnaire. Information obtained included individual demographic and medical information, travel patterns, vaccination status and travel health practices. Results: Four hundred and ninety-five (74%) eligible travellers seen at THVC responded to the questionnaire. Their mean age was 36 years; 77% were professionals, managers, executives, and businessmen, students, and white collar workers. Asia was the main travel destination, and most travelled for leisure and resided in hotels or hostels. The median duration of travel was 16 days. Although >90% had previously travelled overseas, only 20% had previously sought pre-travel advice. Malays were significantly underrepresented (P <0.01); and Caucasians and Eurasians were significantly more likely (P <0.01) to have previously sought pre-travel advice compared with Chinese, Indians and Malays. Factors associated with seeking pre-travel advice included travel outside of Asia, especially Africa and South America. Conclusion: Singaporean travellers travel more often to cities rather than rural areas, compared with non-Asian travellers. Asia is the preferred destination, and travel outside of Asia is perceived as more risky and is associated with seeking pre-travel advice and vaccinations. Travel patterns and behaviours need to be taken into account when developing evidence-based travel medicine in Asia. Key words: Cross-sectional survey, Health behaviour, Travel, Vaccination

Running a travel clinic

Annually, 1.5 billion passengers travel by air and 700 million travellers cross international borders, and around 50% of them can become unwell in some way. In today's world travel is important for business people as it is for humanitarian groups and immigrants, as it is also for holiday makers. All travellers need to be aware of potential health problems and consequences of their travel, and they need up to date authoritative advice. Travel health clinics provide this advice in a structured, practical and authoritative format. Such a format is discussed, and applied with the skills of medical, nursing and management practitioners. The four steps for giving travellers the foundation for healthy journeys are all explored: to assess pre-health, to analyse itineraries, to select appropriate vaccines, and to provide education about the prevention and self-treatment of travel-related diseases.

Diarrhea and respiratory symptoms among travelers to Asia, Africa, and South and Central America from Scotland

Surveillance using admissions to hospital, while being useful, is a poor indicator of the real incidence of disease encountered by travelers. An alternative is self-reported illness among those who attended at a pretravel clinic prior to their travels. Estimates of incidence and risk factors were determined for attendees at a travel clinic in Scotland using a questionnaire. Analysis for risk factors was carried out for those travelers visiting countries in Africa, Asia, or South and Central America, who had traveled for 1 week or more and had returned between 1997 and 2001 (N= 4,856). Multivariate logistic regression was used to test the hypotheses that time abroad and age-group would be significant for both respiratory and diarrheal symptoms regardless of which of the three geographical areas are visited. From 2006 returned questionnaires (response rate = 41.3%), diarrhea and respiratory symptoms were reported by 44.2 and 16.8% of respondents, respectively; the incidence was significantly greater among travelers to Asia for both diarrheal (55.5%) and respiratory (23.7%) symptoms than among travelers to Africa (36.6 and 12.2%, respectively) or South and Central America (39.5 and 16.2%, respectively). For diarrhea, age was a highly significant risk factor for travelers to Asia, South and Central America, and Africa. Being a self-organized tourist/backpacker, traveling to Asia was associated with increased risk, while for Africa and South and Central America visiting family or friends was associated with a lower risk. For travelers to Asia, traveling to the Indian subcontinent was significantly associated with increased risk. The majority of travelers had an adverse event while traveling abroad, with diarrhea and respiratory conditions being especially common despite attending a travel clinic for advice prior to departure. However, the limitations of this surveillance-based strategy have highlighted the requirement for more research to understand more fully the issues of risk and incidence among travelers to high-risk destinations from Scotland.

Recomendaciones al viajero en situaciones especiales

The increase in the hope and quality of life, along with the greater rapidity and comfort of the different means of transport have made possible that travellers with chronic diseases, pregnant and kids makes tourist trips to tropical or subtropical zones. On the other hand the increase of the international cooperation has caused the appearance of long stay travellers who live in conditions such as the local population. These travellers have special characteristics due to their physical training conditions, chronic treatments, or the way of life during the travel that them makes more susceptible to suffer problems of health during the travel. For this reason the usual recommendations for travellers are insufficient in these groups and is necessary to make an individualized travel advice that considers these factors. This revision shows the most important warnings that must be made in these groups of special travellers.

Prevention of travel-related infectious diseases in families of internationally adopted children

Pretravel consultation before international adoption must encompass standard advice for those who travel, advice for those who are exposed to the newly adopted child, and information about caring for a new child during travel. Children who travel to meet siblings may need special accommodations before and during travel. Data on the health of internationally adopted children illustrate the risk of exposing family members and close contacts to some infectious diseases during or after international adoption. Parents, family members, and close contacts of the newly adopted child should be given advice to reduce their own and their child's risk. Targeted preadoption counseling, close attention to hygiene and safety advice, and prompt identification and treatment of infections lead to the safest and most trouble-free adoption travel experience.

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.

Review of 1 year's activity in the Grampian travel clinic: the importance of the oil industry

BACKGROUND

A review of the activities of the Grampian travel clinic was carried out over 1 year to obtain an overall perspective of the clinic workload and to determine how much of the workload was dependent on the oil industry.

METHODS

A specially designed data collection sheet was completed for each of the 669 consultations conducted at the Grampian travel clinic, Aberdeen, between February 1, 2002, and January 31, 2003.

RESULTS

Patients attending the clinic came in equal numbers from the city of Aberdeen and the Grampian region. Twenty-five percent were traveling for work purposes: 87.4% of this travel was oil related, and most patients were headed to Africa. The commonest vaccines given were for yellow fever, Japanese B encephalitis, and rabies, reflecting the specialist nature of the clinic. Most travelers did leave adequate time for immunization before travel. The public is still apprehensive about using mefloquine as malarial prophylaxis.

CONCLUSIONS

Most attendees were traveling on holiday, but a quarter of the consultations were for travel related to the oil industry. Almost 70% of attendees had already visited their general practitioner and were therefore attending the clinic for specialist advice and vaccines. There is a need for increased clinic capacity.

Yellow fever vaccine: An updated assessment of advanced age as a risk factor for serious adverse events

Since 1996, the scientific community has become aware of 14 reports of yellow fever vaccine (YEL)-associated viscerotropic disease (YEL-AVD) cases and four reports of YEL-associated neurotropic disease (YEL-AND) worldwide, changing our understanding of the risks of the vaccine. Based on 722 adverse event reports after YEL submitted to the U.S. Vaccine Adverse Event Reporting System in 1990-2002, we updated the estimates of the age-adjusted reporting rates of serious adverse events, YEL-AVD and YEL-AND. We found that the reporting rates of serious adverse events were significantly higher among vaccinees aged > or =60 years than among those 19-29 years of age (reporting rate ratio = 5.9, 95% CI 1.6-22.2). Yellow fever is a serious and potentially fatal disease. For elderly travelers, the risk for severe illness and death due to yellow fever infection should be balanced against the risk of a serious adverse event due to YEL.

Health protection: communicable disease, public health and infection control educational programmes—a case study from the UK

The health protection (HP) landscape is changing. Issues related to infectious diseases in the context of global health are receiving the attention of world leaders and policy makers. In the UK, the national health policies resonate with such transformations, presenting a range of opportunities and challenges. The opportunities include the formation of a new national organisation dedicated to protecting the people's health and reducing the impact of infectious disease, the Health Protection Agency. The opportunities also include the opening of non-medical specialists's pathways in public health. The challenges represent the limited number of centres offering infection control education; the hospital focus and bias of the courses; new, resurgent and emerging infections; globalisation and travel; bacterial resistance; vaccine safety and coverage; bioterrorism; global response capacity; and visa restrictions. Within this context, this paper presents a case study of a HP educational programme at a British university in the south of England. It outlines the course design and philosophy, participants, recruitment, aims, descriptions and learning outcomes. A range of teething problems associated with the initiation and running of such programmes is considered. These include aspects related to the university, features associated with the modules, characteristics of the students, and other interconnected larger scale international issues. Some suggestions for the way forward are presented. Collectively, attention to the suggested measures can ensure that the processes that teaching programmes embrace to refine their content and delivery will equip tomorrow's professionals with the requisite HP knowledge and skills.

Immunizations for the college student: a campus perspective of an outbreak and national and international considerations

Although vaccine-preventable diseases have declined to record-low levels in the United States, infectious disease "epidemics" on college campuses continue. A large student body with variable immunization status makes a college campus fertile ground for the spread of communicable diseases. The presence of international students and an increasingly large number of students traveling abroad make it essential that individuals charged with defining and instituting health-related policies for the university have knowledge about health issues occurring in foreign countries as well. Several safe and effective vaccines are available that offer protection to young adults from a variety of infectious diseases in the United States. Because vaccine-preventable diseases can cause both human and economic problems for colleges and universities, administrators should take steps to assure that the students on college campuses benefit from these vaccines.

Health care of the long-term traveller

Long-term travellers are exposed to a greater extent and a greater depth of risk than short-term travellers. This includes both physical and psychological illness and vulnerability. We need a paradigm of care both before, during and after travel which includes evidence-based medicine but extends beyond it into a more creative response to the whole person needs of this unique group of people. Caring for long-term travellers in the variety and complexity of their physical, social and mental health needs is one of the most rewarding branches of travel medicine [Zuckerman J. Travel medicine; recent developments. Br Med J 2002;325:260-4; Zuckerman J. Travel medicine BMJ careers; 26 June 2004, p. 277-8.].

Nationwide survey of the role of travel medicine in primary care in Germany

BACKGROUND

With more persons traveling to (sub)tropical destinations, travel medicine is an increasing challenge for the health care system in many countries. This study investigated the role and scope of travel medicine provided by general practitioners (GPs) in primary health care, assessed the determinants of specific prophylactic recommendations, and identified the needs of GPs regarding training and cooperation in travel medicine.

METHODS

A national survey was conducted among randomly selected GPs in Germany. Information on the type and extent of activities in travel medicine, the number and characteristics of patients, the use of specific information systems, and training and cooperation, was obtained with a standardized postal questionnaire. Representativeness was assessed by a computer-assisted telephone survey among nonrespondents. Univariate and multivariate statistical analysis was performed.

RESULTS

Of all GPs (n=1,320), 95% provided medical pretravel advice or post-travel counseling (13.2 patients/month). The most common topics in pretravel consultation were immunizations (95%), malaria chemoprophylaxis (94%), advice on exposure prophylaxis (41%), and advice on protection from sexually transmitted infections (STIs) (43%). GPs frequently advised certain patient groups (e.g., cardiovascular patients 68%, pregnant women 20%). Travelers' diarrhea was the most common topic in post-travel consultation (89%), followed by fever (38%). Of the GPs, 25% cooperated regularly with institutions with special expertise in travel medicine or tropical diseases. Sixty-four percent had received some training in travel medicine, and 86% stated a need for additional training. In the multivariate analysis, independent determinants for advice on exposure prophylaxis and STI risks included special training in travel medicine, use of country-specific information sources, and location of the practice in the former West Germany and urban areas.

CONCLUSIONS

Travel medicine is of importance in primary health care in Germany. There is a need for improved counseling on exposure and STI prophylaxis. GPs' training in travel medicine and cooperation with institutions such as institutes, clinics and laboratories for tropical medicine should be improved.

Antibiotics for Travelers: What's Good and What's Not

International travel to exotic destinations continues to increase, as does the risk for illness during travel. Health problems during travel are common. Although many medical problems that travelers incur are noninfectious in origin (eg, injuries, environment-associated illness), travelers often are at risk for acquiring a variety of infections. Many travel-related infections also occur commonly in the developed world, whereas other infections of travelers may be geographically restricted to specific world regions and/or are infrequently encountered in developed nations. Antibiotics play an important role in the treatment and prevention of a variety of bacterial and parasitic infections in travelers. This article reviews antibiotics of particularly high utility to travelers, with emphasis on selected agents that, with appropriate advice from a travel medicine specialist, can be used safely for prophylaxis and self-treatment during travel. The role of antibiotics in selected high-risk travelers also is discussed.