Travel medicine and mHealth technology: a study using smartphones to collect health data during travel

Surveillance of global, travel-related illness using a novel app: a multivariable, cross-sectional study

INTRODUCTION

Current traveller health surveillance is 'top-down'. Mobile-based surveillance could capture infection symptoms in real time. We aimed to evaluate the spectrum of illness in travellers using a mobile app-based system.

METHODS

This study (ClinicalTrials.gov NCT04672577) used an application called Infection Tracking in Travellers (ITIT) that records travel-related illness symptoms with associated geolocation and weather data. The free ITIT app is available in 14 languages. Participants were recruited globally from April 2022 to July 2023. Participants >18 years of age travelled internationally and provided electronic consent. Incentives included the provision of travel health information imported from the WHO website. Symptoms were recorded with daily pop-up questionnaires and symptom severity was assessed using a Likert scale. Two post-travel questionnaires were administered. Logistic mixed models examined factors relating to symptom presence, and a random forest model examined symptom impact.

RESULTS

609 participants were recruited until July 2023. Participants had an average age of 37 years (18-79), and an average travel duration of 26 days (2-281). Most participants were travelling for leisure/tourism (401; 66%), followed by 'visiting friends and relatives' (99; 16%) and business travel (80; 13%). All continents were visited by at least one traveller. Of 470 registered trips, symptoms were reported on 163 trips (35%). Gastrointestinal symptoms were reported on 87 trips (19%) and respiratory symptoms on 81 trips (17%). The most important factors in predicting the presence of symptoms were duration of travel, travelling in winter and high humidity. Diarrhoea, headache and nausea were symptoms with most impact on daily activities. Post-travel questionnaires showed that 12% of surveyed participants experienced symptoms with several episodes of self-treatment. Two diagnoses were recorded: Lyme disease and amoebic dysentery.

CONCLUSION

The digital tool ITIT successfully captures the spectrum of travel-related illness. This detailed epidemiology is crucial for outbreak detection and for the formulation of travel medicine guidelines.

TRIAL REGISTRATION NUMBER

NCT04672577.

The Implementation of a GPS-Based Location-Tracking Smartphone App in South Africa to Improve Engagement in HIV Care: Randomized Controlled Trial

BACKGROUND

Mobile health interventions are common in public health settings in Africa, and our preliminary work showed that smartphones are increasing in South Africa. We developed a novel smartphone app-CareConekta-that used GPS location data to characterize personal mobility to improve engagement in HIV care among pregnant and postpartum women living with HIV in South Africa. The app also used the user's location to map nearby clinics.

OBJECTIVE

We aimed to describe the feasibility, acceptability, and initial efficacy of using the app in a real-world setting.

METHODS

We conducted a prospective randomized controlled trial at a public sector clinic near Cape Town, South Africa. We enrolled 200 pregnant (third trimester) women living with HIV who owned a smartphone that met the required specifications. All participants installed the app, designed to collect 2 GPS heartbeats per day to geolocate the participant within a random 1-km fuzzy radius (for privacy). We randomized (1:1) participants to a control arm to receive the app with no additional support or an intervention arm to receive supportive phone calls, WhatsApp (Meta Platforms, Inc) messages, or both from the study team when traveling >50 km from the study area for >7 days. In addition to mobility data collected daily through the phone, participants completed questionnaires at enrollment and follow-up (approximately 6 months post partum).

RESULTS

A total of 7 participants were withdrawn at enrollment or shortly after because of app installation failure (6/200, 3%) or changing to an unsuitable phone (1/200, 0.50%). During the study period, no participant's smartphone recorded at least 1 heartbeat per day, which was our primary feasibility measure. Of the 171 participants who completed follow-up, only half (91/171, 53.2%) reported using the same phone as that used at enrollment, with the CareConekta app still installed on the phone and GPS usually enabled. The top reasons reported for the lack of heartbeat data were not having mobile data, uninstalling the app, and no longer having a smartphone. Acceptability measures were positive, but participants at follow-up demonstrated a lack of understanding of the app's purpose and function. The clinic finder was a popular feature. Owing to the lack of consistent GPS heartbeats throughout the study, we were unable to assess the efficacy of the intervention.

CONCLUSIONS

Several key challenges impeded our study feasibility. Although the app was designed to reverse bill participants for any data use, the lack of mobile data was a substantial barrier to our study success. Participants reported purchasing WhatsApp data, which could not support the app. Problems with the web-based dashboard meant that we could not consistently monitor mobility. Our study provides important lessons about implementing an ambitious GPS-based study under real-world conditions in a limited-resource setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03836625; https://clinicaltrials.gov/ct2/show/NCT03836625.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-4190-x.

Travel behaviours and health outcomes during travel: Profiling destination-specific risks in a prospective mHealth cohort of swiss travellers

BACKGROUND

We used a mobile application to determine the incidence of health events and risk behaviours during travel by country and identify which health risks are significantly elevated during travel compared with at home.

METHOD

TOURIST2 is a prospective cohort study of 1000 adult travellers from Switzerland to Thailand, India, China, Tanzania, Brazil and Peru, planning travel of ≤4 weeks between 09/2017 and 04/2019. The incidence rate ratio (IRR) in each country was calculated.

RESULTS

All countries had significantly higher incidence of health events than at home. The most elevated symptoms were sunburn, itching from mosquitoes, and gastrointestinal disorders (e.g. vomiting, diarrhoea), corresponding with universally high food/drink risk behaviours. Peru had the highest incidence of both overall negative health events and severe health events (172.0/1000 travel-days). Traffic accidents were significantly higher in Peru (IRR: 2.4, 1.2, 4.7), although incidence of transportation risk was highest in India and Thailand. In Tanzania, incidence of negative mental health events was significantly lower than at home, although it was elevated in other countries. Sexual risk behaviours were high in Brazil.

CONCLUSIONS

Our study improves the understanding of the non-infectious disease related health challenges travellers face and provides evidence for more personalised traveller support.

Mobile apps for travel medicine and ethical considerations: A systematic review

BACKGROUND

The advent of mobile applications for health and medicine will revolutionize travel medicine. Despite their many benefits, such as access to real-time data, mobile apps for travel medicine are accompanied by many ethical issues, including questions about security and privacy.

METHODS

A systematic literature review as conducted following PRISMA guidelines. Database screening yielded 1795 results and seven papers satisfied the criteria for inclusion. Through a mix of inductive and deductive data extraction, this systematic review examined both the benefits and challenges, as well as ethical considerations, of mobile apps for travel medicine.

RESULTS

Ethical considerations were discussed with varying depth across the included articles, with privacy and data protection mentioned most frequently, highlighting concerns over sensitive information and a lack of guidelines in the digital sphere. Additionally, technical concerns about data quality and bias were predominant issues for researchers and developers alike. Some ethical issues were not discussed at all, including equity, and user involvement.

CONCLUSION

This paper highlights the scarcity of discussion around ethical issues. Both researchers and developers need to better integrate ethical reflection at each step of the development and use of health apps. More effective oversight mechanisms and clearer ethical guidance are needed to guide the stakeholders in this endeavour.

Healthy, safe and responsible: the modern female traveller

One-half of all travellers are women; yet, there is a distinct lack of detailed travel health knowledge on topics of unique relevance to women. While there is medical advice relating to stages in the female lifecycle, it neglects women-specific practical aspects despite their ability to harm travellers’ health and cause inconvenience. This paper discusses comprehensively three major aspects of travel as they relate to women. First, it suggests the management of personal hygiene, bodily functions, menstruation and sexual behaviour, and alerts to the limited knowledge on travel mental health issues.

Second, apart from travelling in a female body with its specific demands, being a woman requires special attention to safety and security. Within various travel contexts, women have many opportunities for minimising potential risks.

Finally, guided by travel medicine’s acknowledgment of its role in the concept of responsible travel, this article goes beyond the usual general statements and broad advice and offers detailed and practical suggestions on how the female traveller can contribute to the overall goal of minimising any potential harm to fellow humans and the natural environment. Recognising the scarcity of women-specific travel information, pathways to better education, and a range of suggestions for urgent research facilitate the provision of high-quality travel health care tailored specifically to women’s needs.

Predicting morbidity in older travellers during a short-term stay in the tropics: the ELDEST study

BACKGROUND

Older persons may suffer more from travel-related health problems because of ageing and underlying chronic disorders. Knowledge on who is more likely to have these health problems helps to tailor travel health advice more specifically. This study aimed to determine predictors of travel-related morbidity in older travellers by assessing their pre-travel characteristics and performance using physical and cognitive functioning tests.

METHODS

Multicentre prospective cohort study among older travellers (≥60 years) who consulted one of the participating Dutch travel clinics. Handgrip strength and cognitive performance were measured pre-travel. Participants completed questionnaires before departure and 1 and 4 weeks after return. A diary recorded health complaints during travel until 2-week post-travel.

RESULTS

In total, 477 travellers completed the study (follow-up rate of 97%). Participants' median age was 66 years. The most visited regions were South-East Asia (34%) and South Asia (14%). Median travel duration was 19 days. Polypharmacy (≥5 medications per day) was not uncommon (16%). The median Charlson Comorbidity Index (CCI) score was 0. Self-reported travel-related infectious diseases concerned primarily respiratory tract infections (21%) and gastroenteritis (10%) whereas non-infectious complaints were injuries (13%), peripheral edema (12%) and dehydration (3%). Medical assistance was sought by 18%, mostly post-travel from their general practitioner (87%). Self-reported physical and mental health-related quality of life significantly improved during and after travel. Predictors for an increased risk of travel-related morbidity were higher CCI score, more travel experience, longer travel duration, higher number of daily medications, visiting northern Africa or South-East and East Asia, and phone and social media use.

CONCLUSION

Older Dutch travellers are generally fit, well-prepared and suffer not only from common infectious health problems, but also from injuries. Travel improved their self-perceived health. The predictors could be used to identify the more at-risk older traveller and to decrease travel-related morbidity by optimizing pre-travel advice.

The COVID-19 pandemic offers a key moment to reflect on travel medicine practice

COVID-19 provides an opportunity to review travel health advice priorities. Infectious and non-infectious diseases are key for travel medicine, Research is warranted to stimulate an evidence-based balance in what travel medicine experts communicate to their clients

Evaluation of a web-based self-reporting method for monitoring international passengers returning from an area of emerging infection

OBJECTIVES

Emerging infectious diseases are a public health issue of international concern. Identifying methods to limit their expansion is essential. We assessed the feasibility of a screening strategy in which each traveler would actively participate in the screening process after an intercontinental flight by reporting their own health status via a web-based self-administered questionnaire.

PATIENTS AND METHODS

In 2015 and 2017, we invited passengers arriving at or departing from Pointe-à-Pitre international airport to answer an online health questionnaire during the four days following their arrival from or at Paris-Orly international airport. SPIRE 1 was intended for passengers arriving at Pointe-à-Pitre and was conceived as a pilot study. SPIRE 2 was an improved version of SPIRE 1 and consisted in three parts, which permitted to further assess the benefits of pre-flight request and email follow-up. Endpoints were the connection rates and response rates to online health questionnaire.

RESULTS

For SPIRE 1, 4/1038 travelers (0.4%) completed the two steps of the online health questionnaire. In SPIRE 2, response rates ranged from 3/1059 (0.3%) to 19/819 (2.3%). Response rates were significantly better when passengers were approached before their flight.

CONCLUSIONS

The yield of an online health questionnaire was unexpectedly low.

Measuring mobility, disease connectivity and individual risk: a review of using mobile phone data and mHealth for travel medicine

RATIONALE FOR REVIEW

The increasing mobility of populations allows pathogens to move rapidly and far, making endemic or epidemic regions more connected to the rest of the world than at any time in history. However, the ability to measure and monitor human mobility, health risk and their changing patterns across spatial and temporal scales using traditional data sources has been limited. To facilitate a better understanding of the use of emerging mobile phone technology and data in travel medicine, we reviewed relevant work aiming at measuring human mobility, disease connectivity and health risk in travellers using mobile geopositioning data.

KEY FINDINGS

Despite some inherent biases of mobile phone data, analysing anonymized positions from mobile users could precisely quantify the dynamical processes associated with contemporary human movements and connectivity of infectious diseases at multiple temporal and spatial scales. Moreover, recent progress in mobile health (mHealth) technology and applications, integrating with mobile positioning data, shows great potential for innovation in travel medicine to monitor and assess real-time health risk for individuals during travel.

CONCLUSIONS

Mobile phones and mHealth have become a novel and tremendously powerful source of information on measuring human movements and origin-destination-specific risks of infectious and non-infectious health issues. The high penetration rate of mobile phones across the globe provides an unprecedented opportunity to quantify human mobility and accurately estimate the health risks in travellers. Continued efforts are needed to establish the most promising uses of these data and technologies for travel health.

Standard pre-travel consultation versus shorter consultation combined with smartphone support: a randomized controlled trial

Immediate and long-term recalls of a pre-travel consultation are suboptimal. We aimed to assess the role of online consultation for travellers. We randomized travellers into two study groups. In the intervention arm, each traveller was given a short pre-travel consultation of 8-12 minutes, combined with the option of smartphone support before and during the trip. In the control arm, each traveller was given a standard length pre-travel consultation of 18-22 minutes. Endpoints included knowledge about potential risks, travellers' satisfaction, time allocated to each traveller and clinical events. We enrolled 75 patients in the intervention group and 74 patients in the control group. Online consultation was used 33 times, by 24 travellers, both before and during the trip. Important health hazards that were addressed included animal and insect bites (8), treatment of diarrhea (4), malaria prophylaxis (2) and altitude sickness prophylaxis (5). Other consultations consisted mainly of reassurances of worried travellers and provision of data. Knowledge about travel-related risks was higher in the control group before travelling (8.86 ± 1.12 vs 8.34 ± 1.32, P = 0.014), and there was a trend towards higher levels of knowledge also during the trip (8.29 ± 1.35 vs 7.89 ± 1.39, P = 0.06). Travellers' satisfaction before and during the trip was similar in both groups: median 10 (10, 10) in both groups before traveling (P = 0.51) and median 9 (8, 10) in both groups during the trip (P = 0.71). In the intervention group, time allocated to each traveller was <12 minutes. There were no differences in the number of clinical events (P > 0.2 for all comparisons). Online WhatsApp support addressed several important travel-related hazards but, when combined with a shortened pre-travel consultation, was associated with a lower level of knowledge about health risks. Therefore, such smartphone support should augment, rather than replace, pre-travel consultation.

Does the DOSPERT scale predict risk-taking behaviour during travel? A study using smartphones

BACKGROUND

Despite the continuing growth of international tourism, very little research has been done on the link between individual risk attitudes and health behaviours during travel. Our study uses a validated risk-taking questionnaire Domain-Specific Risk-Taking Scale (DOSPERT) and data from a smartphone application to study the association between pre-travel risk attitudes and the occurrence of behaviours during travel.

METHODS

A prospective cohort of travellers to Thailand used a smartphone application to answer a daily questionnaire about health behaviours and events. Prior to travel, participants completed the DOSPERT, a validated 30-item scale that assesses risk-taking and perception in five content domains: financial decisions, health/safety, recreational, ethical and social decisions. Multiple linear regression models were used to model the relationship between DOSPERT risk-taking subdomain score and health behaviour.

RESULTS

Of the 75 travellers that completed the study, 70 (93.3%) completed the DOSPERT pre-travel. Men, backpackers and young travellers reported a higher willingness to take recreational risks than women, luxury travellers and older travellers. Incidence of drug and alcohol risk behaviours during travel, itching from mosquitoes, smoking and failing to use a seatbelt in automobiles while at home were all significantly associated with an individual's score on the health and safety DOSPERT subdomain.

CONCLUSIONS

In our study, individual scores on risk-taking in the health and safety subdomain of the DOSPERT questionnaire seem to be predictive of health behaviours both during travel and at home. By pairing new methods of data collection with questionnaires such as DOSPERT that identify key traveller characteristics to intervene on, travel medicine doctors will be able to provide more specialised health advice, ensuring that all travellers receive well-rounded advice about the full range of health challenges they will face during travel.

Real-time incidence of travel-related symptoms through a smartphone-based app remote monitoring system: a pilot study

Trip Doctor®, a Smartphone-based app monitoring system, was developed to detect infections among travelers in real-time. For testing, 106 participants were recruited (62.2% male, mean age 36 years (SD = 11)). Majority of trips were for tourism and main destinations were in South East Asia. Mean travel duration was 14 days (SD = 10). Diarrhea was the most frequently reported symptom (15.5%). The system demonstrated adequate usability and is ready to be used on a larger scale.

Redefining priorities towards graded travel-related infectious disease research

Our knowledge of the health problems and infections encountered by international travellers has evolved considerably in the past decades. The growth of global networks such as the GeoSentinel Surveillance network, TropNet Europe, EuroTravNet and networks based in North America have provided valuable information on the frequency of a wide array of travel-related diseases and accidents, including details on the destination of travel and trends over time. The information gained from these network studies has provided important data for the practice of travel medicine and in some instances for the development of practice guidelines. However, network data due to a lack of denominators usually cannot serve as a basis for a GRADE approach to guideline development. Although epidemiological network studies will continue to serve an important role in travel medicine we encourage an additional strong focus towards translational scientific research questions and towards the broader use of novel techniques to obtain more accurate epidemiological analyses to address the many unanswered questions in our field.