Factors Affecting Pre-Travel Health Seeking Behaviour and Adherence to Pre-Travel Health Advice: A Systematic Review

Concerns about vaccines and vaccination behavior among Japanese budget travelers to India

BACKGROUND

Low vaccination coverage among travelers poses a critical challenge to global health security. Indeed, public concerns regarding vaccines can lead to vaccine reluctance and refusal, but evidence about the impacts of concerns regarding vaccines on the uptake of travel vaccinations remains sparse. We examined the associations between concerns about vaccines and vaccination behavior among travelers.

METHODS

Japanese travelers aged 18 years or older, who stayed at a guesthouse in New Delhi, India, were targeted (n = 153). We conducted cross-sectional surveys from August 23 to September 2, 2019, and from February 19 to March 5, 2020. We examined the associations of three concerns regarding vaccines (5-point scale)-serious side effects from vaccines, vaccine safety, and vaccine effectiveness-with the uptake of travel vaccinations.

RESULTS

In total, 60 participants (39.2 %) had been vaccinated for this or a past trip. After adjusting for all potential confounding variables, concerns about serious side effects from vaccines and vaccine safety were negatively associated with the uptake of travel vaccinations. The ORs (95 % CIs) for 1-point increases in concerns about serious side effects from vaccines and vaccine safety were 0.72 (0.52, 0.99) and 0.71 (0.52, 0.96), respectively. Sensitivity analyses did not change the results substantially.

CONCLUSIONS

Concerns about vaccine safety issues were negatively associated with the uptake of travel vaccinations among the participants, with no corresponding association observed for vaccine effectiveness. Addressing concerns about vaccine safety issues, rather than vaccine effectiveness may contribute to an increased uptake of travel vaccinations.

Rabies knowledge gaps and risk behaviour in Dutch travellers: An observational cohort study

BACKGROUND

Travellers visiting rabies-endemic countries are at risk of rabies infection. Assessing travellers' knowledge and risk perception of rabies and risk behaviour during travel can help identify knowledge gaps and improve pre-travel risk education.

METHODS

Cohort study in Dutch adult travellers, using two surveys: one before travel to assess knowledge and perception of rabies, and one after return to identify risk behaviour during travel.

RESULTS

The pre-travel and post-travel survey were completed by 301 and 276 participants, respectively. 222 participants had travelled to a high-risk rabies-endemic country. 21.6 % of the participants scored their rabies knowledge as poor. Some participants were unaware cats or bats can transmit rabies (26.6 % and 13.6 %, respectively), or that post-exposure prophylaxis (PEP) is required for certain exposures such as skin abrasions without bleeding or licks on damaged skin (35.5 % and 18.9 %, respectively), while 27.9 % of participants did not know PEP needs to be administered within one day. 115 participants (51.8 %) reported any form of contact with any animal during travel. Two participants reported animal exposure, of which one took adequate PEP measures. Risk factors for animal contact abroad were regularly touching cats or dogs at home or abroad, longer travel duration, having pets during childhood and being an animal lover.

CONCLUSIONS

Pre-travel rabies risk education currently does not meet travellers' needs, which is reflected in knowledge gaps and engagement in risk behaviour during travel. During pre-travel health advice, avoiding animal contact abroad should be emphasized, and additional education is required about indications for PEP.

Exploring the utilization and perceptions of pre-travel health consultations in primary care settings in Saudi Arabia: a cross-sectional study

BACKGROUND

International travel exposes individuals to diverse health risks, necessitating proactive pre-travel health preparations. Saudi Arabia has witnessed increased outbound travel. This study addresses a critical gap in knowledge by investigating the utilization and perceptions of pre-travel health consultations among adults in the Eastern Province of Saudi Arabia.

METHODS

This cross-sectional study surveyed patients at the Family and Community Medicine Center of Imam Abdulrahman Bin Faisal University during January 2024 to explore perceptions of pre-travel health consultations among the Saudi Arabian population. Adults aged 18 years or older in the waiting area were invited to complete a self-administered questionnaire.

RESULTS

Of the 772 participants, 624 (80.8%) engaged in international travel within the last year. However, 593 (76.8%) had never sought pre-travel health consultations. Age, gender, and education level significantly influenced the pursuit of pre-travel health advice, with older individuals, females, and those with higher educational attainment more likely to seek consultations. Participants perceived vaccination recommendations (597, 77.4%) and disease prevention information (678, 87.8%) as crucial parts of pre-travel health consultations. However, barriers to seeking advice included perceived low risk (445, 74.8%), lack of awareness (215, 36.3%), time constraints (128, 21.6%), and cost concerns (92, 15.5%).

CONCLUSION

The low prevalence of pre-travel health consultations among travelers highlights the need for targeted educational campaigns and the integration of travel health services into primary healthcare. Addressing the identified barriers and leveraging preferred information sources are crucial steps towards enhancing the uptake of pre-travel health consultations, ultimately improving the health and safety of international travelers from the region.

A Smartphone App for Real-Time Assessment of Malaria Prophylaxis Adverse Events

Background: Growth of international travel to malarial areas over the last decades has contributed to more travelers taking malaria prophylaxis. Travel-related symptoms may be wrongly attributed to malaria prophylaxis and hinder compliance. Here, we aimed to assess the frequency of real-time reporting of symptoms by travelers following malaria prophylaxis using a smartphone app. Method: Adult international travelers included in this single-center study (Barcelona, Spain) used the smartphone Trip Doctor® app developed by our group for real-time tracking of symptoms and adherence to prophylaxis. Results: Six hundred four (n = 604) international travelers were included in the study; 74.3% (449) used the app daily, and for one-quarter of travelers, malaria prophylaxis was prescribed. Participants from the prophylaxis group traveled more to Africa (86.7% vs. 4.3%; p < 0.01) and to high travel medical risk countries (60.8% vs. 18%; p < 0.01) and reported more immunosuppression (30.8% vs. 23.1% p < 0.01). Regarding symptoms, no significant intergroup differences were observed, and no relationship was found between the total number of malarial pills taken and reported symptoms. Conclusions: In our cohort, the number of symptoms due to malaria prophylaxis was not significantly higher than in participants for whom prophylaxis was not prescribed, and the overall proportion of symptoms is higher compared with other studies.

Imported malaria into Australia: surveillance insights and opportunities

BACKGROUND

Malaria continues to pose a significant burden in endemic countries, many of which lack access to molecular surveillance. Insights from malaria cases in travellers returning to non-endemic areas can provide valuable data to inform endemic country programmes. To evaluate the potential for novel global insights into malaria, we examined epidemiological and molecular data from imported malaria cases to Australia.

METHODS

We analysed malaria cases reported in Australia from 2012 to 2022 using National Notifiable Disease Surveillance System data. Molecular data on imported malaria cases were obtained from literature searches.

RESULTS

Between 2012 and 2022, 3204 malaria cases were reported in Australia. Most cases (69%) were male and 44% occurred in young adults aged 20-39 years. Incidence rates initially declined between 2012 and 2015, then increased until 2019. During 2012-2019, the incidence in travellers ranged from 1.34 to 7.71 per 100 000 trips. Cases were primarily acquired in Sub-Saharan Africa (n = 1433; 45%), Oceania (n = 569; 18%) and Southern and Central Asia (n = 367; 12%). The most common countries of acquisition were Papua New Guinea (n = 474) and India (n = 277). Plasmodium falciparum accounted for 58% (1871/3204) of cases and was predominantly acquired in Sub-Saharan Africa, and Plasmodium vivax accounted for 32% (1016/3204), predominantly from Oceania and Asia. Molecular studies of imported malaria cases to Australia identified genetic mutations and deletions associated with drug resistance and false-negative rapid diagnostic test results, and led to the establishment of reference genomes for P. vivax and Plasmodium malariae.

CONCLUSIONS

Our analysis highlights the continuing burden of imported malaria into Australia. Molecular studies have offered valuable insights into drug resistance and diagnostic limitations, and established reference genomes. Integrating molecular data into national surveillance systems could provide important infectious disease intelligence to optimize treatment guidelines for returning travellers and support endemic country surveillance programmes.

A decision support tool for risk-benefit analysis of Japanese encephalitis vaccine in travellers

BACKGROUND

During pre-travel consultations, clinicians and travellers face the challenge of weighing the risks verus benefits of Japanese encephalitis (JE) vaccination due to the high cost of the vaccine, low incidence in travellers (~1 in 1 million), but potentially severe consequences (~30% case-fatality rate). Personalised JE risk assessment based on the travellers' demographics and travel itinerary is challenging using standard risk matrices. We developed an interactive digital tool to estimate risks of JE infection and severe health outcomes under different scenarios to facilitate shared decision-making between clinicians and travellers.

METHODS

A Bayesian network (conditional probability) model risk-benefit analysis of JE vaccine in travellers was developed. The model considers travellers' characteristics (age, sex, co-morbidities), itinerary (destination, departure date, duration, setting of planned activities) and vaccination status to estimate the risks of JE infection, the development of symptomatic disease (meningitis, encephalitis), clinical outcomes (hospital admission, chronic neurological complications, death) and adverse events following immunization.

RESULTS

In low-risk travellers (e.g. to urban areas for <1 month), the risk of developing JE and dying is low (<1 per million) irrespective of the destination; thus, the potential impact of JE vaccination in reducing the risk of clinical outcomes is limited. In high-risk travellers (e.g. to rural areas in high JE incidence destinations for >2 months), the risk of developing symptomatic disease and mortality is estimated at 9.5 and 1.4 per million, respectively. JE vaccination in this group would significantly reduce the risk of symptomatic disease and mortality (by ~80%) to 1.9 and 0.3 per million, respectively.

CONCLUSION

The JE tool may assist decision-making by travellers and clinicians and could increase JE vaccine uptake. The tool will be updated as additional evidence becomes available. Future work needs to evaluate the usability of the tool. The interactive, scenario-based, personalised JE vaccine risk-benefit tool is freely available on www.VaxiCal.com.

Malaria in Austria : A retrospective analysis of malaria cases diagnosed at a reference center in 2010-2020

BACKGROUND

Although malaria is not endemic to Austria, each year infections are imported by travellers, migrants and refugees. This study aims to provide an overview of malaria cases diagnosed at an Austrian institute for tropical medicine between 2010 and 2020.

METHODS

A retrospective, descriptive study was conducted based on the data of malaria cases confirmed at the Institute of Specific Prophylaxis and Tropical Medicine of the Medical University of Vienna. Laboratory diagnostics included microscopy, polymerase chain reaction (PCR) and real-time quantitative PCR.

RESULTS

Overall, 122 cases were identified. Annual case numbers were consistently higher from 2016 to 2020 than during the first half of the decade. Most malaria cases were diagnosed during summer and early autumn. This seasonal trend was not observed during the year 2020. With 55.1% (65/118) Plasmodium falciparum was the most common species, followed by Plasmodium vivax (19.5%, 23/118). The majority of patients were male (71.1%, 86/121) and the median age was 34.5 years (interquartile range, IQR 22.5-47.0 years). With a median age of 20.0 years (IQR 14.0-32.0 years), patients with P. vivax infections were younger than those infected with other Plasmodium species. Moreover, they were mostly male (82.6%, 19/23).

CONCLUSION

From 2010 to 2020, the number of malaria cases diagnosed at the center increased. Growing international mobility and changing travel behavior could at least partly be responsible for this trend and there are indications that particularly P. vivax infections were imported by migrants and refugees.

Post-infectious irritable bowel syndrome following a diagnosis of traveller's diarrhoea: a comprehensive characterization of clinical and laboratory parameters

BACKGROUND

Prolonged or recurrent gastrointestinal symptoms may persist after acute traveller's diarrhoea (TD), even after adequate treatment of the primary cause. This study aims to describe the epidemiological, clinical and microbiological characteristics of patients with post-infectious irritable bowel syndrome (PI-IBS) after returning from tropical or subtropical areas.

METHODS

We conducted a retrospective study of patients presenting between 2009 and 2018 at the International Health referral centre in Barcelona with persistent gastrointestinal symptoms following a diagnosis of TD. PI-IBS was defined as the presence of persistent or recurrent gastrointestinal manifestations for at least 6 months after the diagnosis of TD, a negative stool culture for bacterial pathogens and a negative ova and parasite exam after targeted treatment. Epidemiological, clinical and microbiological variables were collected.

RESULTS

We identified 669 travellers with a diagnosis of TD. Sixty-eight (10.2%) of these travellers, mean age 33 years and 36 (52.9%) women, developed PI-IBS. The most frequently visited geographical areas were Latin America (29.4%) and the Middle East (17.6%), with a median trip duration of 30 days (IQR 14-96). A microbiological diagnosis of TD was made in 32 of these 68 (47%) patients, 24 (75%) of whom had a parasitic infection, Giardia duodenalis being the most commonly detected parasite (n = 20, 83.3%). The symptoms persisted for a mean of 15 months after diagnosis and treatment of TD. The multivariate analysis revealed that parasitic infections were independent risk factors for PI-IBS (OR 3.0, 95%CI 1.2-7.8). Pre-travel counselling reduced the risk of PI-IBS (OR 0.4, 95%CI 0.2-0.9).

CONCLUSIONS

In our cohort, almost 10% of patients with travellers' diarrhoea developed persistent symptoms compatible with PI-IBS. Parasitic infections, mainly giardiasis, seem to be associated with PI-IBS.

Profiles of travelers to intermediate-high health risk areas following the reopening of borders in the COVID-19 crisis: A clustering approach

BACKGROUND

The reactivation of international travel in 2021 has created a new scenario in which the profile of the traveler to medium-high health risk areas may well have changed. However, few studies have analyzed this new profile since the reopening of borders in that year.

METHODS

We designed an ad hoc questionnaire that was administered face-to-face by our medical team during appointments with 330 travelers in the second half of 2021. Information was collected on the following topics: sociodemographic and socioeconomic status; type of travel and previous travel experience; health status and risk perception (of COVID-19 and tropical infectious diseases). Using all features simultaneously, an unsupervised machine learning approach (k-means) is implemented to characterize groups of travelers. Pairwise chi-squared tests were performed to identify key features that showed statistically significant differences between clusters.

RESULTS

The travelers were clustered into seven groups. We associated the clusters with different intensities of perceived risk of acquiring COVID-19 and tropical infectious diseases on the trip. The perceived risk of both diseases was low in the group "middle or lower middle class young inexperienced male tourist" but high in the group "middle or lower middle-class young with children inexperienced business traveler".

CONCLUSIONS

Broadening our knowledge of the profiles of travelers to intermediate-high health risk areas would help to tailor the health advice provided by practitioners to their characteristics and type of travel. In a changing health context, the k-means approach supposes a flexible statistical method that calculates travelers' profiles and can be easily adapted to process new information.

Pre-travel vaccine information needs, attitudes, drivers of uptake and the role for decision aids in travel medicine

BACKGROUND

Many travellers do not receive vaccines pre-travel. Tools such as vaccine decision aids could support informed vaccine decision-making. We aimed to characterise Australians' pre-travel vaccine attitudes, behaviours and information needs and examine the role for decision aids in travel medicine.

METHODS

Online cross-sectional survey of Australian adults in December 2022. We included questions on demographics, pre-travel health-seeking behaviour, and information needs. We measured vaccine confidence (Vaccine Confidence Index Index) and used hypothetical disease scenarios to evaluate behavioural and social drivers of vaccination. We used multivariable logistic regression models to identify predictors of vaccine uptake and thematically analysed free-text responses.

RESULTS

We received complete survey responses from 1223/1326 Australians (92% response rate). Amongst those reporting previous overseas travel, 67% (778/1161) reported past pre-travel health encounter(s) and 64% (743/1161) reported past pre-travel vaccination. Half (50%) strongly agreed that vaccines were important for their health; fewer strongly agreed that vaccines were safe (37%) and effective (38%). In multivariable analyses, past pre-travel vaccine uptake was associated with increasing age (OR = 1.17 [95% CI 1.08-1.27] p < 0.001 per ten-year increase) and travel to higher-risk destinations (OR = 2.92 [2.17-3.93] p < 0.001); travellers visiting friends and relatives (VFRs) were less likely to have received pre-travel vaccines (OR = 0.74 [0.56-0.97] p = 0.028). Predictors for wanting vaccination against hypothetical diseases included past pre-travel vaccination (Disease X: OR 2.60 [1.91-3.56] p < 0.001) and confidence in vaccine safety (Disease X: OR 7.18 [5.07-10.18], p < 0.001); past VFR travel was predictive of not wanting vaccination (Disease X: OR 0.72 [0.52-1.00], p = 0.049). Most (63%) were interested in using a vaccine decision aid, generally together with a trusted health professional.

CONCLUSIONS

Health professionals play an important role in supporting pre-travel vaccine decision-making. However, our findings indicate that reliable, accurate and engaging digital resources, such as decision aids, could support travellers to make informed pre-travel vaccine decisions.

Healthcare seeking during travel: an analysis by the GeoSentinel surveillance network of travel medicine providers

BACKGROUND

International travellers may seek care abroad to address health problems that arise during their trip or plan healthcare outside their country of residence as medical tourists.

METHODS

Data were collected on travellers evaluated at GeoSentinel Network sites who reported healthcare during travel. Both unplanned and planned healthcare were analysed, including the reason and nature of healthcare sought, characteristics of the treatment provided and outcomes. Travellers that presented for rabies post-exposure prophylaxis were described elsewhere and were excluded from detailed analysis.

RESULTS

From May 2017 through June 2020, after excluding travellers obtaining rabies post-exposure prophylaxis (n= 415), 1093 travellers reported care for a medical or dental issue that was an unanticipated part of the travellers' planned itinerary (unplanned healthcare). Travellers who sought unplanned healthcare abroad had frequent diagnoses of acute diarrhoea, dengue, falciparum malaria and unspecified viral syndrome, and obtained care in 131 countries. Thirty-four (3%) reported subsequent deterioration and 230 (21%) reported no change in condition; a third (n = 405; 37%) had a pre-travel health encounter. Forty-one travellers had sufficient data on planned healthcare abroad for analysis. The most common destinations were the US, France, Dominican Republic, Belgium and Mexico. The top reasons for their planned healthcare abroad were unavailability of procedure at home (n = 9; 19%), expertise abroad (n = 9; 19%), lower cost (n = 8; 17%) and convenience (n = 7; 15%); a third (n = 13; 32%) reported cosmetic or surgical procedures. Early and late complications occurred in 14 (33%) and 4 (10%) travellers, respectively. Four travellers (10%) had a pre-travel health encounter.

CONCLUSIONS

International travellers encounter health problems during travel that often could be prevented by pre-travel consultation. Travellers obtaining planned healthcare abroad can experience negative health consequences associated with treatments abroad, for which pre-travel consultations could provide advice and potentially help to prevent complications.

Rabies post-exposure prophylaxis of international travellers - Results from two major German travel clinics

BACKGROUND

Travel to regions with rabies risk has increased. However, data on adequate rabies post exposure prophylaxis (PEP) abroad is scarce. The aim of this study was to assess the appropriateness of medical management following suspected rabies exposure (SRE) in international travellers.

METHOD

A cross-sectional questionnaire-based study in returning travellers with reported SRE who sought post-exposure medical care was conducted in two large German travel clinics.

RESULTS

The 75 included SRE cases had a median age of 34 years (range 26-43) and showed a female predominance (59%, 44/75). Most participants returned from Asia (47%, 34/72). About 28% had received pre-exposure prophylaxis (PrEP, ≥2 vaccine doses) (20/71). In 51% the animal was actively approached (34/67). All patients had category II/III exposure according to the World Health Organization (65% category III, 49/75). With 78% (52/67), most patients cleaned the wound after SRE; 36% (24/67) used water and soap. Only 57% (41/72) of participants sought medical care during their trip. Overall, 45% (33/74) received rabies vaccination abroad which corresponds to 80% out of those who sought healthcare (33/41).

CONCLUSIONS

Awareness for appropriate first aid and the urgency of seeking timely professional treatment including PEP after an SRE seems to be insufficient in German travellers. Travel practitioners need to educate travellers about rabies risk, prevention measures and the correct behaviour after SRE including adequate wound treatment and seeking immediate medical help for PEP. PrEP should be offered generously especially to travellers with high rabies-exposure risk and those visiting areas with limited healthcare access.

Perceptions of travel-related health risks and pre-travel health-seeking behaviour among students: A qualitative analysis

BACKGROUND

The impact of the COVID-19 pandemic on travel risk perceptions and pre-travel healthcare attendance is unknown. We aimed to explore barriers and enablers to engagement in and uptake of pre-travel advice (PTA) among university students, a recognised at-risk group for travel-related morbidity and poor PTA uptake. Additionally, we aimed to explore whether the COVID-19 pandemic has influenced attitudes towards future PTA.

METHODS

Semi-structured interviews were conducted with university students (October-December 2021). Thematic analysis of the data was conducted using the Health Belief Model (HBM) framework.

RESULTS

We interviewed 18 students (11 male, median age 24). Students' risk perceptions relating to travel-related illnesses were influenced by past experiences, travel destination, vaccination status and knowledge. Barriers to seeking PTA included a lack of perceived need and concerns about accessibility/availability, whereas potential benefits included reduced health risks, vaccine-induced protection, and knowledge gain. Cues to seeking future PTA were perceived risks of travel-related illness, perceived high-risk destination, itinerary-related vaccine requirements, perceived benefits of advice and concerns about COVID-19 infection. COVID-19 risk perceptions did not consistently align with those of other travel-related illness. We used findings to inform recommendations.

CONCLUSION

The current COVID-19 pandemic offers an opportunity to increase students' risk awareness and promote preventive travel health behaviours. Recommendations to improve students' future engagement in PTA include: 1) increasing awareness of risks associated with travel, 2) emphasising PTA benefits, and 3) ensuring PTA is convenient, accessible and affordable.

Pretravel preparation and factors associated with willingness to seek pretravel consultation among Taiwanese travelers

BACKGROUND

Although globalization promotes economic development, cross-border infectious disease transmission is still a serious threat to health. Taiwan is geographically close to Southeast and South Asia, but the needs and expectations of Taiwanese travelers with regard to travel medicine are still largely unknown. This study aimed to clarify the pretravel preparations, needs, willingness to seek pretravel consultation, and factors associated with willingness, in order to provide valuable information for improvement of healthcare service.

METHODS

Data were collected with anonymous structured questionnaires distributed to 477 visitors who tried to get travel health information from New Southbound Health Center between June and November 2019. A multivariate stepwise logistic regression analysis was applied to identify factors associated with the visitors' willingness to seek pretravel consultation.

RESULTS

A total of 304 questionnaires (64%) were collected. Eighty-three percent of the respondents were willing to seek pretravel consultation. A higher level of education (odds ratio 3.6 [95% CI 1.58-8.22]), having a plan to obtain travel medical insurance (2.5 [1.18-5.28]), concern with gastrointestinal diseases (2.0 [1.04-3.94]), concern with mosquito-borne diseases (2.0 [2.07-3.95]), and concern with noncommunicable diseases (2.2 [1.02-4.96]) were independent factors associated with willingness to seek pretravel consultation.: CONCLUSIONS: We found that most of the travelers were willing to seek pretravel consultation. Our study highlighted the need to enhance awareness about travel-related illness among these travelers. Strategies should be tailored according to these findings to help prevent epidemics and improve healthcare service in the future.

Travel patterns and advice-seeking behaviour of pregnant women in the Australian context: A multicentre cross-sectional analysis

BACKGROUND

Travel poses risks to pregnant women, but little data exist describing the travel habits of women during pregnancy or pre-travel recommendations given.

AIMS

To examine travel patterns of pregnant women including frequency of pre-travel consultation, and advice recalled.

MATERIALS AND METHODS

Cross-sectional analysis of post-partum women admitted to five Victorian maternity hospitals between 21 May 2019 and 22 April 2020 in Australia.

RESULTS

Forty-four percent (182/410) of women travelled during pregnancy, 32.9% (135/410) interstate and 19.5% (80/410) internationally. Fifty-five percent travelled for leisure (118/215) and 27% to visit friends/relatives (58/215). Overall, 68.1% (124/182) sought pre-travel advice, primarily from an obstetrician (60.5%, 75/124) or general practitioner (29.8%, 37/124). Only one woman attended a travel clinic. The most common reason for not seeking pre-travel advice was the belief that travel posed no risk (63.4%, 45/71). Pre-travel advice was sought least by those visiting friends/relatives (61.4%, 35/57). Women recalled recommendations regarding travel restrictions by gestational age and venous thromboembolism precautions, but not infectious disease prevention for those to whom it was relevant. Of international travellers, 48.8% (39/80) sought advice from the internet, one-third (13/39) as an alternative to seeing a healthcare provider.

CONCLUSIONS

Travel is common during pregnancy and women seek pre-travel advice from the healthcare provider they see most often during pregnancy. All pregnant women should be provided with consistent, evidence-based pre-travel advice regardless of whom they consult. Further work is needed to educate and provide resources to maternity care providers to optimise pre-travel counselling.

Underestimation of travel-associated risks by adult and paediatric travellers compared to expert assessment: A cross-sectional study at a hospital-based family pre-travel clinic

BACKGROUND

Travellers' perception of their risk for acquiring travel-related conditions is an important contributor to decisions and behaviors during travel. In this study, we aimed to assess the differences between traveller-perceived and expert-assessed risk of travel-related conditions in children and adults travelling internationally and describe factors that influence travellers' perception of risk.

METHODS

Children and adults were recruited at the Hospital for Sick Children's Family Travel Clinic between October 2014 and July 2015. A questionnaire was administered to participants to assess their perceived risk of acquiring 32 travel-related conditions using a 7-point Likert scale. Conditions were categorized as vector-borne diseases, vaccine-preventable diseases, food and water borne diseases, sexually transmitted infections and other conditions. Two certified travel medicine experts reviewed each patient's chart and assigned a risk score based on the same 7-point Likert scale. Traveller and expert risk scores were compared using paired t-tests.

RESULTS

In total, 207 participants were enrolled to participate in this study, 97 children (self-reported, n = 8; parent-reported, n = 89), and 110 adults. Travel-related risk for adults and parents answering for their children were significantly underestimated when compared to expert-assessed risk for 26 of the 32 assessed conditions. The underestimated conditions were the same for both adults and parents answering for children. Travel-related risk was not over-estimated for any condition.

CONCLUSIONS

Adults underestimated their children's and their own risk for most travel-related conditions. Strategies to improve the accuracy of risk perception of travel-related conditions by travellers are needed to optimize healthy travel for children and their families.

Using social media listening and data mining to understand travellers' perspectives on travel disease risks and vaccine-related attitudes and behaviours

BACKGROUND

Travellers can access online information to research and plan their expeditions/excursions, and seek travel-related health information. We explored German travellers' attitude and behaviour toward vaccination, and their travel-related health information seeking activities.

METHODS

We used two approaches: web 'scraping' of comments on German travel-related sites and an online survey. 'Scraping' of travel-related sites was undertaken using keywords/synonyms to identify vaccine- and disease-related posts. The raw unstructured text extracted from online comments was converted to a structured dataset using Natural Language Processing Techniques. Traveller personas were defined using K-means based on the online survey results, with cluster (i.e. persona) descriptions made from the most discriminant features in a distinguished set of observations. The web-scraped profiles were mapped to the personas identified. Travel and vaccine-related behaviours were described for each persona.

RESULTS

We identified ~2.6 million comments; ~880 k were unique and mentioned ~280 k unique trips by ~65 k unique profiles. Most comments were on destinations in Europe (37%), Africa (21%), Southeast Asia (12%) and the Middle East (11%). Eight personas were identified: 'middle-class family woman', 'young woman travelling with partner', 'female globe-trotter', 'upper-class active man', 'single male traveller', 'retired traveller', 'young backpacker', and 'visiting friends and relatives'. Purpose of travel was leisure in 82-94% of profiles, except the 'visiting friends and relatives' persona. Malaria and rabies were the most commented diseases with 12.7 k and 6.6 k comments, respectively. The 'middle-class family woman' and the 'upper-class active man' personas were the most active in online conversations regarding endemic disease and vaccine-related topics, representing 40% and 19% of comments, respectively. Vaccination rates were 54%-71% across the traveller personas in the online survey. Reasons for vaccination reluctance included perception of low risk to disease exposure (21%), price (14%), fear of side effects (12%) and number of vaccines (11%).

CONCLUSIONS

The information collated on German traveller personas and behaviours toward vaccinations should help guide counselling by healthcare professionals.

Using the Health Belief Model to examine travelers' willingness to vaccinate and support for vaccination requirements prior to travel

Data from a survey of 1478 travelers and multistep group structural equation model analysis revealed that the Health Belief Model constructs of cues to action (trust in third-party information sources), perceived severity of and susceptibility to COVID-19, and beliefs about the protection benefits of a COVID-19 vaccine, subsequently elicited willingness to vaccinate and beliefs that others should vaccinate prior to travel and enhanced support for pre-travel vaccination mandates. Also, significant differences in the perceived protection benefits of the vaccine and willingness to vaccinate were found across groups of travelers who travel more or less frequently and those with and without a prior positive test for COVID-19. The study provides a theoretically informed understanding of the dynamics that may enable the success of important health-related travel policy in the wake of COVID-19 and future pandemics and identifies the communication mechanisms that must be leveraged by governments and travel authorities in enforcing policy.

No time to die: An in-depth analysis of James Bond's exposure to infectious agents

Global travelers, whether tourists or secret agents, are exposed to a smörgåsbord of infectious agents. We hypothesized that agents pre-occupied with espionage and counterterrorism may, at their peril, fail to correctly prioritize travel medicine. To examine our hypothesis, we examined adherence to international travel advice during the 86 international journeys that James Bond was observed to undertake in feature films spanning 1962-2021. Scrutinizing these missions involved ∼3113 min of evening hours per author that could easily have been spent on more pressing societal issues. We uncovered above-average sexual activity, often without sufficient time for an exchange of sexual history, with a remarkably high mortality among Bond's sexual partners (27.1; 95% confidence interval 16.4-40.3). Given how inopportune a bout of diarrhea would be in the midst of world-saving action, it is striking that Bond is seen washing his hands on only two occasions, despite numerous exposures to foodborne pathogens. We hypothesize that his foolhardy courage, sometimes purposefully eliciting life-threatening situations, might even be a consequence of Toxoplasmosis. Bond's approach to vector-borne diseases and neglected tropical diseases is erratic, sometimes following travel advice to the letter, but more often dwelling on the side of complete ignorance. Given the limited time Bond receives to prepare for missions, we urgently ask his employer MI6 to take its responsibility seriously. We only live once.

Seroprevalence of hepatitis B antibodies among international and domestic university students

Chronic hepatitis B prevalence is low in most Australian populations, with universal infant HBV vaccination introduced in 2000. Migrants from high prevalence countries are at risk of acquisition before arrival and non-immune adults are potentially at risk through skin penetrating procedures and sexual contact, particularly during international travel. The risk profile of young adult students, many from high prevalence countries, is inadequately understood. A cross-sectional online survey conducted among university students collected data on demographic, vaccination and travel characteristics and blood samples were tested for hepatitis B surface antibody (HBsAb) and hepatitis B core antibody (HBcAb). Analyses identified factors associated with HBsAb seroprevalence and self-reported vaccination. The serosurvey was completed by 804 students born between 1988 and 1993, with 613/804 (76.2%, 95% CI 73.2-79.1) self-reporting prior HBV vaccination. Overall, 526/804 (65.4%, 95% CI 62.0%-68.6%) students were seropositive to HBsAb, including 438/613 (71.5%, 95% CI 67.8-74.9) students self-reporting a prior HBV vaccine and 88/191 (46.1%, 95% CI 39.2-53.2) students self-reporting no prior HBV vaccine. Overall, 8/804 (1.0%, 95% CI 0.5%-2.0%) students were HBcAb positive, of whom 1/804 (0.1%, 95% CI 0.02%-0.7%) was currently infectious. The prevalence of chronic HBV infection was low. However, more than one in four students were susceptible to HBV and over-estimated their immunity. Future vaccination efforts should focus on domestic students born before the introduction of the infant program and all international students. Screening and vaccination of students, including through campus-based health services, are an opportunity to catch-up young adults prior to undertaking at-risk activities, including international travel.

A Normative Behavior of Pre-Travel Health Consultation and the Associated Factors among Travelers

Introduction: Travelers may transmit diseases due to their behavior of travel, consequently travelers should consider preventive measurement through pre-travel health consultation seeking behavior. Pre-travel health consultation is a particular preparation ideally conducted by international travelers to obtain risk assessment and management to prevent the transmission of diseases. This study investigates the relationship of socio-demographic characteristics and itinerary on pre-travel health consultation behavior among international travelers in Badung, Bali.Methods: A descriptive-correlative design using a cross-sectional approach employed 125 participants determined by a purposive sampling technique performed in the ten tourist destinations of Badung Regency. Data collection was conducted on February 15th until March 5th, 2020. Data demography, travel plan, and anonymous questionnaires regarding pre-travel health consultation behavior are used in this research. The Gamma coefficient correlation and Kruskal-Wallis statistic tests were performed in the study for bivariate analysis.Results: The results showed that age (p<0.0001; r=-0.650) and past-travel history to Bali (p=0.004; r=-0.475) were significantly correlated with pre-travel health consultation behavior among international travelers in Badung, Bali. Meanwhile sex, nationality, last education, travel duration, and types of the destination visited were not significantly associated with pre-travel health consultation behavior among international travelers in Badung, Bali (p>0.05).Conclusion: The age and past-travel history to Bali seem to be predictors for travelers to uptake pre-travel health consultation, thus nurses should be able to promote the implementation of pre-travel health consultation by utilizing the media promotion appropriately adjusted to the age of travelers and travel experience.

Travelers' Attitudes, Behaviors, and Practices on the Prevention of Infectious Diseases: A Study for Non-European Destinations

BACKGROUND

The aim of this study was to improve our comprehension of the attitudes, behaviors, and practices related to the health risks of travel to non-European destinations.

METHODS

This cross-sectional study utilized an online questionnaire disseminated through social networks.

RESULTS

About 79% of the respondents reported that they informed themselves or would inform themselves about travel-related health risks before departure. The most used sources of information were the Internet (52%) and health professionals (42%). Older age groups were positively associated with seeking pretravel health information (OR = 2.44, CI 95%: 1.18-5.01, in the age group 25-34 years and OR = 14.6, CI 95%: 1.77-119.50, in subjects over 65 years). Travelers visiting friends and relatives (VFRs) were less likely to seek health information (OR = 0.49; CI 95%: 0.26-0.95). About 13.9% of participants had doubts about the practice of vaccination. Those who sought information on social media had a higher probability of refusing vaccination (OR = 3.24; CI 95%: 1.02-10.19).

CONCLUSIONS

The data demonstrate that VFRs and the younger population are less informed about travel risks compared with other travelers. This study also revealed the importance that digital information assumes for travelers. Therefore, decisive efforts should be made to ensure that travelers can find correct and reliable information on the Web, particularly on social media.

COVID-19 in comparison with other emerging viral diseases: risk of geographic spread via travel

Purpose of review

The COVID-19 pandemic poses a major global health threat. The rapid spread was facilitated by air travel although rigorous travel bans and lockdowns were able to slow down the spread. How does COVID-19 compare with other emerging viral diseases of the past two decades?

Recent findings

Viral outbreaks differ in many ways, such as the individuals most at risk e.g. pregnant women for Zika and the elderly for COVID-19, their vectors of transmission, their fatality rate, and their transmissibility often measured as basic reproduction number. The risk of geographic spread via air travel differs significantly between emerging infectious diseases.

Summary

COVID-19 is not associated with the highest case fatality rate compared with other emerging viral diseases such as SARS and Ebola, but the combination of a high reproduction number, superspreading events and a globally immunologically naïve population has led to the highest global number of deaths in the past 20 decade compared to any other pandemic.

Are patients with cognitive impairment fit to fly? Current evidence and practical recommendations

BACKGROUND

The worldwide prevalence of dementia is increasing and represents a major public health concern. In the last decades, air travel services have undergone an impressive expansion and one of ten passengers is aged 65 years and older. While air travel can be stressful at all ages and health conditions, older individuals with cognitive impairment carry a greater risk for air-travel-related complications. Consequently, demands to general practitioners for assessing their older patient's fitness to fly are increasing.

METHODS

We conducted a search of the literature in PubMed on the impact of in-flight environmental changes on passengers with cognitive impairment and possible resulting complications. This set the base for a discussion on pharmacological and non-pharmacological interventions aimed at preventing in-flight complications in this vulnerable population.

RESULTS

While our research strategy identified a total of 11 articles related to older age and air travel, only three focused on passengers with cognitive impairment. Our literature review showed that the airplane environment may lead to a large spectrum of symptoms in passengers of all age groups. However, passengers with cognitive impairment due to neurodegenerative diseases are at increased risk for experiencing the most extreme symptoms such as acute confusional state. Non-pharmacological and pharmacological interventions at different stages of the travel process (before, during and after) can help prevent complications in this vulnerable population.

CONCLUSION

The decision to let a patient with cognitive impairment fly requires a solid understanding of the in-flight environmental changes and their impact on older patients with cognitive impairment. Moreover, a sound weighing of the risks and benefits while considering different aspects of the patient's history is demanded. In this regard, the role of the treating physicians and caregivers is essential along with the support of the medical department of the airline.

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.

End of year editorial: hot topics in travel medicine

COVID-19 will reshape travel medicine, in particular in relation to business travellers and the use of digital technologies. Although the hot topic in travel medicine was the COVID-19 pandemic, travel-associated measles, yellow fever and rabies deserve some special attention.

Aetiology of fever in returning travellers and migrants: a systematic review and meta-analysis

BACKGROUND

Numerous publications focus on fever in returning travellers, but there is no known systematic review considering all diseases, or all tropical diseases causing fever. Such a review is necessary in order to develop appropriate practice guidelines.

OBJECTIVES

Primary objectives of this review were (i) to determine the aetiology of fever in travellers/migrants returning from (sub) tropical countries as well as the proportion of patients with specific diagnoses, and (ii) to assess the predictors for specific tropical diseases.

METHOD

Embase, MEDLINE and Cochrane Library were searched with terms combining fever and travel/migrants. All studies focusing on causes of fever in returning travellers and/or clinical and laboratory predictors of tropical diseases were included. Meta-analyses were performed on frequencies of etiological diagnoses.

RESULTS

10 064 studies were identified; 541 underwent full-text review; 30 met criteria for data extraction. Tropical infections accounted for 33% of fever diagnoses, with malaria causing 22%, dengue 5% and enteric fever 2%. Non-tropical infections accounted for 36% of febrile cases, with acute gastroenteritis causing 14% and respiratory tract infections 13%. Positive likelihood ratios demonstrated that splenomegaly, thrombocytopenia and hyperbilirubinemia were respectively 5-14, 3-11 and 5-7 times more likely in malaria than non-malaria patients. High variability of results between studies reflects heterogeneity in study design, regions visited, participants' characteristics, setting, laboratory investigations performed and diseases included.

CONCLUSION

Malaria accounted for one-fifth of febrile cases, highlighting the importance of rapid malaria testing in febrile returning travellers, followed by other rapid tests for common tropical diseases. High variability between studies highlights the need to harmonize study designs and to promote multi-centre studies investigating predictors of diseases, including of lower incidence, which may help to develop evidence-based guidelines. The use of clinical decision support algorithms by health workers which incorporate clinical predictors, could help standardize studies as well as improve quality of recommendations.

Navigating the risks of flying during COVID-19: a review for safe air travel

RATIONALE FOR REVIEW

With air travel restarting, there has been much discourse about the safety of flying during the pandemic. In travel medicine, risk assessment includes estimating baseline risk to the traveller, recognizing factors that may modify that risk, considering the role of interventions to decrease that risk and accounting for a traveller's perception and tolerance of risk. The goals of this review are to identify the in-flight transmission risks of commercial air travel, provide recommendations about the risks of flying during the pandemic and propose strategies to mitigate the spread of COVID-19.

KEY FINDINGS

The airline industry has taken a layered approach to increase passenger safety through effective onboard ventilation, extended ventilation at the gate, boarding and deplaning strategies, improved aircraft disinfection and pre-flight screening such as temperature checks and COVID-19 testing. Proximity to an index case may contribute to the risk of transmission more than the seat type or location. The use of face masks has significantly reduced onboard transmission, and mandatory in-flight mask-wearing policies are being enforced. Innovations such as digital health passports may help standardize screening entry requirements at airports and borders, allowing for a safer return to travel.

RECOMMENDATIONS

In-flight transmission of SARS-CoV-2 is a real risk, which may be minimized by combining mitigation strategies and infection prevention measures including mandatory masking onboard, minimizing unmasked time while eating, turning on gasper airflow in-flight, frequent hand sanitizing, disinfecting high touch surfaces, promoting distancing while boarding and deplaning, limiting onboard passenger movement, implementing effective pre-flight screening measures and enhancing contact tracing capability. Assessing risk is a cornerstone of travel medicine. It is important to evaluate the multiple factors contributing to the cumulative risk of an individual traveller during the COVID-19 pandemic and to employ a multi-pronged approach to reduce that risk.

Travel-related fever in the time of COVID-19 travel restrictions

Travel-related infections with prolonged incubation periods should be considered in febrile patients despite the current epidemiological situation, especially if alternative more frequent diagnoses, such as COVID-19, are not confirmed.

COVID-19's impact on travel medicine surpasses that of all other emerging viral diseases

COVID-19 has devastated economies, led to widespread lockdowns and an extent of travel restrictions that the world has not seen for decades.

Dengue, chikungunya and Zika in GeoSentinel surveillance of international travellers: a literature review from 1995 to 2020

INTRODUCTION

GeoSentinel is a global surveillance network of travel medicine providers seeing ill-returned travellers. Much of our knowledge on health problems and infectious encountered by international travellers has evolved as a result of GeoSentinel surveillance, providing geographic and temporal trends in morbidity among travellers while contributing to improved pre-travel advice. We set out to synthesize epidemiological information, clinical manifestations and time trends for dengue, chikungunya and Zika in travellers as captured by GeoSentinel.

METHODS

We conducted a systematic literature search in PubMed on international travellers who presented with dengue, chikungunya or Zika virus infections to GeoSentinel sites around the world from 1995 until 2020.

RESULTS

Of 107 GeoSentinel publications, 42 articles were related to dengue, chikungunya and/or Zika. The final analyses and synthesis of and results presented here are based on the findings from 27 original articles covering the three arboviral diseases.

CONCLUSIONS

Dengue is the most frequent arboviral disease encountered in travellers presenting to GeoSentinel sites, with increasing trends over the past two decades. In Southeast Asia, annual proportionate morbidity increased from 50 dengue cases per 1000 ill returned travellers in non-epidemic years to an average of 159 cases per 1000 travellers during epidemic years. The highest number of travellers with chikungunya virus infections was reported during the chikungunya outbreak in the Americas and the Caribbean in the years 2013-16. Zika was first reported by GeoSentinel already in 2012, but notifications peaked in the years 2016-17 reflecting the public health emergency in the Americas at the time.

Travel-related hepatitis E: a two-decade GeoSentinel analysis

BACKGROUND

Hepatitis E virus (HEV) is widely distributed worldwide and is endemic in developing countries. Travel-related HEV infection has been reported at national levels, but global data are missing. Moreover, the global availability of HEV diagnostic testing has not been explored so far. The aim of this study is to describe the epidemiology of HEV infections in returning travellers and availability of HEV diagnostic testing in the GeoSentinel surveillance network.

METHODS

This was a multicentre retrospective cross-sectional study. All confirmed and probable HEV travel-related infections reported in the GeoSentinel Network between 1999 and 2018 were evaluated. GeoSentinel sites were asked to complete a survey in 2018 to assess the availability and accessibility of HEV diagnostic procedures (i.e. serology and molecular tests) throughout the study period.

RESULTS

Overall, 165 travel-related HEV infections were reported, mainly since 2010 (60%) and in tourists (50%). Travellers were exposed to hepatitis E in 27 countries; most travellers (62%) were exposed to HEV in South Asia. One patient was pregnant at the time of HEV infection and 14 had a concomitant gastrointestinal infection. No deaths were reported. In the 51% of patients with information available, there was no pre-travel consultation. Among 44 GeoSentinel sites that responded to the survey, 73% have access to HEV serology at a local level, while 55% could perform (at a local or central level) molecular diagnostics.

CONCLUSION

Reported access to HEV diagnostic testing is suboptimal among sites that responded to the survey; this could negatively affect diagnosing HEV. Pre-travel consultations before travel to South Asia and other low-income and high-prevalence areas with a focus on food and water precautions could be helpful in preventing hepatitis E infection. Improved HEV diagnostic capacity should be implemented to prevent and correctly diagnose travel-related HEV infection.

Travellers with type 1 diabetes: questionnaire development and descriptive analysis of knowledge and practices

BACKGROUND

Little is known about the awareness of travellers with diabetes about the health effects of international travel. This study aimed to design and validate a questionnaire to examine the travel health knowledge, attitudes and practices of people living with type 1 diabetes.

METHODS

A set of 74 items based on a conceptual framework analysis underwent revision and its content validity was established. Items were grouped into three domains. A development study was conducted to establish evidence regarding their factorial structure. A construct validation study was then conducted in which the retained items were tested in an independent sample using confirmatory factor analysis (CFA).

RESULTS

Four factors emerged from our development study and were labelled as pre-travel preparation-insect bites, pre-travel preparation-consultation, insulin and glycaemic control and travel risk behaviour. A CFA confirmed the factorial structure identified in the development study in an independent sample. Each factor loading had a significant (P < 0.001) loading of at least 0.4. The factor correlations ranged between 0.1 and 0.6, indicating good discriminant validity. The highest mean domain score in our sample of 268 participants related to insulin and glycaemic control (6.45), followed by travel risk behaviour (5.21) and pre-travel preparation (4.15).

CONCLUSIONS

This valid questionnaire for measuring the degree of preparedness of travellers with type 1 diabetes may prove a useful tool in studies involving travellers with type1 diabetes. Our results suggest that improvements are needed in relation to timely pre-travel consultation and screening for diabetic complications.

Patterns of illness and injury on Antarctic research cruises, 2004-2019: a descriptive analysis

BACKGROUND

Before the impact of the coronavirus disease 2019 pandemic, cruise travel had experienced exponential growth in the preceding decade. Travel medicine practitioners were increasingly called upon to provide pre-cruise travel advice and medical clearance. Demand for these services will return at some time in the future.

METHODS

The clinical conditions seen in those presenting for care on six small-vessel scientific cruises to Antarctica were analysed.

RESULTS

Personnel presented on 196 occasions resulting in 257 consultations (when initial plus all follow-up consultations were included). Personnel presented with a clinical condition at a rate of 17.9 per 1000 person-days at sea. The total consultation rate was 23.5 per 1000 person-days at sea. Injury accounted for 24% of all presentations at a rate of 4.3 per 1000 person-days at sea. Dermatological, soft tissue and musculoskeletal, general malaise and motion sickness were the four most common presentations.

CONCLUSIONS

Pre-cruise advice for travellers planning small-vessel cruises to polar regions needs to include skin care, prevention and management of sea sickness and how to reduce the risk of injury. Those providing medical care on such cruises should be prepared to manage a wide range of clinical presentations.

Yellow fever vaccination: how much do travelers from Eastern India know?

Introduction: International tourism has grown tremendously in the past 2-3 decades in India resulting in exposure of travelers to varied spectrum of diseases prevalent in different parts of the world. Immunization plays a prominent role in protection of the exposed individuals. The objective of the present study was to assess the awareness and knowledge regarding yellow fever and other travel vaccinations amongst travelers of eastern India. Materials and methods: In the present cross-sectional study, participants attending Yellow Fever Vaccination Clinic at All India Institute of Medical Sciences, Bhubaneswar, during August-September 2018 were approached. Newly registered participants aged 15 y and above were interviewed consecutively till the required sample size of 300 was fulfilled. Awareness and knowledge regarding travel vaccinations and their adverse effects were assessed with pretested structured interview schedule. Bivariate and multivariate logistic regressions were done to assess the association of various factors with awareness of travel vaccinations. Results: Among the participants, most of them were males (90.7%), belonged to the age group of 15-45 y (87.3%), married (64.3%), graduates (19%), and were working (78.3%). Most of the participants were traveling to South Africa (85.4%). Only 57.3% participants were aware of any travel vaccinations. Only 37.5% participants knew that yellow fever vaccine confers lifelong immunity. On multivariate logistic regression higher education, working occupation and history of previous vaccination were significantly associated with awareness of travel vaccinations. Conclusion: Awareness regarding travel vaccinations is important to prevent fatal diseases like yellow fever. Vital information pertaining to diseases in different locations and availability of vaccines for prevention needs to be disseminated to the travelers to prevent occurrence of travel bound diseases.

Re-starting travel in the era of COVID-19: preparing anew

Travel, a major contributor to global economy, needs to adapt to the coronavirus disease 2019 (COVID-19) pandemic. Restarting business and travel share convergent considerations. Travel health preparation will require detailed assessment to specifically address COVID-19: the individual’s personal risk stratification, elements of travel and policies imposed on each traveller and itinerary. Precise details of the trip will help to formulate beneficial recommendations.

Dengue vaccine development by the year 2020: challenges and prospects

The first licensed dengue vaccine led to considerable controversy, and to date, no dengue vaccine is in widespread use. All three leading dengue vaccine candidates are live attenuated vaccines, with the main difference between them being the type of backbone and the extent of chimerization. While CYD-TDV (the first licensed dengue vaccine) does not include non-structural proteins of dengue, TAK-003 contains the dengue virus serotype 2 backbone, and the Butantan/Merck vaccine contains three full-genomes of the four dengue virus serotypes. While dengue-primed individuals can already benefit from vaccination against all four serotypes with the first licensed dengue vaccine CYD-TDV, the need for dengue-naive population has not yet been met. To improve tetravalent protection, sequential vaccination should be considered in addition to a heterologous prime-boost approach.