Symptoms of infectious diseases in travelers with diabetes mellitus: a prospective study with matched controls

Travel health practices, behaviours and experiences of people living with type 1 diabetes

INTRODUCTION

There are limited data regarding the international travel history and preparation, as well as glycaemic control practices, risk behaviours and experiences of people with type 1 diabetes during travel. Our review aimed to address the research question: 'What are the health practices, behaviours and experiences of people with type 1 diabetes when travelling?'

METHODS

We conducted a mixed-methods narrative review using adapted review methods from the Centre for Reviews and Dissemination and standards developed by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. MEDLINE, Scopus, PubMed and CINAHL, and the reference lists of all eligible studies were searched.

RESULTS

Nine records comprising of 11 studies were included, with data heralding from various countries, published between 1990 and 2022. We identified three main themes: travel preparation (type of travel, planning and advice seeking); issues related to air travel (airports and airport security, hypoglycaemia and hyperglycaemia, and insulin) and general travel-related issues (illness and medical treatment, type 1 diabetes management, and major concerns and barriers).

CONCLUSIONS

Our findings highlighted the lack of quality data regarding type 1 diabetes and travel within the extant literature, as well a pressing need for empirical studies to be undertaken and consensus guidelines developed to improve the travel experiences of people with type 1 diabetes. Unless change is made, people with type 1 diabetes will continue to experience preventable risk and harm while travelling.

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.

Retrospective analysis of older travellers attending a specialist travel health clinic

Background

Older people represent a significant proportion of overseas travellers. The epidemiology of older international travellers is not well described in the literature. This study aims to identify demographics, travel characteristics and the medical profile of older travellers seeking pre-travel health advice in a specialist travel medicine clinic.

Methods

Records of travellers aged 60 years and older attending the Tropical Medical Bureau clinic in Galway, Ireland between 2014 and 2018 were examined. Descriptive and inferential.analysis of data was performed.

Results

A total of 337 older travellers sought pre-travel health advice during the study period. The mean age of the cohort was 65.42 (±10) years. Most of the travellers (n = 267, 80%) had at least one travelling companion. Nearly half of older travellers (n = 155, 46.8%) were travelling with a single companion. Tourism was the main reason for travel for the majority (n = 260, 77.6%), followed by visiting friends and relatives (VFR) (n = 23, 6.9%) travellers. The mean interval remaining before the planned trip was 4.36 (±2) weeks, and the mean duration of travel was 3.16 (±1) weeks. The most popular single country of destination was India with 33 (9.8%) visitors, and South East Asia was the most popular region with 132 (39.2%) older travellers. The majority of travellers (n = 267, 79.2%) had a documented pre-existing medical condition. The most commonly reported medical conditions were hypertension (n = 26, 7.7%), dyslipidaemia (n = 18, 5.3%), diabetes mellitus (n = 12, 3.5%), insect bite sensitivity (n = 11, 3.3%), and hypothyroidism (n = 9, 2.6%). Antihypertensive agents (n = 32, 9.4%) and statins (n = 24, 7.1%) were the most frequently used medications. Typhoid (n = 112, 33.2%) and hepatitis A (n = 84, 24.9%) were the most common vaccinations administered to older travellers at the clinic.

Conclusions

This study provides an insight into the demographics, travel characteristics, and medical profile of elderly travellers seeking advice at a large travel clinic in Ireland. A wide range of travel destinations, diseases and medication use was reported among this group of travellers, which may enable travel medicine physicians to provide more tailored advice and to more appropriately counsel older travellers.

What do we know about travel for children with special health care needs? A review of the literature

BACKGROUND

Children travel with their families, including children with chronic illness. We know that adults with chronic illness who travel are more likely than their healthy peers to become sick while traveling. A review of the literature was undertaken to identify what is known about traveling with children with special health care needs and to identify gaps in our knowledge.

METHODS

An Online search of the PubMed, CINAHL and Google databases of English language literature was conducted June 2016, October 2017, June 2018 and April 2019 using the terms children and travel, air travel, travel health, disabled child, children with special healthcare needs, parents of disabled children, vacations, recreation, international, wheelchairs, planning techniques, asthma, diabetes, altitude, cystic fibrosis, inflammatory bowel disease, sickle cell disease, depression, food allergies, Attention Deficit Hyperactivity Disorder (ADHD), and seizures. The search was limited to years 2000-2019. A secondary search of relevant articles was conducted using the reference sections of articles identified in the primary search.

RESULTS

185 papers were examined for travel health related outcomes for children and adults with chronic diseases. Articles were excluded if they addressed the educational needs of students with disabilities traveling abroad, did not directly address travel health (e.g travel skills, travel itineraries), contained outdated policy statements, or were case reports of a single patient. The remaining 84 papers were organized and reviewed by organ systems. The articles were primarily descriptive and did not lend themselves to a systematic review.

CONCLUSION

Children traveling with chronic and complex health conditions are a heterogeneous group of vulnerable travelers. Closing the knowledge gap about how to best help these travelers requires a multipronged approach. Research is urgently needed to identify best practices for five of the most common chronic childhood diseases: asthma, depression, ADHD, food allergies and autism. For less common illnesses, ones typically cared for in specialty clinics, expert consensus opinion and multi-center studies are needed. Families and disease advocacy societies should be included in the research as they may have already identified the most pressing travel-related health concerns and solutions for these problems.

Symptoms of infectious diseases in HIV-positive travellers: A prospective study with exposure-matched controls

BACKGROUND

Recently, the number of HIV-infected travellers to (sub)tropical areas has increased substantially. In the Netherlands, HIV-positive travellers with CD4-cells of <500/mm³ are advised to carry stand-by antibiotic treatment against travellers' diarrhoea. Our aim was to determine whether HIV infection is associated with travel-related symptomatic diseases.

METHODS

A prospective study was performed among HIV-infected travellers and age-matched HIV-uninfected travel companions serving as controls, attending two travel clinics in Amsterdam. Participants filled out daily questionnaires before, during, and after their trip.

RESULTS

Overall, 52 pairs were included. All participants were male, and 91.3% were born in a Western country. Prevalence of travel-related diarrhoea was 50% among HIV-positive travellers and 40% among controls. No significant differences were observed for incident travel-related diarrhoea (incidence rate ratio = 1.60, 95%CI = 0.79-3.27) or duration of symptoms (odds ratio = 1.49, 95%CI = 0.65-3.45). There were no significant differences in symptom incidence or duration for travel-related vomiting, cough, rhinitis, pruritus, fatigue, or nausea. Only 6.3% of HIV-positive travellers with CD4-cells of <500/mm³ and diarrhoea used their stand-by antibiotic treatment as recommended.

CONCLUSION

Travel-related symptoms were not significantly more frequent or longer lasting among HIV-infected travellers compared to controls. Most HIV-infected travellers with CD4-cells of <500/mm³ and diarrhoea did not take stand-by antibiotic treatment. These results may question the need for routine prescription of stand-by antibiotics among this specific risk group. Further research, especially among HIV infected VFR travellers and in larger study groups is needed.

Travel-related health problems in the immunocompromised traveller: An exploratory study

BACKGROUND

Immunocompromised travellers (ICTs) are at increased risk of travel-related health problems. Therefore, they are advised to attend specialised pre-travel clinics for advice on vaccination, malaria chemoprophylaxis and on-demand antibiotics. However, studies yield conflicting data regarding travel-related health problems encountered by ICTs; questioning the rationale for certain advices, and particularly the advice of on-demand antibiotics.

OBJECTIVE

To evaluate self-reported travel-related health problems, antibiotic use, medical visits and risk behaviours in ICTs and controls.

METHODS

We conducted a questionnaire-based observational study with pilot character. We recruited participants from a (medical) pre-travel clinic. Telephone interviews were conducted 2-4 weeks post-travelling, applying a structured questionnaire.

RESULTS

We included 30 ICTs and 30 controls. More ICTs than controls reported travel-related health problems, antibiotic use and medical visits, although not statistically significant. Travellers' diarrhoea appeared to be more severe in ICTs. Furthermore one ICT was hospitalized post-travel due to pneumonia. Of ICTs, 2/30 (7%) used on demand antibiotics while not indicated (according to the protocol of the Dutch national coordinating centre for travel advice or prescribed by a physician). Reversely, 6/30 (20%) did not use on demand antibiotics while actually indicated according to this protocol.

DISCUSSION

Our findings substantiate the recommendation of on demand antibiotics. However, ICTs did often not use on demand antibiotics correctly; they therefore need very careful instructions.

Diabetes and the occurrence of infection in primary care: a matched cohort study

Background

People with diabetes may be at higher risk for acquiring infections through both glucose-dependent and biologic pathways independent of glycemic control. Our aim was to estimate the association between diabetes and infections occurring in primary care.

Methods

Using the Newfoundland and Labrador Sentinel of the Canadian Primary Care Sentinel Surveillance Network, patients with diabetes ≥18 years between 1 January 2008 and 31 March 2013 were included with at least 1-year of follow-up. We randomly matched each patient with diabetes on the date of study entry with up to 8 controls without diabetes. Primary outcome was the occurrence of ≥1 primary care physician visits for any infectious disease. Secondary outcomes included primary visits for head & neck, respiratory, gastrointestinal, genitourinary, skin and soft tissue, musculoskeletal, and viral infections. Using multivariable conditional logistic regression analysis, we measured the independent association between diabetes and the occurrence of infections.

Results

We identified 1779 patients with diabetes who were matched to 11,066 patients without diabetes. Patients with diabetes were older, had a higher prevalence of comorbidities, and were more often referred to specialists. After adjusting for potential confounders, patients with diabetes had an increased risk of any infection compared to patients without diabetes (adjusted odds ratio = 1.21, 95% confidence interval 1.07–1.37). Skin and soft tissue infections had the strongest association, followed by genitourinary, gastrointestinal, and respiratory infections. Diabetes was not associated with head and neck, musculoskeletal, or viral infections.

Conclusion

Patients with diabetes appear to have an increased risk of certain infections compared to patients without diabetes.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-2975-2) contains supplementary material, which is available to authorized users.

Benefits of flu vaccination for persons with diabetes mellitus: A review

Diabetes mellitus imposes a significant and increasing burden on society, with major consequences for human health, welfare and the economy worldwide. Persons with diabetes mellitus are at increased risk of developing severe complications after influenza virus infection and guidelines advise vaccination. The present evidence for influenza vaccine effectiveness in persons with diabetes mellitus is mainly based on observational studies with clinical endpoints like hospitalization and death, indicating a beneficial reduction of morbidity and mortality. Further supportive evidence comes from serological studies, in which persons with diabetes mellitus usually develop similar antibody levels after vaccination as healthy people. Observational studies may be prone to selection bias, and serological studies may not completely mirror vaccine effectiveness in the field. Although more controlled trials in persons with diabetes mellitus with laboratory-confirmed, influenza-specific outcomes would be desirable to better estimate the effect of vaccination, the currently available data justify routine influenza vaccination in persons with diabetes mellitus. As in this risk group, the use of influenza vaccine is far below target worldwide, efforts should be made to increase vaccination coverage.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Health risks of young adult travelers with type 1 diabetes

AIM

International travel has become popular among young adults. This study evaluated the rate and characteristics of travel-associated health risks among young adults with type 1 diabetes mellitus (T1DM) compared with healthy same-aged individuals.

METHODS

A retrospective study was conducted of 47 young adults with T1DM and 48 without (controls). Structured questionnaires accessed information regarding 154 international trips during the preceding 5 years and lasted 7 days and longer.

RESULTS

Mean ± SD ages of the diabetic and control groups were 26.6 ± 5.0 and 26.9 ± 2.6 years, respectively. Mean trip durations were 80.0 (range 7.0-390.0) and 87.6 days (range 7.0-395.0), respectively. The number of trips per person was 1.5 ± 0.6 and 1.7 ± 0.8, and the proportion of trips to developing countries 64 and 61%, respectively. There were no differences between the groups in rates of travel-related diseases that required medical consultation (11% vs 15% for all trips). No patient sought medical attention for acute problems related to diabetes management. Prior to 71% of their trips to developing countries, respondents with diabetes consulted their diabetes physician; prior to 26% of their trips they switched from an insulin pump to injections; during 41% of the trips they increased glucose monitoring; and for the period of 11% of the trips they defined their metabolic control as poor. Self-reported mean hemoglobin A1c (HbA1c) levels before and after trips were 7.65 ± 1.45 and 7.81 ± 1.23%, respectively (p = 0.42, paired t-test).

CONCLUSIONS

Young adults with type 1 diabetes did not report more travel-related diseases than did healthy individuals. Most reported reasonable to good glycemic control during the trip without severe consequences.

Health risks of travelers with medical conditions--a retrospective analysis

BACKGROUND

Traveling the world may result in infection with tropical or other travel-associated diseases. This applies increasingly also to people with immune-compromising and other medical conditions, as well as to elderly individuals. To reduce exposure and susceptibility to health risks, there is a need for appropriate pre-travel advice for these particular groups of travelers.

METHODS

In this observational study, we analyzed the overall risk of health problems among travelers with underlying medical conditions who attended the University of Amsterdam's Academic Medical Center's (AMC) travel clinic from January to October 2010. Telephone questionnaires were administered to 345 travelers with underlying conditions and 100 healthy travelers.

RESULTS

The most common underlying medical conditions studied included: (1) diabetes mellitus; (2) impaired immunity due to use of immune-suppressing medication; (3) reduced gastric barrier; and (4) HIV infection. The overall incidence of travel-related diseases (TRDs) was higher among those patients with underlying medical conditions compared to healthy travelers [incidence rate ratio (IRR) 2.26, 95% CI (1.29-3.98)]. Of all diseases reported, gastrointestinal disease, fever, and respiratory problems were reported most frequently. Travel to Central America, South Central Asia, Northeast Asia, and North Africa was associated with increased risk of contracting TRD. Hepatitis B protection was absent or unknown in 75% of these travelers.

CONCLUSIONS

Travelers with medical conditions had a higher risk of obtaining TRD, predominantly gastrointestinal in nature.