Recent developments: Travel medicine

Tuberculosis infection in children visiting friends and relatives in countries with high incidence of tuberculosis: A study protocol

INTRODUCTION

Tuberculosis (TB) is a global infectious disease. In low-incidence countries, paediatric TB affects mostly immigrant children and children of immigrants. We hypothesize that these children are at risk of exposure to Mycobacterium tuberculosis when they travel to the country of origin of their parents to visit friends and relatives (VFR). In this study, we aim to estimate the incidence rate and risk factors associated to latent tuberculosis infection (LTBI) and TB in VFR children.

METHODS AND ANALYSIS

A prospective study will be carried out in collaboration with 21 primary health care centres (PCC) and 5 hospitals in Catalonia, Spain. The study participants are children under 15 years of age, either immigrant themselves or born to immigrant parents, who travel to countries with high incidence of TB (≥ 40 cases/100,000 inhabitants). A sample size of 492 children was calculated. Participants will be recruited before traveling, either during a visit to a travel clinic or to their PCC, where a questionnaire including sociodemographic, epidemiological and clinical data will be completed, and a tuberculin skin test (TST) will be performed and read after 48 to 72 hours; patients with a positive TST at baseline will be excluded. A visit will be scheduled eight to twelve-weeks after their return to perform a TST and a QuantiFERON-TB Gold Plus test. The incidence rate of LTBI will be estimated per individual/month and person/year per country visited, and also by age-group.

ETHICS AND DISSEMINATION

The study protocol was approved by the Clinical Research Ethics Committee of the Hospital Universitari Mútua Terrassa (code 02/16) and the Clinical Research Ethics Committee of the Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (code P16/094). Articles will be published in indexed scientific journals.

TRIAL REGISTRATION

Clinical-Trials.gov: NCT04236765.

Traveling with children: beyond car seat safety

OBJECTIVE

To spread knowledge and instigate the health professional to give advice on childcare during travels and on child transport safety.

SOURCES OF DATA

Literature review through the LILACS and MEDLINE(®) databases, using the terms: travel, safety, protective equipment, child, preventive medicine, retrieving articles published in the last 21 years.

SUMMARY OF THE FINDINGS

The authors analyzed 93 articles, of which 66 met the inclusion criteria after summaries were read. For drafting this article, the following sub-themes were proposed: getting ready to travel with children; knowing some of the transfer risks (air, land and water transportation) and exploring the destination with children (sun exposure, accommodations, altitude, food, traveler's diarrhea, insect bites) and return from the trip with children.

CONCLUSIONS

Over the years, there has been an increase in the number of children who travel around the world. However, this population is still subject to health problems while traveling and may be even more susceptible than the adult age group. These problems arise from a variety of factors, including exposure to infectious organisms, the use of certain types of transportation, and participation in some activities, such as hiking at high altitudes, among others. However, when traveling with children, these risk factors can be overlooked; a trip that is considered safe for an adult might not be a good choice for this age group. The pediatric consultation should be a good opportunity to optimize preventive guidelines at the pre-trip planning.

Tuberculosis in travellers

Tuberculosis (TB) incidence is increasing in many countries which are popular with international travellers. The development of active TB is a two-stage process; the risk of acquiring new TB infection depends primarily on the risk of contact with an individual with infectious TB, and the risk of disease on the immune status of the newly infected person. The risk of TB infection is low for most holiday-makers, but among long-term travellers to countries with high TB incidence, the risk may be similar to that experienced by the local population (0.5-2.5% per year); the risk to people working in health care is particularly high. Effective pre-travel advice involves assessing the traveller's risk of TB infection and disease. Recommendations on the prevention of TB in travellers vary between countries. Possible strategies include avoidance of exposure; BCG vaccination; and tuberculin skin testing before and after travel, with preventive therapy for those whose post-travel skin tests indicate recent infection. For those at highest risk of progression to disease, there may be value in preventive therapy during travel to reduce the risk of new TB infection. Further information on the contribution of recent travel to incident TB in industrialised countries would be valuable.

Pre-travel health advice for human immunodeficiency virus-infected travelers, from Rio de Janeiro

Counseling for human immunodeficiency virus infected travelers is becoming increasingly specialized. Previous studies have reported the experience of HIV-infected travelers from temperate-climate countries but little is known about HIV-infected travelers from tropical countries. A retrospective study was conducted on HIV-infected travelers presenting at a travel health clinic in Rio de Janeiro. Eleven journeys by ten people were recorded. Brazil (Amazon region and Northeast) was the destination for six journeys. Other destinations were Peru, Angola, Europe and Asia. Nine attendees were undergoing antiretroviral therapy. Few HIV-infected people from Rio de Janeiro consulted a travel medicine specialist before traveling. Since they travel to destinations in Brazil and abroad where there are endemic diseases not encountered in Rio de Janeiro, careful pre-travel planning needs to be undertaken. Strategies for increasing the frequency of pre-travel consultations need to be developed, such as closer collaboration between HIV clinics and travel health clinics.

Global health training and international clinical rotations during residency: current status, needs, and opportunities

Increasing international travel and migration have contributed to globalization of diseases. Physicians today must understand the global burden and epidemiology of diseases, the disparities and inequities in global health systems, and the importance of cross-cultural sensitivity. To meet these needs, resident physicians across all specialties have expressed growing interest in global health training and international clinical rotations. More residents are acquiring international experience, despite inadequate guidance and support from most accreditation organizations and residency programs. Surveys of global health training, including international clinical rotations, highlight the benefits of global health training as well as the need for a more coordinated approach. In particular, international rotations broaden a resident's medical knowledge, reinforce physical examination skills, and encourage practicing medicine among underserved and multicultural populations. As residents recognize these personal and professional benefits, a strong majority of them seek to gain international clinical experience. In conclusion, with feasible and appropriate administrative steps, all residents can receive global health training and be afforded the accreditation and programmatic support to participate in safe international rotations. The next steps should address accreditation for international rotations and allowance for training away from continuity clinics by residency accreditation bodies, and stipend and travel support for six or more weeks of call-free elective time from residency programs.

Travel medicine and HIV infection

Summary:

The number of HIV-infected persons who travel is increasing. This increase arises from those who have benefited from advances in antiretroviral therapy. The key to successful travel is careful pre-trip planning although many patients do not obtain advice before travelling. Travel advice for HIV patients is becoming increasingly specialized, and includes travel vaccination and highly active antiretroviral therapy-related issues. A closer collaboration between HIV and travel health clinics could provide better care for HIV-infected individuals.

Travel medicine in Eastern Europe--the Hungarian way

At the end of the 1980s, a new peoples' migration began, during which the inhabitants of the former Eastern bloc discovered the Western world and the interest of Western tourists turned towards Eastern Europe. Thus, a "travel industrial revolution" took place in Eastern Europe, albeit 20 years after the corresponding Western revolution. Both the common features of their past political systems and the local peculiarities of several Eastern European countries could affect the later development of the ideas and microstructures of travel medicine. By reassessing those particularities that have influenced the formation and development of travel medicine in Eastern European countries, based upon Hungarian experiences, the author has reviewed the primary, secondary, and tertiary tasks required in travel medicine and the "four-leaved-clover structure" of travel medicine, which supports it and makes possible its flexible adaptation to local peculiarities. Building upon the experiences gathered in Western countries, with an already established travel medicine structure, Eastern European travel medicine has the chance to create an appropriate, open, and polychromic interdisciplinary science. However, when building a travel medicine system, we must preserve our traditional primary prevention activity: the well-proven triad of vaccination, chemoprophylaxis, and travel advice. We must also consider the divergent social backgrounds, cultural traditions, and local particularities of the pre-existing health care system. A very strong stress must also be placed on the secondary prevention (preparing patients suffering from preexisting diseases), psychosocial preparation, and evaluation of risk factors, use of possible protective devices, and the possibilities and limitations of self-therapy. A medical provider network abroad must be established by Hungarian travel medicine specialists for tertiary prevention, and to oversee well-established protocols for repatriation.

Preparing children for travel in Asia

Families are traveling with their children in increasing frequency. Travel to Asia offers children many opportunities to learn about new cultures and history. It also offers the potential for exposure to numerous infectious agents not commonly encountered in the United States. Families must begin to prepare for travel to Asia weeks before departure. Children should be up to date on routine vaccinations. Appropriate education should be given on arthropod avoidance and malaria prophylaxis. Additional education and possible prophylaxis should be completed for other infectious agents frequently encountered in Asia. With appropriate pretrip immunizations and prophylaxis, children can travel to Asia with minimal risk of acquiring infection. This article provides general advice to assist providers with pretravel preparation and education of families traveling with children to Asia.

Global health in medical education: a call for more training and opportunities

Worldwide increases in global migration and trade have been making communicable diseases a concern throughout the world and have highlighted the connections in health and medicine among and between continents. Physicians in developed countries are now expected to have a broader knowledge of tropical disease and newly emerging infections, while being culturally sensitive to the increasing number of international travelers and ethnic minority populations. Exposing medical students to these global health issues encourages students to enter primary care medicine, obtain public health degrees, and practice medicine among the poor and ethnic minorities. In addition, medical students who have completed an international clinical rotation often report a greater ability to recognize disease presentations, more comprehensive physical exam skills with less reliance on expensive imaging, and greater cultural sensitivity. American medical students have become increasingly more interested and active in global health, but medical schools have been slow to respond. The authors review the evidence supporting the benefits of promoting more global health teaching and opportunities among medical students. Finally, the authors suggest several steps that medical schools can take to meet the growing global health interest of medical students, which will make them better physicians and strengthen our medical system.

Case report: bilateral calf (tibial) deep venous thrombosis following air travel

OBJECTIVES

To describe an interesting case of bilateral calf (tibial) deep venous thrombosis (DVT) in a traveller.

METHODS

Clinical case notes and reports of further investigations were analysed in the light of the existing literature concerning DVT and travellers.

RESULTS

A 56-year-old university lecturer presented within 48 h of a return to New Zealand from international travel abroad. An otherwise fit and healthy man he developed bilateral calf pains most notable on arising the day of presentation, although he reported some mild pain in the lower legs within 5 h of landing at Auckland. He reported no other complaints. Physical examination was unremarkable, except for the bilateral calf tenderness and being overweight. An urgent outpatient ultrasound to both lower limbs was reported as follows: 'There is evidence of extensive thrombus involving the paired posterior tibial veins of both calves'. He was admitted to hospital for 24 h and started on low-molecular weight heparin. On completion of the course of heparin, he was further treated orally with warfarin. A follow-up assessment with a Clinical Haematologist occurred one month after hospitalisation.

CONCLUSIONS

The present case illustrates bilateral calf (tibial) DVT in an otherwise fit male traveller following extensive long haul travel. It also illustrates the need to consider the possible diagnosis and the need for bilateral ultrasound scanning of the legs, particularly in travellers undertaking long haul air travel, who are symptomatic. All travellers undertaking extensive, long-haul air travel need to be warned of the risks of DVT and venous thromboembolism (VTE) and advised of appropriate preventive measures as have been outlined. In addition, all travellers should be aware of the signs and symptoms of DVT/VTE and of the need to seek medical advice should they develop them; in order to help prevent progression of a DVT to a VTE.

Hematuria in children due to schistosomiasis in a nonendemic setting

Infection with Schistosoma hematobium is common in immigrants from tropical Africa and commonly presents with painless hematuria. Since chronic, heavy infection can lead to significant morbidity, it is imperative for clinicians who serve the immigrant and refugee population to become familiar with this traditionally exotic disease. Increased awareness will allow earlier diagnosis and treatment of infection, avoiding complications and minimizing expensive and invasive diagnostic procedures.

Risk assessment in travel medicine

Risk assessment is an integral part of pre-travel and post- assessment. Risk assessment largely determines what health and safety advice and interventions are given within the relevant prevailing travel health guidelines. Risk assessment needs time and depends on information, including that given by the traveller. Risk assessment also needs to be documented. Risk assessment of the traveller preferably starts before they enter the consulting room, where travellers may complete a pre-travel health questionnaire. Armed with this information, risk assessment may be assisted by access to computerised travel health databases and the published literature. Experience of travel to the destination may also assist in risk assessment and the tour operator, overseas employer or agency, the traveller or even the travel health advisers themselves may provide this information.

Travel and health status: a survey follow-up study

BACKGROUND

To date there is little sound knowledge on the relationship between travel and health status as perceived by the traveller. Our aim was to investigate the frequency and risk factors of travel-associated illnesses and injuries and identify potential protective factors.

METHODS

All adults enrolled in a health insurance scheme who planned to travel in 2002 were eligible for participation in a baseline survey. Pre-travel written questionnaires and post-travel telephone interviews were conducted with responders. We analysed travel-associated health problems using descriptive methods and multivariate logistic regression.

RESULTS

From 8316 persons who returned a pre-travel questionnaire, a sample of 2384 were chosen, of whom 1471 completed post-travel interviews. 10.1% of all travellers reported travel-associated illnesses, and 1.8% suffered from injuries during travel. Among travellers to European destinations, 6.0% reported an illness as opposed to 16.2% of travellers to overseas destinations. Predictors for travel-associated illness were age <30 years (OR 1.48), duration of travel >4 weeks (OR 3.35) and travel destination. Perceived health status as scored by the travellers improved after travel. The frequency of medical consultations and personal health-related expenses decreased significantly shortly after travel.

CONCLUSIONS

In this study, travel had a positive effect on the perceived health status of the traveller. The positive effects of travel seemed to outweigh the impact of health problems. Travel did not lead to increased health-related costs, neither in individual health expenses nor indirectly through increased medical consultation rates.

Travel medicine: an Australian perspective

Travel medicine is emerging as a new multidisciplinary specialty area catering for an increasing number of travellers worldwide. Travel health advisers are engaged in the provision of pre-travel health advice, chemoprophylaxis against travel-related diseases, traveller's medical kits, and post-travel assessments and eradication treatment for various travel-related diseases. They are also in a key position to liaise with public health authorities on possible imported disease risks. In terms of risk assessment and provision of preventive measures, vector-borne diseases, in particular malaria and the arboviral diseases, stand out as major concerns for travellers, however, common problems, such as travellers' diarrhoea and respiratory tract infection, also need to be addressed. Travel and aviation medicine have many linkages, especially in terms of fitness to fly and dealing with problems that may arise in travellers due to physiological and psychological stresses of travel. In the face of recent terrorism and conflict, travel advisories have assumed great importance in travellers planning. Travel insurance remains an important safety net for travellers, which provides coverage for medical and dental treatment abroad as well as an emergency assistance service, which may include aeromedical evacuation.

"I hate needles" and other factors impacting on travel vaccine uptake

Travel vaccines comprise an essential component of pretravel health advice; however, many travelers do not take advantage of this preventive health strategy to decrease their risk of travel-related illness. Factors that impact on a traveler's decision on whether or not to be vaccinated are related to the knowledge, attitudes and beliefs of the traveler regarding travel vaccines, vaccine-preventable diseases, and other factors. Further research is required to increase travelers' awareness of the need for pretravel vaccination and then to translate that awareness into positive attitudes leading to increased travel vaccine uptake.

Health Risks Associated with Visiting Friends and Relatives in Developing Countries

An increasingly large proportion of immigrants to developed countries is arriving from less developed countries in Africa, Asia, and Latin America. When these immigrants return to their country of origin to visit friends and relatives, they are at high risk of acquiring tropical infections, compared with other travelers. Immigrants who return to their country of origin to visit friends and relatives (VFRs) are more likely to travel to rural areas for long periods of time, to consume contaminated food and beverages, and to have more prolonged, intimate contact with local populations. As a group, they are less likely to seek pretravel advice or take antimalarial chemoprophylaxis. This article discusses the increased risk of tuberculosis, malaria, food- and waterborne illnesses, hepatitis A, and HIV and other sexually transmitted infections in VFRs.