Epidemiologic basis for the practice of travel medicine

Health hazards and medical treatment of volunteers aged 18-30 years working in international social projects of non-governmental organizations (NGO)

The specific health risk profile and diversity of treatments sought by young volunteers participating in international social projects should differ from those of their older colleagues. In the absence of any data to identify whether this was correct, a retrospective analysis was performed using a standardized questionnaire. Questions included what diseases occurred, and details of the frequency and types of treatment sought during their stay - (e.g. self-treatment, medical/dental intervention, or local healer). The 153 participants were aged 18-30 years and worked in a non-governmental organization for >6 months. The participants were: 53% female, mean age 20 years, and mean duration of stay was 11.2 months. Their NGO placement abroad was in Latin America 65.4%, 14.4% in Africa, and 9.8% in Asia. 83% of the young volunteers had received some advice regarding travel medicine before their departure. However, they suffered from more injuries compared to private travellers, and febrile infections were more common when compared to older studies. 21.2% suffered from dental problems and 50% of them sought medical treatment. This study highlights a previously unreported higher risk profile of specific health problems occurring in young NGO volunteers, including some potentially life-threatening diagnoses that differed from their older colleagues and normal travellers. It is recommended that young volunteers should receive age specific, comprehensive pre-departure training in health and safety, first aid, and management of common health problems. A medical check-up upon returning home should be mandatory. The provision of a basic first aid kit to each volunteer before departure is also recommended.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Travel health: sun protection and skin cancer prevention for travellers

The UK population likes to travel to sunny parts of the world, where the risk of sunburn is greater than it is at home. Sunburn and the cultural desire for a tan is one of the risk factors for the increase in skin cancer. The rise in foreign travel has resulted in an increased demand for pre-travel health services, with nurses in primary care acting as the main providers.Within these consultations, the traveller and their travel plans are risk assessed.Travel health consultations give an ideal opportunity to discuss and advise the public regarding sun burn and skin cancer protection. However, there are also other ways to impart safety in the sun message to travellers. Skin protection is a health promoting activity provided as a part of public health provision and all nurses can play a role in prevention.

Imported disease in emergency departments: an undiscovered country?

BACKGROUND

The incidence of imported disease within the emergency department (ED) is not known, but a significant number of patients present to medical services after return from traveling. Unless practitioners in ED are aware of the potential for nonendemic disease in the population of patients they attend, there is a possibility that imported diseases will not be diagnosed in the acute setting.

METHOD

A questionnaire was sent to all medical practitioners involved in assessing patients presenting to the EDs of hospitals. This questionnaire consisted of five clinical scenarios describing acute presentations of imported diseases but without a travel history included. Responses were requested to ascertain whether practitioners would elucidate the travel history and consequently establish the correct diagnosis.

RESULTS

A response rate of 96% was achieved. When presented with a clinical scenario suggesting imported disease, travel history is only elicited in 16% of cases by the acute care practitioners. A correct diagnosis was given in 22% of responses. Interestingly, there was generally no significant correlation between eliciting a travel history and establishing the correct diagnosis.

CONCLUSIONS

When presented with a clinical scenario that describes an imported disease, medical practitioners in EDs do not routinely establish a travel history or consider the diagnosis of imported disease. There may be a high potential for imported disease to be missed in the ED.

Where have you been? The potential to overlook imported disease in the acute setting

OBJECTIVES

The incidence and prevalence of imported disease within the emergency department is not known. It is known, however, that a significant number of patients attend medical practitioners after they return from travelling. If practitioners working in emergency departments are unaware of the potential for nonendemic disease in the population of patients they attend, there is a possibility that imported diseases will remain undiagnosed in the acute setting.

METHODS

The medical records of all patients attending a medium-sized accident and emergency department over the period of a week were reviewed to ascertain whether a travel history was recorded in patients who potentially have an imported disease, and whether imported diseases were considered in the differential diagnosis.

RESULTS

A travel history was recorded in only 2% of all patients attending the accident and emergency department (5.3% of those with a potential of having imported disease). This figure is unchanged if only patients with nontraumatic conditions are considered, or if those patients with low risk of imported disease are removed from the calculations.

CONCLUSIONS

It appears that medical practitioners in emergency departments do not routinely establish a travel history, or consider the diagnosis of imported disease, when presented with a clinical scenario that describes a possible imported disease. Consequently, there is a high potential for imported disease to be missed in the emergency department.

Travel-related hepatitis B: risk factors and prevention using an accelerated vaccination schedule

Rates of global travel and tourism are increasing dramatically, especially to regions with medium or high endemicity for hepatitis A and B, such as Asia, Africa, Latin America, and the Middle East. International travelers to these areas should be protected against both hepatitis A and B, regardless of their anticipated length of stay. However, many travelers depart within weeks of planning their trip (too late to complete the accelerated 0-, 1-, 2-month regimen for hepatitis B), and a majority of those traveling depart without being vaccinated. Although extended-stay travelers are at high risk for hepatitis B, short-stay travelers also are at risk. The most commonly encountered risk factors for travel-related hepatitis B are casual sexual activity with a new partner, medical and dental care abroad, and in the expatriate community, adoption of children who are hepatitis B carriers. Although efficacy studies of accelerated schedules for hepatitis B immunization have not been conducted, the results of immunogenicity studies in healthy volunteers who received an accelerated, 3-dose regimen on a 0-,7-, and 21-day schedule suggest that excellent, rapid, and long-term protection will be conferred. More data are needed to assess the efficacy of accelerated schedules in persons aged >40 years and to determine whether a fourth dose of hepatitis B vaccine is needed in all age groups.

Quality of travel health advice in higher-education establishments in the United Kingdom and its relationship to the demographic background of the provider

BACKGROUND

The number of international trips undertaken by residents of the United Kingdom has risen dramatically over the past 50 years. Likewise, the numbers studying in higher education have also shown a huge increase. This study aimed to assess the appropriateness of advice given to traveling students by higher education-based health services and to relate this to the demography and experience of the professionals involved.

METHODS

A postal questionnaire describing three hypothetical groups of students traveling to different parts of the world was sent to 335 doctors and nurses. These clinicians belonged to the British Association of Health Services in Higher Education. They worked in 105 practices that serve higher-educational establishments in the United Kingdom. Main outcome measures included whether appropriate immunizations were advised and given correctly through the National Health Service (NHS) or privately, and whether appropriate advice was given regarding malaria, human immunodeficiency virus (HIV), and miscellaneous risks. The sources of information used to advise travelers were also asked, and the effect of demographic characteristics of the respondents on the quality of advice was investigated.

RESULTS

Two hundred fifteen (64%) questionnaires were returned. The mean score for whether the correct immunizations were advised was 77%, and for whether these were given correctly through the NHS or privately was 79.6%. For malaria, HIV, and miscellaneous risks, the scores were lower at 65%, 38%, and 32%, respectively. The score for correct immunizations was significantly affected by sex, with females respondents scoring higher (p = .036). Previous training in travel medicine improved scores for immunizations (p = .034) and for the correct choice being given through the NHS or privately (p = .006). Age, hours worked, role, and size of practice had no influence on scores. Charts in the general practice free newspapers were the most popular source of information.

CONCLUSIONS

Practices serving higher-education establishments usually give appropriate advice to travelers in terms of the immunizations required, whether these are available through the NHS or privately, and about reducing risks of malaria. This is not the case regarding advice pertaining to HIV and miscellaneous risks. Previous training in travel medicine seems to correlate with the giving of more appropriate advice.

Travel health knowledge, attitudes and practices among United States travelers

BACKGROUND

Large numbers of United States residents travel each year to countries where malaria, hepatitis A, hepatitis B and other vaccine-preventable diseases are prevalent. However, relatively little is known about how United States travelers perceive risks associated with travel or how they prepare for their international voyages. This airport survey was therefore performed to determine the travel health knowledge, attitudes and practices (KAP) of United States travelers.

METHODS

Questionnaires were administered to international travelers, aged 18 years or more, departing from the John F. Kennedy International Airport in New York who were going to destinations that were high risk for malaria or hepatitis A.

RESULTS

Overall, 404 questionnaires were completed, including 203 focused on malaria and 201 on vaccine-preventable diseases. Latin America and Asia were the most common destinations. Only 36% of travelers sought travel health advice, despite the fact that more than half prepared their trip at least a month in advance. Only 17% of travelers considered themselves at high risk for hepatitis A. Although the majority of travelers (73%) to a high-risk malaria-endemic region perceived malaria as a high health risk, only 46% of them were carrying antimalarial medications. Additionally, although the majority of travelers believed that vaccines were effective for prevention, few were vaccinated for their journey: 11% for tetanus, 14% for hepatitis A, 13% for hepatitis B, and 5% for yellow fever.

DISCUSSION

This airport survey demonstrated important shortcomings in the travel health KAP of international travelers. A substantial proportion of the travelers were not adequately protected against malaria, hepatitis A or hepatitis B. Future efforts need to focus on improving the level of awareness of travelers regarding their risk of disease acquisition overseas and the importance of pre-travel education, immunizations, and malaria chemoprophylaxis.

Travel health insurance: indicator of serious travel health risks

BACKGROUND

Travel health risks documented by questionnaire surveys obtained (e.g., during homebound flights) are incomplete since they miss most patients who need to be repatriated.

METHODS

All patient claim files were reviewed from 1997 to 1998, of the largest Swiss travel insurance company.

RESULTS

Among 242 claims, 69.4% were due to illness, 30.6% due to accidents; infections were the most frequent illnesses, the extremities were the most frequently traumatized part of the body. Although the illness-to-accident ratio was 1:5 in industrialized countries and the Caribbean, it exceeded 3:0 in some developing regions. Accident proneness was noted in the first week abroad.

CONCLUSION

Even if no denominator data are available, this analysis offers an insight in travel health risks, allowing comparison of the occurrences of very different, serious, health problems abroad.

Assessment of travellers who return home ill

Every year, millions of people travel abroad, exposing themselves to various diseases. Advice on risk avoidance and on self-medication is not always successful; sometimes travellers return home ill or become unwell soon afterwards. There are many possible causes for such illnesses, and physicians should try to establish whether the disease is specifically associated with the recent journey. The approach to assessment of the ill traveller should make use not only of signs and symptoms, but also of geography and epidemiology. Travellers with fever need immediate attention to rule out serious and potentially life-threatening conditions. Faced with a difficult diagnosis, physicians should consult with experts in tropical and travel medicine.

Preparing the traveller

The four steps for giving travellers the foundation for healthy journeys are to assess their health, analyse their itineraries, select vaccines, and provide education about prevention and self-treatment of travel-related diseases. This process takes time. Since there is a risk of information overload, travellers should leave the clinic with some written advice for reinforcement. The order of these steps can be tailored to what best suits the travel clinic, but vaccinating early in the process allows monitoring for adverse reactions. Face-to-face discussion is vital for explaining the use and side-effects of medications. Those who provide a travel medicine service should be seeing many travellers and should seek specialist training. In 2003, the International Society of Travel Medicine introduced a certificate of knowledge examination in travel medicine. We cannot make travellers bullet-proof but it is possible to make them bullet-resistant. The pre-travel visit should minimise health risks specific to the journey, give travellers the capability to handle most minor medical problems, and allow them to identify when to seek local care during the trip or on return.

Potential cost-savings and quality improvement in travel advice for children and families from a centralized travel medicine clinic in a large group-model health maintenance organization

BACKGROUND

Cost, as well as accuracy and quality of medical care, is an important factor from the perspective of the health care payer. We evaluated the potential pharmacy cost savings, appropriateness of recommendations, and patient satisfaction associated with a proposed centralized travel medicine service in a large group-model health maintenance organization (HMO).

METHODS

From computerized pharmacy records, we identified 101 children 18 years of age or younger from six different facilities of Kaiser Permanente in northern California who obtained malaria prophylaxis, typhoid vaccine, or yellow fever vaccine for international travel from their primary care practitioner. We obtained records of all vaccinations and prescriptions provided to each patient and interviewed their parents concerning medical services they received in preparation for travel. We compared what vaccinations and prescriptions were actually given to expert recommendations, and compared total pharmacy costs for actual versus recommended care.

RESULTS

Travel advice obtained from primary care practitioners in this system was often inefficient and varied from expert recommendations. Primary care practitioners frequently overestimated risk, leading to unnecessary prescribing, especially of mefloquine and typhoid vaccine. This created potential cost-savings of US $12 per patient (17% of total pharmacy costs per patient). We were unable to quantify additional savings that could result from improved efficiency of providing care.

CONCLUSIONS

A travel medicine clinic staffed by practitioners who provide expert and current advice may provide savings in pharmaceutical costs as well as improvements in quality of care compared to primary care practitioners without expertise in travel medicine.

Predictors of pretravel consultation in tourists from Quebec (Canada)

BACKGROUND

Although many tourists from Quebec (Canada) each year visit destinations at risk for infectious diseases, only a few of them seek travel health advice. To identify the determinants of travel health consultation, we conducted a study among Quebec's tourists visiting two popular sun destinations.

METHODS

A conceptual model based on psychosocial determinants of human behavior was constructed. A cross-sectional survey was carried out, from January to April 1999, on two samples of travelers planning to visit Mexico and the Dominican Republic. One sample was composed of people who did not consult a travel clinic (cluster sampling in seven flights), and the other sample was one of clients of travel clinics (purposive selection of 13 specialized clinics located in Quebec). A 34-item self-administered bilingual questionnaire was distributed to travelers. Statistical analysis included a multivariate approach (logistic regression).

RESULTS

A total of 2,242 travelers were surveyed (response rate in flight 75% and in clinics 99%). We present only results reported by French-speaking tourists: 1,152 who did not consult a travel clinic and were reached in flight, and 449 who were reached in clinics. Multivariate analyses indicated that travel agent recommendation was the most important predictor of consultation among travelers (OR 8.0, 95% CI 5.1-13), especially among those under 45 years of age and those who never sought pretravel consultation before (OR 21, 95% CI 11-41). Other important predictors were: traveling for the first time, traveling with children, previous consultation, perception about efficacy of immunization, risk perception, and information from travel agent, family doctor, and pharmacist.

CONCLUSIONS

Despite its limitations, this study provides data that should help improve public health interventions aimed at encouraging travelers to get a pretravel consultation.

Health professionals' attitudes toward acute diarrhea management

BACKGROUND

Travelers' diarrhea is the most frequent health problem in those participating in international journeys, and is responsible for many consultations abroad and on return home.

METHODS

A questionnaire assessing attitudes toward treatment and management of travel-related and nontravel-related diarrhea was administered to 542 GPs, nurses and pharmacists.

RESULTS

Health professionals' attitudes to management of acute diarrhea are variable, with marked divergence regarding adherence to published "good practice" guidelines and recommendations. Inconsistencies exist in stated attitudes toward prescribing antispasmodics and antimotility agents and actual prescribing behavior.

CONCLUSIONS

Current treatment guidelines may be outdated. Inappropriate or delayed treatment disadvantages the patient. Limiting the use of antidiarrheal agents can deny access, for those inflicted with diarrhea, to a medication which may shorten symptomatology and morbidity, and speed the return to normality. Review of guidelines for diarrhea management in adults is overdue, as is standardization of treatment response. Educational initiatives are required to encourage active intervention and improved provision of care.

How important a priority is travel medicine for a typical British family practice?

BACKGROUND

Primary care teams have to supply travel health advice to increasing numbers of long haul travelers but there is a shortage of information derived from general practice settings about the risks patients are exposed to. We aimed to determine the numbers of our patients visiting high-risk destinations, to see if they reported complying with health advice, and whether or not they became ill.

METHODS

We performed a retrospective study in a typical British, town center, family practice in Mansfield, Nottinghamshire. A postal questionnaire survey was sent to 200 adults, aged between 16 and 76, randomly selected from the practice register, and 351 adults who had attended the practice travel clinic over a 1-year period between 1997-1998.

RESULTS

Responses were received from 84% of the random sample and 86% of the travel clinic group. Out of 11,000 patients registered with the practice, we identified 187 patients who had traveled to high-risk destinations such as Africa, Asia, South America or the Caribbean. The majority of these had attended the practice travel clinic. Despite this, 41% became ill (mainly diarrhea), 10% were sufficiently ill to be confined to bed. Fifty-nine percent of patients who required malaria chemoprophylaxis reported they had not complied fully with advice given. Reported illness rates for medium and low risk destinations were 27 and 19% respectively.

CONCLUSIONS

The results suggest that giving health advice to long haul travelers should be an important priority for primary care teams. Travelers have a high episode rate of illness and put themselves at risk of acquiring malaria. Most travelers to high-risk destinations do attend the travel clinic for health advice but compliance with that advice is poor. People traveling to lower risk destinations still experience an appreciable rate of illness and are less likely to be seen in the travel clinic.

Persistent diarrhea in the returned traveler

In conclusion, the causes of chronic diarrhea in the returned traveler are protean. Careful evaluation requires an understanding of where the traveler has been, when they were there, the type of diarrheal illness, medications taken, and knowledge of the patients' other medical problems. Protozoa, particularly G. lamblia, C. parvum, and C. cayatenensis, are among the more commonly identified agents. If the patient is immunocompromised, microsporidia and Isospora become more likely, and a prior history of antimicrobial use raises the possibility of C. difficile colitis. Occasionally helminths, which establish intimate contact with the intestinal mucosa, may also cause prolonged diarrhea. If these and other gastrointestinal insults, such as tropical sprue, small bowel overgrowth, lactose intolerance, and processes unrelated to travel are excluded by more invasive studies or clinical history, the patient can be reassured that idiopathic chronic diarrhea is usually self-limited.

Prevalence, Intensity, and Sex Differences in Travel Related Stressors

Background: The objective of this study was to investigate anxiety provoking features of international travel and the degree of anxiety experienced in travelers and in people who had not traveled abroad in the previous year. Methods: A retrospective study of a 20% age- and sex-stratified quota sample of patients aged 15 years and over who had attended a group medical center in Stirling during 1994 was carried out. A standardized, structured, 16-point questionnaire was presented to people who attended the center for any purpose. A comparison, in terms of sex and intensity of travel-related worry, was made between foreign travelers and nontravelers within the preceding year. Experience of actual illness in relation to travel-related worry was also investigated. Results: One thousand seven hundred and seventy one respondents met quota entry criteria, and 1649 subjects, 836 men and 935 women, completed the questionnaire (response rate 97%). Seven hundred and forty three subjects had traveled abroad. Travel-related worries were common, e.g., worries about infected food (32.1%), contaminated water (32.0%), and flying (24.4%). Females were more worried than males, and nontravelers were more worried than travelers regarding many travel-related stressors. The intensity of certain travel-related worries was greater for nontravelers than travelers. Conclusions: For travelers, worries about infected food, contaminated water, and illness appeared justified by actual experience of travelers' diarrhea.