Unintentional injury during foreign travel: a review

Recreational substance use among international travellers

BACKGROUND

Drug tourism reflects the expanding illicit drug market, posing health risks in unfamiliar travel settings. Existing knowledge specifically addressing substance use among international travellers is sparse and has not been reviewed to date. This review aimed to describe the recreational substance abuse in international travellers.

METHODS

A literature search was conducted on PubMed, Google Scholar and Scopus using keywords related to recreational substances and international travellers. A total of 11 021 articles were reviewed, charted and summarized for the evidence on prevalence, patterns and characteristics of substance abuse and their health- and non-health-related problems on international travellers.

RESULTS

A total of 58 articles were included. Most were cross-sectional studies and review articles. In total, 20 articles addressed the prevalence of substance abuse in travellers, 33 looked at characteristics and patterns of substance abuse in travellers and 39 investigated the health- and non-health-related problems from substance abuse. Estimated prevalence of recreational substances abuse varied from 0.7% to 55.0%. Rates of substances abuse were 9.45-34.5% for cannabis, 20.4-35.9% for alcohol intoxication, 2.82-40.5% for MDMA, 2-22.2% for cocaine, 2-15% for psychedelic agents and 2% for methamphetamine. The prevalence varied according to travellers' characteristics and travel destinations. Direct health problems included neuropsychiatric problems. Indirect problems included accident and unintentional injuries, crime and violence, risky sexual behaviours and sexual violence and blood-borne infections. Non-health-related problems included air rage, deportation and violation of local laws.

CONCLUSION

Substance abuse among international travellers is an underestimated problem that requires intervention. These findings emphasize the importance of addressing this issue to mitigate both health and well-being problems among travellers whilst promoting safer and more responsible travel experiences. In the context of travel health practices, practitioners should counsel travellers whose itineraries may include substance abuse, informing them about associated risks and consequences.

Traumatic brain injury related deaths in residents and non-residents of 30 European countries: a cross-sectional study

The incidence and mortality of traumatic brain injuries (TBI) among non-residents to countries where they occur remains unknown, warranting epidemiological research. Epidemiological data are key to inform prevention and public health policies related to TBI, as well as to help promote safe travelling practice. The aim of this study was to analyse the epidemiological patterns of TBI-related deaths among residents and non-residents in 30 European countries in 2015 using standardised European level data on causes of death. A large-scale cross-sectional study analysing TBI-related deaths in 30 European countries in 2015 among residents and non-residents to the country of occurrence of the death was conducted. Data from death certificates collected on European level by Eurostat were used to calculate the numbers of TBI-related deaths and estimate crude and age-standardised mortality rates. Rates were stratified by country, sex, age-group and by resident status. External causes of the injury were determined using the provided ICD-10 codes. 40,087 TBI-related deaths were identified; overall about 3% occurred among non-residents with highest proportions in Turkey (11%), Luxembourg (9%) and Cyprus (5%). Taking into account tourism intensity in the countries, Bulgaria, Greece and Austria showed highest rates of TBI-related deaths in non-residents: 0.7,0.5 and 0.5 per million overnight stays, respectively. The pooled age-standardised TBI-related mortality in non-residents was 0.2 (95% CI 0.1-0.3), among residents 10.4 (95% CI 9.4-11.5) per 100,000. In non-residents, TBI-related deaths were shifted to younger populations (86% in < 35 years); in non-residents 78% were 15-64 years old. Falls were predominant among residents (47%), and traffic accidents among non-residents (36%). Male:female ratio was higher among non-residents (3.9), compared to residents (2.1). Extrapolating our findings, we estimate that annually 1022 TBI-related deaths would occur to non-residents in the EU-27 + UK and 1488 in Europe as a continent. We conclude, that the primary populations at risk of TBI-related deaths in European countries differ in several characteristics between residents and non-residents to the country of the occurrence of death, which warrants for different approaches in prevention and safety promotion. Our findings suggest that TBI occurring in European countries among non-residents present a problem worthy of attention from public health and travel medicine professionals and should be further studied.

Risk of deaths due to injuries in travellers: a systematic review

BACKGROUND

Annual global travel reached an all-time high of 1.4 billion international tourist visits in 2019. It is estimated that injury accounts for close to 25% of deaths in travellers, most of which are theoretically preventable. However, there are limited data available on injury occurrence and outcomes in travellers. Our objective was to better understand the relative risk of dying from injury that arises from the novel environments and behavioural changes associated with foreign travel.

METHODS

A systematic literature review was conducted (PubMed, Embase and Scopus) according to PRISMA guidelines that included studies published in English since 1990 that reported injury deaths in tourists per 100 000-person years or as a proportion of total tourist deaths in comparison to a non-traveller population. We also included studies that reported data allowing calculation of these rates. Relative rates or proportions of overall injury mortality, mortality due to traffic accidents, drowning and homicide were summarized.

RESULTS

In total, 1847 articles were identified, 105 underwent full-text review, and 10 articles were suitable for data extraction. There was great variability of relative risk reported, but overall, travellers appear to have a higher risk of injury mortality than domestic populations, with relative rates of injury death ranging from 1.04 to 16.7 and proportionate mortality ratios ranging from 1.43 to 3.

CONCLUSIONS

Tourists should be aware of the increased risk of dying from road traffic hazards, drowning and homicide while traveling abroad. Specific geographies and activities associated with higher risk should be emphasized. Travel medicine practitioners and organizations that send people abroad should counsel travellers regarding these risks and seek ways to reduce them, including encouraging potential risk-mitigating behaviours. There is a need to improve systems of data collection and reporting on injury deaths in travellers and to study the impact of pre-travel and institutional interventions aimed at reducing this risk.

[Travelling with children and adolescents with rheumatic diseases]

Due to the underlying disease and immunosuppressive treatment, pediatric patients with rheumatic diseases are at increased risk for (long distance) travel-related health problems. A pretravel comprehensive consultation is therefore strongly recommended. Whether a child with rheumatic disease is sufficiently fit for travel essentially depends on the disease activity, the age of the child and the intended travel destination. Depending on the level of immunosuppression, the risks for this patient group include (travel-related) infections and the possibility of disease activity flares. Of particular importance is adequate exposure prevention: standard vaccinations should be updated and indications for travel vaccinations evaluated in advance of travelling. In this context, potential contraindications, especially for live vaccines, in the case of specific immunosuppressive treatment should be considered. In the event of travel to malaria endemic areas, the necessity for chemoprophylaxis or stand-by medication must be evaluated but caution is needed regarding potential drug interactions. Detailed education about careful hand, food and contact hygiene is critical. Because photosensitivity may be increased in some rheumatic diseases and/or medications, UV protection is crucial. Barriers (clothes and mosquito nets) and age-appropriate chemical insect repellents should be used to prevent insect-borne diseases. Before start of travel, possibilities for on-site medical help in the event of disease deterioration and/or infection should be evaluated. This should be included in the assessment of the patient's ability to travel. Travelers with rheumatic disease should carry a first aid kit that includes both a sufficient supply of regular antirheumatic medication and supplemental medication in case of a disease flare. Storage conditions must be taken ínto account for some medications. Ultimately, the success of a journey depends on the planning from the perspective of the child with its specific needs.

Travel medicine meets conservation medicine in St. Kitts: Disinhibition, cognitive-affective inconsistency, and disease risk among vacationers around green monkeys (Chlorocebus sabaeus)

Despite concern about environmental protection, travelers often underestimate the contribution they may have to disease transmission to other species, as well as the risk of becoming infected themselves. Tourists in general tend to accept more physical risks when traveling than when at home, and much of this can be blamed on the temporary loss of situational awareness and loss of inhibition with a corresponding relaxed attitude toward safety. To better understand environmental attitudes and travel health knowledge and behaviors, a detailed survey of adult tourists was distributed on the island of St. Kitts, home to many green monkeys. Data from 1097 respondents were collected at two locations where cruise ship passengers typically visit the island. Results revealed that even though individuals with more positive environmental attitudes were more willing to take steps to mitigate tourism-related disease transmission, they were also more likely to report wanting to touch or feed a monkey/ape. Similarly, those more willing to prevent the spread of diseases (e.g., wear a mask and report any illnesses to park authorities) were actually more likely to want to touch or feed a monkey/ape. The human desire for physical contact with other species may be partly the result of biophilia, emotionally arousing events (like contact with exotic species) that can lead to further disinhibition, and social media platforms that provide opportunities for exhibitionism. The attitude-behavior incongruency identified here may also be explained through cognitive-affective inconsistency: environmentally-oriented individuals believe that it is prudent to take steps to prevent zoonotic disease transmission but also desire to touch or feed exotic species as it may be emotionally rewarding. Individuals for whom physically interacting with monkeys/apes may be emotionally rewarding may not alter their behavior in response to cognitive means of persuasion; techniques aimed at appealing to emotions may be more effective.

Travel patterns, risk behaviour and health problems of travellers with rheumatic diseases compared to controls: A multi-centre, observational study

BACKGROUND

Patients with chronic conditions travel around the world more than ever. Only few studies have examined travel patterns and health outcomes of patients with rheumatic diseases during international travel.

METHOD

We conducted a multi-centre prospective cohort study in Switzerland, in which we studied the immunogenicity and safety of vaccinations in patients with rheumatic diseases and travellers without rheumatic diseases (controls). Participants who travelled internationally received questionnaires 1 and 13 weeks post-travel. We compared travel patterns, risk behaviours, and travel-associated problems during and after the trips in both groups.

RESULTS

274 participants returned post-travel questionnaires (65 rheumatic patients, 209 controls). Controls more frequently travelled to subtropical/tropical destinations and stayed longer abroad. 64% of all participants experienced health problems during travel (74% rheumatic patients vs. 62% controls, P = 0.11). Pre-travel, patients reported a higher susceptibility to gastrointestinal infections . During travel, a higher percentage of rheumatic patients cancelled the day programme due to health problems (13% vs. 4%, P = 0.024). The main problems in rheumatic patients occurred due to the underlying rheumatic diseases, or were of psychological nature. Although not statistically significant, infectious disease symptoms (rhinitis, cough) occurred more frequently in controls. When only considering subtropical/tropical destinations, rheumatic patients more frequently had gastrointestinal problems during travel - and skin infections after the trip.

CONCLUSIONS

This study does not support the notion that patients with rheumatic diseases should avoid international travel for an increased risk of infections. In patients with subtropical/tropical destinations, however, gastrointestinal problems may be increased during travel - and skin infections post-travel.

Spectrum of illness among returned Australian travellers from Bali, Indonesia: a 5-year retrospective observational study

BACKGROUND

Bali, Indonesia, presents significant infectious and non-infectious health risks for Australian travellers. Understanding this spectrum of illnesses has the potential to assist clinicians in evaluating unwell returning travellers and guide provision of pre-travel advice.

AIM

To describe the spectrum of illnesses seen in returned travellers from Bali.

METHODS

Using a novel text mining approach, we performed a retrospective, observational study of all adult emergency department presentations to a metropolitan health service in Melbourne, from 2011 to 2015. Outcome measures included demographic, clinical and laboratory features of travel-related illnesses.

RESULTS

A total of 464 patients met inclusion criteria. Gastroenteritis (119/464, 26%), systemic febrile illness (88/464, 19%) and respiratory tract infection (51/464, 11%) were the most common diagnoses. Dengue was the most common laboratory-confirmed diagnosis (25/464, 5%). No cases of malaria were identified. Common non-infectious presentations included traumatic injury (47/464, 10%) and animal bites requiring rabies post-exposure prophylaxis (29/464, 6%). A total of 110 patients (24%) was admitted to the hospital; those presenting with systemic febrile illness were more likely to be admitted compared to those presenting with other illnesses (odds ratio 3.42, 95% confidence interval 2.02-5.75, P < 0.001).

CONCLUSION

This is the first study to use a text mining approach to identify and describe emergency department presentations related to diseases acquired in Bali by Australian travellers. Although infections are important causes of illness, trauma and animal bites account for a significant number of hospital presentations. Our findings contribute to the knowledge on the health risks for travellers to Bali, and will assist clinicians in relevant pre- and post-travel evaluations.

Epidemiological and clinical profile of Korean travelers receiving international medical repatriation

The aim of this study was to investigate the experiences of medical transportation of Korean travelers who suffered accidents abroad and then transferred home by our aeromedical team.We collected demographic and clinical data on patients injured while traveling abroad from January 2013 to July 2017. Descriptive analyses based on 4 different transportation methods and transport time since hospitalization were performed.A total of 33 patients were repatriated during the study period. Of these, 28 (84.8%) were trauma cases with pedestrian injuries being the most common (11 cases; 39.3%). Twenty patients were repatriated by flight-stretchers, 6 by flight-prestige, 2 by ship, and 5 by air ambulance. The air ambulance was the most expensive (average 61,124 US Dollars) mode of transportation (P = .001) and the ship took the longest time (14 hours) to transport patients back to Korea from regions with similar distance (P = .0023).We experienced medical repatriation of 33 seriously injured Korean travelers back to South Korea. Transfer time should be an important considering factor and directly contacting and communicating with the specialized staff of foreign hospitals could also be very important to reduce unnecessary overseas hospital stay and cost incidence.

A challenging entanglement: health care providers' perspectives on caring for ill and injured tourists on Cozumel Island, Mexico

Purpose: Despite established knowledge that tourists often fall ill or are injured abroad, little is known about their treatment. The intent of this study was to explore health care professionals’ treatment provision experiences on Cozumel Island, Mexico. Methods: 13 semi-structured interviews were undertaken with professionals across a number of health care vocations on Cozumel Island. Interviews were transcribed and thematically analysed to determine common challenges faced in the provision of treatment for transnational tourists. Results: Three thematic challenges emerged from the data: human and physical resource deficiencies, medical (mis)perceptions held by patients and complexities surrounding remuneration of care. Health care providers employ unique strategies to mitigate these challenges. Conclusion: Although many of these challenges exist within other touristic and peripheral spaces, we suggest that the challenges experienced by Cozumel Island’s health care professionals, and their mitigation strategies, exist as part of a complex entanglement between the island’s health care sector and its dominant tourism landscape. We call on tangential tourism services to take a larger role in ensuring the ease of access to, and provision of quality health care services for tourists on Cozumel Island.

Pharmacy travel health services: current perspectives and future prospects

Rates of international travel are increasing annually, with particular growth observed in travel to Southeast Asia and to emerging economies. While all patients traveling across geographic regions are recommended to receive a pre-travel consultation to consider their individual risks, many do not, or receive care and recommendations that are not consistent with current evidence-based guidelines. As experts in drug therapy, and given the largely preventive nature of most travel health recommendations, pharmacists are well suited to help address this need. Pharmacists generally possess a high degree of knowledge and confidence with more commonly observed travel health topics in community practice such as travelers' diarrhea; however, training in more specialized travel health topics such as travel vaccinations and traveling at altitude has generally been lacking from pharmacy curricula. Pharmacists with an interest in providing pre-travel consultations are encouraged to pursue additional training in this specialty and to consider Certificate in Travel Health designation from the International Society of Travel Medicine. Future roles for pharmacists to include the prescribing of medications and vaccines for travel and the in-pharmacy administration of travel vaccinations may improve patient access to pre-travel consultations and recommended preventive measures, improving the health of travelers and potentially reducing the burden of communicable disease worldwide. Pharmacists providing travel care to patients are also reminded to consider noninfectious risks of illness and injury abroad and to counsel patients on strategies to minimize these risks in addition to providing drug and vaccine recommendations.

Summary of the Statement on International Travellers Who Intend to Visit Friends and Relatives

BACKGROUND

Travellers intending to visit friends and relatives (VFRs) are a specific group of travellers who have been identified as having an increased risk of travel-related morbidity.

OBJECTIVE

To provide recommendations for risk reduction in international VFRs.

METHODS

Recommendations regarding VFRs were developed based on available travel medicine literature and CATMAT expert opinion. Specific travel-related risks, including infectious disease epidemiology and burden in this population, were reviewed and recommendations were provided to attempt to mitigate these risks. Previous CATMAT statements related to VFRs were referred to and reiterated.

RECOMMENDATIONS

Rates of travel-related illness in VFRs tend to be higher for many conditions. Disease-specific risk factors and recommendations are discussed throughout this Statement. CATMAT recommends that VFRs' vaccinations be up-to-date and they be counselled on the importance of various risk reduction activities such as the use of malaria prophylaxis, safe sex practices and injury prevention. Pre- and/or post-travel tuberculosis testing is indicated in certain situations.

CONCLUSION

The pre-travel health assessment is an important opportunity to address with VFRs issues regarding health beliefs, health behaviours, current health status and the possibility of pre-existing conditions. Discussions addressing the importance of adherence to health advice and potential challenges to achieving adherence may be necessary.

Croatia is a safe tourist destination - study of foreign citizen mortality in Splitsko-dalmatinska and Primorsko-goranska County during the period 2001-2010

AIM

To investigate the mortality rate of foreign citizens in Croatia.

METHODS

Data were collected from the Departments for Forensic Pathology in Split and Rijeka, which are the autopsy centers of the counties with approximately 35% of total foreign visitors, as well as from the Croatian Central Bureau for Statistics for the period 2001-2010. The mortality rate (number of deaths of members of each nationality per 100000 entrances ratio) and standardized mortality ratio (ratio between the observed and expected number of deaths) were calculated, and χ(2) goodness of fit test was used for statistical analyses.

RESULTS

There were 447 deaths (325 men, 72.7%) of foreign citizens (mortality rate of 0.0015%). A total of 207 deaths (46.3%) were by natural causes, more often among older people, and 240 deaths (53.7%) were injury deaths, more often among younger people, mostly by drowning or traffic-related (22.2% and 18.6% of all deaths, respectively). Most represented were citizens of German, Austrian, Czech, and Italian nationality, with 115 (25.7%), 59 (13.2%), 58 (13.0%), and 52 deaths (11.6%), respectively. Mortality rate by nationality showed no significant difference (P<0.05). The standardized mortality ratio was lowest in Hungarian and Czech citizens (0.17) and highest in US citizens (0.35).

CONCLUSIONS

Croatia has low foreign citizens' mortality rate and could be considered a safe tourist destination.

Travel Medicine

Injuries to children while traveling is an important topic in travel medicine. Traffic injuries and drowning are the first and second leading causes of death in children who travel, and are a far greater risk than infectious and chronic diseases. Effective prevention strategies are available, particularly for travelers who find themselves in unfamiliar environments and who may be unaware of the potential risks to their family. Despite greater understanding and increased research efforts in this field, data on the magnitude and severity of injuries are still incomplete or unreliable in many countries, but some general advice to parents, children, and adolescents can help keep them safe while traveling.

Risk perception of travelers to tropical and subtropical countries visiting a swiss travel health center

BACKGROUND

This study assessed the risk perception ratings of travelers pre- and post-travel and in comparison to the ratings by travel health experts. While most surveys on travel health knowledge, attitudes, and practices focus on malaria and vaccine-preventable diseases, noninfectious travel risks were included in this study.

METHODS

Pre- and post-travel perception of nine travel-associated health risks was recorded among 314 travelers to tropical and subtropical destinations. All travelers sought pre-travel health advice at the Travel Clinic of the Swiss Tropical and Public Health Institute in 2008 and 2009. In addition, 18 Swiss travel health experts provided an assessment of the respective risks. A validated visual psychometric measuring instrument was used [pictorial representation of illness and self measure (PRISM)].

RESULTS

Travelers and experts rated most risks similarly, except for accidents and sexually transmitted infections (STIs) which experts rated higher. Compared to other risks, accidents ranked highly in both groups and were the only risk perceived higher after travel. Pre- and post-travel perceptions of all other risks were similar with a tendency to be lower after travel. Travelers perceived mosquitoes to be the highest risk before travel and accidents after travel.

CONCLUSION

Travelers' risk perception appears to be accurate for most risks stated in this study. However, travel health professionals should be aware that some perception patterns among travelers regarding travel-related health risks may be different from professional risk assessment. Important but insufficiently perceived health risks, such as sexual behavior/STIs and accidents, should be considered to be part of any pre-travel health advice package.

Comparison of injuries experienced by international tourists visiting Australia and Australian residents

This article compares the epidemiological profile of injury-related hospitalized morbidity of international tourists in New South Wales (NSW) with the hospitalized injury profile of NSW residents. Injury-related hospitalizations were identified from the NSW Admitted Patients Data Collection during 1 July 2000 to 30 June 2009. Injuries were identified using a principal diagnosis code of injury (ie, ICD-10-AM range S00-T98) and the presence of an external cause code (ie, ICD-10-AM range V00-Y98). Overseas tourists were more likely to be hospitalized for an injury following air and water transport, near-drowning, and pedestrian-related injuries. Sport or leisure-related activities were the most common activity conducted at the time of the incident. International tourists are at a higher risk of experiencing injuries particularly following recreational pursuits, while as a pedestrian, in vehicle crashes for older age groups, as a result of interpersonal violence for young males, and following a poisoning or cut/pierce injury for young females. Prevention measures should be undertaken to limit the incidence of injury among international tourists, particularly during active recreational activities and while using the roadways.

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.

Injury deaths among Finnish residents travelling abroad

The increasing international mobility raises the possibility of foreign nationals dying abroad. Here, a descriptive, retrospective and population-based study of deaths abroad among Finnish residents from 1969 to 2007 is presented. The data were collected from the Statistics Finland data based on certificates of cause of death issued after repatriation of the corpse and after review of medical documents or a medico-legal autopsy. The frequency of injury deaths, proportional mortality rates (PMRs) and mortality risk estimates (MREs) were measured. During the study period, 6894 Finnish residents died abroad. Spain, Sweden and Thailand were the top three destination countries for number of deaths, accounting together for 40.3% of all the deaths. Cardiovascular diseases were the most common cause of deaths. The overall injury deaths represented 26.7% of all deaths abroad and occurred at a higher proportion than in Finland (PMR: 3.3). The most common injury deaths were traffic accident and drowning, which together represented more than 50% of all unintentional injury deaths. High PMRs were found for traffic accidents in Russia, Germany and the US and for drowning in Spain, Portugal, Greece and Turkey. The MRE for injury deaths was 73.5 per 100,000 person-years of exposure. Finnish travellers abroad are a population subgroup with a high risk of injury death. Common travel health interventions must be backed by actions to prevent injuries abroad, particularly traffic accident and drowning.

Characteristics of tourist patients in an emergency department in a Mediterranean destination

BACKGROUND

Tourists are exposed to traditional health problems of the host country, such as trauma and the exacerbation of previously existing illnesses during their travels.

OBJECTIVE

The purpose of this study is to determine the clinical characteristics of tourist patients and any predictors of hospital admission.

MATERIAL AND METHOD

This retrospective observational study was carried out in the tertiary care hospital emergency department (ED) of a Mediterranean destination city, Antalya, Turkey. Hospital data from all tourist patients presenting or transferred to the ED between August 2003 and September 2004 were evaluated. Tourist patients were defined as all non-Turkish citizens.

RESULTS

A total of 961 tourist patients was studied, of whom 295 (31%) were admitted and 666 (69%) were discharged. Fifteen patients died in the hospital, 49 critically ill patients were transferred back to their home country, and 153 patients underwent a surgical intervention. The most common discharge diagnoses were trauma (405, 42%), nonspecific symptoms (106, 11%), and circulatory disorders (108, 11%). Admitted tourist patients were significantly older than those discharged; however, there were no differences in sex among the groups. Applying a logistic regression model, age, tachycardia, mode of arrival, and triage category were all found to be significant predictors of admission, but only the initial Glasgow Coma Scale was found to be a significant predictor of mortality. In total, 347 patients were from European Union (EU) countries, and 614 were from non-EU countries. A significant difference was found between the EU and non-EU patient groups according to age, mortality, admission rate, exposure to trauma, ED length of stay, hospital length of stay. Tourist patients from EU countries were older, had higher mortality, lesser trauma exposure, longer ED, and hospital length of stay.

CONCLUSION

EDs can be expected to manage tourist patients presenting for traumatic injuries and circulatory disorders. Clinical differences relating to patients' nationality might help in the development of targeted patient education and injury-prevention programs. Emergency physicians and the tourism industry should recognize the challenges of caring for this growing and aged patient population.

Recreational travel fatalities in US national parks

BACKGROUND

Injuries are a public health problem affecting traveling populations such as tourists visiting National Parks. This study investigates the distribution of visitor fatalities in US National Park Service (NPS) units and identifies the predeath activities and contributing factors associated with them.

METHODS

A retrospective study was conducted of visitor fatalities from all NPS units during 2003 and 2004.

RESULTS

There were 356 reported fatalities during 2003 and 2004. Fatalities were most common during the summer months and on weekends. Males accounted for 75% of the reported fatalities, and visitors aged 20 to 29 and 50 to 59 years accounted for 51% of all deaths. Only 99 of 388 (26%) NPS units reported at least 1 fatality, and only 10 units reported 10 or more fatalities. However, these 10 units were responsible for 36% of all fatalities. Lake Mead National Recreation Area, Blue Ridge Parkway, Grand Canyon National Park, Great Smoky Mountains National Park, and Yosemite National Park reported the highest number of fatalities. Domestic visitors accounted for 73% of the fatalities, and European visitors accounted for 13%. Transportation and water-based activities recorded the highest number of fatalities. Motor vehicle crashes accounted for 20% of fatalities and was followed by suicide (17%), swimming (11%), hiking (10%), plane crashes (9%), climbing (6%), and boating (5%) incidents.

CONCLUSIONS

Fatalities in NPS units are not widespread and are related to more common events such as motor vehicle crashes, suicide, swimming, and hiking rather than exotic causes such as bears or other wildlife. It is recommended that preventive techniques first be developed in the 10 NPS units responsible for 36% of the total NPS-wide fatalities.

Survey of visitors to a National Park in the savannah region of northeast Brazil: Practices, incidents and hazardous situations

BACKGROUND

Wilderness travellers to remote National Parks of Brazil may be particularly at risk of tropical diseases and injury. The aim of this study was to describe injury and illness, potentially hazardous situations, accidents and other incidents experienced by travellers to a remote National Park in Brazil.

METHOD

The study was done in the National Park, "Serra da Capivara", in Piauí State northeast Brazil. Key informants were interviewed using semi-structured interviews, and a self-administered questionnaire was used for visitors. Questions included information on health problems and risk behaviour in the park, as well as pre-travel health advice.

RESULTS

In total, 14 tour guides, 7 hotel managers and 17 health professionals were interviewed, as key informants. Eighty visitors returned the completed questionnaires (60 Brazilian, 20 foreigners). The key informants reported different risk behaviour of groups and individuals travellers, and incidents most commonly mentioned were minor injuries, insect bites/bee stings and allergic reactions. Seventy percent of the Brazilian and 55% of the foreign visitors had obtained pre-travel health advice, but only 5% of Brazilians and 15% of foreign visitors has obtained this advice from a physician. The most common source of information was other people who already had visited the park and travel books. Of the Brazilians, 13.3% reported some health incident during their stay, most commonly bee bites and headache. Two foreign travellers reported three incidents (insect bites/bee stings, diarrhoea and sunburn). Most commonly reported hazardous situations perceived by the tourists were possible accidents caused by falling from a stairway or falling stones, poisonous animals and insect bites/bee stings.

CONCLUSIONS

Surveys conducted at remote tourist destinations are a feasible approach to report vulnerable situations, practices and incidents of visitors to a National Park. We have shown that most travellers are not adequately prepared and many experienced vulnerable situations during their visit to the National Park. It is important that visitors to National Parks in Brazil are encouraged to obtain travel health advice. The most common and potentially serious incident (bee stings) is rarely addressed in pre-travel health advice. Travel health advisers should ensure that they have access to locally relevant information for travellers, so that appropriate preventive measures can be instituted.

Medical problems encountered among travelers in Bahrain International Airport clinic

BACKGROUND

The Middle East is one of the most rapidly growing destination for travelers. Objective. The aim of this study was to determine the medical conditions affecting travelers needing medical assistance in Bahrain International Airport (BIA).

METHOD

Logbook documenting medical conditions of travelers presenting to the BIA clinic from January 1 till the end of December 2004 was reviewed.

RESULTS

A total of 3,350 travelers attended the clinic, constituting 0.12% of the disembarking and transit travelers. Most common conditions faced were respiratory problems (24.4%), followed by headaches (19.2%), trauma, musculoskeletal pains (12.9%), and gastrointestinal problems (11.0%). Only 2.1% of all complaints were referred to secondary care. The majority of cases were handled by the nurse.

CONCLUSIONS

Majority of the patients examined had acute minor medical problems. Ninety-eight percent of conditions affecting travelers were handled in the airport clinic by the nurse and the family physician. Airport clinic could serve as an efficient emergency triage system for filtering serious illnesses needing urgent management.

Accidents and repatriation

Accidents and injury contribute greatly to the morbidity and mortality of travellers worldwide, with road traffic accidents being a major contributer. Those travelers with serious illness and injury may need specialised medical evacuation services, which may involve an air ambulance and a specialised medical team. Such aeromedical repatriations require considerable organisation and liaison between the sending and receiving medical services and other interested parties. However, the majority of travellers requiring emergency assistance are stable patients requiring referral for medical or dental attention or special requirements for carriage on scheduled aircraft.

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.

Pretravel health advice among international travelers visiting Cuzco, Peru

BACKGROUND

Cuzco, a Peruvian city of historical interest located 3,326 m above sea level, is a frequent destination for tourists. We conducted a descriptive study to assess the extent and sources of pretravel health advice received by international travelers before their arrival to Cuzco.

METHODS

Data were collected as part of a health survey among travelers. Between August and November 2002, travelers between 15 and 65 years old were invited to fill out a questionnaire in the departing area of Cuzco's international airport.

RESULTS

A total of 5,988 travelers participated. The mean age was 35.4 years (SD 11.4 yr); 50.6% were female and 50.8% were single. Tourism was the reason for traveling in 90.2% of the participants, and 89.3% of them were traveling with companions. Pretravel health information was received by 93.6%. The median number of information sources was two, with books (41.5%), travel medicine clinics (38.8%), the Internet (23.3%), and general practitioners (22.7%) as the main sources. Most frequently received recommendations were about safe food and water consumption (85%), use of insect repellents (66.0%), sunburn protection (64.4%), and condom use (22%). Only 16.5% took medication to prevent altitude sickness, and 14.2% took medication to prevent traveler's diarrhea. Variables independently associated with receiving pretravel health information from a health care professional were female gender, country of residence other than the United States, length of stay in Cuzco > 7 days, length of stay in other Peruvian cities > 7 days, tourism as the main reason for visiting Cuzco, traveling with companions, and consulting of more than one source of information.

CONCLUSIONS

Most travelers arriving to Cuzco had received pretravel health information, and the majority obtained it from more than one source. Recommendations addressed for specific health risks, such as altitude sickness prophylaxis, were received by few travelers.

Reported fatal and non-fatal incidents involving tourists in Hawaii Volcanoes National Park, 1992-2002

Objectives. To examine fatal and non-fatal incidents involving tourists in Hawaii Volcanoes National Park. Methods. Official press releases from the public relations office at Hawaii Volcanoes National Park were examined for reports of fatal and non-fatal incidents involving tourists. Results. Between 1992 and 2002 there were 65 press releases reporting 40 fatalities, 45 serious injuries, 53 minor injuries, and 25 no injury events. Severity information was unavailable for four additional tourists. Aircraft and backcountry incidents each accounted for 30% of all incidents followed by road incidents (22%) and frontcountry incidents (17%). Aircraft incidents reported 17 fatalities, backcountry incidents accounted for 10 fatalities, frontcountry incidents reported seven fatalities, and road incidents totaled six fatalities. One fatality was classified as a suicide. Backcountry (23) and road (10) incidents had the highest number of serious incidents. Male tourists (62) were more frequently involved in incidents than female tourists (41) and tourists aged 20-29 years and 40-49 years accounted for the highest number of fatalities and total incidents. Conclusions. Helicopter tours, hiking in areas with active lava flows, falls into steam vents and earthcracks, and driving unfamiliar rental cars in unfamiliar locations are the major activities resulting in death and serious injury. Additional factors such as tourists ignoring warning signs, wandering off-trail or hiking at night, tourists misinformed by guidebooks and other tourists, and tourists with pre-existing heart and asthma conditions are contributing causes in many incidents. The findings of this study provide information that allows prospective tourists, tourism managers, and travel health providers make informed decisions that promote safe tourism and can aid future efforts in developing preventative strategies at tourist destinations with similar environments and activities. However, in order for preventative strategies to be most effective, future research using medical or emergency response records and employing an injury epidemiology framework that identifies the cause of fatal and non-fatal injuries is recommended.