Risk and spectrum of diseases in travelers to popular tourist destinations

Travel-related respiratory symptoms and infections in travellers (2000-22): a systematic review and meta-analysis

BACKGROUND

Respiratory tract infections (RTIs) are common in travellers due to the year-round or seasonal presence of respiratory pathogen and exposure to crowded environments during the itinerary. No study has systematically examined the burden of RTI infections among travellers. The aim of this systematic review and meta-analysis is to evaluate the prevalence of RTIs and symptoms suggestive of RTIs among travellers according to risk groups and/or geographic region, and to describe the spectrum of RTIs.

METHODS

The systematic review and meta-analysis was registered in PROSPERO (CRD42022311261). We searched Medline, Embase, Scopus, Cochrane Central, Web of Science, Science Direct and preprint servers MedRxiv, BioRxiv, SSRN and IEEE Xplore on 1 February 2022. Studies reporting RTIs or symptoms suggestive of RTIs in international travellers after 1 January 2000 were eligible. Data appraisal and extraction were performed by two authors, and proportional meta-analyses were used to obtain estimates of the prevalence of respiratory symptoms and RTIs in travellers and predefined risk groups.

FINDINGS

A total of 429 articles on travellers' illness were included. Included studies reported 86 841 symptoms suggestive of RTIs and 807 632 confirmed RTIs. Seventy-eight percent of reported respiratory symptoms and 60% of RTIs with available location data were acquired at mass gatherings events. Cough was the most common symptom suggestive of respiratory infections, and the upper respiratory tract was the most common site for RTIs in travellers. The prevalence of RTIs and respiratory symptoms suggestive of RTIs were 10% [8%; 14%] and 37% [27%; 48%], respectively, among travellers. Reporting of RTIs in travellers denoted by publication output was found to correlate with global waves of new respiratory infections.

INTERPRETATION

This study demonstrates a high burden of RTIs among travellers and indicates that travellers' RTIs reflect respiratory infection outbreaks. These findings have important implications for understanding and managing RTIs among travellers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Traveler's knowledge, attitude, and practice about travel health insurance: A community-based questionnaire study

BACKGROUND

Travel, especially international travel, has become one of the most popular leisure activities in the world. The risk of accidents and travel-related illnesses, including infectious and non-communicable diseases, should not be neglected. To provide a more comprehensive pre-travel consultation to international travelers, this study aimed to investigate the knowledge, attitude, and practice of travelers about travel health insurance.

METHODS

This was a cross-sectional study. Anonymous structured questionnaires were distributed to 1000 visitors to the Taiwan International Travel Fair in May 2019.

RESULTS

The top three important travel health insurances were accidental death and disablement insurance (92%), accidental medical reimbursement (90.4%), and 24-hour emergency assistance (89%). In addition to education level, travel-associated illness, and special activities during travel, a significant association was observed between the willingness to buy various travel health insurances and the willingness of pre-travel consultation.

CONCLUSIONS

Most travelers would buy travel health insurance; however, disproportional respondents understood the content of travel health insurance. Most travelers considered travel clinics to be the most reliable information source regarding travel health insurance. Therefore, travel medicine specialists are encouraged to offer more information about travel health insurance during pre-travel consultation.

Morbidity among Israeli backpack travelers to tropical areas

BACKGROUND

Travelers to tropical areas may be susceptible to illness or injuries. This study aims to assess morbidity among travelers during their travel and compare those who became ill or were injured with those who did not.

METHODS

This prospective study included 400 travelers who were counselled by a physician in pre-travel clinics in central Israel between 2017 and 2018. Participants were interviewed within a month after their return regarding morbidity during travel, including health problems that started one week following their return.

RESULTS

Most travelers (N = 320, 80%) reported at least one illness or injury. Illnesses/injuries were more common among females than males (84.9% vs. 75.1%, p = 0.01), travel periods longer than 30 days (87.7% vs. 77.2%, p = 0.03), and travelers accompanied by their friends or solo travelers compared with those who traveled with their family/partner (83.8% and 70.0%, respectively, p = 0.002). The most common complaint was diarrhea (N = 159, 49.6%), followed by high-altitude sickness (N = 118, 36.9%) and fever (N = 100, 31.2%). Altitude sickness symptoms were more common in females than in males (58.9% vs. 41.0%, p = 0.006) and in those who ascended rapidly in comparison to those who ascended gradually (58.7% vs. 44.6%, p = 0.04). Animal injury was reported by 30 (7.5%) participants yet only eight (27.0%) received medical care, seven of whom (23.3%) were vaccinated against rabies.

CONCLUSIONS

Being a female, traveling with friends or alone and longer travel periods were associated with illness/injury. Practitioners at pre-travel clinics should inform travelers of the possible risks including the potential severe consequences of rabies and altitude sickness.

Travel-Related Risk Behaviors and Antibiotic Use Among Older Travelers

Background

Antibiotic stewardship in the pretravel care of older adults is important to effectively treat infections while minimizing harm from side effects and unnecessary antibiotic use. The objective of this study was to compare the characteristics, risk behaviors, infectious diseases, and antibiotic use between older (≥60 years) and younger (18-59 years) travelers.

Methods

TravMil is a prospective, observational cohort of United States (US) Department of Defense beneficiaries traveling outside the continental US for ≤6.5 months. For this analysis, we included adults enrolled pretravel between January 2010 and August 2018 and excluded active duty personnel on deployment. Pre and post-travel surveys captured trip characteristics, exposures, illnesses, and antibiotic use.

Results

A total of 1742 travelers were analyzed: 747 (42.9%) were aged ≥60 years and 995 (57.1%) were aged 18-59 years. Older travelers were less likely to engage in high-risk dietary behaviors and experience travelers' diarrhea than younger travelers (18.2% vs 22.9%; P < .05). Influenza-like illness (12.5%) and febrile illness (3.4%) occurred less frequently in the older cohort. Antibiotic use for self-treatment was common in both age groups (25.7% vs 26.7%) and often inappropriate, for example, for treatment of occasional loose stool or mild travelers' diarrhea (67.0% [67/100] in older adults vs 57.6% [83/144] in younger adults; P < .05), and influenza-like illness (63.4% [64/101] vs 58.6% [68/116], respectively; P < .05).

Conclusions

Older travelers were less likely to engage in high-risk behaviors and experience travelers' diarrhea, and both age groups experienced mild, self-limited infections. Inappropriate use of antibiotics was common, suggesting that antimicrobial stewardship should be emphasized at pretravel counseling with international travelers.

Revisiting travellers' diarrhoea justifying antibiotic treatment: prospective study

BACKGROUND

As antimicrobials increase the risk of acquiring multidrug-resistant (MDR) bacteria, unnecessary antibiotics should be avoided for travellers' diarrhoea (TD). Antibiotics are recommended in TD accompanied by fever or incapacitation (TD justifying use of antibiotics, TDjuAB). Seeking tools for reducing antibiotic use, we explored factors predisposing to TDjuAB and scrutinized antibiotic treatment among those with TDjuAB [TDjuAB(+) subgroup] and those with diarrhoea not justifying antibiotics [TDjuAB(-) subgroup].

METHODS

We conducted a study among 370 prospectively recruited visitors to the tropics. Stool samples and questionnaires were collected before and after travel. Enteric pathogens were analysed by qPCR for enteropathogenic (EPEC), enteroaggregative (EAEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC) and enteroinvasive (EIEC) E. coli/Shigella, Campylobacter, Salmonella, Yersinia and Vibrio cholerae, and for ETEC's toxins LT (heat-labile), STh (human heat-stable) and STp (porcine heat-stable). TD was defined by the WHO criteria and TDjuAB as diarrhoea accompanied by fever, and/or disrupting or preventing daily activities. Multivariable analysis was applied-separately for travel-related factors and pathogens-to identify risk factors for TDjuAB(+).

RESULTS

Among the 370 travellers, TD was contracted by 253 (68%), categorized as TDjuAB(+) in 93/253 (37%) and TDjuAB(-) in 160/253 (63%) of the cases. Antibiotics were used for TD by 41% in TDjuAB(+) and by 7% in the TDjuAB(-) group. Relative risk ratios (RRR)s are presented for both the TDjuAB(+) and the TDjuAB(-) groups. TDjuAB(+) was associated with long travel duration and young age. Among the 298 subjects not having taken antibiotics, increased RRRs were found e.g. for findings of Campylobacter coli/jejuni and ETEC's STh toxin.

CONCLUSIONS

The first to analyse risk factors for TDjuAB, our study presents RRRs for demographic and behavioural factors and for various pathogens. Only less than half of those in the TDjuAB(+) group took antibiotics, which demonstrates that most cases meeting the current criteria recover without antimicrobial treatment.

Travellers' risk behaviors and health problems: Post-travel follow up in two travel medicine centers in Italy

OBJECTIVES

We examined the association between travellers' characteristics, compliance with pre-travel recommendations and health problems.

METHODS

Volunteer travellers were enrolled and data collected using a questionnaire between 30-60 days after returning home. We analyzed the associations through bivariate and multivariate models.

RESULTS

Of the 468 enrolled travelers, 68% consumed raw food and 81% food containing milk and/or eggs. 32% consumed street vendor food and 30% drinks containing ice. 24% used the recommended mechanical prophylaxis measures. 46% got sick during and/or after travel (gastrointestinal symptoms most frequently). Factors predisposing to health problems were female gender, youth/middle age, intermediate travel duration and profession. The American continent and staying in hostels and tents were significantly associated with febrile illness. Street vendor food was significantly associated with skin reactions.

CONCLUSIONS

Adherence to behavioral recommendations remains low. Travellers must be informed of health risks during and after travel.

Risk factors for symptoms of infection and microbial carriage among French medical students abroad

Objectives

To investigate symptoms of infections and their risk factors among French medical students undertaking an internship abroad.

Methods

Clinical follow up, and qPCR-based respiratory, gastrointestinal, and vaginal pathogen carriages were prospectively assessed pre-travel and post-travel, in a cohort of medical students departing from Marseille, France.

Results

293 students were included. 63.5%, 35.8%, and 3.6% of students reported gastrointestinal, respiratory, and vaginal symptoms, respectively. The acquisition rate of Enteroaggregative Escherichia coli and Enteropathogenic E. coli was 40.9% and 18.6%, respectively. A significant increase was observed for rhinovirus and Streptococcus pneumoniae by comparing the prevalence of pathogens in pre-travel and post-travel samples. Gardnerella vaginalis and Atopobium vaginae acquisition rates were 12.9% and 13.9%, respectively. Being female, primarily traveling to Vietnam, and living in basic accommodation conditions were independent risk factors for reporting respiratory symptoms. Students reporting respiratory symptoms were three times more likely to acquire S. pneumoniae. Traveling primarily to north India and Senegal were independent risk factors for diarrhea.

Conclusion

This study makes it possible to identify the leading infectious diseases linked to travel in a group of French medical students undertaking an internship abroad and the risk factors on which to base targeting students for reinforced pre-travel advice.

Fever in the Returned Traveler

International travel is associated with a risk of infections not typically seen in high-income settings. Malaria is the most important tropical infection in travelers, but epidemics of dengue, chikungunya, and Zika emphasize that clinicians need to be aware of the rapidly changing distribution of many arboviruses. A detailed travel history and a syndromic approach to the investigation and management of patients is key. Consultation with a specialist is often recommended to ensure that appropriate management and investigations are undertaken in febrile returned travelers.

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Travel, especially to low-income regions, is associated with an increased risk of infections not typically seen in high-income countries (e.g., malaria, enteric fever, dengue, chikungunya, Zika, and schistosomiasis).

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Although gastroenteritis, respiratory tract infections, and self-limiting viral infections are common, a minority of patients will have a potentially life-threatening tropical infection.

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The evaluation of an ill returned traveler requires a detailed travel history with an understanding of the geographic distribution of infections, risk factors for acquisition, incubation periods, clinical presentations, and appropriate laboratory investigations.

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A syndromic approach to specific investigations, and to presumptive therapy pending laboratory confirmation of the diagnosis, is appropriate.

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Travel is also a risk factor for acquisition of antimicrobial-resistant bacteria, such as those containing extended spectrum β-lactamases, that become part of the traveler's colonizing flora.

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As a rule, malaria should be excluded in all travelers presenting with a fever who have visited the tropics.

Incidence of health problems in travelers to Southeast Asia: a prospective cohort study

BACKGROUND

There are few studies of the incidence of health problems among travelers to Southeast Asia. The current study sought to determine the incidence of self-reported health problems among travelers visiting the region.

METHODS

A prospective questionnaire-based study was conducted among travelers from high-income countries who visited Southeast Asia. Participants were enrolled at time of their pre-travel visit at Mahidol University, Bangkok, Thailand. Travelers were prospectively followed by self-administered questionnaires 2 weeks after arrival, upon return to their home country and 2 weeks after return.

RESULTS

During January 2018-February 2019, 359 travelers were enrolled in Bangkok, Thailand, and the first questionnaire was administered. Follow-up questionnaires were returned by 191, 96 and 64 participants 2 weeks later, at the end of the trip and 2 weeks after return, respectively. A total of 6094 travel days were included in the final analysis. The incidence of acute diarrhea per month per 1000 travelers was 217 [95% confidence interval (CI), 189-248] episodes; skin problems, 197 (95% CI, 170-227); respiratory symptoms, 133 (95% CI, 111-158); fever, 49 (95% CI, 36-65); and potential rabies exposure, 34 (95% CI, 24-48). The incidence of acute diarrhea episodes per month per 1000 travelers was significantly higher during the first 2 weeks of travel compared with subsequent weeks of travel: 325 (95% CI, 291-362) vs 132 (95% CI, 110-1157) (P < 0.05). The incidence of outpatient visits and hospitalizations per month per 1000 travelers was 49 (95% CI, 36-65) and 5 (95% CI, 2-10), respectively.

CONCLUSIONS

In this prospective cohort study we observed substantial burden of acute diarrhea and skin and respiratory symptoms among travelers to Southeast Asia. The higher incidence of diarrhea in the first 2 weeks of travel should be further investigated.

Retrospective analysis of older travellers attending a specialist travel health clinic

Background

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

Methods

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

Results

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

Conclusions

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

Malaria standby emergency treatment (SBET) for travellers visiting malaria endemic areas: a systematic review and meta-analysis

BACKGROUND

Malaria prevention methods for travellers to low or moderate malaria risk areas vary and remain controversial. Standby emergency treatment (SBET) for malaria is one possible strategy increasingly recommended since 1988 with little evidence on its effectiveness or how it is truly being used.

METHODS

A systematic review and meta-analysis were performed based on a structured search in Embase, Medline, PubMed, Cochrane and Web of Science on 7 September 2018. The primary outcome was the overall prevalence of SBET use in travellers, and secondary outcomes were the proportion carrying SBET, the response to fever [use of SBET, health facility attendance and use of malaria rapid diagnostic test (mRDT)], adverse events to SBET and the proportion using SBET incorrectly (incorrect dosage/duration). The pooled SBET use prevalence was analysed using a random effects model. A descriptive summary was done to present secondary outcomes. The study protocol was registered with PROSPERO CRD42018103703.

RESULTS

A total of 11 studies were eligible for inclusion among the 1027 titles identified by our search. The studies included 7/11 prospective cohort studies that recruited pre-travel clinic attendees in Europe and 4/11 cross-sectional studies, of which 3 recruited travellers at airports before their return home from Southeast Asia and Africa and 1 from an employee registry including long-term travellers. The overall pooled prevalence of SBET use among the 26 403 travellers was 2.5% (95% confidence interval, 1.1-4.3%; range, 0.4-10.8%). There was significant variation in the proportion of travellers carrying SBET medication (40-100%), the proportion of travellers with appropriate response to fever (23-100%), adverse events (0-33%) and incorrect dosage/duration of SBET (0-100%).

CONCLUSION

Adherence to the proposed recommendations for SBET use, notably the response to fever, was poor. If the use of SBET is to be pursued, modifications to the current SBET strategy should be considered, such as better selection of travellers at higher risk for malaria and the potential addition of mRDTs.

Travelers' knowledge, attitudes, and behavior related to infectious diseases in Italy

The objectives of this investigation were to examine the travelers’ knowledge, attitudes, and behavior about travel-related diseases and to evaluate the factors that influence their knowledge, attitudes, and behavior. A cross-sectional study was performed between May and September 2018 among a random sample of individuals attending randomly selected travel agencies in the geographical areas of Caserta and Naples, Italy. One fourth of participants (25.6%) had a poor level of knowledge, 50.2% a moderate, and only 24.2% a good level about the most common infectious diseases in the destination country. Those who had received information from physicians about the most common infectious diseases in the destination country and who do not need additional information were significantly more likely to have a good level of knowledge. A large majority (91%) showed no concern about the risk of getting an infectious disease during the travel. Almost half of the respondents had received information concerning the most common infectious diseases in the destination country and the related prevention measures. This information was more likely acquired by those graduated, those who know the foods that can cause the infectious diseases, and those who self-perceived a well health status, and less likely by those who had a poor level of knowledge about the most common infectious diseases in the destination country and who were going to Asia and South America. Education and communication activities regarding all aspects of travel-related diseases are needed to increase the knowledge and the access to preventive measures.

Prospective study evaluating immune-mediated mechanisms and predisposing factors underlying persistent postinfectious abdominal complaints

BACKGROUND

The role of persistent immune activation in postinfectious irritable bowel syndrome (PI-IBS) remains controversial. Here, we prospectively studied healthy subjects traveling to destinations with a high-risk to develop infectious gastroenteritis (IGE) in order to identify immune-mediated mechanisms and risk factors of PI-IBS.

METHODS

One hundred and one travelers were asked to complete questionnaires on psychological profile and gastrointestinal (GI) symptoms before travel, 2 weeks, 6 months and 1 year after travel. At each visit, blood was collected for PBMC isolation and rectal biopsies were taken. PI-IBS was diagnosed using the Rome III criteria and subjects with persistent postinfectious abdominal complaints (PI-AC) were identified using 3 GSRS symptoms (ie, loose stools, urgency and abdominal pain).

RESULTS

Forty-seven of the 101 subjects reported IGE during travel. After 1 year, two subjects were diagnosed with PI-IBS and eight subjects were presented with PI-AC versus two subjects with IBS and two with abdominal complaints in the non-infected group. PBMC analysis showed no differences in T and B cell populations in subjects with PI-AC vs healthy. Additionally, no differences in gene expression were observed in the early postinfectious phase or after 1 year. Regression analysis identified looser stools, higher anxiety and somatization before infection and several postinfectious GI symptoms as risk factors for PI-AC.

CONCLUSIONS

The incidence of PI-IBS is low following travelers' diarrhea and there is need for larger studies investigating the role of immune activation in PI-IBS. Psychological factors before infection and the severity of symptoms shortly after infection are risk factors for the persistence of PI-AC.

Antibiotic resistance in travellers' diarrhoeal disease, an external perspective

BACKGROUND

There are many recommendations on the use of antibiotics for prophylaxis and treatment of travellers' diarrhoea (TD). As pharmacists with a special interest in antimicrobial stewardship, we examine and offer our perspective on advice that is recommended to travellers in terms of prevention, treatment and management of TD with a focus on antibiotic use and resistance.

METHODS

Publications on TD were identified through PubMed, Google Scholar and Cochrane Library databases searches using search terms 'travellers diarrhoea', 'travellers diarrhoea', 'travellers' diarrhoea' 'guidelines', 'expert opinion', 'expert reviews', 'South Asia' and 'South East Asia' (S and SE Asia), 'antibiotics', 'resistance genes', 'travel advice', 'pharmacists', 'guidelines', 'prevention' and 'treatment'. References of articles were also screened for additional relevant studies.

RESULTS

Whilst most guidelines and expert reviews were in agreement with the restricted use of antibiotics unless there was a clinical need, the literature review identified gaps in research into behaviours of travellers regarding non-compliance with the pre-travel advice provided and the need for in depth training and education for all healthcare professionals in providing 'tailored' advice for travellers going to high-risk destinations.

CONCLUSIONS

Travellers should be made aware of the problems of antimicrobial resistance in their destination and home countries and offered alternative forms of prophylaxis for TD. Strategies for prevention of TD, other than the use of antibiotics, also need to be emphasized. All healthcare professionals involved in giving advice about TD should be familiar with the epidemiology of the condition as this will inform responsible behaviours, risk assessment and management strategies in different geographical areas.

Incidence and spectrum of health problems among travellers to Myanmar

BACKGROUND

The number of international travellers visiting Myanmar increases each year. However, information about pre-travel preparation and incidence of health problems among these travellers is limited.

METHODS

This cross-sectional study was conducted at three international airports in Thailand. Travellers returning from Myanmar completed questionnaires querying demographic profile, pre-travel health preparations and health problems during their stay in Myanmar.

RESULTS

From March 2015 to May 2017, we collected and analysed questionnaires completed by 397 Thai and 467 non-Thai travellers (total: 50.1% men, median age 37 years). Non-Thai travellers were from Europe (59%), Northern America (21.4%), Asia (16.5%) and Australia or New Zealand (3.0%). Approximately 74% of non-Thais sought pre-travel health information; only 36% of Thais did so. Tourism was the main purpose for travel among both Thais (58.4%) and non-Thais (85.2%). Non-Thais were more likely than Thais to travel as backpackers and perform outdoor activities such as trekking, cycling or swimming. The average length of stay in Myanmar among non-Thais was significantly longer than that of Thais (26.58 days vs 7.08 days, P < 0.001). Health problems were reported by 22.9% of non-Thais; the most common was diarrhoea (21.0%) followed by upper respiratory tract symptoms (9.2%), fever (3.4%) and skin problems (3.0%). Only 12.6% of Thais reported health problems, the most common being upper respiratory tract symptoms (7.6%), followed by diarrhoea (3.1%), fever (2.8%) and skin problems (2.0%). Most health problems were mild and self-limited in both groups. Only one Thai and eight non-Thai travellers required a doctor's visit during their trip to Myanmar, and two non-Thais required hospitalization.

CONCLUSIONS

Health problems are not very common among travellers to Myanmar. Overall, health problems were reported among 18.2% of travellers in our study. Most problems were mild, with spontaneous recovery. Only two foreign travellers required hospitalization.

Real-time incidence of travel-related symptoms through a smartphone-based app remote monitoring system: a pilot study

Trip Doctor®, a Smartphone-based app monitoring system, was developed to detect infections among travelers in real-time. For testing, 106 participants were recruited (62.2% male, mean age 36 years (SD = 11)). Majority of trips were for tourism and main destinations were in South East Asia. Mean travel duration was 14 days (SD = 10). Diarrhea was the most frequently reported symptom (15.5%). The system demonstrated adequate usability and is ready to be used on a larger scale.

Mefloquine for preventing malaria during travel to endemic areas

BACKGROUND

Mefloquine is one of four antimalarial agents commonly recommended for preventing malaria in travellers to malaria-endemic areas. Despite its high efficacy, there is controversy about its psychological side effects.

OBJECTIVES

To summarize the efficacy and safety of mefloquine used as prophylaxis for malaria in travellers.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published on the Cochrane Library; MEDLINE; Embase (OVID); TOXLINE (https://toxnet.nlm.nih.gov/newtoxnet/toxline.htm); and LILACS. We also searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP; http://www.who.int/ictrp/en/) and ClinicalTrials.gov (https://clinicaltrials.gov/ct2/home) for trials in progress, using 'mefloquine', 'Lariam', and 'malaria' as search terms. The search date was 22 June 2017.

SELECTION CRITERIA

We included randomized controlled trials (for efficacy and safety) and non-randomized cohort studies (for safety). We compared prophylactic mefloquine with placebo, no treatment, or an alternative recommended antimalarial agent. Our study populations included all adults and children, including pregnant women.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility and risk of bias of trials, extracted and analysed data. We compared dichotomous outcomes using risk ratios (RR) with 95% confidence intervals (CI). Prespecified adverse outcomes are included in 'Summary of findings' tables, with the best available estimate of the absolute frequency of each outcome in short-term international travellers. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 20 RCTs (11,470 participants); 35 cohort studies (198,493 participants); and four large retrospective analyses of health records (800,652 participants). Nine RCTs explicitly excluded participants with a psychiatric history, and 25 cohort studies stated that the choice of antimalarial agent was based on medical history and personal preference. Most RCTs and cohort studies collected data on self-reported or clinician-assessed symptoms, rather than formal medical diagnoses. Mefloquine efficacyOf 12 trials comparing mefloquine and placebo, none were performed in short-term international travellers, and most populations had a degree of immunity to malaria. The percentage of people developing a malaria episode in the control arm varied from 1% to 82% (median 22%) and 0% to 13% in the mefloquine group (median 1%).In four RCTs that directly compared mefloquine, atovaquone-proguanil and doxycycline in non-immune, short-term international travellers, only one clinical case of malaria occurred (4 trials, 1822 participants). Mefloquine safety versus atovaquone-proguanil Participants receiving mefloquine were more likely to discontinue their medication due to adverse effects than atovaquone-proguanil users (RR 2.86, 95% CI 1.53 to 5.31; 3 RCTs, 1438 participants; high-certainty evidence). There were few serious adverse effects reported with mefloquine (15/2651 travellers) and none with atovaquone-proguanil (940 travellers).One RCT and six cohort studies reported on our prespecified adverse effects. In the RCT with short-term travellers, mefloquine users were more likely to report abnormal dreams (RR 2.04, 95% CI 1.37 to 3.04, moderate-certainty evidence), insomnia (RR 4.42, 95% CI 2.56 to 7.64, moderate-certainty evidence), anxiety (RR 6.12, 95% CI 1.82 to 20.66, moderate-certainty evidence), and depressed mood during travel (RR 5.78, 95% CI 1.71 to 19.61, moderate-certainty evidence). The cohort studies in longer-term travellers were consistent with this finding but most had larger effect sizes. Mefloquine users were also more likely to report nausea (high-certainty evidence) and dizziness (high-certainty evidence).Based on the available evidence, our best estimates of absolute effect sizes for mefloquine versus atovaquone-proguanil are 6% versus 2% for discontinuation of the drug, 13% versus 3% for insomnia, 14% versus 7% for abnormal dreams, 6% versus 1% for anxiety, and 6% versus 1% for depressed mood. Mefloquine safety versus doxycyclineNo difference was found in numbers of serious adverse effects with mefloquine and doxycycline (low-certainty evidence) or numbers of discontinuations due to adverse effects (RR 1.08, 95% CI 0.41 to 2.87; 4 RCTs, 763 participants; low-certainty evidence).Six cohort studies in longer-term occupational travellers reported our prespecified adverse effects; one RCT in military personnel and one cohort study in short-term travellers reported adverse events. Mefloquine users were more likely to report abnormal dreams (RR 10.49, 95% CI 3.79 to 29.10; 4 cohort studies, 2588 participants, very low-certainty evidence), insomnia (RR 4.14, 95% CI 1.19 to 14.44; 4 cohort studies, 3212 participants, very low-certainty evidence), anxiety (RR 18.04, 95% CI 9.32 to 34.93; 3 cohort studies, 2559 participants, very low-certainty evidence), and depressed mood (RR 11.43, 95% CI 5.21 to 25.07; 2 cohort studies, 2445 participants, very low-certainty evidence). The findings of the single cohort study reporting adverse events in short-term international travellers were consistent with this finding but the single RCT in military personnel did not demonstrate a difference between groups in frequencies of abnormal dreams or insomnia.Mefloquine users were less likely to report dyspepsia (RR 0.26, 95% CI 0.09 to 0.74; 5 cohort studies, 5104 participants, low certainty-evidence), photosensitivity (RR 0.08, 95% CI 0.05 to 0.11; 2 cohort studies, 1875 participants, very low-certainty evidence), vomiting (RR 0.18, 95% CI 0.12 to 0.27; 4 cohort studies, 5071 participants, very low-certainty evidence), and vaginal thrush (RR 0.10, 95% CI 0.06 to 0.16; 1 cohort study, 1761 participants, very low-certainty evidence).Based on the available evidence, our best estimates of absolute effect for mefloquine versus doxycyline were: 2% versus 2% for discontinuation, 12% versus 3% for insomnia, 31% versus 3% for abnormal dreams, 18% versus 1% for anxiety, 11% versus 1% for depressed mood, 4% versus 14% for dyspepsia, 2% versus 19% for photosensitivity, 1% versus 5% for vomiting, and 2% versus 16% for vaginal thrush.Additional analyses, including comparisons of mefloquine with chloroquine, added no new information. Subgroup analysis by study design, duration of travel, and military versus non-military participants, provided no conclusive findings.

AUTHORS' CONCLUSIONS

The absolute risk of malaria during short-term travel appears low with all three established antimalarial agents (mefloquine, doxycycline, and atovaquone-proguanil).The choice of antimalarial agent depends on how individual travellers assess the importance of specific adverse effects, pill burden, and cost. Some travellers will prefer mefloquine for its once-weekly regimen, but this should be balanced against the increased frequency of abnormal dreams, anxiety, insomnia, and depressed mood.

What proportion of international travellers acquire a travel-related illness? A review of the literature

INTRODUCTION

As international travel increases, travellers may be at increased risk of acquiring infectious diseases not endemic in their home countries. Many journal articles and reference books related to travel medicine cite that between 22-64% of international travellers become ill during or after travel; however, this information is minimal, outdated and limited by poor generalizability. We aim to provide a current and more accurate estimate of the proportion of international travellers who acquire a travel-related illness.

METHODS

We identified studies via PubMed or travel medicine experts, published between January 1, 1976-December 31, 2016 that included the number of international travellers acquiring a travel-related illness. We excluded studies that focused on a single disease or did not determine a rate based on the total number of travellers. We abstracted information on traveller demographics, trip specifics, study enrollment and follow-up and number of ill travellers and their illnesses.

RESULTS

Of 743 studies, nine met the inclusion criteria. The data sources were from North America (four studies) and Europe (five studies). Most travellers were tourists, the most frequent destination regions were Asia and Africa, and the median trip duration ranged from 8-21 days. Six studies enrolled participants at the travellers' pre-travel consultation. All studies collected data through either extraction from the medical record, weekly diaries, or pre- and post-travel questionnaires. Data collection timeframes varied by study. Between 6-87% of travellers became ill across all studies. Four studies provided the best estimate: between 43-79% of travellers who frequently visited developing nations (e.g. India, Tanzania, and Kenya) became ill; travellers most frequently reported diarrhoea.

CONCLUSION

This is the most comprehensive assessment available on the proportion of international travellers that develop a travel-related illness. Additional cohort studies would provide needed data to more precisely determine the rates of illness in international travellers.

KEYWORDS

International travel, travel, illness.

Pre-travel advice at a crossroad: Medical preparedness of travellers to South and Southeast-Asia - The Hamburg Airport Survey

BACKGROUND

Specific travel-related recommendations exist for the prevention or self-treatment of infectious diseases contracted by travellers to the tropics. In the current study, we assessed the medical preparedness per these recommendations, focusing on whether travellers carried antidiarrheal and antimalarial medication with them stratified by type of pre-travel advice.

METHODS

We surveyed travellers departing from Hamburg International Airport to South or Southeast Asia, using a questionnaire on demographic, medical and travel characteristics.

RESULTS

975 travellers were analysed - the majority (817, 83%) being tourists. A large proportion packed any antidiarrheal medication (612, 63%) - most frequently loperamide (440, 72%). Only 176 of 928 (19%) travellers to destinations with low-to medium risk for malaria packed a recommended antimalarial medication. The majority (162, 17%) of them carried antimalarials as stand-by emergency treatment (SBET). 468 (48%) travellers had a pre-travel medical consultation. This lead to higher odds of carrying SBET- with the highest odds associated with a consultation at a travel medicine specialist (OR 7.83 compared to no consultation).

CONCLUSIONS

Attending a travel medicine specialist was associated with better adherence to current recommendations concerning the carriage of stand-by emergency treatment of malaria. However, the proportion of travellers seeking pre-travel health advice was overall low in our population. Promoting pre-travel consultations may, therefore, lead to higher adherence to the current recommendations in travel medicine.

Primates on display: Potential disease consequences beyond bushmeat

Human interactions with nonhuman primates vary tremendously, from daily cultural engagements and food commodities, to pet ownership and tourist encounters. These interactions provide opportunities for the exchange of pathogenic organisms (both zoonoses and anthroponoses). As exposures are not limited to areas where bushmeat usage continues to be a major problem, we must work to understand better our motivations for engaging in activities like owning primates as pets and having direct physical contact with wild primates within the context of nature-based tourism. These topics, and the theoretical potential for pathogen transmission, are reviewed in the present manuscript. This is followed by a case study utilizing 3845 survey responses collected from four international locations known for primate-based tourism, with results indicating that while a majority of people understand that they can give/get diseases to/from wild primates, a surprising percentage would still touch or feed these animals if given the opportunity. Many people still choose to touch and/or own primates, as their drive to bond with animals outweighs some basic health behaviors. Desires to tame, control, or otherwise establish emotional connections with other species, combined with the central role of touch for exploring our environment, necessitate the development of better communication and educational campaigns to minimize risks of emerging infectious diseases.

A closer look at travellers' infections abroad: Finnish nationwide data with incidences, 2010 to 2012

BACKGROUND

Although infections represent the most common health problem of travellers abroad, data on morbidity and incidences of various infections are scarce.

METHOD

Data on infections of Finnish travellers during 2010-2012 were retrieved from the database of SOS International, an assistance organization covering 95% of Finns requiring aid abroad. The study included 30,086 cases. For incidence calculation, the data were linked to the numbers of Finns visiting these regions during the same period as recorded by the Official Statistics of Finland.

RESULTS

The incidence of infections was particularly high in Africa, southern Europe plus the eastern Mediterranean, and Asia plus Oceania. The most frequent diagnoses were acute gastroenteritis (38.0%) and respiratory-tract infections (RTI) (34.5%), followed by infections of the ear (12.6%), skin or subcutaneous tissue (5.1%), urogenital tract (4.2%), eye (3.1%), and systemic febrile infections (2.2%). Vaccine-preventable diseases (VPD) accounted for 0.8% of cases, with varicella as most (49%) and influenza as second-most (27%) common.

CONCLUSIONS

Incidence of infections was higher in southern than in eastern and western Europe. Gastroenteritis and RTI proved the most frequent diagnoses, whereas systemic febrile infections were uncommon. Despite pre-travel immunizations, VPDs still occurred; pre-travel consultation should cover both varicella and influenza.

Travelers' health problems and behavior: prospective study with post-travel follow-up

Background

The annual number of international tourist arrivals has recently exceeded one billion, yet surprisingly few studies have characterized travelers’ behavior, illness, and risk factors in a prospective setting. Particularly scarce are surveys of data spanning travel, return, and follow-up of the same cohort.

This study examines behavior and illness among travelers while abroad, after return home, and at follow-up. Patterns of behavior connected to type of travel and illness are characterized so as to identify risk factors and provide background data for pre-travel advice.

Methods

Volunteers to this prospective cohort study were recruited at visits to a travel clinic prior to departure. Data on the subjects’ health and behavior were collected by questionnaires before and after journeys and over a three-week follow-up. In addition, the subjects were asked to fill in health diaries while traveling.

Results

The final study population consisted of 460 subjects, 79 % of whom reported illness during travel or on arrival: 69 % had travelers’ diarrhea (TD), 17 % skin problems, 17 % fever, 12 % vomiting, 8 % respiratory tract infection, 4 % urinary tract infection, 2 % ear infection, 4 % gastrointestinal complaints other than TD or vomiting, and 4 % other symptoms. Of all subjects, 10 % consulted a doctor and 0.7 % were hospitalized; 18 % took antimicrobials, with TD as the most common indication (64 %). Ongoing symptoms were reported by 25 % of all travelers upon return home.

During the three-week follow-up (return rate 51 %), 32 % of respondents developed new-onset symptoms, 20 % visited a doctor and 1.7 % were hospitalized.

Factors predisposing to health problems were identified by multivariable analysis: certain regions (Southern Asia, South-Eastern Asia, and Eastern Africa), female gender, young age, and long travel duration.

Conclusions

Despite proper preventive measures like vaccinations, malaria prophylaxis, and travel advice, the majority of our subjects fell ill during or after travel. As the symptoms mostly remained mild, health care services were seldom needed. Typical traveler profiles were identified, thereby providing a tool for pre-travel advice. The finding that one third reported new-onset illness during follow-up attests to the importance of advising clients on potential post-travel health problems already during pre-travel visits.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1682-0) contains supplementary material, which is available to authorized users.

Health problems and health care seeking behavior among adult backpackers while traveling in Thailand

Background

Health problems among travelers in developing countries are not uncommon. Little is known about the occurrence of health problems and their impacts among backpackers in Thailand. The objective of this study was to assess the health problems and the health seeking behavior among adult backpackers who visited Thailand.

Methods

This was a cross-sectional questionnaire-based study. Data were collected from foreign adult backpackers in Khao San Road, Bangkok. They were asked about their demographic data, health problems (if any), and health-care seeking behavior if they became ill.

Results

During May to July 2015, 420 backpackers were enrolled in this study. Of these, 51.4 % were male with a median age of 26.4 years. Up to 66.9 % were of European origin, while 17.4 % were North American. Fifty-eight percent sought pre-travel consultation before traveling. In this study, 10.2 % (43/420) of the participants reported at least health problem during travel. Most of them (79.1 %) had single episode of illness. Of this, diarrhea was the most common health problem (30.4 %), followed by abdominal pain (14.3 %), skin problems (8.9 %), respiratory problems (8.9 %), accident-associated injury (7.1 %), and febrile illness (7.1 %). One third of backpackers with health problems spontaneously recovered without any treatment, while nearly a quarter treated themselves with standby medication, and one in five had to buy over the counter medication. Just over 9 % of backpackers with a health problem sought medical care at a hospital. Among travellers with health problems, 72.1 % reported that their health problems did not significantly impact to their trip, while 23.3 % had to delay or postpone their trip for at least 1 day, and 4.7 % had to cancel some trip and/or activity. Longer duration of stay was significantly related to higher occurrence of health problems while traveling.

Conclusions

Approximately 10 % of adult backpackers experienced some health problems during their trip in Thailand. Although most of their health problems were mild, up to 22 % of backpackers with health problems need to seek medical care either in a clinic or in a hospital.

Travel medicine and mHealth technology: a study using smartphones to collect health data during travel

BACKGROUND

mHealth methodology such as smartphone applications offers new opportunities to capture the full range of health risks during travel in real time. Our study aims to widen the scope of travel health research in tropical and subtropical destinations by using a smartphone application to collect detailed information on health behaviours, clinical symptoms, accidents and environmental factors during travel.

METHODS

We enrolled travel clinic clients in Zurich and Basel ≥18 years of age travelling to Thailand for <5 weeks. Sociodemographic, clinical and risk behaviour information was collected pre-travel. Participants were equipped with a smartphone and an application that (1) actively administers a daily self-report questionnaire on the health risks, behaviours and symptoms the traveller encountered, and (2) passively collects information on the traveller's location and environmental conditions by transformation of raw GPS data.

RESULTS

A prospective cohort of 101 travellers planning travel to Thailand between January and June 2015 was recruited. Of the 101 enrolled travellers, 75 (74.3%) answered at least one questionnaire during travel, 10 (9.9%) had technical difficulties and 16 (15.8%) dropped out. Those who completed questionnaires were a median of 27.0 years old (range 18-57). Travellers filled out a median of 12.0 questionnaires during their trip (range 1-30), corresponding to a median completion rate of 85.0% days of travel. The typical example of a healthy female traveller shows that many and diverse health issues arise during a trip that clusters on certain days. The rich data on behaviour and local environment may be used to explain the occurrence and clustering of health issues.

CONCLUSIONS

Use of a smartphone app to collect health information is technically feasible and acceptable amongst a traveller population, minimizes recall bias and greatly increases the quality and quantity of data collected during travel. mHealth technology shows great potential for innovation in travel medicine.

Travelers to the FIFA world cup 2014 in Brazil: Health risks related to mass gatherings/sports events and implications for the Summer Olympic Games in Rio de Janeiro in 2016

BACKGROUND

Health threats during mass gatherings, such as the FIFA world cup 2014 differ from traditional health risks. The influence of event type, demographics of attendees and environmental conditions are still not fully understood.

METHODS

An observational, prospective case-control survey conducted at the Frankfurt international airport in Germany on 544 travelers to the FIFA world cup 2014 and 432 regular travelers to Brazil departing after the end of the world cup.

RESULTS

Travelers to the FIFA world cup 2014 were predominantly male whereas the gender distribution in the control group was more balanced. The majority in both groups obtained insect bites and sunburns as environmental risk factors. Every third traveler suffered from diarrheal complaints in both groups, whereas the proportion of travelers with flu-like symptoms was higher in the case group. Travelers to the FIFA world cup 2014 indicated alcohol intake and sexual contacts outside of a relationship more frequently than travelers in the control group.

CONCLUSIONS

The additional health risks of travelers to sporting events as the FIFA world cup 2014 should be addressed in addition to traditional health threats in pre-travel counseling for the Summer Olympic Games 2016 in Brazil.

Travellers' profile, travel patterns and vaccine practices--a 10-year prospective study in a Swiss Travel Clinic

BACKGROUND

The travel clinic in Lausanne serves a catchment area of 700 000 of inhabitants and provides pre- and post-travel consultations. This study describes the profile of attendees before departure, their travel patterns and the travel clinic practices in terms of vaccination over time.

METHODS

We included all pre-travel first consultation data recorded between November 2002 and December 2012 by a custom-made program DIAMM/G. We analysed client profiles, travel characteristics and vaccinations prescribed over time.

RESULTS

Sixty-five thousand and forty-six client-trips were recorded. Fifty-one percent clients were female. Mean age was 32 years. In total, 0.1% were aged <1 year and 0.2% ≥80 years. Forty-six percent of travellers had pre-existing medical conditions. Forty-six percent were travelling to Africa, 35% to Asia, 20% to Latin America and 1% (each) to Oceania and Europe; 19% visited more than one country. India was the most common destination (9.6% of travellers) followed by Thailand (8.6%) and Kenya (6.4%). Seventy-three percent of travellers were planning to travel for ≤ 4 weeks. The main reasons for travel were tourism (75%) and visiting friends and relatives (18%). Sixteen percent were backpackers. Pre-travel advice were sought a median of 29 days before departure. Ninety-nine percent received vaccine(s). The most frequently administered vaccines were hepatitis A (53%), tetanus-diphtheria (46%), yellow fever (39%), poliomyelitis (38%) and typhoid fever (30%).

CONCLUSIONS

The profile of travel clinic attendees was younger than the general Swiss population. A significant proportion of travellers received vaccinations that are recommended in the routine national programme. These findings highlight the important role of travel clinics to (i) take care of an age group that has little contact with general practitioners and (ii) update vaccination status. The most commonly prescribed travel-related vaccines were for hepatitis A and yellow fever. The question remains to know whether clients do attend travel clinics because of compulsory vaccinations or because of real travel health concern or both.

Health risks facing travelers to Russia with special reference to natural-focal diseases

BACKGROUND

Russia, an enormous country almost completely located within temperate latitudes, has a broad spectrum of natural landscapes which attract increasing numbers of tourists, from arctic deserts in the north to steppes and deserts in the south. Currently, tourism is undergoing active development in Russia: new travel routes, including ones that involve visiting the wilderness, are steadily appearing. Among the multitude of infectious diseases that can endanger travelers, natural-focal diseases, whose agents and/or carriers are integral to natural landscapes, are especially prominent. Some of the results of the study of natural-focal infections and parasitoses, which are necessary to evaluate the recreational and travel potential of the Russian Federation, are presented and discussed in this article.

METHOD

A cartographical and statistical analysis of infectious and parasitic natural-focal diseases, spanning more than a decade (1997-2013), is the basis of this article.

RESULTS

This analysis, along with that of additional cartographical and textual sources, reveals that natural-focal infections are most diverse between 48° N and 60° N and least diverse in the northern regions of the Far East of Russia. Different regions have different numbers of nosoforms and different morbidity level, which signifies an irregularity in the distribution of parasitic diseases.

CONCLUSIONS

This medico-geographical information may be useful both for individual tourists planning trips to Russia and tour agencies organizing tour groups. It also can be used by health advisers when they consult people before a trip, to assess the actual risks, suggest a number of precautions and pick the particular diseases out of those listed that actually constitute a risk in certain regions, and suggest a suitable preventative treatment if needed.

Illness and risk behaviour in health care students studying abroad

CONTEXT

The numbers of university students studying abroad increase every year. These students are not tourists as their studies require different types of travel that expose them to different risks. Moreover, health care students (HCSs) may be exposed to even greater risks according to their travel destinations and itineraries. Clearly, research-based pre-travel advice is needed.

METHODS

This study reports on a prospective survey conducted from April 2010 to January 2014 of health care and non-health care students from Swedish universities in Umeå, Stockholm and Gothenburg studying abroad.

RESULTS

Of the 393 students included in the study, 85% responded. Over half (55%) were HCSs. Pre-travel health information was received by 79% and information on personal safety by 49% of HCSs. The rate of illness during travel was 52%. Health care students more often travelled to developing regions and were at increased risk for travellers' diarrhoea. One in 10 experienced theft and 3% were involved in traffic accidents. One in five met a new sexual partner during travel and 65% of these practised safe sex. Half of all participants increased their alcohol consumption while abroad; high alcohol consumption was associated with increased risk for being a victim of theft, as well as for meeting a new sexual partner during travel.

CONCLUSIONS

University authorities are responsible for the safety and well-being of students studying abroad. This study supplies organisers and students with epidemiological data that will help improve pre-travel preparation and increase student awareness of the potential risks associated with studying abroad.

Illness and injury of travellers abroad: Finnish nationwide data from 2010 to 2012, with incidences in various regions of the world

Binary file ES_Abstracts_Final_ECDC.txt matches

Respiratory infections in travelers returning from the tropics

Respiratory tract infections (RTIs), beside diarrheas, skin lesions, and fevers of unknown origin, are one of the most common health problems acquired by travelers going to tropical and subtropical countries. Visitors to African, Asian, or South American destinations, typically characterized by harsh environmental conditions and poor sanitation standards, are at risk of exposure to a large number of pathogens causing infectious diseases. The infections are transmitted from contaminated food and water, through the air, direct contact, or by insects. The main modes of RTIs transmission include droplet infection and direct contact. The clinical spectrum of RTIs in travelers is broad, from upper respiratory tract infections, pharyngitis, bronchitis, pneumonia, to influenza-like illness. The spectrum of microbial agents causing respiratory infections include numerous viruses and bacteria, rarely fungi, and parasites. Most travelers complain of mild infections, only a small minority seek medical assistance and report to health care facilities. Because of the risk of importing pathogens into Europe or North America and transferring them onto the local population, it is important to present the scale of the problem in relation to rapid development of tourism industry and an increasing number of intercontinental journeys. The aim of the study was to discuss the occurrence of travel-related respiratory infections among representatives of temperate climate traveling to and returning from the tropics.

Assessment of returning travellers with fever

Millions of people travel to the tropics each year and a significant minority of them become ill, either during their stay, or shortly after their return. Most have mild, self-limiting illnesses, but a few will have a life-threatening condition. This article outlines how to evaluate fever in the returning traveller and discusses important infection control and public health measures. A detailed travel history, which takes into account travel destinations, specific activities and risk factors in relation to the onset of symptoms, is essential for constructing a comprehensive list of differential diagnoses and guiding appropriate investigations. Importantly, all travellers returning from the tropics with a fever should be investigated for malaria, even if their return was 3 months ago or longer.

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.

A quality improvement initiative using a novel travel survey to promote patient-centered counseling

BACKGROUND

We sought to evaluate and provide better itinerary-specific care to precounseled travelers and to assess diseases occurring while traveling abroad by surveying a community population. An additional quality improvement initiative was to expand our post-travel survey to be a more valuable tool in gathering high-quality quantitative data.

METHODS

From de-identified data collected via post-travel surveys, we identified a cohort of 525 patients for a retrospective observational analysis. We analyzed illness encountered while abroad, medication use, and whether a physician was consulted. We also examined itinerary variables, including continents and countries visited.

RESULTS

The 525 post-travel surveys collected showed that the majority of respondents traveled to Asia (31%) or Africa (30%). The mean number of travel days was 21.3 (median, 14). Univariate analysis demonstrated a statistically significant increase of risk for general illness when comparing travel duration of less than 14 days to greater than 14 days (11.3% vs 27.7%, p < 0.001). Duration of travel was also significant with regard to development of traveler's diarrhea (TD) (p = 0.0015). Destination of travel and development of traveler's diarrhea trended toward significance. Serious illness requiring a physician visit was infrequent, as were vaccine-related complications.

CONCLUSIONS

Despite pre-travel counseling, traveler's diarrhea was the most common illness in our cohort; expanded prevention strategies will be necessary to lower the impact that diarrheal illness has on generally healthy travelers. Overall rates of illness did not vary by destination; however, there was a strong association between duration of travel and likelihood of illness. To further identify specific variables contributing to travel-related disease, including patient co-morbidities, reason for travel, and accommodations, the post-travel survey has been modified and expanded. A limitation of this study was the low survey response rate (18%); to improve the return rate, we plan to implement supplemental modalities including email and a web-based database.

Health problems awareness during travel among faculty members of a large university in Latin America: preliminary report

Health safety during trips is based on previous counseling, vaccination and prevention of infections, previous diseases or specific problems related to the destination. Our aim was to assess two aspects, incidence of health problems related to travel and the traveler's awareness of health safety. To this end we phone-interviewed faculty members of a large public University, randomly selected from humanities, engineering and health schools. Out of 520 attempts, we were able to contact 67 (12.9%) and 46 (68.6%) agreed to participate in the study. There was a large male proportion (37/44, 84.1%), mature adults mostly in their forties and fifties (32/44, 72.7%), all of them with higher education, as you would expect of faculty members. Most described themselves as being sedentary or as taking occasional exercise, with only 15.9% (7/44) taking regular exercise. Preexisting diseases were reported by 15 travelers. Most trips lasted usually one week or less. Duration of the travel was related to the destination, with (12h) or longer trips being taken by 68.2% (30/44) of travelers, and the others taking shorter (3h) domestic trips. Most travelling was made by air (41/44) and only 31.8% (14/44) of the trips were motivated by leisure. Field research trips were not reported. Specific health counseling previous to travel was reported only by two (4.5%). Twenty seven of them (61.4%) reported updated immunization, but 11/30 reported unchecked immunizations. 30% (9/30) reported travel without any health insurance coverage. As a whole group, 6 (13.6%) travelers reported at least one health problem attributed to the trip. All of them were males travelling abroad. Five presented respiratory infections, such as influenza and common cold, one neurological, one orthopedic, one social and one hypertension. There were no gender differences regarding age groups, destination, type of transport, previous health counseling, leisure travel motivation or pre-existing diseases. Interestingly, the two cases of previous health counseling were made by domestic travelers. Our data clearly shows that despite a significant number of travel related health problems, these highly educated faculty members, had a low awareness of those risks, and a significant number of travels are made without prior counseling or health insurance. A counseling program conducted by a tourism and health professional must be implemented for faculty members in order to increase the awareness of travel related health problems.

Effect of travel on influenza epidemiology

To assess the attack and incidence rates for influenza virus infections, during October 2006-October 2007 we prospectively studied 1,190 adult short-term travelers from the Netherlands to tropical and subtropical countries. Participants donated blood samples before and after travel and kept a travel diary. The samples were serologically tested for the epidemic strains during the study period. The attack rate for all infections was 7% (86 travelers) and for influenza-like illness (ILI), 0.8%. The incidence rate for all infections was 8.9 per 100 person-months and for ILI, 0.9%. Risk factors for infection were birth in a non-Western country, age 55-64 years, and ILI. In 15 travelers with fever or ILI, influenza virus infection was serologically confirmed; 7 of these travelers were considered contagious or incubating the infection while traveling home. Given the large number of travelers to (sub)tropical countries, travel-related infection most likely contributes to importation and further influenza spread worldwide.

[The elderly travellers]

We attend a considerable increase in the number of old travellers, because of facilitation of transport, and increase of the life expectation without incapacity. This way, practicians will be more and more confronted with old travellers avid councils before their departure. In spite of the risk of intercurrent pathologies, data shows that the age in itself is not a contra-indication of travel: the stage of life considered as a limit becomes a period privileged to discover the world. On a theoretical plan, the ageing characterized by a reduction of the functional reserve of organ, represents more a fragility than a contra-indication. On the other hand, comorbidities and their accumulation make elderly more vulnerable to medical complications potentially serious and in conditions of stress than can gather a travel. We could propose to the vulnerable old patient avid to leave, in coordination with the geriatrician and the travel doctor, a personalized prevention in the form of a consultation "old traveller" where we would adopt a geriatric approach to review the compatibility between the health and the type of travel, in particular at elderly with polypathologies and many treatments.

Profile of travel-associated illness in children, Zürich, Switzerland

BACKGROUND

The number of families traveling with their children to their country of origin and/or to tropical destinations has increased in Switzerland and includes a changing profile and multinational range of patients. Defining the profile of reported travel-associated illnesses will help to improve the prevention and treatment of such illnesses in children.

METHODS

This study includes children aged up to 16 years who sought medical advice for a presumed travel-related illness at the emergency room of the University of Zürich Children's Hospital during the period July 2007 to December 2008.

RESULTS

We analyzed data on 328 children (58.8% male, mean age: 4.62 y) who presented with travel-associated illness. Our analysis included 155 traditional (mainly tourist) travelers, 162 children who were visiting friends and relatives (VFR), and 11 immigrants. Some 11% were hospitalized. No deaths occurred. The main conditions recorded were diarrheal illness (39%), respiratory (28.7%) and febrile/systemic illness (13.4%). With increasing age, the proportion of children with diarrheal disease increased, while the proportion with respiratory illness declined. There were significant associations between geographic area of exposure and the profile of travel-related disease (p < 0.001). Among 36 children with more serious diseases requiring hospitalization, 12 (3.7% overall) presented with potentially serious diseases: malaria (n = 2), Salmonella typhi (n = 3), Salmonella paratyphi (n = 2), meningococcal meningitis (n = 1), tuberculosis (n = 2), visceral leishmania (n = 1), and hepatitis A (n = 1). Eleven of the 12 children presenting with these potentially serious illnesses were VFR or immigrant children.

CONCLUSION

The main diagnoses for ill-returned Zürich children who presented for emergency care were diarrhea, respiratory, and febrile/systemic illness. A broad spectrum of morbidity was seen including meningococcal meningitis, malaria, tuberculosis, typhoid fever, leishmania, and hepatitis A. Diagnoses varied between geographic regions visited, and VFR child travelers constituted a large proportion of sick-returned children presenting for emergency care.

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 risk behaviours and uptake of pre-travel health preventions by university students in Australia

Background

Forward planning and preventative measures before travelling can significantly reduce the risk of many vaccine preventable travel-related infectious diseases. Higher education students may be at an increased risk of importing infectious disease as many undertake multiple visits to regions with higher infectious disease endemicity. Little is known about the health behaviours of domestic or international university students, particularly students from low resource countries who travel to high-resource countries for education. This study aimed to assess travel-associated health risks and preventative behaviours in a sample of both domestic and international university students in Australia.

Methods

In 2010, a 28 item self-administered online survey was distributed to students enrolled at the University of New South Wales, Sydney, Australia. Multiple methods of distributing links to the online survey were utilised. The survey examined the international travel history, travel intentions, infection control behaviours and self-reported vaccination history.

Results

A total of 1663 respondents completed the online survey, 22.1% were international students and 83.9% were enrolled at an undergraduate level. Half had travelled internationally in the previous 12 months, with 69% of those travelling only once during that time with no difference in travel from Australia between domestic and international students (p = 0.8). Uptake of pre-travel health advice was low overall with 68% of respondents reporting they had not sought any advice from a health professional prior to their last international trip. Domestic students were more likely to report uptake of a range of preventative travel health measures compared to international students, including diarrhoeal medication, insect repellent, food avoidance and condoms (P < 0.0001). Overall, students reported low risk perception of travel threats and a low corresponding concern for these threats.

Conclusions

Our study highlights the need to educate students about the risk associated with travel and improve preventative health-seeking and uptake of precautionary health measures in this highly mobile young adult population. Although immunisation is not an entry requirement to study at Universities in Australia, large tertiary institutions provide an opportunity to engage with young adults on the importance of travel health and provision of vaccines required for travel, including missed childhood vaccines.

Morbidity of foreign travelers in Attica, Greece: a retrospective study

Over the last decade, travel medicine was mainly focused on the epidemiology of diseases among travelers to developing countries. However, less is known about travel-related morbidity in Europe. We evaluated the demographic and clinical characteristics of foreign travelers to Greece during a 5-year period (01/01/2005 - 31/12/2009) who sought medical services from a network of physicians performing house-call visits (SOS Doctors) in the area of Attica, Greece. Overall, 3,414 foreign travelers [children (≤18 years of age): 27%] were identified; 151 (4.4%) required transfer to a hospital. The most common clinical entities were: respiratory disorders (34%), diarrheal disease (19%), musculoskeletal (12%), dermatologic (7%), non-diarrheal gastrointestinal (6%), and genitourinary (5%) disorders. Respiratory disorders were the most frequent diagnosis during all seasons, followed by diarrheal gastrointestinal and musculoskeletal disorders. Respiratory and dental conditions were observed significantly more frequently in children. Respiratory disorders were observed significantly more frequently during winter (47%) compared to spring (36.7%), summer (30.9%), and autumn (30.5%), (p < 0.01). Despite the limitations of the retrospective methodology, our findings suggest that mild, self-limited respiratory events may be the prevalent cause for seeking primary health care during travel to Greece. Our findings may be extrapolated to other countries with similar climatic and socioeconomic status.

Reiseimpfungen und allgemein empfohlene Impfungen

Nach Schätzungen der World Tourism Organisation (WTO) verreisen jedes Jahr ca. 7,2 Millionen Deutsche nach Übersee. Hiervon entfällt ein Großteil auf Reisen in nicht tropische Gebiete: die USA, gefolgt von der Türkei und Tunesien, sind die häufigsten Ziele von Interkontinentalreisenden (www.world-tourism.org). Im Gegensatz hierzu sind Ost- und vor allem Westafrika, die von erkrankten Tropenrückkehrern am häufigsten als Infektionsgebiete genannt werden, bei den Reisezielen nur zu einem sehr geringen Ausmaß vertreten. Die internationale Reisetätigkeit boomt weltweit und gerade in Deutschland genießen Auslandsreisen einen besonderen Stellenwert. Die Forschungsgruppe Urlaub und Reisen gibt die Gesamtzahl der grenzüberschreitenden Reisen, die von Deutschen getätigt wurden, mit 56–63 Millionen pro Jahr an. Von den geschätzten 7,2 bis 7,8 Millionen interkontinentalen Reisen führten ca.4 Millionen in die Tropen.