Pre-travel health care of immigrants returning home to visit friends and relatives

Using the Health Belief Model to Predict Pre-Travel Health Decisions among U.S.-Based Travelers

International travelers are at increased risk of infectious disease, but almost half of Americans traveling to lower- and middle-income countries seek no health information before traveling. The Health Belief Model (HBM) can help evaluate decisions by categorizing behaviors into five categories: susceptibility, severity, benefits, barriers, and self-efficacy. This study sought to use the HBM to elucidate what may influence an individual to make certain pre-travel health decisions. We surveyed 604 participants who had recently traveled to an at-risk country. Participants were subset into nested groups: full population, sought any health information, and visited a clinic or health care provider (HCP). Survey questions were categorized according to the HBM, assembled into a priori models, and analyzed in each group using logistic regression with three main outcome variables: "Sought any pre-travel health information," "Visited clinic or HCP," and "Received vaccine." Of the 604 participants, 333 (55%) sought any health information, 245 (41% of total) reported visiting an HCP, and 166 (27% of total) reported receiving a vaccine before traveling. Models containing variables from the susceptibility and benefits categories were most successful in predicting all three outcomes; susceptibility was a more relevant consideration in information seeking and seeing a provider than vaccination, whereas benefits was relevant for all outcomes. Our results emphasize the importance of an individual's perceived susceptibility to disease and perceived benefit of interventions in predicting pre-travel health behaviors. Understanding this interaction can help shape how HCPs and public health entities can encourage health care seeking and vaccine uptake in travelers.

Travel Medicine

International travel can cause new illness or exacerbate existing conditions. Because primary care providers are frequent sources of health advice to travelers, they should be familiar with destination-specific disease risks, be knowledgeable about travel and routine vaccines, be prepared to prescribe chemoprophylaxis and self-treatment regimens, and be aware of travel medicine resources. Primary care providers should recognize travelers who would benefit from referral to a specialized travel clinic for evaluation. Those requiring yellow fever vaccination, immunocompromised hosts, pregnant persons, persons with multiple comorbid conditions, or travelers with complex itineraries may warrant specialty referral.

Travelers and travel vaccines at six health care systems in the Vaccine Safety Datalink

BACKGROUND

Studying the safety of travel vaccines poses challenges since recipients may be traveling during the risk window for adverse events and the identification of a suitable comparison group can also be difficult. The examination of traveler characteristics, travel vaccination patterns, and health care utilization using electronic health record (EHR) data can inform the feasibility of future travel vaccine safety studies.

METHODS

A retrospective cohort study of health plan members in the Vaccine Safety Datalink Project aged 9 months and older who had a travel-related encounter or received a travel vaccine from 2009 to 2018 was performed. Travel regions visited, travel duration, type of travel vaccine received (typhoid, yellow fever, Japanese encephalitis, rabies, and cholera), and timing of vaccination date before departure date were described. Sociodemographic information, clinical characteristics, and health care utilization were compared between travelers who received travel vaccines and travelers who did not.

RESULTS

A total of 1,026,822 unique travelers departing from the United States were identified; 612,795 travelers received 898,196 doses of travel vaccines. The most commonly administered travel vaccine was typhoid vaccine and 77% of all travel vaccines were given more than one week prior to departure. Compared with travelers without travel vaccines, travelers with travel vaccines were overall similar but as a group were slightly younger, healthier, and had lower Hispanic representation. Health care utilization dramatically decreased during travel. Outpatient visits decreased from 294.8 visits per 10,000 person-days before travel to 24.2 visits per 10,000 person-days during reported travel dates.

CONCLUSIONS

Through the EHR information from almost a million travelers, a departure date and duration of travel were successfully captured for the majority of travelers with corresponding health care utilization data. Time after vaccination and prior to departure can potentially be used in the future to compare travelers who receive travel vaccines with travelers who do not receive travel vaccines when looking at adverse events of interest after vaccination.

Underestimation of travel-associated risks by adult and paediatric travellers compared to expert assessment: A cross-sectional study at a hospital-based family pre-travel clinic

BACKGROUND

Travellers' perception of their risk for acquiring travel-related conditions is an important contributor to decisions and behaviors during travel. In this study, we aimed to assess the differences between traveller-perceived and expert-assessed risk of travel-related conditions in children and adults travelling internationally and describe factors that influence travellers' perception of risk.

METHODS

Children and adults were recruited at the Hospital for Sick Children's Family Travel Clinic between October 2014 and July 2015. A questionnaire was administered to participants to assess their perceived risk of acquiring 32 travel-related conditions using a 7-point Likert scale. Conditions were categorized as vector-borne diseases, vaccine-preventable diseases, food and water borne diseases, sexually transmitted infections and other conditions. Two certified travel medicine experts reviewed each patient's chart and assigned a risk score based on the same 7-point Likert scale. Traveller and expert risk scores were compared using paired t-tests.

RESULTS

In total, 207 participants were enrolled to participate in this study, 97 children (self-reported, n = 8; parent-reported, n = 89), and 110 adults. Travel-related risk for adults and parents answering for their children were significantly underestimated when compared to expert-assessed risk for 26 of the 32 assessed conditions. The underestimated conditions were the same for both adults and parents answering for children. Travel-related risk was not over-estimated for any condition.

CONCLUSIONS

Adults underestimated their children's and their own risk for most travel-related conditions. Strategies to improve the accuracy of risk perception of travel-related conditions by travellers are needed to optimize healthy travel for children and their families.

Travelers' Attitudes, Behaviors, and Practices on the Prevention of Infectious Diseases: A Study for Non-European Destinations

BACKGROUND

The aim of this study was to improve our comprehension of the attitudes, behaviors, and practices related to the health risks of travel to non-European destinations.

METHODS

This cross-sectional study utilized an online questionnaire disseminated through social networks.

RESULTS

About 79% of the respondents reported that they informed themselves or would inform themselves about travel-related health risks before departure. The most used sources of information were the Internet (52%) and health professionals (42%). Older age groups were positively associated with seeking pretravel health information (OR = 2.44, CI 95%: 1.18-5.01, in the age group 25-34 years and OR = 14.6, CI 95%: 1.77-119.50, in subjects over 65 years). Travelers visiting friends and relatives (VFRs) were less likely to seek health information (OR = 0.49; CI 95%: 0.26-0.95). About 13.9% of participants had doubts about the practice of vaccination. Those who sought information on social media had a higher probability of refusing vaccination (OR = 3.24; CI 95%: 1.02-10.19).

CONCLUSIONS

The data demonstrate that VFRs and the younger population are less informed about travel risks compared with other travelers. This study also revealed the importance that digital information assumes for travelers. Therefore, decisive efforts should be made to ensure that travelers can find correct and reliable information on the Web, particularly on social media.

Travel health seeking behaviours, masks, vaccines and outbreak awareness of Australian Chinese travellers visiting friends and relatives - Implications for control of COVID-19

BACKGROUND

The COVID-19 pandemic has highlighted the role of international travel in spreading infections. Travellers visiting friends and relatives (VFR) are at higher risk of acquiring infections than other travellers, therefore improving the travel health behaviour of these travellers is important. Ethnic Chinese are one of the largest migrant groups in many countries, yet there have been no published studies regarding this population as VFR travellers. We present findings of a study of Australian Chinese VFR travellers relevant to the pandemic response.

METHODS

In 2013, five focus groups were conducted with Australian Chinese VFR travellers, exploring topics such as vaccines, face masks, outbreaks and travel health seeking behaviour. Participants were aged 18 years or older and had travelled to China for VFR purposes in the preceding 18 months. Sessions were recorded and transcribed, and thematic analysis was undertaken.

RESULTS

Participants viewed VFR travel as low risk, and underestimated the risks associated with travelling during an outbreak. However, they were generally willing to receive pre-travel vaccination specifically for an outbreak, but not otherwise. Attitudes towards face masks and other infection control measures were mixed. Multiple factors influenced their travel health behaviour, including low risk awareness, misconceptions, and cultural barriers to seeking health care.

CONCLUSION

Our research found that Chinese VFR travellers undertake suboptimal precautions related to VFR travel, associated with an underestimation of risks. While they share many characteristics with other VFR travellers, unique cultural health beliefs should be taken into account when developing risk communication and educational interventions as part of a pandemic response.

Epidemiological and Clinical Characteristics of International Travelers with Enteric Fever and Antibiotic Resistance Profiles of Their Isolates: a GeoSentinel Analysis

Enteric fever, caused by Salmonella enterica serovar Typhi (S Typhi) and S. enterica serovar Paratyphi (S Paratyphi), is a common travel-related illness. Limited data are available on the antimicrobial resistance (AMR) patterns of these serovars among travelers. Records of travelers with a culture-confirmed diagnosis seen during or after travel from January 2007 to December 2018 were obtained from GeoSentinel. Traveler demographics and antimicrobial susceptibility data were analyzed. Isolates were classified as nonsusceptible if intermediate or resistant or as susceptible in accordance with the participating site's national guidelines. A total of 889 travelers (S Typhi infections, n = 474; S Paratyphi infections, n = 414; coinfection, n = 1) were included; 114 (13%) were children of <18 years old. Most individuals (41%) traveled to visit friends and relatives (VFRs) and acquired the infection in South Asia (71%). Child travelers with S Typhi infection were most frequently VFRs (77%). The median trip duration was 31 days (interquartile range, 18 to 61 days), and 448 of 691 travelers (65%) had no pretravel consultation. Of 143 S Typhi and 75 S Paratyphi isolates for which there were susceptibility data, nonsusceptibility to antibiotics varied (fluoroquinolones, 65% and 56%, respectively; co-trimoxazole, 13% and 0%; macrolides, 8% and 16%). Two S Typhi isolates (1.5%) from India were nonsusceptible to third-generation cephalosporins. S Typhi fluoroquinolone nonsusceptibility was highest when infection was acquired in South Asia (70 of 90 isolates; 78%) and sub-Saharan Africa (6 of 10 isolates; 60%). Enteric fever is an important travel-associated illness complicated by AMR. Our data contribute to a better understanding of region-specific AMR, helping to inform empirical treatment options. Prevention measures need to focus on high-risk travelers including VFRs and children.

Surveying Health-Related Knowledge, Attitudes, and Behaviors of U.S.-Based Residents Traveling Internationally to Visit Friends and Relatives

U.S. residents traveling internationally to regions with increased risk of infectious diseases infrequently seek pretravel health care. First- and second-generation immigrants traveling to their countries of origin and visiting friends and relatives (VFRs) have increased risk of certain infectious diseases and are more likely to participate in high-risk activities. In an online survey of 994 U.S. residents with two foreign-born parents who went on at least one international trip to an at-risk country (defined as having a typhoid vaccine recommendation) in the prior 3 years, respondents were questioned about their international travel over the previous 3 years and their knowledge and individual risk of disease. Participants reported infrequently seeking pretravel health information (32% of trips) or consulting a healthcare provider before their trips (15% of trips). Participants reported seeking pretravel health information less often for VFR trips home (22%) than to other regions (30%). Perceived risk of disease was directly associated with seeking pretravel health information (82% for the highest and 13% for the lowest perceived risk), consulting a healthcare provider (55% for the highest and 5% for the lowest perceived risk), and reporting travel-associated illness (54% for the highest and 10% for the lowest perceived risk). Respondents were generally knowledgeable about cholera, hepatitis B, malaria, and rabies but had low knowledge of hepatitis A and typhoid. Understanding where VFR travelers lack understanding of disease transmission and which travelers are ideal targets for interventions has the potential to shape physician recommendations and public health strategy in this vulnerable population.

Travel health risk perceptions of Chinese international students in Australia - Implications for COVID-19

BACKGROUND

International students frequently return to their country of origin to visit friends and relatives (VFR), and are at increased risk of travel-associated infections. Little is known of their travel health seeking behaviours. China is the biggest source of international students studying in Australia and the unprecedented epidemic of COVID-19 in China makes this an important area of research.

METHODS

Focus groups of Chinese international students were conducted to explore travel health-related knowledge, attitudes and practices. Eligible participants were studying in Sydney, and had travelled to China and Hong Kong to visit friends and relatives in the preceding 18 months. A variety of topics were explored, using a focus group guide. Thematic analysis was undertaken on the transcripts using nVivo software. The list of codes and themes were not pre-determined but developed through content analysis.

RESULTS

Two focus groups were held with a total of 28 participants. Risk perception about VFR travel was generally low among Chinese international students. Pre-travel healthcare was not sought. Students strongly relied on the Internet, social media, parents and friends in China for travel health advice.

CONCLUSION

This research provides insights into Chinese international students as VFR travellers. It confirms students could be a risk population for importations of infections such as COVID-19 because of low risk perception and lack of seeking travel health advice. This can inform health promotion strategies for students.

Traveler's diarrhea in children: New insights and existing gaps

The number of children accompanying their parents in international travel is increasing steadily, and with the rising global migration, children more frequently accompany their parents or caregivers for visiting friends or relatives (VFR). As compared to travel for tourism, VFR children are at higher risk of acquiring local diseases, as they more often stay in rural areas in resource-poor locations, have longer periods of visit, are less likely to attend pre-travel consultations, and less frequently adhere to recommended precautions. Travelers's diarrhea (TD) is the most common travel-associated illnesses in children. This review updates the existing knowledge on TD in children, regarding its distinctive epidemiology, risk factors, preventive measures, clinical manifestations, complications, causative microorganisms and management. Despite the limited focused research on pediatric TD, which challenges the formulation of children-oriented evidence-based guidelines, practical recommendations are suggested.

Characteristics and preparation of the last-minute traveler: analysis of vaccine usage in the Global TravEpiNet Consortium

BACKGROUND

Last-minute travellers (LMTs) present challenges for health care providers because they may have insufficient time for recommended vaccinations or pre-travel preparation. Our objective was to obtain a better understanding of LMTs in order to help travel medicine providers develop improved strategies to decrease the number of LMTs and potentially reduce travel-related morbidity.

METHODS

We defined LMTs as travellers with a departure date of 7 days or fewer from the medical encounter. We analysed the characteristics and health preparation of 12 494 LMTs who presented to a network of US clinical practices for pre-travel health advice between January 2009 and December 2015.

RESULTS

LMTs comprised 16% of all travellers. More LMTs than non-LMTs travelled for business or to visit friends and relatives (VFR) (26% vs 16% and 15% vs 8%, respectively; P < 0.0001). More LMTs also travelled for longer than 1 month (27% vs 21%; P < 0.0001) and visited only urban areas (40% vs 29%; P < 0.0001). At least one travel vaccine was deferred by 18% of LMTs because of insufficient time before departure. Vaccines that required multiple vaccinations, such as Japanese encephalitis and rabies, were the most likely to be deferred because of time constraints.

CONCLUSION

Interventions to improve the timing of pre-travel health consultations should be developed, particularly for business and VFR travellers. Recently endorsed accelerated vaccine schedules for Japanese encephalitis and rabies may help some LMTs receive protection against these infections despite late presentation for pre-travel health care.

New guidelines for the prevention of imported malaria in France

Prevention of malaria is based on personal vector-control measures (PVCMs) to avoid mosquito bites at night and chemoprophylaxis if justified by the risk of contracting the disease. The most effective PVCM is the use of insecticide-treated mosquito nets. The decision to prescribe chemoprophylaxis, mainly to prevent Plasmodium falciparum infection, depends on the benefit-risk ratio. Overall, the risk of contracting malaria is 1,000-fold lower during a stay in the tropical regions of Asia or the Americas than in sub-Saharan Africa. For "conventional" stays (less than one month with nights spent in urban areas) in low-risk settings in tropical Asia and America, the risk of being infected with Plasmodium parasites (≤1/100,000) is equivalent or lower than that of experiencing serious adverse effects caused by chemoprophylaxis. Preventive medication is therefore no longer recommended. By contrast, in other settings and particularly in sub-Saharan Africa, chemoprophylaxis is the most effective measure against malaria. However, it is worth noting that no single preventive measure provides full protection. Regardless of the level of risk or chemoprophylaxis-related indication, protection against mosquito bites and rapid management of febrile illness after returning from an endemic area are also critical to prevent malaria. Finally, migrants of sub-Saharan origin visiting friends and relatives in their country of origin form a high-risk group who should be recommended chemoprophylaxis in the same way as any other travelers-with a preference for the least expensive molecules (doxycycline).

Impact of pre-travel consultation on clinical management and outcomes of travelers' diarrhea: a retrospective cohort study

Background

International travelers are at high risk of acquiring travelers’ diarrhea. Pre-travel consultation has been associated with lower rates of malaria, hepatitis, and human immunodeficiency virus (HIV) infections. The objective was to study the impact of pre-travel consultation on clinical management and outcomes of travelers’ diarrhea.

Methods

This retrospective cohort study analyzed 1160 patients diagnosed with travelers’ diarrhea at Mayo Clinic Rochester, MN from 1994 to 2017. Variables included high-risk activities, post-travel care utilization, antimicrobial prescriptions, hospitalizations, and complications. Travelers were divided into those who sought (n = 256) and did not seek (n = 904) pre-travel consultation. The two groups were compared using the Wilcoxon test for continuous variables and chi-square test for categorical variables. Multivariate logistic regression was used to adjust for differences in traveler characteristics.

Results

More pre-travel consultation recipients were young Caucasians who had more post-travel infectious disease (ID) consultation [OR 3.1 (95% CI 1.9–5.3)], more stool sampling [OR 1.6 (95% CI 1.1–2.4)], and more antimicrobial prescriptions [OR 1.6 (95% CI 1.1–2.5)] for travelers’ diarrhea compared to the non-pre-travel consultation group. The pre-travel consultation group had shorter hospital stays (mean 1.8 days for pre-travel versus 3.3 days for non-pre-travel consultation group, p = 0.006) and reduced gastroenterology consultation rates [OR 0.4 (95% CI 0.2–0.9)]. 23 patients with positive stool cultures had Campylobacter susceptibilities performed; 65% (15/23) demonstrated intermediate susceptibility or resistance to ciprofloxacin.

Conclusion

Pre-travel consultation was associated with higher rates of stool testing and antimicrobial prescriptions. The high rate of quinolone-resistant Campylobacter in our small sample suggests the need for judicious antimicrobial utilization. The pre-travel consultation group did have a shorter duration of hospitalization and reduced need for gastroenterology consultation for prolonged or severe symptoms, which are positive outcomes that reflect reduced morbidity of travelers’ diarrhea.

Hepatitis A in Switzerland: An analysis of 29 years of surveillance data and contemporary challenges

BACKGROUND

Hepatitis A (HA) incidence declined in most European countries in the past decades. We analysed HA notification data for Switzerland of 29 years looking for disease- and notification system-related factors possibly contributing to observed trends.

METHOD

Notification data were descriptively analysed using five time intervals (1988-1993, 1994-1999, 2000-2005, 2006-2011, 2012-2016); and notification rates were calculated.

RESULTS

From 1988 to 2016, the HA notification rate decreased from 9.5 to 0.5 per 100'000 population in Switzerland. Median age and the proportion of hospitalised cases increased over time. In the 1988-1993-time period, intravenous drug use was the most frequently mentioned risk exposure while consumption of contaminated food/beverages was most frequently mentioned in the 2012-2016-time period.

CONCLUSIONS

Notification data does not allow reliably identifying current risk groups (e.g. travellers) due to low case numbers, limited availability and reliability of information. It is important to document changes in the surveillance system for later analyses and interpretation of long-term trends. Population susceptibility likely increases underlining the importance of continued and continuous surveillance and prevention efforts despite decreasing case numbers. Operational research is recommended to further investigate observed trends of HA and to enhance the abilities for decision making from Swiss HA surveillance data.

Demographic and Travel Characteristics of Travel-Associated Zika Virus Infection Case-Patients in San Diego County, California (January 1, 2016-March 31, 2017)

Most Zika disease cases diagnosed in the continental US have been associated with travel to areas with risk of Zika transmission, mainly the Caribbean and Latin America. Limited information has been published about the demographic and travel characteristics of Zika case-patients in the United States, besides their age and gender. During 2016-2017 the County of San Diego Health and Human Services Agency, California, expanded the scope and completeness of demographic and travel information collected from Zika case-patients for public health surveillance purposes. The majority (53.8%) of travel-related Zika virus infection case-patients (n = 78) in the county were Hispanic, significantly higher (p ≤ 0.05) than the 33.0% of Hispanics in the county. Foreign-born residents, mainly from Mexico, were also overrepresented among cases compared to their share in the county population (33.3 vs. 23.0%; p ≤ 0.05). Seventeen (21.8%) patients reported a primary language other than English (14 Spanish). Most case-patients traveled for tourism (54%) or to visit friends and relatives (36%). This surveillance information helps identify higher-risk populations and implement culturally targeted interventions for Zika prevention and control.

German travelers' preferences for travel vaccines assessed by a discrete choice experiment

BACKGROUND

Many travelers to regions with endemic infectious diseases do not follow health authorities' recommendations regarding vaccination against vaccine-preventable infectious diseases, before traveling. The determinants of individual travelers' decisions to vaccinate before traveling are largely unknown. This study aimed to provide this information using a discrete choice experiment (DCE) administered to four types of German travelers: (1) business travelers; (2) travelers visiting friends and relatives (VFR); (3) leisure travelers; and (4) backpackers.

METHODS

A DCE survey was developed, pretested and administered online. It included a series of choice questions in which respondents chose between two hypothetical vaccines, each characterized by four disease attributes with varying levels describing the of risk, health impact, curability and transmissibility of the disease they would prevent (described with four disease attributes with varying levels of risk, health impact, curability and transmissibility), and varying levels of four vaccine attributes (duration of protection, number of doses required, time required for vaccination, and vaccine cost). A random-parameters logit model was used to estimate the importance weights each traveler type placed on the various attribute levels. These weights were used to calculate mean monetary equivalents (MMEs) of changes in each attribute (holding all others constant) and of hypothetical disease-vaccine combinations.

RESULTS

All traveler types' choices indicated that they attached the greatest importance to the risk and health impact of disease and to the vaccine cost whereas the other disease and vaccine attributes were less important for their decisions about travel vaccines. An option of not choosing any of the vaccine-pairs presented was rarely selected indicating that travelers' generally prefer to be vaccinated rather than not. The MMEs of changes in vaccine attributes indicated a very high variability between the individual travelers within each type.

CONCLUSIONS

The travelers' responses indicated strong preferences for selecting vaccination rather than opting out of vaccination, and disease risk, health impact and vaccine cost were the most important features for vaccine choice.

Improving access and provision of pre-travel healthcare for travellers visiting friends and relatives: a review of the evidence

BACKGROUND

Travellers visiting friends and relatives (VFR travellers) in their country of origin are at increased risk of a range of preventable infections. Risks are broadly related to circumstances of travel, risk misconceptions and access to health services. Despite nearly two decades of literature highlighting these increased risks little impact has been made on their risk disparity.

METHODS

This review draws on evidence from travel medicine literature, supplemented by evidence from the broader field of immigrant health, and is structured to include strategies that aim to reduce barriers at the patient, provider and health system level.

RESULTS

For the travel medicine provider, tailored risk communication that is cognisant of the unique health beliefs and barriers to travel health for VFR travellers is needed, including enhanced communication through the use of interpreters and supplementary written communication. Primary care providers are uniquely placed to identify future travel plans among immigrant patients, however, greater awareness of VFR traveller risks and training in travel medicine are required. Community health promotion interventions that are culturally appropriate, translated into multiple languages and takes into account the cumulative risk of multiple return visits are key to normalizing travel healthcare seeking behaviours and improving awareness of VFR travel risks. Currently, there are few examples of novel strategies to engage migrant communities in travel health with no formal evaluations of their effectiveness. Best practice includes the use of community-consulted approaches in collaboration with government, primary care and travel medicine.

CONCLUSIONS

Multifactorial barriers related to health beliefs and access to health services require a range of strategies and interventions in both reaching and providing advice to VFR travellers. To improve the evidence base, future research should focus on the evaluation of novel strategies that address these barriers and improve access and provision of pre-travel healthcare to VFR travellers.

Travel Characteristics and Pretravel Health Care Among Pregnant or Breastfeeding U.S. Women Preparing for International Travel

OBJECTIVE

To study characteristics and preventive interventions of adult pregnant and breastfeeding travelers seeking pretravel health care in the United States.

METHODS

This cross-sectional study analyzed data (2009-2014) of pregnant and breastfeeding travelers seen at U.S. travel clinics participating in Global TravEpiNet. Nonpregnant, nonbreastfeeding adult female travelers of childbearing age were used for comparison. We evaluated the prescription of malaria chemoprophylaxis and antibiotics for this population as well as the administration of three travel-related vaccines: hepatitis A, typhoid, and yellow fever. We also evaluated use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis and influenza vaccines, because these are widely recommended in pregnancy.

RESULTS

Of 21,138 female travelers of childbearing age in Global TravEpiNet, 170 (0.8%) were pregnant and 139 (0.7%) were breastfeeding. Many traveled to destinations endemic for mosquito-borne illnesses, including malaria (pregnant: 95%; breastfeeding: 94%), dengue (pregnant: 87%; breastfeeding: 81%), or yellow fever (pregnant: 35%; breastfeeding: 50%). Compared with nonpregnant, nonbreastfeeding adult female travelers, eligible pregnant travelers were less likely to be vaccinated against hepatitis A (28% compared with 51%, P<.001) and typhoid (35% compared with 74%, P<.001). More than 20% of eligible pregnant travelers did not receive influenza vaccination. Yellow fever vaccine was occasionally provided to pregnant and breastfeeding travelers traveling to countries entirely endemic for yellow fever (6 [20%] of 30 pregnant travelers and 18 [46%] of 39 breastfeeding travelers). Half of pregnant travelers and two thirds of breastfeeding travelers preparing to travel to malaria-holoendemic countries received a prescription for malaria prophylaxis.

CONCLUSION

Most pregnant and breastfeeding travelers seen for pretravel health consultations traveled to destinations with high risk for vector-borne or other travel-related diseases. Destination-specific preventive interventions were frequently underused.

A descriptive study of advising practices during travel health consultations in France

BACKGROUND

Recommendations for improving traveler adherence address both the content of the advice given and the structure of the consultation. The objective of this article is to describe how travel health consultations are structured in France.

METHODS

A questionnaire based on both theoretical foundations and recommendations in the literature was sent to health professionals who practice in travel clinics, all of them members of France's Société de Médecine des Voyages.

RESULTS

The response rate was 78.5% (176/224). One hundred thirty nine respondents (78.9%) reported that treatment (vaccinations, in particular) and advising were done at separate times in the consultation. The majority of respondents questioned the traveler on his wishes, difficulties, expectations, experiences, and previous knowledge. A third explored the traveler's perceptions regarding the seriousness of diseases, the effectiveness of prevention measures and the latter's adverse effects with a difference when health professionals were practicing >5 years and/or had received specific training ( P  < 0.05). At the end of the consultation, 92% of the respondents asked the traveler whether he understood the advice given. One hundred thirty seven respondents (77.8%) gave travelers a booklet with additional advice, and 66.5% gave them a website where they could find health advice on their destination. Travelers were almost never offered group consultations or the opportunity to work on real-life situations. When there were language barriers, the respondents were more likely to seek help from a French-speaking member of the traveler's entourage (48.9%) than from an interpreter (22.7%).

CONCLUSIONS

While the majority of practitioners follow most of the recommendations regarding the structure of travel health consultations, some of the factors that enhance traveler learning are underutilized, reducing the likelihood that travelers will apply the advice given. The study illustrates the need to develop more educational intervention methods and to evaluate their impact on travelers.

Risk activities and pre-travel health seeking practices of notified cases of imported infectious diseases in Australia

BACKGROUND

Travellers are at risk of acquiring infectious diseases during travel, with risks differing by destination, travel and traveller characteristics. A pre-travel health consultation may minimize this risk. However, uptake of pre-travel health advice remains low. We investigated pre-travel health preparations and disease-specific risk behaviours among notified cases of selected travel-associated infectious diseases imported into Australia.

METHODS

Prospective enhanced surveillance of notified cases of typhoid, paratyphoid, measles, hepatitis A, hepatitis E, malaria and chikungunya was conducted in two Australian states between February 2013 and January 2014. Details of pre-travel health preparation and disease-specific risk behaviours were collected.

RESULTS

Among 180 cases associated with international travel, 28% were <18 years, 65% were VFR travellers and 22% were frequent travellers, having travelled ≥5 times in the past 5 years. 25% had sought pre-travel advice from a healthcare provider, and 16% reported a pre-travel vaccine. Seeking pre-travel health advice did not differ by immigrant status ( P  = 0.22) or by reason for travel ( P  = 0.13) but was more commonly sought by first time travellers ( P  = 0.03). Travellers visiting friends and relatives were more likely to report at-risk activities of brushing teeth with tap water ( P  < 0.001) and eating uncooked food ( P  = 0.03) during travel compared to other travellers.

CONCLUSIONS

Pre-travel health advice seeking practices and vaccine uptake was suboptimal among cases of notified disease. The results of this study highlight the need for a better understanding of barriers to pre-travel health seeking, particularly among high risk travellers, to reduce the importation of infectious diseases into Australia.

Challenges to providing pre-travel care for travellers visiting friends and relatives: an audit of a specialist travel medicine clinic

Travellers visiting friends and relatives (VFRs) often have complex pre-travel needs. We identified the characteristics, destinations, vaccinations and pre-travel advice provided to VFRs and compared these with non-VFR travellers. The significant differences we found suggest that future research should focus on improving the uptake of recommended interventions in VFR travellers.

Malaria after international travel: a GeoSentinel analysis, 2003-2016

BACKGROUND

More than 30,000 malaria cases are reported annually among international travellers. Despite improvements in malaria control, malaria continues to threaten travellers due to inaccurate perception of risk and sub-optimal pre-travel preparation.

METHODS

Records with a confirmed malaria diagnosis after travel from January 2003 to July 2016 were obtained from GeoSentinel, a global surveillance network of travel and tropical medicine providers that monitors travel-related morbidity. Records were excluded if exposure country was missing or unascertainable or if there was a concomitant acute diagnosis unrelated to malaria. Records were analyzed to describe the demographic and clinical characteristics of international travellers with malaria.

RESULTS

There were 5689 travellers included; 325 were children <18 years. More than half (53%) were visiting friends and relatives (VFRs). Most (83%) were exposed in sub-Saharan Africa. The median trip duration was 32 days (interquartile range 20-75); 53% did not have a pre-travel visit. More than half (62%) were hospitalized; children were hospitalized more frequently than adults (73 and 62%, respectively). Ninety-two per cent had a single Plasmodium species diagnosis, most frequently Plasmodium falciparum (4011; 76%). Travellers with P. falciparum were most frequently VFRs (60%). More than 40% of travellers with a trip duration ≤7 days had Plasmodium vivax. There were 444 (8%) travellers with severe malaria; 31 children had severe malaria. Twelve travellers died.

CONCLUSION

Malaria remains a serious threat to international travellers. Efforts must focus on preventive strategies aimed on children and VFRs, and chemoprophylaxis access and preventive measure adherence should be emphasized.

Missed Opportunities for Measles, Mumps, Rubella Vaccination Among Departing U.S. Adult Travelers Receiving Pretravel Health Consultations

Background

Measles outbreaks continue to occur in the United States and are mostly due to infections in returning travelers.

Objective

To describe how providers assessed the measles immunity status of departing U.S. adult travelers seeking pretravel consultation and to assess reasons given for nonvaccination among those considered eligible to receive the measles, mumps, rubella (MMR) vaccine.

Design

Observational study in U.S. pretravel clinics.

Setting

24 sites associated with Global TravEpiNet (GTEN), a Centers for Disease Control and Prevention-funded consortium.

Patients

Adults (born in or after 1957) attending pretravel consultations at GTEN sites (2009 to 2014).

Measurements

Structured questionnaire completed by traveler and provider during pretravel consultation.

Results

40 810 adult travelers were included; providers considered 6612 (16%) to be eligible for MMR vaccine at the time of pretravel consultation. Of the MMR-eligible, 3477 (53%) were not vaccinated at the visit; of these, 1689 (48%) were not vaccinated because of traveler refusal, 966 (28%) because of provider decision, and 822 (24%) because of health systems barriers. Most MMR-eligible travelers who were not vaccinated were evaluated in the South (2262 travelers [65%]) or at nonacademic centers (1777 travelers [51%]). Nonvaccination due to traveler refusal was most frequent in the South (1432 travelers [63%]) and in nonacademic centers (1178 travelers [66%]).

Limitation

These estimates could underrepresent the opportunities for MMR vaccination because providers accepted verbal histories of disease and vaccination as evidence of immunity.

Conclusion

Of U.S. adult travelers who presented for pretravel consultation at GTEN sites, 16% met criteria for MMR vaccination according to the provider's assessment, but fewer than half of these travelers were vaccinated. An increase in MMR vaccination of eligible U.S. adult travelers could reduce the likelihood of importation and transmission of measles virus.

Primary Funding Source

Centers for Disease Control and Prevention, National Institutes of Health, and the Steve and Deborah Gorlin MGH Research Scholars Award.

Travel medicine: Part 1-The basics

International travels for tourism and business purposes continue to increase annually, while the global terrorism and the risk of lethal viral infections are currently real concerns. It is important that primary care physicians assess travel risk and adequately prepare the prospective traveler for trips. Appropriate vaccines should be administered and an emergency self‐kit recommended. Patient should be educated about safe travel habits and a posttravel follow‐up process established. Further, traveling healthcare professionals may be called upon to assist an ill patient at any time during their journey. In these 2‐part special articles, we provide a practical brief summary of up‐to‐date travel medicine basics for primary care physicians.

International Travelers' Sociodemographic, Health, and Travel Characteristics: An Italian Study

BACKGROUND

Approximately the 8% of travelers requires medical care, with the diagnosis of a vaccine-preventable disease. The aim of our study was to analyze the socio-demographic, health and travel characteristics of the Italian international travelers.

METHODS

We conducted a cross sectional study from January 2015 to June 2016, at the Travel Medicine Clinic of Siena, asking the doctor to interview patients who attended the Clinic, recording socio-demographic and travel information, malaria prophylaxis, vaccinations. The data were organized in a database and processed by software Stata®.

RESULTS

We collected 419 questionnaires. Patients chose 71 countries for their travels; the favorite destinations were: India (6.31%), Thailand (6.31%), and Brazil (5.10%). The mean length of stay was 36.17 days. Italians, students, and freelancers tended to stay abroad for a longer time (mean: 36.4 days, 59.87 days and 64.16 days respectively). 33.17% of our sample used drugs for malaria chemoprophylaxis: 71.9% of them used Atovaquone/Proguanil (Malarone®), 26.6% used Mefloquine (Lariam®), 1.5% other drugs. The vaccinations that travelers mostly got in our study were to prevent hepatitis A (n = 264), the typhoid fever (n = 187), the Tetanus + Diphtheria + Pertussis (n = 165), the Yellow fever (n = 118) and the cholera (n = 78). Twenty-eight (6.68%) refused some recommended vaccinations. The vaccines mostly refused were for Typhoid fever (n = 20), hepatitis a (n = 9), and cholera (n = 9).

CONCLUSION

Our results demonstrated that Italian international travelers are at-risk because of their poor vaccinations adherence. This implies that pre-travel counseling is fundamental to increase the knowledge of the risks and the compliance of future travelers.

Characteristics of US Travelers to Zika Virus-Affected Countries in the Americas, March 2015-October 2016

Zika virus has recently been introduced to the Americas and is spreading rapidly. We evaluated the characteristics of US travelers to Zika virus–affected countries who were seen at Global TravEpiNet sites during March 2015–October 2016. Nearly three quarters of travelers were men or women of reproductive age.

Mosquito Exposure and Chikungunya and Dengue Infection Among Travelers During the Chikungunya Outbreak in the Americas

AbstractTravelers are at risk for arbovirus infection. We prospectively enrolled 267 Department of Defense beneficiaries traveling to chikungunya-outbreak regions in the Americas between December 2013 and May 2015 and assessed travel characteristics and serologic exposure to chikungunya virus (CHIKV) and dengue virus (DENV). Ten ill-returning travelers were also assessed retrospectively. Self-reported mosquito exposure was common (64% of 198 evaluable travelers saw mosquitoes; 53% of 201 reported ≥ 1 bite). Increased exposure was associated with active-duty travelers (odds ratio [OR] = 2.6 [1.3-5.4] for seeing mosquitoes) or travelers visiting friends and relatives (VFR) (OR = 3.5 [1.0-10.0] for high-intensity bite exposure). Arbovirus infection was defined as seroconversion on plaque reduction neutralization testing (PRNT) of pre- and posttravel sera. For ill subjects enrolled posttravel, infection was defined by a positive convalescent PRNT and/or a positive reverse transcription polymerase chain reaction for CHIKV or DENV. We identified seven cases of arbovirus infection: four with CHIKV, five with DENV, and two with both. The composite attack rate for CHIKV and DENV infection was 3.7% of 108 evaluable, immunologically naïve, prospectively assessed travelers; there was serologic and/or polymerase chain reaction evidence of arbovirus infection in three of four evaluable (three of 10 total) ill-returning travelers. We identified both symptomatic and asymptomatic cases. Military purpose of travel and VFR travel accounted for five of seven cases. Pretravel counseling is important and should target higher risk groups. Given a shared vector between CHIKV, DENV, and Zika virus (ZIKV), this study can also help guide counseling for travelers to ZIKV-outbreak regions.

Guillain-Barré Syndrome Associated with Zika Virus Infection in a Traveler Returning from Guyana

Zika virus (ZIKV) is a mosquito-borne flavivirus with a significant public health impact highlighted by the ongoing epidemic in the Americas. We describe a 44-year-old male presenting to our tropical medicine center with complaints of fever, headache, joint pain, and rash after recent travel to Guyana. The patient subsequently developed gait imbalance and lower extremity weakness with clinical examination, cerebrospinal fluid studies, and magnetic resonance imaging of the spine consistent with a diagnosis of Guillain-Barré syndrome (GBS). ZIKV infection was confirmed via detection of ZIKV RNA in urine by polymerase chain reaction. The patient was treated with intravenous immunoglobulin and experienced near-complete neurologic recovery, reporting ongoing mild paresthesia up to 2 months later. This case highlights the diagnostic challenges posed by ZIKV and underscores the need for clinician awareness of the potential for neurological complications such as GBS with ZIKV infection.

Self-reported illness among Boston-area international travelers: A prospective study

BACKGROUND

The Boston Area Travel Medicine Network surveyed travelers on travel-related health problems.

METHODS

Travelers were recruited 2009-2011 during pre-travel consultation at three clinics. The investigation included pre-travel data, weekly during-travel diaries, and a post-travel questionnaire. We analyzed demographics, trip characteristics, health problems experienced, and assessed the relationship between influenza vaccination, influenza prevention advice, and respiratory symptoms.

RESULTS

Of 987 enrolled travelers, 628 (64%) completed all surveys, of which 400 (64%) reported health problems during and/or after travel; median trip duration was 12 days. Diarrhea affected the most people during travel (172) while runny/stuffy nose affected the most people after travel (95). Of those with health problems during travel, 25% stopped or altered plans; 1% were hospitalized. After travel, 21% stopped planned activities, 23% sought physician or other health advice; one traveler was hospitalized. Travelers who received influenza vaccination and influenza prevention advice had lower rates of respiratory symptoms than those that received influenza prevention advice alone (18% vs 28%, P = 0.03).

CONCLUSIONS

A large proportion of Boston-area travelers reported health problems despite pre-travel consultation, resulting in inconveniences. The combination of influenza prevention advice and influenza immunization was associated with fewer respiratory symptoms than those who received influenza prevention advice alone.

The contribution of travellers visiting friends and relatives to notified infectious diseases in Australia: state-based enhanced surveillance

Immigrants and their children who return to their country of origin to visit friends and relatives (VFR) are at increased risk of acquiring infectious diseases compared to other travellers. VFR travel is an important disease control issue, as one quarter of Australia's population are foreign-born and one quarter of departing Australian international travellers are visiting friends and relatives. We conducted a 1-year prospective enhanced surveillance study in New South Wales and Victoria, Australia to determine the contribution of VFR travel to notifiable diseases associated with travel, including typhoid, paratyphoid, measles, hepatitis A, hepatitis E, malaria and chikungunya. Additional data on characteristics of international travel were collected. Recent international travel was reported by 180/222 (81%) enhanced surveillance cases, including all malaria, chikungunya and paratyphoid cases. The majority of cases who acquired infections during travel were immigrant Australians (96, 53%) or their Australian-born children (43, 24%). VFR travel was reported by 117 (65%) travel-associated cases, highest for typhoid (31/32, 97%). Cases of children (aged <18 years) (86%) were more frequently VFR travellers compared to adult travellers (57%, P < 0·001). VFR travel is an important contributor to imported disease in Australia. Communicable disease control strategies targeting these travellers, such as targeted health promotion, are likely to impact importation of these travel-related infections.

Refusal of recommended travel-related vaccines among U.S. international travellers in Global TravEpiNet

BACKGROUND

International travellers are at risk of travel-related, vaccine-preventable diseases. More data are needed on the proportion of travellers who refuse vaccines during a pre-travel health consultation and their reasons for refusing vaccines.

METHODS

We analyzed data on travellers seen for a pre-travel health consultation from July 2012 through June 2014 in the Global TravEpiNet (GTEN) consortium. Providers were required to indicate one of three reasons for a traveller refusing a recommended vaccine: (1) cost concerns, (2) safety concerns or (3) not concerned with the illness. We calculated refusal rates among travellers eligible for each vaccine based on CDC recommendations current at the time of travel. We used multivariable logistic regression models to examine the effect of individual variables on the likelihood of accepting all recommended vaccines.

RESULTS

Of 24 478 travellers, 23 768 (97%) were eligible for at least one vaccine. Travellers were most frequently eligible for typhoid (N = 20 092), hepatitis A (N = 12 990) and influenza vaccines (N = 10 539). Of 23 768 eligible travellers, 6573 (25%) refused one or more recommended vaccine(s). Of those eligible, more than one-third refused the following vaccines: meningococcal: 2232 (44%) of 5029; rabies: 1155 (44%) of 2650; Japanese encephalitis: 761 (41%) of 1846; and influenza: 3527 (33%) of 10 539. The most common reason for declining vaccines was that the traveller was not concerned about the illness. In multivariable analysis, travellers visiting friends and relatives (VFR) in low or medium human development countries were less likely to accept all recommended vaccines, compared with non-VFR travellers (OR = 0.74 (0.59-0.95)).

CONCLUSIONS

Travellers who sought pre-travel health care refused recommended vaccines at varying rates. A lack of concern about the associated illness was the most commonly cited reason for all refused vaccines. Our data suggest more effective education about disease risk is needed for international travellers, even those who seek pre-travel advice.

Changing Patterns in Enteric Fever Incidence and Increasing Antibiotic Resistance of Enteric Fever Isolates in the United States, 2008-2012

BACKGROUND

Enteric fever in the United States has been primarily associated with travel and with worrisome changes in global patterns of antimicrobial resistance. We present the first comprehensive report of National Typhoid and Paratyphoid Fever Surveillance System (NTPFS) data for a 5-year period (2008-2012).

METHODS

We reviewed data on laboratory-confirmed cases reported to NTPFS, and related antimicrobial susceptibility results of Salmonella Typhi and Paratyphi A isolates sent for testing by participating public health laboratories to the Centers for Disease Control and Prevention's National Antimicrobial Resistance Monitoring System laboratory.

RESULTS

During 2008-2012, 2341 enteric fever cases were reported, 80% typhoid and 20% paratyphoid A. The proportion caused by paratyphoid A increased from 16% (2008) to 22% (2012). Foreign travel within 30 days preceding illness onset was reported by 1961 (86%) patients (86% typhoid and 92% paratyphoid A). Travel to southern Asia was common (82% for typhoid, 97% for paratyphoid A). Among 1091 (58%) typhoid and 262 (56%) paratyphoid A isolates tested for antimicrobial susceptibility, the proportion resistant to nalidixic acid (NAL-R) increased from 2008 to 2012 (Typhi, 60% to 68%; Paratyphi A, 91% to 94%). Almost all NAL-R isolates were resistant or showed decreased susceptibility to ciprofloxacin. Resistance to at least ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole (multidrug resistant [MDR]) was limited to Typhi isolates, primarily acquired in southern Asia (13%). Most MDR isolates were also NAL-R.

CONCLUSIONS

Enteric fever in the United States is primarily associated with travel to southern Asia, and increasing resistance is adding to treatment challenges. A bivalent typhoid and paratyphoid vaccine is needed.

Travelers' Diarrhea in Children at Risk: An Observational Study From a Spanish Database

BACKGROUND

Gastrointestinal symptoms are a common cause of consultation about children traveling to or coming from developing countries. The aim of this study was to identify the risk factors associated with gastrointestinal syndrome in children who travel.

METHODS

A prospective observational analytical and multicenter study was performed within +Redivi, a Spanish Tropical Medicine network on imported infections, from January 2009 to December 2013. All participants aged 16 years and younger were included in the analysis. Ethical approval was obtained from all the participating centers.

RESULTS

A total of 606 children ≤16 years of age were registered in the +Redivi database during the study period. Median age was 8.7 years (interquartile range, 4.4-12.4 years), 65.8% (399/606) were immigrants, 90% were >2 years old and 54% were male. Median travel duration, excluding immigrants, was 50 days (interquartile range, 30-150 days). Children with gastrointestinal symptoms represented 13.5% (82/606) of total consultations. A significant association was found in bivariate analysis between gastrointestinal disorder and age <2 years (P < 0.01) and travel duration (P = 0.046). Immigrants had less gastrointestinal disorders than tourists (P < 0.05). The most prevalent infection was protozoan in 23.4% (142/606), and Giardia intestinalis was the most common pathogen in 10.1% (61/606) of total children. Independent risk factors for gastrointestinal symptoms were tourist and traveler child visiting friends and relatives (P = 0.03), travel duration <90 days (P = 0.008) and bacterial cause (P < 0.001).

CONCLUSIONS

Traveling children who developed a gastrointestinal syndrome represented 13.5% of the total pediatric consultations in +Redivi. Independent risk factors were tourist or traveler visiting friends and relatives, travel duration <90 days and bacterial infection. G. intestinalis was the most common infectious agent causing a gastrointestinal disorder in the traveler children.

Pre-travel advice seeking from GPs by travellers with chronic illness seen at a travel clinic

PURPOSE

Travellers are ageing and frequently report chronic illness. Pre-travel health advice is crucial, particularly in this subgroup, and general practitioners (GPs) are first in line for treatment adjustment before departure. Our aim is to evaluate pre-travel health advice seeking from GPs by travellers with chronic illness seen at a travel clinic.

METHODS

A cross-sectional observational survey using a questionnaire was conducted between August 2013 and July 2014 in travellers attending the travel medicine clinic of a tertiary university hospital in France.

RESULTS

During the study, 2019 travellers were included. Mean age was 39.4 years (±18.8). Three hundred and ninety-one (19.4%) travellers reported a history of a chronic illness. Arterial hypertension and diabetes mellitus were the most frequently reported illnesses, affecting, respectively, 168 (8.3%) travellers and 102 (5.1%). Hajj pilgrims were more likely to report a history of chronic illness than other travellers. Only 810 (40.1%) travellers sought pre-travel advice from their GP. Six hundred and fifty-two (40.1%) healthy travellers and 158 (40.5%) travellers reporting chronic illness sought pre-travel advice from their GP (P = 0.96).

CONCLUSION

Travellers with a history of chronic illness do not seek pre-travel health advice from their GP more frequently than healthy travellers. Travel health specialists are generally not the best practitioners to manage the care of underlying medical conditions presenting risks during travel. However, GPs offer continuity and disease management expertise to improve the specificity of pre-travel planning. Thus, ongoing collaboration between the traveller, GP and travel health specialist is likely to yield the best outcomes.

Characteristics and pre-travel preparation of travelers at a Canadian pediatric tertiary care travel clinic: A retrospective analysis

BACKGROUND

International travelers are susceptible to a wide spectrum of travel related morbidities. Despite rising number of international travelers in Canada, the demographics, risk profiles, and preventative strategies of high-risk traveler groups, including pediatric travelers visiting friends and relatives (VFRs) are not well described.

METHODS

A descriptive analysis was conducted on pre-travel consultations completed between January 2013 and August 2014 at a large pediatric tertiary care center in Toronto, Canada. Data on demographics, travel characteristics, and pre-travel interventions were extracted from 370 pre-travel consultations. Results were compared between all VFR and non-VFR travelers, as well as between children traveling to visit friends and relatives, for vacation, and for education and/or volunteer purposes.

RESULTS

Forty-eight percent of consultations were for children <18 years of age (n = 177), of which 31% were for young children (<5 years of age). Young children were more likely to travel to visit friends and/or relatives than for other purposes (29% vs 9%, p < 0.0001). Children VFRs (cVFRs) were more likely to travel for >28 days than children traveling for vacation (43% vs 1%, p < 0.0001), and children traveling for education/volunteer purposes (43% vs 21%, p = 0.03). Around half of cVFRs traveled to destinations in Asia (51%). The majority stayed with locals, friends and/or relatives (85%), and nearly all traveled to urban destinations (98%). The most prescribed interventions for children were azithromycin (84%), Dukoral (66%), and the hepatitis A vaccine (60%). Atovaquone/proguanil was the most commonly prescribed antimalarial for children.

CONCLUSION

Children that travel to visit friends and relatives represent a unique travel group and may require specific considerations during pre-travel preparations. Our findings can help develop targeted pre-travel strategies for children VFRs.

General Practitioners' Perception of Risk for Travelers Visiting Friends and Relatives

BACKGROUND

General practitioners (GPs) are an important source of pre-travel health advice for travelers; however, only a few studies have investigated primary healthcare provider-related barriers to the provision of pre-travel health advice, particularly to travelers visiting friends and relatives (VFR). We aimed to investigate Australian GPs' knowledge, attitudes, and practices with regard to VFR travelers.

METHODS

A postal survey was sent to randomly sampled GPs in Sydney, Australia, in 2012. The questionnaire investigated GPs' perception of risk and barriers to the provision of advice to VFR travelers.

RESULTS

Of 563 GPs, 431 (76.6%) spoke a language other than English (LOTE) with 361 (64.1%) consulting in a LOTE. Overall, 222 (39.4%) GPs considered VFR travelers to be at higher risk than holiday travelers, with GPs consulting in English only [adjusted odds ratio (aOR) 1.65, 95% confidence interval (CI) 1.11-2.44, p = 0.01] and GPs considering long-term migrants as VFR travelers (aOR 1.86 95% CI 1.07-3.23, p = 0.03) remaining significant on multivariate analysis.

CONCLUSIONS

Multilingual GPs are a valuable resource to reducing language and cultural barriers to healthcare. Targeted education of this subgroup of GPs may assist in promoting pre-travel health assessments for VFR travelers. Awareness of the need for opportunistic targeting of migrants for pre-travel consultation through routine identification of future travel is needed.

Characteristics of Travelers to Asia Requiring Multidose Vaccine Schedules: Japanese Encephalitis and Rabies Prevention

BACKGROUND

Japanese encephalitis (JE) and rabies are serious vaccine preventable diseases which are an important consideration for travelers to Asia.

METHODS

Five Boston-area travel clinics collected demographic data, trip information, and interventions for travelers to Asia seen at pre-travel consultations from March 1, 2008, through July 31, 2010. We evaluated travelers for proportion vaccinated for JE and rabies, those traveling for >1 month, and whether travelers had adequate time to complete the JE series (clinic visit ≥28 days before departure) and rabies pre-exposure prophylaxis (clinic visit ≥21 days before departure).

RESULTS

Among 15,440 travelers from five Boston Area Travel Medicine Network travel clinics, Asia was the most common destination region, visited by 5,582 (36%) of travelers. Among these travelers, 4,810 (86%) planned to travel to only one Asian subregion. Median trip duration was 17 days, with more than 20% traveling for >1 month. The most common destinations were South (41%), Southeast (26%), and East (23%) Asia. Of those traveling to South, Southeast, or East Asia, over one-third with trips >1 month had insufficient time to complete a series for either JE or rabies vaccine. Overall, only 10% of travelers were vaccinated (past and pre-travel visit) for either JE or rabies, with lowest percentages among travelers visiting friends and relatives. Most travelers received advice on vector precautions (96%) and rabies prevention, which included avoiding animal contact, washing wounds, and obtaining appropriate post-exposure prophylaxis (88%).

CONCLUSION

Given the insufficient time for completion and relatively low vaccination rates, greater awareness of earlier pre-travel consultations, at least 4-6 weeks before travel, and accurate risk assessment for travelers are important. Effective counseling about vector avoidance, rabies, and animal bite prevention and management remains critical.

Chinese travellers visiting friends and relatives--A review of infectious risks

BACKGROUND

Travellers are potential vectors in the transmission of infectious diseases across international borders. Travellers visiting friends and relatives (VFR) have a particularly high risk of acquiring certain infections during travel. Chinese VFR travellers account for a substantial proportion of all travel in Western countries with high migrant populations.

METHODS

A literature review was undertaken regarding major infectious disease risks for VFR travellers visiting China. This included an examination of the previous pandemics arising in China, the likelihood of future outbreaks in China from H5N1 and H7N9 avian influenza viruses, the potential role of travellers in disease transmission, and the special risks for VFR travellers.

RESULTS

China has been the origin of several influenza pandemics in past few decades, and the origin of several emerging infectious diseases with pandemic potential, including SARS. Travel to and from China has the potential for global spread of emergent infectious diseases, as seen in the SARS outbreak in 2003. For VFR travellers, the risk of other infectious diseases may also be greater in China compared to their countries of migration, including hepatitis A and B, dengue fever, typhoid, and other diseases.

CONCLUSIONS

VFR travel to China may be associated with increased risk of acquiring a range of infectious diseases, and also poses a potential risk for importation of future pandemics to other countries. Chinese VFR travellers need to be cognisant of these risks and health professionals should consider educational interventions to minimise these risks.

Are French general practitioners consulted before travel to developing countries? A cross-sectional study conducted in a French airport

BACKGROUND

General practitioners (GPs) could play a central role in preventing travel-related health issues. The aim of this study was to assess, in travellers departing to developing countries from a French airport, the proportion of individuals having sought GP counseling before departure and to identify determinants for having consulted a GP.

METHODS

Cross-sectional study conducted between November 2012 and July 2013, in all adults living in France. Sociodemographic, health characteristics, type of travel and resources consulted before departure were collected. A descriptive analysis was performed. Determinants for having consulted a GP before departure were investigated using a logistic regression analysis.

RESULTS

Of the 360 travellers included, 230 (64%) sought health counseling before departure. GPs were the main source of information for 134 (58%) travellers having sought health information and the only one for 49 (21%). Almost half of the travellers (48%) departing to sub-Saharan countries did not seek health counseling from a medical doctor (GP, non-GP specialist, specialist consulted in an international vaccination center or occupational physician). Individuals significantly more likely to travel without having consulted a GP were young and male, held foreign nationality, had travelled more than five times before, rarely consulted their GP and were travelling to a non-malarious area.

CONCLUSION

GPs were the main but not the only source of information and counseling before traveling to a developing country. This study helps identify the characteristics of individuals likely to travel without having consulted a GP before departure.

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.

A profile of travelers--an analysis from a large swiss travel clinic

BACKGROUND

Globally, the Swiss have one of the highest proportions of the population traveling to tropical and subtropical countries. Large travel clinics serve an increasing number of customers with specific pre-travel needs including uncommon destinations and preexisting medical conditions. This study aims to identify health characteristics and travel patterns of travelers seeking advice in the largest Swiss travel clinic so that tailored advice can be delivered.

METHODS

A descriptive analysis was performed on pre-travel visits between July 2010 and August 2012 at the Travel Clinic of the Institute of Social and Preventive Medicine, University of Zurich, Switzerland.

RESULTS

A total of 22,584 travelers sought pre-travel advice. Tourism was the main reason for travel (17,875, 81.5%), followed by visiting friends and relatives (VFRs; 1,715, 7.8%), traveling for business (1,223, 5.6%), and "other reasons" (ie, volunteer work, pilgrimage, study abroad, and emigration; 1,112, 5.1%). The main travel destination was Thailand. In the VFR group, the highest proportions of traveling children (258, 15.1%) and of pregnant or breastfeeding women (23, 3.9%) were observed. Mental disorders were more prominent in VFRs (93, 5.4%) and in travel for "other reasons" (63, 5.7%). The latter stayed for the longest periods abroad; 272 (24.9%) stayed longer than 6 months. VFR travelers received the highest percentage of yellow fever vaccinations (523, 30.5%); in contrast, rabies (269, 24.2%) and typhoid vaccinations (279, 25.1%) were given more often to the "other travel reasons" group.

CONCLUSIONS

New insights into the characteristics of a selected and large population of Swiss international travelers results in improved understanding of the special needs of an increasingly diverse population and, thus, in targeted preventive advice and interventions.

Risk factors and pre-travel healthcare of international travellers attending a Dutch travel clinic: a cross-sectional analysis

BACKGROUND

The number of international travellers is currently estimated to exceed one billion annually. To address travel related health risks and facilitate risk reduction strategies, detailed knowledge of travellers' characteristics is important.

METHOD

In this cross-sectional study, data of a 20% sample of travellers visiting the Academic Medical Center (AMC) travel clinic Amsterdam from July 2011 to July 2012 was collected. Itineraries and protection versus exposure rates of preventable infectious diseases were mapped and reported according to STROBE guidelines.

RESULTS

1749 travellers were included. South-Eastern Asia, South-America and West-Africa were most frequently visited. 26.2% of the population had pre-existing medical conditions (often cardiovascular). Young and VFR travellers had a longer median travel time (28 and 30 days) compared to the overall population (21 days). Young adult travellers were relatively often vaccinated against hepatitis B (43.9% vs. 20.5%, p < .001) and rabies (16.6% vs. 4.3%, p < .001). VFRs were less often vaccinated against hepatitis B (11.6% vs. 30.6%, p < .001) and rabies (1.3% vs. 9.0%, p .012) compared to non-VFR travellers.

CONCLUSIONS

Pre-travel guidelines were well adhered to. Young adult travellers had high-risk itineraries but were adequately protected. Improvement of hepatitis B and rabies protection would be desirable, specifically for VFRs.

Pre-exposure rabies vaccination among US international travelers: findings from the global TravEpiNet consortium

BACKGROUND

People who travel to areas with high rabies endemicity and have animal contact are at increased risk for rabies exposure. We examined characteristics of international travelers queried regarding rabies vaccination during pretravel consultations at Global TravEpiNet (GTEN) practices during 2009-2010.

MATERIAL AND METHODS

We performed bivariate and multivariable analyses of data collected from 18 GTEN clinics. Travel destinations were classified by strength level of rabies vaccination recommendation.

RESULTS

Of 13,235 travelers, 226 (2%) reported previous rabies vaccination, and 406 (3%) received rabies vaccine at the consultation. Common travel purposes for these 406 travelers were leisure (26%), research/education (17%), and nonmedical service work (14%). Excluding the 226 who were previously vaccinated, 8070 (62%) of 13,009 travelers intended to visit one or more countries with a strong recommendation for rabies vaccination; 1675 (21%) of these 8070 intended to travel for 1 month or more. Among these 1675 travelers, 145 (9%) were vaccinated, 498 (30%) declined vaccination, 832 (50%) had itineraries that clinicians determined did not indicate vaccination, and 200 (12%) remained unvaccinated for other reasons. In both bivariate and multivariate analyses, travelers with trip durations >6 months versus 1-3 months (adjusted odds ratio [OR]=4.9 [95% confidence interval [CI] 2.1, 11.4]) and those traveling for "research/education" or to "provide medical care" (adjusted OR=5.1 [95% CI 1.9, 13.7] and 9.5 [95% CI 2.2, 40.8], respectively), compared with leisure travelers, were more likely to receive rabies vaccination.

CONCLUSIONS

Few travelers at GTEN clinics received rabies vaccine, although many planned trips 1 month long or more to a strong-recommendation country. Clinicians often determined that vaccine was not indicated, and travelers often declined vaccine when it was offered. The decision to vaccinate should take into account the strength of the vaccine recommendation at the destination country, duration of stay, availability of postexposure prophylaxis, potential for exposure to animals, and likelihood of recurrent travel to high-risk destinations.

[Prior health advice to immigrants who travel to visit family and friends]

Objetivo

Los inmigrantes que realizan o proyectan viajes para visitar a sus familiares en sus países de origen (inmigrantes-visiting friends and relatives [I-VFR]) tienen un riesgo superior a adquirir enfermedades relacionadas con el viaje que otros viajeros. El objetivo principal de este estudio es analizar los conocimientos de la población inmigrante sobre la necesidad de recibir consejo sanitario (CS) antes de realizar viajes internacionales en general y, específicamente, antes de viajar a sus países de origen.

Diseño

Estudio observacional y multicéntrico.

Emplazamiento

Participaron 10 médicos de familia de 10 Centros de Salud de Cataluña y Aragón.

Participantes

Quinientos cincuenta y cinco inmigrantes ≥ 15 años de edad, que consultaron a su médico de familia y accedieron a responder un cuestionario. Se realizó un muestreo oportunista.

Resultados

Consideraban necesario recibir CS antes de realizar un viaje internacional 389 (70,1%) personas; 406 (73,2%) eran I-VFR y 145 (35,7%) habían solicitado CS previamente al viaje, con mayor frecuencia a su médico de familia (n = 60; 41,1%).

No habían solicitado CS 261 (65,2%) sujetos, siendo el motivo más frecuente por considerarlo innecesario 173 (42,6%).

Conclusiones

Los I-VFR no suelen solicitar CS previo a viajar, fundamentalmente por considerarlo innecesario. Cuando lo solicitan, con gran frecuencia se dirigen en primera instancia a su médico de familia.