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International health--a traveler's alert.

The human population of the earth is estimated to be approximately four billion people, the majority of whom live in developing countries of Africa, Asia, and Latin America. They are the poorer segment of the world's population and live in the world's warmest places. Infectious communicable endemic diseases also abound in these poverty areas. Millions of Americans travel to these less developed countries (LDCs), thus exposing themselves to unfamiliar health conditions. The United States no longer requires an immunization certificate for travelers from these LDCs. Tropical diseases also represent a type of pathology infrequently seen by many American medical practitioners. Additionally, the curricula of medical schools allocate only a fractional amount of time to specific disease problems of LDCs. Important gaps exist in both knowledge and application of knowledge in terms of many such diseases.The international travelers to LDCs must not be lulled into believing that travel precautions are unnecessary. Lack of preparedness can be hazardous and even fatal to international travelers. Those who purchase souvenirs such as art works and handicrafts often are not aware that these items may pose health hazards. The health professions, particularly the public health department official, should develop a continuing health education regimen in the area of health care for international travelers. The American traveling public deserves better service in this matter.

Global Health↗

Advice for the international traveller.

International travel has increased in recent years. The spectrum of disease associated with travel is wide. All travellers should be encouraged to seek pre-travel medical advice which include the need for vaccination and malaria prophylaxis and advice on preventive health measures during travel. The returning traveller with an illness should be advised to seek post-travel treatment.

Antimalarials↗

Travel medicine for West Virginians.

Preparation for overseas travel often involves a prolonged search for expertise and necessary vaccinations that can be a formidable challenge to patients and physicians alike. Many primary care providers find themselves ill-equipped to provide up-to-date information for travel to undeveloped countries where there may be risks of diarrhea, malaria and other exotic diseases. However, basic travel advice can easily be incorporated into most practices with the help of regularly updated reference materials such as the CDC's Health Information for International Travel. More advanced assistance along with the necessary vaccinations is available throughout West Virginia at a number of travel clinics which are discussed in this article. Through greater awareness of travel issues and timely referral, physicians may expedite their patients' travel plans while safeguarding their health abroad.

Diarrhea↗

Malaria and travelers--practical aspects.

As international air travel becomes more and more common, we are witnessing an increase in the incidence of imported malaria caused by Plasmodium falciparum, a fatal variety resistant to antimalarial drugs. With the development of drug resistance, travelers can no longer rely on chemoprophylaxis alone for absolute protection against malaria; they need to take a number of complementary measures. The most important among these are steps to prevent mosquito bites (mosquito screens and nets impregnated with insecticide, insecticides and repellents in various formulations; nocturnal air-conditioning) which can be instituted anywhere. Chemoprophylaxis must be adapted in each case with regard to individual characteristics (laboratory and medical status), the drug used (contraindications, side effects) and the travel itinerary (departure date, places to be visited, duration of journey). The back-up treatment prescribed for a traveler before his departure is intended as cover in the event that the chemoprophylaxis used should prove to be ineffective. If people planning trips to malarious regions are to apply preventive measures, they have to be informed, aware and motivated. Information is an integral part of prevention. Objective, scientifically accurate information is provided by specialized centres and official bodies in the form of recommendations subject to regular updating. A recommendation of a nonmedical nature must be given by travel agents and tour operators, by airlines and shipping companies, embassies and consulates, and also by the media at peak periods of travel to the tropics. Information disseminated on this scale will produce the required degree of awareness, and the travelers targeted will then probably consult a doctor for the chemoprophylaxis they need.

Animals↗

Counseling the international traveler. Update '93.

The itinerary of international travelers will largely determine the amount of pretravel counseling, number of immunizations and type of malaria prophylaxis they will need. The countries visited are also the best predictor of traveler's diarrhea. Only yellow fever and cholera vaccines are required for entry into certain countries; the latter generally given only to satisfy entry requirements. Polio vaccine is important for some areas and is frequently neglected. For most malarious areas, chloroquine once per week is recommended. Mefloquine should be prescribed weekly for travelers going to chloroquine resistant malarious areas. Traveler's diarrhea is best prevented by avoiding high risk foods and beverages. Antibiotics, generally not recommended for prophylaxis, are very effective in treatment. Travelers should be reminded to advise physicians of their travel history during future medical encounters so that otherwise exotic tropical diseases, possibly contracted during travel, may be considered in diagnoses.

Antimalarials↗

[Vaccinations of the traveller].

Travelers' immunization has 2 aims: for the traveler, to prevent the risk of contracting an endemic disease during his stay abroad; for the community to prevent the risk of importing an infectious agent yet unknown in the country. Travelling offers an opportunity to update routine immunizations: tetanus, diphtheria, poliomyelitis, hepatitis B; for young people: measles and rubella; for elderly people: influenza. Two vaccinations are compulsory: yellow fever for travelers to tropical Africa and Amazonian forest; meningococcus A + C for Mecca pilgrims. Other vaccines are recommended for travelers to specific areas: typhoid fever, hepatitis A, cholera in countries with poor hygiene; rabies for exposed travelers (expatriates, trekkers...); Japanese encephalitis for persons spending a month or longer in rural agricultural areas during the monsoon season; tickborne encephalitis for persons visiting forested areas of central Europe from may to september. Yet, most of travelers' diseases such as malaria cannot be prevented by vaccination and appropriate preventive measures (chemoprophylaxis and protection against insects) should be taken.

Adolescent↗

Oral health care in the lives of Gypsy Travellers in east Hertfordshire.

OBJECTIVE: To explore Gypsy Travellers' perceptions of dental health and dental service use within the context of culture, environment and the use of other services. SETTING: The author was a community dental officer and the study formed part of a MSc dissertation in dental public health. SUBJECTS AND METHODS: Information was obtained from semi-structured interviews with 43 Gypsy Travellers supplemented by a questionnaire and clinical screening of 72 Travellers. MAIN OUTCOME MEASURES: Place of residence, registration with GMP and GDP, school attendance, caries, normative and perceived barriers to care. RESULTS: The Travellers in the study had a high level of unmet need, low dental registration and very little use of preventive services. Travellers have no cultural barriers to dental care. Control of their travelling was the major factor determining access to education and health services. CONCLUSIONS: There is inequity of dental health and dental service use with more disadvantage being experienced by Travellers on unauthorized and transit sites.

Adolescent↗

TRAVELLERS: a school-based early intervention programme helping young people manage and process change, loss and transition. Pilot phase findings.

OBJECTIVE: This paper outlines the conceptual background and findings from the pilot phase of TRAVELLERS--an early intervention programme designed to enhance protective factors for young people experiencing change, loss and transition events and early signs of emotional distress. The pilot study aimed to determine whether TRAVELLERS was a feasible, acceptable and promising intervention for young people within secondary schools in Aotearoa/New Zealand. METHOD: The conceptual origins of the TRAVELLERS programme are described in terms of: adolescent mental health concerns; emerging mental health promotion theory and practice; and prevention and early intervention models. The key elements of the TRAVELLERS programme are described. The programme was piloted in two secondary schools, one rural and one urban with 34 participants (females n = 24, males n = 10). Evaluation methods included: review of programme materials; identification of potential selection tools appropriate to Year 9 students; analysis of selection questionnaire; and conduct of feedback from participants, facilitators and parents/caregivers. RESULTS: The TRAVELLERS programme provides a means of identifying and selecting young people who may benefit from participating in an early intervention programme. The programme has achieved a statistically significant reduction in participants' distress (p < 0.01). Young people were overwhelmingly enthusiastic about most aspects of TRAVELLERS. School personnel reported that TRAVELLERS was an appropriate and acceptable programme to the school. CONCLUSIONS: Targeted interventions provided within a supportive school environment can contribute to enhancing protective factors such as personal and interpersonal coping strategies, increased help-seeking behaviour, and young people feeling more positive about themselves and their lives. The pilot programme has been amended and prepared for a two year trial phase in 10 secondary schools during 2002-2003.

Adolescent↗

Traveling patterns in cellular automata.

A method to identify the invariant subsets of bi-infinite configurations of cellular automata that propagate rigidly with a constant velocity nu is described. Causal traveling configurations, propagating at speeds not greater than the automaton range, mid R:numid R:</=r, are considered. The sets of traveling configurations are presented by finite automata and its topological entropy is calculated. When the invariant subset of traveling configurations has nonzero topological entropy, the dynamics is dominated by the interaction of domains, composed of traveling patterns of finite size. The sets of traveling patterns and domains are presented by finite automata. End-resolving CA are shown to always have sets of traveling configurations that are spatially periodic with zero entropy, except possibly for traveling configurations at top speed. The elementary CA are examined exhaustively along these lines. (c) 1996 American Institute of Physics.

Journal Article↗

Travel risks in a time of terror: judgments and choices.

Shortly after the 2002 terrorist attacks in Bali, readers of Conde Nast Traveler magazine were surveyed regarding their views on the risks of travel to various destinations. Their risk estimates were highest for Israel, and lowest for Canada. Estimates for the different destinations correlated positively with (1) one another, (2) concern over aspects of travel that can make one feel at risk (e.g., sticking out as an American), (3) worries about other travel problems (e.g., contracting an infectious disease), and (4) attitudes toward risk. Respondents' willingness to travel to a destination was predicted well by whether their estimate of its risk was above or below their general threshold for the acceptability of travel risks. Overall, the responses suggest orderly choices, based on highly uncertain judgments of risks. Worry played a significant role in these choices, even after controlling for cognitive considerations, thereby supporting the recently proposed "risk as feelings" hypothesis. Thus, even among people who have generally consistent and defensible beliefs, emotions may affect choices. These results emerged with people selected for their interest in and experience with the decision domain (travel), but challenged to incorporate a new concern (terror).

Journal Article↗

Malaria prophylaxis for long-term travellers.

These guidelines are designed to assist healthcare workers who are advising long-term travellers on malaria prophylaxis, defined for the purpose of this document as those travelling for longer than 6 months. The document focuses on long-term use of antimalarials for adults, but also identifies specific issues for women and children. However, data on the long-term use of antimalarials is limited for all travellers and few data are available on the incidence of malaria in travellers overseas or, indeed, deaths overseas from malaria. Whilst all available evidence is taken into account, the advice provided also reflects experienced professional opinion. This document has been written on behalf of the Health Protection Agency's Advisory Committee on Malaria Prevention for UK Travellers, and is designed to act as a supplement to the 'Guidelines for malaria prevention in travellers from the United Kingdom for 2003'. The latter document contains a more complete description of antimalarials and additional preventive measures, together with recommendations for malaria chemoprophylaxis for individuals countries. Decisions on the terms under which different drugs are licensed for use are the responsibility of the Committee on Safety of Medicines. This paper should also, therefore, be used in conjunction with Summary of Product Characteristics (data sheets).

Adult↗

Hepatitis A immunity and travel history.

Travel histories were taken from 1111 British travellers. Serological testing showed that increasing age and a past history of jaundice were associated with a greater likelihood of travellers being immune to hepatitis A. Neither travel to nor the duration of stay in areas of increased hepatitis A endemicity influenced the level of hepatitis A immunity. It is concluded that travel histories from British citizens normally resident in the U.K. cannot be used to identify those travellers in whom serological prescreening would be of value prior to immunoglobulin prophylaxis.

Adult↗

Pre-exposure rabies prophylaxis for the international traveller: a decision analysis.

To determine for which travellers pre-exposure rabies prophylaxis is indicated, a decision tree-based model has been developed which enables the comparison of one million travellers going to rabies-endemic areas who receive a pre-exposure rabies prophylaxis to one million travellers also going to rabies-endemic areas who are not vaccinated. Using data obtained from a review of the literature, probabilities were assigned to each significant outcome. When numbers were not available, estimates were used and tested with a sensitivity analysis. Routine pre-exposure prophylaxis would prevent 0.054 cases per million adult travellers per month at a cost of 5 billion (thousand million) Canadian dollars. In the worst-case scenario, which concerns children, the cost per case prevented per year of stay would be $275,000 dollars. Our decision analysis leads us to believe that routine pre-exposure prophylaxis given to travellers heading for rabies-endemic regions of the world is not indicated. We conclude that pre-exposure rabies prophylaxis is a medical decision that must be individualized for every traveller and should be particularly considered for children at high risk of being exposed to rabies, who are leaving for a long stay (more than one year) and who will not have rapid access to medical services and rabies immunobiologics.

Adult↗

Tick-borne rickettsioses in international travellers.

BACKGROUND: Tick-borne rickettsioses are of emerging importance in today's travel medicine but have until recently received little attention. We describe the current knowledge of tick-borne rickettsioses as they relate to international travel, their microbiological diagnosis, treatment, possible prevention, and future prospects. METHODS: Literature-based review and personal observations. RESULTS: During the last decade, some 400 cases of tick-borne rickettsioses have been reported in international travellers, the vast majority being African tick bite fever caused by Rickettsia africae and Mediterranean spotted fever caused by Rickettsia conorii. Only a minority of infected travellers can recall a preceding tick bite. Most patients present with a mild-to-moderately severe flu-like illness typically accompanied by a cutaneous rash and an inoculation eschar at the site of the tick bite, but potentially life-threatening disease with disseminated vaculitis is occasionally seen. Definite microbiological confirmation of tick-borne rickettsioses by isolation or antigen detection is only available at reference laboratories and diagnosis must in most cases rely on clinical and epidemiological data supported by serology. Doxycycline is the recommended treatment for tick-borne rickettsioses and prevention is based on personal protective measures against tick bites when travelling in endemic areas. CONCLUSION: Tick-borne rickettsiosis should be suspected in febrile returnees from endemic areas, especially in cases with skin eruptions. Travellers to endemic areas should be encouraged to use personal protective measures against tick bites.

Humans↗

Fever in travelers returning from tropical areas: prospective observational study of 613 cases hospitalised in Marseilles, France, 1999-2003.

BACKGROUND: Febrile travelers may pose a diagnostic challenge for Western physicians who are frequently involved in the assessment of these patients but unfamiliar with tropical diseases. Evaluation of this situation requires an understanding of the common etiologies, which are associated with the demographics of travelers and the destinations. METHODS: We conducted a 5-year prospective observational study on the etiologies of fever in travelers returning from the tropics admitted to the infectious and tropical diseases unit of a university teaching hospital in Marseilles, France. RESULTS: A total of 613 patients were enrolled, including 364 migrants (59.4%), 126 travelers (20.6%), 37 visitors (6%), 24 expatriates (3.9%), and 62 patients (10.1%) who could not be classified. Malaria was the most common diagnosis (75.2%), with most cases (62%) acquired by migrants from the Comoros archipelago and who had traveled to these islands to visit friends and relatives. Agents of food-borne and water-borne infections (3.9%) and respiratory tract infections (3.4%) were also frequently identified as the cause of fever. Other infections included emerging diseases such as gnathostomiasis, hepatitis E infection and rickettsial diseases, as well as common infections or exotic diseases. CONCLUSIONS: Although we have identified here various causes of imported fever, 8.2% of the fevers remained unexplained. An improved approach to diagnosis may allow for the discovery of new diseases in travelers in the future.

Adult↗

Hostellers' knowledge of transmission and prevention of avian influenza when travelling abroad.

BACKGROUND: Little is known about hostellers' knowledge of transmission and prevention of avian influenza when travelling abroad. This study was designed to investigate these in the Australian context. METHODS: In 2006, hostellers attending a travellers' information evening in Brisbane, Queensland, were asked to complete self-administered questionnaires. RESULTS: Forty-two questionnaires (60.8%) were returned. Over two-thirds of attendees were females (71.4%, 30). About two-thirds of the hostellers attending the travellers' information evening reported being aged 29 years or younger (64.2%, 27). On a five-point rating scale, the median rating of hostellers indicated that they were moderately concerned about avian influenza (3.0) with the range being 1-5. About one-fifth of hostellers did not know or were not sure what the source of avian influenza infection in humans was and most of this group also did not know how bird flu was prevented (p<0.05). Almost all hostellers (40, 95.2%) responded to the question concerning the source of infection for avian influenza. Nominated sources of infection included handling sick poultry (69.0%, 29), eating poultry (45.2%, 19), contact with humans who have avian influenza (38.1%, 16), and handling healthy poultry (26.2%, 11). More than four-fifths 35 (83.3%) of hostellers responded to the question concerning precautions against avian influenza. Nominated precautions included hand washing (28.6%, 12), avoiding birds (23.8%, 10), avoiding affected areas (14.3%, 6), not eating poultry (7.1%, 3), and avoiding poultry droppings (7.1%, 3). Hand washing was the only measure to prevent bird flu that was significantly more likely to be nominated following the travel health lecture (p<0.05). CONCLUSIONS: Hostellers attending the travellers' information night in Australia reported having moderate concern about avian influenza. They also had a variable knowledge of the sources of infection of avian influenza. Most hostellers correctly identified infected poultry as a source; however, human-to-human transmission as the predominant current source of avian influenza infections in humans was incorrectly identified by nearly two-fifths of hostellers. Although hostellers responded positively to hand washing advice provided in the travel health lecture, reinforcement of other possible measures to prevent avian influenza, particularly the possible role of antiviral drugs, may be needed.

Adult↗

Special health considerations for travelers.

Special health considerations include many issues that affect travelers at both ends of the age spectrum. Pulmonary diseases may seriously alter the physiologic responses to both cabin pressures in commercial airliners and exposure to high altitudes, but many of these responses can be predicted by blood gas determinations and simple measurements of pulmonary function conducted at sea level. Cardiac events represent the most common and unpredictable health problems that threaten both serious morbidity and death for adult travelers. Diabetic travelers require insulin dosage adjustments during east-west travel and well-stocked travel kits with adequate supplies. Human immunodeficiency virus-infected travelers require consideration of their levels of immunosuppression at the time of immunizations and special precautions for preventing potentially chronic enteric infections. Young children pose similar questions, and there is the additional problem posed by a limited number of readily available antimalarial agents for pediatric use.

Aircraft↗

Immunizations for international travel.

Many infections encountered by international travelers can be prevented by adherence to personal protective measures and appropriate vaccinations. This review outlined the incidence and importance of the major vaccine-preventable infectious diseases encountered by U.S. travelers, as well as the indications, contraindications, and side effects of available vaccines. Official proof of yellow fever vaccine often is required for entry into some countries. Based on endemic or epidemic infections at destinations, planned activities, and age and medical history of international travelers, other vaccines may be recommended. Many clinicians will be familiar with some of the infections and vaccines that may be used in travelers; other vaccines may be encountered infrequently and associated with significant risk of adverse effects. Since vaccines do not provide complete protection and some travel-related infections do not have vaccines available yet (e.g., malaria and dengue fever), physicians need to be vigilant concerning febrile illness in returning travelers.

Cholera↗