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Self-reported illness and risk behaviours amongst Canadian travellers while abroad.

403 travellers who attended The University of Calgary International Travel Clinic between August 1, 1987 and June 1, 1988, were asked to return a questionnaire detailing health, illness and risk factors while abroad. Of the 296 respondents, most travelled for fewer than 6 weeks time; destinations were primarily areas where chloroquine-resistant Plasmodium falciparum had been reported. Diarrhea was experienced by 57.3% of respondents; eating food purchased from street vendors was found to be a significant risk factor. Travellers who made trips exceeding 60 days' duration were significantly more likely to experience skin rashes, fevers or diarrhea, although it could not be determined whether this was due to their higher likelihood of undertaking high-risk behaviours, or to a higher number of person-days at risk. The findings of this high rate of illness while abroad underscores the need for specific advice on appropriate risk avoidance behaviours when pre-travel medical visits occur. Further prospective studies to determine effectiveness of such advice, and the patterns of illness based on person-days at risk, are required.

Adult↗

Health promotion and disease prevention for the international traveler.

International travel is becoming increasingly popular with Americans, whether for business or pleasure. Approximately 10 to 15 million U.S. citizens travel abroad each year, and more than 8 million of these travel to developing nations. Travelers risk exposure to viral, bacterial and parasitic diseases not often encountered in the United States. Clients planning an international journey should be encouraged to obtain advice from their primary care practitioner. This article reviews the health care needs of the international traveler, including predeparture evaluation, required and recommended immunizations, and advice on disease-prevention measures.

First Aid↗

Review article: prevention and treatment of travellers' diarrhoea.

Travellers' diarrhoea is a common problem worldwide and is likely to continue to increase with the expansion of foreign travel. ETEC is the most frequently isolated enteropathogen although other bacteria, parasites and viruses may be important, depending on the geographic location. New pathogens may well emerge in the future. Prevention must be the ultimate goal but while awaiting effective vaccines we must be content with the traditional dietary advice and its often unpalatable and unacceptable restrictions. Antibiotic prophylaxis is clearly effective but for the present should be restricted to high risk individuals and in those in whom any disruption of a short stay would be critical. For those taking antibiotic prophylaxis advice, as always, should be given regarding the possible adverse effects. Concern about the emergence of resistant strains may be less with the new 4-fluoroquinolone antibiotics. Alternatives for prophylaxis include bismuth subsalicylate which is safe and not an environmental hazard. We must await developments in the Lactobacillus sp. story to see whether the use of probiotics have any role in the prevention of travellers' diarrhoea. Antimotility agents have no place in prophylaxis. The cornerstone of treatment of travellers' diarrhoea is the maintenance of fluid and electrolyte balance. It is particularly important in infants and young children and should be given in the form of oral glucose-electrolyte solutions of which there are many effective preparations. A variety of antibiotics are now known to reduce the duration of travellers' diarrhoea but there is still concern about the risk of therapy for what is usually a minor illness of inconvenience. However, when the loss of 1 or 2 days during a short visit is critical, one could opt for a short course of antibiotics (trimethoprim-sulphamethoxazole, or a 4-fluoroquinolone for 3 days or less) in combination with an antidiarrhoeal trimethoprim alone agent such as loperamide.

Anti-Bacterial Agents↗

[Traveler's diarrhea. Incidence--pathogens--pathophysiology--clinical aspects--prevention and therapy].

About one-third of travellers will be affected by travellers' diarrhoea. Regions with low risk are Northern Europe, the United States, Australia and New Zealand. Intermediate risk is found in Southern Europe, most islands of the Caribbean, Japan, Israel and Southern Africa and high risk in developing countries. Among the most commonly isolated pathogens are enterotoxigenic E. coli, Salmonella, Shigella, Campylobacter, G. lamblia, E. histolytica and viruses. The individual risk depends on the age and constitution of the traveller, on styles of travel and on previous expositure in developing countries. Travellers' diarrhoea is usually a short self-limited disease for 2-5 days. Nutritional prophylaxis along the principle "boil it, cook it, peel it, or forget it" is useful. Prophylaxis with non-antibiotic drugs is only justified in special cases.

Bacteria↗

Parasitic diseases. International travel. Preparing your patient.

Patients who travel to developing nations are those most likely to encounter parasitic diseases. Using a risk assessment approach and the resources introduced in this article, the primary care physician can prepare them for travel and continue their care on return. Immunizations and patient education are the major modes of prevention, coupled with chemoprophylaxis for malaria and traveler's diarrhea. Traveling pregnant women and young children need special precautions. A large body of preventive and therapeutic knowledge, including parasitology, is at the core of emporiatrics, the science of travel medicine.

Aged↗

[Health information of intercontinental Spanish travelers].

To investigate the level of health information and degree of protection of Spanish travelers to tropical and temperate zones, 910 individuals were interviewed in the Prat del Llobregat airport before their departure. Very low levels of protection were detected, regarding both compulsory and optional vaccines as well as antimalarial protection. It was found out that the information sources that had been consulted were not the optimal ones and that they had delivered remarkably inaccurate advice. Only 44% had received some type of vaccination. Important geographic errors were recorded regarding vaccination against yellow fever. Few travelers received optional vaccines, although these provide protection against highly prevalent diseases in tropical areas. Errors in antimalarial chemoprophylaxis were related both to drug dosage and their adequacy to the corresponding areas. Travelers prematurely interrupted prophylaxis in a progressive fashion depending on the number of elapsed weeks. Only 33% of the 39% who started prophylaxis before leaving completed it correctly. Travelers from health care professions had a higher rate of early abandonment of antimalarial prophylaxis and a worse immune protection against yellow fever, with a 5% signification level (p less than 0.05) when compared with the rest of travelers. Suggestions to improve this situations are made, such as an adequate education of health professionals and the general population, the reshaping of official vaccination centers and the introduction of adequate antimalarial drugs in the Spanish pharmacopeia.

Adolescent↗

Immunizations, medications, and common sense for the international traveler.

Health advice for international travelers should be individualized, taking into account the itinerary, the lifestyle of the traveler, the duration of travel, the patient's medical history, and other modifying factors. Although patients often seek advice because of immunization requirements, the pretravel visit should consider additional indicated immunizations; health maintenance advice regarding food, drink, and activities; malaria prevention when indicated; and diarrhea management. The traveler should be advised about a basic medical kit and receive information as to where to seek medical advice should serious illness develop while travelling.

Diarrhea↗

Assuring safe travel for today's elderly.

The increased availability of time and resources has made travel attractive to many elderly patients. Both healthy and chronically ill geriatric patients can travel safely and without medical complications in many circumstances. Many of these patients, however, have special health needs that call for specific advice from practitioners. Patients with medical problems, such as chronic obstructive pulmonary disease, cardiovascular disease, thrombotic disease, sinus conditions, or diabetes, should be aware of possible complications involved in travel. In addition, medical advice regarding vaccinations, traveler's diarrhea, jet lag, and malaria prophylaxis should be tailored to this population. Such a prescribed regimen may make travel safe and feasible for many geriatric patients.

Aged↗

Travelers' diarrhea. NIH Consensus Development Conference.

Diarrhea is the major health problem in travelers to developing countries. Travel to high-risk areas in Latin America, Africa, the Middle East, and Asia is associated with diarrhea rates of 20% to 50%. The syndrome is caused by an infection acquired by ingesting fecally contaminated food or beverages. Escherichia coli, a common species of enteric bacteria, is the leading pathogen, although a host of other bacteria, viruses, and protozoa have been implicated in some cases. Prudent dietary and hygienic practices should be followed, and they will prevent some, but not all, diarrhea. Antimicrobial agents are not recommended for prevention of TD. Such widespread usage in millions of travelers would cause many side effects, including some severe ones, while preventing a disease that has had no reported mortality. Instead of universal antimicrobial prophylaxis, a more sensible approach is rapid institution of effective treatment that can shorten the disease to 30 hours or less in most people. For mild diarrhea, an antimotility drug such as diphenoxylate or loperamide could be taken. Alternatively, bismuth subsalicylate, which works somewhat slower, can be used. For more severe diarrhea, an antimicrobial drug may be used for treatment, and trimethoprim-sulfamethoxazole, trimethoprim alone, and doxycycline are among the choices. These drugs could be carried by the traveler for use in the event of illness. Oral rehydration should be instituted when necessary. The millions of Americans who travel annually to developing countries and their physicians must be warned of the potential risks of prophylactic antimicrobial drugs, with the attendant side effects in otherwise healthy individuals, and should be informed of the alternative method of prompt, effective treatment of diarrhea.

Anti-Bacterial Agents↗

[Health advice before travel to tropical countries].

Some 8% of Swiss citizens travel in the developing countries annually. Advising these travellers is an important task for the physician, though the most frequent infections are the less serious travellers' diarrhea and common colds. To some extent the more serious tropical diseases can be avoided by appropriate measures, e.g. vaccination (against yellow fever, tetanus, polio etc). and by chemoprophylaxis (malaria). Individual fitness for travel should be checked prior to any journey abroad, and special advice must be given to travellers with special risks (e.g. pregnant women, infants, persons with chronic diseases, diabetics etc.). Most important during a stay in the tropics is a sensible way of life with enough sleep, general hygiene, especially with regard to food, and avoidance of untreated water. Further safety measures are recommended for bathing, strong sun exposure, mountaineering above 10,000 ft and in general for exposure to special health risks. Recognition of risks and their avoidance is often the best prophylaxis.

Acclimatization↗

[Travel diarrhea: attempt at a clinical-epidemiologic evaluation].

Traveller's diarrhea is the most common tourist's disease in the tropics. Therefore epidemiological data for the evaluation of factors influencing the attack rates and the severity of the disease are being required. This paper deals with the data of 1058 Austrian tourists travelling to warm climate countries. 47.3% of all travellers suffered from an episode of traveller's diarrhea during their stay. However, it could be evaluated that besides the destination seasonal influences were very important. Factors like individual hygiene and accommodation did not influence the attack rates. Age and environmental conditions, however, did partially influence the frequency of diarrhea. Furthermore, additional symptoms were interpreted and it could be seen that suspected heterogenicity of etiology leads to a similar pattern of clinical symptoms. Clinical evaluation proves that traveller's diarrhea is commonly not severe, but due to the incidence and duration of the disease it is a major health problem in modern tourism.

Cross-Cultural Comparison↗

Reduction of the aerobic Gram negative bacterial flora of the gastro-intestinal tract and prevention of traveller's diarrhea using oral erythromycin.

Traveller's diarrhea is mostly due to aerobic Gram-negative bacterial species, especially enterotoxigenic Escherichia coli. Until today no fully satisfactory prophylactic regimen has been designed. We have previously reported that erythromycin can eliminate Enterbacteriaceae from the human faecal flora during several weeks without recolonization by highly resistant Gram-negative aerobic organisms. This effect has been reproduced in 17 out of 18 volunteers taking 1, 2 or 3 g per day of oral erythromycin base during 5 days. This effect is due to the very high faecal concentrations of the antibiotic (2,000-4,000 micrograms/g) compared to the MIC of erythromycin on aerobic Gram-negative species (10-500 micrograms/ml). MIC of erythromycin on bacterial species which cause traveller's diarrhea are within the same range. These considerations led us to perform a double-blind, randomized, placebo-controlled clinical trial of the efficacy of 1 g daily intake of erythromycin base in preventing traveller's diarrhea. Fourty-eight US citizens travelling to Acapulco (Mexico) were enrolled in the study. Mean duration stay was 5.87 days. Seven out of 24 subjects of the placbo group experienced diarrhea and non (p=0.0047) in the treated group. Study should be undertaken to evaluate the efficacy of oral erythromycin in preventing traveller's diarrhea in other parts of the world.

Adult↗

Should travellers in rabies endemic areas receive pre-exposure rabies immunization?

A questionnaire survey was conducted in 1,882 foreign travellers, 74% of which were Europeans, after being in Thailand for an average of 17 days, about the history of potential rabies exposure during their visits. Dog bite and dog lick were experienced in 1.3% and 8.9% of the travellers respectively. The exposed individuals tended to stay in Thailand longer and the incidents occurred mainly in cities rather than in the rural areas. Thirty-one (1.6%) of all travellers had a history of rabies vaccination, 9 as a result of dog bite or dog lick in Thailand whereas the remaining 22 had already received the vaccine prior to coming to Thailand. Such high prevalences of potential rabies exposure and rabies vaccination may justify the inclusion of rabies vaccine into the multiple vaccination program for travellers to rabies endemic countries. This was favoured by over half of the travellers interviewed.

Adult↗

Travel vaccinations and immunisations.

Health advice and choosing the right vaccinations for the traveller is becoming more complex. If there are any doubts about which vaccinations to offer a traveller don't hesitate to seek advice from travel medicine experts. Where a patient cannot recall their vaccination details, it is better to re-vaccinate rather than risk infection. Finally, it is important to remind the traveller that the commonest diseases acquired overseas (for example, traveller's diarrhoea, malaria, injuries) are not preventable by vaccines.

Drug Administration Routes↗

Staying healthy while travelling.

By ensuring that the issues raised in this article are appropriately discussed with each traveller at the pre-travel consultation, the chance of staying healthy while travelling is considerably enhanced. If all else fails, the traveller should be well equipped with a first aid medical kit (Table 2) and instructions on how and when to take medications. They should know how to treat travellers diarrhoea, recognise signs and symptoms of malaria and the difference between a bacterial infection and viral infection. Bon voyage!

Accident Prevention↗

Travel medicine. 2. Upon return.

The volume of international travel and diversity of destinations have increased dramatically in recent decades and continue to grow. The scope and variety of travel related health problems increase accordingly, with 15% to more than 50% of travellers to developing countries reporting some illness. Infections acquired abroad may be acute and life-threatening, requiring urgent, sometimes empirical, intervention. They may also be chronic and associated with late complications, particularly in immigrants, refugees and long term travellers. We present a perspective on and practical approach to the management of illness in returned travellers.

Humans↗

Safety of commercial air travel following myocardial infarction.

BACKGROUND: Travelers occasionally suffer myocardial infarction (MI) while abroad. Existing guidelines recommend a 4- to 24-week convalescent period following MI before air travel should be permitted. HYPOTHESIS: Air travel may be undertaken safely in the early post-MI period. METHODS: The aeromedical transport records of two international medical assistance companies over a 3-yr period were reviewed. We identified 209 patients who suffered MI; 13 transported by private air ambulance were excluded. We reviewed the aeromedical transports of the remaining 196 adults carried on commercial aircraft between 3-53 d post-MI to investigate the safety of air travel in this group. Data were recorded regarding patient age; sex; location of MI; complications of MI; presence of medical escort; duration of flight(s); use of oxygen, medications, or cardiac monitoring during transport; and development of symptoms in flight. RESULTS: Within 7 d of their acute MI 3 patients (2%) were transported; 87 (44%) between days 8-14 post-MI; 65 (33%) between days 15-21; 27 (14%) between days 22-28; and 14 (7%) more than 28 d post-MI. Some 187 patients (95%) were transported without incident; 9 (5%) patients experienced symptoms requiring evaluation by the escorting physician. Of the 9, 6 problems occurred in patients being transported less than 14 d post-MI. Symptoms resolved spontaneously or immediately after physician intervention in all but one case. CONCLUSION: International aeromedical transport of patients may be safely accomplished 2-3 wk after an acute MI when an accompanying physician is present. Recommendations for delaying travel more than 4 wk after infarction are not supported by clinical experience and should be revised.

Adult↗

Limitations of typhoid vaccination for travellers.

Around one-third of travellers to endemic areas receive pre-travel typhoid vaccination, increasingly with the new parenteral vaccination Typhim Vi (Mérieux). More than 200 cases of Salmonella typhi and S. paratyphi infection are imported into the UK each year. Despite the widespread use of immunisation, non-specialist clinicians and the travelling public do not appear to fully appreciate the limitations of currently available vaccination. These limitations are not adequately highlighted in either the Green Book of Immunisation against Infectious Diseases (HMSO, 1992) or the new handbook Health Information for Overseas Travel (HMSO, 1995) which are important sources of reference for clinicians and practice nurses. This may delay consideration of diagnosis and presentation for treatment in immunised travellers.

Adult↗