Travel-associated Illness Research Articles

Health risks, travel preparation, and illness among public health professionals during international travel

Few data currently exist on health risks faced by public health professionals (PHP) during international travel. We conducted pre- and post-travel health surveys to assess knowledge, attitudes, and practices (KAP), and illnesses among PHP international travelers. Anonymous surveys were completed by PHP from a large American public health agency who sought a pre-travel medical consult from September 1, 2009, to September 30, 2010. Surveys were completed by 122 participants; travelers went to 163 countries. Of the 122 respondents, 97 (80%) reported at least one planned health risk activity (visiting rural areas, handling animals, contact with blood or body fluids, visiting malarious areas), and 50 (41%) reported exposure to unanticipated health risks. Of the 62 travelers who visited malarious areas, 14 (23%) reported inconsistent or no use of malaria prophylaxis. Illness during travel was reported by 33 (27%) respondents. Most of the PHP travelers in our study reported at least one planned health risk activity, and almost half reported exposure to unanticipated health risks, and one-quarter of travelers to malarious areas reported inconsistent or no use of malaria chemoprophylaxis. Our findings highlight that communication and education outreach for PHP to prevent travel-associated illnesses can be improved.

Pre-Travel Health Preparation of Pediatric International Travelers: Analysis From the Global TravEpiNet Consortium.

Children frequently travel internationally. Health-related data on such children are limited. We sought to investigate the demographics, health characteristics, and preventive interventions of outbound US international pediatric travelers. We analyzed data from 32 099 travelers presenting for pre-travel healthcare at the Global TravEpiNet (GTEN), a national consortium of 19 travel clinics, from January 1, 2009 to June 6, 2012. A total of 3332 (10%) of all GTEN travelers were children (<18 years of age). These children traveled mostly for leisure (36%) or to visit friends or relatives (VFR) (36%). Most popular destination regions were Africa (41%), Southeast Asia (16%), Central America (16%), and the Caribbean (16%). Compared with children traveling for leisure, VFR children were more likely to present <14 days before departure for pre-travel consultation (44% vs 28%), intended to travel for 28 days or longer (70% vs 22%), and to travel to Africa (62% vs 32%). Nearly half of the pediatric travelers (46%) received at least 1 routine vaccine, and most (83%) received at least 1 travel-related vaccine. Parents or guardians of one third of the children (30%) refused at least 1 recommended travel-related vaccine. Most pediatric travelers visiting a malaria-endemic country (72%) received a prescription for malaria chemoprophylaxis. Ten percent of travelers seeking pre-travel healthcare at GTEN sites are children. VFR-travel, pre-travel consultation close to time of departure, and refusal of recommended vaccines may place children at risk for travel-associated illness. Strategies to engage pediatric travelers in timely, pre-travel care and improve acceptance of pre-travel healthcare interventions are needed.

Dermatological conditions in international pediatric travelers: Epidemiology, prevention and management

With an increasing number of children traveling internationally, there has been growing interest in studying the burden of travel-associated illnesses in children. We reviewed recently published (2007-2012) studies on travel-associated illness in children, and extracted the reported spectrum of dermatological conditions in children. Dermatologic problems are among the leading health concerns affecting children during and after return from international travel. Most are mild and self-limited, but an extended spectrum of conditions has been reported from a large retrospective multicenter study. Children may be especially at risk for infections related to environmental exposures, arthropod-related problems, and animal bites. Of note are also tropical and cosmopolitan systemic infections with potential for transmission in the receiving communities. Implications for pre- and post-travel care of children are emphasized.

Travel-associated Illness Trends and Clusters, 2000–2010

Longitudinal data examining travel-associated illness patterns are lacking. To address this need and determine trends and clusters in travel-related illness, we examined data for 2000–2010, prospectively collected for 42,223 ill travelers by 18 GeoSentinel sites. The most common destinations from which ill travelers returned were sub-Saharan Africa (26%), Southeast Asia (17%), south-central Asia (15%), and South America (10%). The proportion who traveled for tourism decreased significantly, and the proportion who traveled to visit friends and relatives increased. Among travelers returning from malaria-endemic regions, the proportionate morbidity (PM) for malaria decreased; in contrast, the PM trends for enteric fever and dengue (excluding a 2002 peak) increased. Case clustering was detected for malaria (Africa 2000, 2007), dengue (Thailand 2002, India 2003), and enteric fever (Nepal 2009). This multisite longitudinal analysis highlights the utility of sentinel surveillance of travelers for contributing information on disease activity trends and an evidence base for travel medicine recommendations.

Pre-Travel Health Care of Immigrants Returning Home to Visit Friends and Relatives

Immigrants returning home to visit friends and relatives (VFR travelers) are at higher risk of travel-associated illness than other international travelers. We evaluated 3,707 VFR and 17,507 non-VFR travelers seen for pre-travel consultation in Global TravEpiNet during 2009–2011; all were traveling to resource-poor destinations. VFR travelers more commonly visited urban destinations than non-VFR travelers (42% versus 30%, P < 0.0001); 54% of VFR travelers were female, and 18% of VFR travelers were under 6 years old. VFR travelers sought health advice closer to their departure than non-VFR travelers (median days before departure was 17 versus 26, P < 0.0001). In multivariable analysis, being a VFR traveler was an independent predictor of declining a recommended vaccine. Missed opportunities for vaccination could be addressed by improving the timing of pre-travel health care and increasing the acceptance of vaccines. Making pre-travel health care available in primary care settings may be one step to this goal.

Profile of Travel‐Associated Illness in Children, Zürich, Switzerland

The number of families traveling with their children to their country of origin and/or to tropical destinations has increased in Switzerland and includes a changing profile and multinational range of patients. Defining the profile of reported travel-associated illnesses will help to improve the prevention and treatment of such illnesses in children. This study includes children aged up to 16 years who sought medical advice for a presumed travel-related illness at the emergency room of the University of Zürich Children's Hospital during the period July 2007 to December 2008. We analyzed data on 328 children (58.8% male, mean age: 4.62 y) who presented with travel-associated illness. Our analysis included 155 traditional (mainly tourist) travelers, 162 children who were visiting friends and relatives (VFR), and 11 immigrants. Some 11% were hospitalized. No deaths occurred. The main conditions recorded were diarrheal illness (39%), respiratory (28.7%) and febrile/systemic illness (13.4%). With increasing age, the proportion of children with diarrheal disease increased, while the proportion with respiratory illness declined. There were significant associations between geographic area of exposure and the profile of travel-related disease (p < 0.001). Among 36 children with more serious diseases requiring hospitalization, 12 (3.7% overall) presented with potentially serious diseases: malaria (n = 2), Salmonella typhi (n = 3), Salmonella paratyphi (n = 2), meningococcal meningitis (n = 1), tuberculosis (n = 2), visceral leishmania (n = 1), and hepatitis A (n = 1). Eleven of the 12 children presenting with these potentially serious illnesses were VFR or immigrant children. The main diagnoses for ill-returned Zürich children who presented for emergency care were diarrhea, respiratory, and febrile/systemic illness. A broad spectrum of morbidity was seen including meningococcal meningitis, malaria, tuberculosis, typhoid fever, leishmania, and hepatitis A. Diagnoses varied between geographic regions visited, and VFR child travelers constituted a large proportion of sick-returned children presenting for emergency care.

Global TravEpiNet: A National Consortium of Clinics Providing Care to International Travelers—Analysis of Demographic Characteristics, Travel Destinations, and Pretravel Healthcare of High-Risk US International Travelers, 2009–2011

International travel poses a risk of destination-specific illness and may contribute to the global spread of infectious diseases. Despite this, little is known about the health characteristics and pretravel healthcare of US international travelers, particularly those at higher risk of travel-associated illness. We formed a national consortium (Global TravEpiNet) of 18 US clinics registered to administer yellow fever vaccination. We collected data regarding demographic and health characteristics, destinations, purpose of travel, and pretravel healthcare from 13235 international travelers who sought pretravel consultation at these sites from January 2009 through January 2011. The destinations and itineraries of Global TravEpiNet travelers differed from those of the overall population of US international travelers. The majority of Global TravEpiNet travelers were visiting low- or lower-middle-income countries, and Africa was the most frequently visited region. Seventy-five percent of travelers were visiting malaria-endemic countries, and 38% were visiting countries endemic for yellow fever. Fifty-nine percent of travelers reported ≥1 medical condition. Atovaquone/proguanil was the most commonly prescribed antimalarial drug, and most travelers received an antibiotic for self-treatment of travelers' diarrhea. Hepatitis A and typhoid were the most frequently administered vaccines. Data from Global TravEpiNet provide insight into the characteristics and pretravel healthcare of US international travelers who are at increased risk of travel-associated illness due to itinerary, purpose of travel, or existing medical conditions. Improved understanding of this epidemiologically significant population may help target risk-reduction strategies and interventions to limit the spread of infections related to global travel.

Travel-Associated Health Risks for Patients With Inflammatory Bowel Disease

There are few data on risk of travel for patients with inflammatory bowel disease (IBD). We assessed rates of illness while traveling among patients with IBD. We performed a retrospective, case-controlled study of illnesses among 222 patients with IBD and 224 healthy individuals (controls) during 1099 total trips. Data were retrieved by structured questionnaires, personal interviews, and chart review. Participants had 142 episodes of illness during the trips; 92% were enteric disease. An episode of illness occurred during 79/523 (15.1%) trips made by patients with IBD compared with 63/576 (10.9%) trips made by controls (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.01-2.0; P = .04). However, this difference was mostly attributable to the increased incidence of illness among IBD patients traveling in industrialized countries. In contrast, the rate of illness among travelers to developing countries was similar among patients with IBD and controls (34/200, 17% vs 52/243, 21% of trips, respectively; P = .24). Moreover, numerically more controls that traveled to the tropics developed illness than travelers with IBD (43/135 vs 23/97, respectively; P = .18). In multivariate analysis, factors that increased risk for travel illness included frequent flares of IBD (OR, 1.9; 95% CI, 1.1-3.4; P = .02) and prior IBD-related hospitalizations (OR, 3.5; 95% CI, 1.3-9.3; P = .01); remission within 3 months before traveling reduced the risk for illness (OR, 0.3; 95% CI, 0.16-0.5; P < .001). Use of immunomodulatory drugs was not independently associated with risk of illness during travel. Patients with IBD have a higher rate of illness compared with controls during trips to industrialized countries, but not to developing or tropical regions. These findings indicate that most travel-associated illnesses stem from sporadic IBD flares rather than increased susceptibility to enteric infections.

International Travel and the Elite Athlete

International travel is a frequent occurrence in the life of the elite athlete; such travel can pose challenges to the sport medicine practitioner. Travel is also the reality of many recreational level or sub-elite athletes as opportunities for international competition and training proliferate. An appreciation of the range of responsibilities associated with the preparation for and the strategies to facilitate such travel is essential for any physician charged with the care of athletes and teams. An appreciation of (1) the medical and public health challenges associated with competition in a particular setting; (2) the requirements for vaccination and immunization; (3) the strategies for the management of jet lag and climatic or environmental extremes; (4) the range of supplies and equipment necessary for travel to certain locales; (5) the need to ensure the availability of ample familiar and nutritious foods; (6) the potential need for specialty care in strange settings; (7) the management of common travel-associated illness; and (8) the challenges associated with the evacuation of an injured athlete are fundamental to the successful management of international travel involving athletes and teams. The adoption of a methodical approach to pre-trip planning can ensure an enhanced travel experience, illness-free training and competition, and facilitate optimal performance.

Endocrine disruptors, travel-associated illness, and media violence: important health considerations for children and adolescents

This article addresses three important topics that are part of contemporary life for children: endocrine disruptors, hazards of international travel, and the impact of media violence on children and adolescents. Practitioners will learn about phthalates and Bisphenol-A as endocrine disruptors. In published studies, elevated phthalates were associated with an increase in pubertal gynecomastia and premature thelarche. Bisphenol-A was judged by the Food and Drug Administration as having some concern for potential effects on brain, behavior, and prostate gland in fetuses, infants, and young children: hence, the decision to take reasonable steps to reduce exposure of infants. In travel-related diseases, diarrheal disease (primarily Campylobacter and Salmonella), dermatologic conditions (animal bites), systemic febrile illness (malaria and dengue fever), and respiratory illnesses predominate. Children and adolescents spend more than 7 h using media per day. The degree to which media violence can be linked to behavior is not conclusive, but the prevention message for practitioners is important because parents can have an important mitigating effect. Endocrine disruptors, travel-related diseases, and media violence are part of modern day life for our children. Pediatricians need to stay abreast of recent findings and have access to up-to-date resources to assist them in providing contemporary advice and guidance to patients and families.

Evaluating a Sick Child after Travel to Developing Countries

Every year, millions of children travel internationally with their families, many to developing countries. Although the vast majority experience uneventful travel and return home well, it is not uncommon for children to present as ill during or after travel. Although the majority of travel-associated illness is mild and self-limited, serious conditions regularly occur. Almost all life-threatening conditions after travel present with fever, and malaria is the most important of these to rapidly exclude. Gastrointestinal symptoms are common after travel in the developing world, and most diarrhea in child travelers has a bacterial source. Children who have a rash in association with fever or who appear ill should receive a priority work-up focused on ruling out serious conditions. Many children traveling internationally experience respiratory illness during or shortly after travel, mainly common upper respiratory infections, yet serious conditions, such as tuberculosis, may occur. Eosinophilia is common in the returned pediatric traveler, particularly those with prolonged stays in the tropics. Not all eosinophilia is caused by parasitic infection; drug reactions, asthma, and other allergic conditions are also common causes. With a focus first on ruling out life-threatening disease and subsequently on an informed and efficient path to diagnosis and treatment, clinicians may confidently provide care for this challenging group of patients.

Illness in French Travelers to Senegal: Prospective Cohort Follow‐up and Sentinel Surveillance Data

To investigate travel-associated illnesses in French travelers to Senegal. A prospective cohort follow-up was conducted in 358 travelers recruited at a pre-travel visit in Marseille and compared to data from ill travelers collected from the GeoSentinel data platform in two clinics in Marseille. In the cohort survey, 87% of travelers experienced health complaints during travel, which most frequently included arthropod bites (75%), diarrhea (46%), and sunburns (36%). Severe febrile illness cases, notably malaria and salmonella, were detected only through the surveillance system, not in the cohort follow-up. Food hygiene was inefficient in preventing diarrhea. Arthropod bites were more frequent in younger patients and in patients with pale phototypes. Sunburns were also more frequent in younger patients. Finally, we demonstrate that mild travel-related gastrointestinal symptoms and the lack of arthropod bites are significantly associated with poor observance of antimalarial prophylaxis. In this study, we suggest the complementary nature of using cohort surveys and sentinel surveillance data. Effective protection of skin from arthropod bites and sun exposure should result in significantly reduced travel-associated diseases in Senegal. Travelers to Senegal should be informed that diarrhea is extremely common despite preventive measures, but it is mild and transitory and should not lead to the disruption of malaria chemoprophylaxis.

Sex and Gender Differences in Travel‐Associated Disease

No systematic studies exist on sex and gender differences across a broad range of travel-associated diseases. Travel and tropical medicine GeoSentinel clinics worldwide contributed prospective, standardized data on 58,908 patients with travel-associated illness to a central database from 1 March 1997 through 31 October 2007. We evaluated sex and gender differences in health outcomes and in demographic characteristics. Statistical significance for crude analysis of dichotomous variables was determined using chi2 tests with calculation of odds ratios (ORs) and 95% confidence intervals (CIs). The main outcome measure was proportionate morbidity of specific diagnoses in men and women. The analyses were adjusted for age, travel duration, pretravel encounter, reason for travel, and geographical region visited. We found statistically significant (P < .001) differences in morbidity by sex. Women are proportionately more likely than men to present with acute diarrhea (OR, 1.13; 95% CI, 1.09-1.38), chronic diarrhea (OR, 1.28; 95% CI, 1.19-1.37), irritable bowel syndrome (OR, 1.39; 95% CI, 1.24-1.57), upper respiratory tract infection (OR, 1.23; 95% CI, 1.14-1.33); urinary tract infection (OR, 4.01; 95% CI, 3.34-4.71), psychological stressors (OR, 1.3; 95% CI, 1.14-1.48), oral and dental conditions, or adverse reactions to medication. Women are proportionately less likely to have febrile illnesses (OR, 0.15; 95% CI, 0.10-0.21); vector-borne diseases, such as malaria (OR, 0.46; 95% CI, 0.41-0.51), leishmaniasis, or rickettsioses (OR, 0.57; 95% CI, 0.43-0.74); sexually transmitted infections (OR, 0.68; 95% CI 0.58-0.81); viral hepatitis (OR, 0.34; 95% CI, 0.21-0.54); or noninfectious problems, including cardiovascular disease, acute mountain sickness, and frostbite. Women are statistically significantly more likely to obtain pretravel advice (OR, 1.28; 95% CI, 1.23-1.32), and ill female travelers are less likely than ill male travelers to be hospitalized (OR, 0.45; 95% CI, 0.42-0.49). Men and women present with different profiles of travel-related morbidity. Preventive travel medicine and future travel medicine research need to address gender-specific intervention strategies and differential susceptibility to disease.

Travel health. Part 2: advising travelers visiting friends and relatives abroad

International travel has become more accessible and affordable, and travel, particularly to tropical and malaria regions, has increased by up to 8% annually. This change in travel has surprisingly not resulted in an increase in imported diseases. Surveillance reports of hepatitis A and enteric fever have not increased and a significant and sustained fall in malaria over the decade has been described. Nurses in primary care are the predominant providers of pre-travel health services and they have an important and influential role in preventing travel-associated illness. This is the second article in a 3-part series on the spectrum of health issues associated with travel. Part one discussed pre-travel health advice, including risk assessment and educating travellers. This article explores the highest risk group of traveller, those visiting friends and relatives (VFRs). The article highlights the specific disease risks for VFRs and how these may be influenced by their health beliefs. The article explores ways in which nurses can optimize the travel health consultation to ensure that the specific needs ofVFRs are met and that they receive accurate and achievable advice.

Imported infectious disease and purpose of travel, Switzerland.

We evaluated the epidemiologic factors of patients seeking treatment for travel-associated illness from January 2004 through May 2005 at the University Hospital of Zurich. When comparing persons whose purpose of travel was visiting friends and relatives (VFR travelers; n = 121) with tourists and other travelers (n = 217), VFR travelers showed a distinct infectious disease and risk spectrum. VFR travelers were more likely to receive a diagnosis of malaria (adjusted odds ratio [OR] = 2.9, 95% confidence interval [CI] 1.2-7.3) or viral hepatitis (OR = 3.1, 95% CI 1.1-9) compared with other travelers but were less likely to seek pretravel advice (20% vs. 67%, p = 0.0001). However, proportionate rates of acute diarrhea were lower in VFR (173 vs. 364 per 1,000 ill returnees). Travel to sub-Saharan Africa contributed most to malaria in VFR travelers. In countries with large migrant populations, improved public health strategies are needed to reach VFR travelers.

Live Nativity and Brucellosis, Sicily

To the Editor: Worldwide, brucellosis remains a major zoonosis and an important cause of travel-associated illness (1). Brucellosis is transmitted to humans through the consumption of infected, unpasteurized, animal-milk products; direct contact with infected animal parts; or inhalation of infected aerosolized particles. We report an outbreak of brucellosis in a small village of the Ionic coast of Messina province (eastern Sicily). In 2003, health authorities in the Messina province were notified of 29 cases of brucellosis; 18 of the patients were members of 9 different families. All patients had observed a Nativity pantomime that used live animals and was organized by the local population. Nativities in Sicily last ≈1 month, during which the sheep are milked, cheese and are produced, and these products are sold or offered fresh to tourists. All 29 patients had consumed dairy products: tuma cheese by 29 (100%) and tuma and by 16 (55%). No other risk factors for brucellosis were reported. Symptoms appeared after a median of 45 days (range 30–70). Eight patients were children (3 male), and 21 were adults (10 male). The median age of the children was 10.5 years (range 6–13) and of the adults, 42 years (range 16–67). Hospitalization was required for 5 patients. For 2 adults, brucellosis was complicated by spondylitis. The real extent of the outbreak was likely large because in Sicily ≈60% of cases may go unreported. Furthermore, we report only the cases that occurred in the villages of Messina province and that were reported to health authorities; but tourists from many other areas in Italy and some from outside Italy generally attend such events. Southern Italy has commonly been implicated as a venue for travel-associated brucellosis (2). In Italy, the overall incidence of brucellosis has gradually declined in the past 30 years, especially in northern Italy, where the disease is now reported only sporadically. This trend, however, has led to an increase in the percentage of total cases in Italians reported from the southern provinces of Calabria, Campagna, Puglia, and Sicily; of the 520 cases reported in 2003, 488 (93.8%) were reported from 4 southern regions, compared with 63.7% in 1994. Sicily alone reported 57.6% of the 2003 cases and for the past decade has had an average annual incidence of >100 cases per million (1,3). The disease is almost always caused by Brucella melitensis (4). The southern localization of the disease in Italy is obviously related to the relative high prevalence of infections in sheep and goats (5). Ovine and caprine population density is higher in the southern regions of Italy than in the rest of the country (6). The Italian brucellosis eradication plan consists of a test-and-slaughter practice. However, in Sicily a vaccination campaign with B. melitensis Rev.1 strain has been started. In 2003, ≈99% of the stock farms were tested, and ≈18% of them were infected (3). The major problems reside with small flocks that undergo frequent transhumance (seasonal movement of herds between regions with different climates) in isolated regions where testing by veterinarians is difficult or avoided by the owners (a typical drawback of test-and-slaughter practices). Technically, is not a cheese, but rather is a cheese by-product. The name ricotta means cooked again, referencing the production method. Ricotta is made from whey drained from tuma, provolone, and other cheeses. Heat is then used to separate, by precipitation, the remaining albumin from the whey left after making lactic acid/rennet–precipitated cheeses. It is eaten as is or used for food seasoning (e.g., classic Italian lasagna and ravioli). A cream made of sieved and sugar is used to prepare many desserts, like cannoli and cassata cake. Being cooked 2 times, should not contain viable Brucella organisms; however, shepherds sprinkle fresh milk on wicker baskets to refresh the they contain, thereby contaminating the product. Tuma is a typical Sicilian fresh cheese made from sheep's milk. It has a cylindrical appearance and is sold fresh, no more than 2 days old. It has no crust, and the dough is white or ivory-white without holes. The texture is very soft, tender, and wet. It is generally served with ham, wines, and fruits as a table cheese. Tuma cheese should be considered as the major vehicle of B. melitensis infection in Sicily. Although most similar dairy products produced in Sicily are derived from organized dairy companies and have been pasteurized, traditional delicacies from small villages may still cause brucellosis outbreaks.

Travel and health status: a survey follow-up study

To date there is little sound knowledge on the relationship between travel and health status as perceived by the traveller. Our aim was to investigate the frequency and risk factors of travel-associated illnesses and injuries and identify potential protective factors. All adults enrolled in a health insurance scheme who planned to travel in 2002 were eligible for participation in a baseline survey. Pre-travel written questionnaires and post-travel telephone interviews were conducted with responders. We analysed travel-associated health problems using descriptive methods and multivariate logistic regression. From 8316 persons who returned a pre-travel questionnaire, a sample of 2384 were chosen, of whom 1471 completed post-travel interviews. 10.1% of all travellers reported travel-associated illnesses, and 1.8% suffered from injuries during travel. Among travellers to European destinations, 6.0% reported an illness as opposed to 16.2% of travellers to overseas destinations. Predictors for travel-associated illness were age <30 years (OR 1.48), duration of travel >4 weeks (OR 3.35) and travel destination. Perceived health status as scored by the travellers improved after travel. The frequency of medical consultations and personal health-related expenses decreased significantly shortly after travel. In this study, travel had a positive effect on the perceived health status of the traveller. The positive effects of travel seemed to outweigh the impact of health problems. Travel did not lead to increased health-related costs, neither in individual health expenses nor indirectly through increased medical consultation rates.

Global virus alert

As recent events involving SARS and bird flu have shown, foreign travel can be a hazardous undertaking. The burden of disease is high with between 20 and 70 per cent of the 50 million people visiting developing countries reporting a travel-associated illness.

International Travel: Recommendations for the HIV-infected Patient.

In order to prevent travel-related diseases in patients infected with HIV, pretravel planning that includes vaccination, chemoprophylaxis, and behavioral modification is recommended. Many HIV-infected individuals successfully treated with highly active antiretroviral therapy may travel safely. However, patients with reduced CD4 lymphocyte counts are at increased risk for bacterial, mycobacterial, viral, fungal, and parasitic infections. Recommendations for vaccination and chemoprophylaxis are based on immune status and risk of infection. The efficacy of vaccination is dependant on CD4 lymphocyte count; inactivated and polysaccharide vaccines are considered safe in this population. Behavioral modifications to prevent food- and waterborne disease are an important component of disease prevention. A travel-health practitioner should review travel duration, destination, and activities, and assess the risk-benefit ratio of vaccination and chemoprophylaxis, in order to reduce the likelihood of travel-associated illness.

Enteric Illness in Ontario, Canada, from 1997 to 2001

Enteric illness is a common problem worldwide. In Ontario (population of 11.4 million, 2001 Census of Canada), laboratory-confirmed cases of “reportable” enteric diseases are reported to local health units. Public health staff members investigate these illnesses and subsequently report details to the Ministry of Health and Long-Term Care through an electronic reporting system. From 1997 to 2001, 44,451 sporadic cases of illness attributable to eight enteric pathogens (Campylobacter, Salmonella, verotoxin-producing Escherichia coli, Yersinia, Shigella, hepatitis A, Listeria, and Clostridium botulinum) were reported. This number was less than the 56,690 cases reported from 1992 to 1996. Campylobacter accounted for the highest annual average incidence rate at 42.3 cases per 100,000 persons, with Salmonella following at 22.6, verotoxin-producing E. coli at 3.7, Yersinia at 3.0, Shigella at 2.7, hepatitis A at 2.3, and Listeria at 0.3. The 4 months from June to September accounted for almost half (46.5%) of all cases. For 74.0% of the outbreaks associated with these eight enteric pathogens, foodborne contamination was identified as the mode of transmission. Poultry and other meat items accounted for 68.4% of the food items when food was identified as the vehicle. Admittedly, the “foods” and “modes of transmission” identified may have been subject to investigator bias based on previous knowledge. The most common risk setting, which was reported in approximately half of the cases, was private homes; travel-associated illness and restaurants were the second and third most frequently reported risk settings at 24.6 and 14.1%, respectively. Findings from this study suggest that public health efforts should be directed toward safe food handling in the home during the summer months.