Travel-associated Risks Research Articles

Advising the immunocompromised traveller: a review of immunocompromise at The London Hospital for Tropical Diseases Travel Clinic between 1st April 2019 and 30th April 2020.

Immunocompromised travellers (ICTs) face greater infectious and non-infectious travel-associated risks than their immunocompetent counterparts. Increasing travel and emergence of novel immunosuppressants poses great challenges for travel medicine practitioners to confidently provide up-to-date evidence-based risk management advice and pre-travel care for ICTs. We reviewed the records of ICTs attending the London Hospital for Tropical Diseases (HTD) Travel Clinic between 1st April 2019 and 30th April 2020 with the aim to describe demographic and travel characteristics, type, and severity of immunocompromise, the degree of risk associated with intended travel and evaluate travel advice. Of the 193 ICTs identified, immunocompromise was due to physiological reasons (42%), chronic infection (17.1%) and immunosuppressive therapy (16.6%). Median age was 38 (range 9 months to 84 years) and male to female ratio 0.75 (83:110). Travel was intended to 80 countries for a median of 16 days (range 2 to 3167), predominantly for leisure (53%), non-medical work (17%) and visiting friends and relatives (12%). Live vaccine safety dominated discussion in the pre-travel consultation. Existing guidelines arguably fell short in dealing with travel risks associated with hyper-specific conditions, targeted immunosuppressants and non-vaccine preventable infections. Our cohort represents a wide spectrum of immunocompromise, for whom we arguably need more measurable ways to approach travel-associated risks. We propose prospective qualitative participatory research to inform our unit of the priorities of ICTs in the pre-travel consultation. We further recommend the formation of a repository of specialists and formulary of complex cases to direct subsequent informative systematic review and prospective risk studies.

International travels with children

International travels with children need special planning and preparation. Besides considering general aspects, such as the age of the child, physical fitness, pre-existing illnesses, type and extent of the journey, climatic conditions at the destination and previous travel experiences, it is important to discuss relevant travel-associated risks in the context of travel consulting. This includes extensive advice concerning mosquito protection and malaria prophylaxis and counselling and implementation of travel vaccinations. Depending on the situation of the family, an individualized travel concept can be prepared, creating the foundation for a possible problem-free international travel.

Characteristics of Polish travellers: six-month experience from the University Centre of Maritime and Tropical Medicine in Gdynia, Poland.

The number of international travels has grown substantially over the last decade, both globally and in Poland. Thousands of Poles travel to tropical or subtropical countries in Asia, Africa or South America each year. The aim of this paper was to discuss the characteristics of Polish travellers seeking pre-travel consultation at the largest diagnostic and treatment travel medicine clinic in Poland. This retrospective study was based on the analysis of medical records of 1291 patients seeking pre-travel advice at the University Centre of Maritime and Tropical Medicine in Gdynia, Poland, between 1 July and 31 December 2022. The study comprised the analysis of the following patient variables: age, sex, travel details (purpose and length of travel, continents and countries to be visited, activities planned). The study also aimed to evaluate the range of prevention measures which were recommended/ administered (preventive vaccinations, chemoprophylaxis). In addition, it assessed the health status of the patients presenting at the travel medicine clinic. Patients who sought pre-travel advice were mostly people aged 18-35 years old (50.1%), travelling for tourism (72.2%), for a maximum period of 4 weeks (85.0%), travelling in December (24.3%) or in November (22.2%). Most of the Polish travellers consulted at the clinic travelled to Asia (56.2%), mainly to Thailand (27.3%), Vietnam (10.8%) or India (8.7%). Most travellers were planning a beach holiday (56.4%). As regards extreme activities, scuba diving was the most popular among the patients involved in the study (22.5%). The most frequently administered immunoprophylaxis were vaccines against typhoid fever (76.3%) and hepatitis A (56.2%). Other commonly recommended/prescribed prevention measures included: probiotics (75.9%), repellents (73.6%), antimalarial drugs (60.9%), and antidiarrheal antibiotics (51.9%). The analysis of patient interviews demonstrated that 42.4% of Polish travellers consulted at the clinic complained of no medical problems while 36.0% were taking chronic medications, mainly for allergies (17.1%) or thyroid disorders (12.2%). A growing number of people from Poland travel to destinations where the risk of infectious disease exposure or transmission is high. Providing a patient with appropriate advice during a pre-travel consultation will help protect the traveller against travel-associated risks at their intended destinations.

University students’ travel risk perceptions and risk-taking willingness during the COVID-19 pandemic: A cross-sectional study

BackgroundStudent travellers are recognised as a group at high risk of travel-related morbidity, but few previous studies have evaluated students' perceptions of or willingness to take risks during travel. Individual risk propensities may influence travellers’ engagement in pre-travel healthcare and can therefore inform strategies in pre-travel risk communication. This study aimed to describe the factors influencing risk-taking willingness, risk perceptions and future health-seeking intention among student travellers. MethodWe conducted a cross-sectional online survey (June–August 2021) among students enrolled at Monash University, Melbourne, Australia. Primary outcomes were travel-related risk-taking willingness and risk perceptions, measured using the health/safety items of the validated Domain-Specific Risk-Taking (DOSPERT) scale. ResultsFour hundred and eighteen students completed the survey. The mean age of respondents was 25.61 years, 78% were female and 46% were born outside Australia. Greater willingness to take risks was predicted by younger age (<25 years), being Australian-born, greater travel experience (3+ trips), having previously sought PTA, and perceiving oneself at low risk of severe COVID-19. We found no significant predictors of risk perception. Increased intention to seek pre-travel advice in the future was associated with greater risk perception, younger age, and perceiving oneself at high risk of severe COVID-19. ConclusionThese findings support the rationale for a greater role of risk communication in travel medicine promotion strategies. We recommend that this could be achieved through 1) increasing risk perception by emphasising potential travel-associated risks, 2) personalising information about travel risks, 3) addressing perceived benefits of engaging in risky behaviours, and 4) reinforcing self-efficacy.

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

BackgroundTravellers' 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. MethodsChildren 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. ResultsIn 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. ConclusionsAdults 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.

738. Comparison of Characteristics of US International Travelers Seeking Pretravel Health Consultations at US Global TravEpiNet Sites Before and During the COVID-19 Pandemic

BackgroundIn January–March 2020, the Centers for Disease Control and Prevention (CDC) issued multiple warnings regarding COVID-19 travel-associated risks. We sought to describe US travelers seeking pretravel consultation regarding international travel at US Global TravEpiNet (GTEN) sites before and after the initial COVID-19 travel warnings.MethodsWe prospectively collected data at 22 GTEN sites pre-COVID-19 (January–December 2019) and 18 GTEN sites during the COVID-19 pandemic (April 2020–March 2021). We excluded travelers evaluated during January–March 2020, when CDC travel guidance was evolving rapidly. Travelers used standardized questionnaires to self-report data regarding demographics and travel-related characteristics. Providers confirmed these data and documented their recommendations during pretravel consultation, which could be performed virtually. We conducted descriptive analyses of differences in demographics, travel-related characteristics, vaccinations, and medications (SAS v9.4; Cary, NC). ResultsCompared with 16,903 pre-COVID-19 consultations, only 1,564 consultations occurred during the COVID-19 pandemic, a 90% reduction (Table). During COVID-19, a greater proportion of travelers were children aged 1–5 years, visiting friends and relatives (VFR), with itineraries ≥ 30 days, and going to Africa; a smaller proportion of travelers were aged > 55 years, or traveling to Southeast Asia or the Western Pacific. During COVID-19, fewer vaccine-eligible travelers received vaccines at the pretravel consultation except for yellow fever, and a greater proportion were referred to another provider for vaccination (Figure). Table. Demographics and travel-related characteristics of international travelers seeking pretravel consultation at Global TravEpiNet sites before and during the COVID-19 pandemic Table continued. Demographics and travel-related characteristics of international travelers seeking pretravel consultation at Global TravEpiNet sites before and during the COVID-19 pandemic Figure. Vaccinations and reasons for nonvaccination among vaccine-eligible international travelers at pretravel consultations at Global TravEpiNet (GTEN) sites before and during the COVID-19 pandemic. Among vaccine-eligible travelers, we summarized those who were vaccinated at the visit (blue) and not vaccinated (orange). We then categorized reasons for nonvaccination into: provider decision (solid), referral to another provider (dots), traveler refusal (striped), or other (hatched). COVID-19 vaccination was not available at GTEN sites during the analysis period; although COVID-19 vaccinations outside of GTEN sites might have affected vaccination recommendations, they were unlikely to have had a large effect given their limited availability in January-March 2021.ConclusionCompared with pre-COVID-19, US travelers seeking pretravel consultations at GTEN sites during the pandemic might be at higher risk for travel-related infections given VFR status, traveling for ≥ 30 days, and going to Africa. Fewer vaccine-eligible travelers were vaccinated at pretravel consultations, which could reflect more virtual pretravel consultations. Counseling and vaccination for international travelers continue to be priorities during the COVID-19 pandemic.Disclosures All Authors: No reported disclosures

Role of gut microbiota in travel-related acquisition of extended spectrum β-lactamase-producing Enterobacteriaceae.

International travel could facilitate the spread of antimicrobial-resistant bacteria including extended spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E). Previous studies, which attempted to understand the role of gut microbiota in the acquisition of antimicrobial resistant bacteria during international travels, are limited to western travellers. We established a prospective cohort of 90 Hong Kong travellers to investigate gut microbiota determinants and associated risk factors for the acquisition of ESBL-E. Baseline characteristics and travel-associated risk factors were gathered through questionnaires. Faecal samples were collected in 3-4days before and after travel. Antimicrobial susceptibility of ESBL-E isolates was tested, and gut microbiota were profiled by 16S rDNA amplicon sequencing. Non-parametric tests were used to detect potential associations, and logistic regression models were used to quantify the associations. Random forest models were constructed to identify microbial predictors for ESBL-E acquisition. In total, 49 (54.4%) participants were tested negative for ESBL-E colonization before travel and were followed up after travel. A total of 60 ESBL-E isolates were cultured from 20 (40.8%) participants. Having low Actinobacteria richness and low abundance of short-chain fatty acid-producing bacteria in the gut microbiota before travel increased the risk of acquiring ESBL-E and the risk can be further exacerbated by eating raw seafood during travel. Besides, post-travel ESBL-E positive participants had increased abundances of several opportunistic pathogens such as Staphylococcus, Enterococcus, Escherichia/Shigella and Klebsiella. The random forest model integrating pre-travel microbiota and the identified travel-related risk factor could predict ESBL-E acquisition with an area under the curve of 75.4% (95% confidence interval: 57.9-93.0%). In this study, we identified both travel-related risk factors and microbiota predictors for the risk of ESBL-E acquisition. Our results provide foundational knowledge for future developments of microbiota-based interventions to prevent ESBL-E acquisition during international travels.

Air travel in a COVID-19 world: Commercial airline passengers' health concerns and attitudes towards infection prevention and disease control measures.

BackgroundCOVID-19 and its associated travel bans have reduced international passenger traffic by over 80% below 2019 levels. If airlines are to resume flying at commercially sustainable levels, they must work to restore passengers confidence and sense of security. This study examined commercial airline passengers’ health concerns and attitudes towards infection prevention and control measures for travel health and safety in the current COVID-19 global pandemic.MethodsA cross-sectional study was conducted inviting adult members of 39 frequent flyer groups across three social media platforms to participate in an online survey.ResultsA total of 205 respondents completed the survey. The majority (75.6%) reported feeling ‘somewhat’ to ‘extremely concerned’ about contracting an infectious disease while flying, particularly respiratory-related. Few (9.8%) reported perceiving their health as an ‘essential priority’ for their preferred airline. Most respondents agreed airlines should provide complimentary hand sanitisers (86.8%), sanitary wipes (82.9%) and masks (64.4%) for passengers to use while flying as well as more information about preventing the spread of infections (90.7%), which would make the majority feel safer to fly.ConclusionCOVID-19 has extensively challenged the air travel industry. Passengers have signalled that they expect more from airlines, and that they would actively engage in additional infection prevention and disease control measures while flying. Airlines must ensure passengers about the steps taken to minimize travel-associated risks, and their commitment towards passengers' health and wellbeing, in order to rebuild consumers’ confidence in the recovery of the air travel industry.

453. Understanding Travel Medicine Provider’s Risk Assessment of Travel-Associated Diseases

BackgroundPre-travel medical consultations attempt to reduce travel-associated risks by behavioral modification, vaccination, and medications. Provider understanding of quantitative risk of commonly discussed travel topics is poorly characterized. We investigated travel medicine provider understanding of quantitative risk of common travel-associated diseases, and explored how providers relay risk estimates to travelers.MethodsAfter institutional review board (IRB) approval, an online anonymous survey was sent to the International Society for Travel Medicine Listserv. Travel medicine experience, practice patterns and demographics were recorded. Respondents estimated quantitative risk of various destination-specific diseases. Descriptive statistics were completed.ResultsOf 114 respondents, most were experienced travel medicine providers (79% saw >6 travel visits monthly). Overall risk estimates are in Table 1. Compared with published literature, providers gave accurate risk estimates for some diseases (yellow fever, traveler’s diarrhea), but overestimated quantitative risk for others (Japanese encephalitis, hepatitis A, cholera). Interquartile range was greatest for Japanese encephalitis and cholera, reflecting a wider range of risk estimates. Most (81%) providers used general risk descriptions (high, low, none) and a minority (14%) discussed quantitative risk with travelers.ConclusionExperienced travel medicine providers overestimated risk of several vaccine preventable illnesses, though risk estimates for others were close to published estimates. Most providers do not use quantitative risk in pre-travel consultations. Improved quantitative risk understanding may improve the quality of pre-travel consultations.Table 1. Provider’s Risk Estimates for Selected Travel-Associated Illnesses Median Interquartile Range Traveler’s diarrhea (India)1:31:2 – 1:5Malaria (W. Africa)1:101:5 – 1:85Hepatitis A (Kenya)1:1001:25 – 1:1,000Influenza (Indonesia)1:1001:20 – 1:500Cholera (Uganda)1:10,0001:500 – 1:100,000Japanese encephalitis (Vietnam)1:10,0001:500 – 1:200,000Tick borne encephalitis (Austria)1:1,0001:100 – 1:10,000Yellow fever (W. Africa)1:2,0001:100 – 1:10,000Yellow fever (Brazil)1:5,0001:200 – 1:25,000Disclosures All authors: No reported disclosures.

Travel Health Survey: Risk Perception, Health-Seeking Behavior, and Subjective Evaluation of Travel Health Services in Egypt

Introduction: Travel health practice and research in Egypt lag behind both needs and demands. This study was done in two parts to assess travel health knowledge, attitude, and practice (KAP) among Egyptian travelers. Methods: This survey was conducted at the departure halls of Cairo International Airport and included 1500 travelers to Africa (excluding North Africa), Southeast Asia, and Latin America. An interview questionnaire was used to measure the KAP of travelers inquiring about different aspects of pre-travel health. Subjective evaluations of travel health services and suggestions for improvement were also solicited. Results: Travelers in this study were mainly males (89.3%), less than 40 years of age (82%), living in urban residences (89.1%), married (65.9%), university educated (83.3%), traveling for work (69.1%) with destinations of Africa (61.3%), Asia (28.4%), and Latin America (10.3%). They had poor travel-associated risk perception, and only 13.4% had risk management plan. Less than half (42.4%) sought information about their destination, and 11.9% sought health information; their source of information was mainly the internet (98.7%). The majority had poor scores on various travel-related practices, including seeking pre-travel health services (87.9%), receiving pre-travel vaccines (91.3%), and using malaria chemoprophylaxis (90.6%). The travel health services were rated good by 0.5% of travelers and bad, very bad, or undetermined by 11.4%, 61.3%, and 26.9% respectively. Conclusion: Egyptian travelers, although mostly educated, had poor travel health perceptions and practices and are unsatisfied with the travel health services in Egypt.

Pre-travel advice, attitudes and hepatitis A and B vaccination rates among travellers from seven countries†.

Background: Knowledge about the travel-associated risks of hepatitis A and B, and the extent of pre-travel health-advice being sought may vary between countries.Methods: An online survey was undertaken to assess the awareness, advice-seeking behaviour, rates of vaccination against hepatitis A and B and adherence rates in Australia, Finland, Germany, Norway, Sweden, the UK and Canada between August and October 2014. Individuals aged 18–65 years were screened for eligibility based on: travel to hepatitis A and B endemic countries within the past 3 years, awareness of hepatitis A, and/or combined hepatitis A&B vaccines; awareness of their self-reported vaccination status and if vaccinated, vaccination within the last 3 years. Awareness and receipt of the vaccines, sources of advice, reasons for non-vaccination, adherence to recommended doses and the value of immunization reminders were analysed.Results: Of 27 386 screened travellers, 19 817 (72%) were aware of monovalent hepatitis A or combined A&B vaccines. Of these 13 857 (70%) had sought advice from a healthcare provider (HCP) regarding combined hepatitis A&B or monovalent hepatitis A vaccination, and 9328 (67%) were vaccinated. Of 5225 individuals eligible for the main survey (recently vaccinated = 3576; unvaccinated = 1649), 27% (841/3111) and 37% (174/465) of vaccinated travellers had adhered to the 3-dose combined hepatitis A&B or 2-dose monovalent hepatitis A vaccination schedules, respectively. Of travellers partially vaccinated against combined hepatitis A&B or hepatitis A, 84% and 61%, respectively, believed that they had received the recommended number of doses.Conclusions: HCPs remain the main source of pre-travel health advice. The majority of travellers who received monovalent hepatitis A or combined hepatitis A&B vaccines did not complete the recommended course. These findings highlight the need for further training of HCPs and the provision of reminder services to improve traveller awareness and adherence to vaccination schedules.

Colonization with extended-spectrum beta-lactamase-producing and carbapenemase-producing Enterobacteriaceae in international travelers returning to Germany

Two hundred and twenty-five healthy German volunteers traveling to 53 different countries (mostly in Asia, Africa and South America) were enrolled in a prospective cohort study. Stool samples and data on potential travel-associated risk factors (such as type of travel, nutritional habits, occurrence of gastroenteritis) were collected before and after traveling. Screening for extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) and carbapenemase-producing Enterobacteriaceae (CPE) was performed using selective media (CHROMagar™ ESBL/CPE plates). Isolates with confirmed ESBL-phenotype were examined for the presence of blaCTX-M, blaTEM, blaSHV, and blaVIM, blaIMP, blaNDM, blaKPC, blaOXA-48 genes by PCR amplification and sequencing. Antimicrobial susceptibility testing was performed using conventional microbroth dilution. Pre-travel analysis of 205 fully evaluable participants revealed an ESBL-PE prevalence rate of 6.8% (14/205). Among 191 participants that were ESBL-negative before travel, 58 (30.4%) were colonized by ESBL-producing Escherichia coli, and 5 (8.6%) additionally carried ESBL-producing Klebsiella pneumoniae upon return. However, no carbapenem-resistant Enterobacteriaceae were detected. ESBL-genotyping revealed that 52/54 (96.6%) E. coli and 4/4 (100%) K. pneumoniae strains available for sequencing produced CTX-M enzymes, mostly CTX-M-15 (33/56, 58.9%), and 2/54 (3.7%) E. coli strains produced SHV-12 enzymes. Travel to India was associated with the highest ESBL-PE acquisition rate (11/15, 73.3%; p=0.015), followed by South East Asia (22/46, 47.8%; p=0.038). Evaluation of travel-associated risk factors demonstrated significance for the occurrence of gastroenteritis (p=0.011). Strictly practiced hand hygiene and exclusive consumption of packaged beverages showed no protective effect. The ESBL-PE persistence rate after 6 months was 8.6% (3/35). We conclude that global efforts are needed to address the further spread of ESBL-PE in the community. Active surveillance and contact isolation precautions may be recommended at admission to medical facilities especially for patients who traveled to India and South East Asia in the previous 6 months.

Infectious diseases in returned travellers, NSW, 2010-2011.

To quantify the proportion of selected notified diseases in NSW attributable to overseas travel and assess the quality of data on travel-associated risk factors, to inform prevention strategies. 2010 and 2011 notification data for dengue, hepatitis A, hepatitis E, malaria, paratyphoid fever, shigellosis and typhoid fever were extracted from the NSW Notifiable Conditions Information Management System and analysed for travel-associated risk factors. Where place of acquisition was known, the proportion of cases for whom the disease was acquired overseas ranged from 48.7% for shigellosis to 100% for hepatitis E, malaria and typhoid. Over half of hepatitis A (53.3%), hepatitis E (74.2%), malaria (54.5%), paratyphoid (53.3%) and typhoid (65.7%) cases were associated with travel to the person's country of birth. Hepatitis A vaccination rates were significantly lower among overseas-acquired than locally-acquired cases (4.8% vs 22.2%, Χ(2)=6.58, p<0.02). A large proportion of selected enteric and vectorborne disease case notifications were associated with overseas travel. All potential travellers should be made aware of the risks and available preventive measures, such as vaccination against hepatitis A and typhoid fever, taking precautions with food and water and use of malaria chemoprophylaxis, where appropriate. Improvements in data on risk factors, reason for travel and barriers to the use of preventive measures would better inform prevention strategies.

Business travelers: vaccination considerations for this population

Illness in business travelers is associated with reduced productivity on the part of the employee as well as the employer. Immunizations offer a reliable method of preventing infectious diseases for international business travelers. The authors review the travel patterns of business travelers, available data on illnesses they encounter, their potential travel-associated risks for vaccine-preventable diseases and recommendations on immunizations for this population. Routine vaccines (e.g., measles, tetanus and influenza) should be reviewed to assure that they provide current coverage. The combined hepatitis A and hepatitis B vaccine with a rapid schedule offers options for those with time constraints. Other vaccine recommendations for business travelers need to focus on their destinations and activities and underlying health, taking into account the concept of cumulative risk for those with frequent travel, multiple trips or long stays.

Aggregate travel vs. single trip assessment: Arguments for cumulative risk analysis

Vaccine recommendations for travellers are based on individual risk assessments of multiple factors, most importantly the destination and duration of the impending trip. Many people undertake frequent trips, but existing WHO, CDC and national advisory board recommendations do not explicitly consider cumulative travel-associated risks. Given the period of protection provided by many vaccines, in particular rabies, hepatitis A, hepatitis B and yellow fever vaccines, an aggregate multi-trip risk assessment which views vaccines as an investment for future travel health may be more appropriate than separately evaluating the risks for each trip.

Knowledge and practices about rabies among travel medicine consultants in Greece

The number of travellers returning with animal bites from rabies enzootic areas has increased in Greece. The aim of this study was to assess the knowledge of travel-associated risk and preventive measures for rabies. A questionnaire was sent to Travel Medicine consultants in all prefectures. Of 100 Travel Medicine consultants, advice about rabies was given to long-term travellers, business travellers, travellers to rural areas, and travellers engaged in animal activities in rabies enzootic countries by 44%, 22%, 58%, and 75% of them respectively. Avoidance of animals, post-exposure medical assistance, return back to their country, and special caution about children was recommended by 89%, 95%, 8%, and 65% of them, respectively. Rabies pre-exposure vaccination was recommended for travellers to rural areas, long-term travellers, and travellers engaged in animal activities by 61%, 35%, and 81% of them, respectively. Regarding post-exposure vaccination, 78% and 37% answered correctly with regards to travellers with no pre-exposure prophylaxis and travellers with pre-exposure prophylaxis, respectively. Counselling about rabies and management of risk exposure needs to be improved. Our findings indicate the need to promote continuous training in Travel Medicine in Greece and provide practical information about rabies prophylaxis.

Foreign Travel Is a Major Risk Factor for Colonization with Escherichia coli Producing CTX-M-Type Extended-Spectrum β-Lactamases: a Prospective Study with Swedish Volunteers

Foreign travel has been suggested to be a risk factor for the acquisition of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. To our knowledge, this has not previously been demonstrated in a prospective study. Healthy volunteers traveling outside Northern Europe were enrolled. Rectal swabs and data on potential travel-associated risk factors were collected before and after traveling. A total of 105 volunteers were enrolled. Four of them did not complete the study, and one participant carried ESBL-producing Escherichia coli before travel. Twenty-four of 100 participants with negative pretravel samples were colonized with ESBL-producing Escherichia coli after the trip. All strains produced CTX-M enzymes, mostly CTX-M-15, and some coproduced TEM or SHV enzymes. Coresistance to several antibiotic subclasses was common. Travel to India was associated with the highest risk for the acquisition of ESBLs (88%; n = 7). Gastroenteritis during the trip was an additional risk factor (P = 0.003). Five of 21 volunteers who completed the follow-up after 6 months had persistent colonization with ESBLs. This is the first prospective study demonstrating that international travel is a major risk factor for colonization with ESBL-producing Enterobacteriaceae. Considering the high acquisition rate of 24%, it is obvious that global efforts are needed to meet the emergence and spread of CTX-M enzymes and other antimicrobial resistances.

Measles transmission in immunized and partially immunized air travellers

Most cases of measles in Australia are associated with travel or acquired from travellers from overseas. This study presents a series of three secondary cases of measles acquired through contact with a case of infectious measles acquired in China. Two of the cases were fully immunized siblings sitting eight rows behind the index case on a 4(1/2)-h flight from Singapore. The third case was acquired in the airport where the index case was in transit. The report highlights the travel-associated risk of measles and discusses the heredity of vaccine-induced measles immunity.

Imported Typhoid Fever in Switzerland, 1993 to 2004

In industrialized countries, typhoid fever occurs mainly in returned travelers. To determine the need for preventive strategies, eg, for vaccination, continuous monitoring is needed to assess where the risk for travelers is highest. To investigate where the risk for travelers to acquire typhoid fever is highest, 208 patients with typhoid fever and recent travel were matched with travelers' statistics collected by the Swiss Federal Office of Statistics. At the beginning of the study period, up to 30 infections with Salmonella typhi were recorded per year in Switzerland. Since 2001, less than 15 confirmed cases per year occurred. A majority of the 208 (88.5%) typhoid cases were associated with recent travel. Countries with highest risk were Pakistan (24 per 100,000), Cambodia (20 per 100,000), Nepal (14 per 100,000), India (12 per 100,000), and Sri Lanka (9 per 100,000). We found that over a 12-year period (1993-2004), the travel-associated risk of typhoid fever is highest for destinations in the Indian subcontinent. All other regions showed a decline, most markedly in southern Europe. Our results suggest that typhoid fever vaccination should be recommended for all travelers to countries in South Asia. Otherwise, vaccination of tourists to frequently visited low- and intermediate-risk areas is not necessary, unless there are behavioral risk factors.

A Description of Travel Medicine in General Practice: A Postal Questionnaire Survey

Travel-related diseases are important aspects of public health. The number of UK residents traveling abroad is increasing at a rate of 16% a year, thereby increasing exposure to travel-related morbidity. Provision of comprehensive pretravel health advice is essential to reduce this trend. In the UK, pretravel health advice is predominantly provided through general practices. A postal questionnaire was sent to all 91 general practices in South Cheshire Health Authority. The questionnaires were to be completed by the lead advisor in travel medicine for each practice. Questions were asked on service provision, training and reference resources used, subjects advised on, and health promotion material used. Nonresponders were contacted and sent a further questionnaire. A response rate of 86% (78/91) was achieved. Of the lead advisors, 97% were nurses and 3% general practitioners. Thirty-eight sources of advice were quoted, the commonest of which comprised wall immunization charts (72%). Duration of consultation ranged from less than 5 min to over 30 min, with a median and mode of 11 to 15 min. Most respondents reported advising on most travel-associated risks, 40% of practices lacked a protocol, and 83% of providers had attended a training course on travel medicine for 2 days or less. This survey identified inadequacies of training and use of multiple sources of reference which may lead to inconsistencies in advice. Most practitioners could not define their workload in travel medicine. For effective protection of travelers, a careful risk assessment, clear risk communication and health education with detailed health promotion are necessary, but these are not likely to be provided within an average consultation time of 11 to 15 min. There is no evidence of consistent governance, planned training and monitoring of service quality of travel medicine practice. This may be due to lack of a national policy on best practice and guidance in this subject. National protocols with validated information resources, set standards of training, along with adequate consultation time for educating, advising, and prescribing, will lead to improved health of the traveling public.