Travel-related Diseases Research Articles

Travel Risks and Preventive Strategies: An Overview

Travel health risks are primarily classified as infectious or non-infectious. Travel-related risks vary according to traveler factors, destination factors, type and reason of travel, duration of travel, accommodations, and budget [ 1 , 2 ]. Although infectious disease mortality is estimated to be less than 1% of deaths during travel, infection with lethal diseases such as malaria occurs due to lack of effective preventive services before travel. Also, the risk of infectious disease is higher for those who travel to developing countries [ 1 ]. Many overseas deaths are due to natural causes, with cardiovascular disease being the most common cause [ 1 , 3 ]. Traffic accidents are estimated to be the most common cause of death among travelers to developing countries [ 4 ]. It is clear that evaluation of underlying medical conditions in travelers and providing preventive strategies can reduce potential harm (morbidity or mortality) to travelers [ 1 , 3 ]. The following underling diseases are important to identify and address: asthma, diabetes, immunocompromised states such as HIV infection, predisposition to deep venous thrombosis (DVT), blood disorders, and asplenia [ 1 ]. Travel-related infectious disease prevention strategies have been described in textbooks [ 1 ] and by the Center for Disease Control [ 5 ]. Unfortunately, travelers do not seek pre-travel health advice and the health system ignores it [ 3 , 6 ]. Many factors play a role in disease acquisition by travelers and its prevention. Behavioral factors play a crucial role. These include poor insight to behaviors such as food habits, vaccinations, and prophylaxis [ 1 , 3 , 6 ]. Another factor affecting disease acquisition and prevention is the destination. For example, the risk of malaria is higher in malaria-endemic areas such as sub-Saharan Africa [ 1 ]. The type of and reason for travel are other factors. The risk to business travelers is usually less than to other travelers; however, the risk varies according to the activities carried out. Business travelers may be at risk for low back pain or other musculoskeletal complaints from frequent air travel. Poor health literacy of immigrants expose them to higher risk when staying with local families because they do eat selectively or heed advice about preventable disease [ 1 , 2 ]. A pre-travel preventive strategic approach is necessary to reduce travel risk. This approach includes a comprehensive medical history and a medical examination. Individualized preventive strategies such as vaccinations, drug prophylaxis and medications, and pre-travel advice should be provide based on these factors. It is highly recommended that pre-travel assessment and advice should be carried out 6 to 12 weeks prior to travel [ 1 , 2 ].

Practices and Attitudes to Prevention of Travel-related Infectious Diseases in United Arab Emirates

Introduction: Among the United Arab Emirates (UAE) population more and more people now consider travelling abroad. This is potentially problematic because travelling enhances exposure between hosts and pathogens and so people that travel are putting their health at risk. This concern makes it necessary that public education is provided to inform people of the risks of travelling abroad so that such risks can be minimized. Guidelines and advice on travelling abroad are available and easily accessible but several studies have shown that travellers do not always follow such advice. In this study, the aim was to look into the practices and attitudes of UAE residents in relation to prevention of travel-related infectious diseases. Methods: A cross-sectional study was conducted from February to April 2015, in different emirates of the UAE. A self-administered anonymous questionnaire was developed based on material acquired from similar studies. The methodology applied quota sampling whereby adults above the age of 18 who’d travelled abroad in the past year were chosen from the seven emirates. The number of participants selected from each emirate was proportionate to the population size of each state. Results: A total of 385 questionnaires were completed. A remarkable 70% of respondents indicated that they had not taken on any precautionary measures prior to travel. Of greater interest was that only 21% of participants had taken advice on health prior to travel, while the outstanding majority 79% reported that they had not taken advice. The most common source of advice had been taken from family and friends among those who had taken advice at 41%, while only 15.4% had acquired it from specialized travel medicine clinics. High risk perception, spending more preparation time and travelling for longer durations were important factors that encouraged pretrial health consultation and undertook preventive measures. Conclusion: This study revealed that UAE residents had not taken adequate measures to prevent travel related infectious diseases. Despite the limitations of this study, it still provides sufficient data to improve public health intervention directed at encouraging travellers to acquire pre travel health consultation.

Challenges and risks for older travellers with multimorbidity: Focus on pharmacotherapy

The number of older travellers continues to increase internationally. Consequently, physicians are frequently confronted with situations relating to travelling of older people with multiple chronic morbidities and taking multiple medications. The risk of travel-related diseases is more than 2-fold in people with underlying medical conditions in comparison to healthy travellers. Although many guidelines on travelling with a particular chronic disease exist so far, it can be a challenge to tailor these considerations to an individual with multimorbidity. It is important that the health needs and potential vulnerability of the older traveller are recognized by physicians and patients alike. Educating patients on this topic could provide a significant benefit – helping them to enjoy their travel by being well prepared.

Travellers returning ill from the tropics - a descriptive retrospective study.

International travel continues to increase in frequency. Health care providers need a wide understanding of the spectrum of travel related diseases and their management. This retrospective study analyses the demographic and clinical data of 360 travellers returning from the tropics presenting to an outpatient clinic at a tertiary hospital between 2003 - 2007. The aim of this study was to analyse the frequency of presenting symptoms and diseases in ill returning travellers and to correlate them to the areas visited and the duration and purpose of travel. The main symptoms during travel were diarrhoea (n = 200, 56 %) and fever (n = 124, 34 %). Travellers not visiting friends and relatives but with close contact to the local population were at more than two-fold increased risk of diarrhoea (Odds Ratio [OR] 2.5; 95 % confidence interval [CI] 1.1-6.0, p = 0.03) and fever (OR 2.4; 95 % CI 1.1-5.3; p = 0.02) compared to tourist travellers. Travellers visiting friends and relatives (VFR) were not at increased risk for diarrhoea (OR 0.6; 95 % CI 0.3-1.3; p = 0.17), or fever (OR 1.5; 95 % CI 0.7-3.4; p = 0.28). Thirty-two percent of all travellers (n = 115) were diagnosed with a specific pathogen. Malaria (6 %), giardiasis (6 %) and amebiasis (4 %) were the most frequently detected pathogens. The odds of malaria as a cause of the presenting illness was lower among travellers reporting pre-travel advice. Specific antimicrobial treatment was required in around one third of the patients.

Management of Children with Travel-related Illness Evaluated in a Pediatric Emergency Room.

Children travelling are potentially exposed to a wide spectrum of illness, which includes not only mild self-limiting disease but also severe illness requiring hospitalization. Risk factors for hospitalization need to be analyzed to inform prevention and treatment strategies for travel-related disease, to make travelling for children-from a medical perspective-more secure. We performed a cross-sectional analysis on children with travel-related disease presenting at the Emergency Room of University of Zurich Children's Hospital between July 2007 and December 2012. The profile of children being hospitalized was compared with that of children treated as outpatients. Eight hundred and one children (57.4% male) were included in the study. Eighty-three children (10.4%) were treated as inpatients. Compared with outpatients, inpatients were significantly more likely to be male, to have travelled to Southern Asia, to have a diagnosis of Salmonella typhi or Salmonella paratyphi (3.6 % vs. 0.1%, P < 0.0001), pyogenic abscess (3.6% vs. 0.1 %, P < 0.0001) or malaria (1.4 % vs. 0.2%, P = 0.0384). Neurologic diagnoses (such as seizure disorder: 3.6% vs. 0.4%, P < 0.0001) were diagnosed more often among inpatients. Furthermore, inpatients presented more often with nonspecific findings such as dehydration (8.5% vs. 0.6%, P < 0.0001). No correlation with inpatient care was seen for visiting friends and relatives/immigrant travel. Children acquire a wide spectrum of travel-related illness. A careful, detailed travel history is important in children presenting in the emergency room with symptoms suggesting infectious disease.

Ross River virus disease in two Dutch travellers returning from Australia, February to April 2015

We report two cases of Ross River virus (RRV) infection in Dutch travellers who visited Australia during February to April 2015. These cases coincided with the largest recorded outbreak of RRV disease in Australia since 1996. This report serves to create awareness among physicians to consider travel-related RRV disease in differential diagnosis of patients with fever, arthralgia and/or rash returning from the South Pacific area, and to promote awareness among professionals advising travellers to this region.

A “Syndromic” Approach for Diagnosing and Managing Travel-Related Infectious Diseases in Children

ri P mary care physicians practicing in the United States are often less familiar with many of the common as well as more exotic diseases that children can acquire when traveling abroad. This review will focus mainly on infectious diseases specifically associated with travel-related exposures. While having access to reference material to help guide diagnostic resources and therapy is useful, it is most useful to have a consistent well-organized approach to help identify specific risk factors associated with both the most common and the most severe illnesses potentially occurring in a child who has recently traveled internationally. According to the National Travel and Tourism Office the number of Americans traveling abroad increased to more than 61.9 million in 2013. The main areas of travel included Europe at 34.6%, the Caribbean at 24.8%, Asia at 18.8%, South America at 7.3%, Central America at 6.9%, Africa at 3.1%, the Middle East at 5.9%, and Oceania at 1.9%. Nearly 27% of travel was to visit friends and families. This category accounts for a significant portion of the travel in the pediatric age groups. Although travel to Asia and Africa accounted for only 21.9% of US traveler the majority of travelrelated illnesses were acquired from Asia (32.6%) and sub-Saharan Africa (26.7%) according to a recent geosentinel-illness surveillance of returned international travelers presenting to the GeoSentinel Network. As

Travel Diarrhea in Childhood “First Part; what do we know?”

Travel-related diseases such as diarrhea, malaria, cutaneous larva migraines and respiratory infections, are common in children and adults. Diarrhea is one of the most common and mortal diseases among childhood particularly in those who travel to developing countries [ ADDIN EN.CITE Leung 2006 1 (1, 2) 1 <key app=EN db-id=5sew2wd0qr0vwmezef4v55vs2p9azrzzf5pp>1 <ref-type name=Journal Article>17 Leung, A. K. Robson, W. L. Davies, H. D. Traveleras diarrhea Adv Ther Adv Ther 519-27 23 4 2006 0741-238X (Print) 0741-238X (Linking) Fox 2013 3 3 <key app=EN db-id=5sew2wd0qr0vwmezef4v55vs2p9azrzzf5pp>3 <ref-type name=Journal Article>17 Fox, T. G. Manaloor, J. J. Christenson, J. C. Travel-related infections in children Pediatr Clin North Am Pediatr Clin North Am 507-27 60 2 2013 1557-8240 (Electronic) 0031-3955 (Linking) 1 , 2 ]. Although its pathogen depends on the country which is visited, there is a similarity between pathogens which affect adults and children [ ADDIN EN.CITE Ang 2008 2 (3) 2 <key app=EN db-id=5sew2wd0qr0vwmezef4v55vs2p9azrzzf5pp>2 <ref-type name=Journal Article>17 Ang, J. Y. Mathur, A. Traveleras diarrhea: updates for pediatricians Pediatr Ann Pediatr Ann 814-20 37 12 2008 0090-4481 (Print) 0090-4481 (Linking) 3 ]. Among bacterial pathogen, Enterotoxic E-Coli is most common in pediatrics. Traveler’s Diarrhea (TD) is commonly self-limited and does not need specific aggressive treatment but supportive care for limiting dehydration and other complication is mandatory. “The attack rate is highest for travelers from a developed country who visit a developing country”[ ADDIN EN.CITE Leung 2006 4 (1) 4 <key app=EN db-id=5sew2wd0qr0vwmezef4v55vs2p9azrzzf5pp>4 <ref-type name=Journal Article>17 Leung, A. K. Robson, W. L. Davies, H. D. Traveleras diarrhea Adv Ther Adv Ther 519-27 23 4 2006 0741-238X (Print) 0741-238X (Linking) 1 ]. Also, traveling in the summer season to tropical developing countries with endemic infectious diarrhea increases the risk of TD. There are many conflicts in pediatrics TD managements. Antiemetic and anti-motility medications are not routinely recommended except in cases with severe and uncontrolled symptoms. Loperimide (in cases older than 6 years old without dysentery, febrile and toxic symptoms) among anti motility medications and ondansetron, metoclopramide, or dimenhydrinate among antiemetic medications are suggested for children with considerably refractive symptoms [ ADDIN EN.CITE http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-7-international-travel-infants-children/traveling-safely-with-infants-and-children 7 (4) 7 <key app=EN db-id=5sew2wd0qr0vwmezef4v55vs2p9azrzzf5pp>7 <ref-type name=Web Page>12 http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-7-international-travel-infants-children/traveling-safely-with-infants-and-children 4 ]. Anti-motility drugs might also be able to decrease the risk of transmission by reducing the amount of fecal materials. Moreover, Antibiotics selection depends on the age groups and characterized pathogens. More important than treatment, the prevention of it by providing pre-travel medical advice and information about endemic diseases in target countries is more effective [ ADDIN EN.CITE Kamat 2006 6 (5) 6 <key app=EN db-id=5sew2wd0qr0vwmezef4v55vs2p9azrzzf5pp>6 <ref-type name=Journal Article>17 Kamat, D. Mathur, A. Prevention and management of travelersa diarrhea Dis Mon Dis Mon 289-302 52 7 2006 1557-8194 (Electronic) 0011-5029 (Linking) 5 ]. As Sheila Mackell demonstrated in the Journal of Clinical Infectious Disease; “Most of the data available today describe travelers' diarrhea in adults. Children traveling to distant destinations from their home country have not been well studied, yet treatment parameters exist in practice and will be reviewed here”[ ADDIN EN.CITE Mackell 2005 5 (6) 5 <key app=EN db-id=5sew2wd0qr0vwmezef4v55vs2p9azrzzf5pp>5 <ref-type name=Journal Article>17 Mackell, S. Traveleras diarrhea in the pediatric population: etiology and impact Clin Infect Dis Clin Infect Dis S547-52 1 41 2005 1537-6591 (Electronic) 1058-4838 (Linking) 6 ]. On the other hand, because TD occurs in developing countries there is a lock of information about pathogenesis, accuracy of treatment and management. Therefore, almost the most common pathogen in developing countries e.g. in Asia and Africa is non-identified pathogen. This means more studies are needed to be conducted on pathogenesis, pathogen frequency, prevention, management especially in specific conditions such as children with immunodeficiency. In the second part, we will discuss about future aspects of TD in pediatrics.

Immediate Recall of Health Issues Discussed During a Pre‐Travel Consultation

An important role of pre-travel consultations is to improve travelers' understanding of travel-related diseases, but the efficacy of education provided is unknown. This study sought to assess recall and knowledge immediately following a pre-travel consultation. The study was conducted at a hospital-based pre-travel clinic in Melbourne, Australia. Travelers aged ≥16 years seen between September 2010 and March 2012 were invited to complete an anonymous self-administered questionnaire immediately following their consultation to assess knowledge of appropriate preventive measures and presumptive self-treatment strategies for common travel risks. The doctor of each participating traveler also completed a survey regarding issues discussed. A total of 300 participants were recruited (34% male, median age 31 years). Most were traveling for vacation (77%) and reported previous travel (95%). Main travel destinations were Asia (43%), Americas (21%), and Africa (17%). Doctors' and travelers' surveys showed variable levels of concordance: 94% of patients recalled discussion of malaria, 84% rabies, and 76% dengue. For malaria, 95% remembered discussions regarding insect repellents, and 92% recalled that medical advice should be sought if fever developed. For travelers with whom rabies was discussed, 94% recalled that medical advice must be urgently sought following a bite/scratch. For travelers' diarrhea (TD), 99% knew to drink only boiled/bottled water, but 13% did not recall avoiding unpeeled fruit/vegetables as a prevention strategy. There was 20% discordance between doctors and travelers regarding antibiotics for TD self-treatment, but only 4% discordance regarding prescription of malaria prophylaxis. Factors associated with improved recall were doctor discussion, previous travel, and a university education. Key travel health messages are well assimilated after pre-travel consultation. However, large amounts of information are discussed and immediate recollection of all information is not possible. This study reinforces the importance of providing supplementary information (eg, written and/or electronic resources) to accompany pre-travel consultations.

Radiology preparedness in ebola virus disease: guidelines and challenges for disinfection of medical imaging equipment for the protection of staff and patients.

The overlap of early Ebola virus disease (EVD) symptoms (eg, fever, headache, abdominal pain, diarrhea, emesis, and fatigue) with symptoms of other more common travel-related diseases (eg, malaria, typhoid fever, pneumonia, and meningococcemia) may result in delayed diagnosis of EVD before isolation of infected patients. Radiology departments should consider policies for and approaches to decontamination of expensive and potentially easily damaged radiology equipment. In addition, the protection of radiology personnel must be considered during the work-up phase of undiagnosed EVD patients presenting to emergency departments. The purpose of this article is to consider the effect of EVD on radiology departments and imaging equipment, with particular consideration of guidelines currently available from the Centers for Disease Control and Prevention that may be applicable to radiology.

Fever, Rash and Fungemia in a Traveler from South China

Introduction: Penicillium (Talaromyces) marneffei is a dimorphic fungus that is endemic in Southeast Asia and South China, but rarely seen the United States except in immunosuppressed patients who have had travel-related exposure. Case Presentation: A 28 year-old man with advanced HIV/AIDS presented with dyspnea, cough and fever two weeks after returning from Shenzhen, South China. He was treated for presumptive Pneumocystis jiroveci pneumonia with improvement in his symptoms and was then started on antiretroviral therapy. Three weeks later he developed rash and fever, and blood culture grew Penicillium (Talaromyces) marneffei. Conclusion: This case highlights the importance of obtaining a detailed travel history in order to incorporate travel-related diseases in a differential diagnosis.

Effectiveness of pre-travel consultation in the prevention of travel-related diseases: a retrospective cohort study.

This study aims to evaluate the effectiveness of pre-travel counselling carried out in Travel Clinics. This is a retrospective cohort. Three hundred international travellers were enrolled; 150 people were from users of Bari Travel Clinic, 150 were users of a travel agency. Enrolled subjects were interviewed using a questionnaire. The average age of the enrolled subjects was 37.5 ± 13.9, without statistically significant differences between the two groups. 86% of cases and 19.3% of the controls reported the use of anti-malaria prophylaxis (p < 0.0001). Vaccination against cholera was given to 62% of cases and 7.3% of the controls (p < 0.001). Travel Clinic users, 6% reported diarrhoea and these figures were 27% in the control group (p < 0.0001). The proportion of those interviewed who reported fever (3.7) or insomnia (1.3) did not differ between the two groups. Mosquito bites were reported by 8% of cases and 20% of the controls (p = 0.003). Three cases of malaria were reported among the controls but no cases were detected among the cases (chi-square = 3.03; p = 0.08). Our study demonstrated the effectiveness of pre-travel counselling; in the future, new studies must investigate the cost-effectiveness of pre-travel prevention measures.

Travel-related infection in European travelers, EuroTravNet 2011.

Limited data exist on infectious diseases imported to various locations in Europe, particularly after travel within the continent. To investigate travel-related disease relevant to Europe that is potentially preventable through pre-travel intervention, we analyzed the EuroTravNet database of 5,965 ill travelers reported by 16 centers in "Western" Europe in 2011. There were 54 cases of vaccine-preventable disease, mostly hepatitis A (n = 16), typhoid fever (n = 11), and measles (n = 8); 6 cases (including 3 measles cases) were associated with travel within "Western" Europe. Malaria was the most commonly diagnosed infection (n = 482, 8.1% of all travel-related morbidity). Among patients with malaria, the military most commonly received pre-travel advice (95%), followed by travelers for missionary, volunteer, research, or aid work (81%) but travelers visiting friends and relatives (VFRs) were least likely to receive pre-travel advice (21%). The vast majority (96%) of malaria patients were resident in "Western" Europe, but over half (56%) were born elsewhere. Other significant causes of morbidity, which could be reduced through advice and behavioral change, include Giardia (n = 221, 3.7%), dengue (n = 146, 2.4%), and schistosomiasis (n = 131, 2.2%). Of 206 (3.5%) travelers with exposure in "Western" Europe, 75% were tourists; the highest burden of disease was acute gastrointestinal infection (35% cases). Travel from "Eastern" Europe (n = 132, 2.2%) was largely associated with migration-related travel (53%); among chronic infectious diseases, tuberculosis was frequently diagnosed (n = 20). Travelers VFRs contributed the largest group of malaria patients (46%), but also had the lowest documented rate of pre-travel health advice in this subset (20%). Overall, 44% of nonimmigrant ill travelers did not receive pre-travel advice. There is a burden of infectious diseases in travelers attending European health centers that is potentially preventable through comprehensive pre-travel advice, chemoprophylaxis, and vaccination. Targeted interventions for high-risk groups such as travelers VFRs and migration-associated travelers are of particular importance.

Risk factors for infections in international travelers: an analysis of travel-related notifiable communicable diseases.

We sought to describe travel-related illness among our residents and gain insight into targeting pre-travel health advice to prevent travel-related illness. A supplemental travel questionnaire was developed and administered for cases with a legally notifiable communicable disease reported in 2011-2012, who spent at least part of their exposure period outside the United States. Among 451 cases meeting the eligibility criteria, 259 were interviewed. Forty four percent reported receiving pre-travel advice. Two-thirds adhered fully with risk behavior recommendations; 94% followed immunization recommendations partially or fully; and 84% adhered fully with malaria prophylaxis recommendations. The primary reasons for not obtaining pre-travel advice were being unaware of the need (47.5%), or believing they already knew what to do (34.5%). Adults (OR = 2.8, 95% CI = 1.4-5.5), males (OR = 1.8, 95% CI = 1.1-3.0), those born outside the United States (OR = 2.0, 95% CI = 1.1-3.7), and those with planning time under two weeks (OR = 4.8, 95% CI = 1.5-15.9) or travel duration less than 7 days (OR = 7.9, 95% CI = 3.0-20.9) were more likely to travel without seeking pre-travel advice. The majority of cases reported not receiving pre-travel advice. Understanding the predictors of failure to receive pre-travel advice may help target public health prevention efforts.

Vaccine-Preventable Diseases in Travelers

Travel from the developed world to developing countries is increasing, placing travelers at risk for both vaccine-preventable and non-vaccine-preventable diseases. Between 2007 and 2011, the GeoSentinel network reported 737 returning travelers with a vaccine-preventable disease. While the use of vaccines is essential in preventing travel-related disease, clinicians should also be aware that the vast majority of travel-acquired diseases are non-vaccine-preventable. Immunizations for vaccine-preventable diseases can be divided into three groups: routine travel vaccines, special travel vaccines, and routine vaccines in the context of travel. Routine travel vaccines include hepatitis A and B, and typhoid; special travel vaccines include yellow fever, meningococcal disease, rabies, polio, and Japanese encephalitis; and routine vaccines include influenza and tetanus-diphtheria-pertussis. Providers should employ a patient- and itinerary-specific approach when recommending vaccines for travel.

Tour Leaders’ Knowledge of and Attitudes toward Rabies Vaccination, Taiwan

Tour Leaders’ Knowledge of and Attitudes toward Rabies Vaccination, Taiwan

Climate change effects on Chikungunya transmission in Europe: geospatial analysis of vector's climatic suitability and virus' temperature requirements.

BackgroundChikungunya was, from the European perspective, considered to be a travel-related tropical mosquito-borne disease prior to the first European outbreak in Northern Italy in 2007. This was followed by cases of autochthonous transmission reported in South-eastern France in 2010. Both events occurred after the introduction, establishment and expansion of the Chikungunya-competent and highly invasive disease vector Aedes albopictus (Asian tiger mosquito) in Europe. In order to assess whether these outbreaks are indicative of the beginning of a trend or one-off events, there is a need to further examine the factors driving the potential transmission of Chikungunya in Europe. The climatic suitability, both now and in the future, is an essential starting point for such an analysis.MethodsThe climatic suitability for Chikungunya outbreaks was determined by using bioclimatic factors that influence, both vector and, pathogen. Climatic suitability for the European distribution of the vector Aedes albopictus was based upon previous correlative environmental niche models. Climatic risk classes were derived by combining climatic suitability for the vector with known temperature requirements for pathogen transmission, obtained from outbreak regions. In addition, the longest potential intra-annual season for Chikungunya transmission was estimated for regions with expected vector occurrences.In order to analyse spatio-temporal trends for risk exposure and season of transmission in Europe, climate change impacts are projected for three time-frames (2011–2040, 2041–2070 and 2071–2100) and two climate scenarios (A1B and B1) from the Intergovernmental Panel on Climate Change (IPCC). These climatic projections are based on regional climate model COSMO-CLM, which builds on the global model ECHAM5.ResultsEuropean areas with current and future climatic suitability of Chikungunya transmission are identified. An increase in risk is projected for Western Europe (e.g. France and Benelux-States) in the first half of the 21st century and from mid-century onwards for central parts of Europe (e.g. Germany). Interestingly, the southernmost parts of Europe do not generally provide suitable conditions in these projections. Nevertheless, many Mediterranean regions will persist to be climatically suitable for transmission. Overall, the highest risk of transmission by the end of the 21st century was projected for France, Northern Italy and the Pannonian Basin (East-Central Europe). This general tendency is depicted in both, the A1B and B1 climate change scenarios.ConclusionIn order to guide preparedness for further outbreaks, it is crucial to anticipate risk as to identify areas where specific public health measures, such as surveillance and vector control, can be implemented. However, public health practitioners need to be aware that climate is only one factor driving the transmission of vector-borne disease.

Traveler's Health Information on the Internet

Traveling can increase the chances of the traveler becoming ill. An important part of the planning for any trip should include preventive measures for ensuring the traveler's good health and preparing for potential health concerns. Pretrip planning is essential to remaining healthy while away from home. Health risks vary according to the destination, itinerary, duration of the trip, and the medical history of the traveler. Most travel-related diseases can be prevented or minimized with proper planning. Internet resources provide assistance in preparing for a healthy trip as well as providing information on how the traveler can treat illness that occurs during travel.

A Quality Improvement Initiative Using a Novel Travel Survey to Promote Patient‐Centered Counseling

We sought to evaluate and provide better itinerary-specific care to precounseled travelers and to assess diseases occurring while traveling abroad by surveying a community population. An additional quality improvement initiative was to expand our post-travel survey to be a more valuable tool in gathering high-quality quantitative data. From de-identified data collected via post-travel surveys, we identified a cohort of 525 patients for a retrospective observational analysis. We analyzed illness encountered while abroad, medication use, and whether a physician was consulted. We also examined itinerary variables, including continents and countries visited. The 525 post-travel surveys collected showed that the majority of respondents traveled to Asia (31%) or Africa (30%). The mean number of travel days was 21.3 (median, 14). Univariate analysis demonstrated a statistically significant increase of risk for general illness when comparing travel duration of less than 14 days to greater than 14 days (11.3% vs 27.7%, p < 0.001). Duration of travel was also significant with regard to development of traveler's diarrhea (TD) (p = 0.0015). Destination of travel and development of traveler's diarrhea trended toward significance. Serious illness requiring a physician visit was infrequent, as were vaccine-related complications. Despite pre-travel counseling, traveler's diarrhea was the most common illness in our cohort; expanded prevention strategies will be necessary to lower the impact that diarrheal illness has on generally healthy travelers. Overall rates of illness did not vary by destination; however, there was a strong association between duration of travel and likelihood of illness. To further identify specific variables contributing to travel-related disease, including patient co-morbidities, reason for travel, and accommodations, the post-travel survey has been modified and expanded. A limitation of this study was the low survey response rate (18%); to improve the return rate, we plan to implement supplemental modalities including email and a web-based database.

Expatriates: Special Considerations in Pretravel Preparation

Expatriates comprise a diverse set of travelers who face unique medical, psychiatric, and non-health-related risks as a result of increased exposure to host country environment and associated lifestyle. Expatriates have an increased risk of developing malaria, gastrointestinal disorders, latent tuberculosis, vaccine-preventable infections, and psychological disorders, when compared with other travelers, yet the majority of existing pretravel guidelines have been designed to suit the needs of nonexpatriates. Although greater interest in expatriate health issues has led to improved characterization of illness in this population, expatriate-specific risk mitigation strategies—including modifications to chemoprophylaxis recommendations, limiting tuberculosis exposure, and prevention of occupational or sexual blood-borne virus transmission—are poorly described. Occupations and destinations affect travel-related disease risk and should inform the pretravel consultation.