Travellers' diarrhoea

Travellers' diarrhoea each year affects six million persons. At highest risk are those originating in an industrialized country for a visit in the Third World; their incidence of diarrhoea is 20-56% for the first 14 days of the stay abroad. Younger travellers, those who care less, and those with a lack of nonspecific gastrointestinal immune factors are more susceptible. The ailment mostly takes a mild and short course. Travellers' diarrhoea is usually due to faecally contaminated food and beverages, the predominant agent being enterotoxigenic E. coli. Therefore, the traditional rules of nutritional prophylaxis play the main role in prevention; drug prophylaxis can hardly ever be recommended.     

Travellers' diarrhoea

Although TD is usually a mild and self-limited illness, 30–50% of travellers from industrialized to less developed countries are affected. Enterotoxigenic E. coli (ETEC) remain the most frequent cause, being identified in 40–70% of cases.TD frequently occurs within the first 2 weeks of arrival in the foreign country. The clinical manifestation is variable, but watery diarrhoea is the most common clinical presentation. Chronic diarrhoea or remitting symptoms after empirical therapy in the returning traveller are indications for a stool culture and a careful search for stool parasites.Since the major precaution against TD is to avoid exposure to the infectious agents, careful selection of food and beverage is crucial.Bismuth subsalicylate has been proven to be safe and effective in the treatment and prophylaxis of TD. The tablet form has removed the inconvenience of previously required luggage space.Doxycycline, trimethoprim/sulphamethoxazole, trimethoprim and the quinolones have been shown to be effective for prevention of diarrhoea. However, side-effects, superinfection, development of antibiotic resistance and easy-to-treat illness may limit the use of these antimicrobial agents to those travellers with concomitant serious medical conditions that would be adversely affected by diarrhoea, or travellers with unaffordable temporary incapacity.A new oral-killed whole-cell and B-subunit cholera toxin vaccine was demonstrated to induce protection against severe ETEC-associated diarrhoea. This is a promising field under investigation.Finally, fluid replacement is the most important aspect of treatment. Patients with moderate to severe TD can be treated with one of the above-mentioned antimicrobial agents for 3–5 days. Selection of the antimicrobial agent is based on the pattern of resistance and the enteric organism prevalent in the geographical area. While TMP-SMX remains active against the strains prevalent in Mexico during summertime, the quinolones represent the choice for the therapy of diarrhoea acquired in the high-risk areas of South America, Africa and Asia.     

Referral of travellers from Australia by general practitioners for travel health advice

Background. General practitioners (GPs) may refer travellers to practice staff and to outside agencies to assist in the provision of travel health advice and preventive measures. In Australia, little is known about the referral patterns of travellers for travel health advice by GPs in the Australian context. This study was designed to investigate how frequently GPs' practice staff became involved in providing basic travel health advice and travel vaccination and to identify referral sources and how frequently GPs referred travellers to these sources for travel health advice. Method. In 2000, 433 GPs from western Sydney and Townsville were randomly selected from the register of the Australian Medical Association's Medical Directory of Australia database and sent self-administered questionnaires. Two reminders were sent. Results. Two hundred and thirteen questionnaires (43%) were returned. Approximately two thirds of the sample were male (133/207, 64.3%) and one third female (74/207, 35.7%). The mean age of the GPs was 46.7 (SD+/-12.1) years. About one tenth of GPs reported having a Yellow Fever Licence (11.3%, 23/203). The majority of GPs did not use their practice staff for giving travel health advice (60.7%, 122/201) or giving travel vaccinations (55.7%, 112/201). More than three quarters of GPs would never refer their patients for travel health advice to GPs with a special interest in travel medicine (76.4%, 152/199), specialists (76.8%, 152/198), or other agencies (77.8%, 63/81). Almost half of GPs stated that they would refer to travel clinics at least sometimes (46.6%, 95/204). Conclusions. GPs do sometimes refer travellers to specialised practices for travel health advice, especially to travel clinics, but also to other agencies, possibly for specialised services, such as yellow fever vaccination. Further studies may be needed on capacity of general practice staff to contribute to the travel health consultation and also the reasons and the appropriateness of the referral to outside agencies, where this occurs. Practices may need to consider further training of their auxiliary health staff in travel medicine, so that they can become more involved in the provision of travel health advice and immunization, where possible.     

Health advice given by general practitioners for travellers from Australia

Objectives: To investigate the prevalence of travel health advice and written documentation reported to be given by general practitioners to travellers from Australia. Design and setting: A postal questionnaire was sent to general practitioners (GPs). Participants: 433 GPs were randomly selected from the register of the Medical Directory of Australia from the areas of western Sydney and Townville. Results: Two hundred and thirteen questionnaires (49.2%) were returned. Approximately two-thirds of the sample was male (133/207,64.3%) and one-third female (74/207,35.7%). The mean age of the GPs was 46.7 (SD+/-12.1) years. The GPs reportedly saw an average of 3.9 (SD+/-11.8) travellers per week. Most GPs (160/202,79.2%) reported that they spent between 5-25 min for pre-travel consultations. GPs generally reported giving advice to travellers on travel vaccines, malaria prophylaxis, personal protective measures against insect bites, geographic diseases, clothing, and sexually transmitted infections. The majority of GPs did not routinely give information on travel insurance, unsafe sex, barotrauma, in-flight exercise, jet lag or first aid knowledge. Most GPs reported not routinely giving written documentation in the form of written travel health advice, a doctor's letter or a travellers' vaccination record. Conclusions: GPs report seeking core information needed for formulating travel health advice. GPs also provided travellers with health advice on most of the areas, which need to be covered in the pre-travel consultation. More GPs may wish to consider advising travellers about the importance of travel insurance and managing common maladies of travellers, such as motion sickness, barotrauma, and jet lag. With limited time in general practice to advise travellers, more GPs should consider providing written advice and documentation for travel, including a travellers' vaccination record.     

Enterotoxin-producing bacteria isolated from Swedish travellers with diarrhoea

The isolation rate of bacterial enteropathogens of different species, particularly enterotoxin-producing Gram-negative bacteria, was determined in stool specimens from Swedish travellers with diarrhoea. Overall, bacterial enteropathogens were identified in 101 (47%) of the 217 travellers on their return home. The most common isolates were enterotoxin-producing bacteria (20%), Salmonellae (18%) and Campylobacter (8%), whereas Shigellae (3%) and Yersinia (0.5%) were rarely identified. Mixed infections were only found in 8 (4%) of the stool specimens. Enterotoxigenic bacteria of Escherichia coli (ETEC), Klebsiella, Morganella, Citrobacter, Pseudomonas and EF-group 10 species were identified. ETEC accounted for 37/43 (86%) enterotoxin-producing strains, and among them 54% produced heat-stable enterotoxin (ST) alone, 16% heat-labile enterotoxin (LT) alone and 30% both LT and ST. Four of the enterotoxin-producing non-E. coli strains produced ST and 2 produced LT alone. The isolation rate of enterotoxin-producing bacteria was somewhat higher in travellers visiting Africa, Asia and Latin America (24%) than in those travelling to Southern Europe (14%). Salmonellae, on the other hand, were identified in stools significantly more often after travel to Southern Europe (26%) than to various subtropical and tropical areas (12.5%).     

Poliovirus immunisation for travellers

Mass immunisation against poliomyelitis using principally oral live attenuated trivalent vaccine (OPV) has eradicated wild-type poliovirus transmission in the industrialised countries of the Western hemisphere and most other countries, and the global eradication of poliomyelitis is within reach. The risk of oral polio vaccine-associated poliomyelitis has been estimated by WHO at 0.5-3.4 cases per million of susceptible children, and by the Centers for Disease Control and Prevention (USA) at 1 case per 2.4 million doses of OPV. This has led to the reintroduction and use of inactivated vaccine in the USA and a number of other countries. The current risk of poliomyelitis for travellers is reviewed together with the application of strategies for immunisation against these infections.     

Australian senior adventure travellers to Peru: Maximising older tourists' travel health experience

Financially comfortable, with ample spare time and much better health, older people travel more than ever and to more adventurous destinations. Taking Australian senior adventure travellers to Peru as an example, travel health preparations need to take into account the phenomenon 'senior traveller', the destination with its attractions and challenges, and age-related changes and restrictions. The need for routine travel health advice, vaccinations and prophylaxis remains unchanged. However, more emphasis should be placed on locality-specific issues so that age-appropriate advice and preparations maximize the chances for a safe and memorable travel experience.     

Medical kits for business travellers

A survey of occupational physicians of the Food Industry Medical Officers Group was undertaken to establish details of medical kits supplied by their organizations to business travellers. The most common approach was an in-house medical kit with instructions emphasizing self treatment of the common ailments of travellers such as motion sickness, sleeplessness, diarrhoea, indigestion and headaches. The majority of kits included a small supply of needles, syringes, IV cannulae etc either in a commercial 'Aids Kit' or as inhouse supplies. Antimalarials were provided either as a standard kit item or as required. About half provided antibiotics for the self treatment of infections. Very few provided a telephone number for use in the event of medical emergencies. A standard medical kit specification is proposed.     

Trips to the South--a health hazard. Morbidity of Finnish travellers

In all, 2665 Finns chosen at random who had made short visits to Spain and her islands, to North Africa or to Thailand, or who had taken an around-the-world tour or a West African cruise were asked to answer a questionnaire concerning the state of their health while abroad. One-third (33%) reported they were ill or had been ill; 48% had had some health complaint during the trip which in 93% lasted for 2 weeks or less. The most common health problems were diarrhoea (18%), sunburn (10%), upper respiratory symptoms with or without headache or fever (10%), insect stings (3%), and problems related to excessive consumption of alcohol (1.5%). 7% deemed it possible that they had contracted a venereal disease. The incidence of the complaints varied with the geographical area visited. It is concluded that mass tourism is accompanied by a morbidity whose dimensions are far from fully recognized.