Sexually transmitted infections and HIV among travellers: a review

Sexually transmitted infections are often acquired during travel. Infections are most often seen in young adults, travelling without a regular partner and among those who have higher numbers of partners while at home. Alcohol and recreational drug use may increase risk. The risks are highest from having unprotected sex with local partners in developing countries where the prevalence of infection can be many times higher than at home. The risks of acquiring HIV are highest in Africa, followed by South Asia. Special precautions are required by those going to work in health-care settings in high HIV prevalence countries. Travellers may benefit from advice about safer sex, condom use, emergency contraception and vaccination against hepatitis B. In special circumstances a starter pack for HIV post-exposure prophylaxis should be considered. Following return travellers should consider attending specialist services for a screen for sexually transmitted infections and HIV if they are concerned about exposure whilst travelling. A number of reports suggest that travel clinics need to pay more attention to the sexual health of travellers.     

Prevention of travel-related infectious diseases: knowledge, practices and attitudes of Swedish travellers

More Swedish residents travel to countries where they are at risk for contracting malaria, hepatitis, and other serious travel-related diseases. To safeguard the public's health, it is important to determine if travellers accurately perceive health risks and take appropriate preventative measures before and during their trips. This study examined travel health knowledge, attitudes and practices among Swedish residents traveling to destinations with risk of malaria and hepatitis. Self-administered anonymous questionnaires were distributed to Swedish residents (n=957) waiting to board intercontinental flights at the Stockholm-Arlanda International Airport. A majority of travellers sought general information (74%) and travel health advice (59%) prior to departure. Most perceived vaccination as safe and effective, but only 40% and 3% of travellers reported adequate vaccine coverage against hepatitis A or hepatitis B, respectively. Although most did not know the actual malaria risk at the destination, 97% of persons flying to high-risk areas were carrying malaria medication. The study results were in line with those found in surveys conducted in other countries, and demonstrate need for further health education among travellers to risk destinations. Efforts should focus on reaching more travellers, providing clear information and improving compliance with recommended travel health advice.     

Travelling for work: seeking advice in South Africa

Sub-Saharan Africa is a common destination for occupational travellers from South Africa. Adequate preventive measures require timeous medical consultation before travel. A secondary analysis of datasets of over 8000 occupational travellers who visited travel clinics in South Africa indicated that 82% were travelling to African countries and over 50% consulted less than a week before travel. For the 70% who consult less than 10 days before departure, yellow fever certificates issued at consultation would not be valid for entry to endemic countries, although they may be protected from contracting yellow fever. The 'last minute' travel medicine consultation appears to be more common in South Africa than in Europe and North America. This may preclude South African health professionals from providing occupational travellers adequate disease prevention, particularly against vaccine-preventable infectious diseases.     

Tuberculosis in travellers

Tuberculosis (TB) incidence is increasing in many countries which are popular with international travellers. The development of active TB is a two-stage process; the risk of acquiring new TB infection depends primarily on the risk of contact with an individual with infectious TB, and the risk of disease on the immune status of the newly infected person. The risk of TB infection is low for most holiday-makers, but among long-term travellers to countries with high TB incidence, the risk may be similar to that experienced by the local population (0.5-2.5% per year); the risk to people working in health care is particularly high. Effective pre-travel advice involves assessing the traveller's risk of TB infection and disease. Recommendations on the prevention of TB in travellers vary between countries. Possible strategies include avoidance of exposure; BCG vaccination; and tuberculin skin testing before and after travel, with preventive therapy for those whose post-travel skin tests indicate recent infection. For those at highest risk of progression to disease, there may be value in preventive therapy during travel to reduce the risk of new TB infection. Further information on the contribution of recent travel to incident TB in industrialised countries would be valuable.     

Is there a need for a travel vaccination against tick-borne encephalitis?

Tick - borne encephalitis is a vector-borne disease primarily transmitted to humans by the bite of infected ticks. Clinical presentations range from mild meningitis to severe encephalitis with or without myelitis and may result in long-term neurological equelae or death. The disease can successfully be prevented through active immunization. BE is endemic in regions of at least 26 European countries. The risk of contracting TBE in the most affected countries has increased in the past 20 to 30 years, between 1974 and 2003, the number of reported clinical TBE cases increased by an appalling 400%, the only exception having been Austria. Because of increasing international travel streams of tourists from non-endemic countries to TBE risk areas, the infection is now becoming a more important issue of travel medicine.The risk depends on both the travelling season and the degree of unprotected outdoor exposure to forest areas (e.g. bicycling, camping, hiking, etc.). Tourists are by no means aware of the actual risk potential, especially when travelling to a knowingly 'safe' Europe. Vaccination against tick-borne encephalitis may be required for some tourists, depending on travel destination and behaviour. Implementing general guidelines for the use of TBE travel vaccination should be put on the agenda for travel medicine.     

Immunisation of the travelling child

As a direct consequence of the current increase in international mobility, a significant increase in family travel is occurring. Protection against vaccine preventable diseases in the travelling child plays a key role both from an individual and a public health perspective: pre-travel immunisation protects travelling children and, at the same time, prevents the importation of pathogens that can spread throughout the community. Children immunisation presents unique challenges in travel medicine practice: some vaccines cannot be given below a definite age for several reasons and altering the standard schedule of routine vaccines is sometimes needed to ensure early protection. Furthermore, the risk for some travel-related diseases is higher among children. The aim of this review is to analyse the main epidemiological and clinical aspects relevant to immunisation of travelling children and to provide travel medicine practitioners with a practical approach to this issue.     

Vaccination options for last-minute travellers in need of travel-related prophylaxis against hepatitis A and B and typhoid fever: a practical guide

Last-minute travellers represent a particular challenge to travel healthcare professionals, as standard vaccination schedules can take a few months to complete. This has led researchers to investigate the value of alternative accelerated schedules and existing schedules among this group, particularly with respect to time taken for an individual to seroconvert, duration of protection and multiple vaccination requirements. This paper reviews the available options for the three most common vaccine preventable diseases among travellers-hepatitis A, hepatitis B and typhoid fever. Studies suggest that even if the first dose of hepatitis A vaccine is given on the day of travel, this will provide adequate protection, and that immunity to typhoid fever can be provided in over 70% of travellers following vaccination 1 week prior to departure. For hepatitis B, an accelerated schedule of 0, 7 and 21-days has been shown to induce early protection, and is considered to be of benefit to the last-minute traveller. Practical guidelines on vaccination options from one week up to one month, as well as one month or more prior to travel are presented. This should provide guidance for travel healthcare professionals, and reassure last-minute travellers that they need not begin their journey unprotected against these three serious infectious diseases.     

Hepatitis B vaccination in correctional health care workers

BACKGROUND: Data on bloodborne pathogen risk among health care workers (HCWs) employed in the correctional setting are sparse, even though the prevalence of bloodborne infections, including hepatitis B virus (HBV), among inmates is high. To address this, we determined prevalence and correlates of hepatitis B virus vaccination status in correctional health care workers (CHCWs) employed in 3 state correctional health care facilities. METHODS: A confidential, self-administered cross-sectional survey was performed. RESULTS: Four hundred eleven (69.8%) of 588 eligible participants completed the survey. Of these, 264 (64.2%) reported receiving a primary hepatitis B (HB) vaccine series. Vaccination rates varied by state and by job category. Parenteral exposures were not uncommon; 8.6% (n = 24) of clinical CHCWs and 2.0% (n = 7) of nonclinical CHCWs reported one or more needlesticks in the 6-month period prior to the study. Among clinical staff, vaccination correlated with licensure (RN or MD) and race (white) and in nonclinical staff with history of close contact with HBV infected inmates and with needlestick injury. CONCLUSION: Although the HB vaccination rate among CHCWs was generally high, given their potential risk of exposure to HBV, universal vaccination should be encouraged and should include those nonclinicians with job duties that may involve potential exposure to blood/body fluids.     

Hepatitis A vaccines and the elderly

Hepatitis A virus (HAV) exposure in unprotected adults may cause severe and serious symptoms, with risk of both morbidity and mortality increasing with age. As seroprevalence of HAV is low in industrialised countries, and an increasing number of people, with an increasing median age, travel from areas of low HAV endemicity to high endemicity, pre-travel vaccination is warranted. Vaccination of the elderly against HAV, however, may be associated with reduced seroprotection, since the immune response decreases with age. Studies with monovalent hepatitis A vaccine or combined hepatitis A and B vaccine show good efficacy in adults in general. Few studies have assessed the immune response in older adults. The only prospective study with monovalent hepatitis A vaccine in the elderly showed a reduced seroprotection of approximately 65% after a single primary dose in subjects over the age of 50 years, while seroprotection was 98% in this age group after receiving a booster dose. The only prospective study with combined hepatitis A and B vaccine in younger subjects or older than 40 years showed similar seroprotection (99-100%) against HAV compared to a monovalent vaccine after receiving three doses. As data on seroprotection for HAV in the elderly are limited, further studies are needed to elucidate how optimal protection in the elderly can be achieved. In the mean time, based on the available data, the suggestion is made to screen elderly travellers to areas endemic for HAV for the presence of naturally acquired immunity, and, if found susceptible, be immunised well in advance of their trip, to allow time for post-vaccination antibody testing and/or administration of a second dose of the vaccine.     

Linking yellow fever vaccinator approval and renewal with training in travel medicine in New Zealand

Yellow fever is a mosquito-borne disease, which can cause serious illness. The World Health Organization (WHO) requires travellers to have vaccination against Yellow fever for all international travel going into and from Yellow fever endemic areas in order to prevent the spread of this potentially deadly disease. Only clinics and hospitals authorised by health departments of national governments can administer the disease. Yellow fever vaccination centres are often subject to inspection in many countries, although the requirements for Yellow fever vaccinators (YFV) vary from country to country. In New Zealand, approval of YFV now requires specific postgraduate training in travel medicine or its equivalent, as well as continuing professional development to maintain this status. It is expected that this will assist in improving standards of travel medicine practice in New Zealand.     

Pre-travel preparation and outcome of HIV-infected travellers from a UK clinic

Objectives. To review the pre-travel preparations and travel health outcomes of HIV-infected individuals. Methods. A prospective questionnaire-based study among English speaking adults with HIV infection attending an outpatient clinic from July to November 2000. Results. Baseline and follow-up questionnaire data were available for 34 individuals whose median CD4 count was 451 cells/mm(3). Eleven of these (32%) had sought travel advice before departure. Eight (23.5%) had been vaccinated or were planning vaccination against at least one condition and 17 (50%) listed travel-specific medications they planned to take with them. Those who were travelling to Africa were more likely to be vaccinated than those who were not travelling to Africa (3/4 vs 5/30, respectively, P=0.03). Those travelling to Europe were less likely to be vaccinated than those who were not (1/16 vs 7/18, P=0.04). The median duration of travel was 14 days (1-180). Fifteen subjects (44%) became ill while abroad. Those who became ill abroad were more likely to have visited Asia (P=0.003) and less likely to have visited the Americas (P=0.02) than those who did not become ill abroad. In addition, they tended to have stayed abroad for longer periods (P=0.07) and had visited more countries (P=0.04) than those who did not become ill abroad. Sixteen individuals (47%) reported illness on their return to the UK. Conclusions. HIV-infected travellers have an increased susceptibility to opportunistic and other travel-related infections and the need for appropriate advice, vaccination and prophylactic therapy is important. Health care provision in this field is in need of uniform guidelines to coordinate travel health management for this particular high risk group.     

Descriptive analysis of malaria prophylaxis for travellers from Greece visiting malaria-endemic countries

International travel is changing the epidemiology of imported malaria. Our aim was to study malaria prophylaxis administered to travellers from Greece. The study was conducted during 2008-2009. Data were collected using a standardized form. A total of 2337 travellers were studied; prophylaxis was recommended to 60.2% of them. Of the 2337 travellers, 32.6% travelled to sub-Saharan Africa, 25.5% to South America, 11.8% to Indian subcontinent, 11.7% to Middle East, and 4.4% to Southeast Asia; prophylaxis was recommended to 77.4%, 64%, 80.6%, 4.8% and 73.5% of them, respectively. According to the purpose of travel, prophylaxis was recommended to 85.4% of those travelling for work, 75.2% of those visiting friends and relatives, and 62% of those travelling for recreation. Prophylaxis advised was provided to 68.5%, 66.2%, 61.5%, and 18.9% to those staying at a residence of local people, camping, hotels, and cruise ships, respectively. Regarding long-term travellers, malaria prophylaxis was recommended to 42.6%. Recommendation of malaria prophylaxis was significantly statistically in association with destination countries, purpose of travel, type of residence in endemic areas There is a need to improve recommendations for malaria prophylaxis for travellers from Greece, and to increase awareness and education of professionals providing travel health services in Greece.     

International travel among HIV-positive and HIV-negative men who have sex with men, San Francisco, USA

We measured the prevalence of international travel, the demographic and risk profile of international travellers and risk and preventive behaviours of travellers among HIV-negative and HIV-positive men who have sex with men (MSM), based in San Francisco, CA, USA, through the addition of questions to the local implementation of the National HIV Behavioral Surveillance survey in 2008. Of 270 MSM participating in the survey, slightly more than one-quarter (26.3%) had travelled internationally in the last year. Those with a history of international travel were more likely to be foreign born, of a higher socioeconomic status and HIV uninfected. Of eight HIV-positive MSM who travelled internationally (11.3% of HIV-positive MSM), all were on antiretroviral therapy and only three recalled being vaccinated for hepatitis A and B. Human papillomavirus infection was also higher among international travellers. Travel health services must be improved to address special needs of this population of international travellers.     

Rate of malarial infection among foreigners in a tertiary hospital of Thailand: change of epidemiology and importance of travel medicine (1996-2005)

BACKGROUND & OBJECTIVES: Malaria is still an important infectious disease in Thailand. The study of the incidence of malaria can provide useful data for disease prevention and control. At present, trade and travel can impact on vector-borne diseases, including malaria. Transmission of malaria from an endemic to a non-endemic area can be expected and this can affect the pattern of malaria epidemiology. METHODS: Analysis of rate of malarial infection among foreigners in a tertiary hospital of Thailand in the past decade (1996-2005) was carried out by scrutinising the available published and unpublished. RESULTS: According to this study, two main groups of travellers, the migrant workers from the nearby countries, who bring malaria from the endemic area in their countries and the naive cases as the travellers from the western countries, who expose to malaria during their travelling in Thailand, can be identified. CONCLUSION: Change of epidemiology due to high rate of infection in non-Thai patients and importance of travel on the epidemiology of malaria can be seen from this study.     

Travel-related health problems of Hong Kong residents: Assessing the need for travel medicine services

BACKGROUND: Although there has been a marked increase in travel among Hong Kong residents, travel-related health risks have not been well characterized nor has their use of travel medicine services. OBJECTIVES: To assess the travel health care needs of Chinese residents in Hong Kong by examining travel health problems of returning Hong Kong residents and by understanding their use of travel health services before or after travel. METHODS: Review of available data followed by a cross-sectional telephone survey of 280 travellers and 15 service providers. A structured pre-tested questionnaire was used for data collection. Household members, who were ethnic Chinese, aged 15-64 years, able to communicate in Cantonese, and who had travelled at least once during the preceding 12 months were invited to participate. RESULTS: There was a scarcity of travel medicine services in Hong Kong. The most common destinations for travellers were countries in the Asia-Pacific region, especially mainland China (33%). Twenty percent of the respondents developed health problems during or shortly after travel. Although only 9% of respondents had received pre-travel health advice, 61% used some form of precautions. Twelve percent had lost at least a day due to travel-related health problems. The service providers agreed that there are demands for travel health services. However, half of the service providers had not been trained in travel or tropical medicine. CONCLUSIONS: This study indicates the need for specialized travel medicine services in Hong Kong to improve the health of travellers.     

Epidemiology and clinical aspects of imported tropical diseases]

The number of people travelling of the tropical countries is in constant progression and today represents about 5% of the population of the developed countries. Mortality is mainly accidental. Morbidity essentially concerns transmissible diseases. Diarrhoeal symptoms occur in 20-55% of travellers, are bacterial in 2 cases out of 3, and can be prevented. Cholera should soon have an efficient oral vaccine. Hepatitis A is frequent in some travellers (2-3%) and can be prevented by vaccination. Hepatitis E is beginning to be observed. Strongyloidiasis can in some cases evolve to serious complications; it may be latent, so should be sought systematically after any visit to the tropics. Most affections on returning to the industrialised world concern paludism of the Plasmodium falciparum type, leading to a still high mortality rate of 400 per year in Europe, while the preventive and curative means available are sufficient. Any fever should therefore be suspected and suitable treatment given. Other causes of fever are acute viral hepatitis, typhoid fever, the arboviroses, and numerous other conditions. Dermatoses represent the third reason for consultation on returning. These mainly concern pruriginous symptoms with filariases and abnormal hosts being evidenced. Furunculous lesions indicate a diagnosis of cutaneous leishmaniosis or myases. Any form of pruritus should suggest a diagnosis of HIV infection, or pruritus should suggest a diagnosis of HIV infection, or particularly trypanosomiasis. The risk of sexually transmissible disease is overall 6-fold higher in tropical travellers; advice before travelling is therefore of paramount importance. Should a seropositive subject travel to the tropics?(ABSTRACT TRUNCATED AT 250 WORDS)     

Protection against tick-borne encephalitis (TBE) for people living in and travelling to TBE-endemic areas

Once considered a local health issue confined to certain regions in Russia and Central and Eastern Europe, tick-borne encephalitis (TBE) is now considered an international health concern, and the most important and widespread viral disease transmitted by ticks in Europe. The number of reported TBE cases continues to increase in many endemic regions, and new foci have been identified. Increases in travel, access to high-risk areas, and the pursuit of leisure activities within TBE-endemic areas are placing more people at risk of TBE. Travellers from non-endemic regions are often unaware of the risk of acquiring TBE and therefore many travellers are not protected against TBE. Active immunization is the most effective way to avoid TBE and its potentially life-threatening sequelae. After a tick bite, no post-exposure treatment including active/passive vaccination is available or recommended in the immunologically naive patient. Available vaccines have undergone a series of modifications and improvement in both composition (with special formulations for children) and schedules to further enhance the safety of immunization and to meet the needs of vaccinees. Efforts to develop internationally recognized recommendations for TBE vaccination for travellers are underway.     

Travellers to high UV-index countries: sun-exposure behaviour in 7822 French adults

BACKGROUND: Travel health information includes warning on sun exposure, particularly for fair-skinned individuals travelling to tropical countries. METHOD: A self-completed questionnaire on sun exposure behaviour was sent to the 12,741 French adults enrolled in the SU.VI.MAX cohort. Among the 7822 participants, 196 (110 women and 86 men) declared at least one visit to a high UV-index country over the past year for more than 1 month, subsequently referred to as long-term travellers. The remaining 7626 participants (non-travellers) accounted for 4862 women and 2764 men. RESULTS: Women travellers declared more frequently skin exposure to the sun over the past year, practised tanning in high UV-index areas more than 2h daily, experienced intensive sun exposure than non-travellers. Moreover, they asserted that basking in the sun is very important. Comparable results were found in men. The use of sun protection products was similar in travellers and non-travellers, but women tended to use sunscreen products more often, more regularly and with a higher sun protection factor (SPF) than men. CONCLUSIONS: Specific health education campaigns and pre-travel advice aiming to reduce sun exposure and to improve protective measures against ultraviolet (UV) radiation should be addressed to travellers to countries with high UV-index.