Challenges with medical tourism.

PURPOSE OF REVIEW: With the return of international travels to almost prepandemic levels, the number of patients who travel abroad to seek healthcare services is once again growing rapidly. Nevertheless, the expected benefits of medical tourism may be challenged by serious infectious complications. This review summarizes the evolving published evidence on infectious complications related with medical tourism of the last eighteen months. RECENT FINDINGS: There has been an increase of reported infectious complications in patients who had received healthcare abroad. Such complications were frequently associated with serious and prolonged morbidity, repeated treatments and hospitalizations, high healthcare costs, and occasionally fatalities. A devastating outbreak of fungal meningitis occurred among US residents who underwent epidural anesthesia for cosmetic surgery in two clinics in Mexico. Overall, as of July 5, 2023 there were 31 cases with severe cerebrovascular complications and eight deaths. Infections caused by nontuberculum mycobacteria and Candida sp have been also reported the last years. SUMMARY: Considering the expected expansion of medical tourism in the forthcoming years, public health authorities and scientific societies should raise awareness of such infections among physicians and other healthcare professionals and issue recommendations for their management. A system to report complications in patients receiving healthcare abroad is needed.

COVID-19 Outbreak on a Passenger Ship and Assessment of Response Measures, Greece, 2020.

We describe response measures to an outbreak involving 128 (33.4%) coronavirus disease cases (46.1% asymptomatic) among 383 persons onboard a passenger ship. Multivariate analysis indicated that dining in certain rooms and bar areas, nationality, working department (for crew members), and quarantining onboard the ship were significantly associated with infection.

Preparedness of paediatric international travellers departing from Athens, Greece: an 18-month airport-based survey.

AIM: The number of children who travel to tropical and subtropical areas has increased. This study aimed to assess the preparedness of children departing from Greece to Africa and Asia, in terms of vaccination and malaria chemoprophylaxis. METHODS: An 18-month airport-based study was conducted in Athens between November 2011 and April 2013. RESULTS: Of the 183 children studied, 122 (66.7%) had a foreign nationality. Their main destinations were the Indian subcontinent (43.2%), South-East Asia (30.6%) and sub-Saharan Africa (14.2%). Just under three-quarters (73.2%) of the children were travelling to visit friends and relatives. Forty (21.9%) children had received pretravel services. Children visiting friends and relatives sought pretravel services less frequently than those who were not (17.9% versus 32.7%; p = 0.033). Female children and Greek nationals were significantly more likely to seeking pretravel services than males and foreign nationals (p = 0.007 and <0.001, respectively). The rabies and the typhoid fever vaccines were administered inadequately to children travelling to endemic areas, but malaria chemoprophylaxis was generally justified. CONCLUSION: Travel medicine services for children in Greece should be improved. There is a particular need to communicate with the parents of children visiting friends and relatives.

Asclepieia in ancient Greece: pilgrimage and healing destinations, the forerunner of medical tourism.

Asclepios, the first physician-demigod in Greek mythology, was born in Thessaly of the God Apollo and Coronis, a mortal mother. Asclepieia were healing sanctuaries dedicated to Asclepios. Asclepieia were located throughout the Eastern Mediterranean area, in ancient Greece and the Roman world. Travelers from all over the Mediterranean area seeking healing made pilgrimages to the Asclepieia, the early forerunner of "medical tourism".

Travel vaccines throughout history.

Vaccinations are an important component of travel medicine. Beyond protection of travelers, vaccines are administered to prevent the importation of vaccine-preventable diseases at home and at destination. Proof of immunization to travel dates back to the first smallpox vaccine, developed by Edward Jenner in 1796. However, it took one century to generate the next vaccines against cholera, rabies, and typhoid fever. During the 20th century the armamentarium of vaccines used in travelers largely expanded with yellow fever, poliomyelitis, tetravalent meningococcal, and hepatitis A vaccines. The International Certificate of Inoculation and Vaccination was implemented in 1933. Currently there are vaccines administered to travelers following risk assessment, but also vaccines required according to the 2005 International Health Regulations and vaccines required at certain countries. Finally, within less than one year after the declaration of the coronavirus disease 2019 (COVID-19) pandemic, the first COVID-19 vaccines were launched and approved for emergency use to control the pandemic. Despite practical and ethical challenges, COVID-19 vaccine verifications have been widely used since spring 2021 in many activities, including international travel. In this article, we review the course of development of travel vaccines focusing on those for which a proof of vaccination has been or is required.

High heterogeneity on the accepted vaccines for COVID-19 certificates in European countries.

BACKGROUND: We aimed to elucidate which vaccines were accepted by European countries as valid proof of vaccination against COVID-19 for international travelers. METHOD: On 27-September-2021 a cross-sectional study was conducted on VisaGuide.World, that reports on valid vaccines for international travelers. Other databases, lay press and regulatory agencies were also checked. The main outcome measure was which of the vaccines included on the WHO emergency use listing (EUL) [ChAdOx1 (Vaxzevria, Covishield),BNT162b2,mRNA-1273,Ad26.CoV2.S,BBIBP-CorV,CoronaVac] and Sputnik V, were accepted in each country. The influence of the vaccines approved for COVID-19 vaccination programs on the vaccines recognized as proof of vaccination was assessed. RESULTS: There was a remarkable heterogeneity on the vaccines accepted as proof of vaccination among 46 countries. Russia accepted only one. Cyprus, Greece and Slovenia accepted all vaccines considered. Eleven countries accepted the seven WHO EUL vaccines: eight EU countries, plus Iceland, Norway and Switzerland. Seven EU countries accepted only the four EMA-authorized vaccines. Considering Covishield as equivalent to Vaxzevria, 69% of countries recognized only vaccinated travelers who received any of the vaccines approved for vaccination programs in the country of arrival as valid. CONCLUSION: Vaccines accepted as proof of vaccination should be harmonized. Accepting any of the WHO EUL vaccines would be a scientifically sound objective.

Catheter-Associated Urinary Tract Infections, Bacteremia, and Infection Control Interventions in a Hospital: A Six-Year Time-Series Study.

Catheter-associated urinary tract infections (CAUTIs) are among the most common healthcare-associated infections. Urine catheters are often reservoirs of multidrug-resistant (MDR) bacteria and sources of pathogens transmission to other patients. The current study was conducted to investigate the correlation between CAUTIs, MDR bacteremia, and infection control interventions, in a tertiary-care hospital in Athens, from 2013 to 2018. The following data were analyzed per month: 1. CAUTI incidence; 2. consumption of hand hygiene disinfectants; 3. incidence of isolation of MDR carrier patients, and 4.incidence of bacteremia/1000 patient-days [total resistant a.Gram-negative: carbapenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, and Klebsiella pneumoniae; b.Gram-positive: vancomycin-resistant Enterococci and methicillin-resistant Staphylococcus aureus]. The use of scrub disinfectant solutions was associated with decreased CAUTI rate in Total Hospital Clinics (OR: 0.97, 95% CI: 0.96−0.98, p-value: <0.001) and in Adults ICU (OR: 0.79, 95% CI: 0.65−0.96, p-value:0.018) while no correlation was found with isolation rate of MDR-carrier pathogens. Interestingly, an increase in total bacteremia (OR: 0.81, 95% CI: 0.75−0.87, p-value:<0.001) or carbapenem-resistant bacteremia correlated with decreased incidence of CAUTIs (OR: 0.96, 95% CI: 0.94−0.99, p-value: 0.008). Hand hygiene measures had a robust and constant effect on infection control, reducing the incidence of CAUTIs.

Role of diabetes mellitus in the clinical course and outcome of SARS-CoV-2 infected patients.

PURPOSE: Our aim was to study patients with diabetes mellitus and SARS-CoV-2-infection diagnosed during the first pandemic wave in Greece. METHODS: Cases were retrieved from the national database of SARS-CoV-2 infections. RESULTS: We studied 2624 SARS-CoV-2 infected cases, including 157 with diabetes. Patients with diabetes more often had other comorbidities (68.8 vs. 24.1%; p-value < 0.001). Among patients with diabetes, 149 (94.9%) developed symptomatic disease (COVID-19) compared to 1817 patients (73.7%) without diabetes (p-value < 0.001). A total of 126 patients with diabetes and COVID-19 were hospitalized and 41 died (27.5% case-fatality rate compared to 7.5% among patients without diabetes; p-value < 0.001). Patients with diabetes more often were hospitalized, developed complications, were admitted to the intensive care unit (ICU), received invasive mechanical ventilation, and died compared to patients without diabetes (p-values < 0.001 to 0.002 for all comparisons). Multivariate logistic regression analyses revealed that diabetes, having other comorbidities, and older age were significantly associated with higher risk for hospitalization, ICU admission, invasive mechanical ventilation, and death, and that obesity was significantly associated with higher risk for hospitalization, ICU admission, and mechanical intubation, while female gender protected against these outcomes. CONCLUSION: COVID-19 is associated with increased rates of serious morbidity and adverse outcome in patients with diabetes and represents a severe illness for them.

Effectiveness of maternal vaccination with quadrivalent inactivated influenza vaccine in pregnant women and their infants in 2019-2020.

OBJECTIVES: Influenza is associated with an increased risk for serious illness, hospitalization, and death in pregnant women and young infants. Our aim was to estimate the effectiveness of a quadrivalent inactivated influenza vaccine (QIV) in pregnant women and their infants during 2019-2020. METHODS: A QIV vaccine was offered to pregnant women followed in a maternity hospital. Women were contacted weekly during the influenza season and asked about symptoms. Polymerase chain reaction testing in pharyngeal samples was offered to pregnant women and infants with influenza-like illness. A Bayesian beta-binomial model was used. RESULTS: We studied 636 pregnant women (406 vaccinated and 230 unvaccinated) and 474 infants (281 of mothers vaccinated in pregnancy and 193 of unvaccinated mothers). Using a Bayesian beta-binomial model, it was estimated that influenza vaccination of pregnant women reduced their logit to develop laboratory-confirmed influenza by -4.2 (95% CI -3,7 - 4,7) and the logit of their infants to develop laboratory-confirmed influenza by -4.2 (95% CI -3.6, -4.9). The QIV effectiveness against laboratory-confirmed influenza was 43.5% in pregnant women and 31.4% in infants. CONCLUSION: Maternal influenza vaccination with QIV in pregnancy reduced the odds of pregnant women and their infants to develop influenza. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov identifier is NCT04723771.

Vaccination coverage rates and attitudes towards mandatory vaccinations among healthcare personnel in tertiary-care hospitals in Greece.

OBJECTIVES: Our aim was to estimate vaccination and susceptibility rates against vaccine-preventable diseases among healthcare personnel (HCP) in eight hospitals. METHODS: Cross-sectional survey. RESULTS: A total of 1284 HCP participated (physicians: 31.3%, nursing personnel: 36.6%, paramedical personnel: 11.1%, administrative personnel: 13.2%, supportive personnel: 7.3%). Vaccination rates were 32.9% against measles and mumps, 38.1% against rubella, 5.7% against varicella, 9.2% against hepatitis A, 65.8% against hepatitis B, 31.8% against tetanus-diphtheria, 7.1% against pertussis, 60.2% against influenza, and 80.1% against COVID-19. Susceptibility rates were as follows: 27.8% for measles, 39.6% for mumps, 33.4% for rubella, 22.2% for varicella, 86.3% for hepatitis A, 34.2% for hepatitis B, 68.2% for tetanus-diphtheria, and 92.9% for pertussis. Older HCP had higher susceptibility rates against mumps, rubella, varicella, hepatitis A, hepatitis B, tetanus-diphtheria, and pertussis (p-values <0.001 for all). Mandatory vaccinations were supported by 81.85% of HCP. CONCLUSIONS: Although most HCPs supported mandatory vaccinations, significant vaccination gaps, and susceptibility rates were recorded. The proportion of susceptible HCP to measles, mumps, rubella, and varicella has increased in the past decade, mostly because of reduction in acquired cases of natural illness. Vaccination programs for HCP should be developed. A national registry to follow HCP's vaccination rates is urgently needed.

Infectious complications related to medical tourism.

BACKGROUND: Medical tourism has been increasing dramatically globally, with people travelling from developed countries to low-income or middle-income countries, often to avoid high costs or long delays associated with seeking healthcare in their countries of origin. The current review summarizes healthcare-related infections associated with medical tourism, focusing on cosmetic surgery and organ transplantation. METHODS: A systematic MEDLINE and PubMed search from January 2010 to December 2019 yielded 80 relevant articles, including 49 articles on medical tourism-related infections focusing on cosmetic surgery and organ transplantation, which were included in this reviews. RESULTS: The literature reveals specific types of cross-border, healthcare-related infections depending on medical intervention. Destinations include low-income countries such as countries of Asia and the Indian subcontinent, middle-income countries including Central and South America, and high-income countries such as the United States and Europe. In terms of type of infections, in 36 (68%) and 15 (28.3%) studies, wound and blood-borne infections were documented, respectively, while in 21 studies (58.3%) non-tuberculous mycobacteria were isolated, including Mycobacterium abscessus, Mycobacterium chelonae, Mycobacterium senegalense and Mycobacterium fortuitum. The choices of medical tourists could have significant consequences for them and their home countries, including infectious complications and importation of pathogens, particularly antibiotic-resistant microorganisms, with public health implications. CONCLUSIONS: There is a need for public health strategies in order to prevent morbidity and mortality as well as future management and education of patients engaging in medical tourism.

Post-COVID Syndrome: Incidence, Clinical Spectrum, and Challenges for Primary Healthcare Professionals.

Post-COVID syndrome also known as long COVID refers to symptoms persisting for more than three weeks after the diagnosis of COVID-19. We reviewed the current evidence on post-COVID syndrome, focusing on its clinical manifestations and addressing the challenges for its management in primary healthcare. The incidence of post-COVID syndrome is estimated at 10-35%, while for hospitalized patients it may reach 85%. Fatigue is the most common symptom reported in 17.5-72% of post-COVID cases, followed by residual dyspnea with an incidence ranging from 10-40%. Mental problems, chest pain, and olfactory and gustatory dysfunction may affect up to 26, 22 and 11% of patients, respectively. More than one third of patients with post-COVID syndrome have pre-existing comorbidities, hypertension and diabetes mellitus being the most common. Beyond the prolonged duration of symptoms, the scarce published data indicate that most patients with post-COVID syndrome have a good prognosis with no further complications or fatal outcomes reported. Given the clinical spectrum of patients with post-COVID syndrome, most of them will be managed by primary healthcare professionals, in conjunction with pre-existing or new co-morbidities, which, in turn, may increase the burden of COVID-19 on primary healthcare. In conclusion approximately 10% of patients with COVID-19 may have symptoms persisting beyond three weeks, fulfilling the criteria of post-COVID syndrome. Primary healthcare professionals have a key role in the management of patients with post-COVID syndrome. Research is needed to elucidate the pathogenesis, clinical spectrum, and prognosis of post-COVID syndrome.

Post-COVID Syndrome: An Insight on Its Pathogenesis.

Post-COVID syndrome is increasingly recognized as a new clinical entity in the context of SARS-CoV-2 infection. Symptoms persisting for more than three weeks after the diagnosis of COVID-19 characterize the post-COVID syndrome. Its incidence ranges from 10% to 35%, however, rates as high as 85% have been reported among patients with a history of hospitalization. Currently, there is no consensus on the classification of post-COVID syndrome. We reviewed the published information on post-COVID syndrome, putting emphasis on its pathogenesis. The pathogenesis of post-COVID syndrome is multi-factorial and more than one mechanism may be implicated in several clinical manifestations. Prolonged inflammation has a key role in its pathogenesis and may account for some neurological complications, cognitive dysfunction, and several other symptoms. A multisystem inflammatory syndrome in adults (MIS-A) of all ages has been also described recently, similarly to multisystem inflammatory syndrome in children (MIS-C). The post-infectious inflammatory pathogenetic mechanism of MIS-A is supported by the fact that its diagnosis is established through serology in up to one third of cases. Other pathogenetic mechanisms that are implicated in post-COVID syndrome include immune-mediated vascular dysfunction, thromboembolism, and nervous system dysfunction. Although the current data are indicating that the overwhelming majority of patients with post-COVID syndrome have a good prognosis, registries to actively follow them are needed in order to define the full clinical spectrum and its long-term outcome. A consensus-based classification of post-COVID syndrome is essential to guide clinical, diagnostic, and therapeutic management. Further research is also imperative to elucidate the pathogenesis of post-COVID syndrome.

Determinants of intention to get vaccinated against COVID-19 among healthcare personnel in hospitals in Greece.

BACKGROUND: To investigate intention rates to get vaccinated against COVID-19 among healthcare personnel (HCP) in Greece. METHODS: Cross-sectional survey. RESULTS: The response rate was 14.5%. Of 1521 HCP with a known profession, 607 (39.9%) were nursing personnel, 480 (31.6%) physicians, 171 (11.2%) paramedical personnel, 72 (4.7%) supportive personnel, and 191 (12.6%) administrative personnel. Overall, 803 of 1571 HCP (51.1%) stated their intention to get vaccinated while 768 (48.9%) stated their intention to decline vaccination. Most HCP (71.3%) who reported intent to get vaccinated noted contributing to the control of the pandemic and protecting their families and themselves as their reasons, while the most common reason for reporting intent to decline vaccination was inadequate information about the vaccines (74.9%), followed by concerns about vaccine safety (36.2%). Logistic regression analysis revealed that the probability of intending to get vaccinated increased with male gender, being a physician, history of complete vaccination against hepatitis B, history of vaccination against pandemic A (H1N1) in 2009-2010, belief that COVID-19 vaccination should be mandatory for HCP, and increased confidence in vaccines in general during the COVID-19 pandemic. The following factors were associated with a lower intention to get vaccinated: no vaccination against influenza the past season, no intention to get vaccinated against influenza in 2020-2021, and no intention to recommend COVID-19 vaccination to high-risk patients. CONCLUSION: There is an urgent need to built safety perception towards COVID-19 vaccines and raise vaccine uptake rates by HCP, and thus to protect the healthcare workforce and the healthcare services.

In-flight transmission of COVID-19 on flights to Greece: An epidemiological analysis.

BACKGROUND: The emergence in China in late 2019 and subsequent progression of a pandemic of a respiratory disease named coronavirus disease 2019 (COVID-19) was highly facilitated by international travel. We present 5 cases of probable in-flight transmission in Greece. METHODS: We studied international passengers arriving to or departing from Greece from February 26 through March 9, 2020. Contact tracing extended up to 4 days before the onset of symptoms and focused on close contacts. Close contacts were defined as persons sitting within a distance of <2 m for >15 min, including passengers seated two seats around the index case and all crew members and persons who had close contact with the index case. RESULTS: We investigated 18 international flights with 2224 passengers and 110 crew members. Main countries of departure included Northern Italy, Israel and the United Kingdom. In accordance with the national surveillance investigation, in these flights there were 21 index cases and 891 contact traced cases. Six index cases were symptomatic during the flight. Of the 891 contact traced cases, 4 passengers and 1 crew member developed laboratory-confirmed infection (3 with COVID-19 and 2 with asymptomatic infection); they travelled on the same flight with two COVID-19 cases. CONCLUSIONS: Air travel has played a central role in the progression of the COVID-19 pandemic. However, there are scarce data about in-flight transmission. Our extensive investigation showed five cases of probable in-flight transmission. Efforts should be placed in order to ensure the prompt implementation of appropriate infection control measures on board.

A case of Crimean-Congo haemorrhagic fever imported in Greece: Contact tracing and management of exposed healthcare workers.

BACKGROUND: Nosocomial transmission is a major mode of infection of Crimean-Congo haemorrhagic fever (CCHF). In May 2018, a patient with CCHF was hospitalised in Greece. OBJECTIVE: Our aim was to present the management of healthcare workers (HCWs) to the CCHF case. METHODS: Contact tracing, risk assessment and follow-up of exposed HCWs were performed. Testing (RT-PCR and/or serology) was offered to contacts. Post-exposure prophylaxis (PEP) with ribavirin was considered for high-risk exposures. RESULTS: Ninety-one HCWs were exposed to the case. Sixty-six HCWs were grouped as high-risk exposures. Ribavirin PEP was offered to 29 HCWs; seven agreed to receive prophylaxis. Forty-one HCWs were tested for CCHF infection; none was found positive. Gaps in infection control occurred. DISCUSSION: CCHF should be considered in patients with compatible travel history and clinical and laboratory findings. Early clinical suspicion and laboratory confirmation are imperative for the implementation of appropriate infection control measures. Ribavirin should be considered for high-risk exposures. Infection control capacity for highly pathogenic agents should increase.

Vaccinations and Malaria Chemoprophylaxis of Adolescents Traveling From Greece to International Destinations: A Nine-Year Prospective Study.

BACKGROUND: There are few publications focusing on vaccination and malaria chemoprophylaxis in adolescent travelers. We assessed pretravel vaccinations and malaria chemoprophylaxis of adolescents 12-18 years old traveling from Greece to international destinations. METHODS: We prospectively studied 239 adolescents 12-18 years old during 2008-2016. A standard questionnaire was used to collect data. RESULTS: Adolescents sought pretravel services at a mean of 24.1 days before departure. Their main destinations were sub-Saharan Africa (79 adolescents; 33.1%), Latin America (56; 23.5%) and North America (26; 10.9%). Almost half (46.1%) of them planned to stay abroad for at least 3 months. Sixteen (7.4%) adolescents planned to visit friends and relatives. The yellow fever vaccine and the typhoid vaccine were the most frequently administered vaccines (74.1% and 20.5%, respectively), while the hepatitis A vaccine and the tetanus-diphtheria vaccine accounted for most routine vaccinations (18% and 14.2%, respectively). The rabies and the typhoid fever vaccines were administered inadequately to adolescents traveling to endemic areas. Malaria chemoprophylaxis should have been prescribed in many cases traveling to sub-Saharan Africa and the Indian subcontinent. CONCLUSIONS: Only a small number of adolescents from Greece traveling abroad seek pretravel counseling. We found significant gaps in typhoid fever and rabies vaccinations of adolescents traveling to endemic areas. We also found gaps in prescription of malaria chemoprophylaxis for those traveling to high-risk areas. There is a need to develop communication strategies to access adolescent travelers and improve appropriate vaccination and use of malaria chemoprophylaxis.

Preparedness of adolescents departing from Athens International Airport to Africa or Asia: A five-year airport-based prospective study.

BACKGROUND: The number of adolescents who travel has increased. We estimated the preparedness of adolescents (12-18 years) departing from Athens to Africa and Asia. METHODS: An airport-based survey was conducted from 2011 to 2015. RESULTS: Sixty-eight adolescents participated; 27/68 (40%) had the Greek nationality. Their main destinations were the Indian subcontinent (37%) and South-East Asia (32%). Most adolescents planned to stay for <1 month (69%) or for 1-3 months (22%). Their main purpose for travel was to visit friends and relatives (VFRs) (60%). Compared to non-VFR adolescents, VFRs more frequently travelled to sub-Saharan Africa and Southeast Asia, stayed in local residences and for longer periods. Twenty-one (31%) adolescents sought pre-travel counseling (in 57% of cases 8-14 days before departure). Having the Greek nationality was the only significant factor associated with an increased probability for seeking pre-travel counseling. Vaccination against rabies, typhoid fever, Japanese encephalitis and meningococcus was highly inadequate for adolescents travelling to endemic areas. Significant gaps in malaria chemoprophylaxis were found in those travelling to the Indian subcontinent. CONCLUSIONS: Less than one third of adolescents travelling to Africa and Asia seek counseling. There is a need to access adolescent travellers in Greece and improve pre-travel vaccinations and malaria chemoprophylaxis.

Health problems of newly arrived migrants and refugees in Europe.

Background: The number of migrants and refugees in Europe in the past few years has increased dramatically due to war, violence or prosecutions in their homeland. Migration may affect physical, mental and social health. The objective of this article is to assess migrants and refugees' health problems, and to recommend appropriate interventions. Methods: A PubMed search of published articles on health problems of newly arrived migrants and refugees was conducted from 2003 through 2016, focusing on the current refugee crisis in Europe. Results: In addition to communicable diseases, such as respiratory, gastrointestinal and dermatologic infections, non-communicable diseases, including chronic conditions, mental and social problems, account for a significant morbidity burden in newly arrived migrants and refugees. Vaccine-preventable diseases are also of outmost importance. The appropriate management of newly arrived refugees and migrants' health problems is affected by barriers to access to health care including legal, communication, cultural and bureaucratic difficulties. There is diversity and lack of integration regarding health care provision across Europe due to policy differences between health care systems and social services. Conclusion: There is a notable burden of communicable and non-communicable diseases among newly arrived migrants and refugees. Provision of health care at reception and temporary centres should be integrated and provided by a multidisciplinary team Appropriate health care of migrants and refugees could greatly enhance their health and social status which will benefit also the host countries at large.