Ready-To-Go Questionnaire - Development and validation of a novel medical pre-travel risk stratification tool.

BACKGROUND: There are no validated pre-travel self-assessment tools to stratify travellers' health risks and identify their needs for pre-travel medical preparation. This study presents a novel pre-travel risk stratification tool (Ready-To-Go Questionnaire). METHODS: The Ready-To-Go Questionnaire was developed by travel medical experts. It assesses information on travellers' itinerary and current health status, thereby assigning travellers to one out of four risk categories. To explore the Ready-To-Go Questionnaire's validity, we analysed the agreement between the risk categories resulting from the questionnaire and predefined validation criteria. This study was carried out at the Travel Clinic, University of Zurich, Switzerland. RESULTS: One hundred travellers attending a pre-travel consultation were included. 82% corresponded to the substantial-risk category, 17% to the high-risk category, 1% to the moderate-risk category and 0% to the low-risk category. The concordance between the risk categories and the consultants' risk assessment, was 0.39 and 0.29 (unweighted/weighted Cohen's Kappa). No significant concordance was found between the risk categories and additional validation criteria. CONCLUSION: The Ready-To-Go Questionnaire is a medical triage tool developed to identify different levels of travel-related health risks. This tool assists in better understanding travellers' needs, shaping modern travel consultations and offering patient-centred travel medicine services. CLINICAL TRIAL REGISTRATION NUMBER: ISRCTN10172086.

Air travel and COVID-19 prevention in the pandemic and peri-pandemic period: A narrative review.

Air travel during the COVID-19 pandemic is challenging for travellers, airlines, airports, health authorities, and governments. We reviewed multiple aspects of COVID peri-pandemic air travel, including data on traveller numbers, peri-flight prevention, and testing recommendations and in-flight SARS-CoV-2 transmission, photo-epidemiology of mask use, the pausing of air travel to mass gathering events, and quarantine measures and their effectiveness. Flights are reduced by 43% compared to 2019. Hygiene measures, mask use, and distancing are effective, while temperature screening has been shown to be unreliable. Although the risk of in-flight transmission is considered to be very low, estimated at one case per 27 million travellers, confirmed in-flight cases have been published. Some models exist and predict minimal risk but fail to consider human behavior and airline procedures variations. Despite aircraft high-efficiency filtering, there is some evidence that passengers within two rows of an index case are at higher risk. Air travel to mass gatherings should be avoided. Antigen testing is useful but impaired by time lag to results. Widespread application of solutions such as saliva-based, rapid testing or even detection with the help of "sniffer dogs" might be the way forward. The "traffic light system" for traveling, recently introduced by the Council of the European Union is a first step towards normalization of air travel. Quarantine of travellers may delay introduction or re-introduction of the virus, or may delay the peak of transmission, but the effect is small and there is limited evidence. New protocols detailing on-arrival, rapid testing and tracing are indicated to ensure that restricted movement is pragmatically implemented. Guidelines from airlines are non-transparent. Most airlines disinfect their flights and enforce wearing masks and social distancing to a certain degree. A layered approach of non-pharmaceutical interventions, screening and testing procedures, implementation and adherence to distancing, hygiene measures and mask use at airports, in-flight and throughout the entire journey together with pragmatic post-flight testing and tracing are all effective measures that can be implemented. Ongoing research and systematic review are indicated to provide evidence on the utility of preventive measures and to help answer the question "is it safe to fly?".

Public health emergencies of international concern: a historic overview.

RATIONALE: The International Health Regulations (IHR) have been the governing framework for global health security since 2007. Declaring public health emergencies of international concern (PHEIC) is a cornerstone of the IHR. Here we review how PHEIC are formally declared, the diseases for which such declarations have been made from 2007 to 2020 and justifications for such declarations. KEY FINDINGS: Six events were declared PHEIC between 2007 and 2020: the 2009 H1N1 influenza pandemic, Ebola (West African outbreak 2013-2015, outbreak in Democratic Republic of Congo 2018-2020), poliomyelitis (2014 to present), Zika (2016) and COVID-19 (2020 to present). Poliomyelitis is the longest PHEIC. Zika was the first PHEIC for an arboviral disease. For several other emerging diseases a PHEIC was not declared despite the fact that the public health impact of the event was considered serious and associated with potential for international spread. RECOMMENDATIONS: The binary nature of a PHEIC declaration is often not helpful for events where a tiered or graded approach is needed. The strength of PHEIC declarations is the ability to rapidly mobilize international coordination, streamline funding and accelerate the advancement of the development of vaccines, therapeutics and diagnostics under emergency use authorization. The ultimate purpose of such declaration is to catalyse timely evidence-based action, to limit the public health and societal impacts of emerging and re-emerging disease risks while preventing unwarranted travel and trade restrictions.

The Impact of Receiving Pretravel Health Advice on the Prevention of Hajj-Related Illnesses Among Australian Pilgrims: Cohort Study.

BACKGROUND: Pretravel health advice can play a crucial role in improving both travelers' awareness about disease risk and compliance with preventive measures. General practitioners (GPs) and the internet have been reported internationally to be the main sources of health advice for travelers to non-mass gathering (MG) destinations. However, few studies have attempted to investigate the sources of health advice among travelers to MGs including the Hajj pilgrimage, and none of these studies further investigated the impact of pretravel advice on pilgrims' health behaviors. OBJECTIVE: The objective of this study was to investigate the impact of the source of pretravel health advice (from GPs and specialized Hajj travel agents) on Hajj pilgrims' awareness of and compliance with health recommendations, and the incidence of Hajj-associated illnesses. METHODS: A prospective cohort study (before and during Hajj) was conducted among Australian pilgrims aged ≥18 years in 2015. RESULTS: A total of 421 pilgrims participated prior to Hajj, and 391 (93%) provided follow-up data during Hajj. All participants obtained pretravel health advice from one or more sources, with Hajj travel agents (46%) and general practitioners (GPs; 40%) the most commonly reported sources. In total, 288 (74%) participants reported Hajj-related symptoms, of which 86% (248/288) were respiratory symptoms. Participants who obtained pretravel health advice from travel agents were more likely to be aware of the official Saudi recommendations (adjusted odds ratio [aOR] 2.1, 95% CI 1.2-3.8; P=.01), receive recommended vaccines before travel (aOR 2.4, 95% CI 1.4-3.9; P=.01), use hand sanitizers including soap (aOR 2.5, 95% CI 1.1-6.1; P=.03), and wash their hands after touching an ill person during Hajj (aOR 2.9, 95% CI 1.1-7.1; P=.01), compared to those who sought advice from GPs. However, neither advice from travel agents nor GPs was associated with a lower incidence of Hajj-related illnesses. CONCLUSIONS: Advice from travel agents appeared to be accessed by more travelers than that from GPs, and was associated with an increased likelihood of positive travel health behaviors.

A Primary Care-Based Quality Improvement Initiative to Increase Identification of Pediatric International Travelers.

Children who travel internationally to visit friends and relatives (VFRs) are at risk for travel-related illness, but underuse pretravel health services. Although primary care clinics can identify travelers and address pretravel health needs, to date, there are few published reports on effective primary care-based pretravel interventions. We developed a quality improvement initiative to increase traveler identification at a primary care clinic serving families that frequently travel to VFRs. Interventions included a screening question asked at all clinic visits, provider and staff training, travel fliers, and health recommendation sheets for families. Interventions were implemented during 2017 and 2018 peak travel seasons. Travel visit rates and characteristics during the intervention period were compared with pre-intervention baseline periods (April-August, 2015-16). Surveys with providers were conducted to assess disruptiveness of the interventions, and rates of duplicate travel visits were assessed. A total of 738 unique travel events were identified during peak travel seasons from 2015 to 2018, encompassing travel to 29 countries across five continents. Overall, there were 428 unique travel events (3.0% of all clinic visits) during peak seasons 2017-18, compared with 310 unique travel events (2.2% of all clinic visits) during peak seasons 2015-16 (rate ratio 1.34 [95% CI: 1.16-1.56], P < 0.001). None of the 18 healthcare providers or staff surveyed found new travel screening processes to be disruptive or bothersome. Implementation of a primary care-based multimodal travel screening and education initiative was associated with a significantly increased rate of travel visits.

Travel medicine consultation: An opportunity to improve coverage for routine vaccinations.

BACKGROUND: Travelers may be responsible for the spread of vaccine-preventable diseases upon return. Travel physicians and family physicians may play a role in checking and updating vaccinations before traveling. Our aim was to evaluate the vaccine coverage for mandatory and recommended vaccination in travelers attending a travel medicine clinic (TMC). METHODS: Vaccine coverage was measured using the current French immunization schedule as reference for correct immunization, in travelers providing a vaccination certificate during the TMC visit (university hospital of Saint-Étienne), between August 1, 2013 and July 31, 2014. RESULTS: In total, 2336 travelers came to the TMC during the study period. Among the 2019 study participants, only 1216 (60.3%) provided a vaccination certificate. Travelers who provided a vaccination certificate were significantly younger than travelers who did not (mean age: 34.8±17.8 vs. 46±18.4 years, P<0.005) and were less likely to be Hajj pilgrims. Vaccine coverage against Tetanus, Diphtheria, and Poliomyelitis (Td/IPV vaccine) was 91.8%, 78.6% against Measles, Mumps, and Rubella (MMR), and 59.4% against Viral Hepatitis B (HBV). BCG vaccine coverage was 71.9%. Older travelers were less likely to be correctly vaccinated, except against HBV as vaccinated travelers were significantly older than unvaccinated travelers. CONCLUSION: Obtaining information about immunization in travelers is difficult. Coverage for routine vaccines should be improved in this population. Travel medicine consultations could be the opportunity to vaccinate against MMR, HBV, and Td/IPV.

Health Guidelines for Travel Abroad.

Most travel medical care is provided by patients' primary care physicians; only 10% of international travelers visit a travel clinic. The main purposes for travel include vacationing, visiting friends and family, business, and for educational purposes. The purposes of the pretravel consultation are to estimate risk and provide recommendations to mitigate risk.

When travel is a challenge: Travel medicine and the 'dis-abled' traveller.

Travellers with recognised disabilities or the dis-ability to function as required during a trip have been overlooked in the travel medicine literature. This paper provides a starting point for further discussion and research into this neglected traveller population. In contrast, tourism research has explored travel with a disability for some time in order to understand the travellers' needs and to improve services accordingly. The contemporary bio-psycho-social understanding of disability serves as the framework for exploring motivations to travel as well as barriers, such as inter and intrapersonal, economic, structural and attitudinal obstacles. The demands of complex travel planning are acknowledged. Attention is also drawn to the particular issue of acquired disability. The theoretical discussion is complemented by travellers' own accounts using as examples mobility impairment on aeroplanes, sensory impairments, and obesity. These insights should inform high quality travel health care starting with an exploration of the health professionals' own views on such endeavours. Important are appropriate communication skills, an understanding of the travellers'/carers' views, wishes and judgment of abilities, as well as the appreciation of the reason for the trip, destination and planned activities. Challenging may be the need to accept that the traveller/carer will be more knowledgeable about the disability, needs, potential problems and solutions than the health professional. Finally, medical requirements for destination and activity need to be combined with the medical requirements for the dis-abling condition. Scarce literature and increasing numbers of travellers with disabilities should make this field a research priority in travel medicine. Unless there is an absolute medical contraindication, travel health professionals should encourage and support travellers for whom travel is a challenge.

Prevalencia de la eosinofilia y factores relacionados en los viajeros e inmigrantes de la red +REDIVI / Eosinophilia prevalence and related factors in travel and immigrants of the network +REDIVI

Algunas enfermedades infecciosas han adquirido más relevancia por el aumento de los movimientos poblacionales. La eosinofilia es un hallazgo frecuente en inmigrantes y en viajeros. Una de las causas más frecuentes de eosinofilia es la infección por helmintos y algunos protozoos intestinales. El objetivo de este trabajo es describir las características epidemiológicas de los casos con eosinofilia y su asociación con la presencia de parásitos en la red de datos REDIVI. Se trata de un estudio observacional multicéntrico prospectivo, donde se incluyen los casos diagnosticados de eosinofilia registrados en la Red cooperativa para el estudio de las infecciones importadas por viajeros e inmigrantes (+REDIVI) desde enero de 2009 hasta diciembre de 2012. Se registraron en la red un total de 5.255 episodios durante el periodo de estudio, y la eosinofilia fue un hallazgo en el 8,1 al 31,3% de los casos (dependiendo del tipo migratorio). Fueron hombres el 60,2%, con una mediana de 31,0años, inmigrantes el 72,4% y asintomáticos el 81,2%. Los parásitos más frecuentemente identificados fueron S.stercoralis(34,4%), Schistosoma sp. (11,0%) y uncinarias (8,6%). Existía asociación entre eosinofilia y presencia de parásitos para todos los helmintos (excepto para larva migrans cutánea). La sintomatología y la duración del viaje no determinaron significativamente la presencia de eosinofilia. Ante una eosinofilia en una persona que ha vivido en zonas endémicas de helmintiasis es aconsejable realizar estudios dirigidos para su diagnóstico, independientemente del tipo migratorio, la duración de la estancia o la presencia de sintomatología (AU)

The population movements during the last decades have resulted in a progressively increasing interest in certain infectious diseases. Eosinophilia is a common finding in immigrants and travelers. One of the most common causes of eosinophilia is helminth infection, and some intestinal protozoa. The aim of this paper is to describe the epidemiological characteristics of cases with eosinophilia and its association with the presence of parasites in the REDIVI data network. This is a multicenter prospective observational study that includes patients diagnosed with eosinophilia registered in the cooperative network for the study of infectious diseases in travelers and immigrants (+REDIVI) from January 2009 to December 2012. A total of 5,255 episodes were recorded in the network during the study period, and eosinophilia was observed in 8.1-31.3% of cases (depending on the immigration group). There were 60.2% men, with a median age of 31years. There were 72.4% immigrants, and 81.2% were asymptomatic. The most commonly identified parasites were S.stercoralis (34.4%), Schistosoma sp. (11.0%), and hookworm (8.6%). The relationship between eosinophilia and parasite infection was significant for all helminths (except for cutaneous larva migrans). The symptoms and duration of the journey did not significantly determine the presence of eosinophilia. In the case of eosinophilia in a person who has lived in helminth endemic areas, it is advisable to carry out targeted studies to diagnose the infection, regardless of immigration type, length of stay, or the presence of symptoms (AU)

Global trends in center accreditation by the Joint Commission International: growing patient implications for international medical and surgical care.

Millions of patients travel internationally for medical and surgical care. We found that the annual number of centers accredited by the Joint Commission International increased from one center in 1999 to 132 centers in 2016; there are currently 939 accredited centers across 66 countries. Public health and medicolegal implications related to medical travel deserve attention.

Pre-travel care for immunocompromised and chronically ill travellers: A retrospective study.

BACKGROUND: Immunocompromised and chronically ill travellers (ICCITs) are susceptible to travel related diseases. In ICCITs, pre-travel care regarding vaccinations and prophylactics is complex. We evaluated the protection level by preventive measures in ICCITs by analysing rates of vaccination protection, antibody titres, and the prescription of standby antibiotics. METHODS: We analysed, and reported according to STROBE guidelines, pre-travel care data for ICCITs visiting the medical pre-travel clinic at the Academic Medical Centre, The Netherlands from 2011 to 2016. RESULTS: We analysed 2104 visits of 1826 ICCITs. Mean age was 46.6 years and mean travel duration 34.5 days. ICCITs on immunosuppressive treatment (29.7%), HIV (17.2%) or diabetes mellitus (10.2%) comprised the largest groups. Most frequently visited countries were Suriname, Indonesia, and Ghana. Most vaccination rates were >90%. Of travellers in high need of hepatitis A and B protection, 56.6 and 75.7%, underwent titre assessments, respectively. Of ICCITs with a respective indication, 50.6% received a prescription for standby antibiotics. CONCLUSION: Vaccination rates in our study population were overall comparable to those of healthy travellers studied previously in our centre. However, regarding antibody titre assessments and prescription of standby antibiotics, this study demonstrates that uniform pre-travel guidelines for ICCITs are highly needed.

To prevent and deal with medical problems on board. / Prévenir et gérer les problèmes médicaux en navigation.

As more and more quality of life becomes a goal of personnel and sustainable development, long-distance travel is becoming more widespread. Sailing around the world is an example of this evolution. The keys to a successful journey are rigorous preparation and adherence to some prevention rules. Medical or surgical emergencies are rare, and can often be dealt with by remote medical contact. New communication technologies such as satellite phones make it possible to seek medical advice from professionals, or even for sailers to treat themselves with very short prior training, provided that the required equipment and medicines have been embarked before leaving. Sophisticated rescue can also be organized. These technological innovations have changed the security and lives of sailors and explorers in remote areas of the world.

La qualité de la vie étant un objectif de développement personnel et durable, les voyages au long cours se généralisent. Les périples à la voile sont un exemple de cette évolution. Les clés pour un périple réussi sont une préparation rigoureuse et le respect de quelques règles de prévention. Les urgences médicales sont rares et peuvent être souvent maîtrisées par un contact médical à distance. Les nouveaux moyens de communication tels que téléphones satellite permettent de demander des conseils médicaux à des professionnels, voire même aux navigateurs de se traiter eux-mêmes après une très courte formation préalable, pour autant que le matériel et les médicaments nécessaires aient été embarqués avant de partir. Les progrès technologiques ont changé la sécurité et la vie des navigateurs et explorateurs aux confins reculés de la planète.

Zika virus: practical guidelines. / Virus Zika : recommandations pratiques.

Zika virus suddenly emerged in Latin America in 2015­2016. Congenital malformations have been observed in infected pregnant women, causing a major public health impact in affected countries, particularly in Brazil. In addition, sexual transmission of Zika virus has been well documented. This led to the development of prevention strategies and recommendations for travellers visiting at risk countries. These documents are regularly amended depending on the evolution of scientific knowledge, the epidemiologic trends and the national and international guidelines. Through practical cases, we present here the guidelines developed by the Geneva University Hospitals.

Le virus Zika a émergé brusquement en 2015­2016 en Amérique latine. Lors de cette épidémie, des complications fœtales ont pu être observées avec des conséquences majeures sur la santé publique de ces pays, en particulier au Brésil. De plus, une transmission par voie sexuelle du virus a été bien documentée. Il a ainsi été nécessaire de développer des stratégies de prévention et des recommandations pour les voyageurs visitant des pays à risque. Ces documents sont évolutifs en fonction des connaissances scientifiques, de l'épidémiologie de la maladie et des recommandations nationales et internationales. Par l'intermédiaire de cas illustratifs, nous présentons les recommandations utilisées aux Hôpitaux universitaires de Genève.

Multidrug-resistant bacteria and travel. / Bactéries multirésistantes et voyage.

Antimicrobial resistance is a global problem which affects also tropical countries. Travelers to these regions expose themselves to the risk of being colonised and infected with multidrug-resistant bacteria. The region visited, the occurrence of diarrhoea and the use of antibiotics are the principal risk factors leading to colonisation with multidrug-resistant Enterobacteriaceae, which can affect up to 80% of travellers. Colonisation with meticillin resistant Staphylococcus aureus and vancomycin resistant enterococci are often due to contacts with the health care system of the visited country. For the practitioner evaluating a patient returning from abroad it is important to consider the risk of infection with multidrug-resistant bacteriae. Screening for these bacteriae in the stool or by mucocutaneous swabs can be discussed in certain situations.

La résistance aux antibiotiques est un problème global qui touche aussi les pays tropicaux. Les voyageurs dans ces régions s'exposent donc au risque d'être colonisés et infectés avec des germes multirésistants. La région visitée, la survenue de diarrhées et la prise d'antibiotiques sont les facteurs de risque principaux pour une colonisation digestive avec des entérobactéries multirésistantes qui peut aller jusqu'à 80 %. Les colonisations par les staphylocoques dorés résistant à la méticilline et les entérocoques résistant à la vancomycine sont souvent dues à un contact avec les services médicaux dans les pays visités. Pour le praticien, il est important de tenir compte du risque d'infections avec des bactéries multirésistantes chez les patients au retour d'un voyage. Un dépistage de ces germes dans les selles ou par des frottis mucocutanés peut être discuté dans certaines situations.