key: cord-0008097-tq37yb7c
authors: Patel, D.; Simons, H.
title: Travel Health
date: 2019-02-20
journal: Public Health
DOI: 10.1016/j.puhe.2019.02.001
sha: f846d90f8cafb860bb8516b43c4ba9ef8b4c021b
doc_id: 8097
cord_uid: tq37yb7c

nan

Travel and public health are inextricably linked: international travellers not only have a higher and well-recognized risk of illness and injury but also have the potential to either import non-endemic diseases into their country of origin or export non-endemic diseases to the country they visit. In 2003, severe acute respiratory syndrome (SARS) showed us how easily an outbreak could spread, and in this highly mobile world with its increasing pace and scale of travel, the interface between travel medicine and public health has never been more important.

In 2017, the total number of international tourist arrivals (overnight visitors) at destinations around the world was 1326 million -86 million more than in 2016 (7% rise). 1 This upsurge represented the highest growth in international tourist arrivals since 2010 and surpassed the forecast by the United Nations World Tourism Organization of a 3.8% increase per year between 2010 and 2020. 2 This trend looks set to continue. There have been worldwide events, such as recent disease outbreaks (i.e. Ebola virus disease, Middle East respiratory syndrome, yellow fever and Zika), natural disasters and global uncertainties, such as the risk of terrorism, turbulent international political climates and austerity, that might be expected to impact traveller behaviour. Despite these, generally the urge to travel and discover new places appears undiminished. For some countries (i.e. Egypt and Tunisia), the previous drop-off in tourism, due to the lack of traveller confidence after acts of terrorism targeted against tourist visitors, recovered significantly during 2018 as travel advisories related to risk of terrorism were downgraded. 1, 3 The global increase in travel overall is reflected in the UK, with 72.8 million visits overseas by UK residents in 2017, an increase of 3% compared with 2016 continuing the year-on-year increase since 2012. 4 With the changing patterns of travel, over the past 30 years, travel medicine has developed as a distinct discipline. It is delivered in a variety of settings from primary to tertiary care and offered either as part of routine medical services or privately. Travel medicine focusses on the identification and risk assessment of health hazards that might be encountered during international travel, and the planning of strategies to prevent or reduce such risks, through shared decisionmaking. Although the greatest risks to health during travel are accidents and exacerbations of existing medical conditions, studies have found infectious disease to be a common cause of morbidity. A recent review of the literature suggested that between 43 and 79% of travellers who visited developing nations such as India, Kenya and Tanzania became ill, most frequently with travellers' diarrhoea. 5 The pretravel consultation underpins travel medicine practice; the primary objectives are to assess the traveller's plans and determine potential health hazards, educate the traveller, provide preventive measures such as vaccines and malaria prophylaxis, and enable the traveller to manage their health while abroad. This requires those advising travellers to not only have a detailed knowledge of vaccines and malaria chemoprophylaxis, destination-related risks and the consequences of travelling with underlying conditions, but also to be familiar with a broad range of topics, including geography, disease epidemiology, public health, immunology, traveller behaviour, international health law and risk communication. While many consultations will be straightforward, increasingly the health professional may encounter a traveller with a complex travel itinerary, medical history or both.

Over the last two decades, there has been an exponential growth in international travel for leisure, as well as improved access to previously undiscovered holiday destinations. Travel makes the opportunity for adventure and 'extreme' and possibly hazardous activity accessible to all, together with the potential for exposure to travel-related infectious disease. In addition, traveller demographics are changing: those with complex pre-existing medical conditions that may predispose to specific travel-related health risk, including older travellers, families with young children or pregnant women, have a need and determination to travel. Travellers are also online doing their own research, and their judgement can be poor. The reason for travel is also becoming more varied; while holiday or leisure travel predominates, travelling for business, as a pilgrim, for medical treatment (medical tourism), to undertake humanitarian work, as a trekker, or to visit friends and relations (or any combinations of these reasons) is increasingly reported. So, the health professional must think about the broader picture and consider the individual's reason for travel, medical history and itinerary (including destination, type of accommodation and activities), tailoring discussion and facilitating shared decision-making around interventions (e.g. wisdom of travel, risk of diseasedwhich may require careful interpretation of the limited evidencedand recommendations for malaria prophylaxis or vaccinations). While there will be familiar themes to every travel consultation, Available online at www.sciencedirect.com Public Health j o urna l h om epag e: www.elsevier .com /puhe p u b l i c h e a l t h 1 6 8 ( 2 0 1 9 ) 1 4 8 e1 4 9 each will be unique, making travel medicine both interesting and challenging.

With any travel medicine interaction, the worldwide context also needs to be considered: travel medicine is dynamic and diverse, and access to real-time and reliable resources, offering accurate and timely information, is paramount. Recent global health events underline the importance of keeping up to date and, where possible, ahead of the curve when advising the traveller. Some events may be predictable and others less so. Expert public health bodies such as the US Centers for Disease Control and Prevention, the European Centre for Disease Prevention and Control, the World Health Organization and in the UK, Health Protection Scotland, Public Health England and the UK National Travel Health Network and Centre (NaTHNaC) monitor emerging and rapidly developing global situations that have the potential to impact both travellers and public health. For example, from January 2018 to January 2019, the NaTHNaC posted 84 news items on their website (www.travelhealthpro.org) that described global health events of importance to British travellers with recommendations as to how to mitigate those risks. Topics were wide-ranging including advice for humanitarian aid workers travelling to Bangladesh, guidance for those planning a visit to China during the New Year celebrations, alerts, health advice and updates on disease outbreaks including Ebola virus disease, dengue, Nipah, yellow fever, and Zika virus, and situation reports relating to drug and multidrug resistance, epidemiology of malaria in UK travellers and vaccine supply and shortages.

Traveller numbers will continue to increase and, with advances in technology, travel will provide even more exciting opportunities in increasingly exotic locations. The London to Sydney flight time could be halved, journeys to the bottom of the sea may become a mainstream holiday option, and the race for space will allow travellers to experience the curvature of the earth from the ultrahigh altitude. Travel medicine will continue to evolve in response to these changing needs, and the next 30 years promises to be as dynamic, diverse, challenging and testing as the last; the health professional of tomorrow will be advising not only the international tourist but also, possibly, the space tourist.

World Tourism Organization. UNWTO tourism highlights

What proportion of international travellers acquire a travel-related illness? A review of the literature

Authors declare that there are no conflicts of interest. r e f e r e n c e s