Effect of Maximizing a Travel Medicine Clinic s Prevention Strategies

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1 Effect of Maximizing a Travel Medicine Clinic s Prevention Strategies Lynn L. Horvath, Clinton K. Murray, and David P. Dooley Background: Even among travelers who undergo evaluation in travel medicine clinics, illnesses develop despite the emphasis placed on prevention. It is possible that travel-associated disease rates may be modified by maximizing access to care and augmenting educational methods of disease prevention. Use of alternative preventive measures such as alcohol hand gel sanitizers may also alter illnesses among travelers. Methods: We assessed medical outcomes in a travel population cared for in the setting of free vaccinations, medications, and travel medicine consultation, in which personal preventive measures were presented in numerous formats by a physician specializing in infectious diseases. An initial demographic questionnaire was administered at the time of travel consultation. A post-travel telephone interview conducted 2 weeks after return from travel evaluated illness while abroad, illness upon return, and adherence to travel recommendations. An assessment was also performed regarding the utility of an alcohol hand gel sanitizer. Results: One hundred fifty-five travelers were evaluated (primarily older, well-educated US-born travelers, on vacation with family or coworkers). Travelers filled their prescriptions 98% of the time; 77% reported adherence to antimalarial chemoprophylaxis. Sixty-four percent of travelers developed illness abroad, and 20% developed illness upon return. The most frequent complaints were diarrhea and upper respiratory illness. Ten percent of travelers altered their itinerary owing to illness. The use of alcohol hand gel sanitizers did not appear to impact the development of diarrhea or respiratory illnesses. Conclusion: In this small group of travelers, access to free consultation, vaccinations, and medications along with presentation of personal protective measures in various formats did not seem to influence the development of illnesses among travelers. Although not rigorously analyzed, alcohol hand gel sanitizers did not seem to alter diarrhea or respiratory tract illness rates. These data highlight the need for new or more effective methods to prevent illness among travelers. Lynn L. Horvath, MD: Department of Clinical Investigation, Brooke Army Medical Center, Fort Sam Houston, TX, USA; Clinton K. Murray, MD, and David P. Dooley, MD: Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA. Disclaimer: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense or the U.S. government. This work was prepared as part of their official duties. This data was presented in part at the 8th Conference of the International Society of Travel Medicine in May 2003 (Poster P012.02) in New York, NY, and at the 52nd Annual Meeting of the American Society of Tropical Medicine and Hygiene (ASTMH) in December 2003 (Poster 521) in Philadelphia, PA, USA. Reprint requests: Lynn L. Horvath, MAJ, MC, Brooke Army Medical Center, Department of Clinical Investigation, 3400 Rawley East Chambers Avenue, Suite A, Fort Sam Houston, TX, USA J Travel Med 2005; 12: Travel medicine clinics specialize in health maintenance by providing counseling, medications, and vaccinations to preserve the health of those traveling.the predominant focus is on the prevention of commonly encountered illnesses such as diarrhea and respiratory illness and the prevention of potentially lethal diseases such as malaria and yellow fever. 1 5 Emphasis is also placed upon illnesses that occur after return from travel. 5,6 Efficacy of preventive measures including personal protective measures, vaccines, and medications can approach 100% if used appropriately, but this is unlikely to occur. Inadequate adherence is common among travelers, with 50% drinking tap water and 40% not taking malaria chemoprophylaxis as directed. 1 3,5 Strategies to maintain travelers health while abroad might include maximizing access to health care, convenience of obtaining prescriptions and vaccinations, and reinforcement of recommendations. Our travel medicine clinic avoids potential barriers to care as it is a selfreferral clinic that provides medical evaluation, medications, and vaccinations free of charge. Counseling about prevention is reinforced by providing data in numerous formats, including a thorough evaluation by a physician specializing in infectious diseases, with a comprehensive discussion of strategies to avoid illnesses as well as handouts detailing prevention and management strategies for vector-borne and diarrheal disease. The 332

2 Horvath et al, Maximizing Travel Medicine Prevention Strategies 333 possible utility of alcohol hand gel sanitizers in the prevention of illness is also addressed. In this setting of being able to maximize a traveler s preventive health care, we set out to characterize the illnesses that developed among our patients during travel and upon return, along with adherence to our recommendations. Materials and Methods Population and Setting Our clinic provides free travel medicine consultation to active duty and retired US military personnel and their dependents. All travelers are seen by a board-certified physician or fellow specializing in infectious diseases. During each 30-minute appointment, a pertinent travel history is obtained followed by a comprehensive discussion of travel illness preventive measures emphasizing vector avoidance, prevention of diarrhea, and the use of an alcohol hand gel sanitizer.the US Centers for Disease Control and Prevention recommendations are followed for diarrhea, malaria, and vaccine prescriptions.travelers pick up prescribed medications and obtain vaccinations, both free of charge, in separate sections of the hospital. Travelers are provided handouts on the prevention of vector-borne and food-borne diseases.vector-borne disease prevention behavior includes the use of N,Ndiethyl-m-toluamide (DEET), permethrin-impregnated clothes, and insect netting; wearing adequate clothing; and altering outdoor activities to avoid peak vector biting times. A diarrhea-management algorithm outlining indications for antimotility agents and/or antimicrobial agents based upon the number of bowel movements and systemic complaints is also provided. Study Design This study was a prospective survey, with demographic data collected at the time of travel clinic counseling, followed by a post-travel telephone survey with a collection of data on travel exposures and illnesses acquired. The study enrollment period encompassed August 2002 to August All travelers were offered an opportunity to enroll in the study after evaluation by the physician specializing in infectious diseases. Travelers were eligible for enrollment if they were traveling for less than 4 months outside of the United States. Active duty military travelers were not enrolled if they were being deployed as a part of combat operations. Subjects who agreed to participate signed a written informed consent document; this study was approved by the Brooke Army Medical Center Investigational Review Board (C d). Travelers completed a demographic questionnaire. A date approximately 2 weeks after return from their travel was then determined for a follow-up telephone interview. All post-travel phone interviews were conducted between October 2002 and January During the follow-up interview, the traveler was assessed for adherence with travel recommendations, occurrence of illness either abroad or upon return from travel, and potential causes of those illnesses.adherence to filling prescriptions and acquiring vaccinations, and to advice or medication use as suggested by physician counselors was determined by verbal report at the time of the post-travel telephone interview. Results Study Demographics One hundred seventy-five subjects were enrolled in the study. Eighteen subjects never traveled. Reasons given for not traveling included hospitalization prior to travel (2), emergency surgery (2), cancellation of their missionary trip (2), passport difficulty (1), and fear of severe acute respiratory syndrome (1); ten subjects did not give any explanation for the cancellation of their trip. Of the remaining 157 individuals, two (1%) were unable to be reached for the follow-up telephone interview. The demographics and travel characteristics of the 155 subjects analyzed are reported in Tables 1 and 2.The population was composed predominately of older, USborn travelers who were well educated, of moderate to high income, and with extensive prior overseas travel experience. Subjects were typically traveling with family or coworkers for vacation purposes of 1 to 4 weeks duration and residing in hotels.thirty-eight (25%) travelers reported they lived with locals while traveling; five of these travelers were foreign-born immigrants to the United States and were traveling to their native-born country to visit friends and relatives. Central and South America were prominent travel destinations (for 26% and 18%, respectively), although, in general, travel was worldwide. Adherence to Prescriptions and Recommendations One hundred twenty of 123 (98%) vaccine prescriptions, 152 of 155 (98%) antimicrobial and antimotility prescriptions, and 77 of 77 (100%) malaria prophylaxis prescriptions were filled by the subjects. Twenty-eight travelers received mefloquine, 20 chloroquine, 13 doxycycline, 12 atovaquone/proguanil, 3 primaquine, and 1 minocycline (chronically taken for acne) for malarial prophylaxis. Seventy-seven percent of travelers reported taking 100% of the antimalarial prophylaxis while traveling. Upon questioning during the 2-week follow up telephone interview, 88% reported having completed the medication upon return (atovaquone/proguanil and primaquine) or continuing to take it (mefloquine, chloroquine, and doxycycline). Vivid

3 334 Journal of Travel Medicine, Volume 12, Number 6 dreams or sleep disturbances occurring after medications were begun were reasons given by 6 travelers (8%) for missing doses (4 on mefloquine and 2 on chloroquine). Nine travelers (12%) were nonadherent owing to gastrointestinal distress (5 on doxycycline, 3 on atovaquone/proguanil, and 1 on mefloquine). Among subjects prescribed antimalarial agents for geographic risk, adherence to personal protective measures for the prevention of vector-borne disease was 84% for the use of DEET,41% for avoiding activities at night, 30% for the use of mosquito netting,and 18% for impregnating clothes with permethrin. Activities associated with diarrhea risk were commonly described among travelers, with 90 (58%) having used ice, 53 (34%) having drunk tap water,and 23 (15%) having eaten food from street vendors. High-risk behaviors associated with the acquisition of diarrhea were even more prevalent among the 38 travelers who lived with locals, including 25 Table 1 Demographics of 155 Travelers Who Completed the Study Demographics n (%) Female sex 70 (45) Average age in yr; range 58.3; Marital status Married 125 (81) Single, never married 11 (7) Widowed 13 (8) Divorced 6 (4) Education < High school 4 (3) High school graduate 8 (5) Some college 35 (23) College graduate 39 (25) Postgraduate degree 69 (45) Salary (US $/yr)* < 20,000 3 (2) 20,000 40, (13) 40,000 75, (32) 75, , (28) > 100, (25) Prior travel outside United States Never 3 (2) Once 7 (5) 2 or 3 11 (7) 4 or 5 25 (16) > (70) Tobacco use None 139 (91) Cigarettes 8 (5) Smokeless tobacco 3 (2) Cigars 1 (1) Pipes 2 (1) Born in United States 140 (90) *Five participants did not complete the question. Two participants did not complete the question; one smoked cigarettes and cigars. (66%) having eaten raw vegetables and salads, 22 (58%) having drunk tap water, and 9 (24%) having eaten food from street vendors. Illness Overseas Forty-five travelers (30%) reported having had diarrhea.eleven were on guided tours (22% of those on such tours), 4 were on cruises (25% of those on cruises), 15 were on self-guided tours staying in hotels (30% of such travelers), and 15 were living with locals (39% of such travelers). Diarrhea presentations in relation to destina- Table 2 Characteristics of Travel Travel Characteristic n (%) Type Guided tour 49 (32) Cruise 16 (10) Self-guided tour (stayed in hotels) 50 (32) Lived with local resident(s) 38 (25) Adventure tour 2 (1) Reason for travel Vacation 81 (52) Temporary military duty 24 (15) Business 17 (11) Visiting family 15 (10) Other (volunteer, missionary) 18 (12) Travel companion Spouse/family 77 (50) Coworkers 41 (26) Friends 19 (12) Alone 14 (9) Other (tour group) 4 (3) Duration < 1 wk 13 (8) 1 2 wk 61 (39) 2 4 wk 54 (35) 1 3 mo 27 (17) Number of regions in itinerary (74) 2 26 (17) 3 12 (8) 4 2 (1) Destination (region)* Central America 41 South America 26 Sub-Saharan Africa 24 East Asia 22 Southeast Asia 19 South Africa 14 Northern Europe 12 Southern Europe 12 Western Asia 11 Caribbean 7 Pacific Islands 7 Oceania 6 South Asia 6 Northern Africa 6 North America 2 *> 155 visits to regions owing to visits to more than one region.

4 Horvath et al, Maximizing Travel Medicine Prevention Strategies 335 tions traveled are presented in Table 3.The travelers with diarrhea averaged three to five bowel movements per day and 1 day s duration.of those with diarrhea,14 (31%) reported abdominal pain, 11 (24%) nausea and/or emesis, 3 (7%) subjective fever, and 1 (2%) blood in the stools.thirty-one (69%) took antimotility agents, and 10 (22%) took the prescribed antimicrobials. Surprisingly, 18 subjects took an antimotility agent and 4 took an antibiotic with an antimotility agent, even though they had never had any of the above symptoms. Seven patients altered their itinerary owing to diarrhea but in each case for no more than 1 day. Other nondiarrheal illnesses reported while abroad were described in 54 (35%) travelers.twenty-five (46%) of such illnesses were upper respiratory tract infections, 10 (19%) were headaches, 4 (7%) were dermatitis, and 3 (6%) were heat injuries.ten travelers sought medical care for their illness, with 8 changing their itinerary. Assessing those who always (41) versus those who never (44) used alcohol hand sanitizer, 31% versus 23% developed diarrhea and 19% versus 11% developed a cold, respectively. The difference was not statistically significant between groups (chi-square test). Local homeopathic medications were used by three travelers during their trip. Two travelers reportedly managed their acute diarrhea effectively (diarrhea resolution occurred in 1 and 4 days) with cashew tree bark tea and without using their antimicrobial or antimotility agents.the third patient suffered from altitude sickness, which improved after implementing acetazolamide, provided by the travel clinic, along with coca tea obtained locally. Table 3 Diarrhea Episodes in Relation to Destination of Travel No. of No. of Travelers Travel Destination Travelers to Region Who by Region to Region Developed Diarrhea (%) South Asia 6 4 (67) Caribbean 7 4 (57) Western Asia 11 6 (55) Northern Europe 12 5 (42) Sub-Saharan Africa 24 9 (38) Northern Africa 6 2 (33) Oceania 6 2 (33) Southern Europe 12 4 (33) South America 26 8 (31) Pacific Islands 7 2 (29) Southeast Asia 19 5 (26) Central America (24) South Africa 14 3 (21) East Asia 22 3 (14) North America 2 0 (0) Illness upon Return Thirty-one travelers (20%) developed an illness within 2 weeks of returning.twelve (39%) developed a cold, and 9 (29%) developed diarrhea. Six subjects with diarrhea reported having fever, abdominal pain, nausea, or vomiting, with 3 of those self-medicating with the antimotility agents and antibiotics prescribed for the trip. Overall, 7 sought medical attention, of whom 4 called the travel medicine clinic for evaluation of their problems. One subject was diagnosed with pinworms and treated accordingly, with a resolution of the symptoms. Discussion Travel health clinics aim to optimize travelers health during and upon return from foreign travel by maximizing preventive health measures. Our travel clinic attempts to overcome barriers to adherence by providing free evaluations, vaccinations, and prescriptions. In addition, personal protective measures are presented in different formats, including 30-minute interviews by a physician specializing in infectious diseases and trained in travel medicine, as well as handouts highlighting key preventive areas. In this extensively traveled, well-educated travel population with moderate to high incomes, great efforts were made to maximize the prevention of travelrelated illnesses; vaccine and medication prescriptions were indeed filled 98% of the time, although adherence to malaria chemoprophylaxis occurred only 77% of the time. Nevertheless, dietary indiscretions were rampant. Sixty-four percent of travelers became ill abroad and another 20% upon return. Predominant illnesses were diarrhea and upper respiratory illness. Ten percent of subjects were sick enough to alter their travel itineraries. Our data on travelers diarrhea are similar to those from previous travel studies based upon country of departure and country of travel. 1 5 Diarrhea occurred in 30% of travelers while abroad,of which 42% met the definition of travelers diarrhea, with 16% altering their itinerary owing to diarrhea alone. Travelers often participated in diarrhea risk-associated activities, including drinking tap water, using ice, and eating street vendor food. Seventy-eight percent of travelers thought that they could identify the type of exposure leading to illness, implying they knew the risk-associated activities but elected not to adhere strictly to preventive advice.this risk activity may have been related to the travelers knowledge that they had medications to combat diarrhea if it occurred, as 80% took an antimicrobial and/or antimotility agent after the development of diarrhea. Of the 152 antimicrobial prescriptions for diarrhea, 10 (7%) travelers took the medication for diarrhea, of whom 4 should not have based upon the diarrhea-management algorithm given to the traveler.we speculate that adher-

5 336 Journal of Travel Medicine, Volume 12, Number 6 ence to behavioral advice may have suffered because of our travelers awareness that effective remedies (at least for diarrhea) were at hand; the availability of therapy has been recognized as lowering barriers to risky behavior in other settings. 7 Although only 3 days worth of antimicrobials were given to travelers, it is unclear if the health expenditure in this setting is cost effective if only 6 (4%) appropriately used the medication. Illness upon return was also seen in our population at similar rates (20%) to those in previous studies. 5 The most frequent illnesses were upper respiratory tract infections (39%) and diarrhea (29%). No serious illnesses were encountered that might require hospital admission, such as dengue, malaria, or severe respiratory tract illnesses. 6 Twenty-three percent of travelers who became ill upon return sought medical attention; however, only half of those called the travel clinic for advice despite encouragement to do so during the initial consultation visit. Given that the post-travel telephone interview did not occur until approximately 2 weeks after return from travel, we may have missed illnesses with longer incubation periods.we suspect that this is unlikely, however, as our infectious disease consultative service is free to these travelers and is easily contacted about any serious or rare travel-related illnesses. Alcohol hand gel sanitizers have been recommended in hospitals to prevent the spread of nosocomial bacteria. 8 Travelers may not always have access to soap and clean water, engendering the concept that alcohol hand gel sanitizers may be an effective option to prevent the development of diseases transmitted through hand contact, including some diarrhea and upper respiratory tract pathogens. Studies have shown an enhanced activity of alcohol gels in comparison to soap and water in reducing adeno-, rhino-, and rotavirus concentrations from the hands. 9 Lower rates of upper respiratory illness and fewer missed school or workdays were described among university students when the product was introduced into dormitories. 10 However, the utility of these agents for the prevention of travel-related infections has not been previously investigated. Our own evaluation of the utility of alcohol hand gel sanitizers did not reveal a significant difference in the frequency of diarrhea or respiratory infections among those who claimed to always use the product compared with those who never used the product. Our numbers were not large for this analysis, however, and this study therefore lacks the power to exclude a possibly clinically significant effect of this hand preparation on acquiring infections during travel. This point is deserving of a prospective, controlled study. Although it may be true that our mostly ex-military population was highly traveled and this may have caused them to view our advice with some indifference, previous studies of travelers have also observed the generally well-traveled character of their groups.we suspect that our observations may be generalizable to this experienced travel group as a whole. In addition, we acknowledge that the number of travelers analyzed was limited, but even with our inability to randomize travelers to fee or nofee service, we believe the results have significant implications for the design of and provision for travelers health services and as an impetus for future research. Our data do not support the proposition that vulnerable and medically underserved groups, such as travelers visiting friends and relatives, might be significantly helped by the easy provision of free access to travel advice, medications, and vaccinations; indeed, we studied no travelers who faced such monetary obstacles. Of those who reported they resided with friends and families while traveling, we noted similar rates of adherence to malaria personal protective measures and the development of nondiarrheal illnesses but higher rates of dietary indiscretions and the subsequent development of diarrhea. Optimizing measures to prevent illness while traveling and upon return is the focus of travel medicine consultation.access to free care, vaccinations, and medications along with the presentation of personal protective measures in various formats did not seem to greatly impact the frequency of illness among travelers in this study; however, serious diseases such as malaria were prevented. Although not rigorously analyzed, alcohol hand gel sanitizers did not seem to alter the development of diarrhea or respiratory illness. Continued efforts are needed to determine more effective measures to prevent illness among travelers. Declaration of Interests The authors state they have no conflicts of interest. References 1. Kemmerer TP, Cetron M, Harper L, Kozarsky PE. Health problems of corporate travelers: risk factors and management. J Travel Med 1998; 5: Hilton E, Edwards B, Singer C. 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