Research articles Illness and injury of travellers abroad: Finnish nationwide data from 2010 to 2012, with incidences in various regions of the world

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1 Reserh rtiles Illness n injury of trvellers ro: Finnish ntionwie t from 2010 to 2012, with inienes in vrious regions of the worl H Siikmäki 1,2, P Kivelä 1, M Fotopoulos 2, J Ollgren 3, A Kntele (nu.kntele@hus.fi) 1,4,5 1. Inflmmtion Center, Clini for Infetious Diseses, University of Helsinki n Helsinki University Hospitl, Helsinki, Finln 2. SOS Interntionl, Freerikserg, Denmrk 3. Ntionl Institute for Helth n Welfre, Helsinki, Finln 4. Deprtment of Meiine, University of Helsinki, Helsinki, Finln 5. Unit of Infetious Diseses, Deprtment of Meiine Soln, Krolinsk Institutet, Stokholm, Sween Cittion style for this rtile: Siikmäki H, Kivelä P, Fotopoulos M, Ollgren J, Kntele A. Illness n injury of trvellers ro: Finnish ntionwie t from 2010 to 2012, with inienes in vrious regions of the worl. Euro Surveill. 2015;20(19):pii= Aville online: Artile sumitte on 16 July 2014 / pulishe on 14 My 2015 The numer of interntionl tourist rrivls rehe 1,000 million in Assessment of trvellers helth prolems hs relie on proportionte moriity t. Given the lk of t on numer of visitors to eh region, inienes hve een impossile to lulte. This stuy, lrgest yet reporting trvellers helth prolems, is the first to present iniene of illness n injury. Dt on Finnish trvellers with helth prolems ro uring 2010 to 2012 were retrieve from the tse of n ssistne orgnistion, SOS Interntionl, overing 95% of those requiring i ro. The numers were ompre with those of Finnish trvellers in the tse of the Offiil Sttistis of Finln. The SOS Interntionl tse inlue 50,710 ses: infetions onstitute the most ommon helth prolem (60%), followe y injuries (14%), iseses of skin (5%), musuloskeletl system n onnetive tissue (5%), igestive trt (3%), n vsulr system (2%). Gstroenteritis (23%) n respirtory infetions (21%) prove the most frequent ignoses. Overll iniene of illness or injury ws high in Afri (97.9/100,000 trvel ys; 95% Byesin reile intervl (BCI): ), southern Europe plus the estern Meiterrnen (92.3; 95% BCI: ) n Asi (65.0; 95% BCI: ). The t show signifint ifferenes etween geogrphil regions, initing the min risks n thus proviing estintion-speifi tools for trvellers helthre. Introution The nnul numer of interntionl tourist rrivls glolly exeee 1,000 million in 2012 n is expete to reh 1,800 million y 2030 [1]. Of those trvelling from evelope to eveloping ountries, over hlf hve een reporte to fll ill while ro n 8% to require meil ttention [2]. The growing volume of trvel mens n inrese uren on helthre oth in host ountries n t home. Assessment of trvellers helth prolems hs lrgely een se on lultions of proportionte moriity of returning trvellers s reporte y speilise entres for trvel n tropil meiine [3-6]. Dt on illness or injury while ro hve een ollete hiefly fter trvel from questionnires, telephone surveys [2,7-14] n insurne lims [15,16], t reore uring tul trvel re sre. While few stuies hve reviewe emergeny-ssistne servies of iniviul insurne ompnies [17-19], omprehensive informtion on trvellers helth prolems ro is non-existent. Furthermore, epiemiologil t llowing lultion of the iniene of the whole spetrum of helth prolems in reltion to numer of trvellers seem to e ompletely lking [20]. The stuy presente here rws on the prtiulr onitions foun in Finln, ountry with popultion of 5.5 million [21]. Approximtely 95% of those requiring help of n ssistne orgnistion euse of helth prolems while ro re reore in the tse of SOS Interntionl (SOS), serving severl insurne ompnies. In ition, Finln is mong the few ountries monitoring their nnul numer of trvellers to vrious estintions. Aoring to the Offiil Sttistis of Finln (OSF) tse [22], in 2012 Finns me 7.7 million visits ro in whih they stye for t lest overnight. Comining these two lrge tsets enle etermintion not only of trvellers proportionte moriity ut, more importntly, lso iniene of helth prolems. 1

2 Figure 1 Overview of ourse of Finnish trvellers helth prolems ro n stuy popultion, (n = 50,710) Methos All Finnish trvellers who stye t lest one night ro n = 14,104,000 Stye helthy uring trvel Di not seek meil re H no trvel insurne (30%) Me insurne lim fter trvel (75%) Were hnle ro y other ssistne orgnistions (out 5%) Fell ill or were injure uring trvel Sought meil re H trvel insurne (70%) Were reporte to the ssistne orgnistion use y the insurne ompny uring trvel (25%) Were hnle ro y SOS Interntionl n = 51,088 (out 95%) Finl stuy popultion n = 50, ses exlue Soure: Feertion of Finnish Finnil Servies. Vkuutustutkimus [Insurne survey 2012] [30]. Soure: Clims speilist Ilkk Vlnne, Euroopplinen, personl ommunition, 2 Otoer Soure: Meil iretor Ari Kinnunen, EMA Finln, n Meil Diretor Puli Hpsri, MeFlight Finln, personl ommunition, 3 Septemer Exlue euse of inomplete informtion. Assistne orgnistion t SOS, serving Nori n Blti insurne ompnies, provies trvellers with 24-hour emergeny ssistne ro: vie, meil evlution, referrl to tretment, ost overge n rrngement of trnsporttion if inite for meil resons. SOS overs pproximtely 95% of ll Finnish ses (77% of inptients, 99.8% of outptients) hnle ro y ssistne orgnistions (Figure 1); reors for 2010 to 2012 were inlue in this nlysis. All SOS t re proesse in omputerise tse. Coorinting otors re ssigne to pproximtely 86% of inptient n 1% of outptient ses. They sty in ontt with the ptient n liniin ro, exmine meil reports, evlute tretment n give orers for reptrition. Non-meil ssistne oorintors see to the unomplite inptient n outptient ses, reoring ignoses provie y liniins ro. Informtion ville for our stuy omprise ge, sex, time n ountry of illness or injury, inptient or outptient sttus, min ignosis, reptrition n eth. Reserh lerne ws reeive from SOS. Definitions A se ws efine s Finnish trveller ro with one episoe of illness or injury, hnle y SOS uring 2010 to A person with severl seprte episoes ws ounte more thn one. Clssifition s inptient ws se on informtion from the hospitl ro. Any se not reore s n inptient ut who h t lest one outptient visit ws lssifie s n outptient se. Deese trvellers who h not een registere s inptients were entere s outptient ses, with their ignoses eing unville. Reptritions were groupe y return: s plnne, ir mulne, or other rerrnge trnsport. The t olletion proeure inlue s inptients those outptient ses whose flights h to e resheule. To esrie the stuy popultion n proportionte moriity of ll ses, ountries were lssifie into the following geogrphil regions: southern Europe (the Blkn sttes, Cyprus, Greee, Itly, Mlt, Portugl inluing Meir, Spin inluing the Cnry Islns); rest of Europe; the estern Meiterrnen (Isrel, Turkey); North Afri; su-shrn Afri; western Asi; south-entrl Asi (from Pkistn to Bnglesh); south-est Asi; north-est Asi; Centrl n South Ameri n the Crien; North Ameri; Austrli, New Zeln n Oeni. For iniene lultions, the geogrphil lssifition ws moifie to e omptile with the OSF lssifition [22]. Trvel sesons were tegorise y first te of symptom onset or injury, eing ivie into winter (Otoer to Mrh) n summer (April to Septemer). Dignoses Coorinting otors enoe ignoses pplying the Interntionl Sttistil Clssifition of Diseses n Relte Helth Prolems 10th revision (ICD-10) [23]. Assistne oorintors reore them s open text. For our stuy, single oorinting otor, one of the reserhers (H.S.), enoe these ignoses y pplying ICD-10. The ignosti tegories were those of ICD-10, exluing infetions, whih we seprte from the orgn-speifi lssifition into tegory of their own. Dt on Finnish trvellers Otine from the tse of OSF, the pre-existing trveller t ontine nnul numers n mein urtion of t-lest-overnight leisure n usiness visits ro, n trvellers ge groups y region n ountry. Country-speifi t were ville for those reeiving more thn 50,000 visitors per yer. OSF t h initilly een ollete y monthly smple-se omputer-ssiste telephone interviews with Finnish resients ge 15 to 74 yers; the upper ge limit ws extene to 84 yers in Drwn systemtilly 2

3 Tle 1 Chrteristis of outptient n inptient ses mong trvellers ro n risk ftors for hospitlistion, (n = 50,710) Chrteristi Totl Outptient ses Inptient ses P vlue Risk ftors for hospitlistion Univrile OR (95% CI) Multivrile OR (95% CI) Numer of ses, n 50,710 42,371 8,339 NA NA NA Sex, n (%) Mle 22,849 (45.1) 18,500 (43.7) 4,349 (52.2) < ( ) 1.33 ( ) Femle 27,861 (54.9) 23,871 (56.3) 3,990 (47.8) < Age in yers Mein ge (IQR) 45 (21 61) 44 (20 61) 48 (27 64) < NA NA Age groups, n (%) ,752 (19.2) 8,687 (20.5) 1,065 (12.8) < ( ) 0.61 ( ) ,872 (13.6) 5,528 (13.0) 1,344 (16.1) < ( ) 1.08 ( ) ,373 (16.5) 6,978 (16.5) 1,395 (16.7) ( ) 0.85 ( ) ,135 (22.0) 9,373 (22.1) 1,762 (21.1) < ( ) 0.86 ( ) ,576 (24.8) 10,301 (24.3) 2,275 (27.3) < ( ) 1.13 ( ) ,002 (3.9) 1,504 (3.5) 498 (6.0) < ( ) 1.83 ( ) Region, n (%) Europe n estern Meiterrnen 36,699 (72.4) 31,208 (73.7) 5,491 (65.8) NA NA NA Southern Europe 27,202 (53.6) 24,278 (57.3) 2,924 (35.1) < ( ) 0.16 ( ) Estern Meiterrnen 7,539 (14.9) 5,684 (13.4) 1,855 (22.2) < ( ) 0.55 ( ) Rest of Europe e 1,958 (3.9) 1,246 (2.9) 712 (8.5) ( ) 0.73 ( ) Afri 3,262 (6.4) 2,739 (6.5) 523 (6.3) NA NA NA North Afri 3,121 (6.2) 2,721 (6.4) 400 (4.8) < (0.18 4) 8 (4 0.33) Su-Shrn Afri f 141 (0.3) 18 (0.04) 123 (1.5) < ( ) ( ) Asi 10,119 (20.0) 8,019 (18.9) 2,100 (25.2) NA NA NA South-est Asi 9,514 (18.8) 7,746 (18.3) 1,768 (21.2) < (8 0.37) 0.37 ( ) South-entrl Asi g 361 (0.7) 167 (0.4) 194 (2.3) < ( ) 1.77 ( ) North-est Asi 194 (0.4) 90 () 104 (1.2) ( ) 1.49 ( ) Western Asi 50 (0.1) 16 (0.04) 34 (0.4) < ( ) 2.96 ( ) The Ameris 609 (1.2) 402 (0.9) 207 (2.5) NA NA NA Centrl n South Ameri n the Crien 366 (0.7) 214 (0.5) 152 (1.8) ( ) 1.13 ( ) North Ameri 243 (0.5) 188 (0.4) 55 (0.7) < ( ) 0.31 (2 0.42) Austrli, New Zeln n Oeni 21 (0.04) 3 (0.007) 18 () < ( ) 5.17 ( ) Seson, n (%) Winter h 30,032 (59.2) 25,054 (59.1) 4,978 (59.7) NA 1.00 NA Summer i 20,678 (40.8) 17,317 (40.9) 3,361 (40.3) ( ) NA Dignosti tegory, n (%) Infetions 30,386 (59.9) 26,324 (62.1) 4,062 (48.7) NA Injuries 7,095 (14.0) 5,592 (13.2) 1,503 (18.0) < ( ) 1.66 ( ) Skin iseses 2,639 (5.2) 2,615 (6.2) 24 (0.3) < ( ) ( ) Musuloskeletl n onnetive tissue iseses 2,621 (5.2) 2,475 (5.8) 146 (1.8) < ( ) 0.38 ( ) Diseses of the igestive trt 1,292 (2.5) 836 (2.0) 456 (5.5) < ( ) 3.24 ( ) Vsulr iseses 1,081 (2.1) 369 (0.9) 712 (8.5) < ( ) ( ) Other 5,596 (11.0) 4,160 (9.8) 1,436 (17.2) < ( ) 2.30 ( ) CI: onfiene intervl; IQR: interqurtile rnge; NA: not pplile; OR: os rtio. The vlues in ol inite t for min geogrphil regions. A se ws efine s Finnish trveller ro with one episoe of illness or injury, hnle y SOS Interntionl uring 2010 to A person with severl seprte episoes ws ounte more thn one. Devition from verge effet use s referene in vriles region n ge group. Blkn sttes, Cyprus, Greee, Itly, Mlt, Portugl inluing Meir, Spin inluing Cnry Islns. Isrel, Turkey. e Europen ountries not inlue in southern Europe. f inluing South Afri. g from Pkistn to Bnglesh. h From Otoer to Mrh. i From April to Septemer. 3

4 Tle 2 Chrteristis of ses mong trvellers ro y ignosti tegory, (n = 50,710) Chrteristi Totl Infetions Injuries Skin iseses Musuloskeletl n onnetive tissue iseses Diseses of the igestive trt Vsulr iseses Other P vlue e Totl numer, n (%) 50,710 (100) 30,386 (59.9) 7,095 (14.0) 2,639 (5.2) 2,621 (5.2) 1,292 (2.5) 1,081 (2.1) 5,596 (11.0) < Inptient ses, n (%) 8,339 (16.4) 4,062 (13.4) 1,503 (21.2) 24 (0.9) 146 (5.6) 456 (35.3) 712 (65.9) 1,436 (25.7) < Cse hrteristis Mle, n (%) 22,849 (45.1) 13,451 (44.3) 3,218 (45.4) 939 (35.6) 1,254 (47.8) 642 (49.7) 621 (57.4) 2,724 (48.7) < Mein ge in yers (IQR) 45 (21 61) 40 (15 59) 48 (27 62) 46 (23 59) 60 (47 67) 50 (30 63) 64 (56 70) 49 (26 64) < Winter seson f, n (%) 30,032 (59.2) 18,380 (60.5) 3,694 (52.1) 1,485 (56.3) 1,638 (62.5) 768 (59.4) 730 (67.5) 3,337 (59.6) < Region, n (%) g Southern Europe 27,202 (100) 15,406 (56.6) 4,005 (14.7) 1,263 (4.6) 1,806 (6.6) 601 (2.2) 647 (2.4) 3,474 (12.8) < Estern Meiterrnen 7,539 (100) 4,858 (64.4) 1,008 (13.4) 377 (5.0) 309 (4.1) 204 (2.7) 137 (1.8) 646 (8.6) < Rest of Europe 1,958 (100) 840 (42.9) 557 (28.4) 47 (2.4) 61 (3.1) 87 (4.4) 96 (4.9) 270 (13.8) < North Afri 3,121 (100) 2,516 (80.6) 189 (6.0) 202 (6.5) 44 (1.4) 56 (1 8) 13 (0.4) 101 (3.2) < Su-Shrn Afri 141 (100) 70 (49.6) 28 (19.9) 1 (0.7) 3 (2.1) 5 (3.5) 4 (2.8) 30 (21.3) < South-entrl Asi 361 (100) 257 (71.2) 45 (12.5) 5 (1.4) 5 (1.4) 12 (3.3) 12 (3.3) 25 (6.9) < South-est Asi 9,514 (100) 6,081 (63.9) 1,113 (11.7) 711 (7.5) 354 (3.7) 269 (2.8) 141 (1.5) 845 (8.9) < North Ameri 243 (100) 60 (24.7) 46 (18.9) 7 (2.9) 18 (7.4) 27 (11.1) 8 (3.3) 77 (31.7) < Centrl n South Ameri n the 366 (100) 220 (60.1) 53 (14.5) 18 (4.9) 9 (2.5) 10 (2.7) 9 (2.5) 47 (12.8) Crien Other h 265 (100) 78 (29.4) 51 (19.2) 8 (3.0) 12 (4.5) 21 (7.9) 14 (5.3) 81 (30.6) < A se ws efine s Finnish trveller ro with one episoe of illness or injury, hnle y SOS Interntionl uring 2010 to A person with severl seprte episoes ws ounte more thn one. Other thn ute gstroenteritis. Criovsulr, ererovsulr, other vsulr iseses. Neoplsms; hemtologil iseses; enorine, nutritionl n metoli iseses; mentl n ehviourl isorers; neurologil iseses; eye iseses; er iseses; respirtory iseses; genitourinry iseses; pregnny, hilirth n perintology; unlssifie symptoms. e Teste using hi-squre test, exept for ge, for whih the Kruskl Wllis test ws use. f From Otoer to Mrh. g Proportion of ignosti tegory oring to region (perentges in rows). h Western Asi, north-est Asi, Austrli, New Zeln, Oeni. from the entrl popultion register, the smple totlle 26,400 iniviuls nnully in 2010 n 2011, n 28,200 in 2012 [22]. Clultion of iniene Proportionte moriity figures were retrieve for ll ses in the SOS tse, wheres iniene lultion ws restrite to ults for omptiility with the OSF popultion: only ses ge yers in n yers in 2012 were inlue, n the geogrphil lssifition of OSF ws pplie (Nori ountries, Blti sttes n Russi, estern n western Europe; southern Europe n the estern Meiterrnen; Afri; Asi n Oeni; the Ameris) [22]. Iniene figures were lulte s follows: Totl numer of trvel ys = mein urtion of trip estimte % of trvellers with insurne numer of trvellers Iniene per 100,000 trvel ys = (numer of ses/ totl numer of trvel ys) x 100,000. Finns hve ess to stte-provie helthre in ountries following Europen Union (EU) legisltion; reimursement for osts elsewhere n lso e otine y pplition to the Soil Insurne Institution of Finln (Kel) [24]. As ompre with the numer of ses hnle y SOS, the proportion Kel overs is 50% higher in ountries following EU legisltion thn elsewhere. In the Nori n Blti ountries, the proportion exees 50% (Timo Prtio, Senior Sttistil Anlyst, Kel, personl ommunition, 7 Otoer 2013) n, furthermore, Finns visits to these ountries n to Russi re 4

5 Figure 2 Overll iniene of illness n injury mong ult Finnish trvellers in vrious regions, (9,953,000 trvellers) Afri Southern Europe n the estern Meiterrnen Asi n Oeni Estern n western Europe The Ameris Overll iniene of illness n injury per 100,000 trvel ys The rs represent 95% Byesin reile intervls. Iniene per 100,000 trvel ys = (numer of ses ivie y numer of trvel ys) x 100,000. Trvellers ge yers in n trvellers ge yers in 2012 [22]. Figures for Nori n Blti ountries n Russi re not presente here; inienes for these ountries re not omprle with those of other regions euse proportionlly more ses re overe y the Soil Insurne Institution of Finln (Kel) [24] n trips re shorter thn to other regions [22]. Blkn sttes, Cyprus, Greee, Itly, Isrel, Mlt, Portugl inluing Meir, Spin inluing the Cnry Islns, Turkey. Dt soure: Tle 3. shorter thn elsewhere [22]. As suh ifferenes might hmper omprison with other regions, we hose not to present inienes for the Nori or Blti ountries or Russi. Sttistil methos Desriptive sttistis were nlyse with Mirosoft Exel 2010 n IBM SPSS Differenes etween groups were teste with hi-squre n Stuent s t-tests n the Kruskl Wllis test, s pproprite. Risk ftors of hospitlistion were nlyse with logisti regression. Vriles with p < in univrile nlysis were inlue in multivrile moel. For vriles lking referene tegory, evition from the verge effet ws use. We estimte 95% Byesin reile intervls (BCIs) for trvel ys of trvellers with insurne, n thus 95% BCIs for inienes, using Byesin moelling with Mrkov hin Monte Crlo (MCMC) Gis smpling with informtive priors. The following ssumptions were me: the proportion of trvellers with insurne ws lower (55 70%) for estern n western Europe n higher (75 85%) for more istnt estintions; trip urtions were istriute similrly in ll three yers of the stuy ( ). In estimting the numers of trvellers to eh estintion, smpling vrition in the numers of those nswering ws tken into ount. Results Stuy popultion in the SOS Interntionl tse n se hrteristis The nlysis inlue 50,710 ses; 83.6% were trete s outptients, 16.4% s inptients. The mein ge ws 45 yers (interqurtile rnge (IQR): 21 61); 54.9% were women (Tle 1). Most ses (n = 36,699; 72.4%) were reporte to SOS in Europe plus the estern Meiterrnen. Spin h the highest numer, 18,583 (36.6%), of whom 13,435 (72.3%) were in the Cnry Islns. Between regions, hrteristis of ses iffere signifintly. Mein ges rnge from 31 yers (IQR: 22 45) for ses in north-est n western Asi, Austrli, New Zeln n Oeni to 52 yers (IQR: 23 65) in southern Europe (p < 0.001). The proportion of men rnge from 38.1% of ses in Austrli, New Zeln, n Oeni to 54.5% of those in south-est Asi (p < 0.001). Most ses were reporte uring winter in ll regions exept in Europe plus the estern Meiterrnen (p < 0.001) (t not shown). Dignoses n reptritions Infetions (59.9%) n injuries (14.0%) onstitute the lrgest ignosti tegories for outptients n inptients like (Tle 1, Tle 2). The risk of hospitlistion prove gretest mong ses with vsulr iseses. Multivrile nlyses showe other risk ftors of hospitlistion to e mle sex, ge or 60 yers, n trvel to su-shrn Afri, Austrli, New Zeln n Oeni, or to Asi (other thn south-est Asi) (Tle 1). Signifint intertions were foun etween ll these vriles. Aute gstroenteritis (11,543 ses) prove oth the most ommon ignosis (22.8% of ll) n infetion (38.0%). Respirtory trt infetions (n = 10,475) were nerly s ommon (20.7% of ll, 34.5% of infetions). Injuries omprise 5,567 (78.5%) trums n 1,528 (21.5%) others. Of the trums, 4,270 (76.7%) were superfiil, 952 (17.1%) frtures n 287 (5.2%) intrrnil injuries. Return trvel itinerries remine unhnge for 48,842 ses (96.3%), n ir mulne ws use for 113 (%), n 1,556 (3.1%) h some other hnge trnsport rrngement. Deths totlle 199 (0.4%). Iniene of illness or injury Overll iniene of illness n injury ws gretest in Afri n southern Europe plus the estern Meiterrnen, s well s Asi plus Oeni; inienes were lowest in the Ameris n estern plus western Europe (Tle 3, Figure 2). Looking t iniviul ountries t ville for omprison, iniene 5

6 Tle 3 Iniene of illness n injury mong ult Finnish trvellers, y geogrphil region n selete ountries, (9,953,000 trvellers)* Ault Finnish trvellers Numer of trvel ys of trvellers with trvel insurne,e Regions n ountries with more thn 50,000 Finnish trvellers/yer Mein ge group in yers Numer of trvellers Mein urtion of trip in ys Numer of ses ro hnle y SOS Interntionl f,g Mein ge (IQR) Outptient ses Inptient ses Iniene of illness n injury mong ult trvellers per 100,000 trvel ys h Outptients Inptients Totl iniene Estern n western Europe i ,244, ,322,303 (12,630,000 18,670,000) 39 (25 55) ( ) 3.0 ( ) 7.7 ( ) Germny ,193, ,488,135 (2,967,000 4,117,000) 44 (30 56) ( ) 2.2 ( ) 3.0 ( ) Unite Kingom , ,717,048 (2,409,000 5,618,000) 38 (27 52) ( ) 0.6 ( ) 0.9 ( ) Frne , ,998,866 (1,548,000 2,590,000) 41 (27 58) ( ) 4.6 ( ) 5.4 ( ) The Netherlns , ,565 (577,100 1,271,975) 35 (19 53) ( ) 1.6 ( ) 2.0 ( ) Poln , ,757 (453,100 1,929,000) 49 (41 55) ( 1.7) 1.1 ( ) 1.8 ( ) Austri , ,087 (703,300 1,147,000) 39 (29 53) ( ) 10.6 ( ) 13.9 ( ) Switzerln , ,127 (326, ,900) 38 (30 46) ( ) 11.6 ( ) 14.1( ) Hungry , ,073,219 (717,700 1,578,000) 49 (29 63) ( ) 1.7 ( ) 2.4 ( ) Belgium , ,066 (115, ,700) 39 (27 54) ( ) 9.5 ( ) 11.9 ( ) Southern Europe ,970, ,069,515 (24,130,000 35,220,000) 54 (39 64) 22,816 3, ( ) 13.1 ( ) 92.3 ( ) n the estern Meiterrnen j Spin inluing Cnry Islns ,703, ,229,947 (11,280,000 20,600,000) 60 (45 66) 12,801 1, ( ) 12.3 ( ) 98.3 ( ) Spin exluing Cnry Islns , ,206,151 (4,753,000 8,096,000) 59 (38 67) 3, ( ) 12.6 ( ) 67.9 ( ) Cnry Islns , ,662,893 (6,249,025 15,730,000) 60 (47 66) 9,436 1, ( ) 12.6 ( ) ( ) Greee , ,120,660 (3,870,000 6,843,000) 50 (36 60) 5, ( ) 5.3 ( ) ( ) Itly , ,524,458 (2,070,000 3,081,000) 42 (27 54) ( ) 2.1 ( ) 5.9 ( ) Turkey , ,635,836 (2,076,000 3,351,000) 47 (33 69) 4,151 1, ( ) 52.3 (4 66.0) ( ) Portugl , ,884,158 (1,259,000 2,766,000) 57 (39 65) ( ) 2.4 ( ) 4.3 ( ) BCI: Byesin reile intervl; IQR: interqurtile rnge. Dt from the Offiil Sttistis of Finln (OSF): overnight leisure n usiness trips ro; inlues trvellers ge yers in n trvellers ge yers in 2012 [22]. The geogrphil lssifition use y OSF ws pplie for the lultion of iniene. Country-speifi t from OSF were only ville for ountries reeiving more thn 50,000 Finnish visitors per yer. Estimte proportion of trvellers with trvel insurne ws 70%; soure: [30]. An ssumption ws me tht the proportion of trvellers with insurne ws lower (55 70%) for estern n western Europe n higher (75 85%) for more istnt estintions. e Numer of trvel ys lulte s follows: mein urtion of leisure n usiness trips multiplie y numer of trvellers with trvel insurne. f Inlues ses ge yers in n those ge yers in A se ws efine s Finnish trveller ro with one episoe of illness or injury, hnle y SOS Interntionl uring 2010 to A person with severl seprte episoes ws ounte more thn one. g Dt of SOS Interntionl over out 95% of Finnish ses hnle y ssistne orgnistions of insurne ompnies. h Iniene per 100,000 trvel ys = (numer of ses ivie y numer of trvel ys) x 100,000. i Figures for Nori n Blti ountries n Russi re not presente here; inienes for these ountries re not omprle with those of other regions euse proportionlly more ses re overe y the Soil Insurne Institution of Finln (Kel) [24] n trips re shorter thn to other regions [22]. j Blkn sttes, Cyprus, Greee, Isrel, Itly, Mlt, Portugl inluing Meir, Spin inluing Cnry Islns, Turkey. 6

7 Tle 3 Iniene of illness n injury mong ult Finnish trvellers, y geogrphil region n selete ountries, (9,953,000 trvellers) Ault Finnish trvellers Numer of trvel ys of trvellers with trvel insurne,e Regions n ountries with more thn 50,000 Finnish trvellers/yer Mein ge group in yers Numer of trvellers Mein urtion of trip in ys Numer of ses ro hnle y SOS Interntionl f,g Mein ge (IQR) Outptient ses Inptient ses Iniene of illness n injury mong ult trvellers per 100,000 trvel ys h Outptients Inptients Totl iniene Asi n Oeni , ,270,311 (8,932,000 20,680,000) 47 (39 64) 6,429 1, ( ) 14.4 ( ) 65.0 ( ) Thiln , ,049,129 (2,534,000 6,278,000) 48 (34 59) 6,047 1, ( ) 34.0 ( ) ( ) Chin , ,915,398 (1,452,000 2,525,000) 35 (28 48) ( ) 4.1 ( ) 7.2 ( ) The Ameris , ,218,042 (4,574,000 10,950,000) 39 (29 55) ( ) 2.8 ( ) 7.6 ( ) Unite Sttes , ,194,332 (2,302,000 7,272,000) 38 (28 51) ( ) 1.1 ( ) 4.7 ( ) Afri , ,743,830 (1,661,000 4,266,000) 41 (31 53) 2, ( ) 17.2 (1 27.2) 97.9 ( ) Egypt , ,016,085 (605,300 1,547,000) 41 (31 53) 2, ( ) 33.9 ( ) ( ) BCI: Byesin reile intervl; IQR: interqurtile rnge. Dt from the Offiil Sttistis of Finln (OSF): overnight leisure n usiness trips ro; inlues trvellers ge yers in n trvellers ge yers in 2012 [22]. The geogrphil lssifition use y OSF ws pplie for the lultion of iniene. Country-speifi t from OSF were only ville for ountries reeiving more thn 50,000 Finnish visitors per yer. Estimte proportion of trvellers with trvel insurne ws 70%; soure: [30]. An ssumption ws me tht the proportion of trvellers with insurne ws lower (55 70%) for estern n western Europe n higher (75 85%) for more istnt estintions. e Numer of trvel ys lulte s follows: mein urtion of leisure n usiness trips multiplie y numer of trvellers with trvel insurne. f Inlues ses ge yers in n those ge yers in A se ws efine s Finnish trveller ro with one episoe of illness or injury, hnle y SOS Interntionl uring 2010 to A person with severl seprte episoes ws ounte more thn one. g Dt of SOS Interntionl over out 95% of Finnish ses hnle y ssistne orgnistions of insurne ompnies. h Iniene per 100,000 trvel ys = (numer of ses ivie y numer of trvel ys) x 100,

8 Tle 4 Iniene of injuries n infetions mong ult Finnish trvellers in vrious geogrphil regions n selete ountries, (9,953,000 trvellers) Regions n ountries visite, Regions n ountries with more Numer thn 50,000 Finnish trvellers/yer Estern n western 401 Europe g Germny 26 Unite Kingom 13 Frne 50 The Netherlns 10 Poln 4 Austri 103 Switzerln 39 Hungry 6 Belgium 7 Southern Europe n the estern 4,034 Meiterrnen h Spin inluing Cnry Islns 1,863 Spin exluing Cnry Islns 631 Cnry Islns 1,232 Greee 1,137 Itly 53 Turkey 775 Portugl 26 Asi n Oeni 1,089 Thiln 946 Chin 27 The Ameris 89 Unite Sttes 34 Afri 181 Egypt 144 Numer of ses,e n iniene (per 100,000 trvel ys) f of injuries n infetions mong ult trvellers Lrgest ignosti min tegories Lrgest infetion sutegories Injuries totl Infetions totl Aute gstroenteritis Aute respirtory infetions Iniene 2.6 ( ) 0.8 ( ) 0.4 ( 0.7) 2.6 ( ) 1.2 ( ) 0.5 ( ) 11.7 ( ) 9.6 ( ) 0.6 ( 1.3) 4.2 ( ) 14.0 ( ) 12.7 ( ) 10.3 ( ) 14.6 ( ) 22.5 ( ) 2.1 ( ) 29.7 ( ) 1.4 ( ) 8.2 ( ) 23.7 ( ) 1.4 ( ) 1.3 ( ) 0.9 ( ) 6.7 ( ) 15.6 ( ) Numer ,607 8,128 1,945 6,183 2, , ,042 4, ,977 1,904 Iniene 3.0 ( ) 0.6 ( ) ( ) 0.8 ( ) 0.1 (0 0.5) 0.5 ( ) 0.9 ( ) 2.0 ( ) 0.6 ( 1.3) 1.8 ( ) 50.6 ( ) 55.0 ( ) 31.7 ( ) 72.3 ( ) 52.8 ( ) 2.1 ( ) ( ) 0.9 ( ) 37.4 ( ) ( ) 2.0 ( ) 3.5 ( ) 1.2 ( ) 77.0 ( ) ( ) Numer ,655 2, , , ,663 2, ,684 1,631 Iniene 1.3 ( ) ( ) 0.0 (0 0) 0.5 ( 0.8) 0.1 (0 0.5) 0.0 (0 0) 0.6 ( 1.2) 0.3 (0 1.0) (0 0.6) 0.6 (0 2.4) 16.2 ( ) 15.1 ( ) 7.2 ( ) 21.4 ( ) 11.9 ( ) 0.3 ( ) 67.9 ( ) 0.3 ( ) 20.6 ( ) 59.0 ( ) 0.8 ( ) 1.8 ( ) ( ) 63.0 ( ) ( ) Numer ,199 4, ,164 1, ,170 1, Iniene 0.9 ( ) ( ) 0.1 (0 0.3) 0.1 (0 0.3) 0.0 (0 0) (0 0.8) (0 0.7) 0.8 ( 1.8) (0 0.6) 0.6 (0 2.4) 21.4 ( ) 27.6 ( ) 16.1 ( ) 36.7 ( ) 21.9 ( ) 1.0 ( ) 3 ( ) 0.4 ( ) 8.9 ( ) 27.8 ( ) 0.7 ( ) 1.0 ( ) 0.4 ( 0.9) 6.6 ( ) 18.6 ( ) BCI = Byesin reile intervl. Dt from the Offiil Sttistis of Finln (OSF): overnight leisure n usiness trips ro; inlues trvellers ge yers in n trvellers ge yers in 2012 [22]. The geogrphil lssifition use y OSF ws use for the lultion of iniene. Country-speifi t from OSF were only ville for ountries reeiving more thn 50,000 Finnish visitors per yer. Inlues ses ge yers in n yers in 2012, who sought meil re ro uring 2010 to 2012, hnle y SOS Interntionl. A se ws efine s Finnish trveller ro with one episoe of illness or injury, hnle y SOS Interntionl uring 2010 to A person with severl seprte episoes ws ounte more thn one. e The t of SOS Interntionl over out 95% of Finnish ses hnle y ssistne orgnistions of insurne ompnies. f Iniene per 100,000 trvel ys = (numer of ses ivie y numer of trvel ys) x 100,000. g Figures for Nori n Blti ountries n Russi re not presente here; inienes for these ountries re not omprle with those of other regions euse proportionlly more ses re overe y the Soil Insurne Institution of Finln (Kel) [24] n trips re shorter thn to other regions [22]. h Blkn sttes, Cyprus, Greee, Isrel, Itly, Mlt, Portugl inluing Meir, Spin inluing Cnry Islns, Turkey. 8

9 Figure 3 Infetions n injuries of Finnish trvellers y geogrphil regions, (9,953,000 trvellers) A B Perentges of ll ignoses (pie hrts) E C D 37 8 Infetions Injuries Other Iniene per 100,000 trvel ys (oxes) X X Infetions Injuries A: estern n western Europe; B: southern Europe n the estern Meiterrnen; C: Afri; D: Asi n Oeni; E: the Ameris. Other refers to ignoses other thn infetions or injuries (skin iseses; musuloskeletl n onnetive tissue iseses; iseses of the igestive trt; vsulr iseses; neoplsms; hemtologil iseses; enorine, nutritionl n metoli iseses; mentl n ehviourl isorers; neurologil iseses; eye iseses; er iseses; respirtory iseses; genitourinry iseses; pregnny, hilirth n perintology; unlssifie symptoms). Inlues ses ge yers in , n those ge yers in A se ws efine s Finnish trveller ro with one episoe of illness or injury, hnle y SOS Interntionl uring 2010 to A person with severl seprte episoes ws ounte more thn one. Figures for Nori n Blti ountries n Russi re not presente here; inienes for these ountries re not omprle with those of other regions euse proportionlly more ses re overe y the Soil Insurne Institution of Finln (Kel) [24] n trips re shorter thn to other regions [22]. Dt soure: Tle 4. prove highest in Egypt, Turkey, n Thiln, n vrie etween ountries within southern Europe. Infetion iniene ws gretest in Afri, followe y southern Europe plus the estern Meiterrnen, n Asi plus Oeni. As for injuries, iniene prove highest in southern Europe plus the estern Meiterrnen (Tle 4, Figure 3). Disussion Prinipl finings For ees, trvel meiine reserh hs striven to outline the risks of helth prolems t vrious estintions. As t hve een unrelte to numers of trvellers per site, the min point of ritiism hs een tht proportions of helth prolems esily suffer istortion [20]. Some reports hve esrie single importe iseses in reltion to ntionl trvel sttistis [25] or Worl Tourism Orgniztion t [26,27], ut thorough overview of trvellers helth risks hs een lking. Our investigtion rws on the exeptionl sitution in Finln, with two lrge tses ville: one mintine y single trvellers ssistne orgnistion, overing out 95% of Finnish ses, n the other y OSF, proviing numeril t on Finnish trvellers to vrious estintions. Comining these enle not only virtully omprehensive ntionwie nlysis of proportionte moriity for vrious ignoses, ut lso iniene lultion of helth prolems ro. These t revel the gret iniene of infetions n the signifint ifferene in iniene of illness n injury etween the vrious regions. 9

10 Strengths n weknesses The mjor novelty of our work lies in presenting inienes of illnesses n injuries in vrious geogrphil regions. Even though the proportionte moriity t presente in this n previous [2-19] stuies re very informtive, the iniene figures re of speil vlue, s they esrie more urtely the risks for trvellers n, s illustrte in Figure 3, llow omprisons etween vrious regions. Our stuy smple represents the most severe ses, yet the tul iniene of helth prolems mong trvellers neeing meil re ro my in relity e sixfol higher thn tht presente here (Figure 1). While this stuy is, to the est of our knowlege, the lrgest to te reporting helth prolems of trvellers while ro, the t o not over trvellers who i not ontt insurne ompnies/ssistne orgnistions, nor those without insurne, or those mking lim fterwrs iretly to the insurne ompny. Aoring to Finln s lrgest trvel insurne ompny, the lst group mentione omprise mostly unomplite outptient ses, while nerly ll inptients ro re re for y ssistne orgnistions (Ilkk Vlnne, Clims Speilist, Euroopplinen, personl ommunition, 2 Otoer 2013). As our stuy mteril overs 95% of ll Finnish ses hnle y ssistne orgnistions, the t represent quite omprehensively the most serious helth prolems fe y Finnish trvellers. The SOS tse lke informtion on urtion of n reson for trvel, n itinerry of iniviul ses, n no evlutions oul e me in reltion to these ftors. Stuies relying on questionnires n telephone interviews [2,7-14] represent trvellers own reports, not evlutions me y helthre professionls; those se on trvel insurne lims [15,16] re mixture of oth. One of the strengths of our stuy is t olletion iretly from liniins treting the ptient ro. Results in reltion to finings in other stuies Finings on proportionte moriity In our stuy, infetions lerly outnumere ll other helth prolems uring trvel. The proportion of infetions prove higher thn in stuies from Switzerln, Austrli n Norwy, lso using t of ssistne orgnistions (60% vs 20 40%) [17-19], possily euse, inste of orgn-speifi tegories, we groupe ll infetions together, in tegory of their own. The most ommon single ignosis ws ute gstroenteritis (23%), onsistent with previous finings on illness ro [2,8-14,28], ounting for one thir of inptient ses. Respirtory infetions prove nerly s ommon (21%), yet with less frequent hospitlistion thn for gstroenteritis. In prospetive stuies, respirtory infetions hve een reporte in 2 26% of trvellers [2,7-14]. Finings on iniene of illness n injury The overll iniene prove highest in Afri, southern Europe plus the estern Meiterrnen, n Asi plus Oeni. One remrkle fining ws tht in southern Europe plus the estern Meiterrnen, figures for injuries n infetions prove higher thn those for estern plus western Europe. The infetion profile iffere from tht in Afri n Asi: inste of ute gstroenteritis, iniene in southern Europe plus the estern Meiterrnen ws highest for respirtory trt infetions, exept for Turkey, whih showe the opposite. Comprisons of iniene figures were possile etween ountries with more thn 50,000 nnul visitors. Some ution shoul, however, e use when mking omprisons, sine ifferenes etween helthre servies my influene the figures in Europe: in ountries with lrge numers of tourists, suh s Spin, there re privte linis iretly ontting ssistne orgnistions, wheres for ountries with fewer privte hospitls, the proportion of ses reporte to SOS my remin smller. In estern plus western Europe, where t oul e ompre etween severl ountries, there ws on the whole minor iniene of helth prolems. The iniene of injuries ws high in Austri n Switzerln, proly mostly ounte for y skiing ients (Mikel Fotopoulos, SOS Interntionl, personl ommunition, 14 July 2014). In southern Europe plus the estern Meiterrnen, omprisons oul e me etween Greee, Itly, Portugl, Spin, n Turkey. In Itly n Portugl, overll iniene of illness n injury prove similr to tht in estern plus western Europe. The high overll iniene in Turkey ws ttriute to gstroenteritis, wheres the next highest figures in Greee n Spin were minly ue to respirtory trt infetions. Greenwoo et l. esrie low risk of gstroenteritis for southern Europe [27], yet we foun n elevte iniene in Greee n Spin. The iniene figures reflet not only helth hzrs, ut lso the hrteristis of trvellers: in the multivrile nlysis, vsulr iseses, mle sex n ge 60 yers, for exmple, were risk ftors for hospitlistion. Likelihoo of illness inreses with urtion of trvel [2,29]. In the OSF t, the frther the estintion, the longer ws the sty (Tle 3). For trvellers to southern Europe plus the estern Meiterrnen, the mein urtion ws longest for the Cnry Islns; intermeite for minln Spin, Greee n Portugl; n shortest for Turkey n Itly. The overll iniene of illness n injury prove, however, highest in Turkey n the Cnry Islns, followe y Greee n minln Spin. Thus, length of sty lone oes not ount for these ifferenes. Within this sme region, trvellers to the Cnry Islns were oler, n to Itly younger thn those to other estintions, onsistent with the 10

11 ge istriution of our ses. Trvellers ge n trvel urtion my thus prtly explin the high iniene in the Cnry Islns n the low in Itly. Nevertheless, it ppers tht the overll iniene in southern Europe plus the estern Meiterrnen exeee tht elsewhere in Europe. Conlusions This stuy shows ler preominne of infetions mong Finnish trvellers helth prolems. This investigtion is the first to present suh omprehensive t on iniene of illnesses n injuries uring trvel. It thus provies tools for risk ssessment, estintionspeifi trvel ounselling n post-trvel evlution. As the types of exposure in given estintion re like for ll trvellers, regrless of the ountry of origin, the results of this stuy shoul e pplile to ny ountry with similr trvel pttern. A noteworthy onlusion is tht trvel within Europe is not without risk. Pre-trvel vie my lso e neee lso for visitors to southern Europe. *Errtum In Tle 3, the numer of trvellers in estern n western Europe were inorret. Also the mein ge group for Spin exluing the Cnry Islns ws inorret. These errors were orrete on 25 My 2015, t the request of the uthors. Aknowlegments The stuy ws supporte y the Mu Kuistil Memoril Fountion n the Finnish Governmentl Susiy for Helth Siene Reserh. The stuy sponsors h no role in stuy esign n the olletion, nlysis, n interprettion of t n the writing of the rtile n the eision to sumit it for pulition. We thnk Ilkk Vlnne (Clims Speilist, Euroopplinen), Ari Kinnunen (Meil Diretor, EMA Finln), Puli Hpsri (Meil Diretor, MeFlight Finln), Timo Prtio (Senior Sttistil Anlyst, the Soil Insurne Institution of Finln), n Tru Tmminen (Sttistiin, the Offiil Sttistis of Finln) for proviing informtion invlule for the interprettion of the results. We thnk Crol Norris for eiting the finl mnusript. Conflit of interest None elre. Authors ontriutions Stuy onept n esign: HS, AK; quisition of t HS, MF; nlysis n interprettion of t HS, PK, AK; sttistil nlysis HS, PK, JO; rfting of the mnusript HS, AK; ritil omments on the mnusript PK, MF, JO; finl pprovl of the version pulishe HS, PK, MF, JO, AK. Referenes 1. Worl Tourism Orgniztion (UNWTO). UNWTO tourism highlights, 2013 eition. Mri: UNWTO; [Aesse 26 Fe 2014] version ville from: en/pulition/unwto-tourism-highlights-2013-eition 2. Hill DR. Helth prolems in lrge ohort of Amerins trveling to eveloping ountries. J Trvel Me. 2000;7(5): Aville from: org/1310/ PMID: Freemn DO, Wel LH, Kozrsky PE, Fisk T, Roins R, von Sonnenurg F, et l. Spetrum of isese n reltion to ple of exposure mong ill returne trvelers. N Engl J Me. 2006;354(2): Aville from: NEJMo PMID: Gutret P, Shlgenhuf P, Gurt J, Cstelli F, Brouqui P, von Sonnenurg F, et l. Multienter EuroTrvNet/GeoSentinel stuy of trvel-relte infetious iseses in Europe. 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