Health Risks of Young Adult Travelers With Type 1 Diabetes

Transcription

1 391 ORIGINAL ARTICLE Health Risks of Young Adult Travelers With Type 1 Diabetes Yael Levy-Shraga, MD, Uri Hamiel, MD, Marianna Yaron, MD, and Orit Pinhas-Hamiel, MD Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children s Hospital, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Maccabi Health Care Services, Juvenile Diabetes Center, Raanana, Israel DOI: /jtm Aim. International travel has become popular among young adults. This study evaluated the rate and characteristics of travel-associated health risks among young adults with type 1 diabetes mellitus (T1DM) compared with healthy same-aged individuals. Methods. A retrospective study was conducted of 47 young adults with T1DM and 48 without (controls). Structured questionnaires accessed information regarding 154 international trips during the preceding 5 years and lasted 7 days and longer. Results. Mean ± SD ages of the diabetic and control groups were 26.6 ± 5.0 and 26.9 ± 2.6 years, respectively. Mean trip durations were 80.0 (range ) and 87.6 days (range ), respectively. The number of trips per person was 1.5 ± 0.6 and 1.7 ± 0.8, and the proportion of trips to developing countries 64 and 61%, respectively. There were no differences between the groups in rates of travel-related diseases that required medical consultation (11% vs 15% for all trips). No patient sought medical attention for acute problems related to diabetes management. Prior to 71% of their trips to developing countries, respondents with diabetes consulted their diabetes physician; prior to 26% of their trips they switched from an insulin pump to injections; during 41% of the trips they increased glucose monitoring; and for the period of 11% of the trips they defined their metabolic control as poor. Self-reported mean hemoglobin A1c (HbA1c) levels before and after trips were 7.65 ± 1.45 and 7.81 ± 1.23%, respectively (p = 0.42, paired t-test). Conclusions. Young adults with type 1 diabetes did not report more travel-related diseases than did healthy individuals. Most reported reasonable to good glycemic control during the trip without severe consequences. The number of people undertaking international travel has increased dramatically in the last 50 years, with more than 1 billion people traveling outside their country of residence in International travel has become particularly popular among young adults, who generally have fewer obligations and, therefore, more time to travel. Often, young adults prefer backpacking trips of longer duration than conventional vacations and using inexpensive lodging such as youth hostels. 2 Backpackers are generally considered to have higher travel-related health risks than other travelers. First, backpackers have a higher risk of illness. It is estimated that 62 to 82% of backpackers experience some type Corresponding Author: Yael Levy-Shraga, MD, Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children s Hospital, Sheba Medical Center, Tel Hashomer 52621, Ramat Gan, Israel. yael.levy.shraga@gmail.com of illness or injury abroad. 3 5 Although most travelers report mild illnesses, up to 8% become ill enough to seek health care either while abroad or on returning home. 6 8 In addition, food poisoning and travelers diarrhea are more common among backpackers. Because backpackers tend to be particularly concerned with travel costs, they are less discriminating about where and what they eat, and are more likely to contract endemic infectious diseases, especially travelers diarrhea. 9 Furthermore, backpackers are more likely to take part in adventure sports and other high-risk behavior, such as drinking alcohol to hazardous levels. 10 Therefore, they may be more likely to be involved in accidents than people traveling as part of an organized tour group or for business purposes. 2 Coping with health issues is more complicated for travelers with underlying medical conditions For example, in some developing countries medicines and first aid supplies may be difficult to obtain, and the hazard of purchasing substandard medicines is imminent International Society of Travel Medicine, Journal of Travel Medicine 2014; Volume 21 (Issue 6):

2 392 Levy-Shraga et al. Because travelers, particularly backpackers, may have limited space for medical supplies, selection of the most necessary items is important. 17 For individuals with type 1 diabetes mellitus (T1DM), safe and healthy travel necessitates managing glucose levels under conditions that may be particularly challenging, because of changes in routines regarding level of physical activity, nutrition, and the risk of infectious diseases. All these parameters might cause glycemic dysregulation. Other important issues are the medical supplies needed for managing diabetes and refrigeration of insulin while traveling. However, systematic research concerning risks and health problems of travelers with T1DM has been limited. 18,19 To our knowledge, no study has yet been conducted in young adults, specifically among backpackers with T1DM. A retrospective study was conducted to evaluate the degree of glycemic control and practical difficulties, as well as the incidence and characteristics of travel-associated risks among young adults with T1DM traveling internationally in comparison to same-aged individuals without diabetes. Methods Study Population Young adults with T1DM attending the Pediatric Endocrinology and Diabetes Unit of Safra Children s Hospital and the Juvenile Diabetes Center of Maccabi Health Care Services were recruited. In addition, an online survey was done. The control population was composed of volunteers without diabetes, who were recruited from family members and friends of hospital personnel. All participants gave informed consent and the study was approved by the Sheba Medical Center Ethics Review Committee. Procedures A structured questionnaire was developed by the study investigators. Questions dealt with medical history and history of trips abroad of at least 1 week s duration during the preceding 5 years. Medical history included: diabetes duration, comorbidities, medications regularly consumed, mode of insulin administration [multiple daily injections (MDIs) vs insulin pump], and the average frequency of glucose monitoring per day. In addition, the participants were asked to state the number of times the following events had occurred since their being diagnosed with diabetes: diabetes-related hospital admissions, diabetic ketoacidosis (DKA), and a severe hypoglycemic event. Severe hypoglycemia was defined according to the Diabetes Control and Complications Trial protocol to include coma, seizures, and any other sign of inability to self-treat. 20 Details on traveling included the countries of destination, the duration of travel, and characteristics of the travel (tourism, business trip, backpacking, organized or nonorganized tour). Participants were asked whether they consulted with a travelers clinic and with their diabetes physician regarding their travel. For each trip, the questionnaire included items about diabetes management while traveling (mode of insulin injection and glucose monitoring), illnesses suffered, medications taken during the trip, the medical supplies needed (such as insulin syringes, pen needles, glucometer, test strips, lancing devices, insulin pump and infusion sets), and avoidance of places or experiences because of the disease. For comparison, an identical questionnaire, with the exclusion of the diabetes-specific items, was administered to young healthy adults of similar age. Participants were asked to fill in a separate questionnaire for each trip. Definitions Travel destinations were classified as developing countries and developed countries. Countries in Central and South America, Southeast Asia (excluding Japan, South Korea, and Singapore), and Africa (excluding South Africa) were classified as developing countries. Developed countries included Japan, South Korea, Singapore, South Africa, and countries in Europe and North America. Backpacking trips were characterized by the use of a backpack or easily carried luggage for long distances and the use of inexpensive lodging such as youth hostels. Any illness episode during the travel (injury, infectious disease, any pain or discomfort) was designated as travel-related disease. Because each trip constituted distinct at-risk events, and study participants undertook one or more trips during the 5-year study period, the rate of illness was analyzed per trip rather than per patient. Statistical Analysis Statistical analyses were performed using the R version (R Foundation for Statistical Computing, Vienna, Austria). Continuous variables with plausible normality assumption were analyzed by the two-tailed Student t-test. For continuous variables without the normality assumption and for ordinal variables, the Wilcoxon rank test was used to compare means. For categorical variables with two levels, the z-test was used to compare two proportions, whereas for categorical variables with more than two levels, one way analysis of variance (ANOVA) was used. p-values <0.05 were considered statistically significant. Results Forty-seven patients with T1DM and 48 healthy young adults filled out questionnaires. Demographic characteristics of the two groups are shown in Table 1. There were no statistically significant differences between the groups with regard to age and sex distribution. Celiac and thyroid diseases were more prevalent in the diabetes group, and smoking was less prevalent.

3 Travelers With T1DM 393 Table 1 Demographic characteristics of the two groups T1DM group (n = 47) Control group (n = 48) p-value Age, mean ± SD 26.6 ± 5.0 (18 32) 26.9 ± 2.6 (19 31) 0.64 (range), years Females, n (%) 29 (61.7%) 25 (52.1%) 0.17 Smokers, n (%) 3 (6.4%) 10 (20.1%) 0.02 Other diseases, n (%) Celiac disease 4 (8.5%) Thyroid disease 6 (12.8%) 1 (2.1%) 0.02 Other diseases 3 (6.4%) 2 (4.2%) 0.31 T1DM, type 1 diabetes mellitus. The mean age at diagnosis of the 47 T1DM patients was 13.5 ± 5.8 years, and the mean duration of the disease at the time of their completing the questionnaire was 12.5 ± 7.0 years. Of the 47 patients, 62% used insulin pumps. The mean number of glucose measurements per day was 5.8± 2.3. The rate of diabetes-related hospitalizations was 6.1 per 100 patient years; the rate of DKA was 4.0 per 100 patient years; and the rate of severe hypoglycemia, 8.4 per 100 patient years. The data regarding hospitalization, DKA, and severe hypoglycemic events covered the entire period of time since diagnosis, excluding the time of traveling. No statistically significant differences were observed between those with and without diabetes regarding the total number of trips, the number of trips per person, the length of trips, the proportion of trips to developing countries, and the purpose of the trips (tourist trips vs business) (Table 2). In the diabetes group, 91% of the trips were nonorganized, compared with 100% of those of the controls (p = 0.003). Regarding trips to developing countries, 80% backpacked in the diabetes group compared with 92% in the control group (p = 0.049). In the diabetes group, fewer traveled alone (p = 0.03), and more bought special medical equipment prior to the trip (p < 0.001). The latter included medical supplies for treating diabetes such as syringes, needles, pump supplies, glucose meters, and special coolers for insulin. During trips to developing countries, there was no statistically significant difference between the groups in the proportion taking medications (except insulin) or seeking professional medical help. Medical treatment was required in 8 trips (11%) in the diabetes group and in 12 trips (15%) in the control group (p = 0.25). The medical problems encountered in the diabetes group were: acute gastroenteritis (two cases), skin infection (two cases), urinary tract infection (one case), mild injury (two cases), and animal bite (one case). The medical problems encountered by the control groups were: acute gastroenteritis (three cases), skin infection (one case), respiratory infection (three cases), acute otitis (one case), acute pharyngitis (one case), abdominal pain (one case), and dental problems (two cases). For both groups, the majority of illnesses contracted abroad were infectious diseases. No patient sought medical help for acute problems related to diabetes management. Table 3 presents the responses to questions related to diabetes management during travel. The data were analyzed per number of trips, regarding all trips, and separately for trips to developing countries and those to developed countries. Prior to 71% of the trips to developing countries, individuals consulted with their diabetes physicians and during 7% of the trips, there was at least one phone consultation regarding diabetes. Prior to 26% of the trips to developing countries, individuals switched from the use of an insulin pump to MDI. During 91% of trips to developing countries, individuals disclosed the fact that they had diabetes to their companions. For 55% of all trips, travelers reported blood glucose monitoring at the same frequency as their home routine; for 38%, the frequency was greater; and for 7%, the frequency was less than their home routine. Respondents defined their metabolic control as reasonable to good during 93% of all trips. Mean reported hemoglobin A1c (HbA1c) levels before and after trips were 7.65 ± 1.45% (60 ± 8 mmol/mol) and 7.81± 1.23% (62± 10 mmol/mol), respectively (p = 0.42, paired t-test). Two events of high blood glucose without DKA were reported, and eight of severe hypoglycemia; all were managed without seeking professional medical help. There was no need for glucagon injections. The eight events of severe hypoglycemia occurred in four different patients, of whom three had experienced severe hypoglycemic events prior to the trip. Discussion The study presented here evaluated travel-associated health risks among young adults with T1DM (mean age 26.5 ± 5.0 years, range 18 32) compared with healthy individuals of the same age during a total of 154 international trips. Most of the trips were to developing countries, of which 86% involved backpacking. There was no statistically significant difference in the rates of travel-related diseases between those with and without diabetes. Most reported reasonable to good glycemic control, and none sought medical treatment for diabetes-related problems. International tourism, including travel to developing countries, has grown in popularity. It is increasingly recognized as an important aspect of individual well-being and quality of life. The exact numbers of travelers with diabetes who visit developing countries is not known. In a study published in 1991, 0.4% of 2,445 travelers to the developing world who consulted a travel clinic had T1DM. 21 A study published in 2010 reported that 3.1% of visitors in a travel clinic had diabetes, 19 a rate comparable to the prevalence of the disease in the general population. 22 The number of Israeli travelers to developing countries is estimated at approximately 170,000 annually, 23 with Asia (49.2%), Latin America

4 394 Levy-Shraga et al. Table 2 Travel characteristics of the two study groups T1DM group (n = 47) Control group (n = 48) p-value Total number of trips Number of trips per person, mean ± SD, (range) 1.5 ± 0.6 (1 3) 1.7 ± 0.8 (1 3) 0.29 Mean length of trip in days, mean ± SD (range) 80.0 ± 92.2 (7 390) 87.6 ± 96.1 (7 395) 0.73 Proportion of trips to developing countries, n (%) 46 (64%) 50 (61%) 0.35 Main destinations, n (%) Southeast Asia 23 (32%) 18 (22%) Latin America 21 (29%) 29 (35%) Africa 2 (3%) 3 (4%) Europe and North America 26 (36%) 32 (39%) Consultation at travelers clinic 27 (37%) 37 (45%) 0.17 Travel for the purpose of tourism, n (%) All countries 68 (94%) 74 (90%) 0.16 Developing countries 46 (100%) 49 (98%) 0.17 Nonorganized trip, n (%) All countries 66 (91%) 82 (100%) Developing countries 44 (96%) 50 (100%) 0.06 Backpacking, n (%) All countries 37 (51%) 51 (62%) Developing countries 37 (80%) 46 (92%) Travel companions (alone/family/friends) All countries Alone 7 (10%) Alone 15 (18%) Family 15 (21%) Family 10 (12%) Friends 50 (69%) Friends 57 (70%) Developing countries Alone 5 (11%) Alone 11 (22%) Family 7 (15%) Family 1 (2%) Friends 34 (74%) Friends 38 (76%) Purchase of special medical equipment prior to the trip All countries 36 (50%) 12 (15%) <0.001 Developing countries 27 (59%) 10 (20%) <0.001 Use of medication during the trip (other than insulin) All countries 19 (26%) 13 (16%) Developing countries 13 (29%) 13 (26%) 0.4 Required medical consultation during the trip All countries 8 (11%) 12 (15%) 0.25 Developing countries 6 (13%) 12 (24%) T1DM, type 1 diabetes mellitus. (23.4%), and Africa (23.2%) being the most popular destinations. The majority (87%) travel for pleasure, 6% for business, and 7% as representatives of governmental organizations. 24 The data from this study showed no statistically significant difference in the destinations chosen by travelers with T1DM and healthy same-aged controls. In previous studies of travelers with diabetes the mean age range of participants was higher (mean age years in different studies) and the duration of trips was shorter (21 34 days). 14,18,19,25 Apparently the character of the trips was different, with more of organized tour groups or business travel. Despite the similarities in mode of travel and destinations of the two groups in this study, a tendency to more caution was observed among those with diabetes: 4% of their trips to developing countries were organized (vs none of healthy controls) and 20% were not backpacking (vs 8% of healthy controls). The degree of caution is also evident in the findings that during trips to developing countries, those with diabetes tended more often to travel with companions (friends or family members) rather than alone, compared with same-aged healthy adults. The data show similar risks among young adults with and without diabetes for developing travel-related diseases. Evidence from clinical studies about health risks in travelers with T1DM is limited and not consistent. Two studies found high risk for travel-related diseases among those with diabetes. 14,18 However, a prospective study with a matched control group found that T1DM patients traveling to developing countries do not have symptomatic infectious diseases more often or for a longer duration than do travelers without diabetes. 19 Recommendations for travelers with diabetes that have been detailed in the literature include receiving a diabetes-specific checkup prior to the trip, increasing glucose monitoring during the trip and adjusting insulin doses accordingly, and maintaining adequate levels of hydration and nutrition. 11,26 Procuring and packing proper diabetes supplies before travel is important

5 Travelers With T1DM 395 Table 3 Diabetes management while traveling; the rates were analyzed per number of trips Trips to all countries (n = 72) Trips to developing countries (n = 46) Trips to developed countries (n = 26) Consultation with diabetes physician prior to the trip 44 (61%) 33 (71%) 11 (42%) Phone consultation regarding diabetes during the trip 5 (7%) 3 (7%) 2 (8%) Avoidance of places due to diabetes 7 (10%) 4 (9%) 3 (11%) Travel with other individuals with diabetes 10 (14%) 6 (13%) 4 (15%) Disclosure of diabetes to travel companions 65 (90%) 42 (91%) 23 (88%) Changed mode of treatment from pump to injection prior to the trip 12 (17%) 12 (26%) 0 Glucose monitoring Less than usual 5 (7%) 2 (5%) 3 (11%) Same as usual 40 (55%) 25 (54%) 15 (58%) More than usual 27 (38%) 19 (41%) 8 (31%) Glucose control Poor 5 (7%) 5 (11%) 0 Reasonable 36 (50%) 21 (46%) 15 (58%) Good 31 (43%) 20 (43%) 11 (42%) because supplies are difficult to obtain in some developing countries. Recommendations for supplies include at least twice the requirement of insulin, insulin pens and needles, syringes, pump supplies, glucose strips, and ketone strips 11,26 and storing them in a carry-on bag and not in checked luggage. It is also recommended to take two different glucose meters with extra batteries for each, two glucagon kits protected against breakage and from freezing of the vehicle, and a special cooler to refrigerate the insulin. 26 Treatment for hypoglycemia is crucial including some solid options (ie, glucose tablets), as some countries may try to confiscate liquid glucose formulations. A letter from a physician listing supplies and their necessity is a must for travelers with diabetes crossing international borders. It is also recommended to arrive at the airport early, as transfers through airport security with diabetes supplies may take a longer time. In this study, travelers with diabetes consulted their diabetes physicians prior to only 71% of their trips to developing countries and 42% of their trips to developed countries. Consultation prior to the trip is essential for travelers to discuss the recommendations mentioned earlier and to prepare themselves accordingly. In 90% of all trips, individuals told their travel companions that they had diabetes; this is very important for managing severe hypoglycemia. On the other hand, during only 7% of the trips did travelers contact their diabetes physicians by phone regarding their disease diabetes management. It suggested that the consultation prior to the trip should include establishing a means of contact with the diabetes team during travel. Managing glucose levels while traveling may be challenging because of dietary changes, increased physical activity, and the effects of low temperature on glucometers. Yet, only in 38% of all trips was blood glucose monitoring increased during the journey. This is consistent with a study that showed that 36% of patients with diabetes increased the frequency of blood glucose monitoring during travel. 18 However, in this study, 55% of T1DM patients reported worse glucose control while traveling than during the preceding period, and serious deterioration in glucose control occurred in 2 of the 19 participants in the study group. In this study, poor metabolic control was reported in only 7% of all trips. The two events of high blood glucose without DKA and eight events of severe hypoglycemia were managed without seeking professional medical help. The need for glucagon injections did not arise. These data demonstrate that even with less than optimal attention to diabetes-related issues, management of diabetes during traveling is now possible. Newer insulin preparations and injection devices may have eased management. Interestingly, switching from the use of an insulin pump to injections was reported prior to 26% of trips to developing countries, while it was not reported at all before trips to developed countries. Respondents explained that this change was based on advice passed on among the travelers rather than a formal recommendation. The reason may have been the limited space available for carrying sufficient supplies or the difficulties with customs regulations. Some limitations of this study should be acknowledged. As with any retrospective study based on a questionnaire, recollection bias could skew the results in unpredictable directions. However, we attempted to limit this bias by including trips taken only within the last 5 years. In addition, the study is subject to selection bias, that is, the study population does not represent the general population of young adults with diabetes. This is due to the generally good disease management reported prior to the trips, as demonstrated by a relatively high frequency of daily blood glucose measurements, relatively low HbA1c levels, and low incidence of acute diabetes complications. However, it is possible that individuals with diabetes who choose to travel have better glycemic control than those who do not travel. Though actual measurements of glucose levels during travel were not available for this retrospective

6 396 Levy-Shraga et al. study, prospective investigation of glucose control during travel compared with routine daily life is a direction for future research. In conclusion, young adults with diabetes do not seem to be at increased risk for travel-related diseases compared with healthy individuals of the same age. In the study population, events of glycemic dysregulation during travel were all managed without medical intervention and without severe consequences. This supports the safety of international travel for young adults with diabetes to the same extent as their peers, under the stipulation that appropriate safety measures are taken. This conclusion applies to individuals who routinely maintain good metabolic control. Trips should be well planned with careful consideration of potential difficulties: transporting insulin, adjustment of insulin dosage, and sufficient glucose monitoring. Patients should be encouraged to inform their travel companions about their condition so that the latter can be of assistance in the event of a problem. Adherence to the recommendations of both travelers and caregivers could improve travel safety. Acknowledgment We thank Ms. C. Cohen for her excellent editorial help. Declaration of Interests The authors state they have no conflicts of interest to declare. References 1. UNWTO. World tourism barometer. Vol Available at: (Accessed 2014 Mar). 2. Leggat PA, Shaw MM. Travel health advice for backpackers. J Travel Med 2003; 10: Shaw MT, Leggat PA, Weld LH, et al. Illness in returned travellers presenting at GeoSentinel sites in New Zealand. Aust N Z J Public Health 2003; 27: Peach HG, Bath NE. Health and safety problems and lack of information among international visitors backpacking through North Queensland. J Travel Med 2000; 7: Crouse BJ, Josephs D. Health care needs of Appalachian trail hikers. J Fam Pract 1993; 36: Ryan ET, Wilson ME, Kain KC. Illness after international travel. N Engl J Med 2002; 347: Freedman DO, Weld LH, Kozarsky PE, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med 2006; 354: Ross AG, Olds GR, Cripps AW, et al. Enteropathogens and chronic illness in returning travelers. N Engl J Med 2013; 368: Leggat PA, Leggat FW. Travel insurance claims made by travelers from Australia. J Travel Med 2002; 9: McNulty AM, Egan C, Wand H, Donovan B. The behaviour and sexual health of young international travellers (backpackers) in Australia. Sex Transm Infect 2010; 86: Ericsson CD. Travellers with pre-existing medical conditions. Int J Antimicrob Agents 2003; 21: McCarthy AE, Mileno MD. Prevention and treatment of travel-related infections in compromised hosts. Curr Opin Infect Dis 2006; 19: Committee to Advise on Tropical Medicine and Travel (CATMAT). The immunocompromised traveller. An Advisory Committee Statement (ACS). Can Commun Dis Rep 2007; 33(ACS-4): Wieten RW, Leenstra T, Goorhuis A, et al. Health risks of travelers with medical conditions a retrospective analysis. J Travel Med 2012; 19: Ben-Horin S, Bujanover Y, Goldstein S, et al. Travel-associated health risks for patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2012; 10: , 5 e Gurgle HE, Roesel DJ, Erickson TN, Devine EB. Impact of traveling to visit friends and relatives on chronic disease management. J Travel Med 2013; 20: Goodyer L, Gibbs J. Medical supplies for travelers to developing countries. J Travel Med 2004; 11: Driessen SO, Cobelens FG, Ligthelm RJ. Travel-related morbidity in travelers with insulin-dependent diabetes mellitus. J Travel Med 1999; 6: Baaten GG, Roukens AH, Geskus RB, et al. Symptoms of infectious diseases in travelers with diabetes mellitus: a prospective study with matched controls. J Travel Med 2010; 17: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993; 329: Hill DR. Pre-travel health, immunization status, and demographics of travel to the developing world for individuals visiting a travel medicine service. Am J Trop Med Hyg 1991; 45: Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: estimates for the year 2000 and projections for Diabetes Care 2004; 27: Mizrachi E, Steinlauf S, Schwartz E. Morbidity of Israeli travelers after traveling to developing countries. Harefuah 2010; 149: , Stienlauf S, Meltzer E, Leshem E, et al. The profile of Israeli travelers to developing countries: perspectives of a travel clinic. Harefuah 2010; 149: , Burnett JC. Long- and short-haul travel by air: issues for people with diabetes on insulin. J Travel Med 2006; 13: Brubaker PL. Adventure travel and type 1 diabetes: the complicating effects of high altitude. Diabetes Care 2005; 28: