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MODEL
Travel Medicine and Infectious Disease (2014) xx, 1e5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
Effectiveness of pre-travel consultation in the prevention of travel-related diseases: A retrospective cohort study Silvio Tafuri*, Rocco Guerra, Maria Serena Gallone, Maria Giovanna Cappelli, Serafina Lanotte, Michele Quarto, Cinzia Germinario Department of Biomedical Science and Human Oncology, Aldo Moro University of Bari, Italy Received 13 December 2013; received in revised form 9 October 2014; accepted 13 October 2014
KEYWORDS Pre-travel counselling; Effectiveness; Anti-malaria prophylaxis
Summary Background: This study aims to evaluate the effectiveness of pre-travel counselling carried out in Travel Clinics. Methods: This is a retrospective cohort. Three hundred international travellers were enrolled; 150 people were from users of Bari Travel Clinic, 150 were users of a travel agency. Enrolled subjects were interviewed using a questionnaire. Results: The average age of the enrolled subjects was 37.5 13.9, without statistically significant differences between the two groups. 86% of cases and 19.3% of the controls reported the use of anti-malaria prophylaxis (p < 0.0001). Vaccination against cholera was given to 62% of cases and 7.3% of the controls (p < 0.001). Travel Clinic users, 6% reported diarrhoea and these figures were 27% in the control group (p < 0.0001). The proportion of those interviewed who reported fever (3.7) or insomnia (1.3) did not differ between the two groups. Mosquito bites were reported by 8% of cases and 20% of the controls (p Z 0.003). Three cases of malaria were reported among the controls but no cases were detected among the cases (chi-square Z 3.03; p Z 0.08). Conclusions: Our study demonstrated the effectiveness of pre-travel counselling; in the future, new studies must investigate the cost-effectiveness of pre-travel prevention measures. ª 2014 Elsevier Ltd. All rights reserved.
* Corresponding author. Department of Biomedical Science and Human Oncology, Aldo Moro University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy. Tel.: þ39 0805478481; fax: þ39 0805478472. E-mail address: [email protected] (S. Tafuri). http://dx.doi.org/10.1016/j.tmaid.2014.10.012 1477-8939/ª 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Tafuri S, et al., Effectiveness of pre-travel consultation in the prevention of travel-related diseases: A retrospective cohort study, Travel Medicine and Infectious Disease (2014), http://dx.doi.org/10.1016/j.tmaid.2014.10.012
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MODEL
2
1. Introduction In 2011 the World Tourism Organization reported 980 million travellers crossed an international border; this is an important increase because in 2001 this number accounted for 675 million [1]. Following this explosive increase in international travel, the practice of travel medicine continues to grow. Many studies have documented that 20%e64% of international travellers will develop some health problem while abroad [2]. Travelling overseas, in fact, may carry health risks that do not exist in industrialized countries [3]. A survey published in 2013, that enrolled about 42,000 ill travellers who had returned and had been seen between 2007 and 2011, showed that many travel-related illnesses were due to gastrointestinal, febrile and dermatologic diseases [4]. Moreover, an increasing number of travellers are exposed to arthropod-borne diseases [5], including malaria. Data of EuroTravNet, a network of clinicians who are specialists in tropical and travel medicine, showed that in Europe most cases of febrile systemic illnesses in travellers were due to malaria and dengue fever, with an increase in malaria cases reported from 2008 to 2010 [6]. Finally, jet lag affects most air travellers crossing five or more time zones; it tends to be worse on eastward bound flights than on westward ones [7]. The increase in travel medicine knowledge over the past 30 years makes pre-travel counselling an essential part of primary care. A successful pre-travel consultation involves hazards analysis and counselling to make the patient aware of travel risks [8]. Health care recommendations for travellers must be specifically tailored to the individual, since each traveller has a different underlying medical status. These recommendations should be made in such a manner that apprises the traveller of the risks involved but does not instill undue anxiety [9]. Effective pre-travel consultation begins with a process of assessing and conveying the epidemiologic likelihood of disease and injury connected with the trip which depends on traveller- and itinerary-specific factors [8]. Ideally pre-travel health counselling is based on the traveller’s health history and immunization status, planned or intended activities, destinations, itinerary and the duration of travel [10,11]. Pre-travel consultation should include reviewing routine and destination-specific immunizations. Decisions regarding immunizations for travellers are predicated upon an evaluation of the endemic and epidemic infections in the traveller’s target country. Yellow fever is required for some countries on arrival, while other immunizations (such as the cholera vaccine) are required only under specific circumstances or may be recommended for persons at high risk or for all travellers. Counselling has to include some advices about the prevention of diarrhoea (consumption of cooked meat and fish, avoidance of unpasteurized milk or milk products, unpeeled fruits, raw salads and ice or water which has not been boiled) and mosquito bites (proper use of insect repellents and mosquito netting) [9]. Chemoprophylaxis is recommended for at-risk travellers visiting malaria endemic regions and during the consultation physicians have to explain the risk of malaria and prescribe
S. Tafuri et al. appropriate drugs; the majority of travellers with imported malaria have not used these [12]. In many countries, travel clinics have been established to guarantee pre-travel consultation, the prescription of drugs and the administration of vaccines for international travellers. From many years, international and national public health authorities and a lot of scientific groups have been engaged in the research of the evidence that can support prevention policies (evidence based public health) [13]. Even if travel medicine is currently practiced in many countries, only a few studies in the past investigated the effectiveness of pre-travel consultation in changing the behaviours of travellers and in reducing the incidence of travel-related diseases in international travellers. Since 2008 Travel Clinic has been activated in Bari General Hospital. Travellers who are going overseas access the Travel Clinic and this service is free of charge; travellers only have to pay for anti-malaria drugs. Every year, about 1000 travellers access the Clinic. This study aims to evaluate the effectiveness of pretravel counselling in a group of international travellers who attended the Travel Clinic at Bari General Hospital.
2. Materials and methods To evaluate the effectiveness of counselling in changing behaviour and health outcome, a retrospective cohort study was conducted. We enrolled travellers who attended the Travel Clinic at Bari General Hospital during 2012 and who were going to visit developing countries (such as Sub-Saharan Africa) where malaria is endemic and the use of anti-malaria drugs was recommended; they were “exposed subjects”. The list of travellers was randomly selected from the database of the Travel Clinic patients who match the inclusion criteria. “Non exposed subjects” were those persons who in 2012 visited low socio-economic level countries where malaria is endemic and the use of anti-malaria drugs was recommended but who had not attended public health clinics for counselling before travelling. The list was randomly derived from the management system of a travel agency. Enrolled subjects were contacted by telephone by the Travel Clinic’s doctors and, after an explanation of the rationale of the study, verbal informed consent was required to participate in the study. Each of those enrolled was interviewed by telephone using a standardized questionnaire that investigated gender, age, duration of the trip, compliance with malaria prophylaxis and cholera vaccination before travelling, the supply of drugs and insect repellents for the journey, water safety, consumption of high-risk food (such as raw vegetables, raw seafood, ice cream in bulk, drinks containing ice), health problems occurred during the journey or within three days of return (diarrhoea or intestinal problems, fever, mosquito bites, insomnia) or doctor consultation upon return. The same people questioned the cases and the controls. The forms were computerized onto a database built by FileMaker Pro software and analysed with the statistical software STATA MP11.
Please cite this article in press as: Tafuri S, et al., Effectiveness of pre-travel consultation in the prevention of travel-related diseases: A retrospective cohort study, Travel Medicine and Infectious Disease (2014), http://dx.doi.org/10.1016/j.tmaid.2014.10.012
+
MODEL
Effectiveness of pre-travel consultation: A retrospective cohort study T-test student for unpaired samples were used to compare the averages of quantitative variables between exposed and non exposed subjects. The Chi-square test was used to compare the proportions. To investigate the role of age, sex, duration of the trip, attendance at the Travel Clinic on behaviour and health problems, a multiple logistic regression model was set; odds ratio (OR) with confidence intervals at 95% were calculated. For each test a p < 0.05 was considered significant. Sample size calculation showed that we had to enrol >100 people for each brace then we enrolled 150 exposed and 150 non exposed subjects.
3. Results The study sample was made up of 168 (56%) males and 132 (44%) females. In particular, the group of “exposed” was made up of 93 (62%) males and 57 (38%) females, while the “non exposed” group included 75 (50%) males and 75 (50%) females (chisquare Z 1.38; p Z 0.036). The average age of the enrolled subjects was 37.5 13.9, without statistically significant differences between the group of users of the Travel Clinic (37.4 11.9) and the other group (37.7 15.7; t Z 0.21; p Z 0.41). The response rate was 100% in both groups. The average duration of the trip was between of 17.1 44.3 days and it was longer among exposed people (21.5 59.1) than in the other group (12.6 20.5; t Z 1.7; p Z 0.042). The users of the Travel Clinic used malaria prophylaxis, vaccination against cholera and insect repellents more frequently (Table 1). The proportion of people who supply drugs for travel was similar in the two groups (Table 1). Thirteen (4.3%) of those interviewed reported drinking unsafe water; this proportion did not differ between exposed (n Z 7/150; 4.6%; 95% CI Z 0.1e8.1) and non exposed subjects (n Z 6/150; 4%; 95% CI Z 0.8e7.1; chisquare 0.08; p Z 0.777). Forty-five (15%) of enrolled subjects ate some food with elevated risk of traveller’s diarrhoea (such as raw fruit or vegetables, drink with ice or ice cream); this proportion was higher in the non-exposed people (n Z 36/150; 24%; 95% CI Z 17.1e30.9) than in the people attending the Travel Clinic (n Z 9/150; 6%; 95% CI 2.2e9.9; chisquare Z 19.06; p < 0.0001). Fifty (16.7%) reported diarrhoea or gastrointestinal symptoms, 9 (6%; 95% CI Z 2.1e9.9) in the group of exposed subjects and 41 (27.3%; 95% CI Z 20.2e34.5) in the other group (chi-square Z 24.6; p < 0.0001). Only 11 (3.7%)
3
of those enrolled people reported fever during the trip; this proportion did not differ between exposed (n Z 4/150; 2.7%; 95% CI Z 0.5e5.2) and not exposed people (n Z 7/ 150; 4.6%; 95% CI Z 1.2e8.1; chi-square Z 0.89; p Z 0.35). Mosquito bites were reported by 42 (14%) of those interviewed, 12 (8%; 95% CI Z 3.6e12.4) Travel Clinic patients and 30 (20%; 95% CI Z 13.5e26.5) of the other group (chi-square Z 8.9; p Z 0.0003). 4 (1.3%) persons reported insomnia, with no difference between exposed (3/150; 2%; 95% CI Z 0.2e4) and non exposed (1/150; 0.6%; 95% CI Z 0.6e1.9; chi-square Z 1.01; p Z 0.31). Twenty-nine (9.7%) of those interviewed attended their General Practitioner or the hospital after the trip; this proportion was higher in the non exposed group (n Z 21/ 150; 14%; 95% CI Z 8.3e19.6) than in the people attending Travel Clinic (n Z 8/150; 5.3%; 95% CI Z 1.7e9.0; chisquare Z 6.4; p Z 0.011). Three (1% of the enrolled patients) cases of malaria were reported; all were in the non exposed people (chisquare Z 3.03; p Z 0.08). Multiple logistic regression showed that taking prophylaxis against malaria was associated with older age expressed in years (OR Z 1.03; 95% CI Z 1.01e1.06; z Z 2.9; p Z 0.009) and attendance of the Travel Clinic (OR Z 32.7; 95% CI Z 16.3e64.2; z Z 10.11; p < 0.0001). Vaccination against cholera was associated with age (OR Z 1.03; 95% CI Z 1.004e1.05; z Z 2.28; p Z 0.023) and attendance of the Travel Clinic (OR Z 24.2; 95% CI Z 11.5e50.6; z Z 8.45; p < 0.0001). The model did not show any determinant of the attitude to supply drugs for travel. The attitude to supply mosquito repellents was associated with the age (OR Z 1.02; 95% CI Z 1.001e1.05; z Z 2.09; p Z 0.037) and attendance of the Travel Clinic (OR Z 6.49; 95% CI Z 2.86e14.73; z Z 4.47; p < 0.0001). People attending the Travel Clinic seemed to be protected against diarrhoea and gastrointestinal symptoms (OR Z 0.16; 95% CI Z 0.07e0.34; z Z 4.62; p < 0.0001). No risk factors for fever and insomnia were revealed by the multiple logistic analysis. The number of days of the trip seemed to be associated with the risk of medical consultation after the journey (OR Z 1.02; 95% CI Z 1.006e1.05; z Z 2.51; p Z 0.012), but attending the Travel Clinic reduced this risks (OR Z 0.29; 95% CI Z 0.11e0.72; z Z 2.67; p Z 0.008).
4. Discussion Our survey, that involved 300 international travellers, showed the effectiveness of pre-travel counselling both in
Table 1 Percentages of subjects who before travelling took prophylaxis against malaria, vaccination against cholera, insect repellents and who took supply drugs to travel.
Prophylaxis against malaria Vaccination against cholera Medication for travel related illness Insect repellents
Consulted a travel clinic (% 95% CI)
Visited a travel agency (%; 95% CI)
Chi-square
p
129 (86%; 81.0e92.1) 93 (63.7%; 55.8e71.6) 143 (95.3%; 91.9e98.7) 142 (94.6%; 91.0e98.3)
29 (19.3%; 12.9e25.7%) 11 (7.3%; 3.1e11.5) 135 (90.0%; 85.1e94.8) 112 (74.6% 67.6e81.7)
135.6 103.1 3.12 23.1
MODEL
Travel Medicine and Infectious Disease (2014) xx, 1e5
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/tmid
Effectiveness of pre-travel consultation in the prevention of travel-related diseases: A retrospective cohort study Silvio Tafuri*, Rocco Guerra, Maria Serena Gallone, Maria Giovanna Cappelli, Serafina Lanotte, Michele Quarto, Cinzia Germinario Department of Biomedical Science and Human Oncology, Aldo Moro University of Bari, Italy Received 13 December 2013; received in revised form 9 October 2014; accepted 13 October 2014
KEYWORDS Pre-travel counselling; Effectiveness; Anti-malaria prophylaxis
Summary Background: This study aims to evaluate the effectiveness of pre-travel counselling carried out in Travel Clinics. Methods: This is a retrospective cohort. Three hundred international travellers were enrolled; 150 people were from users of Bari Travel Clinic, 150 were users of a travel agency. Enrolled subjects were interviewed using a questionnaire. Results: The average age of the enrolled subjects was 37.5 13.9, without statistically significant differences between the two groups. 86% of cases and 19.3% of the controls reported the use of anti-malaria prophylaxis (p < 0.0001). Vaccination against cholera was given to 62% of cases and 7.3% of the controls (p < 0.001). Travel Clinic users, 6% reported diarrhoea and these figures were 27% in the control group (p < 0.0001). The proportion of those interviewed who reported fever (3.7) or insomnia (1.3) did not differ between the two groups. Mosquito bites were reported by 8% of cases and 20% of the controls (p Z 0.003). Three cases of malaria were reported among the controls but no cases were detected among the cases (chi-square Z 3.03; p Z 0.08). Conclusions: Our study demonstrated the effectiveness of pre-travel counselling; in the future, new studies must investigate the cost-effectiveness of pre-travel prevention measures. ª 2014 Elsevier Ltd. All rights reserved.
* Corresponding author. Department of Biomedical Science and Human Oncology, Aldo Moro University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy. Tel.: þ39 0805478481; fax: þ39 0805478472. E-mail address: [email protected] (S. Tafuri). http://dx.doi.org/10.1016/j.tmaid.2014.10.012 1477-8939/ª 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Tafuri S, et al., Effectiveness of pre-travel consultation in the prevention of travel-related diseases: A retrospective cohort study, Travel Medicine and Infectious Disease (2014), http://dx.doi.org/10.1016/j.tmaid.2014.10.012
+
MODEL
2
1. Introduction In 2011 the World Tourism Organization reported 980 million travellers crossed an international border; this is an important increase because in 2001 this number accounted for 675 million [1]. Following this explosive increase in international travel, the practice of travel medicine continues to grow. Many studies have documented that 20%e64% of international travellers will develop some health problem while abroad [2]. Travelling overseas, in fact, may carry health risks that do not exist in industrialized countries [3]. A survey published in 2013, that enrolled about 42,000 ill travellers who had returned and had been seen between 2007 and 2011, showed that many travel-related illnesses were due to gastrointestinal, febrile and dermatologic diseases [4]. Moreover, an increasing number of travellers are exposed to arthropod-borne diseases [5], including malaria. Data of EuroTravNet, a network of clinicians who are specialists in tropical and travel medicine, showed that in Europe most cases of febrile systemic illnesses in travellers were due to malaria and dengue fever, with an increase in malaria cases reported from 2008 to 2010 [6]. Finally, jet lag affects most air travellers crossing five or more time zones; it tends to be worse on eastward bound flights than on westward ones [7]. The increase in travel medicine knowledge over the past 30 years makes pre-travel counselling an essential part of primary care. A successful pre-travel consultation involves hazards analysis and counselling to make the patient aware of travel risks [8]. Health care recommendations for travellers must be specifically tailored to the individual, since each traveller has a different underlying medical status. These recommendations should be made in such a manner that apprises the traveller of the risks involved but does not instill undue anxiety [9]. Effective pre-travel consultation begins with a process of assessing and conveying the epidemiologic likelihood of disease and injury connected with the trip which depends on traveller- and itinerary-specific factors [8]. Ideally pre-travel health counselling is based on the traveller’s health history and immunization status, planned or intended activities, destinations, itinerary and the duration of travel [10,11]. Pre-travel consultation should include reviewing routine and destination-specific immunizations. Decisions regarding immunizations for travellers are predicated upon an evaluation of the endemic and epidemic infections in the traveller’s target country. Yellow fever is required for some countries on arrival, while other immunizations (such as the cholera vaccine) are required only under specific circumstances or may be recommended for persons at high risk or for all travellers. Counselling has to include some advices about the prevention of diarrhoea (consumption of cooked meat and fish, avoidance of unpasteurized milk or milk products, unpeeled fruits, raw salads and ice or water which has not been boiled) and mosquito bites (proper use of insect repellents and mosquito netting) [9]. Chemoprophylaxis is recommended for at-risk travellers visiting malaria endemic regions and during the consultation physicians have to explain the risk of malaria and prescribe
S. Tafuri et al. appropriate drugs; the majority of travellers with imported malaria have not used these [12]. In many countries, travel clinics have been established to guarantee pre-travel consultation, the prescription of drugs and the administration of vaccines for international travellers. From many years, international and national public health authorities and a lot of scientific groups have been engaged in the research of the evidence that can support prevention policies (evidence based public health) [13]. Even if travel medicine is currently practiced in many countries, only a few studies in the past investigated the effectiveness of pre-travel consultation in changing the behaviours of travellers and in reducing the incidence of travel-related diseases in international travellers. Since 2008 Travel Clinic has been activated in Bari General Hospital. Travellers who are going overseas access the Travel Clinic and this service is free of charge; travellers only have to pay for anti-malaria drugs. Every year, about 1000 travellers access the Clinic. This study aims to evaluate the effectiveness of pretravel counselling in a group of international travellers who attended the Travel Clinic at Bari General Hospital.
2. Materials and methods To evaluate the effectiveness of counselling in changing behaviour and health outcome, a retrospective cohort study was conducted. We enrolled travellers who attended the Travel Clinic at Bari General Hospital during 2012 and who were going to visit developing countries (such as Sub-Saharan Africa) where malaria is endemic and the use of anti-malaria drugs was recommended; they were “exposed subjects”. The list of travellers was randomly selected from the database of the Travel Clinic patients who match the inclusion criteria. “Non exposed subjects” were those persons who in 2012 visited low socio-economic level countries where malaria is endemic and the use of anti-malaria drugs was recommended but who had not attended public health clinics for counselling before travelling. The list was randomly derived from the management system of a travel agency. Enrolled subjects were contacted by telephone by the Travel Clinic’s doctors and, after an explanation of the rationale of the study, verbal informed consent was required to participate in the study. Each of those enrolled was interviewed by telephone using a standardized questionnaire that investigated gender, age, duration of the trip, compliance with malaria prophylaxis and cholera vaccination before travelling, the supply of drugs and insect repellents for the journey, water safety, consumption of high-risk food (such as raw vegetables, raw seafood, ice cream in bulk, drinks containing ice), health problems occurred during the journey or within three days of return (diarrhoea or intestinal problems, fever, mosquito bites, insomnia) or doctor consultation upon return. The same people questioned the cases and the controls. The forms were computerized onto a database built by FileMaker Pro software and analysed with the statistical software STATA MP11.
Please cite this article in press as: Tafuri S, et al., Effectiveness of pre-travel consultation in the prevention of travel-related diseases: A retrospective cohort study, Travel Medicine and Infectious Disease (2014), http://dx.doi.org/10.1016/j.tmaid.2014.10.012
+
MODEL
Effectiveness of pre-travel consultation: A retrospective cohort study T-test student for unpaired samples were used to compare the averages of quantitative variables between exposed and non exposed subjects. The Chi-square test was used to compare the proportions. To investigate the role of age, sex, duration of the trip, attendance at the Travel Clinic on behaviour and health problems, a multiple logistic regression model was set; odds ratio (OR) with confidence intervals at 95% were calculated. For each test a p < 0.05 was considered significant. Sample size calculation showed that we had to enrol >100 people for each brace then we enrolled 150 exposed and 150 non exposed subjects.
3. Results The study sample was made up of 168 (56%) males and 132 (44%) females. In particular, the group of “exposed” was made up of 93 (62%) males and 57 (38%) females, while the “non exposed” group included 75 (50%) males and 75 (50%) females (chisquare Z 1.38; p Z 0.036). The average age of the enrolled subjects was 37.5 13.9, without statistically significant differences between the group of users of the Travel Clinic (37.4 11.9) and the other group (37.7 15.7; t Z 0.21; p Z 0.41). The response rate was 100% in both groups. The average duration of the trip was between of 17.1 44.3 days and it was longer among exposed people (21.5 59.1) than in the other group (12.6 20.5; t Z 1.7; p Z 0.042). The users of the Travel Clinic used malaria prophylaxis, vaccination against cholera and insect repellents more frequently (Table 1). The proportion of people who supply drugs for travel was similar in the two groups (Table 1). Thirteen (4.3%) of those interviewed reported drinking unsafe water; this proportion did not differ between exposed (n Z 7/150; 4.6%; 95% CI Z 0.1e8.1) and non exposed subjects (n Z 6/150; 4%; 95% CI Z 0.8e7.1; chisquare 0.08; p Z 0.777). Forty-five (15%) of enrolled subjects ate some food with elevated risk of traveller’s diarrhoea (such as raw fruit or vegetables, drink with ice or ice cream); this proportion was higher in the non-exposed people (n Z 36/150; 24%; 95% CI Z 17.1e30.9) than in the people attending the Travel Clinic (n Z 9/150; 6%; 95% CI 2.2e9.9; chisquare Z 19.06; p < 0.0001). Fifty (16.7%) reported diarrhoea or gastrointestinal symptoms, 9 (6%; 95% CI Z 2.1e9.9) in the group of exposed subjects and 41 (27.3%; 95% CI Z 20.2e34.5) in the other group (chi-square Z 24.6; p < 0.0001). Only 11 (3.7%)
3
of those enrolled people reported fever during the trip; this proportion did not differ between exposed (n Z 4/150; 2.7%; 95% CI Z 0.5e5.2) and not exposed people (n Z 7/ 150; 4.6%; 95% CI Z 1.2e8.1; chi-square Z 0.89; p Z 0.35). Mosquito bites were reported by 42 (14%) of those interviewed, 12 (8%; 95% CI Z 3.6e12.4) Travel Clinic patients and 30 (20%; 95% CI Z 13.5e26.5) of the other group (chi-square Z 8.9; p Z 0.0003). 4 (1.3%) persons reported insomnia, with no difference between exposed (3/150; 2%; 95% CI Z 0.2e4) and non exposed (1/150; 0.6%; 95% CI Z 0.6e1.9; chi-square Z 1.01; p Z 0.31). Twenty-nine (9.7%) of those interviewed attended their General Practitioner or the hospital after the trip; this proportion was higher in the non exposed group (n Z 21/ 150; 14%; 95% CI Z 8.3e19.6) than in the people attending Travel Clinic (n Z 8/150; 5.3%; 95% CI Z 1.7e9.0; chisquare Z 6.4; p Z 0.011). Three (1% of the enrolled patients) cases of malaria were reported; all were in the non exposed people (chisquare Z 3.03; p Z 0.08). Multiple logistic regression showed that taking prophylaxis against malaria was associated with older age expressed in years (OR Z 1.03; 95% CI Z 1.01e1.06; z Z 2.9; p Z 0.009) and attendance of the Travel Clinic (OR Z 32.7; 95% CI Z 16.3e64.2; z Z 10.11; p < 0.0001). Vaccination against cholera was associated with age (OR Z 1.03; 95% CI Z 1.004e1.05; z Z 2.28; p Z 0.023) and attendance of the Travel Clinic (OR Z 24.2; 95% CI Z 11.5e50.6; z Z 8.45; p < 0.0001). The model did not show any determinant of the attitude to supply drugs for travel. The attitude to supply mosquito repellents was associated with the age (OR Z 1.02; 95% CI Z 1.001e1.05; z Z 2.09; p Z 0.037) and attendance of the Travel Clinic (OR Z 6.49; 95% CI Z 2.86e14.73; z Z 4.47; p < 0.0001). People attending the Travel Clinic seemed to be protected against diarrhoea and gastrointestinal symptoms (OR Z 0.16; 95% CI Z 0.07e0.34; z Z 4.62; p < 0.0001). No risk factors for fever and insomnia were revealed by the multiple logistic analysis. The number of days of the trip seemed to be associated with the risk of medical consultation after the journey (OR Z 1.02; 95% CI Z 1.006e1.05; z Z 2.51; p Z 0.012), but attending the Travel Clinic reduced this risks (OR Z 0.29; 95% CI Z 0.11e0.72; z Z 2.67; p Z 0.008).
4. Discussion Our survey, that involved 300 international travellers, showed the effectiveness of pre-travel counselling both in
Table 1 Percentages of subjects who before travelling took prophylaxis against malaria, vaccination against cholera, insect repellents and who took supply drugs to travel.
Prophylaxis against malaria Vaccination against cholera Medication for travel related illness Insect repellents
Consulted a travel clinic (% 95% CI)
Visited a travel agency (%; 95% CI)
Chi-square
p
129 (86%; 81.0e92.1) 93 (63.7%; 55.8e71.6) 143 (95.3%; 91.9e98.7) 142 (94.6%; 91.0e98.3)
29 (19.3%; 12.9e25.7%) 11 (7.3%; 3.1e11.5) 135 (90.0%; 85.1e94.8) 112 (74.6% 67.6e81.7)
135.6 103.1 3.12 23.1
