Professional Documents
Culture Documents
A cumulative
Introduction
T h e last few decades have witnessed a remarkable growth in international
travel. T h i s has followed increased trade, political , cultural and sports
exchanges between nations, military manoeuvres, pilgrimages, labour and
o163-4453/9o/o4oo27 + I6 So2.oo/o
28
]. H. C O S S A R E T . 4 L .
Between 1977 and I985 travellers returning to Scotland and one group of
visitors to Scotland have been issued with a standard questionnaire to record
personal and travel details which include age, gender, occupation, country,
town and type of accommodation, dates of travel, reasons for travel, pre-travel
health status, symptomatic complaints with date of onset and duration, any
factors to which illness might be attributed, and whether the help of a doctor
or hospital was required. T h e questionnaires were returned to C D S U using a
prepaid reply envelope. Most travellers were issued with the questionnaire at
their return airport (Glasgow or Edinburgh), some by travel agents, employers,
and tourism departments, and the remainder by C D S U in response to public
d e m a n d following media publicity which had highlighted specific episodes of
travel related illness. T h e questionnaire was updated to include details on
smoking habits (I98o), to make completion and computer analysis easier
(I98I), and to enquire about pre-travel health advice (I985), but the basic
information collected remained otherwise essentially unchanged t h r o u g h o u t
the period of study. This enabled valid comparative analyses to be carried out.
Initially the data collected were analysed manually, thereafter computers
were used (initially at C D S U , and latterly Glasgow University mainframe),
and the information analysed using the Statistical Packages for the Social
29
rotary 18%
Alimentary and other 8%
(N=I3 816)
Gostro-enteritis 5 8 %
(b)
Malaria 389
ther 14%
Fig. I. Types of travel illness. (a), Illness reported by travellers (from questionnaire studies
from z977-z985). (b), Diagnoses recorded in in-patients (from Ruchill Hospital ID Wards
I January I985 to 3~ December I985),
recorded on the Infectious Diseases (ID) Unit Record Sheet for admissions to
Ruchill Hospital were used to compile a profile on those with a travel
associated illness. These details included age, gender, ethnic origin, diagnosis,
length of stay in hospital, whether the illness was considered to be associated
with travel, the country visited and the number of days since returning to the
U.K.
The information collected by these methods was used to define a perspective
of travellers from the west of Scotland and of travel related illnesses. Due to
the retrospective nature of the data collections, questionnaire revision and
incomplete responses, the numbers analysed under different categories o f
study, of necessity, have differing totals.
Results
Thirteen thousand, eight hundred and sixteen completed questionnaires were
returned. The response rate ranged from 2o-77 ~o amongst individual groups
(a)
3000~-
(b)
r,o 2500 ~T
2000~
!iiiiiiii
!i!!!i!!i
i!iii!iii
;;~;
isoo[
,ooo[ i
::::::1::
iiiii!ii!
iiiiiiii!
iiiiiii!i
i!i!iii!i!iiiiiii
i@
iiiil
E
g;
,e
..~
Age groups
Age groups
Fig. 2. Distribution of travellers by age group and illness. (a) Age of travellers and health
experience (from questionnaire studies). (IN), Total; ([]), number unwell. (b) Travel
associated admissions (from Ruchill Hospital).
32
J. H. C O S S A R
E T AL.
(I9)
-(67)
(74)
(27)
(36)
(37)
(21)
(32)
(36)
(44)
(32)
(20)
(77)
(46)
4962 (37)
(19-77)
Winter
Total
Unwell (%)
355
--
--
(20)
I3I
380
843
226
I68
637
I 194
7035
7oi
581
I20
189
914
13 4 7 4
----(I2)
--(18)
-(2i)
-(32)
-67 (20)
(12-32)
Total
-44
----50
--147
-57
-44
-342
Overall (%)
(3)
( < x)
(I)
(3)
(6)
(2)
(2)
(5)
(9)
(52)
(5)
(5)
(I)
(2)
(7)
13 816 (IOO)
( < 1-52)
0"001).
T h e majority of travellers stayed in hotel accommodation (69 % of 8870
study total), spent between I I and 15 days abroad (92 % of 9236 study total),
solely went for holiday purposes (96 % of 96o6 study total), during the
summer (96 % of I3 327 total), could be assigned to socio-economic groups i
33
4oo I
550
500
250
,
E 200
Z
[50
LX.X+X.:.X.>v.v.v.'.v.v.,
5O
0
.......................................
~::::1:;::::[
:.:.:.:.:.:.:31 oyo x.;:>x"
:!:!:::!:i:
l :x,x,x
~:~:~:~42..o
:~: o/c :x.:.x.:
~:~:~:~1:~:
............
:i:!:!:!:i:
3 6% ii!~!i!~!!
Travel agent
(22%)
Familydoctor
(I l%)
Other
(14%)
l.
36%
:::::::::::::::::::::::::::::::::::::::::::
!i:;:;::iii2 6 % !:;i~i....
::i::i::
Fig. 3. Pro-travel health advice, source and health experience. (Ul), Total 645; ([])~ 3I %
unwell (I99).
to 3 (66 % of 6624 total), and set off in good health (97 % of 9744 total). In view
of these findings comparisons with the minorities outside these broad
categories, which involve widely disparate proportions of travellers, require to
be interpreted with caution. T h e proportion (z 1%) who stayed in self-catering
accommodation reported a lower attack rate (26%) than those using other
types of accommodation, as did the 4 % staying abroad for more than 30 days
(23 % unwell) when compared to groups with a different length of stay abroad;
similar group comparisons revealed the lowest rates amongst those travelling
for business and holiday purposes ( < z %), IO % unwell, and in the employers
and managers, socio-economic group (9 %), 26 % unwell, compared with other
socio-economic groups. T h o s e with a pre-existing health problem (3%)
reported a higher illness rate (46 %).
Amongst the 645 travellers providing information on the use of pre-travel
health advice (Fig. 3), 284 (32 %) sought such advice of w h o m IO5 (37 %)
reported illness compared to 94 (26%) of those who did not seek advice
(56 %). T h e travel agent was most frequently consulted for advice and these
z33 travellers (22%) reported the least illness; the family doctor was least
consulted and amongst these 66 travellers (z 1%) the highest attack rate was
recorded (42 %). D u e to overlap in the numbers of travellers seeking advice
from two or more sources, the proportions in Fig. 3 add up to more than
IO0 %.
JIN 21
34
J.H. C O S S A R
ET AL.
Asian)
(male Caucasian)
17;24%
3;4%
(female African)
(male African) 2
4%
ale Caucasian)
(female Asian) 14; 20%
Fig. 4. Travel associated admissions (from Ruchill Hospital). (m), Male Asian; ([~) male
Caucasian; ([]), male African; ([])~ female Asian [], female Caucasian; ([]), female African.
35
Without
antibody*
(%)
~ One
/ t y p e (%)
(4)
- -
- -
- -
(i)
-2 ( < I)
(o-4)
Two
types (%)
(4)
(4)
(3)
(3)
(7)
(6)
22 (5)
(3-7)
All three ~
typest (%)J
(I3)
(I8)
(I7)
(8)
(14)
(i7)
Total
number
tested
(78)
(78)
(80)
(89)
(78 )
(77)
378 (80)
(77-89)
68 (I4)
(8-18)
Overall
23
II9
66
9I
ioo
7I
470
- -
(%)
(5)
(25)
(I4)
(19)
(2i)
(I5)
(I00)
(5-25)
* At a titre of < 8.
t At a titre of > 8.
Seropositive
(%)
Total number
tested
IO-I9
20-29
30-39
40-49
50-59
60 +
Not known
Totals
Range
(3 )
(38)
(48)
(85)
(78)
(89)
(63)
328 (64)
(3o--89)
23
I I9
66
91
I o o
71
41
511
- -
Overall
(%)
(5)
(23)
(I3)
(I 8)
(20)
(I4)
(8)
(IOO)
(5-23)
36
j.H. COSSAR E T
AL.
Discussion
37
38
,1. H. C O S S A R E T A L .
39
References
I. World Tourism Organisation. Tourism compendium, World total. Madrid. I987.
2. Communicable Diseases (Scotland) Unit. Current Notes: Typhoid. CDS Weekly Rep
x986; 86[o5: Io.
3. Chaudhuri AKR. Tourist hepatitis in the West of Scotland. Scott MedJ I978; 23 : 213-214.
4. Follett EAC, McMichael S. Acute hepatitis A infection in West Scotland. Scott Med J
I98I; 26: I35-I37.
5. Follett EAC, McMichael S, Stewart J, Cromack S. Acute hepatitis A in West Scotland in
I98I, a change in pattern. Scott Med J I983; 28: 30-33.
4o
J. H. COSSAR ET AL.
86134: I6.
I6. Wilson HD. Giardiasis among a party of high school pupils following a visit to Russia.
Health Bull (Edinb) I983; 41/3 : I55-I62.
17. Sharp JCM. Infections acquired abroad. Practitioner I984; 228: 749-753.
I8. Communicable Diseases (Scotland) Unit. Current Notes. Enteric Fever. CDS Weekly Rep
I986; 86]o4: 8.
I9. Communicable Diseases (Scotland) Unit. Current Notes. Gastro-intestinal illness--the
Gambia. CDS Weekly Rep 1985; 85/49: 8.
20. Communicable Diseases (Scotland) Unit. Current Notes. Leishmaniasis. CDS Weekly
Rep 1985; 8547: 9.
2I. Jones L, Davies SN, Newland AC, Jenkins GC. A narrow escape from splenectomy. Br
Med J I985 ; 29o : 687-688.
22. Public Health Laboratory Service. Communicable Disease Surveillance Centre. Lassa
fever. CDR 1985; 85110: I.
23. Cooper CB, Grandsen WR, Webster M et al. A case of Lassa fever: experience at St
Thomas's Hospital. Br Med J I982; 285: lOO3-IOO5.
24. Duggan AJ, Hutchison MP. Sleeping sickness in Europeans : a review of lO9 cases. J Trop
Med Hyg I966; 69: I 2 4 - I 3 I .
25. Lawson JHL. Legionnaires' d i s e a s e - the Benidorm episode. Scott Med J I978; 23:
121--124 .
26. Cossar JH, Dewar RD, Fallon RJ, Grist NR, Reid D. Legionella Pneumophila in tourists.
Practitioner 1982; 226: 1543-1548.
27 . Public Health Laboratory Service. Communicable Disease Surveillance Centre. Legionnaires' disease: Morocco. CDR 1985; 85145: i.
28. Communicable Diseases (Scotland) Unit. Current Notes. Diphtheria. CDS Weekly Rep
1985; 85/5I: 9.
29. Communicable Diseases (Scotland) Unit. Current Notes. Diphtheria. CDS Weekly Rep
1986; 861o8: 12.
30. Schmitz H, Kern P, Dietrich M. High risk of cytomegalovirus mononucleosis in adult
Europeans visiting tropical areas. Lancet 1985 ; ii: 503-504.
31. Phillips-Howard PA, Bradley DJ, Blaze M, Hurn M. Malaria in Britain : 1977-86. Br Med
J 1988; 296: 245-248.
32. Communicable Diseases (Scotland) Unit. Current Notes. Acquired immune deficiency
syndrome (AIDS). CDS Weekly Rep 1986; 86/06: 8-9.
33- Public Health Laboratory Service. Communicable Disease Surveillance Centre and the
Communicable Diseases (Scotland) Unit, with Middlesex Hospital Medical School
Academic Department of Genito-urinary Medicine. Sexually transmitted diseases
surveillance, United Kingdom, 1983. CDS Weekly Rep 1985 ; 85115: xi-xvi.
34. Communicable Diseases (Scotland) Unit. Current Notes. Neisseria gonorrheae, Antibioticresistant strains. CDS Weekly Rep 1986; 861o6: 8- 9.
4I
35- Reid D, Dewar RD, Fallon RJ, Cossar JH, Grist NR. Infection and travel: the experience
of package tourists and other travellers. J Infect r98o; z: 365-370.
36. Reid D. Tourism and illness. Proc R Soc Edinb r982; 8zB: 23-25.
37. Dewar RD, Cossar JH, Reid D, Grist NR. Illness amongst travellers to Scotland: a pilot
study. Health Bull (Edinb) I983; 4x13: x55-z62.
38. Cossar JH, Dewar RD, Reid D, Grist NR. Travel and Health: illness associated with
winter package holidays. J R Coll Gen Pract z988; 33: 642-645.
39- Cossar JH, Dewar RD, Fallon RJ et al. Rapid response health surveillance of Scottish
tourists. Travel Traffic Med Int I984; z ' * , 23-27.
4o. Cossar JH, Reid D, Grist NR, Dewar RD, Fallon RJ, Riding MR, Bell EJ. Illness
associated with international travel : a ten year review. Travel Med Int I985 ; 3: I, I3-I8.
4 I. Grist NR, Cossar JH, Reid D, Dewar RD, Fallon RJ, Riding MH, Bell EJ. Illness
associated with a package holiday in Rumania. Scott Med J x985 ; 3o: I56-I6O.
42. Cossar JH. Travel associated illnesses. J R Soc Med I988; 8I: 25o-25i.
43. Cossar JH. Travelling and touring problems. Br J Sports Med I988; 22/3: 12o--12I.
44. Paixao MT, Cossar JH, Reid D. Mortality amongst travellers from Scotland. In: Travel
Medicine (Proceedings of the First Conference on International Travel Medicine, Zurich
i988) Berlin: Springer-Verlag, x989: 65-66.
45. Cossar JH. A review of travel-associated illness. In: Travel Medicine (Proceedings of the
First Conference on International Travel Medicine, Zurich I988) Berlin: Springer-Verlag,
z989 : 5o-54 .
46. Bell EJ, Grist NR, Cossar JH, Dewar RD, Reid D. Poliomyelitis worldwide. Br Med J
~98r; z8z: 3Io.
47. Cossar JH, Follett EAC, Riding MH, Reid D. How necessary is Immunoglobulin for
travellers going abroad ? Community Meal 1989 ; ** I x : 9-12.
48. Cossar JH, Reid D. Not atl travellers need immunoglobulin for hepatitis A. Br M e d J I987 ;
z 9 4 : I5O3.
49. Reid D, Cossar JH, Ako T I , Dewar RD. Do travel brochures give adequate advice on
avoiding illness ? Br Med J I986; z93: I472.
5o. The Scottish Health Education Group. Holiday information and checklist. (A guide to good
health on holiday for travellers) I986.
5I. Cossar JH. Inadequate pre-travel health a d v i c e - - a n answer? In: Travel Medicine
(Proceedings of the First Conference on International Travel Medicine, Zurich I988)
Berlin: Springer-Verlag, I989: 544-546.
52. Cossar JH, Walker E, Reid D, Dewar RD. Computerised advice on malaria prevention and
immunisation. Br M e d f f I988; z96: 358.
53. Kyriazopoulou VG, Bell EJ. A micrometabolic inhibition test for the estimation of
poliomyelitis neutralising antibodies. Bull W H O z972; 47: I7I-r75.
54. Fallon RJ, Abraham WH. Scottish experiences with the serological diagnosis of
Legionnaires' disease. Ann Intern Med I979; 9o: 684-686.
55. Cruickshank R, Duguid JP, Marmion BP, Swain RHA. Medical Microbiology Vol 2 I2th
ed. Edinburgh: Churchill Livingstone, I975; 417-418.
56. Barr A, Dow B, Watson WC, Hunter E. Detection and quantitation of tetanus antitoxin in
blood donations. J Clin Pathol I975; z8: 969-97I.
57. Steffen R, van der Linde F, Syr K, Schar M. Epidemiology of diarrhoea in travellers.
f f A M A i983; z49: II76--118o.
58. PeltolaH, KyronseppaH, HolsaP. T r i p s t o t h e South - - a health hazard. ScandJlnfectDis
I983; x5: 375-38I.
59. McEwan A, Jackson MH. Illness among Scots holidaymakers who had travelled abroad,
summer I983. C D S Weekly Rep I987; 87]x6: 7-9.
60. Cvjetanovic B. Diarrhoeal diseases in the Mediterranean area: report on a W H O meeting.
Copenhagen, WHO Regional Office for Europe, I988 (ICP/CDS oI9/6).
6I. Sharp JCM. Imported infections into Scotland, I975. C D S Weekly Rep I976; 76126: v-vi.
62. Campbell DM. Imported infections in Scotland, I986. C D S Weekly Rep I987; 87147:
7-8.
63. Fuller GN, Journeaux SF, Corner K, Lant AF. The risks of staying in London : a review
of overseas visitors admitted to a London hospital. J R Soc Med I988 ; 8x : 267-269.
42
J. H. COSSAR E T A L .
64 . Business Statistics Office. Business monitor annual statistics. Overseas travel and tourism.
( M Q 6) Table 8A. London: H M S O , I986; x3.
65. Cossar JH, Hamlet N, Walker E. International travel medicine, ff R Coll Gen Pract I989;
39 : 259.
66. Walker E, Cossar JH, Dewar RD, Reid D. Computerised advice on malaria prevention and
immunisations. J R Coll Gen Pract I987; 37: 223.
67. World Health Organisation. Poliomyelitis in I986, x987 and I 9 8 8 - Part L I V E R I989;
64 : 273-280.
68. Department of Health and Social Security. Immunisation against infectious disease i984;
London : H M S O .