Principles and Practice of Travel Medicine

Principles and Practice of Travel MedicineSECOND EDITION

EDITED BY

Jane N. Zuckerman MD, FRCP, FRCPath, FFPH, FFPM, FFTM, FIBiol, FHEADirector WHO Collaborating Centre for Travel Medicine Director UCL Medical Student Occupational & Royal Free Travel Health CentreAcademic Centre for Travel Medicine & Vaccines Sub-Dean ElectivesVice-President, Faculty of Pharmaceutical MedicineEditor-in-Chief, Journal of Travel Medicine & Infectious DiseaseUniversity College London Medical SchoolLondon United Kingdom

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Library of Congress Cataloging-in-Publication Data Principles and practice of travel medicine / edited by Jane N. Zuckerman. – 2nd ed. p. cm. Includes bibliographical references and index. ISBN 978-1-4051-9763-2 (hardback : alk. paper) 1. Travel–Health aspects. I. Zuckerman, Jane N. RA783.5.P75 2012 616.9'802–dc23

2012014995

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: Small images (×7) courtesy of CDC; Large background image courtesy of Morguefile / rmpinhoCover design: Steve Thompson

Set in 10/12 pt Minion by Toppan Best-set Premedia Limited

01 2013

v

Contents

Thestrategyofstandbyemergencyself-treatment,143Patricia Schlagenhauf

11 Emergingandre-emerginginfectiousdiseases,146Francisco G. Santos O’Connor

Section III Prevention and management of travel-related diseases

12 Skintropicalinfectionsanddermatologyintravellers,167Francisco Vega-López and Sara Ritchie

13 Travellers’diarrhoea,197Charles D. Ericsson

14 Vaccine-preventabledisease,209Jay Halbert, Phyllis Kozarsky, Jane Chiodini, Nicholas Zwar, Gary Brunette and Jane N. Zuckerman

15 Returnedtravellers,260Nicholas J. Beeching, Tom E. Fletcher and Limin Wijaya

Section IV Hazards of air and sea travel

16 Aviationmedicine,289Michael Bagshaw

17 Aviationpsychology,315Robert Bor, Carina Eriksen, Margaret Oakes and Philip Baum

18 Expeditionandextremeenvironmentalmedicine,328Sean Hudson, Andrew Luks, Piers Carter, Luanne Freer, Caroline Knox, Chris Imray and Lesley Thomson

19 Travelhealthatsea:cruiseshipmedicine,380Robert E. Wheeler

Section V Environmental hazards of travel

20 Travel-relatedinjury,397Robert Grenfell

Contributorlist,vii

Preface,xii

Section I Travel medicine

1 Trendsintravel,3Thomas L. Treadwell

2 Tourism,aviationandtheimpactontravelmedicine,9Anne Graham

3 Epidemiologyofhealthrisksandtravel,19Hans D. Nothdurft and Eric Caumes

4 Fitnesstotravel,27Dominique Tessier

5 Managementofatravelclinic,37Abinash Virk and Elaine C. Jong

Section II Infectious diseases and travel

6 Epidemiologyandsurveillanceoftravel-relateddiseases,47Tomas Jelinek

7 Virusinfectionsintravellers,55Arie J. Zuckerman

8 Bacterialinfectionsintravellers,99Ann L.N. Chapman and Christopher J. Ellis

9 Vector-borneparasiticdiseases,112Emma C. Wall and Peter L. Chiodini

10 Malariaandtravellers,126 Malaria,126

David J. Bell and David G. Lalloo

Malariachemoprophylaxis,133Patricia Schlagenhauf, Catherine Jeppesen, Laura K. Erdman, Melanie Newport, and Kevin C. Kain

vi  Contents

21 Internationalassistanceandrepatriation,403Alex T. Dewhurst and John C. Goldstone

22 Venomousbitesandstings,415R. David G. Theakston and David G. Lalloo

23 Ophthalmicconditionsintravellers,434Clare Davey and James Tee

Section VI Practical issues for travellers

24 Travellingwithchildren(includinginternationaladoptionissues),447Philip R. Fischer and Andrea P. Summer

25 Women’shealthandtravel,463I. Dale Carroll and Susan Anderson

26 Theimmunocompromisedtraveller,503Robert J. Ligthelm and Pieter-Paul A.M. van Thiel

27 High-risktravellers,515Kathryn N. Suh, Anne E. McCarthy, Maria D. Mileno and Jay S. Keystone

28 Aidworkers,expatriatesandtravel,531Kenneth L. Gamble, Deborah M. Hawker, Ted Lankester and Jay S. Keystone

29 Thehealthofmigrantsandrefugees,556Louis Loutan, Sophie Durieux-Paillard and Ariel Eytan

30 Visitingfriendsandrelatives,566Delane Shingadia

31 Travelmedicine,ethicsandhealthtourism,571Deborah Bowman and Richard Dawood

32 Medico-legalissuesintravelmedicine,579Jennifer G. Baine and Paul S. Auerbach

33 Travellers’safetyandsecurity,588Peter A. Leggat and Jeff Wilks

34 Theinternationalathlete:travellinghealthytoglobalsportingevents,601Travis W. Heggie, Sarah Borwein and Marc T.M. Shaw

35 Spacetourism–thefutureintravelhealth?,612Kevin J. Fong and Mark H. Wilson

Index,623

vii

Contributor list

Robert BorClinical, Counselling and Health PsychologistRoyal Free HospitalLondon, UK

Sarah BorweinDirectorTravel Safe, Central Health Medical PracticeHong Kong SAR, China

Deborah BowmanProfessor of Bioethics, Clinical Ethics and Medical LawSt George’s, University of LondonLondon, UK

Gary BrunetteChief Travelers’ Health BranchCenters for Disease Control and PreventionAtlanta, GA, USA

I. Dale CarrollMedical DirectorThe Pregnant TravelerSpring Lake, MI, USA

Piers CarterDirectorExpedition MedicineBedfordshire, UK

Eric CaumesProfessor of Infectious and Tropical DiseasesUniversity Pierre et Marie Curie;Vice Chairman, Department of Infectious and Tropical DiseasesTeaching Hospital Pitié SalpêtrièreParis, France

Susan AndersonClinical Associate ProfessorStanford University School of MedicineStanford, CA, USA

Paul S. AuerbachRedlich Family Professor of SurgeryDivision of Emergency MedicineDepartment of SurgeryStanford University School of MedicineStanford, CA, USA

Michael BagshawVisiting Professor of Aviation MedicineKing’s College London and Cranfield UniversityLondon, UK

Jennifer G. BaineStaff PhysicianSports MedicineSan Francisco State UniversitySan Francisco, CA, USA

Philip BaumManaging DirectorGreen Light LtdEditor, Aviation Security InternationalLondon, UK

Nicholas J. BeechingLiverpool School of Tropical MedicineLiverpool, UK

David J. BellConsultant in Infectious DiseasesBrownlee Centre, Gartnavel General HospitalGlasgow, UK

viii  Contributor list

Ann L.N. ChapmanConsultant Physician in Infectious DiseasesSheffield Teaching Hospitals NHS Foundation TrustSheffield, UK

Jane ChiodiniSpecialist Nurse in Travel MedicineThe Village Medical CentreGreat DenhamBedfordshire, UK

Peter L. ChiodiniHospital for Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondon, UK

Clare DaveyRoyal Free Hampstead NHS TrustLondon, UK

Richard DawoodMedical Director and Specialist in Travel MedicineFleet Street ClinicLondon, UK

Alex T. DewhurstMiddlesex HospitalLondon, UK

Sophie Durieux-PaillardProgramme Santé MigrantsDepartment of Community Medicine and Primary CareUniversity Hospitals of GenevaGeneva, Switzerland

Christopher J. EllisBirmingham Heartlands HospitalBirmingham, UK

Laura K. ErdmanSAR labs, Sandra Rotman Centre for Global Health UHN-Toronto General Hospital, University of TorontoToronto, ON, Canada

Charles D. EricssonProfessor of MedicineDr. and Mrs. Carl V. Vartian Professor of Infectious DiseasesHead, Clinical Infectious Diseases;Director, Travel Medicine Clinic;Director, Infectious Disease Fellowship ProgramUniversity of Texas Medical School at HoustonHouston, TX, USA

Carina EriksenRegistered and Chartered PsychologistSouth West London and St George’s Mental Health TrustLondon, UK

Ariel EytanUnité de Psychiatrie PénitentiaireDepartment of PsychiatryUniversity Hospitals of GenevaGeneva, Switzerland

Philip R. FischerProfessor of PediatricsMayo ClinicRochester, MN, USA

Tom E. FetcherLiverpool School of Tropical MedicineLiverpool, UK

Kevin J. FongWellcome Trust Engagement FellowConsultant Anaesthetist University College London Hospital;Honorary Senior Lecturer, Department of Physiology University College LondonLondon, UK

Luanne FreerMedical Director Yellowstone National ParkFounder/Director, Everest ERHimalayan Rescue AssociationNepal

Kenneth L. GamblePresident, Missionary Health Institute;Lecturer, University of TorontoToronto, ON, Canada

John C. GoldstoneMiddlesex HospitalLondon, UK

Anne GrahamReader in Air Transport and TourismUniversity of WestminsterLondon, UK

Robert GrenfellPublic Health PhysicianGrenfell Health Consulting Pty LtdNatimukVictoria, Australia

Contributor list  ix

Jay HalbertSpecialist Paediatric RegistrarUniversity College London HospitalLondon, UK

Deborah M. HawkerClinical PsychologistInterHealthLondon, UK

Travis W. HeggieBowling Green State UniversityDivision of Sport Management, Recreation and TourismBowling Green, OH, USA;Senior Research FellowJames Cook University, School of Public Health, Tropical Medicine, and Rehabilitation SciencesTownsville, QLD, AustraliaAustralia

Sean HudsonFounder/Director Expedition Medicine UKMedical Director Aegis IraqMedical Officer Ski Patrol Mount HuttCanterbury, New Zealand

Chris ImrayProfessor of Vascular SurgeryWarwick Medical SchoolConsultant SurgeonUHCW NHS TrustCoventry, UK

Tomas JelinekMedical DirectorBerlin Centre for Travel MedicineBerlin, Germany

Catherine JeppesenConsultant MicrobiologistDorset County Hospital NHS Foundation TrustDorset, UK

Elaine C. JongClinical Professor of Medicine EmeritusPast Director, Travel and Tropical Medicine ServiceDivisions of Emergency Medicine, and Allergy and Infectious DiseasesUniversity of WashingtonSeattle, WA, USA

Kevin C. KainCanada Research Chair in Molecular Parasitology Professor of MedicineUniversity of Toronto;Director, Centre for Travel and Tropical DiseaseToronto General Hospital;SAR labs, Sandra Rotman Centre for Global Health, UHN-Toronto General Hospital, University of TorontoToronto, ON, Canada

Jay S. KeystoneProfessor of MedicineUniversity of TorontoToronto, ON, Canada

Caroline KnoxMedical DirectorExpedition MedicineBedfordshire, UK

Phyllis KozarskyProfessor of Medicine/Infectious DiseasesChief, Travel and Tropical MedicineEmory UniversityAtlanta, GA, USA

David G. LallooProfessor of Tropical MedicineLiverpool School of Tropical MedicineLiverpool, UK

Ted LankesterDirector of Health Services, InterHealth, London;Director of Community Health Global Network;External Lecturer Oxford University Department of Public Health;External Lecturer London School of Hygiene and Tropical MedicineLondon, UK

Peter A. LeggatProfessor and Deputy Head, School of Public Health, Tropical Medicine and Rehabilitation SciencesJames Cook UniversityTownsville, QLD, Australia;Visiting Professor, School of Public HealthUniversity of the WitwatersrandJohannesburg, South Africa

x  Contributor list

Robert J. LigthelmEducational Consultant in Travel Medicine and Diabetes Mellitusformerly Consultant Internal and Travel Medicine at the Havenziekenhuis and Institute for Tropical DiseasesErasmus UniversityMedical Consultant at Executive Health CareHoofddorp, The Netherlands

Louis LoutanDivision of International and Humanitarian MedicineDepartment of Community Medicine and Primary CareUniversity Hospitals of GenevaGeneva, Switzerland

Andrew LuksAssociate ProfessorPulmonary and Critical Care MedicineUniversity of WashingtonSeattle, WA, USA

Anne E. McCarthyProfessor of MedicineUniversity of Ottawa;Director, Tropical Medicine and International Health ClinicDivision of Infectious DiseasesDivision of Infectious Diseases Ottawa Hospital General CampusOttawa, ON, Canada

Maria D. MilenoAssociate Professor of MedicineAlpert Medical School of Brown UniversityCodirector, Travel Clinic, Miriam HospitalProvidence, RI, USA

Melanie NewportProfessor in Infectious Diseases and Global HealthBrighton and Sussex Medical SchoolBrighton, UK

Hans D. NothdurftUniversity of MunichMunich, Germany

Margaret OakesTrainee Counselling PsychologistCity UniversityLondon, UK

Sara RitchieUniversity College London Hospitals NHS Foundation TrustLondon, UK

Francisco G. Santos O’ConnorSpecialist in Medical MicrobiologyEuropean Centre for Disease Prevention and ControlStockholm, Sweden

Patricia SchlagenhaufProfessorUniversity of Zürich Centre for Travel Medicine WHO Collaborating Centre for Travellers’ HealthZürich, Switzerland

Marc T.M. ShawAdjunct Professor, School of Public Health, Tropical Medicine, and Rehabilitation SciencesJames Cook UniversityTownsville, QLD, Australia;Medical Director Worldwise Travellers Health Centres of New Zealand;Travel Medicine Provider, New Zealand Academy of SportAuckland, New Zealand

Delane ShingadiaConsultant in Paediatric Infectious DiseasesGreat Ormond Street HospitalLondon, UK

Kathryn N. SuhAssociate Professor of MedicineUniversity of OttawaOttawa, ON, Canada

Andrea P. SummerAssociate Professor of PediatricsMedical University of South CarolinaCharleston, SC, USA

James TeeRoyal Free Hampstead NHS TrustLondon, UK

Dominique TessierBleu Réseau d’Experts, Groupe Santé Voyage, and Hôpital Saint-MontrealQuébec, Canada

Contributor list  xi

R. David G. TheakstonEmeritus Professor (University of Liverpool)Alistair Reid Venom Research UnitLiverpool School of Tropical MedicineLiverpool, UK

Lesley ThomsonConsultant AnaesthetistPlymouth Hospital NHS TrustPlymouth, UK

Thomas L. TreadwellDirector, Infectious Disease Clinic;Program Director, Internal MedicineMetrowest Medical Center;Assistant Clinical Professor MedicineBoston University School of MedicineFramingham, MA, USA

Pieter-Paul A.M. van ThielInfectious Disease Physician and Consultant Tropical Medicine for the (Netherlands) Ministry of DefenseCenter for Tropical and Travel MedicineAcademic Medical Center, University of AmsterdamAmsterdam, The Netherlands

Francisco Vega-LópezUniversity College London Hospitals NHS Foundation TrustLondon, UK

Abinash VirkAssociate Professor of Medicine, College of MedicineMayo ClinicRochester, MN, USA

Emma C. WallHospital for Tropical DiseasesLondon, UK

Robert E. WheelerVoyager Medical SeminarsAmherst, NH, USA

Limin WijayaDepartment of Infectious DiseaseSingapore General HospitalSingapore

Jeff WilksPrincipal, Tourism Safety Group;Adjunct Professor, School of Public HealthTropical Medicine and Rehabilitation SciencesJames Cook UniversityTownsville, QLD, Australia

Mark H. WilsonConsultant NeurosurgeonImperial Hospitals NHS TrustHonorary Senior LecturerImperial College LondonPre-Hospital Care SpecialistLondon’s Air AmbulanceLondon, UK

Arie J. ZuckermanEmeritus Professor of Medical MicrobiologyUCL Medical School; Formerly Principal and Dean of the Royal Free Hospital School of Medicine and later of the Royal Free and University College London Medical School; Honorary Consultant to the Royal Free NHS Trust; Director of the WHO Collaborating Centre for Reference and Research on Viral DiseasesUniversity College London Medical SchoolLondon, UK

Jane N. ZuckermanSenior Lecturer and Sub-Dean for ElectivesUCL Medical School; Honorary Consultant, Royal Free NHS Foundation Trust and Great Ormond Street Hospital for Sick Children; Director of the Royal Free Travel Health Centre and Director of the WHO Collaborating Centre for Reference, Research and Training in Travel MedicineUniversity College London Medical SchoolLondon, UK

Nicholas ZwarProfessor of General PracticeSchool of Public Health and Community MedicineUniversity of New South WalesSydney, Australia

xii

Preface

stretches to exploring space, so the chapter on space tourism may well be considered as the future in travel health.

Knowledge of all the above and other aspects of travel health and medicine are, therefore, an essential requirement for the many healthcare professionals providing advice and clinical care of the traveller. This is, however, dependent on understanding the science, which defines the practice, and the chapter on epidemiology and surveillance and the epi-demiology of health risks and travel should be useful in underpinning best clinical practice in travel medicine. The recent European outbreak of measles is a case in point, which then informed the appropriate travel health vaccine recommendations. The desire to travel will undoubtedly continue unabated and will expand the minds of ever-increasing numbers of travellers. Lest we forget, the new chapter ‘Tourism, aviation and its impact on travel medicine’ acts as a timely reminder of how travel and tourism of what-ever sort, are ever closely intertwined with health.

I am grateful to many friends and colleagues, who have contributed so willingly and enthusiastically to this book, through which we hope to stimulate healthcare professionals to consider issues in travel medicine as part of their clinical practice. I also hope that this reference book will enhance the profile of travel medicine and contribute to its continu-ing development as a distinct specialty.

I would also like to express my sincere gratitude to the editorial and production staff of Wiley-Blackwell, in par-ticular Kate Newell and Maria Khan, for their patience and unwavering support.

Finally, this book is dedicated to my mother, who still speaks through me, and without whom I would not be the person I am today, and my father, who inspired me to com-plete the two editions of the Principles and Practice of Travel Medicine, and who is stalwart in his support. I am particularly indebted to my husband for always being there for me as well as always encouraging me, and to Iris, who has been more than a cousin and is like a sister to me. This second edition of the book would never have been realised without you all.

‘Like all great travellers, I have seen more than I remember, and remember more than I have seen.’ Benjamin Disraeli

Jane N. ZuckermanLondon

Travel medicine: where have we been, where are we now and where are we going are the intriguing and pertinent issues to consider. Where have we been? We have come a long way since the age of Galileo: ‘Yet I do seriously and on good grounds affirm it possible to make a flying chariot in which a man may sit and give such a motion unto it as shall convey him through the air’ (John Wilkins, 1640), through to the Wright brothers inventing and building the first successful aeroplane in 1903. Where are we now? With the Airbus A380, the largest passenger airliner in the world, taking travellers with increasing speed to numerous destinations around the globe. And where are we going? With 430 travellers signed up to fly with Virgin Galactic, travel to space may yet prove to be the ultimate tourist destination. We really have travelled a long, long way . . . and we will continue to do so. The ever-increasing need for travel medicine specialists to meet the travel health needs of travellers could not be more evident.

This second edition of the Principles and Practice of Travel Medicine aims to provide practitioners with a reference re -source to support the clinical practice of travel medicine. Several chapters have been updated: the new chapter dedi-cated to malaria includes recommendations for prophylaxis and strategies for stand-by self-treatment, while the chapter on vaccine-preventable diseases includes new developments in licensed vaccines as well as continent-based recommen-dations for their administration. Other important topics of clinical practice include the travel health management of high-risk travellers, who should always be evaluated with care and advised accordingly. They include the diabetic trav-eller, the immunocompromised, those with cardiovascular, renal, neurological, gastrointestinal, malignant and other disorders, psychological and psychiatric illnesses, pregnant women, children and the elderly. New chapters address other emerging clinical travel medicine issues such as health tourism and considerations on meeting the travel health needs of those visiting friends and relatives, alongside the updated chapter on the important topic of migrant health. With increasing numbers of more adventurous travellers tackling travel at altitude for example, the chapter on travel medicine and extreme environments will be of particular interest to those whose practice involves meeting the travel health needs of such intrepid travellers. Of course the most intrepid will be those travellers whose adventurous streak

Section I Travel medicine

Chapter 1 Trends in travelThomas L. TreadwellMetroWest Medical Center, Framingham, MA; Boston Medical Center, Boston, MA, USA

3

Introduction

‘The great affair is to move.’ The history of mankind is one of migration as humans travelled in search of food, escaping inhospitable climactic conditions, and in response to hard­ships caused by war, famine, social injustice and poverty. In the nineteenth and early twentieth century alone, 60 million people left Europe to seek better lives and to avoid the hard­ships of war. The health effects of these mass migrations are well known and include epidemics of infectious diseases, physical and psychological trauma, malnutrition and the introduction of diseases into new populations. Regrettably, such forced migrations are still a reality, as recent events in Africa, the Middle East and western Asia demonstrate. The types and severity of health problems seen in migrant popu­lations are far different to those associated with tourism, the focus of this chapter.

In contrast to migration, which usually takes place out of necessity, tourism has become much more common and is associated with much different health risks to those seen in migrant populations. Humans have always yearned to expand their horizons by travelling. During the past 60 years, the explosion in tourism has created new economies in both developed and underdeveloped countries, created tremen­dous life experiences for millions of travellers and spawned a new branch of medicine.

Growth of tourism

Figure 1.1 depicts the dramatic increase in international travel since 1950. In that year, approximately 25 million people travelled abroad as tourists. By the year 2010, the number of international tourist arrivals will approach one billion; estimates are that nearly 8% of the world’s popula­tion will travel to another country [1]. This impressive

growth in international tourism has been approximately 8% per year since 1950. The growth has many causes:• improvements in transportation• changing world economies• increased political stability• the development of tourism as an industry• increases in travel for health and education.The growth of the commercial airline industry in the 1950s, and later the use of jet travel, have been cornerstones of the expansion of international tourism. As the relative cost of air travel has decreased and the ease of arranging flights has improved, this trend continues to drive increases in tourism. Just over half of all international tourists arrive by air. Highway and rail systems have also improved, particularly in Europe and Asia, and although only 3% of tourists arrive by train, roughly 40% reach their destination by car or bus. Only 6% of international travel is currently by boat [1].

Globalisation and improvements in the world economy have obviously been important in tourism. Increases in wealth in both industrialised and developing countries, in part driven by the tourism industry itself, are instrumental in the increase in international travel. Also important is an ageing population with increases in both wealth and leisure time. An important sector of tourism has been the popula­tion of migrants in industrialised countries who have had increased prosperity and who return to developing countries to visit families. This type of tourism is especially important for practitioners of travel medicine [2].

Improvements in political stability have also enhanced the opportunities for international travel. The disintegra­tion of the former Soviet Union and the creation of the European Union are two obvious examples of changes resulting in increased opportunities for both business and leisure travel [3].

The rapid expansion of the tourism industry itself, espe­cially in developing countries, has fuelled export income, which currently stands at more than US$1 trillion per year, or

Principles and Practice of Travel Medicine, Second Edition. Edited by Jane N. Zuckerman.© 2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd.

4 Principles and practice of travel medicine

• A French tourist is 20 times more likely to go to Africa than an American traveller.• Twice as many English tourists visit India and Pakistan as American visitors.• Australian tourists commonly have exotic destinations in Africa and Southern Asia.

Outbound tourism

Most international travel originates in developed countries, more than half of them in Europe (Figure 1.4). Asia and the Pacific have overtaken the Americas as the second most common origin for travel. In fact, emerging countries with rising levels of prosperity have showed higher growth rates

nearly US$3 billion per day [1]. The development of the tourism industry, with its great use of the nternet and advertis­ing strategies, has been important in the expansion of tourism.

Finally, individuals are increasingly travelling for business, health and education. It was hard to imagine even a decade ago that patients from North America would travel to devel­oping countries for surgery and medical treatment that is less expensive than in their own country. The impressive numbers of students who study abroad is of particular inter­est to the field of emporiatrics.

Where are international tourists going?

Most international tourism is for pleasure and is local; intra­regional tourism accounts for nearly 80% of all international arrivals [1]. Moreover, the top destinations of international tourists, listed in Table 1.1, are mostly developed countries in Europe. In fact, Europe has nearly one­half of all interna­tional arrivals, although Asia, the Middle East and Africa have seen significant growth in the past 15 years (Figures 1.2 and 1.3). Since 1995, international arrivals to Asia, the Pacific and Africa have tripled, while during the same period arriv­als to Europe and the Americas showed only modest growth. In addition, most international tourists visiting the Americas arrive in the United States or Canada. However, the fastest growing area in the region is Central America, which is cer­tainly of more interest to practitioners of travel medicine [1]. Examining destinations of international travel in different regions, several patterns emerge.• In the Americas, most travel is ‘north–south’ to Canada, Mexico and the Caribbean. Visitors from the US are much more likely to go to the Caribbean than South America or Central America.

Figure 1.1 International tourist arrivals, 1950–2005 [1].

Table 1.1 International tourist arrivals

Image not available in this digital edition.

Table not available in this digital edition.

Trends in travel 5

top tourism spenders and countries with the largest tour­ism receipts are nearly all developed nations, the relative importance of tourism to developing countries is much greater (Figure 1.5, Table 1.2). Currently, international tourism generates more than US$1 trillion per year and accounts for nearly one­third of the world’s exports of com­mercial services. Perhaps more importantly, tourism is the leading export category for most developing countries. In these countries, tourism creates not only jobs, but much needed infrastructure. Currently, more than 80 countries earned US$1 billion or more. Examining the list of top

than developed countries as markets for the travel industry. This is especially true for northeast and southern Asia, Eastern Europe, and the Middle East. Although intraregional travel still dominates, interregional trips have grown twice as fast in recent years [1].

The economics of tourism

The importance of tourism as a driver of world economy cannot be overstated. Although lists containing the world’s

Figure 1.2 International arrivals (millions) by selected area (adapted from [1]).

Figure 1.3 International arrivals (2008) by selected region (adapted from [1]).

Figure 1.4 Outbound tourism, 2008, millions [1].

Image not available in this digital edition.

Image not available in this digital edition.

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6 Principles and practice of travel medicine

trends in travel that are of more interest and importance for travel medicine:• an ageing population• increases in ecotourism• students abroad• visiting friends and relatives in developing countries.We are currently witnessing the retirement of the wealthiest, healthiest and largest group of elders in human history. In the US alone, nearly one­quarter of the population is above 55 years old, and by the year 2030, there will be more than

spenders (Table 1.3) in international tourism one learns that tourists from the United Kingdom spend nearly as much on foreign travel as travellers from the US; Germans spend more.

Trends in travel types

Although all travel has health risks, the healthy English family on a short holiday to France is of little interest to practitioners of travel medicine. The vast majority of inter­national arrivals involve business or pleasure trips in devel­oped countries. In addition, pleasure travel to less developed countries is often tour­ or resort­based. However, there are

Figure 1.5 International tourist receipts (US$ billion) [1].

Table 1.2 International tourist receipts Table 1.3 Top international tourism spenders

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Table not available in this digital edition.

Table not available in this digital edition.

Trends in travel 7

visiting less­developed countries, staying in crowded condi­tions, staying longer, and more likely to be exposed to con­taminated food and water. Compared to travellers for business and leisure, VFR travellers are less likely to be insured or to seek pre­travel advice. The immunisation status of VFR travellers is often incomplete and uncertain. They often bring their US­born children who have no immunity to malaria, and often sleep without protection from mosquitoes. In the past 15 years, most of the cases of falciparum malaria and all of the cases of typhoid fever seen by our travel clinic were children of immigrants returning from visits abroad. As immigrant populations in the US expand and mature economically, VFR travellers are certain to increase.

Future trends

‘It’s tough to make predictions, especially about the future’ (Yogi Berra). By the year 2020, international arrivals are expected to reach 1.6 billion (Figure 1.1). The economic forces that have made tourism so important for developing countries – improvement in infrastructures, the internet and an expanding population of persons yearning to travel – are some of the many reasons for this expected continued growth. However, after years of steady growth in tourism, there have been recent worldwide decreases in both tourist arrivals and receipts. The major factor in the recent down­turn is obviously worldwide economic recession, but other factors include rising fuel prices, unstable and unfavourable currency exchanges, and even fear of epidemics (influenza). Social and political unrest may also have negative effects, although the region with the most robust growth in recent years, the Middle East, is one of the most volatile (Figure 1.2). Of theoretical concern is the impact of global warming and its relationship to air travel.

70 million individuals above 65 years old. This population yearns for travel, and increasingly exotic travel. Preparing elders for trips presents challenges to healthcare practition­ers and for those interested in expanding infrastructure for tourism. Health risks are clearly greater. A recent study found that of more than 2,400 deaths in Canadian travellers, the average age was 62 and most died of natural causes [4].

An increasingly popular type of travel is ecotourism. This type of adventure travel is often to poorly developed areas in the tropics, with potential exposures to excessive sunlight, vector­borne diseases, and contaminated food and water.

Another trend is the increase in students studying and working abroad. The number of US students abroad has doubled in the past decade to more than a quarter of a million per year. Most of these students have destinations in developed countries, but nearly 20,000 US students study in Mexico and Central America. Many students also spend time working as volunteers in rural and underdeveloped coun­tries, usually working for non­profit organisations. As opposed to short­term tourism, students typically stay for longer periods, take greater risks than older travellers and often have ill­defined itineraries.

Visiting friends and relatives (VFR) is a rapidly increasing reason for international travel (Figure 1.6) and of special interest to emporiatrics [2]. In the US alone, one­fifth of the population (56 million people) are foreign­born or their US­born children. Overall, about a quarter of all interna­tional arrivals are VFR travellers, but 44% of trips abroad from the US, excluding travel to Canada and Mexico, are currently for this reason. Most of these travellers are return­ing to developing countries, half to Latin America and a quarter to Asia. The five top countries for legal immigrants in the US are currently Mexico, India, China, the Philippines and Vietnam.

As a group, VFR travellers are much more likely to acquire illness abroad than other types of tourist. They are usually

Figure 1.6 International tourist arrivals by purpose of visit (adapted from [1]).

Image not available in this digital edition.

8 Principles and practice of travel medicine

References

1. WTO (2009) World Tourism Highlights, 2009 edn. World Tourism Organization, Madrid; http://www.unwto.org (accessed 11 Septem­ber 2012).

2. Angell SY and Cetron MS (2005) Health disparities among travelers visiting friends and relatives abroad. Annals of Internal Medicine 142: 67–73.

3. Handszuh H and Waters SR (1997) Travel and tourism patterns. In: DuPont HL and Steffen R (eds) Textbook of Travel Medicine and Health, pp. 20–26. BC Decker, Ontario.

4. MacPherson DW et al. (2007) Death and international travel – the Canadian experience. Journal of Travel Medicine 14: 77–84.

Chapter 2 Tourism, aviation and the impact on travel medicineAnne GrahamUniversity of Westminster, London, UK

9

Introduction

International tourism demand has grown very considerably over the past few decades. According to the United Nations World Tourism Organization (UNWTO), international tourist arrivals have risen from just 166 million in 1970 to more than 922 million in 2008. Likewise, tourist spending has increased from US$18 billion to US$944 billion. The majority of tourism visits are for leisure, recreation and holiday purposes (51% of all visits in 2008) with 15% for business and a further 27% for visiting friends and relatives (VFR), health, religion and ‘other’. While demand is forecast to be weak in the short term due to the poor economic climate, in the longer term the UNWTO expects healthy growth to return and numbers to reach 1,561 million by 2020 [1]. The World Tourism and Travel Council (WTTC) has also forecast that the travel and tourism economy will grow by 4% per annum in real terms over the next 10 years and will then account for a very significant 275 million jobs or 8.4% of total global employment [2].

Transport is a fundamental component of tourism, pro-viding the vital link between the tourist-generating areas and destinations. Aviation is an increasingly important mode of transport for tourism markets and currently 52% of all inter-national tourists arrive by air (Table 2.1). While geography has meant that, in modern times, air travel has always been the dominant mode for long-distance travel, trends towards airline deregulation, and the subsequent emergence of the low-cost carrier (LCC) sector, have also increased aviation’s significance for short- and medium-haul tourism trips.

Travel medicine meets the health and safety needs of these tourists and air passengers who are going to a variety of destinations and for a range of different purposes. It has evolved from being considered just a component of infec-tious, topical and preventive medicine to becoming a rec-ognised interdisciplinary specialty that has a wide range of contributions from both physical and social science.

Epidemiology, accident and emergency medicine, safety science and ergonomics, tourism studies, management, food safety, leisure studies, law, social psychology, tropical medi-cine and health education are examples of just some of the subjects that have contributed to the development of travel medicine [3].

It is the aim of this chapter to bring together these topics of travel and medicine and to investigate the impact of tourism and aviation trends on travel medicine. This will be undertaken by first identifying the various links and inter-relationships between tourism and travel medicine. This leads on to an assessment of the changing patterns and types of tourism. This then allows the impact of tourism develop-ments on travel medicine to be explored, which is followed by an examination of the effect of airline trends. Finally, conclusions are drawn.

The relationship between tourism and travel medicine

The rise in tourism demand and the rapidly growing mobile population has meant that the health and safety of tourists has become an increasingly important and complex issue. However, it is not just the volume of tourism that is chang-ing, it is also the characteristics of the tourists and their trips. The multidimensional discipline of travel medicine has developed to cope with these changes by covering an increas-ingly diverse range of travel-related health areas, such as guidance about sun-seeking and sexual behaviour, malaria prevention, and advice related to injuries and accidents [4]. As a result there have also been an increasing number of detailed travel medicine manuals that aim to provide comprehensive coverage of all aspects of travel medicine [5, 6].

Travel medicine has to be considered at all stages of the trip, namely the pre-travel planning stage, the journey to and from the destination, the stay at the destination, and

Principles and Practice of Travel Medicine, Second Edition. Edited by Jane N. Zuckerman.© 2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd.

10 Principles and practice of travel medicine

of any operation. The industry also has a role to inform potential tourists of the risks involved. The composite nature of the tourism industry, being made up of a number of individual sectors (e.g. transport, hospitality, attrac-tions, tour operations, travel agency, destination organisa-tions) in both public and private ownership makes this process more difficult. In particular, it makes it problematic to define and identify the individual sector responsibilities to safeguard the health of tourists and to ensure that the advice and information that is being provided is entirely consistent.

The industry is only too aware of the commercial implica-tions (e.g. on tourism volume and sales) of overplaying the potential risks and so here a careful balance has to be found. Labelling a country as high risk for a disease may have serious economic consequences for both the industry and the destination. For example, Figure 2.1 shows the impact that SARS, which was most prevalent in Asia, had on tourism numbers in 2003. Some countries such as Hong Kong expe-rienced a 70% drop in their tourism numbers. The only other region to have experienced a decline in tourism numbers was the Americas, primarily due to 9/11 (and SARS outbreaks in Canada). More recently, between May and July 2009 in Mexico, where the first cases of the swine flu out-break were recorded in April of that year, 2,000 inbound flights were cancelled and Mexico was estimated to have lost between US$200 and US$300 million in tourism income. Overall in 2009 it was expected that arrivals and spending would be down by a third [7]. Communication with the media can be crucially important here as it is often press messages that will act as the most influential trigger in changing tourists’ perception of a destination.

The nature of products that the industry offers, in terms of type and location of destination, mode of transport and type of accommodation, will have a major influence on the risks to which the tourist is exposed. In addition, the amount of contact with the local inhabitants may have an impact. An obvious example is the tourist who chooses to stay in a resort or go on a group tour where the health risks can be more easily managed, compared with one who is seeking greater exposure to the indigenous population and participating in more individual activities where the risks are likely to be greater. In some cases companies may choose products where the risk factors can be better controlled, as with ‘enclave’ or ‘all-inclusive’ resorts in lesser-developed coun-tries. Seasonality and length of stay will also have an impact, as will the purpose of travel. For example, the risks associated with business tourists will usually be perceived as smaller than for other tourists because the majority of these trips are to towns or cities where the visit is spent in a hotel and/or conference centre of a relatively high standard. The excep-tion to this is when it is considered essential to maintain

post-travel follow-up and aftercare. At all times during their trip, tourists are exposed to risk. However, the scale and probability of these risks will vary from rare cases of tourist mortality, for example associated with deep vein thrombosis (DVT), to more frequent but still comparatively unusual cases of malaria and other disease infection or road traffic accidents, to minor but common problems associated with small injuries, diarrhoea and sunburn [3]. The psychological and behavioural aspects of travel associated with issues such as fear of flying, trauma and stress also need to be considered as well as special needs of certain groups of tour-ists, such as the elderly, and any underlying medical condi-tions that exist.

Clearly the increased movements of people across political and physical borders can have a number of unwanted con-sequences for health, particularly as disease knows no fron-tiers. Recent examples include the Severe Acute Respiratory Syndrome (SARS) and A(H1N1) ‘swine’ flu that were spread rapidly and globally by the movement of tourists. In some cases disease may be spread from a remote region to other areas where it is not so familiar and hence it will be more difficult to implement biosecurity and coping strategies.

However, not only does travel have major impacts for health, but also the risks associated with travel have impor-tant implications for health and tourism services. Moreover, the inter-relationship between travel and health can have very significant consequences for the insurance industry and legal sector when issues of litigation may become rele-vant. In terms of the provision of health services, there are numerous examples of where destination countries have benefited from better accident and emergency facilities, and improved cleanliness and hygienic conditions as a result of bringing tourism to the area. Likewise, drugs and vaccines that are initially developed for tourists at a high price, often eventually become more widely available at a significantly lower cost.

For the tourism industry, ensuring that the tourist is in good health and is safe is now a crucially important aspect

Table 2.1 International tourist arrivals by mode of transport 1990–2008 (%)

1990 2000 2005 2006 2007 2008

Air 39 42 45 46 47 52Road 47 45 43 43 42 39Rail 6 5 5 4 4 3Water 8 8 7 7 7 6Total 100 100 100 100 100 100

Source: UNWTO

Tourism, aviation and the impact on travel medicine 11

Figure 2.1 Annual growth rate of international tourist arrivals by major world regions 1999–2008 (%).Source: UNWTO

-15

-10

-5

0

5

10

15

20

25

30

00/99 01/00 02/01 03/02 04/03 05/04 06/05 07/06 08/07

Ann

ual G

row

th (

%)

Europe Asia/Pacific Americas

business contact by making a trip to a country where the health or safety risks for leisure travel are seen to be too high.

Some of the risks will be more specific to the individual tourist, related to their age, medical history and fitness to travel. Other factors include their experience of travel and whether they are frequent or infrequent travellers. A very important aspect is also the behaviour and lifestyle of the tourist. For example, some tourists choose to take more risks when they are away from home and perhaps ignore advice that has been given. Others may travel specifically because of the excitement of the risks that the travel experience brings. In most cases the risks will be highest when the tour-ists are exposed to new hazards that they have previously not encountered.

Changing patterns and types of tourism

The evolution of tourism through the ages has continually led to changes in the patterns and types of tourist. This is just as evident today as it has been in the past. In particular, one of the most notable developments in recent years has been a shift in the global distribution of tourism, with the dominant markets of Europe and America reducing their market share of arrivals from 82% to 73% since 1990. This is partly due to increased travel within other more develop-ing regions, particularly in Asia/Pacific, because of rising living standards and a more liberal air transport environ-ment, which has given many the opportunity to travel by air

for the first time. It is also in part because of the development of long-haul travel, particularly from Europe and North America to other regions. This has been driven by economic deregulation and globalisation, which has encouraged greater mobility of businesses and led to more international busi-ness travel, and for leisure travel due to cheaper costs and changing consumer preferences and motivations.

This increase in long-haul travel may clearly be seen from Table 2.2. Since 1990 there has been higher growth in inter-regional rather than intraregional travel except during the period between 2000 and 2005 when long-haul travel was deterred primarily as a result of 9/11 and SARS. Moreover, the share in international tourist arrivals received by devel-oping countries has steadily risen, from 31% in 1990 to 45% in 2008. This trend is forecast to continue into the future with the UNWTO predicting that long-haul travel will grow at 5.4% per annum until 2020 compared with 3.8% for intra-regional travel [1].

In many Western societies there have been significant changes in family structure, life stage and lifestyle that have affected tourism. For example, there is a tendency to marry later in life and have smaller families at an older age. As this is occurring at the same time as more couples are opting to remain childless, it means that there are a rising number of young couples travelling, who have fewer income and time constraints than families with children. There are also higher divorce rates and a growing number of singles and one-parent families who are travelling.

Another key development has been the growth of the so-called ‘grey’, ‘third age’, ‘mature’, ‘senior’ or over-55s market

12 Principles and practice of travel medicine

example, in 2004 more than 2.4 million students pursued higher education outside their home country and it has been estimated that this will increase threefold to eight million by 2025 [10]. In addition, there have been a growing number of young travellers who are taking gap years either before or after they study. However, the taking of gap years is not now just considered a youth phenomenon, as it used to be. There has been a growth in adults taking a diverse range of gap activities, for example with their families, in between careers or at retirement age – albeit the numbers involved are still quite small. This has led to terms such as ‘career gappers’, ‘golden gapper’, ‘twilight gapper’, ‘mature gapper’ or ‘denture venturers’ [11]. There has also been a growth in travelling to undertake volunteer work – the so-called ‘give back gap’.

For many, attitudes to travel are changing and tourists are becoming more sophisticated and demanding. This is occur-ring as travellers are becoming more experienced and better educated. There is a heightened awareness in foreign culture and there are an increasing number of publications, both books and magazines, about travel. Moreover, travel market-ing has improved, particularly with the use of the internet. This means that travellers are more adventurous and often more environmentally and ethically aware. In addition, many travellers are expecting their holiday experience to be more personalised and to be more related to their individual lifestyle and choice.

[8]. This age group is becoming proportionately more important within the population due to people living longer and birth rates falling in Western economies such as Europe and North America. The propensity to travel of this age group has also increased, not only because this market segment has plenty of time to travel, but also because such travellers are wealthier, healthier and more experienced than before. Moreover, there is less of an expectation that their savings should be left to their offspring and a greater accep-tance that such funds should be used for pursuing leisure activities in later life. Table 2.3 shows how in the UK the share of international holidays taken by the over-55s has increased from 17% in 1997 to 24% in 2008.

At the other end of the age spectrum there are youth travellers. This market has been steadily growing due to a number of demand-related factors such as increased par-ticipation in higher education, falling levels of youth unem-ployment, and increased travel budgets through parental contributions, savings and combining work and travel. There are also supply side factors that have encouraged this such as the rise of LCCs, growth in long-distance travel specifically targeted at young travellers, shorter employment contracts for those working leading to significant gaps in employment, and the growth of dedicated student and independent travel suppliers [9].

Among this youth market there has been a very significant increase in those who are studying and travelling abroad. For

Table 2.2 Average annual growth rate of international tourist arrivals by origin region 1990–2008 (%)

1995/90 2000/95 2005/00 2006/05 2007/06 2008/07

Same region 4.1 4.6 3.4 5.5 6.0 1.8Other regions 4.5 6.4 2.6 7.3 8.1 3.4Overall 4.2 4.9 3.2 5.9 6.4 2.1

Source: UNWTO

Table 2.3 Examples of tourism trends 1997–2008

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

International trips by UK residentsTrips by residents >55 years (%) 17 18 20 20 20 21 22 23 24 25 24 24Air package tours/total air holiday trips (%) 61 60 59 59 57 55 50 48 45 42 42 40

Travel sales in EuropeInternet/Total sales (%) 0 0 0 1 2 4 7 10 13 16 19 23

Sources: UK International Passenger Survey, Danish Centre for Regional and Tourism Research

Tourism, aviation and the impact on travel medicine 13

with visits to a religious place, building or shrine or to a religious event [15]. The largest and most well known of these movements is Hajj, where in 2008, 1.7 million visi-tors from 178 countries travelled to Mecca, compared with around just one million only 10 years previously. Other tour-ists are travelling for mental and physical wellbeing, and there has been a growth of holidays where tourists are seeking therapies and treatments and pursing activities such as yoga and spa holidays. Another growth area is medical tourism, where travellers visit countries where the cost of surgery or dentistry is considerably lower than in their own country, for example for coronary bypass in India or breast augmenta-tion in Cuba. The size of this overall market is hard to esti-mate, but in the UK, health and wellness holidays have been valued at £64 million, compared with £90 million for medical tourism. However, this activity is still comparatively small and in a survey, only 1% of UK adults said that they had had medical treatment abroad in the past three years – which would be equivalent to 700,000 trips [16]. In spite of this niche market status, for certain destinations medical tourism can be significant. For example in India it is expected to be worth $1 billion by 2012 and 3–5% of expenditure on healthcare will be related to medical tourism[17]. One notable example of the development of this type of tourism is ‘Healthcare City’ in Dubai, which is a huge complex that is being developed to become an international centre for both medical and wellness services.

The impact of tourism trends on travel medicine

Travel medicine is having to adapt to these changing patterns and types of tourism. This means taking account of the demand segments that are showing the most growth and the types of product that are rising in popularity. There also has to be consideration of other trends, such as greater flexibility and changing booking habits.

All the changes in family structure, life stage and lifestyle that have been discussed will undoubtedly have some impact on travel medicine. For example, the growth in singles travel-ling may present greater risks and anxieties in some cases. With senior travel, there is still a popular perception that this market consists of frail old people walking round with walking sticks. This is totally incorrect, especially as these travellers represent a number of diverse and heterogeneous groups. In relation to health, these travellers can be divided into the health optimist (those in good health), the travel recipient (those with pre-existing health complications) and the carer (those who have to care for others) [18]. Each segment has different travel medicine needs, although it is the case that the impact of any illness tends to be more

This has resulted in a marked broadening of the range of requirements for the holiday product. Companies are increasingly expected to demonstrate that they are encourag-ing ‘responsible’ travel and there are an expanding number of ‘nature’, ‘green’ or ‘eco’-tourism products on offer. This has also meant that there has been a growth in demand for diverse adventure activities such as mountaineering, white-water rafting, hiking, sailing, rock climbing, recreational diving and mountain climbing [12]. Moreover, there is a rising demand for more extreme and strenuous sports such as BASE jumping, canyoning, coasteering/tombstoning and speedriding, and new adventure destinations such as Georgia, Kyrgyzstan, Ethiopia and Libya [13].

One of the ultimate types of adventure is being offered by the embryonic space tourism industry. Four main kinds of space tourism, namely high-altitude jet fighter flights, atmos-phere zero-gravity flights, short-duration sub-orbital flights and longer-duration orbital trips, may become available in the near future. There have already been several fare-paying tourists visiting the International Space Station via the Russian Soyuz spacecraft and the company involved with organising this, Space Adventures, has more than 200 people prepared to pay the $100,000 for a 90-minute sub-orbital flight. Likewise, Richard Branson’s initiative Virgin Galactic has sold $200,000 flights to 100 individuals [14].

Another trend is that tourists are demanding greater flex-ibility, which is reflected in the trend towards holidays of different and shorter duration, rather than the traditional two-week break. Some of this growth has been fuelled by the development of the LCC sector, which has made it possible for many to afford a weekend break away, particularly in Europe. This has encouraged the growth in activities such as hen and stag weekends, festivals and beach parties, and the development of European nightlife resorts such as Kavos, Zante, Malia, Magaluf and Ayia Napa.

This need for flexibility has also caused a shift towards independent travel rather than organised package holidays and a considerable growth in dynamic packaging, where tourists construct their own individual package tour. For example in the UK, Table 2.3 shows that package tours by air taken by UK residents now account for around 40% of all international holidays compared with 60% just 10 years ago. Travellers are also making their travel arrangements much later than previously. Much of this flexibility has come from the development of the internet as a major distribution channel for travel products. Indeed in Europe, internet travel sales now account for around a quarter of all sales (Table 2.3). In many cases this means that the high street travel agent intermediary is by-passed.

The desire for spiritual and physical wellbeing is also causing a growth in a number of specialist tourism areas. First there has been a rise in religious or pilgrimage travel,

14 Principles and practice of travel medicine

tourists have to seek medical assistance, either at the destina-tion or when they return home.

Other tourism trends can potentially have significant impacts on travel medicine. The preference for booking later may mean that tourists do not have time to seek all the travel advice they need or to have all the required immunisations and vaccinations before they leave for their destination. Also, buying the components of travel (e.g. flight, accommoda-tion) separately rather through a tour operator means that there is no longer one major central source of information and advice related to the trip that is being undertaken. With less use of travel agents, another channel of advice is also no longer available to an increasing number of tourists.

The growing use of the internet for obtaining travel infor-mation and booking trips has a number of potential impacts on travel medicine, particularly on pre-travel advice. It makes it easier to provide up-to-date government advice to a broad audience on countries that should not be visited or are at high risk. Likewise, official health authorities can centralise their advice and rapidly update it when neces-sary. However, such information, as with all advice given on the internet, may not have as strong an influence as face-to-face help.

There has been a significant rise of media interest in travel, and in particular in negative events, and this has led to con-siderable variability in the advice offered on the internet. On the other hand, it does provide greater opportunities for potential tourists to weigh up the costs of reducing the potential risks, for example with the side effects of the drugs associated with preventing malaria. However, the sheer quantity of pre-travel advice now provided on the internet might be unmanageable for some people. In reality, much travel advice is and will remain anecdotal, but there are new ways of communicating this, particularly for young travel-lers, with blogs, wikis and other social networks.

The impact of aviation trends on travel medicine

The emphasis so far has been on health precautions prior to departure and problems encountered at the destination. However, the actual journey to and from the destination raises a number of additional issues related to travel medi-cine. While consideration needs to be given to all modes of transport, the unique characteristics of air travel and its growing importance within tourism mean that this mode is particularly important and hence has received special focus here.

Forecasts for air transport demand mirror those produced for the tourism industry. Passenger numbers are predicted to increase by an average 4.2% annually, which will mean

serious for this age group, particularly if there are underlying medical conditions.

Youth tourism brings other challenges. While this market segment will generally be healthier, these travellers are often those who are prepared to take more risks. This is no doubt related to age, but it may also partly be explained by the fact that such tourists will often be very cost conscious and travelling on tight budgets, and so believe that they cannot afford to avoid the risks if it costs them money to do so. Moreover, an increase in more hedonistic activities with this age group, associated with the enjoyment of alcohol at hen and stag trips and recreational drug use at music festival and resorts, has brought with it behavioural issues related to sexual conduct, violence and crime, which have to be addressed.

The trend towards greater long-haul travel, and in par-ticular to lesser-developed countries in tropic and sub-tropic regions, has given tourists greater exposure to a different health environment. For example, they may experience sig-nificant changes in temperature, altitude and humidity that may affect their health. There may also be increased risks of venomous bites and stings and catching malaria. In addition, the lower quality of accommodation and poorer standards of hygiene and sanitation that can exist in such areas may increase the health risks, particularly if the medical services are not very well developed.

For many tourists, one of the key motivations for travel is the desire for new experiences. This exposure to unfamiliar surroundings will create some risks, but these can usually be managed. However, the growth in adventure tourism has presented new challenges in the field of travel medicine as these activities are based on an experience that involves con-siderably more inherent physical risks to the traveller. If the risk were to be reduced, so would the thrill and excitement of the experience. This is true of most adventure travel, but particularly with the new concept of space tourism, the travel medicine implications are very difficult to predict.

Mass religious gatherings present considerable challenges for travel medicine due to health and safety risks, because of accidents and even loss of life as the result of overcrowding, and health concerns of having such a large concentration of people that could encourage a fertile breeding ground for germs. For example, at the Hajj, there have been a number of deaths due to stampedes and inadequate crowd control in recent years. This has led to the Saudi government making improvements to security and certain facilities, and extend-ing the access hours to religious sites. Moreover, after out-breaks of meningitis in 1987 and 2000–01, it is now a visa requirement that pilgrims going to Mecca have received the meningococcal meningitis vaccination.

The emergence of medical tourism has brought its own risks. For example, where surgery does not go to plan and

Tourism, aviation and the impact on travel medicine 15

processes such as getting to the airport and going through all the airport processes.

The airport experience has changed as airports have had to become larger and more complex to cope with the increas-ing number of passengers. Services are provided on many floor levels and in different terminals, such as at London Heathrow airport, which now has five terminals. This means that there is very often a long distance between check-in and the boarding gates, and transferring between terminals when changing flights can involve a long and time-consuming journey. Passengers have to check in, be processed by secu-rity, customs and immigration authorities, and find their way to the gate for their aircraft – all of which can be stressful for passengers, particularly infrequent flyers who are unfa-miliar with the airport. Enhanced security arrangements due to 9/11 and the liquids scare in 2005 have increased the burden of security checks. On average, international pas-sengers spend 83 minutes in the airport terminal. Sixty-two minutes of the time is landside, with 23% on check-in, 16% on customs and immigration, and 12% on security, which illustrates just how much time has to be spent going through the essential airport processes [25]. Traffic growth means that congestion and longer queues in the terminal are likely. Moreover, more aircraft have to share air space, gates, runway capacity and parking, which again can increase congestion and delays. This is a major issue for the industry as there are currently 154 airports in the world where poten-tial demand exceeds supply (in terms of runway capacity) and a further 83 where potential demand is approaching capacity [26].

Larger airports have, however, provided airport operators with the opportunity to offer a wider range of retail and food and beverage outlets that would not all be economically viable at smaller airports. For some passengers this shopping experience enables them to feel more relaxed and enhances

that by 2027 there will be 11 billion passengers or 30 million passengers per day. Again growth is predicted to be highest in areas outside Europe and North America, and in particu-lar by 2017 the Asia/Pacific region will be the busiest air transport area [19] (Table 2.4). Boeing is predicting an average annual growth rate until 2028 in passenger-kilometres of 6.7% between North America and Southeast Asia, 6% between North Americaand China, and 5.7% between Europe and Southeast Asia and China, compared with an average of 4.9%. Forecasts for traffic to and from the Middle Eastern and African regions are also higher than the norm [20].

The propensity to travel by air varies considerably throughout the world. Australia has 5.6 passengers per head of population followed by the United States with a value of 4.7. At the other extreme Russia and Brazil have values of 0.6, China 0.3 and India 0.1. Even within Europe there is a broad variety of values, with island countries, such as Cyprus, and countries with remote regions, such as Norway, already having values greater than 6, whilsepoorer countries, such as Albania and Macedonia, have measures substantially lower than 1 [21]. There is thus considerable scope for growth in these countries where propensity figures are still low, if and when economic and other conditions become attractive enough to generate and attract substantially more air passengers.

Aviation medicine is a wide-ranging component of travel medicine covering physical and psychological aspects of flying, such as the recognised conditions of motion sickness and fear of flying [22], as well as issues such as fitness to travel [23]. Moreover, the rising numbers of air passengers has meant that air travel has become increasingly compli-cated and considerably more stressful, which introduces more health implications for travellers [24]. This stress is related not only to the actual flight but also the pre-flight

Table 2.4 Past and future airport passenger growth by world region 1999–2027

1999(mns)

2007(mns)

2027(mns)

2007 market share (%)

2027 market share (%)

Forecast annual growth 2007–2027 (%)

Africa 60 138 401 2.9 3.6 5.5Asia 450 1,150 3,918 24.0 35.7 6.3Europe 901 1,472 2,868 30.7 26.1 3.4Latin America/Caribbean 120 328 869 6.8 7.9 5.0Middle East 60 158 387 3.3 3.5 4.6North America 1,411 1,552 2,536 32.3 23.1 2.5World 3,003 4,798 10,976 100 100 4.2

Source: ACI

16 Principles and practice of travel medicine

in the A380 has provided an opportunity for some of carriers that use this aircraft (e.g. Singapore Airlines and Emirates) to offer improved comfort and in-flight services, particularly in the first and business cabins. With a three-cabin configu-ration the numbers of seats is around 550, but if only one class is chosen, as is the case with an order from Air Austral, 840 passengers can be carried, which will indeed be a differ-ent travel encounter yet to be experienced.

Since more people are flying long-haul, aircraft with longer ranges have been introduced, which has reduced the need to make stops for technical reasons. This tends to increase the medical problems associated with flying, and has led to airlines and other bodies having to pay more atten-tion to publicising possible remedies for jet lag, which is caused by the body crossing different time zones [28]. The possibility of developing DVT is also an issue that has grown in importance and in some cases has encouraged airlines to introduce more comfort for long-haul flights, for example by increasing seat pitch. Another area of concern is the poorer quality of air, primarily due to the increase in the intake of reprocessed air in aircraft cabins, as a result of airlines trying to save fuel.

A more impersonal environment on board, due to the increased number of passengers, and boredom, particularly during long-haul flights, is thought to be playing some role in increasing disruptive behaviour among passengers, espe-cially if they have consumed alcohol and are now unable to smoke. ‘Air rage’ has received considerable media attention in recent years and is something that airlines now have to face with increasing frequency [29].

their enjoyment of their airport visit and overall trip. Some airports have gone a stage further, providing passengers with relaxation activities. For example, Singapore Change airport offers a swimming pool, sauna, gym and cinema. On the other hand, for the growing number of passengers who have opted for a journey to a lesser-developed country destina-tion, the airport facilities in such places may be more basic with more cumbersome immigration, customs and security controls, which can increase anxiety levels.

The stresses on board can also in part be related to the larger volume of passengers being flown in each aircraft. Over the years, the average aircraft has increased in size to cope with demand growth and to take advantage of the better economics that are available when flying larger air-craft. Certain regions with specific location characteristics and particularly strong growth have experienced the most notable increases in aircraft size. For example, Figure 2.2 shows that the Middle East and Asia/Pacific regions have encountered the greatest growth and the average number of seats here has increased from around 135 in 1972 to just under 190 in 2008 [27].

One of the most significant recent developments in terms of aircraft size has been the emergence of the world’s largest aircraft, the Airbus A380. This came into service in 2007 and Airbus is predicting that 1,318 of these aircraft will be needed by 2028, particularly for Asia/Pacific (55% of total) and the Middle East (14% of total). While generally larger aircraft tend to mean that the service provided is more impersonal and introduce more scope for passenger and baggage delays because of the sheer volume being handled, the larger space

Figure 2.2 Growth in aircraft size by world region 1972–2008 (%).Source: Airbus

0.0

2.0

4.0

6.0

8.0

10.0

12.0

Latin America

Caribbean

Middle East

Africa

Asia/Pacific

Europe

North America

Ann

ual G

row

th (

%)