travel health information at commercial travel websites

2 7 2

Travel Health Information at CommercialTravel WebsitesLynn L. Horvath, Clinton K. Murray and Herbert L. DuPont

Background: Internet travel purchases accounted for 10% of the travel industry revenue generated in 2001. To ensure thattravelers remain healthy during excursions to developing countries, travel health information needs to be available atcommercial travel websites. We evaluated the current availability of travel health information at these websites.

Methods: The existence, adequacy and ease of access of the travel health information provided on commercial travel websiteswas assessed through a review of the top 25 airline and 20 discount travel websites. Each site was examined to determinewhether it provided general information, such as jet lag, or international travel health information, such as malariaprophylaxis. We also assessed hyperlinks to external travel health information websites, such as the CDC, when provided.

Results: Travel health information was not available at 20 (44%) commercial travel websites, including 36% of airline and55% of the discount travel websites. Twenty-eight percent of airline websites contained general information only, 8% linksonly, and 28% general and international information. Travel health information available at discount travel websites included10% general only, 30% link only, and 5% general and international information. On average, it took three clicks to accesstravel health information. Keywords clicked to access travel health information frequently did not obviously refer to health.Each of the six travel health website links provided accurate vaccine and travel health information. However, several linkslacked disease-specific maps and details of disease risk (i.e. seasonal and regional variations of malaria risk).

Conclusions: Travel health information on commercial travel websites may be the only data available to travelers purchasingonline. The information currently provided is generally inadequate. Ideally, commercial travel websites would provideuniform information that is accurate and easily accessible. Internationally recognized organizations should considerestablishing guidelines for the information provided on commercial travel websites.

Lynn L. Horvath, MD, and Clinton K. Murray, MD:Department of Medicine, Infectious Disease Service,Brooke Army Medical Center, Fort Sam Houston, Texas;Herbert L. DuPont, MD: Internal Medicine and TravelMedicine, St Luke’s Episcopal Hospital, Houston, Texas;Center for Infectious Diseases, University of Texas, HoustonSchool of Public Health, Houston, Texas; Department ofMedicine, Baylor College of Medicine, Houston, Texas.

The authors had no financial or other conflicts of interest todisclose.

The views expressed herein are those of the authors and donot reflect the official policy or position of the Department ofthe Army, Department of Defense, or the US Government.

Reprint requests: Lynn L. Horvath, MD, Brooke Army MedicalCenter, Infectious Disease Service (MCHE-MDI), 3851 RogerBrooke Drive, Fort Sam Houston, TX 78234.

J Travel Med 2003; 10:272–279.

It is estimated that more than 61 million householdsin the US purchased airline tickets and accommodationsonline in 2002. This accounted for approximately 10%of the $20 billion dollar (US) travel industry,and this shareis expected to increase.1 Most of these purchases weremade by travelers looking for airline tickets and hotelreservations discounted specifically for internet consumers.

For many travelers seeking bargains online, this will betheir only opportunity to review pretravel health advice.

Significant illness can occur during travel, especiallyin developing countries.2 Travel industry professionals,such as travel agents, traditionally have the earliest know-ledge of a traveler’s plans, and therefore can most appro-priately direct referral for medical advice.3 Travel healthinformation from these providers has been made availablefrom within the travel industry (i.e. travel brochures) andvia referral to health care professionals, including travelclinics, public health clinics, and general practitioners.4

Although most travel agents do understand the importanceof referral to travel medicine professionals, this need isnot uniformly recognized.5 This is evident in documentedreports of traveler fatalities secondary to inaccurate advicegiven by travel agents.6 A pretravel evaluation by a travelmedicine expert remains the most reliable source of adviceto maintain traveler health.As travel purchases from travelindustry professionals decrease and direct booking onlineincreases, commercial travel websites will need to educatetravelers about healthy travel and direct them to theappropriate travel health resources.

Two travel medicine research teams have attemptedto evaluate the travel health resources available online,but these approaches focused on familiarizing health careproviders with the physician-oriented resources availableon the internet.7,8 The travel health resources available

Horvath e t a l . , Trave l Hea l th In format ion a t Commerc ia l Trave l Websi tes 273

to the common traveler have not been thoroughlyevaluated.Sing et al. looked specifically at the informationavailable to travelers on the websites of 73 internationalairlines in July 1999.Their search discovered only sevenwebsites that provided health information, six of whichaddressed health problems that might be encounteredwhen traveling to high-risk tropical countries.9

With increasing travel purchases online, travel healthinformation provided on the internet, preferably at thewebsite where the purchases are made, could be helpfulto ensure healthy travel. Internet travel health informationmust be complete and accurate,but also easily accessibleand understood. This will provide travelers with anawareness of the health risks associated with travel andprovide them with appropriate referral information.Weevaluated commercial travel websites, consisting of bothairline and the increasingly popular discount travelwebsites (“self-service, internet travel agents”), to deter-mine if these sites are currently providing appropriatetravel health information.

Materials and Methods

Forty-five commercial travel websites were evaluatedduring December 2002. Websites reviewed includedthe top 25 airlines, based upon the total number ofpassengers during the period from January to October2002, as determined by Air Transport World (www.atwonline.com). Twenty discount travel websites wereadditionally evaluated. These websites included the topsix discount travel websites, based upon website activityduring the period from January to June 2002, asdetermined by comScore Media Metrix (www.comscore.com). The 14 remaining discount travel websites wereidentified through a Google websearch using the follow-ing keywords: travel, travel purchase and travel reservations.

Each website was evaluated independently by twoinfectious disease physicians to determine whether travelhealth information was available. If travel health inform-ation was present, it was placed into one of three categories:onsite general travel health information, onsite inter-national travel health information,or hyperlink (link) toa separate travel health information website.General travelhealth information included recommendations to avoida variety of complications of travel, including deep venousthrombosis, jet lag and motion sickness. International travelhealth information included recommendations regardingthe more important risks associated with the specificdestination, including recommended immunizations,malaria prevention, and treatment of diarrhea. Thepresence of a link indicated that an icon at the commercialtravel website immediately connected the user to a travelhealth website such as the Centers for Disease Controland Prevention (CDC) and the World Health Organ-

ization (WHO).The number of clicks and the keywordsclicked to locate the travel health information wererecorded to determine the ease of access to informationat each website.

The information provided at both the commercialtravel websites and travel health links was assessed for theaccuracy of the content provided. In some instances,websites were interactive, and detailed information couldbe obtained about specific destinations. In those cases,we assessed the adequacy of the information providedusing Thailand as our travel destination,looking specificallyat recommendations for malaria and travelers’ diarrhea.Thailand is known to have regional variations for malariarisk, specifically with increased risk and mefloquineresistance along the Thai–Myanmar border. Travelers’diarrhea secondary to Campylobacter spp. in Thailand maybe resistant to fluoroquinolone therapy,necessitating theuse of other antimicrobial agents such as azithromycin.

Results

We reviewed the websites of the top 25 airlines, andthey are listed here in descending order:

American (www.aa.com), United (www.united.com),Delta (www.delta.com), Northwest (www.nwa.com),British Airways (www.britishairways.com/

travel/home/public/en_us),Air France (www.airfrance.com/us),Continental (www.continental.com),Lufthansa (cms.lufthansa.com/de/fly/en/homepage),Southwest (www.southwest.com),Air Canada (www.aircanada.ca/e-home.html),Singapore (www.singaporeair.com/saa/app/saa),USAirways (www.usairways.com),JAL (www.japanair.com/e/),Qantas (www.qantas.com.au/regions/

dyn/home/qualifer-region-au),KLM (www.klm.com/nl_en/index.jsp),Cathay Pacific

(www.cathaypacific.com/intl/0,,,00.html),Iberia (www.iberia.com/iberia_us/home.jsp),Korean (www.koreanair.com),America West (www.americawest.com/homelE.asp),Thai International (www.thaiair.com),Emirates (www.emirates.com),SAS (ibp2.scandinavian.net/planandbook/

searchAvailView.asp?MKT=US),Alitalia (www.alitaliausa.com),Varig (www.reservaciones.com/airlines/varig.shtml),and China Airlines (www.china-airlines.com/

en/index.htm).

Southwest is the only airline among the top 25 airlinecarriers that provides no international destinations.

2 7 4 Journal of Trave l Medic ine , Volume 10, Number 5

Additionally, 20 discount travel websites werereviewed for travel health content. The top six discounttravel websites reviewed are listed here in descendingorder: Expedia (www.expedia.com), Travelocity (www.travelocity.com),Trip Network (www.trip.com),Orbitz(www.orbitz.com), Priceline (www.priceline.com), andHotwire (www.hotwire.com).The remaining 14 discounttravel websites reviewed are listed in alphabetical order:

Airfare Planet (www.airfareplanet.com),Air Gorilla (www.airgorilla.com),Airline Tickets (www.airlinetickets.bz),American Express

(www.itn.net/cgi/get?itn/pl/amexconsumer/index),Cheap Tickets (www.cheaptickets.com),CIAT (www.cheap-international-airline-tickets.com),EZ Ticket Sales (www.ezticketsales.com),Faremax (www.faremax.com),Get Me Ticket (www.GetmeTicket.com),One Travel (www.onetravel.com),

Travel (www.travel.com),Travel Discounters (www.travelDiscounters.com),Travel Hero (www.travelhero.com), andTravel Interface (www.travelinterface.com).

Thorough review of the commercial travel websitesrevealed that 20 of 45 (44%) did not contain any travelhealth information. Of the 56% of websites containingsome form of travel health information, airline websiteswere more likely to provide information than discounttravel websites; 16 of 25 (64%) and nine of 20 (45%),respectively.The travel health information provided variedwidely, and a synopsis of the travel health informationavailable on the websites studied is presented in Table 1.Nine of 45 (20%) websites contained general travel healthinformation only; these included seven of 25 (28%) airlineand two of 20 (10%) discount travel websites. Eight of45 (18%) websites contained no travel health informationat the actual website,but had an icon on the site that linkedthe user directly to a travel health website.Most links were

Table 1 Travel Health Information Available on Airline and Discount Travel Websites

General Link General General General,None Only* Only† and Link and International ‡ International and Link

Airline websitesAlitalia Air Canada United Air France Continental British AirwaysAmerica West Iberia Northwest American § KLM DeltaChina Airlines Korean Cathay PacificEmirates QantasJAL SASLufthansa Singapore AirSouthwest USAirwaysThai International Varig

Discount travel websitesAirfare Planet American Express Cheap Tickets None Travelocity NoneAir Gorilla Get MeTicket EZ TicketsalesAirline Tickets FaremaxCIAT OrbitzExpedia Travel HeroHotwire Trip NetworkOne TravelPricelineTravelTravel DiscountersTravel Interface

*General only: topics typically included are deep venous thrombosis (DVT), jet lag and motion sickness. Note: Of all the commercial travel websitescontaining general travel health information, prevention and/or treatment of DVT, jet lag and motion sickness were discussed on 82%, 76% and 29% ofthe websites, respectively.†Link only: website contained an icon that directly linked to one of the following websites: www.cdc.gov/travel, www.fitfortravel.scot.nhs.uk,www.Frommers.com, www.masta.org, www.travmed.com, or www.who.int/ith.‡ International: topics generally included recommendations for immunizations and avoidance of insect-borne diseases. Note that no websites containedinternational information only.§The American Airlines website contained a link to www.cdc.gov; this required an additional click on “Traveler’s Health” to access travel healthinformation.The Travelocity website covered general and international health topics extensively. The website additionally had icons for CDC and WHO links,both which were not operational.


to the CDC travel website, but six different links wereencountered, including CDC (www.cdc.gov/travel),Fit For Travel (www.fitfortravel.scot.nhs.uk),Frommer’s(www.frommers.com), MASTA (Medical AdvisoryServices for Travellers Abroad) (www.masta.org),TravelMedicine (www.travmed.com), and the WHO (www.who.int/ith).Two of 25 (8%) airline and six of 20 (30%)discount travel websites provided only a link to anothertravel medicine website.Three of 25 (12%) airline websitesprovided both a link and general travel information. Alleight (18%) websites that provided onsite internationaltravel health information also provided general travelhealth information. These included seven of 25 (28%)airline and one of 20 (5%) discount travel websites.Interestingly, only 36% of airline websites and 15% ofdiscount travel websites specifically recommended thattravelers see a physician prior to international travel.

Three commercial travel websites contained parti-cularly thorough discussions of travel health information.Two airline websites (British Airways and Delta) containedgeneral and international travel health information inaddition to an operational link to another travel healthwebsite. The Travelocity website contained extensivecoverage of general and international travel health topics;however, the icons for both the CDC and WHO linkswere not operational.

We assessed the content of the health informationprovided by the website of each travel medicine link, anda summary of the findings is displayed in Table 2. Threeof six websites (CDC, WHO and Travel Medicine)discussed the specific variations of malaria within Thailand,including resistance to mefloquine and recommendedalternative chemoprophylaxis with either atovaquone–proguanil or doxycycline. Only one website (TravelMedicine) mentioned that Campylobacter-associated diarrheamay be resistant to fluoroquinolone therapy in Thailandand recommended azithromycin as an appropriate alter-native therapy.

The ease of access to available information wasassessed utilizing both the number of clicks and ease ofkeyword recognition. A summary of the data on thenumber of clicks and keywords for airline and discounttravel websites is presented in Tables 3 and 4, respectively.Overall, the average number of clicks required to locatetravel health information was three, ranging from one tosix. Three of the 45 (6%) websites, all discount travelwebsites, allowed the user to access travel health inform-ation with as little as one click. However, nine of the 45(20%) websites required four or more clicks to access anytravel health information.None of the 16 airline websitescontaining travel health information used keywords thatwould lead the user to believe that travel health advicewill follow, although “Before You Fly” (Cathay Pacific)and “Trip Planning” (Air France) may imply this. It is

the opinion of the authors that keywords such as “Flyingwith Us”(Qantas),“KLM Services”(KLM) and “Products& Services” (Singapore Air) give the user minimal in-dication that travel health information is soon to follow.The three discount travel websites that allowed access totravel health information with only one click also providedkeywords that obviously referred to travel health inform-ation. The keywords were “Vaccinations” (EZ TicketSales),“Health Advisories” (Faremax), and “Surviving JetLag” (Get Me Ticket).

Discussion

We evaluated commercial travel websites for theexistence, accuracy and ease of access of travel healthinformation. The existence of travel health informationon these websites is truly important, as consumers spendan increasing percentage of their travel dollars online.Unfortunately, roughly half of the commercial travelwebsites that we studied provided no travel healthinformation at all. An even smaller number of websitesactually provided complete and accurate travel healthinformation that was easily accessible. The travel healthinformation at commercial travel websites must improvein order to allow travelers the best chance to maintaingood health.Our concern is that commercial travel web-sites are for-profit travel companies,and they may not evenbe aware of the potential impact they can have on thehealth of travelers.

Several companies have created commercial travelwebsites with outstanding access to travel health inform-ation, and all other commercial travel websites shouldstrive to match and even improve upon the informationprovided by these websites. Travelocity was the mostcomplete of the discount travel websites, and has thepotential to improve even further with operational CDCand WHO links. It should be noted, however, that theauthors of this paper feel that even the CDC and WHOwebsites may not be the best resource for the generaltraveler, as these sites are cumbersome to navigate for thenovice, and use language that is at the level of a medicalprofessional. Two airline websites (Delta and BritishAirways) provided extensive general and internationaltravel health information on their website, in additionto operational travel health links. The Delta websitefurther distinguished itself with its link to Travel Medicine(www.travmed.com), an outstanding travel health web-site geared specifically for travelers. We felt that this sitewas thorough, accurate and easy to both understand anduse. However, all three of the best commercial travelwebsites (Travelocity, Delta and British Airways) couldstill improve the ease of access to the information pro-vided.


Table 2 Content of Travel Health Links

Fit For TravelCDC WHO Travel Frommer’s* MASTA Medicine*

Number of links† 12 4 1 1 1 1Target audience Professionals Professionals Travelers Travelers Travelers ‡ Travelers

and travelersMedical care

List of travel clinicsnear home � � � � � �

List of health careproviders abroad � � � � � �

Travel insurance � � � � � �

MapsMaps included � � � � � �Interactive maps

(click on region) � � � � � �Maps with disease risks � � �§ � � �

General travel healthinformationAltitude sickness � � � � � �DVT/PE � � � � � �Jet lag � � � � � �Motion sickness � � � � � �Pregnant travelers � � � � � �Sun protection � � � � � �STDs � � � � � �

International travel healthinformationSafe food and water

recommendations � � � � � �Travelers’ diarrhea

therapy � � � � � �Prevention of insect

exposures � � � � � �Immunizations

Generalrecommendations � � � � � �

Country-specific � � � � � �Malaria

General information � � � � � �Country-specific � � � � � �Variations within

country noted � � � � � �Medications

Chemoprophylaxis � � � � � �Emergency therapy � � � � � �Side effects/

precautions � � � � � �Other tropical disease

risks � � � � � �Outbreak information � � � � � �

*Frommer’s and Travel Medicine are both commercially oriented travel websites; travel health information is provided at both websites, but they bothsell travel and travel-related items. The primary goal of this link is not to provide travel health information, though basic country-specific travel healthinformation was available at the website.†Number of links refers to the number of times this website was referred to during our study; note that several commercial travel websites referred usersto more than one link.‡Health care providers can subscribe to this site to obtain additional travel health information.§The maps at this website were outstanding–specifically with highlighting of malaria risk regions within each country.

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In order to ensure that travelers have adequate healthinformation before travel, it is essential that 100% ofcommercial travel websites provide travel health inform-ation. Ideally,consumers should be able to access the travelhealth information on these websites from the home page,with one click on an obvious keyword, such as “Traveler’sHealth”.Clicking this keyword should display a page witha selection of both general and international travel healthtopics; the page should also provide the capability to accesstravel health links and obtain accurate country-specificrecommendations. It is of the utmost importance thatcommercial travel websites ensure that the informationprovided is both accurate, up-to-date and easily under-stood by the non-medical professional.

Our study of commercial travel websites revealed thatmuch improvement in this area is needed. Internationalorganizations such as the International Society of TravelMedicine (ISTM) and the World Health Organization,and national organizations such as the American Societyof Tropical Medicine and Hygiene and the Centers forDisease and Prevention (CDC), should consider establish-ing guidelines for the travel health content provided bycommercial travel websites.This would help new as wellas existing commercial travel websites to provide travel

health information to their customers in a uniform andaccurate manner.This would bring us one step closer toensuring healthier travel for all travelers.

Acknowledgments

This review of commercial travel websites wasconducted without monetary support from any of thecompanies named within this manuscript.

It should be noted that this review of the travel healthinformation available on commercial travel websites wascompleted during a discrete period of time in December2002. The information available on the internet is con-stantly changing, and these websites are no exception. Itis therefore possible that information available at thesewebsites will have changed by the time of publication.

These data were presented in abstract and poster form(PO12.06) at the 8th Conference of the InternationalSociety of Travel Medicine in New York,NY,May 2003.

References

1. Tedeschi B.For the web generation, travel is self-service.NewYork Times, 20 October 2002:Sect. E:7 (col. 1).

Table 4 Number of Clicks and Keywords Used to Locate Travel Health Information on 20 Discount Travel Websites

Website Clicks Keywords

International travelhealth information

Travelocity 4 Guides & Advice > Traveler Advice > Healthy Travel > Health Tips*

Travel health linkEZ Ticket Sales 1 Vaccinations (link to www.cdc.gov/travel)Faremax 1 Health Advisories (link to www.cdc.gov/travel)

2 US Dept of State (link to www.state.gov/travel > Traveler’s Health-CDC(link to www.cdc.gov/travel) and Traveler’s Health-WHO (link to www.who.int/ith)

Travel Hero 2 Resources > Travel Health Guidelines (link to www.cdc.gov/travel)Orbitz 3 Customer Care > International Travel > Traveler’s Health (link to www.cdc.gov/travel)Travelocity 5 Guides & Advice > Traveler Advice > Healthy Travel > Creepy, Crawly Critters:

Avoiding Insect Encounters > World Health Organization and Centers for DiseaseControl (links to WHO and CDC websites were not operational)

Trip Network 5 Travel Resources > Travel Tips > Intl Travel > US Dept of State(link to www.state.gov/travel > Traveler’s Health-CDC (link to www.cdc.gov/travel )and Traveler’s Health-WHO (link to www.who.int/ith )

Cheap Tickets 5 Travel Resources > Travel Tips > Intl Travel > US Dept of State(link to www.state.gov/travel > Traveler’s Health-CDC (link to www.cdc.gov/travel ) and Traveler’s Health-WHO(link to www.who.int/ith )

General travel healthinformation

Get Me Ticket 1 Surviving Jet LagAmerican Express 4 Travel Resources > Travel Essentials & Advice > Travel Tips > Personal Safety†

Travelocity 4 Guides & Advice > Traveler Advice > Healthy Travel > Health Tips*

*Travelocity Health Tips: extensive general and international travel health information, including sun exposure, heat exposure, jet lag, altitude sickness,food and water precautions, insect exposure, water exposure, first aid and travel health insurance.†American Express Personal Safety: general information about travel health insurance, food and water precautions.


2. Steffen R,Rickenbach M,Willhelm U,et al.Health problemsafter travel to developing countries. J Infect Dis 1987; 156:84–91.

3. DuPont HL,Steffen R,eds.Textbook of travel medicine andhealth, 2nd edn. Hamilton, Ontario: BC Decker, 2001.

4. Leggat PA.Sources of health advice given to travelers. J TravelMed 2000; 7:85–88.

5. Provost S, Gaulin C, Piquet-Gauthier B, et al. Travel agentsand the prevention of health problems among travelers inQuebec. J Travel Med 2002; 9:3–9.

6. Hall P, Fojtasek M, Pettigrove J, et al. Fatal yellow fever ina traveler returning from Amazonas, Brazil, 2002. MMWR2002; 51:324–325.

7. Freedman DO. Keeping current: travel medicine resourcesavailable on the internet. Infect Dis Clin North Am 1998;12:543–547.

8. Keystone JS, Kozarsky PE, Freedman DO. Internet andcomputer-based resources for travel medicine practitioners.Clin Infect Dis 2001; 32:757–765.

9. Sing A, Salzman JR, Sing H, Sing D. Evaluation of healthinformation provided on the internet by airlines with destina-tions in tropical and sub-tropical countries. Commun DisPublic Health 2000; 3:195–197.

Is a travel kit necessary? Or should travellers use any one of the colored liquids ‘to cure any type of disease’,that is the question. RKES, Benin.

travel health information at commercial travel websites

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