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Incidence of health problems in travelers to Southeast Asia: A prospective

cohort study

Article in Journal of Travel Medicine · June 2019

DOI: 10.1093/jtm/taz045

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 Journal of Travel Medicine, 2019, 1–8
doi: 10.1093/jtm/taz045

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Original Article

Original Article

Incidence of health problems in travelers to Southeast

Asia: a prospective cohort study
Phimphan Pisutsan, MD1, Ngamphol Soonthornworasiri, PhD2, Wasin Matsee, MD1,
Weerapong Phumratanaprapin, MD1, Suda Punrin, MD3,
Wattana Leowattana, MD, PhD1, Chayasin Mansanguan, MD1, Eyal Leshem, MD4,
Watcharapong Piyaphanee MD1 *
1 Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thai-
land 2 Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok,10400 Thailand 3 Queen
Saovabha Memorial Institute, The Thai Red Cross Society, Bangkok, 10330 Thailand and 4 Sackler School of Medicine, Tel
Aviv University, Sheba Medical Center, Ramat Gan, 52621 Israel
http://orcid.org/0000-0002-2905-1034
∗ To whom correspondence should be addressed. Email: watcharapong.piy@mahidol.ac.th

Submitted 16 March 2019; Editorial Decision 14 June 2019; Accepted 14 June 2019

Abstract
Background: There are few studies of the incidence of health problems among travelers to Southeast Asia. The
current study sought to determine the incidence of self-reported health problems among travelers visiting the
region.
Methods: A prospective questionnaire-based study was conducted among travelers from high-income countries
who visited Southeast Asia. Participants were enrolled at time of their pre-travel visit at Mahidol University, Bangkok,
Thailand. Travelers were prospectively followed by self-administered questionnaires 2 weeks after arrival, upon
return to their home country and 2 weeks after return.
Results: During January 2018–February 2019, 359 travelers were enrolled in Bangkok, Thailand, and the first
questionnaire was administered. Follow-up questionnaires were returned by 191, 96 and 64 participants 2 weeks
later, at the end of the trip and 2 weeks after return, respectively. A total of 6094 travel days were included in the
final analysis. The incidence of acute diarrhea per month per 1000 travelers was 217 [95% confidence interval (CI),
189–248] episodes; skin problems, 197 (95% CI, 170–227); respiratory symptoms, 133 (95% CI, 111–158); fever, 49
(95% CI, 36–65); and potential rabies exposure, 34 (95% CI, 24–48). The incidence of acute diarrhea episodes per
month per 1000 travelers was significantly higher during the first 2 weeks of travel compared with subsequent
weeks of travel: 325 (95% CI, 291–362) vs 132 (95% CI, 110–1157) (P < 0.05). The incidence of outpatient visits and
hospitalizations per month per 1000 travelers was 49 (95% CI, 36–65) and 5 (95% CI, 2–10), respectively.
Conclusions: In this prospective cohort study we observed substantial burden of acute diarrhea and skin and
respiratory symptoms among travelers to Southeast Asia. The higher incidence of diarrhea in the first 2 weeks
of travel should be further investigated.
Key words: Incidence, health problem, Southeast Asia

Introduction Severe Acute Respiratory Syndrome, SARS epidemic outbreak)

and 2009 (due to the global economic crisis).1 Over this period,
Southeast Asia is a popular destination for travelers. The number tourism in the region has steadily grown, with the number of
of travelers visiting this region has increased consistently in tourists increasing from 30 million in 1995 to more than 120
recent years, except for a brief decline in 2003 (due to the million in 2016.2,3

© International Society of Travel Medicine 2019. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com
2 Journal of Travel Medicine
International travel poses a number of health risks to travel-
ers. Previous studies estimated that 10–70% of travelers visiting
the tropics develop at least one health problem.4–9 However,
the risk of health problems varies between different tropical
areas. For example, the risk of malaria was highest among
travelers to sub-Saharan Africa, while the risk of diarrhea was
highest among travelers visiting the Indian subcontinent.10–16
Thus, region-specific evaluation of disease burden is needed.
Although some previous studies have estimated the incidence
of health problems among travelers in Southeast Asia, currently
available data are not comprehensive. Several previous studies
have focused on specific health problems, such as diarrhea and
diseases related to animal exposure, while other studies have
reported on the spectrum of diseases, but focused on specific
destination countries, such as Laos and Thailand.7,15, 17–20
Our objective was to describe the incidence and spectrum of
self-reported health problems among travelers visiting Southeast
Asia. We prospectively collected data throughout visitors’ jour-
neys, starting from their arrival, during their trip and after they
returned home. In addition, we assessed the participants’ health
practices and the impacts of health problems during their trip.
Methods
Eligibility
Healthy travelers from developed countries who visited the
Travel Clinic at Mahidol University, Bangkok, Thailand, within
the first 2 weeks of arrival to Southeast Asia were invited to
participate in the study.21 Inclusion criteria were as follows: aged
15 years or older, traveled exclusively within Southeast Asia,
traveled for no less than 1 week and no longer than 4 months,
with English language comprehension, resident of a high-income
country and has no illness at time of recruitment. The study
enrollment and participation flow chart, inclusion and exclusion
criteria are shown in Figure 1.
Study design and questionnaires
Healthy travelers who visited the Thai Travel Clinic at Hospital
for Tropical Diseases, in Mahidol University, Bangkok, Thailand,
for a pre-travel visit for their planned trip in Southeast Asia
were invited to participate in the study. On the enrollment day,
the participants were asked to answer the first questionnaire
(Q1) about their demographic characteristics and travel itinerary.
Follow-up online questionnaires were sent by email to the par-
ticipants at 2 weeks after arrival (Q2), at the end of their trips
(Q3) and at 2 weeks after returning home (Q4). We considered
the most probable cause of several symptoms to be the main
symptom or health problem. For example, fever and cough were
defined as an ‘acute respiratory illness’, whereas fever without
any additional symptoms was considered as ‘fever’. A traveler
may have reported several health problems (episodes) during the
trip. In this case we counted each separate event as an episode of
a health problem. Questionnaires were only available in English.
Statistical analysis
Data were analyzed using SPSS software version 18.0. Continu-
ous data were presented as mean ± SD or median with minimum
and maximum values. Categorical data were presented as num-
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ber and percentage. Incidence was calculated as the number of
episodes in every group divided by the total travel time of the
described group. Fisher’s exact test was used to estimate 95%
confidence interval (CI), and comparison of incidence between
exposure groups was done using mid-p exact test. A P-value of
< 0.05 was considered to indicate statistical significance.
Ethics statement
This research study was approved by the Ethics Committee of
the Faculty of Tropical Medicine, Mahidol University (reference
number: MUTM 2018–002-01). Written informed consent was
obtained from all participants prior to study enrolment.
Results
A total of 359 participants were recruited from January 2018
to February 2019. Of these 359, most were from North America
(172 travelers) and Europe (171 travelers) (Table 1). In total, 191
participants responded to Q2 (2 weeks after arrival; follow-up
rate: 53%) and were included in the data analysis, and 96 and 64
participants responded to Q3 (upon return to home country) and
Q4 (2 weeks after return), respectively. Overall, the demographic
characteristic of study participants who responded to the first
enrollment questionnaire and to the follow-up questionnaires
were similar (Table 1).
Health problems during travel
Overall, 40% (76 of 191) of travelers reported one or more
health problems, reflecting an incidence of 896 (95% CI, 838–
957) per month per 1000 travelers (Table 2 and Supplement
Tables 1 and 2). Diarrhea was the most common health problem
reported by travelers. Most (46/56) diarrheal episodes were
reported as acute diarrhea (duration: < 14 days). The overall
incidence rate of acute diarrhea was 217 (95% CI, 189–248)
per month per 1000 travelers. Skin problems were the second
most common problem reported among travelers, with an overall
incidence rate of 197 (95% CI, 170–227) episodes per month
per 1000 travelers. Fever was reported by 10 participants during
travel in Southeast Asia. Each of these travelers reported only
one episode of fever. The incidence of fever was 49 (95% CI,
36–65) episodes per month per 1000 travelers. During the stay
in Southeast Asia, travelers reported seven episodes of exposure
to potential rabid animal (five reported having been bitten and
two reported having been licked). The incidence rate of rabies
exposure was 34 (95% CI, 24–48) per month per 1000 travelers.
One participant reported jelly fish exposure.
The incidence of any health problem was higher during the
first 2 weeks of travel with the rate of 1324 (95% CI, 1254–
1397) per month per 1000 travels and 561 (95% CI, 516–
609) per month per 1000 travelers during longer travel after the
first 2 weeks (P < 0.05) (Table 3). Acute diarrhea incidence was
higher during the first 2 weeks of travel compared with after the
first 2 weeks (325 vs 132, respectively; P < 0.05) (Table 3). Skin
problems and persistent diarrhea also had significantly higher
incidence during the first 2 weeks compared with later during
longer trips.
Journal of Travel Medicine 3

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Table 1. Demographic characteristics of study participants who responded to the questionnaires

Characteristic Enrollment; Q1 At 2 weeks; Q2 At the end of travel; Q3 2 weeks after

(n = 359) (n = 191) (n = 96) return; Q4 (n = 64)

Gender (n = 359) (n = 191) (n = 96) (n = 64)

Male 186 (51.8%) 95 (49.7%) 50 (52.1%) 35 (54.7%)
Female 173 (48.2%) 96 (50.3%) 46 (47.9%) 29 (45.3%)
Age (years) (n = 359) (n = 191) (n = 96) (n = 64)
Median (min–max) 27 (18–69) 28 (18–69) 28 (18–68) 29 (18–65)
Mean ± SD 30.41 ± 10.395 32.17 ± 11.5 32.77 ± 12.175 34.22 ± 12.503
Region/country of residence (n = 359) (n = 191) (n = 96) (n = 64)
European 171 (47.6%) 83 (43.5%) 44 (45.8%) 25 (39.1%)
North America 172 (47.9%) 103 (53.9%) 49 (51%) 35 (54.7%)
Japan 4 (1.1%) 3 (1.6%) 3 (3.1%) 2 (3.1%)
Australia/New Zealand 12 (3.3%) 2 (1%) 0 2 (3.1%)
Traveler with underlying disease (n = 282) (n = 191) (n = 96) (n = 64)
Hypertension 65 (18.1%) 35 (18.3%) 18 (18.8%) 16 (25%)
Diabetes mellitus 11 (3.1%) 6 (3.1%) 2 (2.1%) 2 (3.1%)
Hyperlipidemia 4 (1.1%) 1 (0.5%) 1 (1%) 1 (1.6%)
Asthma 1 (0.3%) 1 (0.5%) 0 1 (1.6%)
Atopy/Allergy 12 (3.3%) 4 (2.1%) 1 (1%) 2 (3.1%)
Cardiovascular disease 5 (1.4%) 2 (1.0%) 1 (1%) 0
Gastrointestinal disease 2 (0.6%) 2 (1.0%) 0 0
Neurological disease 6 (1.7%) 3 (1.6%) 2 (2.1%) 2 (3.1%)
Psychological disease 1 (0.3%) 1 (0.5%) 0 0
Other 10 (2.8%) 6 (3.1%) 3 (3.1%) 4 (6.3%)
22 (6.1%) 14 (7.3%) 9 (9.4%) 8 (12.5%)
Traveler with travel insurance (n = 357) (n = 190) (n = 95) (n = 63)
300 (84%) 163 (85.8%) 80 (83.3%) 54 (85.7%)
Duration of travel (days) (n = 294) (n = 158) (n = 87) (n = 64)
Median (range) 53.5 (10–125) 47 (10–125) 39 (19–125) 35 (13–125)
Mean ± SD 57.1 ± 31.656 56.18 ± 32.2 48.85 ± 28.428 44.11 ± 27.228
≤ 30 days 77 (26.2%) 42 (26.6%) 28 (32.2%) 27 (42.2%)
>30 days 217 (73.8%) 116 (73.4%) 59 (67.8%) 37 (57.8%)
Countries Visited (n = 356) (n = 190) (n = 96) (n = 64)
Thailand (100%) (100%) (100%) (100%)
Vietnam 177 (49.7%) 96 (50.5%) 48 (50%) 23 (35.9%)
Cambodia 177 (49.3%) 91 (47.9%) 40 (41.7%) 22 (34.4%)
Laos 133 (37.4%) 73 (38.4%) 32 (33.3%) 14 (21.9%)
Indonesia 90 (25.3%) 44 (23.2%) 20 (20.8%) 10 (15.6%)
Malaysia 64 (18.0%) 32 (16.8%) 14 (14.6%) 8 (12.5%)
Singapore 46 (12.9%) 25 (13.2%) 9 (9.4%) 5 (7.8%)
Philippines 46 (12.9%) 26 (13.7%) 7 (7.3%) 1 (1.6%)
Myanmar 40 (11.2%) 21 (11.1%) 8 (8.3%) 6 (9.4%)
Brunei 3 (0.8%) 2 (1.1%) 0 0
East Timor 3 (0.8%) 0 0 0
No plan 16 (4.5%) 7 (3.7%) 1 (1%) 1 (1.6%)
No. of the countries visited (n = 356) (n = 190) (n = 96) (n = 64)
1–3 countries 209 (58.7%) 111 (58.4%) 61 (63.5%) 49 (76.6%)
≥ 4 countries 147 (41.3%) 79 (41.6%) 35 (36.5%) 15 (23.4%)
Purpose of travel (n = 64) (n = 190) (n = 96) (n = 64)
Tourism 315 (88.5%) 169 (88.9%) 86 (89.6%) 58 (90.6%)
Study/research 11 (3.1%) 8 (4.2%) 1 (1%) 0
Otherª 4 (1.1%) 2 (1.1%) 2 (2.1%) 1 (1.6%)
More than one purpose 26 (7.3%) 11 (5.8%) 7 (7.3%) 5 (7.8%)
Style of travel (n = 355) (n = 189) (n = 95) (n = 63)
Backpacker 253 (71.3%) 130 (68.8%) 70 (73.7%) 39 (61.9%)
General tourist 81 (22.8%) 51 (27.0%) 21 (22.1%) 22 (34.9%)
Other 12 (3.4%) 6 (3.2%) 2 (2.1%) 1 (1.6%)
More than one style 9 (2.5%) 2 (1.1%) 2 (2.1%) 1 (1.6%)

Continued.
4 Journal of Travel Medicine

Table 1. Continued

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Characteristic Enrollment; Q1 At 2 weeks; Q2 At the end of travel; Q3 2 weeks after
(n = 359) (n = 191) (n = 96) return; Q4 (n = 64)

Previous travel history in Southeast (n = 355) (n = 188) (n = 95) (n = 63)

Asia 231 (65.1%) 120 (63.5%) 61 (64.2%) 38 (60.3%)
No 124 (34.9%) 69 (36.5%) 34 (35.8%) 25 (39.7%)
Yes
History of illness in previous trip (n = 124) (n = 69) (n = 34) (n = 25)
Not sick 96 (77.2%) 50 (72.5%) 24 (70.6%) 18 (72%)
Sick 28 (26.2%) 19 (27.5%) 10 (29.4%) 7 (28%)
Pre-travel consultation (n = 354) (n = 188) (n = 94) (n = 63)
No 85 (24%) 42 (22.3%) 23 (24.5%) 18 (28.6%)
Yes, travel clinic 131 (37%) 70 (37.2%) 40 (42.6%) 27 (42.9%)
Yes, general practitioner 41 (11.6%) 20 (10.6%) 5 (5.3%) 4 (6.3%)
Yes, Other 55 (15.5%) 31 (16.5%) 15 (16%) 8 (12.7%)
More than one method 42 (11.9%) 25 (13.3%) 11 (11.7%) 6 (9.5%)
a Business, Visiting friends and relatives (VFR), missionary, etc.
b Package tourist, living with the locals, etc.
c Travel agency, guide book, internet, friend, relative, etc.

Table 2. Incidence of health problems among travelers during travel (total number of travel days = 6094)

Number of episodes Incidence/1000 travel days Incidence per month/1000 travelers

Acute diarrhea (14 < days) 44 7.2 (5.2–9.7) 217 (189.1–247.9)

Persistent diarrhea (≥14 days) 12 2.0 (1.0–3.4) 59 (44.9–76.1)
Skin problema 40 6.6 (4.7–8.9) 197 (170.4–226.5)
Respiratory symptom 27 4.4 (2.9–6.4) 133(111.4–157.6)
Other gastrointestinal symptomsb 16 2.6 (1.5–4.3) 79 (62.6–98.5)
Neurologicalc 13 2.1 (1.1–3.6) 64 (49.3–81.7)
Feverd 10 1.6 (0.8–3.0) 49 (36.3–64.8)
Potential rabid animal exposure 7 1.1 (0.5–2.4) 34 (23.6–47.5)
Other animal exposure 1 0.2 (0.004–0.9) 4.9 (1.6–10.2)
Psychologye 3 0.5 (0.1–1.4) 15 (8.4–24.7)
Accident 4 0.7 (0.2–1.7) 20 (12.2–30.9)
Genitourinary tractf 5 0.8 (0.3–1.9) 25 (12.2–30.9)
Overall 182 29.9 (25.7–34.5) 896 (838.3–956.7)

a Including insect bites.

b Including nausea, vomiting, constipation, abdominal pain, bloating, heartburn (not associated with diarrhea episode), etc.
c Including headache, dizziness, fainting, seizure, weakness, etc.
d Without other symptoms.
e Including insomnia, depression, etc.
f Urinary tract infection, 4; bacterial vaginitis, 1.

Health problems following travel
During the first 2 weeks after arriving home, 11 health problems
were reported (Table 4). The incidence of respiratory symptoms
was 134 (95% CI, 112–159) per month per 1000 travelers. Acute
diarrhea, neurological symptom and fever were also reported
post-travel (Supplement Table 3).
Discussion
In our study, 40% of the travelers experienced one or more health
problems during their travel in Southeast Asia. The main strength
of this study was the prospective design that allowed us to
assess the incidence of self-reported health problems in travelers
to Southeast Asia. The overall incidence of health problems
was 896 (95% CI, 838–957) per month per 1000 travelers.
Acute diarrhea, skin problems and respiratory symptoms had
the highest incidence. Higher incidence of acute diarrhea was
reported during the first 2 weeks of travel compared with onset
after 2 weeks of travel.
The overall proportion of travelers who reported health prob-
lems in our study (40%) is low compared with previous similar
prospective studies. A recent study of Finnish travelers found that
79% of travelers reported being ill during travel abroad, while
a study conducted in the USA reported that 64% of travelers
developed at least one health problem during their travel.5,8 It is
important to note that these two studies enrolled travelers who
travel to destinations including West Africa, South America and
the Indian subcontinent. This may have resulted in a higher risk
of health problems compared with the present study, which only
included travelers visiting Southeast Asia. Traveling in Southeast
Asia may be associated with a lower risk than other regions.6,16
Acute diarrhea was the most commonly reported health
problems in this study, with an incidence of 217 (95% CI, 189–
248) per month per 1000 travelers. Previous studies reported
Journal of Travel Medicine
Figure 1. Study flow
the acute diarrheal disease rate range from 20 to 40%.5–8, 15,17
One study among foreign travelers in Southeast Asia revealed
the incidence of 321 per month per 1000 travelers, but both
acute and persistent diarrheas were included in the study.17 The
incidence of acute diarrhea in our population was significantly
higher during the first 2 weeks of travel compared with later
during longer travel. This finding was consistent with a study
in Nepal that demonstrated that a shorter duration of stay was
associated with a higher incidence of travelers’ diarrhea.22 How-
ever, it is important to note that the lower incidence of diarrhea
5
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in the Nepali study was observed only when the duration of
stay was more than 1 year.22 Another study in Nepal also con-
cluded that during the 2-year stay in Nepal, the risk of diarrhea
remained persistently high.23 The decline in the incidence of
diarrhea after only 2 weeks of stay in our study was unique.
Behavioral change could explain some of the higher incidence
but other factors such as change in microbiome or immunologic
change cannot be ruled out. Further research focusing in this
finding is needed to reduce the risk of diarrhea in the first
2 weeks.
6 Journal of Travel Medicine

Table 3. Incidence of health problems among travelers during the first 2 weeks of travel compared with the duration of travel after the first

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2 weeks (travel days = 2674 vs 3420)

During the first 2 weeks After the first 2 weeks

No. of episodes Incidence/1000 Incidence per No. of episodes Incidence/1000 Incidence per P-value
travel days month/1000 travel days month/1000
travelers travelers

Skin problemsa 31 11.6 348 9 2.6 79 <0.05

(7.9–16.5) (312.4–386.5) (1.2–5.0) (62.6–98.5)
Acute diarrhea (<14 days) 29 10.8 325 15 4.4 132 <0.05
(7.3–15.6) (290.6–362.3) (2.5–7.2) (110.4–156.5)
Persistent diarrhea (≥14 days) 9 3.4 101 3 0.9 26 <0.05
(1.5–6.4) (82.2–122.7) (0.2–2.6) 17–38.1)
Respiratory symptoms 15 5.6 168 12 3.5 105 0.22
(3.1–9.3) (143.6–195.4) (1.8–6.1) (85.9–127.1)
Other gastrointestinal symptomsb 10 3.7 112 6 1.8 53 0.13
(1.8–6.9) (99.2–134.8) (0.6–3.8) (39.7–69.3)
Neurologicalc 7 2.6 79 6 1.8 53 0.47
(1.1–5.4) (62.6–98.5) (0.6–3.8) (39.7–69.3)
Feverd 5 1.9 56 5 1.5 44 0.70
(0.6–4.4) (42.3–72.7) (0.5–3.4) (32.0–59.1)
Potential rabid animal exposure 5 1.9 56 2 0.6 18 0.29
(0.6–4.4) (42.3–72.7) (0.1–2.1) (10.7–28.5)
Other animal exposure 0 0 0 1 0.3 9 0.38
(0.01–1.6) (4.1–17.1)
Psychologye 2 0.7 22 1 0.3 9 0.43
(0.1–2.7) (13.8–33.3) (0.01–1.6) (4.1–17.1)
Accident 2 0.7 22 2 0.6 18 0.81
(0.1–2.7) (13.8–33.3) (0.1–2.1) (10.7–28.5)
Genitourinary tractf 3 1.1 34 2 0.6 18 0.47
(0.2–3.3) (23.6–47.5) (0.1–2.1) (10.7–28.5)
Overall 118 44.1 1324 64 18.7 561 <0.05
(36.5–52.9) (1254–1397) (18.4–30.6) (515.5–609.4)

a Including insect bites.

b Including nausea, vomiting, constipation, abdominal pain, bloating, heartburn (not associated with diarrhea episode), etc.
c Including headache, dizziness, fainting, seizure, weakness, etc.
d Without other symptoms.
e Including insomnia, depression, etc.
f Urinary trac infection , 4; bacterial vaginitis , 1.

Table 4. Incidence of health problems among travelers during the 2 weeks following return (post-travel days = 896)

No. of episodes Incidence/1000 post-travel days Incidence per month/1000 travelers

Respiratory symptoms 4 4.5 (1.2–11.4) 134 (112.3–158.7)

Acute diarrhea (≤14 days) 2 2.2 (0.3–8.1) 67 (51.9–85.1)
Neurologicala 2 2.2 (0.3–8.1) 67 (51.9–85.1)
Feverb 2 2.2 (0.3–8.1) 67 (51.9–85.1)
Other gastrointestinal symptomsc 1 1.1 (0.03–6.2) 33 (22.7–46.3)
Overall 11 12.3 (6.1–22.0) 369 (332.3–408.6)

a Including headache, dizziness, fainting, seizure, weakness, etc.

b Without other symptom.
c Including nausea, vomiting, constipation, abdominal pain, bloating, heartburn (not associated with diarrhea episode), etc.

In this study travelers reported several potential rabies expo-
sures. The incidence of potential rabid animal exposure was 34
(95% CI, 24–48) per 1000 travelers per month stay, which is
comparable with the risk found in previous study among foreign
travelers in Southeast Asia.15,19 The result was similar to that
reported in a previous study of foreign travelers in Southeast
Asia (48 per 1000 travelers per month).15 ,19 On the other hand,
a study among Israeli travelers of whom 67% visited Southern
and Southeastern Asian countries found a much lower incidence
rate (2.66 per 1000 traveler per months).24 Most (99 of 163,
61%) of the participants reported previously receiving rabies
pre-exposure prophylaxis. This rate was higher when compared
with other studies conducted in this region, which have reported
rabies pre-exposure prophylaxis in 22–27% of travelers.7,15 In
one study, among 4678 individuals, only 8% reported receiving
rabies pre-exposure prophylaxis within the past 3 years, despite
the fact that pre-exposure prophylaxis has become easier due to
a simplified schedule.25–27 Two of the patients in the current study
Journal of Travel Medicine
did not seek medical care after potential exposure to rabies, and
both of them received no rabies pre-exposure prophylaxis. This
lack of awareness or misunderstanding is a serious concern, and
it could have fatal consequences.
We found out that 12.5% of the participants experienced new
onset of health problems within the first 2 weeks after returning
home. A Finnish study reported that 32% of the participants
became sick during 3 weeks of follow-up, while a study of
American travelers reported a rate of experiencing illness of 26%
within a 2-month period after returning home.5,8 The difference
in the reported incidence might be due to the difference in travel
destinations in the other studies, as well as the longer follow-up
period compared with the current study.
Limitations
This study has several limitations. First, the response rate was
relatively low and declined further with the follow-up question-
naires. This is a frequently observed phenomenon. However, the
overall similar demographic characteristics among the respon-
dents to each questionnaire is reassuring as the representation
in the follow-up questionnaires was not substantially different
from the enrollment group. Second, this was a self-reported
questionnaire study, and health problems reported by travelers
were symptoms-based. Thus, it was not possible to confirm the
diagnoses or to obtain detailed information about each health
problem. Third, we could not specify the country of exposure.
We were only able to report the incidence of health problems in
a region-based manner and could not conduct a country-specific
analysis. Finally, we followed travelers only 2 weeks after they
returned home. We could have missed other health problems with
a longer incubation period.
Conclusion
In this prospective self-reported health problem evaluation, acute
diarrhea was the most common health problem, and the risk of
diarrhea was higher in the first 2 weeks of the trip compared
with the duration of travel after the first 2 weeks. Reasons for the
higher incidence of health problems and especially diarrhea early
during travel should be further investigated. The best strategy
to study the proportion of travelers acquiring travel-associated
health problems is to perform a prospective, multinational study.
Author contributions
P.P. developed the study design; collected, analyzed, interpreted
the data; and wrote the manuscript. W. Piyaphanee was involved
with the development of the study design and data interpretation
and contributed to the writing of the manuscript. N.S. and W.M.
were involved in the study design, data analysis and review of
the manuscript. W. Phumratanaprapin, S.P., W.L. and C.M. were
involved in the study design, data interpretation and review of the
manuscript. E.L. contributed to data analyses and interpretation
and writing of the final manuscript. All authors contributed to
and approved the final manuscript.
Funding
This research was funded by the Faculty of Tropical Medicine,
Mahidol University.
7
Acknowledgments
Downloaded from https://academic.oup.com/jtm/advance-article-abstract/doi/10.1093/jtm/taz045/5520737 by Library - Faculty of Medicine Ramathibodi Hospital user on 06 September 2019
We would like to thank all staffs at Thai Travel Clinic at
Bangkok Hospital for Tropical Diseases for data collection and
all individuals who participated in the study.
Conflict of Interest: None declared.
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