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Travel - Top 30 Publications

A shift from motorised travel to active transport: What are the potential health gains for an Australian city?

An alarmingly high proportion of the Australian adult population does not meet national physical activity guidelines (57%). This is concerning because physical inactivity is a risk factor for several chronic diseases. In recent years, an increasing emphasis has been placed on the potential for transport and urban planning to contribute to increased physical activity via greater uptake of active transport (walking, cycling and public transport). In this study, we aimed to estimate the potential health gains and savings in health care costs of an Australian city achieving its stated travel targets for the use of active transport.

Optimizing a desirable fare structure for a bus-subway corridor.

This paper aims to optimize a desirable fare structure for the public transit service along a bus-subway corridor with the consideration of those factors related to equity in trip, including travel distance and comfort level. The travel distance factor is represented by the distance-based fare strategy, which is an existing differential strategy. The comfort level one is considered in the area-based fare strategy which is a new differential strategy defined in this paper. Both factors are referred to by the combined fare strategy which is composed of distance-based and area-based fare strategies. The flat fare strategy is applied to determine a reference level of social welfare and obtain the general passenger flow along transit lines, which is used to divide areas or zones along the corridor. This problem is formulated as a bi-level program, of which the upper level maximizes the social welfare and the lower level capturing traveler choice behavior is a variable-demand stochastic user equilibrium assignment model. A genetic algorithm is applied to solve the bi-level program while the method of successive averages is adopted to solve the lower-level model. A series of numerical experiments are carried out to illustrate the performance of the models and solution methods. Numerical results indicate that all three differential fare strategies play a better role in enhancing the social welfare than the flat fare strategy and that the fare structure under the combined fare strategy generates the highest social welfare and the largest resulting passenger demand, which implies that the more equity factors a differential fare strategy involves the more desirable fare structure the strategy has.

Notes from the Field: Travel-Associated Melioidosis and Resulting Laboratory Exposures - United States, 2016.

In mid-July 2016, a Pennsylvania resident aged 15 years who had recently returned from Thailand was treated by a pediatrician for sore throat, fever, and bilateral thigh abscesses at the sites of mosquito bites (Figure). She had traveled to northeast Thailand with nine other teens as part of an 18-day service-oriented trip run by an Ohio-based youth tour company that arranges travel to Thailand for approximately 500 persons annually. This trip included construction and agricultural activities and recreational mud exposures. The patient subsequently developed right inguinal lymphadenopathy and worsening abscesses, which prompted specimen collection for culture on August 25. This specimen was sent to a commercial laboratory in New Jersey, which identified Burkholderia pseudomallei, the causative organism of melioidosis, on August 30. The patient did not experience pneumonia or bacteremia, and recovered fully after 2 weeks of intensive therapy with parenteral ceftazidime and a 6-month outpatient course of eradication therapy with doxycycline.

Acute Diarrheal Infections in Adults.

Individualizing immunization for international travelers.

Take into account routine childhood vaccinations, those that are mandatory for specific destinations, and these highly recommended immunizations.

Increasing airline travel may facilitate co-circulation of multiple dengue virus serotypes in Asia.

The incidence of dengue has grown dramatically in recent decades worldwide, especially in Southeast Asia and the Americas with substantial transmission in 2014-2015. Yet the mechanisms underlying the spatio-temporal circulation of dengue virus (DENV) serotypes at large geographical scales remain elusive. Here we investigate the co-circulation in Asia of DENV serotypes 1-3 from 1956 to 2015, using a statistical framework that jointly estimates migration history and quantifies potential predictors of viral spatial diffusion, including socio-economic, air transportation and maritime mobility data. We find that the spread of DENV-1, -2 and -3 lineages in Asia is significantly associated with air traffic. Our analyses suggest the network centrality of air traffic hubs such as Thailand and India contribute to seeding dengue epidemics, whilst China, Cambodia, Indonesia, and Singapore may establish viral diffusion links with multiple countries in Asia. Phylogeographic reconstructions help to explain how growing air transportation networks could influence the dynamics of DENV circulation.

Self-reported infections during international travel and notifiable infections among returning international travellers, Sweden, 2009-2013.

We studied food and water-borne diseases (FWDs), sexually transmitted diseases (STDs), vector-borne diseases (VBDs) and diseases vaccinated against in the Swedish childhood vaccination programme among Swedish international travellers, in order to identify countries associated with a high number of infections. We used the national database for notifiable infections to estimate the number of FWDs (campylobacteriosis, salmonellosis, giardiasis, shigellosis, EHEC, Entamoeba histolytica, yersinosis, hepatitis A, paratyphoid fever, typhoid fever, hepatitis E, listeriosis, cholera), STIs (chlamydia, gonorrhoea and acute hepatitis B), VBDs (dengue fever, malaria, West Nile fever, Japanese encephalitis and yellow fever) and diseases vaccinated against in the Swedish childhood vaccination programme (pertussis, measles, mumps, rubella, diphtheria) acquired abroad 2009-2013. We obtained number and duration of trips to each country from a database that monthly collects travel data from a randomly selected proportion of the Swedish population. We calculated number of infections per country 2009-2013 and incidence/million travel days for the five countries with the highest number of infections. Thailand had the highest number of FWDs (7,697, incidence 191/million travel days), STIs (1,388, incidence 34/million travel days) and VBDs (358, incidence 9/million travel days). France had the highest number of cases of diseases vaccinated against in the Swedish childhood vaccination programme (8, 0.4/million travel days). Swedish travellers contracted most infections in Thailand. Special focus should be placed on giving advice to travellers to this destination.

Molecular Characterization of a Cluster of Imported Malaria Cases in Puerto Rico.

The Caribbean island of Hispaniola is targeted for malaria elimination. Currently, this is the only island with ongoing transmission of malaria in the Caribbean. In 2015, six patients from Puerto Rico and one from Massachusetts, who traveled to Punta Cana, Dominican Republic, were confirmed to be infected with Plasmodium falciparum. Additional molecular analysis was performed at the Centers for Disease Control and Prevention to characterize the drug-resistant alleles and Plasmodium population genetic markers. All specimens carried wildtype genotypes for chloroquine, sulfadoxine-pyrimethamine, and artemisinin resistance genetic markers. A mutation in codon 184 (Y/F) of Pfmdr-1 gene was observed in all samples and they shared an identical genetic lineage as determined by microsatellite analysis. This genetic profile was similar to one previously reported from Hispaniola suggesting that a clonal P. falciparum residual parasite population present in Punta Cana is the source population for these imported malaria cases.

Pre-travel advice at a crossroad: Medical preparedness of travellers to South and Southeast-Asia - The Hamburg Airport Survey.

Specific travel-related recommendations exist for the prevention or self-treatment of infectious diseases contracted by travellers to the tropics. In the current study, we assessed the medical preparedness per these recommendations, focusing on whether travellers carried antidiarrheal and antimalarial medication with them stratified by type of pre-travel advice.

Bariatric surgery tourism hidden costs? How Canada is not doing its part in covering bariatric surgery under the Canada Health Act.

Many Canadians seek medical treatment outside our borders. Waiting times, rather than lack of expertise, are the number one culprit, and with globalization of health care, the number of patients who travel to obtain medical care will continue to rise. Though the provinces have covered the costs of complications from surgeries performed abroad for many years, complications from bariatric surgery performed abroad have been receiving negative attention. This commentary discusses associated costs and questions how the Canada Health Act should be covering bariatric procedures.

Fever and Headache after a Vacation in Thailand.

History 50 year-old man with fever and headache starting one week after returning from his vacation in Thailand. His general practitioner prescribed amoxicillin/clavulanic acid, without further analyses to pinpoint the infection. Examinations The examination of cerebro-spinal fluid was crucial for the final diagnosis. Lumbar puncture demonstrated a predominantly mononuclear pleocytosis of 80 cells/µl (< 5) with an elevated protein of 782 mg/l (< 450); glucose and lactate were within normal limits. Treatment and course Initially we tried to treat a broad range of organisms potentially causing meningitis or encephalitis. Typical bacteria and viruses endemic to Switzerland were not found, thus anti-infective treatment was stopped. Also the search for malaria, HIV, Chikungunya and Dengue infections yielded negative results. After 10 days we received a positive serologic test for Japanese encephalitis virus (JEV). Conclusions The Japanese encephalitis virus is transmitted by mosquitoes and is epidemiologically one of the most important transmissible neurologic diseases in Asia. Although only a minority of infected patients are gravely ill, their sequelae and death toll are considerable. Since 2009 a well-tolerated vaccine is available.

Case Report: Infectious Diseases in Pilgrims Visiting the Holy Land.

Every year Christian pilgrims from around the world visit the holy sites located around the Sea of Galilee. Some become ill during their stay with infectious diseases that were acquired in their country of origin, and are hospitalized at Poriya Medical Center. They pose a diagnostic challenge due to language barriers, the rarity of these infections in Israel, and the fact that diagnostic tests are not readily available. All patient records from 2015 of Holy Land tourists hospitalized at Poriya Medical Center were screened for the diagnosis of imported zoonotic diseases that are not commonly diagnosed in Israel. Three patients who were on a Holy Land tour were hospitalized during 2015 with laboratory-confirmed diagnostically challenging zoonotic infectious diseases: a 91-year-old priest from Ethiopia diagnosed with relapsing fever due to Borrelia recurrentis, an 85-year-old retired mountaineer from New Hampshire diagnosed with human granulocytic anaplasmosis, and a 57-year-old farmer from central Brazil diagnosed with leptospirosis. These case reports emphasize the importance of considering imported zoonotic infectious diseases and obtaining appropriate diagnostic tests when treating Holy Land travelers to Israel.

Case Report: Endemic Amebiasis in Australia: Implications for Residents, Travelers, and Clinicians.

Entamoeba histolytica is considered endemic in Australia; however, cases are rare, occurring almost exclusively in high-risk individuals. We describe a series of locally acquired, complicated cases in low-risk individuals from Far North Queensland in whom the diagnosis was delayed. Amebiasis may pose a greater local threat than is currently recognized.

Travelers' Diarrhea and Other Gastrointestinal Symptoms Among Boston-Area International Travelers.

AbstractThis prospective cohort study describes travelers' diarrhea (TD) and non-TD gastrointestinal (GI) symptoms among international travelers from the Boston area, the association of TD with traveler characteristics and dietary practices, use of prescribed antidiarrheal medications, and the impact of TD and non-TD GI symptoms on planned activities during and after travel. We included adults who received a pre-travel consultation at three Boston-area travel clinics and who completed a three-part survey: pre-travel, during travel, and post-travel (2-4 weeks after return). TD was defined as self-reported diarrhea with or without nausea/vomiting, abdominal pain, or fever. Demographic and travel characteristics were evaluated by χ(2) test for categorical and Wilcoxon rank-sum test for continuous variables. Analysis of dietary practices used logistic generalized estimating equation models or logistic regression models. Of 628 travelers, 208 (33%) experienced TD and 45 (7%) experienced non-TD GI symptoms. Of 208 with TD, 128 (64%), 71 (36%), and 123 (62%) were prescribed ciprofloxacin, azithromycin, and/or loperamide before travel, respectively. Thirty-nine (36%) of 108 took ciprofloxacin, 20 (38%) of 55 took azithromycin, and 28 (28%) of 99 took loperamide during travel. Of 172 with TD during travel, 24% stopped planned activities, and 2% were hospitalized. Of 31 with non-TD GI symptoms during travel, six (13%) stopped planned activities. International travelers continue to experience diarrhea and other GI symptoms, resulting in disruption of planned activities and healthcare visits for some. Although these illnesses resulted in interruption of travel plans, a relatively small proportion took prescribed antibiotics.

On the origin and timing of Zika virus introduction in Brazil.

The timing and origin of Zika virus (ZIKV) introduction in Brazil has been the subject of controversy. Initially, it was assumed that the virus was introduced during the FIFA World Cup in June-July 2014. Then, it was speculated that ZIKV may have been introduced by athletes from French Polynesia (FP) who competed in a canoe race in Rio de Janeiro in August 2014. We attempted to apply mathematical models to determine the most likely time window of ZIKV introduction in Brazil. Given that the timing and origin of ZIKV introduction in Brazil may be a politically sensitive issue, its determination (or the provision of a plausible hypothesis) may help to prevent undeserved blame. We used a simple mathematical model to estimate the force of infection and the corresponding individual probability of being infected with ZIKV in FP. Taking into account the air travel volume from FP to Brazil between October 2013 and March 2014, we estimated the expected number of infected travellers arriving at Brazilian airports during that period. During the period between December 2013 and February 2014, 51 individuals travelled from FP airports to 11 Brazilian cities. Basing on the calculated force of ZIKV infection (the per capita rate of new infections per time unit) and risk of infection (probability of at least one new infection), we estimated that 18 (95% CI 12-22) individuals who arrived in seven of the evaluated cities were infected. When basic ZIKV reproduction numbers greater than one were assumed in the seven evaluated cities, ZIKV could have been introduced in any one of the cities. Based on the force of infection in FP, basic reproduction ZIKV number in selected Brazilian cities, and estimated travel volume, we concluded that ZIKV was most likely introduced and established in Brazil by infected travellers arriving from FP in the period between October 2013 and March 2014, which was prior to the two aforementioned sporting events.

Mosquitoes on a plane: Disinsection will not stop the spread of vector-borne pathogens, a simulation study.

Mosquito-borne diseases are increasingly being recognized as global threats, with increased air travel accelerating their occurrence in travelers and their spread to new locations. Since the early days of aviation, concern over the possible transportation of infected mosquitoes has led to recommendations to disinsect aircraft. Despite rare reports of mosquitoes, most likely transported on aircraft, infecting people far from endemics areas, it is unclear how important the role of incidentally transported mosquitoes is compared to the role of traveling humans. We used data for Plasmodium falciparum and dengue viruses to estimate the probability of introduction of these pathogens by mosquitoes and by humans via aircraft under ideal conditions. The probability of introduction of either pathogen by mosquitoes is low due to few mosquitoes being found on aircraft, low infection prevalence among mosquitoes, and high mortality. Even without disinsection, introduction via infected human travelers was far more likely than introduction by infected mosquitoes; more than 1000 times more likely for P. falciparum and more than 200 times more likely for dengue viruses. Even in the absence of disinsection and under the most favorable conditions, introduction of mosquito-borne pathogens via air travel is far more likely to occur as a result of an infected human travelling rather than the incidental transportation of infected mosquitoes. Thus, while disinsection may serve a role in preventing the spread of vector species and other invasive insects, it is unlikely to impact the spread of mosquito-borne pathogens.

Treating village newcomers and travelers for trachoma: Results from ASANTE cluster randomized trial.

Trachoma is targeted for global elimination. Infection rates with Chlamydia trachomatis are higher in new arrivals to a community and in travelers who leave for extended periods, suggesting they are sources of re-infection. This community-randomized, clinical trial was designed to determine if a surveillance program that targeted newcomers and travelers, identified weekly, would result in more communities achieving levels of infection of ≤1%.

Population Health Implications of Medical Tourism.

Fifteen million U.S. patients each year seek medical care abroad; however, there are no data on outcomes and follow-up of these procedures. This study aims to identify, evaluate, and survey patients presenting with complications from aesthetic procedures abroad and estimate their cost to the U.S. health care system.

Emergence of drug resistant bacteria at the Hajj: A systematic review.

Hajj is the annual mass gathering of Muslims, and is a reservoir and potential source of bacterial transmission. The emergence of bacterial transmission, including multi-drug resistance (MDR) bacteria, during Hajj has not been systematically assessed.

Federal travel restrictions to prevent disease transmission in the United States: An analysis of requested travel restrictions.

Individuals with certain communicable diseases may pose risks to the health of the traveling public; there has been documented transmission on commercial aircraft of tuberculosis (TB), measles, and severe acute respiratory syndrome (SARS). Federal public health travel restrictions (PHTR) prevent commercial air or international travel of persons with communicable diseases that pose a public health threat.

High speed rail and coastal tourism: Identifying passenger profiles and travel behaviour.

In this paper, we characterise tourists most likely to visit a coastal destination by high-speed rail (HSR). Our data came from a survey conducted among HSR passengers during 2014's high season (July and August) at Spain's Camp de Tarragona and Alicante Stations, each of which is near a mass tourism destination on the Mediterranean coast: the Costa Daurada and the Costa Blanca, respectively. We used responses to the survey, which presented binary discrete-choice situations, to construct a database necessary for a logistic regression model that allowed us to examine how passenger profile, trip characteristics, and stay conditions influenced the use of HSR services on visits to each coastal destination. Results highlighted significant differences in the profiles of tourists who arrived at each destination by HSR and, in turn, that no specific tourist profile is associated with HSR, even for two stations that serve sunny beach destinations. Among its implications, to analyse travellers that HSR can attract, it is vital to consider the specific characteristics of each destination and its current market.

Role of classic signs as diagnostic predictors for enteric fever among returned travellers: Relative bradycardia and eosinopenia.

The lack of characteristic clinical findings and accurate diagnostic tools has made the diagnosis of enteric fever difficult. We evaluated the classic signs of relative bradycardia and eosinopenia as diagnostic predictors for enteric fever among travellers who had returned from the tropics or subtropics.

The Growing Trend of Medical Tourism.

What nurses need to know about the risks and benefits for patients.

The interplay of climate, intervention and imported cases as determinants of the 2014 dengue outbreak in Guangzhou.

Dengue is a fast spreading mosquito-borne disease that affects more than half of the population worldwide. An unprecedented outbreak happened in Guangzhou, China in 2014, which contributed 52 percent of all dengue cases that occurred in mainland China between 1990 and 2015. Our previous analysis, based on a deterministic model, concluded that the early timing of the first imported case that triggered local transmission and the excessive rainfall thereafter were the most important determinants of the large final epidemic size in 2014. However, the deterministic model did not allow us to explore the driving force of the early local transmission. Here, we expand the model to include stochastic elements and calculate the successful invasion rate of cases that entered Guangzhou at different times under different climate and intervention scenarios. The conclusion is that the higher number of imported cases in May and June was responsible for the early outbreak instead of climate. Although the excessive rainfall in 2014 did increase the success rate, this effect was offset by the low initial water level caused by interventions in late 2013. The success rate is strongly dependent on mosquito abundance during the recovery period of the imported case, since the first step of a successful invasion is infecting at least one local mosquito. The average final epidemic size of successful invasion decreases exponentially with introduction time, which means if an imported case in early summer initiates the infection process, the final number infected can be extremely large. Therefore, dengue outbreaks occurring in Thailand, Singapore, Malaysia and Vietnam in early summer merit greater attention, since the travel volumes between Guangzhou and these countries are large. As the climate changes, destroying mosquito breeding sites in Guangzhou can mitigate the detrimental effects of the probable increase in rainfall in spring and summer.

Sharing post-AML consolidation supportive therapy with local centers reduces patient travel burden without compromising outcomes.

Acute myeloid leukemia (AML) is frequently treated with induction and consolidation chemotherapy. Consolidation chemotherapy can be delivered on an ambulatory basis, requiring some patients to travel long distances for treatment at specialized centers. We developed a shared care model where patients receive consolidation chemotherapy at a quaternary center, but post-consolidation supportive care at local hospitals. To evaluate the impact of our model on patient travel and outcomes we conducted a retrospective analysis of AML and acute promyelocytic leukemia patients receiving consolidation over four years at our quaternary center. 73 patients received post-consolidation care locally, and 344 at the quaternary center. Gender, age and cytogenetic risk did not significantly differ between groups. Shared care patients saved mean round trip distance of 146.5km±99.6 and time of 96.7min±63.4 compared to travelling to quaternary center. There was no significant difference in overall survival between groups, and no increased hazard of death for shared care patients. 30, 60, and 90day survival from start of consolidation was 98.6%, 97.2%, and 95.9% for shared care and 98.8%, 97.1%, and 95.3% for quaternary center patients. Thus, a model utilizing regional partnerships for AML post-consolidation care reduces travel burden while maintaining safety.

The 2016 American Orthopaedic Association-Japanese Orthopaedic Association Traveling Fellowship.

The American Orthopaedic Association-Japanese Orthopaedic Association (AOA-JOA) Traveling Fellowship, which began in 1992 as a collaborative effort between the 2 orthopaedic communities, is aimed at fostering leadership among early-career surgeons through clinical, academic, and cultural exchange. Over 3 weeks, we experienced an extraordinary journey that led us across nearly 800 miles of the picturesque Japanese countryside, with stops at 6 distinguished academic centers. The opportunity to become personally acquainted with orthopaedic leaders in Japan, learn from their experiences, and immerse ourselves in the ancient and storied culture of a beautiful country was one that we will not soon forget. Along the way, we accumulated a wealth of information while enjoying the legendary hospitality of the Japanese people. There is a ubiquitous challenge in delivering cost-effective, accessible health care while maintaining a commitment to education and research. The U.S. orthopaedic community may take solace in the fact that our Japanese colleagues stand with us as partners in this pursuit, and our relationship with them continues to grow stronger through endeavors such as the AOA-JOA Traveling Fellowship. We look forward to honoring our Japanese colleagues in 2017 when we host them in the United States.

Trump travel ban requires balanced discussion.

The outcomes and controversies of transplant tourism-Lessons of an 11-year retrospective cohort study from Taiwan.

Transplant tourism has increased rapidly in the past two decades, accounting for about 10% of world organ transplants. However it is ethically controversial and discouraged by professional guidelines. We conducted this study to investigate the outcomes and trends of overseas kidney and liver transplantation in Taiwan to provide a sound basis for ethical reflection.

Exploring the potential of open big data from ticketing websites to characterize travel patterns within the Chinese high-speed rail system.

Big data have contributed to deepen our understanding in regards to many human systems, particularly human mobility patterns and the structure and functioning of transportation systems. Resonating the recent call for 'open big data,' big data from various sources on a range of scales have become increasingly accessible to the public. However, open big data relevant to travelers within public transit tools remain scarce, hindering any further in-depth study on human mobility patterns. Here, we explore ticketing-website derived data that are publically available but have been largely neglected. We demonstrate the power, potential and limitations of this open big data, using the Chinese high-speed rail (HSR) system as an example. Using an application programming interface, we automatically collected the data on the remaining tickets (RTD) for scheduled trains at the last second before departure in order to retrieve information on unused transit capacity, occupancy rate of trains, and passenger flux at stations. We show that this information is highly useful in characterizing the spatiotemporal patterns of traveling behaviors on the Chinese HSR, such as weekend traveling behavior, imbalanced commuting behavior, and station functionality. Our work facilitates the understanding of human traveling patterns along the Chinese HSR, and the functionality of the largest HSR system in the world. We expect our work to attract attention regarding this unique open big data source for the study of analogous transportation systems.

Emerging infectious disease agents and blood safety in Australia: spotlight on Zika virus.

Emerging infectious diseases (EIDs) are infectious diseases whose incidence has increased in humans in the past 20 years or could increase in the near future. EID agents may represent a threat to blood safety if they infect humans, cause a clinically significant illness, include an asymptomatic blood phase in the course of infection, and are transmissible by transfusion. EID agents are typically not well characterised, but there is a consensus that we can expect ongoing outbreaks. Strategies to manage the risk to blood safety from EIDs include ongoing surveillance, regular risk assessments, modelling transfusion transmission risk, and deferral of donors with a recent travel history to outbreak areas. The 2015-16 Zika virus (ZIKV) outbreak in the Americas is the largest reported ZIKV outbreak to date, and it highlights the unpredictable nature of EID outbreaks and how quickly they can become a major public health problem. This ZIKV outbreak has provided evidence of a causal link between the virus and microcephaly in newborns. In assessing the potential risk of ZIKV to blood safety in Australia, it should be noted that a relatively small number of imported ZIKV infections have been reported in Australia, there have been no reported cases of local ZIKV transmission, and the geographical distribution of the potential ZIKV mosquito vector in Australia (Aedes aegypti) is limited to northern Queensland. Moreover, reported transfusion-transmitted ZIKV cases worldwide are rare. At present, ZIKV represents a low risk to blood safety in Australia.