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As more students study abroad, travel preparedness key

As the number of students studying abroad has climbed steadily in the past decade, from fewer than 100,000 students in 1997 to more than 260,000 students in 2008/09 (according to the Institute of International Education Open Doors Report). Although the largest number of students study abroad in Europe, there is a significant increase in the numbers of students going to developing countries, where health concerns can be different than in the US.

As worldwide student travel becomes more common, it is important for pediatricians to guide their patients who may be studying in places other than the US about how best to prepare and how to prevent bringing home “unwanted souvenirs,” according to Jay Keystone, MD, MPH, of the University of Toronto.

Keystone — who was one of many panelists who spoke at the 16th Richard J. Duma/NFID Annual News Conference and Symposium on Infectious Diseases in July — told Infectious Diseases in Children that he stresses vaccinations when counseling students and other international travelers.

All of the panelists at the news conference encouraged multifaceted approaches to boost immunization rates, as reports of diseases that were once thought controlled, such as pertussis and measles, are now making a comeback in the US and abroad.

Students should familiarize themselves with diseases that are highly endemic in the areas where they are visiting, and they may need to get immunizations to protect themselves, Keystone said.

“Influenza, hepatitis A, hepatitis B, typhoid and, rarely, cholera are the most frequent causes of vaccine-preventable disease in travelers,” Keystone said.

He advised students to visit a travel health provider about 1 month before departure to allow enough time to get recommended vaccines and prescriptions.

In an interview with Infectious Diseases in Children, Gary Rhodes, PhD, who is the Director of the Center for Global Education at the UCLA Graduate School of Education and Information Studies, discussed a chapter he helped write in the CDC’s recently released 2012 Yellow Book.

“Even if travel is imminent, students should still visit their travel health provider before departure,” Rhodes and colleagues wrote. “The quality of dental and medical care may be different in host countries, more challenging to access, or more expensive than similar care would be in the United States. Students should receive thorough medical and dental examinations, especially those who are going abroad for several months or more.” He suggested that students should see a medical health practitioner as soon as they decide they are interested in study abroad. The lead-time for beginning shots for hepatitis can be long before leaving the US.

CDC officials also recommend that physicians counsel patients and parents about the benefits of bringing a “well-stocked travel health kit,” and counseling about food and water safety while abroad.

In the Yellow Book, Rhodes and colleagues said: “Specific food and water recommendations depend on the destination country; however, some useful tips to help students regarding food and water safety are the following:

• Find out if water is safe to drink.
• Purify unsafe water before drinking or drink only bottled water, making sure that the bottles are sealed when purchased. Use only purified or bottled water for brushing teeth.
• Avoid ice in drinks, since it can also be unsafe, depending on the water used to make it.
• Poor refrigeration, undercooked meat, and food purchased from street vendors could pose problems related to food contamination.”

Keystone also said physicians should emphasize other safety measures, including carrying condoms to help prevent STDs, avoiding contact with animals to eliminate potential rabies contacts and reinforcing safe-driving techniques.

“The No. 1 killer of travelers while they are abroad is not disease,” Keystone said. “About 40% of deaths are related to motor vehicle accidents. In the tropics, especially, the roads are poorly maintained; people pass on hills that they can’t see around. A good piece of advice for patients is to never travel by yourself in rural areas after dark. Also, stay off motorcycles.”

Keystone said the recent outbreak of the rare Escherichia coli O104:H4 strain, which led to 810 hemolytic uremic syndrome cases and 39 deaths in Germany since the beginning of May, is just one example of why students and other travelers must be counseled about properly preparing food and being mindful of what is eaten.

“As we know, it isn’t just individuals that can bring home infection, it is the food we eat,” Keystone said, adding that physicians should suggest students carry an antibiotic in the event of severe illness.

Surveillance provides clues

Keystone said the GeoSentinel Surveillance Network has been integral in detecting global outbreaks and can help arm patients with knowledge about disease trends before departure. According to the GeoSentinel website, this system is a worldwide communication and data collection network for the surveillance of travel-related morbidity. It was initiated in 1995 by the International Society of Travel Medicine (ISTM) and the CDC as a network of ISTM member travel/tropical medicine clinics.

“GeoSentinel is based on the concept that these clinics are ideally situated to effectively detect geographic and temporal trends in morbidity among travelers, immigrants and refugees,” according to the website.

Keystone said there was a recent outbreak of leptospirosis in Borneo, England and New York that was identified quickly on the GeoSentinel site.

“Once all three cases were reported to the surveillance network, within a week, we knew something was going on,” he said. “That’s how the surveillance portion of this network works.”

Returning home

Pediatricians who are seeing patients after they have returned home from studying abroad should keep the country visited in mind when considering illness, Keystone said.

He used typhoid as an example and said between 1999 and 2006, more than 66% of all cases occurred in travelers who had returned from the Indian subcontinent, adding that because medical tourism has become a huge industry, it is important to ask patients about any surgical procedures that may have occurred while the patient was traveling.

“Increasing numbers of Americans are traveling to the developing world and bringing home new bacteria,” he said, pointing to the New Delhi metallo-beta-lactamase 1, or NDM-1 genetic element, which encodes multiple resistance genes. This genetic element was initially isolated from a strain of Klebsiella obtained from a patient who acquired the organism in New Delhi, India, in 2008.

Awareness

Keystone said students traveling to Europe also must be mindful of outbreaks happening now, including measles, the incidence rates of which continue to rise in Europe, with France reporting about 12,000 patients; Italy reporting 1,500 patients; and Germany reporting more than 1,000 patients.

Rhodes said most students will have a very positive and often life-changing experience by studying abroad. However, students may face a wide range of health and safety challenges. Pediatricians can help students and their parents to be aware of the broad range of health and safety challenges that could result in student death or injury abroad. Along with the medical health and road safety issues discussed earlier, access to alcohol may be easier in other parts of the world, and responsible use is important. Obtaining advice on responding to unwanted attention as well as potential sexual harassment and assault is also important. Students should also be aware of culture shock and the associated mental health issues. However, psychosocial issues affecting the student upon their return, including difficulties in readjusting back to American culture, are important to consider as well.

“Sometimes, it is difficult because while they were away, they may have had a great experience, maybe they had a boyfriend or girlfriend who they left behind, and it could be hard for them coming back,” Rhodes said. He encouraged physicians to use and refer the Center’s websites, including the SAFETI Clearinghouse (www.globaled.us/safeti), the Student Study Abroad Handbooks (www.studentsabroad.com), and the Global Scholar Online Courses for Study Abroad at the university level (www.globalscholar.us) and Global Student Online Courses for Study Abroad at the high school level (www.globalstudent.us), as well as other resources linked at the Center’s homepage: http://globaled.us/about.asp, as a resource for patients who may need advice about travel or returning home. – by Colleen Zacharyczuk

For more information:

• CDC. Yellow Book home page. Available at: http://wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm.

Disclosure: Dr. Keystone has been a speaker for Sanofi-Pasteur and GlaxoSmithKline on the subject of immunizations.

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