Risk Assessment and Travelers Characteristics : 6-Month Travel Clinic Experience From Qatar

In the past, travel was considered a luxury good. Over time, however, travel became less expensive and within the reach of millions of people, which led to an increased number of travelers. In 2017, 1.322 billion international arrivals were recorded worldwide,1 compared to 25 million in the 1950s. Previously, North America and Europe dominated the travel markets, but this situation is currently changing. By 2030, most international travel will originate from Africa, Asia, and the Middle East.2 Qatar is a peninsula in the Arabian Gulf with an estimated population of 2,657 million as per the census of the fourth quarter of 2017.3 In 2010, expatriates accounted for 85.7% of the total population of Qatar.4 Since the opening of the new Hamad International Airport (HIA) on April 30, 2014, the only international airport in Qatar, the number of travelers to and from Qatar has increased dramatically. HIA accomplished a new record in passenger traffic and aircraft movements in 2016, handling 37.3 million passengers and 245,800 landings and take-offs. This number increased to 120 million passengers by the end of 2017.5 Travel abroad is associated with risks of acquiring infectious diseases that are associated with food and water, arthropod bites, environmental conditions, and sexual behavior. These risks are usually underestimated by travelers. In a study conducted in European airports, only 50% of travelers to tropical countries sought pre-travel advice, and only one-third of travelers to malaria-endemic countries took antimalarial chemoprophylaxis.6 Because of the increasing number of international travelers to high-risk destinations, pre-travel advice is a key point from the public health perspective and will limit the burden of travel-associated illnesses and the risk of importation of infectious diseases.7 In Qatar, the Hamad Medical Corporation (HMC) is the main governmental healthcare provider. Until the opening of its travel clinic in February 2017, no dedicated travel medicine service existed in HMC. No published data on pre-travel health risk assessment and http://ijtmgh.com Int J Travel Med Glob Health. 2018 Dec;6(4):161-167 doi 10.15171/ijtmgh.2018.29 TMGH IInternational Journal of Travel Medicine and Global Health J


Introduction
In the past, travel was considered a luxury good.Over time, however, travel became less expensive and within the reach of millions of people, which led to an increased number of travelers.In 2017, 1.322 billion international arrivals were recorded worldwide, 1 compared to 25 million in the 1950s.Previously, North America and Europe dominated the travel markets, but this situation is currently changing.By 2030, most international travel will originate from Africa, Asia, and the Middle East. 2 Qatar is a peninsula in the Arabian Gulf with an estimated population of 2,657 million as per the census of the fourth quarter of 2017. 3 In 2010, expatriates accounted for 85.7% of the total population of Qatar. 4 Since the opening of the new Hamad International Airport (HIA) on April 30, 2014, the only international airport in Qatar, the number of travelers to and from Qatar has increased dramatically.HIA accomplished a new record in passenger traffic and aircraft movements in 2016, handling 37.3 million passengers and 245,800 landings and take-offs.This number increased to 120 million passengers by the end of 2017. 5ravel abroad is associated with risks of acquiring infectious diseases that are associated with food and water, arthropod bites, environmental conditions, and sexual behavior.These risks are usually underestimated by travelers.In a study conducted in European airports, only 50% of travelers to tropical countries sought pre-travel advice, and only one-third of travelers to malaria-endemic countries took antimalarial chemoprophylaxis. 6Because of the increasing number of international travelers to high-risk destinations, pre-travel advice is a key point from the public health perspective and will limit the burden of travel-associated illnesses and the risk of importation of infectious diseases. 7n Qatar, the Hamad Medical Corporation (HMC) is the main governmental healthcare provider.Until the opening of its travel clinic in February 2017, no dedicated travel medicine service existed in HMC.
No published data on pre-travel health risk assessment and travelers' characteristics from Qatar was found; the current study is the first of its kind to highlight travel services in Qatar.

Study Population
All of the travelers who presented at the travel clinic in the Communicable Disease Centre (CDC) at HMC from February 2017 to August 2017 were included in the current study.
Patient demographics (gender, age, nationality), travel characteristics (timing of pre-travel consultation, travel destination, number of countries to be visited, departure date, travel duration, reason for travel, and type of accommodation).and medical conditions (chronic diseases, treatments, and pregnancy) were recorded.Additionally, prescribed vaccinations, antimalarial chemoprophylaxis, and stand-by treatment for traveler's diarrhea were documented.

Definitions
Travelers were classified according to travel purpose(s).More than one travel purpose could have been indicated by each traveler, which included tourism, visiting friends and/or relatives (VFR), business, studying, religious/pilgrimage, and others.
Travelers who indicated visiting friends and/or relatives as their travel purpose were defined as VFRs even if additional travel purposes were indicated.

Statistical Analysis
Categorical and continuous values were expressed as frequencies (percentages) and mean ±SD or median and interquartile range (IQR) as appropriate.Descriptive statistics were used to summarize demographic, clinical, and other characteristics of the participants.Associations between two or more qualitative variables were assessed using chi-square (χ 2 ) or Yates corrected chi-square tests as appropriate.Pictorial presentations of the key results were made using appropriate statistical graphs.All P values presented were two-tailed, and a P value <0.05 was considered statistically significant.All statistical analyses were done using statistical packages SPSS 22.0 (SPSS Inc.Chicago, IL) and Epi-info (Centers for Disease Control and Prevention, Atlanta, GA) software.

Travelers' Characteristics
A total of 279 travelers were included in the study (Table 1).The mean number of visits per month was 46.5.The numbers of travelers visiting the travel clinic per month are shown in Figure 1.

Travel Characteristics
Overall, the majority of travelers (156; 56%) visited the clinic more than 2 weeks prior to their travel date; 71 (25%) visited the clinic 1 to 2 weeks prior to their travel date, and 47 (17%) visited the clinic less than a week prior to their travel date.There was significant association between the timing of travel clinic visits prior to travel and travel characteristics (P = 0.002).The percentage of travelers who visited the clinic between 1-2 weeks was significantly higher among tourist travelers (67.6%) when compared to business, religious/ pilgrimage, and other travelers (range = 1.4% to 12.7%; χ 2 =30.04;P = 0.002) (Table 2).
The number of tourists traveling to Tanzania and Kenya was significantly higher (range 63% to 83.3%) than those traveling for religious/pilgrimage, business, VFRs, or other purposes (χ 2 = 319.28;P < 0.001).
The mean travel duration was 46.5 days (range = 3 to 90 days).
In the current study, 58 (21%) travelers were traveling with chronic medical conditions.The most common comorbidities present in these travelers were hypertension, diabetes mellitus, and bronchial asthma found in 6.1%, 3.6%, and 3.2% of all travelers, respectively (Table 3).
A risk assessment indicated that 118 (42.3%) of the 279 travelers were at risk of acquiring malaria based on their travel destination, and anti-malaria prophylaxis was required.Of the at-risk travelers, 81 (69%) travelers were tourists, 16 (14%) were business travelers, 16 (14%) were VFRs.The majority of travelers were given atovaquone-proguanil, and a few of the travelers received mefloquine (Table 4).
Of the 279 travelers in this study, 128 (46 %) were at risk of contracting travelers' diarrhea and required stand-by treatment.All of them were prescribed loperamide plus antibiotics; ciprofloxacin and azithromycin were prescribed in 79 (62%) and 49 (38%) cases, respectively (Table 5).A significant association was observed between the need for stand-by treatment for traveler's diarrhea and travel characteristics (P < 0.001).Higher percentages of tourists and business travelers received stand-by treatments (range = 13% to 76%) compared to religious/pilgrimage, VFRs, and other travelers (range = 3% to 5%; χ 2 = 48.19;P < 0.001).
There was no statistical significance between the types of antibiotics prescribed for travelers' diarrhea (χ 2 = 5.27; P = 0.261).

Discussion
This study provides an overview of the demographics, travel destinations, and travel health-seeking behavior of travelers attending the first travel clinic at HMC, Qatar.
Understanding the demographic features, common travel destinations, and travel-associated risk factors will help establish preventive measures aimed at minimizing the risk of contracting and decreasing the global spread of infectious diseases.
Travelers from Qatar are at increased risk of contracting travel-associated illness because of their destinations which are considered endemic areas for malaria, yellow fever, and other infectious diseases. 8,9anzania (including Zanzibar) with 46 travelers (16.5%) followed by Kenya with 42 travelers (15.1%) were the most common destinations among the travelers in this study (one third of the total travelers from Qatar in the study period).Other top destinations were Saudi Arabia with 36 travelers (12.9%),South Africa with 22 travelers (7.9%), Sri Lanka with 19 travelers (6.8%), Malaysia with 15 travelers (5.4%), Uganda with 13 travelers (4.7%), India with 12 travelers (4.3%), Australia with 11 travelers (3.9%), and Brazil with 9 travelers (3.2%).
The 2 countries visited most by business travelers were Tanzania and India with 8 and 6 travelers, respectively.Kenya with 35 travelers and Tanzania with 29 travelers were the top countries visited by tourists, and Pakistan and Uganda were the top 2 countries visited by 5 VFRs travelers each.In the current study, travel to Africa was more common than travel to other continents compared to other international studies.
South America was the main destination of travelers in a study from Spain, 8 whereas Thailand was the main destination in a study from Sweden, 10 and India was the main destination in a study from the United States. 11Similar to the current research, travel destinations in sub-Saharan Africa were predominant in a study conducted in France. 7imilar to other international studies, the findings of the current study showed that the mean age of travelers was 30.8 years, and most of the travelers were tourists. 8,12The second most common cause for travel is religious/pilgrimage (36 travelers; 12.9%), followed by business (34 travelers; 12.2%), VFRs with 30 travelers (10.7%), study purposes (17 travelers; 7.1%), and other reasons (6 travelers; 1.8%).
The obtained results were unexpected in view of the large number of expatriates residing in Qatar.Qataris make up less than 15% of the total population, followed by other Arab (13%), Indian (24%), Nepali (16%), Filipino (11%), and Bangladesh and Sri Lankan nationalities (5% each). 13It was expected that VFRs and those of Indian, Nepalese, or Filipino nationality would comprise the majority of travelers in this study.This may explain the lack of knowledge and awareness about travel health services.Most of the expatriates in Qatar are single and represent the labor task force, and pre-travel consultation is not a priority for them.The results represent a good opportunity to improve the services offered by HMC to that part of the community, because previously published data from Qatar has shown that diseases like malaria are imported to Qatar. 14FRs are at an increased risk for infectious diseases, because they travel for longer durations, often in rural areas, and share local food with their family.Moreover, they seek pre-travel advice less frequently than tourists.In a US study in  2009, 70% of malaria cases in the United States were observed in VFRs. 15A similar pattern has been observed for typhoid fever. 16he relatively low number of Qatari travelers reflects the fact that the community is still unaware of travel health behaviors, contrary to western nationalities where travel clinics are widespread and travel health services are well established.
In this study, 58 (21%) travelers had chronic medical conditions.The most common comorbidities found among the study participants were hypertension, diabetes mellitus, and bronchial asthma found in 6.1%, 3.6%, and 3.2% of travelers.Only 2.2% of travelers in this study had coronary artery disease.This result contradicts those of other studies which showed that coronary cardiovascular diseases were the most frequent chronic conditions among travelers. 7accines were given to 272 (97%) of the travelers in this study; 188 (69%) travelers received the typhoid vaccine, 168 (62%) received the Tdap, 150 (55%) received the hepatitis A vaccine, 134 (49.3%) received the flu vaccine, and 106 (39%) received the yellow fever vaccine.The increased use of typhoid and hepatitis A vaccines reflects the travel destinations of the participating travelers, where the increased need for Tdap may reflect the decrease in awareness of the importance of updating routine vaccine schedules and the need for vaccines in adults.This also emphasizes the role of travel health services in strengthening such programs by providing routine vaccines during pre-travel visits.
A risk assessment indicated that 118 (42.3%) of the travelers in this study were at risk of acquiring malaria which required standard pre-travel advice on mosquito bite avoidance measures and anti-malaria prophylaxis medications.Among the at-risk travelers, 81 (69%) were tourists, 16 (14%) were business travelers, and 16 (14%) were VFRs.The majority of travelers were given atovaquone-proguanil, while a few travelers received mefloquine.
In this study, 128 (46%) of the travelers were at risk for travelers' diarrhea and required pre-travel advice regarding food and water safety in addition to stand-by treatment for travelers' diarrhea.Loperamide plus antibiotics were prescribed; ciprofloxacin was prescribed for 79 (62%) travelers, while azithromycin was given to 49 (38%) travelers.Africa was the most common travel destination where the emergence of quinolone resistance is seen, albeit without strong evidence of clinical failure outside of SE Asia. 17

What Is Already Known?
• The number of international travelers is increasing, and travelers are choosing more exotic destinations.• Travel abroad is associated with the risk of acquiring infectious diseases associated with food and water, arthropod bites, environmental conditions, and sexual behavior; these risks are usually underestimated by travelers.• Risk assessment is an important part of the travel clinic counseling services and can help identify potential risks to travelers and determine the needed vaccines and prophylaxis medication depending on the travel destination.• VFRs are less likely to visit travel clinics before they travel, and they are less likely to comply with antimalarial prophylaxis.

What This Study Adds?
This study adds information about the preference of international travelers from Qatar regarding the selected destinations, activities and seeking travel medicine clinics which is relatively new service provided in the country and is stressing on the importance of pre-travel assessment specially for high risk travelers.

Conclusion
The current study is the first of its kind to be conducted in Qatar.The findings provide insight into the health conditions, travel destinations, travel duration, and pre-travel medical care of the epidemiologically of travelers from Qatar and should facilitate the targeting of risk reduction strategies for those travelers visiting high-risk destinations.
As travel becomes more frequent among travelers from Qatar, pre-travel counseling and risk assessment is needed to understand the travel-related risks and to better enable preparation for such activity.When travel is high risk due either to individual factors, destinations, or the activities performed during travel, pre-travel assessment should be done in specialized travel clinics.More efforts are needed to increase public awareness on the availability of travel medicine services in Qatar and the importance of pre-travel counselling, especially among high-risk travelers such as VFRs, travelers with chronic medical illnesses, and travelers to high-risk destinations.More studies on the travel habits of Qatar's populations need to be done, especially with the increasing affluence and diverse travel habits in the region.

Figure 1 .
Figure 1.Absolute Number of Travelers Visiting the Travel Clinic by Month.

Table 2 .
Travel Characteristics

Table 3 .
Chronic Medical Conditions Among International Travelers From Qatar

Table 4 .
Malaria Risk and Malaria Prophylaxis According to Reason of Travel Pearson chi-square and Yates corrected chi-square tests. *

Table 5 .
Traveler's Diarrhea Risk and Stand-by Treatment According to Reason for Travel