Sexually transmissible diseases and travel

International travel and sexually transmitted diseases

Despite concerted efforts to control sexually transmitted diseases (STDs) worldwide, they still remain a major public health problem. Out of the 25 organisms known to be transmitted sexually, travelers are at greater risk of acquiring HIV and other STDs in developing countries in view of the high prevalence rates in these countries, particularly after sexual exposure to local commercial sex workers (CSWs). Some of the STDs acquired during international travel are more likely to be resistant to standard antimicrobial regimens for the STDs. HIV, gonorrhoea, syphilis, non-specific urethritis, hepatitis B, hepatitis C, and other STDs are a significant risk for travelers who engage in unprotected sex, especially with overseas CSWs. It is recognized that barrier contraceptives provide considerable protection against STDs, but they are not regarded as 100% protective. Sexual abstinence and sexual monogamy with a 'known' partner carry a much lower risk than the safest of 'safer sex' practices. However, in the event of a sexual exposure to a new partner in the country being visited, prior hepatitis B immunization and the consistent and proper use of a latex condom are strongly advised, followed by proper medical investigations and physical examination on returning home, before sexual activity is resumed.

Sexual tourism: implications for travelers and the destination culture

Health care providers in a variety of settings need to improve their ability--along with the capabilities of supporting laboratories, surveillance systems, and services for sex partner management--to diagnose and treat STI. Whether the travel health care sector, as such, is willing to take on the additional burden of STI-related screening and risk reduction counseling has been raised by some authors. Currently, the burden of providing formalized STI care falls on the public sector; however, in the United States, most STI are actually diagnosed in the offices of private physicians. Given that the United States has the highest STI rates of any industrialized country, the undeniable synergy between STI and HIV acquisition, the failure of many American providers to screen for C trachomatis despite clear guidelines, the global resurgence of syphilis and extension of resistant N gonorrhoeae and of HIV, and the risk behaviors consistently reported by travelers, it is hard to argue against travel specialists' joining the daunting battle against these recalcitrant infections and their often devastating consequences. Most of the relevant diagnostic tests are relatively affordable, and patient-centered risk-reduction counseling, once mastered, can be brief and easily integrated into the overall conversation about protecting oneself during travel.

Sexually transmitted diseases and travel

Sexually transmitted diseases (STDs) are infections and resulting clinical syndromes caused by more than 25 infectious organisms transmitted through sexual activity. International travellers are at great risk of contracting any of these STDs, including HIV, if they have been sexually exposed to persons with any of these diseases. Population movement has been shown to be a major contributing factor in the global spread of STDs. Increased sexual promiscuity and casual sexual relationships tend to occur during travel abroad to foreign countries. Travellers should be aware that the risk of STDs is high especially in the developing countries and sexual encounter with casual partners or commercial sex workers (CSWs) carries a high risk of infection. Prevention of STDs during travel can be achieved by complete abstinence from sexual exposure or adopting safe sexual practices such as consistently and correctly using a latex condom during sexual contact.

Drug use, travel and HIV risk

A study was conducted to examine the travel experiences of a community sample of 160 drug users and 44 non-users recruited as part of a study of HIV risk. Of the sample, 47% (96/204) reported intercity travel in the previous ten years. Results showed that men were more likely to travel than women, Anglos more than minorities, and young persons more than old. When travellers testing HIV-seropositive (n = 13) were compared with seronegative travellers, HIV-positive travellers reported more sex while travelling than HIV-negative persons, but virtually all of the difference reported involved sex with condoms. There were no significant differences in sex risk behaviours while travelling between drug users and non-drug users, or in sex risk behaviors between drug injectors and non-injectors. Travellers had fewer injection partners while travelling than they had while at home. There was also a significant difference in number of sex partners with whom a condom was not used, with fewer sex partners while travelling.

What's driving an epidemic? The spread of syphilis along an interstate highway in rural North Carolina

OBJECTIVES

The purpose of this study was to determine whether county syphilis rates were increased along Interstate Highway 95 (I-95) in North Carolina during a recent epidemic.

METHODS

Ecological data on syphilis cases demographic data, highway data, and drug activity data were used to conduct a cross-sectional and longitudinal study of North Carolina countries from 1985 to 1994. Crude and adjusted incidence rate ratios (IRRs) were determined by means of standard and longitudinal Poisson regression models adjusted for sociodemographic factors and drug use.

RESULTS

Ten-year syphilis rates in I-95 counties greatly exceeded rates in non-I-95 counties (38 vs 16 cases per 100,000 persons) and remained higher after adjustment for race, age, sex, poverty, large cities, and drug activity (adjusted IRR = 2.05, 95% confidence interval [CI] = 1.84, 2.28). Syphilis rates were stable until 1989, when rates increased sharply in I-95 counties but remained stable in non-I-95 counties. Increased drug activity in I-95 counties preceded the rise in syphilis cases.

CONCLUSIONS

A better understanding of the relationship between high-ways and the spread of sexually transmitted diseases may guide future prevention interventions.

The ethnic minority traveler

Although the ethnic minority traveler is exposed to the same risks as other travelers, there are special considerations that make them vulnerable to certain diseases. In addition, many ethnic minority travelers are traditionally underserved by the medical community and often travel without the benefit of adequate counseling and immunization. The specific disease entities covered in this article include parasitic diseases (e.g. malaria, trypanosomiasis, intestinal helminths), tuberculosis, and other respiratory diseases, dengue, and sexually transmitted diseases and HIV.

Medical insurance claims associated with international business travel

OBJECTIVES

Preliminary investigations of whether 10,884 staff and consultants of the World Bank experience disease due to work related travel. Medical insurance claims filed by 4738 travellers during 1993 were compared with claims of non-travellers.

METHODS

Specific diagnoses obtained from claims were analysed overall (one or more v no missions) and by frequency of international mission (1, 2-3, or > or = 4). Standardised rate of claims ratios (SSRs) for each diagnostic category were obtained by dividing the age adjusted rate of claims for travellers by the age adjusted rate of claims for non-travellers, and were calculated for men and women travellers separately.

RESULTS

Overall, rates of insurance claims were 80% higher for men and 18% higher for women travellers than their non-travelling counterparts. Several associations with frequency of travel were found. SRRs for infectious disease were 1.28, 1.54, and 1.97 among men who had completed one, two or three, and four or more missions, and 1.16, 1.28, and 1.61, respectively, among women. The greatest excess related to travel was found for psychological disorders. For men SRRs were 2.11, 3.13, and 3.06 and for women, SRRs were 1.47, 1.96, and 2.59.

CONCLUSIONS

International business travel may pose health risks beyond exposure to infectious diseases. Because travellers file medical claims at a greater rate than non-travellers, and for many categories of disease, the rate of claims increases with frequency of travel. The reasons for higher rates of claims among travellers are not well understood. Additional research on psychosocial factors, health practices, time zones crossed, and temporal relation between travel and onset of disease is planned.

Evaluation of sexual health services within Australia and New Zealand

OBJECTIVE

To examine and compare specialised services for patients with sexually transmitted diseases (STDs) in Australia and New Zealand.

DESIGN

Postal questionnaire survey.

PARTICIPANTS AND SETTING

All STD facilities in Australia and New Zealand in 1993.

MAIN OUTCOME MEASURES

Patient numbers and demography; staffing levels; the role of nurses; diagnostic and treatment protocols; contact-tracing policies; and the availability of specialist medical services and community and education programs.

RESULTS

83 of 100 clinics responded; 52 were urban, 21 rural, and nine remote. 95% were open to men and women. Staffing levels were similar in Australia and New Zealand and there was considerable consistency in diagnostic techniques and treatment among clinics. Australian clinics more often used ciprofloxacin or ceftriaxone as the treatment of first choice for gonorrhoea; New Zealand clinics were more likely to test for Chlamydia using direct immunofluorescence; and Australian clinics were more likely to test for hepatitis A and offer hepatitis B vaccination to a broader range of patients. 88% of clinics always traced contacts for gonorrhoea, 86% for syphilis and 77% for Chlamydia. 98% of clinics offered HIV test counselling, and 78% STD health education.

CONCLUSIONS

The number of sexual health services has increased over the past decade. Other improvements include most clinics being open to both men and women, and consistency in the diagnosis, treatment and contact tracing of STDs. However, given the lack of adequate comparative data and the variable quality of national surveillance data, it is difficult to determine whether current facilities are meeting service needs.

Sexually Transmitted Diseases and Reproductive History in Women with Experience of Casual Travel Sex Abroad

Background: The objective of this study was to determine whether the frequency of sexually transmitted diseases (STDs) and some reproductive events in women with experience of casual travel sex (CTS) abroad with previously unknown male partners differed when compared to women lacking such experience. Methods: Nine hundred and ninety-six women seeking contraceptive advice from two family planning clinics and a youth clinic were studied. Two hundred and seventy-six of these women (27.7%) admitted experience of CTS. Results: Among current STDs, only the prevalence of cervical human papilloma virus infection was significantly higher in women with a history of CTS when compared to the comparison (COMP) group (11.2% vs. 0.7%). A history of gonorrhea, genital chlamydial infection, and genital warts was reported significantly more often in women with, rather than without, CTS (p=0-.005). Women who had experienced CTS had a lower rate of childbirth, but higher rates of legal abortion and pelvic inflammatory disease than did females in the COMP group. Conclusion: The study shows that women with experience of CTS belong to a group at high risk for acquisition of STDs. This increased risk, with the exception of genital warts, was attributed to sexual risk taking in general, not merely to traveling abroad.

Inadequacies in Health Recommendations Provided for International Travelers by North American Travel Health Advisors

The rise of international travel has increased the need for more, improved travel advice from physicians and public health facilities. The quality of the health information given has not been examined on a large-scale basis by many studies, however. Surveys in Canada, Switzerland, and the United States, for example, report that only 20% to 50% of practitioners could give accurate information regarding immunization and prophylaxis about travel-related disease. Anonymous surveys were sent to 1165 American and 96 Canadian public health units and travel clinics. Using five scenarios on travel to developing countries, each source was asked to complete a standardized form giving their recommendations for immunization, antimalarials, travelers' diarrhea, and other travel issues. Of the American respondents, 60% were physicians equally distributed among private practice, university, and corporate clinics; nurses comprised 75% of the Canadian respondents, primarily from public health clinics. The number of travelers counseled per year ranged from 3 to 40,000 (American mean, 448; Canadian mean, 2180). Depending on the scenario, 20 to 75% of the immunization groups recommended were inadequate or inappropriate: most frequently, lack of tetanus/polio boosters; indiscriminant use of yellow fever/cholera vaccines; haphazard advice about meningococcal, rabies, and typhoid vaccines; and a lack of consideration of measles in young adults. Of the antimalarial recommendations given, 20 to 60% were incorrect, including prescribing medication for nonrisk areas, failure to recognize chloroquine-resistant areas, and failure to understand the use of, or contraindications to, mefloquine. Frequently, acclimatization, altitude sickness, sunscreens, and safe-sex issues were omitted. The prevention and treatment of travelers' diarrhea were adequately covered, however. Pre-travel advice given by North American health advisors shows a considerable variability in the accuracy and extent necessary for effective travel disease prevention and treatment. Despite the growing efforts to further educate those responsible, higher quality of health advice needs to become a priority.