Travel-related morbidity in travelers with insulin-dependent diabetes mellitus

Morbidity of Returning Travelers Seen in Community Urgent Care Centers throughout Israel

Information regarding post-travel morbidity is usually reported via dedicated post-travel clinics and mainly relates to travelers returning from low-middle-income countries (LMIC), however, the spectrum of morbidity seen within the community setting is scarcely reported. This prospective observational study among visitors to 17 community Urgent Care Centers (UCC) was designed to evaluate the reasons for post-travel community clinic visits and to compare travelers returning from LMIC to high-income countries (HIC). All visitors within one-month post-travel to all destinations were included. A total of 1580 post-travel visits were analyzed during 25 months. Travelers to LMICs were younger (mean 36.8 years old vs. 41.4 in the HIC group) and stayed longer periods abroad (30.1 ± 41.2 vs. 10.0 ± 10.6 in the HIC group) but more of them had pre-travel vaccines (35.5% vs. 6.6%). Travel-related morbidity was significantly more common in the LMIC group 58.3% (253/434) vs. 34.1% (391/1146) in the HIC group, (p < 0.001). Acute diarrhea was the leading cause of morbidity after visiting LMIC (28.8%) and was significantly more common than in the HIC (6.6%, p < 0.001). Other common morbidities in the LMIC cohort were respiratory (23.3%), cutaneous (15.8%), and injuries (9.9%). In the HIC group, the common morbidities were respiratory (37.3%), and diarrhea composed only 6.6% of the complaints. Our study group represents a less biased sample of travelers to LMIC as well as HIC, therefore, data from the UCC setting and at the specialized travel clinics complete each other in understanding the true extent of morbidity in travelers.

Safe Travel Practices and Awareness among Diabetic Patients

Objective

To measure the knowledge of Saudi patients with diabetes in coping with their condition and to assess their practice of disease control during travels. Study Design. Cross-sectional study using a self-administered questionnaire.

Method

This study was conducted between September 2018 and May 2019 at a University hospital in Riyadh, Saudi Arabia. The questions were adopted from guidelines and advices provided by the CDC, American Diabetic Association, and other references. Bivariate and multivariate analyses were used to identify factors associated with diabetic control during travels.

Results

From the included 242 patients, 33.6% showed the good practice of diabetic control during travels. 23.7% of patients were communicated by their doctors about the importance of consultations before traveling and 20.7% encountered complications during travels. Factors associated with doctors' consultation before travel are patients' concerns about travel duration and possible risks during trip. (OR = 2.588, 95% CI = 5.308-1.261), (OR = 3.525, 95% CI = 8.152-1.525); respectively.

Conclusion

Patient awareness and education about the importance of proper diabetic self-monitoring and control during travels is crucial as the study showed suboptimal diabetes management practice. Practice Implications. Physicians should proactively educate patients about the importance of seeking advice before their travels.

Traveling Across Time Zones With Type 1 Diabetes: A Pilot Study Comparing Insulin Degludec With Insulin Glargine U100

OBJECTIVE

For people with type 1 diabetes, there are limited evidence-based resources to support self-management when traveling across multiple time zones. Here, we compared glycemic control on insulin degludec versus glargine U100 as the basal insulin for adults using multiple daily injections (MDI) while traveling across multiple time zones.

RESEARCH DESIGN AND METHODS

This randomized crossover pilot study compared insulin degludec versus glargine U100 for adults with type 1 diabetes using MDI insulin during long-haul travel to and from Hawaii to New York. Insulin degludec was administered daily at the same time regardless of time zone, and glargine was administered per travel algorithm. Primary end point was the percentage of time in range (TIR) between 70 and 140 mg/dL during the initial 24 h after each direction of travel. Secondary end points included standard continuous glucose monitoring metrics, jet lag, fatigue, and sleep.

RESULTS

The study enrolled 25 participants (56% women, mean ± SD age of 35 ± 14.5 years, HbA1c of 7.4 ± 1.2% [57 ± 13.1 mmol/mol], and diabetes duration of 20.6 ± 15 years). There was no significant difference in glycemic outcomes between the two arms of the study, including TIR, hypoglycemia, or hyperglycemia. Neither group achieved >70% TIR 70-180 mg/dL during travel. Jet lag was greater on glargine U100 in eastward travel but not westward. Fatigue was greater after westward travel on glargine. Sleep was not significantly different between basal insulins.

CONCLUSIONS

In adults with type 1 diabetes using MDI of insulin and traveling across multiple time zones, glycemic outcomes were similar comparing insulin degludec and glargine U100.

Travellers with type 1 diabetes: questionnaire development and descriptive analysis of knowledge and practices

BACKGROUND

Little is known about the awareness of travellers with diabetes about the health effects of international travel. This study aimed to design and validate a questionnaire to examine the travel health knowledge, attitudes and practices of people living with type 1 diabetes.

METHODS

A set of 74 items based on a conceptual framework analysis underwent revision and its content validity was established. Items were grouped into three domains. A development study was conducted to establish evidence regarding their factorial structure. A construct validation study was then conducted in which the retained items were tested in an independent sample using confirmatory factor analysis (CFA).

RESULTS

Four factors emerged from our development study and were labelled as pre-travel preparation-insect bites, pre-travel preparation-consultation, insulin and glycaemic control and travel risk behaviour. A CFA confirmed the factorial structure identified in the development study in an independent sample. Each factor loading had a significant (P < 0.001) loading of at least 0.4. The factor correlations ranged between 0.1 and 0.6, indicating good discriminant validity. The highest mean domain score in our sample of 268 participants related to insulin and glycaemic control (6.45), followed by travel risk behaviour (5.21) and pre-travel preparation (4.15).

CONCLUSIONS

This valid questionnaire for measuring the degree of preparedness of travellers with type 1 diabetes may prove a useful tool in studies involving travellers with type1 diabetes. Our results suggest that improvements are needed in relation to timely pre-travel consultation and screening for diabetic complications.

Retrospective analysis of older travellers attending a specialist travel health clinic

Background

Older people represent a significant proportion of overseas travellers. The epidemiology of older international travellers is not well described in the literature. This study aims to identify demographics, travel characteristics and the medical profile of older travellers seeking pre-travel health advice in a specialist travel medicine clinic.

Methods

Records of travellers aged 60 years and older attending the Tropical Medical Bureau clinic in Galway, Ireland between 2014 and 2018 were examined. Descriptive and inferential.analysis of data was performed.

Results

A total of 337 older travellers sought pre-travel health advice during the study period. The mean age of the cohort was 65.42 (±10) years. Most of the travellers (n = 267, 80%) had at least one travelling companion. Nearly half of older travellers (n = 155, 46.8%) were travelling with a single companion. Tourism was the main reason for travel for the majority (n = 260, 77.6%), followed by visiting friends and relatives (VFR) (n = 23, 6.9%) travellers. The mean interval remaining before the planned trip was 4.36 (±2) weeks, and the mean duration of travel was 3.16 (±1) weeks. The most popular single country of destination was India with 33 (9.8%) visitors, and South East Asia was the most popular region with 132 (39.2%) older travellers. The majority of travellers (n = 267, 79.2%) had a documented pre-existing medical condition. The most commonly reported medical conditions were hypertension (n = 26, 7.7%), dyslipidaemia (n = 18, 5.3%), diabetes mellitus (n = 12, 3.5%), insect bite sensitivity (n = 11, 3.3%), and hypothyroidism (n = 9, 2.6%). Antihypertensive agents (n = 32, 9.4%) and statins (n = 24, 7.1%) were the most frequently used medications. Typhoid (n = 112, 33.2%) and hepatitis A (n = 84, 24.9%) were the most common vaccinations administered to older travellers at the clinic.

Conclusions

This study provides an insight into the demographics, travel characteristics, and medical profile of elderly travellers seeking advice at a large travel clinic in Ireland. A wide range of travel destinations, diseases and medication use was reported among this group of travellers, which may enable travel medicine physicians to provide more tailored advice and to more appropriately counsel older travellers.

MANAGEMENT OF DIABETES DURING AIR TRAVEL: A SYSTEMATIC LITERATURE REVIEW OF CURRENT RECOMMENDATIONS AND THEIR SUPPORTING EVIDENCE

OBJECTIVE

Individuals with diabetes are increasingly seeking pretravel advice, but updated professional recommendations remain scant. We performed a systematic review on diabetes management during air travel to summarize current recommendations, assess supporting evidence, and identify areas of future research.

METHODS

A systematic review of the English literature on diabetes management during air travel was undertaken utilizing PubMed and MEDLINE. Publications regarding general travel advice; adjustment of insulin and noninsulin therapies; and the use of insulin pumps, glucometers and subcutaneous glucose sensors at altitude were included. Gathered information was used to create an updated summary of glucose-lowering medication adjustment during air travel.

RESULTS

Sixty-one publications were identified, most providing expert opinion and few offering primary data (47 expert opinion, 2 observational studies, 2 case reports, 10 device studies). General travel advice was uniform, with increasing attention to preflight security. Indications for oral antihyperglycemic therapy adjustments varied. There were few recommendations on contemporary agents and on nonhypoglycemic adverse events. There was little consensus on insulin adjustment protocols, many antedating current insulin formulations. Most publications advocated adjusting insulin pump time settings after arrival; however, there was disagreement on timing and rate adjustments. Glucometers and subcutaneous glucose sensors were reported to be less accurate at altitude, but not to an extent that would preclude their clinical use.

CONCLUSION

Recommendations for diabetes management during air travel vary significantly and are mostly based on expert opinion. Data from systematic investigation on glucose-lowering medication adjustment protocols may support the development of a future consensus statement.

ABBREVIATIONS

CSII = continuous subcutaneous insulin infusion (device) DPP-4 = dipeptidyl peptidase 4 EGA = error grid analysis GDH = glucose dehydrogenase GOX = glucose oxidase GLP1 = glucagon-like peptide-1 NPH = neutral protamine Hagedorn SGLT2 = sodium-glucose cotransporter-2.

Perspectives on Long-Distance Air Travel with Type 1 Diabetes

We sought to determine the real-life experiences of individuals traveling long distance (across five or more time-zones) with type 1 diabetes (T1D). Five hundred three members of the T1D Exchange online community ( www.myglu.org ) completed a 45-question survey about their travel experiences flying long distance. The cohort was stratified by duration of T1D and whether or not participants used continuous subcutaneous insulin infusion (CSII) therapy and/or a continuous glucose monitor (CGM). In the last 5 years, 71% of participants had flown long distance. When asked about their perceived "fear of flying," CSII users (with and without a CGM) reported their primary anxiety was "losing supplies," while non-CSII users described concerns over "unstable blood glucose (highs and lows)" (P < 0.05). In addition, 74% of participants reported more hypoglycemia and/or hyperglycemia while traveling overseas and 9% had avoided international travel altogether because of problems related to diabetes management. Furthermore, 22% of participants had run out of insulin at some point during a trip and 37% reported inadequate attention in current sources of information to the unpredictability of self-management needs while traveling. Especially problematic for individuals traveling with T1D are a lack of resources adequately addressing (1) protocols for emergencies while abroad, (2) how to navigate airport security, and (3) managing basal insulin rates when crossing time zones. A strong need exists for easily accessible, free resources for traveling with T1D that is tailored to both device use and duration of the disease.

Benefits of flu vaccination for persons with diabetes mellitus: A review

Diabetes mellitus imposes a significant and increasing burden on society, with major consequences for human health, welfare and the economy worldwide. Persons with diabetes mellitus are at increased risk of developing severe complications after influenza virus infection and guidelines advise vaccination. The present evidence for influenza vaccine effectiveness in persons with diabetes mellitus is mainly based on observational studies with clinical endpoints like hospitalization and death, indicating a beneficial reduction of morbidity and mortality. Further supportive evidence comes from serological studies, in which persons with diabetes mellitus usually develop similar antibody levels after vaccination as healthy people. Observational studies may be prone to selection bias, and serological studies may not completely mirror vaccine effectiveness in the field. Although more controlled trials in persons with diabetes mellitus with laboratory-confirmed, influenza-specific outcomes would be desirable to better estimate the effect of vaccination, the currently available data justify routine influenza vaccination in persons with diabetes mellitus. As in this risk group, the use of influenza vaccine is far below target worldwide, efforts should be made to increase vaccination coverage.

Vacation ease: travelling with an insulin pump

BACKGROUND

Vacation travel is a welcome retreat from our everyday world. Whether the trip is trekking in Nepal, a ski vacation in the western Rockies or a beach holiday to the Caribbean, the insulin pump is a constant companion for many people with diabetes. As a healthcare professional assisting individuals in their travel plans, we can contribute to the success of their trip by encouraging early preparation and by sharing practical and timely tips.

PURPOSE

To provide current information and practical insights for healthcare professionals (HCP) who are counseling patients with diabetes travelling with an insulin pump.

LIMITATIONS

There are numerous suggestions for all patients with diabetes who travel. This article will focus on travel recommendations specific to the pump user. Due to the lack of research in this area the information shared is based on evidence where possible and otherwise patient experience.

CONCLUSION

Insulin pump users can enjoy any type of vacation travel. Certain destinations require more preparation than others but regardless of the choice of venue, preplanning in collaboration with a knowledgeable health care provider can contribute to a successful experience.

Health risks of young adult travelers with type 1 diabetes

AIM

International travel has become popular among young adults. This study evaluated the rate and characteristics of travel-associated health risks among young adults with type 1 diabetes mellitus (T1DM) compared with healthy same-aged individuals.

METHODS

A retrospective study was conducted of 47 young adults with T1DM and 48 without (controls). Structured questionnaires accessed information regarding 154 international trips during the preceding 5 years and lasted 7 days and longer.

RESULTS

Mean ± SD ages of the diabetic and control groups were 26.6 ± 5.0 and 26.9 ± 2.6 years, respectively. Mean trip durations were 80.0 (range 7.0-390.0) and 87.6 days (range 7.0-395.0), respectively. The number of trips per person was 1.5 ± 0.6 and 1.7 ± 0.8, and the proportion of trips to developing countries 64 and 61%, respectively. There were no differences between the groups in rates of travel-related diseases that required medical consultation (11% vs 15% for all trips). No patient sought medical attention for acute problems related to diabetes management. Prior to 71% of their trips to developing countries, respondents with diabetes consulted their diabetes physician; prior to 26% of their trips they switched from an insulin pump to injections; during 41% of the trips they increased glucose monitoring; and for the period of 11% of the trips they defined their metabolic control as poor. Self-reported mean hemoglobin A1c (HbA1c) levels before and after trips were 7.65 ± 1.45 and 7.81 ± 1.23%, respectively (p = 0.42, paired t-test).

CONCLUSIONS

Young adults with type 1 diabetes did not report more travel-related diseases than did healthy individuals. Most reported reasonable to good glycemic control during the trip without severe consequences.

Impact of traveling to visit friends and relatives on chronic disease management

BACKGROUND

Travelers visiting friends and relatives (VFR) are known to be at high risk of acquiring infectious diseases during travel. However, little is known about the impact of VFR travel on chronic diseases.

METHODS

This was a nonrandomized, retrospective observational study. Patients were adult VFR travelers who received care from an internal medical clinic serving immigrants and refugees. The primary objective was to determine the impact of VFR travel on markers of chronic disease management including: blood pressure, glycosylated hemoglobin, body mass index, serum creatinine, and anticoagulation.

RESULTS

Of the 110 VFR travelers in our study, N = 48 traveled to Africa and N = 62 traveled to Asia for a mean duration of 59 (range 21-303) days. Of the 433 counseling points discussed at pre-travel visits, 71% were infectious disease prevention, 16% chronic disease related, and 13% travel safety. A total of 63 patients (57%) reported one or more health problems while traveling. Of these, 35 patients (32%) experienced a problem related to a chronic condition. In comparison, 24 (22%) patients experienced an acute infection. Sixty percent of patients were nonadherent to medications during travel. An average increase in diastolic blood pressure of 3.6 mmHg among patients with hypertension was the only statistically significant change in a chronic disease marker when values before and after travel were compared. Subgroup analysis revealed that travel to Africa and nonadherence to medications were also associated with worsening blood pressure control, and patients traveling to Africa experienced a decrease in body mass index.

CONCLUSIONS

This study identified a high proportion of problems related to chronic conditions experienced during VFR travel, while pre-travel appointments tended to focus on infectious disease prevention. A greater emphasis on medication adherence and chronic disease management during VFR travel is also needed during pre-travel preparations.

Health risks of travelers with medical conditions--a retrospective analysis

BACKGROUND

Traveling the world may result in infection with tropical or other travel-associated diseases. This applies increasingly also to people with immune-compromising and other medical conditions, as well as to elderly individuals. To reduce exposure and susceptibility to health risks, there is a need for appropriate pre-travel advice for these particular groups of travelers.

METHODS

In this observational study, we analyzed the overall risk of health problems among travelers with underlying medical conditions who attended the University of Amsterdam's Academic Medical Center's (AMC) travel clinic from January to October 2010. Telephone questionnaires were administered to 345 travelers with underlying conditions and 100 healthy travelers.

RESULTS

The most common underlying medical conditions studied included: (1) diabetes mellitus; (2) impaired immunity due to use of immune-suppressing medication; (3) reduced gastric barrier; and (4) HIV infection. The overall incidence of travel-related diseases (TRDs) was higher among those patients with underlying medical conditions compared to healthy travelers [incidence rate ratio (IRR) 2.26, 95% CI (1.29-3.98)]. Of all diseases reported, gastrointestinal disease, fever, and respiratory problems were reported most frequently. Travel to Central America, South Central Asia, Northeast Asia, and North Africa was associated with increased risk of contracting TRD. Hepatitis B protection was absent or unknown in 75% of these travelers.

CONCLUSIONS

Travelers with medical conditions had a higher risk of obtaining TRD, predominantly gastrointestinal in nature.

Risk behaviors and spectrum of diseases among elderly travelers: a comparison of younger and older adults

BACKGROUND

Elderly travel to the developing world is increasing. Little information is available regarding risk behaviors and health during and after travel in this population.

METHODS

We compared the risk factors and occurrence of travel-related diseases in two populations of Israelis, travelers aged 60 years and older and travelers in the age group of 20 to 30 years. Only people traveling for less than a month were included. Pre-travel, each person received routine counseling regarding travel-associated health risks, was immunized, and given anti-malarial prescriptions as needed. Travelers were surveyed by telephone 6 to 12 months following travel about underlying medical conditions, current medications, and travel history. Risk and preventive behaviors, compliance with anti-malarial prophylaxis, and history of illness during and after travel were assessed.

RESULTS

Of patients who visited the clinic from January to June 2008, 191/208 (91%) travelers aged 60 and older and 203/291 (69%) travelers aged 20 to 30 years were contacted by phone and recruited. Fewer elderly travelers drank open drinks, compared to young travelers (8% vs 35%, p < 0.01), and fewer purchased street food compared to young travelers (16.2% vs 37.9%, p < 0.01). More elderly travelers were fully compliant with their anti-malarial chemoprophylaxis regimen (60.7% vs 33.8%, p < 0.01). More elderly travelers took organized tours (61% vs 2%, p < 0.001). Young travelers more often backpacked (50.7% vs 10.4%, p < 0.001). Illness, most commonly diarrhea, was reported by 18.8% of elderly travelers compared to 34.0% of the young travelers (p = 0.001). In a logistic regression model only travel to East Asia (OR 4.66) (95%CI 1.93-11.22) and traveling under basic conditions (OR 1.94) (95% CI 1.42-3.29) remained significantly associated with illness, irrespective of age.

CONCLUSIONS

Because elderly travelers tend to comply with health-related recommendations better and use less risky travel modes, their risk for illness during travel was lower. Traveling to East Asia and travel mode are associated with illness during travel, irrespective of age.

Symptoms of infectious diseases in travelers with diabetes mellitus: a prospective study with matched controls

BACKGROUND

Travelers with diabetes mellitus to developing countries are thought to have symptomatic infectious diseases more often and longer than travelers without diabetes. Evidence for this is needed. This study evaluates whether travelers with diabetes are at increased risk of symptomatic infectious diseases.

METHODS

A prospective study was performed between October 2003 and February 2008 among adult medication-dependent travelers with diabetes, with their healthy travel companions without diabetes serving as matched controls. Thus, travelers with diabetes and controls were assumed to have comparable exposure to infection. Data on symptoms of infectious diseases were recorded by using a structured diary.

RESULTS

Among 70 travelers with insulin-dependent diabetes, the incidence of travel-related diarrhea was 0.99 per person-month, and the median number of symptomatic days 1.54 per month. For their 70 controls, figures were 0.74 and 1.57, respectively (p > 0.05). Among 82 travelers with non-insulin-dependent diabetes, incidence was 0.75, and the median number of symptomatic days was 1.68. For their 82 controls, figures were 0.70 and 1.68, respectively (p > 0.05). As for other symptoms, no significant travel-related differences were found. Only 17% of travelers with diabetes suffering from diarrhea used their stand-by antibiotics.

CONCLUSIONS

Medication-dependent travelers with diabetes traveling to developing countries do not have symptomatic infectious diseases more often or longer than travelers without diabetes. Routine prescription of stand-by antibiotics for travelers with diabetes to areas with good health facilities is probably not more useful than for healthy travelers.

[Medical clearance for missions abroad (EEU): definitions, recommendations for use and performance]

Standards for medical clearance for private or business missions abroad are--at least in the German speaking countries--not clearly defined and mostly derived from the old terminus "Tropentauglichkeit" which means fit for mission in the tropics. The authors now define a new standard, called "Entsendungstauglichkeitsuntersuchung" which means clearance of fitness for all types of missions abroad, independent of distinct climatic zones. To meet the inhomogenous requirements of different institutions and different types of missions the medical examination proposed follows a modular structure to optimize economic and medical use of resources. Moreover, as Austria, Germany and Switzerland have different legal and economic postulates, the medical examination has to be adapted to the different premises. The definition and description of this special type of "medical clearance for missions abroad" is supplemented by recommendations for definitions of clients who should undergo such an investigation and the professionals who should perform this type of investigation. Additionally, results of this type of medical clearance are defined and prophylactic aspects in terms of pre-travel advice are mentioned.

Long- and short-haul travel by air: issues for people with diabetes on insulin

OBJECTIVE

To determine what problems are experienced by people with diabetes mellitus traveling abroad using insulin, whether appropriate and consistent advice is available to them, and if necessary, how this advice could be improved or enhanced.

DESIGN

Census study by self-administered questionnaire of patients with diabetes who use insulin attending an outpatient clinic.

SETTING

Grampian Diabetes Centre, Woolmanhill Hospital, Aberdeen.

PARTICIPANTS

A total of 493 patients using insulin who attended the clinic in Aberdeen over a period of 3 months.

MAIN OUTCOME MEASURES

Determination of number of patients experiencing problems during travel, of number of patients seeking advice prior to travel and whether it was helpful, and of where respondents would like to access advice.

RESULTS

About 10% of respondents experienced problems while traveling, mostly due to hypoglycemia. Most patients want more advice to be available at the clinic. Long-haul travelers were more likely to ask clinic staff for advice and were more willing to use a clinic Web site (70%) to access information about travel than those traveling shorter distances (54%).

CONCLUSIONS

Patient education may help to reduce the incidence of problems related to travel in those with diabetes mellitus. More than 95% of patients were happy with the advice relating to travel health at the clinic but would like more to be available. It would be useful to improve the consistency of advice within the clinic, and this advice should be readily accessible by all, including fellow healthcare professionals such as General Practitioners (GPs), practice nurses, and travel clinic staff.

Travellers with pre-existing medical conditions

Medical conditions that influence travel include those that compromise the immunity of the traveller and chronic underlying diseases or infirmities. The former includes HIV, transplantation, malignancy and its treatment, IgA deficiency, asplenia and use of immunocompromising drugs like corticosteroids. Chronic conditions include diabetes mellitus, end stage renal disease, diseases associated with compromised cardiac or pulmonary function and certain gastrointestinal diseases including cirrhosis. This review includes practical approaches to each of these conditions with attention to risk assessment and avoidance, vaccination when appropriate and not a risk to the compromised host, and arming the traveller with self-therapy and chemoprophylaxis. Since travellers with underlying conditions are often taking various medications the travel health practitioner must be alert for possible drug/drug interactions and must adjust dosages depending on the level of compromised renal or hepatic function. Finally, education of such travellers is paramount; they must understand that risk avoidance is critical and preventative modalities such as vaccination and chemoprophylaxis are never 100% efficacious.