Victor Balaban

Protective Practices and Respiratory Illness Among US Travelers to the 2009 Hajj

BACKGROUND All mass gatherings can place travelers at risk for infectious diseases, but the size and density of the annual Hajj pilgrimage to the Kingdom of Saudi Arabia (KSA) present important public health and infection control challenges. This survey of protective practices and respiratory illness among US travelers to the 2009 Hajj was designed to evaluate whether recommended behavioral interventions (hand hygiene, wearing a face mask, cough etiquette, social distancing, and contact avoidance) were effective at mitigating illness among travelers during the 2009 Hajj. METHODS US residents from Minnesota and Michigan completed anonymous surveys prior to and following travel to the 2009 Hajj. Surveys assessed demographics, knowledge, attitudes, and practices (KAP) related to influenza A(H1N1), vaccination, health-seeking behaviors, sources of health information, protective behaviors during the Hajj, and respiratory illness during and immediately after the Hajj. RESULTS Pre- and post-travel surveys were completed by 186 participants. Respiratory illness was reported by 76 (41.3%) respondents; 144 (77.4%) reported engaging in recommended protective behaviors during the Hajj. Reduced risk of respiratory illness was associated with practicing social distancing, hand hygiene, and contact avoidance. Pilgrims who reported practicing more recommended protective measures during the Hajj reported either less occurrence or shorter duration of respiratory illness. Noticing influenza A(H1N1) health messages during the Hajj was associated with more protective measures and with shorter duration of respiratory illness. CONCLUSIONS Recommended protective behaviors were associated with less respiratory illness among US travelers to the 2009 Hajj. Influenza A(H1N1) communication and education in KSA during the Hajj may also have been an effective component of efforts to mitigate illness. Evaluations of communication efforts and preventive measures are important in developing evidence-based public health plans to prevent and mitigate disease outbreaks at the Hajj and other mass gatherings.

Travel Characteristics and Risk‐Taking Attitudes in Youths Traveling to Nonindustrialized Countries

BACKGROUND International travel to developing countries is increasing with rising levels of disposable income; this trend is seen in both adults and children. Risk-taking attitude is fundamental to research on the prevention of risky health behaviors, which can be an indicator of the likelihood of experiencing illness or injury during travel. The aim of this study is to investigate whether risk-taking attitudes of youths are associated with travel characteristics and likelihood of experiencing illness or injury while traveling to nonindustrialized countries. METHODS Data were analyzed from the 2008 YouthStyles survey, an annual mail survey gathering demographics and health knowledge, attitudes, and practices of individuals from 9 through 18 years of age. Travelers were defined as respondents who reported traveling in the last 12 months to a destination other than the United States, Canada, Europe, Japan, Australia, or New Zealand. Risk-taking attitude was measured by using a four-item Brief Sensation-Seeking Scale. All p values ≤ 0.05 were considered significant. RESULTS Of 1,704 respondents, 131 (7.7%) traveled in the last 12 months. Females and those with higher household income were more likely to travel (odds ratio = 1.6,1.1). Of those who traveled, 16.7% reported seeking pretravel medical care, with most visiting a family doctor for that care (84.0%). However, one-fifth of respondents reported illness and injury during travel; of these, 83.3% traveled with their parents. Males and older youths had higher mean sensation-seeking scores. Further, travelers had a higher mean sensation-seeking score than nontravelers. Those who did not seek pretravel medical care also had higher mean sensation-seeking scores (p = 0.1, not significant). CONCLUSIONS Our results show an association between risk-taking attitudes and youth travel behavior. However, adult supervision during travel and parental directives prior to travel should be taken into consideration. Communication messages should emphasize the importance of pretravel advice, target parents of children who are traveling, and be communicated through family doctors.

Knowledge, attitudes, and practices of US travelers to Asia regarding seasonal influenza and H5N1 avian influenza prevention measures.

BACKGROUND International travel is a potential risk factor for the spread of influenza. In the United States, approximately 5%-20% of the population develops an influenza-like illness annually. The purpose of this study was to describe the knowledge, attitude, and practices of US travelers to Asia regarding seasonal influenza and H5N1 avian influenza (AI) prevention measures. METHODS We surveyed travelers to Asia waiting at the departure lounges of 38 selected flights at four international airports in New York, Chicago, Los Angeles, and San Francisco. Of the 1,301 travelers who completed the pre-travel survey, 337 also completed a post-travel survey. Univariate and multivariate logistic regression were used to calculate prevalence odds ratios (with 95% CI) to compare foreign-born (FB) to US-born travelers for various levels of knowledge and behaviors. RESULTS Although the majority of participants were aware of influenza prevention measures, only 41% reported receiving the influenza vaccine during the previous season. Forty-three percent of participants reported seeking at least one type of pre-travel health advice, which was significantly higher among US-born, Caucasians, traveling for purposes other than visiting friends and relatives, travelers who received the influenza vaccine during the previous season, and those traveling with a companion. Our study also showed that Asians, FB travelers, and those working in occupations other than health care/animal care were less likely to recognize H5N1 AI transmission risk factors. CONCLUSION The basic public health messages for preventing influenza appear to be well understood, but the uptake of influenza vaccine was low. Clinicians should ensure that all patients receive influenza vaccine prior to travel. Tailored communication messages should be developed to motivate Asians, FB travelers, those visiting friends and relatives, and those traveling alone to seek pre-travel health advice as well as to orient them with H5N1 AI risk factors.

Health risks, travel preparation, and illness among public health professionals during international travel.

BACKGROUND Few data currently exist on health risks faced by public health professionals (PHP) during international travel. We conducted pre- and post-travel health surveys to assess knowledge, attitudes, and practices (KAP), and illnesses among PHP international travelers. METHOD Anonymous surveys were completed by PHP from a large American public health agency who sought a pre-travel medical consult from September 1, 2009, to September 30, 2010. RESULTS Surveys were completed by 122 participants; travelers went to 163 countries. Of the 122 respondents, 97 (80%) reported at least one planned health risk activity (visiting rural areas, handling animals, contact with blood or body fluids, visiting malarious areas), and 50 (41%) reported exposure to unanticipated health risks. Of the 62 travelers who visited malarious areas, 14 (23%) reported inconsistent or no use of malaria prophylaxis. Illness during travel was reported by 33 (27%) respondents. CONCLUSIONS Most of the PHP travelers in our study reported at least one planned health risk activity, and almost half reported exposure to unanticipated health risks, and one-quarter of travelers to malarious areas reported inconsistent or no use of malaria chemoprophylaxis. Our findings highlight that communication and education outreach for PHP to prevent travel-associated illnesses can be improved.

Health Risks and Travel Preparation Among Foreign Visitors and Expatriates During the 2008 Beijing Olympic and Paralympic Games

During the 2008 Olympic and Paralympic Games, we conducted surveillance of illnesses among travelers at six Beijing clinics. Surveys asked about demographic, pre-travel, and vaccination information, and physician-provided diagnoses. Of 807 respondents, 38% and 57% were classified as foreign visitors (FV) and expatriates, respectively. Less than one-half of FV sought pre-travel advice; sources included health-care providers and friends/family. FV vaccination rate was also low; however, most vaccines given were recommended by the Centers for Disease Control and Prevention. The most common FV diagnoses were respiratory, injury/musculoskeletal, and gastrointestinal illnesses; for expatriates, injury/musculoskeletal, respiratory, and dermatologic were the most common illnesses. Respiratory illnesses in expatriates were significantly less in 2008 than during 2004-2007 (chi(2) = 10.2; P = 0.0014), suggesting that control programs may have reduced pollutants/respiratory irritants during the 2008 Games. We found no previous studies of health outcomes among expatriates living in cities with mass travel events. These findings highlight the need to continuously disseminate information to health-care providers advising travelers.

Predictors of protective behaviors among American travelers to the 2009 Hajj

BACKGROUND Respiratory-borne infectious diseases can spread rapidly at mass gatherings. The 2009 Hajj took place during the influenza A (H1N1) pandemic. This study investigates factors associated with compliance with recommended influenza A (H1N1)-related health practices and behaviors among American pilgrims to the 2009 Hajj: receiving seasonal influenza vaccinations, receiving influenza A (H1N1) vaccinations, and behaviors intended to mitigate respiratory illness. METHODS American residents from Minnesota and Michigan completed anonymous surveys prior to and following travel to the 2009 Hajj. Surveys assessed demographics; knowledge, attitudes and practices (KAP) related to influenza A (H1N1); seasonal and H1N1 vaccinations; health-seeking behaviors; sources of health information; and protective behaviors during the Hajj. RESULTS Pre- and post-travel surveys were completed by 186 participants. Receiving seasonal influenza vaccination was reported by 138 (63%) respondents, and 80 (36%) reported receiving an influenza A (H1N1) vaccine. One hundred forty-four (79%) respondents reported engaging in protective behaviors during the Hajj to prevent illness. In multivariable models, greater perceived severity of influenza A (H1N1) before traveling was associated with: seasonal influenza vaccination (OR=1.74, 95% CI=1.14-2.62, p=.01), influenza A (H1N1) vaccination (OR=2.02, 95% CI=1.35-3.02, p=.001), and engaging in protective behaviors during the Hajj (OR=1.62, 95% CI=1.00-2.63, p=.003). CONCLUSIONS This study found that accurate knowledge of influenza A (H1N1) symptoms, transmission, and prevention was associated with greater perceived severity of influenza A (H1N1); and perceived influenza A (H1N1) severity was associated with engaging in recommended protective health practices. Understanding the barriers to and facilitators of compliance with recommended behaviors can help guide the development of tailored outreach strategies to mitigate the impact and spread of respiratory disease.

Respiratory illness in households of school-dismissed students during pandemic (H1N1) 2009.

To the Editor: In response to the emergence of pandemic (H1N1) 2009 virus (1), the Centers for Disease Control and Prevention (CDC) issued interim guidance for preventing spread of the pandemic virus in schools. Initial guidance recommended that dismissal of students be considered for schools with confirmed cases of pandemic (H1N1) 2009 infection. The guidance was subsequently revised to recommend monitoring for respiratory illness and exclusion of ill students until they were noninfectious, rather than dismissal. In Chicago, Illinois, USA, the first cases of pandemic (H1N1) 2009 infection were identified on April 28, 2009, of which 1 occurred in an elementary school student (2). In accordance with CDC guidance at the time, the school (school A) was closed for 1 week, April 29–May 5, 2009. CDC and the Chicago Department of Public Health investigated respiratory illnesses among students and their households during the period surrounding the school closure. A telephone survey of students’ households was conducted during May 15–20, 2009 (3). One adult member of each household was asked whether any household members had been “sick with cold or flu symptoms or fever” since April 12. Age, date of illness onset, and symptoms and signs (fever, cough, sore throat, rhinorrhea or nasal congestion [runny or stuffy nose]) were recorded. Acute respiratory illness was defined as >1 symptom or sign from the list provided. Influenza-like illness was defined as fever plus cough or sore throat. Reports were excluded if onset date was before April 12 or unknown. Descriptive analysis was performed, and household attack rates were calculated. Dates of onset were used to evaluate timing of illness in relation to school closure and possible transmission within households. The investigation was approved as nonresearch by CDC. Of 609 eligible households, 439 (72%) had a working telephone number, of which 170 (39%) completed the survey. Thirty-nine (23%) households, representing 181 persons, reported 58 illnesses that met the acute respiratory illness definition, of which 37 (64%) also met the influenza-like illness definition. Median age was 10 years (range <1–48 years). Of 57 household members for whom age and student status were recorded, 42 (74%) were students at school A. Thirty-four (60%) reported onset of symptoms before or on the day of school dismissal (Figure). Figure Respiratory illness in households of school-dismissed students during the pandemic (H1N1) 2009 outbreak, Chicago, Illinois, USA, 2009. Arrows indicate dates when school A closed and reopened. Household attack rates ranged from 10% to 100% (median 25%). Five (13%) households reporting illness had no ill students who attended school A. In 4 of 11 households reporting >2 illnesses, students became ill before nonstudent household members. In the remaining 7 households, onset dates did not suggest student-to-nonstudent transmission. Even though the school was closed almost immediately after the first pandemic (H1N1) 2009 case was confirmed in a student, onset of ≈60% of reported illnesses occurred before or on the day of school dismissal, suggesting that unrecognized transmission was already occurring in the school or community. These results are supported by data on confirmed cases of pandemic (H1N1) 2009 in Chicago, which suggest that community transmission was high during the survey period (2). Our results also indicated that at least some illness among school A households originated from sources other than the school and support the approach of considering school dismissal only in conjunction with other community mitigation strategies. In Hong Kong Special Administrative Region, People’s Republic of China, where all primary schools, kindergartens, and child care centers were immediately closed for 14 days after identification of the first local case of pandemic (H1N1) 2009, school closures were concluded to have substantially decreased transmission (4). The applicability of these findings to communities where such sweeping measures might be less acceptable is unclear. If school dismissal is considered as a strategy, dismissal early in the pandemic most likely would have the most impact, depending on duration of dismissal, other mitigation measures, and compliance with social distancing recommendations (which was mixed during the 2009 pandemic [3,5]). Polling of parents whose children experienced school dismissal showed high acceptance of short-term (3–5 days) dismissals and low economic impact, especially on lower income families (3,6). However, dismissal for longer periods needs to be balanced by the adverse impact on education, loss of student services, and socioeconomic impact on families (7–9). This investigation was limited by the relatively low response rate; however, demographics for the sample in our study were similar to those of the school as a whole (3). Other limitations included the exclusive use of reported symptoms to document illness, possible unrecognized asymptomatic cases, and absence of similar data from later in the pandemic. The 1-week closure period might not have provided enough information to capture any effect, and comparative data were not available from schools that were not dismissed during the pandemic. Further investigation is needed to evaluate the efficacy and impact of school dismissal, including the timing of dismissal in relation to recognition of cases in a school or community and the impact of school dismissal relative to other community mitigation strategies.