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Travel – a risk factor for disease and spread of antibiotic resistance
Umeå University, Faculty of Medicine, Department of Clinical Microbiology, Infectious Diseases.ORCID iD: 0000-0001-9532-8065
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

As international travel is rapidly increasing, more people are being exposed to potentially more antibiotic resistant bacteria, a changed infectious disease epidemiology, and an increased risk of accidents and crime. Research-based advice is needed to adequately inform travellers about these risks. We studied travellers who sought advice from the Travel Medicine Clinic at the Department of Infectious Diseases, Umeå University Hospital, as well as university students from Umeå, Stockholm, and Gothenburg travelling abroad for study, research, and clinical exchange programs.

From retrospective data at the Travel Medicine Clinic, we found that pre-existing health problems were rare among travellers from Umeå seeking pre- travel health advice and vaccinations. In addition, we found that the travel destination and the sex of the traveller affected vaccination levels. Although hepatitis A is endemic to both Thailand and Turkey, compared to travellers to Thailand few travellers to Turkey visited the clinic for hepatitis A vaccination. The data also revealed that more women than men were vaccinated against Japanese encephalitis despite comparable trips.

A prospective survey study showed that travellers felt that the pre-travel health advice they received was helpful. Two-thirds of the travellers followed the advice given although they still fell ill to the same extent as those who were not compliant with the advice. Factors outside the control of travellers likely affect the travel-related morbidity. Compared to older travellers, younger travellers were less compliant with advice, fell ill to a greater extent, and took greater risks during travel.

In a prospective survey study, we found that healthcare students had higher illness rates and risk exposure when abroad compared to students from other disciplines. This difference was mainly due to the fact that healthcare students more often travelled to developing regions during their study period abroad. When abroad, half of all students increased their alcohol consumption and this was linked to an increased risk of theft and higher likelihood of meeting a new sex partner.

The healthcare students participating in the survey study also submitted stool samples before and after travel. These samples were tested for the presence of antibiotic resistance, both by selective culturing for ESBL-PE (Extended-Spectrum Beta-Lactamase Producing Enterobacteriaceae) as well as by metagenomic sequencing. About one-third (35%) of the students became colonised by ESBL-PE following their study abroad. The strongest risk factor for colonisation was travel destination; for example, 70% of students who had travelled to India became colonised. Antibiotic treatment during travel was also a significant risk factor for colonisation.

The stool samples from a subset of study subjects were analysed using metagenomic sequencing. From this we learned that although the majority of resistance genes in the gut microbiome remained unchanged following travel, several clinically important resistance genes increased, most prominently genes encoding resistance to sulphonamide, trimethoprim, and beta-lactams. Overall, taxonomic changes associated with travel were small but the proportion of Proteobacteria, which includes several clinically important bacteria (e.g., Enterobacteriaceae), increased in a majority of the study subjects.

Clearly, there are risks associated with international travel and these risks include outside factors as well as the personal behaviour of travellers. We believe our results can be used to develop better pre-travel advice for tourists as well as university students studying abroad resulting in safer travel.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2015. , 66 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1754
Keyword [en]
Accident Prevention; Alcohol Drinking; Anti-Bacterial Agents; Antimalarials; Beta-Lactamases; Drug-Resistance, Bacterial; Enterobacteriaceae; Health Knowledge, Attitudes, Practice; High-Throughput Nucleotide Sequencing; Medication Adherence; Metagenome; Metagenomics; Patient Compliance; Proteobacteria; Risk Reduction Behaviour; Risk-Taking; Safe Sex; Travel medicine; Travel; Vaccination
National Category
Infectious Medicine Microbiology in the medical area
Research subject
Infectious Diseases; Microbiology
Identifiers
URN: urn:nbn:se:umu:diva-111057ISBN: 978-91-7601-348-9 (print)OAI: oai:DiVA.org:umu-111057DiVA: diva2:866644
Public defence
2015-11-27, Sal A5, byggnad 6A, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Funder
The Kempe Foundations
Available from: 2015-11-06 Created: 2015-11-02 Last updated: 2015-12-11Bibliographically approved
List of papers
1. Travel and vaccination patterns: a report from a travel medicine clinic in northern Sweden
Open this publication in new window or tab >>Travel and vaccination patterns: a report from a travel medicine clinic in northern Sweden
2011 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, E-ISSN 1651-1980, Vol. 43, no 9, 714-720 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The Travel Medicine Clinic in Umeå is one of Sweden's largest public providers of vaccination and counselling prior to international travel. During the study period it was the only travel medicine clinic in Umeå. This study describes the demography of the visitors to the clinic and travel destinations and durations, as well as vaccinations administered. METHODS: This was a retrospective study for the period January 2005 to April 2008 based on pre-travel consultation questionnaires and on vaccine expenditure data. A 10% sample of 16,735 first visits prior to international travel was consecutively selected according to the chronology of the visits. RESULTS: Data on 1698 travellers were included in the study. Thailand was the most common destination among visitors, accounting for one third of all destinations. Medical problems affecting pre-travel health planning were rare. Four out of 5 visitors (79%) received only 1 vaccination, mainly for hepatitis A. Travellers to Thailand more often sought travel health advice compared to travellers to Turkey, despite the fact that the 2 destinations were almost equally distributed among travellers from Umeå. We found differences between men and women in money spent on vaccines and in particular in vaccination against Japanese encephalitis. CONCLUSIONS: To assess the optimal vaccination level at a travel medicine clinic is difficult. Decisions are affected by general recommendations and the risk perception of the travel medicine practitioner, as well as the risk perception of the traveller. The sex difference found in this study might be due to gender differences in risk perception and should be further investigated.

Keyword
Travel medicine, vaccination patterns, travel trends, sex differences, vaccination policies
National Category
Infectious Medicine
Identifiers
urn:nbn:se:umu:diva-64535 (URN)10.3109/00365548.2011.581306 (DOI)000293913800007 ()21585242 (PubMedID)
Available from: 2013-01-31 Created: 2013-01-31 Last updated: 2017-12-06Bibliographically approved
2. Travel health advice: Benefits, compliance, and outcome
Open this publication in new window or tab >>Travel health advice: Benefits, compliance, and outcome
2014 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, E-ISSN 1651-1980, Vol. 46, no 6, 447-453 p.Article in journal (Refereed) Published
Abstract [en]

Background: Travel health advice is an important and difficult part of a pre-travel consultation. The aim of this study was to determine whether the travel health advice given is followed by the traveller and whether it affects disease and injury experienced during travel. Methods: A prospective survey study was carried out from October 2009 to April 2012 at the Travel Medicine Clinic of the Department of Infectious Diseases, Umea University Hospital, Umea, Sweden. The Travel Medicine Clinic in Umea is the largest travel clinic in northern Sweden. Results: We included 1277 individuals in the study; 1059 (83%) responded to the post-travel questionnaire. Most visitors (88%) remembered having received travel health advice; among these, 95% found some of the health advice useful. Two-thirds (67%) claimed to have followed the advice, but fell ill during travel to the same extent as those who did not. Younger travellers (< 31 y) found our travel health advice less beneficial, were less compliant with the advice, took more risks during travel, and fell ill during travel to a greater extent than older travellers. Conclusions: Helping travellers stay healthy during travel is the main goal of travel medicine. Younger travellers are a risk group for illness during travel and there is a need to find new methods to help them avoid illness. Travellers find travel health advice useful, but it does not protect them from travel-related illness. Factors not easily influenced by the traveller play a role, but a comprehensive analysis of the benefits of travel health advice is needed.

Keyword
Travel health advice, illness during travel, risk behaviour during travel, risk groups in travel medicine, compliance with travel health advice
National Category
Infectious Medicine
Identifiers
urn:nbn:se:umu:diva-90428 (URN)10.3109/00365548.2014.896030 (DOI)000336454800007 ()24694214 (PubMedID)
Available from: 2014-07-09 Created: 2014-06-23 Last updated: 2017-12-05Bibliographically approved
3. Illness and risk behaviour in health care students studying abroad
Open this publication in new window or tab >>Illness and risk behaviour in health care students studying abroad
2015 (English)In: Medical Education, ISSN 0308-0110, E-ISSN 1365-2923, Vol. 49, no 7, 684-691 p.Article in journal (Refereed) Published
Abstract [en]

Context: The numbers of university students studying abroad increase every year. These students are not tourists as their studies require different types of travel that expose them to different risks. Moreover, health care students (HCSs) may be exposed to even greater risks according to their travel destinations and itineraries. Clearly, research-based pre-travel advice is needed.

Methods: This study reports on a prospective survey conducted from April 2010 to January 2014 of health care and non-health care students from Swedish universities in Umeå, Stockholm and Gothenburg studying abroad.

Results: Of the 393 students included in the study, 85% responded. Over half (55%) were HCSs. Pre-travel health information was received by 79% and information on personal safety by 49% of HCSs. The rate of illness during travel was 52%. Health care students more often travelled to developing regions and were at increased risk for travellers' diarrhoea. One in 10 experienced theft and 3% were involved in traffic accidents. One in five met a new sexual partner during travel and 65% of these practised safe sex. Half of all participants increased their alcohol consumption while abroad; high alcohol consumption was associated with increased risk for being a victim of theft, as well as for meeting a new sexual partner during travel.

Conclusions: University authorities are responsible for the safety and well-being of students studying abroad. This study supplies organisers and students with epidemiological data that will help improve pre-travel preparation and increase student awareness of the potential risks associated with studying abroad.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-106313 (URN)10.1111/medu.12753 (DOI)000356388100008 ()26077216 (PubMedID)
Available from: 2015-07-17 Created: 2015-07-10 Last updated: 2017-12-04Bibliographically approved
4. Risk factors for colonization with extended-spectrum beta-lactamase producing Enterobacteriaceae in healthcare students on clinical assignment abroad: A prospective study
Open this publication in new window or tab >>Risk factors for colonization with extended-spectrum beta-lactamase producing Enterobacteriaceae in healthcare students on clinical assignment abroad: A prospective study
Show others...
2015 (English)In: Travel Medicine and Infectious Disease, ISSN 1477-8939, E-ISSN 1873-0442, Vol. 13, no 3, 223-229 p.Article in journal (Refereed) Published
Abstract [en]

Background: The increase of antibiotic resistance in clinically important bacteria is a worldwide threat, especially in healthcare environments. International travel is a risk factor for gut colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE). The risk for healthcare students of being colonized with ESBL-PE when participating in patient-related work abroad has not been previously investigated. Methods: Swedish healthcare students travelling for pre-clinical and clinical courses outside Scandinavia submitted faecal samples and survey data before and after travel. The faecal samples were screened for ESBL-PE and carbapenemase-producing Enterobacteriaceae (CPE). Screening results and survey data were analysed to identify risk factors for colonization. Results: In the 99 subjects who submitted a full set of samples, 35% were colonized with a new ESBL-PE strain during travel. No CPE was found. The most important risk factor for ESBL-PE colonization was travel destination, and the highest colonization rate was found in the South East Asia region. Antibiotic treatment during travel was an independent risk factor for ESBL-PE colonization but patient-related work was not significantly associated with an increased risk. Conclusions: Patient-related work abroad was not a risk factor for ESBL-PE suggesting that transmission from patients is uncommon. Pre-travel advice on avoiding unnecessary antibiotic treatment during travel is recommended.

Keyword
Anti-bacterial agents, Drug resistance, Beta-lactamases, Enterobacteriaceae, Travel
National Category
Infectious Medicine
Identifiers
urn:nbn:se:umu:diva-106613 (URN)10.1016/j.tmaid.2015.04.007 (DOI)000357348200005 ()25982453 (PubMedID)
Available from: 2015-07-28 Created: 2015-07-24 Last updated: 2017-12-04Bibliographically approved
5. The Human Gut Microbiome as a Transporter of Antibiotic Resistance Genes between Continents
Open this publication in new window or tab >>The Human Gut Microbiome as a Transporter of Antibiotic Resistance Genes between Continents
Show others...
2015 (English)In: Antimicrobial Agents and Chemotherapy, ISSN 0066-4804, E-ISSN 1098-6596, Vol. 59, no 10, 6551-6560 p.Article in journal (Refereed) Published
Abstract [en]

Previous studies of antibiotic resistance dissemination by travel have, by targeting only a select number of cultivable bacterial species, omitted most of the human microbiome. Here, we used explorative shotgun metagenomic sequencing to address the abundance of >300 antibiotic resistance genes in fecal specimens from 35 Swedish students taken before and after exchange programs on the Indian peninsula or in Central Africa. All specimens were additionally cultured for extended-spectrum beta-lactamase (ESBL)-producing enterobacteria, and the isolates obtained were genome sequenced. The overall taxonomic diversity and composition of the gut microbiome remained stable before and after travel, but there was an increasing abundance of Proteobacteria in 25/35 students. The relative abundance of antibiotic resistance genes increased, most prominently for genes encoding resistance to sulfonamide (2.6-fold increase), trimethoprim (7.7-fold), and beta-lactams (2.6-fold). Importantly, the increase observed occurred without any antibiotic intake. Of 18 students visiting the Indian peninsula, 12 acquired ESBL-producing Escherichia coli, while none returning from Africa were positive. Despite deep sequencing efforts, the sensitivity of metagenomics was not sufficient to detect acquisition of the low-abundant genes responsible for the observed ESBL phenotype. In conclusion, metagenomic sequencing of the intestinal microbiome of Swedish students returning from exchange programs in Central Africa or the Indian peninsula showed increased abundance of genes encoding resistance to widely used antibiotics.

National Category
Microbiology in the medical area Pharmacology and Toxicology
Identifiers
urn:nbn:se:umu:diva-110685 (URN)10.1128/AAC.00933-15 (DOI)000367591800082 ()26259788 (PubMedID)
Available from: 2015-10-26 Created: 2015-10-26 Last updated: 2017-12-01Bibliographically approved

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