Principles and Practice of Travel Medicine

Principles and Practice

of Travel Medicine

Principles and Practice

of Travel Medicine

SECOND EDITION

EDITED BY

Jane N. Zuckerman

MD, FRCP, FRCPath, FFPH, FFPM, FFTM, FIBiol, FHEA

Director WHO Collaborating Centre for Travel Medicine

Director UCL Medical Student Occupational & Royal Free Travel Health Centre

Academic Centre for Travel Medicine & Vaccines

Sub-Dean Electives

Vice-President, Faculty of Pharmaceutical Medicine

Editor-in-Chief, Journal of Travel Medicine & Infectious Disease

University College London Medical School

London

United Kingdom

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Library of Congress Cataloging-in-Publication Data

Principles and practice of travel medicine / edited by Jane N. Zuckerman. – 2nd ed.

p. cm.

Includes bibliographical references and index.

ISBN 978-1-4051-9763-2 (hardback : alk. paper) 1. Travel–Health aspects. I. Zuckerman, Jane N.

RA783.5.P75 2012

616.9'802–dc23

2012014995

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may

not be available in electronic books.

Cover image: Small images (×7) courtesy of CDC; Large background image courtesy of

Morguefile / rmpinho

Cover design: Steve Thompson

Set in 10/12 pt Minion by Toppan Best-set Premedia Limited

01 2013

v

Contents

The strategy of standby emergency self-treatment, 143

Patricia Schlagenhauf

11 Emerging and re-emerging infectious diseases, 146

Francisco G. Santos O’Connor

Section III Prevention and management of

travel-related diseases

12 Skin tropical infections and dermatology in

travellers, 167

Francisco Vega-López and Sara Ritchie

13 Travellers’ diarrhoea, 197

Charles D. Ericsson

14 Vaccine-preventable disease, 209

Jay Halbert, Phyllis Kozarsky, Jane Chiodini,

Nicholas Zwar, Gary Brunette and Jane N. Zuckerman

15 Returned travellers, 260

Nicholas J. Beeching, Tom E. Fletcher and Limin Wijaya

Section IV Hazards of air and sea travel

16 Aviation medicine, 289

Michael Bagshaw

17 Aviation psychology, 315

Robert Bor, Carina Eriksen, Margaret Oakes and

Philip Baum

18 Expedition and extreme environmental medicine, 328

Sean Hudson, Andrew Luks, Piers Carter,

Luanne Freer, Caroline Knox, Chris Imray and

Lesley Thomson

19 Travel health at sea: cruise ship medicine, 380

Robert E. Wheeler

Section V Environmental hazards of travel

20 Travel-related injury, 397

Robert Grenfell

Contributor list, vii

Preface, xii

Section I Travel medicine

1 Trends in travel, 3

Thomas L. Treadwell

2 Tourism, aviation and the impact on travel

medicine, 9

Anne Graham

3 Epidemiology of health risks and travel, 19

Hans D. Nothdurft and Eric Caumes

4 Fitness to travel, 27

Dominique Tessier

5 Management of a travel clinic, 37

Abinash Virk and Elaine C. Jong

Section II Infectious diseases and travel

6 Epidemiology and surveillance of travel-related

diseases, 47

Tomas Jelinek

7 Virus infections in travellers, 55

Arie J. Zuckerman

8 Bacterial infections in travellers, 99

Ann L.N. Chapman and Christopher J. Ellis

9 Vector-borne parasitic diseases, 112

Emma C. Wall and Peter L. Chiodini

10 Malaria and travellers, 126

Malaria, 126

David J. Bell and David G. Lalloo

Malaria chemoprophylaxis, 133

Patricia Schlagenhauf, Catherine Jeppesen,

Laura K. Erdman, Melanie Newport, and

Kevin C. Kain

vi Contents

21 International assistance and repatriation, 403

Alex T. Dewhurst and John C. Goldstone

22 Venomous bites and stings, 415

R. David G. Theakston and David G. Lalloo

23 Ophthalmic conditions in travellers, 434

Clare Davey and James Tee

Section VI Practical issues for

travellers

24 Travelling with children (including international

adoption issues), 447

Philip R. Fischer and Andrea P. Summer

25 Women’s health and travel, 463

I. Dale Carroll and Susan Anderson

26 The immunocompromised traveller, 503

Robert J. Ligthelm and Pieter-Paul A.M. van Thiel

27 High-risk travellers, 515

Kathryn N. Suh, Anne E. McCarthy, Maria D. Mileno

and Jay S. Keystone

28 Aid workers, expatriates and travel, 531

Kenneth L. Gamble, Deborah M. Hawker,

Ted Lankester and Jay S. Keystone

29 The health of migrants and refugees, 556

Louis Loutan, Sophie Durieux-Paillard and Ariel Eytan

30 Visiting friends and relatives, 566

Delane Shingadia

31 Travel medicine, ethics and health tourism, 571

Deborah Bowman and Richard Dawood

32 Medico-legal issues in travel medicine, 579

Jennifer G. Baine and Paul S. Auerbach

33 Travellers’ safety and security, 588

Peter A. Leggat and Jeff Wilks

34 The international athlete: travelling healthy to global

sporting events, 601

Travis W. Heggie, Sarah Borwein and

Marc T.M. Shaw

35 Space tourism – the future in travel health?, 612

Kevin J. Fong and Mark H. Wilson

Index, 623

vii

Contributor list

Robert Bor

Clinical, Counselling and Health Psychologist

Royal Free Hospital

London, UK

Sarah Borwein

Director

Travel Safe, Central Health Medical Practice

Hong Kong SAR, China

Deborah Bowman

Professor of Bioethics, Clinical Ethics and Medical Law

St George ’ s, University of London

London, UK

Gary Brunette

Chief Travelers ’ Health Branch

Centers for Disease Control and Prevention

Atlanta, GA, USA

I. Dale Carroll

Medical Director

The Pregnant Traveler

Spring Lake, MI, USA

Piers Carter

Director

Expedition Medicine

Bedfordshire, UK

Eric Caumes

Professor of Infectious and Tropical Diseases

University Pierre et Marie Curie;

Vice Chairman, Department of Infectious

and Tropical Diseases

Teaching Hospital Piti é Salp ê tri è re

Paris, France

Susan Anderson

Clinical Associate Professor

Stanford University School of Medicine

Stanford, CA, USA

Paul S. Auerbach

Redlich Family Professor of Surgery

Division of Emergency Medicine

Department of Surgery

Stanford University School of Medicine

Stanford, CA, USA

Michael Bagshaw

Visiting Professor of Aviation Medicine

King ’ s College London and Cranfi eld University

London, UK

Jennifer G. Baine

Staff Physician

Sports Medicine

San Francisco State University

San Francisco, CA, USA

Philip Baum

Managing Director

Green Light Ltd

Editor, Aviation Security International

London, UK

Nicholas J. Beeching

Liverpool School of Tropical Medicine

Liverpool, UK

David J. Bell

Consultant in Infectious Diseases

Brownlee Centre, Gartnavel General Hospital

Glasgow, UK

viii Contributor list

Ann L.N. Chapman

Consultant Physician in Infectious Diseases

Sheffi eld Teaching Hospitals NHS Foundation Trust

Sheffi eld, UK

Jane Chiodini

Specialist Nurse in Travel Medicine

The Village Medical Centre

Great Denham

Bedfordshire, UK

Peter L. Chiodini

Hospital for Tropical Diseases

London School of Hygiene and Tropical Medicine

London, UK

Clare Davey

Royal Free Hampstead NHS Trust

London, UK

Richard Dawood

Medical Director and Specialist in Travel Medicine

Fleet Street Clinic

London, UK

Alex T. Dewhurst

Middlesex Hospital

London, UK

Sophie Durieux - Paillard

Programme Sant é Migrants

Department of Community Medicine and Primary Care

University Hospitals of Geneva

Geneva, Switzerland

Christopher J. Ellis

Birmingham Heartlands Hospital

Birmingham, UK

Laura K. Erdman

SAR labs, Sandra Rotman Centre for Global Health

UHN - Toronto General Hospital, University of Toronto

Toronto, ON, Canada

Charles D. Ericsson

Professor of Medicine

Dr. and Mrs. Carl V. Vartian Professor of Infectious

Diseases

Head, Clinical Infectious Diseases;

Director, Travel Medicine Clinic;

Director, Infectious Disease Fellowship Program

University of Texas Medical School at Houston

Houston, TX, USA

Carina Eriksen

Registered and Chartered Psychologist

South West London and St George ’ s Mental Health Trust

London, UK

Ariel Eytan

Unit é de Psychiatrie P é nitentiaire

Department of Psychiatry

University Hospitals of Geneva

Geneva, Switzerland

Philip R. Fischer

Professor of Pediatrics

Mayo Clinic

Rochester, MN, USA

Tom E. Fetcher

Liverpool School of Tropical Medicine

Liverpool, UK

Kevin J. Fong

Wellcome Trust Engagement Fellow

Consultant Anaesthetist

University College London Hospital;

Honorary Senior Lecturer, Department of Physiology

University College London

London, UK

Luanne Freer

Medical Director Yellowstone National Park

Founder/Director, Everest ER

Himalayan Rescue Association

Nepal

Kenneth L. Gamble

President, Missionary Health Institute;

Lecturer, University of Toronto

Toronto, ON, Canada

John C. Goldstone

Middlesex Hospital

London, UK

Anne Graham

Reader in Air Transport and Tourism

University of Westminster

London, UK

Robert Grenfell

Public Health Physician

Grenfell Health Consulting Pty Ltd

Natimuk

Victoria, Australia

Contributor list ix

Jay Halbert

Specialist Paediatric Registrar

University College London Hospital

London, UK

Deborah M. Hawker

Clinical Psychologist

InterHealth

London, UK

Travis W. Heggie

Bowling Green State University

Division of Sport Management, Recreation and Tourism

Bowling Green, OH, USA;

Senior Research Fellow

James Cook University, School of Public Health,

Tropical Medicine, and Rehabilitation Sciences

Townsville, QLD, Australia

Australia

Sean Hudson

Founder/Director Expedition Medicine UK

Medical Director Aegis Iraq

Medical Offi cer Ski Patrol Mount Hutt

Canterbury, New Zealand

Chris Imray

Professor of Vascular Surgery

Warwick Medical School

Consultant Surgeon

UHCW NHS Trust

Coventry, UK

Tomas Jelinek

Medical Director

Berlin Centre for Travel Medicine

Berlin, Germany

Catherine Jeppesen

Consultant Microbiologist

Dorset County Hospital NHS Foundation Trust

Dorset, UK

Elaine C. Jong

Clinical Professor of Medicine Emeritus

Past Director, Travel and Tropical Medicine Service

Divisions of Emergency Medicine, and Allergy and

Infectious Diseases

University of Washington

Seattle, WA, USA

Kevin C. Kain

Canada Research Chair in Molecular Parasitology

Professor of Medicine

University of Toronto;

Director, Centre for Travel and Tropical Disease

Toronto General Hospital;

SAR labs, Sandra Rotman Centre for Global Health,

UHN - Toronto General Hospital, University of Toronto

Toronto, ON, Canada

Jay S. Keystone

Professor of Medicine

University of Toronto

Toronto, ON, Canada

Caroline Knox

Medical Director

Expedition Medicine

Bedfordshire, UK

Phyllis Kozarsky

Professor of Medicine/Infectious Diseases

Chief, Travel and Tropical Medicine

Emory University

Atlanta, GA, USA

David G. Lalloo

Professor of Tropical Medicine

Liverpool School of Tropical Medicine

Liverpool, UK

Ted Lankester

Director of Health Services, InterHealth, London;

Director of Community Health Global Network;

External Lecturer

Oxford University Department of Public Health;

External Lecturer London School of Hygiene and Tropical

Medicine

London, UK

Peter A. Leggat

Professor and Deputy Head, School of Public Health,

Tropical Medicine and Rehabilitation Sciences

James Cook University

Townsville, QLD, Australia;

Visiting Professor, School of Public Health

University of the Witwatersrand

Johannesburg, South Africa

x Contributor list

Robert J. Ligthelm

Educational Consultant in Travel Medicine and Diabetes

Mellitus

formerly Consultant Internal and Travel Medicine at the

Havenziekenhuis and Institute for Tropical Diseases

Erasmus University

Medical Consultant at Executive Health Care

Hoofddorp, The Netherlands

Louis Loutan

Division of International and Humanitarian Medicine

Department of Community Medicine and Primary Care

University Hospitals of Geneva

Geneva, Switzerland

Andrew Luks

Associate Professor

Pulmonary and Critical Care Medicine

University of Washington

Seattle, WA, USA

Anne E. McCarthy

Professor of Medicine

University of Ottawa;

Director, Tropical Medicine and International

Health Clinic

Division of Infectious Diseases

Division of Infectious Diseases

Ottawa Hospital General Campus

Ottawa, ON, Canada

Maria D. Mileno

Associate Professor of Medicine

Alpert Medical School of Brown University

Codirector, Travel Clinic, Miriam Hospital

Providence, RI, USA

Melanie Newport

Professor in Infectious Diseases and Global Health

Brighton and Sussex Medical School

Brighton, UK

Hans D. Nothdurft

University of Munich

Munich, Germany

Margaret Oakes

Trainee Counselling Psychologist

City University

London, UK

Sara Ritchie

University College London Hospitals NHS Foundation

Trust

London, UK

Francisco G. Santos O ’ Connor

Specialist in Medical Microbiology

European Centre for Disease Prevention and Control

Stockholm, Sweden

Patricia Schlagenhauf

Professor

University of Z ü rich Centre for Travel Medicine

WHO Collaborating Centre for Travellers ’ Health

Z ü rich, Switzerland

Marc T.M. Shaw

Adjunct Professor, School of Public Health, Tropical

Medicine, and Rehabilitation Sciences

James Cook University

Townsville, QLD, Australia;

Medical Director

Worldwise Travellers Health Centres of New Zealand;

Travel Medicine Provider, New Zealand Academy of Sport

Auckland, New Zealand

Delane Shingadia

Consultant in Paediatric Infectious Diseases

Great Ormond Street Hospital

London, UK

Kathryn N. Suh

Associate Professor of Medicine

University of Ottawa

Ottawa, ON, Canada

Andrea P. Summer

Associate Professor of Pediatrics

Medical University of South Carolina

Charleston, SC, USA

James Tee

Royal Free Hampstead NHS Trust

London, UK

Dominique Tessier

Bleu R é seau d ’ Experts, Groupe Sant é Voyage, and H ô pital

Saint - Montreal

Qu é bec, Canada

Contributor list xi

R. David G. Theakston

Emeritus Professor (University of Liverpool)

Alistair Reid Venom Research Unit

Liverpool School of Tropical Medicine

Liverpool, UK

Lesley Thomson

Consultant Anaesthetist

Plymouth Hospital NHS Trust

Plymouth, UK

Thomas L. Treadwell

Director, Infectious Disease Clinic;

Program Director, Internal Medicine

Metrowest Medical Center;

Assistant Clinical Professor Medicine

Boston University School of Medicine

Framingham, MA, USA

Pieter - Paul A.M. van Thiel

Infectious Disease Physician and Consultant Tropical

Medicine for the (Netherlands) Ministry of Defense

Center for Tropical and Travel Medicine

Academic Medical Center, University of Amsterdam

Amsterdam, The Netherlands

Francisco Vega - L ó pez

University College London Hospitals NHS Foundation

Trust

London, UK

Abinash Virk

Associate Professor of Medicine, College of Medicine

Mayo Clinic

Rochester, MN, USA

Emma C. Wall

Hospital for Tropical Diseases

London, UK

Robert E. Wheeler

Voyager Medical Seminars

Amherst, NH, USA

Limin Wijaya

Department of Infectious Disease

Singapore General Hospital

Singapore

Jeff Wilks

Principal, Tourism Safety Group;

Adjunct Professor, School of Public Health

Tropical Medicine and Rehabilitation Sciences

James Cook University

Townsville, QLD, Australia

Mark H. Wilson

Consultant Neurosurgeon

Imperial Hospitals NHS Trust

Honorary Senior Lecturer

Imperial College London

Pre - Hospital Care Specialist

London ’ s Air Ambulance

London, UK

Arie J. Zuckerman

Emeritus Professor of Medical Microbiology

UCL Medical School; Formerly Principal and Dean of the

Royal Free Hospital School of Medicine and later of the

Royal Free and University College London Medical School;

Honorary Consultant to the Royal Free NHS Trust;

Director of the WHO Collaborating Centre for Reference

and Research on Viral Diseases

University College London Medical School

London, UK

Jane N. Zuckerman

Senior Lecturer and Sub - Dean for Electives

UCL Medical School; Honorary Consultant, Royal Free

NHS Foundation Trust and Great Ormond Street Hospital

for Sick Children; Director of the Royal Free Travel Health

Centre and Director of the WHO Collaborating Centre for

Reference, Research and Training in Travel Medicine

University College London Medical School

London, UK

Nicholas Zwar

Professor of General Practice

School of Public Health and Community Medicine

University of New South Wales

Sydney, Australia

xii

Preface

stretches to exploring space, so the chapter on space tourism

may well be considered as the future in travel health.

Knowledge of all the above and other aspects of travel

health and medicine are, therefore, an essential requirement

for the many healthcare professionals providing advice and

clinical care of the traveller. This is, however, dependent on

understanding the science, which defi nes the practice, and

the chapter on epidemiology and surveillance and the epi￾demiology of health risks and travel should be useful in

underpinning best clinical practice in travel medicine.

The recent European outbreak of measles is a case in point,

which then informed the appropriate travel health vaccine

recommendations. The desire to travel will undoubtedly

continue unabated and will expand the minds of ever -

increasing numbers of travellers. Lest we forget, the new

chapter ‘ Tourism, aviation and its impact on travel medicine ’

acts as a timely reminder of how travel and tourism of what￾ever sort, are ever closely intertwined with health.

I am grateful to many friends and colleagues, who have

contributed so willingly and enthusiastically to this book,

through which we hope to stimulate healthcare professionals

to consider issues in travel medicine as part of their clinical

practice. I also hope that this reference book will enhance

the profi le of travel medicine and contribute to its continu￾ing development as a distinct specialty.

I would also like to express my sincere gratitude to the

editorial and production staff of Wiley - Blackwell, in par￾ticular Kate Newell and Maria Khan, for their patience and

unwavering support.

Finally, this book is dedicated to my mother, who still

speaks through me, and without whom I would not be the

person I am today, and my father, who inspired me to com￾plete the two editions of the Principles and Practice of Travel

Medicine , and who is stalwart in his support. I am particularly

indebted to my husband for always being there for me as well

as always encouraging me, and to Iris, who has been more

than a cousin and is like a sister to me. This second edition of

the book would never have been realised without you all.

‘ Like all great travellers, I have seen more than I remember,

and remember more than I have seen. ’ Benjamin Disraeli

Jane N. Zuckerman

London

Travel medicine: where have we been, where are we now and

where are we going are the intriguing and pertinent issues to

consider. Where have we been? We have come a long way

since the age of Galileo: ‘ Yet I do seriously and on good

grounds affi rm it possible to make a fl ying chariot in which a

man may sit and give such a motion unto it as shall convey

him through the air ’ (John Wilkins, 1640), through to the

Wright brothers inventing and building the fi rst successful

aeroplane in 1903. Where are we now? With the Airbus A380,

the largest passenger airliner in the world, taking travellers

with increasing speed to numerous destinations around the

globe. And where are we going? With 430 travellers signed up

to fl y with Virgin Galactic, travel to space may yet prove to be

the ultimate tourist destination. We really have travelled a

long, long way . . . and we will continue to do so. The ever -

increasing need for travel medicine specialists to meet the

travel health needs of travellers could not be more evident.

This second edition of the Principles and Practice of Travel

Medicine aims to provide practitioners with a reference re -

source to support the clinical practice of travel medicine.

Several chapters have been updated: the new chapter dedi￾cated to malaria includes recommendations for prophylaxis

and strategies for stand - by self - treatment, while the chapter

on vaccine - preventable diseases includes new developments

in licensed vaccines as well as continent - based recommen￾dations for their administration. Other important topics

of clinical practice include the travel health management of

high - risk travellers, who should always be evaluated with

care and advised accordingly. They include the diabetic trav￾eller, the immunocompromised, those with cardiovascular,

renal, neurological, gastrointestinal, malignant and other

disorders, psychological and psychiatric illnesses, pregnant

women, children and the elderly. New chapters address other

emerging clinical travel medicine issues such as health

tourism and considerations on meeting the travel health

needs of those visiting friends and relatives, alongside the

updated chapter on the important topic of migrant health.

With increasing numbers of more adventurous travellers

tackling travel at altitude for example, the chapter on travel

medicine and extreme environments will be of particular

interest to those whose practice involves meeting the travel

health needs of such intrepid travellers. Of course the most

intrepid will be those travellers whose adventurous streak

Section I

Travel medicine

Chapter 1 Trends in travel

Thomas L. Treadwell

MetroWest Medical Center, Framingham, MA; Boston Medical Center, Boston, MA, USA

3

Introduction

‘ The great affair is to move. ’ The history of mankind is one

of migration as humans travelled in search of food, escaping

inhospitable climactic conditions, and in response to hard￾ships caused by war, famine, social injustice and poverty. In

the nineteenth and early twentieth century alone, 60 million

people left Europe to seek better lives and to avoid the hard￾ships of war. The health effects of these mass migrations are

well known and include epidemics of infectious diseases,

physical and psychological trauma, malnutrition and the

introduction of diseases into new populations. Regrettably,

such forced migrations are still a reality, as recent events in

Africa, the Middle East and western Asia demonstrate. The

types and severity of health problems seen in migrant popu￾lations are far different to those associated with tourism, the

focus of this chapter.

In contrast to migration, which usually takes place out of

necessity, tourism has become much more common and is

associated with much different health risks to those seen in

migrant populations. Humans have always yearned to

expand their horizons by travelling. During the past 60 years,

the explosion in tourism has created new economies in both

developed and underdeveloped countries, created tremen￾dous life experiences for millions of travellers and spawned

a new branch of medicine.

Growth of tourism

Figure 1.1 depicts the dramatic increase in international

travel since 1950. In that year, approximately 25 million

people travelled abroad as tourists. By the year 2010, the

number of international tourist arrivals will approach one

billion; estimates are that nearly 8% of the world ’ s popula￾tion will travel to another country [1] . This impressive

growth in international tourism has been approximately 8%

per year since 1950. The growth has many causes:

• improvements in transportation

• changing world economies

• increased political stability

• the development of tourism as an industry

• increases in travel for health and education.

The growth of the commercial airline industry in the 1950s,

and later the use of jet travel, have been cornerstones of the

expansion of international tourism. As the relative cost of air

travel has decreased and the ease of arranging fl ights has

improved, this trend continues to drive increases in tourism.

Just over half of all international tourists arrive by air.

Highway and rail systems have also improved, particularly in

Europe and Asia, and although only 3% of tourists arrive by

train, roughly 40% reach their destination by car or bus.

Only 6% of international travel is currently by boat [1] .

Globalisation and improvements in the world economy

have obviously been important in tourism. Increases in

wealth in both industrialised and developing countries, in

part driven by the tourism industry itself, are instrumental

in the increase in international travel. Also important is an

ageing population with increases in both wealth and leisure

time. An important sector of tourism has been the popula￾tion of migrants in industrialised countries who have had

increased prosperity and who return to developing countries

to visit families. This type of tourism is especially important

for practitioners of travel medicine [2] .

Improvements in political stability have also enhanced

the opportunities for international travel. The disintegra￾tion of the former Soviet Union and the creation of the

European Union are two obvious examples of changes

resulting in increased opportunities for both business and

leisure travel [3] .

The rapid expansion of the tourism industry itself, espe￾cially in developing countries, has fuelled export income,

which currently stands at more than US$1 trillion per year, or

Principles and Practice of Travel Medicine, Second Edition. Edited by Jane N. Zuckerman.

© 2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd.

4 Principles and practice of travel medicine

• A French tourist is 20 times more likely to go to Africa than

an American traveller.

• Twice as many English tourists visit India and Pakistan as

American visitors.

• Australian tourists commonly have exotic destinations in

Africa and Southern Asia.

Outbound tourism

Most international travel originates in developed countries,

more than half of them in Europe (Figure 1.4 ). Asia and the

Pacifi c have overtaken the Americas as the second most

common origin for travel. In fact, emerging countries with

rising levels of prosperity have showed higher growth rates

nearly US$3 billion per day [1] . The development of the

tourism industry, with its great use of the nternet and advertis￾ing strategies, has been important in the expansion of tourism.

Finally, individuals are increasingly travelling for business,

health and education. It was hard to imagine even a decade

ago that patients from North America would travel to devel￾oping countries for surgery and medical treatment that is

less expensive than in their own country. The impressive

numbers of students who study abroad is of particular inter￾est to the fi eld of emporiatrics.

Where are international

tourists going?

Most international tourism is for pleasure and is local; intra￾regional tourism accounts for nearly 80% of all international

arrivals [1] . Moreover, the top destinations of international

tourists, listed in Table 1.1 , are mostly developed countries

in Europe. In fact, Europe has nearly one - half of all interna￾tional arrivals, although Asia, the Middle East and Africa

have seen signifi cant growth in the past 15 years (Figures 1.2

and 1.3 ). Since 1995, international arrivals to Asia, the Pacifi c

and Africa have tripled, while during the same period arriv￾als to Europe and the Americas showed only modest growth.

In addition, most international tourists visiting the Americas

arrive in the United States or Canada. However, the fastest

growing area in the region is Central America, which is cer￾tainly of more interest to practitioners of travel medicine [1] .

Examining destinations of international travel in different

regions, several patterns emerge.

• In the Americas, most travel is ‘ north – south ’ to Canada,

Mexico and the Caribbean. Visitors from the US are much

more likely to go to the Caribbean than South America or

Central America.

Figure 1.1 International tourist arrivals, 1950 –2005 [1].

Publisher's Note:

Image not available

in the electronic edition

Publisher's Note:

Table not available

in the electronic edition

Trends in travel 5

top tourism spenders and countries with the largest tour￾ism receipts are nearly all developed nations, the relative

importance of tourism to developing countries is much

greater (Figure 1.5 , Table 1.2 ). Currently, international

tourism generates more than US$1 trillion per year and

accounts for nearly one - third of the world ’ s exports of com￾mercial services. Perhaps more importantly, tourism is the

leading export category for most developing countries. In

these countries, tourism creates not only jobs, but much

needed infrastructure. Currently, more than 80 countries

earned US$1 billion or more. Examining the list of top

than developed countries as markets for the travel industry.

This is especially true for northeast and southern Asia,

Eastern Europe, and the Middle East. Although intraregional

travel still dominates, interregional trips have grown twice

as fast in recent years [1] .

The economics of tourism

The importance of tourism as a driver of world economy

cannot be overstated. Although lists containing the world ’ s

Figure 1.2 International arrivals (millions) by selected area (adapted from [1]).

Figure 1.3 International arrivals (2008) by selected region (adapted from [1]).

Figure 1.4 Outbound tourism, 2008, millions [1].

Publisher's Note:

Image not available

in the electronic edition

Publisher's Note:

Image not available

in the electronic edition

Publisher's Note:

Image not available

in the electronic edition