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      Self-Reported Stomach Upset in Travellers on Cruise-Based and Land-Based Package Holidays

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          International travellers are at a risk of infectious diseases not seen in their home country. Stomach upsets are common in travellers, including on cruise ships. This study compares the incidence of stomach upsets on land- and cruise-based holidays.


          A major British tour operator has administered a Customer Satisfaction Questionnaire (CSQ) to UK resident travellers aged 16 or more on return flights from their holiday abroad over many years. Data extracted from the CSQ was used to measure self-reported stomach upset in returning travellers.


          From summer 2000 through winter 2008, 6,863,092 questionnaires were completed; 6.6% were from cruise passengers. A higher percentage of land-based holiday-makers (7.2%) reported stomach upset in comparison to 4.8% of cruise passengers (RR = 1.5, p<0.0005). Reported stomach upset on cruises declined over the study period (7.1% in 2000 to 3.1% in 2008, p<0.0005). Over 25% of travellers on land-based holidays to Egypt and the Dominican Republic reported stomach upset. In comparison, the highest proportion of stomach upset in cruise ship travellers were reported following cruises departing from Egypt (14.8%) and Turkey (8.8%).


          In this large study of self-reported illness both demographic and holiday choice factors were shown to play a part in determining the likelihood of developing stomach upset while abroad. There is a lower cumulative incidence and declining rates of stomach upset in cruise passengers which suggest that the cruise industry has adopted operations (e.g. hygiene standards) that have reduced illness over recent years.

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          Most cited references 19

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          Global etiology of travelers' diarrhea: systematic review from 1973 to the present.

          Fifty-one published studies of travelers' diarrhea (TD) were examined to look for regional differences in pathogens identified. Enterotoxigenic E. coli was detected in 1,678/5,518 (30.4%) of TD cases overall, with rates in Latin America/Caribbean (L. America), Africa, south Asia, and Southeast Asia of 1,109/3,302 (33.6%), 389/1,217 (31.2%), 153/499 (30.6%), and 36/500 (7.2%), respectively (P < 0.001). Enteroaggregative E. coli was the second most common agent in L. America, found in 166/689 (24.1%), compared with 3/165 (1.8%) in Africa and 33/206 (16%) in south Asia (P < 0.001). Other significantly regional differences were seen for enteropathogenic E. coli, diffusely adherent E. coli, Campylobacter, Shigella spp., Salmonella, Aeromonas spp., Plesiomonas, Vibrios, rotavirus, noroviruses, Giardia, and Entoamoeba histolytica. The regional differences in pathogen identification identified will serve as a baseline for antimicrobial therapy recommendations and vaccines strategies.
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            A global study of pathogens and host risk factors associated with infectious gastrointestinal disease in returned international travellers.

            Infectious gastrointestinal disease (IGD) is a significant cause of morbidity in returned international travellers. This study aims to elucidate host and travel characteristics associated with IGD presentation, and describe the broad spectrum of aetiological pathogens responsible by geographic region of acquisition and reason for travel. We analyzed demographic, clinical and microbiological data recorded for ill, returned international travellers presenting to GeoSentinel Surveillance Network sites globally during the period September 1996-December 2005. A total of 25,867 returned travellers were analyzed, of whom 7442 (29%) patients had a total of 8273 IGD diagnoses. Multivariate analysis demonstrated that IGD presentation was associated significantly with female sex (OR: 1.11; p=0.001); younger age group; attending a pre-travel medical appointment (OR: 1.28; p 28 days) was associated with lower risk (OR: 0.93; p=0.04). Of the 2902 clinically significant pathogens isolated, 65% were parasitic, 31% bacterial and 3% viral. Presentation of IGD by specific pathogen varied markedly dependent on geographic region of recent travel, and reason for travel. Host characteristics, region of travel and category of traveller, significantly impact on the relative likelihood of presenting with a broad range of pathogen-specific IGD.
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              Gastrointestinal infection among international travelers globally.

              Data on relative rates of acquisition of gastrointestinal infections by travelers are incomplete. The objective of this study was to analyze infections associated with oral ingestion of pathogens in international travelers in relation to place of exposure. We performed a multicenter, retrospective observational analysis of 6,086 travelers ill enough with any gastrointestinal infection to seek medical care at a GeoSentinel clinic after completion of travel during 2000 to 2005. We determined regional and country-specific reporting rate ratios (RRRs) in comparison to risk in northern and western Europe. Travel to sub-Saharan Africa (RRR = 282), South America (RRR = 203), and South Asia (RRR = 890) was associated with the greatest rate of gastrointestinal infections. RRRs were moderate (25-142) for travel to Oceania, the Middle East, North Africa, Central America, the Caribbean, and Southeast Asia. RRRs were least (<28) following travel to southern, central, and eastern Europe; North America; Northeast Asia; and Australasia. Income level of the country visited was inversely proportional to the RRR for gastrointestinal infection. For bacterial and parasitic infections examined separately, the regions group in the same way. RRRs could be estimated for 28 individual countries and together with regional data were used to derive a global RRR map for travel-related gastrointestinal infection. This analysis of morbidity associated with oral ingestion of pathogens abroad determines which parts of the world currently are high-risk destinations.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                10 January 2014
                : 9
                : 1
                [1 ]Gastrointestinal, Emerging and Zoonotic Infections Department, Public Health England, London, United Kingdom
                [2 ]EU Shipsan Trainet Project, Public Health Program, European Agency for Health and Consumers, Luxembourg, Luxembourg
                [3 ]Federation of Tour Operators, London, United Kingdom
                [4 ]Travel and Migrant Health Section, Public Health England, London, United Kingdom
                [5 ]Department of Hygiene and epidemiology, Medical Faculty, University of Thessaly, Larissa, Greece
                [6 ]Norwich Medical School, University of East Anglia, Norwich, United Kingdom
                The Australian National University, Australia
                Author notes

                Competing Interests: All authors work in Public Health Microbiology or Epidemiology. Professor Cartwright has undertaken paid work on behalf of the Travel Industry to investigate outbreaks. Professor Hadjicristodoulou rans an EU funded project called SHIPSAN TRAINET that was involved with passenger ship hygiene and Professor Nichols has also contributed to this project. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

                Conceived and designed the experiments: GN NL RC JL CH JJ. Performed the experiments: NL GN RC. Analyzed the data: NL GN RC JL JJ. Wrote the paper: NL GN JL RC CH JJ.


                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Pages: 7
                This study was not formally funded and analysis was performed within the SHIPSAN TRAINET project (EU Project No. 2007206). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Research Article
                Population Biology
                Infectious Disease Epidemiology
                Clinical Epidemiology
                Disease Informatics
                Economic Epidemiology
                Epidemiological Methods
                Infectious Disease Epidemiology
                Infectious Diseases
                Gastrointestinal Infections
                Infectious Disease Control
                Infectious Disease Modeling
                Travel-Associated Diseases



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